Status of the management of hypertension and diabetes in rural Kenya: a multi-institutional joint intervention of cross-sectional surveys.

Introduction: the aim of this study was to analyze the status of the management of vascular risk factors (hypertension and diabetes) at hospital level (3, 4 and 5) in Murang'a County (Kenya) health system. Methods: between July and December 2018 we performed a joint intervention about the strategies for improving care management of hypertension and diabetic patients in Murang'a (Kenya). A survey based on the recommendations from WHO about management of diabetes and hypertension was completed for 9 health-care centers. The survey made use of a semi-structured questionnaire, while the units of analysis for the survey were households. Results: the number of patients recorded at medical registers with diabetes and hypertension registered in public hospitals in Murang'a County were 6628 (0.45%) and y 6694 (0.45%), respectively. In the surveyed health-care centers, no hospital use electrogram and only one had troponin test. No hospital stocked Isosorbide dinitrate and Glicerine trinitate to prevent chest pain in patients with a heart condition. Only 3 of the clinics performed visual acuity examination and no facility did neurologic examination for neuropathy complications. No public hospital had HbA1 and did microalbuminuria test available. Conclusion: it is necessary to improve to establish screening methods, diagnosis, treatment and follow-up of patients with hypertension and diabetes in Murang'a County at the various levels of health care.

Goiter surgery recommendations in sub-Saharan Africa in humanitarian cooperation.

Background: The standard treatment for endemic goiter is usually total thyroidectomy. In low- and middle-income countries, the management of thyroid disease, which is commonplace in fully developed countries, is not always possible. The purpose of this study is to establish a treatment algorithm to calculate the extent of thyroidectomy based on the risk factors of each patient. Methods: This is a retrospective observational study conducted during the period between 2017 and 2019. A total of 287 patients with thyroid pathology were treated in Maragua Hospital (Kenya). The results of surgical treatment were analyzed after the implementation of an individualized treatment protocol. Results: One hundred and sixty patients with different types of goiter underwent surgery: solitary nodule (54.4%), multi-nodular goiter (30.6%), diffuse goiter (10.6%), and intrathoracic goiter (3.8%). The techniques used were hemithyroidectomy (78.8%), Dunhill thyroidectomy (9.4%), bilateral subtotal thyroidectomy (6.9%), and total thyroidectomy (3.1%). There was no mortality. The surgical morbidity rate was 16% (only one major complication (3b)). Two cases of dysphonia were resolved in the first week. There were three cases of symptomatic hypocalcaemia, two of which resolved in the first week and the other of which was definitive. The follow-up at 6 months was 67%. The cancer rate found in the resection specimens was 5%. Discussion: The implementation of individualized surgical protocols for thyroid surgery in sub-Saharan Africa can improve outcomes. The cooperation projects can increase access to complex surgical treatment for patients with limited resources in low- and middle-income countries.

Humanitarian Surgical Missions in Times of COVID-19: Recommendations to Safely Return to a Sub-Saharan Africa Low-Resource Setting.

BACKGROUND: Since the declaration of the pandemic, humanitarian medicine has been discontinued. Until now, there have been no general recommendations on how humanitarian surgical missions should be organized. METHODS: Based on our experience in the field of humanitarian surgical missions to Sub-Saharan Africa, a panel of recommendations in times of COVID-19 was developed. The fields under study were as follows: (1) Planning of a multidisciplinary project; (2) Organization of the infrastructure; (3) Screening, management and treatment of SARS-COV-2; (4) Diagnostic tests for SARS-COV-2; (5) Surgical priorization and (6) Context of patients during health-care assistance. We applied a risk bias measurement to obtain a consensus among humanitarian health-care providers with experience in this field. RESULTS: A total of 94.36% of agreement were reached for the approval of the recommendations. Emergency surgery must be a priority, and elective surgery adapted. For emergency surgery, we established a priority level 1a (< 24 h) and 1b (< 72 h). For an elective procedure, according our American College of Surgeon adaptation score, process with more than 60 points should be reconsidered. Due to the low life expectancy in many African countries, we consider 45-50 years as age of risk. In case of SARS-COV-2 active infection or high clinical suspicion, the screening, management and treatment should be following the international guidelines adapted to duration of the stay, available infrastructure, size of the cooperation team and medical resources. CONCLUSIONS: Humanitarian surgical mission in times of COVID-19 is a challenge that must extrapolate the established recommendations to the local cooperation environment.

Isoperistaltic versus antiperistaltic ileocolic anastomosis. Does it really matter? Results from a randomised clinical trial (ISOVANTI).

BACKGROUND: Right hemicolectomy is a very common surgery. Many studies compare different options for laparoscopic ileocolic anastomoses: intra- or extracorporeal; handsewn or stapled; side-to-side or end-to-side. However, there are no studies about the influence that peristalsis could have on this anastomosis. The aim of this study is to compare safety and feasibility of isoperistaltic and antiperistaltic anastomosis in terms of postoperative morbidity and mortality between both groups. The secondary endpoint is to compare long-term functional outcomes (chronic diarrhoea) and quality of life (GIQLI questionnaire) after a 1-year follow-up period. METHODS: A double-blind, randomised, prospective trial in patients undergoing scheduled surgery for right colon cancer with laparoscopic right hemicolectomy and isoperistaltic (ISO) or antiperistaltic (ANTI) ileocolic anastomoses. RESULTS: Hundred and eight patients were included in the study. Patients were randomised either to isoperistaltic or antiperistaltic configuration (54 ISO/ANTI). No significant differences in baseline variables were found. No differences in surgical time (130 [120-150] min ISO vs. 140 [127-160] ANTI, p = 0.481), nor in anastomotic time (19 [17-22] vs. 20 [16-25], p = 0.207) and nor in postoperative complications: 37.0% ISO versus 40.7% ANTI, (p = 0.693) were found. There were no differences in postoperative ileus (p = 0.112) nor in anastomotic leakage (3.7% vs. 5.56%, p = 1.00). Differences in "time to first flatus" and "time to first deposition" were found in favour of the antiperistaltic group (p = 0.004 and p = 0.017). Anastomotic configuration did not influence hospital stay (3 days [2-6] isoperistaltic vs. 3 [2-4] antiperistaltic, p = 0.236). During follow-up, there were no differences between the two groups at 1, 6 and 12 months (p = 0.154, p = 0.498 and p = 0.683), nor in chronic diarrhoea rates in GIQLI scores (24% ISO vs. 31.4% ANTI, p = 0.541). CONCLUSIONS: The isoperistaltic and antiperistaltic ileocolic anastomosis present similar results in terms of performance, safety and functionality. However, further studies must be carried out in order to assess relationship between postoperative ileus and anastomosis configuration. TRIAL REGISTRATION: Randomised Clinical trial (Identifier: NCT02309931).

El colgajo V-Y como método de reparación de defectos perianales extensos / V-Y advancement flaps for extensive perianal defect repair

INTRODUCCIÓN: Algunas enfermedades perianales precisan cirugías agresivas que crean la necesidad de recurrir a técnicas reparadoras para reconstruir la integridad de esta región. El objetivo de este estudio es analizar los resultados a corto y largo plazo tras reconstrucción perianal con colgajos V-Y. MÉTODO: Se ha revisado retrospectivamente nuestra base de datos institucional prospectiva (2000-2013), y se ha incluido en el presente análisis a todos los pacientes a los que se ha realizado una reconstrucción perianal con colgajo V-Y, tras escisión amplia perianal por enfermedad benigna o maligna. Se recogieron datos demográficos, quirúrgicos y la morbilidad a corto y largo plazo. RESULTADOS: Se analizó a un total de 10 pacientes, 6 varones y 4 mujeres, con edad media de 58,1 ± 17,4 años. El tiempo quirúrgico fue 143,5 ± 41,3 min y la estancia hospitalaria media tras la cirugía 7,8 ± 7,7 días. En 8 pacientes aparecieron complicaciones postoperatorias: dehiscencia parcial del colgajo (n = 6) y estenosis anal tardía (n = 4). En ningún caso se produjo la pérdida del colgajo. Siete pacientes presentaron buenos resultados en cuanto a la continencia anal, 2 pacientes incontinencia variable y en un caso se realizó una colostomía terminal por incontinencia grave. CONCLUSIÓN: Los colgajos V-Y son una técnica factible y efectiva para cubrir grandes defectos tras cirugías perianales agresivas; sin embargo, no están exentos de morbilidad postoperatoria

OBJECTIVES: Some perianal pathologies require aggressive surgery that will need techniques to allow to re-establish the integrity of the perianal region. The purpose is to analyze short and long term results after perineal reconstruction with V-Y flaps. OBJECTIVES: Some perianal pathologies require aggressive surgery that will need techniques to allow to re-establish the integrity of the perianal region. The purpose is to analyze short and long term results after perineal reconstruction with V-Y flaps. METHODS: A retrospective review of prospectively collected database was conducted at Virgen de la Arrixaca's Hospital in Murcia (España) between January 2000 and December 2013. The study includes all patients who underwent a perineal reconstruction with V-Y flaps. Demographic and surgical data and short-/long- term morbidity was recorded. RESULTS: 10 patients were included, 6 males and 4 females. The average age was 58,1 ± 17,4 years. Surgical indication included both malignant and benign pathologies. Operating time was 143,5 ± 41,3 min. R0 resection was performed in all cases although histopathological analysis showed involvement of the deeper margin in 3 cases. Length of hospital stay was 7,8 ± 7,6 days. Regarding complications: 6 patients had partial dehiscence of the flap. None of the patients lost the flap completely. The most frequent late complication was anal stenosis (n = 4). Follow up showed total continence in 7 patients. Two patients had variable fecal and/or flatus incontinence. A colostomy was made in one case due to severe incontinence. CONCLUSIONS: V-Y flaps are an effective and feasible technique to cover large perianal defects after aggressive surgeries. However, this technique is not free of postoperative morbidity

V-Y advancement flaps for extensive perianal defect repair. / El colgajo V-Y como método de reparación de defectos perianales extensos.

OBJECTIVES: Some perianal pathologies require aggressive surgery that will need techniques to allow to re-establish the integrity of the perianal region. The purpose is to analyze short and long term results after perineal reconstruction with V-Y flaps. METHODS: A retrospective review of prospectively collected database was conducted at Virgen de la Arrixaca's Hospital in Murcia (España) between January 2000 and December 2013. The study includes all patients who underwent a perineal reconstruction with V-Y flaps. Demographic and surgical data and short-/long- term morbidity was recorded. RESULTS: 10 patients were included, 6 males and 4 females. The average age was 58,1±17,4 years. Surgical indication included both malignant and benign pathologies. Operating time was 143,5±41,3min. R0 resection was performed in all cases although histopathological analysis showed involvement of the deeper margin in 3 cases. Length of hospital stay was 7,8±7,6 days. Regarding complications: 6 patients had partial dehiscence of the flap. None of the patients lost the flap completely. The most frequent late complication was anal stenosis (n=4). Follow up showed total continence in 7 patients. Two patients had variable fecal and/or flatus incontinence. A colostomy was made in one case due to severe incontinence. CONCLUSIONS: V-Y flaps are an effective and feasible technique to cover large perianal defects after aggressive surgeries. However, this technique is not free of postoperative morbidity.

Utility of rectoscopy in the assessment of response to neoadjuvant treatment for locally advanced rectal cancer.

BACKGROUND/AIMS: The management of locally advanced rectal cancer has changed substantially over the last few decades with neoadjuvant chemoradiotherapy. The aim of the present study is to compare the results between neoadjuvant post-treatment rectoscopy and the anatomopathological findings of the surgical specimen. PATIENTS AND METHODS: We conducted a prospective study of 67 patients with locally advanced adenocarcinoma of the rectum (stages II and III). Two groups were established: One with complete clinical response (cCR) and one without (non-cCR), based on the findings at rectoscopy. Assessment of tumor regression grade in the surgical specimen was determined using Mandard's tumor regression scale. RESULTS: Seventeen patients showed a cCR. Thirty-five biopsies were negative and 32 were positive for malignancy. All the cCR patients had a negative biopsy (P < 0.0001). All 32 positive biopsies revealed the presence of adenocarcinoma, and of the 35 negative biopsies, 18 had no malignancy and 17 were diagnosed with adenocarcinoma (P < 0.0001). Sixteen of the 17 cCR patients showed a complete pathological response and one patient showed the presence of adenocarcinoma. Of the 50 non-cCR patients 48 revealed the presence of adenocarcinoma and two had absence of malignancy. According to the Mandard classification, 16 of the 17 cCR patients were grade I and 1 grade II; 2 non-cCR patients were grade I, 7 grade II, 13 grade III, 19 grade IV, and 9 grade V. CONCLUSIONS: Endoscopic and histological findings could be determinants in the assessment of response to neoadjuvant treatment.

The influence of the percentage of the common limb in weight loss and nutritional alterations after laparoscopic gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is considered the gold standard for the treatment of morbid obesity. There is no consensus over ideal limb length when the bypass is created and published studies do not take into account the influence of the common limb (CL) on weight loss. The objective was to study the influence of the common limb after RYGB. The setting was the Virgen de la Arrixaca University Clinical Hospital in Murcia, Spain. MATERIAL AND METHODS: This prospective study includes 151 patients undergoing laparoscopic RYGB surgery for morbid obesity. The patients were divided into 2 groups according to their body mass index. The small intestine (SI) was measured using micro forceps so that the percentage of common limb (%CL) could then be compared against the total SI in each patient. The percentage of excess weight loss (%EWL) in relation to the %CL was calculated at 3, 12, and 24 months. A series of tests was conducted simultaneously to analyze nutritional deficiencies and their relation to the %CL. RESULTS: The total jejunoileal segment and the %CL in the groups of both obese and super-obese patients had no influence on the %EWL in either group for any of the periods studied. The patients with a %CL<50% had greater nutritional deficiencies in the follow-up period and required supplements and more frequent laboratory tests. CONCLUSIONS: The %CL has no effect on weight loss in RYGB patients. A lower %CL is related to greater nutritional deficiencies.

Aprendizaje de la cirugía del cáncer de recto por laparoscopia sin aumento de la morbimortalidad / The learning curve of laparoscopic treatment of rectal cancer does not increase morbidity

INTRODUCCIÓN: El tratamiento del cáncer de recto por laparoscopia es controvertido por su complejidad técnica. Estudios prospectivos aleatorizados han demostrado claras ventajas para el paciente, con resultados oncológicos equiparables a la cirugía abierta, aunque durante el aprendizaje de esta cirugía puede existir un aumento de las complicaciones y peor pronóstico. OBJETIVO: Nuestro objetivo es analizar cómo influye la curva de aprendizaje del cáncer de recto por vía laparoscópica en los resultados intra y postoperatorios, así como en los marcadores oncológicos. PACIENTES Y MÉTODOS: Se realizó una revisión retrospectiva de los 120 primeros pacientes intervenidos de neoplasia de recto por vía laparoscópica. La población a estudio se ordenó cronológicamente por fecha de intervención y se dividió en un primer grupo que contenía las 40 primeras intervenciones, y un segundo grupo que contenía las 80 siguientes. Las intervenciones fueron realizadas por el mismo equipo quirúrgico con una amplia experiencia en el tratamiento del cáncer colorrectal abierto, además de estar capacitados para realizar cirugía laparoscópica avanzada. Se analizaron sexo, ASA, localización del tumor, neoadyuvancia, técnica quirúrgica, tiempo operatorio, conversión, complicaciones postoperatorias, estancia hospitalaria, número de ganglios, estadio y afectación de márgenes. RESULTADOS: Se observaron diferencias significativas en cuanto a tiempo quirúrgico (224 min en el primer grupo, 204 min en el segundo grupo), con una mayor tasa de conversión en el primer grupo (22,5%) frente al segundo (11,3%). No se apreciaron diferencias significativas en cuanto a la tasa de cirugía conservadora de esfínteres, estancia hospitalaria, complicaciones posquirúrgicas, número de ganglios afectos/aislados ni márgenes circunferencial y distal afectos. CONCLUSIÓN: Es posible realizar el aprendizaje de esta compleja cirugía sin comprometer la seguridad y resultado oncológico del paciente

INTRODUCTION: The treatment of rectal cancer via laparoscopy is controversial due to its technical complexity. Several randomized prospective studies have demonstrated clear advantages for the patient with similar oncological results to those of open surgery, although during the learning of this surgical technique there may be an increase in complications and a worse prognosis. OBJECTIVE: Our aim is to analyze how the learning curve for rectal cancer via laparoscopy influences intra- and postoperative results and oncological markers. A retrospective review was conducted of the first 120 patients undergoing laparoscopic surgery for rectal neoplasia. The operations were performed by the same surgical team with a wide experience in the treatment of open colorectal cancer and qualified to perform advanced laparoscopic surgery. We analyzed sex, ASA, tumor location, neoadjuvant treatment, surgical technique, operating time, conversion, postoperative complications, length of hospital stay, number of lymph nodes, stage and involvement of margins. RESULTS: Significant differences were observed with regard to surgical time (224 min in the first group, 204 min in the second group), with a higher rate of conversion in the first group (22.5%) than in the second (11.3%). No significant differences were noted for rate of conservative sphincter surgery, length of hospital stay, post-surgical complications, number of affected/isolated lymph nodes or affected circumferential and distal margins. CONCLUSIONS: It is possible to learn this complex surgical technique without compromising the patient's safety and oncological outcome

The learning curve of laparoscopic treatment of rectal cancer does not increase morbidity.

INTRODUCTION: The treatment of rectal cancer via laparoscopy is controversial due to its technical complexity. Several randomized prospective studies have demonstrated clear advantages for the patient with similar oncological results to those of open surgery, although during the learning of this surgical technique there may be an increase in complications and a worse prognosis. OBJECTIVE: Our aim is to analyze how the learning curve for rectal cancer via laparoscopy influences intra- and postoperative results and oncological markers. A retrospective review was conducted of the first 120 patients undergoing laparoscopic surgery for rectal neoplasia. The operations were performed by the same surgical team with a wide experience in the treatment of open colorectal cancer and qualified to perform advanced laparoscopic surgery. We analyzed sex, ASA, tumour location, neoadjuvant treatment, surgical technique, operating time, conversion, postoperative complications, length of hospital stay, number of lymph nodes, stage and involvement of margins. RESULTS: Significant differences were observed with regard to surgical time (224 min in the first group, 204 min in the second group), with a higher rate of conversion in the first group (22.5%) than in the second (11.3%). No significant differences were noted for rate of conservative sphincter surgery, length of hospital stay, post-surgical complications, number of affected/isolated lymph nodes or affected circumferential and distal margins. CONCLUSIONS: It is possible to learn this complex surgical technique without compromising the patient's safety and oncological outcome.

Apendicectomía laparoscópica mediante incisión única transumbilical: experiencia inicial / Single incision transumbilical laparoscopic appendectomy: initial experience

Introducción La apendicitis es el proceso abdominal de urgencia más común. El tratamiento es quirúrgico y la cirugía laparoscópica mediante una única incisión (CLIU) implica la realización de la cirugía laparoscópica a través de un único punto transumbilical, en un intento de superar los resultados de la cirugía laparoscópica. Material y método Entre junio de 2009 y agosto de 2010, 73 pacientes con sospecha de apendicitis aguda fueron operados por la técnica CLIU. Todos los pacientes fueron intervenidos por el mismo equipo quirúrgico y el ombligo fue el único punto de entrada. El dolor postoperatorio se evaluó en el momento del alta de acuerdo a una escala numérica. Resultados Ninguno de los pacientes requirió conversión a laparoscopia convencional. El tiempo quirúrgico medio fue de 40±14 (16-80) min. No hubo complicaciones intraoperatorias ni postoperatorias. La media de dolor postoperatorio fue de 3±1 (1-7) y la estancia media hospitalaria fue de 18±7 (9-42) horas. Conclusión La CLIU es una técnica segura y eficaz para la apendicitis. En el futuro los procedimientos más comunes se podrán realizar a través del ombligo, siendo necesaria una alta experiencia en cirugía laparoscópica avanzada para introducir esta nueva técnica con seguridad sin añadir morbimortalidad (AU)

Introduction Appendicitis is the most common abdominal emergency. The treatment is surgical and single incision laparoscopic surgery (SILS) involves performing laparoscopic surgery through a single transumbilical point, in an attempt to improve the results of laparoscopic surgery. Material and method A total of 73 patients with suspected acute appendicitis were operated on using the SILS technique between June 2009 and August 2010. All patients were operated on by the same surgical team, and the navel was the only point of entrance. Post-surgical pain was assessed using a numerical scale at the time of discharge. Results None of the patients required conversion to conventional laparoscopy. The mean surgical time was 40±14 (16-80) minutes. There were no complications during or after the surgery. The mean post-surgical pain score was 3±1 (1-7) and the mean hospital stay was 18±7 (9-42) hours. Conclusion SILS is a safe and effective technique for appendicitis. In the future, the most common surgical procedures could be performed through the navel. This would be by surgeons, highly experienced in advance laparoscopic surgery in order to introduce this new technique safely without increasing morbidity and mortality (AU)

[Single incision transumbilical laparoscopic appendectomy: initial experience]. / Apendicectomía laparoscópica mediante incisión única transumbilical: experiencia inicial.

INTRODUCTION: Appendicitis is the most common abdominal emergency. The treatment is surgical and single incision laparoscopic surgery (SILS) involves performing laparoscopic surgery through a single transumbilical point, in an attempt to improve the results of laparoscopic surgery. MATERIAL AND METHOD: A total of 73 patients with suspected acute appendicitis were operated on using the SILS technique between June 2009 and August 2010. All patients were operated on by the same surgical team, and the navel was the only point of entrance. Post-surgical pain was assessed using a numerical scale at the time of discharge. RESULTS: None of the patients required conversion to conventional laparoscopy. The mean surgical time was 40±14 (16-80) minutes. There were no complications during or after the surgery. The mean post-surgical pain score was 3±1 (1-7) and the mean hospital stay was 18±7 (9-42) hours. CONCLUSION: SILS is a safe and effective technique for appendicitis. In the future, the most common surgical procedures could be performed through the navel. This would be by surgeons, highly experienced in advance laparoscopic surgery in order to introduce this new technique safely without increasing morbidity and mortality.

Screening for the effectiveness of conservative treatment in chronic anal fissure patients using anorectal manometry.

PURPOSE: Chemical sphincterotomy (CS) is routinely applied in order to avoid the irreversible anal incontinence associated with the surgical treatment of chronic anal fissure (CAF). However, CS has a lower cure rate than surgery. We developed a screening test (using anal manometry) to separate those patients that are unlikely to benefit from CS and should undergo a more aggressive treatment. METHODS: Changes in pressure both at rest and during voluntary contraction of the anal sphincter in 187 patients with chronic anal fissure and 25 healthy subjects (control group) of both sexes were measured. Patients were then sequentially treated (1:1:1) with botulin toxin injections (TOX) (n = 63) or ointments of either nitroglycerine (NTG) (n = 65) or diltiazem (DTZ) (n = 59) for 2 months. The cure rate (overall and for each treatment group) and its relationship with changes in anal pressure were determined. RESULTS: The overall cure rate was 53% (NTG = 54%, DTZ = 53% and TOX = 51%). Healing was not related to differences in resting or voluntary contraction pressure. However, the probability of healing was associated with an increase in the percentage change between resting and squeeze pressure (PI index) higher than 150% (190 +/- 122), similar to that of the control subjects (200 +/- 115). Failure of CS was observed in patients with a lower PI (114 +/- 77). CONCLUSIONS: The ratio resting/voluntary contraction pressure may be predictive of healing in CAF, thus allowing the selection of patients at high risk of failure of conservative treatment.

Gastrojejunal anastomotic stenosis in laparoscopic gastric bypass with a circular stapler (21 mm): incidence, treatment and long-term follow-up.

BACKGROUND: One of the keys to the long-term success of laparoscopic gastric bypass (LGBP) is performing a small-diameter gastrojejunal anastomosis, which occasionally involves an increased incidence of stenosis. METHODS: Between May 2000 and October 2008, 676 patients underwent LGBP with a no. 21 circular stapler to create the gastrojejunoanastomosis (GJA). We define stenosis when clinical symptoms suggest an obstruction and it is impossible to pass a 10-mm endoscope through the GJA. The treatment of patients with stenosis was endoscopic dilation with 10-15-mm balloons. RESULTS: A total of 23 patients (3.4%) developed stenosis of whom 20 were females (3%) and three males (0.4%) with a mean age of 40.7+/-11.6 years (range, 16-71 years) and a body mass index of 48.1+/-6.9 kg/m2 (range, 34-78 kg/m2). The time between surgery and the onset of symptoms was 46.8+/-24.5 days (range, 15-93 days). The stricture was resolved in all patients with endoscopic dilation: 18 patients with one dilation, three patients with two dilations and two patients with three dilations. There were no complications. CONCLUSIONS: The incidence of gastrojejunal anastomotic stenosis in LGBP performed with a 21-mm circular stapler is low, and endoscopic dilation is an effective and complication-free treatment in 100% of cases.

[Long-term results of laparoscopic gastric bypass in patients with morbid obesity. a prospective study of 508 cases]. / Resultados a largo plazo del bypass gástrico laparoscópico en pacientes con obesidad mórbida. Estudio prospectivo de 508 casos.

INTRODUCTION: Although there are publications on the short-medium term results of gastric bypass, publications of long-term results are very limited and the results are less documented. PATIENTS AND METHOD: In this article we present the experience of the same surgical team with laparoscopic gastric bypass over 7 years, with a follow-up of 97% of the patients. From March 2000 until May 2007, 508 laparoscopic gastric bypasses were performed by the same surgical team. RESULTS: Of the 508 patients who were subjected to laparoscopic gastric bypass, 353 were women (69.5%) and 155 were men (30.5%), with a mean age of 40 years (16-71), a mean pre-operative weight of 131.3 +/- 24.5 kg (80-230) and a mean BMI of 48.3 +/- 7 (34-78). There were early complications (< 30 days) in 14.7% of the patients and delayed complications (> 30 days) in 7.3%. The mean operation time was 125.8 +/- 35.6 minutes (60-300). The mean hospital stay was 3 +/- 2.6 days (1-40). The mortality of the series was 0.8%. The EWL and BMI loss at 3 and 5 years was 77.8% and 75.1% and 82.7% and 79.8%, respectively. CONCLUSIONS: Laparoscopic gastric bypass is an effective technique for the long-term treatment of morbid obesity, with a low number of complications, low mortality, excellent weight loss and recovery or improvement of the comorbidities associated with these patients.

Resultados a largo plazo del bypass gástrico laparoscópico en pacientes con obesidad mórbida. Estudio prospectivo de 508 casos / Long-term results of laparoscopic gastric bypass in patients with morbid obesity. A prospective study of 508 cases

Introducción. En la actualidad hay publicaciones de los resultados del bypass gástrico a corto-medio plazo, pero a largo plazo las publicaciones son escasas y los resultados están menos documentados. Pacientes y método. En este artículo presentamos la experiencia con el bypass gástrico laparoscópico de un mismo equipo quirúrgico a lo largo de 7 años, con un seguimiento del 97% de los pacientes. Desde marzo de 2000 hasta mayo de 2007, en nuestro hospital, un mismo equipo quirúrgico realizó 508 bypass gástricos por vía laparoscópica. Resultados. De los 508 pacientes sometidos a bypass gástrico laparoscópico, 353 (69,5%) eran mujeres y 155 (30,5%), varones, con una media de edad de 40 (16-71) años, un peso medio preoperatorio de 131,3 ± 24,5 (80-230) kg y un índice de masa corporal (IMC) medio de 48,3 ± 7 (34-78). Ocurrieron complicaciones precoces ( 30 días) en el 7,3% de los pacientes. El tiempo operatorio medio fue de 125,8 ± 35,6 (60-300) min. La estancia hospitalaria media fue de 3 ± 2,6 (1-40) días. La mortalidad de la serie fue del 0,8%. El porcentaje de peso perdido y el de exceso de IMC perdido a los 3 y 5 años ha sido del 77,8 y el 75,1% y del 82,7 y el 79,8%, respectivamente. Conclusiones. El bypass gástrico por laparoscopia es una técnica eficaz para el tratamiento a largo plazo de la obesidad mórbida, con escaso número de complicaciones, baja mortalidad, excelente pérdida de peso y curación o mejora de las comorbilidades asociadas en estos pacientes (AU)

Introduction. Although there are publications on the short-medium term results of gastric bypass, publications of long-term results are very limited and the results are less documented. Patients and method. In this article we present the experience of the same surgical team with laparoscopic gastric bypass over 7 years, with a follow-up of 97% of the patients. From March 2000 until May 2007, 508 laparoscopic gastric bypasses were performed by the same surgical team. Results. Of the 508 patients who were subjected to laparoscopic gastric bypass, 353 were women (69.5%) and 155 were men (30.5%), with a mean age of 40 years (16-71), a mean pre-operative weight of 131.3 ± 24.5 kg (80-230) and a mean BMI of 48.3 ± 7 (34-78). There were early complications ( 30 days) in 7.3%. The mean operation time was 125.8 ± 35.6 minutes (60-300). The mean hospital stay was 3 ± 2.6 days (1-40). The mortality of the series was 0.8%. The EWL and BMI loss at 3 and 5 years was 77.8% and 75.1% and 82.7% and 79.8%, respectively. Conclusions. Laparoscopic gastric bypass is an effective technique for the long-term treatment of morbid obesity, with a low number of complications, low mortality, excellent weight loss and recovery or improvement of the comorbidities associated with these patients (AU)

Clinical pathway for laparoscopic gastric bypass.

BACKGROUND: Patients undergoing bariatric surgery are ideal candidates for a clinical pathway, as it is a standardized, common, and elective procedure and most patients have a predictable clinical course. OBJECTIVE: The aim of developing this clinical pathway is the result of a wide consolidated experience with patients undergoing laparoscopic Roux-en-Y gastric bypass, the purpose of which is to minimize complications without affecting patient care or the outcome of the procedure. PATIENTS AND METHOD: The clinical pathway was applied to the 311 patients that received a laparoscopic Roux-en-Y gastric bypass. The clinical pathway includes a temporary matrix, which shows the sequence of events that will occur on each of the days between patient admission and discharge. It also includes medical interventions, nursing care, medication, determinations, physical activity, diet, and information for the patient. RESULTS: Complications occurred in 36 patients (11.5%): 14 patients (4.5%) during admission and 22 patients (7%) after discharge. Of the 22 patients presenting with complications after discharge, 12 required readmission to hospital (3.8%), and the other 10 were treated on an ambulatory basis. CONCLUSIONS: We can say that, because of its frequency and predictability, laparoscopic Roux-en-Y gastric bypass is nowadays a procedure for systematization using a clinical pathway, providing it is controlled by a team with a wide experience in bariatric surgery. This clinical pathway is to offer our patients with morbid obesity a laparoscopic Roux-en-Y gastric bypass with the smallest possible range of complications.