Ventral ETEP Versus REPA, Comparison of Two Novel Minimally Invasive Techniques for Midline Defects.

Introduction: This report aimed to compare ventral extended vision extraperitoneal (ETEP) and preaponeurotic repair (REPA) techniques in terms of surgical procedure, outcomes, and patient evolution. Methods: This was a retrospective study performed at a tertiary care academic center between 2017 and 2022. All consecutive patients operated on for midline hernias and rectus diastasis using REPA and ETEP were included. Follow-up visits were at 15 days, 30 days, and 6 months postoperative. Age, sex, BMI, American Surgical Anesthesiologic Classification (ASA), surgical time, need for conversion to open surgery, time of stay, seroma, hematoma, surgical site infection (SSI), recurrence, and re-interventions were assessed. Results: For the present study, 148 patients were included. From them, 62 patients received the REPA procedure and 86 were operated on using the ETEP technique. REPA average time was 105 minutes (interquartile range [IR] 80-130), and ETEP average time was 120 minutes (RIC 95-285) (p = 0.03). Ambulatory procedures were 32.3% (n = 20) REPA and 20.9% (n = 18) ETEP (p = 0.23). In REPA, the mean time for drain extraction was 11.92 days and 8 days in ETEP (p < 0.001). Seroma incidence was identified in 40.3% (n = 25) of the REPA cases and 5.8% (n = 5) of the ETEP procedures (p = 0.001). In a multivariate analysis for seroma incidence REPA technique was associated with a significant risk of its incidence [odds ratio (OR) 16, 67 95% confidence interval ((CI95) 4.67-59.52), p < 0.001]. Conclusion: REPA and ETEP are safe and reproducible. Both approaches reported short hospitalization times and almost no major complications. We found a longer surgical time in ETEP and a higher incidence of seroma in REPA.

Sleeve Gastrectomy Reduces Oxidative Stress and Reverses Mitochondrial Dysfunction Associated with Metabolic Syndrome.

INTRODUCTION: Previous studies have detected mitochondrial alterations in tissues of individuals with obesity and type 2 diabetes mellitus (T2DM). Metabolic surgery could be an effective treatment to improve mitochondrial morphology and reduce oxidative stress (OS). METHODS: An experimental study was carried out using 48 male Wistar rats, divided into 6 groups (n = 8): control (C), induced Metabolic Syndrome (MS); intervention with sleeve gastrectomy (SG), MS + SG with 6 weeks postoperatively (MS + SG6), MS + SG with 12 weeks postoperatively (MS + SG12), and MS + SG with 24 weeks postoperatively (MS + SG24). Biochemical markers indicative of MS (glycemia, cholesterol, and triglyceride levels) and oxidative stress markers (nitric oxide levels, Superoxide dismutase and Myeloperoxidase activity) were determined. To study mitochondrial morphology, tissue sections of the thoracic aorta, stomach, liver, heart, and kidney were observed by electron microscopy. RESULTS: MS group exhibited elevated glycemic values and dyslipidemia. SG and MS + SG groups showed improvements in glycemia and lipid profiles compared to MS. OS biomarkers indicated reduced oxidative stress in SG and MS + SG groups compared to MS. Electron microscopy revealed mitochondrial alterations in MS. SG group showed no changes compared to the control. MS + SG6 and MS + SG12 groups showed a recovery of mitochondrial morphology until reaching images similar to the control in MS + SG24. CONCLUSION: Metabolic surgery could improve mitochondrial function by restoring mitochondrial morphology and architecture and, consequently, reducing systemic oxidative stress and remitting associated metabolic alterations.

Development and Implementation of an Enhanced Recovery Protocol for Bariatric Patients in a Third World Environment.

Introduction: An applicable and reproducible enhanced recovery protocol was developed and implemented to improve our outcomes in a third-world environment. Methods: We compared the results obtained prospectively. The group treated before the application of the enhanced recovery protocol was called usual care (UC) and included all bariatric surgeries operated on between 2014 and 2017. The new protocol was applied between 2017 and 2019 including all operated patients, and this group was called Fast Track (FT). The variables analyzed were the length of stay, readmissions, and complications recorded during the first 30 days. We also analyzed the milligrams of morphine used by each patient, and a cost analysis was performed. Results: During the study period, 816 patients were studied. Of these, 385 (47.2%) belonged to the UC group and 431 (52.8%) to the FT group. The mean hospital stay was 58.5 hours (UC) versus 40.3 hours (FT) (P = .0001). When comparing the global morbidity of both groups, we did not find significant differences (P = .47). There was also no statistically significant difference when comparing major complications (P = .79). No mortality was recorded. Morphine indication reported a statistically significant difference that favored FT. Costs were significantly higher in UC than in FT (P < .0001). Conclusions: We believe that the implementation of an enhanced recovery protocol in bariatric surgery is a reliable measure and can be implemented even in an underdevelopment environment enlarging the benefit for patients.

Pharmacological Action of Atorvastatin and Metformin on Non-alcoholic Fatty Liver Disease on an Experimental Model of Metabolic Syndrome.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most frequent cause of chronic liver disease in the world. It is known that there is a pathogenic relation between liver damage and the inflammatory and oxidative environment present in Metabolic Syndrome (MS). OBJECTIVE: To study the pharmacological action of atorvastatin and metformin in an experimental model of MS. METHODS: We used 40 male rats (Wistar) divided into the following groups: Control (A) (n=8), induced MS (B) (n=8), MS + atorvastatin treatment (C)(n=8), MS + metformin treatment (D) (n=8) and MS + combined treatment (E) (n=8). MS was induced by administering 10% fructose in drinking water for 45 days. Atorvastatin 0.035 mg/day/rat, metformin 1.78 mg/day/rat, and a combination of both drugs were administered for 45 days. Metabolic, oxidative (nitric oxide, myeloperoxidase and superoxide dismutase) and inflammatory (fibrinogen) parameters were determined. Histological sections of liver were analyzed by light microscopy. RESULTS: The glycemia, lipid profile and TG/HDL-C index were altered in MS group. After pharmacological treatment, metabolic parameters improve significantly in all treated groups. Inflammatory and oxidative stress biomarkers increase in MS. Treated groups showed an increase in NO bioavailability, no difference in MPO activity and an increase in fibrinogen. Atorvastatin showed a decrease in SOD while Metformin and combination treatment showed an increase in SOD compared to MS. In MS, we observed histological lesions consistent with NAFLD. However, after a combined treatment, we observed total regression of these lesions. CONCLUSION: Our results showed that there is an important synergy between atorvastatin and metformin in improving liver involvement in MS.

Procedimiento heller-dor laparoscópico, tratamiento de la acalasia / Heller-dor laparoscopic procedure, treatment of achalasia / Heller-dor procedimento laparoscópico, tratamento da acalasia

Incisión supraumbilical, colocación de trocar de 10 mm, técnica Hasson. Otros trocares bajo visión directa. Apertura de membrana freno esofágica y liberación de esófago de pilares, identificación de nervio vago anterior, separando y preservándolo. Disección de fibras musculares longitudinales y sección de las fibras circulares hasta exposición mucosa esofágica, 6 cm en esófago y 2 cm a nivel gástrico. Funduplicatura tipo Dor con puntos separados 3.0 a nivel de fondo gástrico, muscular esofágica y pilares diafragmáticos. Extracción de trocares bajo visión, exsuflación de neumoperitoneo. Cierre de laparotomía umbilical. Síntesis cutánea.

[Safeness and reproductivity of a laparoscopic colorectal program in two tertiary care academic centers of South America]. / Seguridad y reproducibilidad de la cirugía colorrectal laparoscópica en dos centros académicos de tercer nivel en Sudamérica.

OBJETIVO: Evaluar la reproducibilidad y la seguridad de un programa de cirugía colorrectal laparoscópica en dos centros de Sudamérica. MÉTODO: Se realizó un estudio analítico-descriptivo. Se revisaron retrospectivamente los registros clínicos de pacientes sometidos a cirugía videolaparoscópica colorrectal desde el año 2012 hasta el año 2018, en dos centros académicos de tercer nivel argentinos. Se analizaron datos demográficos, indicaciones y tiempos quirúrgicos, tasa de conversión, evolución posoperatoria, morbimortalidad y resecabilidad oncológica, y se comparó con el abordaje convencional. RESULTADOS: Se realizaron 505 cirugías. La edad media de los pacientes fue de 63.4 años y el 50.9% eran hombres. El tiempo operatorio medio fue de 175 minutos. La principal indicación fue cáncer de colon. La incidencia de conversión fue del 9.5%. El promedio de ganglios por pieza quirúrgica en patología neoplásica fue de 15.9. La morbilidad fue del 35.4%, en su mayoría complicaciones menores. La tasa de fístulas fue del 11.7%. La mortalidad a 30 días fue del 2.5%. CONCLUSIÓN: La cirugía colorrectal laparoscópica podría representar una opción segura y reproducible en un centro de tercer nivel de un país en desarrollo. OBJECTIVE: To evaluate the feasibility and safeness of a colorectal laparoscopic program in two centers form South America. METHOD: We retrospectively review the records of patients who underwent laparoscopic colorectal surgery from 2012 to 2018 in two tertiary care academic centers. Surgical indication, operative time, conversion rate, lymph nodes harvested, surgical margins and complications were analyzed. This results were then compared to the open approach. RESULTS: We collected data from 505 patients, mean age 63.4, 50.9% male. The most frequent indication was colon cancer, mean operative time was 175 minutes. Conversion rate was 9.5%, mean nodes harvested was 15.9 with free resection margins in every case. Morbidity was 35.4% at 30 days, most of them were minor complications. The leak rate was 11.7 %. The 30-day mortality was 2.5%. CONCLUSION: The laparoscopic approach for colorectal surgery might represent a safe and feasible option in an tertiary care hospital from a developing country.

Solid pseudopapilar neoplasm of the pancreas.

Solid pseudopapillary tumor of the pancreas is a rare entity, more frequent in women between the 2nd and 4th decades. The diagnosis is usually incidental and it can be reached by computed tomography or magnetic resonance imaging. Subsequent pathological confirmation is necessary for an adequate treatment. A retrospective study of six cases was carried out. All the patients were female, between 14 and 56 years of age, in which 50% the tumor were an incidental finding. We had three cases located in the head and three in the body of the pancreas. We performed three pancreaticoduodenectomies and three distal pancreatectomies with splenic preservation, without disease recurrence.

El tumor sólido-quístico de páncreas es poco frecuente y predomina en mujeres entre la segunda y la cuarta décadas de la vida. Los pacientes son generalmente asintomáticos. El diagnóstico se realiza por imágenes con tomografía o resonancia magnética, y con la posterior confirmación patológica para poder ofrecer un tratamiento adecuado. Presentamos una serie de seis casos. Todas las pacientes fueron de sexo femenino, de entre 14 y 56 años. El 50% fueron un hallazgo incidental. Tuvimos tres casos localizados en la cabeza y tres en el cuerpo del páncreas. Se realizaron tres duodenopancreatectomías cefálicas y tres pancreatectomías distales con preservación esplénica, con buena evolución y sin recidiva.

Mielolipoma retroperitoneal perirrenal: reporte de un caso.

El mielolipoma es un tumor benigno de baja incidencia cuya localización más frecuente son las glándulas suprarrenales. Histológicamente se caracteriza por células con precursores mieloides y eritroides mezcladas con tejido adiposo maduro. El diagnóstico en general es incidental en una prueba de imagen. Clínicamente cursa asintomático, aunque los de mayor tamaño tienen más riesgo de complicaciones como sangrado o efecto de masa. Los hallazgos incidentales < 4 cm se deben controlar con imágenes; los > 7 cm, o que generen síntomas, deben ser tratados de forma quirúrgica. Se reporta un caso de mielolipoma extrasuprarrenal en un paciente de 78 años.Myelolipoma is a relatively rare benign tumor which is most commonly located in the adrenal glands. Histologically is characterized by eritroid and myeloid precursor cells intermixed with mature adipose tissue. The diagnosis is generally incidental in abdominal imaging studies. Clinically most are asymptomatic, nevertheless larger tumors are at greater risk for complications such as hemorrhage or compression of surrounding structures. Incidental findings smaller than 4 cm should be followed-up by imaging. Tumors measuring more than 7 cm or those that are symptomatic a surgical approach is mandated. We present the case of a 78-year-old man with an extra-adrenal myelolipoma.

Intramural esophageal bronchogenic cyst.

ANTECEDENTES: Los quistes broncogénicos esofágicos son sacos cerrados originados de brotes anormales del tubo -traqueobronquial primitivo. Estas lesiones suelen ser asintomáticas, por lo que pueden hallarse incidentalmente o pueden causar síntomas por compresión de estructuras adyacentes. Son lesiones muy poco comunes; se han publicado unos 23 casos en adultos. CASO CLÍNICO: Presentamos el caso de un varón de 44 años con un cuadro de tos de larga duración, sin otro síntoma. Para descartar las causas más comunes de sus síntomas se realizan estudios que objetivan la presencia de una lesión intramural de 40 × 43 mm. Se realiza videotoracoscopia para su resección y estudio, resultando ser un quiste broncogénico. BACKGROUND: Bronchogenic cysts are close sacks originated from abnormal development of the tracheobronchial tree. These lesions are usually asymptomatic or can cause symptoms, by compression of adjacent structures. This pathology is so unusual that there are only about 23 cases published in adults. CASE REPORT: We report a case of a 44 year-old man with persistent cough, without other symptom. The most common causes for his symptoms were ruled out, so imaging studies were made, showing at the medial portion of the esophagus, located intramural a 40 × 43 mm ovoid lesion. Resected by video-assisted thoracoscopy for its study. With findings attributable to bronchogenic cyst.

Short-term and oncological outcomes in laparoscopic colectomy in colon cancer stage I-III with 3-year follow-up.

BACKGROUND: Laparoscopic colectomy (LC) presents similar short-term results and oncological outcomes to conventional colectomy (CC) in colon cancer. OBJECTIVES: Compare short-term and oncological outcomes at 3-year follow up between LC and CC. MATERIALS AND METHODS: Patients who underwent LC and CC for colon cancer between January 2010 and December 2017 were retrospectively analyzed. Short-term results and oncological outcomes were studied. RESULTS: Two hundred sixty-nine patients were included in the study. CC was performed in 37.5% and LC in 62.5%. LC presented shorter operative time (157 vs. 175 min, p = 0.01), shorter length of stay (8.4 vs. 10.5 days, p = 0.02), lees readmission (6% vs. 15%, p = 0.02), and lower morbidity (40% vs. 56%, p = 0.01). No differences were found for overall survival (OAS) (LC = 87.1% vs. CC = 82.8%, p = 0.28) and disease-free survival (DFS) (LC = 78.2% vs. CC = 75.3%, p = 0.47). Recurrence was observed in 37 patients (LC = 16.1% vs. CC = 18.3%, p = 0.53). No differences were found for local recurrence (LC = 6.5% vs. CC = 8.6%, p = 0.49) and distant recurrence (LC = 12.1% vs. CC = 16.1%, p = 0.3). Stage analysis showed no difference for recurrence, OAS, and DFS. CONCLUSIONS: LC is a safe procedure with short-term outcomes, OAS, DFS, and recurrence similar to CC. LC should be the initial indication in non-metastatic colon cancer in our population.

ANTECEDENTES: La colectomía laparoscópica (CL) presenta resultados a corto plazo y oncológicos similares a los de la colectomía convencional (CC) en cáncer de colon. OBJETIVO: Comparar los resultados a corto plazo y oncológicos a 3 años de seguimiento entre la CL y la CC. MATERIAL Y MÉTODOS: Pacientes intervenidos de CL y CC por cáncer de colon entre enero de 2010 y diciembre de 2017. Se estudiaron los resultados a corto plazo y oncológicos. RESULTADOS: Se incluyeron 269 pacientes (62.5% CL y 37.5% CC). La CL presentó menor tiempo quirúrgico (157 vs. 175 min; p = 0.01), menor estadía hospitalaria (8.4 vs. 10.5 días; p = 0.02), menor reinternación (6% vs. 15%; p = 0.02) y menor morbilidad (40 vs. 56%; p = 0.01). No se observan diferencias para sobrevida global (87.1% CL y 82.8% CC; p = 0.28) y sobrevida libre de enfermedad (78.2% CL y 75.3% CC; p = 0.47). Hubo recidiva en 37 pacientes (16.1% CL y 18.3% CC; p = 0.53). No se encontraron diferencias en recidiva local (6.5% CL y 8.6% CC; p = 0.49), a distancia (12.1% CL y 16.1% CC; p = 0.3), al dividir la recidiva, la sobrevida global y la sobrevida libre de enfermedad por estadios. CONCLUSIONES: La CL es un procedimiento seguro, con una sobrevida global, una sobrevida libre de enfermedad y una tasa de recidiva similares a las de la CC. La CL debería ser la indicación inicial en el cáncer de colon no metastásico en nuestra población.

[Accelerated recovery in elective laparoscopic colorectal surgery: two years of experience. ] / Recuperación acelerada en cirugía colorrectal laparoscópica electiva: dos años de experiencia.

Background: Accelerated recovery protocols in colorectal surgery have enhanced the perioperative cares optimizing recovery in this group of patients. A reduction in surgical stress and therefore early hospital discharge and lower morbidity is pursued, however, the literature offers few outcomes regarding its application in developing countries. Objective: to analyze short- and medium-term outcomes of the application of an accelerated recovery protocol in a terciary care hospital in Argentina. Methods: In the period between January 2015 and March 2017 patients were included prospectively and consecutively with indication of elective laparoscopic colorectal surgery and under strict follow-up according to the protocol created by the institution. Patients older than 80 years, ASA IV, emergency surgeries and conventional approach were excluded. We analyzed demographic data, diagnosis of surgery, type of intervention, hospital stay, complications, readmissions and reinterventions at 30 postoperative days. Results: Sixty-four patients with a mean age of 62 years were included. The mean hospitalization was 4.9 days, with 10.9% readmissions and 4.7% of reinterventions. We recorded 69% of the patients whit not complications at all and 5 major complications (8%) . Conclusion: Based on the adaptation of the international guidelines to our health reality, it is feasible to create an accelerated recovery protocol applicable in our country, with a low complication rate and early discharge.

Introducción: El desarrollo de los protocolos de recuperación acelerada en cirugía colorrectal ha revalorizado los cuidados que conforman la recuperación perioperatoria de los pacientes sometidos a cirugía. Se persigue una reducción del stress quirúrgico y por tanto alta precoz y menor morbilidad, sin embargo, la literatura aporta pocos resultados respecto a su aplicación en países en desarrollo. Objetivo: analizar los resultados a corto y mediano plazo de un protocolo de recuperación acelerada en un hospital de alta complejidad de nuestro medio. En el periodo comprendido entre enero 2015 y marzo 2017 se incluyeron pacientes de manera prospectiva y consecutiva con indicación deAñadir colaborador/a cirugía colorrectal laparocopica electiva y bajo estricto seguimiento según protocolo creado por la institución. Fueron excluidos pacientes mayores de 80 años, ASA IV, cirugías de urgencia y abordaje convencional. Se analizaron datos demográficos indicación de cirugía, tipo de intervención, estadía hospitalaria en días, complicaciones, readmisiones y reintervenciones a los 30 días de postoperatorio. Resultados: Fueron incluidos 64 pacientes con una edad media de 62 años. El promedio de internación en días fue de 4,9, con 10,9% de reinternaciones y 4,7% de reintervenciones. El 69% de los pacientes no presento complicaciones, registrándose 5 complicaciones mayores (8%). Conclusión: A partir de la adecuación de los lineamientos internacionales a nuestra realidad sanitaria, es factible la creación de un protocolo de recuperación acelerada aplicable en nuestro medio, con baja tasa de complicaciones y alta precoz.

Impact of Gastric Bypass on Erosive Esophagitis and Barret's Esophagus.

BACKGROUND: The association between gastroesophageal reflux disease (GERD) and obesity is clearly defined. The incidence of erosive esophagitis (EE) and Barrett's esophagus (BE) are as high as 26 and 6%, respectively. Gastric bypass (GBP) is considered the gold standard for obese patients with GERD. Evidence about the impact of GBP on EE and BE is not yet clear but more inspiring every day. METHODS: Obese patients operated by GBP with EE or BE were included for this study. Demographics, BMI, %EWL, and the evolution of EE and BE with pre and postoperative upper endoscopy were analyzed. RESULTS: In this study, 64 patients were included, 55 with EE and 9 with BE. The preoperative BMI was 44.29 km/m2 ± 3.5 and the %EWL was 78.5 ± 5.8 in the first year postoperative. Preoperatively, EE was distributed as follows: A: 54.5% (30), B: 34.5% (19), C: 9% (5), D: 2% (1). BE findings were the following: short segment (SSBE): 45% (4) and long segment (LSBE): 55% (5). Postoperatively, 80% of the patients with EE resolved their condition, 11% improved, 7% had no changes, and 2% worsened. From the patients with SSBE, 75% resolved their condition and 40% with LSBE resolved their condition after 24 months and no patient progressed to dysplasia. CONCLUSION: Patients with EE had a statistically significant resolution after GBP. BE was improved or even resolved in many patients without acquiring significance but also without progression. Long-term surveillance data is necessary to define the certain evolution of EE and BE after GBP.

Esophagitis evolution after sleeve gastrectomy or gastric bypass in consecutive cases.

BACKGROUND: Erosive esophagitis (EE) is related to esophageal mucosal damage caused by GERD and is implicated in the development of Barret´s esophagus and adenocarcinoma, which incidence is rising in association with obesity. It is known that the correlation between symptoms and endoscopic findings is relatively poor, with a predictive value of only 40%. The objective of this study is to report the incidence of EE 1 year after sleeve gastrectomy (SG) and gastric bypass (GBP) in consecutive patients in order to obtain an objective parameter of the impact of the two most popular bariatric procedures on esophageal mucosa. METHODS: A retrospective review of a prospective database including every primary GBP and SG consecutive cases performed between January 2014 and December 2016. Esophagitis evolution was compared between patients with adequate weight loss versus those with inadequate weight loss. The comparison of baseline and 1-year EE, BMI, %EWL, and %TWL was made by using the Chi square test for categorical variables and Student "t" test for continuous samples. RESULTS: Two hundred and twenty-seven patients were included. GBP was performed to 35.2% (n = 80) and SG to 64.8% (n = 147). Pre- and postoperatively EE evolution in GBP decreased from 54 to 26.2% (p = 0.002) and in SG increased from 8.2 to 30% (p = 0.04) Barret´s esophagus in GBP decreased from 7.5 to 5% (p = 0.001). No statistical difference was observed when we compared the evolution of EE in patients with adequate or inadequate weight loss in both groups. CONCLUSIONS: The incidence of EE 1 year after SG is greater than GBP. Moreover, not only GBP seems to improve this condition, but also SG tends to worsen EE. These results are to be associated with GERD disease.

Efficacy and reproducibility of lymphatics mapping technique with sentinel lymph node biopsy in melanoma.

INTRODUCTION: The study of the Sentinel Lymph Node (SLN) in Melanoma is a procedure that aims the identification of the first node to which the affected cutaneous sector drains in order to avoid unnecessary lymphadenectomies. The present study documents the frequency of identification of SLN; the relationship between positive SLN (PSLN) and recurrence, between the Breslow index (BI) and PSLN, and between BI and disease recurrence. METHOD: We analyzed the records of 148 patients with melanoma stages I and II undergoing lymphatic mapping and GC biopsy from 1999 to 2017 in a third level institution in Córdoba, Argentina. We performed preoperative lympho centellography, lymphatic mapping with combined technique and SLN biopsy. Postoperative controls were established in order to detect recurrences. RESULTS: SLN was identified in 145 patients (97.9%), being positive in 25 cases (17.2%). Recurrence was detected in 10 (8.3%) patients with negative SLN (NSLN), and in 2 (9.09%) with PSLN (p = 0.188). The median BI was 2 mm in PCG patients and 1.2 mm in GCN patients (p = 0.002). The mean BI in patients with recurrence was 2.77 mm, and 2.01 mm in those who did not show relapse (p = 0.311). CONCLUSIONS: The combined technique allows a high GC identification rate. A greater tendency to recurrence was observed in the presence of CPG. A statistically significant relationship between GCP and IB was found. The GC technique is effective and replicable in our environment.

INTRODUCCIÓN: El estudio del ganglio centinela (GC) en el melanoma maligno es un procedimiento que busca la identificación del primer ganglio al cual drena el sector cutáneo comprometido a fin de evitar linfadenectomías innecesarias. El presente estudio documenta la frecuencia de identificación del GC y la relación entre GC positivo (GCP) y recurrencia, entre el índice de Breslow (IB) y GCP, y entre el IB y la recurrencia de la enfermedad. MÉTODO: Se analizaron los registros de 148 pacientes con melanoma maligno en estadios I y II sometidos a mapeo linfático y biopsia de GC desde 1999 hasta 2017 en una institución de tercer nivel de Córdoba, Argentina. Se realizaron linfocentellografía preoperatoria, mapeo linfático con técnica combinada y biopsia de GC. Se establecieron controles posoperatorios reglados a fin de detectar recurrencias. RESULTADOS: Se identificó el GC en 145 pacientes (97.9%) y resultó positivo en 22 (17.2%). Se detectó recurrencia en 10 pacientes (8.3%) con GC negativo (GCN), y en 2 (9.09%) con GCP (p = 0.188). La mediana del IB fue de 2 mm en los pacientes con GCP y de 1.2 mm en los pacientes con GCN (p = 0.002). La media del IB en los pacientes con recurrencia fue de 2.77 mm, y en los que no mostraron recaída fue de 2.01 mm (p = 0.311). CONCLUSIONES: La técnica combinada permite una alta tasa de identificación del GC. Se observó una mayor tendencia a la recurrencia en presencia de GCP. Se comprobó una relación estadísticamente significativa entre GCP e IB. La técnica del GC es efectiva y replicable en nuestro medio.

Obese Patients with Type 2 Diabetes: Outcomes After Laparoscopic Sleeve Gastrectomy.

Background: Bariatric surgery is superior to medical treatment for type 2 diabetes mellitus (T2DM) control in obese patients. Reports in the literature have been mainly based on Roux-en-Y gastric bypass (RYGB) or adjustable gastric band. The aim of this study was to analyze mid- and long-term metabolic results after laparoscopic sleeve gastrectomy (LSG). Methods: Obese patients with T2DM undergoing LSG were included in this study. Selection criteria for T2DM remission were: post-operatory fasting glucose (FG) level <100 mg/dL, and hemoglobin A1c (HbA1c) <6% without medication. Results: Between January 2009 and July 2016, 166 T2DM obese patients underwent LSG and completed ≥1 year follow-up. There were 101 women (60.8%; mean age 49.07 ± 12.8 years). Initial body mass index (BMI) was 46.44 ± 7.68 kg/m2. Mean time since T2DM diagnosis was 5.95 years (1-28). Preoperative HbA1c was 7.53% ± 0.97%. Before LSG, 75.3% (n = 125) were receiving oral hypoglycemic agents, and 13.25% (n = 22) insulin. Mean follow-up was 65 ± 10 months. Complete T2DM remission was achieved in 78.3%, 76.2%, and 71.4% at 1, 3, and ≥5 years respectively; in the long term, 7.2% attained partial remission, 10% improved, and 11.4% experienced recurrence of the disease. Remission rate was significantly lower in patients under insulin therapy preoperatively, and in patients with T2DM diagnosed ≥5 years before consultation (P = .0004 and .0001, respectively). Conclusions: At mid- and long-term follow-up, T2DM control was satisfactory after LSG. Preoperative insulin therapy and T2DM duration ≥5 years were predictors of less favorable outcomes.

ALPPS torniquete complicado con giro de la vena suprahepática izquierda. Nuevas complicaciones en nuevas hepatectomías / ALPPS tourniquet complicated with twisting of the left hepatic vein. New complications in new hepatectomies

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[Hepatic Parasitosis: Atypical presentation] / Parasitosis Hepática: Presentación atípica.

Benign solid liver tumors are composed by a heterogeneous group of lesions. Hepatic parasitosis is an infrequent etiological cause of benign solid liver tumors. Objective. To present the case of a patient with benign solid liver tumors treated with right portal vein embolization and, later, with hepatectomy. Clinical case. 60-year-old, male patient diagnosed with multiple solid liver tumors, due to a generalized case of jaundice. The decision to perform surgery was made on the basis of the clinical symptoms and the impossibility of discarding malignancy through complementary tests. Before surgery, hepatic volumetry and right portal vein embolization were done to increase future hepatic remnant. Right hepatectomy and hepatic resection of segment IVa were performed. The patient evolved positively from jaundice and the anatomopathological results showed a lesion related to hepatic parasitosis. Conclusion. In the presence of a solid liver tumor, it is necessary to rule out the malignant etiology of the lesion. If this is not possible, or if the patient continues with the symptomatology, surgical resection is prescribed, taking into account the volume of the hepatic gland and future hepatic remnant.

Los tumores hepáticos sólidos benignos están formados por un grupo heterogéneo de lesiones. Las parasitosis hepáticas conforman una causa etiológica poco frecuente de tumores hepáticos sólidos benignos. Objetivo. Reportar el caso de un paciente con tumores hepáticos solidos benignos tratado con embolización portal derecha y posteriormente hepatectomía. Caso clínico. Paciente de 60 años, sexo masculino, al cual se le diagnostican múltiples tumores hepáticos sólidos, debido a cuadro de ictericia generalizada. Debido al cuadro sintomático, y al no poder descartar malignidad con las pruebas complementarias, se decide realizar cirugía. Previamente se realiza volumetría de la glándula hepática y embolización portal derecha para aumentar el remanente hepático futuro. Se realiza hepatectomía derecha y segmentectomía hepática IVa. Evoluciona con mejoría del cuadro ictérico y el resultado anatomopatológico informa lesión vinculable a parasitosis hepática. Conclusión. Ante la presencia de un tumor hepático sólido, es necesario descartar etiología maligna de la lesión. Si no es posible descartar esto, o si el paciente persiste con sintomatología, la resección quirúrgica está indicada, teniendo en cuenta el volumen de la glándula hepática y del remanente hepático futuro.

Gastroesophageal reflux disease and morbid obesity: evaluation and treatment.

Gastroesophageal reflux disease (GERD) is markedly increased among the obese population being recognized as one of the many obesity-related comorbidities. This concept should raise awareness, making physicians investigate more profoundly about this disease in this kind of patients. Currently, bariatric surgery is considered the gold standard treatment for morbid obesity. However, not all the operations are appropriate for the treatment of GERD and not all the patients are willing to receive bariatric surgery for the treatment of GERD. Even though sleeve gastrectomy has emerged as a suitable treatment option for morbid obesity, it has been related to development of de novo GERD or worsening the pre-existing one. Conversely, results after Roux-en-Y gastric bypass have been encouraging in this aspect, and it seems to be the best option for patients who suffer both diseases. Therefore, the presence of GERD should not be ignored at the time of deciding which type of surgery will be offered to the patient.

Impact on Dyslipidemia After Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Improvement of dyslipidemia is an important benefit of bariatric surgery. The benefits of laparoscopic sleeve gastrectomy (LSG) among dyslipidemia are still a matter of debate. METHODS: We conducted a retrospective descriptive study between 2010 and 2013. Obese patients undergoing LSG, with recorded dyslipidemia at admission and a follow-up for at least 1 year, were included for analysis. Demographic characteristics, medication in use, and a complete lipid profile were collected before surgery. After surgery, weight was controlled at 1, 3, 6, and 12 months. Lipid profile was re-evaluated 1 year after surgery. Patients were divided according to weight loss into two groups: (A) adequate weight loss and (B) inadequate weight loss. Lipid profile evolution was then compared between groups. RESULTS: One hundred seven patients met the inclusion criteria. Pre-op mean BMI was 45.13 ± 7.5 kg/m2. One year after LSG, mean BMI was 30.6 ± 7.1 kg/m2 with a change in BMI of 11.5 ± 6.6 kg/m2, a %TWL of 26.9 ± 13.5%, and a %EWL of 60.3 ± 36.6%. Hypercholesterolemia and hypertriglyceridemia remission was achieved in 45 and 86% of the patients and improved in another 19 and 4% respectively. Seventy-four percent improved HDL levels. LDL levels improved in 39% and remitted in 37%. Medication was discontinued in 43.7%. HDL increase and LDL, TG, and non-HDL-C decrease were significantly greater in group A. CONCLUSIONS: LSG produces an improvement in lipid profile, with a significant increase in HDL and a decrease in LDL, triglycerides, and non-HDL-C.

Long-Term Relationship Between Tobacco Use and Weight Loss after Sleeve Gastrectomy.

BACKGROUND: Smoking cessation had been typically associated with weight gain. We have reported that there is no relationship between tobacco use and weight loss after bariatric surgery in the short term. The objective of this study was to establish the relationship between weight loss and the smoking habit in patients undergoing bariatric surgery and to analyze weight loss on severe smokers and on those patients who stopped smoking during the long-term postoperative period. METHODS: One hundred eighty-four patients included in our previous study were contacted by phone at 7 years after sleeve gastrectomy. They were again divided into three groups: (A) smokers, (B) ex-smokers, and (C) non-smokers. Demographics and weight loss at 6, 12, 24, and 7 years were analyzed. Smokers were subdivided for further analysis into the following: group A1: heavy smokers, group A2: non-heavy smokers, group A3: active smokers after surgery, and group A4: quitters after surgery. Student test was used for statistics. RESULTS: One hundred two patients were included. The follow-up was 80.74 ± 7.25 month. Group A: 29 patients, group B: 34 patients, and group C: 39 patients. Mean BMI was 34.35 ± 8.44 kg/m2 and the %EWL was 56.95 ± 27. The subgroup analysis showed the following composition: group A1: 6 patients, group A2: 23 patients, group A3: 23 patients, and group A4: 6 patients. Weight loss difference among groups and subgroups was statistically non-significant. CONCLUSIONS: This study reaffirms the hypothesis that weight loss among bariatric patients is independent from smoking habit even at long-term follow-up and regardless from cessation.