Tratamiento endoscópico de una fístula aguda tras gastrectomía vertical laparoscópica / Endoscopic treatment of an acute fistula after laparoscopic sleeve gastrectomy / Tratamento endoscópico de uma fístula aguda após gastrectomia vertical laparoscópica

La fístula gástrica aguda es una de las principales complicaciones vinculadas a la gastrectomía vertical laparoscópica (GVL). Existen múltiples opciones terapéuticas para su resolución, siendo el tratamiento endoscópico mediante colocación de clips o stents uno de los más importantes. La aplicabilidad de cada método va a depender del tipo de fístula y del estado del paciente. Presentamos el caso de una mujer de 35 años, que desarrolla una fístula aguda posterior a una GVL. Se realiza tratamiento endoscópico con colocaciónn del sistema "over-the-scope clip" (Ovesco®) a nivel del orificio fistuloso, con posterior colocaciónn de stent metálico auto expandible.

Acute gastric fistula is one of the main complications associated with laparoscopic vertical gastrectomy (LVG). There are multiple therapeutic options for its resolution, being endoscopic treatment by placing clips or stents one of the most important. The applicability of each method will depend on the type of fistula and the patient's condition. We present the case of a 35-year-old woman who developed an acute fistula after LGV. Endoscopic treatment is performed with placement of the over-the-scope clip system (Ovesco®) at the level of the fistulous orifice, with subsequent placement of a self-expanding metal stent.

A fístula gástrica aguda é uma das principais complicações associadas à gastrectomia vertical laparoscópica (GVL). Existem múltiplas opções terapêuticas para a sua resolução, sendo o tratamento endoscópico com colocação de clipes ou stents uma das mais importantes. A aplicabilidade de cada método dependerá do tipo de fístula e do estado do paciente. Apresentamos o caso de uma mulher de 35 anos que apresentou uma fístula aguda após GVL. O tratamento endoscópico foi realizado com a colocação do sistema de clipe over-the-scope (Ovesco®) no nível do orifício fistuloso, com posterior colocação de stent metálico autoexpansível.

Gastro-gastric Fistula: Late Complication After Roux-en-Y Gastric Bypass.

INTRODUCTION: Gastro-gastric fistula is a rare complication after divided Roux-en-Y gastric by-pass. VIDEO CONTENT: 52-year-old male with a BMI over 49 who underwent divided Roux-en-Y gastric by-pass presented with weight regain 2 years later and a type 2 gastro-gastric fistula. Laparoscopic revision, excision of the fistula with re-do of gastrojejunal anastomosis and remnant gastrectomy, was performed CONCLUSION: Laparoscopic resolution is a technical challenge in this case due to the local inflammatory environment.

Gastric Fistula After Sleeve Gastrectomy: Clinical Features and Treatment Options.

PURPOSE: To trace the clinical profile of fistula cases after sleeve gastrectomy (SG) and evaluate the efficacy and safety of endoscopic treatments and the admission costs of these patients. METHODS: This is a retrospective study of patients who developed gastric fistulas after SG. All patients were submitted to surgical and/or endoscopic interventions (self-expandable stent, septotomy, and balloon dilation). The main studied variables were need for reoperation, number of endoscopic procedures, endoscopic complications, time until fistula diagnosis, fistula location, time until resolution, length of hospital stay, and health costs. RESULTS: The sample was mainly female (76.2%) with a mean age of 39.5 years and a BMI of 39.6 kg/m2. In 90.5% of cases, the fistula occurred in the topography of the His angle. Thirteen patients required surgical intervention. Of the patients who underwent endoscopic interventions, it was necessary to place more than one self-expandable stent of a maximum duration of 4 weeks. Six patients underwent more than two sessions of septotomy. There was one case of bleeding after septotomy. Dilatation was required in 71.4% of patients and an average of two sessions (1-5) per patient. The diagnosis of fistula occurred 14.4 days after surgery. The average time to resolve fistulas was 50.6 days. The average hospital stay was 75.8 days. The total cost of hospitalization was on average US$ 75,180.00. CONCLUSION: The surgical and endoscopic treatment of gastric fistulas after SG was safe and effective. There was a very low rate of complications. The time of onset of fistulas was not decisive for patient improvement.

Novel Endoscopic Management of a Chronic Gastro-Gastric Fistula Using a Cardiac Septal Defect Occluder.

PURPOSE: Closure of GG fistulas after RYGB is challenging due to epithelialization of the tract. Common endoscopic therapies are less efficacious than surgical revision, which is unfortunately fraught with high morbidity and mortality. Cardiac septal defect occluders (CSDO) have been successfully used for the management of gastrointestinal fistulas, but use has never been reported in management of GG fistulas. Thus, we describe the first off-label use of CSDO for the treatment of a GG fistula. MATERIALS AND METHODS: Endoscopy and fluoroscopic examination determined the appropriate size of CSDO for closure. A guidewire was placed in the remnant stomach followed by placement of the delivery system. Then, under fluoroscopy, we deployed the first flange of the CSDO in the remnant stomach. Then, under fluoroscopy and endoscopic visualization, the second flange is deployed in the gastric pouch. RESULTS: A 51-year-old woman, status-post RYGB in 2008, presented with a 6-month history of weight regain and reflux. She had regained weight to 84 kg (BMI = 32 kg/m2) when she was found to have a GG fistula. She underwent successful CSDO placement and, 3 months later, had lost 10 kg with significant improvement in her reflux. Repeat evaluation confirmed successful fistula closure. CONCLUSION: The use of CSDO was technically feasible and appeared to be effective and safe. Future studies should continue to investigate the role of CSDO in management of this challenging condition.

Robot-assisted surgery and endoscopic management of gastrocolic fistula: A rare complication of acute pancreatitis in a patient who had undergone sleeve gastrectomy.

Ten years after undergoing sleeve gastrectomy, a 39-year-old man developed pancreatitis and, after recovery, presented with severe diarrhea. An image study showed barium contrast passing from the stomach to the colon. Before surgery, initial treatment consisted of parenteral nutrition and antibiotics. The patient then underwent robot-assisted resection of a gastrocolic fistula and omentoplasty. However, 72 h after surgery, the amount of suction drainage suggested that the fistulous track repair was leaking. Therefore, we decided to perform endoscopy to place a self-expanding covered stent at the gastroesophageal junction as well as a nasojejunal tube to continue nutritional supplementation. After the patient had fasted for 2 weeks, there was no evidence of leakage in the image studies. The patient was discharged after he had clinically improved, and the stent was removed at the end of 8 weeks. The combination of robot-assisted surgery and endoscopic management is effective for treating gastrocolic fistula.

Efficacy of the cardiac septal occluder in the treatment of post-bariatric surgery leaks and fistulas.

BACKGROUND: Endoscopy has evolved to become first-line therapy for the treatment of post-bariatric leaks; however, many sessions are often required with variable success rates. Due to these limitations, the use of the cardiac septal defect occluder (CSDO) has recently been reported in this population. METHODS: The study population was a multicenter retrospective series of patients with post-bariatric surgical leaks who underwent treatment with CSDO placement. Data on the type of surgery, previous treatment details, fistula dimensions, success rate, and adverse events were collected. Leaks were grouped according to the International Sleeve Gastrectomy Expert Panel Consensus. Outcomes included technical and clinical success and safety of the CSDO. Regression analysis was performed to determine the predictors of response. RESULTS: Forty-three patients with leaks were included (31 sleeve gastrectomy and 12 Roux-en-Y gastric bypass). They were divided into acute (n = 3), early (n = 5), late (n = 23), and chronic (n = 12). Forty patients had failed previous endoscopic treatment and 3 patients had CSDO as the primary treatment. Median follow-up was 34 weeks. Technical success was achieved in all patients and clinical success in 39 patients (90.7%). All chronic, late, and early leaks were successfully closed, except one undrained late leak. The 5 patients with early leaks had an initial satisfactory response, but within 30 days, drainage recurred. The CSDOs were removed and replaced with larger-diameter devices leading to permanent defect closure. Acute leaks were not successfully closed in all 3 patients. Regression analysis showed that chronicity and previous treatment were associated with fistula closure; success rates for late/chronic leaks versus acute/early leaks were 97.1% and 62.5%, respectively (P = .0023). CONCLUSION: This observational study found that the CSDO had a high efficacy rate in patients with non-acute leaks, with no adverse events. All early, late, and chronic leaks were successfully closed, except for one undrained late leak. However, early leaks required a second placement of a larger CSDO in all cases. These results suggest that the CSDO should be considered for non-acute fistula and that traditional closure methods are likely preferred in the acute and early settings.

Gastrocolic fistula secondary to adenocarcinoma of the transverse colon: a case report.

INTRODUCTION: Gastrocolic fistula is a rare complication of adenocarcinoma of the colon. Despite radical resections, these patients usually have a poor prognosis with a mean survival of 23 months and long-term survival is rarely reported. CASE PRESENTATION: A 48-year-old Latino-American man presented with watery diarrhea, diffuse abdominal pain and weight loss for 3 months. A computed tomography scan revealed a mass in the splenic flexure that had infiltrated his stomach and diaphragm. Panendoscopy and colonoscopy confirmed the presence of a fistula between the distal transverse colon and the stomach, which was secondary to a colon cancer. His colon, stomach and left diaphragm were resected en bloc. A histological examination revealed a moderately differentiated adenocarcinoma of the colon that had infiltrated the full width of the gastric wall with 37 negative lymph nodes and clear surgical margins. Adjuvant chemotherapy with capecitabine and oxaliplatin was administered after surgery. Our patient is alive and without any recurrence 5 years after surgery. CONCLUSIONS: En bloc resection with adjuvant chemotherapy offers the best treatment option for gastrocolic fistulas. This is one of the patients with greater survival reported in the medical literature.

Endoscopic treatment of the fistulas after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

OBJECTIVE: to evaluate the use of endoscopic self-expandable metallic prostheses in the treatment of fistulas from sleeve gastrectomy and Roux en y gastric bypass. METHODS: all patients were treated with fully coated auto-expandable metallic prostheses and were submitted to laparoscopic or CT-guided drainage, except for those with intracavitary drains. After 6-8 weeks the prosthesis was removed and if the fistula was still open a new prostheses were positioned and kept for the same period. RESULTS: the endoscopic treatment was successful in 25 (86.21%) patients. The main complication was the migration of the prosthesis in seven patients. Other complications included prosthesis intolerance, gastrointestinal bleeding and adhesions. The treatment failed in four patients (13.7%) one of which died (3.4%). CONCLUSION: endoscopic treatment with fully coated self-expandable prosthesis was effective in treating most patients with fistula after sleeve gastrectomy and roux en y gastric bypass.

Padrão atípico de secreção de cortisol em profissionais de Enfermagem / Estándar atípico de la secreción de cortisol em profissionales de Enfermería / Atypical secretion of cortisol in Nursing professionals

RESUMO Objetivo Descrever a frequência de profissionais de enfermagem de unidades hospitalares com alteração no padrão diurno de secreção de cortisol. Método Foram incluídos 56 profissionais de enfermagem randomicamente selecionados, alocados nas unidades ambulatório, clínica médica, clínica cirúrgica, centro cirúrgico, pronto socorro infantil e adulto, unidade de terapia intensiva adulto e pediátrica de um hospital universitário. Para avaliação do padrão diurno de secreção de cortisol foram coletadas amostras de saliva em dois dias úteis consecutivos de trabalho. Resultados 42,5% dos profissionais de enfermagem apresentaram padrão atípico de secreção de cortisol. Além disso, quanto maior o tempo de trabalho na profissão, maior a concentração de cortisol (r=0,346; p=0,020). Conclusão Mais de um terço da amostra de profissionais de enfermagem apresentou padrões atípicos de secreção de cortisol, sugerindo que estes profissionais podem estar expostos a uma sobrecarga não apenas mental, mas biológica, estando expostos ao risco para o adoecimento por doenças relacionadas ao estresse.

RESUMEN Objetivo Describir la frecuencia de profesionales de enfermaría de unidades hospitalarias con cambio en el patrón diurno de la secreción de cortisol. Método Se han incluido 56 profesionales de enfermaría aleatoriamente seleccionados, ubicados en las unidades ambulatorio, clínica médica, clínica quirúrgica, centro quirúrgico, emergencias adulto y pediátrica, unidades de cuidados intensivos adulto y pediátrica de un hospital universitario. Para evaluación del patrón diurno de secreción de cortisol se recolectaron muestras de saliva en dos días laborables consecutivos, y para las manifestaciones psicológicas. Resultados 42,5% de los profesionales de enfermaría presentaron estándar atípico de secreción de cortisol. Además, cuanto mayor sea el tiempo de trabajo en la profesión, mayor la concentración de cortisol (r=0,346; p=0,020). Conclusión Más de un tercio de las muestras de profesionales de enfermaría presentaron estándares atípicos de la secreción de cortisol, sugiriendo que estos profesionales pueden estar expuestos a una sobrecarga no sólo mental, pero biológica, estando expuestos al riesgo de enfermarse por enfermedades relacionadas al estrés.

ABSTRACT Objective To describe the frequency with which nursing staff in hospitals presents an altered diurnal pattern of cortisol secretion. Method These findings were based on results obtained from 56 randomly selected professional nursing staff working in outpatient clinics, medical clinics, surgical clinics, operating theaters, pediatric and adult emergency units, adult and pediatric intensive care units of a university hospital. The analysis of the diurnal cortisol pattern was based on saliva samples collected over two consecutive working days. Results 42.5% of these nursing staff members presented an atypical pattern of cortisol secretion. Furthermore, the longer the period of exercising this profession, the higher the cortisol concentration (r=0.346; p=0.020). Conclusion Over one-third of nursing staff samples displayed atypical cortisol secretion patterns. This suggests that these professionals are exposed, not only to a mental, but also to a biological, overload and thus, to a risk of contracting stress-related illnesses.

[Rupture of splenic artery pseudoaneurysm: an unusual cause of upper gastrointetinal bleeding]. / Ruptura de pseudoaneurisma de la arteria esplénica: una causa poco frecuente de hemorragia digestiva alta.

BACKGROUND: Bleeding from a pancreatic pseudocyst is a severe complication after pancreatitis that can lead to a massive gastrointestinal blood loss. Pseudocyst rupture into the stomach is an unusual complication. CLINICAL CASE: We report the case of a 34-year-old woman with a history of alcoholism and a pancreatic pseudocyst. One year after follow-up of her pseudocyst, she arrived at the emergency room with an episode of upper gastrointestinal bleeding. An upper digestive endoscopy showed active bleeding in the subcardial fundus, which could not be endoscopically controlled. Abdominal angio-CT confirmed the diagnosis of a splenic artery pseudoaneurysm in close contact with the back wall of the stomach, as well as a likely fistulization of it. The patient was urgently operated and a distal splenopancreatectomy and fistulorrhaphy was performed. CONCLUSION: The rupture of a splenic artery pseudoaneurysm may rarely present as upper gastrointestinal bleeding. This may be lethal if not urgently treated.

Antecedentes: tras una pancreatitis, el sangrado de un pseudoquiste pancreático es una complicación grave que puede conducir a una hemorragia digestiva masiva. La ruptura de ese pseudoquiste en el estómago es rara. Caso clínico: se comunica el caso de una paciente femenina de 34 años de edad, con antecedentes de alcoholismo y un pseudoquiste pancreático. Después de abandonar el estudio y seguimiento del pseudoquiste pancreático un año más tarde reingresó de urgencia debido a un cuadro de hemorragia digestiva alta. En una endoscopia del tubo digestivo alto se encontró sangrado activo en la región del fundus gástrico, que no pudo controlarse. La angio-tomografía axial computada abdominal confirmó el diagnóstico de pseudoaneurisma de la arteria esplénica, en íntimo contacto con la pared posterior del estómago y quizá fistulizado al mismo. La paciente se intervino con carácter urgente realizándose esplenopancreatectomía distal y fistulorrafia. Conclusión: en raras ocasiones la ruptura de un pseudoaneurisma de la arteria esplénica puede iniciarse como una hemorragia digestiva alta, que puede ser letal si no es tratada con urgencia.

Control personal de la conducta y la manga gástrica laparoscópica / Personal behavioral control and laparoscopic gastric sleeve

El objetivo del estudio fue describir las habilidades de autocontrol, la autoeficacia percibida y el locus de control en pacientes obesos que se desean someter a una Manga Gástrica Laparoscópica. Participaron 40 obesos (22 mujeres y 18 hombres), con edades entre los 19 y 65 años (M= 41.72; DT= 12.09) que asistieron a una clínica privada en Caracas. Se aplicaron los inventarios durante el proceso preoperatorio al procedimiento. Los resultados sugieren que la muestra presenta mayor facilidad en la autorregulación y autoeficacia para llevar a cabo la ingesta alimentaria que la actividad física. Las creencias respecto al locus de control se caracterizaron por ser moderadas, obteniéndose un balance entre estas creencias de control. A partir de los resultados, se sugiere entrenar en habilidades de auto-regulación, así como trabajar en el cambio de creencias relacionadas con el peso, tanto las de eficacia personal como las creencias de control, todo lo cual facilitaría la posterior adhesión a las prescripciones del procedimiento

The goal of the study was to describe the self-control, self-efficacy and locus of control skills in obese patients who undergo to Laparoscopic Gastric Sleeve. Participants were 40 obeses (22 women and 18 men) between 19 and 65 years old (M = 41.72, SD = 12.09), who had been attended at private clinic in Caracas city. It were applied tests in the preoperative process to the procedure. The results suggest that the sample had more facility in self-regulation and self-efficacy to carry out food intake than physical activity. Beliefs about locus of control were characterized to be moderate, obtaining a balance between these control beliefs. From the results, we suggest to train in self-regulation skills, as working on change weight-related beliefs, both personal efficacy and control. All of them would facilitate the subsequent adhesion to the procedure requirements