Effect of bismuth subgallate on the quality of life in patients undergoing Scopinaro's biliopancreatic diversion.

BACKGROUND: Malabsorptive techniques, such as biliopancreatic diversion, described by Scopinaro, can cause disabling steatorrhea that affects patients' quality of life. Although it usually improves over time, a reduced group of patients can require treatment. The objective of the present study was to assess the effects of bismuth subgallate on the quality of life (QoL) of patients undergoing Scopinaro's biliopancreatic diversion (SBPD) for morbid obesity. The study was conducted at the Hospital Universitario Insular de Gran Canaria, Spain, a public hospital. METHODS: A prospective, observational study in clinical practice was performed to ascertain the effects of bismuth subgallate on QoL in a group of patients undergoing SBPD who reported disabling diarrhea and related odor. Patients received treatment with 2 courses of oral bismuth subgallate, 200 mg every 8 hours for 12 weeks, with a 4-week rest period. Pretreatment and posttreatment surveys were performed. The Gastrointestinal Quality of Life Index (GIQLI) questionnaire was used, which evaluates symptoms, physical status, emotional status, social performance, and treatment effects. RESULTS: Sixty patients--90% women--with a mean age of 45.6 years were included in the study, 65% of which had superobesity. GIQLI scores obtained at treatment completion were significantly higher--both overall and in the various domains--than those obtained before treatment onset (P<.01). When the morbid obesity and superobesity groups were analyzed separately, a significant increase in the scores for both patient groups was also observed (P< .01). CONCLUSIONS: In clinical practice, treatment with bismuth subgallate resulted in a short-term improvement of QoL for patients undergoing SBPD.

Right colon carcinoma infiltrating the alimentary limb in a patient with biliopancreatic diversion.

Biliopancreatic diversion (BPD) has excellent results, with the average patient losing 60% to 80% of the excess weight in the first 2 years. However, the BPD works by malabsorption and malabsorptive problems may be experienced with the operation. Therefore, monitoring is necessary for life. In the recent literature there is some debate over the possibility that this technique can increase the risk of colon cancer secondary to the action of the unabsorbed food and bile acid on colonic mucosa. We report the case of a 42-year-old patient with a previous bariatric surgery (BPD with 50 cm common channel; 300 cm alimentary limb) who developed a very aggressive right colon cancer 6 years after the operation. We also review our series of 330 patients operated on during a 14-year period to try to answer if there is any relationship between BPD and colon cancer.

Hypercalcemia associated with adenosquamous pancreatic carcinoma: a reason to initiate palliative treatment.

BACKGROUND: hypercalcemia in patients with diagnosed carcinoma has predominantly a humoral basis mediated by parathyroid hormone-related protein (PTH-rP). Among the reported cases, hypercalcemia associated with the majority of abdominal malignancies indicates an advanced stage of disease. CASE REPORT: we present a case of a 78-year-old patient with an adenosquamous pancreatic carcinoma associated with humoral hypercalcemia mediated by PTH-rP. CONCLUSION: in this case, demonstration of unexpectantly rapid increase in calcium serum correlated with aggressive tumor growth led us to raise the hypothesis that PTH-rP could be a mediator of invasion and dissemination secreted by some tumors, and probably indicates the appropriate time to initiate palliative treatment.

Perforated gastrointestinal stromal tumor in Meckel's diverticulum treated laparoscopically.

Gastrointestinal stromal tumors (GIST) can represent a source of substantial gastrointestinal hemorrhage. Bleeding is described as a frequent cause of clinical presentation and commonly patients received surgical treatment on an urgent basis to drain the hematoma. However, a literature review has shown that perforation with peritonitis is very uncommon and rarely reported. These tumors are usually located in the stomach, and primary ileal and Meckel's localization is rare, occurring in less than 10% of cases in many series. In the English literature, we have found seven well-reported cases of GIST in a Meckel's diverticulum that presented with perforation and peritonitis; these case were found through a MEDLINE search of the terms: "perforated" GISTs in "Meckel's" GISTs. Herein, we describe a rare case of a perforated GIST in Meckel's diverticulum that caused severe peritonitis and that was treated with minimally invasive surgery.

Fistula to the native esophagus after pharyngogastrostomy for malignant disease: A rare phenomenon in esophageal surgery.

This article features the case study of a 32-year-old female patient who had undergone surgery to remove a cervical spine tumor and who later developed cervical esophagus necrosis secondary to the erosion caused by an osteosynthesis 13 years after her prosthetic cervical surgery. Barium swallow did not show anything abnormal, but after an emergency spiral computerized axial tomography (CAT) scan, a paravertebral abscess was found, along with displacement of the fixation plate and the disappearance of the esophageal silhouette on coronal sections. The patient underwent surgery to drain the abscess, extract the osteosynthesis materials and the stabilization plates, and to perform a temporary esophageal exclusion. Two months after this surgery the esophagus was reconstructed by performing a retrosternal pharyngogastrostomy without resection of the remaining cervicothoracic esophagus due to severe fibrosis and the absence of local recurrence. During the immediate post operatory period the patient developed a cervical fistula and after a month of conservative treatment, severe dysphagia was observed. Imaging tests showed a spontaneous fistula from the pharynx to the native esophagus, which prompted extraordinary treatment. Therefore, a jejunal loop was taken to the esophagus in the hiatus with a Roux-en-Y anastomosis to resolve this condition.

Intermuscular lipoma of the gluteus muscles compressing the sciatic nerve: an inverted sciatic hernia.

The authors report the case of a 50-year-old woman with a benign intermuscular lipoma of the gluteus compressing the sciatic nerve in its course through the sciatic notch. This benign soft-tissue tumor extended into the pelvis, displacing the rectum laterally. Resection was necessary to alleviate symptoms and prevent irreversible damage of the nerve. Wide exposure of the piriformis muscle and sciatic nerve via a transgluteal approach allowed safe lesion removal, and thus avoiding a laparotomy to resect the intrapelvic extension of the tumor. This report features a curious case of soft-tissue tumor growth across the sciatic foramen forming an inverted sciatic hernia. The authors' proposed approach was simple and safe and avoided a laparotomy.

Derivación biliopancreática laparoscópica: técnica quirúrgica en nuestra curva de aprendizaje / Laparoscopic biliopancreatic diversion: a surgical technique in our learning curve

Objetivo Presentamos nuestra experiencia inicial con la técnica de Scopinaro mediante abordaje laparoscópico para el tratamiento de la superobesidad mórbida. Se repasan aspectos técnicos que hemos aprendido en nuestra curva de aprendizaje. MétodosTreinta y cinco pacientes con criterios de superobesidad mórbida fueron intervenidos de forma consecutiva en un centro concertado de segundo nivel en el periodo comprendido entre noviembre de 2009 y junio de 2010.ResultadosTodas las operaciones se realizaron por laparoscopia sin necesidad de conversión. No hubo complicaciones mayores ni mortalidad. Conclusión La técnica de Scopinaro por laparoscopia se puede realizar en pacientes superobesos con seguridad en centros que incorporen cirujanos experimentados en el manejo de anastomosis y sutura laparoscópica intracorpórea (AU)

Background: We present our initial experience with the laparoscopic BPD technique for super-obese patients. Recommended tips on the technique are summarized. Methods: A total of 35 super-obese patients were submitted to BPD by laparoscopy in November 2009 and June 2010 for the treatment of morbid obesity. Results: All operations were performed by laparoscopy with no need to convert to laparotomy. No mayor complications and mortality related to surgery were observed. Conclusion: The Scopinaro technique can be safely performed in super-obese patients by surgeons with special dedication for bariatric surgery and advanced skills in intracorporealsuturing and knot-tying (AU)

[Laparoscopic biliopancreatic diversion: a surgical technique in our learning curve]. / Derivación biliopancreática laparoscópica: técnica quirúrgica en nuestra curva de aprendizaje.

BACKGROUND: We present our initial experience with the laparoscopic BPD technique for super-obese patients. Recommended tips on the technique are summarized. METHODS: A total of 35 super-obese patients were submitted to BPD by laparoscopy in November 2009 and June 2010 for the treatment of morbid obesity. RESULTS: All operations were performed by laparoscopy with no need to convert to laparotomy. No mayor complications and mortality related to surgery were observed. CONCLUSION: The Scopinaro technique can be safely performed in super-obese patients by surgeons with special dedication for bariatric surgery and advanced skills in intracorporeal suturing and knot-tying.

Technical modifications for laparoscopic cholecystectomy by the left-handed surgeon.

There is a complete paucity of literature for left-handed surgeons. Some studies revealed that left-handed surgical residents have lesser operating skills and some surgeons have considered leaving surgery at some point in their career owing to laterality-related frustrations. Most important, whereas minimally invasive surgical techniques have had a profound impact on the treatment of diseased gallbladder, these procedures do not eliminate laterality related to the discomfort of left-handed surgeons. Usually, left-handed surgeons must teach themselves a procedure. They must make modifications and learn some technical tips to make a more comfortable, convenient, and safe intervention. The aim of this study was to describe some modifications made by a left-handed surgeon to perform 52 safe laparoscopic cholecystectomies with standard right-handed instruments in our hospital. These surgical steps could be used in a reproducible way to minimize the recurring difficulties of left-handed learners in a surgical residency program.

Impact of previous abdominal surgery on colorectal laparoscopy results: a comparative clinical study.

To assess the results of laparoscopic colorectal surgery in patients who have previously undergone abdominal surgery. Between November 2002 and June 2004, 86 patients underwent laparoscopic surgery for colorectal disease at our hospital. Patients were divided into 2 groups depending on whether they had previously undergone abdominal surgery (previous surgery group, n = 27) or not (nonprevious surgery group, n = 59). Data were prospectively collected for statistical analyses of demographic, clinical, and histologic variables. Groups were comparable in age, body mass index, American Society of Anesthesiologists score, diagnosis, technique performed, and tumor size and distance to anal verge. There was no difference in perioperative complication rates. A higher conversion rate was found in the previous surgery group (26.1% vs. 5.1%, P = 0.02). In patients with tumor diseases, resection evaluations were no different regarding specimen length, distal and radial resection margins, or number of lymph nodes harvested. Laparoscopic colorectal surgery has proved to be a reliable technique for patients who have previously undergone abdominal surgery, its results comparable to those obtained with patients who have not.

A comparative clinical study of short-term results of laparoscopic surgery for rectal cancer during the learning curve.

OBJECTIVES: The aim of this study was to assess the results of laparoscopic surgery for rectal carcinoma (LSRC) during the learning curve throughout the introduction of this technique at our medical center. MATERIALS AND METHODS: From January 2003 to April 2004, 40 patients undergoing surgery were assigned to laparoscopic surgery group (LSG) (n=20) or conventional surgery group (CSG) (n=20). Data were prospectively collected to statistically analyze clinical, anatomopathological, and economic variables. RESULTS: Groups were comparable in age, sex, body mass index, American Society of Anesthesiologists score, surgical technique performed, tumor size and distance, Dukes' stage, and proportion of patients with previous abdominal surgery and radiotherapy. There was no difference in operative time. LSG blood loss was lower (p<.0001). LSG peristalsis and oral intake began earlier (p<.0001). LSG hospital stay was shorter (p<.0001). Intraoperative complications (10% LSG vs 15% CSG) and overall morbidity (35% LSG vs 45% CSG) were no different. LSG did not record any anastomotic leakages. Two patients (10%) were converted to open surgery. Regarding oncologic adequacy of resection, specimen length and number of nodes harvested were no different. LSG distal and radial resection margins were greater (p<.0001; p=.03). LSG operative costs were greater (p<.0001). However, CSG hospitalization costs were higher (p<.001). There was no overall difference (p=0.1). CONCLUSIONS: LSRC has been a reliable and efficient technique during the learning curve at our hospital.

Mucinous cystic neoplasm of the pancreas during pregnancy: the importance of proper management.

We describe a case of huge mucinous cystic tumor of the pancreas in a 26-year-old woman during pregnancy. Ultrasonography demonstrated a well-delimited cystic mass in the left upper abdominal quadrant, suggestive of benignity. Magnetic resonance imaging showed a large cystic mass resembling a mucinous cystic tumor of the pancreas. After this assessment the patient underwent surgical exploration and a huge cystic tumor of the pancreas was discovered. The tumor was enucleated and distal pancreatectomy was performed. The resected margin of the specimen was free of tumor. In this case report we discuss the management of mucinous pancreatic tumors during pregnancy and we briefly review the previously reported cases of mucinous pancreatic tumors in pregnant patients. We conclude that surgical resection of these tumors should be strongly considered in pregnancy. Removal of the tumor appears to be a safe procedure without harmful effects to the fetus.

Coeliac axis ligation in a case of unmanageable upper gastrointestinal haemorrhage.

Upper gastrointestinal haemorrhage (UGH) is a frequent reason for referral in gastroenterologic practice. It consists of bleeding that originates in the upper gastrointestinal tract, between the oesophagus and Treitz's angle. Gastroduodenal peptic ulceration, severe lesions of gastric or duodenal mucosa, and esophageal varicose rupture are the most frequently reported causes of UGH. Clinically, it manifests as rectal bleeding or haematemesis. Regardless of the causal lesion, UGH is differentiated by the degree of haemodynamic instability. Thus, initial management of UGH with haemodynamic instability does not depend on the lesion that produces it but rather on controlling the hypovolaemia in all cases. Subsequent therapeutic measures, which in certain cases are defined in early stages of this picture, depend on the aetiology of the lesion causing the UGH and its treatment. We present a case of unmanageable UGH of unknown aetiology despite multiple diagnostic and therapeutic measures, where final successful treatment required an exceptional surgical intervention--celiac axis ligation.