Sigmoid resection and primary anastomosis for perforated diverticulitis with peritonitis: To divert or not to divert-A systematic review and meta-analysis.

BACKGROUND: The role of proximal diversion in patients undergoing sigmoid resection and primary anastomosis for diverticulitis with generalized peritonitis is unclear. The aim of this study was to compare the clinical outcomes of sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with a proximal diversion in perforated diverticulitis with diffuse peritonitis. METHOD: A systematic literature search on sigmoid resection and primary anastomosis and sigmoid resection and primary anastomosis with proximal diversion for diverticulitis with diffuse peritonitis was conducted in the Medline and EMBASE databases. Randomized clinical trials and observational studies reporting the primary outcome of interest (30-day mortality) were included. Secondary outcomes were major morbidity, anastomotic leak, reoperation, stoma nonreversal rates, and length of hospital stay. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes. RESULTS: A total of 17 studies involving 544 patients (sigmoid resection and primary anastomosis: 287 versus sigmoid resection and primary anastomosis with proximal diversion: 257) were included. Thirty-day mortality (odds ratio 1.12, 95% confidence interval 0.53-2.40, P = .76), major morbidity (odds ratio 1.40, 95% confidence interval 0.80-2.44, P = .24), anastomotic leak (odds ratio 0.34, 95% confidence interval 0.099-1.20, P = .10), reoperation (odds ratio 0.49, 95% confidence interval 0.17-1.46, P = .20), and length of stay (sigmoid resection and primary anastomosis: 12.1 vs resection and primary anastomosis with diverting ileostomy: 15 days, P = .44) were similar between groups. The risk of definitive stoma was significantly lower after sigmoid resection and primary anastomosis (odds ratio 0.05, 95% confidence interval 0.006-0.35, P = .003). CONCLUSION: Sigmoid resection and primary anastomosis with or without proximal diversion have similar postoperative outcomes in selected patients with diverticulitis and diffuse peritonitis. However, further randomized controlled trials are needed to confirm these results.

Laparoscopic approach for the treatment of acute complications after appendectomy: a systematic review.

INTRODUCTION: The significance of laparoscopy after appendectomy is still unclear, despite the fact that it is thought to be an appropriate technique for the detection and management of postoperative complications. We aimed to determine the incidence, risk factors, diagnosis, and laparoscopic approach for the treatment of acute complications after appendectomy performing a systematic review of the literature. EVIDENCE ACQUISITION: We performed systematic review of the PubMed/MEDLINE, Embase and GoogleScholar bibliographic databases between 1995 and 2022 regarding laparoscopic resolution of early postoperative complications after appendectomy. Demographics, peri-operative variables, and postoperative outcomes were analyzed. EVIDENCE SYNTHESIS: A total of 9 studies comprising 116 cases of laparoscopic resolution of early complications after appendectomy were included. The primary surgery showed a 60% of perforated or gangrenous appendicitis. Time elapse between the appendectomy and the diagnosis of the postoperative complication was from 2 to 15 days (median 5.8 days). The procedures performed at laparoscopy were as follows: laparoscopic washout and drainage of generalized peritonitis and intra-abdominal abscesses (95.6%), laparoscopic lysis of adhesions due to small bowel obstruction (1.7%), running suturing for unnoticed small bowel lesion (1.7%) and one patient required a right colectomy due to stump leakage (0.8%). Conversion to an open approach was necessary in 9 patients (7.8%). Postoperative complications after early re-laparoscopy washout were reported in 4 publications (15.5%). Finally, 15 (12.9%) patients required an additional intervention. The mean LOS was of 5 days. CONCLUSIONS: Infectious complications are not uncommon after appendectomy, but their incidence increases significantly in complicated appendicitis, with IAA being the most feared complication. When re-exploration is mandatory, the laparoscopic approach is a safe and highly effective tool for the diagnosis and treatment of these complications, adding the benefits of minimally invasive surgery.

Second Laparoscopic Colorectal Resection: Safety and Feasibility.

BACKGROUND: As laparoscopic colorectal surgery continues increasing worldwide, the need of having a second laparoscopic colorectal resection (SLCR) might increase as well. Experience with this challenging procedure is scarce. The aim of this study was to evaluate the safety and feasibility of SLCR. METHODS: A retrospective analysis of a prospectively collected database of patients undergoing colorectal surgery who needed an SLCR during the period 2008-2020 was performed. Demographics, operative variables, and postoperative outcomes were analyzed. A propensity score matching with a control population undergoing a first elective colorectal resection was performed. RESULTS: A total of 1918 patients underwent colorectal surgery and 32 patients (1.7%) who required a SLCR were included for analysis; 17 (53.1%) were male, and the mean age was 71 (39 to 89) years. The median time between the first and second operations was 69 (6 to 230) months. At the second resection: The median operative time was 170 (90 to 380) minutes, there were 3 (9%) intraoperative complications and 2 (6%) conversions. Overall postoperative morbidity and major morbidity rates were 34% and 19%, respectively. Four patients (12.5%) required reoperation and 1 (3.1%) died of septic shock after an anastomotic leak. After propensity score matching, SLCR was more frequently performed by colorectal surgeons, and no differences in perioperative variables were observed compared with the control group. CONCLUSIONS: SLCR can be safely performed without jeopardizing perioperative outcomes. Further studies are needed to confirm the benefits of the minimally invasive approach in colorectal second resection and to elucidate the long-term outcomes.

Conversion from Laparoscopic to Open Appendectomy: Trends, Risk Factors and Outcomes. A 15-Year Single-Center Analysis of 2193 Adult Patients.

BACKGROUND: Laparoscopic appendectomy (LA) has become the standard of care for the management of acute appendicitis in adult patients. Despite the increasing experience in laparoscopy, conversion to open surgery might still occur. We aimed to identify preoperative and intraoperative risk factors for conversion and determine surgical outcomes in this population. METHODS: We performed a retrospective analysis of a consecutive series of patients undergoing LA during the period 2006-2020. The cohort was divided into two groups: patients who underwent a fully laparoscopic appendectomy (FLA) and patients who were converted to open appendectomy (CA). Demographics, perioperative variables and postoperative outcomes were compared between both groups. Independent risk factors for conversion were determined by logistic regression analysis. RESULTS: A total of 2193 patients were included for analysis; 2141 (98%) underwent FLA and 52 (2%) CA. Conversion rates decreased significantly over time (p = 0.006). Patients with CA had significantly higher overall postoperative morbidity rates (FLA 14.9% vs. CA 48.0%, p < 0.0001) and longer mean length of hospital stay (FLA 1.7 vs. CA 5 days). In the multivariate analysis, obesity (p < 0.001), previous abdominal operations (p = 0.013), peritonitis (p = 0.003) and complicated appendicitis (p < 0.001) were independent risk factor for conversion. CONCLUSIONS: Although conversion from laparoscopic to open appendectomy is infrequent and has decreased over time, it is associated with significantly higher postoperative morbidity. Patients with previous abdominal operations, obesity and complicated appendicitis should be thoroughly advised about the higher risk of conversion.

Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis.

BACKGROUND: Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis. MATERIALS AND METHODS: A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes. RESULTS: A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively. CONCLUSION: HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.

Evidence-based approach to the treatment of esophagogastric junction tumors.

The incidence of esophagogastric junction (EGJ) adenocarcinoma is increasing in developed nations due to the rising prevalence of obesity and gastroesophageal reflux disease. Due to the peculiar location in a histological transition zone between the esophagus and the stomach, the management of EGJ tumors is controversial. Two main surgical approaches exist: total gastrectomy with distal esophagectomy or esophagectomy by either transhiatal or transthoracic approach. These operations differ significantly in the extent of lymphadenectomy. In addition, patients with locally advanced disease can receive either preoperative chemoradiation or perioperative chemotherapy. This evidence-based review analyzes current evidence regarding the management of EGJ tumors in order to help defining the best surgical and systemic treatment of these patients.

Open versus hybrid versus totally minimally invasive Ivor Lewis esophagectomy: Systematic review and meta-analysis.

BACKGROUND: Hybrid and minimally invasive approaches have emerged as less invasive alternatives to open Ivor Lewis esophagectomy. The aim of this study was to compare surgical outcomes between open (OE), hybrid (HE), and totally minimally invasive esophagectomy (TMIE). METHODS: A systematic literature search was performed to analyze outcomes after OE, HE, and TMIE with intrathoracic anastomosis. Main outcomes included anastomotic leak rate, overall morbidity, and 30-day mortality. A meta-analysis of proportions was used to assess the effect of each approach on different outcomes. RESULTS: A total of 130 studies comprising 16,053 patients were included for analysis; 8081 (50.3%) underwent OE, 1524 (9.5%) HE, and 6448 (40.2%) TMIE. The risk of anastomotic leak was lower after OE (odds ratio [OR], 0.71; 95% CI, 0.62-0.81; P < .0001). Overall morbidity rate was 45% (95% CI, 38%-52%) after OE, 40% (95% CI, 25%-59%) after HE, and 37% (95% CI, 32%-43%) after TMIE. Risk estimation showed higher odds of postoperative mortality after OE (OR, 2.22; 95% CI, 1.76-2.81; P < .0001) and HE (OR, 1.93; 95% CI, 1.32-2.81; P < .001), compared with TMIE. Median length of hospital stay (LOS) was 14.1 (range, 8-28), 12.5 (range, 8-18), and 11.9 (range, 7-30) days after OE, HE and TMIE, respectively (P = .003). CONCLUSIONS: HE and TMIE are associated with lower rates of overall morbidity, reduced postoperative mortality, and shorter LOS, compared with OE. TMIE is associated with lower mortality rates and shorter LOS than HE. Further efforts are needed to widely embrace TMIE in a safe manner.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis.

BACKGROUND: A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE). METHODS: A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome. RESULTS: A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively. CONCLUSIONS: Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Indocyanine green (ICG) fluorescence imaging for prevention of anastomotic leak in totally minimally invasive Ivor Lewis esophagectomy: a systematic review and meta-analysis.

BACKGROUND: Indocyanine green (ICG) fluorescence imaging is an emerging technology that might help decreasing anastomotic leakage (AL) rates. The aim of this study was to determine the usefulness of ICG fluorescence imaging for the prevention of AL after minimally invasive esophagectomy with intrathoracic anastomosis. METHODS: A systematic literature review of the MEDLINE and Cochrane databases was performed to identify all articles on totally minimally invasive Ivor Lewis esophagectomy. Studies were then divided into two groups based on the use or not of ICG for perfusion assessment. Primary outcome was anastomotic leak. Secondary outcomes included operative time, ICG-related adverse reactions, and mortality rate. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for main outcomes. RESULTS: A total of 3,171 patients were included for analysis: 381 (12%) with intraoperative ICG fluorescence imaging and 2,790 (88%) without ICG. Mean patients' age and proportion of males were similar between groups. Mean operative time was also similar between both groups (ICG: 354.8 vs. No-ICG: 354.1 minutes, P = 0.52). Mean ICG dose was 12 mg (5-21 mg). No ICG-related adverse reactions were reported. AL rate was 9% (95% CI, 5-17%) and 9% (95% CI, 7-12%) in the ICG and No-ICG groups, respectively. The risk of AL was similar between groups (odds ratio 0.85, 95% CI 0.53-1.28, P = 0.45). Mortality was 3% (95% CI, 1-9%) in patients with ICG and 2% (95% CI, 2-3%) in those without ICG. Median length of hospital stay was also similar between groups (ICG: 13.6 vs. No-ICG: 11.2 days, P = 0.29). CONCLUSION: The use of ICG fluorescence imaging for perfusion assessment does not seem to reduce AL rates in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis.

High-volume center analysis and systematic review of stump appendicitis: solving the pending issue.

PURPOSE: Stump appendicitis (SA) is a rare long-term complication after laparoscopic appendectomy (LA) that can be associated with high morbidity due to delayed diagnosis. We aimed to determine the incidence, risk factors, diagnosis, and management of SA by reviewing our large cohort of LA and performing a systematic review of the literature. METHODS: We retrospectively reviewed data of all patients who developed SA after LA between 2006 and 2020. Demographics, peri-operative variables, and postoperative outcomes were analyzed. A systematic review of the PubMed/MEDLINE, Embase and GoogleScholar bibliographic databases was also performed to identify publications regarding SA following LA. RESULTS: A total of 2,019 patients underwent LA; 5 (0.25%) developed SA after a median of 292 days. The most common symptom at presentation was right lower quadrant pain. Four SA (80%) occurred in patients with a history of complicated appendicitis at index operation. All patients were diagnosed with computed tomography and underwent completion stump appendectomy by laparoscopy. No postoperative complications were recorded. A total of 55 studies with 76 cases of SA after LA were identified in the systematic review. Most SA (98.7%) underwent surgery: 52% by laparoscopic approach and 36% through an open approach. Stump appendectomy was performed in 94.4% cases and an extended resection in 5.6%. CONCLUSION: Although SA is a rare complication after LA, a high index of clinical suspicious and imaging studies are key for early diagnosis and treatment. A laparoscopic resection of the inflamed appendiceal stump is feasible, safe, and highly effective. A minority of patients with severe cecum compromise may need extended resections or conversion to open surgery.

Minimally invasive Ivor Lewis esophagectomy: Robot-assisted versus laparoscopic-thoracoscopic technique. Systematic review and meta-analysis.

BACKGROUND: Evidence comparing conventional minimally invasive esophagectomy (CMIE) via laparoscopy and thoracoscopy with robot-assisted minimally invasive esophagectomy (RAMIE) is scarce. The aim of this meta-analysis was to compare surgical outcomes after CMIE and RAMIE with an intrathoracic anastomosis. METHODS: A systematic literature search was performed to identify original articles analyzing outcomes after CMIE and RAMIE. Main surgical outcomes included operative time, intraoperative blood loss, anastomotic leak rates, pneumonia, overall morbidity, length of stay (LOS), and 30-day mortality. Oncologic outcomes included lymph node yield and R0 resections rates. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes. RESULTS: A total of 6,249 patients were included for analysis; 5,275 (84%) underwent CMIE and 974 (16%) RAMIE. Robotic esophagectomy had longer operative time and less intraoperative blood loss. Anastomotic leakage rates were similar with both approaches. Patients undergoing RAMIE had significantly lower rates of postoperative pneumonia (OR 0.46, 95% CI 0.35-0.61, P < .0001) and overall morbidity (OR 0.67, 95% CI 0.58-0.79, P < .0001). Median LOS was similar in both procedures (RAMIE: 12.1 versus CMIE: 11.9 days, P = .64). Similar mortality rates were found after RAMIE and CMIE (OR 0.69, 95% CI 0.34-1.38, P = .29). Lymph node yield was similar in both procedures, but RAMIE was associated with higher rates of R0 resection (OR 2.84, 95% CI 1.53-5.26, P < .001). CONCLUSION: Patients undergoing robotic esophagectomy have less intraoperative blood loss, lower rates of postoperative pneumonia, reduced overall morbidity, and higher rates of R0 resections, as compared with those undergoing a laparoscopic-thoracoscopic esophageal resection.

Re-laparoscopy for the treatment of complications after laparoscopic appendectomy: is it possible to maintain the minimally invasive approach?

Despite laparoscopy is considered an adequate tool for the diagnosis and management of postoperative surgical complications, its role after laparoscopic appendectomy (LA) remains uncertain. The aim of this study was to evaluate whether laparoscopy is useful for treating complications after laparoscopic appendectomy. A retrospective analysis of a prospectively collected database of patients undergoing LA, who needed a reoperation for postoperative complications during the period 2006-2020, was performed. Demographics, operative variables, and postoperative outcomes were analyzed. A total of 2019 LA were performed, and 41 patients (2%) underwent a RL for post appendectomy complications. Twenty-three patients (56%) were male. The mean age was 32 years old (16-92 years). The majority of patients (75%) had a complicated acute appendicitis in the first operation. The most common findings at RL were generalized peritonitis (36.4%) and intraabdominal abscesses (26.8%). Five patients (12.1%) developed stump appendicitis, all of them as a late complication. The procedures were completed laparoscopically in 85% and 6 patients (15%) required conversion to an open approach. Three patients (7.3%) required a percutaneous drainage and two patients (4.9%) needed an additional surgery (laparotomy) after RL, all of them presenting with generalized peritonitis at the RL. No mortality was registered. Re-laparoscopy is feasible, safe, and highly effective for the diagnosis and treatment of post appendectomy complications. RL should be encouraged to avoid more aggressive procedures.

Impacto de la subespecialización en los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III / Outcomes of emergent laparoscopic sigmoid resection for Hinchey III diverticulitis: Does specialization matter?

Introducción: La sigmoidectomía por diverticulitis perforada es una cirugía de urgencia comúnmente realizada por cirujanos generales. Está descripta la correlación positiva entre el volumen del cirujano y los mejores resultados postoperatorios. Sin embargo, existe escasa evidencia de la influencia de la especialización en cirugía colorrectal sobre los resultados de la sigmoidectomía laparoscópica por diverticulitis perforada. Objetivo: Evaluar el impacto de la especialización en cirugía colorrectal en los resultados postoperatorios de la sigmoidectomía laparoscópica por diverticulitis Hinchey III. Diseño: Estudio retrospectivo sobre una base de datos cargada de forma prospectiva. Material y métodos: Se incluyeron pacientes sometidos a sigmoidectomía laparoscópica por diverticulitis perforada Hinchey III. La muestra fue dividida en dos grupos: pacientes operados por un cirujano colorrectal (CC) y aquellos operados por un cirujano general (CG). Las variables demográficas, operatorias y postoperatorias fueron comparadas entre los grupos. El objetivo primario fue determinar si existían diferencias en la proporción de anastomosis primaria, morbilidad y mortalidad a 30 días entre los grupos. Resultados: Se incluyeron 101 pacientes en el análisis; 58 operados por CC y 43 por CG. Los pacientes operados por CC presentaron una mayor proporción de anastomosis primaria (CC: 98,3% vs. CG: 67,4%, p<0,001). Los CG realizaron más estomas (CC: 13,8% vs. CG: 46,5%, p<0,001), presentaron un mayor índice de conversión (CC: 20,6% vs. CG: 39,5%, p=0,03) y una mayor estadía hospitalaria (CC: 6,2 vs. CG: 10,8 días, p<0,001). La morbilidad global (CC: 34,4% vs. CG: 46,5%, p=0.22), dehiscencia anastomótica (CC: 3,5% vs. CG: 6,8%, p=0.48) y la mortalidad (CC: 1,7% vs. CG: 9,3 %, p=0,08) fueron similares entre ambos grupos. Conclusión: La sigmoidectomía laparoscópica de urgencia realizada por CG presenta similar morbilidad y mortalidad postoperatoria que la realizada por CC. Sin embargo, la participación del especialista se asoció a una mayor frecuencia de anastomosis primarias, menos estomas y una estadía hospitalaria más corta.

Background: Sigmoid resection for perforated diverticulitis is one of the most common emergency surgeries and often performed by general surgeons. Relationship between high-volume surgeons and improved postoperative outcomes is well established. However, the influence of colorectal specialization on outcomes after emergency laparoscopic sigmoidectomy for perforated diverticulitis is not well described. Aim: Evaluate the impact of colorectal surgery training on the outcomes after emergency laparoscopic sigmoid resection for Hinchey III diverticulitis. Design: Retrospective analysis of prospectively collected database.Method: Patients undergoing emergent laparoscopic sigmoid resection for perforated (Hinchey III) diverticulitis were identified and stratified by involvement of colorectal or general surgeon. This study was conducted from 2000 to 2018 at a teaching hospital. Primary outcome measures were primary anastomosis, postoperative morbidity and mortality.Results: A total of 101 patients were identified; 58 by colorectal and 43 by general surgeons. Patients in the colorectal surgeon group had higher rates of primary anastomosis (CS: 98, 2% vs. GS: 67, 4%, p<0.001). General surgeons performed more ostomies (CS: 13, 8% vs. GS: 46, 5%, p<0.001), had a higher conversion rate (CS: 20, 6% vs. GS: 39, 5%, p=0.03) and longer mean length of hospital stay (CS: 6, 2 vs. GS: 10, 8 days, p<0.001). Overall morbidity (CS: 34, 4% vs. GS: 46, 5%, p=0.22), anastomotic leak rate (CC: 3,5% vs. CG: 6,8%, p=0.48) and mortality (CS: 1, 7% vs. GS: 9,3 %, p=0.08) were similar between groups. Conclusion: Emergency laparoscopic sigmoid resection by general surgeons wasn ́t associated with higher rates of postoperative morbidity, anastomotic leakage or mortality. However, patients operated by colorectal surgeons had higher rates of primary anastomosis, lower rates of ostomy, conversion and shorter length of hospital stay.

Esophageal achalasia after Roux-en-Y gastric bypass for morbid obesity.

The development of achalasia in patients with a prior Roux-en-Y gastric bypass (RYGB) is rare and it often remains unclear whether the esophageal motility disorder is a pre-existing condition in the obese patient or develops de novo after the procedure. The aim of this study was to review the available evidence regarding the management of patients with achalasia after a RYGB. Intra-sphincteric injection of botulinum toxin and pneumatic dilatation can be used to eliminate the functional obstruction at the level of the gastroesophageal junction. However, considering that achalasia patients after RYGB are often young and these treatment modalities have shown worse long-term outcomes, endoscopic or surgical myotomy is preferred. Per-oral endoscopic myotomy (POEM) is a very effective first line of treatment, and as RYGB is an excellent anti-reflux operation per se, post-POEM reflux may not be an issue in these patients. Laparoscopic Heller myotomy (LHM) is also an effective and safe therapy in achalasia patients with RYGB anatomy, and the gastric remnant can be safely used to perform a fundoplication to cover the myotomy. LHM and POEM are both acceptable primary treatment modalities in this setting. Further studies are needed to elucidate the pathophysiology and optimal management of patients with achalasia after RYGB.

Estudos da estabilidade da secreçäo mucóide / Stability studies of mucus secretion

O objetivo do trabalho, é a determinaçäo de parâmetros definitórios do modelo de comportamento reológico da secreçäo mucóide das expectoraçöes, analisando as variaçöes produzidas em doentes tratadas ou näo como fármacos mucolíticos. Finalmente, é estudada a estabilidade da secreçäo mucóide frente a uma açäo de fricçäo repetitiva, definido o parâmetro de caracterizaçäo (coeficiente de perda logarítmica de viscosidade por ciclo), verificando, desta forma, sua estabilidade

Estudos reológicos realizados no líquido pleural com elevada concentraçäo de hémacias / Rheological studies of pleural secretion with high red cell concentration

O líquido pleural procedente de pacientes portadores de determinadas patologias apresenta uma concentraçäo elevada de hemácias, com valortes superiores a 5.000-6.000 hemácias/ml, valores mínimos necessários para obter uma coloraçäo sanguinolenta da soluçäo extraída. Esta causa obrigará posteriores realizaçöes, neste caso de tipo viscosimétrico, sobre amostras adicionadas de anticoagulante. Por causa disto, é necessário a análise cuidadosa das modificaçöes que o anticoagulante (heparina) exerce sobre os valores obtidos dos parâmetros definitórios do modelo de comportamento reológico do líquido pleural. Procedeu-se, pois, a caracterizaçäo reológica das amostras com elevada concentraçäo hemática, passando, a partir dos valores experimentais obtidos, a realizaçäo do teste estimativo de Darmois, comparativo de populaçöes de médias normais conhecidas