Seeking an Initial-Weight-Independent Metric in a Mediterranean Cohort of Gastric Bypass Patients: the %AWL Revisited.

BACKGROUND: Most relative weight-loss metrics follow the formula "Weight loss(%) = 100 · (Initial BMI - Final BMI) / (Initial BMI-a)," where a is the reference point that defines the metric. The percentage of total weight loss (%TWL, a = 0) and percentage of excess weight loss (%EWL, a = 25) are influenced by a patient's initial weight. Recently, the percentage of alterable weight loss metric (%AWL, a = 13) has been reported to produce initial-weight-independent outcomes. OBJECTIVES: This study aimed to replicate the methodology used for %AWL determination in a Mediterranean cohort of bariatric patients. SETTINGS: Multicenter study in 10 large hospitals in Spain. METHODS: Two large prospective databases were retrospectively searched for all primary laparoscopic gastric bypass patients with 2 years of follow-up. Outcomes at nadir were expressed and analyzed with 26 different metrics (a from 0 to 25), looking for the metric whose outcomes produced (1) the lowest coefficient of variation, (2) no differences between initially lighter and heavier patients, and (3) no correlation with patients' initial BMI. RESULTS: A cohort of 1793 patients was stratified into 4 gender-age groups: younger women (YW, n = 733), older women (OW, n = 674), younger men (YM, n = 197), and older men (OM, n = 189). The calculations suggested an optimal reference point of 18 kg/m2, defining a new metric (percentage of Mediterranean alterable weight loss, %MAWL). When %TWL, %EWL, %AWL, and %MAWL were tested on the whole sample, only %MAWL produced initial-weight-independent results. CONCLUSIONS: In our Mediterranean cohort of patients, a reference point of 18 (and not 13) yielded initial-weight-independent outcomes.

Intestinal obstruction caused by Anisakis.

A 77-year-old male presented to the Emergency Department due to a clinical and radiological pattern of intestinal obstruction. An abdominal computed tomography (CT) scan revealed a dilatation of the jejunum loops with a change in bowel caliber in the proximal ileum and segmental edema of the intestinal wall. An urgent laparotomy was performed which revealed adhesions between intestinal loops and an intraluminal mass in the proximal ileum with a change in the bowel caliber. The affected segment of the proximal ileum measuring 20 cm was resected and a small-bowel manual termino-terminal anastomosis was performed. The patient was discharged seven days following the surgery.

Analysis of mid-term weight loss after Roux-en-Y gastric bypass and sleeve gastrectomy: Proposed percentile charts for total weight loss percentages to be used in daily clinical practice. / Análisis de la pérdida ponderal a medio plazo después del bypass gastroyeyunal en Y de Roux y de la gastrectomía vertical: propuesta de gráficos de percentiles del porcentaje de peso total perdido para su uso en la práctica clínica diaria.

INTRODUCTION: The aim of this study is to analyze weight evolution after the main bariatric surgical techniques (Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]) performed at a representative sample of Spanish hospitals in order to develop percentile charts for the percentage of total weight loss during the first 3 years after surgery. METHODS: A retrospective longitudinal cohort study was conducted based on the data provided by 9 Spanish hospitals. Weight data were analyzed both in % total weight loss and % excess weight lost corresponding to the RYGB (n=1,887) and SG (n=1,210). RESULTS: RYGB continues to be the most frequently performed technique in our sample. In both surgical techniques, maximum weight loss occurred 18 months after surgery. Both techniques followed the same weight evolution, although the % total weight loss values were lower in the case of the SG after 36 months (29.3±10 vs. 33.6±10). Age and gender are decisive in the weight results (better in younger patients for both techniques and better in women for RYGB). CONCLUSIONS: Percentile charts of % total weight loss after bariatric surgery represent a very useful tool and an important advance in the quality of patient management.

Weight Loss Analysis According to Different Formulas after Sleeve Gastrectomy With or Without Antral Preservation: a Randomised Study.

BACKGROUND: The measurement of weight loss after bariatric surgery is under constant review in order to obtain the ideal standard for reporting weight loss. Several formulas have been proposed for this purpose. Our goal is to analyse weight loss after sleeve gastrectomy, with or without antrum preservation through different measurement formulas. METHODS: A prospective randomised study of 60 patients (30 patients with initial section at 3 cm from pylorus and 30 patients at 8 cm from the pylorus). We calculate the following variables at 3, 6 and 12 months from surgery: BMI, excess weight loss (%EWL), percentage of excess of BMI loss (%PEBMIL), expected BMI, % PEBMIL corrected by EBMI and percentage of total weight loss (%TWL). RESULTS: Weight evolution is similar in both groups, reaching a mean BMI of 33.62 ± 4.35 and 34.48 ± 4.23 kg/m2 respectively 12 months after surgery, closer to expected BMI. TWL follows the same trend, with losses exceeding 30%, although 3 cm group is above the tables of percentiles made with our series. Regarding PEBMIL, the 3 cm group reaches 67.8% classified as excellent, while 8 cm group reaches 62.8% classified as a good result. EWL situates the best results for 3 cm group. CONCLUSIONS: Group 3 cm obtained a lower percentage of suboptimal results using EWL. %TWL places the 3 cm group in higher percentile than 8 cm group. Through EBMI, both groups are equally effective. It is necessary to have standardised dynamic tables for each surgical technique, becoming essential elements to measure weight loss after surgery.

Prognostic Factors for Morbimortality in Sleeve Gastrectomy. The Importance of the Learning Curve. A Spanish-Portuguese Multicenter Study.

BACKGROUND: Complications in sleeve gastrectomy (SG) can cast a shadow over the technique's good results and compromise its safety. The aim of this study is to identify risk factors for complications, and especially those that can potentially be modified to improve safety. METHODS: A retrospective multicenter cohort study was carried out, involving the participation of 29 hospitals. Data was collected on demographic variables, associated comorbidities, technical modifications, the surgeon's experience, and postoperative morbimortality. A multivariate logistic regression analysis was carried out on risk factors (RFs) for the complications of leak/fistula, hemoperitoneum, pneumonia, pulmonary embolism, and death. RESULTS: The following data were collected for 2882 patients: age, 43.85 ± 11.6. 32.9 % male; BMI 47.22 ± 8.79; 46.2 % hypertensive; 29.2 % diabetes2; 18.2 % smokers; bougie calibre ≥40 F 11.1 %; complications 11.7 % (2.8 % leaks, 2.7 % hemoperitoneum, 1.1 % pneumonia, 0.2 % pulmonary embolism); and death 0.6 %. RFs for complications were as follows: surgeon's experience < 20 patients, OR 1.72 (1.32-2.25); experience > 100 patients, OR 0.78 (0.69-0.87); DM2, OR1.48(1.12-1.95); probe > 40 F, OR 0.613 (0.429-0.876). Leak RFs were the following: smoking, OR1.93 (1.1-3.41); surgeon's experience < 20 patients, OR 2.4 (1.46-4.16); experience of 20-50 patients, OR 2.5 (1.3-4.86); experience >100 patients, OR 0.265 (0.11-0.63); distance to pylorus > 4 cm, OR 0.510 (0.29-0.91). RFs for death were as follows: smoking, OR 8.64 (2.63-28.34); DM2, OR 3.25 (1.1-9.99); distance to pylorus < 5 cm, OR 6.62 (1.63-27.02). CONCLUSIONS: The safety of SG may be compromised by nonmodifiable factors such as age >65, patient comorbidities (DM2, hypertension), and prior treatment with anticoagulants, as well as by modifiable factors such as smoking, bougie size <40 F, distance to the pylorus <4 cm, and the surgeon's experience (<50-100 cases).

Usefulness of Baltasar's expected body mass index as an indicator of bariatric weight loss surgery.

INTRODUCTION: Determining the best indicator to report weight loss takes on special relevance following bariatric surgery. Our objective is to apply a method proposed by Baltasar et al. to express weight loss results following bariatric surgery. MATERIALS AND METHODS: Anthropometric data were collected from 265 patients who had undergone Sleeve gastrectomy (SG, n = 172) and Roux-en-Y gastric bypass (RYGBP, n = 93) with a 2-year follow-up period. Initial BMI was calculated as well as BMI 2 years after, percentage of excess BMI loss (PEBMIL), expected BMI (EBMI), and corrected PEBMIL. RESULTS: In SG group, average BMI 2 years after surgery fell within a 95 % CI of expected BMI, with an average BMI of 31.58 ± 4.05 kg/m2 in 35-45 BMI group, an average BMI of 33.62 ± 4.96 kg/m2 in 45-55 BMI group, and an average BMI of 37.40 ± 5.93 kg/m2 in 55-65 BMI group. In RYGBP group, average BMI 2 years after the surgery was below than average expected BMI (28.76 ± 3.20 kg/m2 in 35-45 BMI group and 29.71 ± 3.30 kg/m2 in 45-55 BMI group). Results are considered excellent for the group with an initial BMI of above 45 kg/m2. CONCLUSIONS: EBMI is a good weight loss indicator, mainly when 95 % CI is taken into account. EBMI is consistent with the results obtained 2 years after surgery in our patients who underwent SG and RYGBP. Corrected PEBMIL is a good indicator for expressing the percentage of BMI loss and offers more realistic values than conventional formula with a cut-off point of 25 points.

Duodeno-jejunal tube placement in an experimental model of obesity: effects on food behaviour and basal energy expenditure.

BACKGROUND: Metabolic surgery can modulate weight as well as food intake and basal energy expenditure. In this study, we evaluate the effectiveness of duodenal exclusion by analysing anthropometric results, intake variations, food behaviour and calorimetric parameters. METHODS: This is an experimental study with 8-week-old Sprague-Dawley male rats. The sequences used are as follows: Cafeteria diet for 3 weeks, followed by surgery and sacrifice at 4 weeks. Four experimental groups are as follows: two non-obese groups (n = 15; surgery = 10, sham = 5) and two obese groups by cafeteria diet (n = 15; surgery = 10, sham = 5). Surgery performed was duodenal exclusion with physical barrier. Weight, intake, glycaemia and basal energy expenditure by indirect calorimetry were monitored before and after surgery. RESULTS: Weight changes in groups that underwent intervention were significant. The reduction in calorie consumption after surgery was significant in the obese intervention group despite an increased standard feed consumption (161 ± 11 vs 139 ± 13 Kcal/day, p < 0.05; due to a lower consumption of cafeteria diet). In non-obese animals, changes were transient. Basal energy expenditure decreased in both intervention groups: 6.2 ± 0.5 vs 5.5 ± 0.4 Kcal/kg/h in non-obese animals and 5.6 ± 0.3 vs 4.7 ± 0.3 Kcal/kg/h in obese animals (p < 0.05). CONCLUSIONS: Duodeno-jejunal tube placement stops weight gain in obese and non-obese animals. In obese animals, there is an important qualitative change in appetite towards standard feed with a significant decrease in caloric intake. In non-obese animals, changes in quantitative intake are transient. This surgery decreases basal energy expenditure in obese animals. This may be attributed to an enhanced thermogenic effect of food and a slowing in the animal's weight gain.

[Is the morbid obesity surgery profitable in times of crisis? A cost-benefit analysis of bariatric surgery]. / ¿Es rentable operar a los obesos mórbidos en tiempos de crisis? Análisis coste-beneficio de la cirugía bariátrica.

Morbid obesity is a serious health problem whose prevalence is increasing. Expensive co-morbidities are associated to these patients, as well as a reduction in the survival. Bariatric surgery resolves the co-morbidities (type 2 diabetes mellitus, 86.6%; cardiovascular risk, 79.0%; obstructive sleep apnea syndrome, 83.6%; hypertension, 61.7%), reduces the mortality rate (among 31-40%), and increases the morbid obese patients survival over a 10-years period. It provides significant savings for the National Health System. The obese patients consume a 20% plus of health resources and 68% plus of drugs than general population. Bariatric surgery requires an initial investment (diagnosis-related group cost: 7,468 €), but it is recovered in a cost-effectiveness ratio of 2.5 years. Significant savings are obtained from the third year. To the direct economic benefits associated with reduced health expenditures it should be added an increase in tax collection (sick leave and unemployment reduction is estimated in 18%, with a productivity increase of 57% for self-employed people). Bariatric surgery is one of the most cost-effective procedures in the healthcare system.

[Evaluation of surgical skills in medical students using a virtual simulator]. / Evaluación de las habilidades quirúrgicas durante el pregrado mediante la introducción de un simulador virtual.

INTRODUCTION: The use of virtual simulators together with hospital practicals during undergraduate training can improve basic surgical skills, and may even be an important motivating focal point. The aim of this work is to determine the endoscopy skill level and its learning curve in three stages within the Medical degree (second, fourth, and sixth year) using a virtual simulator. MATERIAL AND METHODS: The Lapsim simulator with 7 basic modular exercises was used. Twenty four students (8 second, 8 fourth, and 8 sixth year) were subjected to a training program (basic test plus 3 sessions), and an examination at 30 days. A control group (n=24) from each year were subjected to 2 examinations with an interval of 30 days. RESULTS: All the groups improved significantly after training, and this was maintained in all the exercises after a "wash out" period of 30 days. All the groups achieved lower baseline scores in the "Cutting" and "Lifting and grasping" exercises, considered of intermediate level than any of the others. However, after the training process, they were the only exercises that the sixth year students demonstrated that they were clearly superior to the rest of the years: "Cutting" (94.5%±11 vs 81%±7) (P<.05), "Lifting and grasping" (88.1%±13 vs 68%±11) (P<.001). CONCLUSIONS: The virtual simulator appears to be of greater use for those students in higher years with more clinical experience, there already being a discrimination process during this period. Surgical skills during this phase should be reinforced by means of new teaching challenges, such as simulation programs in the framework of skills laboratories.

Gastric volvulus after sleeve gastrectomy for morbid obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy in morbid obesity has proved to be a safe and reproducible technique. Sleeve gastrectomy, however, is not free of complications. On the other hand, gastric volvulus is reported in those subjects where, either because of laxity of the gastric anatomical fixations or incorrect position of the stomach, rotation or turning is facilitated. CASE: We report the case of a patient with morbid obesity (Bone mass index / BMI 63 Kg/m2), who in the post-operative period immediately following a sleeve gastrectomy, presented early symptoms of upper gastrointestinal occlusion indicative of gastric volvulus of the gastric sleeve. RESULTS: The patient developed a partial obstruction secondary to a mixed volvulus mechanism (organo-axial and partially mesenteric-axial) after sleeve gastrectomy. We performed a laparoscopic antrectomy of the gastric sleeve and then a gastroileal anastomosis, a form of biliopancreatic diversion, with a common channel of 80 cm and alimentary limb of 160 cm). 18 months after, the patient has a BMI of 28 kg/m2 and enjoys a good quality of life. CONCLUSION: Sleeve gastrectomy leaves the stomach with no fixations along the entire greater curvature, which may predispose to volvulus. This complication is a rare finding and not reported to date following this intervention, but still needs to be considered in this type of patient.

Experimental metabolic surgery: justification and technical aspects.

BACKGROUND: Metabolic surgery is a surgical strategy which has shown great potential in the treatment of diseases which may be associated with morbid obesity. It must be developed on the basis of both animal and clinical research. The objective of this study is to set out the various options in experimentation animals and the technical characteristics in operations, and the specific animal care undertaken by our group. METHODS: We identified and reviewed the key points to be considered in animal handling during interventions such as sleeve gastrectomy, Roux-en-Y gastric bypass, ileal transposition and duodenal exclusion. RESULTS: The technical variations found at experimental level are due to the pouch capacity for the Roux-en-Y gastric bypass. Intestinal anastomosis is the variable with the greatest differences found between the various working groups. Ileal transposition is a technique that is undergoing constant review, and the results differ substantially depending on the animal model chosen, and are also metabolically effective in animals with a normal weight. Duodenal exclusion by means of a physical barrier has not been studied sufficiently but could be a pre-operative support for weight loss. CONCLUSIONS: There are experimental technical discrepancies and further studies are necessary to ascertain their efficiency. Metabolic surgery currently complements bariatric surgery and justifies the appearance of new experimental studies. The animal models chosen are very important as only very specific study models will be used in cases in which the technique is sufficiently validated by the research team, as the results to be assessed depend on this.

Simulador de bajo coste para el entrenamiento de habilidades laparoscópicas básicas / Low cost simulator for acquiring basic laparoscopic skills

Introducción La cirugía laparoscópica requiere el conocimiento y tratamiento de un equipo e instrumental diferente al de la cirugía abierta. El objetivo de este estudio es observar si el entrenamiento con un simulador de bajo coste es de utilidad para adquirir habilidades en técnicas laparoscópicas básicas. Material y métodos Estudio aleatorizado en el que participaron 48 sujetos (32 estudiantes y 16 cirujanos). Se diseñaron 2 ejercicios, uno de prensión y otro de corte. Los estudiantes se dividieron en 2 grupos (n=8), el primer grupo realizó los ejercicios en quirófano con la cámara de laparoscopia habitual y el segundo en un aula con una microcámara de bajo coste. Ambos grupos realizaron una primera evaluación, varias sesiones de entrenamiento y una segunda evaluación. Se utilizaron 2 grupos control con estudiantes (n=8) que realizaron las 2 evaluaciones sin entrenamiento. Los cirujanos se dividieron en 2 grupos y realizaron una evaluación, un grupo en quirófano y otro en el aula. Resultados En los grupos con entrenamiento, la mejoría entre la primera evaluación y la segunda para el primer ejercicio fue significativamente mayor que en los grupos sin entrenamiento (p<0,001). Los cirujanos presentaron una puntuación significativamente mejor que los estudiantes en su primera evaluación (p<0,001).Conclusiones El entrenamiento con este simulador de bajo coste ha demostrado ser de utilidad, de forma similar al entrenamiento en el simulador con un sistema de laparoscopia convencional, para adquirir habilidades laparoscópicas básicas. Este sistema de entrenamiento fue capaz de discriminar entre los sujetos con y sin experiencia en cirugía laparoscópica (AU)

Introduction Laparoscopic surgery requires a different set of skills than conventional surgery. The aim of this study was to evaluate the usefulness of a low-cost simulator and camera for the acquisition of basic laparoscopic skills. Material and Methods This randomised trial involved 48 subjects (32 students and 16 surgeons). Two exercises were used, object transfer and cutting. Students were divided into two groups (n=8). One group performed the exercises in the operating theatre with the conventional laparoscopic camera. The second group performed the exercises in a classroom with a low cost micro-camera. Both groups were evaluated before and after five training sessions. Two groups of students were used as controls (n=8), and were evaluated two times without training. The surgeons were divided in two groups (n=8), one was evaluated in the theatre and the other one in the classroom. Results The trained groups showed significant improvements in the first exercise (P <0.001) compared with non-trained groups. There were no differences in scores between the groups with different cameras. The surgeons had better scores than students (P <0.001).Conclusions The improvements in laparoscopic skills on this simulator with a low-cost camera were not significantly different from those gained using the simulator with the conventional laparoscopic camera. This simulator was able to differentiate between experienced and inexperienced subjects (AU)

[Low cost simulator for acquiring basic laparoscopic skills]. / Simulador de bajo coste para el entrenamiento de habilidades laparoscópicas básicas.

INTRODUCTION: Laparoscopic surgery requires a different set of skills than conventional surgery. The aim of this study was to evaluate the usefulness of a low-cost simulator and camera for the acquisition of basic laparoscopic skills. MATERIAL AND METHODS: This randomised trial involved 48 subjects (32 students and 16 surgeons). Two exercises were used, object transfer and cutting. Students were divided into two groups (n=8). One group performed the exercises in the operating theatre with the conventional laparoscopic camera. The second group performed the exercises in a classroom with a low cost micro-camera. Both groups were evaluated before and after five training sessions. Two groups of students were used as controls (n=8), and were evaluated two times without training. The surgeons were divided in two groups (n=8), one was evaluated in the theatre and the other one in the classroom. RESULTS: The trained groups showed significant improvements in the first exercise (P <0.001) compared with non-trained groups. There were no differences in scores between the groups with different cameras. The surgeons had better scores than students (P <0.001). CONCLUSIONS: The improvements in laparoscopic skills on this simulator with a low-cost camera were not significantly different from those gained using the simulator with the conventional laparoscopic camera. This simulator was able to differentiate between experienced and inexperienced subjects.

[The effects of ileal transposition, gastrojejunal bypass and vertical gastroplasty on the regulation of ingestion in an experimental obesity model associated with diabetes mellitus type 2]. / Efectos de la transposición ileal, el bypass gastroyeyunal y la gastroplastia vertical en la regulación de la ingesta en un modelo experimental de obesidad relacionada con diabetes mellitus tipo 2.

AIM: The continual advances in our knowledge of the pathogenesis and hormonal disorders of morbid obesity lead to new studies in experimental animals and the development of new technical options. The aim is to asses whether ileal transposition can be a good treatment of morbid obesity associated with diabetes mellitus due to the action of intestinal peptide Glp-1 (enteroglucagon) compared to gastric bypass and vertical gastroplasty (VGB). MATERIAL AND METHODS: Trial environment: experimental animals ZDF rats (Zucker Diabetic Fatty rats). Subjects of the study: three groups of 10 animals each one divided as: a) ileal tranposition; b) gastro-jejunal bypass; c) vertical gastroplasty. Parameters to determine: weight loss, levels of glycaemia, enteroglucagon, insulin and ghrelin in blood, one week before the operation as a baseline control, and 15 days after the surgical procedure. RESULTS: Gastrojejunal bypass produces the most significant weight loss. There is a significant decrease in intake in all groups. Hyperinsulinaemia and hyperglycaemia tend to decrease after surgery in all groups, but in ileal transposition there is better control of ketosis. After gastrojejunal bypass and ileal transposition, we observed an increase in GLP-1 levels but were only significant in ileal transposition. CONCLUSIONS: Ileal transposition produces a decrease in plasma glucose and better control of diabetes mellitus, which could benefit patients affected by morbid obesity and poor metabolic control. More studies are needed on other models of obesity. A model of exogenous and reversible obesity could be a good option to study the real benefits of the interventions.

Subfascial endoscopic perforator vein surgery (SEPS) modified technique: subaponeurotic approach without balloon.

Subfascial Endoscopic Perforator Vein Surgery (SEPS) is one of the best procedures and a minimally invasive option for treating chronic venous insufficiency. We explain our experience with SEPS, which has been turned into a subaponeurotic approach without balloon, and assess the possible advantages of this technique. The subaponeurotic space was entered using the Visiport Plus (Autusuture, Tyco Healthcare) video-assisted technique, which shows how the trocar enters through the subcutaneous tissue and superficial aponeurosis of the leg. A blunt retractor was inserted which, together with CO2 insufflation (20 mm Hg), enabled the veins to be dissected. Ligation was performed using tripolar sealing. In no case was a balloon used. There were no incidents such as haemorrhage or subcutaneous emphysema during the procedure. The patients (n = 206) remained in the hospital for less than 24 hours and suffered no post-surgical complications. Active ulcers were cured, with no relapses, in 100% of cases. This is a very effective method for treating advanced chronic insufficiency because it prevents local damage and the rate of post-surgical complications is low. Technically it has more advantages because the fact that it does not use a balloon means that it exerts less pressure on the tissues.

Influence of sleeve gastrectomy on several experimental models of obesity: metabolic and hormonal implications.

BACKGROUND: Ghrelin is an important factor in the regulation of intake. Most ghrelin is synthesized in the gastric fundus, but this is not the only location. The aim of this experimental study was to analyze the effect of sleeve gastrectomy (removing fundus) on the volume of intake in four experimental models and determine how this relates to changes in weight, plasmatic levels of glycemia, ghrelin, GLP-1, and insulin. METHODS: Sleeve gastrectomy was performed on four experimental models: (1) non-obesity; (2) exogenous obesity caused by excessive calorie intake; (3) genetically determined obesity (Zucker rats); and (4) genetically determined obesity and type 2 diabetes mellitus (Zucker diabetic fatty; ZDF rats). Model 2 had a control group on which sleeve gastrectomy was not performed. RESULTS: In the non-obese group, there were few changes after intervention, but in model 2, sleeve gastrectomy led to normalization of weight and endocrine-metabolic parameters that were the same as those for non-obese rats. The exception was for GLP-1, which has an anorexigenic effect: GLP-1 remained higher. In Zucker rats, sleeve gastrectomy had a slight effect on all parameters. In ZDF rats, sleeve gastrectomy led to a reduction in intake and a stabilization of weight. CONCLUSIONS: Sleeve gastrectomy is a very good option for exogenous obesity. Normalization of hormonal levels led us to find an extragastric ghrelin production.