Conversion of Adjustable Gastric Banding to Roux-en-Y Gastric Bypass in One or Two Steps: What Is the Best Approach? Analysis of a Multicenter Database Concerning 832 Patients.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is often the preferred conversion procedure for laparoscopic adjustable gastric banding (LAGB) poor responders. However, there is controversy whether it is better to convert in one or two stages. This study aims to compare the outcomes of one and two-stage conversions of LAGB to RYGB. METHODS: Retrospective review of a multicenter prospectively collected database. Data on conversion in one and two stages was compared. RESULTS: Eight hundred thirty-two patients underwent LAGB conversion to RYGB in seven specialized bariatric centers. Six hundred seventy-three (81%) were converted in one-stage. Patients in the two-stage group were more likely to have experienced technical complications, such as slippage or erosions (86% vs. 37%, p = 0.0001) and to have had a higher body mass index (BMI) (41.6 vs. 39.9 Kg/m2, p = 0.005). There were no differences in postoperative complications and mortality rates between the one-stage and two-stage groups (13.5% vs. 10.8%, and 0.7% vs. 0.0% respectively, p = ns). Mean final BMI and %total weight loss (%TWL) for the one-stage and the two-stage groups were 31.6 vs. 32.4 Kg/m2 (p = ns) and 30.4 vs. 26.8 (p = 0.017) after a mean follow-up of 33 months. Follow-up at 1, 3, and 5 years was 98%, 75%, and 54%, respectively. CONCLUSIONS: One-stage conversion of LAGB to RYGB is safe and effective. Two-stage conversion carries low morbidity and mortality in the case of band slippage, erosion, or higher BMI patients. These findings suggest the importance of patient selection when choosing the appropriate conversion approach.

Decision-making in end of life care. Are we really playing together in the same team? / Decisiones en los cuidados al final de la vida. ¿Jugamos en el mismo equipo?

BACKGROUND: Limitation of life-sustaining treatment is increasingly common in critical care units, and controlled donation after circulatory death is starting to be included as an option within patient care plans. Lack of knowledge and misunderstandings can place a barrier between healthcare professionals. OBJECTIVE: To determine the perceptions, knowledge and attitudes of physicians and nurses working in intensive care units regarding Limitation of life-sustaining treatment and controlled donation after circulatory death. DESIGN, SETTINGS AND PARTICIPANTS: Cross-sectional study carried out in 13 Spanish hospitals by means of an ad hoc questionnaire. METHODS: Contingency tables, Pearson's chi-squared test, Student's t-test and the Mann-Whitney u-test were used to carry out descriptive, bivariate and multivariate statistical analyses of responses. RESULTS: Although Limitation of life-sustaining treatment is a widespread practice, the survey revealed that nurses feel excluded from the development of protocols and the decision-making process, whilst the perception of physicians is that they have greater knowledge of the topic, and decisions are reached in consensus. CONCLUSIONS: Multi-disciplinary training programmes can help critical healthcare providers to work together with greater coordination, thus benefitting patients and their next of kin by providing excellent end-of-life care.

[Barriers and motivations of nurses for conducting research in Intensive Care Units and Emergency Medical Service]. / Barreras y motivaciones de los profesionales de enfermería para la utilización de la investigación en Unidades de Cuidados Intensivos y en el Servicio de Emergencias Médicas.

BACKGROUND: The implementation of evidence based practice is essential in clinical practice. However, it is still a challenge in critical care patients. AIM: To identify the barriers for conducting research that nursing professionals perceive in intensive care and medical emergency departments, as well as to investigate the areas of interest and motivations to carry out research projects. METHOD: Cross-sectional and multicentre study carried out in 4 intensive care units and in one Medical Emergency Department emergency pre-hospital carein Catalonia on 2014. The instrument used was The Barriers to Research Utilization Scale which had been previously validated into Spanish. A descriptive and bivariate analysis was performed. A statistical significance of P<.05 was assumed. RESULTS: One hundred seventy-two questionnaires were obtained (69.9% response). Of the total, 135 were from critical care, 27 to pre-hospital care, and 10 from both. Just over half (57.3%) had research experience, although 44.4% had related training. The questionnaire dimension considered most relevant was organisational characteristics. The most important barriers were: there is not enough time at work [3.11 (SD 1.21)], physicians do not collaborate in its implementation [2.99 (SD 1.22)], and nurses are isolated with respect to other professionals [2.86 (SD 1.32)]. Significant differences were observed in the barriers according to research experience and work place. The main motivation was to be updated in critical patient care. CONCLUSIONS: The main barriers perceived are related to the organisation. There are differences in the barriers according to research experience and work place.

[Factors associated with compliance to the semi-recumbent position in the patient on mechanical ventilation: CAPCRI-Q questionnaire]. / Factores relacionados con el cumplimiento de la posición semiincorporada en el paciente con ventilación mecánica según los profesionales: cuestionario CAPCRI-Q.

AIM: To create a questionnaire (CAPCRI-Q) to determine the factors associated with the compliance of the semi-recumbent position in patients under mechanical ventilation. METHODS: A closed questionnaire was created using a literature review and clinical practice. The initial version consisted of 61 items placed into 5 categories: patient factors, team and professionals factors, activity, educational and training factors, and equipment and resources. A Delphi method was used to prepare the questionnaire. Comprehension, relevance and importance of each item were evaluated, as well as the recommendations of experts. A qualitative pilot test with 9 healthcare professionals was performed, followed by a quantitative pilot test with 67 nurses from 6 intensive care units to test the internal consistency of the instrument. RESULTS: Three rounds with 15 experts were required to reach a consensus. The final version of the questionnaire consisted of 36 items enclosed in the same categories as the initial version. The internal consistency analysis showed values greater than 0.800 for each independent item, each category, and for the global questionnaire (0.873; 95%CI: 0.825-0.913). The analysis of the nurses' responses emphasised the importance of the patient factors, as well as organisational and infra-structural factors, for the compliance of the recommendation. CONCLUSIONS: The questionnaire created is reliable and appears to have content validity. The most influential factors for compliance are those related to the patient and the internal organisation. The results of the questionnaire can be used to evaluate the factors influencing the compliance and to establish improvement strategies.

Evaluation of head-of-bed elevation compliance in critically ill patients under mechanical ventilation in a polyvalent intensive care unit.

OBJECTIVES: To evaluate head-of-bed elevation (HOBE) compliance in mechanically ventilated (MV) patients during different time periods, in order to identify factors that may influence compliance and to compare direct-observation compliance with checklist-reported compliance. DESIGN AND SETTING: A prospective observational study was carried out in a polyvalent Intensive Care Unit. PATIENTS: All consecutive patients with MV and no contraindication for semi-recumbency were studied. INTERVENTION AND VARIABLES: HOBE was observed during four periods of one month each for one year, the first period being blinded. HOBE was measured with an electronic device three times daily. Main variables were HOBE, type of airway device, type of bed, nursing shift, day of the week and checklist-reported compliance. No patient characteristics were collected. RESULTS: During the four periods, 2639 observations were collected. Global HOBE compliance was 24.0%, and the median angle head-of-bed elevation (M-HOBE) was 24.0° (IQR 18.8-30.0). HOBE compliance and M-HOBE by periods were as follows: blinded period: 13.8% and 21.1° (IQR 16.3-24.4); period 1: 25.5% and 24.3° (IQR 18.8-30.2); period 2: 22.7% and 24.4° (IQR 18.9-29.6); and period 3: 31.4% and 26.7° (IQR 21.3-32.6) (p<0.001). An overestimation of 50-60% was found when comparing self-reported compliance using a checklist versus direct-observation compliance (p<0.001). Multivariate logistic regression analysis found the presence of an endotracheal tube (ET) and bed without HOBE measuring device to be independently associated to greater compliance (p<0.05). CONCLUSIONS: Although compliance increased significantly during the study period, it was still not optimal. Checklist-reported compliance significantly overestimated HOBE compliance. The presence of an ET and a bed without HOBE measuring device was associated to greater compliance.

Evaluación del cumplimiento de la elevación de la cabecera de la cama en pacientes críticamente enfermos sometidos a ventilación mecánica en una unidad de cuidados intensivos polivalente / Evaluation of the compliance with the elevation of the head of the bed in critically ill patients undergoing mechanical ventilation in a polyvalent intensive care unit

Objetivos. Evaluar el cumplimiento de la elevación de la cabecera de la cama (ECC) en pacientes atendidos con ventilación mecánica (MV) durante distintos periodos de tiempo con el fin de identificar losfactores que pueden influir sobre el cumplimientoy comparar el cumplimiento evaluado mediante observación directa con el cumplimiento evaluado mediante lista de verificación...

Vagal blocking improves glycemic control and elevated blood pressure in obese subjects with type 2 diabetes mellitus.

BACKGROUND: An active device that downregulates abdominal vagal signalling has resulted in significant weight loss in feasibility studies. OBJECTIVE: To prospectively evaluate the effect of intermittent vagal blocking (VBLOC) on weight loss, glycemic control, and blood pressure (BP) in obese subjects with DM2. METHODS: Twenty-eight subjects were implanted with a VBLOC device (Maestro Rechargeable System) at 5 centers in an open-label study. Effects on weight loss, HbA1c, fasting blood glucose, and BP were evaluated at 1 week to 12 months. RESULTS: 26 subjects (17 females/9 males, 51 ± 2 years, BMI 37 ± 1 kg/m(2), mean ± SEM) completed 12 months followup. One serious adverse event (pain at implant site) was easily resolved. At 1 week and 12 months, mean excess weight loss percentages (% EWL) were 9 ± 1% and 25 ± 4% (P < 0.0001), and HbA1c declined by 0.3 ± 0.1% and 1.0 ± 0.2% (P = 0.02, baseline 7.8 ± 0.2%). In DM2 subjects with elevated BP (n = 15), mean arterial pressure reduced by 7 ± 3 mmHg and 8 ± 3 mmHg (P = 0.04, baseline 100 ± 2 mmHg) at 1 week and 12 months. All subjects MAP decreased by 3 ± 2 mmHg (baseline 95 ± 2 mmHg) at 12 months. CONCLUSIONS: VBLOC was safe in obese DM2 subjects and associated with meaningful weight loss, early and sustained improvements in HbA1c, and reductions in BP in hypertensive DM2 subjects. This trial is registered with ClinicalTrials.gov NCT00555958.

Intra-abdominal vagal blocking (VBLOC therapy): clinical results with a new implantable medical device.

BACKGROUND: A new medical device uses high-frequency electrical algorithms to create intermittent vagal blocking (VBLOC therapy). The aim is to assess the effects of vagal blocking on excess weight loss (EWL), safety, dietary intake, and vagal function. METHODS: An open-label, 3-center study was conducted in obese subjects (body mass index [BMI] 35-50 kg/m(2)). Electrodes were implanted laparoscopically on both vagi near the esophagogastric junction to provide electrical block. Patients were followed for 6 months for body weight, safety, electrocardiogram, dietary intake, satiation, satiety, and plasma pancreatic polypeptide (PP) response to sham feeding. To specifically assess device effects alone, no diet or exercise programs were instituted. RESULTS: Thirty-one patients (mean BMI, 41.2 +/- 1.4 kg/m(2)) received the device. Mean EWL at 4 and 12 weeks and 6 months after implant was 7.5%, 11.6%, and 14.2%, respectively (all P < .001); 25% of patients lost >25% EWL at 6 months (maximum, 36.8%). There were no deaths or device-related serious adverse events (AEs). Calorie intake decreased by >30% at 4 and 12 weeks and 6 months (all P 25 pg/mL (P = .02). Three patients had serious AEs that required brief hospitalization, 1 each for lower respiratory tract, subcutaneous implant site seroma, and Clostridium difficile diarrhea. CONCLUSIONS: Intermittent, intra-abdominal vagal blocking is associated with significant EWL and a desirable safety profile.

Laparoscopic adrenalectomy: lessons learned from an initial series of 100 patients.

BACKGROUND: Laparoscopic adrenalectomy is considered the gold standard for the surgical treatment of adrenal disorders in most centers. This study analyzes the authors' experience using the lateral intraperitoneal approach with the first 100 patients. In addition to analyzing the authors' experience, this article aims to contrast it with some published series as an internal quality control. METHODS: In a 10-year period, 138 laparoscopic adrenalectomies were performed for 100 patients. Demographics, surgical results, complications, and long-term outcomes were analyzed. RESULTS: The participants comprised 69 women and 31 men with a mean age of 37 years. The procedures included 24 right, 38 left, and 38 bilateral adrenalectomies. The indications for surgery were Cushing's disease for 33 patients, pheochromocytoma (4 bilateral) for 23 patients, Cushing's syndrome for 18 patients, Conn's syndrome for 16 patients, and incidentaloma for 10 patients. Five procedures were converted to open surgery. Two patients with pheochromocytoma required intraoperative blood transfusion. The mean operative time was 174 min for unilateral adrenalectomies and 302 min for the bilateral procedures. The mean hospital stay was 5 days. Surgical morbidity included an abdominal wall hematoma, a small pneumothorax, and intraabominal bleeding in one patient that required reexploration. There were three operative mortalities not related to the technique. The long-term results showed control of hypercortisolism in all the patients with Cushing's disease and 82% of the patients with pheochromocytoma. Most of the patients with Conn's syndrome (91.4%) became normotensive after surgery. CONCLUSIONS: Laparoscopic adrenalectomy is safe and effective. The complications are mild, and mortality is related more to the patient's condition than to the surgical technique.

Laparoscopic Heller myotomy for classic achalasia: results of our initial series of 20 patients.

BACKGROUND: The aim of this study was to review our results in the surgical management of achalasia by laparoscopic esophageal cardiomyotomy and partial fundoplication. METHODS: The patient population was comprised of a consecutive series of 20 patients with classic achalasia who underwent laparoscopic cardiomyotomy and partial fundoplication. Clinical, radiological, and physiological characteristics were analyzed prospectively, with an emphasis on the outcome and complications. RESULTS: There were 12 women and eight men; their mean age was 37 years. Four intraoperative complications occurred-two mucosal perforations that were resolved laparoscopically and two cases of pneumothorax. The median hospital stay was 4 days (range, 2-14) and the median time to start oral feeding was 3 days (range, 1-7). After a median follow-up of 14 months (range, 2-83), 16 patients were asymptomatic and four had mild heartburn and/or dysphagia. All patients gained weight (median, 8.0 kg; range, 1-23). We observed a median postoperative decrease in esophageal diameter of 1.6 cm (range, 0.2-2.9). Fifteen patients were subjected to physiological esophageal studies; the results showed that power esophageal sphincter pressure had decreased from 32 (range, 15-60) to 12 mmHg (range, 6-25). The median DeMeester score was 14.5 (range, 0.9-194). The median esophageal acid exposure was 3% (range 0-34.6). CONCLUSIONS: Our initial experience with the laparoscopic management of classic achalasia yielded satisfactory clinical, radiological, and physiological results.

Laparoscopic drainage of pancreatic pseudocysts.

BACKGROUND: Laparoscopic drainage of pancreatic pseudocysts (PPs) has been used in selected cases. The aim of this study is to analyze our results with the laparoscopic technique and to compare them with those of a cohort of patients treated by open surgery during the same time period. PATIENTS AND METHODS: Ten patients underwent laparoscopic drainage of PPs during a 7-year period [laparoscopic group (LG)]. The type of drainage was chosen according to the size and location of the PP. Demography, surgical details, results, and complications were analyzed and contrasted with those of 6 patients who underwent open drainage [open group (OG)]. RESULTS: All patients presented with mature PPs developed after a documented episode of acute pancreatitis. Mean age of the LG was 42 years (six males and four females). In the OG, mean age was 36 years (five males and one female). Etiology of the pancreatitis was alcoholic in eight patients, biliary in five, toxic in two, and associated with systemic lupus erythematous in one. Laparoscopic procedures included Roux-en-Y cystojejunostomy in four patients, extraluminal cystogastrostomy in four, and intraluminal cystogastrostomy in two. There were no conversions. In the OG, cystogastrostomy was performed in three patients and Roux-en-Y cystojejunostomy in three. One patient in the LG developed upper gastrointestinal bleeding the day after surgery that resolved uneventfully, one patient presented a postoperative abscess that required open drainage, and one patient presented a residual pseudocyst that was treated by endoscopy. Morbidity in the OG included a small bowel obstruction secondary to an internal hernia that required reoperation, pneumonia, and a residual pseudocyst that was treated conservatively in one patient each. At a median follow-up of 22 months (range, 1-72) all patients were asymptomatic with no evidence of recurrent disease by computed tomography scan. CONCLUSION: Laparoscopic drainage of PPs is feasible, safe, and effective. Results are similar to those obtained using the open technique.

Adrenal incidentaloma.

Adrenal incidentalomas are tumors that are serendipitously found by radiological examination. The incidence of adrenal incidentalomas in patients undergoing abdominal CT approaches 1 %. The evaluation of a patient with an adrenal incidentaloma requires, in addition to a clinical history and physical examination, a focused biochemical evaluation to investigate if there is excess secretion of catecholamines, glucocorticoids, or aldosterone. Some tumors have specific features on imaging that identify them as benign or malignant. The recommendations for management of adrenal incidentalomas include resection of all functioning tumors regardless of size, preferably by the laparoscopic approach. Large, non-functional tumors should also be removed. Biochemical and radiological surveillance is recommended for at least one year, if a tumor is left in place.

Laparoscopic approach to fever of unknown origin.

BACKGROUND: Fever of unknown origin (FUO) is difficult to diagnose. Laparotomy is needed to establish the etiologic diagnosis in some patients. The aim of this study was to analyze the feasibility, safety, and success rate of a protocolized laparoscopy in patients with FUO. METHODS: An extensive clinical evaluation was performed before surgery. Laparoscopy included inspection of the abdominal cavity, wedge and tru-cut liver biopsies, lymph node biopsy, splenectomy, and bone marrow biopsy. Histologic analysis, permanent section analysis, and cultures were obtained. RESULTS: The study involved 15 patients with a mean age of 43.6 +/- 14.5 years. The mean operative time was 122 +/- 60 min. Minor complications occurred in 9% of the patients. One patient bled after surgery and underwent reoperation. There was no operative mortality. An etiologic diagnosis was made in 66% of the patients, and laparoscopy helped to rule out intraabdominal pathology in four additional patients, giving a total success rate of 93%. CONCLUSION: Protocolized laparoscopy in patients with FUO is safe, feasible, and accurate.

Accuracy of sentinel lymph node in papillary thyroid carcinoma.

BACKGROUND: The sentinel lymph node has been used in several tumors. The aim of this study was to analyze the accuracy of the sentinel node in papillary thyroid carcinoma. METHODS: A series of 22 patients with papillary thyroid carcinoma were included. Approximately 0.5 cc of isosulfan blue dye was injected at operation to trace the sentinel node. Lymph node dissection of the ipsilateral central compartment and extensive sampling of the jugular compartment were performed in addition to sentinel node resection. Surgical specimens were stained with hematoxylin-eosin, and negative sentinel nodes were subsequently stained with immunohistochemistry for cytokeratin-7. RESULTS: Mean age was 37 +/- 14 years. Twenty patients were women, and 2 were men. Mean tumor size was 2.5 +/- 1 cm. A sentinel lymph node was found in 20 patients. With use of hematoxylin-eosin, metastases were identified in 12/20 sentinel nodes (60%). Eleven patients with positive sentinel nodes presented additional lymph node metastases: 9 in the central compartment, 1 in the jugular compartment, and 1 in both compartments. Two patients with negative sentinel nodes had lymph node metastases elsewhere. When sentinel nodes were processed by immunohistochemistry, accuracy increased to 100%. CONCLUSIONS: Sentinel node is highly accurate for diagnosing metastases in papillary thyroid carcinoma.

Persistent hypercalcitoninemia in patients with medullary thyroid cancer: a therapeutic approach based on selective venous sampling for calcitonin.

BACKGROUND: Persistent or recurrent medullary thyroid carcinoma (MTC) can be cured by microdissection of residual metastatic lymph nodes in the neck. Selective venous sampling can be used for localization. The aim of this study is to prospectively analyze our results with a therapeutic approach based on venous sampling, in patients with hyperthyrocalcitoninemia after thyroidectomy for MTC. METHODS: Selective venous sampling for determination of stimulated calcitonin was obtained in all patients after performing a complete laboratory and imaging workup. Patients with a gradient between the suprahepatic vein and the superior vena cava underwent unilateral or bilateral extensive lymph node dissection. We used the gradient between the right and left jugular veins to decide which side of the neck to operate. Calcitonin levels were obtained after surgery and a pentagastrin test was performed one year later if basal levels remained normal. RESULTS: Mean age of the five women with a neck gradient in the selective venous sampling who underwent neck exploration was 45 years. In all patients metastatic lymph nodes were found at the site suggested by the study. Mean positive/resected lymph nodes were 5/20. Postoperative basal and stimulated levels of calcitonin became normal in two patients at one year of follow up. CONCLUSION: Selective venous sampling is useful to localize recurrent MTC.

Histologic diagnosis of primary hyperparathyroidism: a concordance analysis between three pathologists.

Primary hyperparathyroidism (HPT) is caused by a parathyroid adenoma, hyperplasia or carcinoma. Difficulties for the histologic diagnosis of abnormal parathyroid tissue are widely recognized. The aim of the study was to evaluate the reproducibility of the morphologic criteria through a concordance study among three pathologists. Representative slides of 40 patients with biochemically primary HPT stained with hematoxylin and eosin were blindly reviewed by three pathologists. Each pathologist established the diagnosis of adenoma or hyperplasia and assessed the presence of fat cells, a rim of normal tissue, a fibrous capsule, the number of cellular types, the lobular pattern, and the characteristics of the blood vessel's wall. A concordance analysis was then performed. Mean age of the group was 55 +/- 14 yr, 7 were males and 33 females. The concordance analysis among the three pathologists for the differential diagnosis between adenoma and hyperplasia, showed a Kappa index of 0.5. Kappa index for the presence of fat cells was 0.56, for the presence of a rim of normal tissue 0.47, and for the number of cellular types 0.29. The concordance for the differential diagnosis between parathyroid adenoma and hyperplasia in this study was low.

[Antibiotic therapy in secondary peritonitis: towards a definition of its optimal duration]. / Antibioticoterapia en peritonitis secundaria: hacia una definición de su duración óptima.

BACKGROUND: The optimal time period of antibiotic treatment in secondary peritonitis is still unknown. AIM: To prospectively evaluate: 1) The preferred time period of antibiotic treatment in secondary peritonitis by means of a survey applied to a sample of surgeons, and 2) The outcome of a series of patients with secondary peritonitis in whom the length of antibiotic treatment was based on clinical and laboratory indicators. PATIENTS AND METHODS: A survey presenting the case of a patient with acute appendicitis and secondary peritonitis was applied to 100 Mexican surgeons. The optimal length of antibiotic treatment in that particular patient was asked. Results were tabulated and analyzed. Subsequently, 35 patients with secondary peritonitis were prospectively evaluated. Antibiotics were discontinued when fever relapsed and the white blood count normalized. Clinical characteristics, diagnosis, surgical treatment and outcome were analyzed. Recurrence of sepsis was investigated as the main outcome variable. RESULTS: The survey revealed that 96% surgeons recommended antibiotic treatment for a period longer than one week. In our study group median age was 33 years, 21 were male and 14 female. All patients had a surgical abdominal condition associated to secondary peritonitis. Median period of antibiotic treatment was 3 days. In a follow-up of one month there was no persistent or recurrent sepsis in any patient. CONCLUSIONS: This information may impact in determining the total length of antibiotic therapy if our results are reproduced in studies with more patients.