Irreversible Electroporation in Locally Advanced Pancreatic Adenocarcinoma: Aiming to Improve Overall Survival.

Irreversible electroporation (IRE) is a non-thermic ablation therapy which has been proposed for locally advanced pancreatic adenocarcinoma (LAPC) as well as for the local control of other types of tumors (kidney or liver). Its use has been extended in the last few years worldwide. Its advantage over other ablation techniques is that it only affects the lipids bilayer of the cell membrane avoiding vascular damage. Safety and viability have been demonstrated in recent studies. Overall survival seems (OS) to improve when it is combined with chemotherapy compared to chemotherapy with or without radiotherapy. Clinical trials should confirm these encouraging data.

Preoperative intragastric balloon in morbid obesity is unable to decrease early postoperative morbidity of bariatric surgery (sleeve gastrectomy and gastric bypass): a clinical assay.

INTRODUCTION: There are few studies that investigate the usefulness of the preoperative intragastric balloon (IGB). This study will evaluate if pre-surgical weight loss with IGB reduces morbidity and mortality after surgery. METHOD: Prospective randomised study of patients with morbid obesity treated with gastric bypass or vertical gastrectomy, with two arms: the balloon arm (B-arm), where an IGB was inserted within the 6 months before surgery, and the control arm (C-arm). RESULTS: The study included 66 patients: 65.6% women, 69.6% with bypass. Age: 43 years (SD 10.2) B-arm and 42.6 years (SD 9.2) in the C-arm. We found 34.4% therapeutic failures in IGB. The mean body weight loss, %EWL and BMI reduction before surgery was 16.2 kg (SD 9.84) B-arm versus 4.7 (SD 8.70) in the C-arm, 23.6% versus 4.7% (p < 0.001) and 6.04 versus 1 (p < 0.001), respectively. The hospital stay was 7 days (p25-75: 5-8) B-arm and 7 days (p25-75: 5-9) in the C-arm (p = 0.937). Post-surgical morbidity with IGB was 25% versus 29.5% in the C-arm, p = 0.689. The number needed to treat (NNT) to prevent of post-surgical morbidity was 23 patients. The B-arm presented 54.5% moderate-severe post-surgical adverse events (12.5%) versus 82.6% in the C-arm (23.5%), p = 0.111. The cost of placing a balloon was more than 4000 Euros each. CONCLUSIONS: The preoperative balloon does not achieve a reduction in the post-surgical morbidity, nor does it reduce the hospital stay or rate of re-operations. The balloon achieves a higher weight loss result when compared to a diet programme, its added cost must also be given due consideration. TRAIL REGISTRY: This study has been registered on ClinicalTrials.gov with the Identifier: NCT01998243 (November 28, 2013).

Evolución ponderal y de comorbilidades a largo plazo en pacientes intervenidos de cirugía bariátrica / Long-term outcome of weight and comorbidities in patients undergoing bariatric surgery

Objetivo: analizar la evolución de las comorbilidades mayores e índice de masa corporal a largo plazo en pacientes intervenidos de cirugía bariátrica. Material y métodos: estudio retrospectivo transversal sobre una muestra de 38 pacientes intervenidos de cirugía bariátrica entre los años 2008 y 2011. La muestra se compone de 32 mujeres y 6 varones, con una media de edad de 43,52 años. Las intervenciones quirúrgicas realizadas fueron 8 bandas gástricas, 8 gastrectomías verticales y 22 by-pass. Resultados: la DM mejora en un 71,43% de los casos, la HTA en 47,05%, la DL en un 75% y el SAOS en un 70%. Por encima de los 5 años de seguimiento, el 28,9% de los pacientes presenta obesidad tipo I, el 23,7% presenta sobrepeso, el 23,7% obesidad tipo II y el 23,7% obesidad tipo III. Conclusión: la cirugía bariátrica consigue la resolución de comorbilidades asociadas a la obesidad en un porcentaje muy elevado de casos, siendo la más efectiva la dislipemia. La reganancia de peso a largo plazo sigue siendo un problema en estos pacientes así como su seguimiento por encima de los 5 años.

Objective: The aim of this paper is to analyze the outcome of major comorbidities and body mass index during long-term follow-up in patients undergoing bariatric surgery. Material and methods: A retrospective cross-sectional study was conducted on a sample of 28 patients (32 women and 6 men; mean age: 43.52 years) undergoing bariatric surgery between 2008 and 2011. The surgical procedures performed were adjustable gastric banding (n =8), sleeve gastrectomy (n = 8) and gastric bypass (n = 22). Results: Diabetes mellitus was resolved in 73.43% of cases, hypertension in 47.05%, dyslipidemia in 75% and obstructive sleep apnea syndrome in 70%. Five years after surgery, 28.9% of the patients had obesity class I, 23.7% had overweight, 23.7% had obesity class II and 23.7% had obesity class III. Conclusion: bariatric surgery achieves resolution of comorbidities associated with obesity in a high percentage of cases. This effect is more effective in dyslipidemia. Weight regain in the long-term and follow-up beyond five years after surgery are still pending issues.

Pancreatitis autoinmune: diagnóstico diferencial con adenocarcinoma de páncreas / Autoinmune pancreatitis: Differential diagnosis with pancreatic adenocarcinoma

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Endoscopic extraction of adjustable gastric bands after intragastric migration as a complication of bariatric surgery: technique and advice.

BACKGROUND: Surgery has been the method most widely used to manage the extraction of gastric bands with inclusion as a late complication of bariatric surgery; however, surgical extraction entails morbidity and limits future surgical procedures. The development of endoscopic techniques has provided an important means of improving the treatment of this complication, enabling minimally invasive and safe procedures that have a high success rate. METHODS: A retrospective analysis was conducted of patients who had laparoscopic gastric banding complicated by intragastric migration and were treated endoscopically. A technique already described for managing this complication was employed. An MTW Endoskopie Dormia basket for mechanical lithotripsy or a standard 0.0035-in guidewire was placed around the band, and an MTW Endoskopie emergency lithotripter was used to section it, after which the band was extracted with a standard polypectomy snare. Also analyzed were the initial symptoms of patients with this complication, the mean time from surgery to development of the event, the success rate of endoscopic treatment, and complications, Results: A total of 127 patients had undergone gastric banding surgery in our Bariatric Surgery Center; of these, 12 patients (9.4 %) developed a complication such as intragastric migration of the band. Weight gain and pain were the main symptoms in 11 patients (92 %), and the mean time to the development of symptoms was 51.3 months. A single endoscopic treatment was successful in 7 of 9 patients (78 %). Only 1 complication, involving ventilation during anesthesia, occurred; no other adverse events were recorded. CONCLUSIONS: The endoscopic extraction of bands with inclusion is feasible and can be performed easily and successfully. The procedure is available in all hospitals and has a low incidence of related complications, so that unnecessary surgical procedures can be avoided.

[Surgical treatment of sclerosing encapsulating peritonitis]. / Tratamiento quirúrgico de la peritonitis esclerosante.

OBJECTIVES: Sclerosing encapsulating peritonitis (SEP) or abdominal cocoon is a rare disease characterized by the formation of a fibrocollagenous membrane that wraps around the loops of the small bowel, producing obstruction. We present the results of the surgical treatment of this disease in three patients with chronic renal failure who developed SEP during the course of peritoneal dialysis (PD) and provide a literature review on the subject aimed at the general surgeon. PATIENTS AND METHOD: In our area, the PD program treated 150 patients in 14 years, with seven cases of suspected SEP. In three patients, exploratory laparotomy was required. Clinical data, diagnostic imaging tests, type of surgery, immediate postoperative course, and status of the patient during subsequent follow-up are described. RESULTS: In one of the three patients, bowel obstruction led to perforation requiring resection with anastomosis; the postoperative course was complicated and the patient died. In the remaining two patients, elective surgery was performed with the aim of removing the capsule enclosing the intestinal loops. In both patients the immediate postoperative course was favorable, although recurrence of intestinal encapsulation occurred in one patient. CONCLUSIONS: The success of surgery in this disease is determined by the technique used. The correct technique consists of freeing the adhesions and extirpating of the capsule as far as possible. Perforation, as well as resection and intestinal anastomosis, significantly increase mortality.

Tratamiento quirúrgico de la peritonitis esclerosante / Surgical treatment of sclerosing encapsulating peritonitis

Objetivos. La peritonitis esclerosante encapsulante (PES) o cocoon abdominal es una rara enfermedad que se caracteriza por la formación de una membrana fibrocolagenosa que envuelve las asas de intestino delgado y llega a producir cuadros de obstrucción intestinal. En este artículo presentamos los resultados del tratamiento quirúrgico en 3 pacientes con insuficiencia renal crónica que desarrollaron una PES en el curso de la diálisis peritoneal (DP) y se realiza asimismo una revisión de la literatura para acercar esta entidad al cirujano general. Pacientes y método. En nuestra área, el programa de DP ha tratado a 150 pacientes en 14 años, y se ha encontrado 7 casos de sospecha de PES. En 3 pacientes fue preciso realizar una laparotomía exploradora. Se describen los datos clínicos, las pruebas diagnósticas de imagen, el tipo de cirugía, la evolución en el postoperatorio inmediato y la situación del paciente en revisiones posteriores. Resultados. En 1 de los 3 pacientes, una obstrucción intestinal culminó en una perforación que obligó a una resección con anastomosis; la evolución postoperatoria fue muy complicada y desembocó en muerte. En los otros 2 casos, la intervención se realizó de manera electiva con el objetivo de extirpar la cápsula que envolvía las asas intestinales; la evolución postoperatoria inmediata en ambos fue favorable, aunque en uno de ellos terminó por recidivar la encapsulación intestinal. Conclusiones. El éxito de la intervención quirúrgica en esta afección está determinado por la técnica utilizada y el momento de la cirugía. La técnica correcta consiste en la liberación de las adherencias y extirpación de la cápsula en la medida de lo posible. Una complicación del cuadro obstructivo o la realización de resección y anastomosis intestinal aumentan la mortalidad de manera significativa (AU)

Objectives. Sclerosing encapsulating peritonitis (SEP) or abdominal cocoon is a rare disease characterized by the formation of a fibrocollagenous membrane that wraps around the loops of the small bowel, producing obstruction. We present the results of the surgical treatment of this disease in three patients with chronic renal failure who developed SEP during the course of peritoneal dialysis (PD) and provide a literature review on the subject aimed at the general surgeon. Patients and method. In our area, the PD program treated 150 patients in 14 years, with seven cases of suspected SEP. In three patients, exploratory laparotomy was required. Clinical data, diagnostic imaging tests, type of surgery, immediate postoperative course, and status of the patient during subsequent follow-up are described. Results. In one of the three patients, bowel obstruction led to perforation requiring resection with anastomosis; the postoperative course was complicated and the patient died. In the remaining two patients, elective surgery was performed with the aim of removing the capsule enclosing the intestinal loops. In both patients the immediate postoperative course was favorable, although recurrence of intestinal encapsulation occurred in one patient. Conclusions. The success of surgery in this disease is determined by the technique used. The correct technique consists of freeing the adhesions and extirpating of the capsule as far as possible. Perforation, as well as resection and intestinal anastomosis, significantly increase mortality (AU)