Enhanced recovery after bariatric surgery (ERABS) protocol implementation in a laparoscopic center.

INTRODUCTION: Enhanced recovery after bariatric surgery (ERABS) protocols consist of a combination of several preoperative, intraoperative and postoperative methods for the management of the surgical patient. The aim of this study was to evaluate the impact of the ERABS protocol on length of hospital stay (LOS) and postoperative complications. MATERIAL AND METHODS: Retrospective study of patients who underwent elective Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between 2015 and 2018. From 2015 to 2017, patients received traditional management (pre-ERABS group). Those who underwent surgery during 2018 were managed with our ERABS protocol (ERABS group). The primary outcome was LOS. Secondary outcomes were readmission rate and 30-day postoperative complications. RESULTS: A total of 200 patients who received RYGB and SG between 2015 and 2018 were retrospectively analyzed; we included 120 patients in the pre-ERABS group and 80 in the ERABS group. The median LOS was four days [2-49] in the pre-ERABS group, as compared with two days [1-26] in the ERABS group (p < .0001). No significant differences were found in postoperative complication rates, readmissions, and mortality. CONCLUSION: Implementation of the ERABS protocol is related to a better postoperative recovery and allows an early discharge without increasing postoperative complications, readmissions or mortality.

Real-time fluorescence image-guided gastrointestinal oncologic surgery: Towards a new era.

Technological improvements are crucial in the evolution of surgery. Real-time fluorescence-guided surgery (FGS) has spread worldwide, mainly because of its usefulness during the intraoperative decision-making processes. The success of any gastrointestinal oncologic resection is based on the anatomical identification of the primary tumor and its regional lymph nodes. FGS allows also to evaluate the blood perfusion at the gastrointestinal stumps after colorectal or esophageal resections. Therefore, a reduction on the anastomotic leak rates has been postulated as one of the foreseeable benefits provided by the use of FGS in these procedures. Although the use of fluorescence in lymph node detection was initially described in breast cancer surgery, the technique is currently applied in gastric or splenic flexure cancers, as they both present complex and variable lymphatic drainages. FGS allows also to perform intraoperative lymphograms or sentinel lymph node biopsies. New applications of FGS are being developed to assist in the detection of peritoneal metastases or in the evaluation of the tumor resection margins. The present review aims to provide a general overview of the current status of real-time FGS in gastrointestinal oncologic surgery. We put a special focus on the different applications of FGS, discussing the main findings and limitations found in the contemporary literature and also the promising near future applications.

Realización de procedimientos bariátricos por residentes de cirugía general. ¿Compromete la efectividad de la intervención y los resultados postoperatorios? / Surgical resident training program to perform laparoscopic bariatric procedures: Are safety and postoperative outcomes compromised?

Introducción: El objetivo de este estudio es evaluar los resultados de nuestro programa de formación de residentes para la realización de bypass gástrico laparoscópico en Y de Roux (BGLYR). Material y métodos: Estudio retrospectivo en el que se incluyeron pacientes a los que se les realizó un BGLYR en nuestro centro durante el período comprendido entre enero de 2014 y diciembre de 2018. Los residentes de cuarto año de nuestro centro realizaron progresivamente distintos pasos de la intervención siempre tutorizados por cirujanos bariátricos expertos (CBE). Se compararon los resultados obtenidos en las intervenciones en las que el residente ha realizado algún paso o la totalidad del BGLYR (grupo I), con aquellas realizadas en su totalidad por CBE (grupo II). Se analizaron datos demográficos de los pacientes, comorbilidades, resultados intraoperatorios, morbimortalidad postoperatoria y resultados al año de la intervención. Resultados: Se incluyeron 208 pacientes en el estudio, 67 en el grupo I y 141 en el grupo II. Ambos grupos fueron comparables. No se objetivaron diferencias significativas en el tiempo operatorio (166,45min en el grupo I vs. 156,69min en el grupo II; p=0,156). La conversión a cirugía abierta, la estancia hospitalaria y la morbilidad postoperatoria tampoco presentaron diferencias estadísticamente significativas. No hubo mortalidad durante este período. Los resultados tras el primer año fueron similares en ambos grupos. Conclusiones: La realización de distintos procedimientos del BGLYR por residentes es segura y no compromete la efectividad ni los resultados postoperatorios, siempre que se realice bajo la supervisión de un CBE. (AU)

Introduction: Laparoscopic bariatric procedures such as laparoscopic Roux-en-Y gastric bypass (LRYGB) are technically demanding and require a long learning curve. Little is known about whether surgical resident (SR) training programs to perform these procedures are safe and feasible. This study aims to evaluate the results of our SR training program to perform LRYGB. Methods: We designed a retrospective study including patients with LRYGB between January 2014 and December 2018, comparing SR results to experienced bariatric surgeons (EBS). In our country, SR have a five-year surgical formative period, and in the fourth year they are trained for 6 months in our bariatric surgery unit, from January to June. In the beginning, they perform different steps of this procedure, to finally complete an LRYGB. We collected demographic data, comorbidities, intraoperative outcomes, and postoperative complications and outcomes after a one-year follow-up. Results: Two hundred and eight patients were eligible for inclusion: 67 in group I (SR), and 141 in group II (EBS). Both groups were comparable. There was no statistically significant difference in operating time (166.45min in group I vs. 156.69min in group II; P=0.156). Conversion to open surgery, hospital stay, postoperative complications, and short-term outcomes had no significant differences between the two groups. There was no mortality registered during this period. Conclusion: Implementation of LRYGB stepwise learning as part of an SR training program is safe, and results are comparable to EBS, without loss of efficiency. Therefore, it is feasible to train SR in bariatric surgery under EBS supervision. (AU)

Feasibility of at-home continuous overnight pulse oximetry for obstructive sleep apnea screening in bariatric surgery candidates.

PURPOSE: Screening for obstructive sleep apnea (OSA) is recommended in patients scheduled for bariatric surgery because continuous positive airway pressure (CPAP) therapy in patients with moderate-to-severe OSA reduces postoperative complications. However, cardiorespiratory polygraphy (CRP) and polysomnography (PSG) are expensive and time-consuming. The present study aimed to assess whether at-home continuous overnight pulse oximetry can be used to diagnose moderate-to-severe OSA in patients scheduled for bariatric surgery. METHODS: In this prospective observational study, we enrolled consecutive patients scheduled for bariatric surgery. Patients with no prior OSA diagnosis were evaluated using the ESS, SBQ, and preoperative at-home CRP. Correlations were calculated between AHI and oximetry parameters. For each oximetry parameter, a receiver-operating characteristic (ROC) curve was generated to identify optimal cut-off values for diagnosing moderate-to-severe OSA. RESULTS: In total, 117 patients were included. The oxygen desaturation index was the most correlated oximetry parameter; the optimal cut-off value for diagnosing moderate-to-severe OSA was 23.9. The sensitivity and specificity were 80 and 92%, respectively. The area under the ROC curve was 0.935. CONCLUSIONS: At-home continuous overnight pulse oximetry could be used to screen moderate-to-severe OSA in patients scheduled for bariatric surgery because it would allow clinicians to implement early CPAP therapy and avoid preoperative PSG or CRP.

Perforación intestinal en paciente COVID-19 en tratamiento con tocilizumab y corticoides. A propósito de un caso / Intestinal perforation in patient with COVID-19 infection treated with tocilizumab and corticosteroids. Report of a clinical case

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Simultaneous Complex Incisional Hernia Repair and Bariatric Surgery for Obese Patients: a Case Series of a Single-Center Early Experience.

Purpose: Obesity is associated with recurrence of complex incisional hernia repair (CIHR). Bariatric procedure during CIHR can improve recurrence rates without increasing morbidity. This study aimed to describe our results after CIHR in patients with obesity, in which a simultaneous bariatric procedure was performed. Materials and Methods: We performed a retrospective observational study including patients who underwent surgery between January 2014 and December 2018, with a complex incisional hernia (CIH) according to the Slater classification and body mass index (BMI) ≥35. CIHR was the main indication for surgery. We collected demographic data, comorbidities, CIH classification according to the European Hernia Society, type of bariatric procedure, postoperative morbidity using the Dindo-Clavien classification, and short-term results. Computed tomography (CT) is performed preoperatively. Results: Ten patients were included in the study (7 women). The mean BMI was 43.63±4.91 kg/m2. The size of the abdominal wall defect on CT was 8.86±3.93 cm. According to the European Hernia Society classification, all CIHs were W2 or higher. Prosthetic repair of the CIH was selected. Onlay, sublay, preperitoneal, and inlay mesh placement were performed twice each, as well as one modified component separation technique and one transversus abdominis release. Gastric leak after sleeve gastrectomy was the only major complication. Short-term outcomes included one recurrence, and % total weight loss was 24.04±8.03 after 1-year follow-up. Conclusion: The association of bariatric procedures during CIHR seems to be feasible, safe, and could be an option for surgical treatment in selected patients.

Surgical resident training program to perform laparoscopic bariatric procedures: Are safety and postoperative outcomes compromised? / Realización de procedimientos bariátricos por residentes de cirugía general. ¿Compromete la efectividad de la intervención y los resultados postoperatorios?

INTRODUCTION: Laparoscopic bariatric procedures such as laparoscopic Roux-en-Y gastric bypass (LRYGB) are technically demanding and require a long learning curve. Little is known about whether surgical resident (SR) training programs to perform these procedures are safe and feasible. This study aims to evaluate the results of our SR training program to perform LRYGB. METHODS: We designed a retrospective study including patients with LRYGB between January 2014 and December 2018, comparing SR results to experienced bariatric surgeons (EBS). In our country, SR have a five-year surgical formative period, and in the fourth year they are trained for 6 months in our bariatric surgery unit, from January to June. In the beginning, they perform different steps of this procedure, to finally complete an LRYGB. We collected demographic data, comorbidities, intraoperative outcomes, and postoperative complications and outcomes after a one-year follow-up. RESULTS: Two hundred and eight patients were eligible for inclusion: 67 in group I (SR), and 141 in group II (EBS). Both groups were comparable. There was no statistically significant difference in operating time (166.45min in group I vs. 156.69min in group II; P=0.156). Conversion to open surgery, hospital stay, postoperative complications, and short-term outcomes had no significant differences between the two groups. There was no mortality registered during this period. CONCLUSION: Implementation of LRYGB stepwise learning as part of an SR training program is safe, and results are comparable to EBS, without loss of efficiency. Therefore, it is feasible to train SR in bariatric surgery under EBS supervision.

Incidencia de la patología abdominal quirúrgica urgente durante la pandemia por SARS-CoV-2 / Incidence of surgical abdominal emergencies during SARS-CoV-2 pandemic

INTRODUCCIÓN: Desde la aparición en diciembre de 2019 del SARS-CoV-2 en la ciudad de Wuhan, China, hemos experimentado un descenso en los ingresos en nuestro Servicio y disminución de la actividad quirúrgica urgente. Por ello, el objetivo de este estudio fue analizar la incidencia de la patología abdominal urgente potencialmente quirúrgica en nuestro centro durante la epidemia por COVID-19. MÉTODOS: Se diseñó un estudio retrospectivo que incluyó a todos los pacientes ingresados por patología abdominal urgente potencialmente quirúrgica en nuestro Servicio de Cirugía General y del Aparato Digestivo desde el 24 de febrero de 2020 hasta el 19 de abril de 2020. RESULTADOS: Se incluyeron 89 pacientes con una edad media de 58,85 ± 22,2. La mediana de tiempo transcurrido desde el inicio de los síntomas hasta la consulta en el Servicio de Urgencias fue de 48 (P25-P75 = 24-96) horas. A su llegada a Urgencias 18 (20%) pacientes presentaban criterios de síndrome de respuesta inflamatoria sistémica (SRIS). Se realizaron 51 (57%) intervenciones quirúrgicas. La tasa de complicaciones postquirúrgicas a los 30 días fue del 31% y la tasa de mortalidad de 2%. Con respecto al mismo período de los años 2017 a 2019, la media de ingresos desde Urgencias en nuestro Servicio descendió un 14% durante el período de epidemia. CONCLUSIONES: Se ha producido un descenso en el número de pacientes que son ingresados por patología abdominal urgente potencialmente quirúrgica durante la epidemia por COVID-19 en nuestro centro

INTRODUCTION: Since the appearance of SARS-CoV-2 in December 2019 in the Chinese city of Wuhan, we have experienced a reduction in admissions in our Service and a decrease in urgent surgical activity. Therefore, this study aimed to assess the incidence of potentially surgical abdominal emergency in our center during the epidemic of COVID-19. METHODS: A retrospective study was designed. It included all patients admitted for urgent abdominal pathology with potential surgical treatment in our General and Digestive Surgery Department from February 24, 2020 to April 19, 2020. RESULTS: Eighty-nine patients with a mean age of 58.85±22.2 were included. The median time from symptom onset to the Emergency Department (ED) visit was 48 (P25-P75 = 24-96) hours. On arrival at the ED, 18 (20%) patients presented with systemic inflammatory response syndrome criteria. Fifty-one (57%) surgical procedures were performed. The rate of post-surgical complications at 30 days was 31% and the mortality rate was 2%. Concerning the same period from 2017 to 2019, the mean number of admissions from the ED to our Department decreased by 14% during the epidemic period. CONCLUSION: There has been a decrease in the number of patients admitted for urgent, potentially surgical, abdominal pathology during the period of the COVID-19 epidemic in our center

Incidence of surgical abdominal emergencies during SARS-CoV-2 pandemic. / Incidencia de la patología abdominal quirúrgica urgente durante la pandemia por SARS-CoV-2.

INTRODUCTION: Since the appearance of SARS-CoV-2 in December 2019 in the Chinese city of Wuhan, we have experienced a reduction in admissions in our Service and a decrease in urgent surgical activity. Therefore, this study aimed to assess the incidence of potentially surgical abdominal emergency in our center during the epidemic of COVID-19. METHODS: A retrospective study was designed. It included all patients admitted for urgent abdominal pathology with potential surgical treatment in our General and Digestive Surgery Department from February 24, 2020 to April 19, 2020. RESULTS: Eighty-nine patients with a mean age of 58.85±22.2 were included. The median time from symptom onset to the Emergency Department (ED) visit was 48 (P25-P75 = 24-96) hours. On arrival at the ED, 18 (20%) patients presented with systemic inflammatory response syndrome criteria. Fifty-one (57%) surgical procedures were performed. The rate of post-surgical complications at 30 days was 31% and the mortality rate was 2%. Concerning the same period from 2017 to 2019, the mean number of admissions from the ED to our Department decreased by 14% during the epidemic period. CONCLUSION: There has been a decrease in the number of patients admitted for urgent, potentially surgical, abdominal pathology during the period of the COVID-19 epidemic in our center.

Laparoscopic staged colon-first resection for metastatic colorectal cancer: Perioperative and midterm outcomes from a single-center experience.

INTRODUCTION: The present study aimed to evaluate the short- and mid-term outcomes of laparoscopic colon-first staged resection for colorectal cancer (CRC) and colorectal cancer liver metastases (CRCLM). METHODS: This study included patients with metastatic CRC who underwent laparoscopic surgical staged resection for the primary tumor and CRCLM between June 2013 and December 2018. Data collection included the baseline patient's and tumor features, the perioperative and histopathologic outcomes from both surgical procedures, and the oncologic follow-up. RESULTS: Twenty-five patients were eligible for the study. Three major and 22 minor laparoscopic liver resections were performed following laparoscopic CRC surgery. Five patients required conversion to laparotomy during CRCLM resection, but no conversion was needed for the colorectal procedures. The rate of severe intraoperative complications (CLASSIC grade III-IV) was 8% and 16% during CRC and CRCLM resection, respectively. Three patients (12%) developed major postoperative complications (Clavien-Dindo grade > III) after both interventions, including one death due to intraoperative bleeding. During a median follow-up of 30 months, 15 patients were diagnosed with disease recurrence. The 3-year disease-free survival and overall survival were 33.3% and 73.9%, respectively. CONCLUSIONS: Laparoscopic staged resection for CRC and CRCLM is safe, feasible, and offers acceptable midterm oncological outcomes in patients with metastatic colorectal cancer.

Sífilis gástrica y su importancia en el diagnóstico diferencial en pacientes VIH / No disponible

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Gastric syphilis and its importance for a differential diagnosis in HIV patients.

A 41-year-old male, with history of HIV presented to emergency department with two months of abdominal pain and a weight loss. Radiological and endoscopic examinations where suggestive of gastric cancer. However, biopsies ruled out malignancy. The reaginic and anti-treponemal tests were positive, so the histological study was repeated with anti-Treponema pallidum monoclonal antibodies. The presence of spirochetes was confirmed. After three weeks of penicillin-based treatment, the gastric lesions and symptoms were resolved.