Long-term results of a randomized trial comparing banded versus standard laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Banded Roux-en-Y gastric bypass was designed to avoid or diminish weight regain in the long term. In 2008, we published the initial results of a pilot study design to comparatively evaluate surgical morbidity, mortality, and maximum weight loss in patients undergoing banded and unbanded laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study analyzes the 5-year results. METHODS: A randomized, controlled trial was carried out in 60 morbidly obese patients who underwent LRYGB. Patients were divided in 2 groups. Half of the patients underwent the banded version of the LRYGB, and half underwent the unbanded version. The 5-year excess weight loss (EWL) and loss of body mass index (BMI) were comparatively analyzed. RESULTS: There were 58 females and 2 males with a mean preoperative BMI of 47±4.9 kg/m(2). A total of 21 patients with banded LRYGB and 22 with unbanded LRYGB completed 5-year follow-up. One patient died 3 years after surgery from metastatic melanoma. EWL at 5 years was 61.6%±19.6% versus 59.8%±15.9% (P = ns), and loss of BMI was 32.9%±5.2% versus 32.8%±4.3% (P = ns), respectively, for the banded and unbanded group. CONCLUSIONS: In this small study, there were no statistical differences in the EWL and the BMI lost at 5 years between the group of patients who underwent banded and unbanded LRYGB.

Pancreatic incidentalomas.

Pancreatic incidentalomas are defined as asymptomatic pancreatic lesions, discovered incidentally by imaging for an unrelated indication. They are being discovered with increasing frequency as the use of high quality cross sectional imaging is becoming more widespread. These lesions cover a wide spectrum of pathology from benign simple cysts through potentially malignant lesions such as intraductal papillary mucinous neoplasia, to frankly malignant adenocarcinoma. In this article we outline the incidence, imaging characteristics and natural history of the various incidental lesions with emphasis to neuroendocrine tumors. A diagnostic approach is also suggested, including the rational use of further imaging, serum biochemistry and the utility of ultrasound guided aspiration of cyst fluid if present. We examine several proposed classification systems and discuss the role of surgery, surveillance and prognosis.

[Surgical and medical treatment outcome of enterocutaneus fistulas]. / Resultados del tratamiento médico-quirúrgico de las fistulas enterocutáneas.

INTRODUCTION: Enterocutaneous fistulas are an important complication of gastrointestinal surgery. Most of the cases (75% to 85%) are secondary to postoperative complications and are related to a high morbi-mortality rate, mainly sepsis, malnutrition and fluid and electrolyte imbalance. The aim of this study is to describe the main causes of enterocutaneous fistulas and morbi-mortality associated to treatment in the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. METHODS: Retrospective, observational and longitudinal study. Clinical records of patients with enterocutaneous fistula from January 1999 to December 2003 were reviewed. RESULTS: 51 patients were identified; median age was 45 years (interval 20 to 79 years). Fistula resulted from surgery in 49 cases (96%). A combined therapy of total parenteral nutrition and low residue diet were used in 28 patients (55%). Surgery was performed as definitive treatment in 29 patients (57%). Indications for surgery were: failure to medical treatment in 25 patients (59%) and a persistent high output in 4 (8%). The median of postoperative hospitalization was 11 days (interval 3 to 96 days) and the median of lenght of stay was 30 days (interval 40 to 130 days). There was no mortality. CONCLUSION: Enterocutaneous fistulas require long time of hospitalization. More than 50% of patients need surgery as final treatment.

SECCA procedure for the treatment of fecal incontinence: results of five-year follow-up.

PURPOSE: This study evaluated the long-term (5-year) durability of radiofrequency energy delivery for fecal incontinence. METHODS: This was an extension of the follow-up from our original prospective study in which patients who suffered from fecal incontinence were treated with the SECCA system for radiofrequency energy delivery to the anal canal muscle. The Cleveland Clinic Florida Fecal Incontinence Scale (0-20), fecal incontinence-related quality of life score, and Medical Outcomes Study Short-Form 36 were administered to five years. Differences between baseline and follow-up were analyzed by using paired t-test. RESULTS: A total of 19 patients were treated and followed for five years, including 18 females (aged 57.1 (range, 44-77) years). The mean duration for fecal incontinence was 7.1 (range, 1-21) years. At five-year follow-up, the mean fecal incontinence score had improved from 14.37 to 8.26 (P<0.00025) with 16 patients (84.2 percent) demonstrating>50 percent improvement. All fecal incontinence-related quality of life scores improved, including lifestyle (2.43 to 3.15; P<0.00075), coping (1.73 to 2.6; P<0.00083), depression (2.24 to 3.15; P<0.0002), and embarrassment (1.56 to 2.51; P<0.0003). The social function component of the Short-Form 36 improved from 38.3 to 60 (P<0.05). There was a trend toward improvement in the mental component summary of the Short-Form 36 from 38.1 to 48.14. There were no long-term complications. CONCLUSIONS: Significant and sustained improvements in fecal incontinence symptoms and quality of life are seen at five years after treatment with the SECCA system. This treatment should be considered for patients suffering from fecal incontinence not amenable to surgery and who have failed conservative management.

[Surgical treatment for colonic diverticular disease. Experience in the INCMNSZ]. / Tratamiento quirúrgico para la enfermedad diverticular de colon. Experiencia en el INCMNSZ.

BACKGROUND: Even though most patients with colonic diverticular disease respond to conservative management, some patients persist with symptoms or develop complications that require surgery. The objective of this study was to identify main surgical indications for colonic diverticular disease, and to evaluate the outcomes of surgical treatment. MATERIALS AND METHODS: A retrospective review of patients that underwent a surgical procedure for colonic diverticular disease from 1979 through 2000, was performed. Surgical indications were acute diverticulitis (54%) (group 1), stenosis (19%), fistula (9.54), recurrent diverticulitis (9.5%) and bleeding (8%) (group 2). Results. Seventy-four patients with a mean age of 56 years were studied. Fifty-eight percent were male. Surgical morbidity and mortality rates of acute diverticulitis were 55%, and 15%, respectively. The surgical procedures of this group were proximal stomas (45%), Hartmann's procedures (38%), and resections with primary anastomosis (17%). Second group morbidity and mortality rates were 35 and 5.8%, respectively. Thirty-six patients underwent two or more surgical procedures with statistical significance between first and second groups (61 vs. 28%; p < 0.05). The mortality of two-stage surgeries was lower than derivative procedures (13 vs. 22%; p = 0.009). A high Hinchey's score was the only factor associated with mortality (28.5 vs. 0%; p = 0.042). CONCLUSIONS: Mortality of surgical procedures for colonic diverticular disease is associated with a high Hinchey score. Primary anastomosis is o safe, procedure in some cases.

Tratamiento quirúrgico para la enfermedad diverticular de colon: Experiencia en el INCMNSZ / Surgical treatment for colonic diverticular disease: Experience in the INCMNSZ

Background. Even though most patients with colonic diverticular disease respond to conservative management, some patients persist with symptoms or develop complications that require surgery. The objective of this study was to identify main surgical indications for colonic diverticular disease, and to evaluate the outcomes of surgical treatment. Materials and methods. A retrospective review of patients that underwent a surgical procedure for colonic diverticular disease from 1979 through 2000, was performed. Surgical indications were acute diverticulitis (54%) (group 1), stenosis (19%), fistula (9.5%), recurrent diverticulitis (9.5%) and bleeding (8%) (group 2). Results. Seventy-four patients with a mean age of 56 years were studied. Fifty-eight percent were male. Surgical morbidity and mortality rates of acute diverticulitis were 55%, and 15%, respectively. The surgical procedures of this group were proximal stomas (45%), Hartmann's procedures (38%) and resections with primary anastomosis (17%). Second group morbidity and mortality rates were 35 and 5.8%, respectively. Thirty-six patients underwent two or more surgical procedures with statistical significance between first and second groups (61 vs. 28%; p < 0.05). The mortality of two-stage surgeries was lower than derivative procedures (13 vs. 22%; p = 0.009). A high Hinchey's score was the only factor associated with mortality (28.5 vs. 0%; p = 0.042). Conclusions. Mortality of surgical procedures for colonic diverticular disease is associated with a high Hinchey score. Primary anastomosis is a safe procedure in some cases.

Antecedentes. Aunque la mayoría de pacientes con enfermedad diverticular de colon responde al manejo conservador, algunos persisten con síntomas o presentan complicaciones que requieren cirugía. El objetivo de esta revisión fue identificar las indicaciones quirúrgicas para la enfermedad diverticular de colon y evaluar los resultados en el manejo quirúrgico de la misma. Material y métodos. Se realizó una revisión retrospectiva de pacientes sometidos a cirugía por enfermedad diverticular de colon de 1979 al 2000. Las indicaciones de cirugía fueron diverticulitis aguda (54%) (grupo 1), estenosis (19%), fístula (9.5%), diverticulitis recurrente (9.5%) y hemorragia (8%) (grupo 2). Resultados. Se estudiaron un total de 74 pacientes con una edad promedio de 56 años. Cincuenta y ocho por ciento fueron del sexo masculino. La morbilidad de los pacientes operados por diverticulitis aguda fue de 55% y la mortalidad de 15%. El tipo de cirugías en este grupo fueron estomas derivativos (45%), procedimientos de Hartmann (38%) y resecciones con anastomosis primaria (17%). La morbilidad y la mortalidad de las cirugías del segundo grupo fueron de 35 y 5.8%, respectivamente. Treinta y seis pacientes tuvieron dos o más operaciones, con diferencia significativa al comparar el grupo 1 con el grupo 2 (61 vs. 28%; p < 0.05). La mortalidad de los pacientes que tuvieron un procedimiento resectivo fue menor que cuando se desfuncionalizó (13 vs. 22%; p - 0.009). El único factor asociado con mortalidad fue un Hinchey elevado (28.5 vs. 0%; p - 0.042). Conclusiones. La mortalidad de la cirugía para complicaciones de la enfermedad diverticular de colon se asocia a un grado de Hinchey elevado. La resección con anastomosis primaria es un procedimiento seguro en casos seleccionados.

[Morbi-mortality related to ileostomy and colostomy closure]. / Morbimortalidad asociada al cierre de ileostomía y colostomía en asa.

INTRODUCTION: The main goal of gastrointestinal stomas is to divert the faecal stream from technically difficult anastomoses or intestinal obstruction. Current tendency is to avoid definitive stomas, temporary loop stomas are commonly used to protect high risk anastomosis or sections of the distal bowel. The aim of this study was to determine and compare the morbi-mortality after loop stomas closure. METHODS: Retrolective, observational and comparative study was conducted. The files of patients submitted to loop ileostomy or colostomy closure from 1981 to 2001 were reviewed. Statistical analysis was performed by the Fisher's exact test and the Mann-Whitney U test. RESULTS: From a total of 107 procedures included, 73% were ileostomy closures and 27% colostomy closures. The mean age was 46 years (14-88). Protection of anastomoses was the most common indication in both stoma groups. The colostomy group had a larger interval days between stoma creation and closure than the ileostomy group (172.3 days vs. 125.6 days p = 0.008). Stoma closure was performed by hand sewn sutures in 81.3% patients and by stapled technique in 19.7% patients. The mean operative time for stoma closure was higher for colostomy group than for ileostomy (108.1 min vs. 88.3 min, p = 0.04). Colostomy group patients required a midline abdominal incisions more often than ileostomy group (21.4 vs. 2.5% p = 0.04). Morbidity rates were 7.6% for the ileostomy group and 10.3% for the colostomy group. Colostomy closure required a longer length of stay. There was no mortality. CONCLUSION: The results of this study showed that stoma closure was a well tolerated procedure with low morbidity and no mortality rates. The result suggest that ileostomy closure is a simpler procedure.

Anorectal melanoma: report of three cases with extended follow-up.

Primary anorectal melanoma is rare. There is controversy regarding the best surgical treatment because of its poor prognosis. Three cases with extended follow-up are reported in this article. A 53-year-old woman with rectal bleeding was diagnosed with a melanoma of the rectum and underwent an abdominoperineal resection. The patient died with distant metastases 8 months later. An 80-year-old woman with rectal bleeding was diagnosed with a melanoma of the rectum and underwent a transanal local excision. She remains alive 4 years later but with locally recurrent disease. A 78-year-old man with rectal bleeding was diagnosed with a melanoma of the rectum and underwent an abdominoperineal resection. He died with local and metastatic disease 25 months later. Recent trends favor local excision when technically feasible, although some patients may require an abdominoperineal resection of the rectum, especially for larger tumors.

Rigid rectosigmoidoscopy: still a well-tolerated diagnostic tool.

BACKGROUND: Although rigid rectosigmoidoscopy has been gradually replaced by the use of flexible rectosigmoidoscopy in recent years, it remains an effective, economic and widely available diagnostic tool. The aim of this study was to determine the type and magnitude of symptoms during rigid rectosigmodoscopy. METHODS: Prospective evaluation of patients who underwent diagnostic rigid rectosigmoidoscopy. The main complaints were recorded, and their magnitude quantified using a visual analogue scale. RESULTS: A total of 134 patients (mean age = 48 years) were examined. The prone jackknife position was used in 54% of them and left lateral decubitus in 46%. A complete (full length) examination was achieved in 68%. There were no complications. Sixty percent of patients referred complaints: pain (33%), discomfort by rectal preparation (13%), uncomfortable defecation desire (8%), and discomfort by the position (4%). Median values determined by visual analogue scale for pain, discomfort by rectal preparation, uncomfortable positioning and overall discomfort were graded as 3.3, 3.3, 2.1 and 2, respectively. There was an association between higher magnitude of pain and overall discomfort with female gender, left lateral decubitus position, and full-length exploration (p < 0.05). CONCLUSION: A high percentage of patients have symptoms during rigid rectosigmoidoscopy but the study is usually well tolerated due the low magnitude of pain and discomfort and remains a very cost-effective study.