Esophagectomy with Ileocoloplasty, Last Treatment for a Leak After Laparoscopic Sleeve: "From Less to More".

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is increasingly playing a key role in obesity management. Such operations, however, carry complications sometimes including leaks. The esophageal stent is one of the frequent options used to treat leaks after a sleeve gastrectomy. The fully covered stents are the ones of choice. However, their use can result in serious consequences requiring aggressive solutions. The longer the stent is maintained, there is more risk of withdrawal, even esophageal mucosal avulsion developing stenosis afterward. Endoscopic stenting is a double-edged sword that must be handled cautiously. MATERIALS AND METHODS: A 36-year-old woman with BMI 44 and obstructive apnea syndrome undergoing laparoscopic sleeve gastrectomy in November 2017 with a 36 Fr bougie and reinforced staplers. She presented a leak as immediate complication. It was initially treated with an esophageal stent and removed 2 months afterwards with a mucosal avulsion during the procedure. She developed after an esophageal stenosis which was treated with enteral nutrition and endoscopic dilatations for 6 months without results. RESULTS: We present an open esophagectomy with ileocoloplasty reconstruction due to intrathoracic esophageal stricture after conservative management with partially covered metal stents and dilatations of a leak in a laparoscopic sleeve. She presented a neck leakage in the postoperative period with a good evolution after parenteral nutrition for 3 weeks and antibiotic therapy. She was discharged one month after surgery eating soft food in a reasonable manner. CONCLUSIONS: Although one of the existing options to treat leaks after a sleeve gastrectomy is the use of an esophageal stent, it is essential to choose the correct type, being the fully covered the ones of choice. The use of self-expandable metal stents appears to be a safe and effective method in the treatment of post-LSG leaks. The longer it is maintained, there is more risk in withdrawal, even esophageal mucosal avulsion. Endoscopic stenting is a double-edged sword that must be handled cautiously.

Revision of a Previous Capella Bypass due to dysphagia, GERD and Candy Cane Syndrome.

BACKGROUND: Capella ringed gastric bypass is a technical variant of gastric bypass which seeks to improve long-term outcomes with a greater restriction. Frequent complications are due to the band, due to its inclusion or slippage, without being able to reject others. Our purpose is to present the video of a revisional bariatric surgery made by laparoscopic approach in a patient with a previous open retrogastric retrocolic Capella gastric bypass. MATERIALS AND METHODS: The patient presents dysphagia, gastroesophagic reflux disease (GERD), and pain, with a BMI of 36 kg/m2. Her supplementary tests show a hiatal hernia, GERD, and a Candy Cane Syndrome. The surgery was difficult due to multiple adhesions. Hiatal hernia was repaired and pillars were closed. The band was visualized intraoperatively close to the gastrojejunal anastomosis, although the high endoscopy did not detect neither stenosis nor difficulty of passage to the gastric pouch. It showed the retrogastric gastrojejunal anastomosis with a normal food loop and a 15-cm widened blind loop (Candy Cane Syndrome), which was resected. RESULTS: She had a left pneumonia and damage in left hepatic lobe (LHL). She was discharged after antibiotic treatment for 7 days. The patient has improved clinically, without dysphagia nor GERD. Her current BMI is 29.8 kg/m2. CONCLUSIONS: In conclusion, bariatric revisional surgery can lead to serious complications, but it is justified in patients with poor quality of life. A ringed retrocolic retrogastric bypass poses more difficulties in revisional procedures. It is mandatory to know which technique was performed before. The duration of the procedure can result in more complications like liver damage.

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 / 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

Introducción: El objetivo de este trabajo es analizar la evolución ponderal de las principales técnicas quirúrgicas bariátricas (bypass gastroyeyunal en Y de Roux [BPGY] y gastrectomía vertical [GV]) realizadas en un conjunto representativo de centros nacionales españoles, con el fin de confeccionar unos gráficos de percentiles del porcentaje de pérdida total de peso perdido durante los 3 primeros años después de la cirugía. Métodos: Se realiza un estudio de cohortes longitudinal retrospectivo a partir de los datos aportados por 9 centros hospitalarios españoles. Se han analizado los datos ponderales tanto en porcentaje de pérdida total de peso perdido como en porcentaje de exceso de peso perdido correspondientes al BPGY (n = 1.887) y a la GV (n = 1.210). Resultados: El BPGY sigue siendo la técnica más frecuentemente realizada en nuestra muestra nacional. En ambas técnicas quirúrgicas, la pérdida de peso máxima se produce a los 18 meses de la cirugía. Ambas técnicas siguen la misma evolución ponderal, aunque los valores del porcentaje de pérdida total de peso perdido sean inferiores en el caso de la GV a los 36 meses (29,3 ± 10 vs. 33,6 ± 10). La edad y el género son determinantes en los resultados ponderales (mejores en paciente más jóvenes para ambas técnicas y mejores en mujeres para el BPGY). Conclusiones: Los gráficos de percentiles del porcentaje de peso total perdido después de la cirugía bariátrica representan una herramienta muy útil y un avance importante en la calidad asistencial para el seguimiento ponderal del paciente

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

Factores que condicionan la sensibilidad de la ecografía y la gammagrafía en la localización del adenoma paratiroideo / Factors infuencing the sensitivity of ultrasound and gamma location of the parathyroid adenoma

Introducción: Una correcta localización preoperatoria del adenoma es clave en el tratamiento del hiperparatiroidismo primario (HPTP) mediante paratiroidectomía selectiva. Aunque existen múltiples técnicas de imagen, no siempre consiguen localizar correctamente la/s glándula/s patológica/s. El objetivo es estudiar los factores que puedan influir en la sensibilidad y la concordancia de la ecografía y la gammagrafía 99 mTc-metoxi-isobutil-isonitrilo (MIBI). Métodos: Población a estudio: pacientes intervenidos con HPTP por adenoma con estudio preoperatorio de localización con ecografía y gammagrafía 99 mTc-MIBI. Los pacientes fueron tratados en nuestro centro entre 2004 y 2018. Se han excluido a los que no tuvieran ambas pruebas, las hiperplasias, las neoplasias endocrinas múltiples (MEN) y los adenomas ectópicos no abordables por vía transcervical. Se han estimado la sensibilidad, la concordancia y el valor predictivo positivo (VPP) de las técnicas de imagen con respecto a la localización intraoperatoria, analizando los potenciales factores que pueden influir en ello. Resultados: Se ha analizado a 139 pacientes (82% mujeres, 18% varones). La ecografía ha tenido una sensibilidad del 56,7%, una concordancia (índice kappa) de 0,387 y un VPP del 96,3%. En el caso de la gammagrafía, la sensibilidad ha sido del 81,6%, la concordancia (índice kappa) del 0,669 y su VPP del 97,4%. En el análisis de regresión logística, el factor que ha influido en la localización mediante ecografía ha sido la ausencia de enfermedad tiroidea asociada. En el caso de la gammagrafía, el factor ha sido el peso glandular mayor de 600 mg. Conclusiones: La sensibilidad de la ecografía mejora en ausencia de enfermedad tiroidea y la de la gammagrafía con el peso glandular mayor de 600 mg

Introduction: The treatment of choice for primary hyperparathyroidism (PHPT) when there is proper preoperative localization of the adenoma is minimally invasive parathyroidectomy. However, imaging techniques are not always able to provide the exact location. The objective is to identify potential factors that might influence the sensitivity and concordance of ultrasound (US) and 99mTc-methoxy-isonitrile parathyroid scintigraphy (MIBI-PS) and the actual location of the adenoma. Methods: We reviewed the data of patients who underwent parathyroidectomies for PHPT. All patients had undergone ultrasound and 99mTc-MIBI scintigraphy as a preoperative location study. Multiple endocrine neoplasms, other hyperplasias and non-cervical ectopic adenomas were excluded. The sensitivity, PPV and concordance have been estimated for the location of the gland in both tests compared with the intraoperative location, using a multivariable analysis of the factors that might influence their localization capacity. Results: 139 patients (82% women) have been analysed. The US sensitivity was 56.7%, concordance (Kappa index) 0.387 and PPV 96.3%. The MIBI-PS sensitivity was 81.6%, the concordance (Kappa index) 0.669 and the PPV 97.4%. The factor that improved localization of the glands by US in the multivariable analysis was the absence of a concomitant thyroid pathology. The factor that improved the MIBI-PS results was a gland weight greater than 600 mg. Conclusions: US sensitivity improves when there is no concomitant thyroid pathology. MIBI-PS sensitivity improves when the gland weight is greater than 600 mg

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.

Factors infuencing the sensitivity of ultrasound and gamma location of the parathyroid adenoma. / Factores que condicionan la sensibilidad de la ecografía y la gammagrafía en la localización del adenoma paratiroideo.

INTRODUCTION: The treatment of choice for primary hyperparathyroidism (PHPT) when there is proper preoperative localization of the adenoma is minimally invasive parathyroidectomy. However, imaging techniques are not always able to provide the exact location. The objective is to identify potential factors that might influence the sensitivity and concordance of ultrasound (US) and 99mTc-methoxy-isonitrile parathyroid scintigraphy (MIBI-PS) and the actual location of the adenoma. METHODS: We reviewed the data of patients who underwent parathyroidectomies for PHPT. All patients had undergone ultrasound and 99mTc-MIBI scintigraphy as a preoperative location study. Multiple endocrine neoplasms, other hyperplasias and non-cervical ectopic adenomas were excluded. The sensitivity, PPV and concordance have been estimated for the location of the gland in both tests compared with the intraoperative location, using a multivariable analysis of the factors that might influence their localization capacity. RESULTS: 139 patients (82% women) have been analysed. The US sensitivity was 56.7%, concordance (Kappa index) 0.387 and PPV 96.3%. The MIBI-PS sensitivity was 81.6%, the concordance (Kappa index) 0.669 and the PPV 97.4%. The factor that improved localization of the glands by US in the multivariable analysis was the absence of a concomitant thyroid pathology. The factor that improved the MIBI-PS results was a gland weight greater than 600mg. CONCLUSIONS: US sensitivity improves when there is no concomitant thyroid pathology. MIBI-PS sensitivity improves when the gland weight is greater than 600mg.

Sarcoma de Ewing atípico: un diagnóstico diferencial a tener en cuenta en los tumores del estroma gastrointestinal (GIST) / Ewing's Sarcoma: Differential diagnosis of gastrointestinal stromal tumors (GIST)

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Early and Late Complications in Laparoscopic Gastric Bypass: Comparative Study between Manual and Stapled Anastomosis.

The aim of this study is to evaluate the early and late complications of laparoscopic gastric bypass (GBP) with manual versus stapled gastrojejunal anastomosis. Eighty-two patients with morbid obesity and body mass index (35-56 kg/m2) who underwent GBP were divided into two groups: manual gastrojejunal anastomosis (Group 1) and stapled anastomosis (Group 2). Early and late complications were evaluated. No differences were found between both groups in age, sex, body mass index, American Society of Anesthesia classification, and comorbidity. The mean operative time was 184.8 minutes [standard deviation (SD) = 61]; 203.5 minutes (SD = 51.9) in Group 1 and 167.4 minutes (SD = 64.2) in Group 2 (P = 0.001). The average length of stay was 5.9 days (SD = 3.9) in Group 1 and 5 days (SD = 2.1) in Group 2 (P = 0.039). Early complications were recorded in 9.7 per cent of the cases, without any differences between the two groups: 12.2 per cent in Group 1 and 7.3 per cent in Group 2 (P > 0.05). Late complication rate was 8.5 per cent, significantly higher in Group 1 (14.6%) than in Group 2 (2.4%; P < 0.05). However, in the logistic regression analysis these differences were not statistically significant (OR 0.48; 95% CI 0.03-8.37; P = 0.61). In our series, the GBP with stapled gastrojejunal anastomosis has shown lower hospital length of stay and operative time than the hand-sewn anastomosis. We have not found significant differences between both groups in early complications or in the need for reoperation. Fewer late complications were found in the group of stapled anastomosis; however, this has not been confirmed in the logistic regression analysis.

Conversion of an Open Salmon's Technique to a Laparoscopic Gastric Bypass.

BACKGROUND: There are a growing number of patients who require revisional bariatric surgery due to the failure of their primary procedures. The aim of this video is to present a laparoscopic revisional procedure for dysphagia and gastroesophageal reflux disease (GERD) after an uncommonly performed bariatric surgery, Salmon's technique, consisting of a vertical banded gastroplasty and a horizontal stomach stapling with a Roux-en-Y bypass. METHODS: A 42-year-old obese male, with a history of dyslipidemia and a current body mass index (BMI) of 33, presented with severe dysphagia to solids and frequent spitting 10 years after the primary bariatric surgery (Salmon's procedure) with a BMI of 43. Endoscopy revealed a hiatal hernia. The endoscope passed down without difficulty to the antrum-duodenum and to efferent loop of the small bowel, demonstrating the presence of a fistula in the horizontal stapling of the stomach. Helicobacter pylori was negative. Esophageal transit showed the contrast passing adequately through the esophagogastric junction. Esophageal manometry revealed a hypotensive lower esophageal sphincter (mean pressure of 8 mmHg) and an ineffective peristalsis (40% of waves with normal amplitude and duration). Esophageal pHmetry showed severe GERD with a DeMeester score of 88.5 and a pH less than four, 18.7% of the total time. The patient was on PPIs at the time of symptom evaluation, but stopped the treatment before the performance of the pH study. Laparoscopic conversion to a Roux-en-Y gastric bypass was successfully performed. An extensive adhesiolysis was needed. The esophageal hiatus was dissected and the stomach was partially descended to reduce the hiatal hernia. A subsequent hiatal closure was performed. The efferent loop of the small bowel was freed from the gastric pouch. The new gastric pouch was performed stapling superiorly to the gastric ring and medially to the vertical gastroplasty. The new gastrojejunal anastomosis was performed using a mechanical linear stapler, in an antecolic fashion, and checked for leaks using methylene blue dye. RESULTS: The procedure took 300 min and no intraoperative complications occurred. The patient had an uneventful postoperative course, with a hospital stay of 4 days. One month after the revisional surgery, the patient presented with a stenosis of the gastrojejunal anastomosis, which was successfully solved after two endoscopic dilations. A year and a half after revisional surgery, the patient is completely asymptomatic, has a BMI of 29, and dyslipidemia as the only comorbidity. CONCLUSIONS: Salmon's technique is an uncommon bariatric procedure. Revisional surgery might be needed in case of late complications, like dysphagia and reflux, as it was the case in our patient. In addition, a fistula in the previous horizontal partitioning of the stomach was present. Laparoscopic conversion from Salmon's technique to a gastric bypass was decided. This procedure was successful in solving patient's symptoms and resulted in an increased weight lost. Laparoscopic revisional surgery after an open Salmon's technique is a complex procedure with an increased risk of complications. Our patient developed an anastomotic stenosis 1 month after surgery, probably due to the use of the same gauge as in non-fibrotic tissues.

[Cervical sympathetic chain schwannoma associated with parathyroid adenoma]. / Schwannoma de la cadena simpática cervical asociado a adenoma paratiroideo.

BACKGROUND: Schwannoma is a rare benign tumor derived from nerve sheaths. When derived from the cervical sympathetic chain, it usually presents itself as an asymptomatic mass located in the posterior cervical region, at paravertebral level. Its diagnosis is not easy, usually requiring multiple imaging tests. Its differential diagnosis includes parathyroid adenoma. CLINICAL CASE: A new case of schwannoma of the cervical sympathetic chain in a patient with a synchronous overactive parathyroid adenoma is reported. This case adds to the sixty described in the literature, although to our knowledge no association between schwannoma and parathyroid adenoma has been reported to date. CONCLUSIONS: Despite being a benign tumor, its treatment is a complete surgical resection. The most common complication after the surgery needed for these tumors is ipsilateral Horner syndrome.

Incidence of surgical site infection in colon surgery: comparison with regional, national Spanish, and United States standards.

BACKGROUND: The high prevalence of surgical site infection (SSI) in colon surgery, and the clinical and economic impacts of such infections, make its monitoring and prevention a priority. METHODS: We conducted a prospective cohort study to estimate the rate of SSI in colon surgery and the degree of compliance with antibiotic prophylaxis and pre-operative preparation protocols. The study population comprised patients who underwent colon surgery at the University Hospital of the Alcorcon Foundation in Alcorcon, Spain, from October 2007 to December 2009. Risk factors, the observance of antibiotic prophylaxis, and compliance with pre-operative preparation protocols were monitored; and their influence on SSIs was followed for 30 days after surgery. The main outcome measure was comparisons of the rates of SSI in patients undergoing colon surgery in Madrid and across the whole of Spain and in the United States, as determined in accordance with the surveillance parameters of the National Nosocomial Infections Surveillance (NNIS) index. RESULTS: Among a total of 132 patients, we found a 10.6% rate of SSI. The indirect standardization rate at our hospital was 1.75-fold for the United States and 0.64-fold and 0.61-fold, respectively, the rates for Madrid and all of Spain. The rates of compliance with antibiotic prophylaxis and pre-operative preparation protocols were 93.6% and 56.8%, respectively. No relation could be established between these data and the rate of infection. The risk factors for SSI found in a multivariable analysis were the degree of contamination in surgery and the presence of chronic obstructive pulmonary disease (COPD; p<0.05). CONCLUSIONS: The rate of SSI in our study population was below that for Madrid and Spain but higher than that for the United States. Thorough adherence to the monitoring system was essential for obtaining these results.

Gastrointestinal stromal tumors: diagnosis and treatment.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms of the digestive tract. They originate from the interstitial cells of Cajal and are characterized by the overexpression of KIT protein (tyrosine kinase). Their prognosis has improved significantly with the discovery of imatinib mesylate for advanced GIST treatment. METHODS: We carried out a retrospective, descriptive study of GISTs diagnosed in our center during the past 5 years. We excluded patients with incidental diagnoses in the context of other pathologies because GIST did not affect outcome or prognosis. The variables studied were clinical characteristics, location, size, imaging techniques, resectability, neoadjuvant imatinib, surgical technique, histology, immunohistochemistry, prognostic classification of Fletcher, morbidity, monitoring, and disease-free and overall survival. RESULTS: Nineteen patients were diagnosed (14 males/5 females) with a mean age of 63 years (range: 30-84 years). Diagnosis was incidental in eight patients (42%). Tumor location of the remaining 11 patients (58%) was six tumors of the small intestine (55%), four gastric (36%) and one rectal (9%). Predominant gastrointestinal bleeding and anemia were diagnosed mainly by abdominal computed tomography (CT). At diagnosis, nine patients were considered resectable with radical intent (82%) and the other two patients (18%) received neoadjuvant treatment with a favorable response after 6 months. Three patients were treated with imatinib after surgery (33%). Median survival was 34 months (range: 5-58 months). CONCLUSIONS: Diagnosis of GIST is often incidental. The predominant clinical symptom is usually gastrointestinal bleeding and anemia and the most widely used imaging test is CT. Treatment is surgical unless advanced GIST is diagnosed, which will be treated with imatinib mesylate neoadjuvant therapy. A multidisciplinary approach to this pathology is essential, a fact that affects prognosis and patient survival.

Esophageal resection and immediate reconstruction in esophageal perforations.

BACKGROUND: Esophageal perforation is a disease with high mortality. Treatment is controversial and should be individualized. Elapsed time, location and perforation all play a role in determining the treatment option: from conservative treatment to esophagectomy. We undertook this study to report on primary esophagectomy and reconstruction in esophageal perforations with expert surgeons and selected patients. It is worth noting the rare complication of perforated peptic ulcer on Barrett's esophagus presented in one of our patients. CLINICAL CASES: We report two patients with esophageal perforation (one spontaneous and another due to pneumatic esophageal dilation) treated by primary esophagectomy and reconstruction. The patient with spontaneous perforation had Barrett's esophagus with severe dysplasia and perforated peptic ulcer. CONCLUSIONS: Esophageal resection and immediate reconstruction is controversial. It was decided to resect the esophagus in both cases reported here due to the size of the perforation and esophageal disease in the second case. The primary reason for immediate reconstruction in selected cases is permanent resolution. Primary cervical esophagealgastric anastomosis has a lower risk of contamination and leaks than thoracic anastomosis, resulting in mediastinal drainage and parenteral nutrition. Spontaneous esophageal perforation due to perforated Barrett's ulcer is uncommon. Finally, we must consider the importance of early diagnosis and treatment. It is essential to consider the size of the perforation, location, previous esophageal disease, age and general status of the patient in order to undertake appropriate management. Emergency surgery should be individualized and depends on surgeon's experience.

[Gastric bypass and laparoscopic biliopancreatic diversion with manual anastomosis: results in 250 morbidly obese patients]. / Bypass gástrico y derivación biliopancreática laparoscópica efectuadas con anastomosis manual. Resultados en 250 pacientes obesos móbidos.

BACKGROUND: Gastrojejunostomy anastomosis after a gastric bypass or biliopancreatic diversion can be performed by staples or hand-sewn technique. The aim of this study is to analyze totally hand-sewn anastomosis by laparoscopy. METHODS: Morbid obese patients treated consecutively with a gastric bypass or biliopancreatic diversion in which the main anastomosis was performed with a totally hand-sewn gastrojejunostomy by laparoscopy at Hospital Universitario de Getafe from March-01 to November-07. RESULTS: 250 patients were included: 232 were gastric bypass and the remaining 18, biliopancreatic diversion. Mean BMI was 46 +/- 4. There was only one case of digestive bleeding for a marginal ulcer during immediate postoperative period (6th day). Later, there were 2 cases of complicated ulcers: due to bleeding and perforation. There were no anastomotic leaks from the hand-sewn gastrojejunostomy. A patient was re-operated on 48 hours after bypass due to a leak secondary to a thermal perforation at the lesser curvature. Radiological or endoscopic dilatation were required in 11 stenosis (4.4%) at gastrojejunostomy and none in the biliopancreatic diversion group. Mean surgical time for the anastomosis was 40+/-15 minutes. There were no deaths, sepsis, abdominal abscess, deep venous thrombosis or pulmonary embolism. Average hospital stay was 5.1+/-2.4 days. CONCLUSIONS: Even though most surgeons believe that staples anastomosis is easier, hand-sewn technique can be reproducible by surgeons with laparoscopic sutures experience. This technique has a longer operation time but continuous training provides advanced laparoscopic skills and significantly reduces operation time.

Bypass gástrico y derivación biliopancreática laparoscópica efectuadas con anastomosis manual. Resultados en 250 pacientes obesos móbidos / Gastric bypass and laparoscopic biliopancreatic diversion with manual anastomosis: results in 250 morbidly obese patients

Introducción. En cirugía bariátrica, la reconstrucción del tracto digestivo tras un bypass gástrico (BPG) o una derivación biliopancreática (DBP) se efectúa mediante una anastomosis gastroyeyunal mecánica o manual. El objetivo de este trabajo es analizar la anastomosis gastroyeyunal con sutura manual por laparoscopia. Pacientes y método. Serie de pacientes obesos mórbidos tratados con BPG o DBP con anastomosis gastroyeyunal por técnica manual vía laparoscópica en el Hospital Universitario de Getafe, desde marzo de 2001 a noviembre de 2007. Resultados. Se incluyó a 250 pacientes, de los que 232 fueron intervenidos por BPG y los 18 restantes, por DBP. El índice de masa corporal medio era 46 ± 4. Sólo se registró un caso de hemorragia digestiva (0,4%) por ulcus en la boca en el postoperatorio inmediato (sexto día). En el postoperatorio tardío hubo 2 casos de ulcus complicado (0,8%), 1 caso con hemorragia y 1 con perforación. No hubo ninguna fuga de la anastomosis. Una paciente fue reintervenida a las 48 h por una fuga secundaria a una perforación térmica en la curvatura menor del reservorio gástrico. Se registraron 11 (4,4%) estenosis, que precisaron dilatación radiológica o endoscópica; no hubo ninguna en los casos de derivación. El tiempo medio para la anastomosis fue de 40 ± 15 min. No hubo mortalidad ni se registró ningún caso de absceso, sepsis abdominal o tromboembolia. La estancia hospitalaria media fue de 5,1 ± 2,4 días. Conclusiones. Aunque la mayoría de los cirujanos consideran que la anastomosis mecánica es más sencilla, la técnica manual puede ser reproducida por cirujanos con experiencia en el manejo de suturas y nudos intracorpóreos. La técnica prolonga el tiempo quirúrgico, pero un entrenamiento continuo desarrolla la destreza del cirujano y acorta significativamente el tiempo operatorio The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Background. Gastrojejunostomy anastomosis after a gastric bypass or biliopancreatic diversion can be performed by staples or hand-sewn technique. The aim of this study is to analyze totally hand-sewn anastomosis by laparoscopy. Methods. Morbid obese patients treated consecutively with a gastric bypass or biliopancreatic diversion in which the main anastomosis was performed with a totally hand-sewn gastrojejunostomy by laparoscopy at Hospital Universitario de Getafe from March-01 to November-07. Results. 250 patients were included: 232 were gastric bypass and the remaining 18, biliopancreatic diversion. Mean BMI was 46 ± 4. There was only one case of digestive bleeding for a marginal ulcer during immediate postoperative period (6th day). Later, there were 2 cases of complicated ulcers: due to bleeding and perforation. There were no anastomotic leaks from the hand-sewn gastrojejunostomy. A patient was re-operated on 48 hours after bypass due to a leak secondary to a thermal perforation at the lesser curvature. Radiological or endoscopic dilatation were required in 11 stenosis (4.4%) at gastrojejunostomy and none in the biliopancreatic diversion group. Mean surgical time for the anastomosis was 40±15 minutes. There were no deaths, sepsis, abdominal abscess, deep venous thrombosis or pulmonary embolism. Average hospital stay was 5.1±2.4 days. Conclusions. Even though most surgeons believe that staples anastomosis is easier, hand-sewn technique can be reproducible by surgeons with laparoscopic sutures experience. This technique has a longer operation time but continuous training provides advanced laparoscopic skills and significantly reduces operation time The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)