Tres casos extremos de síndrome de intestino corto: STEP y neoválvulas. Algoritmo de actuación / Three Extreme Cases of Short Bowel Syndrome: STEP and Neovalves. Decision Algorithm

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Long-Term Results of Serial Transverse Enteroplasty with Neovalve Creation for Extreme Short Bowel Syndrome: Report of Two Cases.

OBJECTIVE: The aim of this article was to determine whether serial transverse enteroplasty (STEP) and the creation of a new ileocecal valve in extreme short bowel syndrome (SBS) cases (<45 cm) is effective in intestinal adaptation and improvement of nutritional parameters and serum citrulline levels. PATIENTS AND METHODS: We present 2 cases of SBS treated with STEP. Enterectomy was performed for massive intestinal ischemia secondary to a gastrointestinal stromal tumor in the first case and to catastrophic antiphospholipid syndrome in the second. After enterectomy, the short residual bowel measured 34 cm in the first patient and 45 cm in the second. In both cases STEP, cholecystectomy, and gastrostomy were performed. In the first case a Brooke neovalve was created, and in the other the ileocecal valve was preserved. RESULTS: Both patients could finally be weaned off total parenteral nutrition (TPN) and gastrostomy feeding, maintaining a good nutritional status 1 year after surgery. CONCLUSIONS: In extreme SBS, a minimum length of 80-90 cm of functioning small bowel and an intact ileocecal valve are necessary. We plead for the use of STEP with preservation of the ileocecal valve or creation of a neovalve using the Brooke technique in order to achieve the ultimate goal, which is to wean patients off TPN. After a critical review of different surgical techniques, a treatment algorithm is proposed.

The truncated isoform of somatostatin receptor5 (sst5TMD4) is associated with poorly differentiated thyroid cancer.

Somatostatin receptors (ssts) are expressed in thyroid cancer cells, but their biological significance is not well understood. The aim of this study was to assess ssts in well differentiated (WDTC) and poorly differentiated thyroid cancer (PDTC) by means of imaging and molecular tools and its relationship with the efficacy of somatostatin analog treatment. Thirty-nine cases of thyroid carcinoma were evaluated (20 PDTC and 19 WDTC). Depreotide scintigraphy and mRNA levels of sst-subtypes, including the truncated variant sst5TMD4, were carried out. Depreotide scans were positive in the recurrent tumor in the neck in 6 of 11 (54%) PDTC, and in those with lung metastases in 5/11 cases (45.4%); sst5TMD4 was present in 18/20 (90%) of PDTC, being the most densely expressed sst-subtype, with a 20-fold increase in relation to sst2. In WDTC, sst2 was the most represented, while sst5TMD4 was not found; sst2 was significantly increased in PDTC in comparison to WDTC. Five depreotide positive PDTC received octreotide for 3-6 months in a pilot study with no changes in the size of the lesions in 3 of them, and a significant increase in the pulmonary and cervical lesions in the other 2. All PDTC patients treated with octreotide showed high expression of sst5TMD4. ROC curve analysis demonstrated that only sst5TMD4 discriminates between PDTC and WDTC. We conclude that sst5TMD4 is overexpressed in PDTC and may be involved in the lack of response to somatostatin analogue treatment.

IGF1 modifications after bariatric surgery in morbidly obese patients: potential implications of nutritional status according to specific surgical technique.

OBJECTIVES: IGF1 is decreased in morbidly obese (MO) patients and its changes after bariatric surgery weight loss (WL) are not well known. The aim of this study was to analyse IGF1 modifications in MO patients after WL and its relationship to ghrelin and to different types of surgeries. DESIGN: Retrospective follow-up study at the University Medical Center. METHODS: One hundred and nine MO patients (age 44.19.3, BMI 51.748.75KG/M(2)) were evaluated at baseline and 1 year after surgery: 28 sleeve gastrectomy (SG), 31 distal modified (m), and 50 ringed (r) Roux-en-Y gastric bypass (RYGBP) surgery. Changes in IGF1, IGFBP3, ratio IGF1:IGFBP3, and ghrelin were evaluated 1 year after surgery. RESULTS: Baseline prevalence of low IGF1 (defined by s.d. IGF1<-2) was 22%, and %WL 1 year after surgery was 34.9±8.9%. There was a significant decrease in IGFBP3 in all the procedures, an increase in IGF1:IGFBP3 ratio in rRYGBP and SG, but total IGF1 only increased significantly in SG. Albumin concentrations decreased in mRYGBP, did not change in rRYGBP, but increased in SG after surgery. Total ghrelin concentrations increased after both RYGBPs and decreased after SG (P<0.05 in all cases). The prevalence of low IGF1 decreased in SG (28.6 vs 10.1%, P=0.03) and did not change in RYGPBP techniques. The %albumin change was the only dependent variable associated with the % total IGF1 change. CONCLUSIONS: Recovery of low IGF1 after bariatric surgery was specifically related to the albumin modifications induced by surgery and was not related to ghrelin modifications.

Intact parathyroid hormone measurement at 24 hours after thyroid surgery as predictor of parathyroid function at long term.

BACKGROUND: There is no consensus about the usefulness of postoperative intact parathyroid hormone (iPTH) determination to predict permanent hypoparathyroidism (pHPP). We evaluated the value of calcium (Ca2+) and iPTH concentration at 24 hours after total thyroidectomy (TT) for predicting pHPP. METHODS: Ca2+ and iPTH levels from 70 consecutive patients who underwent TT were measured at 24 hours and 6 months after TT. RESULTS: Five patients (7.1%) developed pHPP. An iPTH concentration ≤5.8 pg/mL at 24 hours after TT identified patients at risk for pHPP (sensitivity, 100%; specificity, 81.5%), but it was not accurate enough to predict its development (positive predictive value, 30%). Conversely, an iPTH level >5.8 pg/mL predicted normal parathyroid function at 6 months (negative predictive value, 100%). Compared with iPTH, a postoperative Ca2+ level ≤1.95 mmol/L was 60% sensitive and 78.5% specific to predict pHPP. CONCLUSIONS: An iPTH concentration >5.8 pg/mL on the first postoperative day rules out pHPP with much better diagnostic accuracy than Ca2+. Postoperative iPTH could be helpful in identifying patients at risk for developing pHPP.

Pancreatic endocrine tumors or apudomas.

INTRODUCTION AND OBJECTIVE: pancreatic endocrine tumors (PET) are difficult to diagnose. Their accurate localization using imaging techniques is intended to provide a definite cure. The goal of this retrospective study was to review a PET series from a private institution. PATIENTS AND METHODS: the medical records of 19 patients with PETs were reviewed, including 4 cases of MEN-1, for a period of 17 years (1994-2010). A database was set up with ten parameters: age, sex, symptoms, imaging techniques, size and location in the pancreas, metastasis, surgery, complications, adjuvant therapies, definite diagnosis, and survival or death. RESULTS: a total of 19 cases were analyzed. Mean age at presentation was 51 years (range: 26-67 y) (14 males, 5 females), and tumor size was 5 to 80 mm (X: 20 mm). Metastatic disease was present in 37% (7/19). Most underwent the following imaging techniques: ultrasounds, computed tomography (CT) an magnetic resonance imaging (MRI). Fine needle aspiration punction (FNA) was performed for the primary tumor in 4 cases. Non-functioning: 7 cases (37%), insulinoma: 2 cases [1 with possible multiple endocrine neoplasia (MEN)], Zollinger-Ellison syndrome (ZES) from gastrinoma: 5 (3 with MEN-1), glucagonoma: 2 cases, 2 somatostatinomas; carcinoid: 1 case with carcinoide-like syndrome. Most patients were operated upon: 14/19 (73%). Four (4/14:28%) has postoperative complications following pancreatectomy: pancreatitis, pseudocyst, and abdominal collections. Some patients received chemotherapy (4), somatostatin (3) and interferon (2) before or after surgery. Median follow-up was 48 months. Actuarial survival during the study was 73.6% (14/19). CONCLUSIONS: age was similar to that described in the literature. Males were predominant. Most cases were non-functioning (37%). Most patients underwent surgery (73%) with little morbidity (28%) and an actuarial survival of 73.6% at the time of the study.

Tumores endocrinos o apudomas pancreáticos / Pancreatic endocrine tumors or apudomas

Introducción y objetivo: los tumores endocrinos pancreáticos (TEP) son difíciles de diagnosticar. Su localización exacta mediante métodos de imagen tiene el propósito de lograr una curación definitiva. El objetivo de este trabajo retrospectivo fue revisar una serie institucional privada de TEP. Pacientes y métodos: se revisaron las historias clínicas de 19 pacientes con TEP, 4 casos con NEM-1, observados durante 17 años (1994-2010). Se creó una base de datos con diez parámetros: edad y sexo, síntomas, métodos diagnósticos de imagen, tamaño y situación en el páncreas, metástasis, cirugía, complicaciones, tratamientos complementarios, diagnóstico definitivo, supervivencia o éxitus. Resultados: en total se analizaron 19 casos. La edad media de presentación fue 51 años (intervalo: 26-67 años) (14 varones y 5 mujeres), con un tamaño del tumor de 5 a 80 mm (X: 20 mm). El 37% (7/19) tenían metástasis. En la mayoría se practicaron los siguientes métodos de imagen: ecografía, TAC y RM. La PAAF del tumor primitivo se practicó en 4 casos. No funcionantes: 7 casos (37%), insulinomas: 2 casos (1 con posible NEM), SZE por gastrinomas: 5 (3 con NEM-1), glucagonoma: 2 casos, 2 somatostatinomas, carcinoide: 1 caso con síndrome carcinoide-like. La mayoría de los enfermos fueron intervenidos quirúrgicamente 14/19 (73%). En cuatro (4/14: 28%) pacientes hubo complicaciones postoperatorias después de pancreatectomías: páncreas, seudoquiste y colecciones abdominales. Algunos casos fueron tratados con quimioterapia (4), somatostatina (3) e interferón (2) antes o después de la cirugía. La mediana de seguimiento fue de 48 meses. La supervivencia actuarial en el momento del estudio fue del 73,6% (14/19). Conclusiones: la edad fue similar a lo descrito en la literatura. El sexo predominante fue el masculino. La mayoría fueron no funcionantes (37%). La mayoría fueron intervenidos quirúrgicamente (73%), con escasa morbilidad (28%) y con una supervivencia actuarial en el momento de cerrar el estudio del 73,6%(AU)

Introduction and objective: pancreatic endocrine tumors (PET) are difficult to diagnose. Their accurate localization using imaging techniques is intended to provide a definite cure. The goal of this retrospective study was to review a PET series from a private institution. Patients and methods: the medical records of 19 patients with PETs were reviewed, including 4 cases of MEN-1, for a period of 17 years (1994-2010). A database was set up with ten parameters: age, sex, symptoms, imaging techniques, size and location in the pancreas, metastasis, surgery, complications, adjuvant therapies, definite diagnosis, and survival or death. Results: a total of 19 cases were analyzed. Mean age at presentation was 51 years (range: 26-67 y) (14 males, 5 females), and tumor size was 5 to 80 mm (X: 20 mm). Metastatic disease was present in 37% (7/19). Most underwent the following imaging techniques: ultrasounds, computed tomography (CT) and magnetic resonance imaging (MRI). Fine needle aspiration punction (FNA) was performed for the primary tumor in 4 cases. Nonfunctioning: 7 cases (37%), insulinoma: 2 cases [1 with possible multiple endocrine neoplasia (MEN)], Zollinger-Ellison syndrome (ZES) from gastrinoma: 5 (3 with MEN-1), glucagonoma: 2 cases, 2 somatostatinomas; carcinoid: 1 case with carcinoide-like syndrome. Most patients were operated upon: 14/19 (73%). Four (4/14: 28%) has postoperative complications following pancreatectomy: pancreatitis, pseudocyst, and abdominal collections. Some patients received chemotherapy (4), somatostatin (3) and interferon (2) before or after surgery. Median follow-up was 48 months. Actuarial survival during the study was 73.6% (14/19). Conclusions: age was similar to that described in the literature. Males were predominant. Most cases were non-functioning (37%). Most patients underwent surgery (73%) with little morbidity (28%) and an actuarial survival of 73.6% at the time of the study(AU)

Effects of two variants of Roux-en-Y Gastric bypass on metabolism behaviour: focus on plasma ghrelin concentrations over a 2-year follow-up.

BACKGROUND: To study the effects of two variants of Roux-en-Y gastric bypass (RYGBP) on plasma ghrelin concentrations according to different exposure of gastric fundus to the nutrient pathway. METHODS: A prospective longitudinal 2-year follow-up study was conducted. Ninety-six morbidly obese (MO) patients (age range: 41.6 +/- 9.6 years, body mass index: 53 +/- 9.5 kg/m(2)) were assigned to two bariatric surgical (BS) procedures: one that preserves food contact with gastric fundus (ringed RYGBP, n = 50) and the other that avoids it (modified RYGBP, n = 46). Different anthropometric and biochemical parameters were studied, focusing on ghrelin concentrations at baseline and 6, 12, and 24 months post-BS. RESULTS: At 24 months post-BS, all metabolic parameters studied had improved in all patients compared with those at 1-year follow-up and baseline (p < 0.05). However, high-density lipoprotein cholesterol concentrations took 2 years to normalise in 80% of patients, interleukin-6 decreased significantly in relation to baseline only after 2 years from BS (p < 0.001), and tumour necrosis factor alpha concentrations did not significantly decrease during the 2 years of follow-up. Plasma ghrelin concentrations increased in both surgical groups compare to baseline during the first year (24.6% in modified RYGBP and 36.62% in ringed RYGBP) and remained stable at the second year of follow-up, with no statistical differences between groups. CONCLUSIONS: In the second year of follow-up after BS, morbidity continued to improve in MO patients despite a lesser weight loss in relation to the first year. An increase in plasma ghrelin concentrations was found, regardless of nutrient contact with gastric fundus. Furthermore, changes in plasma ghrelin concentrations appeared to be independent of weight loss.

Pinça aortomesentèrica, síndrome de l’artèria mesentèrica superior o síndrome de Wilkie. A propòsit d’un cas / Superior Mesenteric Artery Syndrome (Wilkie Syndrome): A Case Report

Introducció. La síndrome de l’artèria mesentèrica superior(SAMS) és poc coneguda, però cal tenir-la en compteen el diagnòstic diferencial dels vòmits com a símptoma principal, sobretot en adolescents, ja que de vegadespoden ser etiquetats d’anorèxia.Cas clínic. Exposem un cas d’una noia de 13 anys ambvòmits persistents postprandials i pèrdua de pes que foudiagnosticada de SMAS per exclusió d’altres diagnòstics(brides de Ladd, pàncrees anular o ectòpic, duplicació intestinalo trastorns de l’alimentació) i que es va intervenirquirúrgicament amb duodenoduodenostomia laterolateral.Comentari. El motiu de presentar aquest cas és cridarl’atenció que els vòmits a l’adolescència poden tenir unaetiologia orgànica com la SAMS, encara que és excepcional.Hem volgut revisar la bibliografia a fi de repassar lescaracterístiques diagnòstiques i el diagnòstic diferencialmés acurat, així com presentar les diferents variacions enel tractament (AU)

Introduction. The superior mesenteric artery syndrome(SMAS) is a little known gastrointestinal disease, which hasto be considered in the differential diagnosis of vomiting,particularly in adolescents, an age group where similarsymptoms may be labeled as anorexia.Case Report. We report the case of a 13 year-old girlwith persistent vomiting after meals, associated withweight loss, and who was diagnosed with SMAS after otherdiagnoses such as Ladd adherences, annular or ectopicpancreas, intestinal duplication, or nutrition disturbances,were excluded. A laterolateral duodenoduodeostomy wasperformed, with resolution of the symptoms.Discussion. Although uncommon, vomiting and weight loss in adolescents may be due to a somatic etiologysuch as SMAS. We have reviewed the literature anddiscussed the clinical characteristics, differential diagnosisand treatment options of SMAS (AU)

Increased exercise capacity after surgically induced weight loss in morbid obesity.

OBJECTIVE: To investigate the effects of surgically induced weight loss on exercise capacity in patients with morbid obesity (MO). RESEARCH METHODS AND PROCEDURES: A prospective 1-year follow-up study was carried out, with patients being their own controls. A symptom-limited cardiopulmonary exercise stress test was performed in 31 MO patients (BMI > 40 kg/m2) before and 1 year after undergoing bariatric surgery. RESULTS: At 1 year after surgery, weight was reduced from 146 +/- 33 to 95 +/- 19 kg (p < 0.001), and BMI went from 51 +/- 4 to 33 +/- 6 kg/m2 (p < 0.001). After weight loss, obese patients performed each workload with lower oxygen consumption, heart rate, systolic arterial pressure, and ventilatory volume (p < 0.001). This reduced energy expenditure allowed them to increase the duration of their effort test from 13.8 +/- 3.8 to 21 +/- 4.2 minutes (p < 0.001). Upon finishing the exercise, MO patients before surgery were able to reach only 83% of their age-predicted maximal heart rate, and their respiratory exchange ratio was 0.87 +/- 0.06. After weight loss, those values were 90% and 1 +/- 0.08, respectively (p < 0.01). When we compared the peak O2 pulse corrected by fat free mass before and after surgery, no significant differences between the groups were found. DISCUSSION: After surgically induced weight loss, MO patients markedly improved their exercise capacity. This is due to the fact that they were able to perform the external work with lower energy expenditure and also to increase cardiovascular stress, optimizing the use of cardiac reserve. There were no differences in cardiac function before and after surgery.

Priorización de pacientes en cirugía bariátrica: índice de riesgo / Patient priorization in bariatric surgery risk index

El incremento de la prevalencia de la obesidad mórbida en los países industrializados, junto a sus consecuencias sanitarias, está provocando un aumento sustancial de la actividad quirúrgica y una sobrecarga global de los servicios de salud. Las enormes listas de espera que se están generando obligan al establecimiento de prioridades, basadas en el riesgo quirúrgico y en las posibilidades de mejorar con la cirugía, que permitan definir el orden de asignación de recursos. Por otro lado, el cirujano está obligado a practicar la técnica más adecuada a cada paciente, por vía abierta o laparoscópica, con un porcentaje mínimo de complicaciones. Los índices de riesgo aplicables en la valoración del grado de prioridad deben basarse en la edad, el sexo, tipo de obesidad (androide o ginoide) y grado (índice de masa corporal), comorbilidad asociada, criterios psicológicos y sociolaborales. Asimismo, debe tenerse en cuenta la posibilidad de adaptación del paciente al grado de restricción y malabsorción producidos por la cirugía, así como la necesaria modificación de los hábitos de vida que contribuyan a su éxito(AU)

[Cardiopulmonary function and exercise capacity in patients with morbid obesity]. / Función cardiopulmonar y capacidad de ejercicio en pacientes con obesidad mórbida.

INTRODUCTION AND OBJECTIVES: The effect of obesity on cardiac function is still under discussion. The objective of this study was to assess cardiopulmonary capacity in morbidly obese patients. Patients and method. A symptom-limited cardiopulmonary exercise stress test was carried out in 31 morbidly obese patients (BMI 50 9 kg/m2) and 30 normal controls (BMI 24 2 kg/m2. Cardiovascular function was evaluated using the oxygen pulse (oxygen uptake/heart rate). RESULTS: There were no differences in age, sex and height between both groups. During the effort the obese subjects presented greater oxygen uptake, heart rate, systolic arterial pressure and minute ventilation and shorter test duration than control group (14 3 vs 27 4 min; p < 0.001). Oxygen pulse values were higher in obese patients. However, after oxygen uptake indexation by fat free mass, these differences disappeared, suggesting a similar cardiovascular function. At the end of the exercise, the control group reached 96% of their age-predicted maximal heart rate and their respiratory exchange ratio was 1 0.2. Obese patients only reached 86% and 0.87 0.2, respectively. CONCLUSIONS: Due to their need of more energy output to move total body mass morbidly obese patients have a reduced exercise capacity. They finish the test having done a submaximal exercise. However, during this effort they show a normal cardiopulmonar capacity.

Función cardiopulmonar y capacidad de ejercicio en pacientes con obesidad mórbida / Cardiopulmonary function and exercise capacity in patients with morbid obesity

Introducción y objetivos. La repercusión de la obesidad sobre la función cardíaca es motivo de controversia. El propósito del presente estudio ha sido determinar la capacidad cardiopulmonar en pacientes con obesidad mórbida. Pacientes y método. Hemos realizado una ergoespirometría limitada por síntomas a 31 pacientes con obesidad mórbida (IMC 50 ñ 9 kg/m2) y a 30 individuos como grupo control (IMC 24 ñ 2 kg/m2). La función cardiovascular ha sido valorada mediante el pulso de oxígeno (consumo de oxígeno/frecuencia cardíaca).Resultados. No existían diferencias en edad, sexo y talla entre ambos grupos. Durante el esfuerzo, los sujetos obesos presentaron un consumo de oxígeno, frecuencia cardíaca, presión arterial sistólica y ventilación por minuto significativamente más elevados que el grupo control, con menor duración de la prueba (14 ñ 3 frente a 27 ñ 4 min; p < 0,001). Los valores de pulso de oxígeno fueron más altos en los pacientes obesos. Sin embargo, tras corregir el consumo de oxígeno por la masa magra, las diferencias en el pulso de O2 desaparecieron, demostrando una función cardiovascular similar. Al final del ejercicio, el grupo control alcanzó el 96 por ciento de su frecuencia cardíaca máxima teórica y su cociente respiratorio fue de 1 ñ 0,2. Los pacientes obesos sólo alcanzaron el 86 por ciento de la frecuencia cardíaca máxima teórica y su cociente respiratorio fue de 0,87 ñ 0,2.Conclusiones. Los pacientes con obesidad mórbida tienen una capacidad de trabajo reducida debido al gran consumo energético que realizan al mover su masa corporal. Finalizan la prueba habiendo realizado un esfuerzo submáximo. No obstante, durante este esfuerzo demuestran una capacidad cardiopulmonar normal (AU)