Anudado deslizante con autobloqueo y de Aberdeen en las suturas bariátricas laparoscópicas. Video / Sliding and self-locking and Aberdeen knot in laparoscopic bariatric sutures. Video

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Inicios de la cirugía bariátrica y metabólica en España / Beginnings of bariatric and metabolic surgery in Spain

La cirugía bariátrica (CB) de bari = peso y iatrein = cura) trata la obesidad y comienza en España en 1973. Su mayor desarrollo ocurre tras la fundación de SECO (Sociedad Española de Cirugía de la obesidad) en 1997. La finalidad de este trabajo es reflejar los cambios que han ocurrido en éstos 42 años

Bariatric surgery (BS) from the Greek bari = weight and iatrein = cure) treats obesity and began in Spain in 1973. Its greatest development occurs after the founding of SECO (Spanish Society of Obesity Surgery) in 1997. The purpose of this work is to reflect the changes that have occurred in these 22 years

Veinticinco años de cruce duodenal. Cómo cambiar al cruce / Twenty-five years of duodenal switch. How to switch to the duodenal switch

Antecedentes: el cruce duodenal (CD) es un procedimiento que combina una gastrectomía vertical (GV) más una derivación biliopancreática (DBP). Objetivos: informar de nuestra experiencia en 950 CD consecutivos en pacientes con obesidad mórbida (OM) realizados de 1994 a 2011 y con 27 años de seguimiento. Entorno: mezcla de enseñanza e institución privada en un hospital comarcal de España. Métodos: revisión retrospectiva de 950 pacientes consecutivos con obesidad mórbida tratados con cirugía de CD. Resultados: se realizaron 518 CD abiertos (CDA) y 432 CD laparoscópicos (CDL). La mortalidad operatoria fue del 0,84% (1,38% en CDA y 0,38% en CDL). El 4,84% tuvo una fuga, dos tuvieron insuficiencia hepática (0,2%) y la desnutrición estuvo presente en el 3,1%. A los cinco años, el porcentaje de sobrepeso perdido (PSP) de índice de masa corporal (IMC) fue del 80% y el porcentaje de pérdida esperada de IMC fue más del 100%. Conclusiones: el CD es la técnica bariátrica más agresiva pero con mejor pérdida de peso a largo plazo. Se describen las complicaciones operatorias y pautas de seguimiento a largo plazo

Background: the duodenal switch (DS) is a procedure that combines a vertical gastrectomy (VG) plus a biliopancreatic diversion (BPD). Objectives: to report our experience in 950 consecutive DS patients with morbid obesity (MO) performed from 1994 to 2011, with 27 years of follow-up. Environment: mix of teaching and private institution in a regional hospital in Spain. Methods: retrospective review of 950 consecutive morbidly obese patients treated with DS surgery. Results: five hundred and eighteen open DS (ODS) and 432 laparoscopic DS (LDS) were performed. Operative mortality was 0.84% (1.38% in ODS and 0.38% in LDS); 4.84% had one leak, two had liver failure (0.2%) and malnutrition was present in 3.1%. At five years, the body mass index (BMI) percentage of lost overweight (%EWL) was 80% and the percentage of expected BMI loss was more than 100%. Conclusions: the DS is the most aggressive bariatric technique but with the best long-term weight loss. Operative complications and long-term follow-up guidelines are described

[Twenty-five years of duodenal switch. How to switch to the duodenal switch]. / Veinticinco años de cruce duodenal. Cómo cambiar al cruce.

INTRODUCTION: Background: the duodenal switch (DS) is a procedure that combines a vertical gastrectomy (VG) plus a biliopancreatic diversion (BPD). Objectives: to report our experience in 950 consecutive DS patients with morbid obesity (MO) performed from 1994 to 2011, with 27 years of follow-up. Environment: mix of teaching and private institution in a regional hospital in Spain. Methods: retrospective review of 950 consecutive morbidly obese patients treated with DS surgery. Results: five hundred and eighteen open DS (ODS) and 432 laparoscopic DS (LDS) were performed. Operative mortality was 0.84% (1.38% in ODS and 0.38% in LDS); 4.84% had one leak, two had liver failure (0.2%) and malnutrition was present in 3.1%. At five years, the body mass index (BMI) percentage of lost overweight (%EWL) was 80% and the percentage of expected BMI loss was more than 100%. Conclusions: the DS is the most aggressive bariatric technique but with the best long-term weight loss. Operative complications and long-term follow-up guidelines are described.

INTRODUCCIÓN: Antecedentes: el cruce duodenal (CD) es un procedimiento que combina una gastrectomía vertical (GV) más una derivación biliopancreática (DBP). Objetivos: informar de nuestra experiencia en 950 CD consecutivos en pacientes con obesidad mórbida (OM) realizados de 1994 a 2011 y con 27 años de seguimiento. Entorno: mezcla de enseñanza e institución privada en un hospital comarcal de España. Métodos: revisión retrospectiva de 950 pacientes consecutivos con obesidad mórbida tratados con cirugía de CD. Resultados: se realizaron 518 CD abiertos (CDA) y 432 CD laparoscópicos (CDL). La mortalidad operatoria fue del 0,84% (1,38% en CDA y 0,38% en CDL). El 4,84% tuvo una fuga, dos tuvieron insuficiencia hepática (0,2%) y la desnutrición estuvo presente en el 3,1%. A los cinco años, el porcentaje de sobrepeso perdido (PSP) de índice de masa corporal (IMC) fue del 80% y el porcentaje de pérdida esperada de IMC fue más del 100%. Conclusiones: el CD es la técnica bariátrica más agresiva pero con mejor pérdida de peso a largo plazo. Se describen las complicaciones operatorias y pautas de seguimiento a largo plazo.

Four decades of bariatric surgery in a community hospital of Spain.

INTRODUCTION: Bariatric surgical practice changes in the community setting may be under-reported. We present the developments in a Spanish bariatric surgical practice in the community setting of Alcoy from its origin in 1977 through the present. METHODS: Bariatric surgical techniques employed in a country community setting over the course of nearly four decades were reviewed retrospectively and qualitatively. RESULTS: Surgeons and medical professionals from Alcoy, Spain were involved in the evolution of bariatric surgery patient management and surgical technique from 1977s through 2017. During the last 40 years, 1,475 patients were treated in our clinics. Spanish bariatric surgeons contributed to advances in gastric bypass in the 1970s, vertical banded gastroplasty in the 1980s, bilio-pancreatic diversion/duodenal switch in the 1990s, and innovations associated with laparoscopy from the 1990s onward. Outcomes and approaches to prevention and treatment of bariatric surgical complications are reviewed from a community perspective. Contributions to the bariatric surgical nomenclature and weight-loss reporting are noted. CONCLUSIONS: The practice of bariatric surgery in the community setting must be updated continuously, as in any human and surgical endeavor. Medical professionals in community bariatric practices should contribute their experiences to the field through all avenues of scientific interaction and publication.

Four decades of bariatric surgery in a community hospital of Spain / Cuatro décadas de la cirugía bariátrica en un hospital comarcal

Introduction: Bariatric surgical practice changes in the community setting may be under-reported. We present the developments in a Spanish bariatric surgical practice in the community setting of Alcoy from its origin in 1977 through the present. Methods: Bariatric surgical techniques employed in a country community setting over the course of nearly four decades were reviewed retrospectively and qualitatively. Results: Surgeons and medical professionals from Alcoy, Spain were involved in the evolution of bariatric surgery patient management and surgical technique from 1977s through 2017. During the last 40 years, 1,475 patients were treated in our clinics. Spanish bariatric surgeons contributed to advances in gastric bypass in the 1970s, vertical banded gastroplasty in the 1980s, bilio-pancreatic diversion/duodenal switch in the 1990s, and innovations associated with laparoscopy from the 1990s onward. Outcomes and approaches to prevention and treatment of bariatric surgical complications are reviewed from a community perspective. Contributions to the bariatric surgical nomenclature and weight-loss reporting are noted. Conclusions: The practice of bariatric surgery in the community setting must be updated continuously, as in any human and surgical endeavor. Medical professionals in community bariatric practices should contribute their experiences to the fi eld through all avenues of scientific interaction and publication (AU)

Introducción: los cambios en la práctica de cirugía bariátrica en un hospital comarcal han sido muy importantes. Presentamos la evolución en el Hospital Comarcal de Alcoy desde su origen en 1977 hasta el presente. Métodos: se revisan retrospectivamente las técnicas quirúrgicas bariátricas empleadas en un entorno comarcal a lo largo en cuatro décadas. Resultados: los cirujanos Alcoy, han estado involucrados en la evolución de la gestión de los pacientes de cirugía bariátrica y las técnicas quirúrgicas desde 1977 hasta la actualidad. Durante los 40 años trascurridos, 1.475 pacientes fueron tratados en nuestras clínicas comenzando con la derivación gástrica (DG) en la década de 1970, la gastroplastia vertical anillada (GVA) en la década de 1980, el cruce duodenal (CD) bilio-pancreático en la década de 1990, y con el acceso por vía laparoscópica desde la década de 1990. Los resultados y los enfoques para la prevención y el tratamiento de las complicaciones de la cirugía bariátrica así como la contribución en la nomenclatura de cirugía bariátrica y la notificación de pérdida de peso son revisados desde una perspectiva comarcal. Conclusiones: la práctica de la cirugía bariátrica en el entorno comarcal debe ser actualizada continuamente. Los cirujanos bariátricos pueden contribuir con sus experiencias en el ámbito comarcal con actualizaciones y publicaciones (AU)

Laparoscopic gastric sleeve, subtotal antrectomy and omentoplasty.

Sleeve-forming gastrectomy (SFG) is the operation to make a gastric sleeve (GS). The video presents the subtotal removal of the antrum and the use of sliding self-locking stitch and Aberdeen knots as suture reinforcement with omentoplasty of the GS staple line with the aim of decreasing bleeding and leaks.

Weight loss reporting: predicted body mass index after bariatric surgery.

BMI and %EBMIL are the most accurate methods for comparing results of patients after bariatric surgery. %EBMIL is based on BMI 25 as a constant end-point for all patients, but BMI 25 is easily achieved by patients with BMI < 50, whereas it is not so feasible for patients with BMI > 50. We were prompted to obtain by statistical methods a mathematical formula able to calculate the final BMI (FBMI) 3 years after the operation, dependent on the initial or preoperative BMI (IBMI) of a multicenter group of morbid obese patients operated with different bariatric techniques. We also obtained a specific formula for each bariatric procedure of this group of patients. We propose the name Predicted BMI for the value obtained with these formulas and its application in the %EBMIL instead of the constant value of BMI 25. We have analyzed the IBMI and FBMI of a multicenter group of 7,410 patients, subjected to different bariatric procedures with a minimum follow-up of 36 months. Statistical methods with a linear regression model have been used to obtain the two types (global and specific) of Predicted BMI. We first obtained a general formula of PBMI = IBMI x 0.4 + 11.75 for the total population of patients, and a second specific formula for each bariatric technique: PBMI = IBMI x 0.43 + 13.25 + technique_correction_adjustment. Predicted BMI and its application to the %EBMIL may result in a more rational comparison of results of bariatric patients, bariatric techniques, and groups of bariatric surgeons. Predicted BMI may advance the BMI that each patient would probably achieve after surgery.

Índice de masa corporal esperable tras cirugía bariátrica / Expected body mass index after bariatric surgery

El índice de masa corporal (IMC) es el método más práctico para medir y comparar la obesidad entre diferentes individuos. El porcentaje perdido del exceso de IMC (PPEIMC) se utiliza para presentar los resultados de los pacientes operados y se basa en la premisa de que un IMC de 25 es el objetivo final, al ser el límite superior de individuos normales. Alcanzar un IMC de 25 es posible en pacientes obesos mórbidos con IMC inicial bajo (<50), pero es poco frecuente en pacientes superobesos con IMC superior a 50. El IMC esperable (IMCE) sería aquel que deberían alcanzar todos los individuos de acuerdo con su IMC inicial. Objetivo El objetivo de este trabajo es buscar por métodos estadísticos una fórmula, basada en hechos clínicos, que identifique el IMCE de acuerdo con el IMC inicial. Pacientes y método Sé ha analizado el IMC inicial y final de un grupo de 135 pacientes operados de obesidad mórbida con la técnica del cruce duodenal con un seguimiento superior a 3 años. Se ha utilizado un método estadístico de regresión lineal para obtener una fórmula que calcule el IMCE de cada paciente operado. Resultado Se ha obtenido un algoritmo en el que el IMCE=IMC inicial×0,33+14. Si se aplicaba el IMCE individualizado en vez de la constante del IMC de 25, el PPEIMC mediano era de 99,48 (rango: 76,75 a 110,46). Conclusión Este resultado evidencia que la aplicación individual del IMCE estima con mayor fiabilidad el éxito o fracaso de las operaciones bariátricas (AU)

Introduction The body mass index (BMI) is the most practical method to measure and compare obesity between individuals. The Percentage of Excess BMI Loss (PEBMIL) is used to present results in operated patients and is based on the premise that a BMI-25 is the final aim, on being the upper limit in normal subjects. It is possible to achieve a BMI-25 in morbid obese (MO) patients with initial low BMIs (<50) but it is rare in overweight (OW) patients with a BMI >50. Expected BMI (EBMI) would be that which should be reached by all subjects depending on their initial BMI. Objective The objective of this study is to search for, using statistical methods, a formula based on clinical evidence that can identify the EBMI depending on the initial BMI. Patients and method We analysed the initial and final BMI in a group of 135 MO patients, operated on using the duodenal switch procedure and with a follow up of over 3 years. A linear regression method has been used to obtain a formula that could calculate the EBMI of each patient operated on. Results We obtained an algorithm in which EBMI=Initial BMI×0.33+14. If we apply the individualised EBMI instead of the BMI-25, the median PEBMIL was 99.48 (range: 76.75–110.46).Conclusion This result suggests that the application of an individual EBMI is a more reliable estimate of the success or failure of bariatric operations (AU)

[Expected body mass index after bariatric surgery]. / Indice de masa corporal esperable tras cirugía bariátrica.

INTRODUCTION: The body mass index (BMI) is the most practical method to measure and compare obesity between individuals. The Percentage of Excess BMI Loss (PEBMIL) is used to present results in operated patients and is based on the premise that a BMI-25 is the final aim, on being the upper limit in normal subjects. It is possible to achieve a BMI-25 in morbid obese (MO) patients with initial low BMIs (<50) but it is rare in overweight (OW) patients with a BMI>50. Expected BMI (EBMI) would be that which should be reached by all subjects depending on their initial BMI. OBJECTIVE: The objective of this study is to search for, using statistical methods, a formula based on clinical evidence that can identify the EBMI depending on the initial BMI. PATIENTS AND METHOD: We analysed the initial and final BMI in a group of 135 MO patients, operated on using the duodenal switch procedure and with a follow up of over 3 years. A linear regression method has been used to obtain a formula that could calculate the EBMI of each patient operated on. RESULTS: We obtained an algorithm in which EBMI=Initial BMIx0.33+14. If we apply the individualised EBMI instead of the BMI-25, the median PEBMIL was 99.48 (range: 76.75-110.46). CONCLUSION: This result suggests that the application of an individual EBMI is a more reliable estimate of the success or failure of bariatric operations.

Conversión laparoscópica de bypass gástrico a derivación biliopancreática. Modificación tipo Scopinaro / Laparoscopic conversion of gastric bypass to biliopancreatic diversion. A Scopinaro type modification

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Sleeve gastrectomy in a 10-year-old child.

Adolescents bariatric surgery (ABS) in morbid obesity (MO), with or without comorbid conditions, is and will be more and more indicated. Restrictive operations have the advantage of no influence on absorption. Laparoscopic sleeve gastrectomy (LSG) can be an excellent alternative. A LSG was done in a 10-year-old boy, body mass index (BMI) 42, who has Blount's disease (tibia vara) with severe pain at the knee joints that made him a wheelchair-bound person. He had a LSG and gallbladder removal without incidents. Eight months later, he has a BMI 28 and almost all his knees pain is gone. No side effects have been detected. A LSG may be the ideal bariatric operation for ABS with MO.

Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) can be complicated, in the early postoperative course, by an esophagogastric junction (EGJ) leak with very serious consequences. A 48-year-old woman developed an EGJ leak 3 days after LSG surgery and was treated with conservative measures. Finally, 6 weeks after the original surgery, a Roux limb was brought to the EGJ and anastomosed side-to-end to the fistula. At the beginning, the Roux limb was the only functioning outlet and finally, 2 months later, both pathways (the gastric sleeve and the Roux-en-Y) are patent at 3 months after surgery. The Roux limb resolved a dangerous EGJ leak after a LSG.

Treatment of gastric leaks with coated self-expanding stents after sleeve gastrectomy.

BACKGROUND: Duodenal switch (DS) is one of the most effective techniques for the treatment of morbid obesity and its co-morbidities, with mortality rate <1%, but with 9.4% morbidity rates (6.5% due to leaks). In our experience, leaks of the staple-line after sleeve gastrectomy (SG) are the most frequent sites of fistula formation and conservative treatment usually takes a long time. We present our experience in the treatment of gastric leaks with coated self-expandable stents (CSES). METHODS: 6 patients had gastric leaks at the gastroesophageal (GE) junction after SG or DS. One patient had a symptomatic gastro-bronchial fistula. Stents were placed by the interventional radiologist under fluoroscopic control and removed endoscopically. In one case, we used an uncoated Wallstent. In two patients, percutaneous microcoil embolization of the fistula was added. RESULTS: The patient treated with the Wallstent required a total gastrectomy 6 months after placement of the uncovered stent. In the other 5 patients, coated stents were successfully removed and the gastric leaks completely sealed. CONCLUSIONS: CSES are proposed as an alternative therapeutic option for the management of GE junction leaks in bariatric surgery with good results in terms of morbidity and survival.

Regastrectomía tubular laparoscópica / Laparoscopic reoperative sleeve gastrectomy

Introducción. La gastrectomía tubular laparoscópica (GTL) surgió como indicación después del cruce duodenal laparoscópico (CDL) y está encontrando cada vez más indicaciones en el tratamiento de la obesidad mórbida. La indicación principal de la GTL es cuando se realiza como primer tiempo del CDL en pacientes con superobesidad. Material y método. Presentamos en este estudio la necesidad de realizar una regastrectomía tubular laparoscópica (RGTL) en el momento de realizar el CDL debido a una dilatación del remanente gástrico en 2 pacientes de nuestra serie. Uno de los pacientes había vuelto a ganar peso y el otro presentó una pérdida insuficiente del peso final. Resultados. En ambos casos la realización de la RGTL fue técnicamente sencilla y sin complicaciones postoperatorias y ambos pacientes comenzaron a perder peso de nuevo. Conclusiones. La dilatación del tubo gástrico es una de las causas de pérdida de peso insuficiente en el CDL. Para corregirlo es suficiente con la realización de una RGTL, con resultados excelentes y poca morbilidad (AU)

Introduction. Laparoscopic sleeve gastrectomy (LSG) was developed after the laparoscopic duodenal switch (LDS) procedure and is increasingly indicated in the treatment of morbid obesity. The main indication for LSG is LDS in patients with superobesity. Material and method. We describe the need to perform laparoscopic reoperative sleeve gastrectomy (LRSG) during LDS due to dilatation of the gastric remnant in two patients in our series. One of the patients had regained weight and the other showed insufficient final weight loss. Results. In both patients, LRSG was technically simple and without postoperative complications. Both patients began to lose weight again. Conclusions. Gastric tube dilation is one of the causes of insufficient weight loss in LDS. To correct this dilatation, LRSG is sufficient, with excellent outcomes and low morbidity (AU)

[Laparoscopic reoperative sleeve gastrectomy]. / Regastrectomía tubular laparoscópica.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) was developed after the laparoscopic duodenal switch (LDS) procedure and is increasingly indicated in the treatment of morbid obesity. The main indication for LSG is LDS in patients with superobesity. MATERIAL AND METHOD: We describe the need to perform laparoscopic reoperative sleeve gastrectomy (LRSG) during LDS due to dilatation of the gastric remnant in two patients in our series. One of the patients had regained weight and the other showed insufficient final weight loss. RESULTS: In both patients, LRSG was technically simple and without postoperative complications. Both patients began to lose weight again. CONCLUSIONS: Gastric tube dilation is one of the causes of insufficient weight loss in LDS. To correct this dilatation, LRSG is sufficient, with excellent outcomes and low morbidity.

Re-sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG. METHODS: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done. RESULTS: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later. CONCLUSION: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG.