Timeline of Intestinal Adaptation After Malabsortive Surgery: Effect of Luminal Nutrients, Biliopancreatic Secretion, and Glutamine Supplementation.

BACKGROUND: The aim of this study was to study the process of intestinal adaptation in the three limbs of the small intestine after malabsorptive bariatric surgery: the biliopancreatic limb, the alimentary limb, and the common channel. These limbs are exposed to different stimuli, namely, gastrointestinal transit and nutrients in the alimentary limb, biliopancreatic secretions in the biliopancreatic limb, and a mix of both in the common channel. We also wished to investigate the effect of glutamine supplementation on the adaptation process. METHODS: Three types of surgery were performed using a porcine model: biliopancreatic bypass (BPBP), massive (75%) short bowel resection as the positive control, and a sham operation (transection) as the negative control. We measured the height and width of intestinal villi, histidine decarboxylase (HDC) activity, and amount of HDC messenger RNA (mRNA) (standard diet or a diet supplemented with glutamine). RESULTS: An increase in HDC activity and mRNA expression was observed in the BPBP group. This increase coincided with an increase in the height and width of the intestinal villi. The increase in villus height was observed immediately after surgery and peaked at 2 weeks. Levels remained higher than those observed in sham-operated pigs for a further 4 weeks. CONCLUSIONS: The intestinal adaptation process in animals that underwent BPBP was less intense than in those that underwent massive short bowel resection and more intense than in those that underwent transection only. Supplementation with glutamine did not improve any of the parameters studied, although it did appear to accelerate the adaptive process.

Two-handed assisted laparoscopic surgery: Evaluation in an animal model.

PURPOSES: To evaluate in an animal model the feasibility of a novel concept of hand-assisted surgery consisting of inserting two hands into the abdomen instead of one. The chosen procedure was retroperitoneal lymph node dissection (L-RPLND) that was performed in five pigs. SURGICAL TECHNIQUE: A Pfannestiel and a transverse epigastric incisions were made through which both hands were introduced. The scope was inserted through the umbilicus. The colon was moved medially and the dissection was performed as in open surgery using short conventional surgical instruments. COMMENTS: The surgery was fulfilled easily and safely in quite a similar way as in open surgery. Two-handed laparoscopy may be indicated in cases that still today require an open approach as apparently makes the operation easier and significantly shortens the surgery time. However, new opinions and trials are required.

Two-handed assisted laparoscopic surgery: Evaluation in an animal model

Purposes To evaluate in an animal model the feasibility of a novel concept of hand-assisted surgery consisting of inserting two hands into the abdomen instead of one. The chosen procedure was retroperitoneal lymph node dissection (L-RPLND) that was performed in five pigs. Surgical Technique A Pfannestiel and a transverse epigastric incisions were made through which both hands were introduced. The scope was inserted through the umbilicus. The colon was moved medially and the dissection was performed as in open surgery using short conventional surgical instruments. Comments The surgery was fulfilled easily and safely in quite a similar way as in open surgery. Two-handed laparoscopy may be indicated in cases that still today require an open approach as apparently makes the operation easier and significantly shortens the surgery time. However, new opinions and trials are required. .

Metabolic disorders of liver and iron in diabetic and non-diabetic patients BMI < 35 or > 35 before gastric bypass.

INTRODUCTION: The presence of abnormalities in the metabolic pathways of iron and liver functioning can produce insulin resistance or metabolic syndrome. Therefore, it is important to examine those alterations that may lead to the development of diseases. Nutritional status is another important factor that is intimately linked to diabetes and obesity. PATIENTS AND METHODS: We studied 131 patients (78 nondiabetic patients and 53 diabetic), 37 patients BMI ≤35 (3 BMI < 25, 18 BMI 25-29.9, 16 BMI 30-34.9) and 94 patients BMI ≥35 (81 BMI 35-49.9 and 13 BMI ≥50). Subjects underwent to laboratory studies related to liver functioning and iron metabolism. Nutritional status was also determined in our patients. RESULTS: Iron was altered 14% of patients BMI >35 and diabetics reached 3% to 25%. Vitamin B12 was low 4% of non-diabetics BMI > 35, and high in 6% of diabetics BMI < 35. The 6% of diabetics BMI < 35 had hyperbilirubinemia. Transaminases are elevated in patients BMI >35 but exacerbated on diabetics. GGT is raised 41% to 47% in BMI >35. ALP is elevated in 25% of diabetics. Total protein and serum albumin were altered in diabetics causing mild malnutrition. 90% of patients had normal nutrition and 10% mild malnutrition. CONCLUSIONS: The metabolisms Hepatic and iron are closely related to the onset of obesity and diabetes. If there is weight gain, cumulative metabolic risks rise. The presence of diabesity and increased duration of diabetes produce altered metabolism. Nutritional status is altered in obesity but is worse with the addition of diabetes.

Introducción: La presencia de anormalidades en las vías metabólicas del hierro y el funcionamiento del hígado pueden producir resistencia a la insulina o síndrome metabólico. Por lo tanto, es importante examinar esas alteraciones que pueden conducir al desarrollo de enfermedades. El estado nutricional es otro factor importante que está íntimamente ligada a la diabetes y la obesidad. Pacientes y métodos: Se estudiaron 131 pacientes (78 pacientes no diabéticos y 53 diabéticos), 37 pacientes IMC ≤35 (3 IMC < 25, 18 IMC 25-29,9, 16 IMC 30-34,9) y 94 pacientes IMC ≥35 (81 IMC 35-49,9 y 13 de IMC ≥50). Los sujetos fueron sometidos a estudios de laboratorio relacionadas con el funcionamiento del hígado y el metabolismo del hierro. Se determinó también el estado nutricional en nuestros pacientes. Resultados: El hierro estuvo alterado en 14% de los pacientes IMC >35 y los diabéticos alcanzaron 3% a 25%. La vitamina B12 fue baja en 4% de los no diabéticos IMC > 35, y alta en el 6% de los diabéticos IMC < 35. El 6% de los diabéticos IMC < 35 tenía hiperbilirrubinemia. Las transaminasas estuvieron elevadas en pacientes IMC > 35, pero exacerbados en los diabéticos. GGT se eleva del 41% al 47% en BMI > 35. ALP estuvo elevada en el 25% de los diabéticos. Las proteínas séricas totales y la albúmina estuvieron alterados en los diabéticos causando desnutrición leve. 90% de los pacientes tenían una nutrición normal y 10% desnutrición leve. Conclusiones: El metabolismo hepático y del hierro están estrechamente relacionadas con el inicio de la obesidad y la diabetes. Si hay un aumento de peso, los riesgos metabólicos acumulados se elevan. La presencia de la diabesidad y el aumento de la duración de la diabetes empeoran el metabolismo. El estado nutricional se altera en la obesidad, pero es peor con la adición de la diabetes.

Glycemic and lipid metabolic disorders in diabetic and non-diabetic patients bmi < 35 or > 35 before gastric bypass.

INTRODUCTION: Obesity and diabetes are diseases with high prevalence worldwide. There is currently no effective medical treatment for combat the weight gain. It is precursor of diseases such as diabetes or metabolic syndrome. It is necessary to know if weight gain has cumulative effects on the glycemic and lipid metabolism as precursors of complications or comorbidities. PATIENTS AND METHODS: We studied 131 patients (78 nondiabetic and 53 diabetic), 37 BMI ≤35 (3 BMI < 25, 18 BMI 25-29.9, 16 BMI 30-34.9) and 94 BMI ≥35 (81 BMI 35-49.9 and 13 BMI ≥50).We analyzed BMI, gender, diabetes and the time of evolution. Lipid profile, glucose, HbA1c and C-peptide evaluated after 12-hour fasting. RESULTS: Diabetic and diabese patients showed high triglycerides. Non-diabetics have impaired glucose (58% BMI < 35 and 36% BMI > 35). The 20% of non-diabetics BMI < 35 had high C-peptide, and 19% of BMI > 35 had high levels. The 5% of diabetics BMI < 35 had low Cpeptide and 36% of BMI > 35 had high levels. HbA1c was higher in 40% of non-diabetic patients BMI < 35 compared to 13% BMI > 35. CONCLUSIONS: Glucose and triglycerides increase with age and years of development of T2DM. Age of 51 and more, and men are more affected. The weight increase has cumulative effect by altering the metabolism favoring the onset of diabetes and comorbidities. Despite having intensive control treatment of diabetes, it continues its deleterious effects on patients through the years.

Introducción: La obesidad y la diabetes son enfermedades de alta prevalencia a nivel mundial. Actualmente no existe un tratamiento médico eficaz para combatir el aumento de peso. La obesidad es precursora de enfermedades tales como la diabetes o el síndrome metabólico. Es necesario saber si el aumento de peso tiene efectos acumulativos sobre el metabolismo de la glucemia y los lípidos como precursores de complicaciones o comorbilidades. Pacientes y métodos: Se estudiaron 131 pacientes (78 no diabéticos y 53 diabéticos), 37 IMC ≤35 (3 IMC < 25, 18 IMC 25-29,9, 16 IMC 30-34,9) y 94 IMC ≥35 (81 IMC 35- 49,9 y 13 de IMC ≥50). Se analizó el IMC, el género, la diabetes y su tiempo de evolución. El perfil lipídico, glucosa, HbA1c y el péptido C fueron evaluados después de un ayuno de 12 horas. Resultados: Los pacientes diabéticos y diabesos mostraron niveles altos de triglicéridos. Los pacientes no diabéticos tienen alteración de la glucosa (58% IMC 35). El 20% de los no diabéticos IMC 35 tenían niveles altos. El 5% de los diabéticos IMC < 35 tenía bajos niveles de péptido C y 36% de IMC > 35 tenían niveles altos. HbA1c fue mayor en 40% de pacientes no diabéticos IMC < 35 frente al 13% de IMC > 35. Conclusiones: La glucosa y los triglicéridos aumentan con la edad y los años de evolución de la DMT2. La edad de ≥51 años y los hombres son los más afectados. El aumento de peso tiene efecto acumulativo alterando el metabolismo favoreciendo la aparición de la diabetes y sus comorbilidades. A pesar de tener un tratamiento de control intensivo de la diabetes, esta continúa con sus efectos nocivos sobre los pacientes a través de los años.

Metabolic disorders of liver and iron in diabetic and non-diabetic patients BMI < 35 or > 35 before gastric bypass / Trastornos del metabolismo del hígado y el hierro en pacientes diabéticos y no diabéticos con imc < 35 ó > 35 antes de bypass gástrico

Introduction: The presence of abnormalities in the metabolic pathways of iron and liver functioning can produce insulin resistance or metabolic syndrome. Therefore, it is important to examine those alterations that may lead to the development of diseases. Nutritional status is another important factor that is intimately linked to diabetes and obesity. Patients and Methods: We studied 131 patients (78 nondiabetic patients and 53 diabetic), 37 patients BMI ≤ 35 (3 BMI < 25, 18 BMI 25-29.9, 16 BMI 30-34.9) and 94 patients BMI ≥ 35 (81 BMI 35-49.9 and 13 BMI ≥ 50). Subjects underwent to laboratory studies related to liver functioning and iron metabolism. Nutritional status was also determined in our patients. Results: Iron was altered 14% of patients BMI >35 and diabetics reached 3% to 25%. Vitamin B12 was low 4% of non-diabetics BMI > 35, and high in 6% of diabetics BMI < 35. The 6% of diabetics BMI < 35 had hyperbilirubinemia. Transaminases are elevated in patients BMI >35 but exacerbated on diabetics. GGT is raised 41% to 47% in BMI >35. ALP is elevated in 25% of diabetics. Total protein and serum albumin were altered in diabetics causing mild malnutrition. 90% of patients had normal nutrition and 10% mild malnutrition. Conclusions: The metabolisms Hepatic and iron are closely related to the onset of obesity and diabetes. If there is weight gain, cumulative metabolic risks rise. The presence of diabesity and increased duration of diabetes produce altered metabolism. Nutritional status is altered in obesity but is worse with the addition of diabetes (AU)

Introducción: La presencia de anormalidades en las vías metabólicas del hierro y el funcionamiento del hígado pueden producir resistencia a la insulina o síndrome metabólico. Por lo tanto, es importante examinar esas alteraciones que pueden conducir al desarrollo de enfermedades. El estado nutricional es otro factor importante que está íntimamente ligada a la diabetes y la obesidad. Pacientes y métodos: Se estudiaron 131 pacientes (78 pacientes no diabéticos y 53 diabéticos), 37 pacientes IMC ≤ 35 (3 IMC < 25, 18 IMC 25-29,9, 16 IMC 30-34,9) y 94 pacientes IMC ≥ 35 (81 IMC 35-49,9 y 13 de IMC ≥ 50). Los sujetos fueron sometidos a estudios de laboratorio relacionadas con el funcionamiento del hígado y el metabolismo del hierro. Se determinó también el estado nutricional en nuestros pacientes. Resultados: El hierro estuvo alterado en 14% de los pacientes IMC >35 y los diabéticos alcanzaron 3% a 25%. La vitamina B12 fue baja en 4% de los no diabéticos IMC > 35, y alta en el 6% de los diabéticos IMC < 35. El 6% de los diabéticos IMC < 35 tenía hiperbilirrubinemia. Las transaminasas estuvieron elevadas en pacientes IMC > 35, pero exacerbados en los diabéticos. GGT se eleva del 41% al 47% en BMI > 35. ALP estuvo elevada en el 25% de los diabéticos. Las proteínas séricas totales y la albúmina estuvieron alterados en los diabéticos causando desnutrición leve. 90% de los pacientes tenían una nutrición normal y 10% desnutrición leve. Conclusiones: El metabolismo hepático y del hierro está estrechamente relacionadas con el inicio de la obesidad y la diabetes. Si hay un aumento de peso, los riesgos metabólicos acumulados se elevan. La presencia de la diabesidad y el aumento de la duración de la diabetes empeoran el metabolismo. El estado nutricional se altera en la obesidad, pero es peor con la adición de la diabetes (AU)

Glycemic and lipid metabolic disorders in diabetic and non-diabetic patients bmi < 35 or > 35 before gastric bypass / Trastornos del metabolismo glicémico y lipídico en pacientes diabéticos y no diabéticos con imc < 35 ó > 35 antes de bypass gástrico

Introduction: Obesity and diabetes are diseases with high prevalence worldwide. There is currently no effective medical treatment for combat the weight gain. It is precursor of diseases such as diabetes or metabolic syndrome. It is necessary to know if weight gain has cumulative effects on the glycemic and lipid metabolism as precursors of complications or comorbidities. Patients and methods: We studied 131 patients (78 nondiabetic and 53 diabetic), 37 BMI ≤ 35 (3 BMI < 25, 18 BMI 25-29.9, 16 BMI 30-34.9) and 94 BMI ≥ 35 (81 BMI 35-49.9 and 13 BMI ≥ 50).We analyzed BMI, gender, diabetes and the time of evolution. Lipid profile, glucose, HbA1c and C-peptide evaluated after 12-hour fasting. Results: Diabetic and diabese patients showed high triglycerides. Non-diabetics have impaired glucose (58% BMI < 35 and 36% BMI > 35). The 20% of non-diabetics BMI < 35 had high C-peptide, and 19% of BMI > 35 had high levels. The 5% of diabetics BMI < 35 had low Cpeptide and 36% of BMI > 35 had high levels. HbA1c was higher in 40% of non-diabetic patients BMI < 35 compared to 13% BMI > 35. Conclusions: Glucose and triglycerides increase with age and years of development of T2DM. Age of 51 and more, and men are more affected. The weight increase has cumulative effect by altering the metabolism favoring the onset of diabetes and comorbidities. Despite having intensive control treatment of diabetes, it continues its deleterious effects on patients through the years (AU)

Introducción: La obesidad y la diabetes son enfermedades de alta prevalencia a nivel mundial. Actualmente no existe un tratamiento médico eficaz para combatir el aumento de peso. La obesidad es precursora de enfermedades tales como la diabetes o el síndrome metabólico. Es necesario saber si el aumento de peso tiene efectos acumulativos sobre el metabolismo de la glucemia y los lípidos como precursores de complicaciones o comorbilidades. Pacientes y métodos: Se estudiaron 131 pacientes (78 no diabéticos y 53 diabéticos), 37 IMC ≤ 35 (3 IMC < 25, 18 IMC 25-29,9, 16 IMC 30-34,9) y 94 IMC ≥ 35 (81 IMC 35- 49,9 y 13 de IMC ≥ 50). Se analizó el IMC, el género, la diabetes y su tiempo de evolución. El perfil lipídico, glucosa, HbA1c y el péptido C fueron evaluados después de un ayuno de 12 horas. Resultados: Los pacientes diabéticos y diabesos mostraron niveles altos de triglicéridos. Los pacientes no diabéticos tienen alteración de la glucosa (58% IMC 35). El 20% de los no diabéticos IMC 35 tenían niveles altos. El 5% de los diabéticos IMC < 35 tenía bajos niveles de péptido C y 36% de IMC > 35 tenían niveles altos. HbA1c fue mayor en 40% de pacientes no diabéticos IMC < 35 frente al 13% de IMC > 35. Conclusiones: La glucosa y los triglicéridos aumentan con la edad y los años de evolución de la DMT2. La edad de ≥51 años y los hombres son los más afectados. El aumento de peso tiene efecto acumulativo alterando el metabolismo favoreciendo la aparición de la diabetes y sus comorbilidades. A pesar de tener un tratamiento de control intensivo de la diabetes, esta continúa con sus efectos nocivos sobre los pacientes a través de los años (AU)

Drain erosion and gastro-jejunal fistula after one-anastomosis gastric bypass: endoscopic occlusion by fibrin sealant.

Leakage and fistula are feared complications after gastro-intestinal anastomosis. A 36-year-old female underwent an one-anastomosis gastric bypass. The 24-h routine radiological study before oral intake showed a tiny leak, which was treated by NPO and I.V. fluids. After 5 days, despite output reduction, total parenteral nutrition was commenced. After 8 days, the leak remained with reduced output. It was then occluded endoscopically by fibrin glue. To our surprise, we found the drain that we had left behind the anastomosis, inside the gastric pouch. We began withdrawing the drain and occluded the defect with 4 ml Tissucol. After 48-h of no output, a repeat radiological study showed persistence of the leak. 6 days later, a radiological study demonstrated total closure of the leak.

Guías para la reposición de las pérdidas sanguíneas en cirugía abdominal de urgencia / Guidelines for blood loss replacement in emergency abdominal surgery

La reposición de la pérdidas sanguíneas en cirugía abdominal urgente desempeña un papel clave para la supervivencia, sobre todo en los pacientes que presentan una pérdida de sangre masiva provocada por la rotura del hígado, el bazo y los vasos mesentéricos, así como en el hemoperitoneo masivo secundario a un embarazo ectópico. Para manejar con éxito a estos pacientes debe seguirse un algoritmo claro previamente consensuado y aceptado por los miembros del servicio, tanto para el rápido diagnóstico y utilización de maniobras quirúrgicas precisas para el control de la fuente de hemorragia como, sobre todo, para el control de la alteración de los factores de la coagulación y la consecuente necesidad de una precisa pauta de uso de los distintos componentes sanguíneos que deben utilizarse en su reposición. El uso de estas guías reduce la mortalidad de forma significativa. En este contexto, el uso de la autotransfusión intraoperatoria ha demostrado ser un procedimiento seguro y con un buena relación coste-efectividad que se puede utilizar incluso por vía laparoscópica. Sin embargo, su utilización está poco extendida, sistematizada y mal organizada, a tenor de los datos publicados en la bibliografía (AU)