Evolución del reflujo gastroesofágico tras la gastrectomía vertical laparoscópica. Estudio radiológico, manométrico y pH-métrico / Evolution of gastroesophageal reflux after laparoscopic vertical gastrectomy. A radiographic, manometric and pH-metric study

Introducción: la relación entre la gastrectomía vertical laparoscópica (GVL) y el reflujo gastroesofágico (RGE) es aún controvertida, por lo que su investigación tiene gran interés para llegar a conclusiones definitivas. Nuestro objetivo es determinar si la GVL modifica el RGE pH-métrico de los pacientes obesos y, en caso de que así sea, analizar algunos factores que pudieran explicarlo. Pacientes y métodos: incluimos los primeros 26 pacientes que recibieron una GVL en nuestro centro. Se realizaron un tránsito baritado, una pH-metría ambulatoria de 24 horas y una manometría intraluminal esofágica (MIE) con cuatro canales previamente y al año de la operación. Resultados: de los datos pH-métricos, el índice de DeMeester mostró un aumento significativo (p = 0.028) tras la intervención, mientras que los demás parámetros fueron similares. Por otra parte, se observó que el 50% de los pacientes con RGE pH-métrico preoperatorio mostraron tasas normales al año de la operación. En la MIE objetivamos que la presión del esfínter esofágico inferior (EEI) disminuyó, así como la amplitud media de las ondas en el tercio distal esofágico (p = 0,007 y p = 0,025, respectivamente). En el estudio radiológico la tasa de hernias de hiato "de novo" fue del 36,4%. Conclusión: la GVL determina un aumento leve del RGE, probablemente relacionado con la aparición de hernias de hiato así como con una disminución de la presión del EEI y de la capacidad de barrido esofágico. Sin embargo, no debe contraindicarse la GVL a pacientes con RGE preoperatorio pH-métrico pues puede negativizarse tras la operación

Introduction: the relationship between laparoscopic vertical gastrectomy (LVG) and gastroesophageal reflux (GER) is still controversial. Therefore, its study is of great interest in order to obtain definitive conclusions. The goal of the study was to establish whether LVG modifies pH-metric GER in obese patients and to analyze the associated factors. Patients and methods: the first 26 patients who underwent LVG in our institution were enrolled in the study. A barium swallow, 24-hour ambulatory pH-metry and four-channel intraluminal esophageal manometry (IEM) were all performed before and one year after surgery. Results: among the pH-metric data, there was a significant increase in the DeMeester index after the procedure (p = 0.028), while other parameters remained unchanged. Furthermore, 50% of patients with preoperative pH-metric GER had normal values at one year after surgery. IEM showed a decrease in lower esophageal sphincter (LES) pressure and in the mean wave amplitude at the distal third of the esophagus (p = 0.007 and p = 0.025, respectively). The rate of newly-developed hiatal hernias in the radiographic study was 36.4%. Conclusion: LVG mildly increases GER, which is likely related to the development of hiatal hernias and a decrease in LES pressure and esophageal sweep. However, LVG should not be contraindicated for patients with preoperative pH-metric GER, as this may clear after the procedure

Evolution of gastroesophageal reflux after laparoscopic vertical gastrectomy. A radiographic, manometric and pH-metric study.

INTRODUCTION: the relationship between laparoscopic vertical gastrectomy (LVG) and gastroesophageal reflux (GER) is still controversial. Therefore, its study is of great interest in order to obtain definitive conclusions. The goal of the study was to establish whether LVG modifies pH-metric GER in obese patients and to analyze the associated factors. PATIENTS AND METHODS: the first 26 patients who underwent LVG in our institution were enrolled in the study. A barium swallow, 24-hour ambulatory pH-metry and four-channel intraluminal esophageal manometry (IEM) were all performed before and one year after surgery. RESULTS: among the pH-metric data, there was a significant increase in the DeMeester index after the procedure (p = 0.028), while other parameters remained unchanged. Furthermore, 50% of patients with preoperative pH-metric GER had normal values at one year after surgery. IEM showed a decrease in lower esophageal sphincter (LES) pressure and in the mean wave amplitude at the distal third of the esophagus (p = 0.007 and p = 0.025, respectively). The rate of newly-developed hiatal hernias in the radiographic study was 36.4%. CONCLUSION: LVG mildly increases GER, which is likely related to the development of hiatal hernias and a decrease in LES pressure and esophageal sweep. However, LVG should not be contraindicated for patients with preoperative pH-metric GER, as this may clear after the procedure.

Papel de las endoprótesis autoexpandibles en el tratamiento de la dehiscencia intratorácica tras el procedimiento de Ivor Lewis / Role of self-expanding stents in the treatment of intrathoracic dehiscence after Ivor Lewis esophagectomy

INTRODUCCIÓN: El papel que desempeñan las endoprótesis autoexpandibles en el tratamiento de las dehiscencias tras la esofagectomía transtorácica no está bien definido y resulta controvertido. Nuestro objetivo es mostrar la experiencia en un hospital de tercer nivel con el empleo de estos dispositivos en las dehiscencias tras la esofagectomía de Ivor Lewis. MÉTODOS: Estudio observacional descriptivo de los pacientes que han presentado una dehiscencia de anastomosis tras una esofagectomía transtorácica y, en especial, de aquellos tratados mediante endoprótesis, en el periodo comprendido entre 2011 y 2016 en nuestro centro hospitalario. RESULTADOS: Diez pacientes (11,8%) presentaron una dehiscencia anastomótica, 8 de los cuales recibieron endoprótesis. Un paciente portador de endoprótesis falleció por causas ajenas a la misma. En un paciente se objetivó migración del dispositivo, manteniéndose una media de permanencia de 47,3 días. La prótesis no fue efectiva en un paciente que tuvo una dehiscencia precoz por isquemia aguda gástrica. Fallecieron los 2 pacientes que no recibieron endoprótesis después de la reintervención. CONCLUSIONES: Las endoprótesis son dispositivos seguros y efectivos que no asocian mortalidad en nuestra serie. Están especialmente indicadas en dehiscencias intermedias o tardías y en pacientes frágiles, pues, junto con el drenaje mediastínico y pleural, evitan reintervenciones gravadas con morbimortalidad. Por tanto, las endoprótesis deben formar parte del arsenal terapéutico habitual para la resolución de la mayoría de las dehiscencias de sutura tras la esofagectomía de Ivor Lewis. La puesta en marcha de estudios prospectivos aleatorizados ayudaría a determinar con mayor precisión el papel que desempeñan estos dispositivos en el tratamiento de las dehiscencias tras una esofagectomía transtorácica

INTRODUCTION: The role that self-expanding stents play in the treatment of dehiscence after transthoracic esophagectomy is not well defined and controversial. Our aim is to describe the experience in a tertiary care hospital using these devices for treating dehiscence after Ivor Lewis esophagectomy. METHODS: Descriptive observational study of patients who suffered anastomotic dehiscence after a transthoracic esophagectomy, and especially those treated with stents, in the period between 2011-2016 at our hospital. RESULTS: Ten patients (11.8%) presented anastomotic dehiscence. Eight patients received stents, one of them died due to causes unrelated to the device. Stent migration was observed in one case, and the devices were maintained an average of 47.3 days. The stent was not effective only in one patient who suffered early dehiscence due to acute ischemia of the stomach. The two patients who did not receive stents died after reoperation. CONCLUSIONS: Stents are safe and effective devices that did not associate mortality in our series. They are especially indicated in intermediate or late-onset dehiscence and in fragile patients. The use of stents, together with mediastinal and pleural drainage, avoid reoperations with morbidity and mortality. Therefore, stents should be part of the usual therapeutic arsenal for the resolution of most suture dehiscences after Ivor Lewis esophagectomy. Randomized prospective studies would help to more precisely determine the role played by these devices in the treatment of dehiscence after transthoracic esophagectomy

Role of self-expanding stents in the treatment of intrathoracic dehiscence after Ivor Lewis esophagectomy. / Papel de las endoprótesis autoexpandibles en el tratamiento de la dehiscencia intratorácica tras el procedimiento de Ivor Lewis.

INTRODUCTION: The role that self-expanding stents play in the treatment of dehiscence after transthoracic esophagectomy is not well defined and controversial. Our aim is to describe the experience in a tertiary care hospital using these devices for treating dehiscence after Ivor Lewis esophagectomy. METHODS: Descriptive observational study of patients who suffered anastomotic dehiscence after a transthoracic esophagectomy, and especially those treated with stents, in the period between 2011-2016 at our hospital. RESULTS: Ten patients (11.8%) presented anastomotic dehiscence. Eight patients received stents, one of them died due to causes unrelated to the device. Stent migration was observed in one case, and the devices were maintained an average of 47.3 days. The stent was not effective only in one patient who suffered early dehiscence due to acute ischemia of the stomach. The two patients who did not receive stents died after reoperation. CONCLUSIONS: Stents are safe and effective devices that did not associate mortality in our series. They are especially indicated in intermediate or late-onset dehiscence and in fragile patients. The use of stents, together with mediastinal and pleural drainage, avoid reoperations with morbidity and mortality. Therefore, stents should be part of the usual therapeutic arsenal for the resolution of most suture dehiscences after Ivor Lewis esophagectomy. Randomized prospective studies would help to more precisely determine the role played by these devices in the treatment of dehiscence after transthoracic esophagectomy.

[Splenic late infarction after laparoscopic gastrectomy: a case report]. / Infarto esplénico tardío tras gastrectomía vertical laparoscópica: a propósito de un caso.

INTRODUCTION: Laparoscopic gastrectomy has emerged in recent years as an effective technique for the treatment of morbid obesity due to low mortality morbidity rates. Its complications include dehiscence suture line, and others such as splenic infarction. We discuss a case of splenic infarction after laparoscopic gastrectomy. CLINICAL CASE: 45 year old male with a BMI of 37.8 kg/m2, diabetes-II for 15 years, the last five in treatment with insulin, a fasting blood glucose around 140mg/dl, HbA1c of 7.3mg/dl and microangiopathy diabetic nephropathy. The patient underwent a laparoscopic sleeve gastrectomy and he was discharged from hospital 48hours later. 1 month later he presented at the hospital for epigastric pain and fever up to 40° C. An intra abdominal abscess was detected and there was no leakage. The spleen was normal. He was treated with radiological drainage. 9 months later the patient consulted again due to epigastric pain in upper left quadrant, associated with low-grade fever. Thoraco-abdominal CT images compatible with splenic infarction. Currently patient remains asymptomatic one year after surgery. DISCUSSION: Laparoscopic sleeve gastrectomy is one of the most popular procedures of bariatric surgery. Less common complications include abscess and the splenic infarction. Usually patients are asymptomatic, but sometimes cause fever and pain. Initial treatment should be conservative. Only in selected cases, would splenectomy be indicated. CONCLUSIONS: Splenic infarction is usually an early complication, but we should keep it in mind as a long term complication for patients with persistent fever and abdominal pain after laparoscopic gastrectomy.