Lessons Learned in Elective Surgeries After 6 Pandemic Waves of SARS-CoV-2. A Single European Center Experience.

BACKGROUND: The reported high surgical morbidity and mortality in patients with SARS-CoV-2 prompted preoperative screening and modification of surgical protocols. Although vaccination and treatment of COVID-19 have resulted in lower hospitalization rates and infection severity, publications on postoperative results have not been updated. The aim of the study was to analyze the outcomes of patients undergoing surgery in two periods with high incidence of SARS-CoV-2 infection, before and after vaccination. MATERIALS AND METHODS: This is a prospective cohort study of patients undergoing surgery in two periods: March-June 2020 (Group2020) and December 2021-February 2022 (Group2022) (after massive vaccination). RESULTS: In total, 618 patients who underwent surgery were included in the analysis (Group2020: 343 vs. Group2022: 275). Significantly more oncological procedures were performed in Group2020, and there were no differences in postoperative complications. Nosocomial SARS-CoV-2 infection occurred in 4 patients in Group2020 and 1 patient in Group2022. In Group 2022, 70 patients (25.4%) had COVID-19 prior to surgery, and 68 (97.1%) were vaccinated. Comparative analysis between patients with past COVID-19 and those without showed no difference in postoperative morbidity and mortality. According to the time elapsed between SARS-CoV-2 infection and surgery (≤ 7 or > 7 weeks), comparative analysis showed no significant differences. CONCLUSION: The establishment of preoperative screening protocols for SARS-CoV-2 infection results in a low incidence of nosocomial infection and optimal postoperative outcomes. Preoperative SARS-CoV-2 infection in vaccinated patients was not associated with increased postoperative complications, even in shorter periods after infection. In surgical patients, individualized preoperative evaluation after SARS-CoV-2 infection may be more important than strict time limitation.

Effect of Obesity and Roux-En-Y Gastric Surgery on Omeprazole Pharmacokinetics.

INTRODUCTION: The prevalence of obesity is increasing globally. The principal aim was to evaluate whether gastric bypass surgery modifies the bioavailability and pharmacokinetic (PK) parameters of omeprazole. METHODS: Controlled, open-label, bioavailability clinical trial in patients undergoing Roux-en-Y gastric bypass (RYGB). Healthy patients with obesity (body mass index >35) were included and assessed for omeprazole PKs before and after RYGB (1 and 6 months). PK sampling was done at baseline and several times up to 12 h after drug dosing. Pre- and post-surgery parameters were compared using paired ANOVA or Wilcoxon tests, and control versus cases using ANOVA or Mann-Whitney tests. Given the post-surgery change in body weight, parameters were corrected by dose/body weight. RESULTS: Fourteen case and 24 control subjects were recruited; 92% were women (N = 35/38). In patients who underwent RYGB, maximum plasma concentration (Cmax) was significantly reduced at 1 and 6 months after surgery compared with presurgery values (p = 0.001). Regarding the AUC, the values are lower at 1 and 6 months after surgery than at baseline (p < 0.001). The drug clearance was also increased in the first month after surgery. No differences were found between patients 6 months after surgery and controls. Cmax and AUC corrected by dose/body weight were significantly different between the baseline surgery subjects and controls. Discusion/Conclusions: Omeprazole bioavailability is reduced in patients with obesity at 1 and 6 months after RYGB. However, omeprazole PK parameters 6 months after RYGB are similar to control subjects, and thus no dose correction is required after RYGB for a given indication.

Thyroid metastases from colorectal cancer 14 years later: A case report and literature review.

Metastases to the thyroid gland are unusual, especially from a colorectal cancer. We present the case of an 85-year-old female with a history of colon cancer in 2004 treated with surgery, who 14 years later develop dysphonia and dysphagia associated to an elevation of carcinoembryonic antigen. A pathologic thyroid mass was evidenced in a positron emission tomography-computed tomography. The colorectal origin of the mass was confirmed with a biopsy. The patient received surgical treatment doing the right hemithyroidectomy. This entity must be suspected in patients with oncological history and a new thyroid nodule. Surgery is a therapeutic option with either curative or palliative intent.

Las metástasis sobre el tiroides son inusuales y las de origen colorrectal son extremadamente infrecuentes. Se presenta el caso de una mujer de 85 años con antecedente de cáncer de colon intervenido en 2004 que 14 años después presenta signos clínicos de disfonía y disfagia relacionados con elevación del CEA. Tras realizarse una PET-TC se evidencia una masa tiroidea y se confirma su origen colorrectal mediante biopsia. La paciente se sometió a una hemitiroidectomía derecha. Esta entidad debe sospecharse en pacientes con antecedentes oncológicos y un nódulo tiroideo de nueva aparición. La intervención es una opción terapéutica con intención curativa y paliativa.

Principales medidas de profilaxis en endoscopia bariátrica. Guía Española de Recomendación de Expertos / No disponible

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Long-term results of botulinum toxin type A in complex abdominal wall repair and review of the literature.

Administration of botulinum toxin (BTX) is being used in cases of complex ventral hernia for the reconstruction of the linea alba and closure of the abdominal wall. However, there are no published results regarding the long-term effects of BTX and its implication in hernia recurrence. Our purpose is to evaluate the outcomes in hernia recurrence of the administration of BTX in complex ventral hernia repair. 36 patients underwent elective surgery for complex ventral hernia and were evaluated retrospectively. The study included patients with a transverse hernia defect ≥ 100 mm and loss of domain hernias, receiving BTX injections 6 weeks prior to elective surgery. Global results and long-term recurrence were analysed. There were no complications related to BTX administration. The mean transverse hernia defect was 139.44 ± 50.98 mm, the mean abdominal cavity volume (ACV) was 10.19 ± 3.33 dm3, the mean hernia sac volume (HSV) was 1.93 ± 1.79 dm3, presenting a mean volume ratio (VR) of 20.71 ± 19.76%. Primary closure was achieved in 28 patients (77.8%), 21 of whom (75%) needed an anterior component separation technique. Recurrence rate was 11.4% at 2-years follow-up. BTX administration is a safe and feasible method for abdominal wall expansion prior to complex incisional hernia repair, achieving high rates of primary closure. Long-term follow-up shows good results in terms of recurrence in these patients.

Main prophylactic measures in bariatric endoscopy. Spanish Expert Recommendations Guideline.

Bariatric endoscopy (BE) encompasses a number of techniques -some consolidated, some under development- aiming to contribute to the management of obese patients and their associated metabolic diseases as a complement to dietary and lifestyle changes. To date different intragastric balloon models, suture systems, aspiration methods, substance injections and both gastric and duodenal malabsorptive devices have been developed, as well as endoscopic procedures for the revision of bariatric surgery. Their ongoing evolution conditions a gradual increase in the quantity and quality of scientific evidence about their effectiveness and safety. Despite this, scientific evidence remains inadequate to establish strong grades of recommendation allowing a unified perspective on prophylaxis in BE. This dearth of data conditions leads, in daily practice, to frequently extrapolate the measures that are used in bariatric surgery (BS) and/or in general therapeutic endoscopy. In this respect, this special article is intended to reach a consensus on the most common prophylactic measures we should apply in BE. The methodological design of this document was developed while attempting to comply with the following 5 phases: Phase 1: delimitation and scope of objectives, according to the GRADE Clinical Guidelines. Phase 2: setup of the Clinical Guide-developing Group: national experts, members of the Grupo Español de Endoscopia Bariátrica (GETTEMO, SEED), SEPD, and SECO, selecting 2 authors for each section. Phase 3: clinical question form (PICO): patients, intervention, comparison, outcomes. Phase 4: literature assessment and synthesis. Search for evidence and elaboration of recommendations. Based on the Oxford Centre for Evidence-Based Medicine classification, most evidence in this article will correspond to level 5 (expert opinions without explicit critical appraisal) and grade of recommendation C (favorable yet inconclusive recommendation) or D (inconclusive or inconsistent studies). Phase 5: External review by experts. We hope that these basic preventive measures will be of interest for daily practice, and may help prevent medical and/or legal conflicts for the benefit of patients, physicians, and BE in general.

Effect of Roux-en-Y gastric surgery on ciprofloxacin pharmacokinetics: an obvious effect?

PURPOSE: To evaluate pharmacokinetic parameters of ciprofloxacin in patients undergoing Roux-en-Y gastric surgery (RYGS). METHODS: Controlled, single-dose, open-label study in patients undergoing RYGS. Healthy overweight/obese patients 18-60 years old were included. The assessment was performed once in control patients and three times in case patients (before surgery and 1 and 6 months after surgery). In each visit, the subjects received a single oral dose of ciprofloxacin 500 mg. Venous blood samples were obtained at baseline and 0.5, 1, 1.25, 1.5, 1.75, 2, 2.5, 3, 4, 8 and 14 h after ciprofloxacin intake. Pre- and post-surgery variables were compared using paired ANOVA or the Wilcoxon tests and control vs cases using ANOVA or Mann Whitney. Given the post-surgery change in body weight, the parameters were corrected by dose (mg)/body weight (kg). The analysis was performed using SPSS. RESULTS: Ciprofloxacin Cmax was significantly reduced 1 month after surgery (1840.9 ± 485.2 vs 1589.6 ± 321.8 ng/ml; p = 0.032) but not 6 months after. Cmax on the sixth month was lower than Cmax in control group (2160.4 ± 408.6 vs 1589.6 ± 321.8 ng/ml; p < 0.001). After correcting by the dose (mg)/patient's body weight, both Cmax and AUClast showed significant decrease 1 and 6 months after surgery: Cmax, 289.1 ± 65.3 and 263.5 ± 52.1 (ng/ml)/(dose (mg)/weight (kg)) respectively vs 429.3 ± 127.6 (ng/ml)/(dose (mg)/weight (kg)) at baseline; AUC, 1340.6 ± 243.0 and 1299.2 ± 415.4 (h × ng/ml)/(dose (mg)/weight (kg)) respectively vs 1896.7 ± 396.8 (h × ng/ml)/(dose (mg)/weight (kg)) at baseline. Cmax 1 month post-surgery showed lower values than the control group (375.4 ± 77.4 vs 263.5 ± 52.1 ng/ml; p < 0.001). CONCLUSION: Ciprofloxacin absorption is impaired 1 month and 6 months after RYGS. The effect on Cmax and AUClast faded on the sixth month due to weight loss. It is no necessary to modify the doses of ciprofloxacin in these patients.

Neoplasia papilar intraductal de la vía biliar: un reto diagnóstico para un correcto tratamiento / Intraductal papillary neoplasm of the bile duct: A diagnostic challenge for optimal treatment

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Función telomérica y sirtuinas 1 y 6 en cáncer colorrectal en pacientes obesos y no obesos. Correlaciones clínicas / Telomere function and sirtuins 1 and 6 in colorectal cancer from obese and non-obese patients. Clinical correlations

La disfunción telomérica constituye un evento frecuente en el cáncer colorrectal (CCR). El objetivo de este trabajo consiste en analizar el estatus telomérico y las sirtuinas 1 y 6, en relación con el pronóstico de pacientes afectados de CCR. Asimismo, se investiga la posible relación existente entre la obesidad y la predisposición a desarrollar CCR. Se han investigado parámetros de función telomérica, como la longitud de los telómeros y la actividad telomerasa, así como la expresión relativa de SIRT1 y SIRT6 en muestras de tejido tumoral colorrectal, tejido no tumoral (control), y tejidos adiposos subcutáneo y omental. La longitud telomérica se determinó por las técnicas TRF (Telomere Restriction Fragment) y por PCR cuantitativa (qRT-PCR). La expresión relativa de SIRT1 y SIRT6 se evaluó por qRT-PCR. Los telómeros tumorales críticamente acortados se relacionan con un pronóstico clínico favorable en CCR y se correlacionan con los niveles de expresión más elevados de SIRT1. La expresión reducida de SIRT1 (RQ ≤ 0,5) se detecta en tumores que confieren una evolución clínica más adversa. Los telómeros de las células no tumorales de pacientes obesos o con sobrepeso son significativamente más largos que los de pacientes con normopeso. En tejido adiposo omental, la longitud telomérica relativa es inferior en pacientes obesos con CCR respecto a pacientes obesos sin CCR. El análisis de la longitud telomérica y de SIRT1 presenta interés en la investigación de la evolución clínica de sujetos afectados de CCR y en el establecimiento de la predisposición de individuos obesos al desarrollo de este tipo tumoral

Telomere dysfunction is a frequent event in colorectal cancer (CRC). The aim of this study consists of analyzing telomere status and sirtuins 1 and 6, in relation to the prognosis of patients affected by CRC. We have also investigated the possible relationship between obesity and the predisposition to develop CRC. Telomere function parameters, such as telomere length and telomerase activity, as well as the relative expression of SIRT1 and SIRT6 in samples of colorectal tumor tissue, non-tumor tissue (control), and subcutaneous and omental adipose tissues have been investigated. The telomere length was determined by TRF (Telomere Restriction Fragment) and quantitative PCR (qRT-PCR). The relative expression of SIRT1 and SIRT6 was assessed by qRT-PCR. The critically shortened tumor telomeres were associated with a favorable clinical prognosis in CRC and correlate with the higher expression levels of SIRT1. Reduced expression of SIRT1 (RQ ≤ 0.5) was detected in tumors that confer a more adverse clinical evolution. The telomeres of the non-tumor cells from obese or overweight patients were significantly longer than those of patients showing normal weight. In omental adipose tissue, telomere length was lower in obese patients with CRC than in obese patients without CRC. Analyses of the telomeric length and SIRT1 seem of interest in the investigation of the clinical evolution of subjects affected by CRC and in the establishment of the predisposition of obese individuals to the development of this tumor type

Squamous Cell Carcinoma of the Peristomal Skin of a Gastrostomy: Case Study.

BACKGROUND: Primary skin tumors that develop at enteral feeding stomas are extremely rare. Ongoing surveillance of these stomas, including the peristomal skin, is essential to early diagnosis and treatment of these tumors. CASE: A 73-year-old man with an esophageal chemical burn caused by swallowing sodium hypochlorite (bleach) approximately 50 years earlier that was initially managed with esophageal exclusion and placement of a gastrostomy device for enteral feeding presented with an exophytic and painful mass of the skin adjacent to his gastrostomy site. The pathologic report confirmed differentiated squamous cell skin carcinoma. CONCLUSION: Skin tumors arising from chronic wounds or ulcers of the skin surrounding a gastrostomy device are rare but should be considered if hypergranulation tissue or a peristomal lesion appears to be nonhealing. WOC nurses are frequently consulted for care of granulomas, and close monitoring is essential for avoiding this potentially fatal complication.

Síndrome de Bouveret / Bouveret Syndrome

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Clinical Relevance of Telomere Status and Telomerase Activity in Colorectal Cancer.

The role of telomeres and telomerase in colorectal cancer (CRC) is well established as the major driving force in generating chromosomal instability. However, their potential as prognostic markers remains unclear. We investigated the outcome implications of telomeres and telomerase in this tumour type. We considered telomere length (TL), ratio of telomere length in cancer to non-cancer tissue (T/N ratio), telomerase activity and TERT levels; their relation with clinical variables and their role as prognostic markers. We analyzed 132 CRCs and paired non-cancer tissues. Kaplan-Meier curves for disease-free survival were calculated for TL, T/N ratio, telomerase activity and TERT levels. Overall, tumours had shorter telomeres than non-tumour tissues (P < 0.001) and more than 80% of CRCs displayed telomerase activity. Telomere lengths of non-tumour tissues and CRCs were positively correlated (P < 0.001). Considering telomere status and clinical variables, the lowest degree of telomere shortening was shown by tumours located in the rectum (P = 0.021). Regarding prognosis studies, patients with tumours showing a mean TL < 6.35 Kb experienced a significantly better clinical evolution (P < 0.001) and none of them with the highest degree of tumour telomere shortening relapsed during the follow-up period (P = 0.043). The mean TL in CRCs emerged as an independent prognostic factor in the Cox analysis (P = 0.017). Telomerase-positive activity was identified as a marker that confers a trend toward a poor prognosis. In CRC, our results support the use of telomere status as an independent prognostic factor. Telomere status may contribute to explaining the different molecular identities of this tumour type.

Telomere length and telomerase activity in non-small cell lung cancer prognosis: clinical usefulness of a specific telomere status.

BACKGROUND: Considering previous data and the need to incorporate new biomarkers for the prognosis of solid tumours into the clinic, our aim in this work consists of evaluating the potential clinical use of telomeres and telomerase in non-small cell lung cancer (NSCLC). METHODS: Telomere status was established by determination of telomere length using the Terminal Restriction Fragment length method, and telomerase activity by the Telomeric Repeat Amplification Protocol in 142 NSCLCs and their corresponding control samples, obtained from patients submitted to surgery. Group-oriented curves for disease-free survival were calculated according to the Kaplan-Meier method considering telomere length, T/N ratio (telomere length in tumour to control tissue) and telomerase activity. RESULTS: Overall, tumours had significantly shorter telomeres compared with telomeres in control tissues (P = 0.027). More than 80 % of NSCLCs displayed telomerase activity. Regarding prognosis studies, patients whose tumours showed a mean telomere length (MTL) <7.29 Kb or T/N ratio <0.97 showed a significantly poor clinical evolution (P = 0.034 and P = 0.040, respectively). As result of a Cox multivariate analysis including pathologic state and lymph node dissemination, the MTL and T/N ratio emerged as independent significant prognostic factors. CONCLUSIONS: Telomerase activity was identified as a marker of poor prognosis. The novel finding of this study is the independent prognosis role of a specific telomere status in NSCLC patients. According to our results, telomere function may emerge as a useful molecular tool that allow to select groups of NSCLC patients with different clinical evolution, in order to establish personalized therapy protocols.

Prognostic value of telomere function in gastric cancers with and without microsatellite instability.

OBJECTIVE: To identify molecular markers that may be useful in the selection of gastric cancer patients with different prognoses, we investigated telomere function in gastric cancers with and without microsatellite instability (MSI). MATERIALS AND METHODS: We analyzed 83 gastric cancers and its paired-normal tissues to investigate MSI and telomere function. MSI was established using five polymorphic human repeat DNA markers. Telomere function was evaluated by determining telomerase activity, telomere length, and telomere-repeat factors 1 and 2 (TRF1 and TRF2) expression. RESULTS: Patients with high microsatellite instability (MSI-H) gastric cancers showed a significantly better prognosis than those affected by microsatellite stable or low microsatellite instability (MSS/MSI-L) tumors (P = 0.03). The lowest expression levels of TRF1 and TRF2 were associated with MSI-H gastric cancers (P = 0.008 and 0.006, respectively). Moreover, a clear trend toward a worse prognosis was found in the group of patients who had tumors with the shortest telomeres (P = 0.01). Cox multivariate analysis showed that MSI emerged as a protective prognostic factor; MSS/MSI-L tumors conferred a significantly poor prognosis in patients (relative risk = 4.862-fold greater than the MSI-H group) (P = 0.033). Telomere length of gastric tumors less than 2.86 kbp was a factor that led to a poor prognosis (relative risk = 4.420, with respect to tumors showing telomere length ≥ 2.86 kbp) (P = 0.002). CONCLUSION: We propose telomere status as a potential molecular marker with usefulness in the establishment of the prognosis of gastric cancers both for the mutator phenotype and for the suppressor pathway.