Emergency laparoscopic intervention for fibrous band-induced intestinal obstruction and ischemia associated with Meckel's diverticulum: A case report.

INTRODUCTION AND IMPORTANCE: Meckel's diverticulum (MD) is a common congenital malformation of the digestive tract, often asymptomatic but occasionally leading to complications such as bowel obstruction and ischemia. Timely recognition and treatment of these complications are crucial. PRESENTATION OF CASE: We report the case of a 27-year-old male patient presenting with complete intestinal obstruction and ischemia of the ileum due to a fibrous band associated with MD. The patient presented with severe abdominal pain lasting for 10 h. Physical examination revealed a distended abdomen, antalgic position, and positive decompression. Laboratory tests showed leukocytosis and elevated lactic acid levels. Computed tomography revealed dilated small bowel loops with signs of intestinal ischemia. Emergency exploratory laparoscopy confirmed a complete ileum with ischemia and identified a fibrous band originating from the mesentery, strangulating the affected loop. The fibrous band was dissected and sectioned, confirming its association with the MD, which was resected with subsequent recovery of peristalsis and vascularization of the compromised segment. The patient had a favorable postoperative recovery without complications. DISCUSSION: MD is a rare cause of bowel obstruction, requiring a high index of suspicion for diagnosis. Despite the challenges in preoperative identification, early surgical intervention is crucial to prevent adverse outcomes. This case emphasizes the importance of promptly recognizing and managing MD-related complications to optimize patient outcomes. CONCLUSION: MD should be considered in cases of acute occlusive abdomen, despite its infrequent occurrence. Early diagnosis and timely surgical intervention are essential to minimize morbidity and mortality associated with MD-related complications.

Laparoscopic right adrenalectomy in a patient with Carney syndrome: A case report.

INTRODUCTION AND IMPORTANCE: Carney complex (CNC) is an extremely infrequent multiple endocrine neoplasia syndrome characterized by distinctive pigmented skin and mucosal lesions, cardiac and noncardiac myxomatous tumors, and multiple endocrine tumors. We herein report a case of CNC and surgical and history of laparoscopic left adrenalectomy complicated with a primary pigmented nodular adrenocortical disease (PPNAD). PRESENTATION OF CASE: We present the case of a 38-year-old woman with a previous diagnosis of CNC and history of laparoscopic left adrenalectomy who consulted for severe depression refractory to medical treatment. In the laboratory tests performed, altered ACTH, prolactin, Somatomedin C-IGF-1 and estradiol. An abdomen and pelvis C/T scan was requested, where an 8 mm lesion was found at the level of the right adrenal gland. Laparoscopic right adrenalectomy was performed. Histopathology of the surgical resection specimen revealed PPNAD. DISCUSSION: CNC is an infrequent syndrome with autosomal dominant inheritance and genetically heterogeneous. PPNAD is a consistent feature in CNC patients, however, reports of Cushing's syndrome in the literature indicate that only 25-45 % of CNC patients have PPNAD. CONCLUSION: PPNAD can be present in patients with Carney complex, with surgical adrenalectomy history. With an adequate selection of patients, laparoscopic adrenalectomy with subsequent hormone replacement therapy should be performed.

Laparoscopic repair of acute traumatic diaphragmatic hernia with mesh reinforcement: A case report.

INTRODUCTION AND IMPORTANCE: Traumatic diaphragmatic injuries are rare and usually occur after thoracoabdominal trauma. Most patients will have other potentially life-threatening injuries. High index of suspicion is the most important attribute. Unfortunately, it is incorrectly diagnosed in up to 33% of cases. If left untreated, the onset of complications carries mortality rates between 25 and 80%. CASE PRESENTATION: We report a case of an acute diaphragmatic laceration in a 29-year-old male with thoracoabdominal trauma due to a road traffic accident. Physical examination revealed an absence of normal breath sounds in the left hemithorax. CT-scan confirmed a voluminous left diaphragmatic hernia with omental, gastric, and transverse colon content, so surgical intervention was advised. During laparoscopy, a 15 cm long and 5 cm wide diaphragmatic defect was identified. The hernia was reduced laparoscopically, and the defect repaired with interrupted non-absorbable sutures. As a reinforcement, a visceral contact prosthesis was placed. The patient had an uneventful recovery and after 12-month follow-up he has no evidence of recurrence. CLINICAL DISCUSSION: Diaphragmatic injuries do not close spontaneously. An abdominal approach is recommended as it allows for evaluation of the entire abdomen and treatment of any associated injury. Watertight closure with nonabsorbable suture and in case of large defects, the placement of a mesh on the peritoneal side of the diaphragm is recommended to reinforce the primary repair. CONCLUSION: Laparoscopic emergency surgery has proved to be effective and safe in selected patients with hemodynamic stability. Patients can expect the benefits of minimal invasive surgery with recurrence rate like the open approach.

Surgical resection of a presacral solitary fibrous tumor with extension to iliac vessels using Karakousis's abdominoinguinal approach: Report of a rare case.

INTRODUCTION AND IMPORTANCE: The solitary fibrous tumor (SFT) is a rare tumor of mesenchymal origin, with a reported incidence of 2.8 cases per 100,000 tumors and with distinctive histopathological and immunohistochemical characteristics. It was initially described as a pleural lesion and subsequently, it was found in different organs and tissues. The abdominoinguinal incision described by Karakousis allows a safe and radical approach for lower quadrants abdominopelvic tumors. CASE PRESENTATION: A 47-year-old man was referred to us with a 5-months history of lower backache radiating to the left lower limb. MRI and CT revealed a retroperitoneal mass of 10 cm extending to left iliac vessels. The initial diagnosis corresponded to a sarcomatous retroperitoneal tumor. It was decided to perform an abdominal exploration using Karakousis's approach for surgical resection. The immunohistochemistry and histopathological study revealed neoplasia compatible with a SFT. It was categorized as low risk for developing metastasis and death from disease, according to the new malignancy criteria. Currently, the patient is asymptomatic and disease-free at 19 months after surgery. CLINICAL DISCUSSION: Most patients with SFTs present symptoms derived from the tumor growth and the compression on adjacent structures with clinical manifestations that are frequently insidious and precede the tumor discovery. The diagnosis is based on histopathological studies. Nonetheless, when they present an extrathoracic location, they represent a diagnostic challenge, due to their variable histological characteristics. CONCLUSION: Presacral SFT is a rare entity, with a scant incidence reported regarding this location and long-term treatment. Surgical resection is needed as the immediate treatment.

Ileocecal intussusception as the initial presentation of endometriosis: case report.

Cecal endometriosis is a rare entity that can present as nonspecific acute abdominal pain and can be complicated by ileocolic intussusception, which is extremely infrequent. We present the case of a 33-year-old woman with no relevant pathological antecedents who consulted for abdominal pain for 5 days, associated with rebound tenderness and abdominal guarding on the right lower quadrant and a palpable mass during the physical examination. Computed tomography was realized and emergency surgery performed due to suspected ileocolic intussusception. The laparoscopic examination identified an ileocolic intussusception associated with a tumor. Conversion to open surgery was needed, and an oncological right hemicolectomy with ileotransverse anastomosis was carried out. Histopathological study reported ileocolic intussusception and a focus of cecal endometriosis. Currently, the patient does not have recurrences. Ileocolic intussusception secondary to deep endometriosis requires great diagnostic presumption in women of childbearing age with acute abdomen diagnosis.

Impact of Gastric Bypass on Erosive Esophagitis and Barret's Esophagus.

BACKGROUND: The association between gastroesophageal reflux disease (GERD) and obesity is clearly defined. The incidence of erosive esophagitis (EE) and Barrett's esophagus (BE) are as high as 26 and 6%, respectively. Gastric bypass (GBP) is considered the gold standard for obese patients with GERD. Evidence about the impact of GBP on EE and BE is not yet clear but more inspiring every day. METHODS: Obese patients operated by GBP with EE or BE were included for this study. Demographics, BMI, %EWL, and the evolution of EE and BE with pre and postoperative upper endoscopy were analyzed. RESULTS: In this study, 64 patients were included, 55 with EE and 9 with BE. The preoperative BMI was 44.29 km/m2 ± 3.5 and the %EWL was 78.5 ± 5.8 in the first year postoperative. Preoperatively, EE was distributed as follows: A: 54.5% (30), B: 34.5% (19), C: 9% (5), D: 2% (1). BE findings were the following: short segment (SSBE): 45% (4) and long segment (LSBE): 55% (5). Postoperatively, 80% of the patients with EE resolved their condition, 11% improved, 7% had no changes, and 2% worsened. From the patients with SSBE, 75% resolved their condition and 40% with LSBE resolved their condition after 24 months and no patient progressed to dysplasia. CONCLUSION: Patients with EE had a statistically significant resolution after GBP. BE was improved or even resolved in many patients without acquiring significance but also without progression. Long-term surveillance data is necessary to define the certain evolution of EE and BE after GBP.

Esophagitis evolution after sleeve gastrectomy or gastric bypass in consecutive cases.

BACKGROUND: Erosive esophagitis (EE) is related to esophageal mucosal damage caused by GERD and is implicated in the development of Barret´s esophagus and adenocarcinoma, which incidence is rising in association with obesity. It is known that the correlation between symptoms and endoscopic findings is relatively poor, with a predictive value of only 40%. The objective of this study is to report the incidence of EE 1 year after sleeve gastrectomy (SG) and gastric bypass (GBP) in consecutive patients in order to obtain an objective parameter of the impact of the two most popular bariatric procedures on esophageal mucosa. METHODS: A retrospective review of a prospective database including every primary GBP and SG consecutive cases performed between January 2014 and December 2016. Esophagitis evolution was compared between patients with adequate weight loss versus those with inadequate weight loss. The comparison of baseline and 1-year EE, BMI, %EWL, and %TWL was made by using the Chi square test for categorical variables and Student "t" test for continuous samples. RESULTS: Two hundred and twenty-seven patients were included. GBP was performed to 35.2% (n = 80) and SG to 64.8% (n = 147). Pre- and postoperatively EE evolution in GBP decreased from 54 to 26.2% (p = 0.002) and in SG increased from 8.2 to 30% (p = 0.04) Barret´s esophagus in GBP decreased from 7.5 to 5% (p = 0.001). No statistical difference was observed when we compared the evolution of EE in patients with adequate or inadequate weight loss in both groups. CONCLUSIONS: The incidence of EE 1 year after SG is greater than GBP. Moreover, not only GBP seems to improve this condition, but also SG tends to worsen EE. These results are to be associated with GERD disease.

Hemicolectomía derecha laparoscópica con abordaje suprapúbico: una técnica novedosa para el tratamiento del cáncer de colon / Suprapubic laparoscopic right hemicolectomy: a novel technique for the treatment of colon cancer

Antecedentes: la hemicolectomía derecha laparoscópica con abordaje suprapúbico (HDLS) y empleo de tecnología robótica o laparoscópica de incisión única ha sido recientemente informada. La utilización de la técnica estándar multipuerto en HDLS no se ha descripto previamente. Material y métodos: entre enero y agosto del año 2018 fueron intervenidos 4 pacientes, 3 mujeres y 1 hombre, con mediana de 64 años de edad y diagnóstico de adenocarcinoma de colon derecho. Resultados: el procedimiento se realizó exitosamente en todos los pacientes, con una mediana de tiempo operatorio de 210 minutos (r:170-240). Ningún paciente tuvo complicaciones y fueron dados de alta en una mediana de 4 días (r:3-5). Todas las piezas quirúrgicas tuvieron márgenes negativos y un recuento ganglionar > 12 ganglios. A 7, 5, 4 y 2 meses del seguimiento, los pacientes se hallan vivos y libres de enfermedad. Conclusión: la técnica de HDLS multipuerto es una alternativa sencilla, factible y segura para el tratamiento del cáncer de colon en pacientes seleccionados, con un resultado funcional, estético y oncológico favorable.

Background: The suprapubic approach for laparoscopic right hemicolectomy has been reported with robotic surgery or single incision laparoscopy. The use of the suprapubic approach for standard multiport laparoscopic right hemicolectomy has not been previously described. Material and methods: Between January and September 2018, four consecutive patients (three women and one man; median age: 64 years) with right-sided colon cancer underwent laparoscopic right hemicolectomy using the suprapubic multiport approach. Results: The procedure was successful in all the patients and mean operative time was 210 minutes (IQR: 170-240). There were no complications and were discharged on postoperative day 4 (IQR: 3-5). All the surgical specimens had negative margins and lymph node count was > 12 lymph nodes. All the patients are alive and free from disease at 7, 5, 4 and 2 months of follow-up. Conclusion: The suprapubic approach for standard multiport laparoscopic right hemicolectomy is an easy, feasible and safe alternative for the treatment of colon cancer in selected patients, with a favorable functional, esthetic and oncological result.

Obese Patients with Type 2 Diabetes: Outcomes After Laparoscopic Sleeve Gastrectomy.

Background: Bariatric surgery is superior to medical treatment for type 2 diabetes mellitus (T2DM) control in obese patients. Reports in the literature have been mainly based on Roux-en-Y gastric bypass (RYGB) or adjustable gastric band. The aim of this study was to analyze mid- and long-term metabolic results after laparoscopic sleeve gastrectomy (LSG). Methods: Obese patients with T2DM undergoing LSG were included in this study. Selection criteria for T2DM remission were: post-operatory fasting glucose (FG) level <100 mg/dL, and hemoglobin A1c (HbA1c) <6% without medication. Results: Between January 2009 and July 2016, 166 T2DM obese patients underwent LSG and completed ≥1 year follow-up. There were 101 women (60.8%; mean age 49.07 ± 12.8 years). Initial body mass index (BMI) was 46.44 ± 7.68 kg/m2. Mean time since T2DM diagnosis was 5.95 years (1-28). Preoperative HbA1c was 7.53% ± 0.97%. Before LSG, 75.3% (n = 125) were receiving oral hypoglycemic agents, and 13.25% (n = 22) insulin. Mean follow-up was 65 ± 10 months. Complete T2DM remission was achieved in 78.3%, 76.2%, and 71.4% at 1, 3, and ≥5 years respectively; in the long term, 7.2% attained partial remission, 10% improved, and 11.4% experienced recurrence of the disease. Remission rate was significantly lower in patients under insulin therapy preoperatively, and in patients with T2DM diagnosed ≥5 years before consultation (P = .0004 and .0001, respectively). Conclusions: At mid- and long-term follow-up, T2DM control was satisfactory after LSG. Preoperative insulin therapy and T2DM duration ≥5 years were predictors of less favorable outcomes.

Gastroesophageal reflux disease and morbid obesity: evaluation and treatment.

Gastroesophageal reflux disease (GERD) is markedly increased among the obese population being recognized as one of the many obesity-related comorbidities. This concept should raise awareness, making physicians investigate more profoundly about this disease in this kind of patients. Currently, bariatric surgery is considered the gold standard treatment for morbid obesity. However, not all the operations are appropriate for the treatment of GERD and not all the patients are willing to receive bariatric surgery for the treatment of GERD. Even though sleeve gastrectomy has emerged as a suitable treatment option for morbid obesity, it has been related to development of de novo GERD or worsening the pre-existing one. Conversely, results after Roux-en-Y gastric bypass have been encouraging in this aspect, and it seems to be the best option for patients who suffer both diseases. Therefore, the presence of GERD should not be ignored at the time of deciding which type of surgery will be offered to the patient.

Multiple primary tumors: Colorectal carcinoma and non-Hodgkin's lymphoma.

INTRODUCTION: Colorectal cancer (CRC) is the third most commonly diagnosed cancer, whereas lymphoma is the sixth leading cause of cancer death, 90% of which corresponds to non-Hodgkin's lymphoma (NHL). The association of these two primary tumors, a solid tumor with an hematological malignancy, is very uncommon. PRESENTATION OF CASE: We report the case of a 47-year-old man who presented with abdominal pain, a right upper quadrant mass and 12 kg of weight loss in 9 months. The computed tomography (CT) showed a large intra-abdominal mass and a wall thickening at the rectosigmoid junction. A colonoscopic biopsy confirmed a colorectal adenocarcinoma and a laparoscopic biopsy of the intraabdominal mass confirmed a diffuse large B-cell NHL. After multidisciplinary discussion it was decided to treat first the NHL with 3 cycles of R-CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisone). The patient experienced a good response with a 70% decrease in the intraabdominal mass and a negative PET/CT. Four months after diagnosis an anterior rectal resection was performed. The patient recovered uneventfully and was discharged 5 days after surgery. The patient finally died 20 months after surgery due to disease progression. DISCUSSION: The association of CRC and NHL is an extremely rare scenario that represents a great multidisciplinary challenge with respect to treatment due to the scarce literature found on this topic. CONCLUSION: When CRC and NHL are present, all the different disease patterns must be considered in a multidisciplinary and patient-oriented fashion, in order to decide the best therapeutic strategy for each individual.

Impact on Dyslipidemia After Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Improvement of dyslipidemia is an important benefit of bariatric surgery. The benefits of laparoscopic sleeve gastrectomy (LSG) among dyslipidemia are still a matter of debate. METHODS: We conducted a retrospective descriptive study between 2010 and 2013. Obese patients undergoing LSG, with recorded dyslipidemia at admission and a follow-up for at least 1 year, were included for analysis. Demographic characteristics, medication in use, and a complete lipid profile were collected before surgery. After surgery, weight was controlled at 1, 3, 6, and 12 months. Lipid profile was re-evaluated 1 year after surgery. Patients were divided according to weight loss into two groups: (A) adequate weight loss and (B) inadequate weight loss. Lipid profile evolution was then compared between groups. RESULTS: One hundred seven patients met the inclusion criteria. Pre-op mean BMI was 45.13 ± 7.5 kg/m2. One year after LSG, mean BMI was 30.6 ± 7.1 kg/m2 with a change in BMI of 11.5 ± 6.6 kg/m2, a %TWL of 26.9 ± 13.5%, and a %EWL of 60.3 ± 36.6%. Hypercholesterolemia and hypertriglyceridemia remission was achieved in 45 and 86% of the patients and improved in another 19 and 4% respectively. Seventy-four percent improved HDL levels. LDL levels improved in 39% and remitted in 37%. Medication was discontinued in 43.7%. HDL increase and LDL, TG, and non-HDL-C decrease were significantly greater in group A. CONCLUSIONS: LSG produces an improvement in lipid profile, with a significant increase in HDL and a decrease in LDL, triglycerides, and non-HDL-C.

Long-Term Relationship Between Tobacco Use and Weight Loss after Sleeve Gastrectomy.

BACKGROUND: Smoking cessation had been typically associated with weight gain. We have reported that there is no relationship between tobacco use and weight loss after bariatric surgery in the short term. The objective of this study was to establish the relationship between weight loss and the smoking habit in patients undergoing bariatric surgery and to analyze weight loss on severe smokers and on those patients who stopped smoking during the long-term postoperative period. METHODS: One hundred eighty-four patients included in our previous study were contacted by phone at 7 years after sleeve gastrectomy. They were again divided into three groups: (A) smokers, (B) ex-smokers, and (C) non-smokers. Demographics and weight loss at 6, 12, 24, and 7 years were analyzed. Smokers were subdivided for further analysis into the following: group A1: heavy smokers, group A2: non-heavy smokers, group A3: active smokers after surgery, and group A4: quitters after surgery. Student test was used for statistics. RESULTS: One hundred two patients were included. The follow-up was 80.74 ± 7.25 month. Group A: 29 patients, group B: 34 patients, and group C: 39 patients. Mean BMI was 34.35 ± 8.44 kg/m2 and the %EWL was 56.95 ± 27. The subgroup analysis showed the following composition: group A1: 6 patients, group A2: 23 patients, group A3: 23 patients, and group A4: 6 patients. Weight loss difference among groups and subgroups was statistically non-significant. CONCLUSIONS: This study reaffirms the hypothesis that weight loss among bariatric patients is independent from smoking habit even at long-term follow-up and regardless from cessation.

Sleeve Gastrectomy after Renal Transplantation.

BACKGROUND: Obesity induces or accelerates diabetes (DBT), hypertension (HT), and dyslipidemia (DSL), which are the main causes of renal failure. Obesity exacerbates in patients after renal transplantation (RT), and it has been associated with increased mortality rate, postoperative complications, and graft loss. We hypothesize that bariatric surgery might have a positive effect on obese patients with history of previous RT. METHODS: This was a retrospective review from prospectively collected data. Patients with sleeve gastrectomy (SG) with history of RT were studied. Demographics, anthropometric data, effect on comorbidities, postoperative course, immunosuppressive treatment, reason for transplantation, kidney function, graft survival, and quality of life associated with SG in obese patients with previous RT were assessed using a survey. RESULTS: From January 1, 2012 to January 1, 2016, five kidney transplant patients were operated on; 80% were female, with an average preoperative BMI of 42.18 ± 8.5 kg/m2 (range 37-54). Related comorbidities: 100% of the patients had HT and DSL, whereas 40% had DBT and gout. The average time gap between RT and SG was 15 ± 8.4 years (range 3-22). Average operative time was 65 ± 12 min (range 60-85), and there were neither complications nor mortality. At 16.8 ± 14.5 months (range 5-46) of follow-up, BMI was 29.8 ± 7.3 kg/m2 (range 26-44). All patients with HT and DSL were able to decrease their medication, showing improvement in blood pressure levels and laboratory test values. Regarding DBT, insulin was discontinued in one case, limiting the treatment to the use of oral hypoglycemic agents only. In another case, insulin dosage was significantly reduced. Graft function and proteinuria level improved in 80% of patients. All patients experienced a significant improvement in their quality of life. CONCLUSION: In this specific group of high-risk patients, SG showed encouraging results in terms of weight loss and resolution/improvement of comorbidities, renal function, and quality of life.

Laparoscopic Sleeve Gastrectomy: Endoscopic Findings and Gastroesophageal Reflux Symptoms at 18-Month Follow-Up.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has shown excellent results in terms of weight loss and resolution of comorbidities. Despite that, the effect of LSG on gastroesophageal reflux disease (GERD) is still a controversial topic. Our objective was to evaluate the presence of gastroesophageal reflux symptoms, erosive esophagitis (EE), and hiatal hernia (HH) in obese patients undergoing LSG. METHODS: Prospective observational study. LSG patients were studied before and at 18-month follow-up. Demographics, anthropometrics, status of comorbidities, perioperative data, GERD symptoms, and esophagogastroduodenoscopy (EGD) findings were evaluated. RESULTS: Between June 2012 and July 2014, 285 patients underwent LSG. Pre- and postoperative data were available in 109 patients; therefore, they were included in the study. There were 72 women (66%), age 40 ± 9 years. Preoperative body mass index (BMI) was 47.8 ± 16 kg/m2. At 18-month follow-up, body mass index and percentage excess weight loss were 29.3 ± 6 kg/m2 and 64% ± 9.4%, respectively. Resolution/improvement of comorbidities was as follows: diabetes 73%, hypertension 57.5%, and obstructive sleep apnea 89%. GERD symptoms increased from 33% to 44% (P = no statistical significance), EE from 20.1% (100% grade A) to 33.9% (74% grade A) (P < .001), and HH from 22% to 34.8% (P < .001). Postoperative findings on symptomatic patients were as follows: EE was found in 64.5%, HH in 23%, while 12.5% had normal EGD. There was a significant association between manifestation of GERD symptoms and the presence of EE on EGD (P < .05). Symptoms de novo were observed in 36.9% of patients, EE in 28.7%, and HH in 16.4%. Complication rate was 3.5%; there was no mortality. CONCLUSION: The prevalence of GERD symptoms, EE, and HH was increased after LSG. At 18-month follow-up, severity of esophagitis was mild, the majority of them being Grade A esophagitis. There was good correlation between manifestation of GERD symptoms and the presence of EE on EGD.

Obstrucción duodenal por páncreas anular / Duodenal obstructon due to anular pancreas

El páncreas anular (PA) es una anomalía congénita infrecuente. Se caracteriza por la presencia de tejido pancreático ectópico alrededor del duodeno y puede estar asociado a obstrucción duodenal. Se presenta un paciente con cuadro de dolor abdominal y vómitos de 12 días de evolución. El laboratorio mostró elevación de lipasa en sangre. La tomografia computarizada de abdomen evidenció estómago y primera porción duodenal distendidos, en relación con una imagen en anillo de 5 cm de diámetro ubicada entre la cabeza del páncreas y la segunda porción del duodeno, sugestiva de PA. Ante la mala respuesta al tratamiento médico con reposo digestivo, sonda nasogástrica y nutrición parenteral, se decide conducta quirúrgica confirmando el diagnóstico de obstrucción duodenal por un PA. Se realiza gastroyeyunostomía en Y de Roux con buena evolución posquirúrgica. El PA puede manifestarse clínicamente como una obstrucción duodenal. Los casos con mala respuesta al tratamiento conservador requieren conducta quirúrgica para confirmar el diagnóstico y resolver la oclusión.

Annular pancreas (AP) is a rare congenital anomaly, characterized by ectopic pancreatic tissue surroun-ding the duodenum, that may associate with duodenal obstructon. We present a patent complaining of 12 days of abdominal pain and vomitis. Blood testis showed hyper-lipasemia. Computed tomography scan demonstrated stomach and frst duodenal porton distended in relaton to a 5 cm diameter image resembling a ring between the pancreatic head and the second porton of the duodenum, a well known characteristic of AP. Following a lack of clinical response to medical treatment, surgery was performed confirming a duodenal obstructon due to AP. Roux-en-Y gastrojejunostomy was done, with good postoperative outicome. Annular pancreas may present as a duodenal obstructon. For these cases, we suggest surgical treatment to confirm diagnosis and resolve the obstructon in cases with negative clinical response to conservative treatment.

Incidental Finding of Gastrointestinal Stromal Tumors during Laparoscopic Sleeve Gastrectomy in Obese Patients.

INTRODUCTION: The frequency of incidental pathology found during laparoscopic bariatric surgery has been estimated to be 2%. Gastrointestinal stromal tumors (GISTs) are infrequent lesions and account for less than 1% of all digestive tract tumors. The reported incidence of this type of tumors during bariatric surgery is around 0.8%. The objective of this study was to evaluate incidence, characteristics, and evolution of incidentally found GISTs in patients undergoing laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity. MATERIAL AND METHODS: A retrospective analysis from a prospectively collected database was conducted. Demographic data, clinical data, laboratory tests, preoperative esophagogastroduodenoscopy (EGD), postoperative pathology report from surgical specimen with tumor markers, and patient's outcomes were evaluated. RESULTS: From June 2006 to January 2014, 915 patients underwent LSG at our institution. Five (0.5%) patients were found to have incidental GIST. There were four (80%) women; average age was 59.6 ± 6.3 years (range 46-63). None of them had symptoms that served as orientation for preoperative diagnosis. EGD findings were non-suggestive of this pathology in any of these cases. Superficial chronic gastritis was the most common finding in the endoscopic biopsy (60%). All the tumors found in the surgical specimen were of low or very low risk of malignancy, with less than 5 mitoses per 50 fields, less than 2 cm in diameter, and disease-free surgical margins. Cluster of differentiation (CD) 117 and CD 34 were positive in 100% of the cases. None of the patients required adjuvant therapy after the surgery. At 5-year follow-up, all patients were asymptomatic and disease free. CONCLUSION: The incidence of unsuspected GIST in LSG specimens in our series was low and similar to what has been reported. The lack of symptoms and the preoperative EGD findings were not suggestive of this diagnosis in any case. The degree of tumor malignancy was low in all patients and LSG was the definitive treatment, without recurrence at 5-year follow-up.

Sweet Eating Habit: Does This Affect the Results After Sleeve Gastrectomy?

BACKGROUND: It is commonly believed that eating habits, specially the sweet eating habit, can predict results after bariatric surgery; for this reason, it is considered one of the selection criteria when deciding the surgical technique. However, there is not enough evidence of its impact on the results after sleeve gastrectomy (SG). OBJECTIVE: To evaluate the relationship between the sweet eating habit and weight loss after SG. DESIGN: Cross-sectional retrospective study. MATERIAL AND METHODS: Group A: nonobese subjects, and group B: patients who underwent SG and had ≥6 months follow-up. Demographics, anthropometrics, percentage excess weight loss (%EWL) at 6, 12, and 24 months, and eating habits before surgery were analyzed. Sweet eating consumption was classified as follows: mild, moderate, and severe. Uni- and bivariate logistic regression analysis according to each variable was performed. RESULTS: Between 2006 and 2011, 157 patients underwent SG at our institution; 36% were male, age 41 years old, and initial body mass index 46 kg/m(2). Mean %EWL at 6, 12, and 24 months was 66%, 77%, and 70%, respectively. Sweet eating consumption: Mild: 59%; Moderate: 38%; and Severe: 3%. No difference was found in sweet eating patterns among groups A and B; %EWL for mild, moderate, and severe sweet eaters at 6 months was 66 ± 16, 66 ± 14, and 65 ± 10, respectively (P = non-significant [NS]). The same analysis was made at 12 months: 76 ± 20, 79 ± 18, and 78 ± 11 (P = NS). At 24 months, only mild and moderate sweet eaters were available for comparison: 69 ± 23 and 73 ± 19, respectively (P = NS). CONCLUSION: Preliminary data suggested that preoperative sweet eating habit would not predict results after SG in terms of weight loss.

Relationship Between Tobacco Use and Weight Loss After Bariatric Surgery.

BACKGROUND: Smoking cessation had been typically associated with weight gain. So far, there are no reports documenting the relationship between weight loss after bariatric surgery and smoking habit. The objective of the study was to establish the relationship between weight loss and smoking habit in patients undergoing bariatric surgery and to analyze weight loss on severe smokers and on those patients who stopped smoking during the postoperative period. METHODS: All patients undergoing laparoscopic sleeve gastrectomy (LSG) with at least 2-year follow-up were included. Patients were divided into three groups: (A) smokers, (B) ex-smokers, and (C) non-smokers. Demographics and weight loss at 6, 12, and 24 months were analyzed. Smokers were subdivided for further analysis into the following: group A1: heavy smokers, group A2: non-heavy smokers, group A3: active smokers after surgery, and group A4: quitters after surgery. Chi-square test was used for statistics. RESULTS: One hundred eighty-four patients were included; group A: 62 patients, group B: 57 patients, and group C: 65 patients. Mean BMI was 34 ± 6, 31 ± 6, and 31 ± 6 kg/m2; mean %EWL was 63 ± 18, 76 ± 21, and 74 ± 22 % at 6, 12, and 24 months, respectively. The subgroup analysis showed the following composition: group A1: 19 patients, group A2: 43 patients, group A3: 42 patients, and group A4: 20 patients. Weight loss difference among groups and subgroups was statistically non-significant. CONCLUSIONS: Our study shows that weight loss evolution was independent from smoking habit. Neither smoking cessation during the postoperative period nor smoking severity could be related to weight loss after LSG.

Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy.

INTRODUCTION: Portal and mesenteric vein thrombosis are relatively uncommon surgical complications, with difficult diagnosis and potentially severe consequences due to higher risk of bowel infarction. The purpose of this study was to present a series of patients who developed postoperative portal vein thrombosis after laparoscopic sleeve gastrectomy. METHODS: This is a retrospective analysis of patients who underwent sleeve gastrectomy between June 2005 and June 2011 who developed portal vein thrombosis. Demographic data, personal risk factors, family history of thrombosis, and postoperative results of thrombophilia study were analyzed in this study. RESULTS: A total of 1,713 laparoscopic sleeve gastrectomies were performed. Seventeen patients (1 %) developed portal vein thrombosis after surgery. Of the 17 patients, 16 were women, 8 had a history of smoking, 7 used oral contraceptives, and 2 had a family history of deep vein thrombosis of the lower limbs. All patients were discharged on the third day of surgery with no immediate complications. Symptoms presented at a median of 15 (range, 8-43) days after surgery with abdominal pain in most cases. One case required emergency laparotomy and splenectomy because of an active bleeding hematoma with massive portomesenteric vein thrombosis. In 11 cases, a thrombosis of the main portal vein was identified, in 15 the right portal branch was compromised, and in 10 the left portal branch. Eleven patients presented thrombosis of the superior mesenteric vein, and ten patients presented a concomitant thrombosis of the splenic vein. A massive PMVT was presented in six cases. Seven patients had a positive thrombophilia study. CONCLUSIONS: Portal vein thrombosis and/or mesenteric thrombosis are relatively uncommon complications in patients undergoing bariatric surgery. In this series, the portomesenteric vein thrombosis was the most common complication after LSG in a high-volume center.