Management of the staple line in laparoscopic sleeve gastrectomy: comparison of three different reinforcement techniques.

BACKGROUND: Nowadays, laparoscopic sleeve gastrectomy (LSG) is one of the most widely performed bariatric procedures. Different techniques have been described to reduce the rate of complications associated with the staple line, but no consensus has been reached. The aim of this study was to determine the incidence of surgical complications after LSG with three different approaches to the staple line. PATIENTS AND METHODS: A retrospective matched analysis was performed, comparing three groups of 100 patients each: partial oversewing of the staple line (PO group), complete oversewing of the staple line (CO group), and reinforcement with buttress material (BM group). Operative time, early surgical complications (superficial surgical site infection, leakage and hemorrhage), length of stay, weight evolution, and revisional surgery rates were analyzed. RESULTS: All three groups were comparable at baseline. All surgeries were performed laparoscopically. Operative time was significantly longer in the CO group (PO: 84.2 ± 22; CO: 104.7 ± 17; BM: 82.3 ± 22; PO vs CO, p = 0.021; BM vs CO, p = 0.011). There were no differences in length of stay, early surgical complications, and weight outcomes at 36 months between the groups. The need for a revisional surgery was significantly higher in the CO group compared to the PO group (PO: 3%; CO: 14%; BM: 9%; PO vs CO, p = 0.005). CONCLUSION: The CO group required a longer operative time. There were no differences in early surgical complications between the groups. The CO group had a higher need for revisional surgery than the PO group.

Effects of COVID-19 lockdown on a bariatric surgery waiting list cohort and its influence in surgical risk perception.

PURPOSE: The COVID-19 outbreak has forced a 2-month lockdown (LD) in Spain. We aimed to assess how that had affected our cohort of bariatric patients waiting for surgery. METHODS: A review of electronic records and a structured phone interview with each patient were conducted. Changes in severity of obesity were analyzed using the Obesity Surgery Score (OSS) and changes in health-related quality of life (HRQoL) using the validated EQ-5D questionnaire. Other miscellaneous questions about behavior modifications and surgical risk perception were also analyzed. RESULTS: All 51 patients fully answered the questionnaires. Mean age was 47 years and mean time on waiting list 91 days. Mean BMI increased during LD (42.7 vs 43.2; p < 0.001). Both OSS (2.84 vs 3; p = 0.011) and EQ-5D (69 vs 64; p < 0.001) mildly worsened during LD, mainly due to psychosocial issues. Twenty-seven patients (53%) thought that perioperative risks were higher under the current circumstances but they were as willing to undergo surgery as those who believed that the risks had not increased (74% vs 87%, p = 0.2). CONCLUSIONS: COVID-19 LD had a significant but mild effect on our cohort of bariatric surgery waiting list patients. Although perioperative risk perception had increased, patients were still willing to undergo their planned surgeries.

A Risk-Based Screening Approach to Patients Needing Surgery During the De-Escalation Phase of COVID-19 Pandemic.

Since the outbreak of COVID-19 pandemic, many national and international surgical societies have produced guidelines regarding the management of surgical patients. During the mitigation phase of the pandemic, most documents suggested to consider postponing elective procedures, unless this might have impacted the life expectancy of patients. As awareness and knowledge about COVID-19 are gradually increasing, and as we enter a phase when surgical services are resuming their activities, surgical strategies have to adapt to this rapidly evolving scenario. This is particularly relevant when considering screening policies and the associated findings. We herein describe a risk-based approach to the management of patients with surgical diseases, which might be useful in order to limit the risks for healthcare workers and patients, while allowing for resuming elective surgical practice safely.

Reversal to Normal Anatomy (With Sleeve Gastrectomy) for Severe Hypoglycemia.

Background. Laparoscopic Roux-en-Y gastric bypass (GBP) is an essential bariatric surgical procedure which is globally performed because of the associated effective weight loss and resolution of metabolic comorbidities, such as diabetes and dyslipidemia. Although some complications may occur, hypoglycemia is a rare complication, which can lead to lethal consequences. We aimed to describe the technical aspects and surgical results after reversal to normal anatomy (RNA). Methods. We conducted a retrospective data analysis including 16 patients who underwent laparoscopic RNA from 2011 to 2018. All data were archived in a prospective database. Previous bariatric surgery and postoperative outcomes were analyzed. Results. Sixteen patients underwent RNA, most of them after GBP, and 15 patients required sleeve gastrectomy. Among them, 80% were women; 5 patients presented with postoperative complications, such as colitis with intra-abdominal collection (n = 1), gastric leak (n = 2) treated with an endoprosthesis, mesenteric venous thrombosis (n = 1), and intra-abdominal bleeding (n = 1). Mean length of hospital stay was 5.93 (3-30). All patients recovered from their initial condition although 3 patients presented with mild hypoglycemia during follow-up. Seven patients regained weight (43.75%), and another 4 developed gastroesophageal reflux disease (25%). Conclusions. These laparoscopic RNA results are acceptable, indicating a clinical improvement in the hypoglycemic syndrome in all patients.

Brush border myosin Ia has tumor suppressor activity in the intestine.

The loss of the epithelial architecture and cell polarity/differentiation is known to be important during the tumorigenic process. Here we demonstrate that the brush border protein Myosin Ia (MYO1A) is important for polarization and differentiation of colon cancer cells and is frequently inactivated in colorectal tumors by genetic and epigenetic mechanisms. MYO1A frame-shift mutations were observed in 32% (37 of 116) of the colorectal tumors with microsatellite instability analyzed, and evidence of promoter methylation was observed in a significant proportion of colon cancer cell lines and primary colorectal tumors. The loss of polarization/differentiation resulting from MYO1A inactivation is associated with higher tumor growth in soft agar and in a xenograft model. In addition, the progression of genetically and carcinogen-initiated intestinal tumors was significantly accelerated in Myo1a knockout mice compared with Myo1a wild-type animals. Moreover, MYO1A tumor expression was found to be an independent prognostic factor for colorectal cancer patients. Patients with low MYO1A tumor protein levels had significantly shorter disease-free and overall survival compared with patients with high tumoral MYO1A (logrank test P = 0.004 and P = 0.009, respectively). The median time-to-disease recurrence in patients with low MYO1A was 1 y, compared with >9 y in the group of patients with high MYO1A. These results identify MYO1A as a unique tumor-suppressor gene in colorectal cancer and demonstrate that the loss of structural brush border proteins involved in cell polarity are important for tumor development.

Human SMC2 protein, a core subunit of human condensin complex, is a novel transcriptional target of the WNT signaling pathway and a new therapeutic target.

Human SMC2 is part of the condensin complex, which is responsible for tightly packaging replicated genomic DNA prior to segregation into daughter cells. Engagement of the WNT signaling pathway is known to have a mitogenic effect on cells, but relatively little is known about WNT interaction with mitotic structural organizer proteins. In this work, we described the novel transcriptional regulation of SMC2 protein by direct binding of the ß-catenin·TCF4 transcription factor to the SMC2 promoter. Furthermore, we identified the precise region in the SMC2 promoter that is required for ß-catenin-mediated promoter activation. Finally, we explored the functional significance of down-regulating SMC2 protein in vivo. Treatment of WNT-activated intestinal tumor cells with SMC2 siRNA significantly reduced cell proliferation in nude mice, compared with untreated controls (p = 0.02). Therefore, we propose that WNT signaling can directly activate SMC2 transcription as a key player in the mitotic cell division machinery. Furthermore, SMC2 represents a new target for oncological therapeutic intervention.

Preventive midline laparotomy closure with a new bioabsorbable mesh: an experimental study.

BACKGROUND: Incisional hernia formation is one of the most frequent complications of midline laparotomies requiring reoperation. The aim of this study was to evaluate the safety and efficacy of prophylactically placing a biodegradable mesh within the incision site at closure in a rat model. METHODS: A 4-cm full-thick midline laparotomy was made in Sprague-Dawley rats along the linea alba and closed by inserting a commercially available web of synthetic polymers (polyglycolic acid-trimethylene carbonate) that are slowly degraded by the body. Host tissue reaction was evaluated ex vivo and compared with that obtained in suture-only-treated rats. Specimens were harvested at 1, 3, and 6mo after surgery and divided for histologic and zymographic analyses and uniaxial material testing. A group of intact nonoperated animals were included to serve as a reference. RESULTS: The excised tissue explants revealed that the performance of the synthetic device was good and resulted in enhanced fibroproliferation, gelatinolytic activity, and angiogenesis within the repair site as compared with the suture-only procedure. Lastly, tensile strength augmented over the suture-only condition. CONCLUSIONS: The preventive introduction of an absorbable mesh stimulates new tissue ingrowth and performance relative to suture repair without prosthesis, probably contributing to eventually reinforce the tension line. These results have a clinical potential in abdominal wall closure, especially in patients with multiple risk factors such as those treated for aortic reconstructive surgery, without the short- and long-term complications related to permanent grafts. However, data are preliminary and should be confirmed with longer follow-ups.

Internet of things and bariatric surgery follow-up: Comparative study of standard and IoT follow-up.

INTRODUCTION: Follow-up of obese patient is difficult. There is no literature related to patient follow-up that incorporates the concept of Internet of Things (IoT), use of WiFi, Internet, or portable devices for this purpose. MATERIAL AND METHODS: This prospective observational study commenced in June 2011. Patients were prospectively offered to participate in the IoT study group, in which they received a WiFi scale (Withing®, Paris) that provides instant WiFi data to the patient and surgeon. Other patients were admitted to the standard follow-up group at the outpatient clinic. A total of 33 patients were included in our study (ten in the IoT group). RESULTS: Twelve patients did not have WiFi at home, ten lacked of computer knowledge, and seven preferred standard for follow-up. All patients underwent different surgical procedures. There were no complications. Excess weight loss (EWL) was similar in both groups. More than 90% of patients were satisfied. In the IoT group, patients considered it valuable in saving time, and considered seeing their evolution graphics extremely motivating. CONCLUSION: IoT technology can monitor medical parameters remotely and collect data. A WiFi scale can facilitate preoperative and follow-up. Standard follow-up in a classical outpatient clinic setting with the surgeon was preferred globally.

Apoptosis-like cell death induction and aberrant fibroblast properties in human incisional hernia fascia.

Incisional hernia often occurs following laparotomy and can be a source of serious problems. Although there is evidence that a biological cause may underlie its development, the mechanistic link between the local tissue microenvironment and tissue rupture is lacking. In this study, we used matched tissue-based and in vitro primary cell culture systems to examine the possible involvement of fascia fibroblasts in incisional hernia pathogenesis. Fascia biopsies were collected at surgery from incisional hernia patients and non-incisional hernia controls. Tissue samples were analyzed by histology and immunoblotting methods. Fascia primary fibroblast cultures were assessed at morphological, ultrastructural, and functional levels. We document tissue and fibroblast loss coupled to caspase-3 activation and induction of apoptosis-like cell-death mechanisms in incisional hernia fascia. Alterations in cytoskeleton organization and solubility were also observed. Incisional hernia fibroblasts showed a consistent phenotype throughout early passages in vitro, which was characterized by significantly enhanced cell proliferation and migration, reduced adhesion, and altered cytoskeleton properties, as compared to non-incisional hernia fibroblasts. Moreover, incisional hernia fibroblasts displayed morphological and ultrastructural alterations compatible with autophagic processes or lysosomal dysfunction, together with enhanced sensitivity to proapoptotic challenges. Overall, these data suggest an ongoing complex interplay of cell death induction, aberrant fibroblast function, and tissue loss in incisional hernia fascia, which may significantly contribute to altered matrix maintenance and tissue rupture in vivo.

A case of pylephlebitis complicating an acute appendicitis: Uncommon cholangitis-like situation.

INTRODUCTION: Pylephlebitis represents an uncommon but serious condition with significant mortality which can complicate intrabdominal sepsis of any etiology. One of the most common predisposing infections is appendicitis. PRESENTATION OF CASE: A 21-year-old male with 4 days of epigastric and right upper quadrant pain with associated fever and chills with hyperbilirubinemia and leukocytosis in blood test was orientated as cholangitis at first diagnostic. Poor response to antibiotic treatment with persistent fever and bacteriemia with E. coli and S. constellatus isolated in blood cultures led to complete the study with a CT scan which revealed an acute appendicitis complicated with thrombosis of the superior mesenteric vein (SMV) up to the splenoportal confluence. Appendectomy, treatment with broad-spectrum antibiotic and anticoagulation treatment led to full recovery. Follow-up after 6 months showed almost complete SMV patency. DISCUSSION: Pylephlebitis can present as a clinical cholangitis-like picture with hyperbilirubinemia with or without liver abscess formation. CT scan seems to be the most sensitive diagnostic test as it identifies the underlying focus of infection, the extension of the thrombosis and detects liver abscesses. Surgical removal of the source of infection as appendectomy and adequate antibiotic treatment adjusted by culture should be initiated promptly. Anticoagulant treatment should be considered in the case of poor clinical outcome or thrombosis progression. CONCLUSION: Pylephlebitis should be suspected mainly in patients with appendicitis and diverticulitis with erratic behavior despite surgical removal and/or antibiotic treatment with abnormal liver tests and persistent bacteriemia. CT scan is the preferred image study.

Robotic and laparoscopic Roux-en-Y gastric bypass after learning curve: 30-day and 12-month outcomes.

This study compares laparoscopic RYGB (L-RYGB) and robotic RYGB (R-RYGB) performed by the same team after the learning curve in both approaches. A retrospective cohort study was done, and the surgical outcome was analyzed in 30 days and 12 months for patients with similar characteristics and an equal number of cases in each group (233 cases). Four hundred and sixty-six patients were included in this study. Mean age was 46.8 ± 8.3 years and 2/3 were women. R-RYGB presented a longer operative time (150.7 versus 135.4 min; p < 0.001) with no differences in the length of hospital stay. The main 30-day complications were G-J stricture, leakage, and intraluminal bleeding. The reoperation rate was 1.6% by leakage (G-J anastomosis) and was higher in R-RYGB (2.1 versus 0.4; p = 0.108). The multivariate analysis identified that L-RYGB was the factor independently associated with a LOS longer than 2 days (odds ratio: 4.7, 95% CI: 2.6-8.2, p value < 0.001). At the FU time (12 months), no differences between the groups were found. The outcomes between the groups after the learning curve did not present differences in terms of 30 days and 12 months of FU when same preoperative characteristics and an equal number of cases in each group are considered. L-RYGB was the unique independent factor associated with long LOS.

The Panoramic View of Revisional Bariatric Surgery.

Introduction: Obesity remains a major public chronic disease, and the multifactorial components of its relapse in many patients remain inevitable. Methods: This article provides a panoramic view of the most commonly performed revisional bariatric surgery (RBS). RBS is a complex procedure; thus, primary procedures should be well chosen and performed to avoid the increasing number of RBS cases. Results: Bariatric surgery is the only successful long-term treatment for obesity. However, a proportion of primary bariatric surgeries has failed during the follow-up period. In recent decades, the solution for these complications is by performing RBS. It is mandatory to understand obesity as a chronic disease to appropriately treat patients. Treatment strategies are needed to determine the indications for revision. RBS requires a meticulous evaluation to facilitate good long-term results. Conclusions: Treatment strategies will be a fundamental pillar to wisely determine the indications for revision and identify the factors influencing failure by prudently and rationally evaluating the revisional procedure that the patient will benefit from and acquiring a high level of surgical skills.

A Comparison of Clinical Outcomes Between Two Different Models of Surgical Robots in Roux-en-Y Gastric Bypass.

Introduction: For the past 20 years, robotic surgical systems have been used for the Roux-en-Y gastric bypass (RYGB). The da Vinci Surgical System (Intuitive Surgical, Inc.) has been one of the most used robotic platforms. This study aims to retrospectively compare the performance of two models of surgical robots. Materials and Methods: A retrospective comparative study was conducted from a prospective database including all patients who underwent robotic RYGB (RRYGB) from 2011 to 2020. Results: Of a total of 277 patients included, 134 were in the RRYGB using the da Vinci S™ (RRYGB-S™) group and 143 were in the RRYGB using the da Vinci Xi™ (RRYGB-Xi™) group. The mean operative time in the RRYGB-S and RRYGB-Xi groups was 154 ± 28 and 151 ± 32 minutes, respectively (P = .510). The was no statistically significant difference in terms of intraoperative complications between the groups with regard to positive blue test, bleeding, and failure of stapler line. The readmission rate was higher in the RRGB-S group (14.1%) than in the RRYGB-Xi group (3.4%) (P = .004), and it was mainly due to major complications (P = .003) including pouch and gastrojejunostomy anastomotic leaks (P = .001). The nonsurgical complications were statistically significantly higher in the RRYGB-S group (7.4%) than in the RRYGB-Xi group (2.1%) (P < .05), as well as the surgical complications were higher in the RRYGB-S group (7.5%) than in the RRYGB-Xi group (0%) (P < .001). The mean percentage of the total weight loss at 1 and 2 years of follow-up did not show any statistically significant difference (P = .547). Conclusions: The higher complication rate in the S surgical system might be correlated with the initial learning curve and stressed the need for proper robotic surgical training and accurate strategies when introducing emerging technologies into the surgical practice.

Laparoscopic Versus Robot-Assisted Roux-en-Y Gastric Bypass: A Center of Excellence for the EAC-BC Experience.

Background: After the first laparoscopic Roux-en-Y gastric bypass (RYGB) in 1994 by Wittgrove, the introduction of robot-assisted procedures was the next step in the surgical race to reduce invasiveness. This breakthrough allowed us to perform bariatric surgery with less surgical trauma in obese patients with metabolic disorders, producing an exponential increase in procedures performed. Methods: This is a retrospective cohort study of a prospective database for patients who underwent RYGB during a 7-year period through two different approaches, laparoscopic and robotic. The robotic cases were performed by two generations of the da Vinci platform (S and Xi), and three groups were identified and compared (L-RYGB, RYGB-S, and RYGB-Xi). Results: A total of 495 patients underwent RYGB, of which 224 by laparoscopy (45.2%) and 271 by robotic approach (54.7%): 134 RYGB-S and 137 RYGB-Xi. The majority of the patients (71.1%) were females, with a mean age of 46.2 years and a mean body mass index of 44 kg/m2. The mean intraoperative time and intraoperative complication rate were higher in the robotic groups, especially in the RYGB-S group. Postoperative complications were higher in the same group, with a rate of 11.9%, where the main leakage occurred on the upper part of the gastric pouch and not in the hand-sewed robotic anastomosis (7.5%). General mortality was 0.6%. We found no significant differences at 1-year percentage of total weight loss (%TWL); at 2 years, the RYGB-Xi group had the lowest %TWL (25.24 ± 14.54, P ≤ .001). Conclusions: The present study reflects our experience during the robotic bariatric introduction and performance since 2011. Features of the da Vinci S platform along our learning curve may explain a higher complication rate. The patients who have been operated by the RYGB-Xi system had lower complications than the laparoscopic group. The robotic approach did not differ with laparoscopy in terms of weight loss and chronic complications after 24 months of follow-up.

Lower gastrointestinal bleeding due to colonic fistula caused by a gossypiboma: Case report and literature review.

INTRODUCTION: Even in modern surgery, human mistakes cannot be totally avoided. Retained surgical items are among the most feared ones. Forgotten sponges inside patients can cause a wide range of complications due to the foreign body reaction, called gossypiboma. The incidence of gossypibomas in the literature is probably underreported due to its legal implications; however, we must know its consequences and highlight the importance of the prevention strategies. We present a case where only preventive measures would have avoided its fatal outcome. PRESENTATION OF CASE: An 85-year-old male, previous left nephrectomy 12 years before, came to the emergency room with hematochezia and hemodynamic instability. An emergent angio-CT revealed a 12 cm mass due to a gossypiboma near the descending colon; the presence of air suggested an infection and/or fistulization to the bowel. It was decided not to perform invasive procedures, resulting in the patient's death. DISCUSSION: Gossypibomas can remain asymptomatic for years, being diagnosed when causing an obstruction, malabsorption, septic symptoms or even spontaneously. This may lead to high morbidity and mortality rates. In order to prevent it, different strategies have been described, with the objective to intensify surveillance. When diagnosed, laparotomy, laparoscopic and even endoscopic procedures have been performed successfully. CONCLUSION: We suggest putting all our efforts in identifying high risk patients and surgeries, training the OR team and enhancing protocols and checklists to minimize any preventable errors.

Effectiveness of Laparoscopic Sleeve Gastrectomy in Super-obese and Non-Super-obese Patients.

OBJECTIVES: The primary aim of this study was to assess the effectiveness of sleeve gastrectomy (SG) in super-obese patients. The secondary aim was to identify patient characteristics associated with worse SG outcomes in this group. METHODS: A retrospective analysis was carried out of our electronic prospective bariatric surgery patient database, including all patients who underwent SG between January 2007 and January 2017. The sample was divided according to the initial body mass index (BMI) (> or <50 kg/m). The initial characteristics and results in terms of weight loss and comorbidity resolution between the groups were compared. A subanalysis of the variable distributions was carried out according to whether or not the final BMI in the super-obese group had reached <35 kg/m. Data analysis was carried out using STATA 13.1, with a P-value <0.05 considered to be significant. RESULTS: The mean initial BMI was 42.8 kg/m in group 1 (<50 kg/m) and 55 kg/m in group 2 (>50 kg/m). The median follow-up (FU) was 56.2 months. Maximum weight loss was attained at the 18-month FU in both groups (BMI: 28.8 and 34.7 kg/m, respectively). At the 5-year FU, percentage of total weight loss was higher in group 2 and percentage of excess weight loss was statistically higher in group 1 (29.6% vs. 33.1% and 67% vs. 59%, respectively). Outcomes for type 2 diabetes mellitus, hypertension, and dyslipidemia were similar in both groups. The variables associated with attaining a final BMI <35 kg/m in the super-obese group were lower initial BMI, absence of baseline weight-related conditions (type 2 diabetes mellitus, obstructive sleep apnea syndrome, home continuous positive airway pressure, arthropathy, heart disease), and absence of gastroesophageal reflux disease. CONCLUSIONS: We observed a statistically significant increase in poor outcomes in patients with a higher initial BMI and with weight-related comorbidities. These parameters could be considered to be potentially good predictors of less satisfactory outcomes in the super-obese patients.

Operative and Postoperative Complications of Laparoscopic Sleeve Gastrectomy in Super and Nonsuper Obese Patients: A Center of Excellence Experience Comparative Study.

Background: Laparoscopic sleeve gastrectomy (LSG) is now one of the most common surgical procedures worldwide. It was initially defined for staged procedures in super or super-super obese, or in very complex patients. The primary objective of the study was to assess the safety of LSG for morbid-obese (MO, body mass index [BMI] >40 kg/m2) and super-morbid-obese (SMO, BMI >50 kg/m2) patients in terms of operative and postoperative complication rate. Methods: This study involves a retrospective analysis of a prospective database that included data for patients who underwent LSG, between 2008 and 2017, in our institution. All LSG procedures were performed by the same two certified bariatric surgeons following a standardized surgical procedure. Data on operative and postoperative complications were collected for all the patients. Results: A total of 713 patients were included in the study 495 (61.42%) were MO (mean age 46.06 ± 11.98 years) and 218 (30.58%) were SMO (mean age 42.98 ± 11.17 years). There were no significant differences between both groups in terms of minor and major postoperative complications or long-term complications. Postoperative mortality was slightly higher in the MO group but without statistically significant differences (MO: 0.2%; SMO: 0%). Long-term reoperation rate and late complications were higher in the MO group 6.12% versus 4.04% and 17.43% versus 15.15%, respectively. Reoperation for gastroesophageal reflux disease was higher in MO patients compared to SMO and weight issues reoperation higher in the SMO. Conclusion: We found LSG as a safe procedure in both groups. Interestingly long-term reoperation and complications rates were higher in the MO group.

MMPs/TIMPs and inflammatory signalling de-regulation in human incisional hernia tissues.

BACKGROUND: Incisional hernia is a common and important complication of laparotomies. Epidemiological studies allude to an underlying biological cause, at least in a subset of population. Interest has mainly focused on abnormal collagen metabolism. However, the role played by other determinants of extracellular matrix (ECM) composition is unknown. To date, there are few laboratory studies investigating the importance of biological factors contributing to incisional hernia development. We performed a descriptive tissue-based analysis to elucidate the possible relevance of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) in association with local cytokine induction in human incisional hernia tissues. The expression profiles of MMPs, TIMPs and pro-inflammatory cytokine signalling were investigated in aponeurosis and skeletal muscle specimens taken intraoperatively from incisional hernia (n= 10) and control (n= 10) patients. Semiquantitative RT-PCR, zymography and immunoblotting analyses were done. Incisional hernia samples displayed alterations in the microstructure and loss of ECM, as assessed by histological analyses. Moreover, incisional hernia tissues showed increased MMP/TIMP ratios and de-regulated inflammatory signalling (tumor necrosis factor [TNFA] and interleukin [IL]-6 tended to increase, whereas aponeurosis TNFA receptors decreased). The changes were tissue-specific and were detectable at the mRNA and/or protein level. Statistical analyses showed several associations between individual MMPs, TIMPs, interstitial collagens and inflammatory markers. The increment of MMPs in the absence of a counterbalance by TIMPs, together with an ongoing de-regulated inflammatory signalling, may contribute in inducing a functional defect of the ECM network by post-translational mechanisms, which may trigger abdominal wall tissue loss and eventual rupture. The notable TIMP3 protein down-regulation in incisional hernia fascia may be of pathophysiological significance. We conclude that this study may help to pinpoint novel hypotheses of pathogenesis that can lead to a better understanding of the disease and ultimately to improvement in current therapeutic approaches.

Elective and emergent laparotomy closure: The importance of protocolizing the technique. / Cierre de la laparotomía electiva y urgente. Importancia de protocolizar la técnica.

BACKGROUND: Incisional hernias are a frequent complication, and their prevention includes proper closure of the abdominal wall. METHODS: A prospective study was conducted at a third-level hospital after the introduction of a midline laparotomy closure protocol. An objective measurement of the suture length to incision length ratio was made. and the postoperative results were analyzed. RESULTS: 127 patients were included and 34 of them (26.8%) had received a technically deficient closure. Incisional hernia was described in 20.5% of cases. An improvement in the quality of the abdominal wall closure was demonstrated over time. CONCLUSION: The abdominal wall closure was deficient in nearly one- quarter of the laparotomies performed at a third-level medical center. A protocol improved the quality of the laparotomy closure.

Ligamentum Teres Cardiopexy as a Late Alternative for Gastroesophageal Reflux Disease in a Patient with Previous Reversal of Gastric Bypass to Sleeve Gastrectomy and Hiatal Hernia Repair.

An important percentage of the patient, undergoing primary or revisional bariatric surgery after sleeve gastrectomy, presents symptomatic gastroesophageal reflux disease (GERD). When and how surgical reinforcement of the lower esophageal sphincter should be performed to prevent acid reflux is still controversial. Here, we describe laparoscopic ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with the previous conversion of gastric bypass to sleeve gastrectomy and hiatal hernia repair. We present the surgical technique performed on a patient with initial gastric bypass who underwent sleeve gastrectomy for hypoglycemia and hiatoplasty for severe GERD. Persistent GERD requested to undergo ligamentum teres cardiopexy. Ligamentum teres cardiopexy combined with the closure of the gastric crus is a late alternative treatment for GERD in patients with previous sleeve gastrectomy and hiatal hernia.