Are There Ideal Small Bowel Limb Lengths for One-Anastomosis Gastric Bypass (OAGB) to Obtain Optimal Weight Loss and Remission of Comorbidities with Minimal Nutritional Deficiencies?

BACKGROUND: Ideal jejunal and ileal lengths in bariatric/metabolic procedures to be left in alimentary continuity still remain unclear. We aimed to evaluate different lengths of biliopancreatic limb (BPL) and common limb (CL) performed in a series of patients submitted to OAGB, and correlate them with weight loss and nutritional deficits. PATIENTS AND METHODS: A prospective observational study of 350 consecutive morbidly obese patients undergoing OAGB was performed. BPL and CL lengths were determined intraoperatively; BPL/TBL and CL/TBL ratios were then calculated. Anthropometric variables, remission of comorbidities and specific supplementation needs were recorded at 1, 2 and 5 years after surgery. RESULTS: Three hundred patients were included for final analysis. BPL length and BPL/TBL ratio directly correlated with Units of BMI lost (UBMIL). Conversely, CL length and CL/TBL ratio showed an inverse correlation with UBMIL. Establishing a BMI ≤ 25 kg/m2 as ideal, the most accurate AUC, to predict achieving an ideal BMI at 1, 2 and 5 years after surgery, was obtained for the CL/TBL ratio, followed by the CL length at 1, 2 and 5 years. An ideal range was established between 0.40 and 0.43 for the CL/TBL ratio, and 200 to 220 cm for the CL length. Among these ranges, there were no cases of protein or calorie malnutrition. CONCLUSION: TBL measurement is essential to obtain optimal outcomes after OAGB, both in terms of excellent weight loss and remission/improvement of comorbidities, as well as with a low risk of nutritional deficiencies. The CL/TBL ratio, followed by CL length, are the most accurate parameters to predict a 5-year postoperative BMI ≤ 25 kg/m2.

Weight loss and improvement of lipid profiles in morbidly obese patients after laparoscopic one-anastomosis gastric bypass: 2-year follow-up.

BACKGROUND: Obesity is the most frequent chronic metabolic disease globally. There is a direct correlation between increasing body mass index (BMI) and elevated total cholesterol (TC), low-density lipoprotein cholesterol (LDL), and triglycerides (Tg), and an inverse correlation with high-density lipoprotein cholesterol (HDL); all these lipid derangements are associated with an increased risk of cardiovascular disease. Our aim was to evaluate lipid profiles in morbidly obese patients before and after one-anastomosis gastric bypass (OAGB) performed at a single-center during a 2-year follow-up. PATIENTS AND METHODS: A prospective, observational and descriptive study was carried out, including morbidly obese patients with at least one lipid abnormality, who underwent laparoscopic OAGB. Lipid profiles were evaluated preoperatively and at different intervals during a 2-year follow-up. RESULTS: A total of 150 patients were included (73 % females and 27 % males). Mean age was 45.83 ± 10.65 years, mean BMI was 42.82 kg/m2 ± 6.43, and mean weight was 116.23 kg ± 22.70; 2 years after surgery, the latter two decreased to 24.73 ± 4.43 (p < 0.001) and 67.34 ± 13.35 (p < 0.001), respectively, thus leading to a mean weight loss (WL) of 48.85 kg ± 15.64 and mean %excess WL of 71.87 ± 13.41. Tg, TC and LDL levels significantly decreased: 123.60 ± 56.34 versus 84.79 ± 33.67, 194.33 ± 43.90 versus 173.65 ± 34.84, and 124.47 ± 36.07 versus 97.36 ± 25.05, respectively (p < 0.001); HDL levels significantly increased: 43.61 ± 9.85 versus 61.56 ± 12.63 (p < 0.001). CONCLUSION: OAGB leads to substantial and durable WL in morbidly obese patients after a 2-year follow-up. Postoperative lipid profiles significantly improved; these changes translate into theoretical relevant cardiovascular risk benefits.

Revision/Conversion Surgeries After One Anastomosis Gastric Bypass-An Experts' Modified Delphi Consensus.

PURPOSE: There is a lack of evidence for treatment of some conditions including complication management, suboptimal initial weight loss, recurrent weight gain, or worsening of a significant obesity complication after one anastomosis gastric bypass (OAGB). This study was designed to respond to the existing lack of agreement and to provide a valuable resource for clinicians by employing an expert-modified Delphi consensus method. METHODS: Forty-eight recognized bariatric surgeons from 28 countries participated in the modified Delphi consensus to vote on 64 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus. RESULTS: A consensus was achieved for 46 statements. For recurrent weight gain or worsening of a significant obesity complication after OAGB, more than 85% of experts reached a consensus that elongation of the biliopancreatic limb (BPL) is an acceptable option and the total bowel length measurement is mandatory during BPL elongation to preserve at least 300-400 cm of common channel limb length to avoid nutritional deficiencies. Also, more than 85% of experts reached a consensus on conversion to Roux-en-Y gastric bypass (RYGB) with or without pouch downsizing as an acceptable option for the treatment of persistent bile reflux after OAGB and recommend detecting and repairing any size of hiatal hernia during conversion to RYGB. CONCLUSION: While the experts reached a consensus on several aspects regarding revision/conversion surgeries after OAGB, there are still lingering areas of disagreement. This highlights the importance of conducting further studies in the future to address these unresolved issues.

Patient Selection in One Anastomosis/Mini Gastric Bypass-an Expert Modified Delphi Consensus.

PURPOSE: One anastomosis/mini gastric bypass (OAGB/MGB) is up to date the third most performed obesity and metabolic procedure worldwide, which recently has been endorsed by ASMBS. The main criticisms are the risk of bile reflux, esophageal cancer, and malnutrition. Although IFSO has recognized this procedure, guidance is needed regarding selection criteria. To give clinicians a daily support in performing the right patient selection in OAGB/MGB, the aim of this paper is to generate clinical guidelines based on an expert modified Delphi consensus. METHODS: A committee of 57 recognized bariatric surgeons from 24 countries created 69 statements. Modified Delphi consensus voting was performed in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was considered to indicate a consensus. RESULTS: Consensus was achieved for 56 statements. Remarkably, ≥ 90.0% of the experts felt that OAGB/MGB is an acceptable and suitable option "in patients with Body mass index (BMI) > 70, BMI > 60, BMI > 50 kg/m2 as a one-stage procedure," "as the second stage of a two-stage bariatric surgery after Sleeve Gastrectomy for BMI > 50 kg/m2 (instead of BPD/DS)," and "in patients with weight regain after restrictive procedures. No consensus was reached on the statement that OAGB/MGB is a suitable option in case of resistant Helicobacter pylori. This is likely as there is a concern that this procedure is associated with reflux and its related long-term complications including risk of cancer in the esophagus or stomach. Also no consensus reached on OAGB/MGB as conversional surgery in patients with GERD after restrictive procedures. Consensus for disagreement was predominantly achieved "in case of intestinal metaplasia of the stomach" (74.55%), "in patients with severe Gastro Esophageal Reflux Disease (GERD)(C,D)" (75.44%), "in patients with Barrett's metaplasia" (89.29%), and "in documented insulinoma" (89.47%). CONCLUSION: Patient selection in OAGB/MGB is still a point of discussion among experts. There was consensus that OAGB/MGB is a suitable option in elderly patients, patients with low BMI (30-35 kg/m2) with associated metabolic problems, and patients with BMIs more than 50 kg/m2 as one-stage procedure. OAGB/MGB can also be a safe procedure in vegetarian and vegan patients. Although OAGB/MGB can be a suitable procedure in patients with large hiatal hernia with concurrent hiatal hernia, it should not be offered to patients with grade C or D esophagitis or Barrett's metaplasia.

Roux-en-Y to One Anastomosis Gastric Bypass Conversion: Description of a Novel Technique.

Introduction: Roux-en-Y gastric bypass (RYGB) remains among the most widely performed bariatric procedures. A significant decline in its indication has been observed due to weight regain and reappearance of comorbidities. Moreover, the lack of effective therapeutic alternatives after failure justifies why other techniques are more frequently chosen. We present a novel technique to convert a failed RYGB into a one anastomosis gastric bypass (OAGB). Case Presentation: A 43-year-old male patient with a body mass index (BMI) of 47 kg/m2 and several comorbidities was submitted to RYGB. Initially his surgery was successful, but after 7 years he visited the bariatric and metabolic surgery clinic with reappearance of all comorbidities, and the same BMI as before having bariatric surgery. After proper evaluation and preparation, conversion to OAGB was decided. After anatomy identification, the alimentary limb was transected 20 cm distal to the gastrojejunal anastomosis, and a new anastomosis with the common channel (CC) was created, to form a new long afferent biliopancreatic limb and a new short efferent CC. Results: The surgical procedure and postoperative course were uneventful. One year after the procedure the patient's BMI was 36 kg/m2. He has been able to stop all medications and therapies related to previous comorbidities. To date, the patient has good dietary and supplementation adherence resulting in no nutritional deficiencies, or gastrointestinal symptoms. Conclusion: This new surgical technique is safe and feasible. Short-term results have shown reasonable weight loss (WL), and especially remission of comorbidities with an improved quality of life.

[Jejunal diverticulitis causing an acute abdomen]. / Diverticulitis yeyunal como causa de abdomen agudo.

Jejunal diverticulosis is a rare acquired-disease which courses asymptomatic in most cases. In spite of the fact that there are some publications of this entity in pediatric patients, most symptomatic cases have been found in adults. Reported herein is the case of a patient that presented to the emergency room with signs and symptoms suggestive of an acute abdomen. After diagnostic workup and operative management, presence and complications of a jejunal diverticulum were found to be the cause of the abdominal pain.

One Anastomosis Gastric Bypass in Morbidly Obese Patients with BMI ≥ 50 kg/m2: a Systematic Review Comparing It with Roux-En-Y Gastric Bypass and Sleeve Gastrectomy.

BACKGROUND: To explore the role of one anastomosis (Mini) gastric bypass (OAGB) for the super-obese patients. METHOD: Literature review was performed in March 2019 as per PRISMA guidelines. RESULTS: A total of 318 patients were identified. Mean age was 31.8 years. Mean body mass index (BMI) was 57.4 kg/m2. The mean operative time was 93.1 min with median length of stay of 4.5 days. The biliopancreatic limb (BPL) varied from 190 to 350 cm(median 280 cm). Early mortality was 0.31% with seven complications (including 1 revisional surgery). Leak rate was 0%. Mean %excess weight loss (EWL) at 12, 18-24 and 60 months was 67.7%, 71.6% and 90.75%, respectively. CONCLUSIONS: OAGB is a safe and effective option for management of super and super-super obese patients with tailoring of the BPL. Larger comparison, follow-up and randomised trials are necessary to validate these findings.

Whipple disease after bariatric surgery: from malabsorption to malnutrition status.

Introduction: Malabsorptive bariatric techniques are associated with nutritional deficiencies. However, when patients do not respond to supplemental intensive treatments they should be closely followed because they can hide other pathological conditions. We present the case of a 47-year-old man with morbid obesity (body mass index [BMI]: 48 kg/m2) who underwent bariatric surgery. In 2016, he presented severe pneumonia and hospitalization at the Intensive Unit Care was required. After this episode, his nutritional state impaired, presenting 6-7 diarrhea/steatorrhea events per-day and requiring several hospitalizations due to the persistence of severe hypoproteinemia. He was given parenteral high-protein associated with low-fat oral diet. He presented a temporary biochemical improvement, but the hypoproteinemia recurred. Finally, tests revealed the presence of Tropheryma whipplei as protein-losing enteropathy. Whipple's disease (WD) is a rare cause of diarrhea and malnutrition, and these symptoms can be confused with the postoperative status of malabsorptive bariatric techniques. WD requires early diagnosis with prolonged antibiotic treatment to avoid severe complications.

Introducción: Las técnicas bariátricas malabsortivas suelen asociarse a deficiencias nutricionales. Sin embargo, cuando los pacientes no responden a tratamientos intensivos suplementarios, deben valorarse otras condiciones patológicas. Presentamos el caso de un hombre de 47 años, obeso mórbido (índice de masa corporal [IMC]: 48 kg/m2) sometido a cirugía bariátrica, que dos años más tarde presentó neumonía severa, por lo que requirió ingreso en la Unidad de Cuidados Intensivos. Posteriormente, el estado nutricional se deterioró, presentando 6-7 episodios de diarrea-esteatorrea/día y requiriendo varias hospitalizaciones por hipoproteinemia severa. Recibió infusión parenteral rica en proteínas asociada con una dieta baja en grasas y presentó mejoría analítica temporal. Finalmente, las pruebas revelaron la presencia de Tropheryma whipplei, una bacteria que genera enteropatía pierde-proteínas. La enfermedad de Whipple (EW) es una causa poco común de diarrea y malnutrición. Estos síntomas pueden confundirse con el posoperatorio de técnicas bariátricas malabsortivas. La EW requiere un diagnóstico precoz con un tratamiento antibiótico prolongado para evitar complicaciones graves.

A 5-Year Follow-up in Children and Adolescents Undergoing One-Anastomosis Gastric Bypass (OAGB) at a European IFSO Excellence Center (EAC-BS).

BACKGROUND: The children and adolescent population with obesity has increased worldwide, both in developing areas and in developed countries. Consequently, the prevalence of morbid obesity among this population has also increased, leading to an exponential growth of bariatric approaches in this population. Many surgeons fear eventual nutritional sequelae after malabsorptive approaches and prefer restrictive or mixed procedures. METHODS: A retrospective review of all the morbidly obese patients between 13 and 19 years, undergoing a one-anastomosis gastric bypass (OAGB) as bariatric procedure between 2004 and 2012, was performed. RESULTS: A total of 39 patients were included, 8 males (20.5%) and 31 females (79.5%), with a mean age of 17.8 ± 2 years (range 13-19 years). Mean preoperative weight was 114.3 ± 20.4 kg and mean BMI 42.2 ± 5.9 kg/m2. Preoperative comorbidities include only type 2 diabetes mellitus (T2DM) in 7.9% of the patients, hypertension in 10.3%, and dyslipidemia in 23.1%. Five years after surgery, mean BMI was 25.9 ± 5.3 kg/m2 and total weight loss 32.1 ± 15.7%. Remission rate of T2DM, hypertension and dyslipidemia was 100%. All the patients received multivitamin and vitamin D supplementation. Anemia secondary to iron deficiency occurred in one female, requiring intravenous iron supplementation during 1 year and later on oral supplementation. CONCLUSIONS: OAGB is a valid alternative for long-term weight loss and remission of comorbidities in childhood and adolescence. No cases of malnutrition or growth disorders were observed.

Laparoscopic resection of gastric schwannoma: A case report.

INTRODUCTION: Gastric schwannomas are an extremely rare presentation of mesenchymal tumors originating from Schwann cells, accounting for 0.2% of all gastric tumors. Patients are usually asymptomatic, so these tumors are frequently detected incidentally. PRESENTATION OF CASE: 68-year old male patient found to have a 5 cm mass in the lesser curvature of the stomach. After a careful preoperative evaluation, complete laparoscopic resection was performed. Pathology review confirmed a completely resected gastric Schwannoma. The patient's recovery was uneventful. At a one-year follow-up he remains asymptomatic and with no evidence of disease. DISCUSSION: We present the uncommon case of a gastric schwannoma that was appropriately treated with a laparoscopic approach and present a current literature review focusing on diagnostic and treatment methods of these rare tumors. CONCLUSION: Schwannomas should be included in the differential diagnosis of gastric tumors and can be appropriately treated with a laparoscopic approach.

Results after Definitive Surgical Treatment in Patients with Enteroatmospheric Fistula.

As enteroatmospheric fistulas (EAF) lack healthy overlying tissue, spontaneous healing is very unlikely. Our aim was to identify risk factors for recurrence and mortality after definitive surgical treatment for EAF. Sixty-two consecutive patients with a diagnosis of EAF were submitted to definitive surgical repair (fistula resection and primary anastomosis) during a 6-year period. Several patient, disease, and operative variables were assessed as risk factors associated to our endpoints: recurrence and mortality. All patients were followed-up until hospital discharge or death. Univariate and multivariate analysis were performed. There were 24 females and 38 males with a median age of 53 years (interquartile ranges 43-63). EAF recurred in 23 patients. Univariate analysis identified several risk factors for recurrence which included performing more than one anastomosis (20 vs 52%, P = 0.013), failure of achieving total abdominal closure (16 vs 47%, P = 0.025), intraoperative hemorrhage >400 cc (28 vs 65%, P = 0.007), presence of multiple fistulas (25 vs 61%, P = 0.008), and preoperative C-reactive protein >0.5 mg/dL (54 vs 82%, P = 0.029). The latter two remained significant after multivariate analysis. Final EAF closure was attained in 47 patients (76%) and 8 more (13%) had a low-output (<50 mL/day) enterocutaneous fistula. Timing of surgery was not related to fistula recurrence. Eight patients died (13%), and fistula recurrence was the only risk factor found related to mortality both through univariate (26 vs 5%, P = 0.043) and after multivariate analysis. EAF management represents a rather challenging problem. Timing for surgical treatment is controversial and is based mostly on patient status and surgeon's criteria. Recurrence is associated to EAF characteristics and an inflammatory state; it was also the only factor associated to mortality.

Author Correction: Evaluation of Weight Loss Indicators and Laparoscopic One-Anastomosis Gastric Bypass Outcomes.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.

Evaluation of Weight Loss Indicators and Laparoscopic One-Anastomosis Gastric Bypass Outcomes.

Mini-gastric bypass/One-anastomosis gastric bypass (MGB-OAGB) is an effective bariatric technique for treating overweight and obesity, controlling and improving excess-weight-related comorbidities. Our study evaluated OAGB characteristics and resulting weight evolution, plus surgical success criteria based on various excess weight loss indicators. A prospective observational study of 100 patients undergoing OAGB performed by the same surgical team (two-year follow-up). Surgical characteristics were: surgery duration, associated complications, bowel loop length, hospital stay, and weight loss at 6 postoperative points. 100 patients were treated (71 women, 29 men); mean initial age was 42.61 years and mean BMI, 42.61 ± 6.66 kg/m2. Mean surgery duration was 97.84 ± 12.54 minutes; biliopancreatic loop length was 274.95 ± 23.69 cm. Average hospital stay was 24 hours in 98% of patients; no surgical complications arose. Weight decreased significantly during follow-up (P < 0.001). Greatest weight loss was observed at 12 months postsurgery (68.56 ± 13.10 kg). Relative weight loss showed significant positive correlation, with greatest weight loss at 12 months and %excess BMI loss > 50% achieved from the 3-month follow-up in 92.46% of patients. OAGB seems to be effective in treating obesity, with short hospital stays. Relative weight loss correlates optimally with absolute outcomes, but both measures should be used to evaluate surgical results.

Open versus closed management of the abdomen in the surgical treatment of severe secondary peritonitis: a randomized clinical trial.

BACKGROUND: Despite recent advances in diagnosis, antimicrobial therapy, and intensive care support, operative treatment remains the foundation of the management of patients with severe secondary peritonitis (SSP). This management is based on three fundamental principles: (1) Elimination of the source of infection; (2) reduction of bacterial contamination of the peritoneal cavity; and (3) prevention of persistent or recurrent intra-abdominal infection. Although recent studies have emphasized the role of open management of the abdomen and planned re-laparotomies to fulfill these principles, controversy surrounds the optimal approach because no randomized studies exist. METHODS: Patients with SSP, documented clinically, with calculated Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores and appropriate ancillary studies, were allocated randomly to two groups for the management of the abdomen after operation for SSP (group A: open; group B: closed). Both surgical strategies were standardized, and patients were followed up until cure or death. RESULTS: During a 24-month period, 40 patients with SSP were admitted for treatment. Patients in group A (n = 20) and group B (n = 20) did not differ in sex, age, site of origin (etiology), APACHE II score (24 vs. 22), SOFA score (15 vs. 15), or previous operative treatment (< or =1: 20 vs. 20). Postoperatively, there were no differences in the likelihood of acute renal failure (25% vs. 40%), duration of mechanical ventilatory support (10 vs. 12 days), need for total parenteral nutrition (80% vs. 75%), or rate of residual infection or need for reoperation because of the latter (15% vs. 10%). Although the difference in the mortality rate (55% vs. 30%) did not reach statistical significance (p < 0.05; chi-square and Fisher exact test), the relative risk and odds ratio for death were 1.83 and 2.85 times higher in group A. This clinical finding, as evidenced by the clear tendency toward a more favorable outcome for patients in group B, led to termination of the study at the first interim analysis. CONCLUSION: This randomized study from a single institution demonstrates that closed management of the abdomen may be a more rational approach after operative treatment of SSP and questions the recent enthusiasm for the open alternative, which has been based on observational studies.

Predictive value of preoperative serum C-reactive protein for recurrence after definitive surgical repair of enterocutaneous fistula.

BACKGROUND: Recurrence rates after surgical repair of enterocutaneous fistula (ECF) have not changed substantially. Serum C-reactive protein (s-CRP) has been used as an indicator of postoperative complications in abdominal surgery. ​ The aim of this study was to determine the predictive value of preoperative s-CRP for recurrence after definitive surgical repair of ECF. METHODS: Fifty consecutive patients with ECF persistence submitted electively to definitive surgical repair (ECF resection with primary anastomosis) were included. Among several variables, preoperative s-CRP (primary independent variable) was assessed as a factor related to recurrence (dependent variable). Univariate and multivariate analyses were performed. RESULTS: ECF recurred in 19 patients (38%). Univariate and multivariate analyses disclosed operative blood loss greater than 325 mL (P < .05) and preoperative s-CRP greater than .5 mg/dL (P < .01) as the only risk factors for recurrence. ECF recurrence rates were significantly higher for patients with preoperative s-CRP above this level (53% vs 11%, P < .01). After conservative and surgical management, overall ECF closure was attained in 40 patients (80%). CONCLUSIONS: Our results suggest that s-CRP may serve as a useful parameter to predict potential failure (recurrence) in patients submitted to definitive closure of ECF.

Laparoscopic One-Anastomosis Gastric Bypass: Technique, Results, and Long-Term Follow-Up in 1200 Patients.

BACKGROUND: Excellent results have been reported with mini-gastric bypass. We adopted and modified the one-anastomosis gastric bypass (OAGB) concept. Herein is our approach, results, and long-term follow-up (FU). METHODS: Initial 1200 patients submitted to laparoscopic OAGB between 2002 and 2008 were analyzed after a 6-12-year FU. Mean age was 43 years (12-74) and body mass index (BMI) 46 kg/m2 (33-86). There were 697 (58 %) without previous or simultaneous abdominal operations, 273 (23 %) with previous, 203 (17 %) with simultaneous, and 27 (2 %) performed as revisions. RESULTS: Mean operating time (min) was as follows: (a) primary procedure, 86 (45-180); (b) with other operations, 112 (95-230); and (c) revisions, 180 (130-240). Intraoperative complications led to 4 (0.3 %) conversions. Complications prompted operations in 16 (1.3 %) and were solved conservatively in 12 (1 %). Long-term complications occurred in 12 (1 %). There were 2 (0.16 %) deaths. Thirty-day and late readmission rates were 0.8 and 1 %. Cumulative FU was 87 and 70 % at 6 and 12 years. The highest mean percent excess weight loss was 88 % (at 2 years), then 77 and 70 %, 6 and 12 years postoperatively. Mean BMI (kg/m2) decreased from 46 to 26.6 and was 28.5 and 29.9 at those time frames. Remission or improvement of comorbidities was achieved in most patients. The quality of life index was satisfactory in all parameters from 6 months onwards. CONCLUSIONS: Laparoscopic OAGB is safe and effective. It reduces difficulty, operating time, and early and late complications of Roux-en-Y gastric bypass. Long-term weight loss, resolution of comorbidities, and degree of satisfaction are similar to results obtained with more aggressive and complex techniques. It is currently a robust and powerful alternative in bariatric surgery.

Pulmonary extraskeletal myxoid chondrosarcoma: A case report and literature review.

BACKGROUND: Extraskeletal myxoid chondrosarcoma (EMC) accounts for the 3% of all soft tissue sarcomas and it's categorized as a tumour of uncertain differentiation. This entity has shown to have the recurrent balanced chromosomal translocation t(9;22) (q22;q12.2), which leads to the oncogenic fusion gene EWSR1-NR4A3. This sarcoma usually presents as a slow growing, palpable mass in the extremities. EMC arising from the lung is extremely infrequent. We report one case of pulmonary extraskeletal mixoid chondrosarcoma and a review of the world literature. CASE REPORT: A 69-year-old male patient presented with intermittent hemoptysis for the last 6 months. A PET/CT scan showed a hypermetabolic solid mass with lobulated borders of approximately 29×26mm in the inferior right lobe. We performed a right thoracotomy with inferior lobectomy and lymphadenectomy of levels VII, VIII, X, and XI levels. The neoplasm was constituted by cords of small cells with small round nucleus and scarce cytoplasm immerse in an abundant myxoid matrix. The immunophenotype was positive for MUM-1, CDK4, MDM2, and showed focal expression for S-100 protein and CD56. The final pathology report revealed a pulmonary extraskeletal mixoid chondrosarcoma. No further surgical interventions or adjuvant therapies were needed. CONCLUSION: EMC is an intermediate-grade neoplasm, characterized by a long clinical course with high potential for local recurrence and distant metastasis. Treatment for EMC is surgical and non-surgical treatment is reserved for recurrence or metastatic disease. Pulmonary extraskeletal myxoid chondrosarcoma is a rare neoplasm with only isolated case reports found in the literature.

[Clinical and biochemical characteristics of patients with morbid obesity at the time of hospital admission and one year after undergoing bariatric surgery]. / Características clínicas y bioquímicas de pacientes con obesidad extrema al ingreso y un año después de someterse a cirugía bariátrica.

BACKGROUND: Three percent of Mexicans suffer from morbid obesity. Comorbidities associated to this condition diminish quality of life, increase mortality and health care costs. Despite bariatric surgery has specific indications and risks, it is the only treatment with effective long-term results. The aim of the study was to evaluate biochemical and clinical patient characteristics, both preoperatively and a year after they underwent bariatric surgery. METHODS: We carried out a quasi-experimental study that evaluates a sample of patients in the Clínica de Obesidad at Hospital de Especialidades (a third level hospital) between March 2011 and October 2015. RESULTS: A total of 150 patients were analyzed (60 % were women). Mean age was 41 ± 9 years and mean body mass index (BMI) was 48 kg/m2 (42-53 kg/m2). Before surgery, type 2 diabetes mellitus (T2DM) was present in 31 %, hypertension in 60 % and 30 % of the patients were "metabolically healthy obese". A year after surgery, the percentage of excess body weight loss was 66 %, T2DM and hypertension remission was 70 % and 50 %, respectively. CONCLUSION: Bariatric surgery is an effective treatment to reduce excess weight. It improves biochemical, and clinical parameters in extreme obese patients.

Introducción: el 3 % de la población mexicana padece obesidad extrema. Sus comorbilidades disminuyen la calidad de vida, aumentan la mortalidad y los costos de atención médica. El único tratamiento con resultados a largo plazo es la cirugía bariátrica, aunque tiene indicaciones y riesgos específicos. Buscamos evaluar las características de los pacientes de cirugía bariátrica al inicio y un año después del tratamiento quirúrgico. Métodos: estudio cuasi experimental con los datos antropométricos, clínicos y bioquímicos de una muestra de pacientes operados en la Clínica de Obesidad del Hospital de Especialidades del Centro Médico Nacional de marzo del 2011 a octubre del 2015. Resultados: fueron analizados 150 pacientes (60 % mujeres), la media de edad fue de 41 ± 9 años y el índice de masa corporal (IMC) de 48 kg/m2 (42-53 kg/m2). Previo a la cirugía, 31 % tenía diabetes mellitus tipo 2 (DM2) y 62 % hipertensión arterial (HAS). El 30 % eran obesos "metabólicamente sanos". Un año después de la cirugía el porcentaje del exceso de peso perdido fue de 66 %. La remisión de DM2 y HAS fue de 70 y 50 %, respectivamente. Conclusión: la cirugía bariátrica es efectiva en la pérdida de peso y en la mejoría de parámetros bioquímicos y clínicos en pacientes con obesidad extrema.

Mammary analog secretory carcinoma of the parotid gland: A case report and literature review.

BACKGROUND: Mammary analog secretory carcinoma (MASC) was first described in 2010 by Skálová et al. This entity shares morphologic and immunohistochemical features with the secretory carcinoma (SC) of the breast. MASC usually presents as an asymptomatic mass in the parotid gland and predominantly affects men. This tumor is considered a low-grade carcinoma but has the potential for high-grade transformation. We report one MASC case and a review of world literature. CASE REPORT: A 66-year-old male patient presented because he noticed a mass of approximately 3×3cm on the right pre-auricular region. Physical examination demonstrated a 3×3.5cm, firm, fixed, non-tender mass in the right pre-auricular region. An MRI of the head and neck showed an ovoid heterogeneous lesion, dependent of the right parotid gland of 27×28mm. We performed a superficial parotidectomy with identification and preservation of the facial nerve. The immunophenotype was positive for epithelial membrane antigen (EMA), CK8/18, vimentin, S-100 protein, and mammoglobin. No further surgical interventions or adjuvant therapies were needed. The patient will have a close follow up. CONCLUSION: The presence of t(12;15) (p13;q25) translocation which results in the ETV6-NTRK3 gene fusion or positive immunochemical studies for STAT5, mammoglobin and S100 protein, are necessary to confirm the diagnosis of MASC. MASC treatment should mimic the management of other low-grade malignant salivary gland neoplasms. The inhibition of ETV6-NTRK3 gene fusion could be used as treatment in the future.