Ainitze Ibarzabal

The Long-term Results of a Randomized Clinical Trial of Laparoscopy-assisted Versus Open Surgery for Colon Cancer

Objective:The aim of this study was to compare the long-term outcome of laparoscopy-assisted colectomy (LAC) and open colectomy (OC) for nonmetastatic colon cancer. Methods:From November 1993 to July 1998 all patients with adenocarcinoma of the colon were assessed for entry in this single center, clinically randomized trial. Adjuvant therapy and postoperative follow-up were similar in both groups. The primary endpoint was cancer-related survival and secondary endpoints were probability of overall survival and probability of being free of recurrence. Data were analyzed according the intention-to-treat principle. Results:Two hundred and nineteen patients entered the study (111 LAC group and 108 OC group). The median follow-up was 95 months (range, 77–133). There was a tendency of higher cancer-related survival (P = 0.07, NS) and overall survival (P = 0.06, NS) for the LAC group. Probability of cancer-related survival was higher in the LAC group (P = 0.02) when compared with OC. The regression analysis showed that LAC was independently associated with a reduced risk of tumor relapse (hazard ratio 0.47, 95% CI 0.23–0.94), death from a cancer-related cause (0.44, 0.21–0.92) and death from any cause (0.59, 0.35–0.98). Conclusions:LAC is more effective than OC in the treatment of colon cancer.

Long-Term Dietary Intake and Nutritional Deficiencies following Sleeve Gastrectomy or Roux-En-Y Gastric Bypass in a Mediterranean Population

BACKGROUND Data on long-term dietary changes and nutritional deficiencies after sleeve gastrectomy (SG) in grade 3 obese patients are scarce. OBJECTIVE To prospectively compare dietary changes and nutritional deficiencies in grade 3 obese patients 5 years after SG and Roux-en-y gastric bypass (GBP). PARTICIPANTS/SETTING Three hundred and fifty-five patients who had SG (n=61) or GBP (n=294) (May 2001-December 2006) at a Spanish university hospital. DESIGN Longitudinal, prospective, observational study. PRIMARY OUTCOMES/STATISTICAL ANALYSES: Changes in energy, macronutrient, and micronutrient intake, and weight loss were analyzed using mixed models for repeated measurements. RESULTS At the 5-year follow-up visit, the percentage of excess weight loss (P=0.420) and daily energy intake (P=0.826), as well as the proportion of energy from carbohydrates (P=0.303), protein (P=0.600), and fat (P=0.541) did not differ between surgical groups. Energy intake (P=0.004), baseline weight (P<0.001), and time period (P<0.001), but not the proportion of different macronutrients or the type of surgery, independently predicted the percentage excess weight loss over time. After SG or GBP, the mean daily dietary intake of calcium, magnesium, phosphorus, and iron was less than the current recommendations. Despite universal supplementation, the prevalence of nutritional deficiencies was comparable after SG or GBP, with 25-hydroxyvitamin D being the most commonly observed deficiency (SG, 93.3% to 100%; GBP, 90.9% to 85.7%, P=not significant). In an adjusted multivariate regression model, energy intake and lipid intake independently predicted plasma 25(OH)-vitamin D levels. CONCLUSIONS Data show that SG and GBP are associated with similar long-term weight loss with no differences in terms of dietary intake. Furthermore, data demonstrate that both types of surgeries carry comparable nutritional consequences.

Hybrid vaginal MA-NOS sleeve gastrectomy: technical note on the procedure in a patient

BackgroundStandard sleeve gastrectomy for the morbidly obese is feasible and safe using the hybrid transvaginal minilaparoscopic-assisted natural orifice surgery (MA-NOS) with available laparoscopic/endoscopic instruments and technology as illustrated by this technical report on a female patient.MethodsThe intervention was a transvaginal sleeve gastrectomy in a 67-year-old woman who was hypertensive, noninsulin-dependent with diabetes with morbid obesity (BMI, 37). Operative field view was maintained at all times with a gastroscope introduced through a transvaginal trocar. The surgeon positioned himself at the right side of the patient using a 2-mm needle port/mini-grasper placed in the left upper quadrant for traction of the greater curvature of the stomach. A 12-mm umbilical trocar was used as the port for insertion of the LigaSure device used for division of the short gastric vessels and the Endo-GIA stapler for creation of the gastric tube. The first assistant used a second mini-grasper for liver retraction and stomach positioning. The resected stomach was retrieved through the vagina. There were no intraoperative complications. The operative time was 150 minutes.ResultsThe advantages of minimally invasive surgery seemed to be enhanced with this hybrid laparoscopic approach. Postoperative course was uneventful. All component steps of a laparoscopic sleeve gastrectomy (LSG) were reproduced. The patient was discharged on the third postoperative day.ConclusionsTransvaginal hybrid MA-NOS sleeve gastrectomy is both feasible and safe. The hybrid technique ensured safety during the performance of the procedure. MA-NOS is a potential option to avoid abdominal incisions and related complications for the laparoscopic resection of large intra-abdominal organs. Combined hybrid laparoscopic NOS for humans is currently a safe and reliable approach for major surgery through the NOS approach in female patients. Hybrid surgery allows controlled implementation of NOS techniques in clinical practice, providing a stepwise progression to the pure NOS approach once the appropriate technology has been developed. Additionally, it is the best way to stimulate the active development and evaluation of the underpinning technologies and instruments for these novel endoscopic surgical approaches. Appropriate clinical indications for these new procedures are yet to be defined. LSG is associated with short-term excess weight loss and resolution of comorbidities comparable to those obtained with other restrictive procedures. The performance of sleeve gastrectomy is an option in selected patients undergoing bariatric surgical treatment, particularly in the super obese and those who are considered high risk because of comorbid disease.

Nystagmus: An Uncommon Neurological Manifestation of Thiamine Deficiency as a Serious Complication of Sleeve Gastrectomy

Wernicke encephalopathy--a debilitating acute or subacute neurological disorder-is caused by a deficiency in thiamine (vitamin B(1)). It is characterized by a classical clinical triad of symptoms: ocular impairment, cerebellar dysfunction, and confusion. Although bariatric surgery can certainly improve the overall health of an obese individual, it can also make him or her more susceptible to serious nutrition deficiencies. Following surgery, inadequate caloric intake, rapid and excessive weight loss, food intolerance, lack of adherence to nutrition supplementation, and/or the onset of prolonged vomiting can lead to severe nutrition deficiencies. It is generally believed that the more malabsorptive the surgery proves, the more likely is it that such a deficiency will occur. The case presented here shows that after sleeve gastrectomy (SG), a patient may also develop dangerous nutrition deficits that can negatively affect his or her life. In this particular case, a patient presented with a severe vitamin B(1) deficiency following SG for morbid obesity. Although patients may exhibit pathophysiologies similar to Wernicke encephalopathy after this surgery, only 2 cases of severe vitamin B(1) deficiency following sleeve gastrectomy have been reported. The grave consequences of thiamine deficiency observed in this patient underscore the importance of supplementation after SG.

Cirugía endoscópica transluminal a través de orificios naturales: estado actual

Resumen La cirugia endoscopica transluminal a traves de orificios naturales, mas conocida por sus siglas inglesas NOTES (natural orifice transluminal endoscopic surgery), es el paradigma de la evolucion de la cirugia minimamente invasiva. La «revolucion» que ha supuesto la cirugia laparoscopica ha introducido nuevas ideas en la cirugia general. Una de ellases que la cirugia moderna es el trabajo de un equipo multidisciplinario, y la cirugia NOTES es un claro ejemplo de ello. El objetivo de este tipo de cirugia es realizar los procedimientos laparoscopicos convencionales sin ninguna incision, usando la tecnologia endoscopica flexible, utilizada habitualmente en el diagnostico y el tratamiento de lesiones intraluminales, y accediendo al interior de la cavidad abdominal a traves de los orificios naturales (boca, ano, vagina e incluso uretra). Este tipo de acceso abre un campo muy interesante para determinados pacientes, como los que tienen un elevado riesgo quirurgico, los obesos morbidos o los que tienen antecedentes de multiples cirugias abdominales previas o infecciones de herida quirurgica. Usando modelos animales se ha podido demostrar que es posible realizar una gran variedad de intervenciones (colecistectomia, apendicectomia, esplenectomia, histerectomia, ligadura de trompas, gastroenteroanastomosis, peritoneoscopia, biopsia hepatica y herniorrafia, entre otras). Sin embargo, y antes de su implementacion en los humanos, esta nueva tecnica debe demostrar que es segura y ofrece ventajas reales para los pacientes. Por tanto, se debe encontrar solucion a una serie de problemas, que incluyen metodos seguros para el cierre de la incision gastrica y evitar la aparicion de infecciones, entre otros. Otro elemento critico para el desarrollo de esta nueva cirugia es la creacion de instrumental apropiado, por lo que es necesario el esfuerzo no solo de los profesionales medicos, sino tambien de los ingenieros y de la industria de dispositivos medicos. En este articulo se describen los importantes avances en NOTES desde su primera descripcion y se analizan los riesgos y los beneficios potenciales asociados a esta tecnica tan innovadora.

Genetic background influences weight-loss trajectories on the mid-term after bariatric surgery

Bariatric surgery (BS) is a highly effective therapy for morbid obesity, yet with a wide inter-individual variability on weight-loss responses. To determine genetic influence on weight loss after BS we compared the within-pairs difference in maximum percentage excess weight loss (%EWL) and the within-pairs %EWL differences over a mean follow-up of 53.6 ± 36.4 months between 47 pairs of first-degree relatives and 47 genetically unrelated control pairs. Within-pairs maximum %EWL difference was similar between first-degree related pairs and control pairs (p = 0.100). Within-pairs %EWL difference increased through follow-up (p < 0.001). However, effect of time was different depending on genetic background (ptime*group = 0.001). Increased variability in mid-term weight response was present in unrelated pairs but not in first-degree pairs (p < 0.001 and p = 0.535, respectively). To assess shared environment influence, 16 married couples were identified and 16 unrelated and non-cohabiting matched pairs were also analyzed. In these analysis within-pairs difference in %EWL also increase over time (p = 0.025) but no group by time effect was observed (ptime×group = 0.177). In conclusion first-degree related participants showed closer weight trajectories after BS time than genetically unrelated subjects. Genetic background might partially explain the variability in mid-term weight-loss after BS.

Criterios de calidad en cirugía bariátrica: revisión de conjunto y recomendaciones de la Asociación Española de Cirujanos y de la Sociedad Española de Cirugía de la Obesidad

Bariatric surgery has proven to be highly effective in controlling obesity and metabolic syndrome; the results of this surgery are not only expressed in terms of weight loss, but also in terms of resolution of comorbidities, improved quality of life and complications. The different parameters used to measure these outcomes require uniformity and reference patterns. Therefore, it is essential to identify those indicators and quality criteria that are helpful in defining the «best practice» principles in bariatric surgery. In this regard, the Section of Obesity of the Spanish Association of Surgeons, in collaboration with the Spanish Society for Bariatric Surgery (SECO), present as an objective to identify the key points that define «quality» in this type of surgery. We describe the main indicators based on the published literature as well as the criteria for referral of the main comorbidities according to the evidence found and grades of recommendation.

Efectos del bypass gástrico sobre el riesgo cardiovascular estimado

INTRODUCTION The major goal of surgical treatment in morbid obesity is to decrease morbidity and mortality associated with excess weight. In this sense, the main factors of death are cardiovascular disease and metabolic syndrome. The objective of this study is to evaluate the effects of gastric bypass on cardiovascular risk estimation in patients after bariatric surgery. MATERIAL AND METHODS We retrospectively evaluated pre and postoperative cardiovascular risk estimation of 402 morbidly obese patients who underwent laparoscopic gastric bypass. The major variable studied is the cardiovascular risk estimation that is calculated preoperatively and after 12 months. Cardiovascular risk estimation analysis has been performed with the REGICOR Equation. REGICOR formulation allows calculating a 10 year risk of cardiovascular events adapted to the Spanish population and is expressed in percentages. RESULTS We reported an overall 4.1±3.0 mean basal REGICOR score. One year after the operation, cardiovascular risk estimation significantly decreased to 2,2±1,6 (P<.001). In patients with metabolic syndrome according to ATP-III criteria, basal REGICOR score was 4.8±3.1 whereas in no metabolic syndrome patients 2.2±1.8. Evaluation 12 months after surgery, determined a significant reduction in both groups (metabolic syndrome and non metabolic syndrome) with a mean REGICOR score of 2.3±1.6 and 1.6±1.0 respectively. CONCLUSION The results of our study demonstrate favorable effects of gastric bypass on the cardiovascular risk factors included in the REGICOR equation.