Amador García Ruiz de Gordejuela

Evaluation of Bone Mineral Density Loss in Morbidly Obese Women After Gastric Bypass: 3-Year Follow-Up

Studies that evaluate the influence of gastric bypass (RYGP) on bone mass are limited to short-term follow-up. We analysed changes in bone mineral density (BMD) three years after surgery and evaluated the main determinants of the development of bone disease. Prospective study of 59 morbidly obese white women aged 46 ± 8 years. BMD scanning using DEXA and plasma determinations of calcium, parathyroid hormone, 25-hydroxyvitamin D and insulin-like growth factor-I were made prior, at 12 months and 3 years after surgery. In the first postoperative year BMD decreased at femoral neck (FN) 10.2 % and in the lumbar spine (LS) 3.2 %, in the third year it additionally decreased 2.7 % and 3.1 %, respectively. BMD at both sites remained above the values of women of the same age. In the follow-up, 1.7 % developed osteoporosis at FN and 6.8 % at LS. Patients with bone disease were older, the percentage of women with menopause was greater in this group and had lower initial and final values of lean mass. The percentage of BMD loss at FN remained positively associated with the percentage of lean mass loss [β 0.304, p = 0.045], and menopause [β 0.337, p = 0.025]. Major osteoporotic fracture and hip fracture risk was low even in menopausal patients (3.1 % and 0.40 %, respectively). After RYGP menopausal women and those with greater lean mass loss are at higher risk of BMD loss but progression to osteoporosis is uncommon and the risk of fracture is low.

Is sleeve gastrectomy as effective as gastric bypass for remission of type 2 diabetes in morbidly obese patients

BACKGROUND The benefits of Roux-en-Y gastric bypass (RYGB) for the control of type 2 diabetes mellitus (T2DM) in morbidly obese patients are well known, although the implicated mechanisms have not yet been elucidated. However, little is known about the remission of T2DM after sleeve gastrectomy (SG). The aim of our study was to compare the outcomes of T2DM after both procedures. METHODS We performed a retrospective analysis of diabetic morbidly obese patients who had undergone RYGB or SG. The variables analyzed included weight, fasting glycemia, and glycosylated hemoglobin. RESULTS A total of 90 patients were included (60 RYGB and 30 SG). The body mass index was 46.22 kg/m(2) for the RYGB group and 56.80 kg/m(2) for the SG group. The fasting glycemia was 10.63 mmol/L and 8.05 mmol/L and the glycated hemoglobin was 8.1% and 7.3% in the RYGB and SG groups, respectively. No significant differences were seen in the amount of weight loss after 2 years between the 2 techniques. Similarly, no significant differences were found in T2DM control after either 1 year (91.8% versus 82.3%) or 2 years (91.8% versus 88.9%). No significant differences were found in the duration of T2DM in either group nor in the percentage of patients treated with insulin and oral hypoglycemic drugs before and 2 years after surgery. CONCLUSION We did not find any significant differences in weight loss or T2DM resolution between the 2 techniques. Our results highlight that 1 of the mechanisms implicated in T2DM remission after bariatric surgery is weight loss. The role of other factors, such as incretins, that we have not studied cannot be ruled out and should be analyzed further.

Gastroplastia tubular plicada, una nueva técnica para el tratamiento de la obesidad mórbida

INTRODUCTION Laparoscopic Gastric Plication is a new technique derived from sleeve gastrectomy. Plication of the greater curvature produces a restrictive mechanism that causes weight loss. The results of the first cases where this technique has been applied in this hospital are presented. METHODS A review was made of patients operated on in our hospital between November 2009 and December 2010. Plication of the gastric greater curvature was performed under general anaesthetic and by laparoscopy using 3 lines of sutures and with an orogastric probe as a guide. The results of the morbidity, mortality and weight loss are presented. RESULTS A total of 13 patients were operated on (7 women). The maximum body mass index (BMI) varied between 37.11 kg/m² and 51.22 kg/m² at the time of the operation. The most frequently found morbidity was nausea and vomiting. Two patients required further surgery due intractable vomiting and total dysphagia; in one the plication unfolded, and in the second it was converted into vertical gastrectomy. CONCLUSIONS Laparoscopic Gastric Plication is a new surgical technique which gives equivalent short-term results as vertical gastrectomy. It is a reproducible and reversible technique with results and indications still to be validated.

Diagnóstico y tratamiento del déficit de hierro, con o sin anemia, pre y poscirugía bariátrica

Bariatric surgery (BS) is an increasingly used therapeutic option for severe obesity which allows patients to achieve sustained weight loss over time and resolution or improvement in most associated pathological conditions. Major mid- and long-term complications of BS include iron deficiency and iron-deficient anemia, which may occur in up to 50% of cases and significantly impair patient quality of life. These changes may be present before surgery. The aim of this review was to prepare schemes for diagnosis and treatment of iron deficiency and iron-deficient anemia before and after bariatric surgery.

Hidatidosis hepática gigante con fístula quistopleural e hidatosis pleural

Resumen Las complicaciones extrahepaticas de la hidatidosis de origen hepatico son infrecuentes y potencialmente graves. Si bien la prevalencia de la hidatidosis en nuestro pais habia disminuido, la creciente inmigracion ha implicado mas casos y mayor gravedad de estos. En esta nota presentamos a un paciente con un quiste hidatidico gigante que clinicamente se inicio como una masa abdominal a estudio. Lo acompanaban 3 quistes mas, uno de ellos fistulizado a la via biliar, sin repercusion clinica ni analitica; otro fistulizado a la cavidad pleural derecha, lo que conlleva hidatidosis pleural e insuficiencia respiratoria por derrame pleural masivo; y el ultimo de ellos calcificado. Este paciente planteo un doble reto diagnostico y terapeutico. En primer lugar, por la forma de presentacion extraordinaria de una enfermedad tan avanzada. En segundo lugar, para el abordaje quirurgico, la disposicion y la extension de la enfermedad hacian dificil plantear una exeresis completa de todos los quistes o una cirugia resectiva clasica.

SADI-S WITH RIGHT GASTRIC ARTERY LIGATION: TECHNICAL SYSTEMATIZATION AND EARLY RESULTS

ABSTRACT Background: Bariatric surgery is performed all over the world with close to 500.000 procedures per year. The most performed techniques are Roux-en-Y gastric bypass and sleeve gastrectomy. Despite this data, the most effective procedure, biliopancreatic diversion with or without duodenal switch, represents only no more than 1.5% of the procedures. Technical complexity, morbidity, mortality, and severe nutritional adverse effects related to the procedure are the main fears that prevent most universal acceptance. Aim: To explain the technical aspects and the benefits of the SADI-S with right gastric artery ligation as an effective simplification from the original duodenal switch. Methods: Were included all patients undergoing this procedure from the November 2014 to May 2016, describing and analysing aspects of this technique, the systematization and early complications associated with the procedure. Results: A series of 67 patients were operated; 46 were women (68.7%); mean age of the group was 44 years old (33-56); and an average BMI of 53.5 kg/m2 (50-63.5). Surgical time was 115 min (80-180). A total of five patients (7.5%) had any complication and two (2.9%) had to be reoperated. There were two patients with leak, one at the duodenal stump and other at the esophagogastric angle. There was no mortality. Patients stayed at the hospital a median of 2.5 days (1-25). Conclusions: SADI-S with right gastric artery ligation is a safe procedure with few preliminary complications. The technical variations introduced to the classical duodenal switch are reproducible and may allow this procedure to be more popular. All the complications in this series were not related to the ligation of the right gastric artery.

SADI-S COM LIGADURA DA ARTÉRIA GÁSTRICA: SISTEMATIZAÇÃO TÉCNICA E OS PRIMEIROS RESULTADOS

Racional: Cerca de 500.000 cirurgias bariatricas sao realizadas a cada ano em todo o mundo. As tecnicas mais realizadas sao o bypass gastrico em Y-de-Roux e a gastrectomia vertical. A derivacao biliopancreatica, com ou sem duodenal switch, e considerada tecnica mais eficaz no tratamento cirurgico do paciente obeso morbido; entretanto, representa nao mais do que 1,5% dos procedimentos na atualidade, pois sua complexidade tecnica, morbimortalidade e graves efeitos adversos nutricionais impedem aceitacao mais universal. Objetivo: Descrever os aspectos tecnicos e os beneficios do SADI-S com ligadura da arteria gastrica direita como um modo simplificado do duodenal switch original. Metodos: Foram incluidos todos os pacientes submetidos a este procedimento entre novembro 2014 e maio de 2016. Alem da descricao da sistematizacao da tecnica operatoria, foram analisadas as complicacoes precoces associadas ao procedimento. Resultados: Uma serie de 67 pacientes foi operada no periodo analisado; 46 eram mulheres (68,7%) e a media de idade foi de 44 anos (33-56). O IMC medio foi de 53,5 kg/m2 (50-63,5). O tempo cirurgico medio foi de 115 min (80-180) e a permanencia hospitalar media foi de 2,5 dias (1-25). Complicacoes foram observadas em cinco pacientes (7,5%) e dois (2,9%) tiveram de ser reoperados. Duas pacientes evoluiram com fistula, uma no coto duodenal e outra na juncao esofagogastrica. Nao houve mortalidade. Conclusao: SADI-S com ligadura da arteria gastrica direita e procedimento seguro com poucas complicacoes precoces. A simplificacao tecnica em relacao ao duodenal switch classico pode permitir que este procedimento se torne mais popular. Todas as complicacoes observadas nesta serie nao estavam relacionadas com a ligadura da arteria gastrica direita.

One stage laparoscopic left adrenalectomy and sleeve gastrectomy by direct supragastric approach

INTRODUCTION The advances in laparoscopic surgical technique and the greater experience of surgical teams have enabled the combination of different surgical techniques in a single procedure. This paper presents a case of a sleeve gastrectomy and a left adrenalectomy by laparoscopy for a morbidly obese patient with Cushings syndrome. PRESENTATION OF CASE A 52 year-old male patient with a BMI of 53 kg/m2 was diagnosed as having Cushings syndrome caused by a left adrenal tumor. Sleeve gastrectomy was performed according to the usual technique. The adrenalectomy was performed at the same time by a left supragastric approach. The evolution was favorable, with 52% of excess weight loss observed after six months. Plasma and urinary cortisol at the 3- and 6-month follow-ups were under normal range and the patient required glucocorticoid therapy, confirming the cure of Cushings syndrome. DISCUSSION Teams with experience of advanced laparoscopic surgery can successfully combine complex procedures in one surgical period. The approach we used for the adrenalectomy proved itself to be feasible after the sleeve gastrectomy. CONCLUSION Both procedures can be safely done in experience teams. Sleeve gastrectomy facilitates the direct supragastric approach.

Nutritional deficiencies and bone metabolism after endobarrier in obese type 2 patients with diabetes

Endobarrier® is a minimally invasive, reversible endoscopic treatment for obesity. It provokes malabsorption along 60 cm of the small intestine, which can contribute to the development of vitamin deficiencies and to changes in bone mineral density (BMD). To determine the prevalence of nutrient deficiencies, changes in body composition and BMD during the first year after Endobarrier® placement. Twenty-one patients with type 2 diabetes met inclusion criteria. Levels of vitamins, micro and macronutrients were assessed prior and at 1, 3 and 12 months post-operatively. DEXA was performed before and 12 months after implant. Nineteen patients completed the 12 months follow-up. Vitamin D deficiency was the most prevalent finding before Endobarrier® implant. The percentage of patients with severe deficiency decreased from 19 to 5% at 12 months after supplementation. Microcytic anaemia was initially present in 9.5% of patients and increased to 26.3% at 12 months. Low ferritin and vitamin B12 levels were observed in 14.2 and 4.8% of patients before the implant and worsened to 42 and 10.5%. Low concentrations of magnesium and phosphorus were also common but improved along the study. A significant but not clinically relevant decrease in BMD of 4.14 ± 4.0% at the femoral neck was observed at 12 months without changes in osteocalcin levels. Vitamin deficiencies are common after Endobarrier® implant. It is therefore important to screen patients prior to and at regular intervals after the implant, and to encourage adherence to diet counselling and supplementation.

Live surgery courses: retrospective safety analysis after 11 editions

INTRODUCTION Live surgery is a topic of interest at every meeting or course in the field of surgery. The potential of laparoscopy for live broadcasting makes it an excellent tool in continuing medical education. Surgeons who participate in live surgeries are usually experienced, but several conditions may influence the results and safety of a procedure. OBJECTIVES To analyze safety and outcomes in a series of patients who underwent surgery in the last 10 years in a live surgery course at our institution. SETTING University public hospital in Spain. METHODS Retrospective review of patients who underwent surgery during these courses from 2006 to 2016. Morbidity, mortality, and long-term results were analyzed. RESULTS Of 107 patients, 74 (68.5%) were women, and 38 (35.2%) had revision surgery. Five had surgery during previous editions. The most performed procedures were Roux-en-Y gastric bypass (38.9%), sleeve gastrectomy (16.7%), and duodenal switch (14%). Ten cases were endoscopic procedures. Morbidity was 13% (14 cases), and 6 required early postoperative revision (5.6%). Most of the complications were Clavien types III and I. Bleeding was the most common (72.4%). There was no anastomotic leak, but 1 duodenal stump leak occurred. During follow-up, 6 patients had a surgical complication and 5 required revision surgery. There was no mortality. DISCUSSION We found higher morbidity and reoperation rates. The conversion rate in long-term follow-up was higher. Despite the educational benefits, we should take into consideration the higher risk to our patients for future editions.