Dulce Momblán

Could age be an indication for laparoscopic colectomy in colorectal cancer

BackgroundThe incidence of colorectal carcinoma increases in the elderly. Regardless of age as an isolated factor, postoperative complications represent the main factor in increasing hospital mortality.MethodsThe aim of this study was to compare the short-term results (first 30 postoperative days) after laparoscopically assisted colectomy (LAC) and open segmental colectomy (OC) in colorectal carcinoma between two groups of patients, older than 70 and younger than 70 years of age. In the study from November 1993 to June 1998, 255 patients were evaluated to participate.ResultsPeristalsis, oral intake, and discharge from the hospital occurred earlier in LAC than in OC treated patients, in the two age groups. The mean operative time was significantly longer in the LAC than in the OC patients in the two age groups. No differences were observed in morbidity between LAC and OC in the group younger than 70 years of age. However, the overall morbidity was significantly lower in the LAC group in patients older than 70 years. One patient in the LAC group older than 70 years died.ConclusionThese results suggest that laparoscopically assisted colectomy may be particularly indicated in elderly patients.

Acute phase response in laparoscopic and open colectomy in colon cancer

PURPOSE: All types of trauma to the organism produce a systemic response that is proportional to the severity of the lesion caused. The more rapid clinical recovery during the postoperative period of patients undergoing laparoscopic-assisted colectomyvs. patients receiving conventional surgery suggests that laparoscopic surgery produces less surgical trauma. The aim of this randomized, prospective study was to compare acute phase postoperative response in patients diagnosed with colon neoplasm undergoing open segmentary colectomyvs. laparoscopic-assisted colectomy. METHODS: From June 1994 to July 1997 the results of 97 patients (58 submitted to open colectomy and 39 undergoing laparoscopic-assisted colectomy) were analyzed. Blood determinations of cortisol, prolactin, C-reactive protein and interleukin-6 were performed before surgery and at 4, 12, 24, and 72 hours after surgery. RESULTS: The plasma levels of cortisol and prolactin were higher in the postoperative period with both surgical techniques with no significant differences being observed. The levels of interleukin-6 achieved a maximum peak at 4 hours after surgery, later showing a decrease and practically achieving basal levels at 72 hours in both groups. The levels of interleukin-6 were higher with significant differences at 4, 12, and 24 hours in the patients undergoing open colectomy. The plasma levels of C-reactive protein were significantly lower at 72 hours in patients receiving laparoscopic-assisted colectomy. CONCLUSIONS: The results obtained in this randomized, prospective study suggest that acute phase systemic response is attenuated in patients undergoing laparoscopic-assisted colectomy in comparison with patients receiving open colectomy.

Long-Term Effects of Roux-en-Y Gastric Bypass Surgery on Plasma Glucagon-Like Peptide-1 and Islet Function in Morbidly Obese Subjects

CONTEXT An enlarged incretin response after Roux-en-Y gastric bypass (RYGBP) has been proposed to promote excessive beta-cell function and mass. OBJECTIVE The objective of the study was to determine whether RYGBP is associated with a steadily increased glucagon-like peptide 1 (GLP-1) response and a disruption of the relationship between insulin sensitivity and insulin secretion required to maintain plasma glucose in the normal range. DESIGN AND PATIENTS This was a cross-sectional study. Twenty-four women divided into three groups according to time after RYGBP (9-15, 21-30, and more than 36 months). Eight normal-weight and eight morbidly obese women served as controls. MAIN OUTCOME MEASURES GLP-1 was determined after a standardized test meal. Insulin secretion (AIRg) and insulin sensitivity (S(I)) were derived from an iv glucose tolerance test. Postprandial glucose profile was recorded with a continuous glucose monitoring system. RESULTS Area under the curve(0-120) of GLP-1 was larger after RYGBP compared with controls (P < 0.01) but was comparable among surgical groups (P =0.314). Time after surgery was not associated with changes in S(I) (P = 0.657), AIRg (P = 0.329), or the disposition index (DI = AIRgS(I), P = 0.915). After surgery, the GLP-1 response and the DI were not significantly correlated (P = 0.304). Glucose less than 50 mg/dl was found in operated subjects, but the proportion did not increase with time after surgery (P = 0.459). Neither the GLP-1 response (P = 0.620) nor the DI (P = 0.457) differed significantly between those with or without hypoglycemic episodes. CONCLUSIONS Although the GLP-1 response to meal intake is steadily elevated after RYGBP, this does not result over time in the development of an inappropriate insulin secretion relative to the prevailing insulin sensitivity or the occurrence of hypoglycemic episodes.

Laparoscopic-assisted approach in rectal cancer patients: lessons learned from >200 patients

BackgroundThe applicability of laparoscopic surgery in the treatment of colorectal diseases is still controversial. Early reports on laparoscopic-assisted colectomy in patients with colon cancer suggested that it minimizes surgical trauma, decreases perioperative complications, and leads to a more rapid recovery. To our knowledge, no previous studies have compared the laparoscopic vs the open approach in rectal cancer. The aim of this paper was to assess the results of laparoscopic techniques in patients with rectal cancer.MethodsFrom March 1998 to February 2003, all patients admitted to our unit with adenocarcinoma of the rectum were evaluated for surgery by the laparoscopic approach.ResultsA total of 220 patients with a mean age of 67.3 years were included in the study. One hundred thirty patients (59%) were treated with neoadjuvant chemoradiotherapy. In >75% of the patients, a surgical procedure with sphincter preservation was perfomed. The rate of conversion to the open approach was 20%. Ten patients had intraoperative complications. Fifty-eight patients (26.3%) developed postoperative complications. The length of hospital stay was 6.8 days. The distribution of tumor stages was as follows: stage I, 16.81%; stage II, 33.6%; stage III, 26.36%; stage IV, 19.09%. The mean number of lymph nodes was 13.8. The incidence of local relapse was 5.3%, with a follow-up of 18 months.ConclusionLaparoscopic surgery can be safely performed in patients with adenocarcinoma of the rectum with good short-term results. Randomized controlled trials are needed to confirm these results.

Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial

Objective: The aim of this study was to assess the impact of personalized prehabilitation on postoperative complications in high-risk patients undergoing elective major abdominal surgery. Summary Background Data: Prehabilitation, including endurance exercise training and promotion of physical activity, in patients undergoing major abdominal surgery has been postulated as an effective preventive intervention to reduce postoperative complications. However, the existing studies provide controversial results and show a clear bias toward low-risk patients. Methods: This was a randomized blinded controlled trial. Eligible candidates accepting to participate were blindly randomized (1:1 ratio) to control (standard care) or intervention (standard care + prehabilitation) groups. Inclusion criteria were: i) age >70 years; and/or, ii) American Society of Anesthesiologists score III/IV. Prehabilitation covered 3 actions: i) motivational interview; ii) high-intensity endurance training; and promotion of physical activity. The main study outcome was the proportion of patients suffering postoperative complications. Secondary outcomes included the endurance time (ET) during cycle-ergometer exercise. Results: We randomized 71 patients to the control arm and 73 to intervention. After excluding 19 patients because of changes in the surgical plan, 63 controls and 62 intervention patients were included in the intention-to-treat analysis. The intervention group enhanced aerobic capacity [&Dgr;ET 135 (218) %; P < 0.001), reduced the number of patients with postoperative complications by 51% (relative risk 0.5; 95% confidence interval, 0.3–0.8; P = 0.001) and the rate of complications [1.4 (1.6) and 0.5 (1.0) (P =  0.001)] as compared with controls. Conclusion: Prehabilitation enhanced postoperative clinical outcomes in high-risk candidates for elective major abdominal surgery, which can be explained by the increased aerobic capacity.

Endoscopic management of early GI hemorrhage after laparoscopic gastric bypass

BACKGROUND Early upper GI hemorrhage (UGH) is a potential complication after laparoscopic Roux-en-Y gastric bypass (RYGBP), and early reoperative intervention is the most accepted treatment. Experience with endoscopic treatment is limited. OBJECTIVE Our purpose was to describe the role of endoscopy and injection therapy in the management of early UGH after laparoscopic RYGBP. DESIGN Case series study. SETTING Endoscopy Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain. PATIENTS We describe the endoscopic treatment of 6 patients with early UGH within 24 hours after a RYGBP. INSTRUMENTATION Upper endoscopy was performed in all 6 cases. The origin of the bleeding was identified at the staple line in all cases, and epinephrine alone or combined with polidocanol was successfully injected in 5 of 6 patients. RESULTS Endoscopic therapy arrested active bleeding without any complications in all cases without the need for further surgery or endoscopic treatments. LIMITATION Our experience is limited to 6 cases. CONCLUSION Early postoperative UGH after RYGBP may be adequately controlled with endoscopic treatment and may obviate the need for surgery. Further data are necessary to evaluate the safety and the efficacy of this approach.

Altered Clock Gene Expression in Obese Visceral Adipose Tissue Is Associated with Metabolic Syndrome

Clock gene expression was associated with different components of metabolic syndrome (MS) in human adipose tissue. However, no study has been done to compare the expression of clock genes in visceral adipose tissue (VAT) from lean and obese subjects and its clinical implications. Therefore, we studied in lean and obese women the endogenous 24 h expression of clock genes in isolated adipocytes and its association with MS components. VAT was obtained from lean (BMI 21–25 kg/m2; n = 21) and morbidly obese women (BMI >40 kg/m2; n = 28). The 24 h pattern of clock genes was analyzed every 6 hours using RT-PCR. Correlation of clinical data was studied by Spearman analysis. The 24 h pattern of clock genes showed that obesity alters the expression of CLOCK, BMAL1, PER1, CRY2 and REV-ERB ALPHA in adipocytes with changes found in CRY2 and REV-ERB ALPHA throughout the 24 h period. The same results were confirmed in VAT and stromal cells (SC) showing an upregulation of CRY2 and REV-ERB ALPHA from obese women. A positive correlation was observed for REV-ERB ALPHA gene expression with BMI and waist circumference in the obese population. Expression of ROR ALPHA was correlated with HDL levels and CLOCK with LDL. Obese subjects with MS exhibited positive correlation in the PER2 gene with LDL cholesterol, whereas REV-ERB ALPHA was correlated with waist circumference. We identified CRY2 and REV-ERB ALPHA as the clock genes upregulated in obesity during the 24 h period and that REV-ERB ALPHA is an important gene associated with MS.

Giant Gastric Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal stromal tumors (GIST) represent 0.1–3 % of gastrointestinal malignancy. Surgery is the mainstay of treatment, but in high-risk tumors, imatinib can help to achieve better oncological outcomes. We present a rare case of a patient with gastric GIST with very aggressive evolution in a short period of time despite the use of neoadjuvant therapy with imatinib.

Endoscopic full-thickness resection of esophagogastric junction gastrointestinal stromal tumor assisted by laparoscopy after neoadjuvant therapy

gastric junction gastrointestinal stromal tumor assisted by laparoscopy after neoadjuvant therapy Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the digestive tract [1]. Surgery is the only potentially curative therapy. However, some tumors are locally advanced, and therefore R0 resection cannot be guaranteed. In this situation, imatinib can allow organ-preserving surgery and optimal oncological outcome [2–5]. GISTs located at the esophagogastric junction (EGJ) are challenging because wedge resection is difficult to achieve, and gastrectomy and/or esophagectomy are associated with morbidity and mortality. Consequently, endoscopic resection could be an ideal alternative to surgery, with comparable oncological outcomes. We present the case of an 82-year-old woman with a 1-month history of progressive dysphagia. An upper endoscopy showed a 6-cm pedunculated polypoid lesion at the EGJ, with a short and wide pedicle that protruded into the gastric fundus. The biopsy demonstrated a highrisk GIST with 20 mitoses per 50 highFig.1 Gastrointestinal stromal tumor at the esophagogastric junction. a Double-contrast radiography. b Computed tomography.

615. Initial experience in robot assisted minimally invasive esophagectomy (ramie)

Introduction: Minimally invasive esophageal surgery includes robot assisted approach. We here present our initial results of robot assisted minimally invasive esophagectomy in terms of quality of oncological resection, morbidity and mortality. Materials and methods: Data from our first 12 consecutive patients submitted to esophagectomy by RAMIE approach were prospectively collected between November 2015 and May 2016. Results: All our 12 patients were male patients with a median age of 64 years. Median BMI was 25 kg/m2 (20-29); ASA score classification was II (83%) and III (17%). Tumor type was adenocarcinoma in 66.7% and squamous cell carcinoma in 33.3% of patients. Tumor location was Siewert I in 16.7%, Siewert II in 8.3% and medium-distal esophagus in 75% of cases. 75% of patients received neoadjuvant treatment. Robot-assisted total esophagectomy was performed in 4 cases (33.3%) and robot-assisted Ivor-Lewis in 8 cases (66.7%). Conversion to thoracoscopy was necessary in one case due to pachypleuritis and there was no need to convert to open surgery. Median operating time was 320 min (210-480). Thoracic end-toend anastomosis was performed in 8 cases (66.7 %) and cervical anastomosis in 4 cases (33.3 %). There were 2 anastomotic leaks (17%). Resection was considered R0 in all cases. Median number of retrieved lymph nodes was 18 (6-35). Median ICU stay was 6.5 days (1-25). Median hospital stay was 13.9 days (8-28). 30-day mortality was 0%. Conclusion: Our first experience in RAMIE is acceptable, with adequate oncologic results and outcomes comparable to those of MIE.