Elia Pérez-Aguirre

Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients

BACKGROUND Bariatric operations achieve a high remission rate of type 2 diabetes in patients with morbid obesity. Malabsorptive operations usually are followed by a higher rate of metabolic improvement, though complications and secondary effects of these operations are usually higher. OBJECTIVES Analyze the results of a simplified duodenal switch, the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) on patients with obesity and type 2 diabetes mellitus (T2 DM). SETTING University Hospital, Madrid, Spain. METHODS Ninety-seven T2 DM patients with a mean body mass index (BMI) of 44.3 kg/m(2) were included. Mean preoperative glycated hemoglobin was 7.6%, and mean duration of the disease was 8.5 years. Forty patients were under insulin treatment. SADI-S was completed with a sleeve gastrectomy performed over a 54 French bougie and a 200 cm common limb in 28 cases and 250 cm in 69. RESULTS Follow up was possible for 86 patients (95.5%) in the first postoperative year, 74 (92.5%) in the second, 66 (91.6%) in the third, 46 (86.7%) in the fourth and 25 out of 32 (78%) in the fifht postoperative year. Mean glycemia and glycated hemoglobin decreased immediately. Control of the disease, with HbA1c below 6%, was obtained in 70 to 84% in the long term, depending on the initial antidiabetic therapy. Most patients abandoned antidiabetic therapy after the operation. Absolute remission rate was higher for patients under oral therapy than for those under initial insulin therapy, 92.5% versus 47% in the first postoperative year, 96.4% versus 56% in the third and 75% versus 38.4% in the fifth. A short diabetes history and no need for insulin were related to a higher remission rate. Three patients had to be reoperated for recurrent hypoproteinemia. CONCLUSION SADI-S is an effective therapeutic option for obese patients with diabetes mellitus.

Single-anastomosis duodenoileal bypass as a second step after sleeve gastrectomy.

BACKGROUND After sleeve gastrectomy, many surgical options are available in patients with insufficient weight loss. Duodenal switch is typically considered the operation that results in higher weight loss, although it is, perhaps unjustly, considered technically difficult and may be accompanied by severe side effects. Single-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplification of the duodenal switch that may behave as a standard biliopancreatic diversion but is easier and quicker to perform. Given its effectiveness as a primary surgery we hypothesized that it would be successful as a second-step operation. The objective of this study was to analyze the weight loss and co-morbidities resolution after a single-anastomosis duodenoileal bypass (SADI) performed as a second step after sleeve gastrectomy. METHODS Sixteen patients with an initial body mass index of 56.4 kg/m(2) and a mean excess weight loss of 39.5% after a sleeve gastrectomy were submitted to a single-anastomosis duodenoileal bypass with a 250-cm common channel. RESULTS There were no postoperative complications. The mean excess weight loss was 72% 2 years after the second-step surgery. The complete remission rate was 88% for diabetes, 60% for hypertension, and 40% for dyslipidemia. The mean number of daily bowel movements was 2.1. One patient suffered an isolated episode of clinical hypoalbuminemia. CONCLUSION SADI is a safe operation that offers a satisfactory weight loss for patients subjected to a previous sleeve gastrectomy. The side effects are well tolerated, and complications are minimal.

Prophylactic Closure of Trocar Orifices with an Intraperitoneal Mesh (Ventralex®) in Laparoscopic Bariatric Surgery

Laparoscopic surgery reduces, but not eliminates, the rate of incisional hernia. It is accepted that large trocar orifices should be sutured, in order to prevent future herniation. In morbidly obese patients, the closure of the anterior fascia is a very difficult job, and it does not prevent from preperitoneal herniation. Ventralex® composite mesh is a very easy-to-place device, which closes satisfactorily both the peritoneal opening and the subcutaneous trocar pathway. We recommend its use for large diameter orifices and Hasson orifices in bariatric patients.

Mucocele of the Gastric Tube after Conversion of Vertical Banded Gastroplasty to Duodenal Switch: Not just a Radiological Image

We present two patients who underwent a duodenal switch operation after a failed vertical banded gastroplasty. Both patients had a complicated postoperative course because of an abdominal infection, and both presented the radiological image of a gastric fundus mucocele in the part of the fundus excluded between two staple-lines. Although initially considered as a radiological image with no clinical significance, the presentation of the second case with the same abdominal complication led us to contemplate the possibility of a connection between the gastric mucocele and the postoperative infection.

Right-Angled Stapled Latero-lateral Duodenojejunal Anastomosis in the Duodenal Switch

A simplified technique to perform the duodeno-enteral anastomosis in the duodenal switch is presented. A linear stapled duodeno-jejunal side-to-side anastomosis is performed. The technique is easy and rapid to perform, avoids passing an anvil through the mouth of the patient and is safe for the patient, with satisfactory short-term results.

Overexpression of c-myc and loss of heterozigosity on 2p, 3p, 5q, 17p and 18q in sporadic colorectal carcinoma

AIM The aim of the present study is to evaluate the prognostic influence of loss of heterozygosity on 2p, 3p, 5q, 17p and 18q, and c-myc overexpression on surgically treated sporadic colorectal carcinoma. METHODS Tumor and non-tumor tissue samples from 153 patients were analyzed. Fifty-one percent of patients were male, and mean age in the series was 67 years. Tumors were located in the proximal colon in 37 cases, in the distal bowel in 37, and in the rectum in 79 patients. c-myc overexpression was studied by means of Northern blot analysis, and loss of heterozygosity through microsatellite analysis. RESULTS c-myc overexpression was detected in 25% of cases, and loss of heterozygosity in at least one of the studied regions in 48%. There was no association between clinical and pathologic features, and genetic alterations. The disease-free interval was significantly shorter for patients with both genetic alterations; the presence of both events was an independent prognostic factor for poor outcome in the multivariate analysis (RR: 4.34, p < 0.0001). CONCLUSIONS The presence of both loss of heterozygosity and overexpression of the c-myc oncogene separates a subset of colorectal carcinoma patients who have a shorter disease-free interval after curative-intent surgery.

Aortic injury during laparoscopic esophageal hiatoplasty

A 75-year-old female patient with a type III hiatal hernia was submitted to laparoscopic mesh hiatoplasty. Soon after the last suture fixed the mesh to the left crura, a hemorrhage was observed. Conversion to open surgery was not performed. The most common sources of bleeding (liver, phrenic arteries, crura, spleen, and short gastric vessels) were discarded as the cause of the hemorrhage. The mesh was set free in order to explore the lower mediastinum. The source of the hemorrhage was identified: it was the last suture fixing the mesh to the left crura, which was found passing through the aortic wall. The hemorrhage stopped as soon as the suture was removed. When facing a hemorrhage during this kind of surgery, it is essential to be methodical to discover the source of the bleeding. First of all, the most common sources of bleeding must be checked out. Injury of the inferior vena cava must also be ruled out, because it is an uncommon but potentially lethal complication. Afterwards, the lower mediastinum must be explored. Conversion to an open approach is needed if the patient becomes unstable or the surgeon does not have enough laparoscopic skills to find and solve the bleeding. Most of the reported cases of aortic injury during laparoscopic hiatoplasty are secondary to vascular injuries during port insertion. When a suture is the cause of bleeding, the removal of the stitch should be enough to stop the bleeding. If there is a tear of the aortic wall, a patch should be employed for the repair. In conclusion, left crura and thoracic aorta are very close to one another. The surgeon must be very careful when working near the left crura, mostly in old patients with a dilated and aneurysmatic aorta.

Hepatectomía derecha asociada a nefrectomía y resección de diafragma como tratamiento de un feocromocitoma maligno recidivado 12 años después de ser intervenido

Malignant pheochromocytomas represent between 5% and 26% of all diagnosed pheochromocytomas. Treatment of these tumors should be multidisciplinary and based on surgery since aggressive surgical treatment provides the only possibility for long-term cure in these patients. In addition, surgery improves the effectiveness of other treatments such as I-MIBG. We report the case of a 53-year-old woman who was referred to our center to assess the surgical resection of a recurrent malignant pheochromocytoma. The patient had undergone open right adrenalectomy 12 years earlier due to pheochromocytoma. We had little information about this previous intervention; we only knew that it was a complex procedure and that the patient had been monitored with follow-up analyses and CT for 6 years, with no evidence of recurrence. The patient had undergone a CT scan for suspected diverticulitis, which revealed a mass measuring 5 cm 12 cm in the old surgical bed. This mass infiltrated segments 6 and 7 of the liver, the right kidney, and surrounded the retrohepatic vena cava (Fig. 1). In addition, there were pathologic lymphadenopathies in the hepatic hilum. As the only symptom, the patient reported headaches and selflimiting episodes of palpitations. Urine analysis of normetanephrine and metanephrine showed much higher levels than normal (metanephrineu/creatinineu ratio 16 607 [0.1–260] and normetanephrineu/creatinineu 22 793 [0.1–560]). Chromogranin A levels were also elevated (110 ng/ml). The study of PTH, thyroid hormones, DHEAS and calcitonin was normal. Complementary studies included a SPECT-CT with I-MIBG, octreotide scan and FNA, which suggested pheochromocytoma recurrence without distant metastasis. After completing the studies, the patient was referred to our center. The patient was treated preoperatively with volume expansion and doxazosin. However, during surgery the patient presented hemodynamic lability with episodes of hypoand hypertension. During surgery, resection of the mass was accompanied by right hepatectomy, right nephrectomy, partial resection of the diaphragm and lymphadenectomy of the interaorto-caval, retropancreatic and hepatic hilar regions (Fig. 2).

Early colonic transhiatal herniation and anastomotic leak after Ivor Lewis esophagectomy

Transhiatal herniation of the abdominal organs is a rare complication after esophagectomy. Surgical treatment is usually mandatory because of the high mortality associated with this condition. We present a case of colonic herniation that could contribute to failure of the esophagogastric anastomosis. Repair of both problems was performed through a right posterior thoracotomy.

Síndrome de Claude Bernar-Horner, parálisis recurrencial e insuficiencia respiratoria aguda secundarias a adenoma folicular de tiroides

Resumen En el presente trabajo se describe el caso de una paciente que sufrio un sindrome de Claude Bernard-Horner derecho, paralisis recurrencial homolateral e insuficiencia respiratoria debidas a la presencia de un adenoma folicular tiroideo. La paciente fue tratada con exito mediante intubacion nasotraqueal, puncion y evacuacion de la masa tiroidea quistica y cirugia diferida que consistio en hemitiroidectomia total derecha.