Jesús Bollo

Laparoscopic sleeve gastrectomy in patients over 60 years: impact of age on weight loss and co-morbidity improvement

BACKGROUND Advanced age has traditionally been considered a relative contraindication to bariatric surgery due to increased perioperative risk and less weight loss. However, it is now being reconsidered in older patients after encouraging results in recent series and the increasing life expectancy. We compared operative and postoperative outcomes of laparoscopic sleeve gastrectomy in patients over 60 years with outcomes in younger patients. We also, analyzed the effect of bariatric surgery on improvement and resolution of co-morbidities in the older group. METHODS From November 2008 to November 2013, 130 patients underwent laparoscopic sleeve gastrectomy. Of these, 28 patients (21.5%) were 60 years or older. Outcomes in terms of perioperative complications, short-term and medium-term weight loss, remission or improvement of co-morbidities and medication requirements were extracted from our prospective database. RESULTS Short-term mortality was 0% and 30-day complication rate was similar in both groups (17.9% versus 17.6% according to Clavien-Dindo classification). At 12 months postsurgery, older patients had lost 49% percent of excess weight compared to 60% in the younger group (P = 0.012). At 2 years, the results were 45% versus 60%, respectively, with P = 0.015. At least 1 major co-morbidity improved in 65.2% of older patients. Before surgery, the older group took an average of 4.3 medications compared to 2.7 at 1 year after surgery (P<0.001). CONCLUSION Laparoscopic sleeve gastrectomy is a safe and effective treatment for morbid obesity in people over 60 years, although younger patients show greater weight loss. Daily medication requirements and co-morbidities decrease significantly in older patients after this procedure.

Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: a systematic review of the literature

AbstractBackground The incidence of perineal hernia after abdominoperineal excision and extralevator abdominoperineal excision ranges from 1 to 26%. In this systematic review, we compared surgical options and postoperative outcomes of perineal hernia repair in this setting from 2012 to 2016 with findings in a review of publications 1944–2011.MethodsWe searched the PubMed database using the keywords “hernia” AND “perineum” identified 392 papers published from 1946 to 2016. Two hundred and ninety-six papers published before 2012 were excluded and 96 were found to be potentially relevant.ResultsTwenty-one studies with a total of 108 patients were included in the final analysis. Perineal hernia repair was performed using the perineal approach in 75 patients (69.44%), the laparoscopic approach in 25 patients (23.14%), the open abdominal approach in three patients (2.77%) and the laparoscopic perineal approach in three patients (2.77%) and the open abdominoperineal approach in two patients (1.8%). Non-absorbable mesh was used in 41 (37.96%) of cases, composite mesh in 20 (18.51%) and biological mesh in 19 (17.59%). Flap reconstruction was used in 25 patients (23.14%). First and second recurrences were observed in 26 (24.07%) and 7 (26.92%) cases, respectively.ConclusionsComparison of perineal hernia repair from 1944 to 2011 and from 2012 to 2016 showed that perineal and laparoscopic approaches are currently the most commonly used techniques. Primary defect closure was abandoned in favor of synthetic or composite mesh placement. Use of flap reconstruction spread rapidly and the recurrence rate was low. Randomized control trials and a larger sample size are needed to confirm these data and to develop a gold standard treatment for secondary hernia repair after abdominoperineal excision or extralevator abdominoperineal excision.

Hemorragia digestiva como primer síntoma de una amiloidosis yeyunal focal

Figura 1 – Tinción con rojo Congo de pared yeyunal. La amiloidosis es un término genérico que hace referencia a un grupo de enfermedades caracterizadas por el depósito extracelular de un material llamado sustancia amiloide. La variedad de sintomatologı́a que provoca la amiloidosis hace que el diagnóstico de la enfermedad sea difı́cil y tardı́o. La afectación gastrointestinal es comú n y la aparición de hemorragia masiva es poco frecuente pero de difı́cil manejo diagnóstico y terapéutico. El depósito de sustancia amiloide en el tracto digestivo se localiza básicamente a nivel de la mucosa y submucosa, como también en la muscular propia y en las paredes de los vasos sanguı́neos, lo que puede ocasionar una gran heterogeneidad de sı́ntomas gastrointestinales. Presentamos un paciente de 75 años sin antecedentes patológicos que ingresa en nuestro hospital por cuadro de deposiciones melénicas de 2 dı́as de evolución sin otra sintomatologı́a asociada. Se evidencia anemización importante con requerimiento transfusional masivo y endoscopia urgente que evidencia sangrado a nivel del yeyuno proximal, sin poder localizar su origen mediante angio-TC y arteriografı́a. Se decide realizar laparotomı́a exploradora, objetivando un tramo de 20 cm de longitud de yeyuno de consistencia fibrótica al tacto y coloración violácea. Se procede a la apertura de dicha asa intestinal objetivando sangrado activo en sábana a nivel de la mucosa yeyunal congestiva, por lo que se decide exéresis de 40 cm de yeyuno con anastomosis termino-terminal manual. El examen anatomopatológico y la tinción con rojo Congo y tioflavina de la pieza quirú rgica proporcionó el diagnóstico de amiloidosis intestinal focal (figs. 1 y 2). El paciente no presentaba manifestaciones extraintestinales en referencia con la amiloidosis ni otros sı́ntomas que enfocaran a una amilodosis secundaria. Se realizaron análisis sanguı́neos que descartaron una macroglobulinemia y el factor reumatoide y la cuantificación de inmunoglobulinas fue negativa. Se realizó una aspiración de médula ósea que descartó la presencia de mieloma mú ltiple.

Migración espontánea de aguja de Kirschner intraperitoneal

Paciente varón de 42 años acude a Urgencias por dolor anal a la defecación y dolor en la fosa ilı́aca izquierda. Como antecedentes patológicos destaca una fractura de acetábulo con luxación de cadera derecha seis meses antes. Sobre dicha fractura se realizó una osteosı́ntesis con placa-tornillos y dos agujas de Kirschner (AK). Se realiza una radiografı́a de abdomen y posteriormente una TC, diagnosticando la migración intraperitoneal a pelvis izquierda contralateral de la AK (fig. 1), en contacto con la pared del recto-sigma sin existir perforación (fig. 2). Mediante una pequeña incisión de Pfannestield se procede a extracción de la AK sin incidencias. c i r e s p . 2 0 1 2 ; 9 0 ( 2 ) : 1 2 1

Endovascular Management of Ureteroarterial Fistula: Single Institution Experience and Systematic Literature Review:

Background: Ureteroarterial fistula (UAF) represents an uncommon complication after urological surgery; however, this is a well-documented condition in patients with predisposing risk factors. The aim of the present study is to report and analyze the endovascular management of a series of patients with UAF, treated in authors’ hospital, and to report and analyze the same data concerning patients retrieved from a systematic literature review. Methods: Authors conducted a retrospective analysis of prospectively collected data and a systematic literature review. The research was carried out through PubMed database searching the following keywords: “uretero arterial fistula” and “uretero iliac fistula.” It includes only articles reporting the endovascular management. Results: Forty-six articles were included in the present study for a total of 94 patients. Risk factors were as follows: chronic indwelling ureteral stents, pelvic surgery, radiotherapy, iliac artery pseudo-aneurysm, and chemotherapy. All patients had gross hematuria at presentation. Stent graft placement was performed in 89 patients, embolization in 5 patients, and iliac internal artery embolization combined with stent graft placement was performed in 24 patients. Four postprocedural complications were observed (4.2%). During a median follow-up of 8 months, 10 complications related to UAF were observed (10.6%): rebleeding (7 cases) and stent thrombosis (3 cases). Two patients died for causes related to UAF (2.1%): rebleeding (1) and retroperitoneal abscess (1). Conclusion: Based on the present data, endovascular treatment is feasible and safe with low postprocedural complications and mortality rate. Considering the increase in surgery and radiotherapy performed, UAF should be always debated in patients with massive hematuria.

Imaging-Guided Preoperative Localization of Intra-Abdominal Local Recurrences of Colorectal Cancer Using The Harpoon Technique.

Background and Aims: Intra-abdominal local recurrences of colorectal cancer can be difficult to localize and excise because they are not easily visible or palpable. Materials and Methods: We report on our experience using the computed tomography–guided harpoon technique to locate and resect these nodules in seven patients. Results: No complications were recorded during the procedures. Six nodes were malignant and all margins were tumor free. Conclusions: Harpoon placement for intra-abdominal local recurrences of colorectal cancer is a feasible and useful technique that provides direct localization and complete excision of lesions.

HPV-related squamous cell carcinoma in a neovagina after male-to-female gender confirmation surgery

Vaginoplasty by penile and scrotal skin inversion is a well-established technique for male-to-female gender confirmation surgery. In this setting, chronic inflammation and lacerations associated with history of human papillomavirus (HPV) infection may induce a high risk of malignant degeneration in the long term. A 78-year-old transgender woman was admitted with genital discomfort and neovaginal discharge. The patient’s history revealed male-to-female gender confirmation surgery with construction of a neovagina by penile and scrotal skin inversion at 33 years of age. Physical examination of the genitalia revealed presence of fecal material, suggestive of recto-neovaginal fistula. A biopsy specimen was positive for well-differentiated HPV-related squamous cell carcinoma. Magnetic resonance imaging (MRI) showed a bulky mass in the posterior wall of the neovagina that infiltrated the urethra, prostatic gland and the anterior rectal wall. Following a multidisciplinary evaluation, we performed a definitive sigmoid colostomy and administered chemotherapy. Long-term follow-up seems advisable in patients after vaginoplasty due to the possibility of delayed development of cancer. Following biopsy, we consider MRI as the modality of choice to identify possible infiltration of the adjacent structures. As data regarding these lesions are scarce and management is complex, a multidisciplinary approach is recommended.

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

Background“Big data” refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.MethodsA systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.ResultsFifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.ConclusionsNSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

Laparoscopic approach for retrorectal tumors—results of a series of 11 cases

Background: Retrorectal tumors (RRTs) are infrequent entity. They originate from totipotential cells located in the retrorectal space, which allows the development of an important diversity of tumors with different potential of malignancy. Their anatomical location can make difficult the surgical approach, and in the recent years, minimally invasive surgical approach has been proposed. The aim of the present study is to analyze the results by laparoscopic approach in a series of 11 cases treated in a 19-year period. Methods: From 1998 to 2016, 11 patients (4 males, 7 females, mean age 54 years) with RRT were treated by laparoscopy and retrospectively reviewed. The tumor size ranged from 5 to 11 cm. Results: The mean operative time was 160 minutes. Con-version to open surgery was observed in one case. Among complications were observed two pelvic abscesses and one surgical wound infection. The mean postoperative hospital stay was 7.5 days. Definitive histology included fibrous tumor [1], neurofibroma [2], hamartoma [2], teratoma [1], schwannoma [2], tail gut [1], salivary gland [1], glomus tumor [1]. At a mean follow-up of 48 months, no recurrences were observed. Conclusions: The minimally invasive approach, for the treatment of RRTs in any site, is a satisfactory option.

Diagnóstico y tratamiento de la enfermedad diverticular del colon derecho: revisión de conjunto

The aim of this narrative review is to define the clinical-pathological characteristics and to clarify the management of right colonic diverticular disease. It is rare in Europe, USA and Australia and more common in Asia. In the recent years its incidence has increased in the West, with various distributions among populations. Many studies have reported that it is difficult to differentiate the presenting symptoms of this disease from those of appendicitis before surgery, because the signs and symptoms are similar, so misdiagnosis is not infrequent. With accurate imaging studies it is possible to reach a precise preoperative diagnosis, in order to assess an accurate treatment strategy. Currently the management of this disease is not well defined, no clear guidelines have been proposed and it is not known whether the guidelines for left colonic diverticular disease can also be applied for it. Several authors have stated that conservative management is the best approach, even in case of recurrence, and surgery should be indicated in selected cases.