Joaquin Ortega

Efficacy and Cost-Effectiveness of the UltraCision® Harmonic Scalpel in Thyroid Surgery: An Analysis of 200 Cases in a Randomized Trial

BACKGROUND Thyroid surgery technique has undergone very few changes in the last century. The UltraCision harmonic scalpel (UHS) (Smithfield, RI) has been widely used in laparoscopic surgery and is documented to be safe and fast for cutting and coagulating tissue. We studied whether the use of the UHS could have advantages in thyroid surgery in terms of operative time, length of hospitalization, morbidity, and general costs. METHOD Our study was a prospective randomized trial of thyroidectomies and lobectomies performed for benign thyroid diseases in an endocrine surgery unit between February 2001 and July 2002. Patients were randomized in two groups: group A (n=100) underwent thyroidectomy using UHS and group B (n=100) with the conventional clamp-and-tie technique. Main outcome measures were demographics, operating time, length of hospitalization, intra- and postoperative complications, sequelae, and general costs. We used the unpaired 2-tailed Students t test and the chi2 test to compare the series. RESULTS The two groups were similar in age and sex. Mean +/- SD operative time was shorter in the UHS group compared with the conventional technique group for both lobectomy (61 +/- 06 vs. 78 +/- 10 minutes) and total thyroidectomy (86 +/- 20 vs. 101 +/- 16 minutes). Length of hospitalization was similar in both groups (1.07 vs. 1.15 days). We did not find statistical differences between the two techniques regarding transient postoperative complications. There were no deaths, no blood transfusions, no intraoperative complications, and no postoperative definitive sequelae. The global charges for every patient were significantly less in the UHS group (985.77 +/- 107.08 euro vs. 1148.40 +/- 153.25 euro). CONCLUSION The use of ultrasonically activated shears resulted in a reduction of 15-20% in operative time and was cost-effective compared to the conventional technique group.

Contribution of hyperammonemia and inflammatory factors to cognitive impairment in minimal hepatic encephalopathy

To assess the contribution of hyperammonemia and inflammation to induction of mild cognitive impairment (or MHE). We analyzed the presence of mild cognitive impairment (CI) by using the PHES battery of psychometric tests and measured the levels of ammonia and of the inflammatory cytokines IL-6 and IL-18 in blood of patients with different types of liver or dermatological diseases resulting in different grades of hyperammonemia and/or inflammation. The study included patients with 1) liver cirrhosis, showing hyperammonemia and inflammation; 2) non-alcoholic fatty liver disease (NAFLD) showing inflammation but not hyperammonemia; 3) non-alcoholic steatohepatitis (NASH) showing inflammation and very mild hyperammonemia; 4) psoriasis, showing inflammation but not hyperammonemia; 5) keloids, showing both inflammation and hyperammonemia and 6) controls without inflammation or hyperammonemia. The data reported show that in patients with liver diseases, cognitive impairment may appear before progression to cirrhosis if hyperammonemia and inflammation are high enough. Five out of 11 patients with NASH, without liver cirrhosis, showed cognitive impairment associated with hyperammonemia and inflammation. Patients with keloids showed cognitive impairment associated with hyperammonemia and inflammation, in the absence of liver disease. Hyperammonemia or inflammation alone did not induce CI but the combination of certain levels of hyperammonemia and inflammation is enough to induce CI, even without liver disease.

Outcome of Esophageal Function and 24-hour Esophageal pH Monitoring after Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass

Background: One of the co-morbidities frequently associated with morbid obesity is gastro-esophageal reflux disease (GERD), present in >50 % of morbidly obese individuals. We compared the anti-reflux effect of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP), and their effect on esophageal function. Methods: 10 patients underwent VBG and 40 patients underwent RYGBP. Anthropometric parameters, symptomatology of GERD, esophageal manometry (EM), isotopic esophageal emptying (IEE) and 24hr esophageal pH monitoring were recorded in all patients preoperatively, and at 3 months and 1 year postoperatively. Results: Preoperatively, there was a high prevalence of GERD, symptomatic and pH-metric in both groups (57% and 80% respectively). The preoperative values of EM and IEE parameters were within the normal range in most patients. After surgery, there was an improvement at 3 months postoperatively in both groups. 1 year after surgery, the VBG group presented symptomatic GERD in 30% and pH-metric reflux in 60% of patients while the RYGBP group presented symptomatic GERD and pH-metric reflux in 12.5% and 15% of patients, respectively. There was an increase in postoperative sensation of dysphagia in both groups (70% VBG, 30% RYGBP) one year after operation. After surgery, differences in all EM parameters were minimal, and never reached statistical significance for any group (VBG and RYGBP). The IEE showed a significantly higher percentage of esophageal retention after surgery, but this retention was always within the normal range. Both groups had an improvement in anthropometric parameters, but 1 year after surgery the results were significantly better in RYGBP patients (70% excess weight loss) than in VBG patients (46% excess weight loss). Conclusion: >50% of morbidly obese individuals suffer from GERD. We did not find changes in esophageal function of morbidly obese patients to explain their gastroesophageal reflux preoperatively and postoperatively. EM and IEE studies are not indicated as standard preoperative tests, except in patients with significant symptoms of gastroesophageal reflux. RYGBP is significantly better than VBG as an anti-reflux procedure, and had better weight loss.

Adrenalectomy for solid tumor metastases: Results of a multicenter European study

BACKGROUND We assessed the results of adrenalectomy for solid tumor metastases in 317 patients recruited from 30 European centers. METHODS Patients with histologically proven adrenal metastatic disease and undergoing complete removal(s) of the affected gland(s) were eligible. RESULTS Non-small cell lung cancer (NSCLC) was the most frequent tumor type followed by colorectal and renal cell carcinoma. Adrenal metastases were synchronous (≤6 months) in 73 (23%) patients and isolated in 213 (67%). The median disease-free interval was 18.5 months. Laparoscopic resection was used in 46% of patients. Surgery was limited to the adrenal gland in 73% of patients and R0 resection was achieved in 86% of cases. The median overall survival was 29 months (95% confidence interval, 24.69-33.30). The survival rates at 1, 2, 3, and 5 years were 80%, 61%, 42%, and 35%, respectively. Patients with renal cancer showed a median survival of 84 months, patients with NSCLC 26 months, and patients with colorectal cancer 29 months (P = .017). Differences in survival between metachronous and synchronous lesions were also significant (30 vs. 23 months; P = .038). CONCLUSION Surgical removal of adrenal metastasis is associated with long-term survival in selected patients.

Endothelial Dysfunction in Morbid Obesity

Morbid obesity is a chronic multifunctional disease characterized by an accumulation of fat. Epidemiological studies have shown that obesity is associated with cardiovascular and metabolic disorders. Endothelial dysfunction, as defined by an imbalance between relaxing and contractile endothelial factors, plays a central role in the pathogenesis of these cardiometabolic diseases. Diminished bioavailability of nitric oxide (NO) contributes to endothelial dysfunction and impairs endothelium- dependent vasodilatation. But this is not the only mechanism that drives to endothelial dysfunction. Obesity has been associated with a chronic inflammatory process, atherosclerosis, and oxidative stress. Moreover levels of asymmetrical dimethyl-L-arginine (ADMA), an endogenous inhibitor of endothelial nitric oxide synthase (eNOS), are elevated in obesity. On the other hand, increasing prostanoid-dependent vasoconstriction and decreasing vasodilator prostanoids also lead to endothelial dysfunction in obesity. Other mechanisms related to endothelin-1 (ET-1) or endothelium derived hyperpolarizing factor (EDHF) have been proposed. Bariatric surgery (BS) is a safe and effective means to achieve significant weight loss, but its use is limited only to patients with severe obesity including morbid obesity. BS also proved efficient in endothelial dysfunction reduction improving cardiovascular and metabolic comorbidities associated with morbid obesity such as diabetes, coronary artery disease, nonalcoholic fatty liver disease and cancer. This review will provide a brief overview of the mechanisms that link obesity with endothelial dysfunction, and how weight loss is a cornerstone treatment for cardiovascular comorbidities obesity-related. A better understanding of the mechanisms of obesity-induced endothelial dysfunction may help develop new therapeutic strategies to reduce cardiovascular morbidity and mortality.

Vertical Banded Gastroplasty Converted to Roux-en-Y Gastric Bypass: Little Impact on Nutritional Status after 5-Year Follow-up

Background: Conversion to a Roux-en-Y gastric bypass (RYGBP) has been advocated after the failure of vertical banded gastroplasty (VBG). The aim of this study was to analyze the differences in anthropometric and nutritional parameters between patients with VBG and those converted to RYGBP. Methods: 45 patients initially underwent VBG. 22 of these patients have maintained this operation for more than 5 years (Group A) and 23 have been converted to RYGBP (Group B), after 2 years of follow-up. We analyzed anthropometric and nutritional parameters (macronutrients,micronutrients and lipid profile), and postoperative morbidity after both procedures. Data were recorded before the first operation and at 6 months, 1, 2 and 5 years follow-up. Results: VBG failure rate was 51%. The 23 patients converted to RYGBP have maintained an excess weight loss (EWL) of 70% 3 years after the revision, and all the complications related to VBG disappeared. Anthropometric parameters were significantly better after RYGBP. We found no significant differences in nutritional status between both groups except for levels of iron, vitamin B12 and transferrin saturation index, which significantly decreased in converted patients. The redo procedure had a low morbidity rate, with no mortality. Conclusion: More than 50% of VBGs failed after 2-year follow-up. Patients converted to RYGBP maintained mean EWL 73% at 5 years. The only significant nutritional deficiencies were iron and vitamin B12, in patients converted to RYGBP.

Cost-effectiveness of laparoscopic vs open adrenalectomy: small savings in an expensive process.

BACKGROUND AND PURPOSE Nowadays, laparoscopy has become the approach of choice for adrenalectomy, especially in cases of benign tumors <6 cm. The authors have studied, in a retrospective trial, two groups of patients who have undergone an adrenalectomy: 10 consecutive patients operated on by an open approach and 10 consecutive patients operated on by laparoscopy. METHODS Laparoscopic adrenalectomies were performed via a transabdominal lateral approach, whereas open adrenalectomies were performed via an anterior transabdominal or posterior retroperitoneal approach. Clinical outcomes were recorded, and special attention was paid to the costs of both techniques, collecting economic data from the costs in outpatient visits, blood and urine tests, diagnostic imaging, hospital admissions prior to surgery, hospital admission for surgery, and surgical expenses. RESULTS Operative time (110 vs 123 minutes), length of postoperative stay (3.7 vs 5.8 days), and time to oral intake (1 vs 2 days) were significantly lower in the laparoscopic group. From the economic point of view, however, there were no significant differences between laparoscopic and open groups (6,306 vs 7,581), and only surgical inhospital stay costs were significantly lower in the laparoscopic series (742 vs 1,191). All the costs generated by surgery (hospital admission for surgery plus surgical expenses) were smaller in the laparoscopic group but constituted only a small part of the general expenses for these patients. The more expensive part of the budget for every patient was the hospital admissions prior to surgery for diagnosis or preoperative treatment. CONCLUSION Laparoscopy is a safe and comfortable approach for adrenalectomy and should be the technique of choice. From the economic point of view, laparoscopic adrenalectomy is cheaper than open adrenalectomy, but in all cases, surgical costs are only a minimal part of the budget, and the greater savings must come from the reduction in the presurgical diagnostic process.

Predictors of psychological symptoms in morbidly obese patients after gastric bypass surgery

BACKGROUND Morbid obesity is associated with debilitating psychosocial consequences, such as depression, anxiety, and low self-esteem. One of the main goals of bariatric surgery should not only be reducing weight and counteracting co-morbid conditions, but also improving postoperative psychosocial functioning. The objective of our study was to determine the preoperative variables that could predict the psychological symptoms 6 and 12 months after surgery to improve the clinical outcome of morbidly obese patients undergoing bariatric surgery. The setting was a university hospital in Spain. METHODS The study group consisted of 60 morbidly obese patients (46 women and 14 men) who had undergone gastric bypass surgery for weight reduction and had ≥ 1 year of follow-up. The patients were evaluated using different questionnaires (Symptom Checklist-90-Revised, Body Shape Questionnaire, Rosenberg Self-Esteem Questionnaire, COPE, Medical Outcomes Study Social Support Survey) at 3 points: before surgery, at 6 months postoperatively, and at 1 year postoperatively. To determine the influence of preoperative variables on long-term psychological status, a step-by-step multivariate linear regression analysis was performed, taking P < .05 as statistically significant. RESULTS The variables of self-esteem, instrumental support, and coping focused in the emotions were the main preoperative predictors for psychological symptoms 6 months after surgery. Preoperative drug abuse as a strategy of problem solving and mainly body image significantly predicted most of the psychological disorders 1 year after surgery. CONCLUSION The study of different psychosocial variables in patients before bariatric surgery is an important aid to predict postoperative psychological functioning. Self-esteem and body image were the most influential factors in the postoperative psychological outcome of morbidly obese patients in our study.

Relationship between insulin resistance, inflammation and liver cell apoptosis in patients with severe obesity

In obesity, insulin resistance appears frequently after activation of proinflammatory molecules. Caspase‐generated cytokeratin‐18 (CK‐18) fragments are produced during the apoptosis of hepatic cells. The main objective in the present study is to investigate the relationship between insulin resistance and caspase‐generated CK‐18 fragments in patients with severe obesity.

Computerized acoustic voice analysis and subjective scaled evaluation of the voice can avoid the need for laryngoscopy after thyroid surgery.

BACKGROUND Because of frequent postoperative alterations in voice, many surgeons include laryngoscopy as a routine examination before/after thyroid surgery. The aim of this work was to determine whether more comfortable and easier subjective or objective postoperative voice assessments could complement or replace laryngoscopy. METHODS Sixty-four consecutive patients scheduled to undergo thyroid surgery underwent preoperative objective computerized acoustic voice analysis (CAVA), subjective scaled evaluation of the voice (SSEV) with the GIRBAS scale, and fiberoptic laryngoscopy. All patients had 7- and 30-day postoperative follow-up assessments using the same tests. RESULTS CAVA measurements of jitter and noise-to-harmonic ratio showed the most frequent variations (36% and 31%, respectively) between the first and second tests. The mean preoperative SSEV GIRBAS value was 1.3 (range, 0-7) and had deteriorated in 36% of patients at 30 days postoperatively. All patients had a normal preoperative laryngoscopy. At 7 days postoperatively, 5 (8%) patients suffered unilateral vocal cord palsy which recovered in 2 (5%) patients after 1 month. GIRBAS values showed differences between patients with and without a vocal cord palsy both 7 and 30 days postoperatively (P < .05). The vocal parameters jitter and shimmer showed differences (P < .02 each) between patients with or without vocal cord palsy. When there was a change in >or=3 vocal parameters, vocal cord palsy was confirmed by laryngoscopy. CONCLUSION After thyroid surgery, vocal cord palsy may be suspected when there is an alteration in GIRBAS scale or in several parameters of the CAVA. Laryngoscopy may only be necessary when the CAVA and SSEV are abnormal.