Lorea Zubiaga

Pre-operative and early post-operative factors associated with surgical site infection after laparoscopic sleeve gastrectomy.

BACKGROUND Surgical procedures on obese patients are expected to have a high incidence of surgical site infection (SSI). The identification of pre-operative or early post-operative risk factors for SSI may help the surgeon to identify subjects in risk and adequately optimize their status. We conducted a study of the association of comorbidities and pre- and post-operative analytical variables with SSI following laparoscopic sleeve gastrectomy for the treatment of morbid obesity. PATIENTS AND METHODS We performed a prospective study of all morbidly obese patients undergoing laparoscopic sleeve gastrectomy as a bariatric procedure between 2007 and 2011. An association of clinical and analytical variables with SSI was investigated. RESULTS The study included 40 patients with a mean pre-operative body mass index (BMI) of 51.2±7.9 kg/m(2). Surgical site infections appeared in three patients (7.5%), of whom two had an intra-abdominal abscess located in the left hypochondrium and the third had a superficial incisional SSI. Pre-operatively, a BMI >45 kg/m(2) (OR 8.7; p=0.008), restrictive disorders identified by pulmonary function tests (OR 10.0; p=0.012), a serum total protein concentration <5.3 g/dL (OR 13; p=0.003), a plasma cortisol >30 mcg/dL (OR 13.0; p=0.003), and a mean corpuscular volume (MCV) <82 fL (OR 1.6; p=0.04) were associated with post-operative SSI. Post-operatively, a serum glucose >128 mg/dL (OR 4.7; p=0.012) and hemoglobin <11g/dL (OR 7.5; p=0.002) were associated with SSI. CONCLUSIONS The study supports the role of restrictive lung disorders and the values specified above for preoperative BMI, serum total protein and cortisol concentrations, and MCV, and of post-operative anemia and hyperglycemia as risk factors for SSI. In these situations, the surgeon must be aware of and seek to control these risk factors.

Efecto de los patrones de conducta alimentaria y de la pérdida de peso preoperatoria sobre los resultados a corto y medio plazo en pérdida de peso tras gastrectomía vertical laparoscópica

INTRODUCTION Weight loss depends directly on the adhesion to the postoperative diet in patients undergoing a sleeve gastrectomy. The aim of this study is to evaluate the effect of different preoperative feeding patterns and the adhesion to a preoperative diet on short and mid- term postoperative weight loss. MATERIAL AND METHODS A prospective study of all morbidly obese patients undergoing a laparoscopic sleeve gastrectomy as a bariatric procedure between 2008 and 2012 was performed. Preoperative feeding patterns and weight loss, preoperatively and postoperatively at 12 and 24 months, were evaluated. RESULTS A total of 50 patients were included, with a mean preoperative BMI of 51,2+7,9 kg/m(2). All the patients presented a feeding pattern of big eaters, 44% of snackers, 40% of sweet eaters and 48% reported regular ingestion of «light» soft drinks. Mean preoperative excess weight loss (EWL) was 13,4% (range 10-31,4%). At 12 months mean EWL was 83,7% and at 24 months 82,4%. Pre and postoperative EWL showed a direct correlation at 12 and 24 months. Mean EWL was significantly lower in snackers, sweet eaters and those drinking «light» soft drinks regularly. CONCLUSION Preoperative weight loss correlates directly with postoperative weight loss at 1 and 2 years. Snackers, sweet eaters and «light» soft drink consumers, associated with a big eater pattern, achieve a significantly lower postoperative weight loss.

Effect of gentamicin lavage of the axillary surgical bed after lymph node dissection on drainage discharge volume

UNLABELLED The purpose of this study was to evaluate the effect of axillary lavage with a gentamicin solution before wound closure on drainage volume. PATIENTS AND METHODS A prospective, randomized study was performed. Inclusion criteria were a diagnosis of breast neoplasms and plans to undergo an elective axillary lymph node dissection due to axillary metastasis. The patients were randomized into 2 groups: patients undergoing 2 lavages with 500 ml normal saline (Group 1) and patients first undergoing lavage with 500 ml normal saline followed by a second lavage with a 500 ml of a gentamicin (240 mg) solution (Group 2). Microbiological samples were obtained before any lavage, after each lavage and at the time of drain removal. RESULTS 40 patients were included. Mean number of days maintaining the drain in place was 7.7 ± 3.2 days in Group 1 and 4.3 ± 1.4 days in Group 2 (p = 0.001). Total drainage volume before removal was 465 ± 250.9 ml in Group 1 and 169 ± 102.2 ml in Group 2 (p = 0.003). After a second lavage with normal saline in Group 1 and after a lavage with gentamicin solution in Group 2, microbiological culture was positive in 10 patients (50%) in Group 1 and 1 case (5%) in Group 2 (p = 0.016). Positive cultures were associated with higher drainage volumes. CONCLUSION The postoperative drainage volume of the axillary drain is significantly lower in the patients undergoing a lavage of the surgical bed with a gentamicin solution than in the control group undergoing a lavage with normal saline. A significant reduction in the contamination is only obtained after a lavage with gentamicin solution. CLINICAL TRIAL REGISTRATION NUMBER NCT01700504.

Evaluación del riesgo quirúrgico de 1.000 episodios consecutivos con el sistema POSSUM. Comparación entre cirugía gastrointestinal programada y urgente

INTRODUCTION The aim of the present study was to assess the predictive capacity of the POSSUM system in a Spanish university hospital, and to determine its behaviour in elective gastrointestinal surgery and compare it with emergency gastrointestinal surgery (operation < 24 hours). PATIENTS AND METHOD A total of 1,000 surgical episodes corresponding to 909 patients who required hospital admission, operated on under general or loco-regional anaesthesia, either in the elective (n= 547 episodes) or the emergency setting (n= 453), were included in the study. RESULTS The overall morbidity was 31.9% (32.8% in elective surgery; 30.7% in emergency surgery). The discriminatory capacity of the POSSUM scale, evaluated using receiver operating characteristic (ROC) curves, was higher for the Portsmouth variant of mortality (Area Under the Curve [AUC] = 0,92) than for morbidity (AUC= 0,74). The goodness of fit between the expected values using the POSSUM scale and those observed was reduced for morbidity (Hosmer-Lemeshow [H-L] = 164.1; p< 0.05). The POSSUM scale predicted a higher number of deaths than those observed, although the Portsmouth variant was better at predicting mortality. The goodness of fit for morbidity was better for elective gastrointestinal surgery (H-L= 27.7) than emergency gastrointestinal surgery (H-L= 177.3). The logistic regression analysis identified (besides the estimated risk using the POSSUM scale itself), surgical complexity, surgery type (elective, emergency), and age of patient, as significant predictive factors of morbidity and mortality. CONCLUSIONS In a Spanish university hospital, the POSSUM system adequately predicts morbidity risk in elective gastrointestinal surgery, and over-estimates morbidity risk in emergency gastrointestinal surgery.

Effect of Peritoneal Lavage with Clindamycin-Gentamicin Solution on Post-Operative Pain and Analytic Acute-Phase Reactants after Laparoscopic Sleeve Gastrectomy.

BACKGROUND Peritoneal lavage has been proposed to remove bacterial contamination and other materials promoting bacterial proliferation and pro-inflammatory cytokines that may enhance local inflammation. The aims of this study were to evaluate the effects of peritoneal lavage with physiologic saline or an antibiotic solution (clindamycin-gentamicin) on post-operative pain and analytic acute-phase reactants and to determine the microbiologic impact of both irrigations on peritoneal contamination in patients undergoing laparoscopic sleeve gastrectomy (LSG) as a bariatric procedure. METHODS The patients were randomized into two groups: Those undergoing an intra-abdominal lavage with physiologic saline (Group 1; n = 40) and those undergoing a similar lavage with a gentamicin-clindamycin solution (Group 2; n = 40). Peritoneal contamination, post-operative pain, and analytic acute-phase reactants 24 h after surgery were investigated. RESULTS The median pain score 24 h after surgery was 3.5 in Group 1 and 1.5 in Group 2 (p = 0.021). The glucose concentration (mean difference 33.1 mg/dL; p = 0.004), aspartate aminotransferase (AST) concentration (mean difference 41.8 U/L; p = 0.009), alanine aminotransferase (ALT) concentration (mean difference 34.2 U/L; p = 0.029), white blood cell count (mean difference 1930/mm(3); p = 0.029); C-reactive protein concentration (mean difference 27.3 mg/L; p = 0.036), and serum lactic acid concentration (mean difference 0.34 mg/L; p = 0.049) were significantly higher in Group 1. Peritoneal contamination also was significantly higher in Group 1 (17.5% vs 0; p = 0.006). CONCLUSIONS Intra-peritoneal irrigation with a gentamicin and clindamycin solution in patients undergoing LSG leads to a reduction in post-operative pain and peritoneal contamination, less alteration of acute-phase reactants, lower blood glucose concentration, a smaller increase in liver enzymes, and a shorter hospital stay.

Effect of Lavage with Gentamicin vs. Clindamycin vs. Physiologic Saline on Drainage Discharge of the Axillary Surgical Bed after Lymph Node Dissection.

BACKGROUND To date, without placement of a drain, seroma formation cannot be avoided after axillary lymph node dissection (ALND). The purpose of this study was to evaluate the effect on drainage volume of pre-closure axillary lavage with physiologic saline, gentamicin solution, or clindamycin solution. METHODS A randomized study was performed between January 2013 and October 2014. Inclusion criteria were a diagnosis of breast neoplasm and plans to undergo an elective ALND because of axillary metastases. The patients were randomized into three groups: Two lavages with 500 mL of physiologic saline (Group 1), lavage with 500 mL of saline followed by lavage with 500 mL of a 240-mg gentamicin solution (Group 2), and lavage with 500 mL of saline followed by lavage with 500 mL of a 600-mg clindamycin solution (Group 3). RESULTS A total of 51 patients were included. The mean number of days with a drain in place was 7.1±3 in Group 1, 4.1±1.2 in Group 2, and 6.4±2.1 in Group 3 (p<0.001). Total drainage volume before tube removal was 435.3±220.1 mL in Group 1, 155.2±82.4 mL in Group 2, and 352.3±212.9 mL in Group 3 (p=0.03). In a pairwise analysis, irrigation with gentamicin solution achieved a lower drainage volume and a reduction in the number of days of drainage maintenance compared with the other two groups. CONCLUSION The post-operative output of the axillary drain is substantially lower in patients undergoing lavage of the surgical bed with a gentamicin solution than in patients undergoing lavage with physiologic saline or clindamycin solution.

Incidence of postoperative nausea and vomiting after laparoscopic sleeve gastrectomy with staple line reinforcement with oversewing and staple line inversion vs buttressing material: A randomized clinical trial

BACKGROUND Postoperative nausea and vomiting are relevant complications after restrictive bariatric procedures, such as sleeve gastrectomy, mainly secondary to a drastic reduction in the gastric volume. However, other causes can be involved. The aim of this study was to determine the incidence of postoperative nausea and vomiting (PONV) after laparoscopic sleeve gastrectomy (LSG), with staple line reinforcement with oversewing vs buttressing material. PATIENTS AND METHODS A prospective randomized clinical trial of all the patients undergoing LSG was performed. Patients were divided into 2 groups: patients undergoing staple line inversion (Group 1) and patients undergoing staple line reinforcement with buttressing material (Group 2). Nausea and vomiting were assessed by the Postoperative Nausea and Vomiting Intensity Scale. RESULTS A total of 100 females were included in the study, 50 in each group. Mean operative time was 66.1 ± 11.6 min in Group 1 and 55.4 ± 9.4 in Group 2 (p < 0.001). There were no significant differences in staple line leaks and bleeds between groups. The PONV intensity score at 6 h was 316.4 in Group 1 and 77.1 in Group 2 (p < 0.001). 24 h after surgery, the PONV intensity score was 86 in Group 1 and 7.9 in Group 2 (p = 0.022). CONCLUSION The reinforcement with a running suture in LSG creates more PONV and increases the duration of the symptoms during the first hours after surgery, and prevents from early oral intake in a greater number of cases, when compared with the use of buttressing material as reinforcement method.

Importance of the gastrointestinal tract in type 2 diabetes. Metabolic surgery is more than just incretin effect.

Bariatric and metabolic surgery is creating new concepts about how the intestine assimilates food. Recent studies highlight the role of the gastrointestinal tract in the genesis and evolution of type 2 diabetes. This article has been written to answer frequent questions about metabolic surgery results and the mechanisms of action. For this purpose, a non-systematic search of different databases was carried out, identifying articles published in the last decade referring to the mechanisms of action of metabolic techniques. Understanding these mechanisms will help grasp why some surgeries are more effective than others and why the results can be so disparate among patients undergoing the same surgical approach.