Manuel Gómez-Fleitas

Effects of weight loss after biliopancreatic diversion on metabolism and cardiovascular profile.

Background: Obesity is associated with increased prevalence of cardiovascular risk factors. Biliopancreatic diversion (BPD) for morbid obesity has been reported to produce anemia and malnutrition in short-term follow-up. The aim of our study was to analyze the effect of weight reduction on cardiovascular profile, renal function and nutritional status. Methods: 35 morbidly obese patients underwent BPD. We analyzed the presence of cardiovascular risk factors, renal status, proteinuria and nutritional status before and 1 year after BPD. Results: Excess weight loss was 67% at 1 year after BPD. All cardiovascular risk factors (hypertension, diabetes, hyperlipidemia) improved during follow-up. We could not find any relevant signs of malnutrition in the patients. Microalbuminuria decreased and proteinuria disappeared after weight loss. We observed less urinary calcium and citrate excretion, with an increase in oxaluria, but these changes did not increase the incidence of renal stones. Conclusions: BPD was followed by improved cardiovascular profile and a lower pro-inflammatory state. BPD did not produce significant malnutrition, anemia or renal stone disease.

Oncoplastic Breast-Conserving Surgery: Analysis of Quadrantectomy and Immediate Reconstruction with Latissimus Dorsi Flap

BackgroundOncoplastic breast-conserving surgery satisfies oncologic principles and improves cosmetic outcomes, even when an important breast volume excision is required.MethodsWe reviewed 28 patients suffering from breast cancer treated with quadrantectomy and immediate myocutaneous latissimus dorsi flap reconstruction. We evaluated the status of the surgical margins, early complications, and cosmetic outcome. Cosmetic assessment was carried out by a panel made up of three women and one man: a female member of an association against breast cancer, a female general practitioner, a female gynecologic resident, and a male breast-specialized surgeon.ResultsFree margins were obtained in all cases. There were 11 postoperative complications: 9 seromas at the donor site, 1 dehiscence of the back wound, and 1 minor partial flap skin necrosis. Chemotherapy and radiotherapy adjuvant treatment was not compromised. The cosmesis outcome was deemed to be good in 43.75% of the cases and satisfactory in 56.25%. The score for overall cosmesis outcome was 6.92 out of 10. Symmetry and the scar of the reconstructed breast were the most influential criteria in the quantitative assessment of overall cosmetic results.ConclusionPartial mastectomy (quadrantectomy) and immediate reconstruction with a myocutaneous latissimus dorsi flap allows extensive resection, which fits oncologic requirements, without serious morbidity and a good cosmetic outcome.

Oncoplastic Techniques Extend Breast-Conserving Surgery to Patients with Neoadjuvant Chemotherapy Response Unfit for Conventional Techniques

BackgroundOncoplastic surgery is extending the role of breast-conserving surgery in an increasing number of patients who are unsuitable for conventional breast-conserving techniques. The aim of this retrospective study was to analyze the surgical approach, oncoplastic surgery guided by bracketing, used in the treatment of patients who required a wide breast tissue excision after neoadjuvant chemotherapy. The parameters evaluated were as follows: margin status, rate of re-excision for positive margin, early ipsilateral recurrence, and cosmetic outcomes.MethodsA total of 23 patients were treated with an oncoplastic breast-conserving surgery one-stage procedure using volume-replacement (20) and volume-displacement techniques (3). We reviewed medical records, mammograms and magnetic resonance images. Cosmetic assessment was carried out by a mixed panel made up of three women: a general practitioner, a resident general surgeon and a nurse.ResultsAll margins were negative and none of the patients had to have a re-excision for positive margins. One ipsilateral local recurrence was observed after a 32-month follow-up period. Cosmetic outcome was good, with an overall score of 8 out of 10.ConclusionsOncoplastic techniques extend breast-conserving surgery to patients with neoadjuvant chemotherapy response unfit for conventional techniques. The surgical approach combining oncoplastic techniques with bracketing allows breast-conserving surgery to be performed in these patients.

Acute cholecystitis in high surgical risk patients: percutaneous cholecystostomy or emergency cholecystectomy?

BACKGROUND Percutaneous cholecystostomy (PC) is an alternative treatment in acute cholecystitis (AC) in high-risk or elderly patients although its advantage over emergency cholecystectomy has not yet been established. STUDY DESIGN AC prospective database analysis in high-risk patients treated by PC (group 1, 29 patients) or emergency cholecystectomy (group 2, 32 patients). Surgical risk was estimated by physiological POSSUM, Charlson, Apache II, and American Society of Anesthesiologists (ASA) scores. RESULTS The groups showed homogeneity concerning age and surgical risk. PC allowed AC resolution in 19 patients (70.4%), but 8 (29.6%) needed emergency cholecystectomy. Morbidity and mortality rates were 31% and 17.2%, respectively. Mortality was significantly associated with ASA IV (P = .01). In group 2, the morbidity rate was 28.1% without mortality. There was no statistical difference in morbidity (P = .6) although mortality was significantly higher in group 1 (P = .02). CONCLUSIONS PC seems of little benefit and ought to be left for those very old patients with surgical contraindication.

Perforated Peptic Ulcer Treated by Simple Closure and Helicobacter Pylori Eradication

Simple closure followed by Helicobacter pylori (Hp) eradication has become the most used procedure in perforated ulcer treatment. However, its efficacy and safety are still to be determined. To assess recurrence and re-perforation rates, and as a secondary objective, to analyze Hp infection rates in perforated ulcer patients and controls, we conducted a prospective study. Ninety-two consecutive patients (ages: 19–96 years) were operated on between 1996 and 2002, and treated by simple closure followed by Hp eradication and NSAID avoidance. The data were prospectively collected in a database. Hp infection was diagnosed in 68 patients (73.9%). Thirty-four patients (37%) consumed nonsteroidal anti-inflammatory drugs (NSAIDs), and 23 (25%) had both Hp infection and NSAID antecedents. The perforation was gastric in 4 cases and pre-pyloric, pyloric or duodenal in 88. There were postoperative complications in 24 patients (26%) and 4 patients died (4.3%). Hp eradication was shown in 46 patients. There was clinical ulcer recurrence in 4 (4.3%); in 3 of them recurrence manifested as re-perforation, all in gastric locations. Overall relapse and re-perforation 1-year crude rates were 6.1% and 4.1%, respectively. Crude rates for non-gastric ulcer recurrence were 0 at 1 year and 2.6% at 2 years and for non-gastric ulcer re-perforation rates were 0 at 1 and 2 years. This therapeutic strategy is associated with a low rate of recurrence and no re-perforations in case of duodenal, pyloric, or pre-pyloric perforated ulcers, but it is not acceptable for perforated gastric ulcers.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissens fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Initial results of robot‐assisted Ivor–Lewis oesophagectomy with intrathoracic hand‐sewn anastomosis in the prone position

There is scanty experience concerning robot‐assisted Ivor–Lewis oesophagectomy, so every new experience is helpful.

Adherence to recommendations by infectious disease consultants and its influence on outcomes of intravenous antibiotic-treated hospitalized patients

BackgroundConsultation to infectious diseases specialists (ID), although not always performed by treating physicians, is part of hospital’s daily practice. This study analyses adherence by treating physicians to written ID recommendations (inserted in clinical records) and its effect on outcome in hospitalized antibiotic-treated patients in a tertiary hospital in Spain.MethodsA prospective, randomized, one-year study was performed. Patients receiving intravenous antimicrobial therapy prescribed by treating physicians for 3 days were identified and randomised to intervention (insertion of written ID recommendations in clinical records) or non-intervention. Appropriateness of empirical treatments (by treating physicians) was classified as adequate, inadequate or unnecessary. In the intervention group, adherence to recommendations was classified as complete, partial or non-adherence.ResultsA total of 1173 patients were included, 602 in the non-intervention and 571 in the intervention group [199 (34.9%) showing complete adherence, 141 (24.7%) partial adherence and 231 (40.5%) non-adherence to recommendations]. In the multivariate analysis for adherence (R2 Cox=0.065, p=0.009), non-adherence was associated with prolonged antibiotic prophylaxis (p=0.004; OR=0.37, 95%CI=0.19-0.72). In the multivariate analysis for clinical failure (R2 Cox=0.126, p<0.001), Charlson index (p<0.001; OR=1.19, 95%CI=1.10-1.28), malnutrition (p=0.006; OR=2.00, 95%CI=1.22-3.26), nosocomial infection (p<0.001; OR=4.12, 95%CI=2.27-7.48) and length of hospitalization (p<0.001; OR=1.01, 95%CI=1.01-1.02) were positively associated with failure, while complete adherence (p=0.001; OR=0.35, 95%CI=0.19-0.64) and adequate initial treatment (p=0.010; OR=0.39, 95%CI=0.19-0.80) were negatively associated.ConclusionsAdherence to ID recommendations by treating physicians was associated with favorable outcome, in turn associated with shortened length of hospitalization. This may have important health–economic benefits and stimulates further investigation.Trial registrationCurrent Controlled Trials ISRCTN83234896. http://www.controlled-trials.com/isrctn/sample_documentation.asp

Fatal portal thrombosis after laparoscopic Nissen fundoplication

Portal and mesenteric vein thrombosis is a very uncommon complication of laparoscopic surgery, especially after anti-reflux procedures. We report the case of a twenty-year-old man with a history of alcohol and cocaine consumption. A Nissen fundoplication was performed. The patient received a single 20-mg dose of enoxaparin (Clexane, Aventis Pharma, Spain) two hours before surgery for antithrombotic prophylaxis. On the seventh postoperative day the patient had a portal and mesenteric venous thrombosis, which was confirmed at laparotomy, with both extensive small-intestine necrosis and partial colon necrosis. Despite anticoagulant therapy, the patient died 24 hours later. Surgical findings were confirmed at necropsy. Portal and mesenteric venous thrombosis is an uncommon but severe and even fatal complication after laparoscopic anti-reflux surgery. When other pro-thrombotic, predisposing conditions such as laparoscopic surgery and cocaine consumption are present, the usual prophylactic doses of low molecular weight heparin might not be sufficient to protect against this life-threatening complication.

Removal of xenoreactive antibodies by protein-A immunoadsorption: experience in 22 patients.

Abstract: The presence of naturally occurring anti‐Galα1–3Gal (antiαGal) Ab in human serum is believed to be a major factor in the pathogenesis of hyperacute rejection of discordant organ xenografts such as the pig‐to‐human combination. Galα1–3Gal epitopes are expressed on pig tissues and the binding of anti‐Galα1–3Gal leads to endothelial cell activation and complement‐mediated hyperacute graft rejection. Several strategies have been suggested in donor animals or in the xenograft recipient to overcome the anti‐αGal barrier. Protein‐A immunoadsorption (PAIA) was developed for the in vivo removal of circulating Ab and it has been shown to be effective in cases where pathogenic auto or alloAb are present. The aim of our study was to analyze the effect of PAIA on total and xenoreactive serum anti‐αGal immunoglobulin levels in a group of patients treated with this technique for different diseases. After three consecutive sessions of PAIA, total and xenoreactive IgG and IgM immunoglobulin levels were decreased by more than 50% of pre‐treatment levels. So we conclude that PAIA is an effective method to significantly reduce circulating Ab, including xenogeneic IgM and IgG Ab. This mode of therapy might be considered as a tool to overcome hyperacute xenograft rejection. PAIA combined with other therapeutic approaches may well protect the xenograft.