Nicolás Quezada

Laparoscopic sleeve gastrectomy conversion to Roux-en-Y gastric bypass: experience in 50 patients after 1 to 3 years of follow-up

BACKGROUND Sleeve gastrectomy (SG) is currently one of the most frequently performed bariatric interventions worldwide due to its simplicity and good weight loss results. Nevertheless, SG failure and complications are increasingly being observed as the number of procedures increases. OBJECTIVES To report our results in converting SG to revisional laparoscopic Roux-en-Y gastric bypass (R-LRYGB). SETTING University Hospital, Chile. METHODS Retrospective analysis of our bariatric surgery database. Patients who underwent R-LRYGB after SG between June 2005 and April 2015 were identified. Demographic characteristics, anthropometrics, preoperative workup, and perioperative data were retrieved. Total weight loss (TWL), excess weight loss (EWL), and clinical progression over 3 years were registered. RESULTS Fifty patients were identified, mean age 39±8.4 years, 42 (84%) women; median body mass index previous to R-LRYGB was 33.8 (31-36) kg/m2. Indications for revision were weight regain (n = 28, 56%), gastroesophageal reflux disease (n = 16, 32%), and gastric stenosis (n = 6, 12%). In weight-regain patients, mean follow-up at 3 years was 72.2% and median percentage of total weight loss at 12 and 36 months was 18.5 (12-24) and 19.3 (8-23), respectively; percentage of excess weight loss at 12 and 36 months was 60.7 (37-82) and 66.9 (26-90), respectively. Over 90% of gastroesophageal reflux disease patients resolved or improved symptoms. All patients with gastric stenosis resolved symptoms after conversion. There were no major complications. CONCLUSION R-LRYGB is a feasible, effective, and well-tolerated alternative in selected patients with failed SG in which other therapies have been insufficient to either maintain weight loss or resolve complications. However, long-term follow-up is still needed.

Distinct patterns in the gut microbiota after surgical or medical therapy in obese patients

Bariatric surgery is highly successful in improving health compared to conventional dietary treatments. It has been suggested that the gut microbiota is a relevant factor in weight loss after bariatric surgery. Considering that bariatric procedures cause different rearrangements of the digestive tract, they probably have different effects on the gut microbiota. In this study, we compared the impact of medical treatment, sleeve gastrectomy and Roux-en-Y gastric bypass on the gut microbiota from obese subjects. Anthropometric and clinical parameters were registered before, 6 and 12 months after treatment. Fecal samples were collected and microbiota composition was studied before and six months post treatment using 16S rRNA gene sequencing and qPCR. In comparison to dietary treatment, changes in intestinal microbiota were more pronounced in patients subjected to surgery, observing a bloom in Proteobacteria. Interestingly, Bacteroidetes abundance was largely different after six months of each surgical procedure. Furthermore, changes in weight and BMI, or glucose metabolism, correlated positively with changes in these two phyla in these surgical procedures. These results indicate that distinct surgical procedures alter the gut microbiota differently, and changes in gut microbiota might contribute to health improvement. This study contributes to our understanding of the impact of weight loss surgery on the gut microbiota, and could be used to replicate this effect using targeted therapies.

Bariatric surgery in 1119 patients with preoperative body mass index<35 (kg/m2): results at 1 year

BACKGROUND The use of body mass index (BMI) as the only criterion to indicate bariatric surgery is currently under discussion. There is growing evidence that supports bariatric surgery in carefully selected patients with lower BMI. OBJECTIVES To report our experience in bariatric surgery in>1000 patients with BMI<35 kg/m(2) and their results at 1 year. SETTING University hospital (censored). METHODS A retrospective analysis was performed in patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (SG) with preoperative BMI<35 kg/m(2) from January 2008 to December 2011. Demographic and anthropometric data, preoperative co-morbidities, and perioperative variables were retrieved. Weight loss and co-morbidities progression were analyzed 1 year after surgery and compared among procedures. A P value<.05 was considered significant. RESULTS We identified 1119 patients: mean age 38.8±11.4, 951 (85%) women, preoperative weight 87.5±9.3 kg and BMI 33.1 (31.9-34.1) kg/m(2). Preoperatively, 11.7% had type 2 diabetes mellitus, 25.9% arterial hypertension, 55.6% insulin resistance, and 53.2% dyslipidemia. In total, 283 patients (25.2%) underwent LRYGB and 836 (74.8%) SG. One year after surgery (follow-up: 66.67%) patients reached 24.5 (22.8-26.4) BMI and the percentage of excess of weight loss (%EWL) was 107.9±36.6%. Diabetes, hypertension, insulin resistance, and dyslipidemia remission/improvement rates were 54/39%, 58/29%, 72/17%, and 54/30%, respectively. CONCLUSIONS Bariatric surgery in selected class I obesity patients can safely be performed. We have observed good results in terms of weight loss and co-morbidity improvement/remission. Long-term follow-up is required.

Laparoscopic versus open approach in the management of appendicitis complicated exclusively with peritonitis: A single center experience

BACKGROUND Controversial evidence exists regarding the laparoscopic approach in patients with acute appendicitis complicated with peritonitis due to a higher rate of surgical complications. The aim of this study was to compare post-operatory outcomes in patients with acute appendicitis complicated exclusively with peritonitis approached by laparoscopy versus open surgery. METHODS Single center retrospective analysis of clinical records of patients with appendicitis complicated with peritonitis operated from January 2003 until October 2013. Demographic data, intra-operative variables, length of stay, surgical complications, mortality, readmissions and reoperations were retrieved. RESULTS 227 patients were identified, 43% males, mean age 39±17 years (range: 12-85 years). Ninety-seven patients (43%) underwent laparoscopic appendectomy, 13 of them were converted to open surgery (13%). Ninety-four patients presented with diffuse peritonitis (41.4%). Laparoscopic appendectomy showed longer operative time but shorter hospital stay (p<0.05). There were no differences in post-operatory complications (intra-abdominal abscess, surgical site infection and prolonged ileus). Laparoscopic appendectomy was associated with lower odds for developing any surgical complication in the multivariate analysis (OR 0.301, p=0.036). CONCLUSION Both approaches showed no differences in complications in the management of appendicitis complicated exclusively with peritonitis. In our experience, laparoscopic appendectomy is a safe approach in cases of appendicitis complicated exclusively with peritonitis.

Nuevos receptores nucleares heterodiméricos: reguladores metabólicos con impacto en fisiopatología y su proyección terapéutica en dislipidemias y diabetes mellitus

The regulation of gene expression is crucial for the normal development and the homeostatic maintenance of body tissues. Thus, its malfunction may determine a variety of human disease conditions. A growing body of evidence has shown the overwhelming relevance of a new class of gene expression regulators: the heterodimeric nuclear receptors, a family of structurally related proteins involved in multiple biological functions. In response to activating ligands, these molecules bind to specific genomic regulatory regions where they can coordinately modify the transcriptional activity of several genes involved in the main metabolic pathways of lipids and carbohydrates in cells. These functional properties have stimulated the study of the relationships between heterodimeric nuclear receptors and various disease conditions, such as dyslipidemias and diabetes mellitus. Here we review the experimental, clinical and epidemiological evidences that support the relevance of these transcriptional regulators in the pathophysiology of the most prevalent and lethal diseases in Western countries. We also explore the potential therapeutic impact of new strategies based in the pharmacological modulation of the heterodimeric nuclear receptors. (Rev Med Chile 2005; 133: 1483-92)

Complete pathological response to Imatinib mesylate in an extraintestinal gastrointestinal stromal tumor

INTRODUCTION Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumors of the digestive tract. Extraintestinal locations (EGIST) have been described showing similar pattern of immunohistochemical markers than GIST. Inhibitors of tyrosine kinases such as Imatinib or Sunitinib are the mainstay treatment in the management of advanced or metastatic GIST. Complete pathological response to these agents is an extremely rare event, especially in the case of EGIST due to its more aggressive behavior reported. PRESENTATION OF CASE Here we describe the case of a 61 years old woman, with an advanced GIST, who was operated after 10 months of Imatinib mesylate. The biopsy demonstrated the extra intestinal location of the tumor and a complete pathological response was confirmed. DISCUSSION Complete pathological response to Imatinib is a rare event. To our knowledge, this is the first report of complete response in an EGIST. New clinical, radiological and metabolic criteria of tumoral response to neoadjuvant treatment are revised. CONCLUSION EGIST complete pathological response to Imatinib can be achieved. However, recommendation of systematic neoadjuvant therapy with Imatinib remains investigational and more studies are warranted in the future.

Emergency right hepatectomy after laparoscopic tru-cut liver biopsy

Highlights • Tru-cut liver biopsy is a common diagnostic procedure for many liver diseases.• Bleeding following tru-cut liver biopsies is uncommon.• Emergency hepatectomy due to hemorrhage following tru-cut liver biopsies is exceptional.

Primary leiomyosarcoma of the greater omentum: a case report

Highlights • Primary leiomyosarcomas of the greater omentum are extremely rare tumors.• It appears that early surgical management is a key factor for the treatment of this disease.• More cases are needed in literature to define the optimal treatment.