Quiteria Hernández

Laparoscopic Versus Open Gastric Bypass in the Treatment of Morbid Obesity: A Randomized Prospective Study

Objective:The objective of the study was to compare the results of open versus laparoscopic gastric bypass in the treatment of morbid obesity. Summary Background Data:Gastric bypass is one of the most commonly acknowledged surgical techniques for the management of morbid obesity. It is usually performed as an open surgery procedure, although now some groups perform it via the laparoscopic approach. Patients and Methods:Between June 1999 and January 2002 we conducted a randomized prospective study in 104 patients diagnosed with morbid obesity. The patients were divided into 2 groups: 1 group with gastric bypass via the open approach (OGBP) comprising 51 patients, and 1 group with gastric bypass via the laparoscopic approach (LGBP) comprising 53 patients. The parameters compared were as follows: operating time, intraoperative complications, early (<30 days) and late (>30 days) postoperative complications, hospital stay, and short-term evolution of body mass index. Results:Mean operating time was 186.4 minutes (125–290) in the LGBP group and 201.7 minutes (129–310) in the OGBP group (P < 0.05). Conversion to laparotomy was necessary in 8% of the LGBP patients. Early postoperative complications (<30 days) occurred in 22.6% of the LGBP group compared with 29.4% of the OGBP group, with no significant differences. Late complications (>30 days) occurred in 11% of the LGBP group compared with 24% of the OGBP group (P < 0.05). The differences observed between the 2 groups are the result of a high incidence of abdominal wall hernias in the OGBP group. Mean hospital stay was 5.2 days (1–13) in the LGBP group and 7.9 days (2–28) in the OGBP group (P < 0.05). Evolution of body mass index during a mean follow-up of 23 months was similar in both groups. Conclusions:LGBP is a good surgical technique for the management of morbid obesity and has clear advantages over OGBP, such as a reduction in abdominal wall complications and a shorter hospital stay. The midterm weight loss is similar with both techniques. One inconvenience is that LGBP has a more complex learning curve than other advanced laparoscopic techniques, which may be associated with an increase in postoperative complications.

Eversion thromboendovenectomy in organized portal vein thrombosis during liver transplantation

Portal thrombosis is no longer considered a contraindication for transplantation because of the technical experience acquired in the field of liver transplantation and the development of various surgical techniques. All the same, the results obtained in portal thrombosis patients are at times suboptimal, and the surgical technique used (thromboendovenectomy or veno‐venous bypass) is also controversial.

Substernal Goiter: Clinical Experience of 72 Cases

The aim of this work was to study the clinical management and surgical approach of substernal goiters. We studied the clinical data, preoperative evaluation, surgical treatment, histopathologic data, complications, and follow-up of 72 patients found to have substernal goiter over a period of 15 years, from a total of 780 patients with goiter who underwent surgery. In this group, 83% were women, and the mean age was 61 years. The most common symptoms were the existence of a palpable cervical mass (93% of cases) and dyspnea (40%). The most successful study to diagnose substernal goiter was computed tomography (100%), followed by chest radiography (75%), gammagraphy (19%), and ultrasound (15%). All but 7 patients received a Kocher cervicotomy, and 49% of the cases underwent a total thyroidectomy. The histologic study revealed 3 carcinomas (4%). There was 1 permanent unilateral recurrent laryngeal nerve injury (1.4%) and 1 instance of permanent hypoparathyroidism (1.4%). We regard surgery as the most successful treatment for patients with substernal goiter, even in those without compressive symptoms. We base our choice on the low morbidity and zero mortality obtained.

Experience with the Circular Stapler for the Gastrojejunostomy in Laparoscopic Gastric Bypass (350 Cases)

Background: The increased incidence of morbid obesity has resulted in an increase in bariatric surgery. The gastrojejunostomy performed during Roux-en-Y gastric bypass (RYGBP) operations has technical variability with different outcomes and complication-rates immediate postoperatively and at long-term follow-up. Methods: Between Jan 2000 and Feb 2005, 350 laparoscopic RYGBP procedures were performed. We present our immediate and follow-up rate of complications with total intraabdominal gastrojejunostomy, performed with the circular stapler. Results: Complications of gastrojejunostomy were detected in 24 patients (6.8%): 3 anastomotic leaks (0.8%); 6 bleeding (1.7%) immediately postoperatively, and 4 stenoses (1.1%), 10 ulcers (2.8%) and 1 stenosis plus ulcer (0.3%) during long-term follow-up. There was no mortality related to the gastrojejunostomy. Conclusions: The gastrojejunostomy with circular stapler is an easily reproducible procedure. The rate of complications has been low. Surgeons who perform laparoscopic RYGBP should have a careful learning curve, and should be aware of the potential complications and their management.

Role of liver transplantation in the management of metastatic neuroendocrine tumors.

INTRODUCTION In the majority of patients transplanted for unresectable liver metastases, long-term results are disappointing because of early tumor recurrence. Due to its biologically less aggressive nature, neuroendocrine metastases (NM) may represent a good indication for liver transplantation (LT). PATIENTS AND METHODS Between January 1996 and May 2000, five patients with NM were transplanted. The primary tumors were located in the pancreas (n=4) and the small bowel (n=1). In three cases there were symptoms related to hormone production: two carcinoids, and one gastrinoma. The management of primary tumors was sequential in three patients with the tumor being resected before LT (one Whipple procedure and two left pancreatectomies). In two patients the resections of the primary tumors and the LT were simultaneous namely one bowel resection and one left pancreatectomy. All patients were treated with chemotherapy. RESULTS Two patients developed recurrent disease succumbing at 15 months (nonfunctioning NE pancreatic head tumor) and 17 months (carcinoid of the pancreatic tail) post-LT. Another patient died at 3 months post-LT due to technical complications. The other two patients are alive and free of recurrence. CONCLUSION Despite the promising results obtained with LT for NM, our experience indicates that patients must be carefully selected. Perhaps the use of more aggressive chemotherapeutic protocols combined with an individualized approach will improve the results.

Results of Laparoscopic Gastric Bypass in Patients ≥55 Years Old

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed surgical intervention for morbid obesity. Some authors considered age ≥55 years as a relative contraindication to bariatric surgery. We examined the operative outcomes, weight loss, hospital stay and resolution of co-morbidities in patients ≥55 years old compared with those <55 years old undergoing LRYGBP. Methods: From Jan 2000 to Feb 2005, 350 LRYGBPs were performed. 48 patients ≥55 years old (13.7%) were compared to the remaining patients. Results: Analysis of the 48 patients ≥55 years old compared with 302 patients <55 revealed no difference in complication rate, although the older patients had a significantly greater percentage of serious complications. Younger patients lost more weight than older patients. Both groups demonstrated resolution of comorbidities, although the difference was not significant. Conclusions: LRYGBP is safe and well tolerated in morbidly obese patients ≥55 years. The older patients had more serious complications and lost less weight; however, their weight loss and resolution of co-morbidities improved their quality of life. Age should not be a contraindication to bariatric surgery.

Laparoscopic gastric bypass in the treatment of morbid obesity

Introduction: Gastric bypass is one of the most commonly used surgical techniques for the management of morbid obesity. It is usually done as an open surgery procedure, and in recent years surgeons have begun to perform it via the laparoscopic approach. The aim of this paper is to describe our surgical technique for laparoscopic gastric bypass (LGBP) and present the short-term results. Materials and methods: Between January 2000 and January 2002 we operated on 50 patients with morbid obesity who met criteria for bariatric surgery. The patients had a mean age of 34 years and a body mass index (BMI) of 47. Results: Conversion was necessary in 4 of the 50 patients (8%). Mean operating time was 181 min, with a difference of 60 min between the first 10 and last 10 cases. There was a 26% rate of complications, 14% of which were early (%<% 30 days) and 12% late (%>%30 days). Mean hospital stay was 4.5 days. Conclusion: LGBP is a technique with good short-term results as far as weight loss is concerned, although it has one of the most complex learning curves in laparoscopic surgery. Surgeons who regard gastric bypass as the technique of choice for the surgical management of morbid obesity should consider performing it via the laparoscopic approach.

Eversion thromboendovenectomy for organized portal vein thrombosis encountered during liver transplantation

INTRODUCTION Due to the technical experience acquired in the field of liver transplantation portal vein thrombosis is no longer considered a contraindication for transplantation. Nevertheless, the results obtained in patients with portal vein thrombosis are at times suboptimal, and there is no consensus on the appropriate surgical technique. PATIENTS AND METHODS Among the 455 liver transplants performed between May 1988 and December 2001, 32 (7%) presented with portal vein thrombosis. Twenty (62%) were type Ib, seven (22%) type II/III, and five (16%) type IV. Twenty-two were men (69%), with a mean age of 50 years (range: 30-70 years); the thrombosis in all cases developed in a cirrhotic liver. The surgical method in all cases consisted of an eversion thromboendovenectomy under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. RESULTS Among the 32 cases undergoing thrombectomy, 31 (96%) were successful with a failure in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis rethrombosed. The 5-year survival rate of the patients in the series was 69%. Only two patients died from causes related to the thrombosis, both showing type IV thrombosis. CONCLUSION The ideal treatment for portal thrombosis during liver transplantation depends on its extension and on the experience of the surgeon. In our experience, eversion thromboendovenectomy resolves most thromboses (types I, II, and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal hemitransposition.

The influence of the percentage of the common limb in weight loss and nutritional alterations after laparoscopic gastric bypass

BACKGROUND Roux-en-Y gastric bypass (RYGB) is considered the gold standard for the treatment of morbid obesity. There is no consensus over ideal limb length when the bypass is created and published studies do not take into account the influence of the common limb (CL) on weight loss. The objective was to study the influence of the common limb after RYGB. The setting was the Virgen de la Arrixaca University Clinical Hospital in Murcia, Spain. MATERIAL AND METHODS This prospective study includes 151 patients undergoing laparoscopic RYGB surgery for morbid obesity. The patients were divided into 2 groups according to their body mass index. The small intestine (SI) was measured using micro forceps so that the percentage of common limb (%CL) could then be compared against the total SI in each patient. The percentage of excess weight loss (%EWL) in relation to the %CL was calculated at 3, 12, and 24 months. A series of tests was conducted simultaneously to analyze nutritional deficiencies and their relation to the %CL. RESULTS The total jejunoileal segment and the %CL in the groups of both obese and super-obese patients had no influence on the %EWL in either group for any of the periods studied. The patients with a %CL<50% had greater nutritional deficiencies in the follow-up period and required supplements and more frequent laboratory tests. CONCLUSIONS The %CL has no effect on weight loss in RYGB patients. A lower %CL is related to greater nutritional deficiencies.

Apendicectomía laparoscópica mediante incisión única transumbilical: experiencia inicial

INTRODUCTION Appendicitis is the most common abdominal emergency. The treatment is surgical and single incision laparoscopic surgery (SILS) involves performing laparoscopic surgery through a single transumbilical point, in an attempt to improve the results of laparoscopic surgery. MATERIAL AND METHOD A total of 73 patients with suspected acute appendicitis were operated on using the SILS technique between June 2009 and August 2010. All patients were operated on by the same surgical team, and the navel was the only point of entrance. Post-surgical pain was assessed using a numerical scale at the time of discharge. RESULTS None of the patients required conversion to conventional laparoscopy. The mean surgical time was 40±14 (16-80) minutes. There were no complications during or after the surgery. The mean post-surgical pain score was 3±1 (1-7) and the mean hospital stay was 18±7 (9-42) hours. CONCLUSION SILS is a safe and effective technique for appendicitis. In the future, the most common surgical procedures could be performed through the navel. This would be by surgeons, highly experienced in advance laparoscopic surgery in order to introduce this new technique safely without increasing morbidity and mortality.