Endoscopic Management of Drain Inclusion in the Gastric Pouch after Gastrojejunal Leakage after Laparoscopic Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity (LRYGBP)

Background. Drain inclusion inside the gastric pouch is rare and can represent an important source of morbidity and mortality associated with laparocopic Roux-en-Y gastric bypass (LRYGBP). These leaks can become chronic and challenging. Surgical options are often unsuccessful. We present the endoscopic management of four patients with drain inclusion. Patients. All four obese morbidly patients underwent LRYGBP and presented a gastro-jejunal fistula after acute anastomotic leakage. During follow-up endoscopy the drain was found inside the gastric pouch. It was moved into the abdominal cavity. Fistula debit reduced significantly and closed. Results. Gastric leak closure in less than 24 hours was achieved in all, with complete resolution of symptoms. These patients benefited exclusively from endoscopic treatment. Conclusions. Endoscopy is useful and technically feasible in chronic fistulas. This procedure is a less invasive alternative to traditional surgical revision. Other therapeutic strategies can be used such as clips and fibrin glue. Drains should not be placed in contact with the anastomosis or stapled lines. Drain inclusion must be suspected when fistula debit suddenly arises. If so, endoscopy is indicated for diagnostic accuracy. Under endoscopy vision, the drain is gently removed from the gastric reservoir leading to sudden and complete resolution of the fistula

Gastrointestinal stromal tumor : cause of gastrointestinal bleeding

Gastrointestinal stromal tumors (GISTs) are rare tumors and can be a cause of gastrointestibnal bleeding, when other causes have already been excluded. This mesenchymal tumors can be diagnosed hardly, and they should be included in any differential diagnosis. Our case illustrates the difficulty of diagnosis and sometimes shows how non-invasive test can be few helpful. Surgery is very often indicated, and becomes therapeutic and diagnostic. GIST tumors are rare and surgical resection with curative intent is the treatment of choice

Utilidad de un cuestionario postal en el seguimiento de la reparación de la hernia incisional: estudio prospectivo de una cohorte

ResumenObjetivoEvaluamos la utilidad de un cuestionario postal en el seguimiento de la cirugía de la eventración.Pacientes y métodoSe analiza prospectivamente una cohorte de 285 pacientes intervenidos por una eventración entre 1998 y 2003 mediante una técnica con malla prefascial y que recibieron un cuestionario de 6 preguntas e ideogramas, con estrategia de reenvíos y llamada telefónica para aumentar la respuesta. Se citaron a examen clínico a los pacientes sin inconveniente a ser visitados. Se revisaron todas las hojas operatorias. Se estudia la respuesta al cuestionario y hallazgos de la visita (test exacto de Fisher y Chi cuadrado), la concordancia con los datos operatorios (índices Kappa de Cohen y de Fleiss) y el valor predictivo del cuestionario.ResultadosUn total de 215 pacientes devolvieron el cuestionario después de tres envíos, con lo que se recogió información de un 75.4% de la cohorte, que aumentó al 94% después de la llamada telefónica. Un total de 168 pacientes (el 78.2%) aceptaron ser visitados, aunque finalmente solo acudieron 62 (el 36.9%). La concordancia entre las respuestas al cuestionario e ideogramas y los datos de las hojas operatorias fue baja (índice Kappa de Cohen de 0.065 e índice Kappa de Fleiss de 0.170).ConclusionesUn cuestionario postal con medidas para aumentar la respuesta puede ser efectivo para recoger información básica sobre la cirugía de la hernia incisional. La utilidad de dicha información resulta cuestionable por falta de cumplimiento de los pacientes en los controles y por dificultades en la comprensión del cuestionario, aunque este sea corto y/o en forma de ideograma.AbstractAimTo assess the usefulness of a short postal questionnaire as a method of follow-up in incisional hernia repair.Patients and methodAll consecutive patients (n=285) undergoing open mesh repair of incisional hernia using an onlay technique between 1998 and 2003 received a six-item self-administered questionnaire complemented with ideograms. Non-responders received two successive new questionnaires and a telephone call. All patients’ operation forms were reviewed. Patients with no objections to physical examination were contacted by phone for an appointment. The Fisher's exact test or the chi-square (χ2) tests were used to compare categorical variables between clinical visits and response to questionnaire. Agreement between response to the questionnaire and data on the operation forms was measured with the Cohen's kappa index and the Fleiss kappa index. The predictive values of the questionnaire were calculated.Results215 patients returned questionnaires after three reminders, allowing us to reach 75.4% of the study cohort, which in turn increased to 94% after the telephone call. A total of 168 (78.2%) patients were willing to come for a physical examination. Finally 62 (36.9%) patients were examined. The overall agreement between response to the questionnaire and data on the operation forms was poor (Cohen's kappa coefficient = 0.065 and Fleiss kappa coefficient = 0.170).ConclusionsA postal questionnaire can be effective to gather information. However, the usefulness of this information in the follow-up was low due to the small percentage of patients examined and difficulties in comprehension despite making the questionnaire short and illustrated by ideograms

Massive necrotizing fasciitis: a life threatening entity

Fascitis necrosant; Diagnòstic; AntibiòticsNecrotizing fasciitis; Diagnostics; AntibioticsFascitis necrosante; Diagnóstico; AntibióticosNecrotizing fasciitis (NF) is a complicated soft tissue infection frequently associated with severe sepsis if an early medical and surgical treatment is not performed. We report two postoperative cases of severe NF after oophorectomy and colorectal resection. Because of the similarity with more benign skin infections at the early steps, clinical suspicion is crucial. Surgical exploration and resection will provide both the diagnosis confirming necrotizing infection of the fascia with vessels and treatment. Also, empirical broad-spectrum antibiotics must be initiated as soon as possible. Regardless of the presence of risk factors, NF is a condition with a high mortality rate and only an expeditious and undelayed treatment may improve the patient’s outcome. Surgical focus control requires wide and repeated resections, and planned reconstructive plastic surgery might be necessary

Raymond C. Read (2007) Arthur Keith, the anatomist who evisioned herniosis

Carta a l'editor de la revista "Hernia" en referència a l'article publicat amb el títol: "Arthur Keith, the anatomist who evisioned herniosis"We would like to add a comment on another important contribution of Arthur Keith to the Weld of herniology, that is, the original and accurate description of the inguinal “shutter” mechanism, a remarkable anatomic action against development of an inguinal hernia. [...] Today, virtual reality surgical simulation models allowing three-dimensional (3D) visualization of the human inguinal anatomy can be used as a complementary tool to assess dynamics of the inguinal area. In fact, using simulations with the Wnite element method we have recently confirmed the physiological “shutter” mechanism already described almost 100 years ago. These virtual reality Wndings are our present tribute to the outstanding anatomic descriptions of Arthur Keith.Postprint (published version

A case of pylephlebitis complicating an acute appendicitis: Uncommon cholangitis-like situation

Appendicitis; Cholangitis presentation; PhylephlebitisApendicitis; Presentación de colangitis; PileflebitisApendicitis; Presentació de colangitis; PileflebitisIntroduction Pylephlebitis represents an uncommon but serious condition with significant mortality which can complicate intrabdominal sepsis of any etiology. One of the most common predisposing infections is appendicitis. Presentation of case A 21-year-old male with 4 days of epigastric and right upper quadrant pain with associated fever and chills with hyperbilirubinemia and leukocytosis in blood test was orientated as cholangitis at first diagnostic. Poor response to antibiotic treatment with persistent fever and bacteriemia with E. coli and S. constellatus isolated in blood cultures led to complete the study with a CT scan which revealed an acute appendicitis complicated with thrombosis of the superior mesenteric vein (SMV) up to the splenoportal confluence. Appendectomy, treatment with broad-spectrum antibiotic and anticoagulation treatment led to full recovery. Follow-up after 6 months showed almost complete SMV patency. Discussion Pylephlebitis can present as a clinical cholangitis-like picture with hyperbilirubinemia with or without liver abscess formation. CT scan seems to be the most sensitive diagnostic test as it identifies the underlying focus of infection, the extension of the thrombosis and detects liver abscesses. Surgical removal of the source of infection as appendectomy and adequate antibiotic treatment adjusted by culture should be initiated promptly. Anticoagulant treatment should be considered in the case of poor clinical outcome or thrombosis progression. Conclusion Pylephlebitis should be suspected mainly in patients with appendicitis and diverticulitis with erratic behavior despite surgical removal and/or antibiotic treatment with abnormal liver tests and persistent bacteriemia. CT scan is the preferred image study

Analysis of the Variability in Different Criteria to Define the Success of Bariatric Surgery : Retrospective Study 5-Year Follow-Up after Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

(1) Background: The current criteria for defining good or bad responders to bariatric surgery based on the percentage of weight loss do not properly reflect the therapeutic impact of the main bariatric techniques. At present there is an urgent need to fill this gap and provide scientific evidence that better define the success or failure of bariatric surgery in the long term. (2) Methods: This is a retrospective database study of a prospective cohort with 5-year follow-up. We established the success or failure of bariatric surgery in terms of weight loss according to a selected criterion: (1) Halverson and Koehler; (2) Reinhold modified by Christou; (3) Biron; (4) TWL > 20%; (5) percentage of changeable weight (AWL > 35%). We analyzed sensitivity and specificity for successful weight loss. (3) Results: 223 (38.7%) patients underwent sleeve gastrectomy (LSG) and 353 (61.2%) underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). The success rates at 5 years are: EWL > 50% 464 (80%), Reinhold 436 (75.6%), Biron 530 (92%), TWL > 20% 493 (85.5%), AWL 35 were the most adequate criteria as their specificities and sensibility were far above >80%. (4) Conclusions: The present study shows how the different definitions of success or failure are inconsistent in relation to the outcomes of BS. However, there are some criteria that associate statistically significant differences for the resolution of comorbidities and show the highest sensitivity and specificity rates

Cambios hemodinámicos en el postoperatorio de la cirugía endovascular de carótida : factores pronósticos

L'angioplàstia carotídia és una alternativa terapèutica per al tractament de la malaltia arterial carotídia en pacients amb un risc quirúrgic elevat, més susceptibles de presentar inestabilitat hemodinàmica en el perioperatori i també de patir més complicacions derivades d'aquesta. L'objectiu principal d'aquest treball és valorar la incidència d'hipotensió (definida com a TAS & 90mmHg) i/o bradicàrdia (definida com a variació & 20% de la FC basal) en les primeres 12 hores postoperatòries de la cirurgia endovascular carotídia, i la seva relació amb variables clíniques o ecogràfiques preparatòries. L'objectiu secundari és valorar la incidència temporal d'aquestes complicacions, i el valor predictiu negatiu de l'absència d'hipotensió i bradicàrdia durant les primeres 6 hores de monitorització.La angioplastia carotídea es una opción terapéutica para el tratamiento de la enfermedad arterial oclusiva carótidea en una población de alto riesgo quirúrgico con más propensión a presentar inestabilidad hemodinámica en el perioperatorio y a sufrir complicaciones derivadas de dicha inestabilidad.El objetivo principal del estudio es evaluar la incidencia de hipotensión (definida como TAS & 90 mmHg) y/o bradicardia (definida como variación & 20% de la FC basal) en las primeras 12 horas del postoperatorio de la cirugía endovascular carotídea y su relación con variables clínicas o ecográficas preoperatorias. Como objetivo secundario evaluamos la incidencia temporal de estas complicaciones y el valor predictivo negativo de la ausencia de hipotensión y bradicardia en las primeras 6 horas de monitorización

Analysis of the Variability in Different Criteria to Define the Success of Bariatric Surgery: Retrospective Study 5-Year Follow-Up after Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

Bariatric surgery; Sleeve gastrectomy; Success criteriaCirurgia bariàtrica; Gastrectomia de màniga; Criteris d'èxitCirugía bariátrica; Gastrectomía de manga; Criterios de éxito(1) Background: The current criteria for defining good or bad responders to bariatric surgery based on the percentage of weight loss do not properly reflect the therapeutic impact of the main bariatric techniques. At present there is an urgent need to fill this gap and provide scientific evidence that better define the success or failure of bariatric surgery in the long term. (2) Methods: This is a retrospective database study of a prospective cohort with 5-year follow-up. We established the success or failure of bariatric surgery in terms of weight loss according to a selected criterion: (1) Halverson and Koehler; (2) Reinhold modified by Christou; (3) Biron; (4) TWL > 20%; (5) percentage of changeable weight (AWL > 35%). We analyzed sensitivity and specificity for successful weight loss. (3) Results: 223 (38.7%) patients underwent sleeve gastrectomy (LSG) and 353 (61.2%) underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). The success rates at 5 years are: EWL > 50% 464 (80%), Reinhold 436 (75.6%), Biron 530 (92%), TWL > 20% 493 (85.5%), AWL 35 were the most adequate criteria as their specificities and sensibility were far above >80%. (4) Conclusions: The present study shows how the different definitions of success or failure are inconsistent in relation to the outcomes of BS. However, there are some criteria that associate statistically significant differences for the resolution of comorbidities and show the highest sensitivity and specificity rates

Bypass infragenicular realizado con venas braquiales

La vena safena interna es considera el conducte òptim per a la revascularització quirúrgica del sector infragenicular però fins a un 25% dels casos, aquesta no es troba disponible o bé no es apte per a bypass. L'objectiu de l'estudi és analitzar els resultats en quant a permeabilitat, taxa de salvament de l'extremitat i morbiditat associada dels procediments de revascularització infragenicular utilitzant les venes braquials (cefàlica i basílica) com a conducte arterial.La vena safena interna se considera el conducto óptimo para la revascularización quirúrgica del sector infragenicular si bien hasta un 25 % de los casos esta no se encuentra disponible o no es apta para bypass. El objetivo del estudio es analizar los resultados en cuanto a permeabilidad, tasa de salvamento de la extremidad y morbilidad asociada de los procedimientos de revascularización infragenicular utilizando las venas braquiales (cefálica y basílica) como conducto arterial