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This study examined the effects of a large-scale flipped learning (FL) approach in an undergraduate course of Digestive System Diseases.This prospective non-randomized trial recruited 404 students over three academic years. In 2016, the course was taught entirely in a Traditional Lecture (TL) style, in 2017 half of the course (Medical topics) was replaced by FL while the remaining half (Surgical topics) was taught by TL and in 2018, the whole course was taught entirely by FL. Academic performance, class attendance and student's satisfaction surveys were compared between cohorts.Test scores were higher in the FL module (Medical) than in the TL module (Surgical) in the 2017 cohort but were not different when both components were taught entirely by TL (2016) or by FL (2018). Also, FL increased the probability of reaching superior grades (scores7.0) and improved class attendance and students' satisfaction.The holistic FL model is more effective for teaching undergraduate clinical gastroenterology compared to traditional teaching methods and has a positive impact on classroom attendances.

Bariatric surgery is one of the most common general surgery procedures in countries that, like Spain, have public healthcare systems, but is also one of the procedures for which patients have to wait the longest. The Spanish Society of Obesity Surgery (SECO) conducted a survey to estimate the situation of bariatric surgery waiting lists in Spain’s public hospitals and to gather information on a number of related aspects. An online survey was sent to the members of the SECO. The survey received 137 visits, all via the click-through link provided, from 52 health centers (47 public and 5 private). The data collected were included in a database and later analyzed using the SPSS18.0 statistical software package. A total of 4724 patients were on bariatric surgery waiting lists (BWLs), at an average of 100 per public hospital. Sixty-eight percent had been waiting for more than 6 months. The mean delay per patient was 397 days, and the longest wait was 1661 days. A further 46.2% of respondents were able to recall cases of patients who in the past 5 years had suffered cardiovascular events with sequelae while awaiting surgery, and 21.2% recalled at least one fatal cardiovascular event in that time. Our data revealed an unacceptably long wait for obesity surgery. Notwithstanding the limitations and potential biases of our research, the long wait for surgery in our context inevitably has serious consequences for a potentially significant number of patients.

The early diagnosis of leakage poses a challenge to bariatric surgeons, who need to suspect and treat it promptly. The aim of this study is to determine the value of clinical signs and complementary tests in its detection.Between January 2007 and 2012, 200 patients underwent surgery for pathological obesity. Perioperative variables were collected prospectively, and univariate and multivariate analyses were conducted to study the factors related to leak occurrence and the predictive value of the tests performed.The study includes 172 proximal gastric bypasses and 28 sleeve gastrectomies. Nine patients (4.5 %) had leaks in the immediate postoperative period. Multivariate analyses found that age over 48 years and preoperative BMI48 kg/m(2) were the patient-related variables associated with a higher risk of leakage. The clinical variables significantly related to postoperative leaks were heart rate over 100 bpm, leukocytes over 15,000/mm(3) and systolic arterial pressure below 100 mmHg. In patients with a clinical suspicion of leakage (n = 19), 7.7 % of abdominal CT scans returned false negatives, versus 28.6 % for oral methylene blue and 22.2 % for upper gastrointestinal (UGI) Gastrografin swallow [Corrected].Bariatric surgery proved to be a safe technique at our medical centre. Patient-related variables associated with a higher risk of leakage were age and BMI. Early clinical signs of leakage were tachycardia, leukocytosis and hypotension. The most reliable diagnostic test was the abdominal CT scan.

Biliopancreatic limb obstruction in Roux-en-Y gastric bypass is an infrequent complication that should be recognized early to avoid the risk of peritonitis and death. In this manuscript, we report a case of acute gastric remnant dilatation secondary to intraabdominal hematoma provoked by trocar injury that was compressing the second portion of duodenum lumen. To treat this problem, we decided on a less invasive treatment consisting of percutaneous decompression of the stomach. The procedure was performed using sonographic guidance with local anesthesia, thus, avoiding a new surgical procedure. In this selected case, percutaneous radiological catheter placement provided an effective decompression of the excluded gastric remnant until spontaneous resolution of the obstruction.

A case is reported of a woman who developed untreatable diarrhea after a prior biliopancreatic diversion (BPD), attributed to the malabsorptive component. Abdominal ultrasound incidentally found focal liver lesions. On fine needle aspiration biopsy, atypia was found, and these hepatic lesions were resected with free margins. The specimen showed liver metastases of an aggressive malignant neuroendocrine neoplasm. The primary site was subsequently identified to be in the pancreas. The physician and surgeon must realize that non-related diseases can develop after bariatric surgery, as in the general population.

Obesity and gastroesophageal reflux disease (GERD) are both high-prevalence diseases in developed nations. Obesity has been identified as an important risk factor in the development of GERD. The objective of this study was to determine the frequency of abnormal esophageal acid exposure in patients candidate for bariatric surgery and its relationship with any clinical and endoscopic findings before surgery.Data collected from a group of 88 patients awaiting bariatric surgery included a series of demographic variables and symptoms typical of GERD. The tests patients underwent included manometry, pH monitoring, and upper gastrointestinal endoscopy. Univariate and multivariate analyses were conducted on the variables related to the onset of reflux.Esophageal pH monitoring tests were positive in 65% of the patients. Manometries showed lower esophageal sphincter hypotonia in 46%, while 20% returned abnormal upper endoscopy results. Out of the 45% of patients who were asymptomatic or returned normal endoscopies, half returned positive esophageal pH tests. In turn, among the 55% of patients who had symptoms or an abnormal upper endoscopy, three quarters had pH tests that diagnosed reflux. pH tests were also positive in 80% of symptomatic patients and 100% of patients with esophagitis (P.042). No statistically significant relationship was found between body mass index, sex, age, manometry, or hiatus hernia and the positive pH monitoring.Frequency of abnormal esophageal acid exposure among obese patients is high. There is a relationship between the presence of symptoms and reflux. But the absence of symptoms does not rule out the presence of abnormal esophageal function tests.

Although several etiological factors have been associated with mesenteric panniculitis, the exact etiology in some cases remains unknown. Herein, we present a retrospective analysis of 8 patients affected with this disorder performed between May 2000 and December 2006. In our series the mean age at which patients presented was 63 years. The majority of the patients were male (with a male: female ratio of 3:1). The most common clinical manifestations were abdominal pain (n = 4) and asthenia (n = 4). Three cases presented with obstructive symptoms and three had a history of abdominal surgery. Notably, seven had a background of tobacco use (five smokers and two ex-smokers) and one patient developed follicular lymphoma. A literature research was carried out to analyze our results and formulate a new hypothesis. In our opinion, we believe that the study of causal factors such as tobacco and its components is required due to the strong association found in this study.

A pesar de que se han reconocido distintos factores precipitantes en la paniculitis mesentérica, su etiología en determinados casos es incierta. Presentamos un análisis retrospectivo de 8 pacientes afectados de paniculitis mesentérica en un periodo comprendido entre mayo 2000 hasta diciembre 2006. En nuestra serie la edad media de presentación fue 63 años, siendo la mayoría de pacientes varones (proporción 3:1). Las manifestaciones clínicas más frecuentes fueron el dolor abdominal (n = 4) y la astenia (n = 4). Tres casos se presentaron como cuadro de obstrucción y tres casos presentaron antecedentes de cirugía abdominal. El antecedente más común fue el tabaquismo (5 casos eran fumadores activos y 2 exfumadores) y hubo un paciente que desarrolló un linfoma folicular en el seguimiento. Revisamos la literatura para analizar nuestros resultados y formular una hipótesis. En nuestra opinión, pensamos que debe ser analizada de forma más exhaustiva la relación entre el tabaco y sus componentes con la aparición de la enfermedad debido a la fuerte asociación encontrada en este estudio.

Inflammatory myofibroblastic tumors (IMTs) or inflammatory pseudotumors (IPs) have been extensively discussed in the literature. They are usually found in the lung and upper respiratory tract. However, reporting of cases involving the biliopancreatic region has increased over recent years. Immunohistochemical study of these lesions limited to the pancreatic head or distal bile duct seems to be compatible with those observed in a new entity called autoimmune pancreatitis, but usually intense fibrotic reaction (zonation) predominates producing a mass. When this condition is limited to the pancreatic head, the common bile duct might be involved by the inflammatory process and jaundice may occur often resembling adenocarcinoma of the pancreas. We have previously reported a case of IMT arising from the bile duct associated with autoimmune pancreatitis which is an extremely rare entity. Four years after Kaush-Whipple resection, radiological examination on routine follow-up revealed a tumor mass, suggesting local recurrence. Ultrasound-guided FNA confirmed our suspicious diagnosis. This present case, as others, suggests that persistent follow-up is necessary in order to prevent irreversible liver damage at this specific location.

Objectives: the aim of this retrospective study was to evaluateearly experience with laparoscopic restorative proctocolectomy byanalyzing the perioperative results of surgical treatment.Patients and methods: seven major surgeries were per-formed in six patients with familial adenomatous polyposis and ul-cerative colitis. All procedures were performed under laparoscopyat our third-level hospital from June 2003 to October 2004.Results: mean surgical time was 287.5 ± 80.7 min, and me-dian blood loss was 300 ± 249.0 cc. There were no conversions;return of peristalsis began at 32 ± 12.4 h; average time to firstoral intake was 64.0 ± 32.8 h, and mean duration of hospital staywas 9.3 ± 1.2 days. There was one case of perineal sepsis due toileal pouch-anal anastomotic leakage, which was successfullytreated with oral intake restriction, parenteral nutrition, and intra-rectal drainage. The most common postoperative complicationwas postoperative ileus.Conclusions: we believe that the laparoscopic approach torestorative proctocolectomy may be considerably improved in ourcenter. Particular aspects for improvement include efforts toachieve lower operating and hospitalization times to equate ourresults with those reported by multicenter studies for laparoscopiccolon cancer surgery. In our opinion, learning and further trainingopportunities should be encouraged to improve surgeon experi-ence in the field of laparoscopy, preferably at centers specializingin restorative proctocolectomy.Key words:Restorative proctocolectomy. Ileoanal pouch. La-paroscopy. Surgery.

Wandering spleen is an uncommon clinical entity, which rarely affects children and adolescents. It is usually described in adults, being most common in the multiparous women of childbearing age. A case of a 14-year-old girl with a past history of splenomegaly and immunoglobulin A (IgA) deficiency, who presented with a sudden onset of abdominal pain, is presented. Diagnosis of hemoperitoneum secondary to torsion of a wandering spleen was made by computed tomography scan and Doppler ultrasound. Laparoscopy revealed hemoperitoneum owing to a ruptured and infarcted spleen. Laparotomy was undertaken and open splenectomy was successfully performed. The patient was discharged after an uneventful postoperative course that was not punctuated by any major complication. Management of this rare surgical emergency is discussed. Based on the details of this case, the authors hypothesize that IgA deficiency causes splenomegaly, which in turn predisposes to ligamentous laxity and splenic torsion.

A 39-year-old woman was referred to our department inJune 2004 with a 1-month history of anemia, recurrent ab-dominal pain, and abdominal distention. She had had a ma-lignant melanoma excised from her back with a sentinelnode biopsy in the axilla, which was considered positive formicrometastases (June 2003); the patient received Kirkwoodinterferon-α2b adjuvant therapy for one year with good tol-erance.Abdominal ultrasounds revealed a mass in the right iliacfossa, and a CT scan showed submandibular nodes as wellas small-bowel intussusception at the ileum, with a largenodular tumor in this same site (Fig. 1). A surgical explo-ration was decided upon. Laparotomy revealed intussuscep-tion of the lower ileum (Fig. 2b.), which was caused bymultiple large polypoid lesions (Fig. 2a) accompanied byenlarged mesenteric lymph nodes. We performed a righthemicolectomy and resected 70 cm from the affected smallbowel and involved mesentery, followed by a side-to-sideileocolic stapled anastomosis. The pathology report con-firmed the presence of various exophytic polypoid tumorspartially occluding the lumen, which were invading the sub-mucosa. Mesenteric lymph nodes were also invaded by the same tumor, which proved to be a metastatic melanoma (pos-itive for S-100 and HMB-45).

Inflammatory myofibroblastic tumor (IMT) or inflammatory pseudotumor has been described in various organs such as the liver, intestinal tract, spleen, kidney, bladder, lung, peritoneum and heart. However, its appearance in the periampullary region is uncommon and has rarely been reported in the literature. It is characterized histologically by myofibroblastic cell proliferation together with a mixed inflammatory infiltrate that clinically and radiologically mimics a malignant tumor. We report a case of IMT located in the distal common bile duct of a 51-year-old woman. She underwent Whipple resection with the initial diagnosis of cholangiocarcinoma; the pathologic diagnosis of the tumor was IMT of the distal bile duct associated with lymphoplasmacytic sclerosing pancreatitis. Referring to previously reported cases, suspected diagnosis of a malignant tumor made surgical excision the primary choice for symptom relief and in order to obtain a definitive diagnosis. IMT relationship with lymphoplasmacytic sclerosing pancreatitis is discussed.

To evaluate the efficiency of laparoscopic cholecystectomy for the treatment of gallstones.Retrospective/prospective multicentric study undertaken by the Department of Surgical Endoscopy of the Spanish Association of Surgeons. Data were introduced into a computerized protocol. Statistical analysis with SPSS 4.0 applying the Student's T test and Pearson's chi square.69 surgeons from 40 Hospitals who have performed laparoscopic cholecystectomies in 2432 patients, diagnosed of gallstones, with an average age of 49 years (9-91) and 80% in women.The operation was completed in 94% of the cases and lasted on an average of 75 minutes (20-120). Surgical findings were 2380 non complicated gallstones, 185 acute cholecystitis (7.6%) and 265 scleroatrophic gallbladders (11%). Intraoperative cholangiography was performed in 9% and gallstones in the common bile duct were diagnosed in 2%, of which 0.3% were treated by laparoscopy and 1% by post-operative endoscopic sphinterotomy Five per cent were converted to laparotomy, of which 29% (1.5% of total patients) were obligatory conversions. Among postoperative complications there were 0.4% lesions due to abdominal puncture, 0.4% lesions of the common bile duct and 2.5% hemorrhages. Post-operative complications were seen in 7.5% of patients. The most frequent complications affected the surgical wounds (3%), whereas bile duct complications represented 0.6% and were most frequent in the series of less than 50 patients. Mortality was 0.12%. Average post-operative hospital stay was 2.5 days (0.5-5).In Spain, laparoscopic cholecystectomy is an effective and safe procedure with results which are comparable to other multicentric studies published in other countries, with a morbidity-morbility index similar to open cholecystectomy and the great added advantage is the avoidance of laparotomy and its inconveniences (pain, longer hospital stay...) and complications.

We describe a case of spontaneous perforation of the esophagus (PEE) that was satisfactorily treated by thoracotomy, primary closure and reinforcement of the suture with a gastric fundal patch (Thal plasty). Emphasis is placed on the need to establish an early diagnosis and the essential points of treatment to obtain a favorable outcome.

En la actualidad el tratamiento de las hernias paraesofágicas (HPE) sigue siendo controvertido. El motivo de este trabajo es llevar a cabo una revisión de la bibliografía en base a por qué se indica la cirugía de estas hernias y cuál de las técnicas existentes es la más adecuada para cada paciente. Se ha intentado profundizar en el estado actual del uso de las mallas en el hiato esofágico, y en el caso de usarlas, sobre los materiales más apropiados para la reparación de los defectos herniarios. En este trabajo se ha elaborado una base de datos de las intervenciones quirúrgicas realizadas por hernias de hiato, llevadas a cabo en el Complejo Hospitalario Universitario de Canarias desde el periodo que abarca desde el 2013 al 2017, donde se ha hecho hincapié en la técnica practicada, en el uso o no de malla, y en el caso de usarla qué tipo, y por último en la evolución de los pacientes operados. El objetivo de este trabajo consiste en comparar nuestra serie con la literatura, y a su vez hacer una revisión de la misma planteando la controversia que existe acerca de cuál es el tratamiento quirúrgico más adecuado y si se debe utilizar mallas o no. Nowadays paraesophageal hernia treatment is still under debate. The purpose of this project is to accomplish a revision of the literature based on why is indicated the hiatal hernia surgery and which techniquesisthe most adequate for each patient. It has been tried to delve into the current use of meshes in esophageal hiatus, and in case of use it, what materials are the most suitable for the hernia defects. In this study it has been developed a data base focused on surgical procedures for hiatal hernia perforned in Complejo Hospitalario Universitario de Canarias from 2013 to 2017, emphasizing the surgical technique, the use of mesh or not, and in case of using it, which type, and finally, the monitoring progress for each patient. The objective of this study is to compare our case series with the literature, and at the same time make a revision suggesting the current controversy about which is the most convenient surgical treatment and in which scenario the mesh must be used or not.