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Introduction Given the difficulty in accessing to the excluded stomach after gastric bypass and the increase in gastroesophageal reflux after sleeve gastrectomy, it is justified to perform a preoperative fibrogastroscopy.The influence of the fibrogastroscopy (FGS) findings in the therapeutic approach is analyzed. Patients and methods A retrospective study of preoperative FGS findings is performed, from 04/06 to 12/12. The influence of the FGS results on the surgical technique selection, in the endoscopic or medical treatment and its relation to gastric fistula is analyzed by means of multivariate regression (confounding factors: Age, body mass index, arterial hypertension, diabetes mellitus, antiplatelet therapy, surgical technique (bariatric surgery, sleeve gastrectomy). Results Three hundred thirty one patients are included: 32.6% biopsy of gastric lesion; 27% gastritis; 18.1% hiatal hernia; 3% metaplasia; 0.6% Barrett esophagus; 2.1% esophagitis; 0.3% dysplasia; 0.3 Schatzky´s ring; 1.5% incompetent cardia; 2.4% duodenitis; 0.3% gastric erosions; 0.6% gastric xanthoma; 1.8%, gastric polyp; 1.6% duodenal ulcer; 0.6% papulo-erosive gastritis; 0.6% esophageal papilloma; 0.3% submucosal tumor. Helicobacter pylori+ 30.2% (triple therapy eradication in all patients). The FGS findings led to a variation in the surgical technique or to the completion of endoscopic treatment in 22.2% of cases.The gastric lesions did not influence the development of gastric fistula. Independent prognostic factors of fistula: Sleeve gastrectomy (7.9% vs. 2.7%; p = 0.02; OR: 1.38 IC95: 1.01-1.87) and the body mass index > 50 kg/m2) (6.7% vs. 2.2%; p = 0.04; OR: 3.7 IC95: 1.12-12.4). Conclusions The diagnosis of gastroesophageal disease through preoperative FGS motivated variations in the therapeutic approach in 52% of patients, so we consider essential to include the preoperative FGS in bariatric surgery.

Resumen Objetivo Analizar de forma critica las complicaciones a largo plazo y los resultados funcionales de una serie de pacientes con reservorio ileoanal para proporcionar a los candidatos a proctocolectomia total una informacion detallada y objetiva sobre las ventajas e inconvenientes de dicha tecnica. Pacientes y metodos Se han estudiado los datos clinicos y patologicos de 141 pacientes a los que se realizo un reservorio ileoanal entre 1985 y 2000. Se han analizado las complicaciones inmediatas y a largo plazo, asi como los resultados funcionales y el grado de satisfaccion de los pacientes mediante entrevista directa o telefonica. Resultados La morbilidad postoperatoria fue del 36%, y requirio reintervencion el 13,4% de los pacientes. Las complicaciones a largo plazo mas frecuentes fueron la reservoritis (18%) y las fistulas perianales o reservoriovaginales (13%). Ambas se asocian con un nivel de satisfaccion medio-bajo (p Conclusiones Los reservorios ileoanales se acompanan de una morbilidad moderada y buenos resultados funcionales, que los candidatos a una proctocolectomia total deben conocer para poder tomar una decision conjunta acerca de la tecnica a realizar en cada caso.

In the original article, an author was missing from the author’s list. Dr. Felipe de la Cruz should be added as a co-author for his work in the study design and review process.

Morbid obesity is a serious health problem whose prevalence is increasing. Expensive co-morbidities are associated to these patients, as well as a reduction in the survival. Bariatric surgery resolves the co-morbidities (type 2 diabetes mellitus, 86.6%; cardiovascular risk, 79.0%; obstructive sleep apnea syndrome, 83.6%; hypertension, 61.7%), reduces the mortality rate (among 31-40%), and increases the morbid obese patients survival over a 10-years period. It provides significant savings for the National Health System. The obese patients consume a 20% plus of health resources and 68% plus of drugs than general population. Bariatric surgery requires an initial investment (diagnosis-related group cost: 7,468 €), but it is recovered in a cost-effectiveness ratio of 2.5 years. Significant savings are obtained from the third year. To the direct economic benefits associated with reduced health expenditures it should be added an increase in tax collection (sick leave and unemployment reduction is estimated in 18%, with a productivity increase of 57% for self-employed people). Bariatric surgery is one of the most cost-effective procedures in the healthcare system.

We present the case of a cirrhotic patient with ascites and an albumin gradient of less than 1.1 g/dl. After endoscopic tests, including upper gastrointestinal endoscopic ultrasound-guided fine-needle aspiration, exploratory laparoscopy was performed to provide the diagnosis, revealing mucin throughout the peritoneal cavity and nodules on the parietal and visceral peritoneum. Histopathological analysis established the diagnosis as peritoneal pseudomyxoma. This uncommon entity, which has a poor prognosis without treatment, is most frequently associated with mucinous tumors of the appendix, and secondly, with tumors of the ovary.

We present the case of a cirrhotic patient with ascites and an albumin gradient of less than 1.1 g/dl. After endoscopic tests, including upper gastrointestinal endoscopic ultrasound-guided fine-needle aspiration, exploratory laparoscopy was performed to provide the diagnosis, revealing mucin throughout the peritoneal cavity and nodules on the parietal and visceral peritoneum. Histopathological analysis established the diagnosis as peritoneal pseudomyxoma. This uncommon entity, which has a poor prognosis without treatment, is most frequently associated with mucinous tumors of the appendix, and secondly, with tumors of the ovary.

The makeup of a new surgical bariatric team may be associated with a higher number of postoperative complications due to the learning curve. The aim of this study was to evaluate the outcomes during the learning curve of laparoscopic gastric bypass (LGBP) depending on surgeons' training. A systematic approach was used to review studies from the Pubmed, Embase (Ovid), Cancer Lit, Biomes Central via Scirus, Current Contens (ISI), and Web of Science (SCI) databases. Two reviewers independently screened all titles/abstracts and included/excluded studies based on full copies of manuscripts. The outcomes included were: specific training of the surgeon, postoperative complications (leaks, occlusion, hemorrhage, pneumonia, etc.), mortality, and surgical technique. One reviewer put data onto an Excel spreadsheet. Statistical analysis was performed with weighted linear regression. We identified 448 citations, of which 120 abstract and 50 full-text publications were reviewed. Fourteen papers were selected. Data from 1,848 patients were included. Eighteen different surgeons were analyzed during their learning curve (including the first author of this study). Surgeons were divided into two groups: (1) without formal laparoscopic bariatric training (13 surgeons) and (2) with formal laparoscopic bariatric training (five surgeons). Postoperative complications were more frequent in group 1: 18.1% (± 7.6) vs. 7.7% (± 1.96, p = 0.046); also, mortality was more frequent in group 1: 0.57% (± 0.87) vs. 0% (p = 0.05). An appropriated training in laparoscopic bariatric surgery contributes to a significant reduction in postoperative complications and mortality during the learning curve of LGBP.

In patients undergoing gastric bypass, massive weight loss and impairment of calcium intake and absorption in the duodenum and proximal jejunum may increase the risk of bone mass loss and fractures. However, few data are available regarding the impact of this surgery on the skeleton. The aim of our study was to examine the skeletal changes in a cohort of morbidly obese Caucasian women during the first year after gastric bypass and to analyse the factors implicated in the development of bone loss.Sixty-two morbidly obese white women aged 45.3 +/- 8.9 years were studied. Anthropometric measurements, bone mineral density (BMD) screening using dual-energy X- ray absorptiometry and plasma determinations of calcium, phosphorus, parathyroid hormone (PTH), 25-hydroxyvitamin D [25(OH) D(3)] and insulin-like growth factor-I (IGF-I) were made prior to and 12 months after surgery.A year after surgery, BMD significantly decreased at the femoral neck (10.2 +/- 5.7%) and at the lumbar spine (3.2 +/- 4.4%). In the follow-up, 16.1% of women had osteopenia at the femoral neck and 19.3% at the lumbar spine, and 1.6% developed osteoporosis at the lumbar spine. Patients with bone disease were significantly older; the percentage of women with menopause was greater in this group and had lower initial and final values of lean mass. However, no differences in body mass index, weight loss, fat mass, calcium, PTH, 25(OH) D(3) or IGF-I values were found between groups. In the logistic regression analysis, lean mass 12 months after surgery and menopause were found to be the main determinants of osteopenia after adjusting for age with odds ratios of 0.82 and 9.13, respectively.There is a significant BMD loss at the femoral neck and lumbar spine a year after gastric bypass. Menopausal patients and those with greater lean mass loss are at greater risk and, consequently, should be closely followed up with periodic densitometries.

Reports on laparoscopic sleeve gastrectomy (LSG) communicate very good short-term results on very high-risk morbid obese patients. However, mid- and long-term results are still unknown. A National Registry has been created in Spain to achieve information on the outcomes of this bariatric procedure.Data were obtained from 17 centers and collected in a database. Technical issues, preoperative comorbid conditions, hospital stay, early and late complications, and short- and mid-term weight loss were analyzed.Five hundred forty patients were included; 76% were women. Mean BMI was 48.1 +/- 10. Mean age was 44.1 +/- 11.8. Morbidity rate was 5.2% and mortality rate 0.36%. Complications presented more frequently in superobese patients (OR, 2.8 (1.18-6.65)), male (OR, 2.98 (1.26-7.0)), and patients55 years old (OR, 2.8 (1.14-6.8)). Staple-line reinforcement was related to a lower complication rate (3.7 vs 8.8%; p = 0.039). Mean hospital stay was 4.8 +/- 8.2 days. Mean follow-up was 16.5 +/- 10.6 months (1-73). Mean percent excess BMI loss (EBL) at 3 months was 38.8 +/- 22, 55.6 +/- 8 at 6 months, 68.1 +/- 28 at 12 months, and 72.4 +/- 31 at 24 months. %EBL was superior in patients with lower initial BMI and lower age. Bougie caliber was an inverse predictive factor of %EBL at 12 and 24 months (RR, 23.3 (11.4-35.2)). DM is remitted in 81% of the patients and HTA improved in 63.2% of them. A second-stage surgery was performed in 18 patients (3.2%).LSG provides good short- and mid-term results with a low morbid-mortality rate. Better results are obtained in younger patients with lowest BMI. Staple-line reinforcement and a thinner bougie are recommended to improve outcome.

Background and aims: The prognostic value of the degree of apoptosis in colorectal cancer is controversial. This study evaluates the putative clinical usefulness of measuring caspase-3 activity as a prognostic factor in colonic cancer patients receiving 5-fluoracil adjuvant chemotherapy. Materials and methods: We evaluated caspase-3-like protease activity in tumours and in normal colon tissue. Specimens were studied from 54 patients. These patients had either stage III cancer (Dukes stage C) or high-risk stage II cancer (Dukes stage B2 with invasion of adjacent organs, lymphatic or vascular infiltration or carcinoembryonic antigen [CEA]>5). Median follow-up was 73 months. Univariate analysis was performed previously to explore the relation of different variables (age, sex, preoperative CEA, tumour size, Dukes stage, vascular invasion, lymphatic invasion, caspase-3 activity in tumour and caspase-3 activity in normal mucosa) as prognostic factors of tumour recurrence after chemotherapy treatment. Subsequently, a multivariate Cox regression model was performed. Results: Median values of caspase-3 activity in tumours were more than twice those in normal mucosa (88.1 vs 40.6 U, p=0.001), showing a statistically significant correlation (r=0.34). Significant prognostic factors of recurrence in multivariate analysis were: male sex (odds ratio, OR=3.53 [1.13-10.90], p=0.02), age (OR=1.09 [1.01-1.18], p=0.03), Dukes stage (OR=1.93 [1.01-3.70]), caspase-3 activity in normal mucosa (OR=1.02 [1.01-1.04], p=0.017) and caspase-3 activity in tumour (OR=1.02 [1.01-1.03], p=0.013). Conclusion: Low caspase-3 activity in the normalmucosa and tumour are independent prognostic factors of tumour recurrence in patients receiving adjuvant 5-fluoracil-based treatment in colon cancer, correlating with poor disease-free survival and higher recurrence rate. © Springer-Verlag 2007., This work was supported by the Spanish government through project FISS 01/1260

The aim of this study was to analyze factors related to morbidity and mortality after gastric bypass and to evaluate lower-risk alternatives in selected patients.A prospective cohort of 761 patients who underwent gastric bypass was included. Prognostic factors were studied using a logistic regression model with SPSS 11.0. Independent variables were age, sex, body mass index (BMI), comorbidities, and the laparoscopic approach. Dependent variables consisted of medical complications, surgical complications, and mortality. We performed a preliminary descriptive study of morbidity and weight loss at 3 months after sleeve gastrectomy.In the postoperative period, 2.8% of patients presented medical complications and 5.4% presented surgical complications. Mortality was 0.52%. Surgical complications were significantly associated with age45 years (P = .04; OR = 2.00 [1.03-3.8]) and male sex (P = .041; OR = 2.40 [1.12-5.14]). Medical complications were significantly associated with a BMI of50 kg/m2 (P = .012; OR = 3.32 [1.23-8.98]), and mortality was significantly associated with a BMI of50 kg/m2 (P = .006) and male sex (P = .006). Sleeve gastrectomy was performed in eight patients with a BMI of60 kg/m2, in three patients with a BMI of50 kg/m2, cardiopulmonary disease and android fat distribution, and in four patients with a BMI of between 35 and 40 kg/m2 and major comorbidity. Morbidity consisted of self-limited febrile syndrome in one patient. There was no mortality. Weight loss at 3 months was 39.8 +/- 5.36% of excess BMI in superobese patients (n = 4) and was 50.2 +/- 11.05% of excess BMI in morbidly obese patients (n = 4).Postoperative morbidity and mortality was significantly higher in male patients, in patients aged more than 45 years, and in those with a BMI of50 kg/m2. Sleeve gastrectomy in selected patients could be a lower-risk alternative.

Background: Severe obesity has been associated with impaired quality of life (QoL). We evaluated the long-term health-related quality of life (HRQoL) after gastric bypass. Methods: A cross-sectional study was conducted on 50 morbidly obese patients >5 years after gastric bypass and on a control group of 78 non-operated morbidly obese patients. Both groups were evaluated for the EuroQol 5D measure and the Goldberg General Health Questionnaire. In addition, the Bariatric Analysis of Reporting Outcome System (BAROS) was applied to the surgical group. Depression and severe life events were included in the analysis. Logistic Regresion Model was used, and age was included in the analysis. Results: Groups were similar except for mean age (lower in the surgical group: 40.5±9.0 vs 46.1±8.8 years, P=0.026). 86.5% of patients had >50% Excess Weight Loss. 85.7% showed an improvement in co-morbid conditions. BAROS Global score: 22% excellent, 56% very good, 18% good, 2% fair and 2% failure. After surgery, significant improvements were reported in self-esteem (94%), work conditions (72.6%), physical activity (66.7%), and sexual interest/activity (50.9%). The control group showed poorer results for the EuroQol 5D in mobility (55% vs 21.6%, P=0.005), difficulty with daily activity (55% vs 13.7%, P=0.005) and self-evaluation of well-being (59.2% vs 78.1%, P=0.005). Patients with depression or insufficient weight loss following surgery presented poorer global evaluation in HRQoL. Conclusion: Gastric bypass resulted in significant long-term improvements in co-morbidities, sustained weight loss and increased HRQoL. Depression and insufficient weight loss were associated with poorer HRQoL in surgical patients.

Objective Urinary dysfunction is a well-known complication of rectal surgery, secondary to injury to the autonomic nervous plexus. The object of this study was to evaluate the incidence, prevalence and type of micturition disorders following rectal cancer surgery and their reversibility during long-term follow-up. Patients and methods A prospective study of 45 patients who underwent surgery for rectal cancer between 1993 and 1998 was undertaken. Those with pre-operative urinary dysfunction were excluded after sequential uroflowmetry and clinical interview. Ten of the surgical interventions were high anterior resections, 18 low anterior resections, and 17 abdominoperineal amputations. Pre-operative radiotherapy was performed in 47.9% of patients. All patients underwent sequential uroflowmetry and a clinical interview 3 and 12 months after the intervention. Subjects who presented micturition disorders underwent urodynamic examination The follow up period was three years. Results Three months after surgery alterations were found in 14 (31.3%) patients; the most frequent were stress incontinence, urinary tenesmus and the urge to urinate. At the 12-month assessment only 6 (13.3%) patients had urinary symptomatology or uroflowmetry abnormalities. After three years, micturition disorders persisted in 3 (6.6%) patients. Conclusion Urinary dysfunction after rectal cancer excision is associated with a high degree of reversibility. Seventy-eight percent of the alterations detected after three months and 50% of those that persisted after a year disappeared during follow up.

The unexpected diagnosis of Crohn's disease (CD) after restorative proctocolectomy is a relatively frequent occurrence. We report a retrospective analysis of the long-term development of patients with an ileal pouch-anal anastomosis (IPAA) in whom the definitive anatomopathological diagnosis was CD, and compare their development with that of patients in whom the diagnosis of ulcerative colitis (UC) was confirmed. We reviewed the clinical data of 112 patients with an IPAA. The definitive diagnosis was CD in 12, and UC in the rest. The mean follow-up period was 76 months (range 12 to 192). We analyzed and compared the epidemiologic and clinical data, postoperative complications, functional results, anxiety, and quality of life in the two groups. Postoperative morbidity and the degree of satisfaction were similar in the two groups. The test showed a lower level of anxiety and higher quality of life in patients with CD. Of all the functional parameters studied, only urgency of defecation presented a higher risk in the CD group (HR: 4.13, CI: 1.41-12.04, p = 0.027). Despite the fact that a diagnosis of CD is currently considered a contraindication for an IPAA, some patients with secondary diagnosis of CD have good functional outcome and quality of life after restorative proctocolectomy. Closure of the temporary ileostomy may be justified in these patients.