Search

Introduction: For the past 20 years, robotic surgical systems have been used for the Roux-en-Y gastric bypass (RYGB). The da Vinci Surgical System (Intuitive Surgical, Inc.) has been one of the mos...

BACKGROUND: Autoimmune thyroid diseases are the most common types of autoimmune diseases, but their physiopathology is still relatively unexplored. Genotype-tissue expression (GTEx) is a publicly available repository containing RNAseq data, including profiles from thyroid. Approximately 14.8% of these glands were affected by focal lymphocytic thyroiditis and 6.3% were annotated as Hashimoto. We interrogated these data to improve the characterization of infiltrating cells and to identify new molecular pathways active in autoimmune thyroiditis. MATERIALS AND METHODS: Histological GTEx images of 336 thyroid samples were classified into three categories, that is, non-infiltrated thyroid, small focal infiltrated thyroid, and extensive lymphoid infiltrated thyroid. Differentially expressed genes among these categories were identified and subjected to in silico pathway enrichment analysis accordingly. CIBERSORTx deconvolution was used to characterize infiltrating cells. RESULTS: As expected, most of the transcriptional changes were dependent on tissue infiltration. Upregulated genes in tissues include—in addition to lineage-specific B and T cell genes—a broad representation of inhibitory immune checkpoint receptors expressed by B and T lymphocytes. CIBERSORTx analysis identified 22 types of infiltrating cells showed that T cells predominate 3:1 over B cells in glands with small infiltrates, only by 1.7:1 in those with large infiltrates. Follicular helper and memory CD4 T cells were significantly more abundant in glands with large infiltrates (p

The risk of recurrence in papillary thyroid carcinoma (PTC) is likely related to the amount of tumour in the metastatic lymph node (LN). Therefore, the current TNM classification (N0/N1) make it necessary to find a method to quantify the LN metastasis (LNM). We propose that the quantitative molecular assay One-Step Nucleic-Acid Amplification (OSNA), which measures the number of cytokeratin-19 (CK-19) mRNA copies as a marker of LNM, could play this role. Our objective was to describe the characteristics of the LNs from PTC, and to compare the morphological characteristics that have been claimed as criteria for metastatic burden with OSNA.Prospective study of LNs from 42 patients. All of the LNs were measured, weighed and analysed by OSNA and also by imprint cytology.A total of 573 LNs were included, 187 (32.6%) of them were OSNA-positives. The global consistency between cytology and OSNA was 87.4%. Significant differences were observed in the CK-19 copy number between the LNMs0.2cm and those3cm, as well as between those from 0.2 to 3cm with respect to those3cm, but not between those0.2cm and those between 0.2 and 3cm. The total tumour load per neck dissection showed no differences based on whether there were ≤5 or5 LNMs.In our series the LNMs3cm show an increased tumour load, but it is unclear if it is necessary to sub-classify the smaller ones as well as the relevance of the number of metastatic nodes according to the cut-off of 5 nodes. We consider that the OSNA analysis avoids the bias of nodal histology and allows for a greater understanding of its real oncological potential.

Resumen Una de las complicaciones mas importantes asociada la cirugia de tiroides y paratiroides es la paralisis de las cuerdas vocales secundaria a la lesion del nervio laringeo recurrente. La paralisis del nervio laringeo recurrente inducida por anestesicos locales es una rara complicacion con muy pocos casos publicados. Las tecnicas patron para el examen de las cuerdas vocales son la fibrolaringoscopia flexible y la videoestrobolaringoscopia. Sin embargo, estas tecnicas son caras, y frecuentemente se asocian con dolor y malestar para los pacientes. Considerando estas desventajas, la ecografia laringea transcutanea es una alternativa en pacientes que se someten a cirugia de tiroides y paratiroides. Presentamos un caso en el que se diagnostico ecograficamente una paralisis bilateral transitoria de las cuerdas vocales tras la infiltracion local de 10 mL de mepivacaina al 2% administrada para la revision de la herida quirurgica por un hematoma subcutaneo ocurrido despues de una paratiroidectomia subtotal.

One of the most important complications associated with thyroid and parathyroid surgery is vocal cord paralysis due to a recurrent laryngeal nerve injury. Recurrent laryngeal nerve injury paralysis induced by local anesthetics is a rare complication with very few published cases. Various techniques are available for diagnosing vocal cord paralysis, including, flexible fiberoptic laryngoscopy, videostrobolaryngoscopy and indirect laryngoscopy. However, these techniques are expensive and are often associated with pain and discomfort among patients. Considering these disadvantages, transcutaneous laryngeal ultrasound is an alternative imaging tool for vocal cord examination in patients undergoing thyroid and parathyroid surgery. We describe a case which was sonographically diagnosed a transient bilateral vocal cord paralysis after the local infiltration of 10 mL of 2% mepivacaine administered for the revision of the surgical wound due to a subcutaneous hematoma that occurred after a subtotal parathyroidectomy.

Cholelithiasis is an issue in bariatric surgery patients. The incidence of cholelithiasis is increased in morbidly obese patients. After bariatric surgery, the management maybe sometimes challenging. There is no consensus about how to deal with cholelithiasis prior to bariatric surgery.A retrospective review from our prospectively collected bariatric surgery database. Primary bariatric procedures from 2009 to 2020 were included. Prevalence of cholelithiasis and its management prior to bariatric surgery and the incidence and management of postoperative biliary events were analyzed.Over 1445 patients analyzed, preoperatively cholelithiasis was found in 153 (10.58%), and 68 out of them (44.44%) were symptomatic. Seventy-six patients had a concomitant cholecystectomy. In those cases, the bariatric procedure did not show increased operative time, length of stay, morbidity, or mortality compared to the rest of primary bariatric procedures. Twelve patients (15.58%) with previous cholelithiasis and no concomitant cholecystectomy presented any kind of biliary event and required cholecystectomy. De novo cholelithiasis rate requiring cholecystectomy was 3.86%. Postoperative biliary events both in de novo and persistent cholelithiasis population did not show any difference between the type of surgery, weight loss, and other characteristics.Cholelithiasis was present in 10.58% of our primary bariatric surgery population. Concomitant cholecystectomy was safe in our series. Non-surgical management of asymptomatic cholelithiasis did not lead to a higher risk of postoperative biliary events. The global postoperative cholecystectomy rate was equivalent to the general population.

Background: After the first laparoscopic Roux-en-Y gastric bypass (RYGB) in 1994 by Wittgrove, the introduction of robot-assisted procedures was the next step in the surgical race to reduce invasiv...

Introduction: Obesity remains a major public chronic disease, and the multifactorial components of its relapse in many patients remain inevitable. Methods: This article provides a panoramic view of the most commonly performed revisional bariatric surgery (RBS). RBS is a complex procedure; thus, primary procedures should be well chosen and performed to avoid the increasing number of RBS cases. Results: Bariatric surgery is the only successful long-term treatment for obesity. However, a proportion of primary bariatric surgeries has failed during the follow-up period. In recent decades, the solution for these complications is by performing RBS. It is mandatory to understand obesity as a chronic disease to appropriately treat patients. Treatment strategies are needed to determine the indications for revision. RBS requires a meticulous evaluation to facilitate good long-term results. Conclusions: Treatment strategies will be a fundamental pillar to wisely determine the indications for revision and identify the factors influencing failure by prudently and rationally evaluating the revisional procedure that the patient will benefit from and acquiring a high level of surgical skills.

This study compares laparoscopic RYGB (L-RYGB) and robotic RYGB (R-RYGB) performed by the same team after the learning curve in both approaches. A retrospective cohort study was done, and the surgical outcome was analyzed in 30 days and 12 months for patients with similar characteristics and an equal number of cases in each group (233 cases). Four hundred and sixty-six patients were included in this study. Mean age was 46.8 ± 8.3 years and 2/3 were women. R-RYGB presented a longer operative time (150.7 versus 135.4 min; p 0.001) with no differences in the length of hospital stay. The main 30-day complications were G-J stricture, leakage, and intraluminal bleeding. The reoperation rate was 1.6% by leakage (G-J anastomosis) and was higher in R-RYGB (2.1 versus 0.4; p = 0.108). The multivariate analysis identified that L-RYGB was the factor independently associated with a LOS longer than 2 days (odds ratio: 4.7, 95% CI: 2.6-8.2, p value 0.001). At the FU time (12 months), no differences between the groups were found. The outcomes between the groups after the learning curve did not present differences in terms of 30 days and 12 months of FU when same preoperative characteristics and an equal number of cases in each group are considered. L-RYGB was the unique independent factor associated with long LOS.

Resumen Introducción: la obesidad en el siglo XXI continúa siendo un problema de salud mundial, la cirugía bariátrica, en la actualidad, es el único tratamiento exitoso a largo plazo para el manejo de ésta y sus comorbilidades, ha tenido un incremento importante en los últimos años apareciendo complicaciones que son objetivos de la cirugía revisional. Objetivos: el presente artículo pretende evaluar las principales cirugías revisionales que han permeado en el campo de la cirugía bariátrica así como nuestra experiencia en los últimos años. Material y métodos: análisis estadístico descriptivo de una cohorte retrospectiva de pacientes sometidos a cirugía de revisión en el Hospital Universitario Vall d'Hebron de Barcelona, España. EAC-BS Center of Excellence. Resultados: se han realizado 1.890 cirugías bariátricas desde los inicios de la cirugía bariátrica en nuestra Unidad hasta el 31 de julio de 2019. 143 (7,56%) corresponden a cirugías de revisión. Las más frecuentes fueron la conversión de gastrectomía vertical (GV) a bypass gástrico (BPG) 30,76% y a SADI-S 20,97%. Dentro de éstas, las principales indicaciones se encuentra el reflujo esofagogástrico (RGE) en un 30,76% y pérdida inadecuada de peso 20,97% en la GV. El BPG requirió conversión a GV en 12,58% y revisión de BGP en 7,69% principalmente por hipoglucemias. Conclusiones: el incremento de cirugía primaria para la obesidad implica que un porcentaje considerable de procedimientos primarios presentarán algún tipo de indicación que requerirá revisión. La cirugía revisional requerirá una evaluación meticulosa debería permitir dar un buen manejo a largo plazo.

Sleeve gastrectomy (SG) has become one of the most performed bariatric procedures worldwide. Its main weaknesses are weight regain and gastroesophageal reflux disease (GERD). Conversion to Roux-en-Y gastric bypass (RYGB) is considered the gold standard to manage GERD and related symptoms. Retrospective evaluation from a prospective bariatric surgery database of all our institution’s patients converted from SG to RYGB due to GERD between January 2010 and December 2018. Clinical characteristics and workups before SG and before and after RYGB were analyzed. During the study period, 35 patients needed a conversion to RYGB, due to GERD or GERD-related symptoms. Mean age was 48.6 years, 85.7% were women, and mean BMI was 31.4 kg/m2. The interval between SG and RYGB was in a range 7 to 70 months (mean 33 months). All conversions were completed laparoscopically, associating a hiatoplasty in 45.7% of cases. A complete remission of symptoms was observed in 74% of patients, some improvement in 20%, and no relief in 6%. There were 3 cases of hiatal hernia persistence and 2 of recidivism. Only 1 patient presented pathological pHmetry, while moderate esophagitis was demonstrated in 2 patients. Conversion to RYGB was effective in almost all patients. Pathological acid exposure and hiatal hernias seem to be the main findings prior to conversion, justifying an exhaustive examination and aggressive approach to the hiatus. Due to the insufficient correlation between symptoms and findings on morphological and functional tests, actively searching for signs of GERD is advisable.

Background. Laparoscopic Roux-en-Y gastric bypass (GBP) is an essential bariatric surgical procedure which is globally performed because of the associated effective weight loss and resolution of metabolic comorbidities, such as diabetes and dyslipidemia. Although some complications may occur, hypoglycemia is a rare complication, which can lead to lethal consequences. We aimed to describe the technical aspects and surgical results after reversal to normal anatomy (RNA). Methods. We conducted a retrospective data analysis including 16 patients who underwent laparoscopic RNA from 2011 to 2018. All data were archived in a prospective database. Previous bariatric surgery and postoperative outcomes were analyzed. Results. Sixteen patients underwent RNA, most of them after GBP, and 15 patients required sleeve gastrectomy. Among them, 80% were women; 5 patients presented with postoperative complications, such as colitis with intra-abdominal collection (n = 1), gastric leak (n = 2) treated with an endoprosthesis, mesenteric venous thrombosis (n = 1), and intra-abdominal bleeding (n = 1). Mean length of hospital stay was 5.93 (3-30). All patients recovered from their initial condition although 3 patients presented with mild hypoglycemia during follow-up. Seven patients regained weight (43.75%), and another 4 developed gastroesophageal reflux disease (25%). Conclusions. These laparoscopic RNA results are acceptable, indicating a clinical improvement in the hypoglycemic syndrome in all patients.

Purpose The COVID-19 outbreak has forced a 2-month lockdown (LD) in Spain. We aimed to assess how that had affected our cohort of bariatric patients waiting for surgery. Methods A review of electronic records and a structured phone interview with each patient were conducted. Changes in severity of obesity were analyzed using the Obesity Surgery Score (OSS) and changes in health-related quality of life (HRQoL) using the validated EQ-5D questionnaire. Other miscellaneous questions about behavior modifications and surgical risk perception were also analyzed. Results All 51 patients fully answered the questionnaires. Mean age was 47 years and mean time on waiting list 91 days. Mean BMI increased during LD (42.7 vs 43.2; p < 0.001). Both OSS (2.84 vs 3; p = 0.011) and EQ-5D (69 vs 64; p < 0.001) mildly worsened during LD, mainly due to psychosocial issues. Twenty-seven patients (53%) thought that perioperative risks were higher under the current circumstances but they were as willing to undergo surgery as those who believed that the risks had not increased (74% vs 87%, p = 0.2). Conclusions COVID-19 LD had a significant but mild effect on our cohort of bariatric surgery waiting list patients. Although perioperative risk perception had increased, patients were still willing to undergo their planned surgeries.

The primary aim of this study was to assess the effectiveness of sleeve gastrectomy (SG) in super-obese patients. The secondary aim was to identify patient characteristics associated with worse SG outcomes in this group.A retrospective analysis was carried out of our electronic prospective bariatric surgery patient database, including all patients who underwent SG between January 2007 and January 2017. The sample was divided according to the initial body mass index (BMI) (or50 kg/m). The initial characteristics and results in terms of weight loss and comorbidity resolution between the groups were compared. A subanalysis of the variable distributions was carried out according to whether or not the final BMI in the super-obese group had reached35 kg/m. Data analysis was carried out using STATA 13.1, with a P-value0.05 considered to be significant.The mean initial BMI was 42.8 kg/m in group 1 (50 kg/m) and 55 kg/m in group 2 (50 kg/m). The median follow-up (FU) was 56.2 months. Maximum weight loss was attained at the 18-month FU in both groups (BMI: 28.8 and 34.7 kg/m, respectively). At the 5-year FU, percentage of total weight loss was higher in group 2 and percentage of excess weight loss was statistically higher in group 1 (29.6% vs. 33.1% and 67% vs. 59%, respectively). Outcomes for type 2 diabetes mellitus, hypertension, and dyslipidemia were similar in both groups. The variables associated with attaining a final BMI35 kg/m in the super-obese group were lower initial BMI, absence of baseline weight-related conditions (type 2 diabetes mellitus, obstructive sleep apnea syndrome, home continuous positive airway pressure, arthropathy, heart disease), and absence of gastroesophageal reflux disease.We observed a statistically significant increase in poor outcomes in patients with a higher initial BMI and with weight-related comorbidities. These parameters could be considered to be potentially good predictors of less satisfactory outcomes in the super-obese patients.

Nowadays, laparoscopic sleeve gastrectomy (LSG) is one of the most widely performed bariatric procedures. Different techniques have been described to reduce the rate of complications associated with the staple line, but no consensus has been reached. The aim of this study was to determine the incidence of surgical complications after LSG with three different approaches to the staple line. A retrospective matched analysis was performed, comparing three groups of 100 patients each: partial oversewing of the staple line (PO group), complete oversewing of the staple line (CO group), and reinforcement with buttress material (BM group). Operative time, early surgical complications (superficial surgical site infection, leakage and hemorrhage), length of stay, weight evolution, and revisional surgery rates were analyzed. All three groups were comparable at baseline. All surgeries were performed laparoscopically. Operative time was significantly longer in the CO group (PO: 84.2 ± 22; CO: 104.7 ± 17; BM: 82.3 ± 22; PO vs CO, p = 0.021; BM vs CO, p = 0.011). There were no differences in length of stay, early surgical complications, and weight outcomes at 36 months between the groups. The need for a revisional surgery was significantly higher in the CO group compared to the PO group (PO: 3%; CO: 14%; BM: 9%; PO vs CO, p = 0.005). The CO group required a longer operative time. There were no differences in early surgical complications between the groups. The CO group had a higher need for revisional surgery than the PO group.

Background: Laparoscopic sleeve gastrectomy (LSG) is now one of the most common surgical procedures worldwide. It was initially defined for staged procedures in super or super-super obese, or in ve...

Seasonality is a phenomenon that is characterized by changes over the year in sleep, mood, behaviour, appetite and body weight. In humans, seasonal variations have been found in certain variables, such as lipid variables and body mass index. We hypothesize that this rhythm could influence the expected variation of the levels of biochemical variables in cases of body weight loss. Thus, the goal of this study was to observe whether the time of year in which bariatric surgery (BS) took place modulated the changes in several variables related to glucidic and lipid metabolism. Blood samples were obtained from 24 women and 10 men before BS and 1 and 3 months after BS. We calculated the percentage of variation that occurred for each individual and for each variable as a function of the time of the year. Data were adjusted to a 12-month period sinusoidal curve, with significance being set at p 0.05. The results showed that almost all of the studied variables changed due to the BS according to a seasonal rhythm. Most of the variables showed a decrease that was most prominent in winter. In the cases of body mass index (BMI), adrenocorticotropin hormone (ACTH), and cortisol, the highest variation occurred in winter. Insulin and cholesterol in high-density lipoproteins (cHLD) variations were higher in springtime. Glucose variation showed a decrease after surgery with acrophase in summer-fall and plasminogen activator inhibitor-1 (PAI-1) and homeostatic model assessment-insulin resistance (HOMA-IR) in spring-summer. Ghrelin levels showed increases with a rhythm of variation with an acrophase in summer-fall. The seasonal rhythm found in this study fits nearly with the inverse of the endogenous circannual rhythm of the variables studied. The time of the year when the highest variation takes place is related to the circannual rhythm of the variable. The results agree with the manifestation of seasonal rhythm in human biochemical variables, which are reflected in the responses to weight loss after BS.

Introduction Lymphadenectomy is recommended during surgery for papillary thyroid carcinoma when there is evidence of cervical lymph node metastasis (therapeutic) or in high-risk patients (prophylactic) such as those with T3 and T4 tumors of the TNM classification. Selective sentinel lymph node biopsy may improve preoperative diagnosis of nodal metastases. Objective To analyze the results of selective sentinel lymph node biopsy in a group of patients with papillary thyroid carcinoma and no evidence of nodal involvement before surgery. Patients and method A retrospective, single-center study in patients with papillary thyroid carcinoma and no clinical evidence of lymph node involvement who underwent surgery between 2011 and 2013. The sentinel node was identified by scintigraphy. When the sentinel node was positive, the affected compartment was removed, and when sentinel node was negative, central lymph node dissection was performed. Results Forty-three patients, 34 females, with a mean age of 52.3 (±17) years, were enrolled. Forty-six (27%) of the 170 SNs resected from 24 (55.8%) patients were positive for metastasis. In addition, 94 (15.6%) out of the 612 lymph nodes removed in the lymphadenectomies were positive for metastases. Twelve of the 30 (40%) low risk patients (cT1N0 and cT2N0) changed their stage to pN1, whereas 12 of 13 (92%) high risk patients (cT3N0 and cT4N0) changed to pN1 stage. Conclusions Selective sentinel lymph node biopsy changes the stage of more than 50% of patients from cN0 to pN1. This confirms the need for lymph node resection in T3 and T4 tumors, but reveals the presence of lymph node metastases in 40% of T1–T2 tumors.

Resumen Introduccion La linfadenectomia en la cirugia del carcinoma papilar de tiroides se aconseja cuando hay evidencia de metastasis ganglionar cervical (terapeutica) o en pacientes de alto riesgo (profilactica), como en los tumores T3 y T4 de la clasificacion TNM. La tecnica de la biopsia selectiva del ganglio centinela puede mejorar el diagnostico prequirurgico de las metastasis ganglionares. Objetivo Analizar el resultado de la biopsia selectiva del ganglio centinela en un grupo de pacientes con carcinoma papilar de tiroides T sin evidencia de afectacion ganglionar antes de la cirugia. Pacientes y metodo Estudio retrospectivo, unicentrico en el que se incluyeron los pacientes intervenidos entre los anos 2011-2013 que fueran clinicamente N0. La identificacion del ganglio centinela se realizo mediante tecnica isotopica. En todos los casos, se practico linfadenectomia del compartimento afecto si el ganglio centinela era positivo, y del compartimento central en caso de ganglio centinela negativo. Resultados Se incluyeron 43 pacientes, 34 mujeres, con una edad media de 52,3 (±17) anos. De los 170 ganglios centinela resecados, 46 (27%) fueron positivos para metastasis, que correspondian a 24 (55,8%) pacientes. En las linfadenectomias se resecaron 612 ganglios. De ellos, 96 (15,6%) fueron positivos para metastasis. Doce de los treinta (40%) pacientes cT1N0 y cT2N0 pasaron a pN1 tras la biopsia selectiva del ganglio centinela, mientras que 12 de los 13 (92%) pacientes cT3N0 y cT4N0, acabaron siendo pN1. Conclusiones La biopsia selectiva del ganglio centinela recalifica mas del 50% de pacientes de cN0 a pN1. Se confirma la necesidad de vaciamiento ganglionar en los tumores T3 y T4, pero pone al descubierto la presencia de metastasis linfaticas en el 40% de los T1-T2.

Laparoscopic single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) is a recently developed one- or two-stage operation based on biliopancreatic diversion that is used to treat morbid obesity. Some midterm outcomes suggest that malabsorption is a possible complication following the procedure. Therefore, conversion to a less malabsorptive procedure may be required. We aim to describe and analyze the outcomes after laparoscopic conversion of SADI-S to non-malabsorptive or less malabsorptive procedures. From January 2015 to April 2017, five patients underwent laparoscopic conversion to single anastomosis duodenojejunal bypass with sleeve gastrectomy (SADJ-S) (video) following SADI-S, and one female patient underwent laparoscopic conversion to gastric bypass (GBP) following SADI-S, after presenting with severe protein-calorie malnutrition, nutritional deficiencies, poor quality of life, or increased number of bowel movements. Mean preoperative BMI was 24.0 kg/m2 (20.4–27.5 kg/m2). Four patients underwent SADI-S to SADJ-S conversions and one underwent a SADI-S to Roux-en-Y duodenojejunal bypass. All cases were performed laparoscopically. No relevant postoperative complications or mortality was reported and the mean hospital stay was 4.6 days. Malabsorptive symptoms resolved in all patients. All patients experienced weight regain. Mean BMI increase was 7.1 kg/m2 (5–10.8 kg/m2). Outcomes of laparoscopic conversion to SADJ-S or GBP after SADI-S were acceptable, showing clinical improvement of malnutrition, nutritional deficiencies, and quality of life in all cases. Weight regain must be advised. These techniques appear feasible and free of severe long-term complications. Further investigation is warranted to understand the best common channel length for patients undergoing SADI-S.

Altres ajuts: The authors want to thank the Dr. Vilallonga Foundation for the financial support in the preparation of this article (http://www.fundacioramonvilallonga.org). Necrotizing 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.

An important percentage of the patient, undergoing primary or revisional bariatric surgery after sleeve gastrectomy, presents symptomatic gastroesophageal reflux disease (GERD). When and how surgical reinforcement of the lower esophageal sphincter should be performed to prevent acid reflux is still controversial. Here, we describe laparoscopic ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with the previous conversion of gastric bypass to sleeve gastrectomy and hiatal hernia repair. We present the surgical technique performed on a patient with initial gastric bypass who underwent sleeve gastrectomy for hypoglycemia and hiatoplasty for severe GERD. Persistent GERD requested to undergo ligamentum teres cardiopexy. Ligamentum teres cardiopexy combined with the closure of the gastric crus is a late alternative treatment for GERD in patients with previous sleeve gastrectomy and hiatal hernia.

Seasonal variations have been described in humans in several variables such as sleep, mood, appetite, food preferences, or body weight. We hypothesized that these variations could also influence the decrease in body weight rate in patients submitted to body weight loss interventions. Thus, here we tested the variations of weight loss according to the time of the year the surgery took place in a group patients (n = 1322) submitted to bariatric surgery in the Hospital Universitari de la Vall d'Hebron in Barcelona (geographical coordinates: 41°25'41″N 2°8'32″E). For the analysis, the percentage of total body weight loss (%TWL), excess body weight loss (%EWL) and percentage of body mass index loss (%BMIL) were calculated at 3 (n = 1255), 6 (n = 1172), 9 (n = 1002), and 12 months (n = 1076) after surgery. For %EWL and %BMIL a statistically significant seasonal variation was detected when the variables were calculated at 3 months, but not at the other times, with more weight loss in summer-fall. However, seasonal variations were not detected for %TWL (p = 0.09). The mean amplitude of the seasonal rhythm for %EWL was of 1.8%, while for the rhythm of %BMIL was 0.7%. Moreover, a second peak was detected in January-February modulating the seasonal rhythm of the two variables. Results confirm seasonal variations in humans and indicate that short term responses to weight loss can be modulated by the time of year.

Background: Robotic bariatric surgery (RBS) has increased in recent years. Many doubts continue to exist regarding its utility in terms of postoperative complications, costs and technical aspects. RBS has increased its number and shows a more technical challenge associated with more post-operative complications compared to primary bariatric surgery. We herein present a single institution experience and review to describe its utility in revisional surgery. Methods: A retrospective review of our experience and a review of the literature has been conducted to evaluate the impact of robotic revisional surgery in the bariatric field. Results: A total of 17 patients (5 female and 12 male) were operated on. Most frequent surgery was conversion of sleeve gastrectomy to gastric bypass (n=9). No leaks were found nor severe complications. A systematic review showed similar results including a decreased number for complications when performing robotic revisional surgery. Conclusions: Revisional robotic surgery shows better results compared to standard laparoscopic revisional bariatric surgery in terms of efficacy, safety and hospital stay. No differences were seen in rates of mortality, morbidity and reintervention between both approaches. We encourage surgeons to learn to perform the robotic technique as part of the process of democratization and standardization of bariatric surgery.

Objective Lymphadenectomy in papillary thyroid carcinoma (PTC) is controversial. It is indicated whenever metastases have been proven before or during surgery and as a prophylactic treatment in high-risk patients. However, 30–50% of cN0 patients become pN1 postoperatively. In PTC, selective-sentinel-lymph-node-biopsy (SLNB) with conventional intraoperative analysis is 8% false negative. One-step nucleic acid amplification (OSNA) is a molecular technique which allows real-time detection of mRNA encoding for cytokeratin 19. OSNA has been introduced in intraoperative analysis of several tumors to reduce false-negative rates and distinguish micrometastasis from macrometastasis. Our objective was to evaluate the impact of the introduction of OSNA in the intraoperative evaluation of the sentinel node (SN) in PTC. Design We analyzed a series of 35 patients subjected to SLNB. Methods All the dissected nodes, SN and non-SN, were evaluated with OSNA and cytology. Results We obtained a total of 110 SN. SLNB proved positive in 14 patients (40%) with cytology and in 23 (65.7%) with OSNA (P P = 0002). The majority of patients with micrometastasis in SN showed only micrometastasis in lymphadenectomy. Conclusions The present study shows selective-sentinel-lymph-node-biopsy with one-step nucleic acid amplification technique to be feasible in papillary thyroid carcinoma. The quantitative nature of one-step nucleic acid amplification paves the way toward a more personalized surgical approach, limiting lymphadenectomy to patients with intraoperative evidence of macrometastasis in the sentinel node.

Highlights • Adrenergic hyperstimulation states can lead to different grades of myocardial dysfunction. • Cardiomyopathy of unknown origin can be caused by an underlying pheochromocytoma. • The onset of adrenergic myocardiopathy as cardiogenic shock is exceptional. • The reversibility of myocardial affection is common after pheochromocytoma resection. • Delayed phechromocytoma resection may lead to irreversible cardiac affection and death., Introduction Pheochromocytomas are infrequent tumors arised from the chromaphine cells of the adrenal sympathetic system. The excess of circulating catecholamines may lead to different cardiovascular disorders from silent alterations of the myocardial conduction to different forms of cardiomyopathy. The onset as cardiogenic shock is exceptional. Presentation of case A 35—year-old male, with a known history of acute myopericarditis of unknown origin which debuted as acute pulmonary edema, was admitted with dyspnea in the context of a new heart failure episode with pulmonary edema. An initial ECG showed segmentary repolarization changes, reversed in subsequent ECGs. The echocardiogram showed severe left ventricular dysfunction and lateral and apical hypokinesia. Subsequent echocardiograms showed partial recovery of alterations and preserved systolic function. A cardiac MRI showed a subepicardial minimum catchment focus and myocardial edema suggestive of adrenergic myocarditis. A solid nodular lesion was found in the left adrenal gland, suggesting a pheochromocytoma. Laparoscopic left adrenalectomy confirmed a 30 mm adrenal tumor without signs of locoregional invasion. The patient had normal catecholamine excretion and heart function a few weeks after surgery. Histopathology confirmed the diagnosis of pheochromocytoma. Discussion and conclusions Adrenergic cardiomyopathy is a rare entity with a variable clinical presentation. The onset as cardiogenic shock is exceptional. The differential diagnosis of a patient with cardiogenic shock of unknown origin should consider the presence of an underlying pheocromocytoma as well as other states of adrenergic hyperstimulation. The reversibility of the myocardial affection in pheocromocytoma-associated myocardiopathy is common after the tumor resection.

BACKGROUND Transcutaneous laryngeal ultrasound (TLUS) has emerged as a promising imaging tool for vocal cord examination in patients undergoing thyroid surgery. The focus of this prospective, double-blind study was to assess the accuracy of TLUS in the diagnosis of vocal cord paralysis in the immediate postoperative period following total thyroidectomy. METHODS The study included 93 patients undergoing total thyroidectomy and assessed by videostrobolaryngoscopy (VSL) and TLUS. VSL was carried out the day before surgery and was repeated at 4 days postoperatively. TLUS was performed before surgery in the preanesthesia holding area and at completion of the procedure in the postanesthesia care unit. The preoperative and postoperative TLUS results were correlated with those of VSL. The statistical analysis included the sensitivity, specificity, positive predictive value, and negative predictive value (with 95% CI) of TLUS for detecting vocal cord paralysis. RESULTS The visualization rate associated with TLUS was 93%. The total vocal cord paralysis rate was 16.1%. The performance of TLUS for diagnosing this condition was as follows: sensitivity, 93.3% (95% CI: 77.3-100%); specificity 96.1% (95% CI: 91.2-100%); positive predictive value, 82.3% (95% CI: 61.2-100%); negative predictive value, 98.6% (95% CI, 95.4-100%). CONCLUSIONS TLUS may be a suitable technique for detecting vocal cord paralysis shortly after total thyroidectomy.

We have investigated the differences in plasma parameters and serum trace elements between "healthy" and unhealthy morbidly obese patients before and after Roux-en-Y gastric bypass surgery.A group of 32 morbidly obese patients undergoing bariatric surgery were divided into three groups. Group 1 subjects were free of dyslipidemia and type II diabetes mellitus (defined as "healthy" obese, DM-DL-); Group 2 subjects had only the presence of dyslipidemia (DM-DL+), while group 3 patients demonstrated the presence of both (DM + DL+). In all patients, we studied haematological, haemostasis, anaemia, coagulation plasma and trace elements parameters before and 1, 6 and 12 months after gastric bypass surgery.We found significant differences in some haematological parameters, including haemostasis (e.g., T-Quick, p = 0.0048) and coagulation (e.g., ATIII and PAI-1, p = 0.001 and p0.0001, respectively) and in anaemia parameters (e.g., folate, cobalamin and transferrin, p = 0.0002, p0.0001 and p = 0.0001, respectively) but also in serum trace elements between the groups. However, the response to bariatric surgery was similar in the three groups.Any healthy morbid obese subject is really metabolically "unhealthy" because he or she has many other haematologic or serum abnormalities that are often not included in the criteria for the definition of "healthy" in these obese subjects.

Purpouse: One Step Nucleic Acid Amplification (OSNA) has been previously proposed for the diagnosis of lymph node metastases (LNMs) from several malignant conditions by quantifying the number of copies of cytokeratin 19 mRNA. Our aim was to evaluate the results obtained by OSNA in the lymph nodes of patients with papillary thyroid carcinoma (PTC) by comparing our results with the findings observed using standard pathological examination.Fifty human lymph nodes (from five patients with diagnosed PTC) were studied. Each node was divided into two: one half was used for molecular study ("OSNA-node"), and the other half was used for conventional staining with hematoxylin and eosin ("HE-non-OSNA node"). Three cytological imprints using Papanicolaou and May-Grunwald-Giemsa strains were obtained from both node halves. The results from each technique were compared, and ROC analysis was performed.The OSNA study showed 22 positive samples for LNM (44%), which demonstrate a high concordance rate with the results observed using conventional pathological examination (cytology of "OSNA-node" and HE of "Non-OSNA node") with specificity and sensitivity values greater than 86% and 89%, respectively. However, both comparisons differed in the number of copies of mRNA as the best cut-off (260 copies in the first case and 93 in the second case).The OSNA results for the detection of LNM in patients with PTC are comparable with those observed using conventional techniques. However, its quantitative nature could be useful to more accurately detect lymph node involvement.

Lymphadenectomy is recommended during surgery for papillary thyroid carcinoma when there is evidence of cervical lymph node metastasis (therapeutic) or in high-risk patients (prophylactic) such as those with T3 and T4 tumors of the TNM classification. Selective sentinel lymph node biopsy may improve preoperative diagnosis of nodal metastases.To analyze the results of selective sentinel lymph node biopsy in a group of patients with papillary thyroid carcinoma and no evidence of nodal involvement before surgery.A retrospective, single-center study in patients with papillary thyroid carcinoma and no clinical evidence of lymph node involvement who underwent surgery between 2011 and 2013. The sentinel node was identified by scintigraphy. When the sentinel node was positive, the affected compartment was removed, and when sentinel node was negative, central lymph node dissection was performed.Forty-three patients, 34 females, with a mean age of 52.3 (±17) years, were enrolled. Forty-six (27%) of the 170 SNs resected from 24 (55.8%) patients were positive for metastasis. In addition, 94 (15.6%) out of the 612 lymph nodes removed in the lymphadenectomies were positive for metastases. Twelve of the 30 (40%) low risk patients (cT1N0 and cT2N0) changed their stage to pN1, whereas 12 of 13 (92%) high risk patients (cT3N0 and cT4N0) changed to pN1 stage.Selective sentinel lymph node biopsy changes the stage of more than 50% of patients from cN0 to pN1. This confirms the need for lymph node resection in T3 and T4 tumors, but reveals the presence of lymph node metastases in 40% of T1-T2 tumors.

Objective The possible differences were investigated in 32 morbidly obese patients depending on whether they were “healthy” or had dyslipidemia and/or type 2 diabetes. Methods Lipid metabolism and insulin resistance were analyzed in subcutaneous (SAT) and visceral adipose tissue (VAT) before and during 6 and 12 months after Roux-en-Y gastric bypass. Results Significant differences have been found in lipoprotein lipase (LPL) and hormone-sensitive lipase (HSL) activities in SAT from the different obese group versus normal weight (control) but not between them. The reduced lipase activities in VAT were 43 and 19% smaller (22 and 4% smaller, respectively, vs. control) than the “healthy” obese group for LPL and HSL, respectively, and were accompanied with a reduced expression of these lipases, as well as decreased expression of FAT/CD36, FABP4, and AQ7 in that tissue. In addition, the expression of the other genes measured showed a downregulation not only versus the “healthy” obese but also versus the normal weight group. Conclusions Being obese is not “healthy,” but it is even less so if morbidly obese patients with diabetes and dyslipidemia were considered. The reduced fat accumulation in these patients may be attributed to the decrease of the expression and activity of the lipases of their adipose tissue.

Iodine deficiency and obesity are worldwide-occurring health problems. Our purpose was to investigate the relationship between morbid obesity and iodine status, including subjects who lost weight after bariatric surgery. Ninety morbidly obese women, 90 women with at least 18 months follow-up after bariatric surgery, and 45 healthy non-obese women were recruited. Urinary iodine concentration (UIC) was measured in a spot urinary sample and expressed as the iodine-to-creatinine ratio. Obese women showed a significantly lower UIC in comparison with non-obese women (96.6 (25.8–267.3) vs. 173.3 (47.0–493.6) μg/g; p

In patients with insufficient weight loss after sleeve gastrectomy (SG) or in super obese individuals, among many surgical options available, a single-anastomosis duodeno-ileal bypass (SADI) after SG (SADI-S) could be considered. Due to the limited information available about the use of SADI as a second-step procedure, the objective of this study was to evaluate the mid-term results and responsiveness of SADI after sleeve gastrectomy. We present prospective data from 30 consecutive patients with a mean BMI of 40.1 kg/m2, a mean excess weight of 44.7 kg, and a mean excess weight loss (EWL) of 37.5%, who were submitted to a SADI as a second-step revisional procedure. There were no intraoperative complications. Four early complications (13.34%) occurred within the first 24 postoperative hours. Six, 12, and 24-month follow-up number of patients available was 30 (100%), 22 (73.3%), and 16 (53.34%), respectively. Percent total weight loss (%WL) was 28.1 at the time of revision and 46.26% 24 months after SADI. Global %EWL was 78.93 ± 35.5. The complete remission rate after SG was 50% for diabetes, 33.3% for dyslipidemia, and 25% for hypertension, and 71.4%, 31.2%, and 27.7%, respectively, after SADI. Three (10%) patients required revisional surgery due to hypoalbuminemia. SADI as a second-step strategy in super obese patients or after failed SG offers a more than satisfactory ponderal weight loss and an acceptable comorbidities resolution. However, the risk of severe malnutrition after distal SADI-S makes necessary a careful patient selection.

Lymphadenectomy in papillary thyroid carcinoma (PTC) continues to be controversial. A better staging method is needed to provide adequate individual surgical treatment. SPECT/CT lymphoscintigraphy and sentinel lymph node (SLN) biopsy may improve lymphatic staging and surgical treatment. Our main objectives were to describe the lymphatic drainage of PTC using lymphoscintigraphy, to evaluate the lymphatic spread (comparing SLN and lymphadenectomy results) and to analyse the impact of SLN identification in surgery. We prospectively studied 24 consecutive patients with PTC (19 women; mean age 52.7 years, range 22–81 years). The day before surgery, lymphoscintigraphy with ultrasound-guided intratumoral injection (99mTc-nanocolloid, 148 MBq) was performed, obtaining planar and SPECT/CT images. All patients underwent total thyroidectomy, SLN biopsy (hand-held gamma probe) with perioperative analysis, central compartment node dissection, or laterocervical lymphadenectomy if perioperative stage N1b or positive SLNs in this lymphatic basin. Lymphoscintigraphy revealed at least one SLN in 19 of 24 patients (79 %) on planar and SPECT/CT images, and in 23 of 24 patients (96 %) during surgery using a hand-held gamma probe. Lymph node metastases were detected with classical perioperative techniques (ultrasound guidance and surgical inspection) in 3 of 24 patients, by perioperative SLN analysis in 10 of 23, and by definitive histology in 13 of 24. The false-negative (FN) ratio for SLN was 7.7 % (one patient with bulky lymph nodes). The FN ratio for perioperative frozen sections was 15.4 % (two patients, one with micrometastases, the other with bilateral SLN). Lymphatic drainage was only to the central compartment in 6 of 24 patients (3 of the 6 with positive SLNs for metastases), only to the laterocervical basin in 5 of 24 patients (all unilateral, 2 of 5 positive SLNs) and to the central and laterocervical compartments in 12 of 24 patients (6 of 12 and 3 of 12 positive SLNs, respectively). Lymphoscintigraphy reveals the lymph node drainage in a high proportion of patients. It detects laterocervical drainage in a significant percentage of patients, allowing the detection of occult lymph node metastases and improving the surgical management in PTC.