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Aim: The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. Method: Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. Results: Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). Conclusion: The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Background Transanal total mesorectal excision (TaTME) is a minimally invasive surgical technique that tries to avoid conversion to open surgery. However, specific intraoperative complications and local recurrences have cast some doubt on the suitability of the technique. The primary endpoint of the present study was a composite outcome of conversion surgery. Secondary objectives were to assess postoperative recovery, and pathological and oncological outcomes. Methods This was a prospective, multicentre, randomized, controlled open-label study of patients diagnosed with mid and low rectal adenocarcinoma who underwent laparoscopic TaTME or laparoscopic total mesorectal excision (LaTME). The TaTME technique comprised intracorporeal resection and anastomosis. Main outcomes were conversion to open surgery. Secondary outcomes were postoperative morbidity, mortality, pathological, oncological results, and survival. Modified intention-to-treat (mITT) and per-protocol analyses were performed. Results The study was conducted between April 2015 and May 2021. Patients were randomized to the LaTME (57 patients) or TaTME (59) group. Fifty patients from the LaTME group and 55 from the TaTME group were eligible for mITT analysis. The procedure was converted to open surgery in 11 patients (11 per cent): 10 (20 per cent) in the LaTME group and 1 (2 per cent) in the laparoscopic TaTME group (difference 18.8, 95 per cent c.i. 30 to 7; P = 0.003). No significant differences were found in terms of postoperative recovery and morbidity at 30 days; nor were there significant differences in anastomotic leakage, although it was less common in laparoscopic TaTME. With a median follow-up of 39 months, there were three instances of local recurrence (6.1 per cent) in the LaTME group and one (1.8 per cent) in the laparoscopic TaTME group (95 per cent c.i. 60 to 69; P = 0.3). Registration number: NCT02550769 (http://www.clinicaltrials.gov). Conclusion The conversion rate was significantly lower in laparoscopic TaTME than in LaTME. At centres with experienced surgeons, laparoscopic TaTME can avoid conversion to open surgery.

Purpose The aim of this study was to determine if the prognostic value of the preoperative neutrophil-to-lymphocyte ratio (NLR) could be modified by the presence of postoperative complications (POC) and their severity in patients with gastric adenocarcinoma resected with curative intent. Methods A retrospective study based on a prospective database of patients with resectable gastric adenocarcinoma treated with radical intention (R0) between January 1998 and February 2012. The primary endpoint was overall survival according to preoperative peripheral blood NLR and postoperative complications. Clinicopathological variables, preoperative blood tests, POC and its severity (Clavien–Dindo classification), type of POC (infectious or not infectious) and mortality were registered. A univariate and multivariate analysis (step forward Cox regression) was performed. The Kaplan–Meier method was used to assess overall survival. Results The 147 patients with gastric cancer who had undergone radical resection were included from an initial cohort of 209 patients. Univariant analysis: type of surgery, pT, pN, postoperative complications (Clavien–Dindo ≥ 3) and preoperative NLR ≥ 2.4 were significantly associated with survival (p p = 0.000), with no difference (p = 0.867) between infectious or non-infectious POC. NLR ≥ 2.4 was associated with infectious POC (p p = 0.02) had a worse prognosis. Multivariate analysis: pN (p p p = 0.04) (HR = 1.55; 95% CI: 1.02–2.3) were independent prognostic factors. Conclusion The preoperative inflammatory state of patients with gastric cancer measured by NLR behaves as an independent prognostic factor, even in patients with POC.

Complex polyps require the use of advanced endoscopic techniques or minimally invasive surgery for their approach. In rectal polyps it is of special relevance to reach a consensus on the best approach to avoid under- or overtreatment that increases unnecessary morbidity and mortality.We describe a prospective, multicenter, pilot clinical trial with a first-in-human medical device. It is hypothesized that UNI-VEC® facilitates transanal laparoendoscopic surgery for the removal of early rectal tumors. The primary objective is to evaluate that it is safe and meets the established functional requirements. Secondary objectives are to evaluate results, complications and level of satisfaction.16 patients were recruited in 12 months with a minimum follow-up of 2 months. The mean size was 3.4 cm with the largest polyp being 6 cm. Regarding location, the mean was 6.6 cm from the anal margin. Endoscopic Mucosal Resection (EMR) (6.3%), Endoscopic Submucosal Dissection ESD (43.8%), REC (6.3%) and TAMIS (43.8%) were performed. The mean time was 73.25 min. The 56.3% used a 30° camera and 43.8% used the flexible endoscope as a viewing instrument. The 56.3% were benign lesions and 43.8% malignant. Complete resection is achieved in 87.5%. Regarding complications, mild bleeding (Clavien I) occurred in 25%, 6.3% and 21.4% at 24 h, 48 h and 7 days respectively. Continence was assessed according to the Wexner scale. At 7 days, 60% showed perfect continence, 26.7% mild FI and 13.3% moderate FI. At 30 days, 66.7% had perfect continence, 20% mild FI and 13.3% moderate FI. At 2 months, 4 patients were reviewed who at 30 days had a Wexner's degree higher than preoperative and perfect continence was demonstrated in 25% of the patients, 50% mild and 25% moderate. In no case did rectal perforation or major complications requiring urgent reintervention occur. As for the level of reproducibility, safety, level of satisfaction with the device and evaluation of the blister, the evaluation on a scale of 0 to 10 (9.43, 9.71, 9.29 and 9.50 respectively). All the investigators have previous experience with transanal devices.The study demonstrates the efficacy and safety of UNI-VEC® for the treatment of rectal lesions. It will facilitate the implementation of hybrid procedures that seek to solve the limitations of pure endoscopic techniques by allowing the concomitant use of conventional laparoscopic and robotic instrumentation with the flexible endoscope.

Bowel dysfunction after rectal cancer surgery may significantly affect the quality of life. Our study aimed to estimate the incidence and characterize the low anterior resection syndrome (LARS).Prospective evaluation of patients treated with anterior resection for rectal cancer at two hospitals followed for 12 months after ileostomy reversal. The assessment was performed at baseline, after neoadjuvant treatment, and 1 month, 6 months, and 12 months after bowel transit reconstruction using several scores (Bristol scale, LARS score, Memorial Sloan Kettering bowel function instrument, Fecal Incontinence Quality of Life, EORTC-QLQ30, and a visual analogue scale).Of 205 patients diagnosed with rectal cancer, 78 were followed for 12 months after the exclusion criteria. "Major LARS" at 1 month, 6 months, and 12 months was 55.6%, 47.3%, and 34.6%, respectively. At 12 months, patients experienced significantly less diarrhea, higher LARS score, more percentage of "major LARS," and worse MSK-BFI score compared to baseline. Regarding the quality of life at 12 months, 77.7% of patients with "major LARS" reported impact according to the anchor question of the LARS score; all FIQL subscales were significantly lower; the overall EORTC-QLQ30 score and the functional subscales significantly correlated with the LARS and the MSK-BFI scores.Bowel dysfunction with an impact on the quality of life is common after rectal cancer surgery. The knowledge of the potential consequences of the treatments is essential to be able to provide patients with the best possible information.

Resumen Introduccion Durante el estado de alarma sanitaria establecido a causa de la pandemia de la COVID-19 se anularon la mayor parte de las consultas externas presenciales y se establecio una consulta telefonica para el seguimiento de pacientes coloproctologicos. El objetivo de este estudio fue analizar la eficacia de la consulta telefonica (teleconsulta) en el seguimiento de los pacientes de una unidad de coloproctologia, en el contexto de la pandemia de COVID-19. Metodo Estudio descriptivo prospectivo de pacientes consecutivos en un solo centro. Se clasifico el resultado de la teleconsulta como alta, visita resuelta o reprogramacion y se analizo por diferentes grupos diagnosticos. Resultados Del 19 de marzo al 17 de abril de 2020 se realizo la teleconsulta de 190 pacientes. La tasa de respuesta fue del 94,2% (179). Las categorias diagnosticas de los pacientes atendidos fueron: 51 (26,9%) neoplasia colorrectal, 48 (25,3%) enfermedad proctologica, 72 (37,9%) disfunciones del suelo pelvico y 19 (10%) otras enfermedades benignas. Se pudo volver a citar a 105 (55,26%) como si hubieran venido de forma presencial. Se dio el alta a 11 (5,8%) pacientes. No se encontraron diferencias significativas entre las distintas categorias diagnosticas y la resolucion de la teleconsulta. Los motivos de reprogramacion se analizan en el estudio. Conclusion En el contexto de pandemia, la teleconsulta ha permitido resolver de forma definitiva el 61% de las visitas de seguimiento y ha evitado la reprogramacion de 116 pacientes. El nuevo paradigma social y sanitario tras la pandemia requerira un replanteamiento de nuestro modelo de atencion sanitaria y, en muchos aspectos, la telemedicina puede ofrecer herramientas para ello.

Resumen Introduccion La gastrectomia vertical (GV) se ha convertido en una tecnica con entidad propia cuya indicacion selectiva o global sigue siendo objeto de controversia. Los resultados ponderales a 5 anos son heterogeneos. El objetivo del estudio es identificar posibles factores pronosticos de perdida de peso insuficiente tras GV. Metodos Estudio multicentrico retrospectivo de GV con seguimiento mayor de un ano. Se considera fracaso si el PSP Resultados Se incluye a 1.565 pacientes intervenidos en 29 hospitales. PSP al ano: 70,58 ± 24,8; a los 3 anos 69,39 ± 29,2; a los 5 anos 68,46 ± 23,1. Pacientes con PSP 50 kg/m2, edad > 50 anos, DM2, HTA, SAOS, cardiopatia, varias comorbilidades asociadas, distancia a piloro > 5 cm, bujia > 40 F, tratamiento con antiagregantes. La sobresutura mejora los resultados. Las variables que mostraron ser factores predictivos de fracaso en el seguimiento fueron la DM2 y el IMC. Conclusion La GV asocia una perdida de peso satisfactoria en el 79% de los pacientes en los primeros 5 anos; sin embargo, algunas variables como el IMC > 50, la DM2, la edad > 50, la presencia de varias comorbilidades, la seccion a mas de 4 cm del piloro o la bujia > 40 F pueden aumentar el riesgo de fracaso ponderal.

Background Colorectal cancer (CRC) screening programs result in the detection of early-stage asymptomatic carcinomas suitable to be surgically cured. Lymph nodes (LN) from early CRC are usually small and may be difficult to collect. Still, at least 12 LNs should be analyzed from colectomies, to ensure a reliable pN0 stage. Presurgical endoscopic tattooing improves LN procurement. In addition, molecular detection of occult LN tumor burden in histologically pN0 CRC patients is associated with a decreased survival rate. We aimed to study the impact of presurgical endoscopic tattooing on the molecular detection of LN tumor burden in early colon neoplasms. Methods A prospective cohort study from a CRC screening-based population was performed at a tertiary academic hospital. LNs from colectomies with and without preoperative endoscopic tattooing were assessed by two methods, hematoxylin and eosin (HE), and RT-LAMP, to detect tumor cytokeratin 19 (CK19) mRNA. We compared the amount of tumor burden and LN yields from tattooed and non-tattooed specimens. Results HE and RT-LAMP analyses of 936 LNs were performed from 71 colectomies containing early carcinomas and endoscopically unresectable adenomas (8 pT0, 17 pTis, 27 pT1, 19 pT2); 47 out of 71 (66.2 %) were tattooed. Molecular positivity correlated with the presence of tattoo in LN [p

On-demand endoscopic insufflation during natural orifice transluminal endoscopic surgery (NOTES) adversely affects microcirculatory blood flow (MBF), even with low mean intra-abdominal pressure, suggesting that shear stress caused by time-varying flow fluctuations has a great impact on microcirculation. As shear stress is inversely related to vascular diameter, nitric oxide (NO) production acts as a brake to vasoconstriction. To assess whether pretreatment by NO synthesis modulators protects gastrointestinal MBF during transgastric peritoneoscopy. Fourteen pigs submitted to cholecystectomy by endoscope CO2 insufflation for 60 min were randomized into 2 groups: (1) 150 mg/kg of N-acetyl cysteine (NAC, n = 7) and (2) 4 ml/kg of hypertonic saline 7.5 % (HS, n = 7), and compared to a non-treated NOTES group (n = 7). Five animals made up a sham group. Colored microspheres were used to assess changes in MBF. The average level of intra-abdominal pressure was similar in all groups (9 mmHg). In NOTES group microcirculation decrease compared with baseline was greater in renal cortex, mesocolon, and mesentery (41, 42, 44 %, respectively, p

Factors underlying variable weight loss (WL) after Roux-en-Y gastric bypass (RYGB) are poorly understood.Our objective was to gain insight on the role of gastrointestinal hormones on poor WL maintenance (P-WLM) following RYGB.First, glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and ghrelin responses to a standardized mixed liquid meal (SMLM) were compared between subjects with good WL (G-WL, n = 32) or P-WLM (n = 22). Second, we evaluated food intake (FI) following blockade of gut hormonal secretion in G-WL (n = 23) or P-WLM (n = 19) subjects. Finally, the impact of dietary-induced WL on the hormonal response in subjects with P-WLM (n = 14) was assessed.This study was undertaken in a tertiary hospital.In studies 1 and 3, the outcomes measures were the areas under the curve of gut hormones following a SMLM; in study 2, FI following subcutaneous injection of saline or octreotide were evaluated.P-WLM associated a blunted GLP-1 (P = .044) and PYY (P = .001) responses and lesser suppression of ghrelin (P = .032) following the SMLM challenge. On saline day, FI in the G-WL (393 ± 143 kcal) group was less than in the P-WLM (519 ± 143 Kcal; P = .014) group. Octreotide injection resulted in enlarged FI in both groups (G-WL: 579 ± 248 kcal, P = .014; P-WLM: 798 ± 284 Kcal, P = .036), but the difference in FI between groups remained (P.001). In subjects with P-WLM, dietary-induced WL resulted in larger ghrelin suppression (P = .046), but no change in the GLP-1 or PYY responses.Our data show gastrointestinal hormones play a role in the control of FI following RYGB, but do not support that changes in GLP-1, PYY, or ghrelin play a major role as determinants of P-WLM after this type of surgery.

Background The anatomic difficulties that we have to deal with in open surgery for rectal cancer have not been overcome with the laparoscopic approach. In the search for a solution, a change of concept arose: approaching the rectum from below. The main objectives of this study were to show the potential advantages of the hybrid transabdominal-transanal total mesorectal excision (taTME). This approach may improve quality of the mesorectal specimens. Second, proctectomy can be technically easier and more safely performed "down to up," which would result in shorter surgical times, lower conversion rates, and less morbidity. Study Design A prospective series of hybrid taTME was conducted from October 2011 to November 2014. Results During the study period, 140 procedures were performed. Mean operative time was 166 minutes. There were no conversions or intraoperative complications. Macroscopic quality assessment of the resected specimen was complete in 97.1% and nearly complete in 2.1%. Thirty-day morbidity was minor (Clavien-Dindo I + II) in 24.2% and major (Clavien-Dindo III + IV) in 10 %. No patient died within the first 30 days postsurgery (Clavien-Dindo V). The mean follow-up was 15 months, with a 2.3% local recurrence rate and a 7.6% rate of systemic recurrence. Conclusions Pathologic analysis showed a very good macroscopic quality of TME specimens, which is the most important prognostic factor in rectal cancer. Intraoperative outcomes regarding conversion, surgical times, and intraoperative complications are very satisfactory. Short-term morbidity and oncologic outcomes are as good as in other laparoscopic TME series.

Our goal was to assess the accuracy of measuring cardiac output (CO) by the FloTrac/Vigileo (CO(V)) device in comparison with thermodilution technique through pulmonary artery catheterization (PAC(TD)) in morbidly obese patients.Cardiac output in 8 morbidly obese patients was assessed twice at upright and lying position breathing ambient air. At least 4 consecutive CO measurements with 10 mL of ice-cold saline injections were performed each time. Simultaneous CO measurements were recorded with both single-bolus thermodilution and CO(V).One hundred thirty-two CO data pairs were collected. The overall mean single-bolus thermodilution 6.2 ± 1.1 L/min was lower than the overall mean CO(V) 7.8 ± 1.6 L/min (P.001). Lin concordance coefficient indicated that overall agreement between PAC(TD) and CO(V) was poor, 0.29. Lin concordance coefficient in sitting position was 0.29, 95% confidence interval (0.17-0.40) and in lying position was 0.30, 95% confidence interval (0.15-0.44). The Bland-Altman plot analysis showed systematically higher values from CO(V) in comparison with PAC(TD). These differences increased in presence of high CO measurements. In 3 of 8 patients, the percentage error was lower than 20%, whereas in the other 5, it was higher than 20%. Of these 5, in 2 cases, the percentage error was greater than 50%.Data obtained using CO(V) vs PAC(TD) measurements showed poor correlation. The results were not interchangeable.

BACKGROUND:Obesity is a global and growing public health problem. Bariatric surgery (BS) is indicated in patients with morbid obesity. To our knowledge, the effects of morbid obesity and BS on ventilation/perfusion ( V.a/ Q.) ratio distributions using the multiple inert gas elimination technique have never before been explored. METHODS:We compared respiratory and inert gas ( V.a/ Q.ratio distributions) pulmonary gas exchange, breathing both ambient air and 100% oxygen, in 19 morbidly obese women (BMI, 45 kg/m2), both before and 1 year after BS, and in eight normal-weight, never smoker, age-matched, healthy women. RESULTS:Before BS, morbidly obese individuals had reduced arterial Po2(76 ± 2 mm Hg) and an increased alveolar-arterial Po2difference (27 ± 2 mm Hg) caused by small amounts of shunt (4.3% ± 1.1% of cardiac output), along with abnormally broadly unimodal blood flow dispersion (0.83 ± 0.06). During 100% oxygen breathing, shunt increased twofold in parallel with a reduction of blood flow to low V.a/ Q.units, suggesting the development of reabsorption atelectasis without reversion of hypoxic pulmonary vasoconstriction. After BS, body weight was reduced significantly (BMI, 31 kg/m2), and pulmonary gas exchange abnormalities were decreased. CONCLUSIONS:Morbid obesity is associated with mild to moderate shunt and V.a/ Q.imbalance. These abnormalities are reduced after BS.

Measurement of the component of fibrosis in Crohn's disease (CD) may have important therapeutic implications. The aim of this study was to characterize the Magnetic Resonance Imaging (MRI) findings that are differentially associated with the presence of fibrosis and those associated with inflammatory activity, using the pathological analysis of surgically resected intestinal lesions as reference standard.MRI studies with identical imaging protocol of 41 CD patients who underwent elective bowel resection within 4 months before surgery were reviewed. MRI evaluated wall thickening, edema, ulcers, signal intensity at submucosa at 70 s and 7 min after gadolinium injection, stenosis, and pattern of enhancement in each phase of the dynamic study and changes on this pattern over time. Pathological inflammatory and fibrosis scores were classified into three grades of severity.In all, 44 segments from 41 patients were analyzed. The pathological intensity of inflammation was associated with the following MRI parameters: hypersignal on T2 (P=0.02), mucosal enhancement (P=0.03), ulcerations (P=0.01), and blurred margins (P=0.05). The degree of fibrosis correlated with the percentage of enhancement gain (P0.01), the pattern of enhancement at 7 min (P0.01), and the presence of stenosis (P=0.05). Using percentage of enhancement gain, MRI is able to discriminate between mild-moderate and severe fibrosis deposition with a sensitivity of 0.94 and a specificity of 0.89.MRI is accurate for detecting the presence of severe fibrosis in CD lesions on the basis of the enhancement pattern.

The aim of this study was to compare short-term results obtained with transanal total mesorectal excision (TME) and laparoscopic surgery.Transanal TME appears as an alternative in the treatment of rectal cancer and other rectal disease. Natural orifices transluminal endoscopic surgery using the rectum as access in colorectal surgery is intuitively better suited than other access routes.All consecutive patients with middle or low rectal cancer submitted to surgery were included into a prospective cohort and treated by transanal TME assisted by laparoscopy. They were compared with a retrospective cohort of consecutive patients of identical characteristics treated by laparoscopic TME in the immediate chronological period.Thirty-seven patients were included in both study groups. No differences were observed between them with respect to baseline characteristics, thus emphasizing the comparability of both cohorts. Surgical time was higher in the laparoscopy group (252 ± 50 minutes) than in the transanal group (215 ± 60 minutes) (P0.01). Moreover, coloanal anastomosis was performed less frequently (16% vs 43%, respectively; P = 0.01) and distal margin was lower (1.8 ± 1.2 mm vs 2.7 ± 1.7 mm, respectively; P = 0.05) in the laparoscopy group than in the transanal one. Although there was no significant difference in 30-day postoperative complication rate (laparoscopy, 51% vs transanal, 32%; P = 0.16), early readmissions were more frequent in the laparoscopy group than in the transanal one (22% vs 6%, respectively; P = 0.03).Evaluation of short-term outcomes demonstrated that transanal TME is a feasible and safe technique associated with a shorter surgical time and a lower early readmission rate.

There is scarce information about predictive factors of hypertension (HT) remission after bariatric surgery (BS). The aims of this study were to determine the clinical characteristics differentiating obese patients with and without HT and to evaluate the predictive factors associated with the risk of persistence of HT after BS.From January 2007 to December 2009, a review of patients who had undergone BS was performed. Patients were classified as hypertensive if having permanent use of antiHT drugs or clinical BP ≥ 140/90 mm Hg. Weight, waist circumference (WC), and blood pressure were determined with standardized procedures.Five hundred twenty-6 patients met the inclusion criteria; 264 (50%) were hypertensive, 74 (34%) of whom had type 2 diabetes. Before BS, older age, male gender, and greater WC differentiated hypertensive from normotensive patients. The prevalence of HT significantly fell to 35% (P.0001) at 12 months after BS. The use of multivariate logistic regression showed that age ≥ 40, male gender and WC ≥ 130 cm were significant predictors of having HT before surgery. Regarding persistence of HT at the 12-month follow-up, the only independent predictors observed were time since diagnosis of HT ≥ 10 years and the number of antiHT drugs used. Presurgical BMI, WC, excess weight (EW), EW loss, surgical procedure, type 2 diabetes, and vitamin D status were not significant predictors.Bariatric surgery is associated with a high rate of HT remission. Older age, male gender, and higher WC differentiated hypertensive-obese from normotensive patients. After BS, longer duration and severity of HT were independently associated with no remission of HT.

One of the most controversial areas in laparoscopic approach is rectal cancer, not only because of the surgical technique but of the best approach to do it. The transanal approach arises like a new alternative for rectal cancer and other rectal pathologies due to solve some of the problems that we can find in conventional laparoscopic approach, mainly in low rectal cancer for the section of the rectum and distal margin.

The transanal minilaparoscopy-assisted natural orifice transluminal endoscopic surgery (NOTES) approach holds significant promise as a safe and less morbid alternative to conventional low anterior rectal resection. Previous reports have shown satisfactory short-term oncologic results. We evaluated the safety and short-term outcomes in rectal cancer subjects who underwent transanal minilaparoscopy-assisted natural orifice surgery total mesorectal excision (TME) rectal resection.Twenty selected patients with rectal cancer were enrolled onto a prospective study of minilaparoscopy-assisted natural orifice surgery TME rectal resection. The study endpoints were safety of access (intra- or postoperative morbidity) and adequacy of oncological resection criteria; intact TME; distal and circumferential margins; and number of lymph nodes retrieved.All procedures were successfully completed with the transanal NOTES and minilaparoscopy technique. The mean age was 65 ± 10 years; 55% of patients were male; the mean body mass index was 25.3 ± 3.8 kg/m(2). Thirty-five percent of tumors were in the distal rectum, 50% in midrectum, and 15% in proximal rectum. Coloanal anastomoses were hand sewn in 65% and stapled in 35%. Mean operative time was 235 ± 56 min. There were no procedure-related complications. Pathologic analysis demonstrated negative distal and circumferential margins in all patients. An average of 15.9 ± 4.3 lymph nodes were retrieved. The mesorectal fascia was intact in all the specimens.This study demonstrates that transanal NOTES with minilaparoscopic assistance in the hands of a specialized team is safe; meets the oncologic requirements for high-quality rectal cancer surgery; and may offer advantages over pure laparoscopic approaches for visualizing and dissecting out the distal mesorectum. Minilaparoscopic assistance allows one to compensate for the limitations of current NOTES instrumentation to ensure the safety and adequacy of oncologic resection in these difficult cases. Careful patient selection, a specialized team, and long-term outcome evaluation are critical before this procedure can be considered for routine clinical use.

Introduction: Sleeve gastrectomy (SG) has become a technique in its own right although a selective or global indication remains controversial. The weight loss data at 5 years are heterogeneous. The aim of the study is to identify possible prognostic factors of insufficient weight loss after SG. Methods: A SG retrospective multicenter study of more than one year follow-up was performed. Failure is considered if EWL > 50%. Univariate and multivariate study of Cox regression were performed to identify prognostic factors of failure of weight loss at 1, 2 and 3 years of follow up. Results: A total of 1,565 patients treated in 29 hospitals are included. PSP per year: 70.58 +/- 24.7; 3 years 69.39 +/- 29.2; 5 years 68.46 +/- 23.1. Patients with EWL < 50 (considered failure): 17.1% in the first year, 20.1% at 3 years, 20.8% at 5 years. Variables with influence on the weight loss failure in univariate analysis were: BMI > 50 kg/m(2), age > 50 years, DM2, hypertension, OSA, heart disease, multiple comorbidities, distance to pylorus> 4 cm, bougie > 40 F, treatment with antiplatelet agents. The reinforcement of the suture improved results. In multivariate study DM2 and BMI are independent factors of failure. Conclusion: The SG associates a satisfactory weight loss in 79% of patients in the first 5 years; however, somevariablessuchasBMI > 50, age > 50, thepresenceofseveralcomorbidities, more than 5 cm section of the pylorus or bougie > 40 F can increase the risk of weight loss failure. (C) 2017 AEC. Published by Elsevier Espanna, S.L.U. All rights reserved.

Sleeve gastrectomy (SG) has become a technique in its own right although a selective or global indication remains controversial. The weight loss data at 5 years are heterogeneous. The aim of the study is to identify possible prognostic factors of insufficient weight loss after SG.A SG retrospective multicenter study of more than one year follow-up was performed. Failure is considered if EWL50%. Univariate and multivariate study of Cox regression were performed to identify prognostic factors of failure of weight loss at 1, 2 and 3 years of follow up.A total of 1,565 patients treated in 29 hospitals are included. PSP per year: 70.58±24.7; 3 years 69.39±29.2; 5 years 68.46±23.1. Patients with EWL50 (considered failure): 17.1% in the first year, 20.1% at 3 years, 20.8% at 5 years. Variables with influence on the weight loss failure in univariate analysis were: BMI50kg/mThe SG associates a satisfactory weight loss in 79% of patients in the first 5 years; however, some variables such as BMI50, age50, the presence of several comorbidities, more than 5cm section of the pylorus or bougie40F can increase the risk of weight loss failure.

Persistent activation of the innate immune system greatly influences the risk of developing metabolic complications associated with obesity. In this study, we explored the therapeutic potential of the specialized pro-resolving mediator (SPM) resolvin D1 (RvD1) to actively promote the resolution of inflammation in human visceral adipose tissue from obese patients. By means of LC-MS/MS-based metabololipidomic analysis we identified unbalanced production of SPMs (i.e. D- and E-series resolvins, protectin D1, maresin 1 and lipoxins) with respect to inflammatory lipid mediators (i.e. leukotriene B4 and prostaglandins) in omental adipose tissue from obese patients. In parallel, high-throughput transcriptomic analysis revealed a unique signature in this tissue characterized by an overactivation of the interleukin (IL)-10 signaling pathway. Incubation of inflamed obese visceral adipose tissues and human macrophages with RvD1 limited the excessive activation of the IL-10 pathway by reducing phosphorylation of signal transducer and activator of transcription (STAT) proteins. Of interest, RvD1 blocked STAT-1 and its target inflammatory genes (i.e. CXCL9) as well as persistent STAT3 activation without affecting the IL-10 anti-inflammatory response characterized by inhibition of IL-6, IL-1β, IL-8 and TNFα. Furthermore, RvD1 promoted resolution by enhancing the expression of the IL-10-target gene heme oxygenase-1 by mechanisms depending on p38 mitogen-activated protein kinase (MAPK) activity. Together, our data show that RvD1 can tailor the quantitative and qualitative responses of human inflamed adipose tissue to IL-10 and provide a mechanistic basis for the immunoresolving actions of RvD1 in this tissue. These findings may have potential therapeutic implications in obesity-related insulin resistance and other metabolic complications.

Natural orifice translumenal endoscopic surgery (NOTES) represents the evolution of surgery towards less invasive procedures. The feasibility of NOTES transrectal approach has increased its clinical applicability. This report describes a first series of minilaparoscopy-assisted transrectal low anterior resection with double purse-string end-to-end circular stapler anastomoses.Between March and April 2012 three selected patients underwent transrectal minilaparoscopy-assisted natural orifice surgery total mesorectal excision for rectal cancer. All the oncologic principles of open/laparoscopic low anterior resection for rectal cancer were strictly fulfilled. Two patients underwent neoadjuvant treatment. Laparoscopic visualization and assistance was provided through one 10-mm umbilical port and two ports, one of which was used as stoma site (5 mm) and the other as a drain site (2 mm needle port). The specimen was transected transanally followed by the confection of double purse-string lateral/end-to-end anastomoses. There were no intraoperative complications.Mean operative time was 143 min. Oral intake was initiated on the second postoperative day. Patients were discharged home by day 5. The pathology unit confirmed that distal and circumferential margins were free of tumor invasion, and quality of mesorectum resection was reported satisfactory. One patient had to be readmitted because of severe dehydration due to increased ileostomy output. The patient was discharged at the third day after the readmission without renal failure.In this preliminary report, transrectal minilaparoscopy-assisted low anterior resection was feasible and safe. Lateral/end-to-end anastomoses can be considered an interesting alternative to the double-stapling technique. However, it is necessary to further study and develop these procedures, along with careful patient selection, before transrectal low anterior resection may be considered for routine clinical use.

Resumen Objetivos Analizar las causas de reclamacion por presuntos defectos de praxis en cirugia bariatrica y los resultados del proceso judicial. Material y metodo Revision de los expedientes de los casos de reclamacion presentados al Servicio de Responsabilidad Profesional del Consejo de Colegios de Medicos de Cataluna desde 1992 hasta 2009 por danos como consecuencia de cirugia bariatrica. Se calculo la tasa de reclamaciones mediante una encuesta en los cirujanos bariatricos. Resultados Se analizaron 49 casos, que representan una tasa de reclamaciones del 0,6% de los pacientes operados. En 23 ocasiones (47%) tuvo lugar el fallecimiento del paciente, en el 14% quedaron secuelas graves, en el 18% secuelas leves y en el 21% hubo una recuperacion completa. Las causas mas frecuentes de muerte fueron peritonitis por dehiscencia de sutura (48%) y complicaciones respiratorias (17,4%). Se considero retrospectivamente que habian existido defectos de praxis en 10 (20%) de los casos reclamados por falta de documento de consentimiento informado adecuado, retraso en el reconocimiento de la complicacion, o error en la interpretacion o tratamiento de la misma. En 10 casos hubo sentencia condenatoria para el medico reclamado, 3 en un juicio penal y 7 en juicio civil, hubo absolucion en 19, acuerdo extrajudicial con pago de indemnizacion en 4, retirada de la reclamacion en 4 y estan todavia pendientes de juicio o de sentencia 12 casos. Conclusion Se demuestra una relativamente baja tasa de reclamaciones por complicaciones relacionadas con la cirugia bariatrica. La muerte del paciente fue la principal causa de reclamacion. El numero de sentencias condenatorias fue relativamente elevado. La deteccion precoz de las complicaciones quirurgicas es indispensable para la reduccion de la litigiosidad relacionada con cirugia bariatrica

Summary Background & aims Extracellular matrix deposition is key event for the development of bowel stenosis in Crohn’s disease patients. Transforming growth factor-β plays a key role in this process. We aimed at characterizing the effects of tocotrienol rich fraction on ECM proteins production and molecules that regulate the synthesis and degradation of extracellular matrix, matrix metalloproteinase-3 and tissue inhibitor of metalloproteinases-1, in human intestinal fibroblasts, and at elucidating whether the effects of tocotrienol rich fraction (TRF) are mediated through inhibition of TGF-β1. Methods HIF were isolated from colonic or ileal tissue from Crohn’s disease patients and control subjects, and were treated with TRF from palm oil either alone or in combination with TGF-β1. Procollagen 1, procollagen 3, TIMP-1 and MMP-3 production, and Smad3 phosphorylation were analyzed by Western-blotting. Results TRF significantly diminished procollagen 1 and 3 synthesis in HIF. Treatment of HIF with TRF increased MMP-3 production but did not modify TIMP-1. TGF-β1 induced Smad3 phosphorylation and enhanced procollagen 1 and 3 and TIMP-1 production. Pre-treatment of HIF with TRF prevented Smad3 phosphorylation and minimized the increase in collagen 1 and 3 production caused by TGF-β1. Conclusions TRF has anti-fibrogenic effects on HIF, decreasing ECM production and increasing its degradation. This effect is mediated, at least in part, by inhibition of TGF-β1.

Postoperative bowel obstruction caused by intra-abdominal adhesions occurs after all types of abdominal surgery. It has been suggested that the laparoscopic technique should reduce the risk for adhesion formation and thus for postoperative bowel obstruction. This study was designed to compare the incidence of bowel obstruction in a randomized trial where laparoscopic and open resection for colon cancer was compared. A retrospective analysis was performed, collecting data of episodes of bowel obstruction with or without surgery. Only episodes treated in the hospital where the index surgery took place were included. Data for 786 patients were collected for the 5-year period after cancer surgery. Baseline characteristics for the evaluated laparoscopic (n = 383) and open (n = 403) groups were comparable. The cumulative obstruction percentages at 5 years for the open and laparoscopic groups were 6.5 and 5.1% respectively and did not significantly differ from each other. Tumor stage seemed to influence the risk for bowel obstruction: 2.8% in stage I, 6.6% in stage II, and 7% in stage III, but the differences were not significant. This analysis does not support the hypothesis that laparoscopy leads to fewer episodes of bowel obstruction compared with open surgery.

Resumen Antecedentes Muchos pacientes con cirugia bariatrica desarrollan complicaciones postoperatorias gastrointestinales que pueden requerir la realizacion de una endoscopia digestiva alta. Objetivo Describir de forma prospectiva las complicaciones gastrointestinales diagnosticadas por endoscopia despues de la cirugia bariatrica. Pacientes y metodos Seguimiento de los pacientes sometidos a cirugia bariatrica laparoscopica entre enero de 1998 y diciembre de 2006. Fueron recogidos los siguientes datos: edad, sexo, indice de masa corporal, comorbilidad, tipo y duracion de la cirugia bariatrica, presentacion clinica de la complicacion, tiempo de la presentacion, tratamiento endoscopico y seguimiento. Resultados Fueron operados 474 pacientes (el 74% mujeres, el 26% hombres) con una edad media de 44 ± 11 anos (rango, 15-66) y un indice de masa corporal medio de 47 ± 7 (rango, 33-82). El procedimiento quirurgico mas frecuente fue la gastroenteroanastomosis en Y de Roux (90%). Identificamos 68 complicaciones (14%) que requirieron una endoscopia digestiva alta: estenosis de la anastomosis (21 casos, 5%), hemorragia digestiva alta (16 casos, 3,6%), epigastralgia (12 casos, 2,5%), vomitos (7 casos, 1,5%), pirosis (6 casos, 1,3%) y otros (6 casos, 1,3%). No encontramos ningun factor pronostico de presentacion de complicaciones que requiriera endoscopia despues de la cirugia. Conclusiones La estenosis de la anastomosis es la complicacion mas frecuente que requiere tratamiento endoscopico despues de cirugia bariatrica. La hemorragia digestiva alta en el postoperatorio inmediato y tardio puede ser tratada de forma adecuada y segura con tecnicas endoscopicas.

Worldwide, morbid obesity incidence has increased dramatically in the last decade and surgery is at this moment recognized as the only effective treatment with long-term sustained weight loss and resolution or significant improvement in comorbidities. Laparoscopic sleeve gastrectomy (LSG) was successfully carried out by several groups as a bridge to future laparoscopic bariatric procedures with acceptable weight loss and reduction in comorbidities. LSG is considered a safe procedure with sporadically reported complications, such as bleeding or leakage from the staple line, strictures, delayed gastric emptying, gastric dilatation and vomiting. The aim of this publication is to describe complications of this procedure analyze different treatments of these events especially the surgical ones, reporting the technical management based on our experience and on the literature.From March 2003 to December 2009, 294 patients underwent LSG in our Department. Complications are reported prospectively.In our series 294 patients were operated and stapler line leak was observed in 11 patients (3.7%). The mean time from the first surgery up to the first reintervention was 15.6±22 days (2 to 78). Only 2 patients (0.68%) had to be operated owing to severe reflux related with the sleeve gastrectomy and the symptomatology was solved with the gastric bypass. Intraabdominal bleeding was observed in 7 patients (2.38%), being reoperated 3 (1.02%) of them. All patients were reoperated by laparoscopic approach and the bleeding vessel was identified in all of them. We identified 3 of 294 patients with strictures (1.02%). One of them was located in the gastroesophageal junction and the other 2 had a central location. The patient with high stenosis required endoscopic dilatation and the other 2 were resolved by a gastric bypass cutting the stomach proximal to the stricture. The global mortality was 0%. All of the patients were reoperated by laparoscopy.LSG is a feasible bariatric procedure carried out increasingly in the last few years with low postoperative complications. Regardless, the knowledge of the potential complications associated to LSG and their management is crucial for patient's safety.

Background: To analyze the feasibility of capecitabine with weekly irinotecan and concurrent radiotherapy followed by laparoscopic-total mesorectal excision (LTME) in rectal cancer patients. Methods: Eligible criteria included adenocarcinoma of the rectum staged by endoscopic ultrasonography (u), spiral abdominal and pelvic CT and chest X-ray. Patients received weekly irinotecan 50 mg/m2 (days 1, 8, 15, 22, 29) and capecitabine (days 1 through 5 for 5 weeks); dose level; (DL) I 250 mg/m2/bid; DL II 375 mg/m2/bid; DL III 500 mg/m2/bid, according to phase I methodology. External beam radiotherapy was delivered up to a total dose of 45 Gy in daily fractions of 1.8 Gy, 5 days a week. LTME was planned 5–7 weeks after CRT. Results: From February 2003 to February 2006, 22 patients were included. Median age was 62 (range 48 to 78). Seven pts were uT3N0 and 15 pts uT3N1. Seven patients were treated at DL I, six at DL II and nine at DL III. Grade 3 adverse events were observed in all levels. The maximum tolerated dose was reached at 375 mg/m2 (DL II). Conversion rate to open surgery was 5%. Median hospital stay was 6.6 days. One month post-surgical complications were noted in five patients (23%). Median excised nodes were 11 (range 4–21). Pathological complete response was observed in two patients (9%). Conclusions: LTME after preoperative CRT with CAPIRI is feasible but severe adverse events were found in all levels despite the use of lower dose of capecitabine than previously published.

Resumen La cirugia endoscopica transluminal a traves de orificios naturales, mas conocida por sus siglas inglesas NOTES (natural orifice transluminal endoscopic surgery), es el paradigma de la evolucion de la cirugia minimamente invasiva. La «revolucion» que ha supuesto la cirugia laparoscopica ha introducido nuevas ideas en la cirugia general. Una de ellases que la cirugia moderna es el trabajo de un equipo multidisciplinario, y la cirugia NOTES es un claro ejemplo de ello. El objetivo de este tipo de cirugia es realizar los procedimientos laparoscopicos convencionales sin ninguna incision, usando la tecnologia endoscopica flexible, utilizada habitualmente en el diagnostico y el tratamiento de lesiones intraluminales, y accediendo al interior de la cavidad abdominal a traves de los orificios naturales (boca, ano, vagina e incluso uretra). Este tipo de acceso abre un campo muy interesante para determinados pacientes, como los que tienen un elevado riesgo quirurgico, los obesos morbidos o los que tienen antecedentes de multiples cirugias abdominales previas o infecciones de herida quirurgica. Usando modelos animales se ha podido demostrar que es posible realizar una gran variedad de intervenciones (colecistectomia, apendicectomia, esplenectomia, histerectomia, ligadura de trompas, gastroenteroanastomosis, peritoneoscopia, biopsia hepatica y herniorrafia, entre otras). Sin embargo, y antes de su implementacion en los humanos, esta nueva tecnica debe demostrar que es segura y ofrece ventajas reales para los pacientes. Por tanto, se debe encontrar solucion a una serie de problemas, que incluyen metodos seguros para el cierre de la incision gastrica y evitar la aparicion de infecciones, entre otros. Otro elemento critico para el desarrollo de esta nueva cirugia es la creacion de instrumental apropiado, por lo que es necesario el esfuerzo no solo de los profesionales medicos, sino tambien de los ingenieros y de la industria de dispositivos medicos. En este articulo se describen los importantes avances en NOTES desde su primera descripcion y se analizan los riesgos y los beneficios potenciales asociados a esta tecnica tan innovadora.

Background Complications in sleeve gastrectomy (SG) can cast a shadow over the technique's good results and compromise its safety. The aim of this study is to identify risk factors for complications, and especially those that can potentially be modified to improve safety. Methods A retrospective multicenter cohort study was carried out, involving the participation of 29 hospitals. Data was collected on demographic variables, associated comorbidities, technical modifications, the surgeon's experience, and postoperative morbimortality. A multivariate logistic regression analysis was carried out on risk factors (RFs) for the complications of leak/fistula, hemoperitoneum, pneumonia, pulmonary embolism, and death. Results The following data were collected for 2882 patients: age, 43.85+/-11.6. 32.9 % male; BMI 47.22+/-8.79; 46.2 % hypertensive; 29.2 % diabetes2; 18.2 % smokers; bougie calibre >= 40 F 11.1 %; complications 11.7 % (2.8 % leaks, 2.7 % hemoperitoneum, 1.1 % pneumonia, 0.2 % pulmonary embolism); and death 0.6 %. RFs for complications were as follows: surgeon's experience < 20 patients, OR 1.72 (1.32-2.25); experience> 100 patients, OR 0.78 (0.69-0.87); DM2, OR1.48(1.12-1.95); probe > 40 F, OR 0.613 (0.429-0.876). Leak RFs were the following: smoking, OR1.93 (1.1-3.41); surgeon's experience< 20 patients, OR 2.4 (1.46-4.16); experience of 20-50 patients, OR 2.5 (1.3-4.86); experience > 100 patients, OR 0.265 (0.11-0.63); distance to pylorus > 4 cm, OR 0.510 (0.29-0.91). RFs for death were as follows: smoking, OR 8.64 (2.63-28.34); DM2, OR 3.25 (1.1-9.99); distance to pylorus< 5 cm, OR 6.62 (1.63-27.02). Conclusions The safety of SG may be compromised by nonmodifiable factors such as age > 65, patient comorbidities (DM2, hypertension), and prior treatment with anticoagulants, as well as by modifiable factors such as smoking, bougie size < 40 F, distance to the pylorus < 4 cm, and the surgeon's experience (< 50-100 cases).

Background: Ferric Carboxymaltose (FCM), Iron Sucrose (IS) and Oral Iron (OI) are alternative treatments for preoper-ative anaemia. Objective: To compare the cost implications, using a cost-minimization analysis, of three alternatives: FCM vs. IS vs. OIfor treating iron-deficient anaemia before surgery in patients with colon cancer. Methods: Data from 282 patients with colorectal cancer and anaemia were obtained from a previous study. One hundred andeleven received FCS, 16 IS and 155 OI. Costs of intravenous iron drugs were obtained from the Spanish Regulatory Agency. Direct and indirect costs were obtained from the analytical accounting unit of the Hospital. In the base case mean costs perpatient were calculated. Sensitivity analysis and probabilistic Monte Carlo simulation were performed. Results: Total costs per patient were 1827R© in the FCM group, 2312R© in the IS group and 2101R©i n the OI group. Costsavings per patient for FCM treatment were 485R© compared to IS and 274R© compared to OI. A Monte Carlo simulationfavoured the use of FCM in 84.7% and 84.4% of simulations when compared to IS and OI, respectively. Conclusions: FCM infusion before surgery reduced costs in patients with colon cancer and iron-deficiency anaemia whencompared with OI and IS. info:eu-repo/semantics/acceptedVersion

Data on the effectiveness of sleeve gastrectomy (SG) in improving or resolving type 2 diabetes mellitus (T2DM) are scarce. A 4-month prospective study was conducted on the changes in glucose homeostasis in 35 severely obese T2DM subjects undergoing laparoscopic SG (LSG) and 50 subjects undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP), matched for DM duration, type of DM treatment, and glycemic control. At 4-months after surgery, LSG and LRYGBP operated subjects lost a similar amount of weight (respectively, 20.6 ± 0.7% and 21.0 ± 0.6%). T2DM had resolved respectively in 51.4% and 62.0% of the LSG and LRYGBP operated subjects (P = 0.332). A shorter preoperative DM duration (P

Background and Aims On-demand insufflation during endoscopic peritoneoscopy causes wide variations in intra-abdominal pressure. Its effects on splanchnic microcirculation may differ from those of steady intra-abdominal pressure, because pressure characteristics affect crucial intravascular hemodynamic forces—pressure and shear—adapting flow to local metabolic needs. Our aim was to assess the effect of natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy on splanchnic microcirculatory blood flow. Methods Twenty-one swine were randomized to the following: cholecystectomy by transgastric NOTES (n = 8), cholecystectomy by standard laparoscopy (Lap) (n = 8), and a sham group (n = 5). During NOTES, CO 2 was manually insufflated with a maximum allowed pressure of 30 mm Hg. In the Lap group, intra-abdominal pressure was maintained at 14 mm Hg. Systemic hemodynamics were measured, and microcirculatory blood flow was quantified by using colored microspheres. Results Mean intra-abdominal pressure was lower in NOTES than in the Lap group ( P = .038). In both groups, cardiac index and preload remained unchanged, whereas systemic vascular resistances increased over time, with a lesser increase in the Lap group (2-way analysis of variance; P = .041). In pneumoperitoneum groups, microcirculatory blood flow decreased similarly in the renal medulla, stomach, small bowel, colon, and mesocolon by 30%, 45%, 34%, 32%, and 37%, respectively. In NOTES, there was a greater microcirculatory blood flow decrease in the renal cortex (NOTES 41% vs Lap 35%; P = .044) and mesentery (NOTES 44% vs Lap 38%; P = .041). Conclusions These findings suggest that both types of pneumoperitoneum have similar physiologic effects on microcirculatory blood flow. However, on-demand pneumoperitoneum (NOTES group) caused a greater microcirculatory blood flow decrease in areas with low metabolic needs, redistributing blood flow toward metabolically active areas.

Context: The mechanisms underlying weight loss after Roux-en-Y gastric bypass (RYGBP) are not well understood. Objective: The objective of the study was to assess the changes in active glucagon-like peptide 1 (GLP-1) and total peptide YY (PYY) after RYGBP and examine their relationship with changes in hunger and satiety. Design:This was a prospective study on the changes in active GLP-1, PYY, hunger, and satiety in response to a standardized test meal in nine normal-glucose-tolerant obese subjects [body mass index (BMI) 47.4 6.1 kg/m 2 ] before and 6 wk after RYGBP. Results: Before surgery, meal ingestion failed to stimulate GLP-1 and PYY secretion. Six weeks after surgery, despite subjects still being markedly obese (BMI 43.6 7.8 kg/m 2 ), the area under the curve0‐120 of GLP-1 and of PYY in response to the standardized test mealweresignificantlyelevated(P0.05andP0.01,respectively). These hormonal responses were significantly larger (P 0.01) than those observed in a group matched for the BMI attained 6 wk after surgery.The2.91.2-and1.61.9-foldincrease,respectively,inthe area under the curve0‐120 of GLP-1 and PYY were accompanied by a significant decrease in fasting (P 0.05) and postprandial hunger (P 0.05) and a significant increase in satiety (P 0.05) after meal intake.Nevertheless,asignificantcorrelationbetweenchangesinthe hormonal and eating behavior parameters was not found. Conclusion: Our data show that RYGBP is associated with an improvement in the active GLP-1 and total PYY response to a liquidmeal intake. Moreover, we provide circumstantial evidence for a potential role of these gastrointestinal hormones on the decreased appetite after RYGBP. (J Clin Endocrinol Metab 91: 1735–1740, 2006)

Objective: To prospectively evaluate the short-term effects of Roux-en-Y gastric bypass (RYGBP) on ghrelin secretion and its relevance on food intake and body weight changes. Research Methods and Procedures: Ghrelin response to a standardized test meal was evaluated in eight obese patients (BMI, 43.5 to 59.1 kg/m2) before and 6 weeks after RYGBP. Ghrelin response was compared with that of an age-matched group of six normal weight individuals (BMI, 19.6 to 24.9 kg/m2). Results: Fasting serum ghrelin levels were lower in obese subjects compared with controls (p < 0.05). Meal ingestion significantly suppressed ghrelin concentration in controls (p < 0.05) and obese subjects (p < 0.05), albeit to a lesser degree in the latter group (p < 0.05). Despite a 10.3 ± 1.5% weight loss, fasting serum ghrelin levels were paradoxically further decreased in obese subjects 6 weeks after RYGBP (p < 0.05). Moreover, at this time-point, food intake did not elicit a significant ghrelin suppression. The changes in ghrelin secretion after RYGBP correlated with changes in insulin sensitivity (p < 0.05) and caloric intake (p < 0.05). Discussion: This study showed that the adaptive response of ghrelin to body weight loss was already impaired 6 weeks after RYGBP. Our study provides circumstantial evidence for the potential role of ghrelin in the negative energy balance in RYGBP-operated patients.

Nonhepatic abdominal surgery, and especially colorectal surgery, is associated with high rates of morbidity and mortality among cirrhotic patients. With proper patient selection and preoperative optimization of the patient's condition, laparoscopic-assisted colectomy could become effective and safe for patients with compensated liver cirrhosis. The aim of this study was to evaluate the safety and feasibility of minimal-access surgery in these patients.Between September 1993 and March 2003, 820 patients underwent laparoscopic-assisted colectomy at our hospital. We studied all patients with liver cirrhosis who underwent this operation.Seventeen patients with cirrhosis were included in the study. Twelve were Child's A and five were Child's B. The mean operative time was 150 min (ranges 75-280), mean estimated blood loss was 245 ml (ranges 100-250). The conversion rate to open surgery was 29% (five patients). Median length of hospital stay was 5 days. The morbidity rate was 29% (five patients). There were no anastomotic leaks or operative-related deaths. The median follow-up was 21 months.Laparoscopic-assisted colorectal surgery can be performed in compensated cirrhotic patients with low morbidity and mortality. Adequate patient selection and expertise in advanced minimal-access surgery are essential to obtain such good results.

Introduccion . El aumento de la complejidad del abordaje diagnostico-terapeutico de los pacientes con cancer colorrectal (CCR) hace aconsejable su atencion en unidades multidisciplinarias especializadas. El objetivo de este estudio fue evaluar la eficacia y la eficiencia de una unidad de cancer colorrectal (UCCR) en el abordaje diagnostico-terapeutico de estos pacientes. Pacientes Y Metodos . Se han seleccionado dos grupos de 50 pacientes con cancer de colon atendidos en nuestro centro antes y despues de la implementacion de la UCCR. Se ha analizado el cumplimiento del protocolo asistencial en relacion con la estadificacion del tumor, el tratamiento quirurgico y complementario, el seguimiento, el intervalo hasta la terapia, la estancia hospitalaria, la morbilidad y mortalidad inmediata, y la duracion global del proceso diagnostico-terapeutico. Ademas, se ha evaluado la carga asistencial y se ha realizado un analisis de minimizacion de costes. Resultados . La UCCR ha permitido reducir el intervalo hasta la cirugia (20,3 ± 12,0 frente a 28,9 ± 20,4 dias; p = 0,05), la estancia hospitalaria (9,8 ± 7,7 frente a 14,5 ± 9,3 dias; p = 0,01), el tiempo transcurrido hasta el inicio del tra-tamiento adyuvante (29,4 ± 10,2 frente a 39,7 ± 19,8 dias; p = 0,03), y la duracion global del proceso (60,4 ± 23,8 frente a 82,1 ± 46,1 dias; p = 0,05), lo que supone un ahorro de 978,85 euros por paciente. Esta mejora ha tenido lugar a pesar del incremento de la carga asistencial (24% en 5 anos en relacion con el numero de ingresos) y no ha afectado la morbilidad (26 frente a 24%; NS) ni la mortalidad inmediata (6 frente a 4%; NS). Conclusion . Las unidades multidisciplinarias especializadas favorecen un abordaje mas eficaz y eficiente de los pacientes con cancer de colon.

Background. The need for preoperative chemoradiation or short-course radiation in all T3 rectal tumors is a controversial issue. A multicenter phase II trial was undertaken to evaluate the efficacy and safety of neoadjuvant capecitabine and oxaliplatin combined with bevacizumab in patients with intermediate-risk rectal adenocarcinoma. Methods. We recruited 46 patients with T3 rectal adenocarcinoma selected by magnetic resonance imaging (MRI) who were candidates for (R0) resection located in the middle third with clear mesorectal fascia and who were selected by pelvic MRI. Patients received four cycles of neoadjuvant capecitabine and oxaliplatin combined with bevacizumab (final cycle without bevacizumab) before total mesorectal excision (TME). In case of progression, preoperative chemoradiation was planned. The primary endpoint was overall response rate (ORR). Results. On an intent-to-treat analysis, the ORR was 78% (n = 36; 95% confidence interval [CI]: 63%–89%) and no progression was detected. Pathologic complete response was observed in nine patients (20%; 95% CI: 9–33), and T downstaging was observed in 48%. Forty-four patients proceeded to TME, and all had R0 resection. During preoperative therapy, two deaths occurred as a result of pulmonary embolism and diarrhea, respectively, and one patient died after surgery as a result of peritonitis secondary to an anastomotic leak (AL). A 13% rate of AL was higher than expected. The 24-month disease-free survival rate was 75% (95% CI: 60%–85%), and the 2-year local relapse rate was 2% (95% CI: 0%–11%). Conclusion. In this selected population, initial chemotherapy results in promising activity, but the observed toxicity does not support further investigation of this specific regimen. Nevertheless, these early results warrant further testing of this strategy in an enriched population and in randomized trials.

One of the most controversial areas in laparoscopic approach is rectal cancer, not only because of the surgical technique but of the best approach to do it. The transanal approach arises like a new alternative for rectal cancer and other rectal pathologies due to solve some of the problems that we can find in conventional laparoscopic approach, mainly in low rectal cancer for the section of the rectum and distal margin. The first case of rectal cancer surgery by transanal approach was published in 2009. Since now, just a few series with a limited number of patients has been done with this technique. Among the different series there are differences, especially with the surgical technique (mainly with the transanal platform). Nowadays, the morbidity and postoperative outcomes have are comparable with the conventional approach. The oncological outcomes have no shown any differences, even long term results are not known at the moment (longer follow-up of 21 months). The results published in transanal approach surgery demonstrate the feasibility and safety of the procedure with an advantage in hostile pelvis (obese, narrow pelvis and males). Randomized studies are needed for long-term functional and oncological outcomes.

PURPOSE: All types of trauma to the organism produce a systemic response that is proportional to the severity of the lesion caused. The more rapid clinical recovery during the postoperative period of patients undergoing laparoscopic-assisted colectomyvs. patients receiving conventional surgery suggests that laparoscopic surgery produces less surgical trauma. The aim of this randomized, prospective study was to compare acute phase postoperative response in patients diagnosed with colon neoplasm undergoing open segmentary colectomyvs. laparoscopic-assisted colectomy. METHODS: From June 1994 to July 1997 the results of 97 patients (58 submitted to open colectomy and 39 undergoing laparoscopic-assisted colectomy) were analyzed. Blood determinations of cortisol, prolactin, C-reactive protein and interleukin-6 were performed before surgery and at 4, 12, 24, and 72 hours after surgery. RESULTS: The plasma levels of cortisol and prolactin were higher in the postoperative period with both surgical techniques with no significant differences being observed. The levels of interleukin-6 achieved a maximum peak at 4 hours after surgery, later showing a decrease and practically achieving basal levels at 72 hours in both groups. The levels of interleukin-6 were higher with significant differences at 4, 12, and 24 hours in the patients undergoing open colectomy. The plasma levels of C-reactive protein were significantly lower at 72 hours in patients receiving laparoscopic-assisted colectomy. CONCLUSIONS: The results obtained in this randomized, prospective study suggest that acute phase systemic response is attenuated in patients undergoing laparoscopic-assisted colectomy in comparison with patients receiving open colectomy.

Laparoscopic surgery for treatment of colorectal cancer has been suggested to enhance tumor dissemination. Recently, molecular techniques have been developed to detect micrometastatic disease in patients with solid tumors, with a higher accuracy than cytologic or immunohistochemical approaches. This study was undertaken to investigate the potential harmful effects of laparoscopic-assisted colectomy on neoplastic cell mobilization in patients with resectable colorectal cancer. Fifty patients with nonmetastatic colorectal cancer were randomly assigned to laparoscopic-assisted (LAC, n = 26) or open (OC, n = 24) colectomy. Peripheral venous blood samples were obtained preoperatively, immediately after tumor removal, and 24 hours later. In 10 patients from each treatment group, portal blood and peritoneal fluid samples were also obtained before and after resection. Neoplastic cells were detected by means of reverse transcriptase-polymerase chain reaction targeted to carcinoembryonic antigen (CEA) transcription. CEA mRNA was detected in peripheral venous blood samples from 35 of 50 colorectal cancer patients preoperatively. Among those 15 baseline-negative patients, four experienced conversion 24 hours after tumor resection (2 [33%] of 6 in the LAC group vs. 2 [22%] of 9 in the OC group; NS). At that time point, clearance of CEA mRNA expression was observed in 14 of the 35 baseline-positive patients (9 [45%] of 20 in the LAC group vs. 5 [33%] of 15 in the OC group; NS). In addition, only one patient in the LAC group with baseline-negative CEA mRNA expression experienced portal blood conversion after tumor removal, although his peripheral blood level remained negative. Finally, baseline peritoneal fluid CEA mRNA expression was never detected, but one patient in each group became positive postoperatively. These results confirm that preoperative and perioperative mobilization of neoplastic cells is a frequent occurrence in patients with colorectal cancer, but the surgical approach (LAC vs. OC) does not seem to be a determining factor.

The incidence of colorectal carcinoma increases in the elderly. Regardless of age as an isolated factor, postoperative complications represent the main factor in increasing hospital mortality.The aim of this study was to compare the short-term results (first 30 postoperative days) after laparoscopically assisted colectomy (LAC) and open segmental colectomy (OC) in colorectal carcinoma between two groups of patients, older than 70 and younger than 70 years of age. In the study from November 1993 to June 1998, 255 patients were evaluated to participate.Peristalsis, oral intake, and discharge from the hospital occurred earlier in LAC than in OC treated patients, in the two age groups. The mean operative time was significantly longer in the LAC than in the OC patients in the two age groups. No differences were observed in morbidity between LAC and OC in the group younger than 70 years of age. However, the overall morbidity was significantly lower in the LAC group in patients older than 70 years. One patient in the LAC group older than 70 years died.These results suggest that laparoscopically assisted colectomy may be particularly indicated in elderly patients.

Several studies have demonstrated the benefits of massive weight reduction following Roux-en-Y gastric bypass (RYGBP) on the metabolic syndrome (1–3). However, the time course of the effects of RYGBP on the metabolic syndrome components and its potential underlying mechanisms has not been reported. In recent years, it has been proposed that low-grade chronic inflammation is a critical factor underlying the metabolic syndrome (4–6). Alternatively, it has been proposed that the metabolic syndrome would be better explained by a combination of factors including but not limited to low-grade systemic inflammation (7). The aim of our study was to evaluate the time course of metabolic syndrome components, insulin sensitivity and inflammatory markers, following laparoscopic RYGBP in severely obese subjects. To discriminate the effects of modest (10% of initial body weight) versus massive weight loss on the evaluated parameters, we assessed subjects at 6 and 52 weeks after surgery. A total of 36 Caucasian, severely obese subjects about to undergo RYGBP surgery (8) were evaluated (Table 1). Twenty normal-weight healthy volunteers, matched for sex and age with the obese subjects, served as controls (Table 1). The study was approved by the hospital ethics committee. Written informed consent was obtained from all participants. The 36 obese, operated subjects were evaluated within 8 weeks before RYGBP and again at 6 and 52 weeks after RYGBP. Control subjects were evaluated on a single occasion. The diagnosis of the metabolic syndrome was based on the revised Adult Treatment Panel III criteria (9). Anthropometrical and blood pressure measurements were performed as previously described (10). Venous blood was collected after an overnight fast. Plasma glucose, total cholesterol, HDL cholesterol, triglyceride levels, insulin, adiponectin, and insulin sensitivity (homeostasis model assessment of insulin resistance [HOMA-IR]) were assessed …

Total proctocolectomy (TP) with ileal pouch-anal anastomosis (IPAA) is currently the surgical treatment of choice for medically refractory ulcerative colitis (UC), familial adenomatous polyposis (FAP), indeterminate colitis, and selected cases of Crohn’s disease (CD) [1]. In contrast to the low mortality rate after IPAA (less than 1 %), the morbidity rate occurs in 19 to 54 % of the cases [2]. Complications after this procedure can be classified as early (anastomotic leaks, pelvic sepsis, pouch bleeding) and late complications (pouchitis, pouch fistulae, small bowel obstruction, malignant transformation, and pouch failure) [2]. The most overall common complicationispouchitis. Inthisletter, wedescribea caseof a recurrent volvulus of the ileal pouch, an extremely rare complication described only once before in the literature [3].

Since the systematic introduction of minimally invasive surgery (MIS) in 1989, questions continue to arise whether MIS compares to conventional surgery in terms of efficacy and safety. Two special triggers for this quest were first the appearance of the port-site metastases after laparoscopic colon resection for cancer and second the progressive imperative to make surgical practice an objective science. Since then evidence-based surgery (EBS) has proven that MIS is a tremendous advancement in Surgery.