Gastrectomía en manga transumbilical con técnica simplificada: técnica y resultados quirúrgicos en 100 pacientes / Simplifi ed transumbilical sleeve gastrectomy: technique and surgical results in 100 patients

Background: The use of transumbilical approach for sleeve gastrectomy has been recently reported, using different technique variations. Aim: To report the technique and surgical results of a transumbilical approach simplified sleeve gastrectomy, using rigid instruments. Material and Methods: Ninety four women and six men, selected by a multidisciplinary team, underwent transumbilical sleeve gastrectomy. The operative technique involved a transumbilical incision, introduction of a SILS® or GelPoint® multiport, and a 5mm metallic accessory trocar laterally in the left flank. Rigid instruments were used in all patients. The greater curvature was dissected from 4-5 cm above the pylorus to the angle of His. Gastric transection was completed with a stapler, and calibrated with a 36 French tube advanced through the pylorus. Hemostasis of the staple line was carried out with metallic clips. A barium swallow was performed in ten randomly chosen patients, confirming the correct tubular shape of the stomach. Results: Body mass index of operated patients ranged from 30 to 43 kg/m². Mean operative time was 56.4 +/- 16.7 minutes. During the early postoperative period, two patients had a hemoperitoneum, one had an antral leak and one had an intestinal perforation. No conversion to conventional laparoscopy or open technique was required. No patient died. The mean length of hospital stay was 2.3 +/- 0.5 days. The cosmetic result was satisfactory for all patients. Conclusions: Transumbilical sleeve gastrectomy is a safe and feasible procedure with the reported technique. The insertion of an accessory 5mm trocar in the left flank simplifies the procedure, allowing the use of rigid instruments.

Introducción: El abordaje transumbilical, ha demostrado ser seguro en diferentes procedimientos. Se han reportado series de casos de gastrectomía en manga transumbilical (GMTU), con diferentes variaciones. Objetivo: Es presentar la técnica y resultados quirúrgicos de una técnica de GMTU simplificada, utilizando instrumental rígido. Material y Métodos: 94 mujeres y seis hombres, fueron sometidos a GMTU, seleccionados por un equipo multidisciplinario. La técnica quirúrgica consiste en una incision transumbilical, introducción de dispositivo SILS® o GelPoint®, y un trocar de 5 mm metálico en el flanco izquierdo. Se utilizó instrumental rígido en todos los pacientes. La disección de la curvatura mayor se realiza desde 4-5 cm proximal al píloro, hasta el pilar izquierdo. La sección gástrica se completa con stapler, calibrando con una sonda de 36 fr transpilórica. Se realiza hemostasia selectiva con clips metálicos. Se realizó estudio baritado a diez pacientes aleatorios, confirmando forma tubular adecuada. Resultados: El rango de IMC preoperatorio fue de 30-43 kg/m². El tiempo operatorio promedio fue de 56,4 +/- 16,7 min. No se requirió conversión a técnica multitrocar o laparotómica. Cuatro pacientes presentaron complicaciones precoces: dos hemoperitoneos, una filtración antral y una enterotomía inadvertida. Se reintervino a dos pacientes. No hubo mortalidad. El tiempo de hospitalización fue de 2,3 +/- 0,5 días. El resultado cosmético fue satisfactorio para todos los pacientes. Conclusión: La GMTU es un procedimiento factible y seguro con la técnica expuesta. La inserción del trocar de 5 mm accesorio, simplifica el procedimiento, permite el uso de instrumental rígido, y lo convierte en un procedimiento reproducible.

Evaluación de función diastólica intraoperatoria con ecocardiografía transesofágica: ¿es útil? / Intraoperative diastolic dysfunction as a risk factor for hemodynamic instability

Background: Diastolic function can be evaluated intraoperatively using transesoptiageal echocardiography. Aim: To study if intraoperative diastolic dysfunction is associated to a greater number of hemodynamic events during surgery and during the postoperative period. Material and methods: Patients with indication of intraoperative transesophageal echocardiography due to cardiovascular diseases were included in the study. Diastolic function was assessed measuring transmitral intraventricular filling delay and pulmonary vein now. Patients were divided, according to diastolic dysfunction, in those with derangements in relaxation, pseudonormalization and restrictive patterns. Hypertension, hypotension, ST segment depression, alterations in myocardial contractility, pulmonary congestion and postoperative oliguria were recorded. Results: Fifty eight patients aged 68± 12 years (39 males), were studied. Forty four had diastolic dysfunction. Intraoperative hypotension occurred in 82 percent of patients with diastolic dysfunction and 16 percent of patients without it. Likewise, hypotension and oliguria during the postoperative period were more common in patients with diastolic dysfunction. Conclusions: In this group of patients with cardiovascular disease, intraoperative diastolic dysfunction is a risk factor for hemodynamic instability.