ABSTRACT
Introduction: Perforated marginal ulcer is a serious event that usually requires reoperation and is associated with morbidity and mortality. Characterization and management of these patients is still debated. Objective: To describe a series of patients subjected to a laparoscopic gastric bypass (LGBP) that evolved with a perforated marginal ulcer. Material and Methods: Records of patients undergoing a LGBP the last 10 years and evolved with a perforated marginal ulcer were retrospectively reviewed. Clinical features, treatment and perioperative morbidity and mortality were analyzed. Results: During this period 2,095 patients were subjected to a LGBP, 12 of them presented a perforated marginal ulcer, corresponding to 10 women and 2 men. Mean age was 39 (21-60) and mean body mass index at the time of initial surgery was 34 (29.3 to 38.6). Ten patients were smoker at the moment of perforation. The occurrence of this happened at a mean of 27 months (range 3-54, median 23.5) after surgery. Eleven cases had a surgical resolution, with a laparoscopic approach in 9 of them and laparotomy on 2. In all cases, a perforated ulcer in the jejunal side of the gastro-jejunal anastomosis was found. There was no mortality or morbidity associated with surgery. Conclusions: In our experience the occurrence of perforated marginal ulcer after a LGBP develops in a small percentage of patients. The laparoscopic approach is of choice, presenting a low morbidity and mortality. Smoking was present in most patients.
Introducción: La perforación de una úlcera marginal es un evento grave que suele requerir una reoperación y se asocia a morbimortalidad. El manejo de estos pacientes es debatido y complejo. Objetivo: Describir una serie de pacientes operados de bypass gástrico laparoscópico (BPGLP) que evolucionaron con una úlcera marginal perforada. Material y Método: Se revisaron retrospectivamente las fichas de pacientes operados de BPGL los últimos 10 años y que evolucionaron con una úlcera marginal perforada. Se analizaron las características clínicas, de tratamiento y morbimortalidad perioperatoria. Resultados: Durante este período se operaron 2.095 pacientes de BPGLP, 12 de los cuales presentaron una úlcera marginal perforada, correspondientes a 10 mujeres y 2 hombres. El promedio de edad fue 39 años (21-60) y el índice de masa corporal (IMC) promedio al momento de la primera cirugía fue 34 (29,3-38,6). Diez pacientes tenían hábito tabáquico activo al momento de la perforación. La ocurrencia de esta sucedió en promedio a los 27 meses (rango 3-54, mediana 23,5) de la cirugía. En 11 casos la resolución fue quirúrgica, mediante abordaje laparoscópico en 9 y laparotomía en 2. En todos los casos se encontró una úlcera perforada en la vertiente yeyunal de la gastro-yeyuno anastomosis. No hubo mortalidad ni morbilidad asociada a la cirugía. Conclusiones: En nuestra experiencia la ocurrencia de úlcera marginal perforada post BPGLP se desarrolla en un bajo porcentaje de pacientes. El abordaje laparoscópico es de elección, presentando una baja morbimortalidad. El hábito tabáquico estuvo presente en la mayoría de los pacientes.
Subject(s)
Humans , Male , Adult , Female , Young Adult , Middle Aged , Gastric Bypass/adverse effects , Laparoscopy/adverse effects , Peptic Ulcer Perforation/surgery , Peptic Ulcer Perforation/etiology , Comorbidity , Retrospective Studies , Risk FactorsABSTRACT
Laparoscopic liver resection is a technique that has boomed over time. Published related reports have increased exponentially in the last decade, leading to comparative studies and meta-analysis. Three types of technical approaches have been identified: pure laparoscopic, hand-assisted and hybrids procedures. While no precise indications exist for each method, the choice of each will depend on the type of surgical procedure and the surgeon's experience. Primarily only benign lesions were accepted for a laparoscopic intervention. Today malignant lesions, including metastases, are being resected via minimally invasive approach. Case selection may benefit in successful operative outcomes. Ideally, single lesions, less than 5 cm, peripheral and located at lateral or peripheral segments (II-VI) are better suited for laparoscopic liver resection. In addition, these procedures will be likely to succeed under expert experienced laparoscopic liver surgeons that have the best available technology within their reach. Reported results support the use of this technique when compared with open surgery in regards to minor: blood loss, use of opioids, time to oral intake, length of stay and complications. Furthermore, total costs are at least similar to the open approach. Most importantly, results from 5-year follow up studies of patients with malignant disease, in terms of disease-free survival and overall survival were equivalent to open surgery...
La resección hepática laparoscópica constituye una técnica que ha tenido gran desarrollo con el tiempo. Los reportes publicados han aumentado, dando paso a estudios comparativos y meta análisis. Se han diferenciado tres tipos de procedimientos, los laparoscópicos puros, los mano-asistidos y los híbridos. Si bien no hay indicaciones precisas para cada técnica, la elección de cada una de ellas dependerá del procedimiento y la experiencia del cirujano. Inicialmente sólo se aceptaba la resección de lesiones benignas, mientras hoy también se acepta para lesiones malignas, incluyendo metástasis. Se ha definido que las lesiones ideales para resecar son: lesiones únicas, menores a 5 cm, de ubicación periférica y de los segmentos laterales o periféricos (II al VI). A esto se suma que sólo cirujanos expertos que cuenten con toda la tecnología necesaria disponible sean los encargados de realizar estos procedimientos. Los resultados reportados avalan el uso de esta técnica al compararla con cirugía abierta en lo que respecta a menores: pérdidas sanguíneas, uso de opioides, tiempo a la ingesta oral, estadía hospitalaria y complicaciones, considerando que los costos totales son al menos similares a la técnica abierta. Sin embargo, lo más importante es que durante el seguimiento de los pacientes con patología maligna, los resultados oncológicos a 5 años han sido equivalentes a la cirugía abierta en lo que respecta a sobrevida libre de enfermedad y sobrevida total...
Subject(s)
Humans , Hepatectomy/methods , Laparoscopy , Liver Neoplasms/surgery , Hepatectomy/adverse effects , Patient SelectionABSTRACT
Gastric carcinoid corresponds to a rare malignancy, whose frequency increases with time. Several arguments attempt to explain this change. It ́s derived from one type of gastric neuroendocrine cell, the enterochromaffin-like cells. Various classifications have been used, however, the 1993 classification of Rindi remains the most used, which includes 3 types of gastric carcinoid based on its associated conditions, frequency, morphology, pathophysiology and prognosis. Also, a fourth type has been recognized that would represent a more aggressive neoplasm, like an adenocarcinoma. Diagnosis requires an upper gastrointestinal endoscopy, biopsies and ideally levels of chromogranin A as a serum marker. Once the type of gastric carcinoid is established the proper management can range from simple observation, endoscopic resection or surgery. In the case of metastatic disease a number of other treatments that might even eventually include liver transplantation are added. It is still much to learn from this disease, with many controversies in the pathophysiology and management, some of which we will try to clarify in the following article...