Comparison of long-term quality of life between Billroth-I and Roux-en-Y anastomosis after distal gastrectomy for gastric cancer: a randomized controlled trial / 中华医学杂志(英文版)

BACKGROUND@#The results of studies comparing Billroth-I (B-I) with Roux-en-Y (R-Y) reconstruction on the quality of life (QoL) are still inconsistent. The aim of this trial was to compare the long-term QoL of B-I with R-Y anastomosis after curative distal gastrectomy for gastric cancer.@*METHODS@#A total of 140 patients undergoing curative distal gastrectomy with D2 lymphadenectomy in West China Hospital, Sichuan University from May 2011 to May 2014 were randomly assigned to the B-I group ( N  = 70) and R-Y group ( N  = 70). The follow-up time points were 1, 3, 6, 9, 12, 24, 36, 48, and 60 months after the operation. The final follow-up time was May 2019. The clinicopathological features, operative safety, postoperative recovery, long-term survival as well as QoL were compared, among which QoL score was the primary outcome. An intention-to-treat analysis was applied.@*RESULTS@#The baseline characteristics were comparable between the two groups. There were no statistically significant differences in terms of postoperative morbidity and mortality rates, and postoperative recovery between the two groups. Less estimated blood loss and shorter surgical duration were found in the B-I group. There were no statistically significant differences in 5-year overall survival (79% [55/70] of the B-I group vs. 80% [56/70] of the R-Y group, P  = 0.966) and recurrence-free survival rates (79% [55/70] of the B-I group vs. 78% [55/70] of the R-Y group, P  = 0.979) between the two groups. The scores of the global health status of the R-Y group were higher than those of the B-I group with statistically significant differences (postoperative 1 year: 85.4 ± 13.1 vs . 88.8 ± 16.1, P  = 0.033; postoperative 3 year: 87.3 ± 15.2 vs . 92.8 ± 11.3, P  = 0.028; postoperative 5 year: 90.9 ± 13.7 vs . 96.4 ± 5.6, P  = 0.010), and the reflux (postoperative 3 year: 8.8 ± 12.9 vs . 2.8 ± 5.3, P  = 0.001; postoperative 5 year: 5.1 ± 9.8 vs . 1.8 ± 4.7, P  = 0.033) and epigastric pain (postoperative 1 year: 11.8 ± 12.7 vs. 6.1 ± 8.8, P  = 0.008; postoperative 3 year: 9.4 ± 10.6 vs. 4.6 ± 7.9, P  = 0.006; postoperative 5 year: 6.0 ± 8.9 vs . 2.7 ± 4.6, P  = 0.022) were milder in the R-Y group than those of the B-I group at the postoperative 1, 3, and 5-year time points.@*CONCLUSIONS@#Compared with B-I group, R-Y reconstruction was associated with better long-term QoL by reducing reflux and epigastric pain, without changing survival outcomes.@*TRIAL REGISTRATION@#ChiCTR.org.cn, ChiCTR-TRC-10001434.

Terapia de presión negativa para el manejo de abdomen catastrófico secundario a íleo biliar / Negative Pressure Therapy for Managing Catastrophic Abdomen following Gallstone Ileus

Introducción: El abdomen catastrófico o abdomen hostil es una entidad quirúrgica de gran importancia por la pérdida de los distintos espacios entre los órganos de la cavidad abdominal y las estructuras de la cavidad abdominal. Estas alteraciones producen cambios anatómicos grandes por un síndrome adherencial severo. Objetivo: Demostrar la presentación de un abdomen catastrófico posterior a manejo de íleo biliar en un paciente adulto. Caso clínico: Paciente masculino de 43 años que producto de un abdomen agudo obstructivo por íleo biliar evolucionó tórpidamente en otra casa asistencial. Se realizaron 3 intervenciones quirúrgicas, hasta llegar a nuestra casa asistencial donde se le trata de manera multidisciplinaria e integral. Estuvo 120 días hospitalizado y se le realizó 5 intervenciones quirúrgicas para aplicación y recambio de terapia de presión negativa abdominal abierta (ABThera). Durante la última intervención al encontrar una cavidad limpia y sin fugas se realiza gastroentero anastomosis en Y de Roux con una buena evolución clínico-quirúrgica hasta el alta, con seguimiento dos meses posteriores por consulta externa. Conclusiones: El abdomen catastrófico es un reto para el manejo por los cirujanos porque se requiere aparte de un vasto conocimiento también el apoyo de otras especialidades para poder combatir esta entidad(AU)

Introduction: Catastrophic abdomen or hostile abdomen is a surgical entity of great significance due to the loss of the different spaces between organs and the structures of the abdominal cavity. These alterations produce major anatomical changes due to a severe adhesive syndrome. Objective: To show the presentation of a catastrophic abdomen following gallstone ileus management in an adult patient. Clinical case: A 43-year-old male patient who, as a consequence of an acute obstructive abdomen due to gallstone ileus, had a torpid evolution into another care facility. Three surgical interventions were performed before he arrived at our care facility, where he was treated in a multidisciplinary and comprehensive way. He was hospitalized for 120 days and underwent five surgical interventions for application and replacement of the open abdomen negative pressure therapy (ABThera). During the last intervention, upon finding a clean cavity without leaks, a Roux-en-Y gastroenteric anastomosis was performed, with a good clinical-surgical evolution until discharge and follow-up of two months thereafter in the outpatient clinic. Conclusions: Catastrophic abdomen is a challenge to be managed by surgeons because it requires, apart from vast knowledge, the support of other specialties to combat this entity(AU)

Choice of digestive tract reconstruction in upper gastric cancer / 中华胃肠外科杂志

With the increasing incidence of upper gastric cancer and early gastric cancer, surgeons have gradually paid attention to the selection of appropriate digestive tract reconstruction methods. At present, the safety of surgery is no longer the main aim pursued by surgeons, and the focus of surgery has gradually changed to postoperative quality of life. Surgical procedures for upper gastric cancer include total gastrectomy (TG) and proximal gastrectomy (PG). Roux-en-Y anastomosis is recommended for digestive tract reconstruction after TG. The classic method of digestive tract reconstruction after PG is distal residual stomach and esophageal anastomosis. However, to prevent esophageal reflux caused by PG, a lot of explorations have been carried out over the years, including tubular gastroesophageal anastomosis, double-flap technique (Kamikawa anastomosis), interposition jejunum, double-tract reconstruction and so on. But the appropriate method of digestive tract reconstruction for upper gastric cancer is still controversial. In this paper, based on literatures and our clinical experience, the selection, surgical difficulties and techniques of digestive tract reconstruction after PG are discussed.

Technical difficulties and countermeasures of digestive tract reconstruction in robotic radical gastrectomy for gastric cancer / 中华胃肠外科杂志

There still remain some problemsin digestive tract reconstruction after robotic radical gastrectomy for gastric cancer at present, such as great surgical difficulties and high technical requirements. Based on the surgical experience of the Gastric Surgery Department of Union Hospital, Fujian Medical University and the literatures at home and abroad, relevant issues are discussed in terms of robotic radical distal gastrectomy (Billroth I, Billroth II, and Roux-en-Y gastrojejunostomy), proximal gastrectomy (double-channel and double-muscle flap anastomosis), and total gastrectomy (Roux-en-Y anastomosis, functional end-to-end anastomosis, FEEA, π-anastomosis, Overlap anastomosis, and modified Overlap anastomosis with delayed amputation of jejunum, i.e. later-cut Overlap). This article mainly includes (1) The principles of digestive tract reconstruction after robotic radical gastrectomy for gastric cancer. (2) Digestive tract reconstruction after robotic radical distal gastrectomy: Aiming at the weakness of traditional triangular anastomosis, we introduce the improvement of the technical difficulty, namely "modified triangular anastomosis", and point out that because Billroth II anastomosis is a common anastomosis method in China at present, manual suture under robot is more convenient and safe, and can effectively avoid anastomotic stenosis. (3) Digestive tract reconstruction after robotic proximal gastrectomy: It mainly includes double channel anastomosis and double muscle flap anastomosis, but these reconstruction methods are relatively complicated, and robotic surgery has not been widely carried out at present. (4) Digestive tract reconstruction after robotic total gastrectomy: The most classic one is Roux-en-Y anastomosis, mainly using circular stapler for end-to-side esophagojejunal anastomosis and linear stapler for side-to-side esophagojejunal anastomosis, for which we discuss the solutions to the existing technical difficulties. With the continuous innovation of robotic surgical system and anastomosis instruments, and with the gradual improvement of anastomosis technology, it is believed that digestive tract reconstruction after robotic radical gastrectomy for gastric cancer will have a good application prospect in gastric cancer surgery.

Aspectos da hipertensão arterial sistêmica antes e após a cirurgia bariátrica do tipo Fobi capella com desvio de y de Roux / Aspects of systemic arterial hypertension before and after fobi capella with deviation Roux-en-y bariatric surgery

A obesidade é uma doença crônica multifatorial que desencadeia diversas comorbidades, sendo a hipertensão arterial uma das principais complicações, tornando-se um risco para o desenvolvimento das doenças cardiovasculares e mortalidade precoce. Assim, este estudo objetivou abordar os aspectos da hipertensão relacionada à obesidade antes e após a realização de cirurgia bariátrica. Tratou-se de um estudo descritivo, envolvendo indivíduos de ambos os gêneros, com idade superior a 18 anos submetidos à cirurgia bariátrica pelo método Fobi Capella com desvio de Y de Roux na cidade de Toledo-PR. Para tanto, 30 participantes responderam um questionário semiestruturado investigando dados sobre a pressão arterial. Os resultados demonstraram que no pré-operatório 66,66% dos avaliados apresentavam hipertensão, sendo os gêneros igualmente afetados, 46,66% referiram três ou mais sintomas da comorbidade e escore de saúde mental (40,8 ±16,7) com repercussão relevante. No pós-operatório os parâmetros de normalidade da pressão arterial foram evidenciados em todos os participantes, 57,14% deixaram de necessitar de medicação de controle e houve uma melhora exponencial do escore de saúde mental (81,9 ±21,7). Concluindo que a cirurgia bariátrica compõe um tratamento altamente eficaz para perda ponderal de peso corroborando para normalização da pressão arterial, redução dos sintomas da hipertensão, da necessidade de tratamento medicamentoso para essa finalidade e melhora da saúde geral do indivíduo.

Obesity is a chronic multifactorial disease that triggers several comorbidities, with arterial hypertension being one of the main complications, becoming a risk for the development of cardiovascular diseases and early mortality. Thus, this study aimed at addressing aspects of hypertension related to obesity before and after bariatric surgery. This is a descriptive study, involving individuals of both genders, aged over 18 years submitted to bariatric surgery by the Fobi Capella method with deviation of Roux-en-Y in the city of Toledo, in the state of Paraná, Brazil. For that purpose, 30 participants answered a semi-structured questionnaire investigating blood pressure data. The results showed that in the pre-surgery period, 66.66% of the patients had arterial hypertension, and the genres were equally affected; 46.66% reported three or more symptoms of comorbidity and mental health score (40.8 ± 16.7) with relevant repercussions. In the post-surgery period, normal blood pressure parameters were evident in all participants, 57.14% no longer required control medication and there was an exponential improvement in the mental health score (81.9 ± 21.7), thus concluding that bariatric surgery is a highly effective treatment for weight loss, corroborating blood pressure normalization, reduction of symptoms of hypertension, the need for drug treatment for this purpose and improvement of the individual's general health.

Gastrectomía vertical versus by-pass gástrico en Y de Roux: resultados a corto y medio plazo / Sleeve gastrectomy vs gastric bypass: results in the short and medium term

Resumen Introducción: La gastrectomía vertical (GV) y el by-pass gástrico (BPG) son los procedimientos más utilizados en el tratamiento de la obesidad. El objetivo de este trabajo es comparar ambas técnicas tanto en pérdida ponderal como en mejoría de las comorbilidades asociadas. Materiales y Método: Estudio observacional ambispectivo de los pacientes sometidos a BPG y GV desde enero de 2011 hasta diciembre de 2013. Se ha analizado la pérdida de peso y de IMC, la tasa de éxito, la reganancia de peso, el impacto en las comorbilidades asociadas y la morbimortalidad de ambas técnicas. Resultados: 172 pacientes fueron intervenidos (92 BPG y 80 GV). El BPG presenta mejores resultados en cuanto a pérdida de peso y mejoría de las comorbilidades. El grupo GV presenta mayor reganancia de peso. Ambos procedimientos presentan resultados similares en cuanto a morbimortalidad.

Introduction: Sleeve gastrectomy (SG) and gastric bypass (GBP) are the most commonly used procedures in the treatment of obesity. The objective of this paper is to compare these two techniques in regard to weight loss and improvement of the associated comorbidities. Material and Method: An ambispective observational study of patients undergoing GBP and SG from January 2011 to December 2013. Weight loss, BMI, success rate, weight regain, impact on associated comorbidities and morbimortality of both techniques were analysed. Results: 172 patients underwent operations (92 GBP and 80 SG). GBP had better results in regard to weight loss and improvement of comorbidities. The SG group had greater weight regain. The two procedures had similar results in regard to morbimortality.

Resultados de la manometría del cuerpo esofágico y del asa de yeyuno en pacientes operados por cáncer gástrico con gastrectomía total 5 años después de la cirugía / Esophageal manometry in patients with total gastrectomy 5 years after surgery

Resumen Introducción: La técnica de elección para la reconstrucción del tránsito intestinal después de una gastrectomía total es la esófago-yeyuno anastomosis en Y de Roux, la cual evita el reflujo de jugo digestivo alcalino. El objetivo del presente estudio es el de analizar la motilidad del esófago y del asa de yeyuno en pacientes operados con gastrectomía total por cáncer gástrico. Pacientes y método: Se estudió prospectivamente una muestra de 17 pacientes intervenidos mediante gastrectomía total 5 años atrás. En todos ellos se realizaron manometrías esofágicas de alta resolución incluyendo los primeros 7 cm del asa de yeyuno. Resultados: Los resultados de la manometría demostraron motilidad esofágica normal a excepción de la presión máxima intrabolo, la cual se encontraba aumentada en todos los pacientes. La motilidad del asa de yeyuno fue desordenada e inefectiva. Conclusiones: La motilidad del cuerpo esofágico es normal 5 años después de la gastrectomía total. Sin embargo, la presión intrabolo máxima se encuentra aumentada; la causa más probable de este hecho estaría constituida por el asa de yeyuno, que ejerce resistencia al paso del bolo debido a que presenta una actividad motora desordenada y poco propulsiva. El impacto clínico de este hecho es, sin embargo, poco importante.

Abstract Introduction: The most preferred technique to reconstruct the intestinal transit after total gastrectomy for gastric cancer is the Roux-en-Y esophagus-gastrostomy which prevents the reflux of alkaline intestinal juice. The purpose of this study was to analyze the esophageal motility and the motility of the jejunal loop in patients subjected to total gastrectomy. Patients and method: A prospective sample of 17 total gastrectomy patients operated on 5 years before was studied using high resolution esophageal manometry including the first 7 cm of the jejunal loop. Results: Manometry results showed normal esophageal body motility with the exception of the maximum intrabolus pressure that was elevated in all patients. The jejunal loop motility was disordered and ineffective. Conclusions: Esophageal body motility was normal 5 years after the surgical procedure. However, maximum intrabolus pressure was elevated and the most plausible reason would be the jejunal loop that exerts resistance to the bolus passage due to its ineffective motility. However, this fact does not have a significant clinical impact.

Efeitos da cirurgia bariátrica na estrutura e na função do ventrículo esquerdo / Effects of bariatric surgery on left ventricular structure and function

Fundamentos: A obesidade está associada a alterações estruturais e funcionais do ventrículo esquerdo (VE). A cirurgia bariátrica tem o potencial de reverter tais achados. Os efeitos do procedimento nas funções diastólica e sistólica do VE não foram claramente definidos. O presente estudo teve por objetivo avaliar as alterações na estrutura e funções sistólica e diastólica do ventrículo esquerdo de pacientes obesos que se submeteram à cirurgia bariátrica. Métodos: Foram avaliados 23 pacientes (16 mulheres e 7 homens, com idade média de 32,9 ± 8,9 anos), com índice de massa corporal ≥ 40 kg/m2 , que foram submetidos à derivação gástrica em Y de Roux (RYGB). As avaliações clínicas eecocardiográficas foram realizadas no pré-operatório e em 3 a 7 meses após a cirurgia. Resultados: Após período médio de seguimento de 4,7 meses, foram observadas reduções significativas no índice de massa corporal (de 46,7 ± 5,3 para 36,2 ± 4,7 kg/m2 ; p < 0,001); na espessura do septo interventricular(de 10,3 ± 1,4 para 8,9 ± 1,2 mm); na parede posterior do VE (de 9,3 ± 1,3 para 8,4 ± 1,1 mm; p < 0,001) e na massa do VE (valor absoluto: de 168,7 ± 35,2 para 149,8 ± 40,7 g, p = 0,008; indexada pela altura: de 45,1 ± 11,3 para 39,7 ± 10,3, p = 0,006). A geometria normal do VE foi observada em 60,9% dos pacientes antes da cirurgia e em 91,3% no período de seguimento. O Doppler tecidual revelou melhora na função diastólica do VE (velocidade de onda E’ mitral lateral, 0,16 ± 0,03 no pré-operatório contra 0,17 ± 0,03 m/s no seguimento; p = 0,026). No pós‑operatório, não houve diferença significativa na função sistólica do VE. Conclusões: Após um seguimento médio de 4,7 meses, a cirurgia bariátrica promoveu melhora na estrutura ventricular esquerda e em um dos parâmetros da função diastólica (velocidade de E’). Não houve alterações nos parâmetros sistólicos do ventrículo esquerdo.

Background: Obesity is associated with changes in left ventricular (LV) structure and function. Bariatric surgery can favorably improve cardiac remodeling. The effects of the procedure in LV diastolic and systolic function have not been clearly defined. The aim of this study was to evaluate the changes in left ventricular structure, systolic and diastolic function in obese patients who have undergone bariatric surgery.Methods: We evaluated 23 patients (16 women, seven men; age, 32.9 ± 8.9 years) with body mass index > 40 kg/m2 who underwent Roux-en-Y gastric bypass (RYGB). Clinical and echocardiographic evaluations were performed preoperatively and 3–7 months after surgery. Results: After a mean follow-up of 4.7 months, significant reductions were observed in body mass index (from 46.7 ± 5.3 to 36.2 ± 4.7 kg/m2; p< 0.001); thickness of the interventricular septum (from 10.3 ± 1.4 to 8.9 ± 1.2 mm); LV posterior wall (from 9.3 ± 1.3 to 8.4 ± 1.1mm; p < 0.001) and LV mass (absolute value: from 168.7 ± 35.2 to 149.8 ± 40.7 g, p = 0.008; indexed by height: from 45.1 ± 11.3 to 39.7 ± 10.3, p = 0.006). Normal LV geometry was observed in 60.9% of patients before surgery and in 91.3% at follow-up. Tissue Doppler imaging revealed improved LV diastolic function (mitral E’ lateral 0.16 ± 0.03 preoperatively vs. 0.17 ± 0.03 m/s at follow-up; p = 0.026). Postoperatively, there was no significant difference in LV systolic function. Conclusions: After a mean follow-up of 4,7 months, bariatric surgery promoted improvement in left ventricular structure and in one of the parameters of diastolic function (E’ velocity). There were no changes in left ventricular systolic parameters.

La hepaticoyeyunostomía en el tratamiento de las afecciones hepatobiliopancreáticas / Hepaticojejunostomy in the treatment of affections

Introducción: el tratamiento de las afecciones del sistema hepatobiliopancreático dista mucho de ser el óptimo a pesar de los avances conseguidos con la incorporación de nuevos procedimientos diagnósticos y terapéuticos; sin embargo, las derivaciones bilioentéricas son consideradas una alternativa valiosa en el tratamiento. Objetivo: caracterizar el tratamiento de las afecciones del sistema hepatobiliopancreático con el uso de la hepaticoyeyunostomía, en el servicio de cirugía general del hospital Dr. Salvador Allende, desde enero de 2000 hasta diciembre de 2013. Métodos: estudio de corte transversal, retrospectivo-prospectivo y descriptivo. La muestra estuvo constituida por 77 pacientes. Resultados: las enfermedades del sistema hepatobiliopancreático malignas representaron el principal diagnóstico entre nuestros pacientes, con 31 por ciento de complicaciones posoperatoria y cuatro (5,19 por ciento) muertes asociadas al proceder. Conclusiones: la hepaticoyeyunostomía es una opción terapéutica segura en aquellos pacientes con enfermedad hepatobiliopancreática cuando no exista la adecuada factibilidad de métodos endoscópicos derivativos, ante el fallo de estos o el fracaso de la descompresión percutánea(AU)

Introduction: the treatment of disorders of the hepatobiliopancreatic system is far from being despite the progress made with the incorporation of new diagnostic and therapeutic procedures; however, biliary-enteric by-passes are considered a valuable alternative in the treatment. Objective: to characterize the treatment of hepatobiliopancreatic system affections using hepaticojejunostomy, in the Department of General Surgery Dr. of Salvador Allende Hospital, from January 2000 to December 2013. Methods: a cross-sectional, retrospective-prospective and descriptive study was carried out. The sample consisted of 77 patients. Results: the malignant disease of the hepatobiliopancreatic system were the main diagnosis among our patients, with 31 percent of postoperative complications and four (5.19 percent) deaths associated with the procedure. Conclusions: hepaticojejunostomy is a safe therapeutic option for patients with hepatobiliopancreatic disease, when there is no adequate feasibility of endoscopic derivative methods, in face of the failure of these or that of percutaneous decompression(AU)

Modified "Roux en Y" hepaticojejunostomy to permit transgastric endoscopic access

PURPOSE: To present an option technique during the accomplishment of a "Roux-en-Y" hepaticojejunostomy that, allows future transgastric endoscopic access to the biloenteric anastomosis. METHODS: The side-to-side "Roux-en-Y" hepaticojejunostomy is carried through transmesocolic, retrogastric short tunnel. A distal jejunal loop of approximately 10,0 to 15,0 cm must be kept far from the anastomosis that allows its setting, without tension, in the anterior gastric wall bellow the small bending, between body and of the stomach antrum. Once the jejunal segment is fixed on the anterior gastric wall, this will allow future endoscopic access to the bilioenteric anastomosis, carried through transgastric punction guided by endoscopic-ultrasound (EUS). CONCLUSION: The modified "Roux en Y" hepaticojejunostomy is a simple and new technique to permit an alternative transgastric endoscopic access to bilioenteric anastomosis. .

Técnica Portie I de derivación gastro-bilio-pancreática en el tratamiento quirúrgico de la obesidad mórbida / Portie I technique of Biliopacreatic diversion for the surgical treatment of morbid obesity

Introducción: la obesidad es una epidemia de nuestro tiempo y la cirugía el único tratamiento efectivo en su solución. Objetivo: exponer la técnica Portie I como tratamiento quirúrgico de la obesidad mórbida y sus comorbilidades más frecuentes. Métodos: entre enero de 2000 y enero 2012 se realiza un estudio prospectivo, descriptivo longitudinal donde incluyeron 683 pacientes con obesidad mórbida tratados con la técnica Portie I. Se evaluaron los tipos de obesidad y las comorbilidades asociadas para diseñar la estrategia quirúrgica. Se muestran los resultados y se clasifican en tempranas y tardías las complicaciones posoperatorias ocurridas. Resultados: predominó el sexo femenino con 465 pacientes y 268 masculinos. Comorbilidades 66 (9,6 porciento) 4 mortalidad (0,5 porciento) pérdida del exceso de peso por encima de 80 porciento en el 75 porciento de los casos a los 5 años. El tiempo quirúrgico promedio fue 3,5 horas (rango de 2,74,3 horas). Conclusiones: La técnica quirúrgica de derivación gastro-bilio-pancreática Portie I es una opción segura y efectiva en la cirugía de la obesidad mórbida(AU)

Introduction: obesity is considered an epidemic nowadays. Though it has several ways of treatment, surgery has been proved to be the best option. Objective: to show Portie I technique for the surgical treatment of morbid obesity and its most frequent comorbidities. Methods: a prospective and descriptive longitudinal study is conducted between January 2000 and January 2012, in which 683 patients with morbid obesity treated with the Portie I surgical technique were included. Different types of obesities and the associated comorbodities were evaluated to set the appropriate surgical strategy. Post-surgical results and classifications of early and late complications are presented. Results: prevalence of 465 female patients over 268 male patients was significant, meanwhile comorbidity was 66 (9.6 percent), mortality was 4 (0.5 percent), weight loss was over 80 percent in 75 percent of the total of cases by the end of 5 years after surgery. Average surgical time was 3.5 hours. (Ranking 2.74.3 hours) Conclusions: the technique of biliopacreatic diversion is an effective and safe surgical option in the management of morbid obesity(AU)

Quiste del colédoco: presentación de quince casos / Choledochal cyst: presentation of fifteen cases

El quiste del colédoco es una rara anomalia congénita que ocurre en los países occidentales con una frecuencia de 1 por cada 2 millones de nacidos vivos. De predominio en el sexo femenino en una relación 4:1. La colangiografia permite clasificarlos en cinco tipos anatómicos y de acuerdo a la unión pancreático biliar en seis tipos. Su etiología no está todavía bien definida. Entre las hipótesis que tratan de explicar su patología están la debilidad de la pared del conducto biliar, la obstrucción distal del colédoco y el reflujo de enzimas pancreáticas al conducto biliar principal. En este informe se presentan quince casos tratados con éxito en el servicio de cirugía ifantil del Hopsital Unversitario de Maracaibo entre 1988 y 2008, todos del tipo 1 en hembras, con un poco más de la mitad entre 1 y 5 años de edad. En 14 casos se practicó la extirpación total con anastomosis hepato-yeyunal en "Y" de Roux y extirpación parcial en uno. Todos sobrevivieron. Entre las complicaciones se citan una dehiscencia de la anastomosis y una eventración posoperatoria en el mismo paciente.

Choledochal cysts are a rare congenital anomaly in occidental countries with a frequences of 1 x 2 million of live births. Predominant in females with a relation 4:1. By colangiography they are classify in five types and according to the pancreatic bile union in six types. Aetiology is still unknown. Among the hypothesis to explain pathogeny we have weak bile un conduct wall, distal choledochal obstruction and pancreatic enzymes reflux into the principal bile duct. In his report we present 15 treated cases with success between 1988 and 2008 in the surgical service for children of the Maracaibo university hospital, all of them type I in female patients with a little more tham half between I and 5 years old. In 14 cases we practice total extirpation with hepato-yeyunal anastomosis in Roux "Y" and partial extirpation in one. All of them survive. As complications they were one anastomosis dehiscence and one postoperative eventration in the same patient.

Hernias internas luego de bypass gástrico en Y de Roux por laparoscopia / Internal hernias after gastric bypass laparoscopic Roux en Y

Presentamos nuestra experiencia en el diagnóstico y tratamiento de los pacientes con hernias internas luego de bypass gástrico en Y de Roux por laparoscopia debido a obesidad mórbida. Se revisaron las historias de una serie de pacientes sometidos a bypass gástrico en Y de Roux por laparoscopia, incluyéndose para el análisis a aquellos casos con diagnóstico de hernia interna posoperatoria. Se determinó el tiempo de presentación, síntomas, hallazgos radiológicos, abordaje quirúrgico, tipo de hernia, técnica quirúrgica, y morbilidad. Desde enero de 2004 a diciembre de 2009 intervenimos 512 pacientes con obesidad mórbida mediante bypass gástrico en Y de Roux por laparoscopia, utilizando una posición antecólica del asa alimentaria, sin cerrar los defectos mesentéricos. Se reoperaron 30 pacientes (5,8%) debido a hernia interna, de los cuales 27 (90%) se pudieron resolver mediante un abordaje laparoscópico. El tiempo promedio de presentación fue de 20 meses, y el principal síntoma dolor abdominal posprandial. La radiología simple de abdomen fue positiva solo en 8 casos (26,6%). Una paciente falleció debido a infarto intestinal masivo y sepsis intraabdominal para una mortalidad de 3,3%. Se concluye que las hernias internas constituyen la complicación tardía con mayor potencial de letalidad luego de bypass gástrico en Y de Roux por laparoscopia, por lo que es necesario un alto índice de sospecha clínico para un diagnóstico y tratamiento tempranos.

We present our experience in the diagnosis and treatment of patients with internal hernias following laparoscopic Roux Y gastric bypass for morbid obesity. The records of a series of patients submitedd to laparoscopic Roux Y gastric bypass were reviewed, including for the analysis those cases with diagnosis of postoperative internal hernia. Time of onset, symptoms, radiologic findings, surgical approach, type of hernia, surgical technique, and morbidity were determined. From January 2004 to December 2009, 512 morbidly obese patientes were submitted to laparoscopic Roux Y gastric bypass, using an antecolic alimentary limb, without closing the mesenteric defects. Thirty patients (5,8%) were reoperated because an internal hernia, 27 ofthem (90%) solved by laparoscopic approach. Mean time of onset was 20 months, and postprandial abdominal pain was the main symptom. Plain abdominal x-ray was positive only in 8 cases (26,6%). One patient died because intestinal infarction and abdominal sepsis for a 3,3% mortality rate. We concluded that internal hernias are late complication with most lethality potential after a laparoscopic Roux Y gastric bypass, a high index of clinical suspicion is necessary for an early diagnosis and treatment.

Calidad de vida en pacientes obesos sometidos a bypass gástrico laparoscópico en "Y" de Roux y gastrectomía vertical laparoscópica / Quality of life in obese patients undergoing laparoscopic gastric bypass

El presente es un estudio prospectivo en el que se evalúan los cambios en la calidad de vida y tolerancia a los alimentos en pacientes con obesidad mórbida, luego de bypass gástrico en "Y" de Roux (BPGYR) y gastrectomía vertical (GV) por laparoscopia, en el Servicio de Cirugía II del Hospital Universitario de Caracas. Desde septiembre de 2008 hasta enero de 2009 se incluyeron de manera prospectiva, no aleatoria, 41 pacientes; 23 sometidos a BGYR y 18 a GV por laparoscopia. Se aplicaron los test de calidad de vida de Moorehead-Ardelt, y el de calidad de alimentación de Suter, a los 3, 6 y 9 meses de posoperatorio. La pérdida del exceso de peso fue satisfactoria para ambos procedimientos, siendo de 60 por ciento para el BGYR y de 71,5 por ciento para la GV. En ambos grupos hubo mejoría estadísticamente significativa (P < 0,01) de la calidad de vida con respecto al preoperatorio, presentando todos los pacientes un puntaje correspondiente a calidad buena o muy buena a los 9 meses del posoperatorio. La tolerancia a los alimentos se vió disminuida a los 3 meses posquirúrgicos en ambas técnicas, con recuperación posterior a los 6 y 9 meses, siendo mejor en el grupo sometido a GV (P< 0,05). Se concluye que ambas técnicas son efectivas, y mejoran la calidad de vida de los pacientes con obesidad mórbida. Hay un deterioro temporal de la tolerancia a los alimentos y calidad de alimentación, que se recupera progresivamente con mejor respuesta a los 9 meses en los pacientes sometidos a GV

The following is a prospective study that evaluate the quality of life and food tolerance changes in patients submitted to Roux en "Y" gastric bypass and sleeve gastrectomy by laparoscopy, at Servicio de Cirugía II of the Hospital Universitario de Caracas. From september 2008 to january 2009, 41 patients were included in a prospective, non randomized way; 23 submitted to Roux en "Y" gastric bypass and 18 to sleeve gastrectomy by laparoscopy. The Moorehead-Ardelt quality of life, and Suter food tolerance tests were applied at 3, 6 and 9 postoperative months. The excess weight loss was statistically satisfactory (P< 0.01) for both procedures, 60 percent for Roux en "Y" gastric bypass and 71.5 percent for sleeve gastrectomy. For both groups there was statistically significant improve (P< 0.01) in quality of life related to the preoperative period, with all patients on good and very good quality of life at 9 months. Food tolerance was worsened at 3 months postsurgery in both techniques, with progressive recovery at 6 and 9 months, doing better the GV group (P< 0.05). We conclude that both techniques are effective, and improve the quality of life of morbidly obese patients. There is a temporary worsening in food tolerance that is progressively recovered with better response at 9 months in patients submitted to sleeve gastrectomy

Tratamiento quirúrgico de la obesidad mórbida / Surgical treatment for morbid obesity

Since the realization in 1991 of the National Institutes of Health Consensus Development Conference Draft Statement on Gastrointestinal Surgery for Severe Obesity, the bariatric surgery become accepted by the medical community as the most long-term efficient procedure for the treatment of morbid obesity. The surgical suggestion is based mainly in the Body Mass Index of the patient wight/height (kg/m2). Bariatric surgical techniques can be classified according to their main mechanism of action in: restrictives (adjustable gastric banding, sleeve gastrectomy, open vertical banded gastroplasty), malabsorptives: biliopancreatic derivation Scopinaro type or biliopancreatic derivation with duodenal switch (Marceau) and finally the Roux-en-Y gastric bypass. All these aspects are treated in the article.

Hepaticocholecystoduodenostomy compared with Roux-en-y choledochojejunostomy for decompression of the biliary tract

The nature of palliative decompressive surgery for unresectable periampullary tumor is usually determined by the experience of the surgeon. We compared hepaticocholecystoduodenostomy [HCD], a new palliative decompressive anastomotic technique, to Roux-en-y choledochojejunostomy [CDJ] in this prospective, randomized study. Twenty patients who were to undergo surgery for palliative bypass were randomized into two groups: group I was subjected to HCD [10 patients] and group II to CDJ [10 patients]. Pre- and postoperative liver function tests, operative time, operative blood loss, onset of postoperative enteral feeding, length of hospital stay and survival rates were compared into the two groups. Effective surgical decompression was observed clinically as well as on analysis of pre- and postoperative liver function tests in both the groups. The results were statistically significant in favor of patients in group I when compared to those of group II with respect to operative time 84.7 [10.3] min vs 133.6 [8.9] min; P=<.0001], operative blood loss 137.8 [37.2] mL vs 201.6 [23.4] mL; P=/001], postoperative enteral feeding 3.3 [0.5] days vs 5.0 [0.7] days; P=<.0001] and length of hospital stay 7.5 [0.7] days vs 9.7 [1.2] days; P=<.0001]. During follow-up, recurrent jaundice was observed in one patient in group I and two patients in group II, while duodenal obstruction developed in one patient in the group I series. Gastrointestinal hemorrhage occurred in one patient belonging to group II. The difference in mean survival time was not statistically significant. Based on this small series, HCD seems to be a better palliative surgical procedure than the routinely performed CDJ

Radiographic study of patients submitted to total gastrectomy using Safatle reconstruction technique / Estudo radiológico em doentes submetidos a gastrectomia total com reconstrução à Safatle

BACKGROUND: Ever since the first total gastrectomy, there has always been a great concern in increasing the survival of patients, and with the advance of techniques, in improving the quality of life of these patients. The most common reconstruction technique of the gastrointestinal transit is the Roux-en-Y. The reposition of a functional pouch in place of the resected stomach was proposed to minimize the postprandial symptoms, improve the nutritional grade and consequently, the quality of life. The Safatle reconstruction of the gastrointestinal transit technique consists of, in short, in the association of the interposition of the jejunal loop with partial transit through the duodenum, with an inverted Roux-en-Y and with the creation of a pouch which resembles the dynamics of the stomach, achieved by duodenojejunal segment which has an antiperistalsis emptying. AIM: To assess, by radiographic means, the emptying of the duodenojejunal pouch in patients submitted to total gastrectomy using the Safatle reconstruction technique. METHOD: Twelve patients submitted to total gastrectomy using the Safatle technique due to gastric cancer were studied. They were summoned to perform contrasted radiographies of the esophagus-duodenum-jejunum by the videofluoroscopic method during the months of July and August, 2005. RESULTS: All the patients presented satisfactory movement of the duodenojejunal pouch and an adequate emptying in antiperistalsis without food stasis. There has been an average 25-minute drainage time of the duodenojejunal pouch. CONCLUSION: The duodenojejunal pouch, in the patients submitted to total gastrectomy using the Safatle reconstruction, presented adequate emptying and movement.

RACIONAL: Desde a primeira gastrectomia total, houve sempre a preocupação em aumentar a sobrevida e, com o aprimoramento das técnicas, de melhorar a qualidade de vida. A técnica mais aceita para a reconstrução do trânsito intestinal após gastrectomia total é a em Y-de-Roux. A reposição de um reservatório funcional no lugar do estômago ressecado foi proposta para minimizar os sintomas pós-prandiais, melhorar o grau nutricional e, conseqüentemente, a qualidade de vida. A técnica de reconstrução do trânsito intestinal pós-gastrectomia à Safatle consiste, em síntese, numa associação da interposição de alça jejunal com trânsito parcial pelo duodeno, com o Y-de-Roux invertido, e com a criação de um reservatório que se aproxima da dinâmica do estômago, obtido à custa de um segmento duodenojejunal com esvaziamento em antiperistalse. OBJETIVO: Avaliar, por método radiológico, o esvaziamento da bolsa duodenojejunal em doentes submetidos a gastrectomia total com reconstrução à Safatle. MÉTODO: Foram estudados 12 doentes submetidos a gastrectomia total por câncer gástrico com reconstrução à Safatle, convocados para realizar radiografias contrastadas de esôfago-duodeno-jejuno pelo método videofluoroscópico nos meses de julho a agosto de 2005. RESULTADOS: Todos os doentes apresentaram motricidade satisfatória da bolsa duodenojejunal com adequado esvaziamento em antiperistalse sem estase alimentar. O tempo de esvaziamento da bolsa duodenojejunal foi de 25 minutos em média. CONCLUSÃO: A bolsa duodenojejunal, nos doentes submetidos a gastrectomia total com reconstrução à Safatle, apresentou adequado esvaziamento e motricidade.

The effects of Roux-en-Y limb length on gastric emptying and enterogastric reflux in rats

PURPOSE: To assess the effects of Roux-en-Y jejunal limb length on gastric emptying and enterogastric reflux. METHODS: Seventy male Wistar rats were submitted to antrectomy with Roux-en-Y reconstruction and then were divided into two groups of 35 animals. Group A, short limb (7.5 cm) and Group B, standard limb (15 cm). Group A and B were subdivided into five subgroups each in order to study enterogastric reflux at 30 and 60 minutes and to evaluate gastric emptying at 5, 10 and 15 minutes. In order to measure gastric emptying and enterogastric reflux, radiotracers 99m Tc-Phytate and 99m Tc-DISIDA were respectively used. RESULTS: For gastric emptying, the radiotracer concentration was lower in Group A than in Group B after five minutes. The enterogastric reflux was present, but there were no significant differences between enterogastric reflux indexes concerning both A and B Groups. CONCLUSION: A standard Roux limb, besides being unable to protect the stomach from the enterogastric reflux, may become a functional barrier for gastric emptying.

OBJETIVO: Determinar os efeitos do comprimento da alça jejunal em Y de Roux sobre o esvaziamento gástrico e o refluxo enterogástrico. MÉTODOS: Setenta e cinco ratos machos foram submetidos à antrectomia com reconstrução em Y de Roux e divididos em dois grupos de 35 animais. Grupo A, alça curta (7,5cm) e Grupo B (15cm), alça de comprimento padrão. Os grupos A e B foram subdivididos em cinco subgrupos cada para o estudo do refluxo enterogástrico aos 30 e 60 minutos e para o estudo do esvaziamento gástrico aos 5, 10 e 15 minutos. 99m Tc-Fitato and 99m Tc-DISIDA foram utilizados para os estudos do esvaziamento gástrico e do refluxo enterogástrico, respectivamente. RESULTADOS: No estudo do esvaziamento gástrico, a concentração do radiotraçador foi menor no grupo A do que no Grupo B aos cinco minutos. Foi encontrado o refluxo enterogástrico, nos grupos A e B, sem diferenças entre eles. CONCLUSÃO: A alça em Y de Roux de comprimento padrão foi ineficaz em proteger o estômago do refluxo enterogástrico, e pode tornar-se uma barreira funcional ao esvaziamento gástrico.

Impacto de la esófagoyeyunoanastomosis mecánica en la gastrectomía total / Esophagojejunostomy in the radical gastrectomy

Introducción: El cáncer gástrico, es la principal causa de mortalidad masculina por cáncer en Chile. Su tratamiento, la gastrectomía total radical, se ha visto revolucionada por la introducción de la sutura mecánica, que supone disminuye la morbimortalidad y tiempo operatorio. Material y método: Estudio descriptivo. Se revisaron todas las gastrectomías totales por cáncer gástrico con sutura mecánica, realizadas en el Hospital Regional de Valdivia y se compararon con igual número realizadas con sutura manual, mediante análisis estadístico por software STATA 10.0. Resultados: Se recolectaron 45 casos, 21 con sutura manual y 24 con sutura mecánica. La edad promedio fue de 61 años para cada grupo. El sexo predominante fue el masculino. La frecuencia de fístulas de la anastomosis esofagoyeyunal fue igual en ambos grupos. Tanto el tiempo operatorio como la estadía postoperatoria también fueron similares. Conclusión: La introducción de la sutura mecánica en la anastomosis esofagoyeyunal, no ha producido un impacto importante en el descenso de la morbilidad, incluyendo la fistula anastomótica; como tampoco en la mortalidad ni en el tiempo operatorio.

Long-term results of large diameter hepaticojejunostomy for treatment of Bile Duct Injuries following cholecystectomy.

OBJECTIVE: Bile Duct Injury (BDI) is one of the most serious complications of cholecystectomy. The authors analyzed the clinical presentation, surgical management and long-term outcome of 19 patients presenting with iatrogenic major BDIs (Straburg type E) following cholecystectomy who underwent Roux-en-Y hepaticojejunostomy. MATERIAL AND METHOD: Between 1992 and 2005, 19 patients with major BDIs (Strasberg type E) following cholecystectomy were included. Operative notes and charts of all patients were reviewed systematically. A follow-up examination of each patient was performed after a median of 22 months (range 1-120). RESULTS: Twelve patients presented with ascending cholangitis, two patients were referred to the hospital with biliary-cutaneous fistula and five patients (26.3%) were identified at the time of operations. All patients were treated with Roux-en-Y hepaticojejunostomy with at least 2 cm of the diameter of the biliary-enteric anastomosis. There was no postoperative mortality. Postoperative complication was found in 5 patients (26.3%). Until now, during the follow-up, neither clinical nor biochemical evidence of recurrent cholangitis has been found. CONCLUSION: Major BDIs are associated with high morbidity rate and prolonged hospitalization. Early detection and referral to an experienced center is crucial in the management of these patients. Roux-en-Y hepaticojejunostomy with large diameter of the biliary-enteric anastomosis is the surgical procedure of choice with good long-term outcome.