Stapling Versus Hand Suture for Gastroenteric Anastomosis in Roux-en-Y Gastric Bypass: a Randomized Clinical Trial.

BACKGROUND: Different anastomotic techniques have been evaluated during a laparoscopic Roux-en-Y gastric bypass (RYGB); however, no techniques have proven to be better than any other regarding complications and the percentage of weight loss (excess weight loss (%EWL)), and there are few controlled prospective studies to compare them. METHODS: A randomized, prospective study was conducted in 238 patients undergoing RYGB for morbid obesity between July 2008 and September 2012 to compare the early and late postoperative complications between the two surgical techniques: gastrojejunal hand-sutured anastomosis (HSA) and circular-stapled anastomosis (CSA). Minimum follow-up was 24 months. RESULTS: The two groups of patients were similar for demographic data and preoperative comorbidities. There were no significant differences between the surgical techniques regarding %EWL at 3, 12, and 24 months. The patients with CSA had a greater frequency of postoperative gastrointestinal bleeding (GIB) (4.2 vs. 0%, p = 0.024) and surgical wound infection (11.1 vs. 3.4%, p = 0.025) than the patients with HSA, with no significant differences in the other early complications. There were no significant differences in either group for late complications (gastrojejunal anastomosis (GJA) stricture, marginal ulcer, GJA perforation, bowel obstruction, and eventration). No significant differences were observed in operative time, rate of reoperation and postoperative length of hospital stay. CONCLUSIONS: HSA and CSA were techniques with similar safety and effectiveness in our study. HSA had a lower rate of bleeding complications and surgical wound infection, although it does require greater experience in laparoscopic hand suturing.

Stimulation of the efferent limb before ileostomy closure: a randomized clinical trial.

BACKGROUND: Postoperative ileus is the most common complication after ileostomy closure with an increase in morbidity, hospital stay, and health care costs. OBJECTIVE: The aim of this study is to assess the utility of a new technique for reducing postoperative ileus after protective ileostomy closure. DESIGN: This is a prospective randomized study registered at ClinicalTrials.gov (NCT01881594). Patients were randomly assigned to undergo either stimulation through the efferent limb of the ileostomy before surgery or nonstimulation before surgery. SETTING: This study was conducted at the Department of Surgery of the Virgen de la Arrixaca Clinical University Hospital (Murcia). PATIENTS: Seventy patients underwent surgery for ileostomy closure. In 35 patients, during the 2 weeks before surgery, daily stimulation of the defunctionalized stomal segment was performed by using a thick solution (500 mL of physiological saline associated with 30 g of thickening agent, Nestle Resource, Vevey, Switzerland). In the other 35 patients, stimulation was not performed before surgery. MAIN OUTCOME MEASURES: The primary outcome was postoperative ileus. The secondary outcomes included time to tolerating a diet and postoperative stay. RESULTS: Both groups of patients were homogenous for demographic data, characteristics of the first rectal cancer operation, and intersurgery periods. After ileostomy closure, the stimulated group of patients had an earlier return to oral tolerance (1.06 vs 2.57 days; p = 0.007) and passage of flatus or stool (1.14 vs 2.85 days; p <0.001) than the nonstimulated group of patients. The incidence of postoperative ileus (2.85% vs 20%; p = 0.024) and hospital stay (2.49 vs 4.61 days; p = 0.002) was also lower in the stimulated patients. LIMITATIONS: Small numbers of patients means that no definitive statements can be made regarding the effectiveness of this technique. CONCLUSIONS: Stimulation of the efferent limb of the ileostomy before closure is a safe technique that reduces postoperative ileus and fosters early intestinal transit and oral tolerance with a shorter postoperative hospital stay.

The evolution of therapeutic strategies for biliary tract complications after liver transplantation over a period of 20 years.

Despite the improved overall outcomes of liver transplantation as a result of advances in surgical techniques and improved immunosuppressive control, biliary complications (BCs) continue to be the most common cause of morbidity in liver transplant recipients. The objectives of this study were to analyze the incidence, type, and management of BCs over a 20-year period. We performed a comparative study of two groups of liver transplant patients in our unit operated on by the same surgical team: group I consists of the first 300 liver transplant patients (1989-1992), and group II is composed of the last 300 liver transplants (2007-2011). We found no significant differences in the number of cases of biliary leakage whether or not a Kehr T-tube was used. However, there was a significant relationship between a greater number of anastomotic strictures and less use of a Kehr T-tube. In our series, there has been a decrease over the years in the number of surgical interventions required to resolve these complications and an increase in radiologic and endoscopic treatment.

Artropatía neuropática del hombro por siringomielia / Neuropathic arthropathy of the shoulder due to syringomyelia

Presentamos el caso de una paciente de 50 años diagnosticada de siringomielia, que consulta por dolor e impotencia funcional en hombro derecho de 72 h de evolución. En la exploración física se apreciaba luxación anterior de la cabeza humeral, obteniéndose por artrocentesis derrame articular serohemático. La radiografía evidenciaba la subluxación y la destrucción parcial de la cabeza humeral. La clínica y las pruebas complementarias no evidenciaron datos que sugiriesen proceso infeccioso o tumoral. El diagnóstico de artropatía neuropática relacionada con siringomielia se estableció sobre la base de los datos clínicos y radiológicos. Creemos de interés clínico para el reumatólogo la inclusión de la artropatía neuropática en el diagnóstico diferencial de las artropatías monoarticulares, inflamatorias o no; agudas y crónicas. Especialmente por lo frecuente de las manifestaciones articulares en la siringomielia y la alta prevalencia de una enfermedad causal de artropatía como la diabetes. Este diagnóstico es un reto por las dificultades para la exclusión de proceso infeccioso concurrente o causal en el contexto de una enfermedad crónica y grave, muy invalidante (AU)