A novel anatomical description of the esophagus: the supracarinal mesoesophagus.

BACKGROUND: During thoracoscopic esophageal resection, while performing the supracarinal lymphadenectomy along the left recurrent laryngeal nerve (LRLN) from the aortic arch to the thoracic apex, we observed a not previously described bilayered fascia-like structure, serving as prolongation of the already known mesoesophagus. METHODS: We retrospectively evaluated 70 consecutively unedited videos of thoracoscopic interventions on esophageal resections for cancer, in order to determine the validity of this finding and to describe its utility for performing a systematic and more accurate dissection of the LRLN and its adequate lymphadenectomy. RESULTS: After mobilization of the upper esophagus from the trachea and tilting the esophagus by means of two ribbons, a bilayered fascia was observed between the esophagus and the left subclavian artery in 63 of the 70 patients included in this study. By opening the right layer, the left recurrent nerve became visualized and could be dissected free in its whole trajectory. Vessels and branches of the LRLN were divided between miniclips. Mobilizing the esophagus to the right, the base of this fascia could be found at the left subclavian artery. After dissecting and clipping the thoracic duct, complete lymphadenectomy of 2 and 4L stations could be performed. Mobilizing the esophagus in distal direction, the fascia continued at the level of the aortic arch, where it had to be divided in order to mobilize the esophagus from the left bronchus. Here, a lymphadenectomy of the aorta-pulmonary window lymph nodes (station 8) can be performed. It seems that from there the fascia continued without interruption with the previously described mesoesophagus between the thoracic aorta and the esophagus. CONCLUSIONS: Here we described the concept of the supracarinal mesoesophagus on the left side. Applying the description of the mesoesophagus will create a better understanding of the supracarinal anatomy, leading to a more adequate and reproducible surgery.

Esofaguectomía «tubeless»: menos es más / “Tubeless” esophagectomy: Less is more

La cirugía del cáncer de esófago es un procedimiento complejo con tasas de morbimortalidad elevadas, por lo que para obtener resultados adecuados se precisa de centros experimentados, un completo soporte multidisciplinar y vías clínicas adecuadas. Se describe la experiencia inicial y la técnica de la esofaguectomía «tubeless» en la que tras realizar una resección esofágica y linfadenectomía mediastínica extendida, al final del procedimiento no son colocados drenajes ni sondas de ningún tipo, con el fin de disminuir la agresividad del mismo, mejorar el bienestar postoperatorio y acelerar la recuperación funcional del paciente. (AU)

The esophageal cancer surgery is a complex procedure with elevated rates of both morbidity and mortality, which is why, in order to achieve adequate results, it should be performed in high volume centers, where complete multidisciplinary support is available and recent clinical guidelines are applied. We describe the initial experience and the technique of “tubeless” esophagectomy where esophageal resection and mediastinal lymphadenectomy are performed and no drains nor tubes of any kind are placed, with the aim to decrease the level of surgical aggression, enhance the postoperative comfort and accelerate the patient́s recovery. (AU)

"Tubeless" esophagectomy: Less is more.

The esophageal cancer surgery is a complex procedure with elevated rates of both morbidity and mortality, which is why, in order to achieve adequate results, it should be performed in high volume centers, where complete multidisciplinary support is available and recent clinical guidelines are applied. We describe the initial experience and the technique of "tubeless" esophagectomy where esophageal resection and mediastinal lymphadenectomy are performed and no drains nor tubes of any kind are placed, with the aim to decrease the level of surgical aggression, enhance the postoperative comfort and accelerate the patient́s recovery.

Resultados de una encuesta nacional sobre el manejo terapéutico del cáncer de esófago / Results of a National Survey about Therapeutic Management in Esophageal Cancer

En la actualidad existen numerosos puntos de controversia en el manejo perioperatorio y quirúrgico de los pacientes con cáncer de esófago. El objetivo de este trabajo es describir las posibles diferencias en el tratamiento coadyuvante y quirúrgico de estos pacientes entre los hospitales de nuestro país mediante un estudio descriptivo de las encuestas respondidas entre febrero y abril de 2020. Se evaluaron las características de cada centro, el número de procedimientos, el manejo del adenocarcinoma de tercio distal y del carcinoma escamoso de tercio medio, el tipo de anastomosis, el empleo de sonda nasogástrica y drenajes y el seguimiento de una vía clínica. La mediana de esofaguectomías anuales por centro es de 10, realizando solamente el 7,1% más de 20. En el adenocarcinoma distal el 62,5% emplea quimiorradioterapia preoperatoria, un abordaje abdominal y transtorácico (57,1%) y una linfadenectomía infracarinal (51,8%) o extendida (41,1%). En el carcinoma escamoso de tercio medio el 89,3% emplea quimiorradioterapia preoperatoria, una cirugía en 3 campos (73,2%) y una linfadenectomía mediastínica ampliada (52%). La anastomosis intratorácica se realiza de forma mecánica en el 77,8% y la cervical preferentemente de forma manual (71,4%). Los drenajes pleurales y abdominales son colocados habitualmente por el 77,6 y el 48,2%, respectivamente, mientras que la sonda nasogástrica es empleada normalmente por el 57,1%. El 57,1% siguen una vía clínica y el 28,6% un protocolo de recuperación intensificada específico. Por tanto, en el manejo del cáncer de esófago, existen claras diferencias entre los hospitales de nuestro país con relación al tratamiento coadyuvante, abordaje quirúrgico, tipo de linfadenectomía y anastomosis practicadas. (AU)

There are numerous controversial aspects in the perioperative and surgical management of patients with esophageal cancer. The aim of this study is to evaluate the differences between the hospitals of our country in the adjuvant and surgical treatment of these patients. We conducted a descriptive study of 56 surveys answered from February to April 2020, evaluating hospital characteristics, number of procedures, management of distal adenocarcinoma and squamous cell carcinoma of the middle third of the esophagus, type of anastomosis, use of nasogastric tube and drains, and clinical follow-up. The median number of annual esophagectomies per hospital was 10, and only 7.1% performed more than 20. In distal adenocarcinoma, 62.5% use preoperative chemoradiotherapy, an abdominal and transthoracic approach (57.1%), and an infracarinal lymphadenectomy (51.8%) or extended to right paratracheal lymph nodes (41.1%). In squamous cell carcinoma of the middle third of the esophagus, 89.3% use preoperative chemoradiotherapy, surgery in three fields (73.2%) and extended mediastinal lymphadenectomy (52%). Intrathoracic anastomosis is performed mechanically in 77.8% and cervical anastomosis preferably manually (71.4%). Pleural and abdominal drains are usually placed by 77.6% and 48.2%, respectively, while the nasogastric tube is normally used by 57.1%. A clinical pathway is followed by 57.1%, and 28.6% use a specific enhanced recovery after surgery protocol. Thus, in the management of esophageal cancer, there are some clear differences between hospitals in our country regarding adjuvant treatment, surgical approach, type of lymphadenectomy and anastomosis performed. (AU)

Results of a National Survey about Therapeutic Management in Esophageal Cancer. / Resultados de una encuesta nacional sobre el manejo terapéutico del cáncer de esófago.

There are numerous controversial aspects in the perioperative and surgical management of patients with esophageal cancer. The aim of this study is to evaluate the differences between the hospitals of our country in the adjuvant and surgical treatment of these patients. We conducted a descriptive study of 56 surveys answered from February to April 2020, evaluating hospital characteristics, number of procedures, management of distal adenocarcinoma and squamous cell carcinoma of the middle third of the esophagus, type of anastomosis, use of nasogastric tube and drains, and clinical follow-up. The median number of annual esophagectomies per hospital was 10, and only 7.1% performed more than 20. In distal adenocarcinoma, 62.5% use preoperative chemoradiotherapy, an abdominal and transthoracic approach (57.1%), and an infracarinal lymphadenectomy (51.8%) or extended to right paratracheal lymph nodes (41.1%). In squamous cell carcinoma of the middle third of the esophagus, 89.3% use preoperative chemoradiotherapy, surgery in three fields (73.2%) and extended mediastinal lymphadenectomy (52%). Intrathoracic anastomosis is performed mechanically in 77.8% and cervical anastomosis preferably manually (71.4%). Pleural and abdominal drains are usually placed by 77.6% and 48.2%, respectively, while the nasogastric tube is normally used by 57.1%. A clinical pathway is followed by 57.1%, and 28.6% use a specific enhanced recovery after surgery protocol. Thus, in the management of esophageal cancer, there are some clear differences between hospitals in our country regarding adjuvant treatment, surgical approach, type of lymphadenectomy and anastomosis performed.

Resultados de la encuesta nacional sobre cuidados perioperatorios en cirugía resectiva gástrica / Results of a national survey about perioperative care in gastric resection surgery

INTRODUCCIÓN: Las medidas de rehabilitación multimodal en cirugía abdominal se están instaurando progresivamente. El objetivo del estudio es evaluar la aplicación de diferentes cuidados perioperatorios en la cirugía gástrica por parte de los cirujanos españoles. MÉTODOS: Estudio descriptivo de 162 encuestas contestadas desde septiembre a diciembre de 2017 acerca del manejo y cuidados perioperatorios en cirugía de resección gástrica no bariátrica. RESULTADOS: Las profilaxis antibiótica y antitrombótica son empleadas siempre por el 96,9 y 99,4%, respectivamente. El tiempo de ayuno para líquidos es mayor de 6 horas para el 62,7%, empleando solo bebidas con sobrecarga de hidratos de carbono prequirúrgicamente el 3%. Tan solo el 32,4 y el 13,3% de las gastrectomías subtotales y totales son realizadas laparoscópicamente. El 56,8% emplea analgesia epidural y los drenajes son colocados siempre por un 53,8% en la gastrectomía total. La sonda nasogástrica es empleada selectivamente por el 34,6% y siempre por el 11,3%. La retirada del catéter vesical es realizada durante las primeras 48 horas por el 77,2%. En las primeras 24 horas postoperatorias, menos del 20% indica la ingesta oral y un 15,4% moviliza a sus pacientes, comenzando la deambulación a partir de las 24 horas el 49,3%. El 30,4% emplea una vía clínica para el cuidado de estos pacientes y solo un 15,2% utiliza un protocolo de recuperación intensificada. CONCLUSIONES: La aplicación de medidas de rehabilitación multimodal en la cirugía de resección gástrica no bariátrica se encuentra poco extendida en nuestro país

INTRODUCTION: Enhanced recovery after surgery programs in abdominal surgery are being established progressively. The aim of this study is to evaluate the application of different perioperative care measures in gastric surgery by Spanish surgeons. METHODS: A descriptive study of 162 surveys answered from September to December 2017 about the management and perioperative care in non-bariatric gastric resection surgery. RESULTS: Antibiotic and antithrombotic prophylaxis are always used by 96.9 and 99.4%, respectively; 62.7% recommend a fasting time for liquids greater than 6 hours and only 3% use preoperative carbohydrate drinks. Only 32.4 and 13.3% of subtotal and total gastrectomies are performed laparoscopically; 56.8% use epidural analgesia and drains are always placed by 53.8% in total gastrectomy. Nasogastric tubes are used selectively by 34.6% and always by 11.3%. Bladder catheters are removed during the first 48 hours by 77.2%. In the first 24 postoperative hours, less than 20% indicate oral intake and 15.4% mobilize their patients; 49.3% indicate walking after the first 24 hours; 30.4% apply a clinical pathway for the care of these patients and only 15.2% used an enhanced recovery after surgery protocol. CONCLUSIONS: The implementation of enhanced recovery after surgery measures in non-bariatric gastric resection surgery is not widespread in our country

Results of a national survey about perioperative care in gastric resection surgery. / Resultados de la encuesta nacional sobre cuidados perioperatorios en cirugía resectiva gástrica.

INTRODUCTION: Enhanced recovery after surgery programs in abdominal surgery are being established progressively. The aim of this study is to evaluate the application of different perioperative care measures in gastric surgery by Spanish surgeons. METHODS: A descriptive study of 162 surveys answered from September to December 2017 about the management and perioperative care in non-bariatric gastric resection surgery. RESULTS: Antibiotic and antithrombotic prophylaxis are always used by 96.9 and 99.4%, respectively; 62.7% recommend a fasting time for liquids greater than 6hours and only 3% use preoperative carbohydrate drinks. Only 32.4 and 13.3% of subtotal and total gastrectomies are performed laparoscopically; 56.8% use epidural analgesia and drains are always placed by 53.8% in total gastrectomy. Nasogastric tubes are used selectively by 34.6% and always by 11.3%. Bladder catheters are removed during the first 48hours by 77.2%. In the first 24 postoperative hours, less than 20% indicate oral intake and 15.4% mobilize their patients; 49.3% indicate walking after the first 24hours; 30.4% apply a clinical pathway for the care of these patients and only 15.2% used an enhanced recovery after surgery protocol. CONCLUSIONS: The implementation of enhanced recovery after surgery measures in non-bariatric gastric resection surgery is not widespread in our country.

Estudio prospectivo de los valores de hormonas y péptidos relacionados con el metabolismo glucolipídico en pacientes obesos mórbidos sometidos a una gastrectomía vertical / Prospective study of gluco-lipidic hormone and peptide levels in morbidly obese patients after sleeve gastrectomy

INTRODUCCIÓN: Diferentes hormonas y péptidos implicados en el apetito y el metabolismo lipídico e hidrocarbonado se han estudiado en relación con la obesidad mórbida y su variación tras cirugía bariátrica. El objetivo de nuestro trabajo es evaluar las variaciones de diferentes moléculas relacionadas con el metabolismo glucolipídico durante el primer año tras una gastrectomía vertical en pacientes obesos mórbidos. MATERIAL Y MÉTODO: Estudio prospectivo en pacientes operados mediante gastrectomía vertical entre noviembre de 2009 y enero de 2011. Se determinaron y analizaron las variaciones en diferentes parámetros clínicos, antropométricos y analíticos relacionados con el metabolismo glucolipídico en todos los pacientes en el preoperatorio, al primer y quinto días, al mes, a los 6 meses y al año postoperatorio, realizando el estudio estadístico con ayuda del programa SPSS 20.0. RESULTADOS: De los 20 pacientes estudiados, el 60% eran mujeres con una mediana de edad de 45 años. La mediana del índice de masa corporal (IMC) preoperatorio fue de 48,5 kg/m2 y el 70% padecían síndrome de apnea obstructiva del sueño (SAOS), el 65% hipertensión arterial (HTA), el 45% dislipidemia y el 40% diabetes mellitus. Al año de la cirugía, el porcentaje de exceso de IMC perdido fue del 72% y la tasa de curación o mejoría de la dislipidemia fue del 100%, de diabetes el 87,5%, de HTA el 84,6% y de SAOS el 57,1%. En ese período los niveles de glucemia en ayunas disminuyeron de forma significativa (p < 0,001), mostrando los niveles de IGF-1 y colesterol HDL un aumento significativo. Los niveles de adiponectina aumentaron y los de leptina (p = 0,003), insulina (p = 0,004) y triglicéridos (p = 0,016) disminuyeron de forma significativa al año de la intervención. Los valores de ACTH (que disminuyeron durante los 6 primeros meses), hemoglobina glucosilada, colesterol total y LDL no experimentaron cambios significativos al año de la intervención. CONCLUSIÓN: La gastrectomía vertical es una técnica que presenta buenos resultados ponderales y de curación de comorbilidades, produciendo modificaciones significativas durante el primer año postoperatorio en los niveles sanguíneos de diferentes parámetros relacionados con el metabolismo glucolipídico como la glucosa, IGF-1, insulina, leptina, triglicéridos y colesterol HDL

INTRODUCTION: Different hormones and peptides involved in lipid and carbohydrate metabolism have been studied in relation to morbid obesity and its variation after bariatric surgery. The aim of this study is toevaluate variations in different molecules related to glico-lipidic metabolism during the first year after sleeve gastrectomy in morbidly obese patients. MATERIAL AND METHODS: Prospective study in patients undergoing sleeve gastrectomy between November 2009 and January 2011. We analyzed changes in different clinical, anthropometric and analytic parameters related with glico-lipidic metabolism in all patients in the preoperative period, first postoperative day, fifth day, one month, 6 months and one year after surgery. Statistical analysis was performed using SPSS 20.0. RESULTS: We included 20 patients, 60% were women with a median of age of 45 years. Median of body mass index (IMC) was 48,5 kg/m2 and 70% had obstructive sleep apnea syndrome (SAOS), 65% arterial hypertension (HTA), 45% dyslipidemia and 40% diabetes mellitus. One year after surgery, the percentage of excess of BMI loss was 72% and the rate of cure or improvement of dyslipidemia was 100%, diabetes 87,5%, HTA 84,6% and SAOS 57,1%. At this time, glycemia levels decreased significantly (P < .001), and levels of IGF-1 and HDL-cholesterol increased significantly. Levels of adiponectine increased and leptine (P = .003), insulin (P = .004) and triglycerides (P = .016) decreased significantly one year after the surgery. ACTH levels (that decreased during first 6 months after surgery), glycosilated hemoglobin, total cholesterol and LDL-cholesterol had no changes one year after surgery. CONCLUSIONS: Sleeve gastrectomy is a surgical technique with good results of weight loss and cure of comorbidities. This procedure induces significant modifications in blood levels of glico-lipidic metabolism related peptides and hormones, such as glucose, IGF-1, insulin, leptin, triglycerides and HDL-cholesterol

A prospective study on inflammatory parameters in obese patients after sleeve gastrectomy.

Different hormones and peptides involved in inflammation have been studied in and related to obesity. The aim of our work is to assess the variations of different molecules related to inflammation in obese patients during the first year following sleeve gastrectomy. This was a prospective study on patients who underwent sleeve gastrectomy. The variations in different clinical, anthropometric, and analytical parameters related to inflammation were determined and analysed in all patients at the preoperative visit and at the first and fifth days, first and sixth months, and 1 year following surgery. We enrolled 20 patients to the study. The median body mass index (BMI) before intervention was 48.5 kg/m2. With respect to comorbidities, 70% of the patients had obstructive sleep apnoea syndrome (OSA), 65% high blood pressure, 45% dyslipidaemia, and 40% diabetes mellitus (DM). The median percentage of BMI lost (%BMIL) 1 year after the intervention was 71%. The dyslipidaemia healing or improvement rate was 100%, whereas it was 87.5% for diabetes, 84.6% for hypertension, and 57.1% for OSA. During the 1-year postintervention period, the average levels of adiponectin increased, although not significantly, whereas those of leptin significantly decreased. In addition, the blood levels of MCP-1, IL-6, CRP, ferritin, and PAI-1 significantly decreased in that period. Sleeve gastrectomy is a surgical technique that is associated with improvements in body weight and comorbid conditions from the first postoperative months, which lead to significant variations in the levels of different inflammation-related parameters and a decrease in the levels of leptin, IL-6, CRP, MCP-1, ferritin, and serpin (PAI-1).

[Prospective study of gluco-lipidic hormone and peptide levels in morbidly obese patients after sleeve gastrectomy]. / Estudio prospectivo de los valores de hormonas y péptidos relacionados con el metabolismo glucolipídico en pacientes obesos mórbidos sometidos a una gastrectomía vertical.

INTRODUCTION: Different hormones and peptides involved in lipid and carbohydrate metabolism have been studied in relation to morbid obesity and its variation after bariatric surgery. The aim of this study is toevaluate variations in different molecules related to glico-lipidic metabolism during the first year after sleeve gastrectomy in morbidly obese patients. MATERIAL AND METHODS: Prospective study in patients undergoing sleeve gastrectomy between November 2009 and January 2011. We analyzed changes in different clinical, anthropometric and analytic parameters related with glico-lipidic metabolism in all patients in the preoperative period, first postoperative day, fifth day, one month, 6 months and one year after surgery. Statistical analysis was performed using SPSS 20.0. RESULTS: We included 20 patients, 60% were women with a median of age of 45 years. Median of body mass index (IMC) was 48,5 kg/m(2) and 70% had obstructive sleep apnea syndrome (SAOS), 65% arterial hypertension (HTA), 45% dyslipidemia and 40% diabetes mellitus. One year after surgery, the percentage of excess of BMI loss was 72% and the rate of cure or improvement of dyslipidemia was 100%, diabetes 87,5%, HTA 84,6% and SAOS 57,1%. At this time, glycemia levels decreased significantly (P<.001), and levels of IGF-1 and HDL-cholesterol increased significantly. Levels of adiponectine increased and leptine (P=.003), insulin (P=.004) and triglycerides (P=.016) decreased significantly one year after the surgery. ACTH levels (that decreased during first 6 months after surgery), glycosilated hemoglobin, total cholesterol and LDL-cholesterol had no changes one year after surgery. CONCLUSIONS: Sleeve gastrectomy is a surgical technique with good results of weight loss and cure of comorbidities. This procedure induces significant modifications in blood levels of glico-lipidic metabolism related peptides and hormones, such as glucose, IGF-1, insulin, leptin, triglycerides and HDL-cholesterol.

Falsa hernia inguinal por endometriosis en el ligamento redondo / False inguinal hernia due to endometriosis in the round ligament

La localización extraperitoneal de la endometriosis es muy infrecuente; el ligamento redondo es una zona de posible asentamiento, lo que condiciona la aparición de una tumoración inguinal en ciertas ocasiones. Presentamos el caso de una paciente de 43 años que consulta por tumoración inguinal derecha de 2 años de evolución con aumento progresivo de su tamaño y molestias locales. A la exploración, se aprecia una tumoración dolorosa que protruye por el orificio inguinal externo. Se la interviene por vía preperitoneal y se evidencia una tumoración adherida al ligamento redondo sin orificios herniarios, por lo que se practica una exéresis amplia y completa de la lesión. El informe histopatológico indicó la presencia de tejido altamente sugestivo de endometriosis del ligamento redondo. Las formas extraperitoneales de endometriosis son infrecuentes y, entre ellas, las de la pared abdominal suelen localizarse en cicatrices laparotómicas y perineales tras intervenciones quirúrgicas. Pueden presentar dispareunia, irregularidades menstruales, dismenorrea e infertilidad o, en ciertos casos, la clínica puede pasar inadvertida. La exéresis completa es la estrategia más apropiada en la enfermedad inguinal localizada; es importante el estudio de exclusión de la endometriosis pélvica intraperitoneal, ya que la asociación de ambas entidades alcanza un 25%(AU)

An extraperitoneal endometriosis is a rare condition, with the round ligament being a possible location, sometimes leading to inguinal tumours. A 43 year-old women, who was seen due to having a tumour in right groin of 2 years progression gradually increasing in size and with local discomfort. On examination a painful tumour was found which protruded from the external inguinal orifice. She was intervened using a preperitoneal approach, showing evidence of tumour adhered to the round ligament with no hernial orifices. An extensive and complete exeresis was performed. The histopathology report indicated the presence of tissue highly suggestive of an endometriosis of the round ligament. Extra-peritoneal forms of endometriosis are uncommon, and among them, they are usually located in the abdominal wall in laparotomy and perineal scars after surgical interventions. They can present as dyspareunia, irregular periods, dysmenorrhea and infertility, or in some cases, the clinical picture may pass unnoticed. Complete removal is the most appropriate strategy in localised inguinal disease, with the study to exclude intraperitoneal pelvic endometriosis being important, since both conditions reach percentages of 25%(AU)

Step-by-step isolated resection of segment 1 of the liver using the hanging maneuver.

The caudate lobe can be the origin of primary liver tumours or the sole site of liver metastases. This lobe is anatomically divided into 3 parts: Spiegel's lobe (Couinaud's segment 1), paracaval portion (Couinaud's segment 9), and the caudate process. In this series of 4 cases, we provide a step-by-step description of a surgical technique variation that can be applied to resections of lesions localized in segment 1. We believe that other than size, lesion removal in this hepatic anatomic area, which is difficult to perform, can be done more easily using this new approach because it requires minimal mobilization without unnecessary parenchyma transection of other liver parts. Therefore, it reduces the risk of lesions in the inferior vena cava and the middle hepatic vein and respects adequate margins without the use of clamping maneuvers and in an acceptable surgical time.