Robotic surgery for the treatment of achalasia.

OBJECTIVE: To describe the experience of the robotic approach for achalasia surgery in a tertiary center. MATERIAL AND METHODS: Patients with achalasia who underwent robotic surgery between May 2010 and April 2019 were analyzed. The study variables were collected in a prospective database and a descriptive analysis was performed. RESULTS: 45 patients (55.6% male) with a mean age of 44 years were included. The main symptom at diagnosis was dysphagia. 19 patients (42.2%) received endoscopic treatment prior to surgery, mostly pneumatic dilation (84.2%). Heller's myotomy associated with Toupet fundoplication was the surgical technique of choice, with a mean operative time of 211 min. The average stay was 5 days. There were 2 postoperative perforations (4.4%). Perioperative mortality was 0%. The mean follow-up was 64 months. At 3 and 5 years, a significant decrease in the Eckardt score was observed and the manometric study showed a decrease in the lower esophageal sphincter pressure at rest of 58% and 70%, respectively, with persistence of hypomotility of the esophageal body. Pathological gastroesophageal reflux was diagnosed in two patients (5.4%) and 4 (10.8%) presented recurrence of symptoms, requiring endoscopic pneumatic dilations. In 2 cases, the dilations were not effective, so an endoscopic myotomy was considered. CONCLUSIONS: In our experience, robotic surgery is a safe and effective procedure for the treatment of achalasia.

Genetic factors associated with alterations in liver function test results in adult hospitalized patients treated with parenteral nutrition: A substudy of a clinical trial.

OBJECTIVES: The presence of phytosterols in vegetable-based lipid emulsions has been associated with alterations in the results of liver function tests (LFTs). Serum levels of phytosterols are under strict genetic control. T-allele carriers in rs41360247 and C-allele carriers in rs4245791 of ABCG8genes are associated with higher phytosterolemia. The objective of this study was to determine the association between these single-nucleotide polymorphisms (SNPs) and LFT result alterations in an adult hospitalized population treated with parenteral nutrition. METHODS: This is a substudy of a previous clinical trial (EudraCT 2014-003597-17). It included adult hospitalized patients who had received at least 7 d of parenteral nutrition with 0.8 g/kg/d of an olive/soybean lipid emulsion, randomized 1:1 to receive the same olive/soybean emulsion or 100% fish oil at a dose of 0.4 g/kg/d for 7 d. Plasma phytosterols and their fractions, rs41360247 and rs4245791 of ABCG8 genes, and LFT were determined. Analyses of variance were performed to determine the association between the SNPs and LFT values, as well as total phytosterol values and their fractions. Simple linear regressions were performed to analyze LFT variations and the different interactions of the SNPs studied with phytosterols and their fractions. Interactions of the synergic variable plasma phytosterol and its fractions with SNPs allow us to study the interaction of the SNPs with phytosterols with a regression. RESULTS: We included 19 participants. In the multivariate model, total phytosterols, sitosterol, and lanosterol were positively associated with increases in γ-glutamyltransferase. Significant increases with stigmasterol were associated with the T allele of rs41360247, whereas campesterol showed only a tendency to increase that was not significant. Increases in alkaline phosphatase were associated with T-rs41360247 independent of the presence of phytosterols. With stigmasterol, C-allele carriers of rs4245791 showed a tendency to increase, and also for sitosterol and lanosterol, although independent of the SNP analyzed. Increases in alanine aminotransferase were positively associated with total phytosterol and sitostanol, whereas lanosterol and stigmasterol were associated with the presence of the T allele of rs41360247. CONCLUSIONS: With both SNPs rs41360247 and rs4245791, the alteration in parameters of liver function in adult patients with short-term parenteral nutrition is conditional.

Clinical, randomized, double blind clinical trial to study the effect of parenteral supplementation with fish oil emulsion in the nutritional support in esophagectomized patients.

INTRODUCTION: Esophagectomy is a major surgery with a high degree of catabolic and post-surgical inflammatory response accompanied by high morbidity and significant mortality. Post-surgical nutritional support via enteral administration of ω-3 fatty acids has been seen to be effective although its bad tolerance. There are few clinical trials with parenteral ω-3 fatty acids in these patients. We propose to investigate the effect of combining a parenteral fish oil lipid emulsion with the standard enteral nutrition (EN) support. MATERIALS AND METHODS: Prospective, single-center, randomized, double-blind study in esophagectomized patients, and treated after surgery with parenteral lipid emulsions of ω-3 fatty acids or a mixture of ω-6 long-chain triglycerides/short-chain triglycerides 50%. These emulsions will be added to the standard nutritional support in continuous infusion until 5 days of treatment have been completed. Patients will be randomized 1:1:1 in Group A receiving 0.4 g/kg/d of fish-oil lipid emulsion and 0.4 g/kg/d of a lipid emulsion mixture of ω-6 long-chain fatty acids (LCT) plus medium-chain fatty acids (MCT) (total dose of 0.8 g/kg/d of lipid emulsion); Group B receiving 0.8 g/kg/d of fish oil lipid emulsion and Group C receiving 0.8 g/kg/d of LCT/MCT emulsion.The main objective is to determine whether 5 days administration of intravenous ω-3 fatty acid lipid emulsion is effective in normalizing interleukin-6 levels compared with LCT/MCT emulsions, and whether a 0.8 g/kg/d dose is more effective than 0.4 g/kg/d. Secondary outcomes include other inflammatory markers such as C-reactive protein, tumor necrosis factor alpha and interleukin-10, and parameters of morbidity, safety, nutrition and mortality.Samples will be collected at the time when surgery is indicated and on days 0, 1, 3, 5 and 21 to determine inflammatory, nutritional, hepatic and safety parameters. In addition, clinical follow-up will be continued throughout the hospital admision and up to 1 year after surgery. DISCUSSION: Studies of ω-3 fatty acids administered parenterally in esophagectomized patients are scarce. This study proposes to investigate the effect of combining fish-oil lipid emulsions administered parenterally with EN support. Potential benefits include fast incorporation of lipids to the cellular membranes and to the inflammatory cascade, and the use of only 1 pharmaconutrient. TRIAL REGISTRATION: FAR-NP-2017-01 EudraCT number: 2016-004978-17.https://reec.aemps.es/reec/public/detail.html searching the EudraCT number. VERSION IDENTIFIER: Version 2, 08/06/2017.

Robotic surgery for the treatment of achalasia. / Cirugía robótica en el tratamiento de la acalasia.

OBJECTIVE: To describe the experience of the robotic approach for achalasia surgery in a tertiary center. MATERIAL AND METHODS: Patients with achalasia who underwent robotic surgery between May 2010 and April 2019 were analyzed. The study variables were collected in a prospective database and a descriptive analysis was performed. RESULTS: 45 patients (55.6% male) with a mean age of 44 years were included. The main symptom at diagnosis was dysphagia. 19 patients (42.2%) received endoscopic treatment prior to surgery, mostly pneumatic dilation (84.2%). Heller's myotomy associated with Toupet fundoplication was the surgical technique of choice, with a mean operative time of 211minutes. The average stay was 5 days. There were 2 postoperative perforations (4.4%). Perioperative mortality was 0%. The mean follow-up was 64 months. At 3 and 5 years, a significant decrease in the Eckardt score was observed and the manometric study showed a decrease in the lower esophageal sphincter pressure at rest of 58% and 70%, respectively, with persistence of hypomotility of the esophageal body. Pathological gastroesophageal reflux was diagnosed in two patients (5.4%) and 4 (10.8%) presented recurrence of symptoms, requiring endoscopic pneumatic dilations. In 2 cases, the dilations were not effective, so an endoscopic myotomy was considered. CONCLUSIONS: In our experience, robotic surgery is a safe and effective procedure for the treatment of achalasia.

Artificial nutritional support in cancer patients after esophagectomy: 11 years of experience.

Esophageal cancer represents a high-risk group of patients. This study determines the association of artificial nutrition with morbidity, mortality, and survival and studies clinical situations that determine the choice between enteral (EN) and parenteral support (PN). This retrospective single-center study compared 2 periods: 1) treatment centered in surgical process with discretionary demand of support, and 2) elective therapeutic and nutritional interventions were systematized. Risks factors that determined use of PN and survival were included in 4 multivariate regression models: 2 logistic, 1 multinomial, and a survival Cox analysis. Significance determined with 95% confidence interval (CI) of 95%; inclusion criteria was P < 0.1. During an 11-yr period, 175 patients were studied. Artificial nutrition consisted of 45 jejunostomy EN, 28 PN, and 102 both. Risk factors that conditioned PN were first period (OR: 2.41; 95% CI: 1.13-5.14), stay in intensive care unit (ICU) >3 days (OR: 1.70; 95% CI: 0.93-3.71), and surgical reintervention (OR: 3.83; 95% CI: 0.94-16.95). Risk factors associated with mortality were first period (OR: 22.7; 95% CI: 2.31-172.05), respiratory infection (OR: 11.23; 95% CI: 2.33-55.5) and coloplasty surgery (OR: 13.16; 95% CI: 2.11-83.33). Longer survival was associated with second period (OR: 2.36; 95% CI: 1.38-4.05) and lower neoplasm staging (OR: 1.43; 95% CI: 1.21-1.69). A multidisciplinary management that includes nutritional support of esophagectomized patients is 1 of the factors that improves survival. Protocol implies greater use of EN; PN remains an important nutritional therapy.

Resultados de la esofagectomía por cáncer tras la creación de un Comité de Tumores Esofagogástricos / Surgical outcomes of esophageal cancer resection since the development of an oesophagogastric tumour board

Introducción El tratamiento del cáncer de esófago con pretensión curativa requiere un planteamiento multidisciplinar. La terapia neoadyuvante, la radicalidad de la resección y la extensión de la linfadenectomía pueden incrementar la morbimortalidad postoperatoria. El objetivo de este estudio es analizar los resultados del tratamiento quirúrgico del cáncer de esófago desde la creación del Comité de Tumores Esofagogástricos. Método sEstudio retrospectivo (de enero de 2005 a marzo de 2012) de todos los pacientes con cáncer de esófago o de la unión esofagogástrica a los que se les realizó una esofagectomía. Se analizaron el tipo de resección, las complicaciones postoperatorias, la mortalidad y la supervivencia. Resultados: A 100 pacientes de un total de 392 diagnosticados se les realizó una esofagectomía. En 74 casos se administró tratamiento neoadyuvante. Se realizaron 82 esofagectomías transtorácicas en 2 o 3 campos, 10 esofagectomías transhiatales y 8 coloplastias. En 98 pacientes la resección fue R0. Se diagnosticaron 9 dehiscencias anastomóticas intratorácicas y 6 cervicales. La morbilidad global fue del 42% y la mortalidad hospitalaria y a los 90 días fue del 2%. La mediana de la estancia hospitalaria fue de 16 días. La supervivencia actuarial al año es del 82% y a los 5 años, del 56%.ConclusionesEl tratamiento quirúrgico con intención curativa de la neoplasia de esófago solo es posible en una cuarta parte de los pacientes diagnosticados. La elevada morbilidad se debe, sobre todo, a complicaciones torácicas (AU)

Introduction Treatment of oesophageal cancer with curative intent requires a multidisciplinary approach. Neoadjuvant therapy, the radicality of resection and extension of lymphadenectomy have been associated with increased operative morbidity and mortality. The aim of this study was to assess the results of surgical treatment of oesophageal cancer since the presence of an interdisciplinary esophagogastric tumour board. Methods Patients with cancer of the oesophagus and oesophagogastric junction who underwent oesophagectomy between January 2005 and March 2012 were included in this retrospective study. Data concerning type of resection, postoperative complications, mortality and survival were analysed. Results Of the 392 patients with a diagnosis of oesophageal cancer over the study period, 100 underwent oesophagectomy. Seventy-four patients received neoadjuvant treatment. Eighty-two patients underwent transthoracic resection while a transhiatal was used in 10 patients. Colon interposition was required in 8 cases. An R0 resection was achieved in 98 patients. Anastomotic leaks developed in 15 patients, 9 were intrathoracic and 6 were cervical. Postoperative morbidity occurred in 42% of patients, and intra-hospital and 90-day mortality was 2%. Median length of hospital stay was 16 days. The respective actuarial survival at 1 and 5 years were 82% and 56%.ConclusionsSurgical treatment with curative intention for oesophageal cancer is only possible in a quarter of patients diagnosed. The high morbidity rate was mainly due to intrathoracic complications (AU)

[Surgical outcomes of esophageal cancer resection since the development of an Oesophagogastric Tumour Board]. / Resultados de la esofagectomía por cáncer tras la creación de un Comité de Tumores Esofagogástricos.

INTRODUCTION: Treatment of oesophageal cancer with curative intent requires a multidisciplinary approach. Neoadjuvant therapy, the radicality of resection and extension of lymphadenectomy have been associated with increased operative morbidity and mortality. The aim of this study was to assess the results of surgical treatment of oesophageal cancer since the presence of an interdisciplinary esophagogastric tumour board. METHODS: Patients with cancer of the oesophagus and oesophagogastric junction who underwent oesophagectomy between January 2005 and March 2012 were included in this retrospective study. Data concerning type of resection, postoperative complications, mortality and survival were analysed. RESULTS: Of the 392 patients with a diagnosis of oesophageal cancer over the study period, 100 underwent oesophagectomy. Seventy-four patients received neoadjuvant treatment. Eighty-two patients underwent transthoracic resection while a transhiatal was used in 10 patients. Colon interposition was required in 8 cases. An R0 resection was achieved in 98 patients. Anastomotic leaks developed in 15 patients, 9 were intrathoracic and 6 were cervical. Postoperative morbidity occurred in 42% of patients, and intra-hospital and 90-day mortality was 2%. Median length of hospital stay was 16 days. The respective actuarial survival at 1 and 5 years were 82% and 56%. CONCLUSIONS: Surgical treatment with curative intention for oesophageal cancer is only possible in a quarter of patients diagnosed. The high morbidity rate was mainly due to intrathoracic complications.

[Supercharged ileocoloplasty: an option for complex oesophageal reconstructions]. / Ileocoloplastia supercharged: una opción para reconstrucciones esofágicas complejas.

INTRODUCTION: Oesophageal reconstruction in a second time is a complex surgical operation which, in some cases, requires combining microvascular techniques to increase vascular flow to the conduit. "Supercharged" ileocoloplasty allows creation of a longer conduit that makes it possible to replace the entire oesophagus. We describe our initial experience with this technique for the total reconstruction of the oesophagus. MATERIAL AND METHODS: A retrospective review of the period from October 2007 to December 2009 identified 4 patients on whom a deferred oesophageal reconstruction was performed with a "supercharged" ileocoloplasty. The indications of this technique, morbidity and mortality, as well as functional results during follow up were evaluated. RESULTS: The indications of this technique were: previous failure of a left colon interposition (1), oesophageal disconnection due to a gastro-pleural fistula (1), total oesophagogastrectomy (1) and partial oesophagogastrectomy (1) due to the ingestion of caustic substances, respectively. Gastrointestinal complications were the most frequent. Two cervical fistulas were diagnosed which were resolved with an absolute diet, antibiotic therapy and enteral nutrition. There was no mortality. After a median follow up of 14.7 months, two patients were nourished exclusively by mouth, one by a mixed route (oral-enteral) and another exclusively by the enteral route due to an oesophageal stenosis 11 centimetres from the dental arch; this patient required dilations and is awaiting a jejunal graft. CONCLUSIONS: "Supercharged" ileocoloplasty is a complex treatment option for the total reconstruction of the oesophagus when no other alternatives are available. Postoperative morbidity is significant but the functional results are good.

Ileocoloplastia supercharged: una opción para reconstrucciones esofágicas complejas / Supercharged ileocoloplasty: an option for complex oesophageal reconstructions

Introducción La reconstrucción esofágica en un segundo tiempo es una intervención quirúrgica compleja que, en algunos casos, requiere asociar técnicas microvasculares para aumentar el flujo vascular a la plastia (supercharged). La ileocoloplastia supercharged permite crear una plastia larga que hace posible sustituir la totalidad del esófago. Describimos nuestra experiencia inicial con esta técnica para la reconstrucción de todo el esófago. Material y métodos La revisión retrospectiva del periodo octubre de 2007 a diciembre de 2009 identificó a 4 pacientes a los que se les realizó una reconstrucción esofágica diferida con una ileocoloplastia supercharged. Se evaluaron las indicaciones de esta técnica, la morbilidad y mortalidad, así como, los resultados funcionales durante el seguimiento. Resultados Las indicaciones de esta técnica fueron: fracaso previo de una interposición de colon izquierdo (1), desconexión esofágica por fístula gastropleural (1), esofagogastrectomía total (1) y esofagogastrectomía parcial (1) por ingesta de cáusticos, respectivamente. Las complicaciones digestivas fueron las más frecuentes. Se diagnosticaron dos fístulas cervicales que se resolvieron con dieta absoluta, antibioticoterapia y nutrición enteral. No hubo mortalidad. Tras una mediana de seguimiento de 14,7 meses, dos pacientes se nutrían exclusivamente por vía oral, uno por vía mixta (oral-enteral) y otro exclusivamente por vía enteral debido a una estenosis esofágica a 11 centímetros de arcada dentaria; este paciente ha precisado dilataciones y está pendiente de un injerto de yeyuno. Conclusiones La ileocoloplastia supercharged es una opción técnica compleja para reconstruir todo el esófago cuando no se dispone de otras alternativas. La morbilidad postoperatoria es significativa pero los resultados funcionales son buenos (AU)

Introduction Oesophageal reconstruction in a second time is a complex surgical operation which, in some cases, requires combining microvascular techniques to increase vascular flow to the conduit. «Supercharged» ileocoloplasty allows creation of a longer conduit that makes it possible to replace the entire oesophagus. We describe our initial experience with this technique for the total reconstruction of the oesophagus. Material and methods A retrospective review of the period from October 2007 to December 2009 identified 4 patients on whom a deferred oesophageal reconstruction was performed with a «supercharged» ileocoloplasty. The indications of this technique, morbidity and mortality, as well as functional results during follow up were evaluated. Results The indications of this technique were: previous failure of a left colon interposition (1), oesophageal disconnection due to a gastro-pleural fistula (1), total oesophagogastrectomy (1) and partial oesophagogastrectomy (1) due to the ingestion of caustic substances, respectively. Gastrointestinal complications were the most frequent. Two cervical fistulas were diagnosed which were resolved with an absolute diet, antibiotic therapy and enteral nutrition. There was no mortality. After a median follow up of 14.7 months, two patients were nourished exclusively by mouth, one by a mixed route (oral-enteral) and another exclusively by the enteral route due to an oesophageal stenosis 11 centimetres from the dental arch; this patient required dilations and is awaiting a jejunal graft. Conclusions«Supercharged» ileocoloplasty is a complex treatment option for the total reconstruction of the oesophagus when no other alternatives are available. Postoperative morbidity is significant but the functional results are good (AU)

Dehiscencias en las gastroplastias cervicales: ¿es posible disminuir su incidencia? / Dehiscence in cervical gastroplasty: is it possible to reduce its incidence?

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