Esophagogastric pathology in morbid obese patient: Preoperative diagnosis, influence in the selection of surgical technique.

INTRODUCTION: Given the difficulty in accessing to the excluded stomach after gastric bypass and the increase in gastroesophageal reflux after sleeve gastrectomy, it is justified to perform a preoperative fibrogastroscopy.The influence of the fibrogastroscopy (FGS) findings in the therapeutic approach is analyzed. PATIENTS AND METHODS: A retrospective study of preoperative FGS findings is performed, from 04/06 to 12/12. The influence of the FGS results on the surgical technique selection, in the endoscopic or medical treatment and its relation to gastric fistula is analyzed by means of multivariate regression (confounding factors: Age, body mass index, arterial hypertension, diabetes mellitus, antiplatelet therapy, surgical technique (bariatric surgery, sleeve gastrectomy). RESULTS: Three hundred thirty one patients are included: 32.6% biopsy of gastric lesion; 27% gastritis; 18.1% hiatal hernia; 3% metaplasia; 0.6% Barrett esophagus; 2.1% esophagitis; 0.3% dysplasia; 0.3 Schatzky´s ring; 1.5% incompetent cardia; 2.4% duodenitis; 0.3% gastric erosions; 0.6% gastric xanthoma; 1.8%, gastric polyp; 1.6% duodenal ulcer; 0.6% papulo-erosive gastritis; 0.6% esophageal papilloma; 0.3% submucosal tumor. Helicobacter pylori+ 30.2% (triple therapy eradication in all patients). The FGS findings led to a variation in the surgical technique or to the completion of endoscopic treatment in 22.2% of cases.The gastric lesions did not influence the development of gastric fistula. Independent prognostic factors of fistula: Sleeve gastrectomy (7.9% vs. 2.7%; p = 0.02; OR: 1.38 IC95: 1.01-1.87) and the body mass index > 50 kg/m2) (6.7% vs. 2.2%; p = 0.04; OR: 3.7 IC95: 1.12-12.4). CONCLUSIONS: The diagnosis of gastroesophageal disease through preoperative FGS motivated variations in the therapeutic approach in 52% of patients, so we consider essential to include the preoperative FGS in bariatric surgery.

Patología esofagogástrica en el obeso mórbido: diagnóstico preoperatorio e influencia en la selección de la técnica quirúrgica / Esophagogastric pathology in morbid obese patient: Preoperative diagnosis and influence in the selection of surgical technique

INTRODUCCIÓN: la dificultad de acceso al estómago excluido tras el bypass gástrico (BG) y el empeoramiento del reflujo gastroesofágico tras la gastrectomía vertical (GV) justifican la fibrogastroscopia (FGS) preoperatoria. Se analiza la influencia de los hallazgos de FGS en la actitud terapéutica. PACIENTES Y MÉTODOS: estudio retrospectivo de hallazgos de FGS previa a cirugía bariátrica desde 04/06 a 12/12. Influencia del resultado FGS en la selección de la técnica quirúrgica y en el tratamiento médico o endoscópico; y su relación con la fístula gástrica mediante regresión multivariada (factores de confusión: edad, índice de masa corporal, hipertensión arterial, diabetes mellitus, tratamiento antiagregante, técnica quirúrgica (bypass gástrico o gastrectomía vertical). RESULTADOS: se incluyen 331 pacientes: 32,6% biopsia de lesión gástrica; 27% gastritis. 18,1% de hernia de hiato; 3% metaplasia, 0,6% Barret, 2,1% esofagitis, 0,3% displasia, 0,3 anillo de Schalzsky, 1,5% de cardias incompetente, 2,4% de duodenitis, 0,3% erosiones gástricas, 0,6% xantoma gástrico, 1,8%, pólipos gástricos, 1,6%, úlcera duodenal, 0,6% gastritis papuloerosiva, 0,6% papiloma esofágico, 0,3% tumor submucoso. Helicobacter pylori+ 30,2% (triple terapia añadida en todos). Variación de técnica quirúrgica o tratamiento endoscópico debido a FGS 22,2%. Las lesiones gástricas no influyeron en el desarrollo de fístula gástrica. Factores pronósticos independientes de fístula: GV (7,9% vs. 2,7%; p = 0,02; OR: 1,38 IC95: 1,01-1,87) y el índice de masa corporal (IMC) > 50 kg/m2 (6,7% vs. 2,2%; p = 0,04; OR: 3,7 IC95: 1,12-12,4). CONCLUSIONES: el diagnóstico de patología esofagogástrica mediante FGS preoperatoria motivó variaciones en la actitud terapéutica del 52% de los procedimientos, por lo que consideramos imprescindible incluir la FGS en el preoperatorio de la cirugía bariátrica

INTRODUCTION: Given the difficulty in accessing to the excluded stomach after gastric bypass and the increase in gastroesophageal reflux after sleeve gastrectomy, it is justified to perform a preoperative fibrogastroscopy. The influence of the fibrogastroscopy (FGS) findings in the therapeutic approach is analyzed. PATIENTS AND METHODS: A retrospective study of preoperative FGS findings is performed, from 04/06 to 12/12. The influence of the FGS results on the surgical technique selection, in the endoscopic or medical treatment and its relation to gastric fistula is analyzed by means of multivariate regression (confounding factors: Age, body mass index, arterial hypertension, diabetes mellitus, antiplatelet therapy, surgical technique (bariatric surgery, sleeve gastrectomy). RESULTS: Three hundred thirty one patients are included: 32.6% biopsy of gastric lesion; 27% gastritis; 18.1% hiatal hernia; 3% metaplasia; 0.6% Barrett esophagus; 2.1% esophagitis; 0.3% dysplasia; 0.3 Schatzky's ring; 1.5% incompetent cardia; 2.4% duodenitis; 0.3% gastric erosions; 0.6% gastric xanthoma; 1.8%, gastric polyp; 1.6% duodenal ulcer; 0.6% papulo-erosive gastritis; 0.6% esophageal papilloma; 0.3% submucosal tumor. Helicobacter pylori+ 30.2% (triple therapy eradication in all patients). The FGS findings led to a variation in the surgical technique or to the completion of endoscopic treatment in 22.2% of cases. The gastric lesions did not influence the development of gastric fistula. Independent prognostic factors of fistula: Sleeve gastrectomy (7.9% vs. 2.7%; p = 0.02; OR: 1.38 IC95: 1.01-1.87) and the body mass index > 50 kg/m2) (6.7% vs. 2.2%; p = 0.04; OR: 3.7 IC95: 1.12-12.4). CONCLUSIONS: The diagnosis of gastroesophageal disease through preoperative FGS motivated variations in the therapeutic approach in 52% of patients, so we consider essential to include the preoperative FGS in bariatric surgery

De cirugía bariátrica a gastrectomía total radical: Cambio del procedimiento quirúrgico previsto por hallazgo operatorio de un tumor carcinoide / From bariatric surgery to a radical total gastrectomy: A change in the proposed surgical procedure due to intraoperative diagnosis of carcinoid tumour

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Procalcitonina y proteína C reactiva como marcadores precoces de infección intraabdominal postoperatoria en pacientes operados de cáncer gastrointestinal / Procalcitonin and C-reactive protein as early indicators of postoperative intra-abdominal infection after surgery for gastrointestinal cancer

OBJETIVO: Evaluar la asociación entre niveles séricos de procalcitonina (PCT) y proteína C reactiva (PCR), en los 3 primeros días de postoperatorio, y la aparición de infección intraabdominal postoperatoria. MÉTODO: Estudio observacional prospectivo que incluye a 67 pacientes intervenidos quirúrgicamente de cáncer colorrectal, gástrico y pancreático. Los niveles séricos de PCT y PCR se midieron antes de la cirugía y a las 24, 48 y 72 h de la misma. Se registraron los valores de PCT y PCR, así como su fiabilidad para la detección de infección intraabdominal postoperatoria. RESULTADOS: La incidencia de infección intraabdominal postoperatoria fue de 13,4%. Los valores de PCR a las 72 h, los valores de PCT a las 24, 48 y 72 h y el cociente entre el valor de PCR a las 72 h y el valor de PCR a las 48 h (PCR D3/PCR D2) se asociaron significativamente con la aparición de infección intraabdominal postoperatoria. La sensibilidad más alta correspondió al valor de PCT a las 72 h (88,9%); la especificidad más alta y el valor predictivo positivo (VPP) más alto, al cociente PCR D3/PCR D2 (96,49 y 71,4%, respectivamente); el valor predictivo negativo (VPN) más alto, al valor de PCT a las 72 h y a las 24 h (97,7 y 96%, respectivamente). CONCLUSIÓN: Los valores de PCT se asocian significativamente con la aparición de infección intraabdominal postoperatoria en los 3 primeros días de postoperatorio. Su sensibilidad y VPP son bajos, pero su VPN es alto, incluso a las 24 h de la cirugía

AIM: to evaluate the association between serum levels of procalcitonin and C-reactive protein, on the first 3 postoperative days, and the appearance of postoperative intra-abdominal infection. METHOD: Prospective observational study including 67 patients operated on for colo-rectal, gastric and pancreatic cancer. Serum levels of procalcitonin and C-reactive protein were analyzed before surgery and daily until the third postoperative day. Values of procalcitonin (PCT) and C-reactive protein (CRP) were recorded as well as their accuracy for detection of postoperative intra-abdominal infection (PIAI). RESULTS: The incidence of postoperative intra-abdominal infection was 13.4%. CRP serum levels at 72 h, PCT serum levels at 24, 48 and 72 h and the ratio between serum levels of CRP at 72 hours and serum levels of CRP at 48 hours (CRP D3/CRP D2) were significantly associated with the appearance of postoperative intra-abdominal infection. The highest sensitivity corresponded to PCT at 72 hours (88.9%); the highest specificity and positive predictive value corresponded to the ratio CRP D3/CRP D2 (96.49% and 71.4%, respectively); the highest negative predictive value to procalcitonin at 72 h and 24 h. CONCLUSIONS: Serum levels of PCT are significantly associated with the appearance of postoperative intra-abdominal infection. Sensitivity and predictive positive values are low, but negative predictive value is high, even at 24 h after surgery

[Procalcitonin and C-reactive protein as early indicators of postoperative intra-abdominal infection after surgery for gastrointestinal cancer]. / Procalcitonina y proteína C reactiva como marcadores precoces de infección intraabdominal postoperatoria en pacientes operados de cáncer gastrointestinal.

AIM: to evaluate the association between serum levels of procalcitonin and C-reactive protein, on the first 3 postoperative days, and the appearance of postoperative intra-abdominal infection. METHOD: Prospective observational study including 67 patients operated on for colo-rectal, gastric and pancreatic cancer. Serum levels of procalcitonin and C-reactive protein were analyzed before surgery and daily until the third postoperative day. Values of procalcitonin (PCT) and C-reactive protein (CRP) were recorded as well as their accuracy for detection of postoperative intra-abdominal infection (PIAI). RESULTS: The incidence of postoperative intra-abdominal infection was 13.4%. CRP serum levels at 72h, PCT serum levels at 24, 48 and 72h and the ratio between serum levels of CRP at 72hours and serum levels of CRP at 48hours (CRP D3/CRP D2) were significantly associated with the appearance of postoperative intra-abdominal infection. The highest sensitivity corresponded to PCT at 72hours (88.9%); the highest specificity and positive predictive value corresponded to the ratio CRP D3/CRP D2 (96.49% and 71.4%, respectively); the highest negative predictive value to procalcitonin at 72h and 24h. CONCLUSIONS: Serum levels of PCT are significantly associated with the appearance of postoperative intra-abdominal infection. Sensitivity and predictive positive values are low, but negative predictive value is high, even at 24h after surgery.