Comparison of flipped learning and traditional lecture method for teaching digestive system diseases in undergraduate medicine: A prospective non-randomized controlled trial.

INTRODUCTION: This study examined the effects of a large-scale flipped learning (FL) approach in an undergraduate course of Digestive System Diseases. METHODS: This prospective non-randomized trial recruited 404 students over three academic years. In 2016, the course was taught entirely in a Traditional Lecture (TL) style, in 2017 half of the course (Medical topics) was replaced by FL while the remaining half (Surgical topics) was taught by TL and in 2018, the whole course was taught entirely by FL. Academic performance, class attendance and student's satisfaction surveys were compared between cohorts. RESULTS: Test scores were higher in the FL module (Medical) than in the TL module (Surgical) in the 2017 cohort but were not different when both components were taught entirely by TL (2016) or by FL (2018). Also, FL increased the probability of reaching superior grades (scores >7.0) and improved class attendance and students' satisfaction. CONCLUSION: The holistic FL model is more effective for teaching undergraduate clinical gastroenterology compared to traditional teaching methods and has a positive impact on classroom attendances.

Frequency of abnormal esophageal acid exposure in patients eligible for bariatric surgery.

BACKGROUND: Obesity and gastroesophageal reflux disease (GERD) are both high-prevalence diseases in developed nations. Obesity has been identified as an important risk factor in the development of GERD. The objective of this study was to determine the frequency of abnormal esophageal acid exposure in patients candidate for bariatric surgery and its relationship with any clinical and endoscopic findings before surgery. METHODS: Data collected from a group of 88 patients awaiting bariatric surgery included a series of demographic variables and symptoms typical of GERD. The tests patients underwent included manometry, pH monitoring, and upper gastrointestinal endoscopy. Univariate and multivariate analyses were conducted on the variables related to the onset of reflux. RESULTS: Esophageal pH monitoring tests were positive in 65% of the patients. Manometries showed lower esophageal sphincter hypotonia in 46%, while 20% returned abnormal upper endoscopy results. Out of the 45% of patients who were asymptomatic or returned normal endoscopies, half returned positive esophageal pH tests. In turn, among the 55% of patients who had symptoms or an abnormal upper endoscopy, three quarters had pH tests that diagnosed reflux. pH tests were also positive in 80% of symptomatic patients and 100% of patients with esophagitis (P<.042). No statistically significant relationship was found between body mass index, sex, age, manometry, or hiatus hernia and the positive pH monitoring. CONCLUSION: Frequency of abnormal esophageal acid exposure among obese patients is high. There is a relationship between the presence of symptoms and reflux. But the absence of symptoms does not rule out the presence of abnormal esophageal function tests.

Tratamiento del fallo hepático después de hepatectomía mediante sistema de diálisis hepática MARS / Treatment of hepatic failure after hepatectomy by the MARS hepatic dialysis system

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Anterior-only Partial Sacrectomy for en bloc Resection of Locally Advanced Rectal Cancer.

Study Design Case report. Objective The usual procedure for partial sacrectomies in locally advanced rectal cancer combines a transabdominal and a posterior sacral route. The posterior approach is flawed with a high rate of complications, especially infections and wound-healing problems. Anterior-only approaches have indirectly been mentioned within long series of rectal cancer surgery. We describe a case of partial sacrectomy for en bloc resection of a locally advanced rectal cancer with invasion of the low sacrum through a combined transabdominal and perineal approach without any posterior incision. Methods Through a midline laparotomy, the tumor was dissected and the sacral osteotomy was performed. Once the sacrum was mobile, the muscular attachments to its posterior wall were cut through the perineal approach. This latter route was also used to remove the whole specimen. Results The postoperative period was uneventful in terms of infection and wound healing, but the patient developed right foot dorsiflexion paresis that completely disappeared in 1 month. Resection margins were negative. After a follow-up of 18 months, the patient has no local recurrence but presented lung and liver metastases. Conclusion In cases of rectal cancer involving the low sacrum, the combination of a transabdominal and a perineal route to carry out the partial sacrectomy is a feasible approach that avoids changes of surgical positioning and the morbidity related to posterior incisions. This strategy should be considered when deciding on undertaking partial sacrectomy in locally advanced rectal cancer.

Hepatolitiasis en la fibrosis quística: una condición especial para el tratamiento quirúrgico / Hepatolithiasis in cystic fibrosis: A special condition for surgical treatment

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Single-incision laparoscopic surgery for colon and rectal cancer: an initial experience with the technique.

BACKGROUND: Single-incision laparoscopic surgery seems destined to take its place in the evolution of minimally invasive surgery. Although isolated cases have been reported in the literature, no series has yet been published on the use of this approach to treat colorectal cancer. We describe the surgical technique and perioperative outcomes of this approach in 15 patients diagnosed for colorectal cancer. METHODS: We have used several devices to gain transumbilical access to the abdominal cavity, usually working with 3 cannulae to insert the instruments. We used a 5 mm endograsper, and articulated rotating (roticulating) endoscissors and endodissector to assist dissection. Vascular control and section of the rectum were performed using roticulating endostaplers. We combined the use of curved and straight instruments as required for each step during surgery. The dissection technique performed was the same as the one we normally use in conventional laparoscopy. Specimens were extracted through the umbilical incision. RESULTS: The most commonly performed procedure was sigmoidectomy (n=7), followed by high anterior resection of the rectum (n=5). The mean surgical time was 185±44.9 minutes. The mean hospital stay was 6.2±4.7 days. Three cases (20%) were converted to conventional laparoscopy. Surgery was curative in all of the patients. CONCLUSIONS: Single-access transumbilical laparoscopic surgery is feasible and safe for treating colorectal carcinoma when performed by surgeons with ample experience in laparoscopic colorectal resection. Further studies are needed to determine the advantages and drawbacks of this procedure.

Which patients benefit most from laparoscopic ventral hernia repair? A comparative study.

PURPOSE: To establish which patients suffering ventral hernia benefit the most from laparoscopic approach. METHODS: From January 2005 to October 2008, 126 patients underwent surgery due to incisional hernia at our University Hospital. Patients were assigned to laparoscopic surgery (n=60) or conventional surgery (n=66) at the surgeon's discretion. Patients were subdivided according to the greater diameter of the defect: (G1, defect <5 cm; G2, defect 5 to 15 cm; and G3, defect >15 cm). Data on patient demographic, clinical, and perioperative variables were collected prospectively. RESULTS: Groups were comparable in terms of sex, body mass index, American Society of Anesthesiologists score, size of defect, and proportion of primary repairs. Four patients were converted to open surgery. Mean hospital stay in the group with the smaller hernias (G1 was 3.16 d laparoscopic surgery vs. 2.87 d conventional surgery, P>0.05). Hospital stay for patients who underwent laparoscopy was shorter in G3 (4.25 d Lap vs. 12.6 d Open; P=0.02). CONCLUSIONS: Patients with very large incisional hernias are those who benefit the most from laparoscopic treatment.

Gastroesophageal junction leak with serious sepsis after gastric bypass: successful treatment with endoscopy-assisted intraluminal esophageal drainage and self-expandable covered metal stent.

We present a case of gastroesophageal junction leak after gastric bypass with serious sepsis and hemodynamic instability. Minimally invasive treatment was performed in two stages: initial sepsis control by lavage and endoscopy-assisted laparoscopic placement of an intraluminal esophageal drainage tube through the leak orifice; this was followed by definitive leak treatment with a self-expandable covered metal stent after achieving hemodynamic stability. Patient evolution was satisfactory without the need for open surgery.

Ivor Lewis esophagectomy in a patient with enlarged azygos vein: a lesson to learn.

We report the case of a 62-year-old patient with congenital interruption of the inferior vena cava and azygos continuation who required transthoracic esophagectomy to remove a tumor in the middle esophagus. The consequences of dividing an enlarged azygos vein in this kind of patient are reported and discussed.

Abdominal wall hematoma after laparoscopic surgery: early treatment with selective arterial transcatheter embolization.

Bleeding from the site of a trocar insertion is a relatively frequent complication after laparoscopic surgery, despite precautionary techniques aimed at reducing such events. It may result in a hemoperitoneum, requiring emergency reintervention or large hematomas of the abdominal wall. In the latter case, although conservative treatment is possible, hospital stay is prolonged and large amounts of blood-bank resources are consumed. Early diagnosis and selective embolization of the bleeding vessel may reduce the severity and consequences of this complication.

[Localization of gastrointestinal bleeding from jejunal diverticuli by methylene blue dye]. / Localización con azul de metileno de la hemorragia digestiva originada en divertículos yeyunales.

Localization of digestive hemorrhage is essential for the management of this entity. However, management is difficult in the small bowel, where emergency situations are rare but may require surgery without precise location of the lesion. We present a case of hemorrhage caused by jejunal diverticulum diagnosed by angiography. A highly selective microcatheter was placed in the bleeding site to achieve staining of the lesion with intraoperative methylene blue.

Localización con azul de metileno de la hemorragia digestiva originada en divertículos yeyunales / Localization of gastrointestinal bleeding from jejunal diverticuli by methylene blue dye

La localización de la hemorragia digestiva es fundamental para controlarla, algo que se complica en el caso del intestino delgado, donde las situaciones de emergencia son infrecuentes pero pueden requerir una laparotomía sin una clara localización de la lesión. Presentamos un caso de una hemorragia secundaria a divertículos yeyunales que se diagnosticó por angiorradiología y canulación selectiva del vaso sangrante, para conseguir el tatuaje de la lesión mediante inyección intraoperatoria de azul de metileno (AU)

Localization of digestive hemorrhage is essential for the management of this entity. However, management is difficult in the small bowel, where emergency situations are rare but may require surgery without precise location of the lesion. We present a case of hemorrhage caused by jejunal diverticulum diagnosed by angiography. A highly selective microcatheter was placed in the bleeding site to achieve staining of the lesion with intraoperative methylene blue (AU)

Impact of previous abdominal surgery on colorectal laparoscopy results: a comparative clinical study.

To assess the results of laparoscopic colorectal surgery in patients who have previously undergone abdominal surgery. Between November 2002 and June 2004, 86 patients underwent laparoscopic surgery for colorectal disease at our hospital. Patients were divided into 2 groups depending on whether they had previously undergone abdominal surgery (previous surgery group, n = 27) or not (nonprevious surgery group, n = 59). Data were prospectively collected for statistical analyses of demographic, clinical, and histologic variables. Groups were comparable in age, body mass index, American Society of Anesthesiologists score, diagnosis, technique performed, and tumor size and distance to anal verge. There was no difference in perioperative complication rates. A higher conversion rate was found in the previous surgery group (26.1% vs. 5.1%, P = 0.02). In patients with tumor diseases, resection evaluations were no different regarding specimen length, distal and radial resection margins, or number of lymph nodes harvested. Laparoscopic colorectal surgery has proved to be a reliable technique for patients who have previously undergone abdominal surgery, its results comparable to those obtained with patients who have not.

[Implementation of laparoscopic rectal cancer surgery]. / Implementación de la cirugía del cáncer de recto por laparoscopia.

INTRODUCTION: The integration of laparoscopic surgery for rectal cancer in clinical practice is one of the challenges faced by surgical societies. The aim of the present study was to analyze the results obtained during the implementation phase of this technique. PATIENTS AND METHOD: From January 2003 to June 2005, 40 patients with rectal carcinoma underwent laparoscopic surgery in our center. Clinical and pathological variables were prospectively collected for statistical analyses. RESULTS: A total of 27 men and 13 women underwent surgery: 11 high (HAR) and 20 low anterior resections (LAR) and 9 abdominoperineal resections (APR) were performed. Operative time was 240.4 +/- 200 min and was greater in the LAR group (259.7 vs 201.5 min; p=.02). The intraoperative complication rate was 22.5% (9% HAR vs 25% LAR; p=NS). The mean length of hospital stay was 8.7 +/- 4.8 days. The rate of postoperative complications was 32.5%. The conversion rate was 15% (6 patients), and was greater in the LAR group (25% vs 0% HAR vs 11.1% APR; p=0.02). The most common intraoperative complication and the most frequent cause of conversion consisted of stapling problems (4 patients). Surgery was considered curative in 34 patients (85%). One case of positive radial margins was encountered (3.3%). The mean distal and radial margins were 3.6 +/- 2.7 cm and 1.1 +/- 0.9 cm respectively. CONCLUSIONS: The overall results during the implementation stage of laparoscopic surgery for rectal surgery were satisfactory. Conversion rates were highest in LAR, which proved to be the most demanding procedure.

The use of preoperative endoscopic tattooing in laparoscopic colorectal cancer surgery for endoscopically advanced tumors: a prospective comparative clinical study.

BACKGROUND: Endoscopic India ink marking techniques are often used for the intraoperative location of colonic polyps and early stage neoplasms. The aim of this study was to compare how effective this technique is compared with conventional localization methods, as well as its influence on the results of colorectal laparoscopy (LSCRC) for endoscopically advanced tumors. METHODS: From January 2003 to January 2005, 47 patients with colorectal carcinomas were included in the study. In one group, lesions were localized preoperatively by endoscopic India ink tattooing (n = 21; tattooed group, TG), while conventional methods were used in the others (n = 26; non-tattooed group, NTG). Patients' perioperative clinical and pathoanatomical data were prospectively collected. RESULTS: Both groups were comparable in age, sex distribution, American Society of Anesthesiologists (ASA) score, body mass index (BMI), technique performed, tumor size and proportion of patients who had previous abdominal surgery. Three patients presented ink spillage without clinical repercussions. Visualization of the correct resection site was higher in the TG (100% vs. 80.8%, P = 0.03). Operative time (147.3 +/- 46.2 vs. 187.0 +/- 52.7 minutes, P = 0.02) and blood loss (99.3 +/- 82.8 vs. 163.6 +/- 96.6 cc, P = 0.03) were lower in the TG. There were no differences between groups regarding peristalsis, introduction of oral intake, hospital stay or intra- and postoperative complication rates. No differences were observed amongst pathoanatomical data studied. CONCLUSIONS: Preoperative endoscopic tattooing is a safe and effective technique for intraoperative localization of advanced colorectal neoplasms, improving the operative results of LSCRC.

Implementación de la cirugía del cáncer de recto por laparoscopia / Implementation of laparoscopic rectal cancer surgery

Introducción. La incorporación de la cirugía laparoscópica del cáncer de recto (CLCR) en la práctica asistencial es uno de los retos que afrontan nuestras sociedades quirúrgicas. El objetivo del presente estudio es analizar los resultados obtenidos durante la fase de implementación de la técnica. Pacientes y método. Entre enero de 2003 y junio de 2005, en nuestro centro se intervino por laparoscopia a 40 pacientes con carcinoma rectal. Recogimos prospectivamente las variables clínicas y anatomopatológicas de los pacientes para su posterior análisis estadístico. Resultados. En 27 varones y 13 mujeres se realizaron 11 resecciones anteriores altas (RAA), 20 bajas (RAB) y 9 resecciones abdominoperineales (RAP). El tiempo quirúrgico fue de 240,4 ± 200 min, mayor para las RAB (259,7 min). La tasa de complicaciones intraoperatorias fue del 22,5% (n = 9). La estancia hospitalaria fue de 8,7 ± 4,8 días. La tasa de complicaciones postoperatorias fue del 32,5% (n = 13). La tasa de conversión fue del 15% (n = 6), mayor en el grupo de RAB (n = 5). Los problemas con la sección distal del recto, con 4 casos, fue la complicación intraoperatoria más frecuente y la causa más frecuente de conversión. Se consideró la cirugía como curativa en 34 casos (85%). Registramos 1 caso de margen de resección circunferencial (MRC) positivo (2,8%). Se obtuvo un margen longitudinal medio de 3,6 ± 2,7 cm y un MRC medio de 1,1 ± 0,9 cm. Conclusiones. Durante la fase de implementación de la CLCR obtuvimos unos resultados globales satisfactorios. La RAB se mostró como el procedimiento más exigente, con una mayor tasa de conversión (AU)

Introduction. The integration of laparoscopic surgery for rectal cancer in clinical practice is one of the challenges faced by surgical societies. The aim of the present study was to analyze the results obtained during the implementation phase of this technique. Patients and method. From January 2003 to June 2005, 40 patients with rectal carcinoma underwent laparoscopic surgery in our center. Clinical and pathological variables were prospectively collected for statistical analyses. Results. A total of 27 men and 13 women underwent surgery: 11 high (HAR) and 20 low anterior resections (LAR) and 9 abdominoperineal resections (APR) were performed. Operative time was 240.4 ± 200 min and was greater in the LAR group (259.7 vs 201.5 min; p=.02). The intraoperative complication rate was 22.5% (9% HAR vs 25% LAR; p=NS). The mean length of hospital stay was 8.7 ± 4.8 days. The rate of postoperative complications was 32.5%. The conversion rate was 15% (6 patients), and was greater in the LAR group (25% vs 0% HAR vs 11.1% APR; p=0.02). The most common intraoperative complication and the most frequent cause of conversion consisted of stapling problems (4 patients). Surgery was considered curative in 34 patients (85%). One case of positive radial margins was encountered (3.3%). The mean distal and radial margins were 3.6 ± 2.7 cm and 1.1 ± 0.9 cm respectively. Conclusions. The overall results during the implementation stage of laparoscopic surgery for rectal surgery were satisfactory. Conversion rates were highest in LAR, which proved to be the most demanding procedure (AU)

Inflammatory myofibroblastic tumor of the distal bile duct associated with lymphoplasmacytic sclerosing pancreatitis. Case report and review of the literature.

Inflammatory myofibroblastic tumor (IMT) or inflammatory pseudotumor has been described in various organs such as the liver, intestinal tract, spleen, kidney, bladder, lung, peritoneum and heart. However, its appearance in the periampullary region is uncommon and has rarely been reported in the literature. It is characterized histologically by myofibroblastic cell proliferation together with a mixed inflammatory infiltrate that clinically and radiologically mimics a malignant tumor. We report a case of IMT located in the distal common bile duct of a 51-year-old woman. She underwent Whipple resection with the initial diagnosis of cholangiocarcinoma; the pathologic diagnosis of the tumor was IMT of the distal bile duct associated with lymphoplasmacytic sclerosing pancreatitis. Referring to previously reported cases, suspected diagnosis of a malignant tumor made surgical excision the primary choice for symptom relief and in order to obtain a definitive diagnosis. IMT relationship with lymphoplasmacytic sclerosing pancreatitis is discussed.