Intestinal stenosis developed after a complete response to chemotherapy in a patient with Crohn´s disease and lymphoma of the jejunum.

An increased risk of hematologic malignancies secondary to long-term immunomodulators and biologics has been described in patients with inflammatory bowel disease1. Here, we present a case of jejunal stricture after chemotherapy treatment in a patient with ileal Crohn´s disease (CD) and jejunal lymphoma. The patient was a 32-year-old male with ileal CD in remission presenting with abdominal pain and distension. Abdominal computed tomography (CT) showed a poorly defined mass in the proximal jejunum, and positron emission tomography (PET) - CT showed hypermetabolic activity at that level. An upper endoscopy evidenced an indurated, friable circumferential mass causing a significant reduction of the intestinal lumen. Histological and cytometry findings led to a diagnosis of large B cell lymphoma, for which the patient received standard treatment (R-CHOP and IPI), achieving complete response. Eight months later, the patient reported abdominal pain and distention. Abdominal CT showed a thickening of a short segment of the proximal jejunum. An upper endoscopy showed a punctiform stenosis, while multiple biopsies showed neither histological recurrence of lymphoma nor signs of IBD. The patient was diagnosed with a post-chemotherapy stricture and underwent progressive endoscopic balloon dilatation. He finally was scheduled for laparoscopic small bowel resection. An histological analysis of the surgical piece revealed a granulomatous reaction with multinucleated foreign body-like giant cells, without evidence of malignancy (recurrence of lymphoma) nor inflammatory infiltrate suggesting CD. The patient currently remains asymptomatic with no new episodes of abdominal pain.

Enfermedad de Forestier-Rotes-Querol (hiperostosis esquelética idiopática difusa) / Forestier Rotes-Querol disease (diffuse idiopathic skeletal hyperostosis)

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Evaluación económica del tratamiento quirúrgico de la obesidad / Economic evaluation of surgical treatment of obesity

INTRODUCCIÓN: La cirugía bariátrica es el mejor tratamiento de la obesidad mórbida a largo plazo. El ahorro generado por la mejoría de las comorbilidades podría justificar el empleo de más recursos sanitarios. MÉTODOS: Estudio observacional, descriptivo, longitudinal y retrospectivo, de pacientes a los que se les realizó un bypass gástrico, en el Hospital Universitario Central de Asturias entre 2003 y 2012. El seguimiento mínimo se estableció en dos años. Calculamos de manera individualizada el coste para cada uno de los pacientes intervenidos (bottom-up), así como según el grupo relacionado por el diagnóstico (GRD) (top-down). RESULTADOS: De los 307 pacientes del estudio, el coste medio del ingreso calculado por GRD fue de 6.545,9€ y el calculado por paciente de 10.572,2€. El GRD 288 representa al 91% de la serie con un valor de 4.631€. El cálculo estimativo del ahorro que supuso en nuestro entorno sanitario la disminución del número de fármacos de 2,86 a 0,78 por paciente medicado, representó 4.433€ por paciente intervenido si padecía todas las comorbilidades analizadas. CONCLUSIONES: El bypass gástrico en el Hospital Universitario Central de Asturias a los dos años de la cirugía, en pacientes con pluripatología consiguió un ahorro solo en fármacos que podría compensar los gastos inherentes al tratamiento quirúrgico. El coste por proceso mediante GRD se mostró insuficiente a la hora de hacer una correcta evaluación económica, por lo que recomendamos un método de evaluación de coste por paciente

INTRODUCTION: Obesity surgery is the best treatment for extreme obesity, with demonstrated long-term positive outcomes. The potential cost-savings generated by the improvement of comorbidities after surgery can justify the allocation of more resources in the surgical treatment of obesity. METHODS: This was an observational, descriptive, longitudinal and retrospective study. Eligible patients underwent Roux-en-Y gastric bypass surgery at the Hospital Universitario Central de Asturias between 2003 and 2012. The established minimum follow-up period was two years. We calculated the individualized cost per patient treated (bottom-up) as well as per Diagnosis-Related Group (DRG) codes (top-down). RESULTS: Our study included 307 patients. The average cost per hospitalization calculated by DRG codes was €6,545.90, and the average cost per patient was €10,572.20. DRG 288 represented 91% of the series, with a value of €4,631. The number of medications also decreased during this period, from 2.86 to 0.78 per medically treated patient, representing a cost reduction of €4,433 per patient with all the obesity-related comorbidities analyzed. CONCLUSIONS: Two years after Roux-en-Y gastric bypass conducted at Hospital Universitario Central de Asturias, the savings in drug costs for patients with multiple pathologies would compensate the inherent costs of the surgical treatment itself. Our results showed that DRG-related costs was insufficient to make a correct economic evaluation, so we recommend an individualized cost calculating method

Prospective Analysis Regarding Health-Related Quality of Life (HR-QOL) between Morbid Obese Patients Following Bariatric Surgery Versus on a Waiting List.

BACKGROUND: Major impairment of health-related quality of life (HRQoL) is one of the main reasons why obese patients request surgical treatment. OBJECTIVE: To prospectively analyze the impact of HRQoL between obese patients who underwent surgery and those who were wait-listed. METHODS: Between April 2017 and March 2018, 70 surgical and 69 wait-listed patients were interviewed twice, at baseline and at the 12-month follow-up. Quality of life was measured by the SF-12v2 and the Impact of Weight on Quality of Life-Lite (IWQoL-Lite) questionnaires. Sociodemographic-, clinical-, and surgical-related variables were collected. RESULTS: One hundred thirty-nine patients were analyzed, showing similar baseline characteristics but differences in HRQoL. Performing more qualified work improved scores on some aspects of the SF-12 survey. In contrast, women scored worse on the self-esteem domain, and men scored worse on the mental health domain. By group, at the 12-month follow-up, statistically significant differences were found among all aspects of the questionnaires between both groups (P < 0.001) and between baseline and postoperative 12-month follow-up in the surgical group (P < 0.001). Furthermore, scores were lower in all domains in the evolution of wait-listed patients, with statistically significant differences among the Bodily Pain, Emotional Role, Mental Health, and Mental Component Summary Domains (P < 0.05). CONCLUSION: HRQoL is a multimodal concept that allows the identification of factors impacting obese patients' quality of life. It promotes the benefit of surgery against waiting list delays, which can take up to 4 years in our hospital. Therefore, HRQoL is an important pillar to justify more resources for reducing unacceptable surgical delays.

Economic evaluation of surgical treatment of obesity. / Evaluación económica del tratamiento quirúrgico de la obesidad.

INTRODUCTION: Obesity surgery is the best treatment for extreme obesity, with demonstrated long-term positive outcomes. The potential cost-savings generated by the improvement of comorbidities after surgery can justify the allocation of more resources in the surgical treatment of obesity. METHODS: This was an observational, descriptive, longitudinal and retrospective study. Eligible patients underwent Roux-en-Y gastric bypass surgery at the Hospital Universitario Central de Asturias between 2003 and 2012. The established minimum follow-up period was two years. We calculated the individualized cost per patient treated (bottom-up) as well as per Diagnosis-Related Group (DRG) codes (top-down). RESULTS: Our study included 307 patients. The average cost per hospitalization calculated by DRG codes was €6,545.90, and the average cost per patient was €10,572.20. DRG 288 represented 91% of the series, with a value of €4,631. The number of medications also decreased during this period, from 2.86 to 0.78 per medically treated patient, representing a cost reduction of €4,433 per patient with all the obesity-related comorbidities analyzed. CONCLUSIONS: Two years after Roux-en-Y gastric bypass conducted at Hospital Universitario Central de Asturias, the savings in drug costs for patients with multiple pathologies would compensate the inherent costs of the surgical treatment itself. Our results showed that DRG-related costs was insufficient to make a correct economic evaluation, so we recommend an individualized cost calculating method.

Evidencia en seguimiento y pronóstico del cáncer de unión esofagogástrica / Evidence in follow-up and prognosis of esophagogastric junction cancer

La supervivencia a cinco años de los tumores de la unión esofagogástrica está en el 50% en los estadios más favorables y con los tratamientos coadyuvantes más eficaces. Más del 40% de los pacientes sufrirá recurrencias en un periodo breve, habitualmente en el primer año tras una cirugía potencialmente curativa y la supervivencia tras esa recurrencia suele ser menor de 6 meses, pues el tratamiento es poco eficaz, sea quimioterapia paliativa, radioterapia o exéresis quirúrgica de las recidivas únicas. El tipo y frecuencia del seguimiento realizado influye en la supervivencia porque la detección de recurrencias asintomáticas permite realizar tratamientos más precoces y efectivos

Five-year survival of tumors of the esophagogastric junction is 50%, in the most favourable stages and with the most effective adjuvant treatments. More than 40% of patients will have recurrences within a short period, usually the first year after potentially curative surgery. Survival after this recurrence is usually less than 6 months because treatment is not very effective, be it palliative chemotherapy, radiotherapy or surgical excision of single recurrences. As the detection of asymptomatic recurrences allows for earlier and more effective treatments to be used, the type and frequency of follow-up has an influence on survival

Evidence in follow-up and prognosis of esophagogastric junction cancer. / Evidencia en seguimiento y pronóstico del cáncer de unión esofagogástrica.

Five-year survival of tumors of the esophagogastric junction is 50%, in the most favourable stages and with the most effective adjuvant treatments. More than 40% of patients will have recurrences within a short period, usually the first year after potentially curative surgery. Survival after this recurrence is usually less than 6 months because treatment is not very effective, be it palliative chemotherapy, radiotherapy or surgical excision of single recurrences. As the detection of asymptomatic recurrences allows for earlier and more effective treatments to be used, the type and frequency of follow-up has an influence on survival.

Laparoscopic treatment of large bowel obstruction due to a self-locating peritoneal dialysis catheter.

INTRODUCTION: Peritoneal dialysis has been used in the treatment of end-stage renal disease for a long time. The development of continuous ambulatory peritoneal dialysis (CAPD) has achieved an acceptable device of renal replacement therapy. PRESENTATION OF CASE: We report a 55 year-old patient who was initiated on CAPD in February 2016. Three months later, the Tenckhoff catheter was removed due to its malfunction, and a new self-locating peritoneal dialysis catheter was placed in the left side of the abdomen. In September 2016, the patient presented with symptoms of intestinal obstruction. A CT scan revealed a collapsed sigmoid colon with the tungsten tip of the catheter supported on the mesosigmoid as the cause of the occlusion. DISCUSSION: Herein, a rare but clinically important case of mechanical large bowel obstruction due to self-locating peritoneal dialysis catheter is presented. The weight added to the tip of the self-locating catheter for the purpose of stretching it, can be dangerous if a displacement takes place. A laparoscopic procedure was performed, resolving the obstruction by reinserting the peritoneal catheter in its right position. CONCLUSION: The weight added to the tip of self-locating catheters is a matter of concern, since intimate contact between the peritoneal catheter and the intestinal wall can result in perforation or intestinal occlusion.

Ergonomía en cirugía laparoscópica: la visión de las cirujanas / Ergonomics in laparoscopic surgery: point of view of the woman surgeons

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[Obesity in the history of surgery]. / La obesidad en la historia de la cirugía.

Obesity is a problem that is reaching epidemic proportions throughout the world and bariatric surgery is now a rapidly growing technique. However existence of obesity in humans has been recognized for thousands of years, as statues dating from the Stone Age period appear to provide the earliest depictions. Hippocrates (466-355 b.C.) and Galen (131-201 a.C.) had a clear understanding of the condition, its consequences and medical treatment. On the other hand bariatric surgery was a xx century treatment, but at the end of the xix century it was known that the massive loss of small bowel or gastric resection after ulcer surgery resulted in persistent weight loss. Malabsorption and gastric restriction in isolation, or more commonly in combination, remain the main options to surgical control of weight. Unfortunately surgery as a non etiological treatment is an imperfect model to treat an incurable disease: morbid obesity. Prevention and better knowledge of disease would allow a tailored medical or surgical approach.

La obesidad en la historia de la cirugía / Obesity in the history of surgery

La obesidad ha alcanzado dimensiones epidémicas mundiales y la cirugía bariátrica, prácticamente desconocida, ha logrado un desarrollo difícil de imaginar hace pocas décadas. No obstante, no puede decirse que la obesidad no existiese en la antigüedad o sea una patología de conocimiento reciente. Ya en la Edad de Piedra hay testimonios de su existencia y los grandes maestros de la medicina Hipócrates (460-355 a.C.) y Galeno (131-201 d.C.) conocían perfectamente la enfermedad y sus consecuencias e incluso los tratamientos médicos actuales remedan los que ellos prescribían. La cirugía comienza esencialmente a mediados del siglo xx, aunque al final del xix ya se dan los primeros pasos experimentales en la comprensión de la fisiopatología de la hipoabsorción intestinal como base del adelgazamiento, o el auge de la resección gástrica por úlcera péptica permite observar que la restricción de la capacidad del estómago promueve la pérdida de peso. Hipoabsorción y restricción gástrica, solas o combinadas, han llegado a nuestros días como principios quirúrgicos inalterables. Sin embargo, como todo tratamiento no etiológico, la cirugía bariátrica es una solución imperfecta para una enfermedad incurable, la obesidad mórbida. Prevención y conocimientos genéticos o moleculares, entre otros, permitirán un tratamiento integral, médico o quirúrgico, adaptado a cada situación clínica del paciente (AU)

Obesity is a problem that is reaching epidemic proportions throughout the world and bariatric surgery is now a rapidly growing technique. However existence of obesity in humans has been recognized for thousands of years, as statues dating from the Stone Age period appear to provide the earliest depictions. Hippocrates (466-355 b.C.) and Galen (131-201 a.C.) had a clear understanding of the condition, its consequences and medical treatment. On the other hand bariatric surgery was a xx century treatment, but at the end of the xix century it was known that the massive loss of small bowel or gastric resection after ulcer surgery resulted in persistent weight loss. Malabsorption and gastric restriction in isolation, or more commonly in combination, remain the main options to surgical control of weight. Unfortunately surgery as a non etiological treatment is an imperfect model to treat an incurable disease: morbid obesity. Prevention and better knowledge of disease would allow a tailored medical or surgical approach (AU)

[Complications of surgical resection of esophageal cancer]. / Complicaciones de la cirugía de exéresis del cáncer de esófago.

Esophageal resection has undergone refinements over recent years, with improved outcomes. However, in-hospital mortality remains above 10% in developed countries and is below 5% in only a select group of hospitals. Morbidity remains high even in high-volume hospitals. We reviewed risk factors in esophageal resection. Pulmonary complications occur mainly in older patients and in those with pulmonary dysfunction, especially %FEV1 or hypoxia. Liver cirrhosis, squamous cell cancer, low patient volume, and cervical anastomoses also increase complication rates. Neoadjuvant chemoradiotherapy, which may be effective in squamous cell tumors, can also increase morbidity. The main cause of morbidity and mortality are pleuropulmonary complications. Also significant are anastomotic leak and esophageal conduit necrosis. A complex procedure such as esophageal resection is better served in specialized teams.

Complicaciones de la cirugía de exéresis del cáncer de esófago / Complications of surgical resection of esophageal cancer

La cirugía del cáncer de esófago está más reglada, hecho que ha propiciado mejores resultados. No obstante, la mortalidad operatoria en países desarrollados supera el 10% y sólo un grupo selecto se acerca al 5%. La morbilidad es elevada incluso en centros experimentados. Hemos revisado factores de riesgo. Las complicaciones respiratorias son más habituales en presencia de edad avanzada y alteraciones de las pruebas respiratorias, sobre todo la de volumen máximo espirado en el primer segundo e hipoxia. Factores como la cirrosis hepática, tipo epidermoide, la poca casuística o la anastomosis cervical generan morbilidad adicional. La quimiorradioterapia neoadyuvante, quizás eficaz en tumores epidermoides, puede añadir más morbilidad. Las complicaciones pleuropulmonares ocupan el primer lugar de morbimortalidad operatoria, sin olvidar que la fístula anastomótica o la necrosis de la plastia obligan a tomar precauciones. La complejidad del tema hace concluir que la resección esofágica por cáncer debe restringirse a grupos con casuística suficiente (AU)

Esophageal resection has undergone refinements over recent years, with improved outcomes. However, in-hospital mortality remains above 10% in developed countries and is below 5% in only a select group of hospitals. Morbidity remains high even in high-volume hospitals. We reviewed risk factors in esophageal resection. Pulmonary complications occur mainly in older patients and in those with pulmonary dysfunction, especially %FEV1 or hypoxia. Liver cirrhosis, squamous cell cancer, low patient volume, and cervical anastomoses also increase complication rates. Neoadjuvant chemoradiotherapy, which may be effective in squamous cell tumors, can also increase morbidity. The main cause of morbidity and mortality are pleuropulmonary complications. Also significant are anastomotic leak and esophageal conduit necrosis. A complex procedure such as esophageal resection is better served in specialized teams (AU)