Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis.

BACKGROUND: Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic treatment using self-expanding stents has been used in the therapeutic management of these complications with preliminary good results. METHODS: We performed a systematic review and meta-analysis of self-expanding stents placement for the management of gastrointestinal leaks after obesity surgery. Overall proportion of successful leak closure, stent migration, and reoperation were analysed as primary outcomes. Secondary outcomes were patients' clinical characteristics, duration and type of stent, other stent complications, and mortality. RESULTS: A meta-analysis of studies reporting stents was performed, including 488 patients. The overall proportion of successful leak closure was 85.89% (95% CI, 82.52-89.25%), median interval between stent placement and its removal of 44 days. Stent migration was noted in 18.65% (95% CI, 14.32-22.98%) and the overall proportion of re-operation was in 13.54% (95% CI, 9.94-17.14%). The agreement between reviewers for the collected data gave a Cohen's κ value of 1.0. No deaths were caused directly by complications with the stent placement. CONCLUSIONS: Endoscopic placement of self-expanding stents can be used, in selected patients, for the management of leaks after bariatric surgery with a high rate of effectiveness and low mortality rates. Nevertheless, reducing stent migration and re-operation rates represents an important challenge for future studies.

Análisis del impacto de la cirugía bariátrica en el gasto farmacológico a medio plazo / Analysis of the impact of bariatric surgery on medium-term pharmacological expenditure

Introducción: La obesidad y las enfermedades asociadas a ella suponen un importante problema, y no solo sanitario, sino también económico, ya que muchas de esas patologías son subsidiarias de tratamiento farmacológico de por vida. La cirugía bariátrica y metabólica, a priori, disminuye la demanda de medicamentos de estos pacientes, pero puede condicionar otro tipo de necesidades farmacológicas. El objetivo del estudio es demostrar si existe un descenso real del gasto farmacológico tras la cirugía bariátrica. Material y métodos: Análisis retrospectivo transversal de los pacientes intervenidos en nuestro centro entre 2012 y 2016, comparando las distintas comorbilidades y los gastos farmacológicos asociados a ellas un mes antes y a los 2años de la cirugía. Resultados: Fueron intervenidos 400 pacientes. Se presentaron los resultados mostrando para cada una de las técnicas quirúrgicas estudiadas las diferencias entre la resolución de las distintas comorbilidades y el ahorro farmacológico generado. La comorbilidad más coste-efectiva del estudio fue la diabetes mellitus tipo2 (DM2). La técnica quirúrgica con mejores resultados fue el bypass metabólico, presentando una diferencia de costes tras la cirugía de 507euros mensuales (p<0,001). Conclusiones: En un seguimiento de 2años tras la cirugía bariátrica se produce un descenso en la prevalencia de las enfermedades asociadas a la obesidad y del gasto farmacológico asociado a ellas, lo que demuestra que este tipo de intervención resulta eficiente a medio plazo. (AU)

Introduction: Obesity and associated diseases represent an important health and economic problem since pharmacological treatment for many of these pathologies needs lifelong subsidies. Theoretically, bariatric and metabolic surgery decreases the medication requirements of patients for these diseases but may result in other types of pharmacological needs. This study aims to demonstrate whether there is a real decrease in pharmacological expenditure after bariatric surgery. Material and methods: Retrospective cross-sectional analysis of patients who were treated in our centre between 2012 and 2016, comparing different associated comorbidities and pharmacological expenses one month before and 2years after surgery. Results: 400 patients were operated. The results were presented, showing the differences between the resolution of the different comorbidities and the pharmacological savings generated for each of the surgical techniques studied. The most cost-effective comorbidity in the study was type2 diabetes mellitus (DM2). The surgical technique with the best results was metabolic bypass, presenting a cost difference after surgery of 507euros per month (P<.001). Conclusions: In a 2-year follow-up after bariatric surgery, a decreased prevalence of obesity-related diseases and associated pharmacological expenditure was observed, showing the efficiency of this intervention over the medium term. (AU)

Analysis of the impact of bariatric surgery on medium-term pharmacological expenditure.

INTRODUCTION: Obesity and associated diseases represent an important health and economic problem since pharmacological treatment for many of these pathologies needs lifelong subsidies. Theoretically, bariatric and metabolic surgery decreases the medication requirements of patients for these diseases but may result in other types of pharmacological needs. This study aims to demonstrate whether there is a real decrease in pharmacological expenditure after bariatric surgery. MATERIAL AND METHODS: Retrospective cross-sectional analysis of patients who were treated in our centre between 2012 and 2016, comparing different associated comorbidities and pharmacological expenses one month before and 2 years after surgery. RESULTS: 400 patients were operated. The results were presented, showing the differences between the resolution of the different comorbidities and the pharmacological savings generated for each of the surgical techniques studied. The most cost-effective comorbidity in the study was type 2 diabetes mellitus (DM2). The surgical technique with the best results was metabolic bypass, presenting a cost difference after surgery of 507 euros per month (P < 0.001). CONCLUSIONS: In a 2-year follow-up after bariatric surgery, a decreased prevalence of obesity-related diseases and associated pharmacological expenditure was observed, showing the efficiency of this intervention over the medium term.

Analysis of the impact of bariatric surgery on medium-term pharmacological expenditure. / Análisis del impacto de la cirugía bariátrica en el gasto farmacológico a medio plazo.

INTRODUCTION: Obesity and associated diseases represent an important health and economic problem since pharmacological treatment for many of these pathologies needs lifelong subsidies. Theoretically, bariatric and metabolic surgery decreases the medication requirements of patients for these diseases but may result in other types of pharmacological needs. This study aims to demonstrate whether there is a real decrease in pharmacological expenditure after bariatric surgery. MATERIAL AND METHODS: Retrospective cross-sectional analysis of patients who were treated in our centre between 2012 and 2016, comparing different associated comorbidities and pharmacological expenses one month before and 2years after surgery. RESULTS: 400 patients were operated. The results were presented, showing the differences between the resolution of the different comorbidities and the pharmacological savings generated for each of the surgical techniques studied. The most cost-effective comorbidity in the study was type2 diabetes mellitus (DM2). The surgical technique with the best results was metabolic bypass, presenting a cost difference after surgery of 507euros per month (P<.001). CONCLUSIONS: In a 2-year follow-up after bariatric surgery, a decreased prevalence of obesity-related diseases and associated pharmacological expenditure was observed, showing the efficiency of this intervention over the medium term.

Reducción en masa de una hernia inguinal incarcerada. Abordaje urgente por laparoscopia / En masse reduction of an incarcerated inguinal hernia. Emergency laparoscopic management

No disponible

Utilidad de la citometría de flujo en la determinación de microagregados plaquetarios en pacientes con stent tratados con clopidogrel / Flow cytometry evaluation of platelet microaggregates determination in patients with coronary stent implants treated with clopidogrel

Introducción: La monitorización de pacientes con síndrome coronario agudo (SCA) con stent cardíaco, tratados con clopidogrel resulta conveniente, dada la frecuencia con que dichos pacientes no responden adecuadamente al tratamiento. En efecto, según nuestra experiencia, aproximadamente un 30% de casos pueden clasificarse como pacientes no respondedores (NR). No está establecido si pacientes NR presentan, como factor de riesgo, mayor número de microagregados plaquetarios (MAP) que los pacientes respondedores (R). La formación de MAP puede afectar a la microcirculación y es un factor de riesgo de formación de trombos mayores, por lo que su estudio puede resultar de gran interés. Material y métodos: Se han valorado 78 pacientes consecutivos con un stent cardíaco implantado. El tratamiento consiste en un bolo inicial de 300 mg de clopidogrel, seguido de una dosis diaria de clopidogrel (75 mg) y ácido acetilsalicílico (100 mg). Aproximadamente 1 semana después de iniciado el tratamiento, se determina, mediante citometría de flujo (EPICS-XL, Beckman-Coulter, Izasa), el número MAP circulantes y los formados ex vivo por acción del ADP 2,5 μM. Para ello, con voluntarios sanos, se selecciona previamente la población plaquetaria, en función del forward y side scatter y por ser eventos CD61- positivos. En esta región se elige la subpoblación que ocupa el 5% superior, en la que, por definición, se encuentran los MAP. Una vez establecido el protocolo de adquisición de datos, se analizan las muestras problema. Los pacientes se clasifican como respondedores o no, en función de la exposición de CD62 plaquetaria inducida por accio´n de ADP 2,5 μM. Resultados: El conjunto de 78 pacientes presenta mayor número de MAP circulantes que los controles (167±58/5.000 plaquetas frente a 113±56/5.000 plaquetas; p<0,001).El incremento en el número de MAP por acción de ADP es similar en los 50 controles y en los 51 pacientes que responden adecuadamente al tratamiento. Los 27 pacientes NR presentan mayor respuesta al ADP que los pacientes R, con un incremento en el número de MAP de 251±75/5.000 plaquetas, significativamente mayor que en los pacientes R (196±67/5.000 plaquetas; p<0,001). Conclusiones: La técnica propuesta posibilita la detección de MAP formados espontáneamente y por acción del ADP, lo que permite monitorizar el tratamiento antiplaquetario en los pacientes SCA con stent implantado(AU)

Introduction: It is not well established whether non-responder patients(NR) to clopidogrel show, as a risk factor, higher number of platelet microaggregates (PMAs) than responder patients (R). These MAPs can affect the microcirculation and is a risk factor to forming larger thrombi, therefore the present study is interesting from this point of view. Material and methods: Seventy-eight acute coronary syndrome (ACS) patients (78% male, aged 62.8±12.23 years) were included in this study. These patients underwent coronary stent implantation and treated with routine medication (clopidogrel 75 mg/day and aspirin 100 mg/day), after a loading bolus of 300 mg clopidogrel. The control group was made up of 50 healthy volunteers matched for age and gender who had not been given any pharmacological treatment. Using whole blood flow cytometry, ADP-stimulated and circulating platelet CD62 expression and platelet microaggregates was determined in the entire study population. After a week of treatment the number of circulating platelet microaggregates was evaluated by flow cytometry (EPICS-XL, Beckman-Coulter, Izasa), and the number of MAPs formed ex vivo by ADP 2.5 μM activation was also evaluated . With this aim, using healthy individuals, the platelet population was selected by their forward and side scatter values and as CD61-positive events. The subpopulation that occupied the upper 5% in this region where MAPs are detected,was chosen. After the analytical conditions were established, samples were analyzed. Patients were responders, or not, depending on the CD62 expression after being activated with ADP 2.5 μM. Results: Seventy-eight patients showed a higher number of circulating MAPs than controls (177±75/5000 platelets vs. 121±62/5000 platelets; P<0.001). The increase in the MAPs number by ADP activation is higher in the 50 controls than in the 51 responder patients (79±45% vs. 23±18%; P<0.001). The 27 NR patients reacted to ADP in a similar way than controls, with a increase in the number of MAPs of 62±43%, significantly higher than in R (P<0.001). The findings of this study demonstrate the beneficial effects of clopidogrel in reducing platelet reactivity in 66% of the study patients. These results demonstrate the wide inter-individual variability in ADP response in patients treated with clopidogrel and imply that individualized monitoring of this type of patient is advisable. Conclusions: The method described enables us to explore platelet microaggregates formation and may be of great help in monitoring clopidogrel efficacy in ACS patients with stent(AU)