Robotic and laparoscopic Roux-en-Y gastric bypass after learning curve: 30-day and 12-month outcomes.

This study compares laparoscopic RYGB (L-RYGB) and robotic RYGB (R-RYGB) performed by the same team after the learning curve in both approaches. A retrospective cohort study was done, and the surgical outcome was analyzed in 30 days and 12 months for patients with similar characteristics and an equal number of cases in each group (233 cases). Four hundred and sixty-six patients were included in this study. Mean age was 46.8 ± 8.3 years and 2/3 were women. R-RYGB presented a longer operative time (150.7 versus 135.4 min; p < 0.001) with no differences in the length of hospital stay. The main 30-day complications were G-J stricture, leakage, and intraluminal bleeding. The reoperation rate was 1.6% by leakage (G-J anastomosis) and was higher in R-RYGB (2.1 versus 0.4; p = 0.108). The multivariate analysis identified that L-RYGB was the factor independently associated with a LOS longer than 2 days (odds ratio: 4.7, 95% CI: 2.6-8.2, p value < 0.001). At the FU time (12 months), no differences between the groups were found. The outcomes between the groups after the learning curve did not present differences in terms of 30 days and 12 months of FU when same preoperative characteristics and an equal number of cases in each group are considered. L-RYGB was the unique independent factor associated with long LOS.

Analysis of the Management of Cholelithiasis in Bariatric Surgery Patients: a Single-Center Experience.

PURPOSE: Cholelithiasis is an issue in bariatric surgery patients. The incidence of cholelithiasis is increased in morbidly obese patients. After bariatric surgery, the management maybe sometimes challenging. There is no consensus about how to deal with cholelithiasis prior to bariatric surgery. MATERIALS AND METHODS: A retrospective review from our prospectively collected bariatric surgery database. Primary bariatric procedures from 2009 to 2020 were included. Prevalence of cholelithiasis and its management prior to bariatric surgery and the incidence and management of postoperative biliary events were analyzed. RESULTS: Over 1445 patients analyzed, preoperatively cholelithiasis was found in 153 (10.58%), and 68 out of them (44.44%) were symptomatic. Seventy-six patients had a concomitant cholecystectomy. In those cases, the bariatric procedure did not show increased operative time, length of stay, morbidity, or mortality compared to the rest of primary bariatric procedures. Twelve patients (15.58%) with previous cholelithiasis and no concomitant cholecystectomy presented any kind of biliary event and required cholecystectomy. De novo cholelithiasis rate requiring cholecystectomy was 3.86%. Postoperative biliary events both in de novo and persistent cholelithiasis population did not show any difference between the type of surgery, weight loss, and other characteristics. CONCLUSIONS: Cholelithiasis was present in 10.58% of our primary bariatric surgery population. Concomitant cholecystectomy was safe in our series. Non-surgical management of asymptomatic cholelithiasis did not lead to a higher risk of postoperative biliary events. The global postoperative cholecystectomy rate was equivalent to the general population.

Laparoscopic Versus Robot-Assisted Roux-en-Y Gastric Bypass: A Center of Excellence for the EAC-BC Experience.

Background: After the first laparoscopic Roux-en-Y gastric bypass (RYGB) in 1994 by Wittgrove, the introduction of robot-assisted procedures was the next step in the surgical race to reduce invasiveness. This breakthrough allowed us to perform bariatric surgery with less surgical trauma in obese patients with metabolic disorders, producing an exponential increase in procedures performed. Methods: This is a retrospective cohort study of a prospective database for patients who underwent RYGB during a 7-year period through two different approaches, laparoscopic and robotic. The robotic cases were performed by two generations of the da Vinci platform (S and Xi), and three groups were identified and compared (L-RYGB, RYGB-S, and RYGB-Xi). Results: A total of 495 patients underwent RYGB, of which 224 by laparoscopy (45.2%) and 271 by robotic approach (54.7%): 134 RYGB-S and 137 RYGB-Xi. The majority of the patients (71.1%) were females, with a mean age of 46.2 years and a mean body mass index of 44 kg/m2. The mean intraoperative time and intraoperative complication rate were higher in the robotic groups, especially in the RYGB-S group. Postoperative complications were higher in the same group, with a rate of 11.9%, where the main leakage occurred on the upper part of the gastric pouch and not in the hand-sewed robotic anastomosis (7.5%). General mortality was 0.6%. We found no significant differences at 1-year percentage of total weight loss (%TWL); at 2 years, the RYGB-Xi group had the lowest %TWL (25.24 ± 14.54, P ≤ .001). Conclusions: The present study reflects our experience during the robotic bariatric introduction and performance since 2011. Features of the da Vinci S platform along our learning curve may explain a higher complication rate. The patients who have been operated by the RYGB-Xi system had lower complications than the laparoscopic group. The robotic approach did not differ with laparoscopy in terms of weight loss and chronic complications after 24 months of follow-up.

The Panoramic View of Revisional Bariatric Surgery.

Introduction: Obesity remains a major public chronic disease, and the multifactorial components of its relapse in many patients remain inevitable. Methods: This article provides a panoramic view of the most commonly performed revisional bariatric surgery (RBS). RBS is a complex procedure; thus, primary procedures should be well chosen and performed to avoid the increasing number of RBS cases. Results: Bariatric surgery is the only successful long-term treatment for obesity. However, a proportion of primary bariatric surgeries has failed during the follow-up period. In recent decades, the solution for these complications is by performing RBS. It is mandatory to understand obesity as a chronic disease to appropriately treat patients. Treatment strategies are needed to determine the indications for revision. RBS requires a meticulous evaluation to facilitate good long-term results. Conclusions: Treatment strategies will be a fundamental pillar to wisely determine the indications for revision and identify the factors influencing failure by prudently and rationally evaluating the revisional procedure that the patient will benefit from and acquiring a high level of surgical skills.

A Comparison of Clinical Outcomes Between Two Different Models of Surgical Robots in Roux-en-Y Gastric Bypass.

Introduction: For the past 20 years, robotic surgical systems have been used for the Roux-en-Y gastric bypass (RYGB). The da Vinci Surgical System (Intuitive Surgical, Inc.) has been one of the most used robotic platforms. This study aims to retrospectively compare the performance of two models of surgical robots. Materials and Methods: A retrospective comparative study was conducted from a prospective database including all patients who underwent robotic RYGB (RRYGB) from 2011 to 2020. Results: Of a total of 277 patients included, 134 were in the RRYGB using the da Vinci S™ (RRYGB-S™) group and 143 were in the RRYGB using the da Vinci Xi™ (RRYGB-Xi™) group. The mean operative time in the RRYGB-S and RRYGB-Xi groups was 154 ± 28 and 151 ± 32 minutes, respectively (P = .510). The was no statistically significant difference in terms of intraoperative complications between the groups with regard to positive blue test, bleeding, and failure of stapler line. The readmission rate was higher in the RRGB-S group (14.1%) than in the RRYGB-Xi group (3.4%) (P = .004), and it was mainly due to major complications (P = .003) including pouch and gastrojejunostomy anastomotic leaks (P = .001). The nonsurgical complications were statistically significantly higher in the RRYGB-S group (7.4%) than in the RRYGB-Xi group (2.1%) (P < .05), as well as the surgical complications were higher in the RRYGB-S group (7.5%) than in the RRYGB-Xi group (0%) (P < .001). The mean percentage of the total weight loss at 1 and 2 years of follow-up did not show any statistically significant difference (P = .547). Conclusions: The higher complication rate in the S surgical system might be correlated with the initial learning curve and stressed the need for proper robotic surgical training and accurate strategies when introducing emerging technologies into the surgical practice.

Robotic Revisional Experience. Single Centre Prospective Cohort Study and Review of the Literature.

Background: Robotic bariatric surgery (RBS) has increased in recent years. Many doubts continue to exist regarding its utility in terms of postoperative complications, costs and technical aspects. RBS has increased its number and shows a more technical challenge associated with more post-operative complications compared to primary bariatric surgery. We herein present a single institution experience and review to describe its utility in revisional surgery. Methods: A retrospective review of our experience and a review of the literature has been conducted to evaluate the impact of robotic revisional surgery in the bariatric field. Results: A total of 17 patients (5 female and 12 male) were operated on. Most frequent surgery was conversion of sleeve gastrectomy to gastric bypass (n=9). No leaks were found nor severe complications. A systematic review showed similar results including a decreased number for complications when performing robotic revisional surgery. Conclusions: Revisional robotic surgery shows better results compared to standard laparoscopic revisional bariatric surgery in terms of efficacy, safety and hospital stay. No differences were seen in rates of mortality, morbidity and reintervention between both approaches. We encourage surgeons to learn to perform the robotic technique as part of the process of democratization and standardization of bariatric surgery.

Management of Leak after Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy.

The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has been introduced in the past few years for the treatment of morbid obesity. SADI-S has shown good results in terms of long-term results and short-term complications. However, the management of patients undergoing SADI-S and suffering from a leak is a great challenge for surgeons. We present an extensive review of the currently available literature on the management of leak after SADI in morbid obese (MO) patients. We aim at providing objective information regarding the optimal management, including diagnosis, technical options for the different strategies that have been proposed, to facilitate the selection of the best individual approach for each MO patient.

Reversal to Normal Anatomy (With Sleeve Gastrectomy) for Severe Hypoglycemia.

Background. Laparoscopic Roux-en-Y gastric bypass (GBP) is an essential bariatric surgical procedure which is globally performed because of the associated effective weight loss and resolution of metabolic comorbidities, such as diabetes and dyslipidemia. Although some complications may occur, hypoglycemia is a rare complication, which can lead to lethal consequences. We aimed to describe the technical aspects and surgical results after reversal to normal anatomy (RNA). Methods. We conducted a retrospective data analysis including 16 patients who underwent laparoscopic RNA from 2011 to 2018. All data were archived in a prospective database. Previous bariatric surgery and postoperative outcomes were analyzed. Results. Sixteen patients underwent RNA, most of them after GBP, and 15 patients required sleeve gastrectomy. Among them, 80% were women; 5 patients presented with postoperative complications, such as colitis with intra-abdominal collection (n = 1), gastric leak (n = 2) treated with an endoprosthesis, mesenteric venous thrombosis (n = 1), and intra-abdominal bleeding (n = 1). Mean length of hospital stay was 5.93 (3-30). All patients recovered from their initial condition although 3 patients presented with mild hypoglycemia during follow-up. Seven patients regained weight (43.75%), and another 4 developed gastroesophageal reflux disease (25%). Conclusions. These laparoscopic RNA results are acceptable, indicating a clinical improvement in the hypoglycemic syndrome in all patients.

Effects of COVID-19 lockdown on a bariatric surgery waiting list cohort and its influence in surgical risk perception.

PURPOSE: The COVID-19 outbreak has forced a 2-month lockdown (LD) in Spain. We aimed to assess how that had affected our cohort of bariatric patients waiting for surgery. METHODS: A review of electronic records and a structured phone interview with each patient were conducted. Changes in severity of obesity were analyzed using the Obesity Surgery Score (OSS) and changes in health-related quality of life (HRQoL) using the validated EQ-5D questionnaire. Other miscellaneous questions about behavior modifications and surgical risk perception were also analyzed. RESULTS: All 51 patients fully answered the questionnaires. Mean age was 47 years and mean time on waiting list 91 days. Mean BMI increased during LD (42.7 vs 43.2; p < 0.001). Both OSS (2.84 vs 3; p = 0.011) and EQ-5D (69 vs 64; p < 0.001) mildly worsened during LD, mainly due to psychosocial issues. Twenty-seven patients (53%) thought that perioperative risks were higher under the current circumstances but they were as willing to undergo surgery as those who believed that the risks had not increased (74% vs 87%, p = 0.2). CONCLUSIONS: COVID-19 LD had a significant but mild effect on our cohort of bariatric surgery waiting list patients. Although perioperative risk perception had increased, patients were still willing to undergo their planned surgeries.

Management of the staple line in laparoscopic sleeve gastrectomy: comparison of three different reinforcement techniques.

BACKGROUND: Nowadays, laparoscopic sleeve gastrectomy (LSG) is one of the most widely performed bariatric procedures. Different techniques have been described to reduce the rate of complications associated with the staple line, but no consensus has been reached. The aim of this study was to determine the incidence of surgical complications after LSG with three different approaches to the staple line. PATIENTS AND METHODS: A retrospective matched analysis was performed, comparing three groups of 100 patients each: partial oversewing of the staple line (PO group), complete oversewing of the staple line (CO group), and reinforcement with buttress material (BM group). Operative time, early surgical complications (superficial surgical site infection, leakage and hemorrhage), length of stay, weight evolution, and revisional surgery rates were analyzed. RESULTS: All three groups were comparable at baseline. All surgeries were performed laparoscopically. Operative time was significantly longer in the CO group (PO: 84.2 ± 22; CO: 104.7 ± 17; BM: 82.3 ± 22; PO vs CO, p = 0.021; BM vs CO, p = 0.011). There were no differences in length of stay, early surgical complications, and weight outcomes at 36 months between the groups. The need for a revisional surgery was significantly higher in the CO group compared to the PO group (PO: 3%; CO: 14%; BM: 9%; PO vs CO, p = 0.005). CONCLUSION: The CO group required a longer operative time. There were no differences in early surgical complications between the groups. The CO group had a higher need for revisional surgery than the PO group.

Abdominal Wall Hernia and Metabolic Bariatric Surgery.

The management of morbidly obese patients with a concomitant ventral hernia (VH) is a great challenge for surgeons. There is controversy over the optimal strategy to tackle both health problems, requiring an individualized approach. Obese patients have a higher recurrence rate after hernia repair, and bariatric surgery in the presence of a VH can be difficult. As morbid obesity is related with severe comorbidities, including increased cardiovascular and anesthetic risks, some advocate for a single-stage strategy. A primary hernia repair carried out during the bariatric surgery, however, may increase morbidity without definitively solving the problem. Biological meshes are expensive and also have a high recurrence rate. The laparoscopic placement of a synthetic mesh offers good results, but it is worrisome because bariatric surgery is a clean-contaminated procedure. Moreover, there is a great chance that a plastic surgery would be necessary after completing the weight-loss process, and the abdominal wall surgery could be performed at that point. There are many arguments, but the evidence is weak. We present an extensive review of the currently available literature on the management of VH in morbidly obese patients. We aim to provide objective information regarding the pros and cons of the different strategies that have been proposed, to facilitate the selection of the best approach to individual morbidly obese patients with abdominal wall hernias precising both of surgical repair.

Operative and Postoperative Complications of Laparoscopic Sleeve Gastrectomy in Super and Nonsuper Obese Patients: A Center of Excellence Experience Comparative Study.

Background: Laparoscopic sleeve gastrectomy (LSG) is now one of the most common surgical procedures worldwide. It was initially defined for staged procedures in super or super-super obese, or in very complex patients. The primary objective of the study was to assess the safety of LSG for morbid-obese (MO, body mass index [BMI] >40 kg/m2) and super-morbid-obese (SMO, BMI >50 kg/m2) patients in terms of operative and postoperative complication rate. Methods: This study involves a retrospective analysis of a prospective database that included data for patients who underwent LSG, between 2008 and 2017, in our institution. All LSG procedures were performed by the same two certified bariatric surgeons following a standardized surgical procedure. Data on operative and postoperative complications were collected for all the patients. Results: A total of 713 patients were included in the study 495 (61.42%) were MO (mean age 46.06 ± 11.98 years) and 218 (30.58%) were SMO (mean age 42.98 ± 11.17 years). There were no significant differences between both groups in terms of minor and major postoperative complications or long-term complications. Postoperative mortality was slightly higher in the MO group but without statistically significant differences (MO: 0.2%; SMO: 0%). Long-term reoperation rate and late complications were higher in the MO group 6.12% versus 4.04% and 17.43% versus 15.15%, respectively. Reoperation for gastroesophageal reflux disease was higher in MO patients compared to SMO and weight issues reoperation higher in the SMO. Conclusion: We found LSG as a safe procedure in both groups. Interestingly long-term reoperation and complications rates were higher in the MO group.

Massive necrotizing fasciitis: a life threatening entity.

Necrotizing fasciitis (NF) is a complicated soft tissue infection frequently associated with severe sepsis if an early medical and surgical treatment is not performed. We report two postoperative cases of severe NF after oophorectomy and colorectal resection. Because of the similarity with more benign skin infections at the early steps, clinical suspicion is crucial. Surgical exploration and resection will provide both the diagnosis confirming necrotizing infection of the fascia with vessels and treatment. Also, empirical broad-spectrum antibiotics must be initiated as soon as possible. Regardless of the presence of risk factors, NF is a condition with a high mortality rate and only an expeditious and undelayed treatment may improve the patient's outcome. Surgical focus control requires wide and repeated resections, and planned reconstructive plastic surgery might be necessary.

Ligamentum Teres Cardiopexy as a Late Alternative for Gastroesophageal Reflux Disease in a Patient with Previous Reversal of Gastric Bypass to Sleeve Gastrectomy and Hiatal Hernia Repair.

An important percentage of the patient, undergoing primary or revisional bariatric surgery after sleeve gastrectomy, presents symptomatic gastroesophageal reflux disease (GERD). When and how surgical reinforcement of the lower esophageal sphincter should be performed to prevent acid reflux is still controversial. Here, we describe laparoscopic ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with the previous conversion of gastric bypass to sleeve gastrectomy and hiatal hernia repair. We present the surgical technique performed on a patient with initial gastric bypass who underwent sleeve gastrectomy for hypoglycemia and hiatoplasty for severe GERD. Persistent GERD requested to undergo ligamentum teres cardiopexy. Ligamentum teres cardiopexy combined with the closure of the gastric crus is a late alternative treatment for GERD in patients with previous sleeve gastrectomy and hiatal hernia.

Seasonal variation of body weight loss after bariatric surgery.

Seasonal variations have been described in humans in several variables such as sleep, mood, appetite, food preferences, or body weight. We hypothesized that these variations could also influence the decrease in body weight rate in patients submitted to body weight loss interventions. Thus, here we tested the variations of weight loss according to the time of the year the surgery took place in a group patients (n = 1322) submitted to bariatric surgery in the Hospital Universitari de la Vall d'Hebron in Barcelona (geographical coordinates: 41°25'41″N 2°8'32″E). For the analysis, the percentage of total body weight loss (%TWL), excess body weight loss (%EWL) and percentage of body mass index loss (%BMIL) were calculated at 3 (n = 1255), 6 (n = 1172), 9 (n = 1002), and 12 months (n = 1076) after surgery. For %EWL and %BMIL a statistically significant seasonal variation was detected when the variables were calculated at 3 months, but not at the other times, with more weight loss in summer-fall. However, seasonal variations were not detected for %TWL (p = 0.09). The mean amplitude of the seasonal rhythm for %EWL was of 1.8%, while for the rhythm of %BMIL was 0.7%. Moreover, a second peak was detected in January-February modulating the seasonal rhythm of the two variables. Results confirm seasonal variations in humans and indicate that short term responses to weight loss can be modulated by the time of year.

Seasonal variations of changes in lipid and glucidic variables after bariatric surgery.

Seasonality is a phenomenon that is characterized by changes over the year in sleep, mood, behaviour, appetite and body weight. In humans, seasonal variations have been found in certain variables, such as lipid variables and body mass index. We hypothesize that this rhythm could influence the expected variation of the levels of biochemical variables in cases of body weight loss. Thus, the goal of this study was to observe whether the time of year in which bariatric surgery (BS) took place modulated the changes in several variables related to glucidic and lipid metabolism. Blood samples were obtained from 24 women and 10 men before BS and 1 and 3 months after BS. We calculated the percentage of variation that occurred for each individual and for each variable as a function of the time of the year. Data were adjusted to a 12-month period sinusoidal curve, with significance being set at p < 0.05. The results showed that almost all of the studied variables changed due to the BS according to a seasonal rhythm. Most of the variables showed a decrease that was most prominent in winter. In the cases of body mass index (BMI), adrenocorticotropin hormone (ACTH), and cortisol, the highest variation occurred in winter. Insulin and cholesterol in high-density lipoproteins (cHLD) variations were higher in springtime. Glucose variation showed a decrease after surgery with acrophase in summer-fall and plasminogen activator inhibitor-1 (PAI-1) and homeostatic model assessment-insulin resistance (HOMA-IR) in spring-summer. Ghrelin levels showed increases with a rhythm of variation with an acrophase in summer-fall. The seasonal rhythm found in this study fits nearly with the inverse of the endogenous circannual rhythm of the variables studied. The time of the year when the highest variation takes place is related to the circannual rhythm of the variable. The results agree with the manifestation of seasonal rhythm in human biochemical variables, which are reflected in the responses to weight loss after BS.

Adrenergic cardiomyopathy and cardiogenic shock as initial presentation of pheochromocytoma. A case report and review of the literature.

INTRODUCTION: Pheochromocytomas are infrequent tumors arised from the chromaphine cells of the adrenal sympathetic system. The excess of circulating catecholamines may lead to different cardiovascular disorders from silent alterations of the myocardial conduction to different forms of cardiomyopathy. The onset as cardiogenic shock is exceptional. PRESENTATION OF CASE: A 35-year-old male, with a known history of acute myopericarditis of unknown origin which debuted as acute pulmonary edema, was admitted with dyspnea in the context of a new heart failure episode with pulmonary edema. An initial ECG showed segmentary repolarization changes, reversed in subsequent ECGs. The echocardiogram showed severe left ventricular dysfunction and lateral and apical hypokinesia. Subsequent echocardiograms showed partial recovery of alterations and preserved systolic function. A cardiac MRI showed a subepicardial minimum catchment focus and myocardial edema suggestive of adrenergic myocarditis. A solid nodular lesion was found in the left adrenal gland, suggesting a pheochromocytoma. Laparoscopic left adrenalectomy confirmed a 30 mm adrenal tumor without signs of locoregional invasion. The patient had normal catecholamine excretion and heart function a few weeks after surgery. Histopathology confirmed the diagnosis of pheochromocytoma. DISCUSSION AND CONCLUSIONS: Adrenergic cardiomyopathy is a rare entity with a variable clinical presentation. The onset as cardiogenic shock is exceptional. The differential diagnosis of a patient with cardiogenic shock of unknown origin should consider the presence of an underlying pheocromocytoma as well as other states of adrenergic hyperstimulation. The reversibility of the myocardial affection in pheocromocytoma-associated myocardiopathy is common after the tumor resection.

Biopsia selectiva del ganglio centinela en el carcinoma papilar de tiroides en pacientes sin evidencia preoperatoria de metástasis ganglionar / Selective sentinel lymph node biopsy in papillary thyroid carcinoma in patients with no preoperative evidence of lymph node metastasis

Introducción: La linfadenectomía en la cirugía del carcinoma papilar de tiroides se aconseja cuando hay evidencia de metástasis ganglionar cervical (terapéutica) o en pacientes de alto riesgo (profiláctica), como en los tumores T3 y T4 de la clasificación TNM. La técnica de la biopsia selectiva del ganglio centinela puede mejorar el diagnóstico prequirúrgico de las metástasis ganglionares. Objetivo: Analizar el resultado de la biopsia selectiva del ganglio centinela en un grupo de pacientes con carcinoma papilar de tiroides T sin evidencia de afectación ganglionar antes de la cirugía. Pacientes y método: Estudio retrospectivo, unicéntrico en el que se incluyeron los pacientes intervenidos entre los años 2011-2013 que fueran clínicamente N0. La identificación del ganglio centinela se realizó mediante técnica isotópica. En todos los casos, se practicó linfadenectomía del compartimento afecto si el ganglio centinela era positivo, y del compartimento central en caso de ganglio centinela negativo. Resultados: Se incluyeron 43 pacientes, 34 mujeres, con una edad media de 52,3 (±17) años. De los 170 ganglios centinela resecados, 46 (27%) fueron positivos para metástasis, que correspondían a 24 (55,8%) pacientes. En las linfadenectomías se resecaron 612 ganglios. De ellos, 96 (15,6%) fueron positivos para metástasis. Doce de los treinta (40%) pacientes cT1N0 y cT2N0 pasaron a pN1 tras la biopsia selectiva del ganglio centinela, mientras que 12 de los 13 (92%) pacientes cT3N0 y cT4N0, acabaron siendo pN1. Conclusiones: La biopsia selectiva del ganglio centinela recalifica más del 50% de pacientes de cN0 a pN1. Se confirma la necesidad de vaciamiento ganglionar en los tumores T3 y T4, pero pone al descubierto la presencia de metástasis linfáticas en el 40% de los T1-T2 (AU)

Introduction: Lymphadenectomy is recommended during surgery for papillary thyroid carcinoma when there is evidence of cervical lymph node metastasis (therapeutic) or in high-risk patients (prophylactic) such as those with T3 and T4 tumors of the TNM classification. Selective sentinel lymph node biopsy may improve preoperative diagnosis of nodal metastases. Objective: To analyze the results of selective sentinel lymph node biopsy in a group of patients with papillary thyroid carcinoma and no evidence of nodal involvement before surgery. Patients and method: A retrospective, single-center study in patients with papillary thyroid carcinoma and no clinical evidence of lymph node involvement who underwent surgery between 2011 and 2013. The sentinel node was identified by scintigraphy. When the sentinel node was positive, the affected compartment was removed, and when sentinel node was negative, central lymph node dissection was performed. Results: Forty-three patients, 34 females, with a mean age of 52.3 (±17) years, were enrolled. Forty-six (27%) of the 170 SNs resected from 24 (55.8%) patients were positive for metastasis. In addition, 94 (15.6%) out of the 612 lymph nodes removed in the lymphadenectomies were positive for metastases. Twelve of the 30 (40%) low risk patients (cT1N0 and cT2N0) changed their stage to pN1, whereas 12 of 13 (92%) high risk patients (cT3N0 and cT4N0) changed to pN1 stage. Conclusions: Selective sentinel lymph node biopsy changes the stage of more than 50% of patients from cN0 to pN1. This confirms the need for lymph node resection in T3 and T4 tumors, but reveals the presence of lymph node metastases in 40% of T1-T2 tumors (AU)

Selective sentinel lymph node biopsy in papillary thyroid carcinoma in patients with no preoperative evidence of lymph node metastasis. / Biopsia selectiva del ganglio centinela en el carcinoma papilar de tiroides en pacientes sin evidencia preoperatoria de metástasis ganglionar.

INTRODUCTION: Lymphadenectomy is recommended during surgery for papillary thyroid carcinoma when there is evidence of cervical lymph node metastasis (therapeutic) or in high-risk patients (prophylactic) such as those with T3 and T4 tumors of the TNM classification. Selective sentinel lymph node biopsy may improve preoperative diagnosis of nodal metastases. OBJECTIVE: To analyze the results of selective sentinel lymph node biopsy in a group of patients with papillary thyroid carcinoma and no evidence of nodal involvement before surgery. PATIENTS AND METHOD: A retrospective, single-center study in patients with papillary thyroid carcinoma and no clinical evidence of lymph node involvement who underwent surgery between 2011 and 2013. The sentinel node was identified by scintigraphy. When the sentinel node was positive, the affected compartment was removed, and when sentinel node was negative, central lymph node dissection was performed. RESULTS: Forty-three patients, 34 females, with a mean age of 52.3 (±17) years, were enrolled. Forty-six (27%) of the 170 SNs resected from 24 (55.8%) patients were positive for metastasis. In addition, 94 (15.6%) out of the 612 lymph nodes removed in the lymphadenectomies were positive for metastases. Twelve of the 30 (40%) low risk patients (cT1N0 and cT2N0) changed their stage to pN1, whereas 12 of 13 (92%) high risk patients (cT3N0 and cT4N0) changed to pN1 stage. CONCLUSIONS: Selective sentinel lymph node biopsy changes the stage of more than 50% of patients from cN0 to pN1. This confirms the need for lymph node resection in T3 and T4 tumors, but reveals the presence of lymph node metastases in 40% of T1-T2 tumors.

Technical Options for Malabsorption Issues After Single Anastomosis Duodenoileal Bypass with Sleeve Gastrectomy.

BACKGROUND: Laparoscopic single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) is a recently developed one- or two-stage operation based on biliopancreatic diversion that is used to treat morbid obesity. Some midterm outcomes suggest that malabsorption is a possible complication following the procedure. Therefore, conversion to a less malabsorptive procedure may be required. We aim to describe and analyze the outcomes after laparoscopic conversion of SADI-S to non-malabsorptive or less malabsorptive procedures. METHODS: From January 2015 to April 2017, five patients underwent laparoscopic conversion to single anastomosis duodenojejunal bypass with sleeve gastrectomy (SADJ-S) (video) following SADI-S, and one female patient underwent laparoscopic conversion to gastric bypass (GBP) following SADI-S, after presenting with severe protein-calorie malnutrition, nutritional deficiencies, poor quality of life, or increased number of bowel movements. RESULTS: Mean preoperative BMI was 24.0 kg/m2 (20.4-27.5 kg/m2). Four patients underwent SADI-S to SADJ-S conversions and one underwent a SADI-S to Roux-en-Y duodenojejunal bypass. All cases were performed laparoscopically. No relevant postoperative complications or mortality was reported and the mean hospital stay was 4.6 days. Malabsorptive symptoms resolved in all patients. All patients experienced weight regain. Mean BMI increase was 7.1 kg/m2 (5-10.8 kg/m2). CONCLUSIONS: Outcomes of laparoscopic conversion to SADJ-S or GBP after SADI-S were acceptable, showing clinical improvement of malnutrition, nutritional deficiencies, and quality of life in all cases. Weight regain must be advised. These techniques appear feasible and free of severe long-term complications. Further investigation is warranted to understand the best common channel length for patients undergoing SADI-S.