Esophagectomy with Ileocoloplasty, Last Treatment for a Leak After Laparoscopic Sleeve: "From Less to More".

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is increasingly playing a key role in obesity management. Such operations, however, carry complications sometimes including leaks. The esophageal stent is one of the frequent options used to treat leaks after a sleeve gastrectomy. The fully covered stents are the ones of choice. However, their use can result in serious consequences requiring aggressive solutions. The longer the stent is maintained, there is more risk of withdrawal, even esophageal mucosal avulsion developing stenosis afterward. Endoscopic stenting is a double-edged sword that must be handled cautiously. MATERIALS AND METHODS: A 36-year-old woman with BMI 44 and obstructive apnea syndrome undergoing laparoscopic sleeve gastrectomy in November 2017 with a 36 Fr bougie and reinforced staplers. She presented a leak as immediate complication. It was initially treated with an esophageal stent and removed 2 months afterwards with a mucosal avulsion during the procedure. She developed after an esophageal stenosis which was treated with enteral nutrition and endoscopic dilatations for 6 months without results. RESULTS: We present an open esophagectomy with ileocoloplasty reconstruction due to intrathoracic esophageal stricture after conservative management with partially covered metal stents and dilatations of a leak in a laparoscopic sleeve. She presented a neck leakage in the postoperative period with a good evolution after parenteral nutrition for 3 weeks and antibiotic therapy. She was discharged one month after surgery eating soft food in a reasonable manner. CONCLUSIONS: Although one of the existing options to treat leaks after a sleeve gastrectomy is the use of an esophageal stent, it is essential to choose the correct type, being the fully covered the ones of choice. The use of self-expandable metal stents appears to be a safe and effective method in the treatment of post-LSG leaks. The longer it is maintained, there is more risk in withdrawal, even esophageal mucosal avulsion. Endoscopic stenting is a double-edged sword that must be handled cautiously.

Revision of a Previous Capella Bypass due to dysphagia, GERD and Candy Cane Syndrome.

BACKGROUND: Capella ringed gastric bypass is a technical variant of gastric bypass which seeks to improve long-term outcomes with a greater restriction. Frequent complications are due to the band, due to its inclusion or slippage, without being able to reject others. Our purpose is to present the video of a revisional bariatric surgery made by laparoscopic approach in a patient with a previous open retrogastric retrocolic Capella gastric bypass. MATERIALS AND METHODS: The patient presents dysphagia, gastroesophagic reflux disease (GERD), and pain, with a BMI of 36 kg/m2. Her supplementary tests show a hiatal hernia, GERD, and a Candy Cane Syndrome. The surgery was difficult due to multiple adhesions. Hiatal hernia was repaired and pillars were closed. The band was visualized intraoperatively close to the gastrojejunal anastomosis, although the high endoscopy did not detect neither stenosis nor difficulty of passage to the gastric pouch. It showed the retrogastric gastrojejunal anastomosis with a normal food loop and a 15-cm widened blind loop (Candy Cane Syndrome), which was resected. RESULTS: She had a left pneumonia and damage in left hepatic lobe (LHL). She was discharged after antibiotic treatment for 7 days. The patient has improved clinically, without dysphagia nor GERD. Her current BMI is 29.8 kg/m2. CONCLUSIONS: In conclusion, bariatric revisional surgery can lead to serious complications, but it is justified in patients with poor quality of life. A ringed retrocolic retrogastric bypass poses more difficulties in revisional procedures. It is mandatory to know which technique was performed before. The duration of the procedure can result in more complications like liver damage.

Factores que condicionan la sensibilidad de la ecografía y la gammagrafía en la localización del adenoma paratiroideo / Factors infuencing the sensitivity of ultrasound and gamma location of the parathyroid adenoma

Introducción: Una correcta localización preoperatoria del adenoma es clave en el tratamiento del hiperparatiroidismo primario (HPTP) mediante paratiroidectomía selectiva. Aunque existen múltiples técnicas de imagen, no siempre consiguen localizar correctamente la/s glándula/s patológica/s. El objetivo es estudiar los factores que puedan influir en la sensibilidad y la concordancia de la ecografía y la gammagrafía 99 mTc-metoxi-isobutil-isonitrilo (MIBI). Métodos: Población a estudio: pacientes intervenidos con HPTP por adenoma con estudio preoperatorio de localización con ecografía y gammagrafía 99 mTc-MIBI. Los pacientes fueron tratados en nuestro centro entre 2004 y 2018. Se han excluido a los que no tuvieran ambas pruebas, las hiperplasias, las neoplasias endocrinas múltiples (MEN) y los adenomas ectópicos no abordables por vía transcervical. Se han estimado la sensibilidad, la concordancia y el valor predictivo positivo (VPP) de las técnicas de imagen con respecto a la localización intraoperatoria, analizando los potenciales factores que pueden influir en ello. Resultados: Se ha analizado a 139 pacientes (82% mujeres, 18% varones). La ecografía ha tenido una sensibilidad del 56,7%, una concordancia (índice kappa) de 0,387 y un VPP del 96,3%. En el caso de la gammagrafía, la sensibilidad ha sido del 81,6%, la concordancia (índice kappa) del 0,669 y su VPP del 97,4%. En el análisis de regresión logística, el factor que ha influido en la localización mediante ecografía ha sido la ausencia de enfermedad tiroidea asociada. En el caso de la gammagrafía, el factor ha sido el peso glandular mayor de 600 mg. Conclusiones: La sensibilidad de la ecografía mejora en ausencia de enfermedad tiroidea y la de la gammagrafía con el peso glandular mayor de 600 mg

Introduction: The treatment of choice for primary hyperparathyroidism (PHPT) when there is proper preoperative localization of the adenoma is minimally invasive parathyroidectomy. However, imaging techniques are not always able to provide the exact location. The objective is to identify potential factors that might influence the sensitivity and concordance of ultrasound (US) and 99mTc-methoxy-isonitrile parathyroid scintigraphy (MIBI-PS) and the actual location of the adenoma. Methods: We reviewed the data of patients who underwent parathyroidectomies for PHPT. All patients had undergone ultrasound and 99mTc-MIBI scintigraphy as a preoperative location study. Multiple endocrine neoplasms, other hyperplasias and non-cervical ectopic adenomas were excluded. The sensitivity, PPV and concordance have been estimated for the location of the gland in both tests compared with the intraoperative location, using a multivariable analysis of the factors that might influence their localization capacity. Results: 139 patients (82% women) have been analysed. The US sensitivity was 56.7%, concordance (Kappa index) 0.387 and PPV 96.3%. The MIBI-PS sensitivity was 81.6%, the concordance (Kappa index) 0.669 and the PPV 97.4%. The factor that improved localization of the glands by US in the multivariable analysis was the absence of a concomitant thyroid pathology. The factor that improved the MIBI-PS results was a gland weight greater than 600 mg. Conclusions: US sensitivity improves when there is no concomitant thyroid pathology. MIBI-PS sensitivity improves when the gland weight is greater than 600 mg

Factors infuencing the sensitivity of ultrasound and gamma location of the parathyroid adenoma. / Factores que condicionan la sensibilidad de la ecografía y la gammagrafía en la localización del adenoma paratiroideo.

INTRODUCTION: The treatment of choice for primary hyperparathyroidism (PHPT) when there is proper preoperative localization of the adenoma is minimally invasive parathyroidectomy. However, imaging techniques are not always able to provide the exact location. The objective is to identify potential factors that might influence the sensitivity and concordance of ultrasound (US) and 99mTc-methoxy-isonitrile parathyroid scintigraphy (MIBI-PS) and the actual location of the adenoma. METHODS: We reviewed the data of patients who underwent parathyroidectomies for PHPT. All patients had undergone ultrasound and 99mTc-MIBI scintigraphy as a preoperative location study. Multiple endocrine neoplasms, other hyperplasias and non-cervical ectopic adenomas were excluded. The sensitivity, PPV and concordance have been estimated for the location of the gland in both tests compared with the intraoperative location, using a multivariable analysis of the factors that might influence their localization capacity. RESULTS: 139 patients (82% women) have been analysed. The US sensitivity was 56.7%, concordance (Kappa index) 0.387 and PPV 96.3%. The MIBI-PS sensitivity was 81.6%, the concordance (Kappa index) 0.669 and the PPV 97.4%. The factor that improved localization of the glands by US in the multivariable analysis was the absence of a concomitant thyroid pathology. The factor that improved the MIBI-PS results was a gland weight greater than 600mg. CONCLUSIONS: US sensitivity improves when there is no concomitant thyroid pathology. MIBI-PS sensitivity improves when the gland weight is greater than 600mg.

[Giant splenic cyst in a teenager girl: Case report]. / Quiste esplénico gigante en una adolescente: Caso clínico.

Giant nonparasitic splenic epidermoid cysts are relatively uncommon. These lesions can lead abdominal pain, but most of then are asymptomatic, and they are discovered incidentally. We report a 13-y old female with a giant splenic epidermoid cystic, given the special interest of diagnostic and therapeutic decision-making of this rare entity. CASE REPORT: A 13-y old female with clinical history of abdominal pain since the last two months. On physical examination a firm, tender mass was palpable in left hypochondrium. Diagnosis of a large cystic splenic mass was made based on ultrasound and abdominal computed tomography scan. Splenectomy was performed, and histopathological-immunohistochemistry studies revealed findings suggestive of primary epithelial cyst. The post-operative clinical course was satisfactory and uneventful. CONCLUSIONS: Treatment of giant nonparasitic splenic cysts is surgical. Preserve splenic parenchyma must be the aim in an individualized decision-making. The different types of surgical modalities will be according to the diagnosis and clinical situation (cyst size, age, comorbidities).

Quiste esplénico gigante en una adolescente: Caso clínico / Giant splenic cyst in a teenager girl: Case report

Los quistes esplénicos gigantes y no parasitarios son infrecuentes. Estas lesiones pueden manifestarse como dolor abdominal, si bien a menudo son asintomáticas y se diagnostican en forma incidental. Objetivo: Presentar el caso de un quiste esplénico epitelial gigante por su interés en la toma de decisiones diagnósticas y terapéuticas, al ser una entidad muy poco frecuente.
 Caso clínico: Paciente de sexo femenino de 13 años de edad que consultó por dolor abdominal de dos meses de evolución. En la exploración física se palpaba una masa de consistencia dura en hemiabdomen izquierdo. En los estudios de imágenes se visualizó una masa esplénica quística gigante. Se realizó esplenectomía obteniendo un quiste subcapsular que comprometía la mayor parte del bazo, el estudio anatomopatológico e inmunohistoquímico fueron compatible con quiste epitelial. La evolución postoperatoria y el posterior seguimiento ambulatorio fueron favorables. Conclusiones: El tratamiento de los quiste esplénicos gigantes no parasitarios es quirúrgico, intentando conservar, en lo posible, la mayor cantidad de tejido esplénico. Este procedimiento debe ser individualizado, considerando el tamaño, las posibilidades diagnósticas, el tejido esplénico residual, la edad del paciente y comorbilidades.

Giant nonparasitic splenic epidermoid cysts are relatively uncommon. These lesions can lead abdominal pain, but most of then are asymptomatic, and they are discovered incidentally. We report a 13-y old female with a giant splenic epidermoid cystic, given the special interest of diagnostic and therapeutic decision-making of this rare entity. Case report: A 13-y old female with clinical history of abdominal pain since the last two months. On physical examination a firm, tender mass was palpable in left hypochondrium. Diagnosis of a large cystic splenic mass was made based on ultrasound and abdominal computed tomography scan. Splenectomy was performed, and histopathological-immunohistochemistry studies revealed findings suggestive of primary epithelial cyst. The post-operative clinical course was satisfactory and uneventful. Conclusions: Treatment of giant nonparasitic splenic cysts is surgical. Preserve splenic parenchyma must be the aim in an individualized decision-making. The different types of surgical modalities will be according to the diagnosis and clinical situation (cyst size, age, comorbidities).

Early and Late Complications in Laparoscopic Gastric Bypass: Comparative Study between Manual and Stapled Anastomosis.

The aim of this study is to evaluate the early and late complications of laparoscopic gastric bypass (GBP) with manual versus stapled gastrojejunal anastomosis. Eighty-two patients with morbid obesity and body mass index (35-56 kg/m2) who underwent GBP were divided into two groups: manual gastrojejunal anastomosis (Group 1) and stapled anastomosis (Group 2). Early and late complications were evaluated. No differences were found between both groups in age, sex, body mass index, American Society of Anesthesia classification, and comorbidity. The mean operative time was 184.8 minutes [standard deviation (SD) = 61]; 203.5 minutes (SD = 51.9) in Group 1 and 167.4 minutes (SD = 64.2) in Group 2 (P = 0.001). The average length of stay was 5.9 days (SD = 3.9) in Group 1 and 5 days (SD = 2.1) in Group 2 (P = 0.039). Early complications were recorded in 9.7 per cent of the cases, without any differences between the two groups: 12.2 per cent in Group 1 and 7.3 per cent in Group 2 (P > 0.05). Late complication rate was 8.5 per cent, significantly higher in Group 1 (14.6%) than in Group 2 (2.4%; P < 0.05). However, in the logistic regression analysis these differences were not statistically significant (OR 0.48; 95% CI 0.03-8.37; P = 0.61). In our series, the GBP with stapled gastrojejunal anastomosis has shown lower hospital length of stay and operative time than the hand-sewn anastomosis. We have not found significant differences between both groups in early complications or in the need for reoperation. Fewer late complications were found in the group of stapled anastomosis; however, this has not been confirmed in the logistic regression analysis.

Conversion of an Open Salmon's Technique to a Laparoscopic Gastric Bypass.

BACKGROUND: There are a growing number of patients who require revisional bariatric surgery due to the failure of their primary procedures. The aim of this video is to present a laparoscopic revisional procedure for dysphagia and gastroesophageal reflux disease (GERD) after an uncommonly performed bariatric surgery, Salmon's technique, consisting of a vertical banded gastroplasty and a horizontal stomach stapling with a Roux-en-Y bypass. METHODS: A 42-year-old obese male, with a history of dyslipidemia and a current body mass index (BMI) of 33, presented with severe dysphagia to solids and frequent spitting 10 years after the primary bariatric surgery (Salmon's procedure) with a BMI of 43. Endoscopy revealed a hiatal hernia. The endoscope passed down without difficulty to the antrum-duodenum and to efferent loop of the small bowel, demonstrating the presence of a fistula in the horizontal stapling of the stomach. Helicobacter pylori was negative. Esophageal transit showed the contrast passing adequately through the esophagogastric junction. Esophageal manometry revealed a hypotensive lower esophageal sphincter (mean pressure of 8 mmHg) and an ineffective peristalsis (40% of waves with normal amplitude and duration). Esophageal pHmetry showed severe GERD with a DeMeester score of 88.5 and a pH less than four, 18.7% of the total time. The patient was on PPIs at the time of symptom evaluation, but stopped the treatment before the performance of the pH study. Laparoscopic conversion to a Roux-en-Y gastric bypass was successfully performed. An extensive adhesiolysis was needed. The esophageal hiatus was dissected and the stomach was partially descended to reduce the hiatal hernia. A subsequent hiatal closure was performed. The efferent loop of the small bowel was freed from the gastric pouch. The new gastric pouch was performed stapling superiorly to the gastric ring and medially to the vertical gastroplasty. The new gastrojejunal anastomosis was performed using a mechanical linear stapler, in an antecolic fashion, and checked for leaks using methylene blue dye. RESULTS: The procedure took 300 min and no intraoperative complications occurred. The patient had an uneventful postoperative course, with a hospital stay of 4 days. One month after the revisional surgery, the patient presented with a stenosis of the gastrojejunal anastomosis, which was successfully solved after two endoscopic dilations. A year and a half after revisional surgery, the patient is completely asymptomatic, has a BMI of 29, and dyslipidemia as the only comorbidity. CONCLUSIONS: Salmon's technique is an uncommon bariatric procedure. Revisional surgery might be needed in case of late complications, like dysphagia and reflux, as it was the case in our patient. In addition, a fistula in the previous horizontal partitioning of the stomach was present. Laparoscopic conversion from Salmon's technique to a gastric bypass was decided. This procedure was successful in solving patient's symptoms and resulted in an increased weight lost. Laparoscopic revisional surgery after an open Salmon's technique is a complex procedure with an increased risk of complications. Our patient developed an anastomotic stenosis 1 month after surgery, probably due to the use of the same gauge as in non-fibrotic tissues.

[Appendicovesical fistula treated with elective laparoscopic surgery]. / Fístula apendicovesical tratada mediante cirugía laparoscópica electiva.

BACKGROUND: appendicovesical fistula is a rare complication of advanced acute appendicitis and represents a rare type of enterovesical fistula. Its symptoms are vague and imprecise and its diagnosis is difficult, requiring a high level of suspicion. Exploratory laparotomy has been the key for diagnosis and definitive treatment for many years, but recently the laparoscopic approach is standing out among different experienced groups as the method of choice. CLINICAL CASE: we report a new case of appendicovesical fistula in a 45 year old female, who was remitted from Urology with symptoms of persistent dysuria and pyuria. She was finally diagnosed by computerized tomography and the appendicovesical fistula was resolved by laparoscopic surgery. This case adds to the one hundred and fifteen cases published so far and to the four treated by the laparoscopic approach. DISCUSSION: conventional imaging methods are not reliable for the diagnosis of enterovesical fistula. Since most appendicovesical fistula are found to be secondary to non-diagnosed and advanced acute appendicitis in the majority of the consulted publications laparotomy is the key for the diagnosis of apendicovesical fistula. However laparoscopy is described as a diagnostic and therapeutic tool in few articles. We only found three articles in the literature referring to the laparoscopic approach as a therapeutic option. CONCLUSION: computerized tomography is the diagnostic method of choice when communication between the digestive tract and urinary tract is suspected, particularly if the suspected fistula is an appendicovesical one. The laparoscopic approach of an appendicovesical fistula is able to confirm the radiological diagnosis and provide a definitive treatment.

Antecedentes: la fístula apendicovesical es una complicación infrecuente de la apendicitis aguda en estadio avanzado y representa un tipo poco habitual de fístula enterovesical. La laparotomía exploradora ha sido durante muchos años pieza clave para el diagnóstico y su tratamiento efinitivo, pero actualmente el abordaje laparoscópico se está imponiendo entre diferentes grupos experimentados. Caso clínico: aportamos un nuevo caso de fístula apendicovesical en una mujer de 45 años de edad remitida del servicio de Urología por disuria y leucocituria permanente; finalmente, el diagnóstico se estableció mediante técnica de imagen (tomografía computada) y se resolvió por laparoscopia. Este caso se suma a los 115 casos descritos hasta ahora en la bibliografía y a los cuatro tratados mediante laparoscopia. Discusión: los métodos de imagen convencionales no son fiables para el diagnóstico de fístula enterovesical. La mayoría de los casos de fístula apendicovesical son secundarios a una apendicitis aguda no evidenciada y evolucionada. En la mayor parte de las publicaciones consultadas la laparotomía es una herramienta de diagnóstico de la fístula apendicovesical y, en pocos artículos, se describe la laparoscopia como alternativa diagnóstica y terapéutica. En la bibliografía sólo se encontraron tres artículos que hacen referencia al abordaje laparoscópico con fines terapéuticos. Conclusión: ante la sospecha de comunicación entre el tubo digestivo y el aparato urinario, la tomografía computada es el método diagnóstico de elección, sobre todo si se sospecha una fístula apendicovesical. El abordaje laparoscópico de la fístula apendicovesical puede confirmar el diagnóstico radiológico a la vez que constituye una opción quirúrgica definitiva.