Diaphragmatic hernia after radiofrequency ablation of liver metastases: a case report and review of the literature.

A diaphragmatic hernia is the protrusion of abdominal tissues into the thoracic cavity secondary to a defect in the diaphragm. Reviewing the literature, we found only 44 references to diaphragmatic hernia secondary to percutaneous radiofrequency treatment. The vast majority of these cases were secondary to the treatment of hepatocellular carcinoma in segments V and VIII. Nevertheless, to date, this is the first reported case of diaphragmatic hernia after radiofrequency ablation of a liver metastasis from colorectal cancer. Complications secondary to diaphragmatic hernias are very diverse. The principal risk factor for complications is the contents of the hernia; when small bowel or colon segments protrude in the thoracic cavity, they can become incarcerated. Asymptomatic cases have also been reported in which the diaphragmatic hernia was discovered during follow-up. The pathophysiological mechanism is not totally clear, but it is thought that these diaphragmatic hernias might be caused by locoregional thermal damage. Given that most communications correspond to asymptomatic and/or treated cases, it is likely that the incidence is underestimated. However, due to the advent of percutaneous treatments, this complication might be reported more often in the future. Most cases are treated with primary herniorrhaphy, done with a laparoscopic or open approach at the surgeon's discretion; no evidence supports the use of one approach over the other. Nevertheless, it seems clear that surgery is the only definitive treatment, as well as the treatment of choice if complications develop. However, in asymptomatic patients in whom a diaphragmatic hernia is discovered in follow-up imaging studies, management should probably be guided by the patient's overall condition, taking into account the potential risks of complications (contents, diameter of the opening into the thoracic cavity …).

Hernia diafragmática tras radiofrecuencia de metástasis hepática. Reporte de caso clínico y revisión de la literatura / Diaphragmatic hernia after radiofrequency ablation of liver metastases: a case report and review of the literature

La hernia diafragmática (HD) es la protrusión de los tejidos abdominales a la cavidad torácica secundaria a un defecto en el diafragma. Tras una revisión de la bibliografía, únicamente se han identificado 44 referencias al respecto, donde se describen 35 casos de HD secundarias a tratamientos percutáneos con radiofrecuencia (RF). En su gran mayoría son secundarias a lesiones por carcinoma hepatocelular en los segmentos V y VIII. No obstante, hasta la fecha, este es el primer caso comunicado de HD tras RF para el tratamiento de una metástasis hepática por carcinoma colorrectal. Las complicaciones secundarias a las HD son muy diversas. El principal factor de riesgo para ello es su contenido; así se describen casos incarceración de colon e intestino delgado. Igualmente, se describen casos asintomáticos en los que la HD ha sido un hallazgo en el seguimiento de los pacientes. El mecanismo fisiopatológico no está del todo esclarecido, pero se especula con la posibilidad de un daño térmico locorregional. Dado que la mayoría de las comunicaciones corresponden a casos sintomáticos y/o tratados, probablemente la incidencia esté infraestimada. No obstante, debido al advenimiento de los tratamientos percutáneos, esta complicación podría verse comunicada en mayor número en los próximos años. Respecto a los tratamientos descritos, en la mayoría de los casos se ha optado por una herniorrafia primaria, con una vía de abordaje abierta o laparoscópica a discreción del cirujano. No se dispone de evidencia que apoye ninguna actitud al respecto, si bien parece claro que el tratamiento quirúrgico es el único definitivo y el de elección en caso de complicación. Sin embargo, en pacientes asintomáticos en quienes la HD sea un hallazgo radiológico de control, el manejo quizá deba guiarse por el estado general del paciente, así como los riesgos potenciales de complicación (contenido, diámetro del orificio herniario…). (AU)

A diaphragmatic hernia is the protrusion of abdominal tissues into the thoracic cavity secondary to a defect in the diaphragm. Reviewing the literature, we found only 44 references to diaphragmatic hernia secondary to percutaneous radiofrequency treatment. The vast majority of these cases were secondary to the treatment of hepatocellular carcinoma in segments V and VIII. Nevertheless, to date, this is the first reported case of diaphragmatic hernia after radiofrequency ablation of a liver metastasis from colorectal cancer. Complications secondary to diaphragmatic hernias are very diverse. The principal risk factor for complications is the contents of the hernia; when small bowel or colon segments protrude in the thoracic cavity, they can become incarcerated. Asymptomatic cases have also been reported in which the diaphragmatic hernia was discovered during follow-up. The pathophysiological mechanism is not totally clear, but it is thought that these diaphragmatic hernias might be caused by locoregional thermal damage. Given that most communications correspond to asymptomatic and/or treated cases, it is likely that the incidence is underestimated. However, due to the advent of percutaneous treatments, this complication might be reported more often in the future. Most cases are treated with primary herniorrhaphy, done with a laparoscopic or open approach at the surgeon's discretion; no evidence supports the use of one approach over the other. Nevertheless, it seems clear that surgery is the only definitive treatment, as well as the treatment of choice if complications develop. However, in asymptomatic patients in whom a diaphragmatic hernia is discovered in follow-up imaging studies, management should probably be guided by the patient's overall condition, taking into account the potential risks of complications (contents, diameter of the opening into the thoracic cavity …). (AU)

Tratamiento de las hipoglucemias graves tras bypass gástrico con pancreatectomía subtotal: a propósito de 2 casos / Case report subtotal pancreatectomy as treatment for severe hypoglycemia after gastric bypass

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Circulating free testosterone in obese men after bariatric surgery increases in parallel with insulin sensitivity.

BACKGROUND AND AIM: Male hypogonadism has been linked to obesity and diabetes. We aimed to study the association of changes in insulin sensitivity and testosterone levels in severe obese patients submitted to bariatric surgery. SUBJECTS AND METHODS: Prospective intervention study with twenty consecutive patients who underwent bariatric surgery studied before and after significant weight loss. Serum testosterone, SHBG, fasting glucose, and insulin were measured among others. Free testosterone was calculated with the Vermeulen formula and insulin sensitivity with the homeostatic model assessment (HOMA). RESULTS: At baseline, thirteen patients had low total testosterone levels, whereas eight of these patients also had free testosterone levels below the reference range obtained from the control group. After bariatric surgery total testosterone, SHBG, and free testosterone significantly increased and achieved normal values in all evaluated patients. Insulin sensitivity improved in all of them. Multivariate linear regression showed that changes in fasting glucose (ß=-1.868, p=0.001), insulin (ß=-3.782, p=0.001), weight (ß=-0.622, p=0.002), and SHBG (ß=-0.635, p=0.022) were associated with changes in free testosterone (adjusted R2=0.936, F=26.613, p=0.001). When insulin resistance calculated by HOMA was in the model instead of insulin and glucose, it also was associated (ß=-3.488, p=0.008) with free testosterone (adjusted R2=0.821, F=11.111, p=0.005). CONCLUSIONS: Circulating tes tos terone in obese men increases after bariatric surgery in parallel with an improvement in insulin sensitivity.

Portal vein arterialization in liver transplantation: an option to restore arterial flow: a case report.

We report a 66-year-old woman who underwent emergency orthotopic liver transplantation due to acute liver failure. The donor's liver graft displayed extensive arteriosclerosis, involving the celiac trunk and hepatic artery. Arterial revascularization of the graft could not be achieved, requiring an arterioportal shunt between the gastroduodenal artery and the portal vein of the recipient. During the early postoperative period, the patient's clinical condition and liver function tests improved rapidly; the patient was discharged on postoperative day 30. Two months later, she developed acute cholangitis. Ischemic-type stenosis of the intrahepatic biliary tree was present, so successful elective retransplantation was undertaken at the ninth postoperative month. In our experience, portal vein arterialization may be useful as a bridging therapy in extreme situations.

Role of calcium malabsorption in the development of secondary hyperparathyroidism after biliopancreatic diversion.

Secondary hyperparathyroidism (SH) is a frequent metabolic complication of bariatric surgery. Around 70%of patients who undergo biliopancreatic diversion (BPD) have this complication in the long term. The aim of this study was to evaluate the relative influence of vitamin D deficiency and calcium malabsorption in the development of SH in patients who underwent BPD. We reviewed the mean values of PTH throughout the post-operative follow-up and of related biochemical data (25-hydroxyvitamin D, calcium, magnesium) of 121 patients who underwent BPD at our institute from November 1996 to November 2004 (mean follow-up 66 months). Mean PTH correlated negatively with mean 25-hydroxyvitamin D (r=-0.27, p=0.003) and with urinary calcium(r=-0.19, p=0.047), and positively with age (r=0.22, p=0.018). However, a high mean PTH was found in 48.7% patients with mean 25-hydroxyvitamin D >or=30 ng/ml and in 80.0% patients with mean 25-hydroxyvitamin D between 20 and 30 ng/ml. The mean PTH was normal in 5 patients without calcium supplements at present, and progressively increased in parallel to the calcium dose in the rest of patients, although mean 25-hydroxyvitamin D levels were not related to the calcium dose. Our data suggest that individual differences in active and/or passive calcium absorption determine intractable SH after BPD in around half of the patients who have normal levels of 25-hydroxyvitamin D and in 80% of patients with 25-hydroxyvitamin D levels between 20 and 30 ng/ml after BPD, worsening with age.

[Hepatic hydatidosis. Radical vs. conservative surgery: 22 years of experience]. / Hidatidosis hepática. Cirugía radical vs. no radical: 22 años de experiencia.

OBJECTIVES: the incidence of hepatic hydatidosis has remarkably decreased in the last years due to the preventive measures adopted to stop the transmission of the parasite. However, surgery carries on being the treatment of choice, although the surgical procedure is still a matter of controversy. The aim of the study was to evaluate the results obtained with the treatment of this condition after two decades according to surgical procedure type. MATERIAL AND METHODS: from 1983 to 2005, 372 patients were operated on for hepatic hydatidic cyst in Hospital Ramón y Cajal. Radical surgery was performed for 162 (43.5%) and conservative surgery for 210 (56.5%). RESULTS: average postoperative hospital stay (8.65 vs. 14.9 days), morbidity (13.3 vs. 31.4%, p < 0.001), and mortality (0 vs. 3.8%, p < 0.01) were lower in the radical surgery group. Recurrence rate was 1.85% after radical surgery versus 11.9% in the conservative surgery group (p < 0.0001). CONCLUSION: radical surgery is associated with lower morbidity, mortality, postoperative hospital stay, and recurrence rates, and represents the treatment of choice for hepatic hydatidosis. However, its indication must depend on the patient characteristics, cyst anatomy, and surgical team experience.

Hidatidosis hepática. Cirugía radical vs. no radical: 22 años de experiencia / No disponible

Introducción: la incidencia de la hidatidosis hepática ha disminuidonotablemente en los últimos años gracias a las medidasde prevención adoptadas para interrumpir la transmisión del parásito.Con todo, la cirugía continúa siendo el tratamiento de elección,si bien su modalidad es todavía motivo de controversia.Objetivos: el objetivo de este trabajo es evaluar los resultadosobtenidos en el tratamiento de esta patología a lo largo de más dedos décadas, atendiendo a la modalidad quirúrgica empleada yafuese cirugía radical o no radical.Material y métodos: se analizaron un total de 372 pacientesintervenidos por quiste hepático hidatídico (QHH) entre 1983-2005 en el Hospital Ramón y Cajal. En162 se efectúa una cirugíaradical (43,5%) y en 210 una no radical (56,5%).Resultados: tanto la estancia media hospitalaria (8,65 días vs.14,9 días) como la morbilidad (13,3 vs. 31,4 %, p < 0,001) y lamortalidad (0 vs. 3,8%, p < 0,01) fueron menores en el grupo decirugía radical. La tasa de recidiva fue del 1,85% tras un abordajeradical frente al 11,9% en los abordajes no radicales (p < 0,0001).Conclusión: la cirugía radical se asocia con una menor morbimortalidad,menor estancia hospitalaria y menor recidiva, constituyendola técnica de elección en la hidatidosis hepática. Sin embargo,su aplicación debe atenerse a las características delpaciente, la anatomía del quiste y el grado de experiencia del equipoquirúrgico

Objectives: the incidence of hepatic hydatidosis has remarkablydecreased in the last years due to the preventive measuresadopted to stop the transmission of the parasite. However, surgerycarries on being the treatment of choice, although the surgical procedureis still a matter of controversy. The aim of the study was toevaluate the results obtained with the treatment of this conditionafter two decades according to surgical procedure type.Material and methods: from 1983 to 2005, 372 patientswere operated on for hepatic hydatidic cyst in Hospital Ramón yCajal. Radical surgery was performed for 162 (43.5%) and conservativesurgery for 210 (56.5%).Results: average postoperative hospital stay (8.65 vs. 14.9days), morbidity (13.3 vs. 31.4%, p < 0.001), and mortality (0 vs.3.8%, p < 0.01) were lower in the radical surgery group. Recurrencerate was 1.85% after radical surgery versus 11.9% in theconservative surgery group (p < 0.0001).Conclusion: radical surgery is associated with lower morbidity,mortality, postoperative hospital stay, and recurrence rates,and represents the treatment of choice for hepatic hydatidosis.However, its indication must depend on the patient characteristics,cyst anatomy, and surgical team experience

[Nutritional effect of bariatric surgery with Scopinaro operation. Analysis of 40 cases]. / Repercusión nutricional de la cirugía bariátrica según técnica de Scopinaro: análisis de 40 casos.

OBJECTIVES: To analyze the influence of bariatric surgery over nutritional status in patients with morbid obesity after 1 year of following. To know the influence of specific factors as age, sex and common channel's length. DESIGN: Retrospective study from 1998-2001. SUBJECT: All patients suffering from morbid obesity that had been operated during this period of time, 40 subjects: 28 women and 12 men with a mean age of 38 +/- 12 years old. Were studied. METHODS: We analyzed the variations of weight and other anthropometric measures, biochemical parameters and the micronutrient (vitamins A, D, E, B12, folate, C, zinc, Calcium, Magnesium) status during 1 year of following after surgery. RESULTS: Percentage weight loss was 29.7 +/- 2.9% without sex differences. A significant (p < 0.005) descent of serum cholesterol, triglycerides, and uric acid level as well as liver function markers was observed. All the hyperglycemic disturbances were reverted. 97% and 48% of the patients developed hypovitaminosis A and D respectively, that was correlated to steatorrhea. Vitamin E deficiency was found in 72% of the patients, and zinc deficiency in 68% CONCLUSIONS: Our expected weight loss 1 year after bariatric surgery is 30%, irrespective of sex and age. This loss is accompanied by a significant improvement in metabolic parameters, but the high prevalence of micronutrients deficiency that was found makes an early supplementation and close follow-in of these patients very advisable.

Repercusión nutricional de la cirugía bariátrica según técnica de Scopinaro: análisis de 40 casos / Nutritional effect of bariatric surgery with scopinaro operation: analysis of 40 cases

Objetivos: Analizar la repercusión de la cirugía bariátrica sobre los valores de antropometría absoluta y relativa, parámetros bioquímicos y niveles vitamínicos tras un año de seguimiento y estudiar la posible influencia del sexo, la longitud del canal común y el grado de esteatorrea en estos pacientes. Material y métodos: Se estudiaron retrospectivamente 40 pacientes (28 mujeres y 12 varones) de edad media de 38 ñ 12 años (18-62) a los que se les practicó derivación biliopancreática según técnica de Scopinaro dejando 70120 cm de canal común y seguidos durante el año posterior a la realización de esta cirugía. Se procedió a control de parámetros antropométricos: índice de masa corporal (IMC), cincunferencia cintura cadera (CC); parámetros bioquímicos: glucosa, ácido úrico, lípidos plasmáticos, proteínas de vida media corta, transaminasas y hemograma; niveles de vitaminas A, E, D, B12, C y ácido fólico y el grado de esteatorrea, que se realizaron antes y un año después de la cirugía. Resultados: Se logró una pérdida de peso del 29,7 por ciento ñ 2,9 sin diferencia entre ambos sexos. En cuanto a los parámetros bioquímicos se constató una reducción estadísticamente significativa en las cifras de colesterol total, triglicéridos, ácido úrico y transaminasas (p < 0,005). Asimismo, se logró la corrección de las alteraciones del metabolismo hidrocarbonato en todos los pacientes. Todos los pacientes presentaron esteatorrea, lo que se correlacionó con déficit de vitamina D (p < 0,005) y A (p = 0,07). También se objetivaron descenso en los niveles zinc, magnesio y fósforo. Conclusiones: Con nuestra técnica la pérdida porcentual esperada de peso al año es de un 30 por ciento sin influencia del sexo ni la edad, lo que se acompaña de una mejoría metabólica significativa. La longitud del canal común influye en la esteatorrea y la pérdida absoluta de peso, condicionando un importante descenso de los niveles de zinc plasmáticos. El porcentaje de pacientes que presentan niveles deficitarios de vitaminas liposolubles es muy elevado, sugiriendo la necesidad de tratamiento suplementario desde el inicio. Esta precaución debería ser mayor en los pacientes que presentan un mayor grado de esteatorrea (AU)

Objectives: To analyze the influence of bariatric surgery over nutritional status in patients with morbid obesity after 1 year of following. To know the influence of specific factors as age, sex and common channel´s length. Design: Retrospective study from 1998-2001. Subject: All patients suffering from morbid obesity that had been operated during this period of time, 40 subjects: 28 women and 12 men with a mean age of 38 ± 12 years old. Were studied. Methods: We analyzed the variations of weight and other anthropometric measures, biochemical parameters and the micronutrient (vitamins A, D, E, B12, folate, C, zinc, Calcium, Magnesium) status during 1 year of following after surgery. Results: Percentage weight loss was 29.7 ± 2.9% without sex differences. A significant (p < 0.005) descent of serum cholesterol, triglycerides, and uric acid level as well as liver function markers was observed. All the hyperglycemic disturbances were reverted. 97% and 48% of the patients developped hypovitaminosis A and D respectively, that was correlated to steatorrhea. Vitamin E deficiency was found in 72% of the patients, and zinc deficiency in 68%. Conclusions: Our expected weight loss 1 year after bariatric surgery is 30%, irrespective of sex and age. This loss is accompanied by a significant improvement in metabolic parameters, but the high prevalence of micronutrients deficiency that was found makes an early supplementation and close follow-in of these patients very advisable (AU)

Docencia en cirugía litiásica biliar en la era laparoscópica / Teaching surgical management of cholelithiasis in the laparoscopic era

Objetivo. Analizar el impacto y la forma de incorporación de la cirugía laparoscópica en la docencia de la cirugía litiásica biliar en los médicos residentes. Pacientes y método. Se han incluido en este estudio 219 pacientes intervenidos en nuestro servicio entre 1995 y 1996 con el diagnóstico de litiasis biliar con o sin coledocolitiasis acompañante como único diagnóstico. De estos pacientes, 123 fueron intervenidos por médicos de plantilla y 96 por médicos residentes, efectuando estos últimos 48 colecistectomías laparoscópicas. Resultados. No se han producido diferencias significativas entre ambos grupos establecidos (médicos de plantilla frente a residentes) en estudios preoperatorios, enfermedad acompañante, indicación quirúrgica, tiempo de ingreso, morbimortalidad e índice de reconversión de cirugía laparoscópica a abierta. Conclusiones. Es posible incorporar la docencia laparoscópica, en el momento actual, al programa de la especialidad de cirugía general y del aparato digestivo, tal como se ha realizado en el Hospital Ramón y Cajal, utilizando el mismo sistema de responsabilidad progresiva que en el resto de técnicas quirúrgicas. No hemos apreciado una curva de aprendizaje significativa en los residentes cuando están adecuadamente formados y se incorporan de manera progresiva a la técnica laparoscópica (AU)

[Excision of esophageal leiomyoma using videothoracoscopy]. / Extirpación de leiomioma esofágico mediante videotoracoscopia.

We report the case of a 57 years old male patient presenting with pyrosis and dysphagia. A mid-third esophageal leiomyoma was diagnosed. The tumour was resected through a right video-thoracoscopic approach and simultaneous intraoperative esophagoscopy was performed. The postoperative course was uneventful and six months after surgery neither relapsing symptoms nor radiologic pathological findings were observed. We consider that symptomatic leiomyoma is a good indication for video-assisted thoracoscopic enucleation. The possible postoperative complications (esophageal fistula, esophageal pseudodiverticulum) may be minimized by means of an adequate surgical technique.