Transumbilical sleeve gastrectomy with an accessory lateral port: surgical results in 237 patients and 1-year follow-up.

BACKGROUND: The transumbilical approach has recently been shown to be safe for several surgical procedures. Case series of sleeve gastrectomy (SG) with a transumbilical approach (TUSG) has been reported with various techniques. The objective of this report is to present the technique, surgical results, and 1-year follow-up results of simplified TUSG using rigid instruments. METHODS: All of the patients who had undergone SG since July 2010 were offered a transumbilical approach. The operative technique involves a transumbilical incision and the introduction of a SILS® or GelPoint® multiport and a 5-mm metallic accessory trocar laterally in the left flank. Rigid instruments were used in all patients. Gastric transection was made 4-5 cm proximal to the pylorus, calibrated with a 36-Fr bougie. Selected hemostasis to the staple line was achieved with metallic clips. RESULTS: A total of 237 patients underwent TUSG. Patient body mass index ranged from 30 to 46 kg/m(2). The mean operative time was 49.5 ± 14.9 min. Six patients presented with early complications, including hemoperitoneum in three cases, antral leak in one case, intestinal perforation in one case, and portal vein thrombosis in one case. Conversion to the multitrocar technique was required in one patient. There were no mortalities. The mean length of hospital stay was 2.2 ± 1 days. The cosmetic result was satisfactory for all of the patients. CONCLUSIONS: TUSG is a safe and feasible procedure using the described technique. The insertion of a 5-mm assistance trocar simplifies the procedure, allowing the use of rigid instruments.

Utility of transesophageal echocardiography during severe hypotension in non-cardiac surgery.

BACKGROUND AND OBJECTIVES: Severe and refractory hypotension is an infrequent perioperative situation during non-cardiac surgery, but determining its etiology is essential for successful management and therapy. METHODS: Adults undergoing non-cardiac surgery were prospectively enrolled in this study. Severe hypotension was defined as a drop from 30% of baseline systolic arterial pressure unresponsive to adequate fluids administration and to ephedrine, according to the anasthesiologist criteria. A multiplanar transesophageal echocardiography (TEE) probe was inserted, prior to any other invasive hemodynamic monitor. RESULTS: Forty two adults (68 ± 12 years) were studied, 84% during elective non-cardiac surgery. Abdominal (open and laparoscopic), thoracic and orthopaedic surgeries were performed most frequently. In all patients, TEE was useful for determining the etiology of severe hypotension. Hypovolemia was diagnosed in 18 patients (42%). Low ejection fraction (EF < 30%) was detected in 5 cases and was successfully treated with vasoactive drugs. Dynamic left ventricular outflow tract obstruction, associated with systolic anterior motion of the mitral valve, was diagnosed in 5 patients; in another 6 patients severe embolism was detected during hip and knee surgery. Myocardial ischemia causing persistent hypotension was detected in 5 patients; in 3 patients, cardiac tamponade was the etiology of severe hypotension. Two patients died; both had severe myocardial ischemia. CONCLUSIONS: Perioperative TEE was performed quickly, proving to be a useful technique in the context of hypotension during non-cardiac surgery. The heart and great vessels could be observed directly and functionally evaluated. Thus, the etiology of severe hypotension could be easily determined and managed.

Analgesic effects of a single preoperative dose of pregabalin after laparoscopic sleeve gastrectomy.

BACKGROUND: The treatment of pain in obese patients is always a challenge. These patients have low pain thresholds, and the use of opioids can be especially harmful. Intraoperative nervous fiber section and the high temperatures of electrical scalpels probably contribute to the generation of postoperative neuropathic pain. We hypothesized that an antineuropathic pain drug like pregabalin could be helpful to optimize postoperative analgesia by reducing the requirement for opioids and their associated side effects. METHODS: Eighty adults undergoing laparoscopic sleeve gastrectomy were randomly assigned to orally receive either placebo capsules (control) or pregabalin (150 mg) 2 h before surgery. Postoperative morphine consumption during the first 24 postoperative hours was registered. Visual analog pain scores (VAS) were assessed at 1, 2, 4, 6, 8, 12, 16, and 24 h after surgery. Both the incidence of adverse reactions and patient satisfaction were also assessed. RESULTS: Over a 24-h period, the morphine consumption in the pregabalin group was 11.51 ± 7.93 mg, whereas in the control group, it was 23.07 ± 9.57 mg (p < 0.0001). VAS scores were significantly lower in the pregabalin group. Postoperative nausea and vomiting and the consumption of antiemetics were reduced in the pregabalin group. CONCLUSIONS: A single preoperative oral dose of 150 mg pregabalin is useful for reducing morphine consumption after a sleeve gastrectomy, and it guarantees effective and safe analgesia with a low incidence of adverse effects.

Anestesia en cirugía laparoscópica / Anesthesia in laparoscopic surgery

Se revisa la técnica anestésica en cirugía laparoscópica, comentando detalles, particularmente en relación a la utilización de neumoperitoneo, a la posición y sus repercusiones fisiológicas. Se detalla la técnica de anestesia de uso más habitual en nuestro Hospital. Se concluye que no siendo una técnica que requiere de una especialización particular, se acompaña de algunas alteraciones que obligan a vigilancia estrecha y monitorización especial