Selected publications from PubMed
Outcomes of Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass Due to GERD-a Retrospective Analysis of 35 Patients.
Curell A, Beisani M, García Ruiz de Gordejuela A, Vilallonga R, Verdaguer Tremolosa M, González López Ó, Caubet Busquet E, Fort López-Barajas JM
Obes Surg. 2021 Sep;31(9):4100-4106 doi: 10.1007/s11695-021-05541-4.
Resource utilization and outcomes in emergency general surgery during the COVID19 pandemic: An observational cost analysis.
Hessheimer AJ, Trapero-Bertran M, Borin A, Butori E, Curell A, Espinoza AS, Jensen J, Turrado V, Morales X, de Lacy AM, Fondevila C
PLoS One. 2021;16(6):e0252919 doi: 10.1371/journal.pone.0252919.
Decline in general surgery emergencies during COVID-19 pandemic. Has its severity increased? Analysis in a large volume hospital in Europe.
Curell A, Adell M, Cirera A, Vilallonga R, Arranz M, Charco R, Gómez-Gavara C
J Visc Surg. 2021 Feb;158(1):94-95 doi: 10.1016/j.jviscsurg.2020.11.002.
[Decline in general surgery emergencies during COVID-19 pandemic. Has its severity increased? Analysis in a large volume hospital in Europe].
Curell A, Adell M, Cirera A, Vilallonga R, Arranz M, Charco R, Gómez-Gavara C
J Chir Visc. 2021 Feb;158(1):99-100 doi: 10.1016/j.jchirv.2020.10.004.
Use of Topical Antibiotics before Primary Incision Closure to Prevent Surgical Site Infection: A Meta-Analysis.
López-Cano M, Kraft M, Curell A, Puig-Asensio M, Balibrea J, Armengol-Carrasco M, García-Alamino JM
Surg Infect (Larchmt). 2019 May/Jun;20(4):261-270 doi: 10.1089/sur.2018.279.
Obesity is considered to be one of the 21st century epidemics. Bariatric surgery has shown excellent results for weight loss and comorbidity resolution in the long-term. In the case of super obese patients, one of the options is to perform a two-step procedure. First, a restrictive procedure such as a sleeve gastrectomy (SG) will allow the patient to lose weight and improve their comorbidities, thus facilitating the surgical technique and perioperative management in the performance of the second and definitive procedure, usually a malabsorptive technique. In this case, a conversion from SG to single anastomosis duodeno-ileal bypass (SADI-S) was performed on a 49-year-old male with a BMI of 38 Kg/m2. He had undergone a SG 7 years earlier, with an initial weight loss of nearly 50 Kg, and a subsequent weight regain of 25 Kg. He had also undergone a laparoscopic cholecystectomy 3 years before the second-step procedure. He showed no symptoms of GERD. A robotically assisted SADI-S was performed. The surgery was uneventful and took 135 minutes. A hand-sewn two-layer duodeno-ileal anastomosis was made 275 cm previous to the ileocecal valve. The postoperative course was also uneventful, and the patient was discharged on the second day after surgery.
Published
Mar 2022
Obesity is the fastest growing disease worldwide in the last few decades. Among its effects, it increases the risk and mortality of cancer in several organs. In fact, nowadays it is thought that around 20% of all cancers can be attributed to obesity. Several obesity-associated conditions have been positively associated with cancer in the gastrointestinal tract. The adenomatous polyposis coli (APC) gene is a key tumor suppressor gene. Mutations in APC have been found in ∼60% of sporadic carcinomas and adenomas, while germ-line mutations in the APC gene result in familial adenomatous polyposis (FAP). Recent studies published in the literature have examined the promotion of carcinogenesis in the gastrointestinal tract in relation to obesity: hypermethylation of APC promoter 1A, genetic and epigenetic events in APC, hyperinsulinemia and high IGF-1 concentrations in blood due to the increase in visceral fat are key factors in the relation between obesity and carcinogenesis. In this surgical open classroom, we will consider two scenarios regarding surgical considerations. The first one is the diagnosis of FAP in an obese patient in need of elective proctocolectomy, while the second one is when a patient with previous bariatric surgery is diagnosed of FAP or an attenuated form of FAP. In the first case, technical considerations will be analyzed, taking into account the increase in complexity and surgical complications that obese patients who need to undergo a restorative proctocolectomy with ileal pouch-anal anastomosis will be exposed to. Secondly, an analysis of the possible complications that patients with previous bariatric surgeries who have to undergo proctocolectomies due to FAP will be performed, with special focus on patients with previous mixed or malabsorptive techniques with duodenal exclusion.
Published
Nov 2021
Abdominal pain is the most frequent cause of hospital admission after Roux-en-Y gastric bypass (RYGBP). Among the different possible underlying conditions that may cause abdominal pain in bariatric surgery patients, internal hernias represent one of the most peculiar and insidious, as the differential diagnosis is challenging, and the consequences of a delayed treatment may be catastrophic. The construction of the RYGBP leads to the creation of "artificial" defects in the mesentery when the Roux limb ascends from the inframesocolic compartment to the superior compartment to be anastomosed to the gastric pouch. These mesenteric defects include the jejuno-jejunal mesenteric defect, Petersen’s defect (the potential defect between the alimentary Roux limb and the transverse mesocolon), and mesocolic defect (the opening in the transverse mesocolon when retrocolic gastrojejunostomy is created, which appears only in retrocolic RYGBP reconstructions). The risk of internal hernias after RYGBP ranges between 2 and 9%. It remains a major concern because they may result in potentially life-threatening small bowel obstruction, ischemia, and necrosis. They can occur at any time during the postoperative period, but they usually appear late with weight loss and the disappearance of perivisceral fat. The diagnosis of internal hernias is a real challenge: they have a variable clinical presentation and the reliability of diagnostic imaging tests is low. In case of suspicion with a normal CT scan, an urgent diagnostic laparoscopy is mandatory. Studies show that the strategy of closing all mesenteric defects in a continuous fashion using non-absorbable sutures can lead to a low internal hernia rate <1% and low morbidity from internal hernia after RYGBP.
Published
May 2021
In this Surgical Open Classroom we will be reviewing the surgical anatomy of the abdominal wall, in-depth knowledge of which is key when performing hernia surgery. There are several anatomical structures which must bw taken into account. First, regarding the anatomy of the abdominal wall, the most important structures are: transversus abdominal muscle, internal oblique muscle, external oblique muscle and rectus abdominis muscles. Together they form the wall that protects the structures contained in the abdominal cavity. Their points of origin and insertion as well as the relationship between them and with other structures must be taken into account to have a better understanding of the pathology of the abdominal wall. Regarding the anatomy of the inguinal canal, it is around 4 cm long and its direction is descendent and oblique. It has two rings and a conduct. The anatomical characteristics of the inguinal canal will be explained in detail. Two anatomical areas must be considered in order to perform a safe surgery. First, the triangle of Doom or vascular triangle, which contains major vessels: external iliac artery and vein. It is limited by the gonadal vessels and vas deferens in men or the round ligament in women. We also have to be careful with the triangle of pain, which contains the lateral femoral cutaneous nerve, the femoral branch of the genitofemoral nerve and the femoral nerve. Its limits are gonadal vessels and the inguinal ligament.
Published
Apr 2021
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In this SOC we review the general recommendations of both the American and the European Societies’ Guidelines regarding the management of acute colonic diverticulitis. None of the existing classifications for left-sided colonic diverticulitis has proved superiority. The most used one is Hinchey’s modified classification. The World Society of Emergency Surgery (WSES) proposes a new one, which divides acute diverticulitis into uncomplicated and complicated. The European Society of Coloproctology (ESCP) defines diverticulosis and divides diverticular disease into 3 entities: Symptomatic Uncomplicated Diverticular Disease (SUDS), diverticulitis (acute or chronic, complicated or uncomplicated) and diverticular bleeding. Prevalence of diverticulitis is hard to estimate. However, it is clear that is increasing throughout the world, even in younger patients. Its pathogenesis is multifactorial. This disease can sometimes be difficult to differentiate from colorectal cancer. Because of this, it is accepted to make a control colonoscopy in complicated cases. For diagnosis, a Contrast-enhanced CT scan is generally recommended. Ultrasound can also be a correct image test, although it has some limitations. Regarding treatment, uncomplicated diverticulitis can be treated in a conservative way, with antibiotics, or even without using them in non-septic patients. These patients can also be treated as outpatients. Management of abscesses depends on their size; when larger than 4-5cm, percutaneous drainage should be considered. Urgent surgery is performed in patients with generalized sepsis and clinical peritonitis, extraluminal air in imaging tests or free fluid. When there is fecal peritonitis, surgical resection must be performed. When peritonitis is purulent, laparoscopic lavage can be an option, although this is still a matter of controversy. There are no significant differences regarding morbimortality between Hartmann’s procedure and primary anastomosis. Elective surgery is only justified to improve quality of life or if there are persistent abscesses or fistulas. There is no evidence of differences between laparoscopic and open surgery. If the source control has been adequate, a 4-day postoperative antibiotic therapy is recommended.
Published
Apr 2021
Mortality during the first year after bariatric surgery has decreased in recent years due to multiple factors, such as the laparoscopic approach, the specific training programs of the different scientific societies and the advances in the perioperative management of these patients. In the short term, the complexity of bariatric techniques and the risk factors of morbidly obese patients cause postoperative emergencies that require early diagnosis and immediate treatment to avoid fatal consequences. In general, a high level of suspicion should be maintained to identify and diagnose these complications, as there is a great discordance between the scarce clinical symptomatology and the severity they usually entail. There are multiple symptoms that can raise an alarm to the clinician: dyspnea and tachypnea, hiccups, fever, bladder spasms… The most important alarm sign when assessing morbidly obese patients after surgery is tachycardia (>100bpm). Anastomotic/staple line leaks – One of the most feared complications of bariatric surgeons: highest RR of multiorgan failure, admission to the intensive care unit, reoperation and readmission – Incidence: 0.1-8.3% after RYGBP; 0-7% after SG – Causes: mechanical or ischemic – Remember that most leaks occur after the patient is discharged from the hospital – Diagnostic test of choice: CT with oral contrast – Management: surgery (peritoneal cavity lavage, drainage placement, primary repair if possible) + allowing enteral nutrition (+ endoscopy in selected cases) Hemorrhagic complications – More frequent in gastric bypass (0.6-4%) – Most cases management is conservative 🡪 diagnostic and/or therapeutic endoscopy – Obese patients are especially sensitive to hypovolemia and also have low baseline hemoglobin levels due to iron deficiency, so the therapeutic response must be rapid – Extraluminal vs endoluminal bleeding (easy vs difficult endoscopic access) – Management: first = resuscitative measures. Consider need of urgent surgical reintervention (alarm signs, drop in hematocrit, first 6h) or endoscopic treatment (late bleedings, persistent or rebleeding) Complications of the abdominal wall – Laparoscopic approach on bariatric surgery has drastically reduced the incidence of incisional hernia (0,5%) – Herniation can be acute in the first hours after surgery as a consequence of abdominal hyperpressure (coughing, vomiting) or several years later – Port hernia, especially in cases debuting in the first postoperative hours, requires urgent surgical revision Surgical site infection – Superficial vs deep infections – Favored by the excess of subcutaneous adipose tissue – Difficult to make an early diagnosis – Depends on surgical technique: ↑surgeries involving circular anastomosis and those that require implantable devices – Management: correct debridement and local cures (may require drainage, negative pressure devices or ATB) Pulmonary thromboembolism – Prevalence: 0.3-2.4% of deep vein thrombosis (DVT); 0.15-0.3% of pulmonary thromboembolism (PTE) – PTE is the main cause of medical mortality after bariatric surgery – Currently insufficient scientific evidence of sufficient quality to establish clear guidelines with a high level of recommendation – Gold standard for the diagnosis of PTE: pulmonary angio-CT scan
Published
Feb 2021
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