Dr. Dulce Momblán is a renowned digestive surgeon in Barcelona with two decades of professional experience. Currently, she is part of the medical staff of Barnaclínic +, where she is an expert in robotic surgery, laparoscopic surgery, esophageal and stomach cancer surgery, achalasia, hiatal hernia, gastroesophageal reflux, obesity surgery, intestinal surgery, inflammatory bowel disease and colon and rectal surgery, among others. With a degree in Medicine and Surgery from the University of Barcelona, she specialized in General and Digestive System Surgery through her MIR residency, which she completed at the Hospital Clinic of Barcelona, to which she is still linked today, as head of the Gastrointestinal Surgery Department. Annually, she performs more than 120 surgeries, most of which are highly complex surgeries. In addition, Dr. Dulce Momblán combines her work with teaching and research, being associate professor at the University of Barcelona and tutor of resident students at the Hospital Clinc. In turn, she has more than 40 scientific publications, and participates regularly in scientific meetings of the specialty.
Selected publications from PubMed
Predictive value of QoR-15 scores at hospital discharge for unplanned healthcare utilization after elective surgery: A prospective observational study.
Dana F, Sebio-García R, González-Colom R, Tena B, Capitan D, Momblan D, Campero B, García E, Rivas E, Zabalegui A, Martínez-Pallí G, Hospital Clinic of Barcelona Prehabilitation Group (+)
Am J Surg. 2026 Jun 17;:117103 doi: 10.1016/j.amjsurg.2026.117103.
A real-life analysis on the indications and prognostic relevance of perioperative chemotherapy in locally advanced resectable gastric adenocarcinoma.
Pardo F, Osorio J, Miranda C, Castro S, Miró M, Luna A, Garsot E, Momblán D, Galofré G, Rodríguez-Santiago J, Pera M, Spanish EURECCA Oesophago-Gastric Cancer Group
Clin Transl Oncol. 2020 Aug;22(8):1335-1344 doi: 10.1007/s12094-019-02261-1.
The stomach is located in the upper left quadrant of the abdomen. Its anterior aspect is related to the left hepatic lobe, diaphragm, transverse colon and greater omentum. Its posterior face is related to the pancreas, spleen and splenic artery, adrenal gland, left kidney and diaphragm. AnteriorPosteriorLeft hepatic lobePancreasDiaphragmSpleenTransverse colonLeft adrenal glandGreater omentumLeft kidney It has an irregular shape with two curvatures: lesser curvature (right side) and greater curvature (left side). The greater omentum is inserted on the greater curvature. Parts of the stomach · Cardias: is the most proximal part of the stomach, adjacent to the lower esophageal sphincter. · Fundus: is the part of the stomach that is above the esophagogastric junction. · Body: between the fundus and the antrum. · Antrum: most distal part of the stomach, its limit in the lesser curvature is the incisura angularis. · Pylorus: is a sphincter that divides the stomach from the duodenum. The stomach wall is composed of four layers: serosa, muscle layer, submucosa and mucosa. Vascularization The arterial vascularization to the stomach is based on the celiac trunk with three main supplies: the left gastric artery (coronary), the hepatic artery and the splenic artery. The left gastric artery, located in the lesser curvature, has anastomosis with the pyloric artery (branch of the hepatic artery) and it can give rise to a branch that transverses the lesser omentum and irrigates the left hepatic lobe. The greater curvature is irrigated by the right and left gastroepiploic arteries, being the former a branch of the hepatic artery and the latter a branch of the splenic artery. Venous drainage The venous web is parallel to the arterial web and drains in it majority to the portal vein although in the gastroesophageal junction the drainage may be to the vena cava through diaphragmatic veins. Lymphatic drainage The lymphatic drainage is originated in the deepest sector of the mucosa to create a web of interweaved in the submucosal layer and in the subserosa. There are three major drainage areas: hepatic, left gastric and splenic. Lymph nodes are divided into groups according to the Japanese classification: GroupLocation1Right paracardial2Left paracardial3Lesser curvaturel4Greater curvature5Suprapyloric6Infrapyloric7Left gastric artery8Common hepatic artery9Celiac trunk10Splenic hilium11Splenic artery12Hepatic hilium13Posterior duodenopancreas14Superior mesenteric artery15Middle colic artery16Paraaortic Type of gastrectomyD1 lymphadenectomyD2 lymphadenectomyTotal1 to 6D1 + 7, 8, 9, 10*, 11, 12Distal1, 3, 4, 5, 6D1 + 7, 8, 9, 10*, 11, 12 10* the performance of the lymphadenectomy of group 10 is discretional and requires a splenectomy. Gastric innervation Gastric nerve supply is both sympathetic and parasympathetic. The sympathetic innervation follows the arterial supply. The parasympathetic innervation arrives to the stomach from the vagal nerves. The left vagal nerve or anterior is not always a single trunk and can be divided into three branches; immediately before the cardias it sends small branches to the fundus and through the lesser omentum it sends branches to the liver, gallbladder, pylorus and duodenum. It gives rise to the nerve of Latarjet, parallel to the lesser curvature and that ends in the “crows fool” at the level of the incisura angularis. The posterior or right vagal nerve is usually a single trunk. Near the cardias it gives rise to a posterior and left branch called the “criminal nerve of Grassi”. The posterior Latarjet nerve descends the lesser curvature.
Published
Aug 2020
Surgical resection remains the most important curative treatment modality for non metastatic esophageal cancer. Historically, two approaches to esophagectomy have coexisted: the transhiatal esophagectomy (THE) and the transthoracic esophagectomy (TTE). The mortality rate in the open era ranged between 3 and 10% and the 5-year-survival rate was 20-30%. Recent years have seen an improvement in the outcomes due to several facts, such as improved patient care and selection with improvement in perioperative care, neoadjuvant treatments and centralization of surgery in high-volume centres. Minimally invasive esophagectomy (MIE) was developed in the 1990s and was popularized in the last decade. Several meta-analyses support the following concepts: Minimally invasive esophagectomy is associated with fewer respiratory complications. MIE is associated with a reduction in morbidity. MIE is associated with faster postoperative recovery. Nonetheless, MIE is technically demanding and programs to introduce the technique are needed. Two classic trials, the TIME-trial (comparing thoraco-laparoscopic vs open esophagectomy) and the MIRO-trial (laparoscopic + thoracotomy vs open esophagectomy) have shown that MIE is associated with: Less blood loss. Lower rate of respiratory infection. Shorter hospital stay. Better quality of life. The quality of the specimen seems comparable between open and MIE techniques in radicality and number of lymph nodes. Long term oncological outcomes (from the TIME-trial) showed no differences at 1-year and 3-years. OPEN APPROACH Transthoracic esophagectomy The distal esophagus and its locoregional lymph nodes in the posterior mediastinum are dissected through an upper abdominal incision. The upper abdominal lymph nodes (including paracardial, lesser curvature and left gastric artery) are dissected and a D1+ or D2 lymphadenectomy is performed. Via a left cervical incision, the cervical esophagus is dissected and the intrathoracic esophagus is dissected bluntly and stripped. A gastric tube is made and positioned in the prevertebral plane to create an anastomosis in the neck. Transthoracic esophagectomy There are several techniques using a transthoracic esophagectomy: Ivor-Lewis: right thoracotomy and laparotomy. McKeown: three stage with neck incision. Sweet: left thoraco-abdominal incision. Both three and two stage esophagectomies involve esophageal resection, creation of a gastric tube, two field lymphadenectomy (celiac trunk and mediastinum) and a cervical anastomosis in three stage esophagectomy and intrathoracic anastomosis in Ivor-Lewis. Differences between approaches The HIVES trial comparing TTE with THE showed no differences regarding in-hospital mortality but higher postoperative complications in the TTE group (pulmonary complications and chyle leakage) with longer postoperative hospital stay. Although there was not a statistically significant difference in 5-year survival, it was 29% in the THE group and 39% in the TTE group. Nonetheless,when the tumor was located in the distal esophagus rather than the esophagogastric junction, an absolute survival benefit of 14% was seen with the TTE. Moreover, in patients with one to eight positive nodes in the resection specimen, 5 year locoregional disease free survival favored the TTE (64% vs 23%). With this data, we can conclude that patients with distal esophageal cancer and limited nodal burden may benefit from a more extensive nodal dissection via a TTE. MINIMALLY INVASIVE ESOPHAGECTOMY (MIE) Recent studies have shown that lymph node yield and surgical margins are similar and perhaps superior with MIE compared to open approaches (TIME-trial and MIRO-trial). The main disadvantage of MIE is that it is technically challenging and needs careful introduction via a structured program. Minimally invasive esophagectomy is associated with less operative trauma and consequently less morbidity. Fewer pulmonary complications are reported during thoracoscopy compared to thoracotomy and, if the prone position is used, omitting complete lung block, even fewer pulmonary complications are expected. In laparoscopic transhiatal dissection there is probably less manipulation and retraction of the mediastinum and thus, fewer hemodynamic complications. FUTURE RESEARCH There are some ongoing randomized controlled trials comparing open esophagectomy with the thoracoscopic approach assisted by robot (ROBOT trial) and there are also RCTs that will compare MIE with open and hybrid techniques (ROMIO trial). Other trials will compare the McKeown and Ivor-Lewis MIE procedures (ICAN trial).
Published
Feb 2020
Hiatal hernia recurrence after laparoscopic repair has been reported in a significant percentage of patients, from 1.2% to 66%. Some authors have reported lower recurrence rates after mesh repair, but due to the differences in technique, type of mesh, and shape and size of the hernia, this data is still controversial. Laparoscopic repair of paraesophageal hernias yields excellent relief of symptoms and improved quality of life despite a high rate of radiographically identified recurrence. Unfortunately there is no universally accepted definition of paraesophageal hernia recurrence. Most of the series rely on barium esophagography, endoscopy or esophageal manometry to document recurrence, with rates being quite high, reaching 66%. Nonetheless, most studies report a symptomatic recurrence rate as low as 3 – 3.5% of cases. Thus, the clinical relevance of radiographic recurrence is controversial. A 2013 study from Johns Hopkins University (Baltimore, USA) reported a correlation between a hiatal hernia recurrence > 2 cm by barium esophagography and significant symptom worsening. Oelschlager et al. reported radiographic recurrence as the greatest vertical height of stomach ≥ 2 cm above the diaphragm. Many studies have reported little or no difference in heartburn, regurgitation, dysphagia, chest pain or satisfaction in patients with and without radiographic recurrence of hiatal hernias. Thus, only a small percentage of patients need reoperation (around 3% in the Luketich et al. large series) When a recurrence is radiographically and clinically diagnosed, the patient should undergo a complete preoperative evaluation. A paper from the University of Creighton group (Nebraska, USA) published in 2006 recommends a preoperative evaluation consisting of: 1. Esophagogram to determine the size of the hiatal hernia and the length of the esophagus. 2. Upper endoscopy to determine the presence or absence of cancer, Barrett’s esophagus, peptic stricture, short esophagus, gastroparesis, Cameron’s ulcer and the type and size of the hiatal hernia. 3. Manometry: the fundoplication pressure and relaxation should be assessed at each centimeter. Relaxation below 85% should be considered abnormal. Normal fundoplication pressure is 20-35 mmHg. 4. pH monitoring: performed selectively in patients with bad response to proton-pump inhibitors, or with endoscopic findings of esophagitis. Hiatal hernia recurrence can be classified into 4 groups: Ia: the entire wrap along with the gastroesphageal junction migrates cephalad. Ib: the wrap remains below the diaphragm but the stomach and the gastroesophageal junction slip cephalad. II: true paraesophageal hernia. III: defective initial construction of the wrap using the gastric body rather than the fundus. Patients with a surgically correctable disorder that is not responsive to aggressive medical management should be candidates for reoperation. The patient should be aware of the difficulty of the operation and of the complications associated with it. 2% to 20% conversion rates have been reported, as well as 16% to 20% of gastric perforation, 25% of pneumothorax and a low rate of reoperation, around 2%. Nonetheless, patients improve with redo surgery. It has been demonstrated in cohort studies that the laparoscopic approach to reoperative hiatal hernia repair is safe and effective. The key steps of reoperative hiatal hernia repair are the following: 1. Entry – insufflation 2. Adhesiolysis: establishing a plane between the caudate lobe and the preaortic fascia continuing into the right crus. 3. Hiatal dissection. 4. Identification and preservation of the vagus nerves: care must be taken dissecting the 12 and 6-7 o’clock positions. The identification of the nerves on the proximal esophagus is easier than distally. 5. Takedown of the previous fundoplication. 6. Crural closure: a mesh may be necessary. 7. Intraoperative endoscopy: identify the true gastroesophageal junction by applying pressure with a grasper and correlating with intra-luminal findings. 8. Evaluation of esophageal length: lengthening procedures may be necessary if it is less than 2.5 cm. 9. Fundoplication. Conclusions Despite the lack of a universally accepted definition of hiatal hernia recurrence, most authors agree that a symptomatic patient with a hiatal hernia recurrence in esophagogram ≥ 2 cm should be considered as having a recurrent hiatal hernia. Evaluation with upper endoscopy, manometry and pH monitoring should be performed to rule out other causes of the symptoms. In patients with no other causes and with a radiographic hiatal hernia recurrence, with symptoms that do not improve despite proton pump inhibitors, surgery should be advised. Both patient and surgeon should be aware of the higher complication rate associated with reoperative surgery even though clinical outcomes are satisfactory.
Published
Jan 2020
Case A 75 year-old man with a medical history of atrial fibrillation and laparoscopic radical prostatectomy for prostate adenocarcinoma. He came to the Emergency Department due to melena and hemodynamic instability with a blood test which found a Hemoglobin level of 7.9 g/dL. And emergent upper endoscopy showed early gastric neoplasia (type IIa + IIc) with a biopsy compatible with gastric adenocarcinoma. A CT scan showed a tumor in the right kidney with no signs of locally advanced gastric cancer. Thus a minimally invasive subtotal gastrectomy with D2 lymphadenectomy was scheduled. Treatment Surgery started with a lymphadenectomy of the greater curvature, with dissection of the gastroepiploic artery and vein. (Later, dissection of the pylorus and postpyloric section with an EndoGIA was performed. Lymphadenectomy of the left gastric artery, celiac trunk, hepatic artery and splenic artery followed. D2 lymphadenectomy with preservation of the ganglionar stations 1 and 2 was performed. Once this was done, the vascularization of the gastric stump was assessed with 5mg of ICG inserted through a central catheter, and the decision to section the stomach in a well-perfused portion of the gastric stump was made, as this would be the site of the gastrojejunal anastomosis. A end-to-side anastomosis was created using an Orvil®. The mesenteric defect was then closed. Outcome The patient had an uneventful postoperative evolution and started oral intake on the first day after surgery. He was discharged on the 4th postoperative day. Pathology reported a T2N0 (0/18) gastric adenocarcinoma. Conclusions Even though leakage after a subtotal gastrectomy with gastrojejunal anastomosis is uncommon, when a leak occurs the consequences are devastating, both in the oncologic long-term as well as in terms of function, morbidity and mortality. The use of tools such as ICG, which provide a guide for safer anastomosis, are useful and may help to further reduce this dreadful complication.
Published
Dec 2019
As explained in previous chapters, fundoplication is routinely performed during paraesophageal hernia repair to prevent postoperative gastroesophageal reflux and to reinforce the repair to prevent recurrence. However, the choice of the best fundoplication technique is still controversial, and a balance must be achieved between adequate reflux control and postoperative dysphagia. Several studies have suggested that patients with paraesophageal hernia suffer from esophageal dysmotility, and, even though esophageal manometry was thought to be a useful tool in assessing esophagus contractility, its measurements are unreliable due to distorted anatomy and deranged intrathoracic pressures. Thus, decision making in the appropriate technique reconstruction of the lower esophageal sphincter becomes cumbersome. Nissen fundoplication (full 360-degree) is associated with the highest risk of postoperative dysphagia, compared to partial fundoplications. It should not be recommended in cases of preoperative diagnosis of esophageal dysmotility. Due to this, some authors advocate for a partial fundoplication in all patients. Huerta et al published in 2018 their results on the treatment of type III and IV paraesophageal hernias with Nissen and Toupet fundoplications and reported no differences on heartburn, dysphagia, regurgitation or use of acid-reducing medications. Follow-up was 2.5 years for the Toupet group and 4.8 years for the Nissen group. The McGill University group (Trepanier et al.) published their long-term outcomes (5 years) on the treatment of large paraesophageal hernias (> 50% of the stomach herniated) comparing Nissen fundoplication to Dor fundoplication. They concluded that Dor fundoplication was associated with less early postoperative dysphagia compared to Nissen fundoplication, but with no difference at 6 months. In addition, there were no differences in the incidence of short-term and long-term self-reported symptoms of reflux or on the percentage of patients using proton pump inhibitors. Although the debate is still ongoing, with advocates for the use of partial fundoplications over Nissen fundoplication due to the risk of dysphagia, most literature is based on retrospective studies. Well-designed trials should be conducted to obtain an answer on which is the best technique for treating patients with paraesophageal hernias.
Published
Oct 2019
Hiatal hernia is defined as a protrusion of abdominal structures different than the esophagus into the thoracic cavity through a widening in the hiatus. Recurrence following primary hiatal hernia repair is an important problem. The radiological incidence of recurrence is 30-42% while symptomatic recurrence seems to affect 5% of patients. Most patients are elderly and have comorbidities. Following the principles of tension-free repair with mesh reinforcement in inguinal and ventral hernia repair that are associated with decreased recurrence rates, it is suggested that crural reinforcement will reduce the rates of hiatal hernia recurrence. Controversies still exist regarding the need for mesh reinforcement of the hiatus and on the type of mesh to be used. This video reviews the literature on this topic. Types of mesh The ideal mesh for cruroplasty should provide strength to reduce the risk of recurrent herniation, avoiding erosion and dysphagia. It should be underlined that, compared to mesh repair of inguinal or ventral hernias, hiatal defects have a dynamic nature in which the continual motion provokes an ongoing friction of the mesh at the esophagus and stomach that can result in mesh erosion. Different materials have been used for hiatal mesh repair: PTFE. Polypropylene. Partially absorbable mesh (poliglecaprone-25, Polypropylene composite) Absorbable: provides the scaffold for tissue in-growth for persistent reinforcement. Human acellular dermal matrix (HACDM). Porcine small intestine submucosa (Surgisis) Gore BioA Also, various mesh shapes have been used: Keyhole shape. U shape. Butterfly shape. Suture versus mesh repair Many studies have shown a decrease in paraesophageal hernia recurrence with the use of mesh repair. A recent meta-analysis (Sathasivam R et al. 2019) demonstrated a significant reduction in recurrent hiatal hernia after mesh repair compared to non-mesh repair (OR 0.48, 95% CI 0.32 – 0.73, p< 0.05). Nonetheless, long term data is inadequate and the studies included are heterogeneous and thus, clear recommendations on the use of mesh repair for hiatal hernias are not possible. Biological A prospective study by the Oregon group (Abdelmoaty et al.) showed that after 1 year follow-up after paraesophageal hernia repair with biologic Phasix-ST, the recurrence rate was 8%, with no reoperation, mesh infection or mesh erosion. Other groups have shown a 9% recurrence rate at the expense of a higher than expected complication rate. Complications of mesh repair Erosion and migration are the most feared complications encountered after mesh repair. A systematic review yielded a 1.9% rate of mesh-associated complications in the series, reporting at least one mesh-related complication. Reports on biological mesh repair have shown no erosions, strictures or dysphagia after more than 4 years’ follow-up. Compared to single closure of the hiatus, several studies have described an increased risk of dysphagia in the early postoperative period after hiatal hernia repair with mesh. The dysphagia rate was similar to single closure after 1 year. A recent systematic review (Li et al. 2019) described 50 cases of mesh erosion reported in the literature. Of these, 50% occurred in the esophagus, 25% in the stomach and 23% in the gastroesophageal junction. There is one report of aorta erosion with early bleeding. 84% of patients complained of dysphagia. Other symptoms were weight loss, epigastric pain, heartburn, regurgitation and bleeding. The interval to mesh erosion diagnosis ranged from 7 days (aorta erosion) to 20 years, but in more than two thirds of patients erosion occurred in the two first years after primary surgery. One third of the patients were treated by minimally invasive procedures (endoscopy, laparoscopy or a combination of both), but half of the patients required open surgery, with 19.6% requiring an esophageal resection and 5.9% total gastrectomy. Conclusions Mesh reinforcement of the hiatus seems to reduce the hiatal hernia recurrence rate. There is no definitive long-term data. Mesh-related complications can be distressing and difficult to treat. There is no clear recommendation on the use of mesh in the hiatus or on its type and shape. There is no clear recommendation on the use of mesh in the hiatus or on its type and shape
Published
Oct 2019
Help your network discover Dr. Dulce Momblán's clinical expertise.
