Recommendations on the management of severe obesity in patients with inflammatory bowel disease of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU), Spanish Society of Obesity (SEEDO), Spanish Association of Surgery (AEC) and Spanish Society of Digestive Endoscopy (SEED)

Obesity is a multifactorial, chronic, progressive and recurrent disease considered a public health issue worldwide and an important determinant of disability and death. In Spain, its current prevalence in the adult population is about 24% and an estimated prevalence in 2035 of 37%. Obesity increases the probability of several diseases linked to higher mortality such as diabetes, cardiovascular disease, hyperlipidemia, arterial hypertension, non-alcoholic fatty liver disease, several types of cancer, or obstructive sleep apnea. On the other hand, although the incidence of inflammatory bowel disease (IBD) is stabilizing in Western countries, its prevalence already exceeds 0.3%. Paralleling to general population, the current prevalence of obesity in adult patients with IBD is estimated at 15-40%. Obesity in patients with IBD could entail, in addition to its already known impact on disability and mortality, a worse evolution of the IBD itself and a worse response to treatments. The aim of this document, performed in collaboration by four scientific societies involved in the clinical care of severe obesity and IBD, is to establish clear and concise recommendations on the therapeutic possibilities of severe or typeIII obesity in patients with IBD. The document establishes general recommendations on dietary, pharmacological, endoscopic, and surgical treatment of severe obesity in patients with IBD, as well as pre- and post-treatment evaluation.

Pilot study: a detailed analysis of the timing of immuno-inflammatory indices in gastric cancer, and their assessment together with TNM as supplementary prognostic factors

An analysis of the prognostic impact of up to 36 immuno-inflammatory indices at 3 different times during the diagnostic-therapeutic process for gastric cancer. The dependent variable was disease-free survival at 3 years. The independent factors obtained were combined with TNM to provide an improved prognostic model.

Results of the national registry of patients diagnosed with inflammatory bowel disease candidates for bariatric surgery (ReNacEIBar)

BACKGROUND

Our aim is to carry out a national registry of patients with inflammatory bowel disease (IBD) who underwent bariatric surgery, as well as evaluate the results and management of this type of patients in the usual clinical practice.

METHODS

National multicentric observational retrospective study, including patients, previously diagnosed with IBD who underwent bariatric surgery from January 2000 to December 2022.

RESULTS

Forty-one patients have been included: 43,9% previously diagnosed with ulcerative colitis, 57,3% Crohn's disease, and an indeterminate colitis (2,4%). The preoperative BMI was 45.8 ± 6,1 kg/m2. Among the bariatric surgeries, 31 (75,6%) sleeve gastrectomy, 1 (2,4%) gastric bypass and 9 (22%) one anastomosis gastric have been carried out. During the postoperative period, 9.8% complications have been recorded. BMI was 29,5 ± 4,7 kg/m2 and percent total weight lost was 33,9 ± 9,1% at 12 months.

CONCLUSIONS

Bariatric surgery in patients with inflammatory bowel disease can be considered safe and effective.

Bile reflux and marginal ulcers after one-anastomosis gastric bypass (OAGB). A narrative review

One-anastomosis gastric bypass has now become the third most commonly performed bariatric technique worldwide. However, as a consequence of the configuration of this surgery, it can present some chronic complications (anastomotic mouth ulcers and biliary reflux) that physicians must come to better understand and assess. In this narrative review, we aimed to update our knowledge of both the diagnosis and treatment of these two complications in the context of bariatric surgeries. We concluded that a series of pre-, intra-, and postoperative preventive strategies should be considered by surgeons to help reduce the appearance of these complications.

Lymphoepithelioma-like gastric adenocarcinoma. Descriptive case series

Lymphoepithelioma-like gastric adenocarcinoma is characterised by a large reactive lymphoplasmacytic infiltrate in the stroma and islets of undifferentiated cells, which express intense and widespread Epstein-Barr virus (EBV). This tumour type has higher survival rates than other gastric cancers, a more proximal location and less lymphatic spread. Our aim is to describe the clinical and pathological characteristics of our series of lymphoepithelioma-like gastric adenocarcinoma. We selected patients who underwent surgery for gastric adenocarcinoma lymphoepithelioma-like variant from 2014 onwards. The results of the following variables were collected: age (years), sex, pre-diagnostic clinical time (months), gastric tumour location, endoscopic biopsy histology, surgical technique, in situ hybridisation for EBER region (Epstein-Barr virus-associated non-coding RNA), microsatellite instability, degree of differentiation, level of resection, tumour size (cm), TNM T value, lymphadenopathy/resected node ratio, overall survival (months) and vital status. Our experience in the lymphoepithelioma-like variant presents as an advanced gastric cancer, possibly related to long-standing prediagnostic symptoms. It behaves as a tumour with expansive local growth with little capacity for lymphatic or metastatic involvement, which could be explained by the prominent intratumoral lymphoid stroma that acts as an antimetastatic barrier.

Surgical indication of type I gastric neuroendocrine tumors

Gastric neuroendocrine tumors (GNETs) account for less than 2% of gastric neoplasms and type 1 GNETs (GNETs-1), which are associated with chronic atrophic gastritis, account for 70-80% of all GNETs. Treatment of GNETs-1 is usually endoscopic, but surgery also has its indications. The aim of this study is to present five case reports of GNETs-1 treated with surgery and to analyze the surgical indications for this type of tumors.

Revisional One-Anastomosis Gastric Bypass (OAGB) After Intrathoracic Migration of Nissen Fundoplication

According to the latest IFSO recommendations, bariatric and metabolic surgery is the recommended treatment for patients with a BMI above 35 kg/m² (with or without associated pathology), achieving good results in terms of weight loss in the medium to long term, as well as improving a significant percentage of comorbidities in this type of patient (diabetes mellitus, arterial hypertension, dyslipidaemia, gastro-esophageal reflux disease (GERD)...). The incidence of GERD is higher in patients with obesity, with more severe symptoms. Over the years, Nissen fundoplication has been the gold standard treatment for patients with GERD who do not respond to medical treatment. However, in patients with obesity, gastric bypass is a valid option to consider. We present the case of a patient who had previously undergone anti-reflux surgery (laparoscopic Nissen) for GERD, with favorable evolution, who presented intrathoracic migration of the same after 8 years, with new onset of symptoms, and who was offered revision bariatric surgery. The video presents on the performance of OAGB in a patient who had previously undergone antireflux surgery, with intrathoracic Nissen. Performing this technique after a previous Nissen fundoplication (as well as migration of the Nissen) is a somewhat more complex procedure than primary surgery but can be performed safely with careful technique (there are often previous adhesions that hinder mobility and separation of the fundoplication) and provides good symptom control.

Recurrence of gastric schwannoma

Gastric schwannoma can be malignant in 13.8% of cases. The prognosis of malignant schwannoma is usually poor, characterized by a rapidly progressive disease course and a poor response to chemotherapy. Normally, the recurrence of schwannoma is due to involvement of the surgical resection margin. In turn, recurrence of malignant gastric schwannoma GS is approximately 50%, 25% locoregional and 25% with liver metastases. Even after a complete gastric resection with associated lymphadenectomy, schwannoma may present liver metastases during follow-up.

Intra-abdominal abscess caused by Streptococcus constellatus in an immunocompetent patient

Streptococcus constellatus is a Gram-positive commensal bacterium of the oropharyngeal, gastrointestinal and urogenital flora. It can cause abscesses in different parts of the body, especially in immunocompromised patients. We present the clinical case of a 33-year-old female patient with a previous history of one anastomosis gastric bypass, among others. The patient was hospitalized two years after surgery for peritonitis secondary to a perforation in the biliopancreatic loop, underwent laparoscopic surgery and was hospitalised for two weeks. Fifteen days after being discharged from the hospital, she went to the emergency service for abdominal pain and fever. An abdominal and pelvic computerized tomography (CT) scan showed a multiloculated pelvic collection with thickened and hypercapillary walls.

Importance of immunohistochemistry in the differential diagnosis of gastric mesenchymal tumors

Although morphology is the key to histological diagnosis, gastric mesenchymal tumors can share very similar growth and cellularity patterns, sometimes being indistinguishable. Therefore, immunohistochemical techniques are going to be crucial in the definitive diagnosis. The objective of this work is to perform an immunohistochemical differential diagnosis of gastric mesenchymal tumors.

Impact of exercise training after bariatric surgery on cardiometabolic risk factors: a systematic review and meta-analysis of controlled trials

The purpose of this systematic review was to provide updated evidence synthesis of the effectiveness of exercise training in patients with obesity undergoing bariatric surgery to improve cardio-metabolic risk. We systematically searched the MEDLINE, EMBASE, Scopus, Cochrane, and Web of Science databases. The studies selected were those in which an exercise-based intervention was performed after bariatric surgery, a control group was present, and at least one of the following outcomes was investigated: VO_2max or VO_2peak, resting heart rate (RHR), blood pressure, lipid profile, glucose, and insulin. The study quality was assessed using the PEDro scale and the data were meta-analyzed with a random effects model, comparing control groups to intervention groups using standardized measurements. Twenty articles were included in the systematic review and fourteen (70%) in the meta-analysis. Significant differences were observed between the control and intervention groups (always in favor of exercise) for absolute VO_2max / VO_2peak (ES = 0.317; 95% CI = 0.065, 0.569; p = 0.014), VO_2max / peak relative to body weight (ES = 0.673; 95% CI = 0.287, 1.060; p = 0.001), HDL cholesterol (ES = 0.22; 95% CI = 0.009, 0.430; p = 0.041) and RHR (ES = -0.438; 95% CI = -0.753, -0.022; p = 0.007). No effects were observed for either systolic or diastolic blood pressure. Exercise training for patients undergoing bariatric surgery appears to be effective in improving absolute and relative VO_2max / VO_2peak, HDL cholesterol and reducing the RHR. More intervention studies using (better) exercise interventions are needed before discarding their effects on other cardiometabolic risk factors. This systematic review and meta-analysis has been registered in Prospero (CRD42020153398).

[Evaluation of treatment with intra-articular injections in osteoarticular pathology of the shoulder in primary care]

MAIN OBJECTIVE

To evaluate the clinical response at 24weeks after injection, measured as pain relief and functional recovery, in painful shoulder syndrome (PSS) in primary care (PC).

DESIGN

Longitudinal case series with injection treatment in the scapulohumeral joint, describing functionality and pain evolution before and at 24weeks post injection.

LOCATION

Non-urban primary care centres.

PARTICIPANTS

Patients with osteoarticular shoulder pathology susceptible to injection, failure of pharmacological treatment and rating on the visual analogue scale (VAS) ≥4 or constant score (CS) ≤70.

INTERVENTIONS

Intra-articular injection of corticosteroid and local anaesthetic into the scapulohumeral joint, describing its evolution at 1, 4, 12 and 24weeks post injection.

MAIN MEASUREMENTS

Infiltration response according to EVA before and after, CS before and after, number of infiltrations, side effects, temporary inability to work (TIL).

RESULTS

Sixty-six patients receiving injection, mean age 51.1years (SD 14.7), 57.6% were women and 63.3% were injection in the right shoulder. A 22.7% required TIL and were discharged with a median of 14days (range 7-56days). They required an injection (80.3%) and the most frequent injection pathology was rotator cuff tendinitis (90.9%). They suffered mild side effects (9.4%). We found a decrease in pain from severe to mild and a functional improvement from poor to good. The variables: being retired (OR: 37.82, P=.001) and having an EVA score prior to injection >8 (OR: 15.67, P=.055, almost significant) were associated with poor response.

CONCLUSIONS

Intra-articular administration of corticosteroids in PSS reduces pain and provides functional improvement after the first week after injection, and is maintained in the long term. This allows a quick recovery to work after an injection at two weeks reducing recovery time by 50%, with few side effects.

Sexuality amongst heterosexual women with morbid obesity in a bariatric surgery programme: A qualitative study

AIMS

The objective of this study is to describe and understand the experiences of sexuality amongst heterosexual women with morbid obesity (MO) who are in a bariatric surgery program.

BACKGROUND

Morbid obesity is a chronic, metabolic disease that affects women's physical, psychological and sexual health. MO is associated with anxiety, depression and body image disorders. Bariatric surgery is a reliable method for weight loss in people with MO.

DESIGN

A qualitative descriptive study research design was adopted.

METHODS

Twenty-one heterosexual women with MO in a bariatric surgery program were recruited through purposive sampling. Data collection included individual semi-structured interviews conducted between November 2018 and May 2019. Interviews were audio recorded, transcribed verbatim and analysed using a computer-assisted qualitative data.

FINDINGS

Three main themes emerged from the analysis: (1) trapped in a body that limits my sexuality; (2) between neglect and hope and (3) the partner as a source of support for sexuality in women with MO.

CONCLUSION

Women hide a body that they do not accept and ignore their own sexuality, focusing on that of their partner. Although the women have doubts about their partners' desire for them, they share the decision-making process with them whilst waiting for bariatric surgery, on which they place all of their hopes for improved sexuality and quality of life.

IMPACT

The findings highlight the importance of exploring the experiences and sexual issues faced by heterosexual women with MO in a bariatric surgery program. Bariatric nurses have a privileged position to assess these women's sexuality, recommend alternatives to sexual intercourse or refer them to sexologists. As part of the multidisciplinary team, nurses can contribute to managing the expectations of women with MO and their partners in relation to the improvement of their sex lives following bariatric surgery.

Intracorporeal Versus Extracorporeal Anastomosis in Patients Undergoing Laparoscopic Right Hemicolectomy: A Multicenter Randomized Clinical Trial (The IVEA-study)

OBJECTIVE

The aim of this study was to evaluate short-term outcomes of performing intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy for right colon neoplasm.

BACKGROUND

Despite advances in the laparoscopic approach in colorectal surgery and the clear benefit of this approach over open surgery, because of the technical difficulty in performing intracorporeal anastomosis (IA), some continue to perform it extracorporeally in right colon surgery.

MATERIALS AND METHODS

This study was a prospective multicenter randomized trial with 2 parallel groups on which either IA or extracorporeal anastomosis was performed in laparoscopic right hemicolectomy for right colon neoplasm, carried out between January 2016 and December 2018.

RESULTS

A total of 168 patients were randomized during the study period. At baseline, the 2 groups were comparable for age, sex, body mass index, surgical risk, and comorbidity. The median length of postoperative hospital stay was 7 days with no differences between the groups. About 70% of patients had an uneventful postoperative period without complications. The most common complications were paralytic ileus (20.63%; 33), surgical site infection (SSI) (10%; 16), and anastomotic leakage (6.25%; 10). The results show a lower level of SSI in the IA group (3.65% vs. 16.67%, P=0.008). Other complications do not show statistically significant differences between groups. Likewise, the incision for the extraction of the specimen was smaller in the IA group (P=0.000) and creation of the anastomosis intracorporeally decreased postoperative pain (P=0.000).

CONCLUSIONS

In comparison to the extracorporeal technique, IA decreased postoperative pain, incision size, and SSI. Further studies will be needed to verify our findings.

Missing Jejunal Perforation During Small Bowel Measurement in Patient Operated by Laparoscopic One-Anastomosis Gastric Bypass

BACKGROUND

Obesity surgery is justified as it produces sustained weight loss, increases life expectancy, and reduces the complications of obesity. For this reason, increasing numbers of patients are undergoing this surgery [1]. Complications following surgical treatment of severe obesity vary based upon the procedure performed and, although it is currently below 7% in more experienced centers, it may increase in more complex surgeries (such as revision surgery) and can be as high as 40% [2, 3]. Patients with early postoperative complications may be managed in specialist centers by the bariatric surgeon during the hospital stay [4]. Missing bowel injury may occur primarily during insertion of a Veress needle and trocar, use of electrosurgery and laser beams, suturing, and adhesiolysis [5]. Less frequently, the bowel perforation is due to the measurement of the loop and goes unnoticed. Perforation of the intestines due to any reason is a severe condition that can clinically present with free intraabdominal air, purulent or even fecal peritonitis, and abdominal compartment syndrome [6]. High clinical suspicion is crucial for early diagnosis. Early recognition of bowel injury and early intervention is crucial to reduce its morbidity and mortality [5].

METHODS

We present a case of a 50-year-old male patient with a BMI of 36.1 kg/m², hypertension, and dyslipidemia who was proposed for bariatric surgery. A laparoscopic one-anastomosis gastric bypass (OAGB) was performed with no intraoperative incidents. Few hours after the surgery, the patient manifests intense abdominal pain and tachycardia (120 bpm) so we decided to order an abdominal CT scan that showed signs of jejunal perforation (pneumoperitoneum, oral contrast extravasation, and small air bubbles next to the jejunum wall).

RESULTS

Emergency laparoscopy was done and showed generalized peritonitis caused by a 4-mm perforation in the mesenteric border of the jejunum with everted mucosa that was located 150 cm from the loop of Treitz. We decided to place three infraumbilical trocars to help us with washing, viewing, and surgical repair. We performed a 2-0 barbed simple suture of the perforation and extensive washing of the entire cavity with 10 L of serum. We left three drains. The patient made an uneventful recovery and was discharged 72 h after surgery with an established oral diet.

CONCLUSIONS

Missing intestinal perforation is an uncommon injury during bariatric surgery, but its early diagnosis is important to avoid endangering the patient's life. Simple postoperative tachycardia in obese patients should be taken seriously as it is a warning signal. Laparoscopic reoperation in these early diagnosed cases is safe and effective, since it allows visualization and washing of the entire cavity. Bowel injuries, which may occur as a result of the insertion of an insufflation needle or trocar, are a rare complication of laparoscopy. In the case we present, the perforation occurred during the small bowel measurement so we insist on the extreme caution that surgeons must take during every detail of the surgical technique. The use of atraumatic forceps, handling of the bowel strictly at the antimesenteric side, and the infusion of sufficient methylene blue in the anastomosis testing are gestures that can help reduce the risk.

Physical Exercise following bariatric surgery in women with Morbid obesity: Study protocol clinical trial (SPIRIT compliant)

BACKGROUND

Severe and morbid obesity are increasing globally, particularly in women. As BMI increases, the likelihood of anovulation is higher. The primary aim of the EMOVAR clinical trial is to examine, over the short (16 weeks) and medium (12 months) term, the effects of a supervised physical exercise program (focused primarily on aerobic and resistance training) on ovarian function in women with severe/morbid obesity who have undergone bariatric surgery. Secondary objectives are to examine the effects of the intervention on chronic inflammation, insulin resistance, arterial stiffness, physical fitness, and health-related quality of life.

METHODS

This is a randomized controlled trial in which ∼40 female bariatric surgery patients, aged between 18 and 45 years old, will be included. Participants assigned to the experimental group will perform a total of 48 sessions of supervised concurrent (strength and aerobic) training (3 sessions/week, 60 min/session) spread over 16 weeks. Patients assigned to the control group will receive lifestyle recommendations. Outcomes will be assessed at baseline, week 16 (i.e., after the exercise intervention) and 12 months after surgery. The primary outcome is ovarian function using the Sex-Hormone Binding Globuline, measured in serum. Secondary outcomes are serum levels of anti-mullerian hormone, TSH, T4, FSH, LH, estradiol, prolactine, and free androgen index, as well as oocyte count, the diameters of both ovaries, endometrial thickness, and uterine arterial pulsatility index (obtained from a transvaginal ultrasound), the duration of menstrual bleeding and menstrual cycle duration (obtained by personal interview) and hirsutism (Ferriman Gallwey Scale). Other secondary outcomes include serum markers of chronic inflammation and insulin resistance (i.e., C-reactive protein, interleukin 6, tumor necrosis factor-alpha, leptin, glomerular sedimentation rate, glucose, insulin and the HOMA-IR), arterial stiffness, systolic, diastolic and mean blood pressure, body composition, and total weight loss. Physical fitness (including cardiorespiratory fitness, muscular strength, and flexibility), health-related quality of life (SF-36 v2) and sexual function (Female Sexual Function Index) will also be measured.

DISCUSSION

This study will provide, for the first time, relevant information on the effects of exercise training on ovarian function and underlying mechanisms in severe/morbid obese women following bariatric surgery.

TRIAL REGISTRATION NUMBER

ISRCTN registry (ISRCTN27697878).

Use of barbed suture for the closure of enterocolotomy after laparoscopic right hemicolectomy with intracorporeal anastomosis. A prospective descriptive study

INTRODUCTION

Performing intracorporeal anastomoses and sutures is possibly the technique that requires the greatest skill in laparoscopic surgery. The appearance of the new barbed sutures in recent years has seemed to facilitate this surgical step. The aim of our study is to evaluate short-term results in patients with neoplasms of the right colon, after laparoscopic right hemicolectomy with intracorporeal anastomosis using barbed suture at the closure of the enterocolotomy.

METHODS

This is a multicenter, prospective, descriptive study that includes patients who underwent laparoscopic right hemicolectomy for neoplastic colonic pathologies between June 2015 and December 2018. In all patients, the intracorporeal anastomosis was performed using the endocutter, and closure of the enterocolotomy was done with a double layer of barbed suture.

RESULTS

A total of 80 patients were treated (47.5% women), with an average age of 70.6±9 (49-92) years. The average operative time was 99.5±38minutes Anastomotic dehiscence was observed in 2.5% of the sample, and 5 patients required re-operation (6.2%) as a result of 2leaks, 2obstructive symptoms and one peritoneal bleeding. Mean hospital stay was 7 (3-173) days.

CONCLUSIONS

The use of barbed suture in laparoscopic right hemicolectomy with intracorporeal anastomosis seems to present a morbidity similar to series described in literature. Prospective, controlled and randomized studies with a larger number of patients would be necessary to confirm these findings.

Photodynamic Therapy for the Treatment of Complex Anal Fistula

BACKGROUND AND OBJECTIVES

To validate and analyze the results of intralesional photodynamic therapy in the treatment of complex anal fistula.

STUDY DESIGN/MATERIALS AND METHODS

This prospective multicentric observational study enrolled patients treated for complex anal fistula who underwent intralesional photodynamic therapy (i-PDT). The included patients were treated from January 2016 to December 2018 with a minimum follow-up of 1 year to evaluate recurrence, continence and postoperative morbidity. Intralesional 5-aminolevulinic acid (ALA) gel (2%) was injected directly into the fistula. The internal and external orifices were closed. After an incubation period of 2 hours, the fistula was irradiated using an optical fiber connected to a red laser (Multidiode 630 PDT) operating at 1 W/cm for 3 minutes (180 J).

RESULTS

In total, 49 patients were included (61.2% male). The mean age was 48 years, and the mean duration of fistula was 13 months. Of the fistulas included, 75.5% were medium transphincteric, and 24.5% were high transphincteric. The median fistula length was 4 ± 1,14 cm (range: 3-5). A total of 41 patients (83.7%) had a previous history of fistula surgery. Preoperatively, some degree of anal incontinence was found in 5 patients (10.2%). No center reported any other procedure-related complications intraoperatively. Phototoxicity was found in one patient. In the first 48 hours after the procedure, fever was reported in 2 patients (4%). At the end of follow-up, total healing was observed in 32/49 patients (65.3%). No patient reported new incontinence postoperatively.

CONCLUSION

i-PDT could be considered a good choice in patients with complex anal fistulas to avoid surgery and its complications. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Supervised exercise following bariatric surgery in morbid obese adults: CERT-based exercise study protocol of the EFIBAR randomised controlled trial

BACKGROUND

There is increasing evidence of weight regain in patients after bariatric surgery (BS), generally occurring from 12 to 24 months postoperatively. Postoperative exercise has been suggested to ad long-term weight maintenance and to improve physical function in BS patients. However, there are a limited number of intervention studies investigating the possible benefits of exercise in this population. The aim of the current report is to provide a comprehensive CERT (Consensus on Exercise Reporting Template)-based description of the rationale and details of the exercise programme implemented in the EFIBAR Study (Ejercicio FÍsico tras cirugía BARiátrica), a randomised controlled trial investigating the effects of a 16-week supervised concurrent (aerobic and strength) exercise intervention program on weight loss (primary outcome), body composition, cardiometabolic risk, physical fitness, physical activity and quality of life (secondary outcomes) in patients with severe/morbid obesity following bariatric surgery.

METHODS

A total of 80 BS patients [60-80% expected women, aged 18 to 60 years, body mass index (BMI) ≥ 40 kg/m2 or ≥ 35 kg/m2 with comorbid conditions)] will be enrolled in the EFIBAR Randomized Control Trial (RCT). Participants allocated in the exercise group (n = 40) will undertake a 16-week supervised concurrent (strength and aerobic) exercise programme (three sessions/week, 60 min/session), starting 7 to 14 days after surgery. The rationale of the exercise programme will be described following the CERT criteria detailing the 16 key items. The study has been reviewed and approved by the Ethics Committee of the Torrecárdenas University Hospital (Almería, Spain) (ref. N° 76/2016).

DISCUSSION

The present study details the exercise programme of the EFIBAR RCT, which may serve: 1) exercise professionals who would like to implement an evidence-based exercise programme for BS patients, and 2) as an example of the application of the CERT criteria.

TRIAL REGISTRATION

The trial was prospectively registered at Clinicaltrials.gov NCT03497546 on April 13, 2018.

Correction to: Effects of Exercise Training on Weight Loss in Patients Who Have Undergone Bariatric Surgery: a Systematic Review and Meta-Analysis of Controlled Trials

In the original article the name of author Enrique G. Artero was misspelled.

Spatial and temporal variations in Spain in the standardised ratio of in-hospital mortality due to colorectal cancer, 2008-2014

Background

Colorectal cancer (CRC) is the second cause of tumour mortality in Spain and Europe. To date, no studies have been conducted in Spain to evaluate the spatial and temporal distribution of the excess risk of death during hospitalisation for CRC.

Methods

A cohort was constructed of all episodes of hospitalisation in Spain due to CRC (codes 153 and 154 of the International Classification of Diseases, 9th edition, Clinical Modification) during the period 2008–2014, based on the minimum basic data set published by the Ministry of Health. Mortality ratios were calculated per region for each of the years analyzed (spatial or cross-sectional analysis) and during the overall study period, for each region independently (temporal or longitudinal analysis). In the first of these analyses, particular note was taken of the regions and years in which the limits of two and three standard deviations were exceeded.

Results

Two hundred and fifty eight thousand, nine hundred and twenty seven episodes of CRC were analysed. The patients were predominantly male (60.6%), with an average hospital stay of 13.16 days. Half underwent surgery during admission and on average presented more than six diagnoses at discharge. The spatial analysis revealed mortality ratios that deviated by at least three standard deviations in the following regions: Islas Canarias, Asturias, Valencia, Extremadura, País Vasco and Andalucía. The longitudinal analysis showed that most regions presented one or more years when CRC mortality was at least 15% higher than expected during the period; outstanding in this respect were Asturias, Navarra and La Rioja, where this excess risk was detected in at least 2 years.

Conclusions

Geographic and temporal patterns of the distribution of the excess risk of mortality from CRC in Spain are described using SMRs. We conclude that during the study period, the geographic pattern of mortality in Spain did not coincide with the excess risk of mortality calculated using the SMR method described by Jarman and Foster. This method of risk estimation can be a useful tool for the study of mortality risk and its spatial variations.

[Cambios en la salud sexual de los pacientes obesos tras cirugía bariátrica]

Introducción

Los objetivos del estudio fueron: 1) evaluar la salud sexual en pacientes con obesidad grave/mórbida candidatos a cirugía bariátrica; y 2) valorar la evolución de la salud sexual tras 12 meses de la cirugía.

Método

Estudio descriptivo, prospectivo desde febrero de 2011 hasta junio de 2014. Se valoró la actividad sexual en los hombres a través del cuestionario EVAS-H y la función sexual en la mujer a través de la escala FSM (44 pacientes).

Resultados

Durante el estudio basal en los hombres, un 21% de la muestra presentó disfunción sexual en diferentes dimensiones, mientras que un 43% presentó problemas de eyaculación precoz. Tras 12 meses de la intervención, se observó un incremento de la actividad sexual global (p = 0.026). En torno al 70-89% de las mujeres, previamente a la cirugía, no presentaban trastorno. En la evolución no se observaron cambios medios relevantes (p > 0.05).

Conclusiones

Los pacientes con obesidad grave/mórbida candidatos a cirugía bariátrica presentan alteraciones considerables en diversas dimensiones de la salud sexual. Después de 12 meses de seguimiento, la salud sexual parece mejorar en los hombres.

Introduction

The aims of the study were: 1) to assess sexual health patients severe/morbid obesity patients candidates for bariatric surgery; and 2) to assess sexual health evolution after 12 months of surgery.

Method

Descriptive, prospective study from February 2011 to June 2014. Sexual activity in men was valued through EVAS-H questionnaire and through FSM scale on women (44 patients).

Results

During the basal study in men, a 21% of the sample showed sexual disfunction in different dimensions, while a 43% showed problems with premature ejaculation. 12 months after surgery, global sexual activity was improved significantly (p = 0,026). Approximately 70-89% of women presented no disturbance before surgery. No average relevant changes were observed within the evolution (p > 0.05).

Conclusions

Morbid/severe obesity patients candidates to bariatric surgery, show considerable alterations on diverse sexual health dimensions. After 12 months following bariatric surgery, men’s sexual health appears to improve.

Analysis and description of disease-specific quality of life in patients with anal fistula

INTRODUCTION

In patients diagnosed with anal fistula, knowing the quality of life specifically related to the disease can help coloproctology specialists to choose the most appropriate therapeutic strategy for each case. The aim of our study is to analyzse and describe the factors related to the specific quality of life in a consecutive series of patients diagnosed with anal fistula.

METHODS

Observational, cross-sectional study carried out from March 2015 to February 2017. All patients were assessed in the colorectal surgery unit of a hospital in southeast of Spain. After performing an initial anamnesis and a physical examination, patients diagnosed with anal fistula completed the Quality of Life in Ppatients with Anal Fistula Questionnaire (QoLAF-Q). This questionnaire specifically measures quality of life in people with anal fistula and its score range is the following: zero impact = 14 points, limited impact = 15 to 28 points, moderate impact = 29 to 42 points, high impact = 43 to 56 points, and very high impact = 57 to 70 points.

RESULTS

A total of 80 patients were included. The median score obtained in the questionnaire for the sample studied was 34.00 (range=14-68). Statistically significant differences between patients with "primary anal fistula" (n=65) and "recurrent anal fistula" (n=15) were observed (mean rank=42.96 vs. mean rank=29.83, p=0.048). Furthermore, an inverse proportion (P=.016) between "time with clinical symptoms" and "impact on quality of life" was found (<6 months: mean rank = 45.55; 6-12 months: mean rank = 44.39; 1-2 years: mean rank = 37.83; 2-5 years: mean rank = 22; >5 years: mean rank = 19.00). There were no statistically significant differences (P=.149) between quality of life amongst patients diagnosed with complex (mean rank = 36.13) and simple fistulae (mean rank = 43.59).

CONCLUSIONS

Anal fistulae exert moderate-high impact on patients' quality of life. "Shorter time experiencing clinical symptoms" and the "presence of primary fistula" are factors that can be associated with worse quality of life.

Sexual satisfaction following bariatric surgery: A prospective exploratory study

INTRODUCTION

Bariatric surgery improves sexual function in obese individuals, although the extent to which sexual satisfaction is improved following surgery is unknown. The aims of this study were 1) to describe sexual satisfaction in severely/morbidly obese men and women candidates for bariatric surgery; 2) to assess the effects of bariatric surgery on sexual satisfaction at 12-months follow-up; and 3) to assess whether weight changes at follow-up following bariatric surgery are associated with changes in sexual satisfaction.

METHODS

We conducted a prospective observational study from February 2011 to June 2014. A total of 44 patients with severe/morbid obesity participated in the study. Sexual satisfaction was assessed (at baseline and 12-months follow-up) through the Index of Sexual Satisfaction (ISS) questionnaire.

RESULTS

Of 44 patients who completed the ISS at baseline (mean age 40.3 [SD=9.4] years and BMI 46.9 [SD=6.2] kg/m²), 17 were lost to follow-up. The baseline ISS total scores were 32.0 (SD=20.1) in women and 24.4 (SD=16.0) in men (P>0.05). The proportion of sexually satisfied men and women at baseline was 62.5% and 46.4%, respectively (P=0.360). At follow-up, sexual satisfaction improved significantly in women (average difference 13.7 units; P=0.032) but not in men (average difference 3.6 units; P=0.717). The percentage of women with sexual satisfaction problems was reduced by 33% at follow-up (P=0.038).

CONCLUSIONS

A relatively large percentage of severely/morbidly obese women and men present clinically significant sexual satisfaction problems before undergoing bariatric surgery. Sexual satisfaction improves significantly 12 months following bariatric surgery, particularly in women.

Influence of psychological variables in morbidly obese patients undergoing bariatric surgery after 24 months of evolution

BACKGROUND

Bariatric surgery is considered a more effective means of achieving weight loss than non-surgical options in morbid obesity. Rates of failure or relapse range from 20 to 30%. The study aims to analyse the influence of psychological variables (self-esteem, social support, coping strategies and personality) in the maintenance of weight loss after bariatric surgery.

METHODS

A cohort study was conducted involving 64 patients undergoing bariatric surgery for 24 months. At the end of the follow-up period, patients were divided into 2sub-cohorts classified as successes or failures. Success or favorable development was considered when the value of percent excess weight loss was 50 or higher.

RESULTS

No statistically significant differences were observed between the 2groups in any variable studied. All patients had high self-esteem (87,3 those who failed and 88,1 those who are successful) and social support (90,2 and 90,9). Patients who succeed presented higher scores for cognitive restructuring (57,1) and were more introverted (47,1), while those who failed scored more highly in desiderative thinking (65,7) and were more prone to aggression (50,7) and neuroticism (51,7).

CONCLUSIONS

High self-esteem and social support does not guarantee successful treatment. The groups differed in how they coped with obesity but the data obtained do not justify the weight evolution. In the absence of psychopathology, personality trait variability between patients is insufficient to predict the results.

Transanal endoscopic microsurgery for the treatment of uncommon rectal lesions

INTRODUCTION

Transanal endoscopic microsurgery (TEM) was developed as a less aggressive alternative treatment for rectal lesions (mainly adenomas and adenocarcinomas). However, its use for other rectal lesions has become more frequent, trying to reduce the morbidity associated with more invasive techniques. The aim of this study is to describe our experience in the use of TEM in other rectal lesions.

METHODS

Retrospective and descriptive study including patients operated with TEM (from June 2008 to December 2016) for the treatment of rectal lesions different from adenomas or adenocarcinomas.

RESULTS

Among the 138 patients treated by TEM in our department, 10 patients were operated on for rectal lesions other than adenomas or adenocarcinomas. Rectal lesions were 3neuroendocrine tumours, a neuroendocrine tumour metastasis, a rectal stenosis, a cloacogenic polyp, an endometrioma, a retrorrectal tumour, a presacral abscess and a lesion in the rectovaginal septum. Mean operative time was 72min and postoperative stay was 4.2 days. Only one patient needed a reoperation, due to rectal bleeding.

CONCLUSIONS

TEM could be a useful tool for the treatment of rectal lesions different from adenomas or adenocarcinomas, potentially decreasing the morbidity associated with more aggressive surgical techniques.

Complicated diverticular disease: Position statement on outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage and laparoscopic approach. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons

The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed.

Using autologous platelet-rich plasma for the treatment of complex fistulas

OBJECTIVE

This study aims to demonstrate the effectiveness and safety of autologous fibrin gel rich in platelet growth factors for the treatment of complex perianal fistulas.

MATERIAL AND METHODS

Prospective epidemiological study. Patients with complex perianal fistula or perianal fistula mere alteration of continence are included. identification of both holes and the journey, curettage of it and instillation of Vivostat PRF® in the way it is done to observe excess material by OFE. The variables analyzed were: age, sex, use of prior Seton clinic prevalent type of fistula, postoperative complications, fistula closure and impaired quality of life using the SF-36 test (v2).

RESULTS

From January 2011 to May 2013 have involved 23 patients, 12 men and 11 women, with an average age of 49 years and a minimum follow-up of 12 months. Two dropped out. 17 patients had low transsphincteric fistulas, 2 and 2 high transsphincteric intersphincteric with impaired continence. The most common symptom is the discharge. Twelve patients had a loose seton (62%), of which nine cured. Of all the patients we have operated the success rate is 62%. No patient developed incontinence after treatment. Only two reported a worse quality of life after surgery.

CONCLUSION

This study demonstrates that there is a clear benefit to the use of Vivostat PRF® as a treatment for complex perianal fistulas. It is a highly reproducible technique with acceptable results and does not produce impairment of continence.

[Revision bariatric surgery after endoscopic sleeve gastroplasty]

BACKGROUND

Attempts are being made in recent years to replace open surgery with endoscopic techniques in some obese patients when medical treatment fails, as they are considered to be less-invasive procedures. To date, there is little scientific evidence regarding their effectiveness.

CLINICAL CASES

The cases are reported of 2 patients who attended our surgery looking for an effective bariatric surgical treatment after failed endoscopic sleeve gastroplasty.

CONCLUSIONS

Laparoscopic sleeve gastrectomy after failure of an endoscopic technique does not offer great variation from the standard technique.

Use of Barbed Sutures in Bariatric Surgery. Review of the Literature

Performing intracorporeal anastomoses and sutures is possibly the technique that requires the greater skill in laparoscopy. The emergence of new barbed sutures seems to facilitate the practice, with bariatric surgery (mainly in mixed and malabsorptive techniques) being one of the specialties that can most benefit from them. This review aims to evaluate barbed sutures' use and safety in bariatric surgery. Barbed sutures might facilitate the practice by improving some aspects of surgery such as reproducibility and operative time, although further research is needed.

[Outcomes, controversies and gastric volume after laparoscopic sleeve gastrectomy in the treatment of obesity]

BACKGROUND

Laparoscopic sleeve gastrectomy is a surgical procedure for the treatment of morbid obesity. However, there are still controversies regarding its efficiency in terms of weight reduction and incidence of complications. In this prospective study, the experience is presented of a referral centre for the treatment of morbid obesity with laparoscopic sleeve gastrectomy.

MATERIAL AND METHODS

A prospective study on 73 patients subjected to laparoscopic sleeve gastrectomy from February 2009 to September 2013. Patients were followed-up for a period of 12 months, evaluating the development of complications, reduction of gastric volume, and the weight loss associated with the surgery, as well as their impact on the improvement of comorbidities present at beginning of the study.

RESULTS

There was a statistically a significantly reduction between the preoperative body mass index (BMI) and the BMI at 12 months after laparoscopic sleeve gastrectomy (p < 0.001), despite there being an increase in the gastric volume during follow-up, measured at one month and 12 months after surgery (p < 0.001). Five patients (6.85%) had complications, with none of them serious and with no deaths in the whole series.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is a safe and effective technique for the treatment of morbid obesity. Its use is associated with a significant reduction in the presence of comorbidities associated with obesity. Multicentre studies with a longer period of monitoring are required to confirm the efficacy and safety of this surgical technique.

Barbed sutures in general and digestive surgery. Review

The appearance of new barbed sutures is an advance in making knots and anastomosis, mainly in laparoscopic surgery, where the majority of the surgeons find themselves limited dealing with these sutures. Through this review we aim to evaluate both the use and the safety of the sutures in General and Laparoscopic Surgery. Barbed sutures seem to ease the procedures improving key aspects such as reproducibility and operative time.

[Making easier what is difficult: continuous suture in intracorporeal anastomosis]

Bariatric surgery requires a high level of training and detailed knowledge of advanced laparoscopy, especially when carrying out intracorporeal anastomosis. The following presentation shows two examples used by our group, which consists of slipknots done at the beginning and the end of the thread that allows us to do the suture quickly and securely.