Antonio Lacy - Academia.edu (original) (raw)

Papers by Antonio Lacy

Clinical nutrition (Edinburgh, Scotland)

BACKGROUND & AIM: Since current protein intake (PI) recommendations for the bariatric surgery (BS... more BACKGROUND & AIM: Since current protein intake (PI) recommendations for the bariatric surgery (BS) patient are not supported by conclusive evidence, we aimed to evaluate the relationship between PI and lean tissue mass (LTM) loss following BS. METHODS: Observational study including patients undergoing gastric bypass (GBP; n = 25) or sleeve gastrectomy (SG; n = 25). Dietary advice and daily PI were assessed prior to, and at 2- and 6-weeks, 4-, 8-, and 12-months after surgery. Body composition was assessed by dual energy X-ray absorptiometry (DXA). LTM loss as percent of weight loss (%LTM loss) at 4- and 12-months after surgery were the main outcome variables. RESULTS: A PI ≥ 60 g/d was associated with lower %LTM loss at 4- (p = 0.030) and 12-months (p = 0.013). Similar results were obtained when a PI ≥ 1.1 g/kg of ideal body weight (IBW)/d was considered. Multilinear regression showed the only independent predictor of %LTM loss at 4-months was PI (expressed as g/kg IBW/d) (OR: -0.376...

Gastrointestinal Endoscopy, 2015

On-demand insufflation during endoscopic peritoneoscopy causes wide variations in intra-abdominal... more On-demand insufflation during endoscopic peritoneoscopy causes wide variations in intra-abdominal pressure. Its effects on splanchnic microcirculation may differ from those of steady intra-abdominal pressure, because pressure characteristics affect crucial intravascular hemodynamic forces-pressure and shear-adapting flow to local metabolic needs. Our aim was to assess the effect of natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy on splanchnic microcirculatory blood flow. Twenty-one swine were randomized to the following: cholecystectomy by transgastric NOTES (n = 8), cholecystectomy by standard laparoscopy (Lap) (n = 8), and a sham group (n = 5). During NOTES, CO2 was manually insufflated with a maximum allowed pressure of 30 mm Hg. In the Lap group, intra-abdominal pressure was maintained at 14 mm Hg. Systemic hemodynamics were measured, and microcirculatory blood flow was quantified by using colored microspheres. Mean intra-abdominal pressure was lower in NOTES than in the Lap group (P = .038). In both groups, cardiac index and preload remained unchanged, whereas systemic vascular resistances increased over time, with a lesser increase in the Lap group (2-way analysis of variance; P = .041). In pneumoperitoneum groups, microcirculatory blood flow decreased similarly in the renal medulla, stomach, small bowel, colon, and mesocolon by 30%, 45%, 34%, 32%, and 37%, respectively. In NOTES, there was a greater microcirculatory blood flow decrease in the renal cortex (NOTES 41% vs Lap 35%; P = .044) and mesentery (NOTES 44% vs Lap 38%; P = .041). These findings suggest that both types of pneumoperitoneum have similar physiologic effects on microcirculatory blood flow. However, on-demand pneumoperitoneum (NOTES group) caused a greater microcirculatory blood flow decrease in areas with low metabolic needs, redistributing blood flow toward metabolically active areas.

Surgery for Obesity and Related Diseases

Context Mechanisms underlying variable weight loss (WL) response following Roux-en-Y gastric bypa... more Context Mechanisms underlying variable weight loss (WL) response following Roux-en-Y gastric bypass (RYGB) are poorly understood. Objective To compare gastrointestinal hormonal responses to meal intake, and fasting plasma concentrations of surrogate markers of enterocyte mass and bile acid effect between subjects with failed (F-WL) or successful WL (S-WL) after RYGB. Setting University Hospital, Spain. Participants Cross-sectional study including 30 non-diabetic subjects, evaluated at ≥24 months after RYGB. Cases (F-WL; n=10) and controls (S-WL; n=20) were selected based on percent excess WL (%EWL) <50% or ≥50% from 12 months onwards after surgery. Groups were matched for gender, age, pre-surgical BMI, and length of follow up. Glucagon-like peptide 1 (GLP-1), peptide YY (PYY), GLP-2, and ghrelin responses to a meal challenge, and fasting plasma concentrations of citrulline and serum fibroblast growth factor 19 (FGF-19) were compared. Results F-WL subjects presented lesser suppres...

Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 2012

Wernicke encephalopathy--a debilitating acute or subacute neurological disorder-is caused by a de... more Wernicke encephalopathy--a debilitating acute or subacute neurological disorder-is caused by a deficiency in thiamine (vitamin B(1)). It is characterized by a classical clinical triad of symptoms: ocular impairment, cerebellar dysfunction, and confusion. Although bariatric surgery can certainly improve the overall health of an obese individual, it can also make him or her more susceptible to serious nutrition deficiencies. Following surgery, inadequate caloric intake, rapid and excessive weight loss, food intolerance, lack of adherence to nutrition supplementation, and/or the onset of prolonged vomiting can lead to severe nutrition deficiencies. It is generally believed that the more malabsorptive the surgery proves, the more likely is it that such a deficiency will occur. The case presented here shows that after sleeve gastrectomy (SG), a patient may also develop dangerous nutrition deficits that can negatively affect his or her life. In this particular case, a patient presented wi...

Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery

Residual beta-cell function and gastrointestinal hormones have been suggested as relevant determi... more Residual beta-cell function and gastrointestinal hormones have been suggested as relevant determinants of improved glycemic control ensuing Roux-en-Y gastric bypass (RYGB). The objective of this study was to compare the glycemic control up to 24 months after RYGB in C-peptide negative morbidly obese (MO) type 1 diabetes mellitus (T1 DM) women (n = 7) and C-peptide positive (>.6 ng/mL) MO women with type 2 diabetes mellitus (T2 DM, n = 7) on basal-bolus insulin therapy. The glucagon-like peptide 1 (GLP-1) and glucagon response to a mixed meal challenge were also compared between groups. Percent excess weight loss (%EWL), HbA1c, and daily insulin dose (DID) after RYGB were compared between groups. The GLP-1 and glucagon response (area under the curve 0-120 minutes) after a mixed meal at last follow-up visit were also compared. At 24-months, marked %EWL was observed in women with T1 DM and women with T2 DM (mean±standard error, 82.6% ± 11.3% and 87.4% ± 30.5%, respectively; P = .722...

Cirugía Española, 2014

One of the most controversial areas in laparoscopic approach is rectal cancer, not only because o... more One of the most controversial areas in laparoscopic approach is rectal cancer, not only because of the surgical technique but of the best approach to do it. The transanal approach arises like a new alternative for rectal cancer and other rectal pathologies due to solve some of the problems that we can find in conventional laparoscopic approach, mainly in low rectal cancer for the section of the rectum and distal margin. The first case of rectal cancer surgery by transanal approach was published in 2009. Since now, just a few series with a limited number of patients has been done with this technique. Among the different series there are differences, especially with the surgical technique (mainly with the transanal platform). Nowadays, the morbidity and postoperative outcomes have are comparable with the conventional approach. The oncological outcomes have no shown any differences, even long term results are not known at the moment (longer follow-up of 21 months). The results published in transanal approach surgery demonstrate the feasibility and safety of the procedure with an advantage in hostile pelvis (obese, narrow pelvis and males). Randomized studies are needed for long-term functional and oncological outcomes.

British Medical Journal, 2006

Objectives To test the hypothesis that, on average, male surgeons are taller and better looking t... more Objectives To test the hypothesis that, on average, male surgeons are taller and better looking than male physicians, and to compare both sets of doctors with film stars who play doctors on screen. Design Comparative study. Setting Typical university hospital in Spain, located in Barcelona and not in a sleepy backwater. Participants Random sample of 12 surgeons and 12 physicians

Cirugía Española, 2003

Material y métodos. Dos encuestas de opinión. Una remitida a todos los miembros de la AEC en abri... more Material y métodos. Dos encuestas de opinión. Una remitida a todos los miembros de la AEC en abril de 2003. Incluía aspectos generales y situaciones clínicas. La otra se remitió a todos los servicios de cirugía del país e incluía aspectos sobre dotación e implantación de la CL.

Surgery for Obesity and Related Diseases, 2014

Background: There is scarce information about predictive factors of hypertension (HT) remission a... more Background: There is scarce information about predictive factors of hypertension (HT) remission after bariatric surgery (BS). The aims of this study were to determine the clinical characteristics differentiating obese patients with and without HT and to evaluate the predictive factors associated with the risk of persistence of HT after BS. of patients who had undergone BS was performed. Patients were classified as hypertensive if having permanent use of antiHT drugs or clinical BP Z140/90 mm Hg. Weight, waist circumference (WC), and blood pressure were determined with standardized procedures. Results: Five hundred twenty-6 patients met the inclusion criteria; 264 (50%) were hypertensive, 74 (34%) of whom had type 2 diabetes. Before BS, older age, male gender, and greater WC differentiated hypertensive from normotensive patients. The prevalence of HT significantly fell to 35% (P o .0001) at 12 months after BS. The use of multivariate logistic regression showed that age Z40, male gender and WC Z130 cm were significant predictors of having HT before surgery. Regarding persistence of HT at the 12-month follow-up, the only independent predictors observed were time since diagnosis of HT Z10 years and the number of antiHT drugs used. Presurgical BMI, WC, excess weight (EW), EW loss, surgical procedure, type 2 diabetes, and vitamin D status were not significant predictors. Conclusions: Bariatric surgery is associated with a high rate of HT remission. Older age, male gender, and higher WC differentiated hypertensive-obese from normotensive patients. After BS, longer duration and severity of HT were independently associated with no remission of HT. (Surg Obes Relat Dis 2014;]:00-00.) r

Obesity Surgery, 2014

Background Despite the health benefits of bariatric surgery (BS) extend beyond WL, better underst... more Background Despite the health benefits of bariatric surgery (BS) extend beyond WL, better understanding of the WL response may help improve the outcomes of BS. In this context, we aimed to assess patterns within the variability of weight loss (WL) after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Methods WL data from 658 subjects that underwent RYGB (n=464) or SG (n=194) as first BS were analyzed. Based on excess WL (EWL), subjects were categorized as good WL responders (EWL≥50 % at nadir weight and throughout follow-up), primarily poor WL responders (1-PWL:EWL<50 % at nadir weight and thereafter), and secondarily poor WL responders (2-PWL:EWL≥50 % at nadir weight, but <50 % at last follow-up visit). Predictors associated with different WL outcomes were ascertained using regression analysis. Results Median follow-up was 55.7 months. Nadir EWL ranged 12.4-143.6 %; last follow-up visit EWL ranged −22.1-143.6 % and weight regain (WR) ranged 0-64.1 kg. Good WL was found in 75.7 of the cohort. 1-PWL response (4.7 %) was characterized by lesser WL but similar WR as compared to good WL and was associated with larger BMI and diabetes prior to surgery. 2-PWL response (19.6 %) was characterized by larger WR as compared to the other groups and was more common following SG. Lesser percentage of medical appointments kept was associated with 1-PWL and 2-PWL. Conclusion Our data show the high inter-individual variability of the WL response at mid-term after RYGB and SG and that poor WL after BS could be illustrated by two different patterns, characterized either by sustained limited WL (1-PWL), or pronounced weight regain (2-PWL).

Diabetes, 2014

Although GLP-1 has been suggested as a major factor for the marked improvement of glucose toleran... more Although GLP-1 has been suggested as a major factor for the marked improvement of glucose tolerance commonly seen after sleeve gastrectomy (SG), several observations challenge this hypothesis. To better understand the role of GLP-1 in the remission of type 2 diabetes mellitus (T2DM) long term after SG in humans, we conducted two separate cross-sectional studies: 1) the GLP-1 response to a standardized mixed liquid meal (SMLM) was compared in subjects with T2DM antedating SG but with different long-term (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;2 years) T2DM outcomes (remission, relapse, or lack of remission) (study 1) and 2) the effect of GLP-1 receptor blockade with exendin (9-39) on glucose tolerance was examined in subjects with T2DM antedating surgery, who had undergone SG and presented with long-term T2DM remission (study 2). In study 1, we observed a comparable GLP-1 response to the SMLM regardless of the post-SG outcome of T2DM. In study 2, the blockade of GLP-1 action resulted in impaired insulin secretion but limited deterioration of glucose tolerance. Thus, our data suggest the enhanced GLP-1 secretion observed long term after SG is neither sufficient nor critical to maintain normal glucose tolerance in subjects with T2DM antedating the surgery.

Journal of the Academy of Nutrition and Dietetics, 2013

Data on long-term dietary changes and nutritional deficiencies after sleeve gastrectomy (SG) in g... more Data on long-term dietary changes and nutritional deficiencies after sleeve gastrectomy (SG) in grade 3 obese patients are scarce. To prospectively compare dietary changes and nutritional deficiencies in grade 3 obese patients 5 years after SG and Roux-en-y gastric bypass (GBP). Three hundred and fifty-five patients who had SG (n=61) or GBP (n=294) (May 2001-December 2006) at a Spanish university hospital. Longitudinal, prospective, observational study. PRIMARY OUTCOMES/STATISTICAL ANALYSES: Changes in energy, macronutrient, and micronutrient intake, and weight loss were analyzed using mixed models for repeated measurements. At the 5-year follow-up visit, the percentage of excess weight loss (P=0.420) and daily energy intake (P=0.826), as well as the proportion of energy from carbohydrates (P=0.303), protein (P=0.600), and fat (P=0.541) did not differ between surgical groups. Energy intake (P=0.004), baseline weight (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), and time period (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), but not the proportion of different macronutrients or the type of surgery, independently predicted the percentage excess weight loss over time. After SG or GBP, the mean daily dietary intake of calcium, magnesium, phosphorus, and iron was less than the current recommendations. Despite universal supplementation, the prevalence of nutritional deficiencies was comparable after SG or GBP, with 25-hydroxyvitamin D being the most commonly observed deficiency (SG, 93.3% to 100%; GBP, 90.9% to 85.7%, P=not significant). In an adjusted multivariate regression model, energy intake and lipid intake independently predicted plasma 25(OH)-vitamin D levels. Data show that SG and GBP are associated with similar long-term weight loss with no differences in terms of dietary intake. Furthermore, data demonstrate that both types of surgeries carry comparable nutritional consequences.

Cirugía Española, 2014

The major goal of surgical treatment in morbid obesity is to decrease morbidity and mortality ass... more The major goal of surgical treatment in morbid obesity is to decrease morbidity and mortality associated with excess weight. In this sense, the main factors of death are cardiovascular disease and metabolic syndrome. The objective of this study is to evaluate the effects of gastric bypass on cardiovascular risk estimation in patients after bariatric surgery. We retrospectively evaluated pre and postoperative cardiovascular risk estimation of 402 morbidly obese patients who underwent laparoscopic gastric bypass. The major variable studied is the cardiovascular risk estimation that is calculated preoperatively and after 12 months. Cardiovascular risk estimation analysis has been performed with the REGICOR Equation. REGICOR formulation allows calculating a 10 year risk of cardiovascular events adapted to the Spanish population and is expressed in percentages. We reported an overall 4.1±3.0 mean basal REGICOR score. One year after the operation, cardiovascular risk estimation significantly decreased to 2,2±1,6 (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). In patients with metabolic syndrome according to ATP-III criteria, basal REGICOR score was 4.8±3.1 whereas in no metabolic syndrome patients 2.2±1.8. Evaluation 12 months after surgery, determined a significant reduction in both groups (metabolic syndrome and non metabolic syndrome) with a mean REGICOR score of 2.3±1.6 and 1.6±1.0 respectively. The results of our study demonstrate favorable effects of gastric bypass on the cardiovascular risk factors included in the REGICOR equation.

Transplantation, 1995

The aim of this prospective study is to evaluate prostanoid (prostacyclin and thromboxane) and li... more The aim of this prospective study is to evaluate prostanoid (prostacyclin and thromboxane) and lipid peroxide levels at the portal and hepatic veins, and their relation to immediate postoperative liver function. Nineteen patients with liver cirrhosis undergoing orthotopic liver transplantation were prospectively studied. Blood samples were obtained within 5 min and 1 and 2 hr after reperfusion of the new liver, through a catheter placed at the portal vein in the recipient and another at the left hepatic vein in the donor liver. Plasma prostacyclin and thromboxane were analyzed by HPLC and RIA. The formation of lipid peroxides was determined and expressed in terms of thiobarbituric acid-reacting substances. Immediate postoperative liver function was evaluated using the transaminase levels within the first 48 hr and the early postoperative graft function score, as described previously. After reperfusion, only determinations at 5 min were related with liver function. Either prostacyclin (R = -0.61, P = 0.004) levels at the hepatic vein or prostacyclin production (subtraction between hepatic and portal vein levels) (R = -0.47, P = 0.04) correlated significantly with the early postoperative graft function score. Besides, there was a significant relationship between lipid peroxide production as measured by thiobarbituric acid-reacting substances and a worse early postoperative graft function score (R = 0.61, P = .005). These results suggest that prostacyclin released after liver grafting attenuates preservation and reperfusion damage of the liver, supporting the hypothesis that there is an imbalance of prostanoids within the microvasculature in patients with a compromised postoperative liver function. Our results agree with the involvement of some degree of lipid peroxidation products in the damage of hepatocytes during anoxia and reperfusion.

Transplant International, 2001

Intrahepatic biliary lesions (IBL) are rare (2-9 %) after orthotopic liver transplantation (OLT).... more Intrahepatic biliary lesions (IBL) are rare (2-9 %) after orthotopic liver transplantation (OLT). The aim was to evaluate the incidence, etiology and outcome. In nine years, a total 532 OLTs were performed in 481 patients. Twentyfour patients developed IBL. Eight were due to HAT, seven to ABOI, three to CDR and six to PI. The time until diagnosis of HAT is longest in patients (14 ? 6) with IBL. ABOI is another cause of IBL. CDR is a rare cause of IBL, however when it takes place, patients must undergo Rtx. Finally, PI is a relevant cause of IBL. In order to suppress the incidence of IBL we should consider 1) the systematic use of Dop-pler-Ultrasound; 2) emergency reoperation of patients with HAT, 3) avoid ABOI in OLT; 4) Rtx in cases of CDR, and 5) OLT should still be performed as an emergency procedure.

Surgical Endoscopy, 2010

The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal e... more The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal endoscopic rectosigmoid resection using transanal endoscopic microsurgery (TEM) was previously demonstrated in human cadavers and a porcine survival model. We report the first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance, performed by a team of surgeons from Barcelona and Boston with extensive experience with NOTES and minimally invasive approaches to colorectal diseases. Transanal endoscopic rectal resection with total mesorectal excision using the TEM platform was performed in a 76-year-old woman with a T2N2 rectal cancer treated with preoperative chemoradiation. Laparoscopic visualization and assistance with retraction and exposure during rectosigmoid mobilization was provided through one 5-mm port, which was later used as the stoma site, and 2-mm needle ports, one of which was used as a drain site. The specimen was transected transanally followed by handsewn coloanal anastomosis. The procedure was completed successfully with an operative time of 4 hours and 30 minutes. Mesorectal excision was complete. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology demonstrated pT1N0 with 23 negative lymph nodes and negative proximal, distal, and radial margins. NOTES transanal endoscopic rectosigmoid resection using TEM and laparoscopic assistance is feasible and safe. Careful patient selection and improvement in NOTES instrumentation are critical to optimize this approach before widespread clinical application.

Surgical Endoscopy, 2012

Bariatric surgery (BS) is widely accepted for the treatment of patients with morbid obesity (MO).... more Bariatric surgery (BS) is widely accepted for the treatment of patients with morbid obesity (MO). We aimed to determine presurgical predictors of and surgical technique-related differences in excess weight loss (EWL) 1 year after BS. This retrospective study included 407 subjects (F/M 3:1, median age = 44 years) who underwent laparoscopic Roux-en-Y gastric bypass (RYGB, n = 307) or sleeve gastrectomy (SG, n = 100) at our University Hospital and were evaluated 1 year after surgery. Baseline median (min-max) body mass index (BMI) was 47 kg/m(2) (range = 36-71). BMI was higher in the SG than in the RYGB group (53 vs. 46 kg/m(2), p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). Simple correlation analysis showed negative associations between EWL and age, BMI, waist circumference (WC), fasting glucose, HbA1c, triglycerides (TG), blood pressure, and total cholesterol (all p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01). EWL (mean ± SD) did not differ by gender (p = 0.2), was lower in diabetic than in nondiabetic subjects (71 ± 17% vs. 79 ± 17%, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), and higher in the RYGB vs. SG group (76 ± 18% vs. 68 ± 15%, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). However, SG vs. RYGB differences in EWL disappeared (p = 0.4) after taking into account baseline BMI. Multiple regression and logistic analysis showed that younger individuals with lower BMI but higher WC, and lower HbA1c and TG, had higher EWL and a higher rate of successful (EWL ≥ 60%) weight loss. Our data indicate that some of the characteristics that would have subjects referred early for BS were associated with higher weight loss. Therefore, the timing of laparoscopic BS might be an important factor for MO individuals in which medical weight loss intervention has failed.

Surgical Endoscopy, 2013

Despite obesity being closely associated with two common risk factors for albuminuria, namely typ... more Despite obesity being closely associated with two common risk factors for albuminuria, namely type 2 diabetes mellitus (T2DM) and hypertension, information on the impact of weight loss on albumin excretion rate in morbidly obese (MO) subjects is scarce. To evaluate the independent contribution of weight loss following bariatric surgery (BS) to the improvement of the albumin-to-creatinine ratio (ACR) in MO subjects with T2DM. Observational prospective study, including consecutive (n = 255) patients undergoing Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG) of whom 37.6 % (n = 96) presented with T2DM. Stepwise logistic regression analysis was used to assess the contribution of T2DM-related, hypertension-related, and weight loss-related variables, and type of surgery to normalization of ACR (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30 mg/g) at 12 and 24 months follow-up. In T2DM subjects, baseline ACR was 85.7 ± 171 mg/g with ACR ≥ 30 mg/g being present in 45.7 % of the cohort. At 12 months, the ACR significantly decreased in T2DM subjects (42.2 ± 142.8 mg/g; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.005) with no further reduction at 24 months after surgery (44.4 ± 227.7; p = 0.862). Among T2DM subjects with ACR ≥ 30 mg/g at baseline, the ACR became &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30 mg/g in 58.5 % and 76.9 % at 12 and 24 months, respectively (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001 relative to baseline). Body mass index (BMI) change from baseline was the only independent predictor of ACR normalization at 12 months [Exp(B) 1.373, 95 % confidence interval 1.075-1.703; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05]. None of the evaluated variables appeared as an independent predictor of ACR normalization at 24 months. Our data suggest that, in MO subjects with T2DM, interventions aiming at slowing the progression of nephropathy should not only focus on optimization of glucose and blood pressure control but also include effective weight loss strategies.

Surgery for Obesity and Related Diseases, 2014

Mechanisms underlying variable weight loss (WL) response after Roux-en-Y gastric bypass (RYGB) ar... more Mechanisms underlying variable weight loss (WL) response after Roux-en-Y gastric bypass (RYGB) are poorly understood. The objective of this study was to compare gastrointestinal hormonal responses to meal intake, and fasting plasma concentrations of surrogate markers of enterocyte mass and bile acid effect between patients with failed (F-WL) or successful WL (S-WL) after RYGB. Cross-sectional study including 30 nondiabetic patients, evaluated at≥24 months after RYGB. Cases (F-WL; n = 10) and controls (S-WL; n = 20) were selected based on percent of excess WL (%EWL)&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;50% or≥50% from 12 months onwards after surgery. Groups were matched for gender, age, presurgical BMI, and length of follow up. Glucagon-like peptide 1 (GLP-1), peptide YY (PYY), GLP-2, and ghrelin responses to a meal challenge, and fasting plasma concentrations of citrulline and serum fibroblast growth factor 19 (FGF-19) were compared. F-WL patients presented lesser suppression of ghrelin (incremental area under the curve [iAUC]: F-WL -12490±6530 versus S-WL -31196±4536 pg×mL(-1)×min; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.01), and lesser increase in the GLP-1 (iAUC: F-WL 3354±737 versus S-WL 5629±542 pmol×L(-1)×min; P = .02) but not in the PYY and GLP-2, response to meal intake. Citrulline concentrations were significantly correlated with time after surgery (rho = .537; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.01). However, citrulline was higher in S-WL compared to F-WL patients (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.05). Serum FGF-19 concentration was similar between groups. Although limited by the cross-sectional design, our data suggest a role of some gastrointestinal hormones as mediators of successful weight loss but argues against larger enterocyte mass after BS as determinant of failed weight loss after RYGB.

Obesity Surgery, 2008

Anastomotic strictures after bariatric surgery are a frequent complication that requires endoscop... more Anastomotic strictures after bariatric surgery are a frequent complication that requires endoscopic management, but the optimal technique for dilation remains to be determined. The aim of this study was to evaluate the safety and efficacy of dilation with Savary-Gilliard bougies (SGB) in morbidly obese patients treated with laparoscopic Roux-en-Y gastric bypass (RYGBP). Retrospective review of prospectively collected data from a series of 474 consecutive patients with laparoscopic bariatric surgery. Four-hundred twenty four of these patients (90%) underwent a laparoscopic RYGBP. A total of 24 patients were referred for anastomotic stricture dilation with SGB from January 1998 to December 2006. A total of 24/424 patients (6%) developed a stricture that was successfully dilated with SGB. Patients were 17 females (71%) and seven males (29%) with a mean age of 41 +/- 11 years (range 24-63) and a mean BMI of 48 +/- 6 (range 40-69). The time between RYGBP and the appearance of stricture-related symptoms ranged from 29 to 154 days (mean, 69 days). The mean number of dilations was 1.6 +/- 0.6. The majority of patients required one (n = 11; 46%) or two (n = 12; 50%) dilations and only one patient required three dilations. During the initial dilation, a final diameter of 11 +/- 1.7 mm (range 7-12.8 mm) was achieved. In all cases, there was complete resolution of symptoms. There were no complications. Dilation with SGB is an effective, safe, and durable method for managing anastomotic strictures after laparoscopic RYGBP.

Clinical nutrition (Edinburgh, Scotland)

BACKGROUND & AIM: Since current protein intake (PI) recommendations for the bariatric surgery (BS... more BACKGROUND & AIM: Since current protein intake (PI) recommendations for the bariatric surgery (BS) patient are not supported by conclusive evidence, we aimed to evaluate the relationship between PI and lean tissue mass (LTM) loss following BS. METHODS: Observational study including patients undergoing gastric bypass (GBP; n = 25) or sleeve gastrectomy (SG; n = 25). Dietary advice and daily PI were assessed prior to, and at 2- and 6-weeks, 4-, 8-, and 12-months after surgery. Body composition was assessed by dual energy X-ray absorptiometry (DXA). LTM loss as percent of weight loss (%LTM loss) at 4- and 12-months after surgery were the main outcome variables. RESULTS: A PI ≥ 60 g/d was associated with lower %LTM loss at 4- (p = 0.030) and 12-months (p = 0.013). Similar results were obtained when a PI ≥ 1.1 g/kg of ideal body weight (IBW)/d was considered. Multilinear regression showed the only independent predictor of %LTM loss at 4-months was PI (expressed as g/kg IBW/d) (OR: -0.376...

Gastrointestinal Endoscopy, 2015

On-demand insufflation during endoscopic peritoneoscopy causes wide variations in intra-abdominal... more On-demand insufflation during endoscopic peritoneoscopy causes wide variations in intra-abdominal pressure. Its effects on splanchnic microcirculation may differ from those of steady intra-abdominal pressure, because pressure characteristics affect crucial intravascular hemodynamic forces-pressure and shear-adapting flow to local metabolic needs. Our aim was to assess the effect of natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy on splanchnic microcirculatory blood flow. Twenty-one swine were randomized to the following: cholecystectomy by transgastric NOTES (n = 8), cholecystectomy by standard laparoscopy (Lap) (n = 8), and a sham group (n = 5). During NOTES, CO2 was manually insufflated with a maximum allowed pressure of 30 mm Hg. In the Lap group, intra-abdominal pressure was maintained at 14 mm Hg. Systemic hemodynamics were measured, and microcirculatory blood flow was quantified by using colored microspheres. Mean intra-abdominal pressure was lower in NOTES than in the Lap group (P = .038). In both groups, cardiac index and preload remained unchanged, whereas systemic vascular resistances increased over time, with a lesser increase in the Lap group (2-way analysis of variance; P = .041). In pneumoperitoneum groups, microcirculatory blood flow decreased similarly in the renal medulla, stomach, small bowel, colon, and mesocolon by 30%, 45%, 34%, 32%, and 37%, respectively. In NOTES, there was a greater microcirculatory blood flow decrease in the renal cortex (NOTES 41% vs Lap 35%; P = .044) and mesentery (NOTES 44% vs Lap 38%; P = .041). These findings suggest that both types of pneumoperitoneum have similar physiologic effects on microcirculatory blood flow. However, on-demand pneumoperitoneum (NOTES group) caused a greater microcirculatory blood flow decrease in areas with low metabolic needs, redistributing blood flow toward metabolically active areas.

Surgery for Obesity and Related Diseases

Context Mechanisms underlying variable weight loss (WL) response following Roux-en-Y gastric bypa... more Context Mechanisms underlying variable weight loss (WL) response following Roux-en-Y gastric bypass (RYGB) are poorly understood. Objective To compare gastrointestinal hormonal responses to meal intake, and fasting plasma concentrations of surrogate markers of enterocyte mass and bile acid effect between subjects with failed (F-WL) or successful WL (S-WL) after RYGB. Setting University Hospital, Spain. Participants Cross-sectional study including 30 non-diabetic subjects, evaluated at ≥24 months after RYGB. Cases (F-WL; n=10) and controls (S-WL; n=20) were selected based on percent excess WL (%EWL) <50% or ≥50% from 12 months onwards after surgery. Groups were matched for gender, age, pre-surgical BMI, and length of follow up. Glucagon-like peptide 1 (GLP-1), peptide YY (PYY), GLP-2, and ghrelin responses to a meal challenge, and fasting plasma concentrations of citrulline and serum fibroblast growth factor 19 (FGF-19) were compared. Results F-WL subjects presented lesser suppres...

Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 2012

Wernicke encephalopathy--a debilitating acute or subacute neurological disorder-is caused by a de... more Wernicke encephalopathy--a debilitating acute or subacute neurological disorder-is caused by a deficiency in thiamine (vitamin B(1)). It is characterized by a classical clinical triad of symptoms: ocular impairment, cerebellar dysfunction, and confusion. Although bariatric surgery can certainly improve the overall health of an obese individual, it can also make him or her more susceptible to serious nutrition deficiencies. Following surgery, inadequate caloric intake, rapid and excessive weight loss, food intolerance, lack of adherence to nutrition supplementation, and/or the onset of prolonged vomiting can lead to severe nutrition deficiencies. It is generally believed that the more malabsorptive the surgery proves, the more likely is it that such a deficiency will occur. The case presented here shows that after sleeve gastrectomy (SG), a patient may also develop dangerous nutrition deficits that can negatively affect his or her life. In this particular case, a patient presented wi...

Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery

Residual beta-cell function and gastrointestinal hormones have been suggested as relevant determi... more Residual beta-cell function and gastrointestinal hormones have been suggested as relevant determinants of improved glycemic control ensuing Roux-en-Y gastric bypass (RYGB). The objective of this study was to compare the glycemic control up to 24 months after RYGB in C-peptide negative morbidly obese (MO) type 1 diabetes mellitus (T1 DM) women (n = 7) and C-peptide positive (>.6 ng/mL) MO women with type 2 diabetes mellitus (T2 DM, n = 7) on basal-bolus insulin therapy. The glucagon-like peptide 1 (GLP-1) and glucagon response to a mixed meal challenge were also compared between groups. Percent excess weight loss (%EWL), HbA1c, and daily insulin dose (DID) after RYGB were compared between groups. The GLP-1 and glucagon response (area under the curve 0-120 minutes) after a mixed meal at last follow-up visit were also compared. At 24-months, marked %EWL was observed in women with T1 DM and women with T2 DM (mean±standard error, 82.6% ± 11.3% and 87.4% ± 30.5%, respectively; P = .722...

Cirugía Española, 2014

One of the most controversial areas in laparoscopic approach is rectal cancer, not only because o... more One of the most controversial areas in laparoscopic approach is rectal cancer, not only because of the surgical technique but of the best approach to do it. The transanal approach arises like a new alternative for rectal cancer and other rectal pathologies due to solve some of the problems that we can find in conventional laparoscopic approach, mainly in low rectal cancer for the section of the rectum and distal margin. The first case of rectal cancer surgery by transanal approach was published in 2009. Since now, just a few series with a limited number of patients has been done with this technique. Among the different series there are differences, especially with the surgical technique (mainly with the transanal platform). Nowadays, the morbidity and postoperative outcomes have are comparable with the conventional approach. The oncological outcomes have no shown any differences, even long term results are not known at the moment (longer follow-up of 21 months). The results published in transanal approach surgery demonstrate the feasibility and safety of the procedure with an advantage in hostile pelvis (obese, narrow pelvis and males). Randomized studies are needed for long-term functional and oncological outcomes.

British Medical Journal, 2006

Objectives To test the hypothesis that, on average, male surgeons are taller and better looking t... more Objectives To test the hypothesis that, on average, male surgeons are taller and better looking than male physicians, and to compare both sets of doctors with film stars who play doctors on screen. Design Comparative study. Setting Typical university hospital in Spain, located in Barcelona and not in a sleepy backwater. Participants Random sample of 12 surgeons and 12 physicians

Cirugía Española, 2003

Material y métodos. Dos encuestas de opinión. Una remitida a todos los miembros de la AEC en abri... more Material y métodos. Dos encuestas de opinión. Una remitida a todos los miembros de la AEC en abril de 2003. Incluía aspectos generales y situaciones clínicas. La otra se remitió a todos los servicios de cirugía del país e incluía aspectos sobre dotación e implantación de la CL.

Surgery for Obesity and Related Diseases, 2014

Background: There is scarce information about predictive factors of hypertension (HT) remission a... more Background: There is scarce information about predictive factors of hypertension (HT) remission after bariatric surgery (BS). The aims of this study were to determine the clinical characteristics differentiating obese patients with and without HT and to evaluate the predictive factors associated with the risk of persistence of HT after BS. of patients who had undergone BS was performed. Patients were classified as hypertensive if having permanent use of antiHT drugs or clinical BP Z140/90 mm Hg. Weight, waist circumference (WC), and blood pressure were determined with standardized procedures. Results: Five hundred twenty-6 patients met the inclusion criteria; 264 (50%) were hypertensive, 74 (34%) of whom had type 2 diabetes. Before BS, older age, male gender, and greater WC differentiated hypertensive from normotensive patients. The prevalence of HT significantly fell to 35% (P o .0001) at 12 months after BS. The use of multivariate logistic regression showed that age Z40, male gender and WC Z130 cm were significant predictors of having HT before surgery. Regarding persistence of HT at the 12-month follow-up, the only independent predictors observed were time since diagnosis of HT Z10 years and the number of antiHT drugs used. Presurgical BMI, WC, excess weight (EW), EW loss, surgical procedure, type 2 diabetes, and vitamin D status were not significant predictors. Conclusions: Bariatric surgery is associated with a high rate of HT remission. Older age, male gender, and higher WC differentiated hypertensive-obese from normotensive patients. After BS, longer duration and severity of HT were independently associated with no remission of HT. (Surg Obes Relat Dis 2014;]:00-00.) r

Obesity Surgery, 2014

Background Despite the health benefits of bariatric surgery (BS) extend beyond WL, better underst... more Background Despite the health benefits of bariatric surgery (BS) extend beyond WL, better understanding of the WL response may help improve the outcomes of BS. In this context, we aimed to assess patterns within the variability of weight loss (WL) after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Methods WL data from 658 subjects that underwent RYGB (n=464) or SG (n=194) as first BS were analyzed. Based on excess WL (EWL), subjects were categorized as good WL responders (EWL≥50 % at nadir weight and throughout follow-up), primarily poor WL responders (1-PWL:EWL<50 % at nadir weight and thereafter), and secondarily poor WL responders (2-PWL:EWL≥50 % at nadir weight, but <50 % at last follow-up visit). Predictors associated with different WL outcomes were ascertained using regression analysis. Results Median follow-up was 55.7 months. Nadir EWL ranged 12.4-143.6 %; last follow-up visit EWL ranged −22.1-143.6 % and weight regain (WR) ranged 0-64.1 kg. Good WL was found in 75.7 of the cohort. 1-PWL response (4.7 %) was characterized by lesser WL but similar WR as compared to good WL and was associated with larger BMI and diabetes prior to surgery. 2-PWL response (19.6 %) was characterized by larger WR as compared to the other groups and was more common following SG. Lesser percentage of medical appointments kept was associated with 1-PWL and 2-PWL. Conclusion Our data show the high inter-individual variability of the WL response at mid-term after RYGB and SG and that poor WL after BS could be illustrated by two different patterns, characterized either by sustained limited WL (1-PWL), or pronounced weight regain (2-PWL).

Diabetes, 2014

Although GLP-1 has been suggested as a major factor for the marked improvement of glucose toleran... more Although GLP-1 has been suggested as a major factor for the marked improvement of glucose tolerance commonly seen after sleeve gastrectomy (SG), several observations challenge this hypothesis. To better understand the role of GLP-1 in the remission of type 2 diabetes mellitus (T2DM) long term after SG in humans, we conducted two separate cross-sectional studies: 1) the GLP-1 response to a standardized mixed liquid meal (SMLM) was compared in subjects with T2DM antedating SG but with different long-term (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;2 years) T2DM outcomes (remission, relapse, or lack of remission) (study 1) and 2) the effect of GLP-1 receptor blockade with exendin (9-39) on glucose tolerance was examined in subjects with T2DM antedating surgery, who had undergone SG and presented with long-term T2DM remission (study 2). In study 1, we observed a comparable GLP-1 response to the SMLM regardless of the post-SG outcome of T2DM. In study 2, the blockade of GLP-1 action resulted in impaired insulin secretion but limited deterioration of glucose tolerance. Thus, our data suggest the enhanced GLP-1 secretion observed long term after SG is neither sufficient nor critical to maintain normal glucose tolerance in subjects with T2DM antedating the surgery.

Journal of the Academy of Nutrition and Dietetics, 2013

Data on long-term dietary changes and nutritional deficiencies after sleeve gastrectomy (SG) in g... more Data on long-term dietary changes and nutritional deficiencies after sleeve gastrectomy (SG) in grade 3 obese patients are scarce. To prospectively compare dietary changes and nutritional deficiencies in grade 3 obese patients 5 years after SG and Roux-en-y gastric bypass (GBP). Three hundred and fifty-five patients who had SG (n=61) or GBP (n=294) (May 2001-December 2006) at a Spanish university hospital. Longitudinal, prospective, observational study. PRIMARY OUTCOMES/STATISTICAL ANALYSES: Changes in energy, macronutrient, and micronutrient intake, and weight loss were analyzed using mixed models for repeated measurements. At the 5-year follow-up visit, the percentage of excess weight loss (P=0.420) and daily energy intake (P=0.826), as well as the proportion of energy from carbohydrates (P=0.303), protein (P=0.600), and fat (P=0.541) did not differ between surgical groups. Energy intake (P=0.004), baseline weight (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), and time period (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), but not the proportion of different macronutrients or the type of surgery, independently predicted the percentage excess weight loss over time. After SG or GBP, the mean daily dietary intake of calcium, magnesium, phosphorus, and iron was less than the current recommendations. Despite universal supplementation, the prevalence of nutritional deficiencies was comparable after SG or GBP, with 25-hydroxyvitamin D being the most commonly observed deficiency (SG, 93.3% to 100%; GBP, 90.9% to 85.7%, P=not significant). In an adjusted multivariate regression model, energy intake and lipid intake independently predicted plasma 25(OH)-vitamin D levels. Data show that SG and GBP are associated with similar long-term weight loss with no differences in terms of dietary intake. Furthermore, data demonstrate that both types of surgeries carry comparable nutritional consequences.

Cirugía Española, 2014

The major goal of surgical treatment in morbid obesity is to decrease morbidity and mortality ass... more The major goal of surgical treatment in morbid obesity is to decrease morbidity and mortality associated with excess weight. In this sense, the main factors of death are cardiovascular disease and metabolic syndrome. The objective of this study is to evaluate the effects of gastric bypass on cardiovascular risk estimation in patients after bariatric surgery. We retrospectively evaluated pre and postoperative cardiovascular risk estimation of 402 morbidly obese patients who underwent laparoscopic gastric bypass. The major variable studied is the cardiovascular risk estimation that is calculated preoperatively and after 12 months. Cardiovascular risk estimation analysis has been performed with the REGICOR Equation. REGICOR formulation allows calculating a 10 year risk of cardiovascular events adapted to the Spanish population and is expressed in percentages. We reported an overall 4.1±3.0 mean basal REGICOR score. One year after the operation, cardiovascular risk estimation significantly decreased to 2,2±1,6 (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001). In patients with metabolic syndrome according to ATP-III criteria, basal REGICOR score was 4.8±3.1 whereas in no metabolic syndrome patients 2.2±1.8. Evaluation 12 months after surgery, determined a significant reduction in both groups (metabolic syndrome and non metabolic syndrome) with a mean REGICOR score of 2.3±1.6 and 1.6±1.0 respectively. The results of our study demonstrate favorable effects of gastric bypass on the cardiovascular risk factors included in the REGICOR equation.

Transplantation, 1995

The aim of this prospective study is to evaluate prostanoid (prostacyclin and thromboxane) and li... more The aim of this prospective study is to evaluate prostanoid (prostacyclin and thromboxane) and lipid peroxide levels at the portal and hepatic veins, and their relation to immediate postoperative liver function. Nineteen patients with liver cirrhosis undergoing orthotopic liver transplantation were prospectively studied. Blood samples were obtained within 5 min and 1 and 2 hr after reperfusion of the new liver, through a catheter placed at the portal vein in the recipient and another at the left hepatic vein in the donor liver. Plasma prostacyclin and thromboxane were analyzed by HPLC and RIA. The formation of lipid peroxides was determined and expressed in terms of thiobarbituric acid-reacting substances. Immediate postoperative liver function was evaluated using the transaminase levels within the first 48 hr and the early postoperative graft function score, as described previously. After reperfusion, only determinations at 5 min were related with liver function. Either prostacyclin (R = -0.61, P = 0.004) levels at the hepatic vein or prostacyclin production (subtraction between hepatic and portal vein levels) (R = -0.47, P = 0.04) correlated significantly with the early postoperative graft function score. Besides, there was a significant relationship between lipid peroxide production as measured by thiobarbituric acid-reacting substances and a worse early postoperative graft function score (R = 0.61, P = .005). These results suggest that prostacyclin released after liver grafting attenuates preservation and reperfusion damage of the liver, supporting the hypothesis that there is an imbalance of prostanoids within the microvasculature in patients with a compromised postoperative liver function. Our results agree with the involvement of some degree of lipid peroxidation products in the damage of hepatocytes during anoxia and reperfusion.

Transplant International, 2001

Intrahepatic biliary lesions (IBL) are rare (2-9 %) after orthotopic liver transplantation (OLT).... more Intrahepatic biliary lesions (IBL) are rare (2-9 %) after orthotopic liver transplantation (OLT). The aim was to evaluate the incidence, etiology and outcome. In nine years, a total 532 OLTs were performed in 481 patients. Twentyfour patients developed IBL. Eight were due to HAT, seven to ABOI, three to CDR and six to PI. The time until diagnosis of HAT is longest in patients (14 ? 6) with IBL. ABOI is another cause of IBL. CDR is a rare cause of IBL, however when it takes place, patients must undergo Rtx. Finally, PI is a relevant cause of IBL. In order to suppress the incidence of IBL we should consider 1) the systematic use of Dop-pler-Ultrasound; 2) emergency reoperation of patients with HAT, 3) avoid ABOI in OLT; 4) Rtx in cases of CDR, and 5) OLT should still be performed as an emergency procedure.

Surgical Endoscopy, 2010

The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal e... more The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal endoscopic rectosigmoid resection using transanal endoscopic microsurgery (TEM) was previously demonstrated in human cadavers and a porcine survival model. We report the first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance, performed by a team of surgeons from Barcelona and Boston with extensive experience with NOTES and minimally invasive approaches to colorectal diseases. Transanal endoscopic rectal resection with total mesorectal excision using the TEM platform was performed in a 76-year-old woman with a T2N2 rectal cancer treated with preoperative chemoradiation. Laparoscopic visualization and assistance with retraction and exposure during rectosigmoid mobilization was provided through one 5-mm port, which was later used as the stoma site, and 2-mm needle ports, one of which was used as a drain site. The specimen was transected transanally followed by handsewn coloanal anastomosis. The procedure was completed successfully with an operative time of 4 hours and 30 minutes. Mesorectal excision was complete. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology demonstrated pT1N0 with 23 negative lymph nodes and negative proximal, distal, and radial margins. NOTES transanal endoscopic rectosigmoid resection using TEM and laparoscopic assistance is feasible and safe. Careful patient selection and improvement in NOTES instrumentation are critical to optimize this approach before widespread clinical application.

Surgical Endoscopy, 2012

Bariatric surgery (BS) is widely accepted for the treatment of patients with morbid obesity (MO).... more Bariatric surgery (BS) is widely accepted for the treatment of patients with morbid obesity (MO). We aimed to determine presurgical predictors of and surgical technique-related differences in excess weight loss (EWL) 1 year after BS. This retrospective study included 407 subjects (F/M 3:1, median age = 44 years) who underwent laparoscopic Roux-en-Y gastric bypass (RYGB, n = 307) or sleeve gastrectomy (SG, n = 100) at our University Hospital and were evaluated 1 year after surgery. Baseline median (min-max) body mass index (BMI) was 47 kg/m(2) (range = 36-71). BMI was higher in the SG than in the RYGB group (53 vs. 46 kg/m(2), p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). Simple correlation analysis showed negative associations between EWL and age, BMI, waist circumference (WC), fasting glucose, HbA1c, triglycerides (TG), blood pressure, and total cholesterol (all p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01). EWL (mean ± SD) did not differ by gender (p = 0.2), was lower in diabetic than in nondiabetic subjects (71 ± 17% vs. 79 ± 17%, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), and higher in the RYGB vs. SG group (76 ± 18% vs. 68 ± 15%, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). However, SG vs. RYGB differences in EWL disappeared (p = 0.4) after taking into account baseline BMI. Multiple regression and logistic analysis showed that younger individuals with lower BMI but higher WC, and lower HbA1c and TG, had higher EWL and a higher rate of successful (EWL ≥ 60%) weight loss. Our data indicate that some of the characteristics that would have subjects referred early for BS were associated with higher weight loss. Therefore, the timing of laparoscopic BS might be an important factor for MO individuals in which medical weight loss intervention has failed.

Surgical Endoscopy, 2013

Despite obesity being closely associated with two common risk factors for albuminuria, namely typ... more Despite obesity being closely associated with two common risk factors for albuminuria, namely type 2 diabetes mellitus (T2DM) and hypertension, information on the impact of weight loss on albumin excretion rate in morbidly obese (MO) subjects is scarce. To evaluate the independent contribution of weight loss following bariatric surgery (BS) to the improvement of the albumin-to-creatinine ratio (ACR) in MO subjects with T2DM. Observational prospective study, including consecutive (n = 255) patients undergoing Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG) of whom 37.6 % (n = 96) presented with T2DM. Stepwise logistic regression analysis was used to assess the contribution of T2DM-related, hypertension-related, and weight loss-related variables, and type of surgery to normalization of ACR (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30 mg/g) at 12 and 24 months follow-up. In T2DM subjects, baseline ACR was 85.7 ± 171 mg/g with ACR ≥ 30 mg/g being present in 45.7 % of the cohort. At 12 months, the ACR significantly decreased in T2DM subjects (42.2 ± 142.8 mg/g; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.005) with no further reduction at 24 months after surgery (44.4 ± 227.7; p = 0.862). Among T2DM subjects with ACR ≥ 30 mg/g at baseline, the ACR became &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30 mg/g in 58.5 % and 76.9 % at 12 and 24 months, respectively (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001 relative to baseline). Body mass index (BMI) change from baseline was the only independent predictor of ACR normalization at 12 months [Exp(B) 1.373, 95 % confidence interval 1.075-1.703; p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05]. None of the evaluated variables appeared as an independent predictor of ACR normalization at 24 months. Our data suggest that, in MO subjects with T2DM, interventions aiming at slowing the progression of nephropathy should not only focus on optimization of glucose and blood pressure control but also include effective weight loss strategies.

Surgery for Obesity and Related Diseases, 2014

Mechanisms underlying variable weight loss (WL) response after Roux-en-Y gastric bypass (RYGB) ar... more Mechanisms underlying variable weight loss (WL) response after Roux-en-Y gastric bypass (RYGB) are poorly understood. The objective of this study was to compare gastrointestinal hormonal responses to meal intake, and fasting plasma concentrations of surrogate markers of enterocyte mass and bile acid effect between patients with failed (F-WL) or successful WL (S-WL) after RYGB. Cross-sectional study including 30 nondiabetic patients, evaluated at≥24 months after RYGB. Cases (F-WL; n = 10) and controls (S-WL; n = 20) were selected based on percent of excess WL (%EWL)&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;50% or≥50% from 12 months onwards after surgery. Groups were matched for gender, age, presurgical BMI, and length of follow up. Glucagon-like peptide 1 (GLP-1), peptide YY (PYY), GLP-2, and ghrelin responses to a meal challenge, and fasting plasma concentrations of citrulline and serum fibroblast growth factor 19 (FGF-19) were compared. F-WL patients presented lesser suppression of ghrelin (incremental area under the curve [iAUC]: F-WL -12490±6530 versus S-WL -31196±4536 pg×mL(-1)×min; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.01), and lesser increase in the GLP-1 (iAUC: F-WL 3354±737 versus S-WL 5629±542 pmol×L(-1)×min; P = .02) but not in the PYY and GLP-2, response to meal intake. Citrulline concentrations were significantly correlated with time after surgery (rho = .537; P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.01). However, citrulline was higher in S-WL compared to F-WL patients (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.05). Serum FGF-19 concentration was similar between groups. Although limited by the cross-sectional design, our data suggest a role of some gastrointestinal hormones as mediators of successful weight loss but argues against larger enterocyte mass after BS as determinant of failed weight loss after RYGB.

Obesity Surgery, 2008

Anastomotic strictures after bariatric surgery are a frequent complication that requires endoscop... more Anastomotic strictures after bariatric surgery are a frequent complication that requires endoscopic management, but the optimal technique for dilation remains to be determined. The aim of this study was to evaluate the safety and efficacy of dilation with Savary-Gilliard bougies (SGB) in morbidly obese patients treated with laparoscopic Roux-en-Y gastric bypass (RYGBP). Retrospective review of prospectively collected data from a series of 474 consecutive patients with laparoscopic bariatric surgery. Four-hundred twenty four of these patients (90%) underwent a laparoscopic RYGBP. A total of 24 patients were referred for anastomotic stricture dilation with SGB from January 1998 to December 2006. A total of 24/424 patients (6%) developed a stricture that was successfully dilated with SGB. Patients were 17 females (71%) and seven males (29%) with a mean age of 41 +/- 11 years (range 24-63) and a mean BMI of 48 +/- 6 (range 40-69). The time between RYGBP and the appearance of stricture-related symptoms ranged from 29 to 154 days (mean, 69 days). The mean number of dilations was 1.6 +/- 0.6. The majority of patients required one (n = 11; 46%) or two (n = 12; 50%) dilations and only one patient required three dilations. During the initial dilation, a final diameter of 11 +/- 1.7 mm (range 7-12.8 mm) was achieved. In all cases, there was complete resolution of symptoms. There were no complications. Dilation with SGB is an effective, safe, and durable method for managing anastomotic strictures after laparoscopic RYGBP.