Publications by authors named "Dimitri Dorcaratto"

35 Publications

Perioperative chemotherapy versus surgery alone for resectable colorectal liver metastases: an international multicentre propensity score matched analysis on long-term outcomes according to established prognostic risk scores.

HPB (Oxford) 2021 May 15. Epub 2021 May 15.

HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.

Background: There is still uncertainty regarding the role of perioperative chemotherapy (CTx) in patients with resectable colorectal liver metastases (CRLM), especially in those with a low-risk of recurrence.

Methods: Multicentre retrospective analysis of patients with CRLM undergoing liver resection between 2010-2015. Patients were divided into two groups according to whether they received perioperative CTx or not and were compared using propensity score matching (PSM) analysis. Then, they were stratified according to prognostic risk scores, including: Clinical Risk Score (CRS), Tumour Burden Score (TBS) and Genetic And Morphological Evaluation (GAME) score.

Results: The study included 967 patients with a median follow-up of 68 months. After PSM analysis, patients with perioperative CTx presented prolonged overall survival (OS) in comparison with the surgery alone group (82.8 vs 52.5 months, p = 0.017). On multivariable analysis perioperative CTx was an independent predictor of increased OS (HR 0.705, 95%CI 0.705-0.516, p = 0.029). The benefits of perioperative CTx on survival were confirmed in patients with CRS and TBS scores ≤2 (p = 0.022 and p = 0.020, respectively) and in patients with a GAME score ≤1 (p = 0.006).

Conclusion: Perioperative CTx demonstrated an increase in OS in patients with CRLM. Patients with a low-risk of recurrence seem to benefit from systemic treatment.
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http://dx.doi.org/10.1016/j.hpb.2021.04.026DOI Listing
May 2021

Multiple small bowel perforations during the treatment of primary intestinal extranodal natural killer/T-cell lymphoma, nasal type.

Br J Haematol 2021 Jun 29;193(5):e39-e42. Epub 2021 Apr 29.

Department of General Surgery, Hospital Clínico, Liver, Biliary and Pancreatic Unit, University of Valencia, Biomedical Research Institute INCLIVA, Valencia, Spain.

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http://dx.doi.org/10.1111/bjh.17229DOI Listing
June 2021

Non-arbitrary minimum threshold of yearly performed pancreatoduodenectomies: National multicentric study.

Surgery 2021 Apr 16. Epub 2021 Apr 16.

Department of Surgery, Liver, Biliary and Pancreatic Unit, Hospital Clínico, University of Valencia, Biomedical Research Institute (INCLIVA), Valencia, Spain.

Background: Annual hospital volume of pancreatoduodenectomies could influence postoperative outcomes. The aim of this study is to establish with a non-arbitrary method the minimum threshold of yearly performed pancreatoduodenectomies in order to improve several postoperative quality outcomes.

Method: Prospective follow-up of patients submitted to pancreatoduodenectomy in participating hospitals during 1 year. The influence of hospital volume on quality outcomes was analyzed by univariable and multivariable models. The minimum threshold of yearly performed pancreatoduodenectomies to improve outcomes was established by Akaike's information criteria.

Results: Data from 877 patients operated in 74 hospitals were analyzed. Of 12 quality outcomes, 9 were influenced by hospital pancreatoduodenectomy volume on multivariable analysis. To decrease the risk of complications and the risk of retrieving an insufficient number of lymph nodes at least 31 pancreatoduodenectomies per year should be performed. To decrease the risk of prolonged length of stay, postoperative death, and affected surgical margins, at least 37, 6, and 14 pancreatoduodenectomies per year should be performed, respectively.

Conclusion: Several postoperative quality outcomes are influenced by the number of yearly performed pancreatoduodenectomies and could be improved by establishing a minimum threshold of procedures. Number of procedures needed to improve quality outcomes has been established by a non-arbitrary method.
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http://dx.doi.org/10.1016/j.surg.2021.03.012DOI Listing
April 2021

What does preoperative three-dimensional image contribute to complex pancreatic surgery?

Cir Esp (Engl Ed) 2021 Jan 27. Epub 2021 Jan 27.

Unidad HBP, Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario de Valencia. Instituto de Investigación Biomédica INCLIVA. Departamento de Cirugía, Universitat de Valencia, Valencia, España.

The possibility of modelling diagnostic images in three dimensions (3D) in pancreatic surgery is a novelty that provides us multiple advantages. A better visualization of the structures allows us a more accurate planning of the surgical technique and makes it easier the surgery in complex cases. We present the case study of a borderline pancreatic head adenocarcinoma patient to illustrate the advantages of 3D modelling in complex pancreatic surgery. The help of 3D technology allowed us to optimally plan the intervention and facilitate surgical resection. The use of this tool could translate into: shorter operative time, fewer intraoperative complications or an increase in R0 resections. The usability of the program used in our case, agile and intuitive, was an added advantage.
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http://dx.doi.org/10.1016/j.ciresp.2020.11.021DOI Listing
January 2021

Neoadjuvant treatment for locally advanced unresectable and borderline resectable pancreatic cancer: oncological outcomes at a single academic centre.

ESMO Open 2020 11;5(6):e000929

CIBERONC, Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain; Department of Medical Oncology, University of Valencia, Valencia, Spain. Electronic address:

Introduction: Pancreatic cancer (PC), even in the absence of metastatic disease, has a dismal prognosis. One-third of them are borderline resectable (BRPC) or locally advanced unresectable PC (LAUPC) at diagnosis. There are limited prospective data supporting the best approach on these tumours. Neoadjuvant chemotherapy (ChT) is being increasingly used in this setting.

Methods: This is a retrospective series of consecutive patients staged as BRPC or LAUPC after discussion in the multidisciplinary board (MDB) at an academic centre. All received neoadjuvant ChT, followed by chemoradiation (ChRT) in some cases, and those achieving enough downstaging had a curative-intent surgery. Descriptive data about patient's characteristics, neoadjuvant treatments, toxicities, curative resections, postoperative complications, pathology reports and adjuvant treatment were collected. Overall survival (OS) and progression-free survival was calculated with Kaplan-Meier method and log-rank test.

Results: Between August 2011 and July 2019, 49 patients fulfilled the inclusion criteria, and all of them received neoadjuvant ChT. Fluorouracil+folinic acid, irinotecan and oxaliplatin was the most frequently used scheme (77%). The most prevalent grade 3 or 4 toxicities were neutropenia (26.5%), neurotoxicity (12.2%), diarrhoea (8.2%) and nausea (8.2%). 18 patients (36.7%) received ChRT thereafter. In total, 22 patients (44,9%) became potentially resectable and 19 of them had an R0 or R1 pancreatic resection. One was found to be unresectable at surgery and two refused surgery. A vascular resection was required in 7 (35%). No postoperative deaths were observed. Postoperative ChT was given to 12 (66.7%) of resected patients. Median OS of the whole cohort was 24,9 months (95% CI 14.1 to 35.7), with 30.6 months for resected and 13.1 months for non-resected patients, respectively (p<0.001).

Conclusion: A neoadjuvant approach in BRPC and LAUPC was well tolerated and allowed a curative resection in 38.8% of them with a potential improvement on OS.
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http://dx.doi.org/10.1136/esmoopen-2020-000929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684818PMC
November 2020

Pancreatic duct ligation reduces premalignant pancreatic lesions in a Kras model of pancreatic adenocarcinoma in mice.

Sci Rep 2020 10 27;10(1):18344. Epub 2020 Oct 27.

Department of Surgery, Hospital del Mar, Barcelona, Spain.

Pancreatic duct ligation (PDL) in the murine model has been described as an exocrine pancreatic atrophy-inducing procedure. However, its influence has scarcely been described on premalignant lesions. This study describes the histological changes of premalignant lesions and the gene expression in a well-defined model of pancreatic ductal adenocarcinoma by PDL. Selective ligation of the splenic lobe of the pancreas was performed in Ptf1a-Cre; K-ras LSLG12Vgeo mice (PDL-Kras mice). Three experimental groups were evaluated: PDL group, controls and shams. The presence and number of premalignant lesions (PanIN 1-3 and Atypical Flat Lesions-AFL) in proximal (PP) and distal (DP) pancreas were studied for each group over time. Microarray analysis was performed to find differentially expressed genes (DEG) between PP and PD. Clinical human specimens after pancreaticoduodenectomy with ductal occlusion were also evaluated. PDL-Kras mice showed an intense pattern of atrophy in DP which was shrunk to a minimal portion of tissue. Mice in control and sham groups had a 7 and 10-time increase respectively of risk of high-grade PanIN 2 and 3 and AFL in their DP than PDL-Kras mice. Furthermore, PDL-Kras mice had significantly less PanIN 1 and 2 and AFL lesions in DP compared to PP. We identified 38 DEGs comparing PP and PD. Among them, several mapped to protein secretion and digestion while others such as Nupr1 have been previously associated with PanIN and PDAC. PDL in Ptf1a-Cre; K-ras LSLG12Vgeo mice induces a decrease in the presence of premalignant lesions in the ligated DP. This could be a potential line of research of interest in some cancerous risk patients.
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http://dx.doi.org/10.1038/s41598-020-74947-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591874PMC
October 2020

Surgical treatment of an intraductal papillary mucinous neoplasm of the biliary tract diagnosed by SpyGlass®.

Rev Esp Enferm Dig 2021 Jan;113(1):45-47

Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario de Valencia, España.

We present the case of a 76-year-old male with a history of acute cholecystitis who underwent a scheduled laparoscopic cholecystectomy. Chronic cholecystitis with a thickened cystic duct was observed intraoperatively. The anatomic pathology report found high-grade dysplasia that affected the distal edge of the cystic duct. In view of these findings, an endoscopic retrograde cholangiopancreatography (ERCP) was performed with SpyGlass® and an excrescent lesion suggestive of malignancy adjacent to the cystic-common bile duct junction was observed. A resection of the extrahepatic bile duct was performed with lymphadenectomy of the hepatic hilum and hepaticojejunostomy in a subsequent procedure. The definitive pathology report confirmed pancreaticobiliary intraductal papillary mucinous neoplasia with high-grade dysplasia and free margins.
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http://dx.doi.org/10.17235/reed.2020.7122/2020DOI Listing
January 2021

The actual management of colorectal liver metastases.

Minerva Chir 2020 Oct 6;75(5):328-344. Epub 2020 Aug 6.

Unit of Liver, Biliary and Pancreatic Surgery, Department of Surgery, Clinic Hospital, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain.

Colorectal cancer is one of the most frequent cancers in the world and between 50% and 60% of patients will develop colorectal liver metastases (CRLM) during the disease. There have been great improvements in the management of CRLM during the last decades. The combination of modern chemotherapeutic and biological systemic treatments with aggressive surgical resection strategies is currently the base for the treatment of patients considered unresectable until few years ago. Furthermore, several new treatments for the local control of CRLM have been developed and are now part of the arsenal of multidisciplinary teams for the treatment of these complex patients. The aim of this review was to summarize and update the management of CRLM, its controversies and relevant evidence.
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http://dx.doi.org/10.23736/S0026-4733.20.08436-9DOI Listing
October 2020

Impact of type and severity of postoperative complications on long-term outcomes after colorectal liver metastases resection.

J Surg Oncol 2020 Aug 26;122(2):212-225. Epub 2020 Apr 26.

Department of Surgery, Liver, Biliary, and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clínico University of Valencia, Valencia, Spain.

Background And Objectives: Postoperative complications (POCs) after hepatic resection for colorectal liver metastases (CRLM) adversely affect long-term survival. The aim of this study was to analyze the effect of POC etiology and severity on overall survival (OS) and disease-free survival (DFS).

Methods: A retrospective study of 254 consecutive hepatectomies for CRLM was performed. Univariate and multivariate analyses were performed to determine the effects of demographic, tumor-related and perioperative variables on OS and DFS. A 1:1 propensity score matching (PSM) was then used to compare patients with different POC etiology: infective (Inf-POC), noninfective (Non-inf POC), and no-complications (No-POC).

Results: Inf-POC, Non-inf POC, and No-POC patients represented 18.8%, 19.2%, and 62% of the sample, respectively. In univariate and multivariate analyses infectious POC were independent risk factors for decreased OS and DFS. After PSM, Inf-POC group presented decreased OS and DFS when compared with Non-inf POC (5-year OS 31.8% vs 51.6%; P = .05 and 5-year DFS 13.6% vs 31.9%; P = .04) and with No-POC (5-year OS 29.4% vs 58.7%; P = .03 and 5-year DFS 11.8% vs 39.7%; P = .03). There were no differences between Non-inf POC and No-POC patients. POC severity calculated using the Comprehensive Complications Index did not influence OS and DFS before and after PSM.

Conclusion: The negative oncological impact of POCs after CRLM resection is determined by infective etiology not by severity.
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http://dx.doi.org/10.1002/jso.25946DOI Listing
August 2020

Acute cholecystitis in elderly and high-risk surgical patients: is percutaneous cholecystostomy preferable to emergency cholecystectomy?

J Gastrointest Surg 2020 11 2;24(11):2579-2586. Epub 2019 Dec 2.

Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia. Biomedical Research Institute INCLIVA, Avd. Blasco Ibañez 17, 46010, Valencia, Spain.

Objective: To investigate whether percutaneous cholecystostomy (PC) for the treatment of acute calculous cholecystitis (ACC) has better results than emergency cholecystectomy (EC) in elderly and high-risk surgical patients.

Methods: Patients ≥ 70 years and/or ≥ ASA-PS 3 with ACC treated with PC or EC between 2005 and 2016 were retrospectively reviewed. Both techniques were compared regarding morbi-mortality, hospital stay, complications and readmissions. A subgroup analysis in higher risk patients (≥ 70 years plus ≥ ASA-PS 3) was also performed. A binary logistic regression analysis for outcome variables to calculate the OR was carried out.

Results: A total of 461 patients were included in the study. The results of PC were worse compared to EC: 30-day mortality (8.6 vs. 1.7%, OR 18.4), 90-day mortality (10.4 vs. 2.1%, OR 10.3), length of stay (days) (13.21 ± 8.2 vs. 7.48 ± 7.67, OR 8.7) and readmission rate (35.1 vs. 12.6%, OR 4.7). Complications were lower for PC (14 vs. 22.6%, OR 0.41), but there were no significant differences in the number of severe complications (Clavien-Dindo ≥ III). Higher-risk subgroup analysis (n = 193; PC = 128, EC = 65) showed similar results to the whole series. Patients with ACC for more than 3 days had more risk of severe complications in both groups (OR 2.26; OR 2.76).

Conclusion: PC was associated with an increased risk of mortality at 30 and 90 days, more readmissions and longer hospital stay. Although PC presents a lower risk of complications, the percentage of severe complications (Clavien-Dindo ≥ III) does not show significant differences.
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http://dx.doi.org/10.1007/s11605-019-04424-5DOI Listing
November 2020

Does the Artery-first Approach Improve the Rate of R0 Resection in Pancreatoduodenectomy?: A Multicenter, Randomized, Controlled Trial.

Ann Surg 2019 11;270(5):738-746

Department of Surgery, Hospital Virgen del Rocío, Sevilla, Spain.

Objective: To compare the rates of R0 resection in pancreatoduodenectomy (PD) for pancreatic and periampullary malignant tumors by means of standard (ST-PD) versus artery-first approach (AFA-PD).

Background: Standardized histological examination of PD specimens has shown that most pancreatic resections thought to be R0 resections are R1. "Artery-first approach" is a surgical technique characterized by meticulous dissection of arterial planes and clearing of retropancreatic tissue in an attempt to achieve a higher rate of R0. To date, studies comparing AFA-PD versus ST-PD are retrospective cohort or case-control studies.

Methods: A multicenter, randomized, controlled trial was conducted in 10 University Hospitals (NCT02803814, ClinicalTrials.gov). Eligible patients were those who presented with pancreatic head adenocarcinoma and periampullary tumors (ampulloma, distal cholangiocarcinoma, duodenal adenocarcinoma). Assignment to each group (ST-PD or AFA-PD) was randomized by blocks and stratified by centers. The primary end-point was the rate of tumor-free resection margins (R0); secondary end-points were postoperative complications and mortality.

Results: One hundred seventy-nine patients were assessed for eligibility and 176 randomized. After exclusions, the final analysis included 75 ST-PD and 78 AFA-PD. R0 resection rates were 77.3% (95% CI: 68.4-87.4) with ST-PD and 67.9% (95% CI: 58.3-79.1) with AFA-PD, P=0.194. There were no significant differences in postoperative complication rates, overall 73.3% versus 67.9%, and perioperative mortality 4% versus 6.4%.

Conclusions: Despite theoretical oncological advantages associated with AFA-PD and evidence coming from low-level studies, this multicenter, randomized, controlled trial has found no difference neither in R0 resection rates nor in postoperative complications in patients undergoing ST-PD versus AFA-PD for pancreatic head adenocarcinoma and other periampullary tumors.
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http://dx.doi.org/10.1097/SLA.0000000000003535DOI Listing
November 2019

The role of endoscopic retrograde cholangiopancreatography in the management of iatrogenic bile duct injury after cholecystectomy.

Rev Esp Enferm Dig 2019 Sep;111(9):690-695

Unidad de Cirugía HBP. Servicio de Cirugía General y del Aparato Digestivo. Departamento de Cirugía. Universitat de Valencia. Valencia, España

Introduction: iatrogenic bile duct injury (IBDI) is a complication with a high morbidity after cholecystectomy. In recent years, endoscopy has acquired a fundamental role in the management of this pathology.

Methods: a retrospective study of IBDI after open cholecystectomy (OC) or laparoscopic cholecystectomy (LC) of patients treated in our center between 1993 and 2017 was performed. Clinical characteristics, type of injury according to the Strasberg-Bismuth classification, diagnosis, repair techniques and follow-up were analyzed.

Results: 46 patients were studied and IBDI incidence was 0.48%, 0.61% for LC and 0.24% for OC. A diagnosis was made intraoperatively in 12 cases (26%) and by endoscopic retrograde cholangiopancreatography (ERCP) in 10 (21.7%) cases. The most common IBDI patient characteristics were acute cholecystitis (20/46, 43.5%), previous admission due to biliary pathology (16/46, 43.2%) and ERCP prior to cholecystectomy (7/46, 18.9%). The most frequent types of IBDI were D (17/46, 36.9%) and A (15/46, 32.6%). The most commonly used treatment was primary suture (13/46, 28.3%) followed by ERCP (11/46, 23.9%) with sphincterotomy and/or stents. In addition, ERCP was performed during the immediate postoperative period in 6 (13%) patients with a surgical IBDI repair in order to resolve immediate complications.

Conclusion: ERCP is useful in the management of IBDI that is not diagnosed intraoperatively. This procedure facilitates the localization of the injured area of the bile duct, therapeutic maneuvers and successful outcomes in postoperative complications.
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http://dx.doi.org/10.17235/reed.2019.6245/2019DOI Listing
September 2019

Impact of Postoperative Complications on Survival and Recurrence After Resection of Colorectal Liver Metastases: Systematic Review and Meta-analysis.

Ann Surg 2019 12;270(6):1018-1027

Department of Surgery, Liver, Biliary and Pancreatic Unit, Hospital Clínico, University of Valencia, Biomedical Research Institute (INCLIVA), Valencia, Spain.

Objective: To study the effect of postoperative complications (POC) on overall survival (OS) and disease-free survival (DFS) after surgical resection of colorectal liver metastases (CRLM).

Summary Background Data: Morbidity rates after liver resection can reach 45%. The negative impact of POC on oncologic outcomes has been reported in various types of cancer, especially colorectal. However, data on the consequences of POC after CRLM resection on long-term survival are scarce.

Methods: Eligible studies examining the association between POC after CRLM resection and OS/DFS were sought using the PubMed and Web of Science databases. A random-effects model was used to calculate pooled effect estimate for OS and DFS hazard ratios (HR), estimating between-study variance with restricted maximum likelihood estimator with Hartung-Knapp adjustment. Subgroup analysis was used to control the effect of POC on OS and DFS for: 1) Method used to define postoperative complications, 2) Exclusion of early postoperative death from survival analysis, 3) Method of data extraction used, and 4) Tumor and treatment characteristics.

Results: Forty-one studies were deemed eligible, including 12,817 patients. POC patients had a significant risk of reduced OS compared with no POC group (HR 1.43 [95% CI: 1.3, 1.57], P < 0.0001). POC had also a negative impact on DFS. The HR for reduced DFS was 1.38 [95% CI 1.27, 1.49], P < 0.0001. The negative impact of POC on survival and recurrence was confirmed in subgroup analysis.

Conclusions: Our findings evidence the negative impact of POC on survival and recurrence after CRLM resection.
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http://dx.doi.org/10.1097/SLA.0000000000003254DOI Listing
December 2019

Pancreatoduodenectomy with artery-first approach.

Minerva Chir 2019 Jun 2;74(3):226-236. Epub 2019 Jan 2.

Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain -

"Artery-first approach" encompasses different aspects for the surgical treatment of pancreatic cancer. It is a surgical technique or set of techniques which share in common the dissection of the main arterial vasculature involved in pancreatic cancer, before any irreversible surgical step is performed. On the other hand it represents the need for a meticulous dissection of the arterial planes and clearing of the retropancreatic tissue between the superior mesenteric artery, the common hepatic artery and portal vein in an attempt to achieve R0 resections. The recent expansion of this approach is based mainly on three factors: venous involvement should not be considered a contraindication for resection, most of the pancreatic resections performed with a standard procedure may be in fact non-oncological (R1) resections and the postero-medial or vascular margin is the most frequently invaded by the tumor. This review aimed to summarize and update the artery-first approach in pancreaticoduodenectomy.
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http://dx.doi.org/10.23736/S0026-4733.18.07944-0DOI Listing
June 2019

Borderline resectable pancreatic cancer. Challenges and controversies.

Cancer Treat Rev 2018 Jul 13;68:124-135. Epub 2018 Jun 13.

CIBERONC Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Spain. Electronic address:

Pancreatic cancer is a dismal disease with an increasing incidence. Despite the majority of patients are not candidates for curative surgery, a subgroup of patients classified as borderline resectable pancreatic cancer can be selected in whom a sequential strategy of neoadjuvant therapy followed by surgery can provide better outcomes. Multidisciplinary approach and surgical pancreatic expertise are essential for successfully treating these patients. However, the lack of consensual definitions and therapies make the results of studies very difficult to interpret and hard to be implemented in some settings. In this article, we review the challenges of borderline resectable pancreatic cancer, the complexity of its management and controversies and point out where further research and international cooperation for a consensus strategy is urgently needed.
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http://dx.doi.org/10.1016/j.ctrv.2018.06.006DOI Listing
July 2018

Outcome quality standards in pancreatic oncologic surgery in Spain.

Cir Esp (Engl Ed) 2018 Jun - Jul;96(6):342-351. Epub 2018 May 19.

Servicio de Cirugía General, Hospital Clínico Universitario de Valencia, Valencia, España; Departamento de Cirugía, Universitat de València, Valencia, España.

Introduction: To establish quality standards in oncologic surgery is a complex but necessary challenge to improve surgical outcomes. Unlike other tumors, there are no well-defined quality standards in pancreatic cancer. The aim of this study is to identify quality indicators in pancreatic oncologic surgery in Spain as well as their acceptable limits of variability.

Methods: Quality indicators were selected based on clinical practice guidelines, consensus conferences, reviews and national publications on oncologic pancreatic surgery between the years 2000 and 2016. Variability margins for each indicator have been determined by statistical process control techniques and graphically represented with the 99.8 and 95% confidence intervals above and below the weighted average according to sample size.

Results: The following indicators have been determined with their weighted average and acceptable quality limits: resectability rate 71% (>58%), morbidity 58% (<73%), mortality 4% (<10%), biliary leak 6% (<14%), pancreatic fistula rate 18% (<29%), hemorrhage 11% (<21%), reoperation rate 11% (<20%) and mean hospital stay (<21 days).

Conclusions: To date, few related series have been published, and they present important methodological limitations. Among the selected indicators, the morbidity and mortality quality limits have come out higher than those obtained in international standards. It is necessary for Spanish pancreatic surgeons to adopt homogeneous criteria regarding indicators and their definitions to allow for the comparison of their results.
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http://dx.doi.org/10.1016/j.ciresp.2018.03.002DOI Listing
January 2019

Is Percutaneous Transhepatic Biliary Drainage Better than Endoscopic Drainage in the Management of Jaundiced Patients Awaiting Pancreaticoduodenectomy? A Systematic Review and Meta-analysis.

J Vasc Interv Radiol 2018 05 13;29(5):676-687. Epub 2018 Mar 13.

Hepatobiliary and Pancreatic Unit, General and Digestive Surgery Department, Hospital Clõnico Universitario de Valencia, Valencia, Spain.

Purpose: To compare postoperative complications in patients who underwent pancreatoduodenectomy after either endoscopic or percutaneous biliary drain (BD).

Material And Methods: Data from studies comparing the rate of postoperative complications in patients who underwent endoscopic BD or percutaneous BD before pancreatoduodenectomy were extracted independently by 2 investigators. The primary outcome compared in the meta-analysis was the risk of postoperative complications. Secondary outcomes were the risks of procedure-related complications, postoperative mortality, postoperative pancreatic fistula, severe complications, and wound infection. For dichotomous variables, the odds ratio (OR) with 95% confidence interval (CI) was calculated.

Results: Thirteen studies, including 2334 patients (501 in the percutaneous BD group and 1833 in the endoscopic group), met the inclusion criteria. Postoperative and procedure-related complication rates were significantly lower in the percutaneous BD group (OR = .7, 95% CI = .52-.94, P = .02 and OR = .44, 95% CI = .23-.84, P = .01, respectively). No significant differences were observed when severe postoperative complications, postoperative mortality, postoperative pancreatic fistula, and wound infection rates were compared.

Conclusions: In patients awaiting pancreatoduodenectomy, preoperative percutaneous BD is associated with fewer procedure-related or postoperative complications than endoscopic drain.
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http://dx.doi.org/10.1016/j.jvir.2017.12.027DOI Listing
May 2018

Does neoadjuvant doxorubicin drug-eluting bead transarterial chemoembolization improve survival in patients undergoing liver transplant for hepatocellular carcinoma?

Diagn Interv Radiol 2017 Nov-Dec;23(6):441-447

Hepatobiliary and Liver Transplant Surgical Unit, St. Vincent's University Hospital, Elm Park, Dublin, Ireland.

Purpose: We aimed to compare the overall (OS) and disease-free survival (DFS) of patients undergoing orthotopic liver transplant (OLT) for hepatocellular carcinoma who did and did not have neoadjuvant doxorubicin drug-eluting bead transarterial chemoembolization (DEB-TACE).

Methods: This is a retrospective study of 94 patients with HCC transplanted between 2000 and 2014 in a single tertiary center. Pre- and postoperative features, DFS and OS were compared between patients who received pre-OLT DEB-TACE (n=34, DEB-TACE group) and those who did not (n=60, non-TACE group). Radiologic and histologic response to neoadjuvant treatment as well as its complications were also studied.

Results: There were no significant differences in post-transplantation DFS and OS rates between groups (5-year DFS: 70% in DEB-TACE group vs. 63% in non-TACE group, P = 0.454; 5-year OS: 70% in DEB-TACE group vs. 65% in non-TACE group, P = 0.532). The DEB-TACE group had longer OLT waiting time compared with the non-TACE group (110 vs. 72 days; P = 0.01). On univariate and multivariate analyses, alpha-fetoprotein (AFP) levels >500 ng/mL prior to OLT were associated with decreased OS and DFS regardless of neoadjuvant approach (hazard ratio of 6, P = 0.001 and 5.5, P = 0.002, respectively).

Conclusion: Patients who underwent neoadjuvant DEB-TACE and OLT for hepatocellular carcinoma had no statistically different OS or DFS at 3 and 5 years from patients undergoing OLT alone.
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http://dx.doi.org/10.5152/dir.2017.17106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5669544PMC
July 2018

Impact of monopolar radiofrequency coagulation on intraoperative blood loss during liver resection: a prospective randomised controlled trial.

Int J Hyperthermia 2017 Mar 5;33(2):135-141. Epub 2016 Oct 5.

c General Surgery Department , Hospital del Mar , Barcelona , Spain.

Purpose: To evaluate the impact of using monopolar thermal coagulation based on radiofrequency (RF) currents on intraoperative blood loss during liver resection.

Materials And Methods: A prospective randomised controlled trial was planned. Patients undergoing hepatectomy were randomised into two groups. In the control group (n = 10), hemostasis was obtained with a combination of stitches, vessel-sealing bipolar RF systems, sutures or clips. In the monopolar radiofrequency coagulation (MRFC) group (n = 18), hemostasis was mainly obtained using an internally cooled monopolar RF electrode.

Results: No differences in demographic or clinical characteristics were found between groups. Mean blood loss during liver resection in the control group was more than twice that of the MRFC group (556 ± 471 ml vs. 225 ± 313 ml, p = .02). The adjusted mean bleeding/transection area was also significantly higher in the control group (7.0 ± 3.3 ml/cm vs. 2.8 ± 4.0 ml/cm, p = .006). No significant differences were observed in the rate of complications between the groups.

Conclusions: The findings suggest that the monopolar electrocoagulation created with an internally cooled RF electrode considerably reduces intraoperative blood loss during liver resection.
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http://dx.doi.org/10.1080/02656736.2016.1231938DOI Listing
March 2017

Total hepatectomy and liver transplantation as a two-stage procedure for fulminant hepatic failure: A safe procedure in exceptional circumstances.

World J Hepatol 2016 Feb;8(4):226-30

Rebeca Sanabria Mateos, Niamh M Hogan, Dimitri Dorcaratto, Helen Heneghan, Venkatesh Udupa, Donal Maguire, Justin Geoghegan, Emir Hoti, Hepatobiliary and Liver Transplant Surgical Unit, St. Vincent's University Hospital, Dublin 4, Ireland.

Aim: To evaluate the outcomes of two-stage liver transplant at a single institution, between 1993 and March 2015.

Methods: We reviewed our institutional experience with emergency hepatectomy followed by transplantation for fulminant liver failure over a twenty-year period. A retrospective review of a prospectively maintained liver transplant database was undertaken at a national liver transplant centre. Demographic data, clinical presentation, preoperative investigations, cardiocirculatory parameters, operative and postoperative data were recorded.

Results: In the study period, six two-stage liver transplants were undertaken. Indications for transplantation included acute paracetamol poisoning (n = 3), fulminant hepatitis A (n = 1), trauma (n = 1) and exertional heat stroke (n = 1). Anhepatic time ranged from 330 to 2640 min. All patients demonstrated systemic inflammatory response syndrome in the first post-operative week and the incidence of sepsis was high at 50%. There was one mortality, secondary to cardiac arrest 12 h following re-perfusion. Two patients required re-transplantation secondary to arterial thrombosis. At a median follow-up of 112 mo, 5 of 6 patients are alive and without evidence of graft dysfunciton.

Conclusion: Two-stage liver transplantation represents a safe and potentially life-saving treatment for carefully selected exceptional cases of fulminant hepatic failure.
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http://dx.doi.org/10.4254/wjh.v8.i4.226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4733465PMC
February 2016

Radiofrequency-induced heating versus mechanical stapler for pancreatic stump closure: in vivo comparative study.

Int J Hyperthermia 2016 05 29;32(3):272-80. Epub 2016 Jan 29.

f Biomedical Synergy, Electronic Engineering Department, Universitat Politècnica de València , Valencia , Spain.

Purpose: The aim of this study was to assess the capacity of two methods of surgical pancreatic stump closure in terms of reducing the risk of pancreatic fistula formation (POPF): radiofrequency-induced heating versus mechanical stapler.

Materials And Methods: Sixteen pigs underwent a laparoscopic transection of the neck of the pancreas. Pancreatic anastomosis was always avoided in order to work with an experimental model prone to POPF. Pancreatic stump closure was conducted either by stapler (ST group, n = 8) or radiofrequency energy (RF group, n = 8). Both groups were compared for incidence of POPF and histopathological alterations of the pancreatic remnant.

Results: Six animals (75%) in the ST group and one (14%) in the RF group were diagnosed with POPF (p = 0.019). One animal in the RF group and three animals in the ST group had a pseudocyst in close contact with both pancreas stumps. On day 30 post-operation (PO), almost complete atrophy of the exocrine distal pancreas was observed when the main pancreatic duct was efficiently sealed.

Conclusions: Our findings suggest that RF-induced heating is more effective at closing the pancreatic stump than mechanical stapler and leads to the complete atrophy of the distal remnant pancreas.
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http://dx.doi.org/10.3109/02656736.2015.1136845DOI Listing
May 2016

Long-term evolution of acinar-to-ductal metaplasia and β-cell mass after radiofrequency-assisted transection of the pancreas in a controlled large animal model.

Pancreatology 2016 Jan-Feb;16(1):38-43. Epub 2015 Nov 18.

General Surgery Department, Hospital del Mar, Passeig Marítim 25-29, Barcelona 08003, Spain.

Background: Pancreatic duct ligation (PDL) has been used as a model of chronic pancreatitis and as a model to increase β-cell mass. However, studies in mice have demonstrated acinar regeneration after PDL, questioning the long-term validity of the model. We aim to elucidate whether RF-assisted transection (RFAT) of the main pancreatic duct is a reliable PDL model, both in short (ST, 1-month) and long-term (LT, 6-months) follow-ups.

Methods: Eleven pigs were subjected to RFAT. Biochemical (serum/peripancreatic amylase and glucose) and histological changes (including a semiautomatic morphometric study of over 1000 images/pancreas and IHC analysis) were evaluated after ST or LT follow-up and also in fresh pancreas specimens that were used as controls for 1 (n = 4) and 6 months (n = 6).

Results: The distal pancreas in the ST was characterized by areas of acinar-to-ductal metaplasia (56%) which were significantly reduced at LT (21%) by fibrotic replacement and adipose tissue. The endocrine mass showed a normal increase.

Conclusion: RFAT in the pig seems to be an appropriate PDL model without restoration of pancreatic drainage or reduction of endocrine mass.
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http://dx.doi.org/10.1016/j.pan.2015.10.014DOI Listing
December 2016

Radiofrequency pancreatic ablation and section of the main pancreatic duct does not lead to necrotizing pancreatitis.

Pancreas 2014 Aug;43(6):931-7

From the *Instituto Municipal de Investigación Médica; Departments of †Surgery and ‡Pathology, Hospital del Mar; and §Department of Animal Surgery, Veterinary Faculty, University of Barcelona, Barcelona; ∥Department of Pathology, Hospital Clínico Universitario "Lozano Blesa," Zaragoza; and ¶Department of Electronic Engineering, Polytechnic University of Valencia, Valencia, Spain.

Objective: The aim of this study was to determine whether radiofrequency ablation (RFA) of the pancreas and subsequent transection of the main pancreatic duct may avoid the risk of both necrotizing pancreatitis and postoperative pancreatic fistula (POPF) formation.

Methods: Thirty-two rats were subjected to RFA and section of the pancreas over their portal vein. Animals were killed at 3, 7, 15, and 21 days (groups 0-3, respectively). Two additional control groups (sham operation and user manipulation only, respectively) of 15 days of postoperative period were considered. Postoperative complications, histological changes (including morphometric and immunohistochemical analysis), and incidence of POPF were evaluated.

Results: A significant increase in serum amylase levels (P < 0.05) on the third postoperative day, which return to baseline levels in the following weeks, was noted in groups 0 to 3. Those groups showed a rapid atrophy of the distal pancreas by apoptosis with no signs of necrotizing pancreatitis or POPF. The distal pancreas in groups 1 to 3 compared with group 0 and control groups showed a significant increase of small islets (<1000 µm).

Conclusions: The rapid acinar atrophy of the distal pancreas after RFA and section of the pancreatic ducts in this model does not lead to necrotizing pancreatitis.
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http://dx.doi.org/10.1097/MPA.0000000000000156DOI Listing
August 2014

Results of a laparoscopic approach for the treatment of acute small bowel obstruction due to adhesions and internal hernias.

Cir Esp 2014 May 12;92(5):336-40. Epub 2013 Sep 12.

Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari del Mar, Universitat Autònoma de Barcelona, Barcelona, España.

Introduction: Laparotomy is the standard approach for the surgical treatment of acute small bowel obstruction (ASBO).

Patients And Methods: From February 2007 to May 2012 we prospectively recorded all patients operated by laparoscopy in our hospital because of ASBO due to adhesions (27 cases) and/or internal hernia (6 cases). A preoperative abdominal CT was performed in all cases. Patients suffering from peritonitis and/or sepsis were excluded from the laparoscopic approach. It was decided to convert to laparotomy if intestinal resection was required.

Results: The mean age of the 33 patients who underwent surgery was 61.1 ± 17.6 years. 64% had previous history of abdominal surgery. 72% of the cases were operated by surgeons highly skilled in laparoscopy. Conversion rate was 21%. Operative time and postoperative length of stay were 83 ± 44 min. and 7.8 ± 11.2 days, respectively. Operative time (72 ± 30 vs 123 ± 63 min.), tolerance to oral intake (1.8 ± 0.9 vs 5.7 ± 3.3 days) and length of postoperative stay (4.7 ± 2.5 vs 19.4 ± 21 days) were significantly lower in the laparoscopy group compared with the conversion group, although converted patients had greater clinical severity (2 bowel resections). There were two severe complications (Clavien-Dindo III and V) in the conversion group.

Conclusions: In selected cases of ASBO caused by adhesions and internal hernias and when performed by surgeons highly skilled in laparoscopy, a laparoscopic approach has a high probability of success (low conversion rate, short hospital length of stay and low morbidity); its use would be fully justified in these cases.
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http://dx.doi.org/10.1016/j.ciresp.2013.05.008DOI Listing
May 2014

Enhanced recovery in gastrointestinal surgery: upper gastrointestinal surgery.

Dig Surg 2013 25;30(1):70-8. Epub 2013 May 25.

Section of Gastrointestinal Surgery, Hospital Universitario del Mar, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain.

Over the last 20 years, a new concept of perioperative patient care based on a construct of evidence-based interventions referred to as 'enhanced recovery after surgery' (ERAS) has been developed. The main pillars of ERAS programs include optimal postoperative pain management and early enteral feeding and mobilization after surgery. Several studies, mostly based on experiences with patients undergoing colonic resection, suggest that ERAS implementation is feasible and safe. However, there are very few well-designed studies that have evaluated the usefulness of ERAS programs after major upper abdominal surgery. The present review focuses on the discussion of the most relevant and recently published data on the application of ERAS programs in pancreatic, hepatic, esophageal and gastric surgery. A total of 23 articles have been reviewed by the authors. The high frequency and the potentially hazardous nature of some postoperative complications associated with major upper abdominal surgery and the lack of well-designed randomized controlled trials are limiting factors for the application of ERAS. However, the present results indicate that the implementation of ERAS programs in pancreatic, hepatic, esophageal and gastric surgery patients contributes to a reduction in complications, length of hospital stay and costs without an increase in mortality or readmission rates.
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http://dx.doi.org/10.1159/000350701DOI Listing
June 2015

Radiofrequency is a secure and effective method for pancreatic transection in laparoscopic distal pancreatectomy: results of a randomized, controlled trial in an experimental model.

Surg Endosc 2013 Oct 13;27(10):3710-9. Epub 2013 Apr 13.

Department of General Surgery, Hospital del Mar, Paseo Maritimo 25-28, 08003, Barcelona, Spain,

Background: Postoperative pancreatic fistula (PPF) is the most frequent and serious complication after laparoscopic distal pancreatectomy (LDP). Our goal was to compare the performance, in terms of PPF prevention, and safety of a radiofrequency (RF)-assisted transection device versus a stapler device in a porcine LDP model.

Methods: Thirty-two animals were randomly divided into two groups to perform LDP using a RF-assisted device (RF group; n = 16) and stapler device (ST group; n = 16) and necropsied 4 weeks after surgery. The primary endpoint was the incidence of PPF. Secondary endpoints were surgery/transection time, intra/postoperative complications/deaths, postoperative plasmatic amylase and glucose concentration, peritoneal liquid amylase and interleukin 6 (IL-6) concentrations, weight variations, and histopathological changes.

Results: Two clinical and one biochemical PPF were observed in the ST and RF groups respectively. Peritoneal amylase concentration was significantly higher in the RF group 4 days after surgery, but this difference was no longer present at necropsy. Both groups presented a significant decrease in peritoneal IL-6 concentration during the postoperative follow-up, with no differences between the groups. RF group animals showed a higher postoperative weight gain. In the histopathological exam, all RF group animals showed a common pattern of central coagulative necrosis of the parenchymal surface, surrounded by a thick fibrosis, which sealed main and secondary pancreatic ducts and was not found in ST group.

Conclusions: The fibrosis caused by an RF-assisted device can be at least as safe and effective as stapler compression to achieve pancreatic parenchyma sealing in a porcine LDP model.
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http://dx.doi.org/10.1007/s00464-013-2952-1DOI Listing
October 2013

[Results of the laparoscopic approach in left-sided pancreatectomy].

Cir Esp 2013 Jan 4;91(1):25-30. Epub 2012 Dec 4.

Unidad de Cirugía Hepato-Bilio-Pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari del Mar, Universitat Autònoma de Barcelona, Barcelona, España.

Introduction: Laparoscopic left-sided pancreatectomy (LLP) is an accepted technique for the treatment of benign and pre-malignant lesions of the left side of the pancreas, but there is still controversy on its use for malignant ones.

Objective: To evaluate our results in LLP as a routine technique for primary lesions of the left pancreas.

Patients And Methods: We performed LLP in 15 patients for primary lesions of the pancreas from November 2007 to November 2011. An intra-abdominal drainage was left in all cases, and the recommendations of the International Study Group for Pancreatic Fistula were followed.

Results: The mean age of the patients was 64±13 years. Six radical spleno-pancreatectomies, 3 corporo-caudal with preservation of the spleen, and 6 pure distal (4 with preservation of the spleen). There was one conversion. The mean surgical time was 230±69 minutes. The mean post-operative stay was 8.1±7.6 days. At 90 days, complications were detected in 4 patients; 3 grade II and one grade V according to the modified classification of Clavien. There was one grade B pancreatic fistula. The diagnosis was a malignant neoplasm in 53% of cases. The number of resected lymph nodes in the cases where a radical resection was planned due to cancer was 21.7±11.5, there being negative margins in all cases.

Conclusions: LLP may be considered as a suitable technique for the treatment of primary pancreatic lesions, including malignant ones, provided that it is performed by groups with experience in pancreatic surgery and highly trained in laparoscopic surgery.
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http://dx.doi.org/10.1016/j.ciresp.2012.05.011DOI Listing
January 2013

Laparoscopic distal pancreatectomy: feasibility study of radiofrequency-assisted transection in a porcine model.

J Laparoendosc Adv Surg Tech A 2012 Apr 30;22(3):242-8. Epub 2012 Jan 30.

General Surgery Department, Hospital del Mar, Barcelona, Spain.

Background And Aim: Despite technological improvements in pancreatic surgery, the incidence and morbidity of pancreatic leak after resection of distal pancreas are persistently high in most series. Laparoscopic distal pancreatectomy (LDP) is today the gold standard procedure for benign and certain malignant neoplasms of the pancreatic body and tail in specialized centers. This study evaluated safety and feasibility of a radiofrequency (RF)-assisted transection device in a porcine model of LDP.

Materials And Methods: LDP was performed on 10 pigs (median weight, 39.6 kg) using a new device based on an internally cooled RF-assisted electrode (Coolinside(®), Apeiron Medical, Valencia, Spain). The animals were subjected to daily observation and then sacrificed and necropsied at 4 weeks postoperatively. Primary end points were the development of postoperative pancreatic fistula using the Pancreatic Anastomotic Leak Study Group definition and/or the presence of abdominal amylase-rich fluid collections or abscesses during necropsy and pathological study and/or dye extravasation from the pancreatic remnant duct. Secondary end points were intra- or postoperative complications, surgery, and transection duration.

Results: No clinically relevant postoperative pancreatic fistulas were observed. In one case a grade A postoperative fistula was diagnosed due to amylase drain concentration of more than 6200 IU/mL on postoperative day 4. Median peritoneal liquid amylase concentration on postoperative day 4 was 2399.0 IU/L (range, 819.2-7122.0 IU/L), similar to the median plasma amylase level of 1520.8 IU/L (range, 1015.3-4056.6 IU/L). Median surgery time was 93.5 minutes (range, 46.0-140.0 minutes), and median transection time was 4.5 minutes (range, 2.0-26.0 minutes). There was one postoperative wound infection. There were no postoperative deaths or major complications. During the histopathological study, the surgical margin of the remaining pancreas showed a common pattern with a central area of necrosis surrounded by granulomatous infiltrate and fibrosis. Ductal obliteration was observed. No purulent inflammatory infiltrate or abscesses were present.

Conclusion: Experimental findings suggest that performing pancreatic transection with Coolinside in a animal model of LDP is feasible and safe.
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http://dx.doi.org/10.1089/lap.2011.0417DOI Listing
April 2012

[Quality of food intake after bariatric surgery: vertical gastrectomy versus gastric bypass].

Cir Esp 2012 Feb 22;90(2):95-101. Epub 2011 Dec 22.

Sección de Cirugía Gastrointestinal, Hospital Universitari del Mar, Institut de Recerca IMIM-Hospital del Mar, Barcelona, España.

Introduction: The different bariatric surgical techniques have an influence on food tolerance and the presence of vomiting. There have been few studies on the impact of these techniques on the quality of food intake.

Patients And Method: A prospective and comparative study was performed on a consecutive patient cohort operated on due to morbid obesity between May 2008 and November 2010. The quality of the diet was evaluated before and at 3, 6, 12 and 24 months postoperatively, using the questionnaire described by Suter et al.

Results: One hundred and five patients (64 vertical gastrectomy [VG] and 41 gastric bypass [GB]) completed the questionnaire before the surgery, and 87 at 3 months, 79 at 6 months, 53 at 12 months, and 18 at 24 months after surgery. The overall score of the questionnaire before surgery was 23.5 ± 2.6, with a significant difference at 3 months (20.4 ± 3.8, P<.001), at 6 months (21.3 ± 4.6, P<.001) and at 12 months (22.4 ± 3.3, P<.044), and with no difference at 24 months (23.2 ± 2.5, P<.622), after surgery. On comparing food intake of VG versus GB, the scores were similar before surgery (23.8 ± 2.4 vs 23.0 ± 2.8, P<.125) as well as in the post-surgical follow up at 3 months (20.5 ± 3,9 vs 20.2 ± 3.7, P<.599), 6 months (21.1 ± 5.3 vs 21.7 ± 3.4, P<.243), 12 months (22.3 ± 3.3 vs 22.7 ± 3.4, P<.140) and 24 months (22.9 ± 3.0 vs 23.6 ± 2.2, P = 1.00).

Conclusions: The worsening of the quality of food intake is common in the first months after bariatric surgery, gradually improving and with no differences being seen between VG and GB.
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http://dx.doi.org/10.1016/j.ciresp.2011.10.002DOI Listing
February 2012
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