Browsing by Author "Quezada, Nicolas"

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    Bariatric Surgery Before and After the SARS-CoV-2 Pandemic: a Comparative Study of Cases Before the Onset of the Pandemic in a High-Volume Academic Center
    (2023) Leon, Paula; Gabrielli, Mauricio; Quezada, Nicolas; Crovari, Fernando; Munoz, Rodrigo
    IntroductionAt the beginning of the pandemic, studies showed a higher risk of severe surgical complications and mortality among patients with perioperative SARS-CoV-2 infection, which led to the suspension of elective surgery. Confinement and lockdown measures were shown to be associated with weight gain and less access to medical and surgical care in patients with obesity, with negative health consequences. To evaluate the safety of bariatric surgery during the pandemic, we compared 30-day complications between patients who underwent bariatric surgery immediately before with those who underwent bariatric surgery during the opening phase of the pandemic.MethodsObservational analytical study of a non-concurrent cohort of patients who underwent bariatric surgery in 2 periods: pre-pandemic March 1 to December 31, 2019, and pandemic March 1 to December 31, 2020. Surgical complications were defined using the Clavien-Dindo classification.ResultsPre-pandemic and pandemic groups included 256 and 202 patients who underwent primary bariatric surgery, respectively. The mean age was 37.6 + 10.3 years. The overall complication rate during the first 30 days of discharge was 7.42%. No differences between groups were observed in severe complications (pre-pandemic 1.56% vs. pandemic 1.98%, p: 0.58). No mortality was reported. Overall 30-day readmission was 3.28% with no differences between groups.ConclusionThe findings of this study did not find a difference in the rate of severe complications, nor also we report severe COVID-19 complications in this high-risk population. During the pandemic, with appropriately implemented protocol, the resumption of bariatric surgery is possible with no increased risk for patients.
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    Bariatric Surgery in Cirrhotic Patients: a Matched Case-Control Study
    (2020) Quezada, Nicolas; Maturana, Gregorio; Irarrazaval, Maria Jesus; Munoz, Rodrigo; Morales, Sebastian; Achurra, Pablo; Azocar, Cristobal; Crovari, Fernando
    Introduction Laparoscopic bariatric surgery (LBS) in liver end-stage organ disease has been proven to improve organ function and patients' symptoms. A series of LBS in patients with cirrhosis have shown good results in weight loss, but increased risk of complications. Current literature is based on clinical series. This paper aims to compare LBS (69% gastric bypass) between patients with cirrhosis and without cirrhosis. Methods We conducted a retrospective 1:3 matched case-control study including bariatric patients with cirrhosis and without cirrhosis. Demographics, operative variables, postoperative complications, long-term weight loss, and comorbidity resolution were compared between groups. Results Sixteen Child A patients were included in the patients with cirrhosis (PC) group and 48 in patients without cirrhosis (control) group. Mean age was 50 years; preoperative BMI was 39 +/- 6.8 kg/m(2). Laparoscopic gastric bypass and laparoscopic sleeve gastrectomy were performed in 69% and 31%, respectively. Follow-up was 81% at 2 years for both groups. PC group had a higher rate of overall (31% vs. 6%;p < 0.05) and severe (Clavien-Dindo >= III; 13% vs. 0%;p = 0.013) complications than that of the control group. Mean %EWL of PC at 2 years of follow-up was 84.9%, without differences compared with that of the control group (83.1%). Comorbidity remission in PC was 14%, 50%, and 85% for hypertension, type 2 diabetes, and dyslipidemia, respectively. Patients without cirrhosis had a higher resolution rate of hypertension (65% vs. 14%,p = 0.03). Conclusion LBS is effective for weight loss and comorbidity resolution in patients with obesity and Child A liver cirrhosis. However, these results are accompanied by significantly increased risk of complications.
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    Enhanced-view totally extraperitoneal (eTEP) approach for the treatment of abdominal wall hernias: mid-term results
    (2022) Quezada, Nicolas; Grimoldi, Milenko; Besser, Nicolas; Jacubovsky, Ioram; Achurra, Pablo; Crovari, Fernando
    Introduction Multiple minimally invasive techniques have been described for ventral hernia repair. The recently described enhanced view totally extraperitoneal (eTEP) ventral hernia repair seems an appealing option since it allows to address midline and lateral hernias, placing the mesh in the retromuscular position without the use of traumatic fixation. Aim To report on the mid-term result of a series of patients with ventral hernias repaired by the eTEP approach. Methods A retrospective analysis of our case series between June 2017 and December 2019. Demographic and clinical data were gathered. Hernia characteristics, surgical details, hernia recurrences, and complications are reported. Results 66 patients were included in the study. Median follow-up was 22 months (interquartile range 12-26). 60% of patients were male. Mean age, BMI, % of Type-2 diabetes and % of smoking were 59 +/- 12 years, 30 kg/m(2), 24% and 23%, respectively. Mean hernia defect size was 5.5 +/- 2.9 cm. Forty-three eTEP Rives-stoppa and 23 eTEP-Transversus abdominis release (14 unilateral, 9 bilateral) were performed. 22 inguinal hernias and 15 lateral defects were simultaneously repaired. We report 1 recurrence (1.5%) and 10 surgical site occurrences (15%; 6 seromas, 2 hematomas and 2 surgical site infections). Four patients required reinterventions (6%). Conclusion eTEP is a promising approach to treat midline hernias and allows the simultaneous treatment of lateral and inguinal defects, keeping the mesh in the retromuscular position. However, comparative studies must be performed to know its real benefit in laparoscopic ventral hernia repair.
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    Five-Year Experience Training Surgeons with a Laparoscopic Simulation Training Program for Bariatric Surgery: a Quasi-experimental Design
    (2023) Duran Espinoza, Valentina; Belmar Riveros, Francisca; Jarry Trujillo, Cristian; Gaete Danobeitia, Maria Ines; Montero Jaras, Isabella; Miguieles Schilling, Mariana; Valencia Coronel, Brandon; Escalona, Gabriel; Achurra Tirado, Pablo; Quezada, Nicolas; Crovari, Fernando; Varas Cohen, Julian
    Purpose Nearly 200,000 laparoscopic Roux-en-Y gastric bypass (LRYGB) are performed yearly. Reported learning curves range between 50 and 150, even 500 cases to decrease the operative risk. Simulation programs could accelerate this learning curve safely; however, trainings for LRYGB are scarce. This study aims to describe and share our 5-year experience of a simulated program designed to achieve proficiency in LRYGB technical skills.Materials and Methods A quasi-experimental design was used. All recruited participants were previously trained with basic and advanced laparoscopic simulation curriculum completing over 50 h of practical training. Ex vivo animal models were used to practice manual and stapled gastrojejunostomy (GJ) and stapled jejunojejunostomy (JJO) in 10, 3, and 4 sessions, respectively. The main outcome was to assess the manual GJ skill acquisition. Pre- and post-training assessments using a Global Rating Scale (GRS; max 25 pts), Specific Rating Scale (SRS; max 20 pts), performance time, permeability, and leakage rates were analyzed. For the stapled GJ and JJO, execution time was registered. Data analysis was performed using parametric tests.Results In 5 years, 68 trainees completed the program. For the manual GJ's pre- vs post-training assessment, GRS and SRS scores increased significantly (from 17 to 24 and from 13 to 19 points respectively, p-value < 0.001). Permeability rate increased while leakage rate and procedural time decreased significantly.Conclusion This simulated training program showed effectiveness in improving laparoscopic skills for manual GJ and JJO in a simulated scenario. This new training program could optimize the clinical learning curve. Further studies are needed to assess the transfer of skills to the operating room.
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    Higher hepatic advanced glycation end products and liver damage markers are associated with nonalcoholic steatohepatitis
    (2022) Priken, Kathleen; Tapia, Gladys; Cadagan, Cynthia; Quezada, Nicolas; Torres, Javiera; D'Espessailles, Amanda; Pettinelli, Paulina
    Advanced glycation end products (AGEs) may be associated with nonalcoholic fatty liver disease (NAFLD) from stimulation of oxidative stress, inflammation, and fibrosis. We hypothesized that patients with NAFLD would have a lower concentration of soluble AGEs receptor and higher quantity of serum and liver AGEs and an increase in hepatic smooth muscle actin alpha (alpha-SMA) and transforming growth factor beta 1 (TGF-beta 1) compared with a control group. We compared the presence of hepatic and serum AGEs, AGE soluble receptor (sRAGE), and markers associated with hepatic damage between NAFLD patients and controls without disease. Histological characteristics, plasma biochemical parameters, serum AGEs, serum receptor sRAGE, and liver proteins (alpha-SMA, TGF-beta 1, AGEs, immunohistochemistry) were assessed in participants aged 18 to 65 years, with NAFLD (simple steatosis [SS]: n = 7; steatohepatitis [NASH]: n = 15) and controls (n = 11). NASH patients presented higher glycated hemoglobin levels (%) (5.7; 5.4-6.3) compared with SS (5.4; 5.2-5.7) and controls (5.4; 5.3-5.5). The NAFLD activity score (NAS) for NASH patients was 4.9 +/- 1.3; for SS patients, 2.0 +/- 1.0. NASH patients showed higher hepatic AGEs, TGF-beta 1, and alpha-SMA compared with SS and control groups. The NAS score indicates that patients with 5 to 8 had higher hepatic AGEs, TGF-beta 1, and alpha-SMA compared with a NAS of 1 to 4 and 0. For alpha-SMA, a NAS of 1 to 4 was higher than NAS 0. No difference was found in serum AGEs and sRAGE between groups. Higher hepatic AGEs, TGF-beta 1, and alpha-SMA were observed with increasing disease severity (according to NAS); therefore, endogenous liver AGEs may participate in hepatic damage progression. (C) 2022 Elsevier Inc. All rights reserved.
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    Morbidity and Mortality in Patients with Perioperative COVID-19 Infection: Prospective Cohort in General, Gastroesophagic, Hepatobiliary, and Colorectal Surgery
    (2021) Inzunza, Martin; Romero, Cecilia; Jesus Irarrazaval, Maria; Ruiz-Esquide, Magdalena; Achurra, Pablo; Quezada, Nicolas; Crovari, Fernando; Munoz, Rodrigo
    Background Severe acute respiratory syndrome due to coronavirus 2 has rapidly spread worldwide in an unprecedented pandemic. Patients with an ongoing COVID-19 infection requiring surgery have higher risk of mortality and complications. This study describes the mortality and morbidity in patients with perioperative COVID-19 infection undergoing elective and emergency surgeries. Methods Prospective cohort of consecutive patients who required a general, gastroesophageal, hepatobiliary, colorectal, or emergency surgery during COVID-19 pandemic at an academic teaching hospital. The primary outcome was 30-day mortality and major complications. Secondary outcomes were specific respiratory mortality and complications. Results A total of 701 patients underwent surgery, 39 (5.6%) with a perioperative COVID-19 infection. 30-day mortality was 12.8% and 1.4% in patients with and without COVID-19 infection, respectively (p < 0.001). Major surgical complications occurred in 25.6% and 6.8% in patients with and without COVID-19 infection, respectively (p < 0.001). Respiratory complications occurred in 30.8% and 1.4% in patients with and without COVID-19 infection, respectively (p < 0.001). Mortality due to a respiratory complication was 100% and 11.1% in patients with and without COVID-19 infection, respectively (p < 0.006). Conclusions 30-day mortality and surgical complications are higher in patients with perioperative COVID-19 infection. Indications for elective surgery need to be reserved for non-deferrable procedures in order to avoid unnecessary risks of non-urgent procedures.
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    Robotic transversus abdominis release using HUGO RAS system: our initial experience
    (2024) Quezada, Nicolas; Irarrazaval, Maria Jesus; Chen, David C.; Grimoldi, Milenko; Pimentel, Fernando; Crovari, Fernando
    BackgroundTransversus abdominis release (TAR) is an effective technique for treating large midline and off-midline hernias. Recent studies have demonstrated that robotic TAR (rTAR) is technically feasible and associated with improved outcomes compared to open surgery. There is no published experience to date describing abdominal wall reconstruction using the novel robotic platform HUGO RAS System (Medtronic (R)).MethodsAll consecutive patients who underwent a rTAR in our institution were included. Three of the four arm carts of the HUGO RAS System were used at any given time. Each arm configuration was defined by our team in conjunction with Medtronic (R) personnel. rTAR was performed as previously described. Upon completion of the TAR on one side, a redocking process with different, mirrored arms angles was performed to continue with the contralateral TAR. Operative variables and early morbidity were recorded.ResultsTen patients were included in this study. The median BMI was 31 (21-40.6) kg/m2. The median height was 1.6 m (1.5-1.89 m). A trend of decreased operative time, console time, and redocking time was seen in these consecutive cases. No intraoperative events nor postoperative morbidity was reported. The median length of stay was 3 (1-6) days.ConclusionRobotic TAR utilizing the HUGO RAS system is a feasible and safe procedure. The adoption of this procedure on this novel platform for the treatment of complex abdominal wall hernias has been successful for our team.
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    Safety of Bariatric Surgery During the Opening Phase After the First Wave of the COVID-19 Pandemic: Experience at an Academic Center
    (2021) Crovari, Fernando; Inzunza, Martin; Irarrazaval, Maria J.; Romero, Cecilia; Achurra, Pablo; Quezada, Nicolas; Gabrielli, Mauricio; Munoz, Rodrigo
    Introduction Increased morbimortality in patients with COVID-19 infection who had undergone surgery has raised concerns about bariatric surgery safety during the current COVID-19 pandemic. Currently, there is scarce literature on safety outcomes after bariatric surgery during the COVID-19 pandemic.
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    Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: is it always necessary to operate? A 5-year, high volume center experience
    (2021) Gabrielli, Mauricio; Jarry, Cristian; Hurtado, Sebastian; Achurra, Pablo; Munoz, Rodrigo; Quezada, Nicolas; Crovari, Fernando
    Purpose This study aims to describe the incidence, associated factors, etiology, and management of small bowel obstructions following laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods A retrospective analysis was conducted between January 15 and December 19 using the surgery database of our hospital. Included LRYGB patients were those that evolved with a prolonged length of stay; readmission; emergency room consult; and re-intervention due to small bowel obstruction (SBO) related symptoms with compatible radiological or intraoperative findings. The LRYGB technique implied an antecolic alimentary limb reconstruction and systematic closure of mesenteric defects. Descriptive and analytical statistics were carried out, using a parametric or non-parametric approach as needed. Results Nine hundred forty-one LRYGB were performed. 9.9% were revisional surgeries of patients with a laparoscopic sleeve gastrectomy. During the study period, 36 SBOs occurred, representing 3.8% of operated patients, with no mortality. 58.3% had successful non-operative management, while 41.7% required surgical exploration, of which 73.3% were treated laparoscopically and 20% needed conversion to open surgery. Etiologies of SBO were jejuno-jejunostomy (JJO) related stenosis (22, 61.1%), internal hernias (6, 16.7%), adherences (3, 8.3%), and other diagnoses (5, 13.9%). Regarding JJO stenosis and internal hernias, median time to diagnosis was 8 days (IQR 7-11) and 12 months (IQR 8.7-16) respectively. Previous sleeve gastrectomy, age, or sex was not associated to the incidence of small bowel obstruction. Conclusions LRYGB is safe when performed by experienced surgeons. SBO due to internal hernias were scarce in this series. JJO stenosis could explain most cases of SBO; under this diagnosis, non-surgical management was successful frequently.