Pr. Dr. Pedro Gutiérrez Contreras

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Pr. Dr. Pedro Gutiérrez Contreras Chirurgie coelioscopique, obésité, endoscopie diagnostique et thérapeutique avancée.

16 años de experiencia nos respaldan, especializados en Cirugía Gastroendoscopica - Bariatra

29/11/2025

Hiatal hernia and reflux
A. Medical Management (First-line for GERD):
1. Proton Pump Inhibitors (PPIs): Gold standard for esophagitis healing and symptom control.
*Limitation: Up to 30% of patients have a suboptimal response. Large hepatic hiatus reduces their effectiveness.
2. H2 Receptor Antagonists (H2RAs): Ranitidine, Famotidine. Alternative for mild/intermittent or nocturnal symptoms.
3. Antacids/Alginates: Rapid but transient symptomatic relief.
4. Lifestyle Modifications:
Weight loss (strong evidence).
Elevate the head of the bed.
Avoid large/fatty meals, chocolate, caffeine, mint, citrus fruits, alcohol, and to***co.
Do not lie down for 2-3 hours after eating. B. Endoscopic Management:
1. Esophageal Dilation: Primary treatment for symptomatic peptic stricture. Requires long-term PPI therapy to prevent recurrence.
2. Treatment of Barrett's Esophagus:
Periodic endoscopic surveillance according to the degree of dysplasia.
Endoscopic Mucosal Resection (EMR): For high-grade dysplasia or visible intramucosal cancer.
Radiofrequency Ablation (RFA) or Cryotherapy: Treatment of choice for high-grade dysplasia and persistent low-grade dysplasia in Barrett's esophagus. Effective in eliminating metaplasia and reducing the risk of cancer.
C. Surgical Management (Fundoplication):
Main Indications:
GERD refractory to maximum doses of PPIs with good symptom-reflux correlation (positive pH monitoring).
Intolerance to or serious adverse effects from PPIs.
Presence of a large (>2 cm) symptomatic or complicated hiatal hernia (especially paraesophageal hiatal hernia).
Complications (recurrent peptic stricture despite PPIs, Barrett's esophagus with dysplasia).
Need for chronic treatment in young patients.
Technique: Laparoscopic (current standard). Complete (Nissen 360°) or partial (Toupet 270°, Dor anterior) fundoplication.
Efficacy: High success rate in symptom and esophagitis control (>85-90% at 5-10 years in expert centers). Better results in patients with a previous response to PPIs and a proven hiatal hernia.

26/11/2025

Life begins with death, and our last day is the beginning of the first.

21/11/2025

Mesh repair is the gold standard, dramatically reducing recurrences by reinforcing the abdominal wall. The laparoscopic approach minimizes trauma with small incisions. This combination offers key advantages: less postoperative pain and reduced use of analgesics, faster recovery, and an earlier return to activities. It presents a lower risk of wound infection and a better cosmetic outcome. Furthermore, it allows for superior visualization when treating multiple or hidden hernias. Scientific evidence supports it as the preferred option for most patients, balancing long-lasting effectiveness with a more comfortable recovery. The final decision should always be individualized.

19/11/2025

Based on scientific evidence, the complications of hiatal hernia (HH) are classified as acute (potentially life-threatening) and chronic (impairing quality of life).

I. Acute Complications (Medical Emergencies)
1. Strangulated Hernia:
• Occurs mainly in paraesophageal hernias (Types II-IV).
• The stomach or other organs (colon, spleen) become trapped in the hiatus, compromising their blood supply.
• Risk: Ischemia, gastric necrosis, and perforation.
• Mortality: Up to 5-8% if emergency surgery is required (Poulose et al., Annals of Surgery, 2012).
• Symptoms: Severe epigastric/chest pain, intractable vomiting, septic shock.
• Symptoms: Severe epigastric/chest pain, intractable vomiting, septic shock. 2. Gastric Perforation:
• Secondary to ulcers in the hernial sac due to ischemia or erosion from NSAIDs.
• Consequence: Peritonitis, mediastinitis. Requires immediate surgery.
II. Chronic Complications (Impaired Quality of Life)
1. Severe Gastroesophageal Reflux Disease (GERD):
• Mechanism: Hernia weakens the lower esophageal sphincter (LES), facilitating acid reflux.
• Impact:
• Chronic heartburn, regurgitation, nighttime cough.
• Esophageal Stricture: Fibrosis due to recurrent inflammation → dysphagia (difficulty swallowing) (Richter, Gut, 2018).
• Barrett's Esophagus: Intestinal metaplasia due to chronic acid damage. Risk of esophageal adenocarcinoma (30-125 times higher vs. general population) (Shaheen et al., NEJM, 2009).
2. Iron Deficiency Anemia:
• Cause: Chronic microbleeds from gastric erosions in the hernial sac (Cameron ulcers) or erosive esophagitis.
• Prevalence: Up to 20% in large hernias (Kohn et al., Surgical Endoscopy, 2015).

3. Respiratory Problems:
• Chronic acid aspiration → recurrent pneumonia, pulmonary fibrosis, exacerbation of asthma/COPD (Mansfield, Journal of Thoracic Disease, 2019).

4. Non-Cardiac Chest Pain:
• Mimics angina due to esophageal/mediastinal irritation. Reduces physical capacity and well-being (Fass, American Journal of Gastroenterology, 2009).

5. Giant Hernias (≥30% of the stomach):
• Early satiety, nausea, postprandial vomiting → malnutrition and weight loss.

19/11/2025

Based on scientific evidence, the complications of hiatal hernia (HH) are classified as acute (potentially life-threatening) and chronic (impairing quality of life).

I. Acute Complications (Medical Emergencies)
1. Strangulated Hernia:
• Occurs mainly in paraesophageal hernias (Types II-IV).
• The stomach or other organs (colon, spleen) become trapped in the hiatus, compromising their blood supply.
• Risk: Ischemia, gastric necrosis, and perforation.
• Mortality: Up to 5-8% if emergency surgery is required (Poulose et al., Annals of Surgery, 2012).
• Symptoms: Severe epigastric/chest pain, intractable vomiting, septic shock.
• Symptoms: Severe epigastric/chest pain, intractable vomiting, septic shock. 2. Gastric Perforation:
• Secondary to ulcers in the hernial sac due to ischemia or erosion from NSAIDs.
• Consequence: Peritonitis, mediastinitis. Requires immediate surgery.
II. Chronic Complications (Impaired Quality of Life)
1. Severe Gastroesophageal Reflux Disease (GERD):
• Mechanism: Hernia weakens the lower esophageal sphincter (LES), facilitating acid reflux.
• Impact:
• Chronic heartburn, regurgitation, nighttime cough.
• Esophageal Stricture: Fibrosis due to recurrent inflammation → dysphagia (difficulty swallowing) (Richter, Gut, 2018).
• Barrett's Esophagus: Intestinal metaplasia due to chronic acid damage. Risk of esophageal adenocarcinoma (30-125 times higher vs. general population) (Shaheen et al., NEJM, 2009).
2. Iron Deficiency Anemia:
• Cause: Chronic microbleeds from gastric erosions in the hernial sac (Cameron ulcers) or erosive esophagitis.
• Prevalence: Up to 20% in large hernias (Kohn et al., Surgical Endoscopy, 2015).

3. Respiratory Problems:
• Chronic acid aspiration → recurrent pneumonia, pulmonary fibrosis, exacerbation of asthma/COPD (Mansfield, Journal of Thoracic Disease, 2019).

4. Non-Cardiac Chest Pain:
• Mimics angina due to esophageal/mediastinal irritation. Reduces physical capacity and well-being (Fass, American Journal of Gastroenterology, 2009).

5. Giant Hernias (≥30% of the stomach):
• Early satiety, nausea, postprandial vomiting → malnutrition and weight loss.

13/11/2025

Tumors about colon, re**um and a**s are increasingly common in young people; multiple factors, including poor diet or "ultra-processed foods", have modified the epidemiology.If you have anorectal symptoms, see your specialist. Not everything is hemorrhoids, and when they are present, they are often just the tip of the iceberg of a more serious condition. Prevention is key!

11/11/2025

3. Emerging Concerns and Long-Term Effects
• Thyroid: The product information contains a specific contraindication for patients with a personal or family history of medullary thyroid carcinoma or MEN 2, based on findings in rodents. A causal link has not been established in humans, but monitoring continues.
• Malnutrition: Extreme appetite suppression can lead to insufficient caloric and nutrient intake, with a risk of vitamin and mineral deficiencies if not monitored.
• Nephropathy (Kidney Damage): Severe dehydration from vomiting or diarrhea can precipitate acute kidney failure, especially in patients with pre-existing kidney disease.
Evidence-Based Conclusion
GLP-1 agonists are a revolutionary class of drugs with proven metabolic and cardiovascular benefits. However, they are not without risks.
• Malnutrition: Extreme appetite suppression can lead to insufficient caloric and nutrient intake, with a risk of vitamin and mineral deficiencies if not monitored.
• Nephropathy (Kidney Damage): Severe dehydration from vomiting or diarrhea can precipitate acute kidney failure, especially in patients with pre-existing kidney disease. • “Devastating” effects are relatively rare, but their impact is significant when they occur (gastroparesis, pancreatitis, surgical complications).
• The most underestimated adverse effect is muscle loss, which can have long-term consequences for metabolic health and physical function if not mitigated with appropriate lifestyle changes.
• The key to minimizing risks is use under strict medical supervision, with gradual dose titration, patient education about side effects, and the implementation of a high-protein diet and strength training.
The evidence continues to evolve, and it is the responsibility of healthcare professionals and patients to weigh these potentially serious risks against the significant benefits these drugs can offer.
P2 Devastating effects

09/11/2025

2. Serious or "Devastating" Adverse Effects (Less Common)
These are the effects that have generated the most alerts from regulatory agencies and the scientific community.
a) Pancreatitis
• Evidence: The product information for these medications includes a warning about the risk of acute pancreatitis. Multiple case studies and some database analyses have indicated an association, although the absolute risk remains low.
• Devastating Potential: Acute pancreatitis is a painful and potentially life-threatening condition that requires hospitalization.
b) Gallbladder Disease
• Evidence: This is one of the best-established adverse effects. Rapid weight loss is a known risk factor for gallstone formation. Clinical trials have shown a significant increase in the incidence of cholelithiasis (gallstones) and cholecystitis (inflammation of the gallbladder), which may require emergency surgery. • Devastating Potential: Acute cholecystitis is a serious condition that often requires emergency cholecystectomy (gallbladder removal).
c) Gastroparesis (Severe Delayed Gastric Emptying)
• Evidence: This is a point of increasing concern. GLP-1 agonists intentionally delay gastric emptying. In some patients, this effect can become extreme and persistent, even after discontinuing the medication. There are numerous case reports and lawsuits alleging debilitating gastroparesis.
• Devastating Potential: Chronic gastroparesis causes nausea, uncontrollable vomiting, abdominal distension, pain, and malnutrition, and can be a debilitating and very difficult-to-manage condition.
d) Pulmonary Aspiration (Anesthetic Risk)
• Evidence: Due to delayed gastric emptying, there is an increased risk of aspiration of gastric contents during general anesthesia. Anesthesiology societies have issued alerts recommending the discontinuation of these drugs (semaglutide for 1 week, tirzepatide for 3-4 weeks) before any procedure requiring sedation.
• Devastating Potential: Aspiration pneumonia is a serious complication that can cause respiratory failure and death.
e) "Loose Skin" Syndrome and Muscle Wasting (Sarcopenia)

P2

09/11/2025

2. Serious or "Devastating" Adverse Effects (Less Common)
These are the effects that have generated the most alerts from regulatory agencies and the scientific community.
a) Pancreatitis
• Evidence: The product information for these medications includes a warning about the risk of acute pancreatitis. Multiple case studies and some database analyses have indicated an association, although the absolute risk remains low.
• Devastating Potential: Acute pancreatitis is a painful and potentially life-threatening condition that requires hospitalization.
b) Gallbladder Disease
• Evidence: This is one of the best-established adverse effects. Rapid weight loss is a known risk factor for gallstone formation. Clinical trials have shown a significant increase in the incidence of cholelithiasis (gallstones) and cholecystitis (inflammation of the gallbladder), which may require emergency surgery. • Devastating Potential: Acute cholecystitis is a serious condition that often requires emergency cholecystectomy (gallbladder removal).
c) Gastroparesis (Severe Delayed Gastric Emptying)
• Evidence: This is a point of increasing concern. GLP-1 agonists intentionally delay gastric emptying. In some patients, this effect can become extreme and persistent, even after discontinuing the medication. There are numerous case reports and lawsuits alleging debilitating gastroparesis.
• Devastating Potential: Chronic gastroparesis causes nausea, uncontrollable vomiting, abdominal distension, pain, and malnutrition, and can be a debilitating and very difficult-to-manage condition.
d) Pulmonary Aspiration (Anesthetic Risk)
• Evidence: Due to delayed gastric emptying, there is an increased risk of aspiration of gastric contents during general anesthesia. Anesthesiology societies have issued alerts recommending the discontinuation of these drugs (semaglutide for 1 week, tirzepatide for 3-4 weeks) before any procedure requiring sedation.
• Devastating Potential: Aspiration pneumonia is a serious complication that can cause respiratory failure and death.
e) "Loose Skin" Syndrome and Muscle Wasting (Sarcopenia)

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