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Our main goal is to describe how to start and develop a multicenter, prospective, randomized, controlled trial. The first step is to have an idea that will become the hypothesis and a main objective. A bibliographic search should be done to check for clinical interest and originality. Moreover, the study must be feasible and should be finished within 4 years. In order to start the multicenter study, a protocol should be written (in accordance with the SPIRIT guidelines Standard Protocol items: Recommendations for Interventional Trials), including the design type, sample size and participating hospitals. Randomization is key to the design and, therefore, the CONSORT (Consolidated Standards of Reporting Trials) guidelines must be followed. However, if the study cannot be randomized, the TREND (Transparent Reporting of Evaluations with Non-Randomized Designs) guidelines are recommended. When the protocol is approved by the Ethics Committee for Clinical Investigation of the hospital, we ought to create visibility. It is suggested to register the trial on ClincalTrials.gov and submit its publication to indexed magazines. Financial resources are necessary to execute the study and maintain an online database. This allows the registry to be updated and accessible to all the participants in the study. What is more, randomization can be done immediately. And last, but not least, is motivation. Multicentricity equals to participation of all the chosen medical centers. Updating and motivating them by sending a newsletter every 1-3 months keeps participants engaged in the study.

Resumen El objetivo de este articulo es ilustrar como poner en marcha y desarrollar un estudio multicentrico prospectivo, controlado y aleatorizado. Por ello, lo primero que se necesita es crear una idea que genere una hipotesis y un objetivo principal. La busqueda bibliografica nos permite ver su relevancia clinica y las evidencias publicadas. Ademas, hay que plantearse si el estudio es viable economicamente y si puede ser completado en un periodo menor a 4 anos. Una vez ideado el estudio multicentrico, para ejecutarlo se debe redactar un protocolo (segun la guia Standard Protocol items: Recommendations for Interventional Trials [SPIRIT 2013]). En el se recogeran el tipo de diseno, el tamano muestral y los centros que participaran. La aleatorizacion es clave en el diseno. Si puede ser aleatorizado, se recomienda utilizar la guia Consolidated Standards of Reporting Trials (CONSORT), si no, la Transparent Reporting of Evaluations with Non-Randomized Designs (TREND). Cuando el protocolo es aprobado por el Comite Etico de Investigacion Clinica del hospital, hay que darle visibilidad. Es por eso que se recomienda su registro en ClincalTrials.gov y su publicacion en revistas indexadas. Para el inicio del estudio, se requiere buscar fuentes de financiacion. Estas permiten tener una base de datos on line, que permiten aleatorizar al momento y mantener el registro al dia desde cualquier centro. Por ultimo, hay que destacar que es imprescindible la motivacion. La multicentricidad solo se entiende si todos los centros participan. Asi que informar de resultados y dar animos cada 1-3 meses (en forma de newsletter) es una manera de conseguir un buen funcionamiento del estudio.

Weight regain following bariatric surgery is not uncommon. Safe, effective weight loss treatment up to 1 year has been reported with the closed-loop gastric electrical stimulation (CLGES) system. Continuous recording of eating and activity behavior by onboard sensors is one of the novel features of this closed-loop electrical stimulation therapy, and may provide improved long-term weight maintenance by enhancing aftercare. Four centers participating in a 12-month prospective multicenter randomized study monitored all implanted participants (n = 47) up to 24 months after laparoscopic implantation of a CLGES system. Weight loss, safety, quality of life (QOL), and cardiac risk factors were analyzed. Weight regain was limited in the 35 (74%) participants remaining enrolled at 24 months. Mean percent total body weight loss (%TBWL) changed by only 1.5% between 12 and 24 months, reported at 14.8% (95% CI 12.3 to 17.3) and 13.3% (95% CI 10.7 to 15.8), respectively. The only serious device-/procedure-related adverse events were two elective system replacements due to lead failure in the first 12 months, while improvements in QOL and cardiovascular risk factors were stable thru 24 months. During the 24 month follow-up, CLGES was shown to limit weight regain with strong safety outcomes, including no serious adverse events in the second year. We hypothesize that CLGES and objective sensor-based behavior data combined to produce behavior change. The study supports CLGES as a safe obesity treatment with potential for long-term health benefits. ClinicalTrials.gov identifier: NCT01448785

Resumen Introduccion La gastrectomia vertical (GV) se ha convertido en una tecnica con entidad propia cuya indicacion selectiva o global sigue siendo objeto de controversia. Los resultados ponderales a 5 anos son heterogeneos. El objetivo del estudio es identificar posibles factores pronosticos de perdida de peso insuficiente tras GV. Metodos Estudio multicentrico retrospectivo de GV con seguimiento mayor de un ano. Se considera fracaso si el PSP Resultados Se incluye a 1.565 pacientes intervenidos en 29 hospitales. PSP al ano: 70,58 ± 24,8; a los 3 anos 69,39 ± 29,2; a los 5 anos 68,46 ± 23,1. Pacientes con PSP 50 kg/m2, edad > 50 anos, DM2, HTA, SAOS, cardiopatia, varias comorbilidades asociadas, distancia a piloro > 5 cm, bujia > 40 F, tratamiento con antiagregantes. La sobresutura mejora los resultados. Las variables que mostraron ser factores predictivos de fracaso en el seguimiento fueron la DM2 y el IMC. Conclusion La GV asocia una perdida de peso satisfactoria en el 79% de los pacientes en los primeros 5 anos; sin embargo, algunas variables como el IMC > 50, la DM2, la edad > 50, la presencia de varias comorbilidades, la seccion a mas de 4 cm del piloro o la bujia > 40 F pueden aumentar el riesgo de fracaso ponderal.

Resumen La cirugia bariatrica ha demostrado ser muy eficaz en el control de la obesidad y el sindrome metabolico. Sus resultados no solo se expresan en terminos de perdida de peso, sino tambien en la resolucion de comorbilidades, mejoria de la calidad de vida y de las complicaciones derivadas. Los diferentes parametros utilizados para medir estos resultados requieren de una uniformidad y de unos patrones de referencia. Por ello, es fundamental establecer cuales son los indicadores y los criterios de calidad que definen las «buenas practicas» en cirugia bariatrica. En este sentido, la Seccion de Obesidad de la Asociacion Espanola de Cirujanos (AEC), en colaboracion con la Sociedad Espanola de Cirugia de la Obesidad (SECO), se plantea como objetivo identificar los puntos clave que definen la calidad en este tipo de cirugia. Para ello se describen los principales indicadores basados en la literatura publicada, asi como los criterios de remision de las principales comorbilidades segun las evidencias encontradas y sus grados de recomendacion.

Bariatric surgery has proven to be highly effective in controlling obesity and metabolic syndrome; the results of this surgery are not only expressed in terms of weight loss, but also in terms of resolution of comorbidities, improved quality of life and complications. The different parameters used to measure these outcomes require uniformity and reference patterns. Therefore, it is essential to identify those indicators and quality criteria that are helpful in defining the «best practice» principles in bariatric surgery. In this regard, the Section of Obesity of the Spanish Association of Surgeons, in collaboration with the Spanish Society for Bariatric Surgery (SECO), present as an objective to identify the key points that define «quality» in this type of surgery. We describe the main indicators based on the published literature as well as the criteria for referral of the main comorbidities according to the evidence found and grades of recommendation.

Adipose tissue (AT) dysfunction in obesity is commonly linked to insulin resistance and promotes the development of metabolic disease. Bariatric surgery (BS) represents an effective strategy to reduce weight and to improve metabolic health in morbidly obese subjects. However, the mechanisms and pathways that are modified in AT in response to BS are not fully understood, and few information is still available as to whether these may vary depending on the metabolic status of obese subjects. Abdominal subcutaneous adipose tissue (SAT) samples were obtained from morbidly obese women (n = 18) before and 13.3 ± 0.37 months after BS. Obese women were stratified into two groups: normoglycemic (NG; Glu

Introduction: Sleeve gastrectomy (SG) has become a technique in its own right although a selective or global indication remains controversial. The weight loss data at 5 years are heterogeneous. The aim of the study is to identify possible prognostic factors of insufficient weight loss after SG. Methods: A SG retrospective multicenter study of more than one year follow-up was performed. Failure is considered if EWL > 50%. Univariate and multivariate study of Cox regression were performed to identify prognostic factors of failure of weight loss at 1, 2 and 3 years of follow up. Results: A total of 1,565 patients treated in 29 hospitals are included. PSP per year: 70.58 +/- 24.7; 3 years 69.39 +/- 29.2; 5 years 68.46 +/- 23.1. Patients with EWL < 50 (considered failure): 17.1% in the first year, 20.1% at 3 years, 20.8% at 5 years. Variables with influence on the weight loss failure in univariate analysis were: BMI > 50 kg/m(2), age > 50 years, DM2, hypertension, OSA, heart disease, multiple comorbidities, distance to pylorus> 4 cm, bougie > 40 F, treatment with antiplatelet agents. The reinforcement of the suture improved results. In multivariate study DM2 and BMI are independent factors of failure. Conclusion: The SG associates a satisfactory weight loss in 79% of patients in the first 5 years; however, somevariablessuchasBMI > 50, age > 50, thepresenceofseveralcomorbidities, more than 5 cm section of the pylorus or bougie > 40 F can increase the risk of weight loss failure. (C) 2017 AEC. Published by Elsevier Espanna, S.L.U. All rights reserved.

To determine possible preoperative predictors for obtaining clinically meaningful weight loss with gastric electrical stimulation (GES) using the “Three-Factor Eating Questionnaire” (TFEQ) as well as epidemiological data. Ninety-seven obese participants in a prospective multicenter randomized study conducted in nine European centers were implanted laparoscopically with the abiliti® closed-loop GES system (CLGES). Five clinical variables and three preoperative TFEQ factor scores (F1—cognitive-restraint, F2—disinhibition, and F3—hunger) were analyzed in order to determine predictors of weight loss success defined as excess weight loss (EWL) > 30% and failure defined as EWL

Introduction: The introduction of laparoscopic surgery (LS) can be considered the most important advancement in our specialty in the past 25 years. Despite its advantages, implementation and consolidation has not been homogenous, especially for advanced techniques. The aim of this study was to analyse the level of development and use of laparoscopic surgery in Spain at the present time and its evolution in recent years. Material and methods: During the second half of 2012 a survey was developed to evaluate different aspects of the implementation and development of LS in our country. The survey was performed using an electronic questionnaire. Results: The global response rate was 16% and 103 heads of Department answered the survey. A total of 92% worked in the public system. A total of 99% perform basic laparoscopic surgery and 85,2% advanced LS. Most of the responders (79%) consider that the instruments they have available for LS are adequate and 71% consider that LS is in the right stage of development in their environment. Conclusions: Basic laparoscopic surgery has developed in our country to be considered the standard performed by most surgeons, and forms part of the basic surgical training of residents. With regards to advanced LS, although it is frequently used, there are still remaining areas of deficit, and therefore, opportunities for improvement. (C) 2013 AEC. Published by Elsevier Espana, S. L. All rights reserved.

Summary Introduction Gastrostomy feeding tube insertion has become a common procedure as it enables patients who require long term enteral feeding. Conventional surgical gastrostomies were the only way of gaining enteral access in patients in which it is not possible to pass an endoscope or a nasogastric tube required for endoscopic or radiological gastrostomies, and in patients in which certain anatomical abnormalities contraindicate performing these techniques. As conventional surgical gastrostomies are associated with high morbidity, especially gastric leakage around the tube, percutaneous laparoscopic assisted gastrostomy (PLAG) may be a better way to gain enteral access. Material and methods Observational study of a prospective cohort of 224 patients on whom a gastrostomy was performed for nutritional support between January 2009 and October 2015 at Virgen del Rocio University Hospital in Seville. The types of gastrostomies carried out were: percutaneous endoscopic gastrostomy (PEG, n = 106), percutaneous radiological gastrostomy (PRG, n = 89), conventional surgical gastrostomy, Open Stamn or Laparoscopic Janeway (SG, n = 9) and percutaneous laparoscopic assisted gastrostomy (PLAG, n = 20), technique that we describe in detail. Short and long term complications are described. Results Many more complications were seen in the conventional gastrostomy group than in the other three groups, especially leakage of gastric content around the tube, with burning and irritation of the skin (66% compared with 2.83% in PEG and 0% in PLAG and PRG). The group with the highest proportion of patients completely free of complications was PLAG (75%), whilst in the conventional surgical gastrostomy group, no patient was completely free of complications. Conclusions We found lower complication rate in PLAG than any other technique. We believe that PLAG could be preferred technique for patients on whom it is not possible to perform PEG or PRG, as it is safe and easy.

Purpose: To analyze the outcomes of patients in whom we performed a SG depending on the calibrating bougie. Methods: Retrospective review of patients who underwent SG. Baseline characteristics were analyzed, and outcomes compared between groups. In order to identify the contribution of each predictor in the %EWL, a linear regression univariate and multivariate model was constructed. Results: 168 LSG were performed (120 women), mean age 42.9 years and BMI 51.1. Mortality rate of 0.3% and morbidity rate of 4.7%. No differences in terms of complications between both groups (5.8% vs 3.2%, p=0.735), while %EWL was statistically superior in the 40fr group (67.4±17.9 vs 58.1±15.6 at 24 months, p=0.012). Age, larger bougie size and arthropathy influenced negatively on the %EWL. In the multivariate analysis, the introduction of the variable “surgeon” produced a reduction of the effect of the bougie size in weight loss at 24 months (mean difference between groups is 7.5; 95% CI (3.4 – 18.3); p=0.173). Conclusions: There are differences regarding %EWL in the medium term favoring the use of a 40Fr bougie against the 58 Fr one, with no differences in terms of complications. As well as the bougie, the surgeon plays an important role in the %EWL.

Background Complications in sleeve gastrectomy (SG) can cast a shadow over the technique's good results and compromise its safety. The aim of this study is to identify risk factors for complications, and especially those that can potentially be modified to improve safety. Methods A retrospective multicenter cohort study was carried out, involving the participation of 29 hospitals. Data was collected on demographic variables, associated comorbidities, technical modifications, the surgeon's experience, and postoperative morbimortality. A multivariate logistic regression analysis was carried out on risk factors (RFs) for the complications of leak/fistula, hemoperitoneum, pneumonia, pulmonary embolism, and death. Results The following data were collected for 2882 patients: age, 43.85+/-11.6. 32.9 % male; BMI 47.22+/-8.79; 46.2 % hypertensive; 29.2 % diabetes2; 18.2 % smokers; bougie calibre >= 40 F 11.1 %; complications 11.7 % (2.8 % leaks, 2.7 % hemoperitoneum, 1.1 % pneumonia, 0.2 % pulmonary embolism); and death 0.6 %. RFs for complications were as follows: surgeon's experience < 20 patients, OR 1.72 (1.32-2.25); experience> 100 patients, OR 0.78 (0.69-0.87); DM2, OR1.48(1.12-1.95); probe > 40 F, OR 0.613 (0.429-0.876). Leak RFs were the following: smoking, OR1.93 (1.1-3.41); surgeon's experience< 20 patients, OR 2.4 (1.46-4.16); experience of 20-50 patients, OR 2.5 (1.3-4.86); experience > 100 patients, OR 0.265 (0.11-0.63); distance to pylorus > 4 cm, OR 0.510 (0.29-0.91). RFs for death were as follows: smoking, OR 8.64 (2.63-28.34); DM2, OR 3.25 (1.1-9.99); distance to pylorus< 5 cm, OR 6.62 (1.63-27.02). Conclusions The safety of SG may be compromised by nonmodifiable factors such as age > 65, patient comorbidities (DM2, hypertension), and prior treatment with anticoagulants, as well as by modifiable factors such as smoking, bougie size < 40 F, distance to the pylorus < 4 cm, and the surgeon's experience (< 50-100 cases).

The particularity of this case is the nutritional management that has managed to avoid the use of prolonged parenteral nutrition and possible complications by placing jejunal tube at the distal end in patients with short bowel. It is a 34-year-old colecistectomizado complicated with postoperative peritonitis and dehiscence; two years he studied with small bowel obstruction, he was made de-volvulus and was complicated with two leak at different times after the second escape took place jejunostomy side double barreled shotgun level dehiscence, presented high debits by afferent loop of the terminal jejunostomy; during admission, polyurethane probe enteral feeding was inserted by the efferent loop jejunostomy. He received jejunal tube feeding laundry in the efferent loop terminal with decreased weight gain and subsequent reconstruction of intestinal transit debit proximal jejunostomy.Lo más característico del presente caso es el manejo nutricional del paciente, que ha logrado evitar la utilización de nutrición parenteral total de forma prolongada y sus posibles complicaciones, mediante la administración de una nutrición enteral a través de una sonda yeyunal en el extremo distal de una ileostomía en un paciente con intestino corto severo. Se trata de un hombre de 34 años de edad, con antecedentes de colecistectomía complicada con peritonitis postquirúrgica y dehiscencia, que a los dos años desarrolló un cuadro de obstrucción de intestino delgado, por lo que se realizó devolvulación de intestino delgado que se complicó con dos fugas intestinales en diferentes tiempos; tras la segunda fuga se realizó yeyunostomía lateral en doble cañón de escopeta a nivel de la dehiscencia; presentó altos débitos por el asa aferente de la yeyunostomía terminal; durante el ingreso se insertó una sonda de poliuretano para alimentación enteral por asa eferente de la yeyunostomía. Recibió nutrición enteral por sonda yeyunal colada en el asa eferente con disminución del débito de yeyunostomía proximal terminal y ganancia de peso con posterior reconstrucción del tránsito intestinal.

Background Laparoscopic approach is the gold standard for surgical treatment of morbid obesity. The single-port (SP) approach has been demonstrated to be a safe and effective technique for the treatment of morbid obesity in several case control studies. Objectives Compare conventional multiport laparoscopy (LAP) with an SP approach for the treatment of morbid obesity using sleeve gastrectomy in terms of postoperative pain using a visual analog scale (VAS) 0–100, surgical outcome, weight loss, and aesthetical satisfaction at 6 months after surgery. Setting University Hospital, Spain. Methods Randomized, controlled pilot study. The trial enrolled patients suitable for bariatric surgery, with a body mass index lower than 50 kg/m 2 and xiphoumbilical distance lower than 25 cm. Patients were randomly assigned to receive LAP or SP sleeve gastrectomy. Results A total of 30 patients were enrolled; 15 were assigned to LAP group and 15 to SP group. No patients were lost during follow-up. Baseline characteristics were similar in both groups. A significantly higher level of pain during movement was noted for the patients in the LAP group on the first (mean VAS 49.3±12.2 versus 34.1±8.9, P = .046) and second days (mean VAS 35.9±10.2 versus 22.1±7.9, P = .044) but not the third day (mean VAS 20.1±5.2 versus 34.12.9 ±4.3, P = .620). No differences regarding pain at rest, operative time, complications, or weight loss at 6 months were observed. Higher aesthetical satisfaction was noticed in SP group. Conclusions In selected patients, SP surgery presented less postoperative pain in sleeve gastrectomy compared with the conventional laparoscopic approach with similar surgical results.

The aim of this study was to investigate the effects of hyaluronidase gel on the prevention of post-operative peritoneal adhesions to prosthetic materials used in laparosopic ventral hernia repair.Ten pigs were included in this study. The animals were anesthetized using Na-penthotal for induction and isofluorane for maintenance. The abdomen was opened and, using helical fasteners, four implantations were performed (squares of 4 x 4 cm). Two of the implants, placed in an upper location, were in polypropylene mesh, and two of the implants, placed in a lower area, were in polytetrafluoroethylene (PTFE-e, Dualmesh Plus Corduroy). The implants located in the right side of animals were painted with hyaluronidase gel. Two helical fasteners, painted and unpainted, were implanted in a medial location. After a five-week period the pigs were operated on again, intraperitoneal adhesion ratios and grades were determined, and the pigs later sacrificed. Specimens having abdominal wall implants were taken for histological studies.Intraperitoneal adhesions decreased in implants painted with hyaluronidase gel in a comparative study with implants located in the left side of animals (not painted). On the other hand the polypropylene mesh, said typically to produce intraperitoneal adhesions, produced almost no adhesion in many animals.Hyaluronidase gel reduces post-operative peritoneal adhesions ratio and grades including in the presence of polypropylene mesh.

To determine the impact of Laparoscopic Sleeve Gastrectomy (LSG) on the resolution of type 2 diabetes (T2DM) and Prediabetes (PDM) in obese patients, as well as potential improvements in other comorbidities.Observational retrospective study. We studied all patients with T2DM (n= 36) or PDM (n= 44) who underwent LSG in our hospital between years 2009 and 2012. PDM was defined as having at least 2 values of HbA1c between 5.7 and 6.4%. Follow-up period was 1-4 years (mean 17.5 months). T2DM remission criteria were fasting plasma glucose (FPG).Objetivos: Evaluar la efectividad de la gastroplastia tubular laparoscópica (GTL) en la resolución de la diabetes tipo 2 (DM2), de la prediabetes (PDM) y de otras comorbilidades en pacientes obesos. Material y métodos: Estudio observacional retrospectivo. Se incluyeron a los pacientes con DM2 (n= 36) o PDM (n= 44) que fueron sometidos a GTL en nuestro hospital entre 2009 y 2012. Se consideró criterio de PDM presentar HbA1c entre 5.7-6.4% en al menos dos ocasiones. Periodo de seguimiento entre 1-4 años (media 17.5 meses). Como criterio de resolución de la DM2 se consideró presentar HbA1c.

Resumen Introduccion El objetivo de este estudio es investigar el efecto de la cola de fibrina y del gel de hialuronidasa en la prevencion de adherencias peritoneales a las protesis intraperitoneales. Material y metodo En este estudio hemos utilizado 20 cerdos, divididos en 2 grupos: en todos los animales se procedio a colocar implantes de 4 × 4 cm: 2 de malla de polipropileno en una posicion mas cefalica, y otros dos de politetrafluoroetileno (Dualmesh® Plus Corduroy) en una posicion mas caudal. Los implantes situados en el lado derecho del animal se impregnaron de inhibidores de la produccion de adherencias (en 10 animales se utilizo cola de fibrina, serie A, y en otros 10 se utilizo gel de hialuronidasa, serie B). Despues de 5 semanas, se procedio al sacrificio de los animales y se evaluaron los resultados (cantidad y calidad de las adherencias formadas, asi como datos histologicos de integracion de las protesis, como mesotelizacion infiltracion por fibroblastos, vasos neoformados, etc.). Resultados Al cabo de 5 semanas se apreciaba que los implantes impregnados de sustancias inhibidoras de la produccion de adherencias presentaban menos adherencias, estas (cuando existian) eran mas laxas, e incluso en muchos casos los implantes estaban perfectamente peritonizados. La integracion de las protesis no estaba afectada por la presencia de los inhibidores. Conclusiones La formacion de adherencias puede disminuirse tras la cirugia abdominal. La disminucion conseguida es mayor en la cantidad que en la consistencia de adherencias. Los resultados son algo mejores en la serie en la que se utilizo hialuronidasa que en la que se utilizo cola de fibrina. La hialuronidasa tiene la ventaja de tener un menor coste.

Percutaneous gastrostomy, is the procedure of choice to provide enteral access in patients requiring nutritional support in this way in the long run, relegating the surgical gastrostomy.We present three patients requiring percutaneous gastrostomy for nutritional support. In two cases was performed endoscopic gastrostomy and another one using interventional radiology.While performing percutaneous gastrostomy clinical incidents were not detected, but when trying the replacement of gastrostomy tubes, showed the presence of gastrocolic fistula that caused failure or turnover in one case, or abdominal pain and diarrhea in the two other cases.Despite being a safe technique, should be done a proper patient selection in order to minimize the potential complications that may occur, as gastrocolic fistula, recommending in doubtful cases test of image such CT (computerized Tomography).Introducción: La gastrostomía percutánea es el procedimiento de elección para proporcionar acceso enteral en pacientes que requieren soporte nutricional por esta vía a largo plazo, relegando a la gastrostomía quirúrgica. Material y métodos: Presentamos tres pacientes con indicación de gastrostomía percutánea para soporte nutricional. En dos casos se realizó la gastrostomía mediante endoscopia y en otro mediante radiología intervencionista. Resultados: Durante la realización de las gastrostomías no se detectaron incidencias clínicas, pero al intentar recambio de las sondas de gastrostomía, se evidenció la presencia de fístula gastrocólica que, ocasionaba imposibilidad del recambio en un caso, o cuadro de dolor abdominal y diarrea en los otros dos casos. Discusión: Pese a ser una técnica segura, la gastrostomía percutánea debe realizarse con una correcta selección de los pacientes para minimizar posibles complicaciones que puedan acontecer, como fístula gastrocólica, recomendando en casos dudosos la realización de prueba de imagen tipo TC (tomografía computerizada).

A 49-year-old man presented at the emergency department for severe epigastric pain and a 48-hour episode of vomiting with a greatly affected general state. This is a patient diagnosed with Behcet’s disease and ankylosing spondylitis, operated for a hiatal hernia two months before his admission, where a laparoscopic Nissen fundoplication and pillars closure were performed. During the immediate postoperative period, he manifested a picture of vomiting and dysphagia after waking up from the anesthetic procedure. Both disappeared with corticosteroid administration. At the admission to the hospital, the patient showed clear signs of difficulty breathing, paleness, sweating, tachypnea, and tachycardia. On examination, we found no breath sounds in the right hemithorax, and the abdominal exploration revealed signs of rigidity of abdominal wall. Chest X-ray (Fig. 1). Our differential diagnosis stated hiatal hernia recurrence vs. secondary acute esophageal perforation for abdominal overpressure due to persistent nausea (Boerhaave syndrome). A thoraco-abdominal CT scan was requested (Fig. 2). An urgent surgery was performed, where we found a complete transhiatal migration from stomach to chest and an associated organoaxial volvulus, as well as a partially disrupted fundoplication. Once the herniated viscera were reintroduced in the abdominal cavity, a proper vascularisation was showed. The fundoplication was rebuilt and the pillars were approached. An abdominal drainage was inserted and removed 4 days after the postoperative period.