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Obesity represents a growing threat to population health all over the world. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the lower esophageal sphincter after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure; that’s why some patients have reflux after sleeve.
To describe a technique and preliminary results of sleeve gastrectomy with a Nissen fundoplication, in order to decrease reflux after sleeve.
In the current article we describe the technique step by step mostly focused on the creation of the wrap and it care.
This procedure was applied in a case of 45 BMI female of 53 years old, with GERD. An endoscopy was done demonstrating a hiatal hernia, and five benign polyps. A Nissen sleeve was performed due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure and was discharged home uneventfully 48 h after.
N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when Roux-en-Y gastric bypass it is not indicated.
In Brazil, there has been a significant increase in obesity rates in all age groups. Data from 2017 show that obesity affects 19% of the population. Due to the magnitude of the problem, public health policies have aimed to prevent complications related to obesity by increasing the offerfor bariatric surgeries.
To analyze the current status of bariatric surgery performed in the Brazilian public health system, including data from macroregions and also the effect of digestive surgery training on the number of procedures.
The database of the public health registry (DATASUS) was assessedbetween 2008 and 2018 for descriptive analysis of data and evaluation of the selected parameters. The main surgical techniques, comorbidities, mortality and the costs profile of the system were evaluated.
There was a 339% increase in the number of bariatric surgeries in the period evaluated. Gastric bypass was performed in 94% of cases whereas sleeve in 2.4%. Other techniques were used in 3.6%. There were discrepancies in the number of surgeries performed in different regions of the country.
There was a considerable advance in the number of bariatric surgeries performed by the public health system between 2008 and 2018. However, there is a need to increase the offer of this service and alsospecialized training, as well as a correction in the distribution of these procedures in the national territory to achieve integrality among its users.
Obesity is a disease of high prevalence in Brazil and in the world, and bariatric surgery, with its different techniques, is an alternative treatment.
To compare techniques: adjustable gastric band (AGB), sleeve gastrectomy), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) analyzing leaks, bleeding, death, weight loss, resolution of type 2 diabetes, systemic arterial hypertension, dyslipidemia and obstructive sleep apnea.
Were selected studies in the PubMed database from 2003 to 2014 using the descriptors: obesity surgery; bariatric surgery; biliopancreatic diversion; sleeve gastrectomy; Roux-en-Y gastric bypass and adjustable gastric banding. Two hundred and forty-four articles were found with the search strategy of which there were selected 116 studies through the inclusion criteria.
Excess weight loss (EWL) after five years in AGB was 48.35%; 52.7% in SG; 71.04% in RYGB and 77.90% in BPD. The postoperative mortality was 0.05% in the AGB; 0.16% on SG; 0.60% in RYGB and 2.52% in BPD. The occurrence of leak was 0.68% for GBA; 1.93% for SG; 2.18% for RYGB and 5.23% for BPD. The incidence of bleeding was 0.44% in AGB; 1.29% in SG; 0.81% in RYGB and 2.09% in BPD. The rate of DM2 resolved was 46.80% in AGB, 79.38% in SG, 79.86% in RYGB and 90.78% in BPD. The rate of dyslipidemia, apnea and hypertension resolved showed no statistical differences between the techniques.
The AGB has the lowest morbidity and mortality and it is the worst in EWL and resolution of type 2 diabetes. The SG has low morbidity and mortality, good resolution of comorbidities and EWL lower than in RYGB and BPD. The RYGB has higher morbidity and mortality than AGB, good resolution of comorbidities and EWL similar to BPD. The BPD is the worst in mortality and bleeding and better in EWL and resolution of comorbidities.
In high-income countries, morbid obesity is a growing health problem that has already reached epidemic proportions. When performing a laparoscopic gastric bypass several operative methods exist.
To describe the institutional experience using a knotless unidirectional barbed suture (V-Loc 180/Covidien, Mansfield, MA) to create a hand-sewn gastrojejunostomy (GJ) and jejunojejunostomy (JJ) during bariatric surgery.
Evaluation of a case series of 87 morbidly obese patients who underwent laparoscopic gastric bypass with a hand-sewn gastrojejunostomy (GJA) and jejunojejunostomy (JJA) between 01/2015 and 06/2017. The patients were divided into two groups: in group I, GJA und JJA sutures were performed using the knotless unidirectional barbed suture; in group II, GJA and JJA were sutured with resorbable multifilament thread (Vicryl® 3/0 Ethicon, Livingstone, UK). The recorded data on gender, age, BMI, ASA score, operative time, postoperative morbidity, length of hospital stay, and reoperation, were analyzed and compared.
All procedures were completed laparoscopically with no mortality. The mean operative time was 123.23 (±30.631) in group I and 127.57 (±42.772) in group II (p<0.05). The postoperative complications did not differ significantly between the two groups. Early complications were observed for two patients (0.9%) in the barbed suture group and for one patient (0.42%) in the multifilament suture group (p<0.05). In group I two patients (0.9%) required reoperation: on the basis of jejunojejunal stenosis in one patient, and local abscess near the gastrojejunostomy, without a leakage, in the other. In group II one patient (0.42%) required reoperation due to stenosis of the GJA. The duration of hospital admission was similar for both groups: 3.36 (±0.743) days in group I vs. 3.38 (±1.058) days in group II (p<0.05).
The novel anastomotic technique is a safe and effective method and can be applied to gastrojejunal anastomosis and jejunojejunal anastomosis in laparoscopic gastric bypass.
: Bariatric surgery promotes significant weight loss and improvement of associated comorbidities; however, nutrients deficiencies and weight regain may occur in the middle-late postoperative period.
To investigate nutritional status in 10 years follow-up.
: Longitudinal retrospective study in which anthropometric, biochemical indicators and nutritional intake were assessed before and after one, two, three, four, five and ten years of Roux-en Y gastric bypass through analysis of medical records.
: After ten years there was a reduction of 29.2% of initial weight; however, 87.1% of patients had significant weight regain. Moreover, there was an increase of incidence of iron (9.2% to 18.5%), vitamin B12 (4.2% to 11.1%) and magnesium deficiency (14.1% to 14.8%). Folic acid concentrations increased and the percentage of individuals with glucose (40.4% to 3.7%), triglycerides (38% to 7.4%), HDL cholesterol (31 % to 7.4%) and uric acid (70.5% to 11.1%) abnormalities reduced. Also, there is a reduction of food intake at first year postoperative. After 10 years, there was an increase in energy, protein and lipid intake, also a reduction in folid acid intake.
: Roux-en Y gastric bypass is an effective procedure to promote weight loss and improve comorbidities associated with obesity. However, comparison between postoperative period of five and 10 years showed a high prevalence of minerals deficiency and a significant weight regain, evidencing the need for nutritional follow-up in the postoperative period.
The bariatric surgery may have negative repercussions on oral conditions.
To evaluate the impact of oral health educational/preventive program developed with patients submitted to gastroplasties.
The sample consisted of 109 patients randomly allocated to two groups: intervention group (IG), where they participated in the oral health promotion program that include multiple educational-preventive approaches; control group (CG), where they received usual care from the bariatric clinic staff, without participation in the program. The oral conditions investigated in the pre-operative and postoperative periods of one month (1M) and six months (6M) were: dental caries, periodontal disease, tooth wear, dental plaque and salivary flow.
After bariatric surgery, patients in IG presented: fewer changes in enamel (6M: p=0.004), dentin (6M: p=0.005) and gingival bleeding (6M: p<0.0001), reduction in plaque index (1M, 6M: p<0.0001) and increased salivary flow (6M: p=0.039), when compared with CG. Incipient tooth wear was recorded in both groups (6M: p=0.713).
There was a positive impact of the implemented program in the prevention of the main oral health problems in patients who underwent gastroplasties, contributing to their quality of life.
Strongly associated with obesity, non-alcoholic fatty liver disease is considered the hepatic manifestation of the metabolic syndrome. It presents as simple steatosis and steatohepatitis, which can progress to cirrhosis and its complications. Among the therapeutic alternatives is bariatric surgery.
To compare the effect of the two most frequent bariatric procedures (sleeve and bypass) on liver disease regarding to epidemiological, demographic, clinical and laboratory parameters.
The results of intraoperative and 12 months after surgery liver biopsies were used. The NAFLD activity score (NAS) was used to assess and compare the stages of liver disease.
Sixteen (66.7%) patients underwent Bypass procedure and eight (33.3%) Sleeve. It was observed that the variation in the NAFLD activity score was significantly greater in the Bypass group than in Sleeve (p=0.028) and there was a trend regarding the variation in fibrosis (p=0.054).
Both surgical techniques were effective in improving the hepatic histology of most operated patients. When comparing sleeve and bypass groups, bypass showed better results, according to the NAS score.
Obesity is a global epidemic8. Surgery has proven to be the most effective treatment for morbid obesity8. The estimated prevalence of non-alcoholic fatty liver disease in obese is three times higher than in the general population8. It progresses to non-alcoholic steatohepatitis in up to 42% of cases, which has become a growing indication for liver transplantation (LT)8. Bariatric surgery in patients with cirrhosis prior to LT may improve access in the waiting list. The number of patients on the waiting list for transplantation having undergone bariatric surgery will grow, with a potential increase in the rate complications. Peptic ulcer (PU) perforation is one of them. Following Roux-en-Y gastric bypass (RYGBP), the modified anatomy and physiology are a risk factor for peptic ulceration of an excluded stomach. Furthermore, LT carries specific risk factors for PU. Diagnosis in the gastric remnant can be challenging due to the absence of endoscopic access.
We report the case of a LT recipient suffering from a perforated PU in the bypassed stomach from RYGBP. To our knowledge, this is the first case reported in a liver transplanted patient.
A 45-year-old woman with a history of open Fobi-Capella RYGBP was diagnosed with primary biliary cirrhosis and listed for LT. Bariatric surgery was carried out seven years before, followed by an emergency reintervention for obstruction of the jejunojejunostomy. Hepatopathy was diagnosed at 41 years of age. The patient presented Ig G antibodies for cytomegalovirus and a negative viral DNA detection by quantitative PCR. There were no other relevant comorbidities.
She was admitted to the emergency department with melena and hematochezia. Physical examination revealed hypotension, paleness, icterus and a pain-free abdomen without ascites. Her Model for End-Stage Liver Disease score was 33. The patient did not smoke, consume alcohol to excess or use nonsteroidal anti-inflammatory drugs, acetylsalicylic acid, or proton pump inhibitors. The Helicobacter pylori (HP) status was unknown, nor it was investigated. The patient was clinically managed with intravenous crystalloids, blood borne products transfusion, PPI and ciprofloxacin. The upper endoscopy was negative and the abdominal Doppler ultrasound showed signs of portal hypertension with patent hepatic vessels. Six days after admission, deceased donor LT was carried out without perioperative complications.
The postoperative immunosuppression regimen consisted of prednisone, tacrolimus and mycophenolate sodium. The prophylactic antibiotics consisted of amikacin and ampicillin until postoperative day (POD) 2 and ivermectin on PODs 2 and 3; sulfamethoxazole was introduced on POD 8. Acetylsalicylic acid and prophylactic low molecular weight heparin were suspended from POD 3 to POD 7 because of anemization without signs of bleeding. Low molecular weight heparin was reintroduced at therapeutic dose because of the thrombosis of a branch of the right portal vein. On POD 7 hepatic biopsy was performed due to elevation in liver enzymes. Moderate acute cellular rejection was diagnosed and treated with pulse therapy of methylprednisolone. Proton pump inhibitors were administered throughout the hospitalization. On POD 14 the patient developed an acute abdomen. An abdominal computed tomography scan with intravenous contrast showed a pneumoperitoneum with foci of free air next to the stomach and free abdominal fluid in small quantity (Figure 1).
An emergency laparotomy was performed and a perforated ulcer of the body of the excluded stomach was found and repaired by simple closure. The ulcer was not resected for pathological examination. On POD 16 routine quantitative PCR for cytomegalovirus DNA was positive (41UI/ml 1,62 log (UI/ml)), but did not require antiviral therapy nor reduction in the immunosuppressive regimen. Prophylactic unfractioned heparin was administered from POD 16. Culture of the abdominal liquid collected intraoperatively showed positive for extended spectrum beta-lactamase producing Klebsiella pneumoniae and Enterococus faecium. Antibiotic treatment consisted of vancomycin, meropenem and fluconazol. The patient was discharged on POD 26 with immunosuppressors, sulfamethoxazole, proton pump inhibitors and prophylactic low molecular weight heparin, the latter being discontinued ten days after this.
In 1994 Cucchi et al.7 first published a paper identifying gastrogastric fistulas (GGF) as a complication of open divided Roux-en-Y gastric bypass (RYGB). The findings showed that GGF develop regardless of the remnant division from the pouch. Some authors attribute GGF to technical failure, early postoperative leaks or even marginal ulcers. Furthermore, diagnosis is usually difficult and requires a high index of suspicion, mainly due to a lack of pathognomonic symptoms and signs14. As of today, there is no consensus regarding an optimal diagnostic pathway for GGF, and management is usually patient tailored13,14.
In this paper, we present a case of a lady treated at our centre with recurrent GGF, and provide an up-to-date literature review of the topic.
Woman of 42 year-old with a BMI of 44 kg/m2 underwent a previous anti-gastric anti-colic RYGB using a circular staple for the gastro-jejunostomy anastomosis (GJA) in Jaber Hospital, Kuwait. Intra-operatively the anvil had an incomplete anastomotic stapler doughnut; however, both the intra-operative methylene blue and air tests were negative. The anastomotic line was the buttressed with 2-0 absorbable sutures. Two days post-operatively the patient developed acute abdominal pain, tachycardia and fever, with a water-soluble contrast study suggesting a GJA leak. A subsequent diagnostic laparoscopy however, was unremarkable, and she was managed conservatively. Seven years later, she again presented complaining of a two month history of progressive epigastric and retrosternal chest pain. Blood investigations showed mild leucocytosis and hyper-amylasemia. Gastroscopy demonstrated bile entry to the gastric pouch, with a corresponding 6-7 mm GGF. A barium swallow confirmed GGF, with no other fistulas nor strictures. She was managed endoscopically with one endo-clip applied to GGF, and its edges were burned using argon plasma coagulation.
After three years she was attended again with abdominal pain and distention, associated with weight regain and vomiting. A barium swallow confirmed recurrence of the fistula (Figure 1), and gastroscopy showed a large fistulous opening measuring 15-20 mm, not feasible for endoscopic intervention.
Rapid and severe weight loss can result in the reduction of the ear tube lining fat tissue and it becomes patent, leading to symptoms such as autophony, aural fullness and tinnitus. Patients after bariatric surgery have, in theory, a predisposition to the development of such alteration.
To evaluate the presence of patent tuba-related complaints in patients undergoing bariatric surgery, correlating with weight and body mass index (BMI) values, as well as demographic data.
Cross-sectional study composed of the evaluation of patients undergoing bariatric surgery through a standardized questionnaire about the presence of symptoms compatible with ear tube patency.
Eighty patients were evaluated, 77 female and three males. The main comorbidity was systemic arterial hypertension (37.5%). Fifteen (18.75%) presented symptoms compatible with patent auditory/Eustachian tube - aural fullness and autophony - postoperatively. In symptomatic individuals the initial weight was 112 kg on average and the preoperative BMI was 45 kg/m², while in asymptomatic individuals the weight was 117 kg and BMI 47 kg/m². There was statistical significance in the comparison between individuals with and without symptoms in the variables of initial weight (p=0.00000), current weight (p=0.00029), preoperative BMI (p=0.00219) and postoperative BMI (p=0.00148).
The presence of symptoms compatible with patent auditory/Eustachian tube was 18.75% of the patients submitted to bariatric surgery in the evaluated sample. Both preoperative weight and BMI were lower in symptomatic patients when compared with the asymptomatic group.
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