RESUMO Objetivo: comparar a prevalência das deficiências de micronutrientes nos pacientes submeti... more RESUMO Objetivo: comparar a prevalência das deficiências de micronutrientes nos pacientes submetidos à gastrectomia vertical (GV) e à derivação gástrica em Y de Roux (DGYR). Métodos: estudo comparativo de 576 pacientes submetidos à cirurgia bariátrica, 338 através de GV e 238 de DGYR e avaliados quanto às dosagens séricas de hemoglobina, ferro, ferritina, zinco e vitamina B12. Estas dosagens foram realizadas nos períodos pré-operatório e três, seis, 12 e 24 meses após a cirurgia, para análise e comparação das deficiências de micronutrientes entre as técnicas. Resultados: o grupo submetido à GV foi composto por 48 homens e 290 mulheres, com IMC médio de 39,4±2,6Kg/m2 e média de idade de 37,2±11 anos; o grupo submetido à DGYR foi composto por 77 homens e 161 mulheres, com IMC médio de 42,7±5,9Kg/m2 e média de idade de 41,9±11,1 anos. Após 24 meses, déficit de hemoglobina se fez presente em 24,4% dos pacientes submetidos à GV e 40% da DGYR (p=0,054); deficiência de ferro em 6,6% da GV ...
Revista do Colegio Brasileiro de Cirurgioes, Jan 27, 2018
to evaluate the weight, nutritional and quality of life of low-income patients after ten years of... more to evaluate the weight, nutritional and quality of life of low-income patients after ten years of Roux-en-Y gastric bypass (RYGB). we conducted a longitudinal, retrospective and descriptive study evaluating the excess weight loss, weight regain, arterial hypertension, type 2 diabetes mellitus, anemia and hypoalbuminemia in 42 patients of social classes D and E submitted to RYGB. We assessed quality of life through the Bariatric Analysis and Reporting Outcome System (BAROS). of the 42 patients, 68.3% defined themselves as doing non-regular physical activity, and only 44.4% and 11.9% had regular medical and nutritional follow-up, respectively. We found a mean excess weight loss of 75.6%±12 (CI=71.9-79.4), and in only one patient there was insufficient weight loss. The mean weight loss was 22.3%±16.2 (CI=17.2-27.3) with 64.04% of the sample presenting regain greater than 15% of the minimum weight; 52.3% of the sample presented anemia after ten years of surgery and 47.6%, iron deficienc...
Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery
Laparoscopic manual suturing is probably the most difficult skill to be acquired in minimally inv... more Laparoscopic manual suturing is probably the most difficult skill to be acquired in minimally invasive surgery. However, laparoscopic exercise endo-sutures can be learned with a simulator and are of great practical importance and clinical applicability, absorbing concepts that are immediately transferred to the operating room. To assess the progression of skills competence in endo-sutures through realistic simulation model of systematized education. Evaluation of the progression of competence of students in three sequential stages of training in realistic simulation, pre-test (V.1), teaching concepts (V.2) and training station for absorption of video concepts in surgery - ergonomics, stereotaxia, ambidexterity, haptic touch, fucral effect, applied in the manufacture of points corresponding to a Nissen fundoplication, in endo-suture for realistic simulation. All students who attended the course absorbed the video concepts in surgery; most participants showed steady and continued impr...
Revista do Colegio Brasileiro de Cirurgioes, Jan 19, 2018
to report a series of cases of robotic bariatric surgery in the treatment of obesity in Brazil. w... more to report a series of cases of robotic bariatric surgery in the treatment of obesity in Brazil. we evaluated patients undergoing robotic bariatric surgery at the Garrido Institute and compared them with a group submitted to conventional laparoscopic surgery. we analyzed 45 patients, with a mean age of 39.44 years, of which 34 were female, with an initial mean BMI of 41.26kg/m2. Among the procedures performed, 91.11% were Roux-en-Y gastric bypass, while 8.89% were sleeve gastrectomy. The mean total surgery time was 158 (±56.54) minutes, with mean docking time of 7.93 (±3.9) minutes, and console time 113.0 (±41.4) minutes. The average pain presented in the post anesthetic recovery was 2.61 (±3.30) points on a scale of 0 to 10; four patients presented with mild signs of nausea, responding well to drug treatment. Only one patient needed ICU admission for a period of two days after surgery due to previous cardiopathy. In two cases, there was an incisional hernia at the trocar site, which...
The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. ... more The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. A prospective clinical trial was conducted with sixty participants with body mass index≥40kg.m during bariatric surgery, randomized into three groups: ideal weight (IW), 20% corrected body weight (CW20) and 40% corrected body weight (CW40). All patients received total intravenous anesthesia. Rocuronium was administered at dose of 0.6mg.kg of Ideal weight for tracheal intubation, followed by infusion of 0.3-0.6mg.kg.h. Train of four (TOF) was used to monitor depth of blockade. After spontaneous recovery TOF-count 2 at the end of surgery, 2mg.kg of sugammadex was administered. Primary outcome was neuromuscular blockade reversal time to TOF≥0.9. Secondary outcome was the occurrence of postoperative residual curarization in post-anesthesia recovery room, searching the patient's ability to pass from the surgical bed to the transport, adequacy of oxygenation, respiratory pattern, ability t...
Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery, 2018
Type 2 diabetes mellitus has a high long-term remission rate after laparoscopic Roux-en-Y gastric... more Type 2 diabetes mellitus has a high long-term remission rate after laparoscopic Roux-en-Y gastric bypass (LRYGB), but few studies have analyzed patients with BMI<35 kg/m2. To compare glycemic control after LRYGB between BMI 30-35 kg/m2 (intervention group or IG) and >35 kg/m2 patients (control group or CG) and to evaluate weight loss, comorbidities and surgical morbidity. Sixty-six diabetic patients (30 in IG group and 36 in CG group) were submitted to LRYGB. Data collected annually after surgery were analyzed with generalized estimating equations. Average follow-up was 4.3 years. There was no statistical difference between groups using complete remission American Diabetes Association criteria (OR 2.214, 95%CI 0.800-5.637, p=0.13). There was significant difference between groups using partial remission American Diabetes Association criteria (p=0.002), favouring the CG group (OR 6.392, 95%CI 1.922-21.260). The higher BMI group also had lower HbA1c levels (-0.77%, 95%CI -1.26 to...
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, Feb 28, 2017
Intragastric balloons (IGBs) are a minimally invasive option for obesity treatment, acting as a s... more Intragastric balloons (IGBs) are a minimally invasive option for obesity treatment, acting as a space-occupying device and leading to weight loss through increased satiety. This device has been growing in popularity owing to its safety profile and good weight loss results. However, there are no published guidelines that standardize the technical aspects of the procedure. To create a practical guideline for intragastric balloon usage. Private and Academic Settings, Brazil. A consensus meeting was held in São Paulo, Brazil, in June 2016, bringing together 39 Brazilian endoscopists with extensive experience in IGBs from all regions of the country. Topics on patient selection, indications, contraindications, multidisciplinary follow-up, technique, and adverse events were discussed in the form of questions. After electronic voting, a consensus was defined when there was ≥70% agreement. Experts were also requested to provide data on their experience with IGBs. The selected experts discuss...
Gastric leak is a severe complication of gastric bypass that is associated with significant morbi... more Gastric leak is a severe complication of gastric bypass that is associated with significant morbidity and mortality. Anastomosis dehiscence usually occurs at gastrojejunal anastomosis and can appear simultaneously with gastric leak, for which treatment can be a challenge. Fistula may have several clinical impacts, depending on patient-related factors, fistula characteristics, onset time, and therapy proposal. Abdominal toilet, drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. Currently, endoscopic stents are gaining space, promoting fistula sealing, secretion deviation, treating gastric stricture, and allowing early oral diet. Herein, we present a case of severe gastrojejunal anastomosis dehiscence treated with partially covered stent. We present a video of a 39-year-old man with a body mass index of 40 Kg/m2 who underwent a Roux-en-Y gastric bypass and presented fever and leukocytosis. Gastr...
Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure. Despite its h... more Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure. Despite its high efficacy, some patients regain part of their lost weight. Several endoscopic therapies have been introduced as alternatives to treat weight regain, but most of the articles are relatively small with unclear long-term data. To systematically assess the efficacy of endoscopic therapies for weight regain after RYGB. We searched MEDLINE, EMBASE, Scopus, Web of Science, Cochrane, OVID, CINAHL/EBSCo, LILACS/Bireme, and gray literature. Primary outcomes were absolute weight loss (AWL), excess weight loss (EWL), and total body weight loss (TBWL). Thirty-two studies were included in qualitative analysis. Twenty-six described full-thickness (FT) endoscopic suturing and pooled AWL, EWL, and TBWL at 3 months were 8.5 ± 2.9 kg, 21.6 ± 9.3%, and 7.3 ± 2.6%, respectively. At 6 months, they were 8.6 ± 3.5 kg, 23.7 ± 12.3%, and 8.0 ± 3.9%, respectively. At 12 months, they were 7.63 ± 4.3 kg, 16.9 ± 1...
Background and study aims Staple-line leaks occur in 1 % - 7 % of patients who undergo sleeve gas... more Background and study aims Staple-line leaks occur in 1 % - 7 % of patients who undergo sleeve gastrectomy, and can be challenging to treat. The success of endoscopic approaches decreases as leaks develop into chronic sinus tracts. Endoscopic septotomy has been used to facilitate healing of refractory leaks by incision and enlargement of the tract to allow direct communication with the gastric lumen and internal drainage. Patients and methods We reviewed the technique and outcomes among patients who underwent endoscopic septotomy at two centers for the management of sleeve gastrectomy-associated gastric fistulas and perigastric collections refractory to occlusive endoscopic therapies. Results Nine patients underwent endoscopic septotomy at a mean of 8.6 weeks after leak diagnosis, following failure of percutaneous and conventional endoscopic modalities. Perigastric collections ranged from 3 cm to 10 cm in size. The mean procedure time for endoscopic septotomy was 87.2 minutes. Multiple endoscopic septotomy procedures (mean 2.3, range 1 - 4) were required to achieve radiological resolution. The mean follow-up period was 21.2 weeks, and all nine patients achieved symptom resolution without the need for surgery. Bleeding at the time of endoscopic septotomy occurred in three patients, and was managed with endoscopic clips and did not require transfusion. No other adverse events or delayed complications were recorded. Conclusions Endoscopic septotomy appears to be a safe and effective technique for the management of sleeve gastrectomy-associated fistulae and collections, including those refractory to other endoscopic and percutaneous methods.
BACKGROUND Bariatric surgery is the most effective treatment for severe obesity, but the surgery ... more BACKGROUND Bariatric surgery is the most effective treatment for severe obesity, but the surgery increases the risk of developing nutritional deficiencies, such as vitamin A deficiency. In human metabolism, vitamin A plays a role in vision. OBJECTIVE To evaluate serum vitamin A, visual function and ocular surface of patients undergoing bariatric surgery. METHODS A cross-sectional and analytical study was conduced with 28 patients undergoing bariatric surgery for at least 6 months. Ophthalmologic evaluation was done through color vision test, contrast sensitivity test, ocular surface tests and confocal microscopy, as well as vitamin A serum measurement. RESULTS Vertical sleeve gastrectomy was performed in seven (25.0%) patients and Roux -en-Y gastric by-pass in 21 (75.0%). Mean serum vitamin A level was 1.7±0.5 µmoL/L. Most patients (60.7%) had symptoms of dry eye. Five (17.9%) patients had contrast sensitivity impairment and 18 (64.3%) color vision changes. In the group of patients ...
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo), 2016
Background: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve ga... more Background: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled. Objective: The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice. Methods: Institutional experience and systematic review from the literature on revisional bariatric surgery. Results: Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral...
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo), 2015
Background : Obesity and type 2 diabetes mellitus are associated to inflammatory state, which can... more Background : Obesity and type 2 diabetes mellitus are associated to inflammatory state, which can be set off by the adipose tissue, once it is a metabolically active organ that can cause a chronic mild inflammatory state. Aim : To evaluate the correlation between preoperative C-reactive protein and postoperative complications risk in obese patients (grades II and III) after Roux-en-Y gastric bypass, with and without type 2 diabetes mellitus. Methods : Between 2008 and 2013 were analysed 209 patients (107 with diabetes), presenting body mass index >40 kg/m2or >35 kg/m2with comorbidities. During the postoperative period, two groups were evaluated: with and without complications. Preoperative ultra-sensitive C-reactive protein was measured by immunonephelometry method. Results : Complications occurred in seven patients (pulmonary thromboembolism, fistula, two cases of suture leak, pancreatitis, evisceration and upper digestive hemorrhage). No statistical significance was found re...
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo), 2015
Background : The indications for sleeve gastrectomy in the surgical treatment of morbid obesity h... more Background : The indications for sleeve gastrectomy in the surgical treatment of morbid obesity have increased worldwide. Despite this, several aspects related to results at medium and long term remain in constant research. Aim : To present the experience of sleeve gastrectomy in a center of excellence in bariatric surgery by analyzing clinical outcomes, complications and follow-up in the medium term. Methods : The study included 120 morbidly obese patients who underwent sleeve gastrectomy and who were followed for at least 24 months. Aspects related to surgical technique, surgical complications and clinical outcome were analyzed. Results : Seventy-five patients were women (62.5%) and the average age was 36 years. The body mass index preoperatively ranged from 35.5 to 58 kg/m2(average of 40.2 kg/m2). The length of stay ranged from 1 to 4 days (mean 2.1 days). Comorbidities observed were hypertension (19%), type 2 diabetes mellitus (6.6%), dyslipidemia (7.5%), sleep apnea (16.6%), re...
Background The incidence of surgical site infection in bariatric patients is significant and the ... more Background The incidence of surgical site infection in bariatric patients is significant and the current recommendations for antibiotic prophylaxis are sometimes inadequate. Objective The aim of this study was to analyze the effect of three prophylactic antibiotic regimens on the incidence of surgical site infection. Methods A prospective, cross-sectional study was conducted between January 2009 and January 2013 in which 896 Roux-en-Y gastric bypasses were performed to treat obesity. The study compared three groups of patients according to the perioperative antibiotic prophylaxis administered intravenously and beginning at anesthesia induction: Group I consisting of 194 patients treated with two 3-g doses of ampicillin/sulbactam; Group II with 303 patients treated with a single 1-g dose of ertapenem; and Group III with 399 patients treated with a 2-g dose of cefazolin at anesthesia induction followed by a continuous infusion of cefazolin 1g throughout the surgical procedure. The rat...
Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery, 2013
Metabolic disorders have high correlation with severe forms of nonalcoholic fatty liver disease. ... more Metabolic disorders have high correlation with severe forms of nonalcoholic fatty liver disease. However, there is no non-invasive method that promotes its proper stratification and biopsy remains the ideal diagnostic tool. To evaluate the prevalence of this disease in obese in preoperative period of Roux-en-Y gastric bypass and metabolic factors correlated with liver histopathology. From a total of 47 patients, 35 were enrolled in the inclusion criteria and 12 excluded due to liver disease and alcohol intake >80 g/week. Were performed clinical and laboratory evaluation before the surgery and intraoperative liver biopsy . The intensity was ranked in grade of steatohepatitis: I (mild to moderate) and II (diffuse inflammation), III ( periportal fibrosis) and IV (cirrhosis). Were compared the following variables: duration of obesity, body mass index, waist-hip ratio, type 2 diabetes mellitus, hypertension and dyslipidemia. Thirty -five patients (68.6 % women , mean age 37 years) wer...
RESUMO Objetivo: comparar a prevalência das deficiências de micronutrientes nos pacientes submeti... more RESUMO Objetivo: comparar a prevalência das deficiências de micronutrientes nos pacientes submetidos à gastrectomia vertical (GV) e à derivação gástrica em Y de Roux (DGYR). Métodos: estudo comparativo de 576 pacientes submetidos à cirurgia bariátrica, 338 através de GV e 238 de DGYR e avaliados quanto às dosagens séricas de hemoglobina, ferro, ferritina, zinco e vitamina B12. Estas dosagens foram realizadas nos períodos pré-operatório e três, seis, 12 e 24 meses após a cirurgia, para análise e comparação das deficiências de micronutrientes entre as técnicas. Resultados: o grupo submetido à GV foi composto por 48 homens e 290 mulheres, com IMC médio de 39,4±2,6Kg/m2 e média de idade de 37,2±11 anos; o grupo submetido à DGYR foi composto por 77 homens e 161 mulheres, com IMC médio de 42,7±5,9Kg/m2 e média de idade de 41,9±11,1 anos. Após 24 meses, déficit de hemoglobina se fez presente em 24,4% dos pacientes submetidos à GV e 40% da DGYR (p=0,054); deficiência de ferro em 6,6% da GV ...
Revista do Colegio Brasileiro de Cirurgioes, Jan 27, 2018
to evaluate the weight, nutritional and quality of life of low-income patients after ten years of... more to evaluate the weight, nutritional and quality of life of low-income patients after ten years of Roux-en-Y gastric bypass (RYGB). we conducted a longitudinal, retrospective and descriptive study evaluating the excess weight loss, weight regain, arterial hypertension, type 2 diabetes mellitus, anemia and hypoalbuminemia in 42 patients of social classes D and E submitted to RYGB. We assessed quality of life through the Bariatric Analysis and Reporting Outcome System (BAROS). of the 42 patients, 68.3% defined themselves as doing non-regular physical activity, and only 44.4% and 11.9% had regular medical and nutritional follow-up, respectively. We found a mean excess weight loss of 75.6%±12 (CI=71.9-79.4), and in only one patient there was insufficient weight loss. The mean weight loss was 22.3%±16.2 (CI=17.2-27.3) with 64.04% of the sample presenting regain greater than 15% of the minimum weight; 52.3% of the sample presented anemia after ten years of surgery and 47.6%, iron deficienc...
Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery
Laparoscopic manual suturing is probably the most difficult skill to be acquired in minimally inv... more Laparoscopic manual suturing is probably the most difficult skill to be acquired in minimally invasive surgery. However, laparoscopic exercise endo-sutures can be learned with a simulator and are of great practical importance and clinical applicability, absorbing concepts that are immediately transferred to the operating room. To assess the progression of skills competence in endo-sutures through realistic simulation model of systematized education. Evaluation of the progression of competence of students in three sequential stages of training in realistic simulation, pre-test (V.1), teaching concepts (V.2) and training station for absorption of video concepts in surgery - ergonomics, stereotaxia, ambidexterity, haptic touch, fucral effect, applied in the manufacture of points corresponding to a Nissen fundoplication, in endo-suture for realistic simulation. All students who attended the course absorbed the video concepts in surgery; most participants showed steady and continued impr...
Revista do Colegio Brasileiro de Cirurgioes, Jan 19, 2018
to report a series of cases of robotic bariatric surgery in the treatment of obesity in Brazil. w... more to report a series of cases of robotic bariatric surgery in the treatment of obesity in Brazil. we evaluated patients undergoing robotic bariatric surgery at the Garrido Institute and compared them with a group submitted to conventional laparoscopic surgery. we analyzed 45 patients, with a mean age of 39.44 years, of which 34 were female, with an initial mean BMI of 41.26kg/m2. Among the procedures performed, 91.11% were Roux-en-Y gastric bypass, while 8.89% were sleeve gastrectomy. The mean total surgery time was 158 (±56.54) minutes, with mean docking time of 7.93 (±3.9) minutes, and console time 113.0 (±41.4) minutes. The average pain presented in the post anesthetic recovery was 2.61 (±3.30) points on a scale of 0 to 10; four patients presented with mild signs of nausea, responding well to drug treatment. Only one patient needed ICU admission for a period of two days after surgery due to previous cardiopathy. In two cases, there was an incisional hernia at the trocar site, which...
The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. ... more The weight parameters for use of sugammadex in morbidly obese patients still need to be defined. A prospective clinical trial was conducted with sixty participants with body mass index≥40kg.m during bariatric surgery, randomized into three groups: ideal weight (IW), 20% corrected body weight (CW20) and 40% corrected body weight (CW40). All patients received total intravenous anesthesia. Rocuronium was administered at dose of 0.6mg.kg of Ideal weight for tracheal intubation, followed by infusion of 0.3-0.6mg.kg.h. Train of four (TOF) was used to monitor depth of blockade. After spontaneous recovery TOF-count 2 at the end of surgery, 2mg.kg of sugammadex was administered. Primary outcome was neuromuscular blockade reversal time to TOF≥0.9. Secondary outcome was the occurrence of postoperative residual curarization in post-anesthesia recovery room, searching the patient's ability to pass from the surgical bed to the transport, adequacy of oxygenation, respiratory pattern, ability t...
Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery, 2018
Type 2 diabetes mellitus has a high long-term remission rate after laparoscopic Roux-en-Y gastric... more Type 2 diabetes mellitus has a high long-term remission rate after laparoscopic Roux-en-Y gastric bypass (LRYGB), but few studies have analyzed patients with BMI<35 kg/m2. To compare glycemic control after LRYGB between BMI 30-35 kg/m2 (intervention group or IG) and >35 kg/m2 patients (control group or CG) and to evaluate weight loss, comorbidities and surgical morbidity. Sixty-six diabetic patients (30 in IG group and 36 in CG group) were submitted to LRYGB. Data collected annually after surgery were analyzed with generalized estimating equations. Average follow-up was 4.3 years. There was no statistical difference between groups using complete remission American Diabetes Association criteria (OR 2.214, 95%CI 0.800-5.637, p=0.13). There was significant difference between groups using partial remission American Diabetes Association criteria (p=0.002), favouring the CG group (OR 6.392, 95%CI 1.922-21.260). The higher BMI group also had lower HbA1c levels (-0.77%, 95%CI -1.26 to...
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, Feb 28, 2017
Intragastric balloons (IGBs) are a minimally invasive option for obesity treatment, acting as a s... more Intragastric balloons (IGBs) are a minimally invasive option for obesity treatment, acting as a space-occupying device and leading to weight loss through increased satiety. This device has been growing in popularity owing to its safety profile and good weight loss results. However, there are no published guidelines that standardize the technical aspects of the procedure. To create a practical guideline for intragastric balloon usage. Private and Academic Settings, Brazil. A consensus meeting was held in São Paulo, Brazil, in June 2016, bringing together 39 Brazilian endoscopists with extensive experience in IGBs from all regions of the country. Topics on patient selection, indications, contraindications, multidisciplinary follow-up, technique, and adverse events were discussed in the form of questions. After electronic voting, a consensus was defined when there was ≥70% agreement. Experts were also requested to provide data on their experience with IGBs. The selected experts discuss...
Gastric leak is a severe complication of gastric bypass that is associated with significant morbi... more Gastric leak is a severe complication of gastric bypass that is associated with significant morbidity and mortality. Anastomosis dehiscence usually occurs at gastrojejunal anastomosis and can appear simultaneously with gastric leak, for which treatment can be a challenge. Fistula may have several clinical impacts, depending on patient-related factors, fistula characteristics, onset time, and therapy proposal. Abdominal toilet, drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. Currently, endoscopic stents are gaining space, promoting fistula sealing, secretion deviation, treating gastric stricture, and allowing early oral diet. Herein, we present a case of severe gastrojejunal anastomosis dehiscence treated with partially covered stent. We present a video of a 39-year-old man with a body mass index of 40 Kg/m2 who underwent a Roux-en-Y gastric bypass and presented fever and leukocytosis. Gastr...
Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure. Despite its h... more Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure. Despite its high efficacy, some patients regain part of their lost weight. Several endoscopic therapies have been introduced as alternatives to treat weight regain, but most of the articles are relatively small with unclear long-term data. To systematically assess the efficacy of endoscopic therapies for weight regain after RYGB. We searched MEDLINE, EMBASE, Scopus, Web of Science, Cochrane, OVID, CINAHL/EBSCo, LILACS/Bireme, and gray literature. Primary outcomes were absolute weight loss (AWL), excess weight loss (EWL), and total body weight loss (TBWL). Thirty-two studies were included in qualitative analysis. Twenty-six described full-thickness (FT) endoscopic suturing and pooled AWL, EWL, and TBWL at 3 months were 8.5 ± 2.9 kg, 21.6 ± 9.3%, and 7.3 ± 2.6%, respectively. At 6 months, they were 8.6 ± 3.5 kg, 23.7 ± 12.3%, and 8.0 ± 3.9%, respectively. At 12 months, they were 7.63 ± 4.3 kg, 16.9 ± 1...
Background and study aims Staple-line leaks occur in 1 % - 7 % of patients who undergo sleeve gas... more Background and study aims Staple-line leaks occur in 1 % - 7 % of patients who undergo sleeve gastrectomy, and can be challenging to treat. The success of endoscopic approaches decreases as leaks develop into chronic sinus tracts. Endoscopic septotomy has been used to facilitate healing of refractory leaks by incision and enlargement of the tract to allow direct communication with the gastric lumen and internal drainage. Patients and methods We reviewed the technique and outcomes among patients who underwent endoscopic septotomy at two centers for the management of sleeve gastrectomy-associated gastric fistulas and perigastric collections refractory to occlusive endoscopic therapies. Results Nine patients underwent endoscopic septotomy at a mean of 8.6 weeks after leak diagnosis, following failure of percutaneous and conventional endoscopic modalities. Perigastric collections ranged from 3 cm to 10 cm in size. The mean procedure time for endoscopic septotomy was 87.2 minutes. Multiple endoscopic septotomy procedures (mean 2.3, range 1 - 4) were required to achieve radiological resolution. The mean follow-up period was 21.2 weeks, and all nine patients achieved symptom resolution without the need for surgery. Bleeding at the time of endoscopic septotomy occurred in three patients, and was managed with endoscopic clips and did not require transfusion. No other adverse events or delayed complications were recorded. Conclusions Endoscopic septotomy appears to be a safe and effective technique for the management of sleeve gastrectomy-associated fistulae and collections, including those refractory to other endoscopic and percutaneous methods.
BACKGROUND Bariatric surgery is the most effective treatment for severe obesity, but the surgery ... more BACKGROUND Bariatric surgery is the most effective treatment for severe obesity, but the surgery increases the risk of developing nutritional deficiencies, such as vitamin A deficiency. In human metabolism, vitamin A plays a role in vision. OBJECTIVE To evaluate serum vitamin A, visual function and ocular surface of patients undergoing bariatric surgery. METHODS A cross-sectional and analytical study was conduced with 28 patients undergoing bariatric surgery for at least 6 months. Ophthalmologic evaluation was done through color vision test, contrast sensitivity test, ocular surface tests and confocal microscopy, as well as vitamin A serum measurement. RESULTS Vertical sleeve gastrectomy was performed in seven (25.0%) patients and Roux -en-Y gastric by-pass in 21 (75.0%). Mean serum vitamin A level was 1.7±0.5 µmoL/L. Most patients (60.7%) had symptoms of dry eye. Five (17.9%) patients had contrast sensitivity impairment and 18 (64.3%) color vision changes. In the group of patients ...
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo), 2016
Background: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve ga... more Background: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled. Objective: The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice. Methods: Institutional experience and systematic review from the literature on revisional bariatric surgery. Results: Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral...
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo), 2015
Background : Obesity and type 2 diabetes mellitus are associated to inflammatory state, which can... more Background : Obesity and type 2 diabetes mellitus are associated to inflammatory state, which can be set off by the adipose tissue, once it is a metabolically active organ that can cause a chronic mild inflammatory state. Aim : To evaluate the correlation between preoperative C-reactive protein and postoperative complications risk in obese patients (grades II and III) after Roux-en-Y gastric bypass, with and without type 2 diabetes mellitus. Methods : Between 2008 and 2013 were analysed 209 patients (107 with diabetes), presenting body mass index >40 kg/m2or >35 kg/m2with comorbidities. During the postoperative period, two groups were evaluated: with and without complications. Preoperative ultra-sensitive C-reactive protein was measured by immunonephelometry method. Results : Complications occurred in seven patients (pulmonary thromboembolism, fistula, two cases of suture leak, pancreatitis, evisceration and upper digestive hemorrhage). No statistical significance was found re...
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo), 2015
Background : The indications for sleeve gastrectomy in the surgical treatment of morbid obesity h... more Background : The indications for sleeve gastrectomy in the surgical treatment of morbid obesity have increased worldwide. Despite this, several aspects related to results at medium and long term remain in constant research. Aim : To present the experience of sleeve gastrectomy in a center of excellence in bariatric surgery by analyzing clinical outcomes, complications and follow-up in the medium term. Methods : The study included 120 morbidly obese patients who underwent sleeve gastrectomy and who were followed for at least 24 months. Aspects related to surgical technique, surgical complications and clinical outcome were analyzed. Results : Seventy-five patients were women (62.5%) and the average age was 36 years. The body mass index preoperatively ranged from 35.5 to 58 kg/m2(average of 40.2 kg/m2). The length of stay ranged from 1 to 4 days (mean 2.1 days). Comorbidities observed were hypertension (19%), type 2 diabetes mellitus (6.6%), dyslipidemia (7.5%), sleep apnea (16.6%), re...
Background The incidence of surgical site infection in bariatric patients is significant and the ... more Background The incidence of surgical site infection in bariatric patients is significant and the current recommendations for antibiotic prophylaxis are sometimes inadequate. Objective The aim of this study was to analyze the effect of three prophylactic antibiotic regimens on the incidence of surgical site infection. Methods A prospective, cross-sectional study was conducted between January 2009 and January 2013 in which 896 Roux-en-Y gastric bypasses were performed to treat obesity. The study compared three groups of patients according to the perioperative antibiotic prophylaxis administered intravenously and beginning at anesthesia induction: Group I consisting of 194 patients treated with two 3-g doses of ampicillin/sulbactam; Group II with 303 patients treated with a single 1-g dose of ertapenem; and Group III with 399 patients treated with a 2-g dose of cefazolin at anesthesia induction followed by a continuous infusion of cefazolin 1g throughout the surgical procedure. The rat...
Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery, 2013
Metabolic disorders have high correlation with severe forms of nonalcoholic fatty liver disease. ... more Metabolic disorders have high correlation with severe forms of nonalcoholic fatty liver disease. However, there is no non-invasive method that promotes its proper stratification and biopsy remains the ideal diagnostic tool. To evaluate the prevalence of this disease in obese in preoperative period of Roux-en-Y gastric bypass and metabolic factors correlated with liver histopathology. From a total of 47 patients, 35 were enrolled in the inclusion criteria and 12 excluded due to liver disease and alcohol intake >80 g/week. Were performed clinical and laboratory evaluation before the surgery and intraoperative liver biopsy . The intensity was ranked in grade of steatohepatitis: I (mild to moderate) and II (diffuse inflammation), III ( periportal fibrosis) and IV (cirrhosis). Were compared the following variables: duration of obesity, body mass index, waist-hip ratio, type 2 diabetes mellitus, hypertension and dyslipidemia. Thirty -five patients (68.6 % women , mean age 37 years) wer...
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