The development of gallbladder carcinoma has been correlated with the presence of a single large ... more The development of gallbladder carcinoma has been correlated with the presence of a single large gallstone in two retrospective studies. The objective of the present study was to determine the number and size of gallstones in patients with gallbladder carcinoma compared to asymptomatic and symptomatic female patients with gallstones. The following three groups of patients were included in this prospective trial: (A) 78 asymptomatic patients with gallstones; (B) 365 symptomatic patients with gallstones; and (C) 149 patients with gallbladder carcinoma. At the end of the operation, the resected gallbladder was opened and the number of stones counted. The maximum size of the stones was determined using calipers. Patients with gallbladder carcinoma were significantly older than patients in the other two groups (P (P
Background. Classic surgical treatment of upper third gastric carcinoma is based on an extended t... more Background. Classic surgical treatment of upper third gastric carcinoma is based on an extended total gastrectomy, including splenectomy. The purpose of this study was to perform a prospective randomized clinical trial comparing the early and late results of total gastrectomy (TG) versus total gastrectomy plus splenectomy (TGS). Methods. One hundred eighty-seven patients with gastric carcinoma were included. In all patients a D2 total gastrectomy was performed. During surgery they were randomized to 1 of 2 operative options. They were monitored to their death or to 5 years later if they were alive. Results. Operative mortality was similar after both operations (3% after TG and 4% after TGS). Septic complications after surgery were higher after TGS compared with TG (P <.04). Five-year survival rates were not statistically different between groups or in subset analysis according to stage of disease. Conclusions. On the basis of the results of the present prospective randomized trial, splenectomy is not necessary in early stages of disease. A low operative mortality rate (less than 3%) must be achieved to obtain good long-term results. (Surgery 2002;131:401-7.)
Background The objective of this study was to evaluate changes in resting energy expenditure (REE... more Background The objective of this study was to evaluate changes in resting energy expenditure (REE), body composition and metabolic parameters, and to investigate predictors of the results in seriously obese patients after Roux-en-Y gastric bypass (RYGBP). Methods 31 patients (BMI 44.4 ±–.8 kg/m2; 27 female, 4 male; 37.3 ±–1.1 y) were evaluated at baseline and 6 months after RYGBP. Weight, REE, waist circumference (WC), fat mass (FM) and fat-free mass (FFM), physical activity, food intake, fasting glucose (GLU), insulin (INS), HOMA-IR and lipid concentrations were measured. Results At 6 months, percentage of weight loss (%WL) was 29.0 ±–.4% and percentage of excess weight loss was (%EWL) 59.7 ±–2.3%. FM loss corresponded to 77.1 ±–2.2% of the weight loss. REE decreased from 33.4 ±–.1 to 30.1 ±–.6 kcal/kg FFM (P–lt;–.05). Significant decreases (P–lt;–.001) were observed in GLU, INS, HOMA-IR, LDL-cholesterol and triglycerides. %EWL was correlated with baseline INS (r––.44; P––.014), baseline HOMA (r––.43; P––.017), change in %FM (r––.67; P–lt;–.001) and change in WC (r––.5; P–lt;–.01). Decrease in REE/FFM (%) was positively correlated with baseline REE/FFM% (r––.51; P–lt;–.005) and change in %FM (r––.69; P–lt;–.001). Initial REE/FFM, baseline energy balance and FM change explain 90% of REE/FFM decrease. Conclusion RYGBP was an effective procedure to induce significant weight loss, fat mass loss and improvement in metabolic parameters in the short term. Metabolic adaptation was not related to FFM wasting but to a higher baseline REE. Fasting hyperinsulinemia was the best single predictor of weight loss after RYGBP.
The usual surgical treatment for patients with Barrett’s esophagus (BE) is a classic Nissen fundo... more The usual surgical treatment for patients with Barrett’s esophagus (BE) is a classic Nissen fundoplication or posterior gastropexy with cardial calibration. However, some surgical reports as well as our experience suggest that the rate of failure of the Nissen fundoplication or Hill’s posterior gastropexy in patients with BE is significantly higher than in those with reflux esophagitis without BE, probably due in part to the persistence of duodenal reflux into the esophagus. Our aim was to determine the late subjective and objective results of an operation consisting in “acid suppression” (vagotomy-partial gastrectomy) and “duodenal diversion” (Roux-en-Y anastomosis) as a primary surgical procedure for patients with BE. Altogether, 210 patients were subjected to this technique. It consisted in a primary operation in 142 patients and revision surgery in 68. They underwent complete clinical, radiologic, endoscopic, histologic, and manometric studies. In some cases 24-hour pH studies, Bilitec studies, gastric emptying, and gastric acid secretion evaluations were performed. There were two deaths (0.95%), and postoperative morbidity was low (5.3%). The late mean follow-up (58 months) for 146 patients who completed a follow-up longer than 24 months showed Visick I and II grades in 91.1% of the cases. In 14.9% of the cases 24-hour pH monitoring showed excessive acid reflux 1 year after surgery. No dysplasia or adenocarcinoma has appeared up to now. Functional studies showed significant alleviation of lower esophageal sphincter (LES) incompetence, with abolition of duodenal reflux into the esophagus. Gastric emptying of solids was normal, and basal and peak gastric acid output remained at a low level 8 to 10 years after surgery. In patients with BE, with severe damage of the LES and esophageal peristalsis, the “suppression diversion” operation completely abolishes the reflux of injurious components of the refluxate and improves sphincter competence. This effect is permanent and avoids the appearance of dysplasia or adenocarcinoma. Le traitement habituel des patients ayant un oesophage de Barrett (OB) consiste en une fundoplicature classique selon Nissen ou en une gastropexie postérieure avec calibration du cardia. Cependant, certaines publications, comme notre expérience, suggèrent que le taux d’échec de la fundoplicature complète selon Nissen ou de la gastropexie postérieure selon Hill est significativement plus élevé en cas d’OB qu’en cas de reflux en l’absence d’OB, probablement en raison de la persistance du reflux duodénal dans l’œsophage. Afin de déterminer les résultats tardifs subjectifs et objectifs d’une opération qui consiste en une suppression de l’acidité (vagotomie, gastrectomie partielle) associée à un diversion duodénale (anastomose en Y), on a étudié les résultats chez 210 patients ayant eu cette intervention: de première intervention pour 142 patients et comme chirurgie revisioneile dans 68 cas. Tous les patients ont eu une étude clinique, radiologique, histologique et manométrique complète. Dans certains cas, on a réalisé des études de pH de 24 heures, une étude Bilitec, une étude de la vidange gastrique ou une évaluation de la sécrétion. Deux patients sont décédés (0.95%). La morbidité postopératoire a été très basse (5.3%). Dans 146 cas où le suivi a été supérieur à 24 mois, avec un suivi moyen à distance de 58 mois, 91% des patients avaient des scores Visick I et II. Cependant, dans 14.9% des cas, la pH-métrie des 24 heures a montré un reflux acide excessif un an après la chirurgie. On n’a observé aucun cas de dysplasie ou d’anénocarcinome jusqu’à présent. Les études fonctionnelles ont montré une amélioration significative dans l’incompétence du sphincter inférieur de l’œsophage. La vidange gastrique pour les solides était normale, alors que les taux de débit acide de base et maximal étaient très bas 8 et 10 ans après chirurgie. Chez un patient présentant un OB, avec des lésions sévères du sphincter inférieur de lœophage et une modification du péristaltisme oesophagien, l’intervention “suppression/diversion” abolit complètement le reflux de composants agressifs et améliore la compétence sphinctérienne. Cet effet est permanent et évite l’apparition de dysplasie ou d’adénocarcinome. El tratamiento quirúrgico habitual del esófago de Barrett es la fundoplicación a lo Nissen o una gastropexia posterior, con calibración del cardias a lo Hill. Sin embargo, algunas publicaciones y nuestra propia experiencia demuestran que en pacientes con Barrett estas técnicas se acompañan de un gran porcentaje de fracasos, que no se observan en pacientes con reflujo esofágico sin enfermedad de Barrett. Para evaluar los resultados tradíos, 210 pacientes con enfermedad de Barrett fueron sometidos a una operación “supresora de la acidez” consistente en: una vagotomía con gastrectomía parcial acompañada de transección duodenal y reconstrucción mediante una anastomosis en Y de Roux. En 142 casos esta técnica constituyó el tratamiento inicial; 62 pacientes fueron sometidos a dicha intervención por fracaso de las operaciones clásicas ya mencionadas. Todas los enfermos habían sido estudiados por completo no sólo desde el punto de vista clínico, radiológico y endoscópico sino también, por lo que al estudio histológico y manométrico se refiere. En algunos casos se realizaron: pHmetría de 24 horas, estudios de Bilitec, de vaciamiento gástrico y de acidez gástrica. Registramos dos muertes (0.95%). La morbilidad postoperatoria fue escasa (5.3%). El seguimiento medio a largo plazo fue de 58 meses; de 146 pacientes, con un seguimiento superior a los 24 meses, el 92.2% se clasificaron como pertenecientes al grado Vlsick I y II. Sin embargo, el 14.9% de los casos en los que se estudió duante 24 horas la pHmetría, mostraron al año de la intervención quirúrgica un reflujo ácido excesivo. Hasta la actualidad no se ha registrado ningún caso de displasia o adenocarcinoma. Los estudios funcionales revelan una significativa mejoría del incompetente esfinter esofágico inferior con abolición del reflujo duodeno-esofágico. El vaciamiento gástrico para sólidos fue normal y la acidez gástrica máxima se mantuvo muy baja a los 8–10 años de la operación. En pacientes con enfermedad de Barrett la técnica quirúrgica propuesta por los autores abole por completo el reflujo y los deletéreos efectos de los distintos componentes del mismo, mejorando la competencia del esfinter. Estos resultados son permanentes sin que la operación induzca al desarrollo de displasias o adenocarcinomas.
Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a ... more Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a long limb Roux-en-Y anastomosis is the "gold standard" technique for these patients. We sought to determine the early and late results of open gastric bypass with resection of the distal excluded stomach in patients with morbid obesity. We included in this prospective study 400 patients who were seen from September 1999 through August 2003 (311 women and 89 men; mean age, 38.5 years). The mean body mass index of the patients was 46 kg/m2. All underwent 95% distal gastrectomy, with resection of the bypassed stomach, leaving a small gastric pouch of 15 to 20 ml. An end-to-side gastrojejunostomy was performed with circular stapler No. 25. The length of the Roux-en-Y loop was 125 to 150 cm. In all patients, a biopsy was taken from the liver and routine cholecystectomy was performed. Follow-up was as long as 36 months. A barium study was performed in all patients at 5 days after surgery. Mortality and postoperative morbidity rates were 0.5% and 4.75%, respectively, mainly due to anastomotic leak in 10 patients (2.5%). Hospital length of stay was 7 days for 95% of the patients. Follow-up data for longer than 12 months were available in 184 patients. There was excess body weight loss of 70% at 24 and 36 months, and there was an inverse correlation among preoperative body mass index and the loss of weight. Anemia was present in 10%, and incisional hernia was present in 10.2%. At 1 year after surgery, the BAROS index demonstrated very good or excellent index in 96.6% of the patients. Gastric bypass with resection of the distal excluded segment has results very similar to those of gastric bypass alone but eliminates the potential risks of gastric bypass such as anastomotic ulcer, gastrogastric fistula, postoperative bleeding due to peptic ulcer and gastritis, and the eventual future development of gastric cancer. It is also possible to perform via laparoscopy, as we started to do recently.
The development of gallbladder carcinoma has been correlated with the presence of a single large ... more The development of gallbladder carcinoma has been correlated with the presence of a single large gallstone in two retrospective studies. The objective of the present study was to determine the number and size of gallstones in patients with gallbladder carcinoma compared to asymptomatic and symptomatic female patients with gallstones. The following three groups of patients were included in this prospective trial: (A) 78 asymptomatic patients with gallstones; (B) 365 symptomatic patients with gallstones; and (C) 149 patients with gallbladder carcinoma. At the end of the operation, the resected gallbladder was opened and the number of stones counted. The maximum size of the stones was determined using calipers. Patients with gallbladder carcinoma were significantly older than patients in the other two groups (P (P
Background The objective of this study was to evaluate changes in resting energy expenditure (REE... more Background The objective of this study was to evaluate changes in resting energy expenditure (REE), body composition and metabolic parameters, and to investigate predictors of the results in seriously obese patients after Roux-en-Y gastric bypass (RYGBP). Methods 31 patients (BMI 44.4 ±–.8 kg/m2; 27 female, 4 male; 37.3 ±–1.1 y) were evaluated at baseline and 6 months after RYGBP. Weight, REE, waist circumference (WC), fat mass (FM) and fat-free mass (FFM), physical activity, food intake, fasting glucose (GLU), insulin (INS), HOMA-IR and lipid concentrations were measured. Results At 6 months, percentage of weight loss (%WL) was 29.0 ±–.4% and percentage of excess weight loss was (%EWL) 59.7 ±–2.3%. FM loss corresponded to 77.1 ±–2.2% of the weight loss. REE decreased from 33.4 ±–.1 to 30.1 ±–.6 kcal/kg FFM (P–lt;–.05). Significant decreases (P–lt;–.001) were observed in GLU, INS, HOMA-IR, LDL-cholesterol and triglycerides. %EWL was correlated with baseline INS (r––.44; P––.014), baseline HOMA (r––.43; P––.017), change in %FM (r––.67; P–lt;–.001) and change in WC (r––.5; P–lt;–.01). Decrease in REE/FFM (%) was positively correlated with baseline REE/FFM% (r––.51; P–lt;–.005) and change in %FM (r––.69; P–lt;–.001). Initial REE/FFM, baseline energy balance and FM change explain 90% of REE/FFM decrease. Conclusion RYGBP was an effective procedure to induce significant weight loss, fat mass loss and improvement in metabolic parameters in the short term. Metabolic adaptation was not related to FFM wasting but to a higher baseline REE. Fasting hyperinsulinemia was the best single predictor of weight loss after RYGBP.
The usual surgical treatment for patients with Barrett’s esophagus (BE) is a classic Nissen fundo... more The usual surgical treatment for patients with Barrett’s esophagus (BE) is a classic Nissen fundoplication or posterior gastropexy with cardial calibration. However, some surgical reports as well as our experience suggest that the rate of failure of the Nissen fundoplication or Hill’s posterior gastropexy in patients with BE is significantly higher than in those with reflux esophagitis without BE, probably due in part to the persistence of duodenal reflux into the esophagus. Our aim was to determine the late subjective and objective results of an operation consisting in “acid suppression” (vagotomy-partial gastrectomy) and “duodenal diversion” (Roux-en-Y anastomosis) as a primary surgical procedure for patients with BE. Altogether, 210 patients were subjected to this technique. It consisted in a primary operation in 142 patients and revision surgery in 68. They underwent complete clinical, radiologic, endoscopic, histologic, and manometric studies. In some cases 24-hour pH studies, Bilitec studies, gastric emptying, and gastric acid secretion evaluations were performed. There were two deaths (0.95%), and postoperative morbidity was low (5.3%). The late mean follow-up (58 months) for 146 patients who completed a follow-up longer than 24 months showed Visick I and II grades in 91.1% of the cases. In 14.9% of the cases 24-hour pH monitoring showed excessive acid reflux 1 year after surgery. No dysplasia or adenocarcinoma has appeared up to now. Functional studies showed significant alleviation of lower esophageal sphincter (LES) incompetence, with abolition of duodenal reflux into the esophagus. Gastric emptying of solids was normal, and basal and peak gastric acid output remained at a low level 8 to 10 years after surgery. In patients with BE, with severe damage of the LES and esophageal peristalsis, the “suppression diversion” operation completely abolishes the reflux of injurious components of the refluxate and improves sphincter competence. This effect is permanent and avoids the appearance of dysplasia or adenocarcinoma. Le traitement habituel des patients ayant un oesophage de Barrett (OB) consiste en une fundoplicature classique selon Nissen ou en une gastropexie postérieure avec calibration du cardia. Cependant, certaines publications, comme notre expérience, suggèrent que le taux d’échec de la fundoplicature complète selon Nissen ou de la gastropexie postérieure selon Hill est significativement plus élevé en cas d’OB qu’en cas de reflux en l’absence d’OB, probablement en raison de la persistance du reflux duodénal dans l’œsophage. Afin de déterminer les résultats tardifs subjectifs et objectifs d’une opération qui consiste en une suppression de l’acidité (vagotomie, gastrectomie partielle) associée à un diversion duodénale (anastomose en Y), on a étudié les résultats chez 210 patients ayant eu cette intervention: de première intervention pour 142 patients et comme chirurgie revisioneile dans 68 cas. Tous les patients ont eu une étude clinique, radiologique, histologique et manométrique complète. Dans certains cas, on a réalisé des études de pH de 24 heures, une étude Bilitec, une étude de la vidange gastrique ou une évaluation de la sécrétion. Deux patients sont décédés (0.95%). La morbidité postopératoire a été très basse (5.3%). Dans 146 cas où le suivi a été supérieur à 24 mois, avec un suivi moyen à distance de 58 mois, 91% des patients avaient des scores Visick I et II. Cependant, dans 14.9% des cas, la pH-métrie des 24 heures a montré un reflux acide excessif un an après la chirurgie. On n’a observé aucun cas de dysplasie ou d’anénocarcinome jusqu’à présent. Les études fonctionnelles ont montré une amélioration significative dans l’incompétence du sphincter inférieur de l’œsophage. La vidange gastrique pour les solides était normale, alors que les taux de débit acide de base et maximal étaient très bas 8 et 10 ans après chirurgie. Chez un patient présentant un OB, avec des lésions sévères du sphincter inférieur de lœophage et une modification du péristaltisme oesophagien, l’intervention “suppression/diversion” abolit complètement le reflux de composants agressifs et améliore la compétence sphinctérienne. Cet effet est permanent et évite l’apparition de dysplasie ou d’adénocarcinome. El tratamiento quirúrgico habitual del esófago de Barrett es la fundoplicación a lo Nissen o una gastropexia posterior, con calibración del cardias a lo Hill. Sin embargo, algunas publicaciones y nuestra propia experiencia demuestran que en pacientes con Barrett estas técnicas se acompañan de un gran porcentaje de fracasos, que no se observan en pacientes con reflujo esofágico sin enfermedad de Barrett. Para evaluar los resultados tradíos, 210 pacientes con enfermedad de Barrett fueron sometidos a una operación “supresora de la acidez” consistente en: una vagotomía con gastrectomía parcial acompañada de transección duodenal y reconstrucción mediante una anastomosis en Y de Roux. En 142 casos esta técnica constituyó el tratamiento inicial; 62 pacientes fueron sometidos a dicha intervención por fracaso de las operaciones clásicas ya mencionadas. Todas los enfermos habían sido estudiados por completo no sólo desde el punto de vista clínico, radiológico y endoscópico sino también, por lo que al estudio histológico y manométrico se refiere. En algunos casos se realizaron: pHmetría de 24 horas, estudios de Bilitec, de vaciamiento gástrico y de acidez gástrica. Registramos dos muertes (0.95%). La morbilidad postoperatoria fue escasa (5.3%). El seguimiento medio a largo plazo fue de 58 meses; de 146 pacientes, con un seguimiento superior a los 24 meses, el 92.2% se clasificaron como pertenecientes al grado Vlsick I y II. Sin embargo, el 14.9% de los casos en los que se estudió duante 24 horas la pHmetría, mostraron al año de la intervención quirúrgica un reflujo ácido excesivo. Hasta la actualidad no se ha registrado ningún caso de displasia o adenocarcinoma. Los estudios funcionales revelan una significativa mejoría del incompetente esfinter esofágico inferior con abolición del reflujo duodeno-esofágico. El vaciamiento gástrico para sólidos fue normal y la acidez gástrica máxima se mantuvo muy baja a los 8–10 años de la operación. En pacientes con enfermedad de Barrett la técnica quirúrgica propuesta por los autores abole por completo el reflujo y los deletéreos efectos de los distintos componentes del mismo, mejorando la competencia del esfinter. Estos resultados son permanentes sin que la operación induzca al desarrollo de displasias o adenocarcinomas.
Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a ... more Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a long limb Roux-en-Y anastomosis is the "gold standard" technique for these patients. We sought to determine the early and late results of open gastric bypass with resection of the distal excluded stomach in patients with morbid obesity. We included in this prospective study 400 patients who were seen from September 1999 through August 2003 (311 women and 89 men; mean age, 38.5 years). The mean body mass index of the patients was 46 kg/m2. All underwent 95% distal gastrectomy, with resection of the bypassed stomach, leaving a small gastric pouch of 15 to 20 ml. An end-to-side gastrojejunostomy was performed with circular stapler No. 25. The length of the Roux-en-Y loop was 125 to 150 cm. In all patients, a biopsy was taken from the liver and routine cholecystectomy was performed. Follow-up was as long as 36 months. A barium study was performed in all patients at 5 days after surgery. Mortality and postoperative morbidity rates were 0.5% and 4.75%, respectively, mainly due to anastomotic leak in 10 patients (2.5%). Hospital length of stay was 7 days for 95% of the patients. Follow-up data for longer than 12 months were available in 184 patients. There was excess body weight loss of 70% at 24 and 36 months, and there was an inverse correlation among preoperative body mass index and the loss of weight. Anemia was present in 10%, and incisional hernia was present in 10.2%. At 1 year after surgery, the BAROS index demonstrated very good or excellent index in 96.6% of the patients. Gastric bypass with resection of the distal excluded segment has results very similar to those of gastric bypass alone but eliminates the potential risks of gastric bypass such as anastomotic ulcer, gastrogastric fistula, postoperative bleeding due to peptic ulcer and gastritis, and the eventual future development of gastric cancer. It is also possible to perform via laparoscopy, as we started to do recently.
The development of gallbladder carcinoma has been correlated with the presence of a single large ... more The development of gallbladder carcinoma has been correlated with the presence of a single large gallstone in two retrospective studies. The objective of the present study was to determine the number and size of gallstones in patients with gallbladder carcinoma compared to asymptomatic and symptomatic female patients with gallstones. The following three groups of patients were included in this prospective trial: (A) 78 asymptomatic patients with gallstones; (B) 365 symptomatic patients with gallstones; and (C) 149 patients with gallbladder carcinoma. At the end of the operation, the resected gallbladder was opened and the number of stones counted. The maximum size of the stones was determined using calipers. Patients with gallbladder carcinoma were significantly older than patients in the other two groups (P (P
Background. Classic surgical treatment of upper third gastric carcinoma is based on an extended t... more Background. Classic surgical treatment of upper third gastric carcinoma is based on an extended total gastrectomy, including splenectomy. The purpose of this study was to perform a prospective randomized clinical trial comparing the early and late results of total gastrectomy (TG) versus total gastrectomy plus splenectomy (TGS). Methods. One hundred eighty-seven patients with gastric carcinoma were included. In all patients a D2 total gastrectomy was performed. During surgery they were randomized to 1 of 2 operative options. They were monitored to their death or to 5 years later if they were alive. Results. Operative mortality was similar after both operations (3% after TG and 4% after TGS). Septic complications after surgery were higher after TGS compared with TG (P <.04). Five-year survival rates were not statistically different between groups or in subset analysis according to stage of disease. Conclusions. On the basis of the results of the present prospective randomized trial, splenectomy is not necessary in early stages of disease. A low operative mortality rate (less than 3%) must be achieved to obtain good long-term results. (Surgery 2002;131:401-7.)
Background The objective of this study was to evaluate changes in resting energy expenditure (REE... more Background The objective of this study was to evaluate changes in resting energy expenditure (REE), body composition and metabolic parameters, and to investigate predictors of the results in seriously obese patients after Roux-en-Y gastric bypass (RYGBP). Methods 31 patients (BMI 44.4 ±–.8 kg/m2; 27 female, 4 male; 37.3 ±–1.1 y) were evaluated at baseline and 6 months after RYGBP. Weight, REE, waist circumference (WC), fat mass (FM) and fat-free mass (FFM), physical activity, food intake, fasting glucose (GLU), insulin (INS), HOMA-IR and lipid concentrations were measured. Results At 6 months, percentage of weight loss (%WL) was 29.0 ±–.4% and percentage of excess weight loss was (%EWL) 59.7 ±–2.3%. FM loss corresponded to 77.1 ±–2.2% of the weight loss. REE decreased from 33.4 ±–.1 to 30.1 ±–.6 kcal/kg FFM (P–lt;–.05). Significant decreases (P–lt;–.001) were observed in GLU, INS, HOMA-IR, LDL-cholesterol and triglycerides. %EWL was correlated with baseline INS (r––.44; P––.014), baseline HOMA (r––.43; P––.017), change in %FM (r––.67; P–lt;–.001) and change in WC (r––.5; P–lt;–.01). Decrease in REE/FFM (%) was positively correlated with baseline REE/FFM% (r––.51; P–lt;–.005) and change in %FM (r––.69; P–lt;–.001). Initial REE/FFM, baseline energy balance and FM change explain 90% of REE/FFM decrease. Conclusion RYGBP was an effective procedure to induce significant weight loss, fat mass loss and improvement in metabolic parameters in the short term. Metabolic adaptation was not related to FFM wasting but to a higher baseline REE. Fasting hyperinsulinemia was the best single predictor of weight loss after RYGBP.
The usual surgical treatment for patients with Barrett’s esophagus (BE) is a classic Nissen fundo... more The usual surgical treatment for patients with Barrett’s esophagus (BE) is a classic Nissen fundoplication or posterior gastropexy with cardial calibration. However, some surgical reports as well as our experience suggest that the rate of failure of the Nissen fundoplication or Hill’s posterior gastropexy in patients with BE is significantly higher than in those with reflux esophagitis without BE, probably due in part to the persistence of duodenal reflux into the esophagus. Our aim was to determine the late subjective and objective results of an operation consisting in “acid suppression” (vagotomy-partial gastrectomy) and “duodenal diversion” (Roux-en-Y anastomosis) as a primary surgical procedure for patients with BE. Altogether, 210 patients were subjected to this technique. It consisted in a primary operation in 142 patients and revision surgery in 68. They underwent complete clinical, radiologic, endoscopic, histologic, and manometric studies. In some cases 24-hour pH studies, Bilitec studies, gastric emptying, and gastric acid secretion evaluations were performed. There were two deaths (0.95%), and postoperative morbidity was low (5.3%). The late mean follow-up (58 months) for 146 patients who completed a follow-up longer than 24 months showed Visick I and II grades in 91.1% of the cases. In 14.9% of the cases 24-hour pH monitoring showed excessive acid reflux 1 year after surgery. No dysplasia or adenocarcinoma has appeared up to now. Functional studies showed significant alleviation of lower esophageal sphincter (LES) incompetence, with abolition of duodenal reflux into the esophagus. Gastric emptying of solids was normal, and basal and peak gastric acid output remained at a low level 8 to 10 years after surgery. In patients with BE, with severe damage of the LES and esophageal peristalsis, the “suppression diversion” operation completely abolishes the reflux of injurious components of the refluxate and improves sphincter competence. This effect is permanent and avoids the appearance of dysplasia or adenocarcinoma. Le traitement habituel des patients ayant un oesophage de Barrett (OB) consiste en une fundoplicature classique selon Nissen ou en une gastropexie postérieure avec calibration du cardia. Cependant, certaines publications, comme notre expérience, suggèrent que le taux d’échec de la fundoplicature complète selon Nissen ou de la gastropexie postérieure selon Hill est significativement plus élevé en cas d’OB qu’en cas de reflux en l’absence d’OB, probablement en raison de la persistance du reflux duodénal dans l’œsophage. Afin de déterminer les résultats tardifs subjectifs et objectifs d’une opération qui consiste en une suppression de l’acidité (vagotomie, gastrectomie partielle) associée à un diversion duodénale (anastomose en Y), on a étudié les résultats chez 210 patients ayant eu cette intervention: de première intervention pour 142 patients et comme chirurgie revisioneile dans 68 cas. Tous les patients ont eu une étude clinique, radiologique, histologique et manométrique complète. Dans certains cas, on a réalisé des études de pH de 24 heures, une étude Bilitec, une étude de la vidange gastrique ou une évaluation de la sécrétion. Deux patients sont décédés (0.95%). La morbidité postopératoire a été très basse (5.3%). Dans 146 cas où le suivi a été supérieur à 24 mois, avec un suivi moyen à distance de 58 mois, 91% des patients avaient des scores Visick I et II. Cependant, dans 14.9% des cas, la pH-métrie des 24 heures a montré un reflux acide excessif un an après la chirurgie. On n’a observé aucun cas de dysplasie ou d’anénocarcinome jusqu’à présent. Les études fonctionnelles ont montré une amélioration significative dans l’incompétence du sphincter inférieur de l’œsophage. La vidange gastrique pour les solides était normale, alors que les taux de débit acide de base et maximal étaient très bas 8 et 10 ans après chirurgie. Chez un patient présentant un OB, avec des lésions sévères du sphincter inférieur de lœophage et une modification du péristaltisme oesophagien, l’intervention “suppression/diversion” abolit complètement le reflux de composants agressifs et améliore la compétence sphinctérienne. Cet effet est permanent et évite l’apparition de dysplasie ou d’adénocarcinome. El tratamiento quirúrgico habitual del esófago de Barrett es la fundoplicación a lo Nissen o una gastropexia posterior, con calibración del cardias a lo Hill. Sin embargo, algunas publicaciones y nuestra propia experiencia demuestran que en pacientes con Barrett estas técnicas se acompañan de un gran porcentaje de fracasos, que no se observan en pacientes con reflujo esofágico sin enfermedad de Barrett. Para evaluar los resultados tradíos, 210 pacientes con enfermedad de Barrett fueron sometidos a una operación “supresora de la acidez” consistente en: una vagotomía con gastrectomía parcial acompañada de transección duodenal y reconstrucción mediante una anastomosis en Y de Roux. En 142 casos esta técnica constituyó el tratamiento inicial; 62 pacientes fueron sometidos a dicha intervención por fracaso de las operaciones clásicas ya mencionadas. Todas los enfermos habían sido estudiados por completo no sólo desde el punto de vista clínico, radiológico y endoscópico sino también, por lo que al estudio histológico y manométrico se refiere. En algunos casos se realizaron: pHmetría de 24 horas, estudios de Bilitec, de vaciamiento gástrico y de acidez gástrica. Registramos dos muertes (0.95%). La morbilidad postoperatoria fue escasa (5.3%). El seguimiento medio a largo plazo fue de 58 meses; de 146 pacientes, con un seguimiento superior a los 24 meses, el 92.2% se clasificaron como pertenecientes al grado Vlsick I y II. Sin embargo, el 14.9% de los casos en los que se estudió duante 24 horas la pHmetría, mostraron al año de la intervención quirúrgica un reflujo ácido excesivo. Hasta la actualidad no se ha registrado ningún caso de displasia o adenocarcinoma. Los estudios funcionales revelan una significativa mejoría del incompetente esfinter esofágico inferior con abolición del reflujo duodeno-esofágico. El vaciamiento gástrico para sólidos fue normal y la acidez gástrica máxima se mantuvo muy baja a los 8–10 años de la operación. En pacientes con enfermedad de Barrett la técnica quirúrgica propuesta por los autores abole por completo el reflujo y los deletéreos efectos de los distintos componentes del mismo, mejorando la competencia del esfinter. Estos resultados son permanentes sin que la operación induzca al desarrollo de displasias o adenocarcinomas.
Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a ... more Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a long limb Roux-en-Y anastomosis is the "gold standard" technique for these patients. We sought to determine the early and late results of open gastric bypass with resection of the distal excluded stomach in patients with morbid obesity. We included in this prospective study 400 patients who were seen from September 1999 through August 2003 (311 women and 89 men; mean age, 38.5 years). The mean body mass index of the patients was 46 kg/m2. All underwent 95% distal gastrectomy, with resection of the bypassed stomach, leaving a small gastric pouch of 15 to 20 ml. An end-to-side gastrojejunostomy was performed with circular stapler No. 25. The length of the Roux-en-Y loop was 125 to 150 cm. In all patients, a biopsy was taken from the liver and routine cholecystectomy was performed. Follow-up was as long as 36 months. A barium study was performed in all patients at 5 days after surgery. Mortality and postoperative morbidity rates were 0.5% and 4.75%, respectively, mainly due to anastomotic leak in 10 patients (2.5%). Hospital length of stay was 7 days for 95% of the patients. Follow-up data for longer than 12 months were available in 184 patients. There was excess body weight loss of 70% at 24 and 36 months, and there was an inverse correlation among preoperative body mass index and the loss of weight. Anemia was present in 10%, and incisional hernia was present in 10.2%. At 1 year after surgery, the BAROS index demonstrated very good or excellent index in 96.6% of the patients. Gastric bypass with resection of the distal excluded segment has results very similar to those of gastric bypass alone but eliminates the potential risks of gastric bypass such as anastomotic ulcer, gastrogastric fistula, postoperative bleeding due to peptic ulcer and gastritis, and the eventual future development of gastric cancer. It is also possible to perform via laparoscopy, as we started to do recently.
The development of gallbladder carcinoma has been correlated with the presence of a single large ... more The development of gallbladder carcinoma has been correlated with the presence of a single large gallstone in two retrospective studies. The objective of the present study was to determine the number and size of gallstones in patients with gallbladder carcinoma compared to asymptomatic and symptomatic female patients with gallstones. The following three groups of patients were included in this prospective trial: (A) 78 asymptomatic patients with gallstones; (B) 365 symptomatic patients with gallstones; and (C) 149 patients with gallbladder carcinoma. At the end of the operation, the resected gallbladder was opened and the number of stones counted. The maximum size of the stones was determined using calipers. Patients with gallbladder carcinoma were significantly older than patients in the other two groups (P (P
Background The objective of this study was to evaluate changes in resting energy expenditure (REE... more Background The objective of this study was to evaluate changes in resting energy expenditure (REE), body composition and metabolic parameters, and to investigate predictors of the results in seriously obese patients after Roux-en-Y gastric bypass (RYGBP). Methods 31 patients (BMI 44.4 ±–.8 kg/m2; 27 female, 4 male; 37.3 ±–1.1 y) were evaluated at baseline and 6 months after RYGBP. Weight, REE, waist circumference (WC), fat mass (FM) and fat-free mass (FFM), physical activity, food intake, fasting glucose (GLU), insulin (INS), HOMA-IR and lipid concentrations were measured. Results At 6 months, percentage of weight loss (%WL) was 29.0 ±–.4% and percentage of excess weight loss was (%EWL) 59.7 ±–2.3%. FM loss corresponded to 77.1 ±–2.2% of the weight loss. REE decreased from 33.4 ±–.1 to 30.1 ±–.6 kcal/kg FFM (P–lt;–.05). Significant decreases (P–lt;–.001) were observed in GLU, INS, HOMA-IR, LDL-cholesterol and triglycerides. %EWL was correlated with baseline INS (r––.44; P––.014), baseline HOMA (r––.43; P––.017), change in %FM (r––.67; P–lt;–.001) and change in WC (r––.5; P–lt;–.01). Decrease in REE/FFM (%) was positively correlated with baseline REE/FFM% (r––.51; P–lt;–.005) and change in %FM (r––.69; P–lt;–.001). Initial REE/FFM, baseline energy balance and FM change explain 90% of REE/FFM decrease. Conclusion RYGBP was an effective procedure to induce significant weight loss, fat mass loss and improvement in metabolic parameters in the short term. Metabolic adaptation was not related to FFM wasting but to a higher baseline REE. Fasting hyperinsulinemia was the best single predictor of weight loss after RYGBP.
The usual surgical treatment for patients with Barrett’s esophagus (BE) is a classic Nissen fundo... more The usual surgical treatment for patients with Barrett’s esophagus (BE) is a classic Nissen fundoplication or posterior gastropexy with cardial calibration. However, some surgical reports as well as our experience suggest that the rate of failure of the Nissen fundoplication or Hill’s posterior gastropexy in patients with BE is significantly higher than in those with reflux esophagitis without BE, probably due in part to the persistence of duodenal reflux into the esophagus. Our aim was to determine the late subjective and objective results of an operation consisting in “acid suppression” (vagotomy-partial gastrectomy) and “duodenal diversion” (Roux-en-Y anastomosis) as a primary surgical procedure for patients with BE. Altogether, 210 patients were subjected to this technique. It consisted in a primary operation in 142 patients and revision surgery in 68. They underwent complete clinical, radiologic, endoscopic, histologic, and manometric studies. In some cases 24-hour pH studies, Bilitec studies, gastric emptying, and gastric acid secretion evaluations were performed. There were two deaths (0.95%), and postoperative morbidity was low (5.3%). The late mean follow-up (58 months) for 146 patients who completed a follow-up longer than 24 months showed Visick I and II grades in 91.1% of the cases. In 14.9% of the cases 24-hour pH monitoring showed excessive acid reflux 1 year after surgery. No dysplasia or adenocarcinoma has appeared up to now. Functional studies showed significant alleviation of lower esophageal sphincter (LES) incompetence, with abolition of duodenal reflux into the esophagus. Gastric emptying of solids was normal, and basal and peak gastric acid output remained at a low level 8 to 10 years after surgery. In patients with BE, with severe damage of the LES and esophageal peristalsis, the “suppression diversion” operation completely abolishes the reflux of injurious components of the refluxate and improves sphincter competence. This effect is permanent and avoids the appearance of dysplasia or adenocarcinoma. Le traitement habituel des patients ayant un oesophage de Barrett (OB) consiste en une fundoplicature classique selon Nissen ou en une gastropexie postérieure avec calibration du cardia. Cependant, certaines publications, comme notre expérience, suggèrent que le taux d’échec de la fundoplicature complète selon Nissen ou de la gastropexie postérieure selon Hill est significativement plus élevé en cas d’OB qu’en cas de reflux en l’absence d’OB, probablement en raison de la persistance du reflux duodénal dans l’œsophage. Afin de déterminer les résultats tardifs subjectifs et objectifs d’une opération qui consiste en une suppression de l’acidité (vagotomie, gastrectomie partielle) associée à un diversion duodénale (anastomose en Y), on a étudié les résultats chez 210 patients ayant eu cette intervention: de première intervention pour 142 patients et comme chirurgie revisioneile dans 68 cas. Tous les patients ont eu une étude clinique, radiologique, histologique et manométrique complète. Dans certains cas, on a réalisé des études de pH de 24 heures, une étude Bilitec, une étude de la vidange gastrique ou une évaluation de la sécrétion. Deux patients sont décédés (0.95%). La morbidité postopératoire a été très basse (5.3%). Dans 146 cas où le suivi a été supérieur à 24 mois, avec un suivi moyen à distance de 58 mois, 91% des patients avaient des scores Visick I et II. Cependant, dans 14.9% des cas, la pH-métrie des 24 heures a montré un reflux acide excessif un an après la chirurgie. On n’a observé aucun cas de dysplasie ou d’anénocarcinome jusqu’à présent. Les études fonctionnelles ont montré une amélioration significative dans l’incompétence du sphincter inférieur de l’œsophage. La vidange gastrique pour les solides était normale, alors que les taux de débit acide de base et maximal étaient très bas 8 et 10 ans après chirurgie. Chez un patient présentant un OB, avec des lésions sévères du sphincter inférieur de lœophage et une modification du péristaltisme oesophagien, l’intervention “suppression/diversion” abolit complètement le reflux de composants agressifs et améliore la compétence sphinctérienne. Cet effet est permanent et évite l’apparition de dysplasie ou d’adénocarcinome. El tratamiento quirúrgico habitual del esófago de Barrett es la fundoplicación a lo Nissen o una gastropexia posterior, con calibración del cardias a lo Hill. Sin embargo, algunas publicaciones y nuestra propia experiencia demuestran que en pacientes con Barrett estas técnicas se acompañan de un gran porcentaje de fracasos, que no se observan en pacientes con reflujo esofágico sin enfermedad de Barrett. Para evaluar los resultados tradíos, 210 pacientes con enfermedad de Barrett fueron sometidos a una operación “supresora de la acidez” consistente en: una vagotomía con gastrectomía parcial acompañada de transección duodenal y reconstrucción mediante una anastomosis en Y de Roux. En 142 casos esta técnica constituyó el tratamiento inicial; 62 pacientes fueron sometidos a dicha intervención por fracaso de las operaciones clásicas ya mencionadas. Todas los enfermos habían sido estudiados por completo no sólo desde el punto de vista clínico, radiológico y endoscópico sino también, por lo que al estudio histológico y manométrico se refiere. En algunos casos se realizaron: pHmetría de 24 horas, estudios de Bilitec, de vaciamiento gástrico y de acidez gástrica. Registramos dos muertes (0.95%). La morbilidad postoperatoria fue escasa (5.3%). El seguimiento medio a largo plazo fue de 58 meses; de 146 pacientes, con un seguimiento superior a los 24 meses, el 92.2% se clasificaron como pertenecientes al grado Vlsick I y II. Sin embargo, el 14.9% de los casos en los que se estudió duante 24 horas la pHmetría, mostraron al año de la intervención quirúrgica un reflujo ácido excesivo. Hasta la actualidad no se ha registrado ningún caso de displasia o adenocarcinoma. Los estudios funcionales revelan una significativa mejoría del incompetente esfinter esofágico inferior con abolición del reflujo duodeno-esofágico. El vaciamiento gástrico para sólidos fue normal y la acidez gástrica máxima se mantuvo muy baja a los 8–10 años de la operación. En pacientes con enfermedad de Barrett la técnica quirúrgica propuesta por los autores abole por completo el reflujo y los deletéreos efectos de los distintos componentes del mismo, mejorando la competencia del esfinter. Estos resultados son permanentes sin que la operación induzca al desarrollo de displasias o adenocarcinomas.
Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a ... more Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a long limb Roux-en-Y anastomosis is the "gold standard" technique for these patients. We sought to determine the early and late results of open gastric bypass with resection of the distal excluded stomach in patients with morbid obesity. We included in this prospective study 400 patients who were seen from September 1999 through August 2003 (311 women and 89 men; mean age, 38.5 years). The mean body mass index of the patients was 46 kg/m2. All underwent 95% distal gastrectomy, with resection of the bypassed stomach, leaving a small gastric pouch of 15 to 20 ml. An end-to-side gastrojejunostomy was performed with circular stapler No. 25. The length of the Roux-en-Y loop was 125 to 150 cm. In all patients, a biopsy was taken from the liver and routine cholecystectomy was performed. Follow-up was as long as 36 months. A barium study was performed in all patients at 5 days after surgery. Mortality and postoperative morbidity rates were 0.5% and 4.75%, respectively, mainly due to anastomotic leak in 10 patients (2.5%). Hospital length of stay was 7 days for 95% of the patients. Follow-up data for longer than 12 months were available in 184 patients. There was excess body weight loss of 70% at 24 and 36 months, and there was an inverse correlation among preoperative body mass index and the loss of weight. Anemia was present in 10%, and incisional hernia was present in 10.2%. At 1 year after surgery, the BAROS index demonstrated very good or excellent index in 96.6% of the patients. Gastric bypass with resection of the distal excluded segment has results very similar to those of gastric bypass alone but eliminates the potential risks of gastric bypass such as anastomotic ulcer, gastrogastric fistula, postoperative bleeding due to peptic ulcer and gastritis, and the eventual future development of gastric cancer. It is also possible to perform via laparoscopy, as we started to do recently.
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