RESUMO
OBJECTIVE: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]). BACKGROUND: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix. METHODS: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50âkg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators. RESULTS: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8â±â5.8âkg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication. CONCLUSION: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.
Assuntos
Índice de Massa Corporal , Gastrectomia/métodos , Derivação Gástrica/métodos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Qualidade de Vida , Centros Médicos Acadêmicos , Adulto , Fatores Etários , Benchmarking , Estudos de Coortes , Feminino , Gastrectomia/efeitos adversos , Derivação Gástrica/efeitos adversos , Saúde Global , Hospitais com Alto Volume de Atendimentos , Humanos , Internacionalidade , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Obesidade Mórbida/diagnóstico , Obesidade Mórbida/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Redução de PesoRESUMO
BACKGROUND: The association between medical and dietetic-behavioral treatments of type 2 diabetes mellitus (T2DM) has demonstrated to have variable results. The surgical treatment of T2DM is justifiable after the observation of a successful glycemic control in patients submitted to Roux-en-Y gastric bypass and biliopancreatic diversion. Experiments have shown an important role of the proximal intestine in glycemia decrease and diabetes control. METHODS: Twenty diabetic patients underwent laparoscopic duodenal-jejunal exclusion. The variables studied were body mass index (BMI), fasting glycemia, glycosylated hemoglobin (HbA1c), and C-peptide, in the preoperative period and after 3 and 6 months. RESULTS: There was a BMI decrease up to the third month and a weight stabilization between the third and sixth months. There was a significant reduction in fasting glycemia (43.8%) and HbA1c (22.8%) up to the sixth month (p<0.001). C-peptide did not show any significant alteration until the third month, although there was a considerable increase (25%) between the third and the sixth months (p<0.001). Only two patients were on oral medication after the sixth month. CONCLUSIONS: Preliminary results have shown an important effect of the laparoscopic duodenal-jejunal exclusion in the treatment of T2DM. Studies with longer follow-up and a larger number of patients are necessary to better define the role of this new and promising procedure.
Assuntos
Diabetes Mellitus Tipo 2/cirurgia , Duodenostomia , Derivação Jejunoileal/métodos , Laparoscopia , Sobrepeso/complicações , Adolescente , Adulto , Índice de Massa Corporal , Diabetes Mellitus Tipo 2/complicações , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Sobrepeso/cirurgia , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
The staplerless Roux-en-Y gastric bypass (RYGBP) is a new option in bariatric surgery. The first to describe it was Himpens (2004) utilizing the LigaSure Atlas (LSA) in a series of 10 patients. The laparoscopic RYGBP is performed utilizing the LSA for the gastric and jejunal partition; after that, an imbricating running suture is performed to ensure stomach and bowel hermetic closure. All anastomoses are hand-sewn. Technical disadvantages are: learning curve; complications related to suture failure; possible thermal/electricity related injuries; longer operating time. Advantages are: stapler-associated bleeding, leaks, staple-line disruption, and fistulas are avoided; cost reduction. The staplerless RYGBP is complex; the surgeon involved requires expertise and ability. This technique will evolve and will be used by more surgeons. It is a new option for the surgeon preoccupied with costs, which is particularly important in developing countries.
Assuntos
Derivação Gástrica/métodos , Anastomose em-Y de Roux , Brasil , Competência Clínica , Custos e Análise de Custo , Eletrocoagulação , Derivação Gástrica/economia , Humanos , Jejunostomia , Laparoscopia , Azul de Metileno , Suturas , Estados UnidosRESUMO
BACKGROUND: Vertical sleeve gastrectomy (VSG) is a surgical technique that involves resection of a significant portion of the stomach. This surgery is sometimes associated with gastric leaks, which can be difficult to treat. The present study reports findings from laparoscopic greater curvature plication (LGCP), which is an alternative bariatric procedure similar to VSG but without the need for gastric resection. METHODS: A prospective study was carried out, following LGCP in 42 morbidly obese patients (30 female/12 male) with a mean age of 33.5 years (23 to 48) and mean BMI of 41 kg/m(2) (35 to 46). Through a five-port approach, the stomach was reduced by dissecting the greater omentum and short gastric vessels, as in VSG, and the greater curvature was then invaginated using multiple rows of non-absorbable suture performed over a 32-Fr bougie to ensure a patent lumen. RESULTS: All procedures were completed laparoscopically. Mean operative time was 50 min (40 to 100 min) and mean hospital stay was 36 h (24 to 96). Patients returned to their regular activities at an average of 7 days (4 to 13) following surgery. No intra-operative complications occurred. All patients experienced excess weight loss (EWL) of at least 20% after 1 month. Mean EWL was 62% (45% to 77%) in nine patients after 18 months. There has been no record of weight regain in any patient to date. CONCLUSIONS: LGCP is feasible, safe, and effective for at least 18 months when performed on morbidly obese patients. Longer follow-up and prospective comparative trials are needed.