LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION.

BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

Laparoscopic redo fundoplication alone, redo nissen fundoplication, or toupet fundoplication combined with roux-en-y distal gastrectomy for treatment of failed nissen fundoplication / Refazer fundoplicatura laparoscópica, refazer fundoplicatura a nissen ou toupet combinada com gastrectomia distal em y-roux para tratamento de recidiva após fundoplicatura a nissen

ABSTRACT BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

RESUMO RACIONAL: A fundoplicatura de Nissen laparoscópica falha em controlar o refluxo gastroesofágico em quase 15% dos pacientes e a maioria deles deve ser reoperada devido aos sintomas. Diferentes técnicas cirúrgicas têm sido sugeridas. OBJETIVOS: Apresentar os resultados pós-operatórios de pacientes submetidos a 3 procedimentos diferentes: Reoperação e fundoplicatura de Nissen laparoscópica apenas (Grupo A), reoperação e fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal (Grupo B) ou reoperação e conversão para Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux (Grupo C). MÉTODOS: estudo prospectivo incluindo 77 pacientes submetidos inicialmente a fundoplicatura de Nissen laparoscópica que apresentaram recidiva do refluxo gastroesofágico após a operação. Eles foram avaliados antes e após a reoperação com questionário clínico e estudos funcionais específicos. Reestabelecida a anatomia da junção esôfago-gástrica, procedeu-se às referidas cirurgias. Nenhum paciente perdeu seguimento. RESULTADOS: Os sintomas persistentes foram observados com maior frequência nos pacientes dos Grupos A ou B, associados à estenose da fundoplicatura, fundoplicatura intratorácico ou fundoplicatura torcida. No Grupo C, os sintomas recorrentes associados a essa alteração anatômica foram observados com pouca frequência. Esfincter esofágico inferior incompetente foi confirmado em 57,7% dos pacientes pertencentes ao Grupo A em comparação com 17,2% após fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal, e 26% após a Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux. Nesse grupo, apesar do alto percentual de pacientes com esfincter esofágico inferior incompetente, 8,7% apresentaram refluxo ácido anormal após a cirurgia. CONCLUSÕES: As técnicas de Nissen ou Toupet combinados com a gastrectomia distal em Y de Roux são seguras e eficazes para o manejo da falha da fundoplicatura a Nissen. A técnica de Toupet é preferível para pacientes que sofrem principalmente com disfagia e dor.

Evaluation of atopy schools for parents.

INTRODUCTION: Atopic dermatitis is a highly prevalent chronic disorder. Therapeutic education in diseases of this kind is essential in order to improve patient management and prognosis. A study was conducted regarding parent satisfaction following educational sessions in an Atopy School organized by a multidisciplinary team. MATERIAL AND METHODS: E-mail surveys with variables scored by means of a Likert scale were administered among the parents participating in the workshops organized by the Atopy School. The educational program comprised four sessions with a duration of 4 hours. RESULTS: Ninety-five percent of the parents were satisfied after participating in the workshops, and were of the opinion that the therapeutic education received was useful for improving control of the illness of their children. Likewise, 85% were satisfied or very satisfied with the help received in the sessions for control of the disease during flare-ups, and 90% considered the data and advice received in the sessions to be of use in improving quality of life of both the children and the family as a whole. CONCLUSIONS: The Atopy School afforded caregiver empowerment, and the parents were satisfied and felt more secure in dealing with the disease of their children-thereby improving the prognosis and quality of life.

Clinical, Endoscopic, and Histologic Findings at the Distal Esophagus and Stomach Before and Late (10.5 Years) After Laparoscopic Sleeve Gastrectomy: Results of a Prospective Study with 93% Follow-Up.

OBJECTIVE: Perform a prospective study based on sequential clinical, endoscopic, and histologic evaluations of the foregut late after laparoscopic sleeve gastrectomy (LSG) in obese patients. After LSG, several studies have suggested an increase in the incidence of clinical gastroesophageal reflux (GERD) while others have reported an improvement but based mainly on clinical questionnaires. METHODS: Prospective study of 104 consecutive patients submitted to LSG. Several postoperative endoscopic and histologic evaluations of the esophagogastric junction (EGJ) and the gastric tube (GT) were performed and correlated with symptomatic findings. RESULTS: According to clinical preoperative findings, patients were divided into non-refluxers (Group I) and refluxers (Group II). Seven patients were unreachable, leaving 97 (93%) for late evaluation. Among Group I, 58.5% developed de novo GERD, while in Group II just 13.6% showed the disappearance of them. Endoscopic evaluations showed progressive deterioration of the EGJ in Group I, with the development of erosive esophagitis (EE), hiatal hernia (HH), and dilated cardia in a large proportion of them. In the GT, the presence of bile was seen in 40%, and an open immobile pylorus was detected in 82%. Short-segment Barrett's esophagus (BE) appeared in 4%. CONCLUSIONS: Patients submitted to LSG showed a significant and progressive increase in the presence of "de novo" GERD. Also, an increased duodenogastric reflux was seen through an open and immobile pylorus. Therefore, based on these results, it seems like LSG is a "pro-reflux" surgical procedure, which should be continuously evaluated late after surgery.

Loss and Regain of Weight After Laparoscopic Sleeve Gastrectomy According to Preoperative BMI : Late Results of a Prospective Study (78-138 months) with 93% of Follow-Up.

INTRODUCTION: The long-term results in sleeve gastrectomy (SG) have been reported in few publications. None of them has evaluated the importance of preoperative BMI (kg/m2) in the final results. OBJECTIVE: To determine the loss and regain of weight after SG, determining the influence of preoperative BMI in final results. MATERIAL AND METHODS: This prospective study included all patients operated between 2006 and 2010. Exclusion criteria corresponded to patients with Barrett's esophagus, type 2 diabetes, and hiatal hernia greater than 3 cm. Patients were followed and controlled "face to face" by the main author. RESULTS: From 109 original patients included in this study, 102 (93.5%) completed the late follow-up. Patients were divided into four groups: (a) I-29 patients with BMI 32.1-34.9; (b) II-56 patients with BMI 35-39.9; (c) III-20 patients with BMI 40-49.9; and (d) IV-4 patients with BMI > 50. There was a significant decrease in the BMI 12 to 24 months after surgery. At the late control, patients in groups III and IV regained weight in 85 and 100%, respectively. Patients in groups I and II had 3.6 and 38% of weight regain. CONCLUSION: The changes in weight after SG are directly related to preoperative BMI: the higher this value, the higher the percentage of failure and weight regain late after surgery. Besides, laparoscopic SG seems to be an adequate operation at late control in terms of loose of weight after surgery in patients with a BMI less than 40 kg/m2 before surgery.

Hallazgos clínicos e histopatológicos en pacientes con adenomiomatosis vesicular / Clinical and histopathological findings in patients with gallblader adenomyomatosis

Objetivo: El objetivo del estudio es describir la presentación clínica e histopatológica de la adenomiomatosis vesicular en una serie de pacientes colecistectomizados. Material y método: Entre el 1 de enero del 2010 y el 30 abril del 2015 se realizaron 6.957 colecistectomías, diagnosticándose adenomiomatosis en 95 de las vesículas extirpadas (1,4%). Se describen los hallazgos clínicos e histopatológicos en estos pacientes. Resultados: En 53 pacientes (55,8%) se presentó dolor abdominal. Alteraciones histológicas concomitantes se presentaron en la mucosa vesicular de 34 pacientes (35,8%), siendo la metaplasia pilórica la más frecuente (21%); y en 8 pacientes (8,4%) se presentó displasia de alto y bajo grado. Las patologías asociadas más frecuentes fueron colelitiasis 82,1% y colecistitis crónica 85,3%. Conclusiones: En la serie estudiada se observaron diversas alteraciones histológicas, incluyendo la displasia de alto grado. La colelitiasis se presentó con una frecuencia elevada.

Aim: The aim of the study was to describe the clinical and histopathologic presentation of adenomyomatosis (ADM) of the gallbladder in a series of patients. Material and method: Between January 1, 2010 to April 30, 2015, 6957 patients underwent cholecystectomy. Among them, ADM was diagnosed in 95 of cholecystectomy specimens (1.4%). Clinical and pathological findings in these patients are described. Results: In 53 patients (55.8%) presented abdominal pain. Concomitant histological changes occurred in the gallbladder mucosa of 34 patients (35.8%), being the most frequent pyloric metaplasia (21%); and in 8 patients (8.4%) high-grade dysplasia and low-grade dysplasia was presented. The most frequent associated pathologies were cholelithiasis in 82.1%, and chronic cholecystitis in 85.3%. Conclusions: In this serie, various histological changes were observed, including high-grade dysplasia. Cholelithiasis was presented with high frequency.

Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients.

Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure. The objective of this study is to describe a series of patients who were subjected to LSG and then developed gastric stenosis, with an emphasis on their treatment and a discussion of the possible underlying mechanisms. From January 2006 to October 2012, 717 patients with morbid obesity underwent LSG in our institution. Out of 717 patients, 571 (79.6 %) were women. The mean age was 36.9 years with a BMI of 37.3 kg/m(2). Five patients (0.69 %) developed gastric stenosis. Treatment of the stenosis was endoscopic dilatations; however, one patient required a conversion to laparoscopic Roux-en-Y gastric bypass. Stenosis after LSG is rare but requires early diagnosis and treatment.

Estudos endoscópico e histológico prospectivos e sequenciais da bolsa gástrica em 130 pacientes obesos mórbidos submetidos à bypass gástrico em Y-de-Roux / Prospective sequential endoscopic and histologic studies of the gastric pouch in 130 morbidly obese patients submitted to Roux-en-Y gastric bypass

RACIONAL: Bypass gástrico em Y-de-Roux é a operação bariátrica mais comumente realizada. Pequena bolsa gástrica é criada, deixando uma anastomose gastrojejunal estreita, com uma alça jejunal mais comprida. Muito pouco é conhecido sobre o comportamento desta bolsa em anos após o procedimento. OBJETIVO: Determinar através de estudos prospectivos endoscópico e histológico seqüenciais o tamanho da bolsa gástrica, o diâmetro da anastomose e o comportamento da infecção por H. pylori após a operação. MÉTODOS: Em 130 pacientes submetidos ao bypass gástrico foram realizadas várias avaliações sequenciais endoscópica (até 120 meses) e histológica de rotina da bolsa gástrica. RESULTADOS: Após a operação, foram realizadas em média 3,6 endoscopias por paciente. Macroscopicamente quase 95% das pequenas bolsas gástricas eram normais, e o principal achado patológico foi uma úlcera marginal. Esofagite erosiva desapareceu em 93% dos pacientes. Não houve aumento no tamanho orocaudal da bolsa durante o período de observação. Não houve dilatação do diâmetro da anastomose gastrojejunal. Perto de 54% de todos os pacientes tinham mucosa fúndica normal, enquanto 18% tinham gastrite crônica ativa, coincidente com a infecção por H. pylori. Cinco pacientes tinham metaplasia intestinal. CONCLUSÃO: Com base nesta avaliação endoscópica sequencial, não houve aumento no tamanho orocaudal da bolsa gástrica, nem do diâmetro da anastomose gastrojejunal. O comportamento do H. pylori foi inconsistente e difícil de interpretar.

BACKGROUND: Roux-en-Y gastric bypass is the most common performed bariatric surgery. A small gastric pouch is created, leaving a narrow gastrojejunal anastomosis, with a long jejunal limb. Very little is known regarding the behavior of this pouch years after surgery. AIM: To determine through prospective sequential endoscopic studies the size of the gastric pouch, the diameter of the anastomosis, and the behavior of H. pylori infection after surgery. METHODS: In 130 patients subjected to resectional gastric bypass, several routine sequential endoscopic (until 120 months) and histological evaluations of the gastric pouch were performed. RESULTS: After surgery, a mean of 3.6 endoscopies/patient were performed. Macroscopically nearly 95% of the small gastric pouches were normal, and the main pathological finding was a marginal ulcer. Erosive esophagitis disappeared in 93% of the patients. There was no increase in the orocaudal size of the pouch during this period of observation. There was no dilatation of the diameter of gastrojejunal anastomosis. Near 54% of all patients had normal fundic mucosa, while 18% had chronic active gastritis, coincident with H. pylori infection. Five patients had intestinal metaplasia. CONCLUSION: Based on this sequential endoscopic evaluation, there was no increase in the orocaudal size of the gastric pouch nor increase in the diameter of the gastrojejunal anastomosis. H. pylori behavior was inconsistent and difficult to interpret.

Classification and management of leaks after gastric bypass for patients with morbid obesity: a prospective study of 60 patients.

The most important and frequent major complication after gastric bypass is the appearance of a leak, which can result in death of a patient. The purpose of this prospective study was to determine the incidence of a postoperative leak, to propose a classification and to evaluate the results of conservative or surgical treatment. All patients submitted to gastric bypass either laparotomic or laparoscopic were included in a prospective protocol. In all radiological evaluation at 4(th) day after surgery was performed. The presence of a leak was evaluated according to the day of appearance, its location and its severity. Results of medical or surgical treatment were analyzed. From 1764 patients submitted to Roux-en-Y gastric bypass, 60 had a postoperative leak (3.4%). This leak appeared early after surgery (before 4 days) in 20%. It was a localized subclinical leak in 20% and clinical - septic in 80%. There were 7 possible anatomic location of a leak, being the gastrojejunal anastomosis the most frequent location (53%) followed by gastric pouch. The highest mortality was associated to the jejuno-jejunal anastomosis. Conservative treatment was employed in near 65% of the patients: The mean time of closure of a leak was 34 days. The appearance of a postoperative leak is a major and serious complication. It can be classified according to the day of appearance, its severity and its location. Conservative or surgical treatment can be employed properly if these 3 parameters are carefully evaluated.

Prospective sequential endoscopic and histologic studies of the gastric pouch in 130 morbidly obese patients submitted to Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass is the most common performed bariatric surgery. A small gastric pouch is created, leaving a narrow gastrojejunal anastomosis, with a long jejunal limb. Very little is known regarding the behavior of this pouch years after surgery. AIM: To determine through prospective sequential endoscopic studies the size of the gastric pouch, the diameter of the anastomosis, and the behavior of H. pylori infection after surgery. METHODS: In 130 patients subjected to resectional gastric bypass, several routine sequential endoscopic (until 120 months) and histological evaluations of the gastric pouch were performed. RESULTS: After surgery, a mean of 3.6 endoscopies/patient were performed. Macroscopically nearly 95% of the small gastric pouches were normal, and the main pathological finding was a marginal ulcer. Erosive esophagitis disappeared in 93% of the patients. There was no increase in the orocaudal size of the pouch during this period of observation. There was no dilatation of the diameter of gastrojejunal anastomosis. Near 54% of all patients had normal fundic mucosa, while 18% had chronic active gastritis, coincident with H. pylori infection. Five patients had intestinal metaplasia. CONCLUSION: Based on this sequential endoscopic evaluation, there was no increase in the orocaudal size of the gastric pouch nor increase in the diameter of the gastrojejunal anastomosis. H. pylori behavior was inconsistent and difficult to interpret.

Late marginal ulcers after gastric bypass for morbid obesity. Clinical and endoscopic findings and response to treatment.

Marginal ulcer (MU) is an occasional complication after gastric bypass which can occur early or late after surgery. In this study, we evaluated the incidence, clinical presentation, and endoscopic behavior of patients with late MU. Five hundred fifty morbidly obese patients were evaluated prospectively performing an endoscopic study 1-8 years after surgery. They were submitted either to laparotomic (n = 392) or laparoscopic (n = 158) approach. Six patients (1%) presented late MU 12 to 84 months after surgery. Four patients had single ulcer, while two patients had multiple ulcers. All were treated with proton pump inhibitors (PPIs). Several endoscopic evaluations were performed in each patient showing healing and no recurrence of the ulcer. Late MU occurs in a small proportion (1%) of patients submitted to gastric bypass. It can be single or multiple. Medical treatment with PPIs achieves healing at a mean time of 7 months. Several endoscopic evaluations should be performed in these patients in order to demonstrate healing of the ulcer and no recurrence.

Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is a surgical procedure that is being increasingly performed on obese patients. The most frequent postoperative complication is the appearance of a gastric leak. PURPOSE: To determine the main clinical features of a group of patients who developed a gastric leak after LSG. MATERIAL: A total of 343 obese patients were submitted to LSG, two hundred and sixty-two women and 81 men with a mean age of 37.3 years and a BMI of 37.5 kg/m(2). Radiological evaluations were performed on all patients on the third day after surgery using liquid sulfate barium, as well as a close clinical control evaluation to monitor the appearance of epigastric pain, fever, tachycardia, C-reactive protein, and leukocytosis. Medical or surgical management of the leak were employed. RESULTS: Fever was the earliest and most frequent symptom, followed by epigastric pain and tachycardia. Leaks were classified based on three parameters: severity or magnitude, location, and time of appearance after surgery. Leaks were classified as early if they appeared 1 to 4 days after surgery, intermediate if they appeared 5 to 9 days after surgery, and late 10 days after surgery. The diagnosis of a leak was confirmed with a barium liquid taken orally by six patients and with an abdominal CAT scan in ten. Surgical management was performed in eight patients, usually in those with early leaks (six patients). Early re-suturing in three patients was successful; however, re-suturing leaks after the third day resulted in failure. Medical management was performed mainly in patients with intermediate and late leaks, mainly through enteral nutrition and percutaneous drainage of the intra-abdominal fluid collection. There was no mortality. The mean healing days of these leaks was 45 days after surgery. CONCLUSION: Close clinical observation detects gastric leaks early on inpatients who underwent LSG. We suggest evaluating these leaks based on three parameters: time of appearance, the location, and its severity, in order to propose the best medical or surgical treatment in these patients.

Late results of the surgical treatment of 125 patients with short-segment Barrett esophagus.

HYPOTHESIS: The results of surgical treatment of patients with long-segment Barrett esophagus (BE) have been extensively reported. However, few publications refer to the results of surgery 5 years after the fact among patients with short-segment BE. This study aimed to determine the late results of 3 surgical procedures in patients with short-segment BE by subjective and objective measurements. DESIGN: Prospective, nonrandomized study starting on March 1, 1987, and ending on December 31, 2005. SETTING: A prospective, descriptive study of a group of patients. PATIENTS: A total of 125 patients with short-segment BE underwent 3 operations in different periods: duodenal switch plus highly selective vagotomy and antireflux technique in 31 patients, vagotomy plus partial gastrectomy and Roux-en-Y loop with antireflux surgery in 58 patients, and laparoscopic Nissen fundoplication in 36 patients. MAIN OUTCOME MEASURES: Late subjective and objective outcomes of the 3 different surgical procedures. RESULTS: No operative mortality and only 2 postoperative complications (1.6%) occurred. The regression from intestinal metaplasia to cardiac or oxyntocardiac mucosa occurred in 60.8% to 65.4% of the patients, at a mean time of 39 to 56 months after surgery. Visick grading showed Visick grade I or II in 86.3% to 100.0% of the patients. No progression to low- or high-grade dysplasia or adenocarcinoma occurred. CONCLUSIONS: On the basis of these results, laparoscopic Nissen fundoplication seems to be the surgical option for patients with short-segment BE because it is less invasive, has fewer side effects, and produces good results in the long-term follow-up.

[Review of the results of medical and surgical treatment of morbid obesity]. / Comparación del tratamiento médico y quirúrgico en pacientes con obesidad grado III (obesidad mórbida).

This is a review of publications comparing the results of medical and surgical treatment of morbid obesity. An overall conclusions is that the frequency of cardiovascular complications or cancer is higher among patients receiving medical treatment. Surgical treatment is associated with a better weight loss, reduction in complications and quality of life. Mortality risk decreases significantly after surgical treatment, when compared with patients receiving medical therapy Therefore, management of morbid obesity should be carried out by multidisciplinary teams with experience on gastrointestinal surgery. In this way the complications and mortality of bariatric surgery would be minimized.

Gastric leak after laparoscopic-sleeve gastrectomy for obesity.

BACKGROUND: One of the most serious complications after laparoscopic sleeve gastrectomy (LSG) is gastric leak. Few publications exist concerning the treatment of gastric leak. We sought to determine by way of a prospective study the clinical presentation, postoperative course, and treatment of gastric leak after LSG for obesity. METHODS: From October 2005 to August 2008, 214 patients with different degrees of obesity underwent LSG. During surgery, each patient received saline with methylene blue by way of nasogastric tube and had a drain placed. All patients underwent radiologic study with liquid barium sulphate on postoperative day 3. RESULTS: Seven patients developed gastric leak. Leak in two patients (28.6%) was diagnosed by upper gastrointestinal tract (UGI) study. Two patients had type I leak (28.6%), and five patients had type II leak (71.4%). Four patients underwent reoperation. Three patients were managed medically with enteral or parenteral feeding; the drain was maintained in situ; and collections were drained by percutaneous punctions guided by computed axial tomography. Mean hospital length of stay was 28.8 days, and time to leakage closure was 43 days after surgery. CONCLUSION: Different ways exist to manage gastric leak, depending on the magnitude of the collection and the clinical repercussions. When treatment necessitates reintervention and is performed early, suture repair is more likely to be successful. Leakage closure time will vary.

Latest results (12-21 years) of a prospective randomized study comparing Billroth II and Roux-en-Y anastomosis after a partial gastrectomy plus vagotomy in patients with duodenal ulcers.

INTRODUCTION: After a partial resection of the stomach, the continuity of the gastrointestinal tract can be restored either by a Billroth II gastrojejunal anastomosis or a Roux-en-Y gastrojejunostomy. Each procedure has its advantages and disadvantages. OBJECTIVE: To determine through a prospective and random clinical trial, the clinical outcome and the endoscopic and histologic alterations of the distal esophagus and the gastric remnant in patients who received a partial distal gastrectomy due to duodenal ulcers and a Billroth II or Roux-en-Y reconstruction. MATERIAL AND METHODS: In this prospective random trial, a total of 75 patients with duodenal ulcers were included. A bilateral selective vagotomy and partial distal gastrectomy were performed in all patients. A Billroth II or Roux-en-Y 60-cm-long loop was randomly used for reconstruction of the gastrointestinal tract. During the latest follow-up clinical evaluation, upper endoscopy and biopsy samples from the distal esophagus and gastric remnant were obtained. RESULTS: There was 1 operative mortality and 6 patients had some morbidity. The average follow-up period was 15.5 years (range, 11-21). Patients with Roux-en-Y gastrojejunostomy were significantly more asymptomatic and had greater Visick I grading than patients with Billroth II reconstruction (P < 0.001). In the distal esophagus, endoscopic findings were normal in 90% of the Roux-en-Y group, but only in 51% of the Billroth II group (P < 0.0009). Nearly 25% of the latter group had the appearance of a short-segment Barrett esophagus compared with 3% of the Roux-en-Y group (P < 0.0001). The gastric remnant endoscopic findings were normal in 100% of the Roux-en-Y group and in 18% of the Billroth II group (P < 0.02). Histologic analyses showed similar proportions of normal fundic mucosa and chronic active fundic gastritis. However, chronic atrophic fundic gastritis and intestinal metaplasia were significantly more frequent after Billroth II reconstruction (P < 0.008). Helicobacter pylorus was present in a similar proportion of patients. CONCLUSIONS: This prospective and random study showed that Roux-en-Y gastrojejunostomy is significantly better than a Billroth II reconstruction in patients with duodenal ulcers, through subjective and objective endoscopic and histologic evaluations during the latest follow-up evaluation.

Inflammatory response measured by body temperature, C-reactive protein and white blood cell count 1, 3, and 5 days after laparotomic or laparoscopic gastric bypass surgery.

BACKGROUND: Morbid obesity is a chronic inflammatory condition due to the production of several cytokines from the adipose tissue. However, what happens with some of these parameters the first days after surgery is unknown. Therefore, the objective of the present study was to determine, through a prospective and descriptive study, the behavior of the C-reactive protein (CRP), the white blood cell count, and the body temperature prior to a gastric bypass and for 5 days afterwards. METHODS: A total of 156 patients with morbid obesity were included in this prospective study. There were 120 women and 36 men, with a mean age of 41 years and a body mass index of 43 kg/m(2). They were submitted either to a laparotomic resectional gastric bypass or to a laparoscopic gastric bypass. Body temperature was measured every 8 h during 5 days. CPR and white blood cells were measured at the first, third, and fifth day after surgery. RESULTS: All patients had a normal postoperative course. Body temperature showed no change. White blood cells increased significantly at the first and third day after surgery but normalized by the fifth day. However, the third day after surgery, laparotomic gastric bypass patients showed a significantly greater increase in the total white blood cell count as well as in segmented neutrophil cells compared to laparoscopic surgery patients. CRP exhibited a similar increase and was more pronounced after a laparotomic approach. CONCLUSION: During the 5 days after gastric bypass, a significant increase in white blood cells and CRP was observed. The increase was significantly greater after a laparotomic bypass compared to the laparoscopic approach.

Incidence of anastomotic strictures after gastric bypass: a prospective consecutive routine endoscopic study 1 month and 17 months after surgery in 441 patients with morbid obesity.

BACKGROUND: Anastomotic stricture after gastric bypass for morbid obesity has been reported as the most frequent complication after surgery. The objective of this study is to determine in a prospective and consecutive endoscopic evaluation the true incidence of this complication early and late after gastric bypass. METHODS: A total of 441 morbidly obese patients were included in this prospective study. They were 358 women and 97 men, with a mean age of 41 years and a mean body mass index of 43 kg/m2. In all an endoscopic evaluation was performed 1 month after surgery, which was repeated in 315 patients (71.6%) 17 months after surgery, independent of the presence or not of symptoms. Anastomotic diameter was measured and strictures were classified as: (a) mild, with a diameter of 7 to 9 mm, (b) moderate with a diameter of 5 to 6 mm, and (c) difficult or critical with a diameter equal or less to 4 mm. Two methods of dilatation were employed: the endoscope itself or Savary-Gilliard dilators. Patients were submitted to laparotomic resectional gastric bypass in whom a circular stapler 25 was employed for gastrojejunal anastomosis or to laparoscopic gastric bypass, in whom hand-sewn one layer continuous suture was employed. RESULTS: One month after surgery, 23% of patients after open gastric bypass employing circular stapler 25 presented anastomotic stricture, being 22% of them critical. After laparoscopic gastric bypass employing hand-sewn anastomosis, 36% of the patients presented strictures, being critical 10% (p>0.17). Patients with mild or moderate strictures needed one or two dilatations. Patients with critical strictures needed three to five dilatations. There were no complications associated to dilatation. Moderate and severe strictures were symptomatic; however 29% of patients with mild strictures were asymptomatic. Endoscopy was repeated in 71% of the whole group 17 months after surgery, demonstrating normal anastomosis in all. CONCLUSIONS: Stricture at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Near 60% present a mild stricture (with a diameter between 7 and 9 mm), being 28% asymptomatic. This complication is easily treated by endoscopic procedure if it is diagnosed early (3 to 4 weeks) after surgery. Routine endoscopy 1 month after surgery is the only objective scientific way to determine the real true incidence of this complication.

Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity.

BACKGROUND: Marginal ulcer (MU) is an occasional complication after gastric bypass. We studied the incidence of this complication by a prospective routine endoscopic evaluation. METHODS: 441 morbidly obese patients were studied prospectively. There were 358 women and 97 men, with mean age 41 years and mean BMI 43 kg/m(2). An endoscopic evaluation was performed in all 1 month after surgery, which was repeated in 315 patients (71%) 17 months after surgery, independent of the presence or absence of symptoms. Patients were submitted either to laparotomic resectional gastric bypass (360 patients), employing a circularstapler-25 or to laparoscopic gastric bypass (81 patients), in whom a hand-sewn anastomosis was performed. RESULTS: One month after surgery, 15 patients (4.1%) of the 360 laparotomic gastric bypass and 10 (12.3%) of the 81 laparoscopic gastric bypass presented an "early" marginal ulcer (p < 0.02). Seven patients among the 25 with MU were asymptomatic (28%). Endoscopy was repeated 17 months after surgery. Among 290 patients with no early MU, one patient (0.3%) presented a "late" MU 13 months after surgery. From the 25 patients with "early" MU, one patient (4%) presented a "late" MU. All these patients were treated with PPIs. CONCLUSION: By performing prospective routine endoscopic study 1 month and 17 months after gastric bypass, two different behaviors were seen regarding the appearance MU: (a) "early" MU, 1 month after surgery in mean 6% and (b) "late" MU, in a very small proportion of patients (0.6%). Among patients with "early" MU, those who had undergone resectional gastric bypass showed significantly less ulcers compared to those patients in whom the excluded distal gastric segment had been left in situ. The operative method may play a significant role in the pathogenesis of MU after gastric bypass.