Assuntos
Cirurgia Bariátrica , COVID-19/epidemiologia , Tomada de Decisões , Acessibilidade aos Serviços de Saúde , Humanos , Controle de Infecções , Pandemias , Seleção de Pacientes , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , SARS-CoV-2 , Sociedades Médicas , Estados Unidos/epidemiologiaAssuntos
Técnicas de Fechamento de Ferimentos Abdominais , Colo/cirurgia , Derivação Gástrica/métodos , Jejuno/cirurgia , Laparoscopia/métodos , Mesentério/cirurgia , Anastomose Cirúrgica/métodos , Colo/anatomia & histologia , Humanos , Jejuno/anatomia & histologia , Mesentério/anatomia & histologiaRESUMO
Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.
RESUMO
Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.
Assuntos
Cirurgia Bariátrica/normas , Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Controle de Infecções/normas , Obesidade/cirurgia , Pandemias/prevenção & controle , Assistência Perioperatória/normas , Pneumonia Viral/prevenção & controle , Cirurgia Bariátrica/métodos , COVID-19 , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Procedimentos Clínicos/normas , Humanos , Controle de Infecções/métodos , Consentimento Livre e Esclarecido/normas , Obesidade/complicações , Seleção de Pacientes , Assistência Perioperatória/métodos , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , SARS-CoV-2RESUMO
INTRODUCTION: Malnutrition increases postoperative morbidity and mortality. The objective of this study was to evaluate preoperative refeeding in malnourished patients at risk of refeeding syndrome (RS). METHODOLOGY: A retrospective study, conducted between June 2016 and January 2017, reported to the CNIL, compared two groups of malnourished patients: a group of refeeding patients (RP) and a group of non-refeeding patients (NRP). The inclusion criteria were weight loss of more than 10% or albuminemia less than 35g/L and RS risk factor. The primary endpoint was postoperative morbidity. The secondary endpoints were weight change and serum albumin over 6 months. RESULTS: Seventy-three patients (30 RP and 43 NRP) were included. At the time of initial management, median weight loss was 18% [1-71], while albuminemia was 26g/L [13-40] in the RP group and 32.5g/L [32-48] in the NRP group (P=0.01). The overall postoperative morbidity rate was 88% (83% RP versus 90% NRP, P=0.47), and there was no significant difference between the 2 groups. The rate of anastomotic complications was 4% for RP versus 26% for NRP (P=0.03) after exclusion of liver surgery. Medium-term weight loss tended to be greater in RP (P=0.7). Nutritional support was continued until the third postoperative month in 13% of RPs vs. no NRPs (P=0.0002). CONCLUSION: After preoperative renutrition, we did not observe a decrease in morbidity but rather a decrease in the rate of anastomotic complications in favor of the RP group. This study underscores the middle-term importance of nutritional management in view of preserving the benefits of preoperative renutrition.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Desnutrição/terapia , Apoio Nutricional/métodos , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Desnutrição/complicações , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Síndrome da Realimentação/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoAssuntos
Derivação Gástrica , Hérnia Abdominal/diagnóstico , Obstrução Intestinal/diagnóstico , Intestino Delgado/irrigação sanguínea , Isquemia/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Hérnia Abdominal/etiologia , Humanos , Obstrução Intestinal/etiologia , Isquemia/etiologia , Complicações Pós-Operatórias/etiologiaRESUMO
BACKGROUND: Severe post-operative malnutrition (SM) is a dreaded complication after gastric bypass often related to the short bowel syndrome consecutive limb length mismeasurement or intestinal resections. Patients with rapid weight loss or malnutrition can experience liver failure with cirrhosis and require liver transplantation (LT). Malnutrition can constitute a contraindication to LT since it negatively impacts on postoperative morbidity. RYGB reversal is an effective option to consider when nutritional support has failed. We describe the performance of a RYGB reversal in a pre-LT setting. MATERIAL AND METHODS: A 36-year-old patient with morbid obesity (weight, 140 kg; BMI, 50.1 kg/m2) underwent a RYGB 9 years ago. She presented with 85 kg weight loss (i.e., 60.7% total body weight loss) associated with SM and hepatocellular insufficiency. LT was considered but contraindicated because of SM. An intensive nutritional support was attempted but failed and the RYGB reversal was recommended. RESULTS: Laparoscopic exploration revealed ascites, cirrhosis, and splenomegaly. The whole small bowel measurement revealed a short gut. Alimentary, biliary, and common channel limb lengths were 250 cm, 150 cm, and 30 cm long. The alimentary limb was stapled off the gastric pouch and the gastrojejunostomy was resected. After resection of the gastrojejunostomy, linear stappled gastro-gastrostomy and jéjuno-jejunostomy were performed to restore the normal anatomy. At 1 year, malnutrition was resolved and the cirrhosis was stabilized. CONCLUSION: Reversal to normal anatomy appeared effective and safe in this setting but must be considered only after failure of intensive medical management. Careful bowel measurement is mandatory to prevent patients from this complication.
Assuntos
Derivação Gástrica/efeitos adversos , Cirrose Hepática , Desnutrição , Complicações Pós-Operatórias , Adulto , Feminino , Humanos , Cirrose Hepática/etiologia , Cirrose Hepática/cirurgia , Desnutrição/etiologia , Desnutrição/cirurgia , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia , ReoperaçãoRESUMO
Sleeve gastrectomy (SG) is currently the most popular bariatric procedure. Portomesenteric venous thrombosis (PVT) is a feared and increasingly reported complication. Herein, we describe the history of a patient who developed a post-operative PVT after SG, aggravated with refractory ascites, and finally required orthotopic liver transplantation (LT). Acquired thrombophilia-anti-cardiolipin syndrome was present. As SG expands worldwide, this first case of LT for PVT following SG may warrant a systematic screening for prothrombotic condition and information on the possible consequences of PVT prior to bariatric surgery.