Incidence of Abnormalities of the Gastric Tube Following Sleeve Gastrectomy and Its Role on Esophagitis Progression.

PURPOSE: The purpose of this study is to determine the incidence of gastric tube abnormalities after SG and its relationship with esophagitis progression. METHODS: Retrospective study which included 459 patients in the postoperative period of SG who underwent an esophagogastroduodenoscopy in both pre- and postoperative periods. The main studied variables were presence of gastric tube abnormalities (dilation, neofundus, twist, and hiatal hernia) and esophagitis progression. RESULTS: Among the 459 patients who underwent SG, 393 (85.6%) were women, and 66 (14.4%) men, with mean age of 40.4 years. Mean preoperative BMI was 39.70 kg/m2. In total, 20.3% of the sample presented progression of esophagitis after surgery. Among the whole sample, 130 (28.3%) presented with an abnormality of the remnant gastric tube. The most common alteration was gastric dilation, which occurred in 16.1% of the patients, followed by gastric twist (10.7%), neofundus (7.4%), and hiatal hernia (0.2%). Patients who presented with any abnormality of the gastric tube were significantly prone to presenting esophagitis progression (p = 0.013). When analyzing each morphological abnormality isolated, there was no statistically significant correlation. CONCLUSION: Abnormalities of the gastric tube are not uncommon after SG and seems to contribute partially to the relevant rates of GERD and esophagitis after this surgery.

GASTRIC TWIST AFTER SLEEVE GASTRECTOMY: A PROPOSAL FOR ENDOSCOPIC CLASSIFICATION.

OBJECTIVE: The twisting of the gastric tube is one of the main causes of persistent reflux and food intolerance after sleeve gastrectomy (SG). To date, there is no classification for gastric twist after SG. This study aimed to propose an endoscopic classification for this condition and outline the clinical profile of these patients with sleeve gastrectomy. METHODS: Patients in the postoperative period of SG presenting endoscopic findings of gastric twist were included. All patients underwent an esophagogastroduodenoscopy 12 months after SG. The classification proposed consists of three degrees: degree I: mild rotation of the staple line without relevant shrinkage of the gastric lumen; degree II: moderate rotation of the staple line, leading to a focal area of fixed narrowing that requires additional maneuvers for its transposition; and degree III: severe rotation of the staple line leading to stenosis, with increased difficulty for transposition or complete blockage. RESULTS: Out of 2,723 patients who underwent SG, 45 (1.6%) presented gastric twist. Most patients were female (85%), with mean age of 39±10.4 years. In all, 41 (91.1%) presented degree I, 3 (6.7%) presented degree II, and 1 (2.2%) had degree III. Most patients were asymptomatic (n=26). Vomiting was the most prevalent symptom (15.5%). Statistically significant correlation of twisting degrees was not observed for both the presence of symptoms and the degrees of esophagitis. CONCLUSION: Gastric twist after SG is rare, with generally mild and asymptomatic presentation. The endoscopic classification was not statistically related to clinical presentation but set the ground for further analysis.

THE ROUTINE USE OF THE METHYLENE BLUE TEST IN SLEEVE GASTRECTOMY: WHY NOT?

BACKGROUND: Although considered a safe procedure, sleeve gastrectomy (SG) has a non-negligible risk of major postoperative complications related to it, with special attention to gastric leaks. AIM: Evaluate the clinical value of the methylene blue test (MBT) in predicting the occurrence of post-SG leaks. METHODS: Retrospective study that included 1136 patients who underwent SG with intraoperative MBT between 2012 and 2016. Sensitivity, specificity, positive predictive value (PPV) and negative predicted value (NPV) were calculated to determine the clinical correlation between the MBT and the occurrence of postoperative leaks. Staple line oversewing was performed in all patients who presented positive MBT. RESULTS: Laparoscopic SG was performed in 97.0% of cases; open in 2.3%, and robotic in 0.7%. MBT was positive in 19 cases (1.67%). One positive MBT occurred during an open SG and the other 18 at laparoscopy. Moreover, there were nine cases (0.8%) of postoperative leaks, among which, only two presented positive MBT. MBT diagnostic value was evaluated through the calculation of sensitivity (22.0%), specificity (98.0%), PPV (11.0%) and NPV (99.0%). There were no cases of allergic reaction or any other side effect with the use of the methylene blue solution. CONCLUSION: MBT showed high specificity and negative predictive value, thus presenting an important value to rule out the occurrence of postoperative leaks.

Is COVID-19 Severity Impacted by Bariatric Surgery in the Early Postoperative Period?

PURPOSE: The aim of this study was to determine the real influence of bariatric surgery on the clinical evolution of patients infected with SARS-Cov-2 in the postoperative period. METHODS: We conducted a retrospective analysis including two groups of patients: those who presented COVID-19 before bariatric surgery and those who presented it within 3 months of postoperative. Primary outcome was related to the severity of COVID-19, measured by the following variables: presence of symptoms, need for hospitalization, ICU admission, and invasive ventilation. Laboratory markers for inflammatory response, glycemic status, and micronutrients were analyzed as secondary outcomes. RESULTS: From the 222 individuals operated on within the study period, only 66 (29.7%) presented COVID-19, 42 (18.9%) in the preoperative period and 24 (10.8%) after the procedure. Mean age was 36.3 ± 9.5 years and mean preoperative BMI was 39.9 ± 4.2 kg/m2. There were no statistically significant differences between the groups regarding symptoms presentation (92.9% × 87.5%, p = 0.66), need for hospitalization (11.9% × 16.7%, p = 0.713), ICU admission (4.8% × 4.2%, p = 1.000), and invasive ventilation (2.4% × 0.0%, p = 1.000). Regarding the quantitative variables, absolute lymphocyte count was significantly lower in the group who presented COVID-19 after surgery (1822.9 ± 482.2 × 2158.6 ± 552.9, p = 0.035). CONCLUSION: Patients who had COVID-19 before and after sleeve gastrectomy did not differ with statistical significance for the presence of symptoms, need for hospitalization, ICU admission, and invasive ventilation.

Impact of bariatric surgery in elderly patients with obesity.

INTRODUCTION: to evaluate the long-term impact of bariatric surgery in the elderly population. METHODS: a retrospective study including all patients older than 60 years who underwent Roux-en-Y gastric bypass (RYGB) at our center and maintained a follow-up longer than 1 year. Clinical and laboratory variables were studied to assess remission of obesity and its comorbidities, as well as variables directly related to the surgical procedure itself, including early and late complications. RESULTS: fifty-six patients were studied, mostly female (76,8%), with a mean age of 64.02 ± 3.34. A rate of complications of 37,5% was observed, with 10,7% requiring hospital admission and emergency surgery. The mean excess weight loss (%EWL) was 74.22% ± 26.76. The remission rates of hypertension and diabetes mellitus were 26.08% and 54.54%, respectively. There was significant difference in BMI reduction (12.25 ± 5.42, p<0.001), total cholesterol (31.37 ± 38.89 p<0,001), LDL cholesterol (23.45 ± 34.9, p=0.002), HDL cholesterol (5.14 ± 11.13, p=0,024), triglycerides (48.85 ± 56.15 p<0.001), HbA1C (1,81 ± 1,97, p<0,001) e PCR (1.43 ± 1.96, p<0.001). CONCLUSION: bariatric surgery was effective in weight loss and remission of comorbidities in the elderly obese population within the long term.

Assessment of the clinical and laboratorial profile of patients with obesity and asymptomatic COVID-19 undergoing bariatric surgery in Brazil.

PURPOSE: to outline the clinical and laboratorial profile of patients with obesity undergoing bariatric surgery who presented positive reverse transcription-polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus-2 (Sars-CoV-2) in the preoperative period without symptoms presentation. METHODS: Case series of 17 patients undergoing bariatric surgery who presented positive RT-PCR for Sars-CoV-2 in the preoperative period, with no reported symptoms. Data collected included demographic characteristics, length of hospital stay, waiting time for surgery, inflammatory markers, serum levels of micronutrients and dengue virus (DENV) serology. RESULTS: In total, 219 patients underwent bariatric surgery in our institution during the study period. The incidence of asymptomatic cases was 7.7%. The sample comprised 88.2% of women, with mean age of 39.3 years and mean preoperative body mass index (BMI) of 37.7 kg/m2. Thirty five percent of the sample had previous diagnosis of diabetes and 29.4% had hypertension. The mean time elapsed between positive RT-PCR and the operation was 17 ± 7.5 days and the mean length of postoperative hospital stay was 1.9 ± 0.43 day. Mean lymphocytes count was 2,409.7/mm3 and the mean platelet-to-lymphocyte ratio was 126.3. Mean C-reactive protein value was 5.8 mg/dL, while ferritin marked 107.4 µg/L. DENV IgG was identified in all patients who tested for it. Mean levels of vitamin D and zinc were 25.6 ng/mL and 79.9 µg/dL, respectively. There were no postoperative complications reported. CONCLUSION: None of the included patients presented any of the laboratory markers related to disease severity. Moreover, it is important to notice that all patients who tested for DENV, had the specific IgG detected in their serum.

Gastric Fistula After Sleeve Gastrectomy: Clinical Features and Treatment Options.

PURPOSE: To trace the clinical profile of fistula cases after sleeve gastrectomy (SG) and evaluate the efficacy and safety of endoscopic treatments and the admission costs of these patients. METHODS: This is a retrospective study of patients who developed gastric fistulas after SG. All patients were submitted to surgical and/or endoscopic interventions (self-expandable stent, septotomy, and balloon dilation). The main studied variables were need for reoperation, number of endoscopic procedures, endoscopic complications, time until fistula diagnosis, fistula location, time until resolution, length of hospital stay, and health costs. RESULTS: The sample was mainly female (76.2%) with a mean age of 39.5 years and a BMI of 39.6 kg/m2. In 90.5% of cases, the fistula occurred in the topography of the His angle. Thirteen patients required surgical intervention. Of the patients who underwent endoscopic interventions, it was necessary to place more than one self-expandable stent of a maximum duration of 4 weeks. Six patients underwent more than two sessions of septotomy. There was one case of bleeding after septotomy. Dilatation was required in 71.4% of patients and an average of two sessions (1-5) per patient. The diagnosis of fistula occurred 14.4 days after surgery. The average time to resolve fistulas was 50.6 days. The average hospital stay was 75.8 days. The total cost of hospitalization was on average US$ 75,180.00. CONCLUSION: The surgical and endoscopic treatment of gastric fistulas after SG was safe and effective. There was a very low rate of complications. The time of onset of fistulas was not decisive for patient improvement.

The Impact of the Gastric Twist on Esophagitis Progression After Sleeve Gastrectomy: Mid-Term Endoscopic Findings.

PURPOSE: To determine the real influence of the gastric twist on the progression of esophagitis after SG, evaluating pre- and late post-operative endoscopic findings. MATERIAL AND METHODS: We retrospectively included 459 patients submitted to SG between 2009 and 2019. The sample comprised patients who performed esophagogastroduodenoscopy (EGD) at the pre-operative and late post-operative periods. RESULTS: Patients were mainly female (85.6%), with a mean age of 40.4 years. Mean follow-up time was 20.8 months. In the pre-operative period, 1.1% of patients had non-erosive esophagitis, 24.2% of patients had grade A erosive esophagitis, and 1.5% of patients had grade B. In the post-operative evaluation, 3.3% had non-erosive esophagitis, 14.8% presented grade A erosive esophagitis, 8.9% had grade B, and 1.3% had grade C esophagitis. There were no cases of Barrett's esophagus. Forty-nine patients (10.7%) presented gastric twist. Comparing patients with and without gastric twist, it was possible to observe that the gastric twist group presented a higher incidence of grade C esophagitis (4.0% × 1.0%), p = 0.017. The correlation between the occurrence of gastric twist and esophagitis progression showed a prevalence ratio of 1.36 (95% CI 0.82-2.25). CONCLUSIONS: SG is responsible for an increase in the prevalence of erosive esophagitis, and the occurrence of gastric twist definitely plays a role on it, expressing a risk of 36% for esophagitis progression and being related to a higher incidence of severe esophagitis.

Metabonomic model for the assessment of type 2 diabetes remission after bariatric/metabolic surgery. / Modelo metabonômico para avaliação da regressão do diabetes mellitus tipo 2 após cirurgia bariátrica.

OBJETIVO: To evaluate the differences in the metabonomic profile of patients who achieved remisison of Type 2 diabetes mellitus (T2DM) after bariatric surgery in relation to those who presented maintenance or recurrence of this condition after surgery. METHODS: Thirthy-three patients with obesity and T2D were submitted to bariatric/metabolic surgery, among which, 22 experienced complete remission of T2D, and 11 did not experience remission in the postoperative period. Blood samples were taken in order to assess the serum profiles through a 1H NMR-based metabonomic study. RESULTS: The metabonomic model for the assessment of T2D recurrence presented an accuracy of 93.9%, sensibility of 81.8%, specificity of 100%, positive predictive value of 100% and a negative predictive value of 91.7%. CONCLUSION: bariatric surgery provide specific effects on the distribution of metabolites in those patients who achieved remission of T2DM, and this new distribution can be assessed through a metabonomic model.

OBJETIVO: avaliar as diferenças no perfil metabonômico de pacientes que atingiram remissão de diabetes mellitus tipo 2 (DM2) após cirurgia bariátrica em relação aos que apresentaram manutenção ou recidiva dessa condição após a cirurgia. MÉTODOS: Participaram do estudo 33 pacientes obesos diabéticos tipo 2, dos quais 22 tiveram remissão completa da DM2 e 11 tiveram recidiva da DM2 ou não apresentaram remissão da doença no pós-operatório. Amostras de sangue foram coletadas para avaliação dos perfis metabonômicos séricos através de um estudo metabonômico baseado em RMN de 1H. RESULTADOS: o modelo metabonômico para avaliação da recidiva da diabetes apresentou uma acurácia de 93,9%, sensibilidade de 81,8%, especificidade de 100%, valor preditivo positivo (VPP) igual a 100% e valor preditivo negativo (VPN) igual a 91,7%. CONCLUSÃO: a cirurgia bariátrica promove efeitos específicos na distribuição dos metabólitos de pacientes que atingiram remissão de DM2, e essa nova distribuição pode ser avaliada através de um modelo metabonômico.

Roux-en-Y gastric bypass for nonobese patients with uncontrolled type 2 diabetes: a long-term evaluation.

BACKGROUND: There is growing evidence that the impact of Roux-en-Y gastric bypass (RYGB) on type 2 diabetes (T2D) occurs regardless of the amount of weight loss. Taking this background into consideration, it is plausible to study this procedure in individuals with lower body mass index (BMI) under clinical treatment failure for uncontrolled T2D. OBJECTIVES: To elucidate the long-term impact of RYGB on T2D regression in a non-obese population. SETTING: Hospital das Clínicas, Federal University of Pernambuco, Brazil. METHODS: Twelve patients with BMI 25 to 30 kg/m2 and inadequately controlled T2D underwent RYGB and were followed up for 6 years. Fasting plasma glucose, glycated hemoglobin, BMI, and the use of insulin and/or oral hypoglycemic agents were assessed. Each variable was analyzed in 3 distinct moments: preoperative evaluation, 2-year postoperative follow-up (2-PO), and 6-year postoperative follow-up (6-PO). RESULTS: There were no cases of early or late mortality. Mean BMI at preoperative evaluation, 2-PO, and 6-PO were 28.1 ± 1.2; 23.2 ± 2.4; and 24.7 ± 3.1, respectively. The lowest BMI at 6-PO was 19.1 kg/m2. Complete remission of T2D was achieved in 16.7%, partial remission in another 16.7%, glycemic control in 25%, and glycemic improvement in 25% of the sample at 6-PO; 16.7% did not present positive glycemic outcomes. Only 1 patient needed to resume insulin administration between 2-PO and 6-PO. CONCLUSIONS: RYGB was found to be safe and effective in treating uncontrolled T2D in non-obese patients, providing improvements in the glycemic patterns in 83.4% of our sample.

Micronutrient deficiencies following bariatric surgery: a comparative analysis between sleeve gastrectomy and Roux-en-Y gastric bypass. / Deficiências de micronutrientes após cirurgia bariátrica: análise comparativa entre gastrectomia vertical e derivação gástrica em Y de Roux.

OBJECTIVE: to compare the prevalence of micronutrient deficiencies in patients submitted to sleeve gastrectomy (SG) and Roux- en-Y gastric bypass (RYGB). METHODS: this is a comparative study of 576 patients submitted to bariatric surgery, 338 to SG and 238 to RYGB, and evaluated for hemoglobin, iron, ferritin, zinc and vitamin B12 serum levels. We performed these dosages in the preoperative period and at three, six, 12 and 24 months after surgery, for analysis and comparison of micronutrient deficiencies among the techniques. RESULTS: the SG group consisted of 48 men and 290 women, with a mean BMI of 39.4±2.6kg/m2, and a mean of age of 37.2±11 years; the group RYGB consisted of 77 men and 161 women, with mean BMI 42.7±5.9kg/m2, and a mean age of 41.9±11.1 years. After 24 months, hemoglobin deficiency was present in 24.4% of the patients submitted to SG and in 40% of the RYGB individuals (p=0.054); iron deficiency was present in 6,6% of SG patients and in 15% of RYGB ones (p=0.127); ferritin deficiency occurred in 17.8% of the SG group and in 23.7% of RYGB one (p=0.399); the Zinc deficiency incidence was 6.6% in SG and 30% in RYGB (p=0.002); and B12 deficiency took place in 6.6% the SG patients and in 8.7% of RYGB ones (p=0.844). CONCLUSION: patients undergoing SG had serum levels of iron and zinc superior to the ones undergoing RYGB, the prevalence of the latter micronutrient deficit being significantly higher in the RYGB group.

OBJETIVO: comparar a prevalência das deficiências de micronutrientes nos pacientes submetidos à gastrectomia vertical (GV) e à derivação gástrica em Y de Roux (DGYR). MÉTODOS: estudo comparativo de 576 pacientes submetidos à cirurgia bariátrica, 338 através de GV e 238 de DGYR e avaliados quanto às dosagens séricas de hemoglobina, ferro, ferritina, zinco e vitamina B12. Estas dosagens foram realizadas nos períodos pré-operatório e três, seis, 12 e 24 meses após a cirurgia, para análise e comparação das deficiências de micronutrientes entre as técnicas. RESULTADOS: o grupo submetido à GV foi composto por 48 homens e 290 mulheres, com IMC médio de 39,4±2,6Kg/m2 e média de idade de 37,2±11 anos; o grupo submetido à DGYR foi composto por 77 homens e 161 mulheres, com IMC médio de 42,7±5,9Kg/m2 e média de idade de 41,9±11,1 anos. Após 24 meses, déficit de hemoglobina se fez presente em 24,4% dos pacientes submetidos à GV e 40% da DGYR (p=0,054); deficiência de ferro em 6,6% da GV e 15% da DGYR (p=0,127); déficit de ferritina em 17,8% da GV e 23,7% da DGYR (p=0,399); deficiência de zinco em 6,6% da GV e 30% da DGYR (p=0,002) e deficiência de B12 em 6,6% da GV e 8,7% da DGYR (p=0,844). CONCLUSÃO: pacientes submetidos à GV apresentaram níveis séricos de ferro e zinco superiores aos pacientes submetidos à DGYR, e a prevalência de déficit deste último micronutriente foi significativamente maior no grupo da DGYR.

Analysis of the lipid profile of patients submitted to sleeve gastrectomy and Roux-en-Y gastric bypass. / Análise do perfil lipídico de pacientes submetidos à gastrectomia vertical e à derivação gástrica em Y de Roux.

OBJECTIVE: to compare the improvements in lipid profile in patients undergoing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). METHODS: in a mixed cohort study, we evaluated 334 patients undergoing SG and 178 patients undergoing RYGB at the University Hospital of the Federal University of Pernambuco and at the Real Hospital Português de Beneficência, Recife, PE, Brazil. We measured serum levels of total cholesterol, LDL, HDL and triglycerides preoperatively and at three, six, 12 and 24 months follow-up. RESULTS: the SG group consisted of 58 men and 276 women. In the group submitted to RYGB, there were 64 men and 114 women. The mean age was 37.2±20.5 years in the SG group and 41.9±11.1 years in the RYGB group. The preoperative mean BMI was 39.4±2.6kg/m2 and 42.7±5.8kg/m2 for the SG and RYGB groups, respectively. In the preoperative period, 80% of the patients had at least one abnormality in the lipid profile. Two years after surgery, there was improvement in total cholesterol, LDL, HDL and triglycerides in the group submitted to RYGB. In the group submitted to SG, after two years there was improvement in total cholesterol, HDL and triglyceride levels. CONCLUSION: both techniques resulted in improvements in the lipid profile, but the RYGB was more effective.

OBJETIVO: comparar as melhorias no perfil lipídico de pacientes submetidos à gastrectomia vertical (GV) e à derivação gástrica em Y de Roux (DGYR). METÓDOS: estudo de coorte misto, em que foram avaliados 334 pacientes submetidos à GV e 178 pacientes submetidos à DGYR no Hospital das Clínicas da Universidade Federal de Pernambuco e no Real Hospital Português de Beneficência, Recife, PE, Brasil. Foram realizadas dosagens séricas de colesterol total, LDL, HDL e triglicerídeos no pré-operatório e com três, seis, 12 e 24 meses de seguimento. RESULTADOS: o grupo submetido à GV foi composto por 58 homens e 276 mulheres. No grupo submetido à DGYR, foram analisados 64 homens e 114 mulheres. A média de idade foi de 37,2±20,5 anos no grupo da GV e de 41,9±11,1 anos no grupo da DGYR. O IMC médio pré-operatório foi de 39,4±2,6kg/m2 e 42,7±5,8kg/m2, para o grupo da GV e da DGYR, respectivamente. No pré-operatório, 80% dos pacientes tinha, no mínimo, uma anormalidade no perfil lipídico. Dois anos após a cirurgia houve melhora do colesterol total, LDL, HDL e triglicerídeos no grupo submetido à DGYR. No grupo submetido à GV, após dois anos houve melhora dos níveis de colesterol total, HDL e triglicerídeos, apenas. CONCLUSÃO: ambas as técnicas resultaram em melhorias no perfil lipídico, porém a DGYR foi mais efetiva.

Gastric twist after sleeve gastrectomy: a proposal for endoscopic classification / Torção gástrica após gastrectomia vertical: uma proposta de classificação endoscópica

ABSTRACT - BACKGROUND: The twisting of the gastric tube is one of the main causes of persistent reflux and food intolerance after sleeve gastrectomy (SG). To date, there is no classification for gastric twist after SG. OBJECTIVE: This study aimed to propose an endoscopic classification for this condition and outline the clinical profile of these patients with sleeve gastrectomy. METHODS: Patients in the postoperative period of SG presenting endoscopic findings of gastric twist were included. All patients underwent an esophagogastroduodenoscopy 12 months after SG. The classification proposed consists of three degrees: degree I: mild rotation of the staple line without relevant shrinkage of the gastric lumen; degree II: moderate rotation of the staple line, leading to a focal area of fixed narrowing that requires additional maneuvers for its transposition; and degree III: severe rotation of the staple line leading to stenosis, with increased difficulty for transposition or complete blockage. RESULTS: Out of 2,723 patients who underwent SG, 45 (1.6%) presented gastric twist. Most patients were female (85%), with mean age of 39±10.4 years. In all, 41 (91.1%) presented degree I, 3 (6.7%) presented degree II, and 1 (2.2%) had degree III. Most patients were asymptomatic (n=26). Vomiting was the most prevalent symptom (15.5%). Statistically significant correlation of twisting degrees was not observed for both the presence of symptoms and the degrees of esophagitis. CONCLUSION: Gastric twist after SG is rare, with generally mild and asymptomatic presentation. The endoscopic classification was not statistically related to clinical presentation but set the ground for further analysis.

RESUMO - RACIONAL: A torção do tubo gástrico ou twist é uma das principais causas de refluxo persistente e intolerância alimentar após a gastrectomia vertical (GV). Até o momento, não há uma classificação proposta para a torção gástrica após GV. OBJETIVO: Propor uma classificação endoscópica para essa condição e descrever o perfil clínico desses pacientes. MÉTODOS: Pacientes no pós-operatório de GV apresentando achados endoscópicos de twist foram incluídos. Os pacientes foram submetidos a uma esofagogastroduodenoscopia 12 meses após a cirurgia. A classificação consiste em três graus. Grau I: rotação leve da linha de grampos, sem redução relevante do lúmen gástrico. Grau II: rotação moderada da linha de grampos, levando a uma área de estreitamento focal que requer manobras adicionais para a progressão do aparelho. Grau III: rotação severa da linha de grampos, levando à estenose, com grande dificuldade de progressão ou obstrução completa. RESULTADOS: Dos 2.723 pacientes que foram submetidos à GV, 45 (1,6%) apresentaram twist. A maioria dos pacientes era do sex feminino (85%), com idade média de 39±10.4 anos. Quarenta e um (91,1%) apresentaram twist grau I, 3 (6,7%) apresentaram twist grau II e apenas 1 (2,2%) apresentou twist grau III. A maioria dos pacientes eram assintomáticos (n=26). O sintoma mais prevalente foi vômito (15,5%). Não foi observada correlação estatisticamente significante entre o grau de twist e a presença de sintomas ou esofagite. CONCLUSÃO: Twist após GV é raro e geralmente assintomático. A classificação endoscópica proposta não foi estatisticamente relacionada com apresentação clínica, porém estabelece um referencial para análises futuras.

Impact of bariatric surgery in elderly patients with obesity / Impacto da cirurgia bariátrica em pacientes idosos portadores de obesidade

ABSTRACT Introduction: to evaluate the long-term impact of bariatric surgery in the elderly population. Methods: a retrospective study including all patients older than 60 years who underwent Roux-en-Y gastric bypass (RYGB) at our center and maintained a follow-up longer than 1 year. Clinical and laboratory variables were studied to assess remission of obesity and its comorbidities, as well as variables directly related to the surgical procedure itself, including early and late complications. Results: fifty-six patients were studied, mostly female (76,8%), with a mean age of 64.02 ± 3.34. A rate of complications of 37,5% was observed, with 10,7% requiring hospital admission and emergency surgery. The mean excess weight loss (%EWL) was 74.22% ± 26.76. The remission rates of hypertension and diabetes mellitus were 26.08% and 54.54%, respectively. There was significant difference in BMI reduction (12.25 ± 5.42, p<0.001), total cholesterol (31.37 ± 38.89 p<0,001), LDL cholesterol (23.45 ± 34.9, p=0.002), HDL cholesterol (5.14 ± 11.13, p=0,024), triglycerides (48.85 ± 56.15 p<0.001), HbA1C (1,81 ± 1,97, p<0,001) e PCR (1.43 ± 1.96, p<0.001). Conclusion: bariatric surgery was effective in weight loss and remission of comorbidities in the elderly obese population within the long term.

RESUMO Introdução: avaliar o impacto da cirurgia bariátrica na população idosa no longo prazo. Métodos: estudo retrospectivo que incluiu todos os pacientes com mais de 60 anos submetidos ao Bypass gástrico em Y de Roux (BGYR) em nosso centro e que mantiveram seguimento superior a 1 ano. Foram estudadas variáveis clínicas e laboratoriais para avaliação da remissão da obesidade e suas comorbidades, além de variáveis diretamente relacionados ao procedimento cirúrgico em si, incluindo complicações precoces e tardias. Resultados: foram estudados 56 pacientes, a maioria do sexo feminino (76,8%), com idade média de 64,02 ± 3,34. Foi observada uma taxa de complicações de 37,5%, com 10,7% requerendo internamento hospitalar e cirurgia de urgência. A média geral da perda do excesso de peso (%PEP) foi de 74,22% ± 26,76. As taxas de remissão de hipertensão e diabetes mellitus foram de 26,08% e 54,54%, respectivamente. Houve variação significativa no IMC (12,25 ± 5,42, p<0,001), colesterol total (31,37 ± 38,89 p<0,001), colesterol LDL (23,45 ± 34,9, p=0,002), colesterol HDL (5,14 ± 11,13, p=0,024), triglicerídeos (48,85 ± 56,15 p<0,001), HbA1C (1,81 ± 1,97, p<0,001) e PCR (1,43 ± 1,96, p<0,001). Conclusão: a cirurgia bariátrica se mostrou eficaz na perda de peso e na remissão de comorbidades na população de idosos com obesidade no longo prazo..

The routine use of the methylene blue test in sleeve gastrectomy: why not? / Uso rotineiro do teste do azul de metileno na gastrectomia vertical: por que não?

ABSTRACT Background: Although considered a safe procedure, sleeve gastrectomy (SG) has a non-negligible risk of major postoperative complications related to it, with special attention to gastric leaks. Aim: Evaluate the clinical value of the methylene blue test (MBT) in predicting the occurrence of post-SG leaks. Methods: Retrospective study that included 1136 patients who underwent SG with intraoperative MBT between 2012 and 2016. Sensitivity, specificity, positive predictive value (PPV) and negative predicted value (NPV) were calculated to determine the clinical correlation between the MBT and the occurrence of postoperative leaks. Staple line oversewing was performed in all patients who presented positive MBT. Results: Laparoscopic SG was performed in 97.0% of cases; open in 2.3%, and robotic in 0.7%. MBT was positive in 19 cases (1.67%). One positive MBT occurred during an open SG and the other 18 at laparoscopy. Moreover, there were nine cases (0.8%) of postoperative leaks, among which, only two presented positive MBT. MBT diagnostic value was evaluated through the calculation of sensitivity (22.0%), specificity (98.0%), PPV (11.0%) and NPV (99.0%). There were no cases of allergic reaction or any other side effect with the use of the methylene blue solution. Conclusion: MBT showed high specificity and negative predictive value, thus presenting an important value to rule out the occurrence of postoperative leaks.

RESUMO Racional: Embora considerada procedimento seguro, a gastrectomia vertical (GV) apresenta risco não desprezível de complicações pós-operatórias importantes relacionadas a ela, com atenção especial para fístulas gástricas Objetivo: Avaliar a aplicabilidade clínica do teste do azul de metileno (TAM) na predição da ocorrência de fístulas após a GV. Método: Estudo retrospectivo que incluiu 1136 pacientes operados entre 2012 e 2016 com aplicação do TAM intraoperatório. Sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) foram calculados na tentativa de determinar a correlação clínica entre os resultados do TAM e a ocorrência de fístulas pós-operatórias. Sobressutura da linha de grampos foi realizada em todos os pacientes que apresentaram TAM positivo. Resultados: GV laparoscópica foi realizada em 97,0% dos casos; por laparotomia em 2,3% e roboticamente em 0,7%. TAM foi positivo em 19 casos (1,67%). Um dos casos positivos ocorreu na laparotomia e os outros 18 na laparoscopia. Ainda, houve nove casos (0,8%) de fístulas pós-operatórias, dentre os quais, apenas dois apresentaram TAM positivo. O valor diagnóstico do TAM foi avaliado através dos cálculos de sensibilidade (22,0%), especificidade (98,0%), VPP (11,0%) e VPN (99,0%). Não houve casos de reação alérgica ou qualquer outro efeito colateral advindo do uso da solução de azul de metileno. Conclusão: TAM mostrou alta especificidade e VPN, apresentando importância em descartar a ocorrência de fístulas pós-operatórias.

Modelo metabonômico para avaliação da regressão do diabetes mellitus tipo 2 após cirurgia bariátrica / Metabonomic model for the assessment of type 2 diabetes remission after bariatric/metabolic surgery

RESUMO Objetivo: avaliar as diferenças no perfil metabonômico de pacientes que atingiram remissão de diabetes mellitus tipo 2 (DM2) após cirurgia bariátrica em relação aos que apresentaram manutenção ou recidiva dessa condição após a cirurgia. Métodos: Participaram do estudo 33 pacientes obesos diabéticos tipo 2, dos quais 22 tiveram remissão completa da DM2 e 11 tiveram recidiva da DM2 ou não apresentaram remissão da doença no pós-operatório. Amostras de sangue foram coletadas para avaliação dos perfis metabonômicos séricos através de um estudo metabonômico baseado em RMN de 1H. Resultados: o modelo metabonômico para avaliação da recidiva da diabetes apresentou uma acurácia de 93,9%, sensibilidade de 81,8%, especificidade de 100%, valor preditivo positivo (VPP) igual a 100% e valor preditivo negativo (VPN) igual a 91,7%. Conclusão: a cirurgia bariátrica promove efeitos específicos na distribuição dos metabólitos de pacientes que atingiram remissão de DM2, e essa nova distribuição pode ser avaliada através de um modelo metabonômico.

ABSTRACT Purpose: To evaluate the differences in the metabonomic profile of patients who achieved remisison of Type 2 diabetes mellitus (T2DM) after bariatric surgery in relation to those who presented maintenance or recurrence of this condition after surgery. Methods: Thirthy-three patients with obesity and T2D were submitted to bariatric/metabolic surgery, among which, 22 experienced complete remission of T2D, and 11 did not experience remission in the postoperative period. Blood samples were taken in order to assess the serum profiles through a 1H NMR-based metabonomic study. Results: The metabonomic model for the assessment of T2D recurrence presented an accuracy of 93.9%, sensibility of 81.8%, specificity of 100%, positive predictive value of 100% and a negative predictive value of 91.7%. Conclusion: bariatric surgery provide specific effects on the distribution of metabolites in those patients who achieved remission of T2DM, and this new distribution can be assessed through a metabonomic model.

Antibiotic prophylaxis in bariatric surgery with continuous infusion of cefazolin: determination of concentration in adipose tissue.

BACKGROUND: The aim of this study was to evaluate the concentration of cefazolin in adipose tissue of patients undergoing bariatric surgery. METHODS: Eighteen patients undergoing bariatric surgery were evaluated during the period from October 2011 to May 2012. All patients had a dosage schedule of antibiotic prophylaxis with cefazolin administered as follows: first, 2 g in anesthetic induction, followed by continuous infusion of 1 g diluted in 250 ml of saline solution. Adipose samples, collected soon after the incision (initial) and before the skin synthesis (final), were analyzed using reverse phase high-pressure liquid chromatography. The level of significance adopted was 5 %. RESULTS: The cefazolin concentration in the adipose tissue samples at the beginning of surgery was an average of 6.66 ± 2.56 ug/ml. The mean concentration before the skin synthesis was 7.93 ± 2.54 ug/ml. Patients with BMI < 40 kg/m(2) had higher initial and final sample concentrations of cefazolin than patients with BMI ≥ 40 kg/m(2). There was no surgical site infection (SSI) in any of the patients. CONCLUSIONS: In bariatric surgeries, addition of a 1 g increase of cefazolin, administered through continuous intravenous infusion, to the currently recommended dose of 2 g administered in anesthetic induction provided a concentration in the adipose tissue above the minimum inhibitory concentration (MIC) of the main causal agents of SSI. An inverse correlation between BMI and concentration of cefazolin in adipose tissue was observed.

Deficiências de micronutrientes após cirurgia bariátrica: análise comparativa entre gastrectomia vertical e derivação gástrica em Y de Roux / Micronutrient deficiencies following bariatric surgery: a comparative analysis between sleeve gastrectomy and Roux-en-Y gastric bypass

RESUMO Objetivo: comparar a prevalência das deficiências de micronutrientes nos pacientes submetidos à gastrectomia vertical (GV) e à derivação gástrica em Y de Roux (DGYR). Métodos: estudo comparativo de 576 pacientes submetidos à cirurgia bariátrica, 338 através de GV e 238 de DGYR e avaliados quanto às dosagens séricas de hemoglobina, ferro, ferritina, zinco e vitamina B12. Estas dosagens foram realizadas nos períodos pré-operatório e três, seis, 12 e 24 meses após a cirurgia, para análise e comparação das deficiências de micronutrientes entre as técnicas. Resultados: o grupo submetido à GV foi composto por 48 homens e 290 mulheres, com IMC médio de 39,4±2,6Kg/m2 e média de idade de 37,2±11 anos; o grupo submetido à DGYR foi composto por 77 homens e 161 mulheres, com IMC médio de 42,7±5,9Kg/m2 e média de idade de 41,9±11,1 anos. Após 24 meses, déficit de hemoglobina se fez presente em 24,4% dos pacientes submetidos à GV e 40% da DGYR (p=0,054); deficiência de ferro em 6,6% da GV e 15% da DGYR (p=0,127); déficit de ferritina em 17,8% da GV e 23,7% da DGYR (p=0,399); deficiência de zinco em 6,6% da GV e 30% da DGYR (p=0,002) e deficiência de B12 em 6,6% da GV e 8,7% da DGYR (p=0,844). Conclusão: pacientes submetidos à GV apresentaram níveis séricos de ferro e zinco superiores aos pacientes submetidos à DGYR, e a prevalência de déficit deste último micronutriente foi significativamente maior no grupo da DGYR.

ABSTRACT Objective: to compare the prevalence of micronutrient deficiencies in patients submitted to sleeve gastrectomy (SG) and Roux- en-Y gastric bypass (RYGB). Methods: this is a comparative study of 576 patients submitted to bariatric surgery, 338 to SG and 238 to RYGB, and evaluated for hemoglobin, iron, ferritin, zinc and vitamin B12 serum levels. We performed these dosages in the preoperative period and at three, six, 12 and 24 months after surgery, for analysis and comparison of micronutrient deficiencies among the techniques. Results: the SG group consisted of 48 men and 290 women, with a mean BMI of 39.4±2.6kg/m2, and a mean of age of 37.2±11 years; the group RYGB consisted of 77 men and 161 women, with mean BMI 42.7±5.9kg/m2, and a mean age of 41.9±11.1 years. After 24 months, hemoglobin deficiency was present in 24.4% of the patients submitted to SG and in 40% of the RYGB individuals (p=0.054); iron deficiency was present in 6,6% of SG patients and in 15% of RYGB ones (p=0.127); ferritin deficiency occurred in 17.8% of the SG group and in 23.7% of RYGB one (p=0.399); the Zinc deficiency incidence was 6.6% in SG and 30% in RYGB (p=0.002); and B12 deficiency took place in 6.6% the SG patients and in 8.7% of RYGB ones (p=0.844). Conclusion: patients undergoing SG had serum levels of iron and zinc superior to the ones undergoing RYGB, the prevalence of the latter micronutrient deficit being significantly higher in the RYGB group.

Análise do perfil lipídico de pacientes submetidos à gastrectomia vertical e à derivação gástrica em Y de Roux / Analysis of the lipid profile of patients submitted to sleeve gastrectomy and Roux-en-Y gastric bypass

RESUMO Objetivo: comparar as melhorias no perfil lipídico de pacientes submetidos à gastrectomia vertical (GV) e à derivação gástrica em Y de Roux (DGYR). Metódos: estudo de coorte misto, em que foram avaliados 334 pacientes submetidos à GV e 178 pacientes submetidos à DGYR no Hospital das Clínicas da Universidade Federal de Pernambuco e no Real Hospital Português de Beneficência, Recife, PE, Brasil. Foram realizadas dosagens séricas de colesterol total, LDL, HDL e triglicerídeos no pré-operatório e com três, seis, 12 e 24 meses de seguimento. Resultados: o grupo submetido à GV foi composto por 58 homens e 276 mulheres. No grupo submetido à DGYR, foram analisados 64 homens e 114 mulheres. A média de idade foi de 37,2±20,5 anos no grupo da GV e de 41,9±11,1 anos no grupo da DGYR. O IMC médio pré-operatório foi de 39,4±2,6kg/m2 e 42,7±5,8kg/m2, para o grupo da GV e da DGYR, respectivamente. No pré-operatório, 80% dos pacientes tinha, no mínimo, uma anormalidade no perfil lipídico. Dois anos após a cirurgia houve melhora do colesterol total, LDL, HDL e triglicerídeos no grupo submetido à DGYR. No grupo submetido à GV, após dois anos houve melhora dos níveis de colesterol total, HDL e triglicerídeos, apenas. Conclusão: ambas as técnicas resultaram em melhorias no perfil lipídico, porém a DGYR foi mais efetiva.

ABSTRACT Objective: to compare the improvements in lipid profile in patients undergoing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Methods: in a mixed cohort study, we evaluated 334 patients undergoing SG and 178 patients undergoing RYGB at the University Hospital of the Federal University of Pernambuco and at the Real Hospital Português de Beneficência, Recife, PE, Brazil. We measured serum levels of total cholesterol, LDL, HDL and triglycerides preoperatively and at three, six, 12 and 24 months follow-up. Results: the SG group consisted of 58 men and 276 women. In the group submitted to RYGB, there were 64 men and 114 women. The mean age was 37.2±20.5 years in the SG group and 41.9±11.1 years in the RYGB group. The preoperative mean BMI was 39.4±2.6kg/m2 and 42.7±5.8kg/m2 for the SG and RYGB groups, respectively. In the preoperative period, 80% of the patients had at least one abnormality in the lipid profile. Two years after surgery, there was improvement in total cholesterol, LDL, HDL and triglycerides in the group submitted to RYGB. In the group submitted to SG, after two years there was improvement in total cholesterol, HDL and triglyceride levels. Conclusion: both techniques resulted in improvements in the lipid profile, but the RYGB was more effective.