Trajectory of NAFLD characteristics after Roux-en-Y gastric bypass: a five-year historical cohort study

Abstract BACKGROUND: The long-term effects of bariatric surgery on the course of non-alcoholic fatty hepatopathy (NAFLD) are not fully understood. OBJECTIVE: To analyze the evolution of NAFLD characteristics through noninvasive markers after Roux-en-Y gastric bypass (RYGB) over a five-year period. DESIGN AND SETTING: Historical cohort study; tertiary-level university hospital. METHODS: The evolution of NAFLD-related characteristics was evaluated among 49 individuals who underwent RYGB, with a five-year follow-up. Steatosis was evaluated through the hepatic steatosis index (HSI), steatohepatitis through the clinical score for non-alcoholic steatohepatitis (C-NASH) and fibrosis through the NAFLD fibrosis score (NFS). RESULTS: 91.8% of the individuals were female. The mean age was 38.3 ± 10 years and average body mass index (BMI), 37.4 ± 2.3 kg/m2. HSI significantly decreased from 47.15 ± 4.27 to 36.03 ± 3.72 at 12 months (P < 0.01), without other significant changes up to 60 months. C-NASH significantly decreased from 0.75 ± 1.25 to 0.29 ± 0.7 at 12 months (P < 0.01), without other significant changes up to 60 months. NFS decreased from 1.14 ± 1.23 to 0.27 ± 0.99 at 12 months (P < 0.01), and then followed a slightly ascending course, with a marked increase by 60 months (0.82 ± 0.89), but still lower than at baseline (P < 0.05). HSI variation strongly correlated with the five-year percentage total weight loss (R = 0.8; P < 0.0001). CONCLUSION: RYGB led to significant improvement of steatosis, steatohepatitis and fibrosis after five years. Fibrosis was the most refractory abnormality, with a slightly ascending trend after two years. Steatosis improvement directly correlated with weight loss.

Trajectory of NAFLD characteristics after Roux-en-Y gastric bypass: a five-year historical cohort study.

BACKGROUND: The long-term effects of bariatric surgery on the course of non-alcoholic fatty hepatopathy (NAFLD) are not fully understood. OBJECTIVE: To analyze the evolution of NAFLD characteristics through noninvasive markers after Roux-en-Y gastric bypass (RYGB) over a five-year period. DESIGN AND SETTING: Historical cohort study; tertiary-level university hospital. METHODS: The evolution of NAFLD-related characteristics was evaluated among 49 individuals who underwent RYGB, with a five-year follow-up. Steatosis was evaluated through the hepatic steatosis index (HSI), steatohepatitis through the clinical score for non-alcoholic steatohepatitis (C-NASH) and fibrosis through the NAFLD fibrosis score (NFS). RESULTS: 91.8% of the individuals were female. The mean age was 38.3 ± 10 years and average body mass index (BMI), 37.4 ± 2.3 kg/m2. HSI significantly decreased from 47.15 ± 4.27 to 36.03 ± 3.72 at 12 months (P < 0.01), without other significant changes up to 60 months. C-NASH significantly decreased from 0.75 ± 1.25 to 0.29 ± 0.7 at 12 months (P < 0.01), without other significant changes up to 60 months. NFS decreased from 1.14 ± 1.23 to 0.27 ± 0.99 at 12 months (P < 0.01), and then followed a slightly ascending course, with a marked increase by 60 months (0.82 ± 0.89), but still lower than at baseline (P < 0.05). HSI variation strongly correlated with the five-year percentage total weight loss (R = 0.8; P < 0.0001). CONCLUSION: RYGB led to significant improvement of steatosis, steatohepatitis and fibrosis after five years. Fibrosis was the most refractory abnormality, with a slightly ascending trend after two years. Steatosis improvement directly correlated with weight loss.

Cecostomía endoscópica percutánea, una terapia eficaz en el síndrome de Ogilvie: relato de caso y revisión bibliográfica / Percutaneous endoscopic cecostomy, effective therapy for the treatment of Ogilvie syndrome: case and literature review

Ogilvie syndrome, or Acute Colonic Pseudo-Obstruction (ACPO) is characterized by colonic distension in the absence of mechanical obstruction. In general, it evolves favorably following a conservative treatment, and surgical procedures are not necessary6. We describe a case of ACPO with evolution of two days, in a 79-year old male patient, with asthma, type 2 diabetes mellitus, systemic arterial hypertension and policystic kidneys. After failure of conservative treatment based on support measures and neostigmine, percutaneous endoscopic support cecostomy, using a gastrostomy tube. The technique and its early execution were chosen considering that it was easy to be implemented, low cost and need for immediate colonic decompression due to high risk of ischemia and perforation of the colon, associated to a rapid clinical deterioration of the patient

El síndrome de Ogilvie o Pseudoobstrucción colónica aguda (ACPO) se caracteriza por la distensión del colon en ausencia de obstrucción mecánica. En general, el tratamiento conservador es favorable, no siendo necesaria una intervención quirúrgica. Describimos el caso de una ACPO con dos días de evolución, en paciente masculino de 79 años, asmático, portador de diabetes mellitus tipo 2, hipertensión arterial sistémica y riñones poliquísticos. Después del fracaso del tratamiento conservador con medidas de soporte y neostigmina, se optó por la realización de cecostomía endoscópica percutánea de protección, utilizando una sonda de gastrostomía. La elección de la técnica y su realización precoz se dio teniendo en vista su facilidad de ejecución, su bajo costo y la necesidad de descompresión colónica inmediata por el elevado riesgo de isquemia y perforación del colon, asociado al rápido empeoramiento clínico del paciente.

Rendez-Vous laparoendoscopic after ERCP failure in patient with Billroth II gastrectomy / Laparoscopía por Rendez-Vous luego de falla de CPRE en un paciente con gastectomía Billroth II

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice in patients with choledocholithiasis. However, despite its high success rate, in some cases it is not successful, requiring alternative therapy. Billroth II partial gastrectomy is a condition associated with an important failure rate of ERCP. When endoscopic treatment fails, surgical exploration of the bile duct is the most common approach. However, the surgery is related to a greater complexity of execution and morbimortality. We describe the case of a patient with choledocholithiasis and Billroth II partial gastrectomy, submitted to the combined treatment called rendez-vous laparoendoscopic, after failure of ERCP, which unites in a single stage the endoscopic treatment of choledocholithiasis and laparoscopic removal of the gallbladder. We conclude that this therapeutic approach was effective, safe, with low cost and without complications.

La colangiopancreatografía endoscópica retrógrada (CPRE) es el tratamiento de elección en pacientes portadores de coledocolitiasis. Sin embargo, a pesar de su elevada tasa de éxito, en algunos casos no es exitosa, exigiendo terapia alternativa. La gastrectomía parcial con reconstrucción a Billroth II es una condición asociada a la importante tasa de fracaso de la CPRE. Cuando el tratamiento endoscópico falla, la exploración quirúrgica de la vía biliar es un enfoque más común. Sin embargo, la cirugía se relaciona con una mayor complejidad de ejecución y morbimortalidad. Describimos el caso de un paciente con coledocolitiasis y gastrectomía parcial con reconstrucción a Billroth II, sometido al tratamiento combinado denominado rendez-vous laparoendoscópico tras fallo de la CPRE, que une en una sola etapa el tratamiento endoscópico de la coledocolitiasis y la retirada laparoscópica de la vesícula biliar. Llegamos a la conclusión de que este enfoque terapéutico fue eficaz, seguro, de bajo costo y sin complicaciones.

Rendez-Vous laparoendoscopic after ERCP failure in patient with Billroth II gastrectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice in patients with choledocholithiasis. However,despite its high success rate, in some cases it is not successful, requiring alternative therapy. Billroth II partial gastrectomy is a condition associated with an important failure rate of ERCP. When endoscopic treatment fails, surgical exploration of the bile duct is the most common approach. However, the surgery is related to a greater complexity of execution and morbimortality. We describe the case of a patient with choledocholithiasis and Billroth II partial gastrectomy, submitted to the combined treatment called rendez-vous laparoendoscopic, after failure of ERCP, which unites in a single stage the endoscopic treatment of choledocholithiasis and laparoscopic removal of the gallbladder. We conclude that this therapeutic approach was effective, safe, with low cost and without complications.

Perforated Meckel's diverticulum.

We report a patient with diffuse peritonitis due to perforation of Meckel's diverticulum. This patient was referred to the operating room and underwent bowel resection segment encompassing the area of the diverticulum and terminoterminal primary enteroanastomosis on two levels with good evolution. The diverticulum complications are often related to the presence of ectopic mucosa, specially the gastric and pancreatic type. Since preoperative diagnosis is difficult and infrequent, in most cases this anomaly is confirmed only during surgery. Surgical resection of the affected intestinal segment is the mainstay of treatment in both diverticula diagnosed incidentally, as the complicated by inflammation, bleeding, obstruction or perforation. We conclude that in cases of acute abdomen punctured, the diagnosis of Meckel's diverticulum should be considered.

Laparoendoscopic rendez-vous: a safe alternative to the treatment of choledocholithiasis.

The choice treatment for choledocholithiasis when associated with lithiasic cholecystitis is endoscopic retrograde cholangiopancreatography (ERCP). However, in some cases this therapeutic fails, which requires an alternative method to extract the stones. The surgical approach tends to be the next step, but it is related to greater complexity of achievement and higher complications rates. In 1993, Deslandres et al. developed the combined treatment called laparoendoscopic rendez-vous, that unites in a single stage the endoscopic treatment of choledocholithiasis and laparoscopic removal of the gallbladder. We report the case of a patient diagnosed with common bile duct (CBD) stones, in which the conventional CPRE was not successful, and was taken to treatment by laparoendoscopic approach. We conclude, based on this case and on other published studies, that this therapeutic modality has advantages for being feasible, presenting low complications rate, shorter hospital stay and acceptable cost.

Biliary ileus: case report / Íleo biliar: caso clinico

Biliary ileusis a uncommon cause of mechanical bowel obstruction, affecting older adult patients who often have other significant medical conditions. It is caused by intestinal impaction of a gallstone that enters the bowel via a cholecysto-enteric fistula. The mortality rate is considerable, ranging between 12 and 27%. Treatment in most cases is surgical, aimed at the resolution of the intestinal obstruction. We report the case of a 55 year old patient diagnosed with biliary ileus, wich evolved without complications after a enterolithotomy. We have concluded, based on the literature that an early diagnosis associated with appropriate therapy can lead to a better prognosis

El íleo biliar es una causa poco frecuente de obstrucción intestinal mecánica, que afecta pacientes de edad avanzada que generalmente tienen comorbilidades significativas. Es causada por la impactación de un cálculo biliar en el intestino, que entra en el tracto digestivo por medio de una fístula colecisto-entérica. La tasa de mortalidad es considerable, que va de 12 a 27%. El tratamiento en la mayoría de los casos es quirúrgico y destinado a la resolución de la obstrucción intestinal. Presentamos el caso de una paciente de 55 años diagnosticada con íleo biliar, que evolucionó sin complicaciones después de enterolitotomia. Llegamos a la conclusión, con base en la literatura, que un diagnóstico precoz asociado con el tratamiento adecuado conduce a un mejor pronóstico

Laparoendoscopic rendez-vous: a safe alternative to the treatment of choledocholithiasis / Rendez-vous láparo-endoscópico: una alternativa segura en el tratamiento de la colecocolitiasis

The choice treatment for choledocholithiasis when associated with lithiasic cholecystitis is endoscopic retrograde cholangiopancreatography (ERCP). However, in some cases this therapeutic fails, which requires an alternative method to extract the stones. The surgical approach tends to be the next step, but it is related to greater complexity of achievement and higher complications rates. In 1993, Deslandres et al. developed the combined treatment called laparoendoscopic rendez- vous, that unites in a single stage the endoscopic treatment of choledocholithiasis and laparoscopic removal of the gallbladder. We report the case of a patient diagnosed with common bile duct (CBD) stones, in which the conventional CPRE was not successful, and was taken to treatment by laparoendoscopic approach. We conclude, based on this case and on other published studies, that this therapeutic modality has advantages for being feasible, presenting low complications rate, shorter hospital stay and acceptable cost

El tratamiento de elección para la coledocolitiasis cuando se asocia con colecistitis litiásica es la colangiopancreatografía retrógrada endoscópica (CPRE). Sin embargo, en algunos casos ese tratamiento falla, requiriendo un método alternativo para extraer los cálculos. El abordaje quirúrgico tiende a ser el siguiente paso, pero se relaciona con una mayor complejidad de ejecución y mayores tasas de complicaciones. En 1993, Deslandres et al. desarrolló el tratamiento combinado llamado rendez-vous laparoendoscópico, que reúne en una sola etapa el tratamiento endoscópico de la coledocolitiasis y la extracción laparoscópica de la vesícula biliar. Presentamos el caso de una paciente diagnosticada con litiasis en la via biliar común, en el que la CPRE convencional no tuvo éxito, fue entonces enviada al tratamiento laparoendoscópico. Llegamos a la conclusión, basado en este caso y en otros estudios publicados, que esta modalidad terapéutica tiene ventajas por ser factible, teniendo bajos índices de complicaciones, menor estancia hospitalaria y costo aceptable