RESUMO
The aim of this study is to evaluate the early and late complications of laparoscopic gastric bypass (GBP) with manual versus stapled gastrojejunal anastomosis. Eighty-two patients with morbid obesity and body mass index (35-56 kg/m2) who underwent GBP were divided into two groups: manual gastrojejunal anastomosis (Group 1) and stapled anastomosis (Group 2). Early and late complications were evaluated. No differences were found between both groups in age, sex, body mass index, American Society of Anesthesia classification, and comorbidity. The mean operative time was 184.8 minutes [standard deviation (SD) = 61]; 203.5 minutes (SD = 51.9) in Group 1 and 167.4 minutes (SD = 64.2) in Group 2 (P = 0.001). The average length of stay was 5.9 days (SD = 3.9) in Group 1 and 5 days (SD = 2.1) in Group 2 (P = 0.039). Early complications were recorded in 9.7 per cent of the cases, without any differences between the two groups: 12.2 per cent in Group 1 and 7.3 per cent in Group 2 (P > 0.05). Late complication rate was 8.5 per cent, significantly higher in Group 1 (14.6%) than in Group 2 (2.4%; P < 0.05). However, in the logistic regression analysis these differences were not statistically significant (OR 0.48; 95% CI 0.03-8.37; P = 0.61). In our series, the GBP with stapled gastrojejunal anastomosis has shown lower hospital length of stay and operative time than the hand-sewn anastomosis. We have not found significant differences between both groups in early complications or in the need for reoperation. Fewer late complications were found in the group of stapled anastomosis; however, this has not been confirmed in the logistic regression analysis.
Assuntos
Anastomose em-Y de Roux/efeitos adversos , Derivação Gástrica/efeitos adversos , Laparoscopia/efeitos adversos , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/epidemiologia , Grampeamento Cirúrgico/efeitos adversos , Adulto , Anastomose em-Y de Roux/métodos , Feminino , Derivação Gástrica/métodos , Humanos , Laparoscopia/métodos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Grampeamento Cirúrgico/métodos , Fatores de TempoRESUMO
BACKGROUND: There are a growing number of patients who require revisional bariatric surgery due to the failure of their primary procedures. The aim of this video is to present a laparoscopic revisional procedure for dysphagia and gastroesophageal reflux disease (GERD) after an uncommonly performed bariatric surgery, Salmon's technique, consisting of a vertical banded gastroplasty and a horizontal stomach stapling with a Roux-en-Y bypass. METHODS: A 42-year-old obese male, with a history of dyslipidemia and a current body mass index (BMI) of 33, presented with severe dysphagia to solids and frequent spitting 10 years after the primary bariatric surgery (Salmon's procedure) with a BMI of 43. Endoscopy revealed a hiatal hernia. The endoscope passed down without difficulty to the antrum-duodenum and to efferent loop of the small bowel, demonstrating the presence of a fistula in the horizontal stapling of the stomach. Helicobacter pylori was negative. Esophageal transit showed the contrast passing adequately through the esophagogastric junction. Esophageal manometry revealed a hypotensive lower esophageal sphincter (mean pressure of 8 mmHg) and an ineffective peristalsis (40% of waves with normal amplitude and duration). Esophageal pHmetry showed severe GERD with a DeMeester score of 88.5 and a pH less than four, 18.7% of the total time. The patient was on PPIs at the time of symptom evaluation, but stopped the treatment before the performance of the pH study. Laparoscopic conversion to a Roux-en-Y gastric bypass was successfully performed. An extensive adhesiolysis was needed. The esophageal hiatus was dissected and the stomach was partially descended to reduce the hiatal hernia. A subsequent hiatal closure was performed. The efferent loop of the small bowel was freed from the gastric pouch. The new gastric pouch was performed stapling superiorly to the gastric ring and medially to the vertical gastroplasty. The new gastrojejunal anastomosis was performed using a mechanical linear stapler, in an antecolic fashion, and checked for leaks using methylene blue dye. RESULTS: The procedure took 300 min and no intraoperative complications occurred. The patient had an uneventful postoperative course, with a hospital stay of 4 days. One month after the revisional surgery, the patient presented with a stenosis of the gastrojejunal anastomosis, which was successfully solved after two endoscopic dilations. A year and a half after revisional surgery, the patient is completely asymptomatic, has a BMI of 29, and dyslipidemia as the only comorbidity. CONCLUSIONS: Salmon's technique is an uncommon bariatric procedure. Revisional surgery might be needed in case of late complications, like dysphagia and reflux, as it was the case in our patient. In addition, a fistula in the previous horizontal partitioning of the stomach was present. Laparoscopic conversion from Salmon's technique to a gastric bypass was decided. This procedure was successful in solving patient's symptoms and resulted in an increased weight lost. Laparoscopic revisional surgery after an open Salmon's technique is a complex procedure with an increased risk of complications. Our patient developed an anastomotic stenosis 1 month after surgery, probably due to the use of the same gauge as in non-fibrotic tissues.
Assuntos
Cirurgia Bariátrica , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Reoperação/métodos , Adulto , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/cirurgia , Refluxo Gastroesofágico/etiologia , Refluxo Gastroesofágico/cirurgia , Humanos , MasculinoRESUMO
INTRODUCTION AND OBJECTIVES: Cardiac adaptation to obesity includes both structural and functional changes in the heart. The therapeutic option of last resort for morbidly obese patients is bariatric surgery. This study aims to assess the anatomical functional changes in the heart for a Spanish cohort of morbidly obese patients, as well as changes after bariatric surgery. METHODS: Patients referred for bariatric surgery were prospectively included. In each case, a transthoracic echocardiography, electrocardiogram, and blood tests were performed before the procedure and repeated 1 year after surgery. RESULTS: Forty-one patients completed the 1-year follow-up. Of these, 82.9% were female. Mean age was 40.2±9.6 years. Prior to surgery, mean body mass index was 47.41 kg/m(2), decreasing to 30.43 kg/m(2) after the procedure. Before surgery, cardiac remodeling was present in 70.7%, most frequently in the form of eccentric hypertrophy (34.1%). At 1-year follow-up, 58.5% showed a normal left ventricular geometric pattern (P=.02). Mitral inflow E/A ratio changed from 1.14 to 1.43 (P<.001). Nevertheless, early mitral velocity measured by Doppler tissue decreased (P=.06). CONCLUSIONS: In morbidly obese patients referred for bariatric surgery, cardiac remodeling is highly prevalent, in most cases in an eccentric manner. Weight loss achieved by bariatric surgery is accompanied by significant improvements in left ventricular structure. Nevertheless, the damage in diastolic function may be permanent despite weight loss.
Assuntos
Cirurgia Bariátrica , Coração/fisiopatologia , Miocárdio/patologia , Obesidade Mórbida/patologia , Obesidade Mórbida/cirurgia , Adulto , Algoritmos , Índice de Massa Corporal , Cardiomegalia/etiologia , Cardiomegalia/terapia , Estudos de Coortes , Diástole/fisiologia , Ecocardiografia , Eletrocardiografia , Feminino , Seguimentos , Ventrículos do Coração/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/fisiologia , Obesidade Mórbida/fisiopatologia , Estudos Prospectivos , Medição de Risco , Função Ventricular Esquerda , Adulto JovemRESUMO
BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms of the digestive tract. They originate from the interstitial cells of Cajal and are characterized by the overexpression of KIT protein (tyrosine kinase). Their prognosis has improved significantly with the discovery of imatinib mesylate for advanced GIST treatment. METHODS: We carried out a retrospective, descriptive study of GISTs diagnosed in our center during the past 5 years. We excluded patients with incidental diagnoses in the context of other pathologies because GIST did not affect outcome or prognosis. The variables studied were clinical characteristics, location, size, imaging techniques, resectability, neoadjuvant imatinib, surgical technique, histology, immunohistochemistry, prognostic classification of Fletcher, morbidity, monitoring, and disease-free and overall survival. RESULTS: Nineteen patients were diagnosed (14 males/5 females) with a mean age of 63 years (range: 30-84 years). Diagnosis was incidental in eight patients (42%). Tumor location of the remaining 11 patients (58%) was six tumors of the small intestine (55%), four gastric (36%) and one rectal (9%). Predominant gastrointestinal bleeding and anemia were diagnosed mainly by abdominal computed tomography (CT). At diagnosis, nine patients were considered resectable with radical intent (82%) and the other two patients (18%) received neoadjuvant treatment with a favorable response after 6 months. Three patients were treated with imatinib after surgery (33%). Median survival was 34 months (range: 5-58 months). CONCLUSIONS: Diagnosis of GIST is often incidental. The predominant clinical symptom is usually gastrointestinal bleeding and anemia and the most widely used imaging test is CT. Treatment is surgical unless advanced GIST is diagnosed, which will be treated with imatinib mesylate neoadjuvant therapy. A multidisciplinary approach to this pathology is essential, a fact that affects prognosis and patient survival.