Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study.

BACKGROUND: Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. METHODS: A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved. RESULTS: A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. CONCLUSION: This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

COVID-19: IFSO LAC Recommendations for the Resumption of Elective Bariatric Surgery.

BACKGROUND: COVID-19 pandemic varies greatly and has different dynamics in every country, city, and hospital in Latin America. Obesity increases the risk of SARS-CoV-2 infection, and it is one of the independent risk factors for the most severe cases of COVID-19. Currently, the most effective treatment against obesity available is bariatric and metabolic surgery (BMS), which further resolves or improves other independent risk factors like diabetes and hypertension. OBJECTIVE: Provide recommendations for the resumption of elective BMS during COVID-19 pandemic. METHOD: This document was created by the IFSO-LAC Executive Board and a task force. Based on data collected from a survey distributed to all IFSO-LAC members that obtained 540 responses, current evidence available, and consensus reached by other scientific societies. RESULTS: The resumption of elective BMS must be a priority maybe similar to oncological surgery, when hospitals reach phase I or II, treating obesity patients in a NON-COVID area, avoiding inadvertent intrahospital contagion from healthcare provider, patients, and relatives. Same BMS indication and types of procedures as before the pandemic. Discard the presence of SARS-CoV-2 within 72 h prior to surgery. Continues laparoscopic approach. The entire team use N95 mask. Minimum hospital stays. Implement remote visits for the follow-up. CONCLUSION: Resumption of elective BMS is crucial because it is not only a weight loss operation but also resolves or improves comorbidities and appears to be an immune restorative procedure of obese patients in the medium term, offering them the same probability of contracting COVID-19 as the regular population.

Correction to: Endoscopic Argon Plasma Coagulation Vs. Multidisciplinary Evaluation in the Management of Weight Regain after Gastric Bypass Surgery: a Randomized Controlled Trial with SHAM Group.

In the original article the captions for Figs. 1-3 are incorrect.

Laparoscopic Common Bile Duct Exploration With Primary Closure After Failed Endoscopic Retrograde Cholangiopancreatography Without Intraoperative Cholangiography: A Case Series from a Referral Center in Bogota, Colombia.

Background: Despite the effectiveness of laparoscopic common bile duct (CBD) surgery, no case series details the use and advantages of laparoscopic CBD exploration (LCBDE) without use of intraoperative cholangiography (IOC) in endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we present a case series regarding our success with LCBDE in managing CBD stones (CBDSs) using laparoscopic technique without IOC. Materials and Methods: We performed a descriptive retrospective observational study. Patients with CBDSs, alone or along with gallbladder stones, were treated through LCBDE with primary CBD closure after failed ERCP. Results: All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%). All procedures were successful, and no conversions occurred. Surgery duration averaged 106 minutes. Intraoperative bleeding averaged 15 cc, and no mortalities occurred. No patients required additional surgery or intensive care unit admission. Hospitalization duration averaged 5 days. Conclusions: Therefore, a laparoscopic approach with primary CBD closure after failed ERCP for complex CBDSs is safe and effective.

Endoscopic Argon Plasma Coagulation vs. Multidisciplinary Evaluation in the Management of Weight Regain After Gastric Bypass Surgery: a Randomized Controlled Trial with SHAM Group.

BACKGROUND: Roux-en-Y gastric bypass is one of the most widely performed bariatric surgeries. However, the relapse of obesity occurs in approximately 20% of patients and enlargement of the anastomosis is one of the factors associated with this relapse. Endoscopic treatment of the anastomosis has been proposed to assist in renewed weight loss. One endoscopic technique is the narrowing of the anastomosis argon plasma coagulation (APC). OBJECTIVE: Evaluate the effectiveness and safety of the endoscopic treatment of an enlarged anastomosis with APC. METHODS: A randomized controlled study was conducted comparing APC to exclusive multidisciplinary management after weight regain. RESULTS: Forty-two patients were divided into two groups: APC (n = 22) and control (n = 20). After 14 months of follow-up with a crossover at 6 months, significant improvement in satiety and greater weight loss were found in the APC group and after crossover. APC was associated with significant weight loss [9.73 (7.46, 12) vs. + 1.38 (- 1.39, 2.15)], a reduction in the anastomosis diameter [p < 0.001], early satiation [0.77 (0.44, 1.11) vs. - 0.59 (- 0.95, - 0.23), p < 0.001], and increased quality of life measured using the EQ5D index [p = 0.04] and EQ5D VAS scale [p = 0.04]. Considering total mean weight loss throughout the entire follow-up, weight loss was similar in both groups (13.02 kg in the APC and 11.52 kg in the control). CONCLUSION: Treatment of the gastrojejunal anastomosis with APC was effective and safe, with significant weight loss, the return of early satiation, and an improvement in quality of life.

Anthropometric Assessment for Bariatric Procedures in the Private Practice of a Registered Dietitian in Colombia.

BACKGROUND: Obesity and its consequences have now reached worldwide pandemic proportions. Among treatments, bariatric interventions are the most effective for weight reduction. Here, we describe the change in anthropometric measurements (AMs) of 615 adult bariatric procedure patients seen in the private practice of a registered dietitian (RD) in Bogotá, Colombia. METHODS: Observational retrospective study of AMs recorded between 1996 and 2013 for patients who had laparoscopic sleeve gastrectomy (LSG, n = 290), laparoscopic adjustable gastric banding (LAGB, n = 207), and laparoscopic Roux-EN-Y gastric bypass (LRYGB, n = 36) or the non-surgical gastric balloon (GB, n = 82) procedure. Patients had three bimonthly follow-up visits. Paired t tests compared baseline (first) and 6-month (fourth) follow-up visit values. RESULTS: Differences in AMs between the baseline and fourth visits were statistically significant for the surgical interventions. A mean weight loss of 22 kg, equivalent to a 22% total body weight loss, together with significant reduction of the waist-to-height-ratio (WHtR)(p < 0.001) and body mass index (BMI)(p < 0.001), was observed across all procedures. CONCLUSIONS: The use of multiple AMs enables a comprehensive assessment of body composition in patients who undergo bariatric procedures. Our study is a useful resource for international future reference and highlights the impact that the RD can have on understanding and influencing the effectiveness of bariatric procedures.

Total clipless cholecystectomy by means of harmonic sealing.

BACKGROUND: In traditional laparoscopic cholecistectomy, the cystic duct and artery are commonly closed by metallic clips just before their division. Although the placement of these clips for occluding cystic artery and duct can be considered safe, biliary leaks and bleeding may occur especially by its dislodgement. AIM: To report a prospective case-series in total clipless cholecystectomy by means of harmonic shears for closure and division of the artery and cystic duct as well removal of the gallbladder from the liver. METHODS: Was evaluate a series of 125 patients who underwent laparoscopic cholecystectomy where the sealing and division of cystic artery and duct was carried out only by harmonic shears. The intact extracted gallbladder was submitted to a reverse pressure test for assessment of the technique safety by means of CO2 insuflation. RESULTS: The most common indication for surgery was gallstones. The mean operative time was 26 min and all gallbladders were dissected intact from the liver bed. There was no mortality and the overall morbidity rate was 0.8% with no hemorrhage or leaks. The reverse pressure test showed that all specimens support at least 36-mmHg of pressure without leaking. CONCLUSION: The harmonic shears is effective and safe in laparoscopic cholecystectomy as a sole instrument for sealing and division of the artery and cystic duct. The main advantages could be related to the safety and decreased operative time.

Total clipless cholecystectomy by means of harmonic sealing / Colecistectomia laparoscópica totalmente ultrassônica sem uso de clipe metálico

BACKGROUND: In traditional laparoscopic cholecistectomy, the cystic duct and artery are commonly closed by metallic clips just before their division. Although the placement of these clips for occluding cystic artery and duct can be considered safe, biliary leaks and bleeding may occur especially by its dislodgement. AIM: To report a prospective case-series in total clipless cholecystectomy by means of harmonic shears for closure and division of the artery and cystic duct as well removal of the gallbladder from the liver. METHODS: Was evaluate a series of 125 patients who underwent laparoscopic cholecystectomy where the sealing and division of cystic artery and duct was carried out only by harmonic shears. The intact extracted gallbladder was submitted to a reverse pressure test for assessment of the technique safety by means of CO2 insuflation. RESULTS: The most common indication for surgery was gallstones. The mean operative time was 26 min and all gallbladders were dissected intact from the liver bed. There was no mortality and the overall morbidity rate was 0.8% with no hemorrhage or leaks. The reverse pressure test showed that all specimens support at least 36-mmHg of pressure without leaking. CONCLUSION: The harmonic shears is effective and safe in laparoscopic cholecystectomy as a sole instrument for sealing and division of the artery and cystic duct. The main advantages could be related to the safety and decreased operative time. .

RACIONAL: A colecistectomia laparoscópica na técnica tradicional oclui o ducto cístico e a artéria cística por clipes cirúrgicos, que podem se deslocar ou desprender no pós-operatório, possibilitando a ocorrência de fístula biliar ou hemorragia. OBJETIVO: Relato prospectivo de série de casos de colecistectomias laparoscópicas sem uso de clipe cirúrgico, sendo que a ligadura e secção da artéria cística e do ducto cístico foram realizadas por meio de bisturi ultrassônico. MÉTODO: Foram incluídos 125 pacientes submetidos à colecistectomia laparoscópica sem utilização de clipe cirúrgico metálico, onde a ligadura da artéria e do ducto cístico e também a remoção da vesícula biliar de seu leito hepático foram realizadas por meio de tesoura ultrassônica. Realizou-se teste de pressão reversa na vesícula biliar removida intacta do leito hepático para verificar a segurança da técnica. RESULTADOS: A principal indicação cirúrgica foi a colelitíase. O tempo cirúrgico médio foi de 26 min e todas as vesículas biliares foram retiradas intactas do leito hepático. Não houve mortalidade e a taxa global de morbidade foi de 0,8%, sem hemorragias ou fístulas. O teste de pressão reversa mostrou que o ducto cístico ocluído pelo bisturi harmônico suportou ao pelo menos 36 mmHg de pressão sem que ocorresse nenhum vazamento. CONCLUSÃO: O bisturi harmônico é eficaz e seguro em colecistectomias laparoscópicas eletivas como um instrumento único para ocluir e seccionar tanto a artéria cística quanto o ducto cístico. Vantagens podem ser apontadas ao método com relação a sua segurança e diminuição do tempo cirúrgico. .

Necesidades nutricionales específicas después de cirugía bariátrica / Specific nutritional requirements following bariatric surgery

La cirugía bariátrica es un procedimiento exitoso y cada vez más utilizado para el tratamiento de la obesidad con presencia de enfermedades asociadas o sin ella. Existen diferentes tipos de procedimientos los cuales se seleccionan dependiendo del tipo de paciente y de la recomendación y experiencia del médico tratante. La cirugía bariátrica per se genera deficiencias nutricionales que deben considerarse de antemano y, por lo tanto, ser tratadas y no obviadas. La administración a ciegas de suplementos nutricionales conlleva a pecar tanto por déficit como por exceso, lo cual genera consecuencias nutricionales a corto y a largo plazo. El cirujano y su equipo deben ir más allá del procedimiento quirúrgico y contribuir con el tratamiento metabólico y nutricional, consiguiendo una mejor calidad de vida para el paciente.

Bariatric surgery is a successful procedure increasingly used for the treatment of obesity with or without the presence of comorbidities. There are several bariatric procedures, which are selected depending on the patient, the recommendation and experience of the physician. Bariatric surgery "per se" generates nutritional deficiencies that must be considered in advance and therefore treated and not obviated. The blind administration of nutritional supplements leads to both deficit and excess, creating short and long term nutritional consequences. The surgeon and his team must go beyond the surgical procedure and consider nutrition as a complementary treatment, which contributes to a better metabolic and nutritional patient's status and therefore a better quality of life.

Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases.

BACKGROUND: One of the complications of laparoscopic adjustable gastric banding is intragastric erosion, leading to a revisional procedure to remove the band. Our aim was to present the procedure and results of endoscopic band removal in a 5-year multicenter experience from the Gastro Obeso Center and Universidade de São Paulo, São Paulo, and Universidade Federal de Pernambuco, Recife, Brazil. METHODS: From 2003 to 2008, 82 patients were diagnosed with band erosion. The clinical data concerning the endoscopic procedure were prospectively recorded and retrospectively reviewed. RESULTS: The average preoperative body mass index was 43.2 kg/m(2) (range 34-50). At the diagnosis of intragastric erosion, the body mass index was 24-41 kg/m(2) (average 31.8). The erosion occurred an average of 16.3 months (range 6-36) postoperatively. The symptoms included pain in 25 (31%), port infection in 21 patients (27%), and weight regain in 20 (25%), and 12 patients (15%) were asymptomatic. Endoscopic removal was possible for 78 patients (95%). In 85% of patients, the band was removed in the first session, with an average duration of 55 minutes (range 25-150). Five cases of pneumoperitoneum occurred after the procedure. Of these, 3 were treated conservatively, 1 was treated by laparoscopy, and 1 was treated by abdominal puncture using the Veress needle. CONCLUSION: Endoscopic removal of eroded laparoscopic adjustable gastric banding is safe and effective. It can be used as a first choice procedure in clinical practice.

Utilización de la citrulina plasmática como marcador de la función intestinal: aplicaciones en trasplante de intestino y otras enfermedades digestivas / Plasma citrulline levels as marker of intestinal function: applications in intestinal transplantation and digestive diseases

El intestino delgado es responsable, no sólo de la digestión y la absorción de los nutrientes, sino también del metabolismo de varios aminoácidos, entre ellos, la glutamina, principal precursor de la citrulina plasmática.El metabolismo único de la citrulina ha atraído interés científico en la aplicación clínica como marcador de la función intestinal en algunas enfermedades y en procedimientos quirúrgicos como el trasplante de intestino delgado y en resecciones intestinales extensas, que desencadenan el síndrome de intestino corto. Se han propuesto diversos marcadores para la valoración de la función intestinal pero, ante la baja sensibilidad y especificidad, además de la difícil aplicación clínica, la citrulina viene mostrándose como una herramienta no invasiva de la valoración de la masa y funcionalidad de los enterocitos. El objetivo de esta revisión es describir la importancia de la citrulina en las principales enfermedades y procedimientos quirúrgicos del intestino delgado, destacando su metabolismo, aplicaciones en el trasplante de intestino y perspectivas de su aplicación clínica en otras enfermedades digestivas.

Human hybrid NOTES transvaginal sleeve gastrectomy: initial experience.

Laparoscopic sleeve gastrectomy is gaining popularity as a treatment of morbid obesity. It is a relatively new procedure with a postoperative follow-up not exceeding 5 years. The natural orifice transluminal endoscopic surgical procedures are also gaining in popularity, and we are now experiencing the first transition from animal to human trials. We describe the first sleeve gastrectomy surgery for morbid obesity using the vagina as the natural orifice in the form of a hybrid natural orifice transluminal endoscopic surgery transvaginal sleeve gastrectomy, including the short-term outcomes and complications.