DIAGNOSTIC ACCURACY OF THE NON-INVASIVE MARKERS NFLS, NI-NASH-DS, AND FIB-4 FOR ASSESSMENT OF DIFFERENT ASPECTS OF NON-ALCOHOLIC FATTY LIVER DISEASE IN INDIVIDUALS WITH OBESITY: CROSS-SECTIONAL STUDY.

BACKGROUND: Non-invasive markers have been developed to assess the presence and severity of liver abnormalities related to non-alcoholic fatty liver disease (NAFLD). OBJECTIVE: To analyze the diagnostic accuracy of non-invasive NAFLD markers (NAFLD liver fat score [NLFS], non-invasive non-alcoholic steatohepatitis detection score [NI-NASH-DS] and fibrosis score based on four variables [FIB-4]) in individuals with obesity undergoing bariatric surgery. METHODS: A descriptive retrospective cross-sectional study was carried out enrolling 91 individuals who underwent bariatric surgery at a tertiary-level public university hospital. Non-invasive NAFLD markers were calculated using laboratory tests, clinical and anthropometric variables and diagnostic accuracy tests were calculated comparing them in relation to the gold-standard test for this analysis (histopathological evaluation). RESULTS: A total of 85.7% of the participants were female and mean age was 39.1±9.8 years. The average body mass index was 38.4±3.6 kg/m2. At histopathological examination, 84 (92.3%) patients presented with steatosis, 82 (90.1%) with some type of fibrosis; 21 (23.1%) patients were diagnosed with NASH according to the NAFLD activity score criteria. The overall accuracy of NLFS score was 58.2% for general hepatic steatosis and 61.5% for moderate to severe steatosis. The overall accuracy of FIB-4 was 95.4% for advanced fibrosis. NI-NASH-DS had a 74.7% overall accuracy for NASH. CONCLUSION: In a population of individuals with obesity, the FIB-4 score had high overall accuracy in assessing the presence of advanced liver fibrosis, whereas the NFLS and NI-NASH-DS had moderate accuracies for the assessment of steatosis and NASH, respectively.

Effects of bariatric surgery on renal function: a retrospective cohort study comparing one-year outcomes between one-anastomosis gastric bypass and Roux-en-Y gastric bypass.

BACKGROUND: Evidence on the effect of one-anastomosis gastric bypass (OAGB) on renal function is limited. OBJECTIVE: To compare the evolution of estimated renal function observed 1 year after OAGB and Roux-en-Y gastric bypass (RYGB) in individuals with obesity. DESIGN AND SETTING: Observational, analytical, and retrospective cohort study. Tertiary-level university hospital. METHODS: This study used a prospectively collected database of individuals who consecutively underwent bariatric surgery. Renal function was assessed by calculating the estimated glomerular filtration rate (eGFR), according to the Chronic Kidney Disease Epidemiology Collaboration. The one-year variation in the eGFR was compared between the procedures. RESULTS: No significant differences in age, sex, obesity-associated conditions, or body mass index were observed among individuals who underwent either OAGB or RYGB. OAGB led to a significantly higher percentage of total (P = 0.007) and excess weight loss (P = 0.026). Both OAGB and RYGB led to significantly higher values of eGFR (103.9 ± 22 versus 116.1 ± 13.3; P = 0.007, and 102.4 ± 19 versus 113.2 ± 13.3; P < 0.001, respectively). The one-year variation in eGFR was 11 ± 16.2% after OAGB and 16.7 ± 26.3% after RYGB (P = 0.3). Younger age and lower baseline eGFR were independently associated with greater postoperative improvement in renal function (P < 0.001). CONCLUSION: Compared with RYGB, OAGB led to an equivalent improvement in renal function 1 year after the procedure, along with greater weight loss.

Diving into the proteomic atlas of SARS-CoV-2 infected cells.

The COVID-19 pandemic was initiated by the rapid spread of a SARS-CoV-2 strain. Though mainly classified as a respiratory disease, SARS-CoV-2 infects multiple tissues throughout the human body, leading to a wide range of symptoms in patients. To better understand how SARS-CoV-2 affects the proteome from cells with different ontologies, this work generated an infectome atlas of 9 cell models, including cells from brain, blood, digestive system, and adipocyte tissue. Our data shows that SARS-CoV-2 infection mainly trigger dysregulations on proteins related to cellular structure and energy metabolism. Despite these pivotal processes, heterogeneity of infection was also observed, highlighting many proteins and pathways uniquely dysregulated in one cell type or ontological group. These data have been made searchable online via a tool that will permit future submissions of proteomic data ( https://reisdeoliveira.shinyapps.io/Infectome_App/ ) to enrich and expand this knowledgebase.

Association of Histopathological and Biochemical Aspects of NAFLD With the Severity of Liver Fibrosis in Individuals With Obesity: Cross-sectional Study.

BACKGROUND: Given the importance of fibrosis in the progression of non-alcoholic fatty liver disease (NAFLD), identifying biochemical and histopathological aspects associated with its severity is important to determine the course of disease in high-risk populations. OBJECTIVES: The study aims to investigate correlations between biochemical and histopathological variables associated with the occurrence and severity of NAFLD-related liver fibrosis in individuals with obesity. METHODS: This is a cross-sectional study which enrolled 171 individuals who underwent bariatric surgery at a tertiary university hospital. Clinical, laboratory, and histopathological hepatic characteristics were analyzed. Univariate and multivariate analyses were carried out to identify factors associated with the outcomes studied (severity of fibrosis staging) through simple and multiple regression models. RESULTS: Female were 87.7%, and the mean age was 38.4 ± 9.3 years. The most common histopathological abnormalities were macrovesicular steatosis (74.9%) and hepatocellular ballooning (40.4%). In the histopathological univariate analysis, liver fibrosis significantly correlated with severities of microvesicular steatosis (p = 0.003), lobular inflammation (p = 0.001), and NAS (p < 0.001). In the multivariate analysis, the degrees of microvesicular steatosis (p < 0.001) and NAS (p < 0.001) independently correlated with fibrosis severity. In the univariate biochemical analysis, fibrosis severity significantly correlated with levels of hemoglobin A1c (p = 0.004) and glucose (p = 0.01). In the multivariate analysis, glucose levels independently correlated with liver fibrosis degree (p = 0.007). CONCLUSION: Significant and independent associations were observed between the intensities of microvesicular steatosis, NAS, and glucose levels and the severity degree of liver fibrosis in individuals with obesity.

Identification of Predictors of Non-alcoholic Steatohepatitis and Its Severity in Individuals Undergoing Bariatric Surgery.

BACKGROUND: As obesity reached epidemic proportions, non-alcoholic fatty liver disease (NAFLD) also had a worrisome parallel increase. The non-invasive differentiation of non-alcoholic steatohepatitis (NASH) from uncomplicated NAFLD remains an important challenge in current clinical practice. OBJECTIVE: To identify predictors of the occurrence and severity of NAFLD and NASH. METHODS: This is an analytical cross-sectional study which included individuals undergoing bariatric surgery. Participants were histologically classified according to the presence NASH and severity of NAFLD. Demographic, clinical, anthropometric, and biochemical aspects were analyzed and compared. RESULTS: Out of 171 individuals, 87.7% were female and the mean age was 38.4±9.3 years. The average BMI was 38±3.0 kg/m2. NAFLD was histologically confirmed in 74.9%; the commonest histopathological abnormalities were macrovesicular steatosis (74.9%) and ballooning (40.4%). Simple steatosis occurred in 30.4%, 44.4% presented with NASH, and 31% had severe NAFLD. NASH associated with higher levels of ALT (0.03), ALP (0.02), and glucose (0.02). Cutoff values were, respectively, 23 U/L, 67 U/L, and 81 mg/dL. Their concomitant use provided an 83.1% specificity for NASH. Severe NAFLD associated with diabetes (p=0.02), higher BMI (p=0.01), AST (p=0.04), ALT (p<0.01), ALP (p=0.01), glucose (p=0.02), and ferritin (p<0.01). BMI over 39.3 kg/m2 and ferritin over 178 ng/mL concomitantly provided a 70.5% accuracy for severe NAFLD. CONCLUSIONS: NASH and severe NAFLD associated with higher levels of ALT, ALP, and glucose. Severe NAFLD associated with higher BMI and higher ferritin levels in this group. The concomitant evaluation of these laboratory tests could help ruling out NASH and safely screening severe NAFLD.

Fibrotic NASH in Individuals with Obesity: a Cross-sectional Analysis of the Prevalence of this Significant Milestone of Disease Progression and Accuracy of a Non-invasive Marker for its Screening.

BACKGROUND: Fibrotic non-alcoholic steatohepatitis (NASH), i.e., the concomitant presence of active inflammation and fibrosis, represents a milestone in the natural history of NAFLD and a critical time point in its progression. The purpose of this study was to analyze the diagnostic accuracy of the non-invasive Fibrotic NASH Index (FNI) in individuals with obesity undergoing bariatric surgery. METHODS: This is a cross-sectional study, enrolling individuals who underwent bariatric surgery with liver biopsy at a tertiary university hospital. FNI was calculated, and a cutoff value was determined. Its diagnostic accuracy was then calculated through comparison with the gold standard test for this analysis (histopathological examination). RESULTS: Of 128 participants, 83.6% were female, and the average age was 39.8 ± 8.7 years. The mean BMI was 38.7 ± 5.7 kg/m2. NAFLD was histologically confirmed in 76.6%, of which 81.6% had NASH. Histologically confirmed fibrotic NASH was observed in 22.7% of the general study population, 29.6% of individuals with NAFLD, and 36.3% of those with NASH. The mean FNI was 0.18 ± 0.19. An optimal cutoff point of 0.21 was determined, with an overall accuracy of 90.1%, an 82.8% sensitivity, a 90.8% specificity, a 72.6% positive predictive value, and a 94.7% negative predictive value. CONCLUSIONS: FNI provided adequate accuracy in detecting and ruling out fibrotic NASH. Considering the importance of fibrotic NASH within the natural history of NAFLD progression and the fact that this marker uses simple variables, it may be of great importance in high-risk populations, and its external validation and use should be encouraged.

Impact of pre-operative weight loss on non-alcoholic fatty liver disease histopathology and insulin resistance in individuals undergoing bariatric surgery: a propensity matched cross-sectional comparison

ABSTRACT BACKGROUND: The effect of weight loss (WL) on histopathological aspects of non-alcoholic fatty liver disease (NAFLD) may provide further insights into the dynamics of hepatic recovery after WL. OBJECTIVE: To analyze the effects of pre-operative WL on insulin resistance- and NAFLD-related histology in individuals undergoing bariatric surgery (BS) with or without pre-operative WL. DESIGN AND SETTING: A matched cross-sectional study was conducted at a public university hospital and a private clinic in Campinas, Brazil. METHODS: An analytical, observational, cross-sectional study was conducted using prospectively collected databases of individuals who underwent BS and liver biopsy at either a public tertiary university hospital (with pre-operative WL) or a private clinic (without pre-operative WL). Random electronic matching by gender, age, and body mass index (BMI) was performed and two paired groups of 24 individuals each were selected. RESULTS: Of the 48 participants, 75% were female. The mean age was 37.4 ± 9.6. The mean BMI was 38.9 ± 2.6 kg/m2. Fibrosis was the most common histopathological abnormality (91.7%). Glucose was significantly lower in the WL group (92 ± 19.1 versus 111.8 ± 35.4 mg/dL; P = 0.02). Significantly lower frequencies of macrovesicular steatosis (58.3% versus 95.8%; P = 0.004), microvesicular steatosis (12.5% versus 87.5%; P < 0.001), and portal inflammation (50% versus 87.5%; P = 0.011) were observed in the WL group. CONCLUSION: Pre-operative WL was significantly associated with lower frequencies of macro- and mi- crovesicular steatosis, portal inflammation, and lower glycemia, indicating an association between the recent trajectory of body weight and histological aspects of NAFLD.

NI-NASH-DS e FIB-4 para avaliação de diferentes aspectos da doença hepática gordurosa não-alcoólica em indivíduos com obesidade: estudo transversal / Diagnostic accuracy of the non-invasive markers nfls, ni-nash-ds, and fib-4 for assessment of different aspects of non-alcoholic fatty liver disease in individuals with obesity: cross-sectional study

ABSTRACT Background: Non-invasive markers have been developed to assess the presence and severity of liver abnormalities related to non-alcoholic fatty liver disease (NAFLD). Objective: To analyze the diagnostic accuracy of non-invasive NAFLD markers (NAFLD liver fat score [NLFS], non-invasive non-alcoholic steatohepatitis detection score [NI-NASH-DS] and fibrosis score based on four variables [FIB-4]) in individuals with obesity undergoing bariatric surgery. Methods: A descriptive retrospective cross-sectional study was carried out enrolling 91 individuals who underwent bariatric surgery at a tertiary-level public university hospital. Non-invasive NAFLD markers were calculated using laboratory tests, clinical and anthropometric variables and diagnostic accuracy tests were calculated comparing them in relation to the gold-standard test for this analysis (histopathological evaluation). Results: A total of 85.7% of the participants were female and mean age was 39.1±9.8 years. The average body mass index was 38.4±3.6 kg/m2. At histopathological examination, 84 (92.3%) patients presented with steatosis, 82 (90.1%) with some type of fibrosis; 21 (23.1%) patients were diagnosed with NASH according to the NAFLD activity score criteria. The overall accuracy of NLFS score was 58.2% for general hepatic steatosis and 61.5% for moderate to severe steatosis. The overall accuracy of FIB-4 was 95.4% for advanced fibrosis. NI-NASH-DS had a 74.7% overall accuracy for NASH. Conclusion: In a population of individuals with obesity, the FIB-4 score had high overall accuracy in assessing the presence of advanced liver fibrosis, whereas the NFLS and NI-NASH-DS had moderate accuracies for the assessment of steatosis and NASH, respectively.

RESUMO Contexto: Marcadores não-invasivos foram desenvolvidos para avaliar a presença e a gravidade de anormalidades hepáticas relacionadas à doença hepática gordurosa não-alcoólica (DHGNA). Objetivo: Analisar a acurácia diagnóstica de marcadores não-invasivos de DHGNA (escore de gordura hepática da DHGNA [NLFS], escore não-invasivo de detecção de esteato-hepatite não-alcoólica [NI-NASH-DS] e escore de fibrose de 4 variáveis [FIB-4]) em indivíduos obesos submetidos à cirurgia bariátrica. Métodos: Foi realizado um estudo descritivo retrospectivo transversal com 91 indivíduos submetidos à cirurgia bariátrica em um hospital universitário público de nível terciário. Marcadores não-invasivos de DHGNA foram calculados por meio de exames laboratoriais, variáveis clínicas e antropométricas; testes de acurácia diagnóstica foram calculados comparando-os em relação ao exame padrão-ouro para essa análise (avaliação histopatológica). Resultados: Um total de 85,7% dos participantes eram do sexo feminino e a média de idade foi de 39,1±9,8 anos. O índice de massa corporal médio foi de 38,4±3,6 kg/m2. Ao exame histopatológico, 84 (92,3%) pacientes apresentavam esteatose, 82 (90,1%) com algum grau de fibrose; 21 (23,1%) pacientes foram diagnosticados com esteato-hepatite não-alcoólica (EHNA) de acordo com os critérios do escore de atividade da DHGNA. A acurácia global do escore NLFS foi de 58,2% para esteatose hepática e 61,5% para esteatose moderada a grave. A acurácia global do FIB-4 foi de 95,4% para fibrose avançada. NI-NASH-DS apresentou uma acurácia global de 74,7% para EHNA. Conclusão: Em uma população de indivíduos com obesidade, o escore FIB-4 teve alta acurácia global para avaliar a presença de fibrose hepática avançada, enquanto o NFLS e o NI-NASH-DS tiveram acurácias moderadas para avaliar a esteatose e EHNA, respectivamente.

Effects of bariatric surgery on renal function: a retrospective cohort study comparing one-year outcomes between one-anastomosis gastric bypass and Roux-en-Y gastric bypass

ABSTRACT BACKGROUND: Evidence on the effect of one-anastomosis gastric bypass (OAGB) on renal function is limited. OBJECTIVE: To compare the evolution of estimated renal function observed 1 year after OAGB and Roux-en-Y gastric bypass (RYGB) in individuals with obesity. DESIGN AND SETTING: Observational, analytical, and retrospective cohort study. Tertiary-level university hospital. METHODS: This study used a prospectively collected database of individuals who consecutively underwent bariatric surgery. Renal function was assessed by calculating the estimated glomerular filtration rate (eGFR), according to the Chronic Kidney Disease Epidemiology Collaboration. The one-year variation in the eGFR was compared between the procedures. RESULTS: No significant differences in age, sex, obesity-associated conditions, or body mass index were observed among individuals who underwent either OAGB or RYGB. OAGB led to a significantly higher percentage of total (P = 0.007) and excess weight loss (P = 0.026). Both OAGB and RYGB led to significantly higher values of eGFR (103.9 ± 22 versus 116.1 ± 13.3; P = 0.007, and 102.4 ± 19 versus 113.2 ± 13.3; P < 0.001, respectively). The one-year variation in eGFR was 11 ± 16.2% after OAGB and 16.7 ± 26.3% after RYGB (P = 0.3). Younger age and lower baseline eGFR were independently associated with greater postoperative improvement in renal function (P < 0.001). CONCLUSION: Compared with RYGB, OAGB led to an equivalent improvement in renal function 1 year after the procedure, along with greater weight loss.

A infecção por Helicobacter pylori e o resultado de seu tratamento de erradicação influenciam a perda de peso e achados endoscópicos após o bypass gástrico em Y de Roux? Um estudo de coorte histórica / Do helicobacter pylori infection and eradication therapy status influence weight loss outcomes and endoscopic findings after roux-en-y gastric bypass?a historical cohort study

ABSTRACT Background: Currently, there is conflicting evidence linking Helicobacter pylori (HP) infection with weight loss and endoscopic findings after Roux-en-Y gastric bypass (RYGB). Objective: To identify correlations between HP infection and its eradication with weight loss and endoscopic findings after RYGB. Methods: This is an observational retrospective cohort study based on a prospectively collected database of individuals who underwent RYGB from 2018-2019 at a tertiary university hospital. HP infection and the HP eradication therapy outcomes were correlated with post-operative weight loss and endoscopic findings. Individuals were classified according to the status of HP infection into four groups: no infection; successful eradication; refractory infection; and new-onset infection. Results: Of 65 individuals, 87% were female and the mean age was 39±11.2 years. Body mass index significantly decreased from 36.2±3.6 to 26.7±3.3 kg/m2 one year after RYGB (P<0.0001). The percentage of total weight loss (%TWL) was 25.9±7.2% and the percentage of excess weight loss was 89.4±31.7%. HP infection prevalence decreased from 55.4% to 27.7% (p=0.001); 33.8% never had HP infection, 38.5% were successfully treated, 16.9% had refractory infection and 10.8 % had new-onset HP infection. %TWL was 27.3±7.5% in individuals who never had HP, 25.4±8.1% in the successfully treated, 25.7±5.2% in those with refractory infection, and 23.4±6.4% in the new-onset HP infection group; there were no significant differences among the four groups (P=0.6). Pre-operative HP infection significantly associated with gastritis (P=0.048). New-onset HP infections significantly associated with a lower frequency of jejunal erosions after surgery (P=0.048). Conclusion: No effects of the HP infection on weight loss were identified in individuals undergoing RYGB. A higher prevalence of gastritis was observed in individuals with HP infection before RYGB. New-onset HP infection after RYGB was a protective factor for jejunal erosions.

RESUMO Contexto: Há evidências conflitantes na literatura atual ligando a infecção por Helicobacter pylori (HP) com a perda de peso e achados endoscópicos após o bypass gástrico em Y de Roux (BGYR). Objetivo: Identificar correlações entre infecção por Helicobacter pylori HP e seu tratamento de erradicação com perda de peso e achados endoscópicos após BGYR. Métodos: Trata-se de um estudo retrospectivo e observacional de coorte histórica, baseado em um banco de dados coletados prospectivamente de indivíduos submetidos ao BGYR de 2018 a 2019 em um hospital terciário universitário. A infecção pelo HP e os resultados da terapia de erradicação do HP foram correlacionados com a perda de peso pós-operatória e os achados endoscópicos. Os indivíduos foram classificados de acordo com o status de infecção pelo HP em quatro grupos: ausência de infecção; erradicação bem-sucedida; infecção refratária; e infecção nova. Resultados: Dos 65 indivíduos, 87% eram do sexo feminino e a média de idade foi de 39±11,2 anos. O índice de massa corporal diminuiu significativamente de 36,2±3,6 para 26,7±3,3 kg/m2 um ano após BGYR (P<0,0001). O percentual de perda de peso foi 25,9±7,2% e o percentual de perda do excesso de peso foi 89,4±31,7%. A prevalência de infecção por HP diminuiu de 55,4% para 27,7% após a cirurgia (P=0,001); 33,8% nunca tiveram infecção por HP, 38,5% tiveram um tratamento bem-sucedido, 16,9% tiveram infecção refratária e 10,8% tiveram nova infecção por HP. Infecção pré-operatória por HP associou-se significativamente à presença de gastrite (P=0,048). Infecções por HP de início recente associaram-se significativamente com menor frequência de erosões jejunais após a cirurgia (P=0,048). Conclusão: Não foram identificados efeitos da infecção por HP na perda de peso em indivíduos submetidos ao BGYR. Maior prevalência de gastrite foi observada em indivíduos com infecção por HP antes da cirurgia. A infecção por HP de início recente após BGYR foi um fator protetor para erosões jejunais.

Is Helicobacter pylori infection associated with non-alcoholic fatty liver disease in individuals undergoing bariatric surgery? Cross-sectional study

ABSTRACT BACKGROUND: A possible direct link between nonalcoholic fatty liver disease (NAFLD) and Helicobacter pylori (H. pylori) infection has recently emerged. OBJECTIVE: This study aimed to analyze associations between the presence of histologically demonstrated NAFLD aspects with H. pylori infection in individuals with obesity undergoing bariatric surgery. DESIGN AND SETTING: An observational analytical cross-sectional study was conducted based on data collected from the medical records of individuals undergoing bariatric surgery at a tertiary university hospital in 2019. METHODS: NAFLD was assessed through histological examination of wedge liver biopsies collected during the proceedings. H. pylori infection was analyzed through the association of the urease test and histological examination performed in biopsies routinely collected during preoperative esophagogastroduodenoscopy. RESULTS: Of the 88 participants, 85% were female, and the average age was 39.1 ± 8.4 years. H. pylori infection was present in 61.4% of the patients. The mean body mass index was 36.6 ± 3.4 kg/m2. The most prevalent histopathological aspects of NAFLD were macrovesicular steatosis (92%), hepatocellular ballooning (92%), lobular inflammation (93.2%), portal inflammation (96.6%), and fibrosis (93.2%). No histopathological aspect of NAFLD was found to be significantly associated with H. pylori infection. CONCLUSION: In this study population, H. pylori infection was not significantly associated with the histopathological aspects of NAFLD in individuals with obesity undergoing bariatric surgery.

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.

Pesquisa pré-operatória de infecção por Helicobater pylori em pacientes bariátricos: a análise histopatológica é necessária? / Pre-operative screening of helicobacter pylori in bariatric patients: is histopathological analysis necessary?

ABSTRACT Background: Helicobacter pylori infection has been reported to lead to post-operative complications after bariatric surgery (BS), especially marginal ulcers. The optimal method for pre-operative screening is yet to be determined. Objective: To analyze the diagnostic accuracy of the endoscopic urease test for the detection of H. pylori in individuals undergoing BS and the main endoscopic and histological changes within this population. Methods: A cross-sectional study was carried out based on a database from medical records of 232 individuals who underwent BS between 2016 and 2019 at a tertiary university hospital. Clinical, anthropometric, and endoscopic data were analyzed. The gold-standard method considered to calculate diagnostic accuracy variables was histopathological examination through hematoxylin-eosin/Giemsa stains. Results: 87.5% of the participants were female; mean age was 38.5±9.5 years and average body mass index was 37.6±3.8 kg/m2. The commonest endoscopic finding was gastritis (50.9%) with a predominance of the mild erosive form (25%). Upon histological examination, 59.1% of the participants had confirmed H. pylori infection. H. pylori infection was associated with higher frequencies of endoscopic duodenitis (23.4% vs 12.6%; P=0.04), histological chronic gastritis (100% vs 56.8%; P<0.0001) and histological acute gastritis (58.4% vs 2.1%; P<0.0001). The urease test had a sensitivity of 79.6% and a specificity of 97.9%, leading to an overall accuracy of 87.1%. Conclusion The endoscopic urease test is highly accurate for pre-operative screening of H. pylori infection in individuals who undergo BS. H. pylori infection was significantly associated with endoscopic (duodenitis) and histopathological (chronic and active gastritis) changes.

RESUMO Contexto: A infecção por Helicobacter pylori tem sido descrita como causa de complicações pós-operatórias após cirurgia bariátrica (CB), especialmente úlceras marginais. O método ideal para a triagem pré-operatória ainda não foi determinado. Objetivo: Analisar a acurácia diagnóstica do teste endoscópico de urease para detecção de H. pylori em indivíduos submetidos à CB e as principais alterações endoscópicas e histológicas observadas nessa população. Métodos: Foi realizado um estudo transversal a partir de um banco de dados de prontuários de 232 indivíduos submetidos à CB entre 2016 e 2019 em um hospital universitário terciário. Dados clínicos, antropométricos e endoscópicos foram analisados. Foi considerado como método padrão-ouro para calcular as variáveis de acurácia diagnóstica o exame histopatológico por colorações de hematoxilina-eosina e Giemsa. Resultados: 87,5% dos participantes eram do sexo feminino; a média de idade foi de 38,5±9,5 anos e o índice de massa corporal médio foi de 37,6±3,8 kg/m2. O achado endoscópico mais comum foi gastrite (50,9%) com predomínio da forma erosiva leve (25%). Ao exame histológico, 59,1% dos participantes apresentaram infecção confirmada por H. pylori. A infecção por H. pylori foi associada a maiores frequências de duodenite endoscópica (23,4% vs 12,6%; P=0,04), gastrite crônica histológica (100% vs 56,8%; P<0,0001) e gastrite aguda histológica (58,4% vs 2,1%; P<0,0001). O teste de urease teve sensibilidade de 79,6% e especificidade de 97,9%, levando à acurácia global de 87,1%. Conclusão: O teste endoscópico de urease tem alta acurácia para triagem pré-operatória da infecção por H. pylori em candidatos à CB. A infecção por H. pylori foi significativamente associada a alterações endoscópicas (duodenite) e histopatológicas (gastrite crônica e ativa).

A realização sistemática de biópsia hepática deveria ser considerada na prática cirúrgica bariátrica? Uma análise das limitações de marcadores não-invasivos de DHGNA / Should routine liver biopsy be considered in bariatric surgical practice? an analysis of the limitations of non-invasive nafld markers

ABSTRACT Background Non-invasive markers are useful and practical tools for assessing non-alcoholic fatty liver disease (NAFLD), but liver biopsy remains the gold-standard method. Liver biopsy can be easily obtained on individuals undergoing bariatric surgery, but there is no ultimate evidence on the relationship between costs, risks and benefits of its systematic performance. Objective To compare the diagnostic accuracy of non-invasive methods with liver biopsy for detection and staging of NAFLD in obese individuals undergoing bariatric surgery. Methods This is a cross-sectional, observational and descriptive study which enrolled individuals who underwent bariatric surgery from 2018 through 2019 at a public tertiary university hospital. Ultrasound scan, hepatic steatosis index, Clinical Non-Alcoholic Steatohepatitis Score (C-NASH), hypertension, alanine aminotransferase (ALT) and insulin resistance (HAIR), aspartate aminotransferase (AST) to Platelet Ratio Index (APRI), NAFLD Fibrosis Score (NFS) and body mass index, AST/ALT ratio, and diabetes (BARD) were the methods compared with the histopathological examination of wedge liver biopsies collected during surgery. Results Of 104 individuals analyzed, 91 (87.5%) were female. The mean age was 34.9±9.7 years. There was no biopsy-related morbidity. The respective overall accuracies of each marker analyzed were: ultrasound scan (79.81% for steatosis), hepatic steatosis index (79.81% for steatosis), HAIR (40.23% for steatohepatitis), C-NASH (22.99% for steatohepatitis), APRI (94.23% for advanced fibrosis), NFS (94.23% for advanced fibrosis), and BARD (16.35% for advanced fibrosis). Discussion Given the high prevalence of liver disease within this population, even the most accurate markers did not present enough discretionary power to detect and/or rule out the NAFLD aspects they were designed to assess in comparison with liver biopsy, which is safe and easy to obtain in these patients. Conclusion Wedge liver biopsy during bariatric surgery helps to diagnose and stage NAFLD, presents low risks and acceptable costs; given the limitations of non-invasive methods, it is justifiable and should be considered in bariatric routine.

RESUMO Contexto Marcadores não-invasivos são ferramentas úteis e práticas para avaliar a doença hepática gordurosa não alcoólica (DHGNA), porém, a biópsia hepática continua sendo o método padrão-ouro. A biópsia pode ser facilmente obtida em indivíduos submetidos à cirurgia bariátrica, mas não há evidências definitivas acerca da relação entre custos, riscos e benefícios de sua realização sistemática. Objetivo Comparar a acurácia diagnóstica de métodos não-invasivos com a biópsia hepática para detecção e estadiamento da DHGNA em obesos submetidos à cirurgia bariátrica. Métodos Trata-se de um estudo transversal, observacional e descritivo que envolveu indivíduos que se submeteram à cirurgia bariátrica de 2018 a 2019 em um hospital universitário público terciário. Ultrassonografia (US), índice de esteatose hepática (HSI), Escore Clínico de Esteato-hepatite Não-Alcoólica (C-NASH), Índice de Hipertensão, alanina aminotransferase (ALT) e resistência à insulina (HAIR), Razão entre aspartato aminotransferase (AST) e plaquetas (APRI), Escore de Fibrose da DHGNA (NFS) e índice de massa corporal (IMC), relação AST/ALT e diabetes (BARD) foram os métodos comparados com o exame histopatológico de biópsias hepáticas em cunha coletadas durante a cirurgia. Resultados De 104 indivíduos analisados, 91 (87,5%) eram do sexo feminino. A média de idade foi de 34,9±9,7 anos. Não houve morbidade relacionada à biópsia. As respectivas acurácias globais de cada marcador analisado foram: US (79,81% para esteatose), HSI (79,81% para esteatose), HAIR (40,23% para esteato-hepatite), C-NASH (22,99% para esteato-hepatite), APRI (94,23% para fibrose avançada), NFS (94,23% para fibrose avançada) e BARD (16,35% para fibrose avançada). Discussão: Considerando a alta prevalência de doença hepática nesta população, mesmo os mais acurados destes marcadores não apresentaram poder discricionário suficiente para detectar e/ou descartar os aspectos da DHGNA que foram desenvolvidos para avaliar em comparação com a biópsia hepática, que é segura e de fácil obtenção nestes pacientes. Conclusão A biópsia hepática em cunha durante a cirurgia bariátrica auxilia no diagnóstico e estadiamento da DHGNA, apresenta baixo risco e custos aceitáveis e, dadas as limitações dos métodos não-invasivos, é justificável e deve ser considerada na rotina bariátrica.

Effect of transient obstructive cholestasis on liver histology: a cross-sectional study

ABSTRACT BACKGROUND: The role of transient obstructive cholestasis on liver histology remains undetermined. OBJECTIVE: To investigate whether transient cholestasis impairs liver histology. DESIGN AND SETTING: Cross-sectional study at a public university hospital (UNICAMP), Brazil. METHODS: 169 individuals undergoing cholecystectomy, with or without cholestasis. were enrolled. Histopathological findings were correlated with clinical and biochemical characteristics. RESULTS: Biliary hepatopathy was more frequent in individuals with resolved cholestasis than in those with active obstruction or no jaundice (P < 0.01), as also were fibrosis and ductular proliferation (P = 0.02). Cholestasis was commoner in individuals with resolved obstruction than in those with no history (P < 0.01) or active cholestasis (P < 0.05). Biliary hepatopathy was associated with longer duration of cholestasis (P < 0.001) and higher bilirubin levels (P = 0.02) in individuals with active obstruction; with lower body mass index (P = 0.02) and longer cholestasis (P < 0.001) in individuals with resolved obstruction; and with longer cholestasis (P < 0.001) and longer interval between endoscopic retrograde cholangiopancreatography and surgery (P = 0.03) overall. In individuals with active obstruction, duration of cholestasis (R = 0.7; P < 0.001) and bilirubin levels (R = 0.6; P = 0.004) were independently correlated with cholestasis severity. Duration of cholestasis (R = 0.7; P < 0.001) was independently correlated with ductular proliferation severity. CONCLUSIONS: Transient cholestasis was associated with significant histopathological changes, even after its resolution. Longer duration of obstruction correlated with greater severity of histopathological changes, especially cholestasis and ductular proliferation. This emphasizes the need for early treatment of obstructive cholestasis.

Revisional surgery in severe nutritional complications after bariatric surgical procedures: report of four cases from a single institution and review of the literature / Cirurgia revisional em complicações nutricionais graves após cirurgia bariátrica: relato de 4 casos de uma única instituição e revisão da literatura

ABSTRACT Introduction: bariatric surgery is currently the only treatment that leads to long-term and sustained weight loss and decreased morbidity and mortality in morbidly obese individuals. Roux-en-Y bypass causes weight loss by restricting food intake associated with reduced intestinal absorption, in addition to multiple endocrine and satiogenic effects. Biliopancreatic diversion promotes weight loss mainly due to poor absorption of the nutrients ingested. Both procedures exclude parts of the gastrointestinal tract. Objective: to describe four cases of revisional surgery after primary bariatric surgery, due to serious nutritional complications, and to review the literature regarding this subject. Methods: a retrospective analysis of patients of Unicamps bariatric center database and review of the literatures were performed. Results: four patients were identified, 2 women and 2 men, with a mean age of 48 years. The mean body mass index before revisional surgery was 23.7 kg/m2. Three patients underwent Scopinaro biliopancreatic diversion, and onde patient underwent Roux-en-Y gastric bypass. The revisional surgeries were revision, conversion, and reversion. One patient died. For the review of the literature 12 articles remained (11 case reports and 1 case series). Another five important original articles were included. Conclusion: fortunately, revision surgery is rarely necessary, but when indicated it has increased morbidity, It can be revision, reverion or conversion according to the severity of the patient and the primary surgery performed.

RESUMO Introdução: atualmente, a cirurgia bariátrica é o único tratamento que leva à perda de peso prolongada e sustentada e diminuição da morbimortalidade em indivíduos obesos mórbidos. O bypass em Y-de-Roux causa perda de peso restringindo a ingestão de alimentos associada à redução da absorção intestinal, além de múltiplos efeitos endócrinos e sacietógenos. O desvio biliopancreático promove a perda de peso principalmente devido à diminuição da absorção dos nutrientes ingeridos. Ambos os procedimentos excluem partes do trato gastrointestinal. Objetivo: descrever 4 casos de cirurgia revisional após cirurgia bariátrica primária, devido a graves complicações nutricionais, bem como realizar uma revisão da literatura sobre esse assunto. Métodos: foi realizada uma análise retrospectiva dos pacientes do banco de dados do serviço de cirurgia bariátrica da Unicamp e revisão da literatura. Resultados: foram identificados 4 pacientes, 2 mulheres e 2 homens, com média de idade de 48 anos, o IMC antes da cirurgia revisional eram em média 23,7. Os pacientes haviam sido submetidos em 3 casos a cirurgia de Scopinaro e 1 caso ao bypass gástrico em Y-de-Roux. As cirurgias revisionais foram de revisão, conversão e reversão. Um paciente evoluiu a óbito. Em relação a revisão da literatura, foram selecionados 12 artigos (11 relatos de casos e 1 série de casos). Outros cinco artigos originais importantes foram incluídos. Conclusão: felizmente, a cirurgia revisional raramente é necessária, mas, quando indicada, apresenta alta morbidade. São cirurgias de revisão, reversão ou conversão, de acordo com a gravidade do paciente e a cirurgia primária realizada.

Is there a link between non-alcoholic fatty liver disease aspects and pancreatic cancer? Results of a case-matched study / Existe ligação entre a doença hepática gordurosa não alcoólica e o câncer de pâncreas? Resultados de estudo caso-controle

ABSTRACT Background and Aims: An association between non-alcoholic fatty liver disease (NAFLD) and pancreatic ductal adenocarcinoma (PDAC) has been previously suggested. This study aims at investigating this association and at identifying potential links between variables of the NAFLD spectrum and PDAC. Methods: A cross-sectional case-matched analytical and comparative study was carried out to analyze patients undergoing surgical resection of PDAC and compare them to a control group of individuals undergoing cholecystectomy at a public tertiary teaching hospital, matched by sex, age and BMI. Hepatic histopathological examinations were compared between cases and controls. Results: Of 56 individuals, 36 were male (64.3%) and the median age was 61.5 years old (interquartile range: 57.5 - 70). The participants' median BMI was 24.3 kg/m2 (interquartile range: 22.1-26.2 kg/m2). Microvesicular steatosis (p=0.04), hepatocellular ballooning (p=0.02), fibrosis (p=0.0003) and steatohepatitis (p=0.03) were significantly more frequent in the group of cases. Odds ratios for hepatocellular ballooning (6.2; 95%CI: 1.2-31.8; p=0.03), fibrosis (9.3; 95%CI: 2.5-34.1; p=0.0008) and steatohepatitis (3.9; 95%CI: 1.1-14.3; p=0.04) were statistically significant in relation to the PDAC prevalence. Conclusions: Significant associations were identified between histopathological aspects of NAFLD (microvesicular steatosis, hepatocellular ballooning, fibrosis, and steatohepatitis) and PDAC.

RESUMO Histórico e objetivos: a associação entre a doença hepática gordurosa não alcoólica (DHGNA) e o adenocarcinoma ductal pancreático (ACDP) foi sugerida anteriormente. Este estudo visa investigar esta associação e identificar possíveis ligações entre as variáveis do espectro da DHGNA e o ACDP. Métodos: foi realizado estudo transversal caso-controle analítico e comparativo para analisar pacientes submetidos a ressecção cirúrgica de ACDP e compará-los a grupo controle de indivíduos submetidos a colecistectomia em hospital público terciário de ensino, pareados por sexo, idade e IMC. Os exames histopatológicos hepáticos foram comparados entre casos e controles. Resultados: dos 56 indivíduos, 36 eram do sexo masculino (64,3%) e a idade mediana era de 61,5 anos de idade (intervalo interquartil 57,5-70). A mediana do IMC dos participantes foi de 24,3 kg/m2 (intervalo interquartil 22,1 26,2). Esteatose microvesicular (p = 0,04), balonização hepatocelular (p = 0,02), fibrose (p = 0,0003) e esteato-hepatite (p = 0,03) foram significativamente mais frequentes no grupo de casos. As razões de chances para balonização hepatocelular (6,2; IC 95%: 1,2 - 31,8; p = 0,03), fibrose (9,3; IC 95%: 2,5 - 34,1; p = 0,0008) e esteato-hepatite (3,9; IC 95%: 1,1 - 14,3; p = 0,04) foram estatisticamente significativas em relação à prevalência de ACDP. Conclusões: houve associações significativas entre aspectos histopatológicos de DHGNA (esteatose microvesicular, balonização hepatocelular, fibrose e esteato-hepatite) e a ocorrência de ACDP.

Correlações entre características da doença hepática gordurosa não-alcoólica e os níveis de adipocinas e citocinas inflamatórias em indivíduos submetidos à cirurgia bariátrica / Correlation between nonalcoholic fatty liver disease features and levels of adipokines and inflammatory cytokines among morbidly obese individuals

ABSTRACT BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is the commonest hepatopathy worldwide. OBJECTIVE: To investigate the correlations between NAFLD histopathological features and the levels of adipokines (adiponectin, leptin, and resistin) and circulating inflammatory markers (interleukin-6 [IL-6], interleukin-8 [IL-8], tumor necrosis factor alpha [TNF-α], and C-reactive protein [CRP]). METHODS: This is an exploratory cross-sectional study, which enrolled 19 women with obesity who underwent bariatric surgery. Biochemical characteristics evaluated included the levels of adiponectin, leptin, resistin, IL-6, IL-8, TNF-α, and CRP. NAFLD was assessed through histological examination of liver biopsies carried out during the surgical procedures. RESULTS: The mean age of the study group was 37.3±8.2 years old; mean BMI was 36.2±2.5 kg/m2. Among individuals with liver fibrosis, the levels of IL-8 were significantly higher (24.4 ± 9.7 versus 12.7 ± 6.6; P=0.016726). The intensity of fibrosis presented a significant negative correlation with the levels of adiponectin (R= -0.49379; P=0.03166); i.e. the higher the levels of adiponectin, the lower the intensity of fibrosis. The intensity of steatohepatitis presented a significant negative correlation with the levels of adiponectin (R= -0.562321; P=0.01221); this means that the higher the levels of adiponectin, the lower the intensity of steatohepatitis. CONCLUSION: Adiponectin levels were inversely correlated with the severity of fibrosis and steatohepatitis, whereas IL-8 levels were higher in individuals with liver fibrosis among individuals with obesity and NAFLD undergoing bariatric surgery. The use of these markers to assess NAFLD may bring significant information within similar populations.

RESUMO CONTEXTO: A doença hepática gordurosa não-alcoólica (DHGNA) é a hepatopatia mais comum no mundo. OBJETIVO: Investigar correlações entre as apresentações histopatológicas da DHGNA e os níveis de adipocinas (adiponectina, leptina e resistina) e marcadores sistêmicos de inflamação (interleucina-6 [IL-6], interleucina-8 [IL-8], fator de necrose tumoral alfa [TNF-α] e proteína C reativa [PCR]). MÉTODOS: Estudo transversal exploratório envolvendo 18 mulheres com obesidade submetidas à cirurgia bariátrica. As características bioquímicas avaliadas incluíram os níveis de adiponectina, leptina, resistina, IL-6, IL-8, TNF-α e PCR. A DHGNA foi avaliada através de exams histológicos de biópsias hepáticas realizadas durantes as cirurgias. RESULTADOS: A idade média foi 37,3±8,2 anos; o índice de massa corporal (IMC) médio foi 36,2±2,5 kg/m2. Entre os indivíduos com fibrose hepática, os níveis de IL-8 foram significativamente mais altos (24,4±9,7 versus 12,7±6,6; P=0,016726). A intensidade da fibrose apresentou uma correlação negativa significativa com os níveis de adiponectina (R= -0,49379; P=0,03166), demonstranso que, quanto maiores os níveis de adiponectina, menor a intensidade da fibrose. A intensidade da esteato-hepatite apresentou uma correlação negativa significativa com os níveis de adiponectina (R= -0,562321; P=0,01221), demonstrando que quanto mais altos os níveis de adiponectina, menor a intensidade da esteato-hepatite. CONCLUSÃO: Os níveis de adiponectina correlacionaram-se negativamente com a severidade da fibrose e da esteato-hepatite, enquanto os níveis de IL-8 foram maiores entre os indivíduos com fibrose hepática. O uso destes marcadores pode trazer informações significativas sobre a DHGNA em populações com obesidade.

Utilização dos níveis de amilase no dreno abdominal para diagnóstico de fístulas anastomóticas após o bypass gástrico em Y de Roux / Drain amylase levels may indicate gastrojejunostomy leaks after roux-en-y gastric bypass

ABSTRACT BACKGROUND: Although the incidence of leaks after Roux-en-Y gastric bypass (RYGB) significantly decreased over time, their detection still remains challenging. OBJECTIVE: This study aimed to determine the usefulness of drain amylase levels to detect leaks after RYGB. METHODS: This is a population-based study which enrolled 170 individuals who underwent RYGB. Drain amylase levels were determined on the first and fourth postoperative days. Two thresholds were evaluated: three times higher than the serum levels (parameter I) and higher than 250 IU/L (parameter II). The main outcomes evaluated were perioperative morbidity, the occurrence of leaks, 30-day readmissions and reoperations, hospital stay, and mortality. RESULTS: Considering the parameter I, high drain amylase levels were significantly associated with leaks (12.5% vs 0; P<0.00001). Considering the parameter II, high drain amylase levels were significantly associated with longer hospital stay (8±5.7 vs 4.5±1.3 days; P=0.00032), 30-day reoperations (50% vs 3%; P=0.000285), and leaks (50% vs 0; P<0.00001). The parameter I presented a sensitivity of 100% and specificity of 95.9%, whereas the parameter II presented a sensitivity of 100% and a specificity of 99.4%. CONCLUSION: The determination of drain amylase levels after RYGB was a significant indicator of leaks, hospital stay, and 30-day reoperations. This finding reinforces the importance of abdominal drainage in the RYGB within this context.

RESUMO CONTEÚDO: Embora a incidência de fistulas após o bypass gástrico em Y de Roux (BGRY) tenha diminuído significativamente com a evolução da técnica, sua detecção continua desafiadora. OBJETIVO: Determinar a acurácia dos níveis de amilase no dreno abdominal para detector fístulas após o BGYR. MÉTODOS: Este é um estudo populacional que avaliou 170 indivíduos submetidos ao BGYR. Os níveis de amilase no dreno foram determinados no primeiro e quarto dias de pós-operatório. Dois pontos de corte foram avaliados: três vezes maior que os níveis séricos (parâmetro I) e acima de 250 UI/L (parâmetro II). Os principais desfechos estudados foram: morbidade perioperatória, ocorrência de fístulas, reinternações e reoperações nos primeiros 30 dias, permanência hospitalar e mortalidade. RESULTADOS: Considerando o parâmetro I, altos níveis de amilase do dreno foram indicadores significativos de fístulas (12,5% vs 0; P<0,00001). Considerando o parâmetro II, altos níveis de amilse no dreno estiveram significativamente associados a maior permanência hospitalar (8±5,7 vs 4,5±1,3 dias; P=0,00032), frequência de reoperações (50% vs 3%; P=0,000285) e ocorrência de fístulas (50% vs 0; P<0,00001). O parâmetro I apresentou sensibilidade de 100% e especificidade de 95,9%, enquanto o parâmetro II apresentou sensibilidade de 100% e especificidade de 99,4%. CONCLUSÃO: A determinação dos níveis de amilase no dreno após o BGYR foi um indicador significativo de fístulas, permanência hospitalar e reoperações. Este achado reforça a importância da drenagem abdominal no BGYR dentro deste contexto.

Bariatric surgery in individuals with severe cognitive impairment: report of two cases / Cirurgia bariátrica em indivíduos com déficits cognitivos graves: relato de dois casos

ABSTRACT CONTEXT: Bariatric surgery has become the gold-standard treatment for refractory morbid obesity. Obesity is frequently associated with certain syndromes that include coexisting cognitive deficits. However, the outcomes from bariatric surgery in this group of individuals remain incompletely determined. CASE REPORT: A 25-year-old male with Prader-Willi syndrome, whose intelligence quotient (IQ) was 54, was admitted with a body mass index (BMI) of 55 kg/m2, associated with glucose intolerance. He underwent the Scopinaro procedure for biliopancreatic diversion, with uneventful postoperative evolution, and presented a 55% loss of excess weight one year after the surgery, with resolution of glucose intolerance, and without any manifestation of protein-calorie malnutrition. A 28-year-old male with Down syndrome, whose IQ was 68, was admitted with BMI of 41.5 kg/m2, associated with hypertension. He underwent Roux-en-Y gastric bypass, with uneventful postoperative evolution. He presented a 90% loss of excess weight one year after the surgery, with resolution of the hypertension. CONCLUSION: Bariatric surgery among individuals with intellectual impairment is a controversial topic. There is a tendency among these individuals to present significant weight loss and comorbidity control, but less than what is observed in the general obese population. The severity of the intellectual impairment may be taken into consideration in the decision-making process regarding the most appropriate surgical technique. Bariatric surgery is feasible and safe among these individuals, but further research is necessary to deepen these observations.

RESUMO CONTEXTO: A cirurgia bariátrica tornou-se o tratamento padrão ouro para a obesidade mórbida refratária. A obesidade está frequentemente associada a certas síndromes nas quais também coexistem déficits cognitivos, entretanto, os resultados da cirurgia bariátrica nesse grupo de indivíduos ainda não foram completamente determinados. RELATO DE CASO: Um homem de 25 anos com síndrome de Prader-Willi, cujo quociente de inteligência (QI) era estimado em 54, foi admitido com índice de massa corporal (IMC) de 55 kg/m2, associado com intolerância à glicose. Foi submetido a uma derivação biliopancreática à Scopinaro, com evolução pós-operatória sem complicações significativas. Apresentou perda de 55% do excesso de peso um ano após a cirurgia, com resolução da intolerância à glicose, sem manifestação de desnutrição proteico-calórica. Outro paciente, homem de 28 anos com syndrome de Down, cujo QI era de 68, foi admitido com IMC de 41,5 kg/m2, associado a hipertensão arterial. Foi submetido ao bypass gástrico em Y de Roux, com evolução pós-operatória sem complicações. Apresentou perda de 90% do excesso de peso após um ano e resolução da hipertensão. CONCLUSÃO: A cirurgia bariátrica em indivíduos com déficits intelectuais é um tópico controverso. Existe uma tendência entre esses indivíduos de apresentar perda de peso e controle de comorbidades significativos, porém menores que os observados na população obesa geral. A gravidade do déficit intelectual pode ser considerada no processo de decisão sobre a técnica cirúrgica mais adequada. A cirurgia bariátrica é factível e segura nesse grupo de indivíduos. Porém, mais estudos são necessários para aprofundar estas observações.