General anesthesia type does not influence serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in video laparoscopic bariatric surgery.

OBJECTIVES: Video laparoscopic bariatric surgery is the preferred surgical technique for treating morbid obesity. However, pneumoperitoneum can pose risks to the kidneys by causing a decrease in renal blood flow. Furthermore, as in other surgical procedures, laparoscopic bariatric surgery triggers an acute inflammatory response. Neutrophil gelatinase-associated lipocalin is an early and accurate biomarker of renal injury, as well as of the inflammatory response. Anesthetic drugs could offer some protection for the kidneys and could attenuate the acute inflammatory response from surgical trauma. The objective of this study was to compare the effects of two types of anesthetics, propofol and sevoflurane, on the serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in laparoscopic bariatric surgery. METHODS: Sixty-four patients scheduled for laparoscopic bariatric surgery were randomized into two anesthesia groups and were administered either total intravenous anesthesia (propofol) or inhalation anesthesia (sevoflurane). In the perioperative period, blood samples were collected at three time points (before anesthesia, 6 hours after pneumoperitoneum and 24 hours after pneumoperitoneum) and urine output was measured for 24 hours. Acute kidney injuries were evaluated by examining both the clinical and laboratory parameters during the postoperative period. The differences between the groups were compared using non-parametric tests. ReBEC (http://www.ensaiosclinicos.gov.br/rg/recruiting/): RBR-8wt2fy RESULTS: None of the patients developed an acute kidney injury during the study and no significant differences were found between the serum neutrophil gelatinase-associated lipocalin levels of the groups during the perioperative period. CONCLUSION: The choice of anesthetic drug, either propofol or sevoflurane, did not affect the serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in laparoscopic bariatric surgery.

General anesthesia type does not influence serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in video laparoscopic bariatric surgery

OBJECTIVES: Video laparoscopic bariatric surgery is the preferred surgical technique for treating morbid obesity. However, pneumoperitoneum can pose risks to the kidneys by causing a decrease in renal blood flow. Furthermore, as in other surgical procedures, laparoscopic bariatric surgery triggers an acute inflammatory response. Neutrophil gelatinase-associated lipocalin is an early and accurate biomarker of renal injury, as well as of the inflammatory response. Anesthetic drugs could offer some protection for the kidneys and could attenuate the acute inflammatory response from surgical trauma. The objective of this study was to compare the effects of two types of anesthetics, propofol and sevoflurane, on the serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in laparoscopic bariatric surgery. METHODS: Sixty-four patients scheduled for laparoscopic bariatric surgery were randomized into two anesthesia groups and were administered either total intravenous anesthesia (propofol) or inhalation anesthesia (sevoflurane). In the perioperative period, blood samples were collected at three time points (before anesthesia, 6 hours after pneumoperitoneum and 24 hours after pneumoperitoneum) and urine output was measured for 24 hours. Acute kidney injuries were evaluated by examining both the clinical and laboratory parameters during the postoperative period. The differences between the groups were compared using non-parametric tests. ReBEC (http://www.ensaiosclinicos.gov.br/rg/recruiting/): RBR-8wt2fy RESULTS: None of the patients developed an acute kidney injury during the study and no significant differences were found between the serum neutrophil gelatinase-associated lipocalin levels of the groups during the perioperative period. CONCLUSION: The choice of anesthetic drug, either propofol or sevoflurane, did not affect the serum levels of neutrophil gelatinase-associated lipocalin during the perioperative ...

Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention.

Gastrobronchial fistula (GBF) is a serious complication following bariatric surgery, whose treatment by thoracotomy and/or laparotomy involves a high morbidity rate. We present the outcomes of endoscopic management for GBF as a helpful technique for its healing process. This is a multicenter retrospective study of 15 patients who underwent gastric bypass (n = 10) and sleeve gastrectomy (n = 5) and presented GBF postoperatively (mean of 6.7 months). Ten patients developed lung abscess and were treated by antibiotic therapy (n = 10) and thoracotomy (n = 3). Abdominal reoperation was performed in nine patients for abscess drainage (n = 9) and/or ring removal (n = 4) and/or nutritional access (n = 6). The source of the GBF was at the angle of His (n = 14). Furthermore, 14 patients presented a narrowing of the gastric pouch treated by 20 or 30 mm aggressive balloon dilation (n = 11), stricturotomy or septoplasty (n = 10) and/or stent (n = 7). Fibrin glue was used in one patient. We performed, on average, 4.5 endoscopic sessions per patient. Endotherapy led to a 93.3% (14 out of 15) success rate in GBF closure with an average healing time of 4.4 months (range, 1-10 months), being shorter in the stent group (2.5 × 9.5 months). There was no recurrence during the average 27.3-month follow-up. A patient persisted with GBF, despite the fibrin glue application, and decided to discontinue it. GBF is a highly morbid complication, which usually arises late in the postoperative period. Endotherapy through different strategies is a highly effective therapeutic option and should be implemented early in order to shorten leakage healing time.

Cirurgia endoscópica transluminal por orifícios naturais: realidade atual: [revisão] / Natural orifice transluminal endoscopic surgery: current situation: [revision]

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. Natural orifice transluminal endoscopic surgery refers to the method of accessing the abdominal cavity through a natural orifice under endoscopic visualization. Since its introduction in 2004, numerous reports have been published describing different surgical interventions. Recently, a group of expert laparoscopic surgeons and endoscopists outlined the limitations of this approach and issued recommendations for progress toward human trials. Transluminal surgery is a new method for accessing the abdomen under direct endoscopic visualization. Preliminary studies have demonstrated the feasibility of this technique in animal models; however, further research is warranted to validate its safety in humans.

[Natural orifice transluminal endoscopic surgery: current situation]. / Cirurgia endoscópica transluminal por orifícios naturais: realidade atual.

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. Natural orifice transluminal endoscopic surgery refers to the method of accessing the abdominal cavity through a natural orifice under endoscopic visualization. Since its introduction in 2004, numerous reports have been published describing different surgical interventions. Recently, a group of expert laparoscopic surgeons and endoscopists outlined the limitations of this approach and issued recommendations for progress toward human trials. Transluminal surgery is a new method for accessing the abdomen under direct endoscopic visualization. Preliminary studies have demonstrated the feasibility of this technique in animal models; however, further research is warranted to validate its safety in humans.

Clinical features of rhabdomyolysis after open and laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Rhabdomyolysis (RML) is caused by muscle injury, this may cause kidneys overload and lead to acute renal failure (ARF). The risk factors for RML in bariatric surgery (BS) are operative time (OT) >4 h and high BMI. The frequency of RML in BS varies from 12.9 to 37.8%. This study has the objective of describing the characteristics associated with RML and ARF in BS. METHODS: We studied retrospectively 114 patients submitted to BS. Criteria for RML were CPK level >950 IU/l (five times the normal value). The variables were BMI, OT, age, intraoperative hydration and diuresis, CPK, creatinine, arterial hypertension, peripheric vascular disease, diabetes, open and laparoscopic techniques--inclusion criteria: patients submitted to gastric bypass; exclusion: renal failure and statins use. RESULTS: RML incidence was 7%. The factors associated with RML in the bivariate analysis were hepatic steatosis, high BMI, high weight, higher excess weight, and prolonged OT. The risk factor for RML in the multivariate analysis was BMI > or = 50 kg/m2. When the OT was below 2 h the incidence of RML was zero, but this was not significant in the multivariate analysis. The factors associated with a higher risk of CPK elevation (multivariate analysis) were hypertension and open technique. CONCLUSION: BS is safe, with low incidence of RML/ARF. High BMI is associated with a higher risk of RML. Probably a longer OT is associated with a higher risk of RML not statistically demonstrated in this study. The factors associated with a higher risk of CPK elevation were hypertension and open technique.

Incidence of lower limbs deep vein thrombosis after open and laparoscopic gastric bypass: a prospective study.

BACKGROUND: Lower limbs deep vein thrombosis (DVT) and pulmonary embolism (PE) are major causes of morbidity and mortality and are even higher in bariatric patients. The longer operative time and higher immobility in these patients increase the DVT risk. Although deaths after bariatric surgery have been reported, there is no consensus regarding the prophylaxis of DVT. This study's objective is to determine the incidence of lower limbs DVT in patients submitted to Roux-en-Y-gastric bypass (RYGBP) under prophylaxis by enoxaparin. METHODS: Patients with body mass index (BMI) equal to or higher than 35 kg/m(2) who submitted to RYGBP by laparotomy or laparoscopy using 40 mg/day of enoxaparin for 15 days were recruited between October 2004 and August 2005. Individuals with previous DVT and heparin allergy were excluded. Patients were tested for DVT using color Doppler ultrasound performed before surgery and on the second and fifth weeks after surgery. RESULTS: The study population included 136 patients, with 126 concluding the protocol. There were 79% (100/126) of female patients aged 19 to 65 years old, with mean of 40 years SD = 10 and BMI between 35 and 61 kg/m(2), mean of 43 kg/m(2) (SD = 5). All patients who submitted to RYGBP were divided as 55% (69/126) by laparoscopy and 45% (57/126) by laparotomy. The incidence rate of lower limbs DVT was 0.79% (1/126). CONCLUSION: The low incidence rate of DVT found in our study suggests that obesity might not be a major risk factor for venous thromboembolism in patients submitted to RYGBP.

Técnica de Lichtenstein sob anestesia local em herniorrafias inguinais / Lichtenstein technique under local anaesthesia in inguinal herniorrhaphies

RACIONAL: Herniorrafia inguinal, um procedimento cirúrgico comum no mundo todo, representa um importante gasto para saúde pública. Variadas abordagens cirúrgicas e opções de procedimentos anestésicos estão disponíveis para o reparo das hérnias inguinais atualmente. O objetivo do presente trabalho consiste em revisar e avaliar o tratamento cirúrgico inguinal pela técnica de Lichtenstein sob anestesia local. MÉTODOS: Dados de pesquisa constituíram-se de artigos científicos publicados e disponibilizados no site do PubMed (www.pubmed.gov). A revisão de literatura baseou-se no cruzamento dos seguintes descritores: herniorrafia inguinal, anestesia local e técnica de Lichtenstein. Cento e oito publicações relacionadas ao tema foram revisadas. CONCLUSÕES: A combinação entre anestesia local e o emprego da técnica livre de tensão de Lichtenstein para o reparo de hérnia inguinal primária demonstrou resultados positivos. A associação descrita mostrou reduções significativas na recorrência de hérnia inguinal e nas complicações pós-operatórias, assim como diminuição da dor crônica eventualmente presente em uma avaliação tardia. O melhor controle da dor pós-operatória imediata, a alta hospitalar precoce e o retorno às atividades laborativas podem ser atribuídos de maneira direta ou indireta às técnicas empregadas, refletindo na satisfação do paciente e em baixos custos para saúde pública.

BACKGROUND: Inguinal herniorrhaphy, a common surgical procedure performed worldwide, represents an important expense for public health. A variety of surgical approaches and options for anesthesical procedures are available nowadays for inguinal hernia repair. The aim of this study is to review and to evaluate the Lichtenstein inguinal surgical treatment under local anesthesia. METHODS: Researching data consisted of scientific articles published and available at PubMed site (www.pubmed.gov). Literature review based on crossing the following headings: inguinal herniorrhaphy, local anesthesia and Lichtenstein technique. One hundred and eight publications related to the subject were reviewed. CONCLUSION: Combination between local anesthesia and tension-free Lichtenstein technique for primary inguinal hernia repair demonstrates positive results. The association described shows a significantly decrease in inguinal hernia recurrence and in postoperative complications, as well as reducing chronic pain that might be present in a late follow-up. The better immediate postoperative pain control, early hospital patient discharge and a faster return to job activities may all be attributed directly or indirectly to the technique implemented, reflecting increased patient satisfaction and lower costs for public health.

Common bile duct investigation in patients with mild biliary pancreatitis. when and how? A prospective analysis of 48 patients.

BACKGROUND/AIMS: To define how and when patients with mild acute biliary pancreatitis must have their biliary tree investigated. METHODOLOGY: We analyzed 48 patients' files with mild biliary pancreatitis between 1995 and 2004. After clinical treatment, magnetic resonance or endoscopic retrograde cholangiopancreatography and then surgery was performed. Statistical data were analyzed through SPSS version 11.0. RESULTS: Of the 48 patients, 13 (27%) patients had choledocholithiasis. Five of these (38%) were diagnosed and treated by endoscopic retrograde cholangiopancreatography and 8 (62%) patients had choledocholithiasis at magnetic resonance cholangiopancreatography. These 8 patients underwent endoscopic retrograde cholangiopancreatography which found common bile duct stones in only 4 (50%) of them that were treated successfully with papillotomy. All patients underwent laparoscopic cholecystectomy at the same hospital stay with a low morbidity and no mortality. CONCLUSIONS: We believe that patients with mild biliary pancreatitis should have their biliary tree investigated just after clinical recovery and as close as possible to the operation because many gallstones pass spontaneously through the papillae. We believe that magnetic resonance cholangiopancreatography can avoid an unnecessary endoscopic retrograde cholangiopancreatography.

Laparoscopic management of intestinal obstruction due to phytobezoar.

Phytobezoars are a rare cause of small-bowel obstruction and an accurate preoperative diagnosis is very difficult. After diagnosis, the majority of patients in this study underwent surgery. The conventional management of small-bowel obstruction is done by laparotomy. Many studies have demonstrated that laparoscopy can be an alternative to laparotomy for the treatment of small-bowel obstruction in select patients, and it also brings the benefits of minimally invasive surgery. This report demonstrates the case of a patient with intestinal obstruction caused by phytobezoar (mango seed) who was treated laparoscopically. During the laparoscopy, a hard mass 5 cm proximal to the ileocaecal junction was palpable with graspers. An ileotomy was then performed. The bezoar was extracted and inserted into a bag. In this case, the intestinal obstruction management by laparoscopy was safe and feasible.

Rhabdomyolysis: diagnosis and treatment in bariatric surgery.

BACKGROUND: Rhabdomyolysis (RML) and subsequent acute renal failure can be serious problems following bariatric operations. Early diagnosis and treatment are important to avoid the complications of RML. METHODS: This review was achieved by searching the key words: Rhabdomyolysis, diagnosis, treatment and bariatric surgery. We included prospective, retrospective, case reports and review articles. RESULTS: RML diagnosis can be done by: signs and symptoms, physical evaluation, laboratory findings and imaging examinations. Muscle weakness, myalgia, decubitus ulcer, proteinuria and myoglobinuria are the more mentioned findings. Elevation of CPK levels is the most sensitive diagnostic evidence of RML. Treatment is geared toward preserving renal function by avoiding dehydration, hypovolemia, tubular obstruction, aciduria, and free radical release. Early recognition allows the administration of fluids, bicarbonate, and mannitol. CONCLUSION: Prophylactic measures and early diagnosis and treatment of rhabdomyolysis in bariatric surgery are imperative to prevent the potential fatal complications of this condition.

Rabdomiólise em pacientes obesos submetidos a derivação gástrica laparotômica e laparoscópica / Rhabdomyolysis in obese patients undergoing laparotomy and laparoscopic gastric bypass

A rabdomiólise (RML) é uma síndrome clínica e metabólica causada por lesão e necrose muscular esquelética com liberação de conteúdo intracelular (mioglobina) na circulação sistêmica, podendo sobrecarregar o sistema de filtração renal e causar insuficiência renal aguda (IRA). É causa frequente de necrose tubular aguda e pode ocorrer em cirurgia bariátrica. Os fatores de risco para RML são: tempo cirúrgico prolongado (> 4h) e IMC elevado. A frequência de RML em cirurgia bariátrica varia de 12,9 por cento a 37,8 por cento na literatura médica. Identificar os fatores de risco para rabdomiólise e IRA é importante para se prevenir estas complicações. Este estudo tem como objetivo avaliar e descrever as características clínicas associadas ao surgimento de RML e IRA em pacientes bariátricos. Foram estudados 114 pacientes obesos submetidos à derivação gástrica (métodos laparoscópico ou aberto) nos Hospitais São Rafael e Cidade, no período de 11 meses, de julho de 2005 a maio de 2006. O tipo de estudo foi uma coorte retrospectiva. O desfecho estudado foi a aquisição de RML associada à IRA. Os critérios para o diagnóstico de RML foram níveis de CK > 950 UI/L ou 5 vezes o normal (190 UI/L), RML grave = CK acima de 4000 UI/L. Os critérios de diagnóstico de IRA foram creatinina ≥ 1,3 mg/dL e elevação da creatinina ≥ 50 por cento dos níveis pré-operatórios. As variáveis medidas foram IMC, tempo cirúrgico, idade, hidratação e diurese trans-operatória, CK, creatinina, HAS, doença vascular periférica, diabetes, técnica operatória aberta e laparoscópica. Os dados foram analisados utilizando-se o programa SPSS versão 10.0 para Windows. Critérios de inclusão: pacientes submetidos a derivação gástrica aberta e videolaparoscópica. Exclusão: pacientes com falência renal e pacientes em uso de estatinas. Foi encontrada incidência de 7 por cento de RML, de 59,6 por cento de elevação de CK e de 3,5 por cento de IRA. Os fatores associados na análise bivariada para o desenvolvimento de RML são: esteatose hepática, IMC elevado, peso elevado, excesso de peso, tempo cirúrgico prolongado. O fator de risco na análise multivariada para RML é IMC elevado (IMC ≥ 50kg/m2). O tempo operatório menor levou a uma incidência mais baixa de RML comparado com outros trabalhos, quando a média de tempo foi menor que 3h a incidência de RML ficou abaixo de 10 por cento, e não ocorreu RML grave. Quando o tempo operatório foi menor do que 2h a incidência de RML foi zero. Medidas para diminuir o IMC no pré-operatório e o tempo cirúrgico são fundamentais para atenuar a incidência de RML após cirurgia bariátrica. Os fatores associados na análise bivariada e multivariada para a elevação da CK acima do valor normal são: HAS e técnica operatória aberta. A CK elevada demonstra que pacientes submetidos a cirurgia bariátrica têm uma incidência alta de compressão muscular e uma percentagem destes pacientes irão desenvolver RML, podendo ocorrer também IRA. A incidência de RML e IRA em pacientes submetidos à cirurgia bariátrica é baixa. Medidas para diminuir a elevação dos níveis de CK e o aparecimento de RML ajudam a diminuir a incidência de IRA em cirurgia bariátrica.

Laparoscopic gastric banding in the rat model as a means of videolaparoscopic training.

BACKGROUND: The development of laparoscopy in bariatric surgery has attracted a large number of surgeons. Learning this method for future clinical practice requires intensive training with inert tissues, simulators and experimental surgery in animals. Performing these procedures in small animals, with the same equipment used in humans, is feasible, allowing familiarization with and comprehension of the basic techniques. Wistar rats weighing 300-600 g were used. The animals were kept in standard laboratory conditions. A laparoscopic video-system, Veress needle, three ports, a 0 degree optic, a laparoscopic needle-holder, two 5-mm graspers, a 5-mm dissection clamp and a 5-mm scissors were used. An orogastric catheter with three 4-0 nylon sutures and one 6-0 nylon suture were also utilized. For the gastric band, we used a plastic device similar to the human gastric band. The present study describes a simple, inexpensive and reproducible technique for laparoscopic gastric banding in a rat model utilizing the same instruments developed for humans. The experimental rat model is more motivating than simulators, requires less space, and has easier maintenance compared with bigger animals, and consequently allows the use of more animals for teaching, training and application in many scientific studies.

Abdominal-wall postherpetic pseudohernia.

Herpes zoster affects 10-20% of the general population. Motor complications sometimes occur in the segments corresponding to the involved sensory dermatomes causing abdominal wall pseudohernias. We present a case of a 57-year-old woman with herpes zoster characteristical rash following T11-T12 right dermatomes. Ten days after dermatologic manifestations onset, she had developed a protrusion at the abdominal wall on the right flank. The electroneuromyography confirmed axonal motor commitment, and morphological defects were ruled out by ultrasonography. The bulge totally disappeared after 4 months of observation. Postherpetic pseudohernia must be suspected when a patient develops signs and symptoms of motor dysfunction that coincide with or follow a herpes zoster eruption resulting in abdominal-wall herniation. A review of the literature concerning these extremely exceptional sequelae of herpes zoster is presented.

Staplerless laparoscopic gastric bypass: a new option in bariatric surgery.

The staplerless Roux-en-Y gastric bypass (RYGBP) is a new option in bariatric surgery. The first to describe it was Himpens (2004) utilizing the LigaSure Atlas (LSA) in a series of 10 patients. The laparoscopic RYGBP is performed utilizing the LSA for the gastric and jejunal partition; after that, an imbricating running suture is performed to ensure stomach and bowel hermetic closure. All anastomoses are hand-sewn. Technical disadvantages are: learning curve; complications related to suture failure; possible thermal/electricity related injuries; longer operating time. Advantages are: stapler-associated bleeding, leaks, staple-line disruption, and fistulas are avoided; cost reduction. The staplerless RYGBP is complex; the surgeon involved requires expertise and ability. This technique will evolve and will be used by more surgeons. It is a new option for the surgeon preoccupied with costs, which is particularly important in developing countries.

Remission of psoriasis after open gastric bypass.

Psoriasis is a frequent skin disease, affecting 2% of the world's population. Stress, alcohol, smoking and obesity may be associated with psoriasis. A 56-year-old man with BMI 46.9 kg/m(2), hypertension and gastroesophageal reflux, had severe psoriasis for the last 39 years, without any remission on multiple treatments. Psoriatic papules and plaques were noted on his face, dorsum of hands, buttocks, knees, and elbows. He underwent open Roux-en-Y gastric bypass. At 4-month follow-up, the patient had lost 23 kg or 34.8% of excess weight, and presented complete remission of the psoriasis without medications. Bariatric surgery for positive metabolic, psychological and lifestyle consequences should be considered a treatment of psoriasis. Long-term observation is necessary.

Laparoscopic cholecystectomy for acute cholecystitis in elderly patients.

BACKGROUND: Acute cholecystitis is the major complication of biliary lithiasis, for which laparoscopic treatment has been established as the standard therapy. With longer life expectancy, acute cholecystitis has often been seen in elderly patients (>65 years old) and is often accompanied by comorbity and severe complications. We sought to compare the outcome of laparoscopic treatment for acute cholecystitis with special focus on comparison between elderly and nonelderly patients. METHOD: This study was a prospective analysis of 190 patients who underwent laparoscopic cholecystectomy due to acute cholecystitis or chronic acute cholecystitis, comparing elderly and nonelderly patients. RESULTS: Of 190 patients, 39 (21%) were elderly (>65 years old) and 151 (79%) were not elderly (< or =65 years), with conversion rates of 10.3% and 6.6% (P=0.49), respectively. The incidence of postoperative complications in elderly and nonelderly patients were the following, respectively: atelectasis 5.1% and 2.0% (P=0.27); respiratory infection 5.1% and 2.7% (P=0.6); bile leakage 5.1% and 2.0% (P=0.27), and intraabdominal abscess 1 case (0.7%) and no incidence (P = 1). CONCLUSION: According to our data, laparoscopic cholecystectomy is a safe and efficient procedure for the treatment of acute cholecystitis in patients older than 65 years of age.

Reparo de hérnia de Grynfeltt com uso de tela de polipropileno sob anestesia local / Grynfeltt's hernia repair with polypropylene mesh and local anesthesia

Hérnias lombares são entidades raras com apenas aproximadamente 300 casos relatados na literatura. Elas se classificam quanto ao local de origem em hérnias lombares difusas, hérnias lombares do triângulo inferior ou de Petit e hérnias lombares do triângulo superior, ou hérnias de Grynfellt / Lumbar hernias are rare entities, wich only 300 cases reported in literature. They are classified concerning the region which are located in diffuse lumbar hérnias, inferior lumbar hernia of Petit and superior lumbar hernia of Grynsellt...