What Is the Best Treatment before Bariatric Surgery? Exercise, Exercise and Group Therapy, or Conventional Waiting: a Randomized Controlled Trial.

OBJECTIVE: This trial's objective was to investigate the effect of an exercise program with and without cognitive-behavioral therapy (CBT), compared by a control group, on weight, functional capacity, and cardiometabolic profile of morbidly obese individuals while waiting for bariatric surgery. MATERIALS AND METHODS: This randomized controlled trial investigated the effect of a 4-month low-intensity exercise program (two weekly sessions of 25 min each) on 66 morbidly obese individuals awaiting bariatric surgery. Participants were randomly divided into three groups: EXER, exercise program; EXER + CBT, exercise program plus support group sessions for lifestyle modification, with a CBT; and CONTROL, routine treatment. They were compared on weight, functional capacity, and cardiometabolic profile. RESULTS: The weight change (Kg) was -7.4 (-9.6 to 5,1); -4,2 (-6,8 to -1.6) and 2.9 (0.4 to 5.3) and the BMI change (kg/m2) was -2.7 (-3.6 to -1.8); -1.4 (-2.4 to -0.4) and 1.1 (0.1 to 2.1) for groups EXER, EXER + CBT, and CONTROL, respectively. Changes were significant when compared to the control group (p < 0.001), but there were no differences between the two intervention arms (p = 0.2). Functional capacity and cardiometabolic parameters significantly improved in the intervention arms and worsened in the control group. The adherence to the exercise program in both groups was above 78 %. CONCLUSION: A 4-month, twice-weekly supervised program of low-intensity physical activity that encourages individuals to adopt a more active lifestyle can positively interfere with weight loss and improvement in functional capacity and cardiometabolic parameters of morbidly obese individuals with and without the aid of support group sessions.

Hiatal hernia and gastroesophageal reflux: Study of collagen in the phrenoesophageal ligament.

BACKGROUND: Gastroesophageal reflux disease (GERD) is defined by the intensity and/or quality of the reflux of gastric or duodenal contents into the esophagus. Surgical treatment of GERD has shown conflicting results and unacceptable recurrence rates, mainly due to herniation of the antireflux valve into the chest. A variety of techniques has been proposed to reduce GERD recurrence, including routine use of prosthesis in cruroplasty. The prevalence of GERD in patients with hiatal hernia (HH) can reach 94 %. It is possible that the phrenoesophageal ligament (POL) engaged in the stabilization of the gastroesophageal junction in the abdomen may be an etiological factor of HH. We conducted a study to evaluate collagen in the constitution of the POL in patients with HH and cadavers without HH. METHODS: POL samples were collected from 29 patients with HH and GERD (cases) and 32 samples from cadavers without HH (controls). Total collagen was quantified through the Picrosirius red histochemical technique, and type-I and type-III collagens were quantified immunohistochemically using a monoclonal antibody. The stained slides were photographed, and images were quantified by computer software (Image Pro Plus) to count the pixels per field. RESULTS: The mean age was 49.5 (±11.5) years for the cases and 38.5 (±13) years for the controls (p < 0.01). Seventeen cases (58.6 %) and six controls (18.75 %) were female (p < 0.01). The quantity of total (p < 0.01), type-I (p < 0.01), and type-III (p < 0.05) collagens was significantly lower by about 60 % in patients with HH compared with controls. CONCLUSION: Our data indicate that the composition of POL for patients with GERD and HH includes less total, type-I, and type-III collagens than that of the POL of cadavers without HH. The quality of the POL may be an etiological factor in the development of HH.

Comparative study of shrinkage, inflammatory response and fibroplasia in heavyweight and lightweight meshes.

PURPOSE: In this manuscript, the authors describe an animal study comparing shrinkage, inflammatory response and fibroplasia in heavyweight (HW-PP) and lightweight polypropylene (LW-PP) meshes. METHODS: Both meshes were fixed on abdominal fascia of 25 Wistar rats (epifascial onlay placement). They were killed at 7, 28 and 90 days to measure the prostheses. Histological analysis was performed with hematoxylin-eosin for cellular counting and immunohistochemistry to measure collagen types I and III. RESULTS: The authors found that the LW-PP mesh presented greater median shrinkage than HW-PP mesh at 7 (P = .036), 28 (P = .674) and 90 days (P = .038) postoperatively. There were more neutrophils on LW-PP mesh (P = .008) at 7 days, gradually diminishing in both prostheses. Lymphocytes were similar between the implants at 7 days, diminishing about 50 % on LW-PP mesh (P < .001) at 90 days. Macrophages and giant cells diminished on LW-PP and increased on HW-PP meshes (P < .001). Collagen I/III ratio presented a progressive, almost fivefold rise at 90 days, on both mesh types (P < .001). The collagen I/III ratio was similar between LW-PP and HW-PP meshes at the three times studied. CONCLUSIONS: It is concluded that LW-PP showed more shrinkage than HW-PP mesh at 7 and 90 days, despite the fact that HW-PP presented more lately foreign body reaction. The collagen I/III ratio was similar between the prostheses and increased during the postimplant period.

Elastic fibers in the anterior abdominal wall.

PURPOSE: The aim of this study was to substantiate the hypothesis as to whether an altered amount of elastic fibers in the linea alba aponeurosis occurs or not in anterior abdominal wall hernias (epigastric, incisional and umbilical), comparing the findings with those of a control group of cadavers without hernias. METHODS: Thirty patients (15 males and 15 females) with anterior abdominal wall hernias were evaluated for analysis of the elastin content in samples from the linea alba aponeurosis, with immunohistochemistry and orcein staining using videomorphometry. RESULTS: The results showed a greater amount of elastin in patients with abdominal wall hernias compared to the control group of cadavers without hernias (P < 0.05). The elastic fibers were greatly thickened, tortuous and fragmented in the patients. CONCLUSION: It is essential to analyze the anterior abdominal wall concerning its anatomical condition and histological components. Altered collagen and elastic fibers play an important role in hernia formation, indicating that the main factor may be biological.

Retraction and fibroplasia in a polypropylene prosthesis: experimental study in rats.

BACKGROUND: The treatment of hernia, independent of anatomical site and technique utilized, generally involves using prostheses, which may cause complications, despite their unarguable advantage in allowing safe reinforcement. An example of this is possible retraction, which causes discomfort and hernia recurrence. Polypropylene is still the most often used biomaterial of the great number available. The purpose of this study is to evaluate the amount of retraction of the polypropylene mesh, as well as the histological reactions that accompany this phenomenon. METHODS: Polypropylene meshes (Marlex) were inserted in an anterior position to the whole abdominal aponeurosis of 25 Wistar rats (Rattus norvegicus albinus). The animals were divided into groups and another intervention was performed 7, 28, and 90 days later to measure the dimensions of the prostheses and to calculate the final area. Histological analysis was performed with hematoxylin-eosin to evaluate neutrophils, macrophages, giant cells, and lymphocytes surrounding the mesh threads in ten random fields of each slide. RESULTS: Seven days after the mesh was inserted, the mean rate of retraction was 1.75% (P = 0.64); at 28 days, it was 3.75% (P = 0.02); and at 90 days, it was 2.5% (P = 0.01). As to the histological analysis, there was a total decline of neutrophils and a progressive increase of macrophages, giant cells, and lymphocytes proportional to the post-implant time of the mesh (P < 0.05). CONCLUSION: There was a statistically significant retraction of 3.75% at 28 days and 2.5% at 90 days after the prosthesis was inserted. There is a well-established sequence of cellular events which aim at synthesizing new connective tissue to reinforce the mesh.

Acute gastric dilatation and necrosis: a case report.

Massive gastric dilatation with necrosis and rupture is a very rare event. Here we describe the case of a 13-year-old girl with acute gastric dilatation, infarction, necrosis and perforation. It began with acute abdominal pain, but an absence of vomiting after eating a heavy meal. Laparotomy showed massive gastric dilatation with infarction and perforation. Early diagnosis is essential to reduce morbidity and mortality, and therefore treatment must be started promptly.

Laparoscopic excision of a retroperitoneal cystic lymphangioma in an elderly patient.

A 68-year-old male patient was referred to our hospital due to protrusion and pain in the right iliac fossa. On physical examination a palpable oval tumor was found. Ultrasonography and computed tomography revealed a cystic mass in right iliac fossa. The tumor was successfully excised laparoscopically and histologically diagnosed as cystic lymphangioma. Retroperitoneal cystic lymphangiomas are rare lesions, most often seen in pediatric patients. Surgical excision is the treatment of choice because of its potential to grow and develop complications, especially due to mass effect. The laparoscopic approach is a safe and effective alternative for treatment of retroperitoneal cystic lymphangioma in the elderly.