COMPLICATIONS AND LATE FOLLOW-UP OF SCOPINARO'S SURGERY WITH GASTRIC PRESERVATION: 1570 PATIENTS OPERATED IN 20 YEARS.

AIMS: Scopinaro-type biliopancreatic diversion (BPD-S) and its variations are the surgeries that offer the best immediate results in weight loss and regain in the late follow-up. It has a high rate of immediate complications and demands control with frequent laboratory tests. The aim of this study was to analyze the late postoperative complications of 1570 patients operated by biliopancreatic diversion with gastric preservation laparoscopic video with up to 20 years of postoperative follow-up. METHODS: In a follow-up period of up to 20 years, the clinical and surgical complications of 1570 patients with grade II or III obesity were evaluated who were operated on from 2001 to 2014 with the same team of surgeons. Clavien Dindo 11 classification was used for analysis and comparison. Laboratory tests and body mass index (BMI) were used in the analysis of late metabolic outcomes. RESULTS: On the one hand, complications in 204 patients were recorded (13%), and 143 patients (9.1%) were reoperated. On the other hand, 61 patients (29.9%), who had postoperative complications were clinically treated with good evolution in 9.2 years (95%CI 8.2-10.3), with a median of 9.5 years (95%CI 6.1-12.9). Gastroileal anastomosis ulcers occurred in 44 patients (2.8%). Patients with malnutrition, severe anemia, or chronic diarrhea were operated on with common loop elongation (n=64 - 4%), conversion to gastric diversion (n=29 - 5%), or reversal of surgery (n=10 - 0.6%). One death was registered throughout casuistry (0.06%). CONCLUSIONS: Metabolic result of DBP-S was considered excellent in most patients, even referring to changes in the frequency of bowel movements, loose stools, and unpleasant odor. Complications are usually serious and most of the patients require surgical treatment. Therefore, the biliopancreatic diversion of Scopinaro should be reserved for exceptional cases, as there are safer surgical alternatives with less serious side effects.

Tratamiento quirúrgico paliativo de los tumores periampulares, una opción de paliación a largo plazo / Palliative surgical treatment of periampullary tumors, an option of long-term palliation

RESUMEN Introducción: los tumores de la encrucijada duodeno-bilio-pancreática o periampulares corresponden a un grupo heterogéneo de tumores. Se originan dentro de los 2 cm de la papila duodenal mayor. En los tumores irresecables, el tratamiento debe estar dirigido a la paliación más efectiva. El tratamiento quirúrgico paliativo va dirigido a resolver la obstrucción biliar, duodenal y el dolor, con el fin de optimizar la calidad de vida de los pacientes. Objetivo: describir el comportamiento del tratamiento quirúrgico paliativo de los tumores periampulares. Materiales y métodos: se realizó una investigación observacional, descriptiva y prospectiva con los pacientes con tumor periampular irresecable tributarios a tratamiento quirúrgico paliativo, en el Servicio de Cirugía General del Hospital Universitario "Comandante Faustino Pérez Hernández", en la ciudad de Matanzas, desde enero del 2010 hasta diciembre del 2019. Resultados: el tumor de páncreas fue el más representado. Todos los pacientes fueron tributarios de derivación biliar quirúrgica paliativa, sin embargo, la derivación gástrica se realizó solo con confirmación endoscópica de infiltración tumoral u obstrucción duodenal y la esplacnicectomía química, siempre que fue factible técnicamente o las condiciones del paciente lo permitieron. La hepaticoyeyunostomía en Y de ROUX fue la derivación biliar de elección. La principal complicación quirúrgica fue la sepsis provocando las muertes. Conclusiones: la paliación quirúrgica es la alternativa de elección con mejores resultados a largo plazo, en los tumores periampulares irresecables con buen estado general, lo que contribuye a una mejor calidad de vida (AU).

ABSTRACT Introduction: the tumors of the duodenal-biliary-pancreatic junction or periampullary tumors correspond to a heterogeneous group of tumor. They originate inside the 2 cm of the major duodenal papilla. In unresectable tumors, the treatment should be intended for the most effective palliation. The surgical palliative treatment is intended for solving biliary, duodenal obstruction, and pain, with the aim of optimizing patients' life quality. Objective: to describe the behavior of the periampullary tumors palliative surgical treatment. Materials and methods: a prospective, descriptive, observational research was carried out in patients with unresectable periampullary tumor tributary to palliative surgical treatment, in the Service of General Surgery of the University Hospital "Comandante Faustino Perez Hernandez", of Matanzas, from January 2010 to December 2019. Results: pancreas tumor was the most represented one. All patients were tributary to biliary palliative surgical derivation, however, gastric derivation was performed only with endoscopic confirmation of tumor infiltration or duodenal obstruction, and chemical splanchnicectomy whenever it was technically feasible and the patient's conditions allowed it. Roux's Y-shaped hepaticojejunostomy was the elective biliary derivation. The main surgical complication was sepsis provoking deaths. Conclusions: surgical palliation is the election alternative with long- term better outcomes, in unresectable periampullary tumors with a good general status, contributing to better life quality (AU).

Colangio-pancreatoscopia SpyGlass® para patología bilio-pancreática / SpyGlass® cholangio-pancreatoscopy for biliary-pancreatic pathology

CONTEXTO CLÍNICO: En Argentina en 2018, la incidencia del cáncer de vía biliar extrahepática y vesícula biliar fue 3,7 cada 100.000 habitantes y el de páncreas de 10,9 cada 100.000 habitantes. La evaluación diagnóstica estándar de los pacientes con estenosis biliar incluye laboratorio (con IgG4 para evaluar patología autoinmune), tomografía computada, eco-endoscopia (con o sin punción aspirativa con aguja fina) y colangiopancreatografía retrógrada endoscópica (CPRE) con cepillado/biopsia biliar. Sin embargo, la sensibilidad de las muestras tomadas por CPRE son limitadas, siendo 45% para el cepillado y 60% cuando se lo combina con toma de muestra con pinzas de biopsia endoscópicas.2 Hasta el 20% de las estenosis biliares permanecen sin establecer si es de origen maligno o benigno luego de una evaluación que incluya todos los métodos anteriores, lo cual se denomina estenosis biliar indeterminada. Estos pacientes requieren una resección quirúrgica mayor (en su mayoría con hepatectomías o pancreatectomías mayores) para su evaluación patológica, aunque entre un 5 y 24% de estas resecciones son finalmente por patologías benignas, lo cual implica riesgos innecesarios de complicaciones severas y mortalidad asociadas a estas cirugías.4 Un abordaje alternativo aunque no menos riesgoso es la observación activa, con repetición de los estudios en un tiempo prudencial para evaluar la progresión de la estenosis; esto implica sin embargo el riesgo de progresión de una enfermedad maligna y su potencial pérdida de oportunidad de resección oncológica. TECNOLOGÍA; El colangio-pancreatoscopio SpyGlass® DS (Boston Scientific®) consiste en un mini-endoscopio (SpyScope®) de un solo uso que se introduce por el canal de trabajo de un duodenoscopio de CPRE y que se adosa a la caña de este duodenoscopio para así poder ser utilizado por el mismo operador. SpyScope® se conecta a un procesador de imágenes y fuente de luz específico, denominado SpyGlass®. Este mini-endoscopio se introduce en la vía biliar o el conducto pancreático y permite visualizar estos conductos. En el caso de las estenosis biliares, permite realizar una evaluación visual de la misma y realizar biopsias mediante una pinza llamada SpyBite® (también de un solo uso). En el caso de la litiasis biliar o pancreática dificultosa permite guiar catéteres de litotricia electrohidráulica o láser bajo visión directa, lo cual es un requisito para la utilización de estos dispositivos. OBJETIVO: El objetivo del presente informe es evaluar la evidencia disponible acerca del desempeño diagnóstico, eficacia, seguridad y aspectos relacionados a las políticas de cobertura del uso de colangio-pancreatoscopia SpyGlass® para estenosis biliares y pancreáticas indeterminadas y para litiasis dificultosas biliares y pancreáticas. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas, en buscadores genéricos de internet, y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas (RS), ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias (ETS), evaluaciones económicas, guías de práctica clínica (GPC) y políticas de cobertura de diferentes sistemas de salud. RESULTADOS: Se incluyeron cuatro ECAs, tres RS, dos estudios observacionales, siete GPC, una evaluación económica, una ETS y cuatro informes de políticas de cobertura de colangio-pancreatoscopia SpyGlass® para patología bilio-pancreática. CONCLUSIONES: Evidencia de baja calidad sugiere que el uso de colangioscopia con SpyGlass® para el diagnóstico de estenosis biliares indeterminadas podría tener un beneficio considerable al indicar en forma temprana una resección quirúrgica mayor o bien evitarla (y sus potenciales beneficios clínicos). Esto sería como resultado de una mayor sensibilidad en el diagnóstico de malignidad con respecto al cepillado o biopsia dirigida por colangiografía endoscópica. Sin embargo, no hay estudios que hayan evaluado en forma directa estos potenciales beneficios clínicos. Evidencia de moderada calidad sugiere que el uso de litotricia guiada con colangioscopia SpyGlass® para el tratamiento de litiasis biliar dificultosa mejoraría el porcentaje de limpieza del conducto con respecto a otras técnicas endoscópicas, lo cual disminuiría el número de procedimientos endoscópicos subsecuentes o de una exploración quirúrgica de la vía biliar. Evidencia de muy baja calidad no permite establecer conclusiones acerca de los beneficios y riesgos del uso de SpyGlass® en litiasis pancreática dificultosa o estenosis pancreáticas de causa indeterminada. Las guías de práctica clínica relevadas recomiendan que el uso de SpyGlass® podría considerarse para el diagnóstico de estenosis biliares indeterminadas con resultados negativos para malignidad en las muestras con técnicas convencionales (cepillado o biopsia por colangiografía endoscópica). Una guía de práctica clínica sobre litiasis biliar dificultosa incluye el uso de SpyGlass® como una de las opciones terapéuticas en los casos en que fallan los tratamientos endoscópicos convencionales de esfinterotomía y/o dilatación papilar con balón. Las políticas de cobertura relevadas no mencionan o no cubren esta tecnología. No se encontraron evaluaciones económicas en la región sobre esta tecnología.

Isolated intestinal transit bipartition: a new strategy for staged surgery in superobesity. / Bipartição de trânsito intestinal isolada: uma nova estratégia para cirurgia em estágios em superobesos.

OBJECTIVE: biliopancreatic diversion with duodenal switch is a complex, malabsorptive procedure, associated with improved weight loss and metabolic control. Staged surgery with sleeve gastrectomy as the first stage is an option for reducing complications in superobese patients. However, some problems persist: large livers can hamper the surgical approach and complications such as leaks can be severe. Intestinal transit bipartition is a modified and simplified model of biliopancreatic diversion that complements sleeve gastrectomy. It is similar to the duodenal switch, but with less complexity and fewer nutritional consequences. This study assessed the feasibility and safety of isolated transit bipartition as the initial procedure in a two-step surgery to treat superobesity. METHODS: this prospective study included 41 superobese patients, with mean BMI 54.5±3.5kg/m2. We performed a laparoscopic isolated transit bipartition as the first procedure in a new staged approach. We analyzed weight loss and complications during one year of follow-up. RESULTS: we completed all the procedures by laparoscopy. After six months, the mean percent excess weight loss was 28%, remaining stable until the end of the study. There were no intraoperative difficulties. Half of the patients experienced early diarrhea, and three had marginal ulcers. There were no major surgical complications or deaths. CONCLUSION: isolated laparoscopic transit bipartition is a new option for a staged approach in superobesity, which can provide a safer second procedure after effective weight loss over six months. It may be useful particularly in the management of patients with severe obesity.

OBJETIVO: o duodenal switch é um procedimento disabsortivo complexo, associado aos melhores resultados de perda de peso e controle metabólico. A cirurgia em etapas, com gastrectomia vertical como primeiro passo, é uma opção para reduzir complicações em pacientes superobesos. No entanto, alguns problemas persistem, como fígados grandes, que dificultam a abordagem cirúrgica, e complicações, como fístulas graves. A bipartição do trânsito intestinal é um modelo modificado e simplificado de desvio biliopancreático que complementa a gastrectomia vertical. É semelhante ao duodenal switch com menores complexidade e consequências nutricionais. Este estudo avaliou a viabilidade e a segurança da bipartição de trânsito isolada como o procedimento inicial para tratar a superobesidade. MÉTODOS: foram incluídos 41 pacientes superobesos, com IMC médio de 54,5±3,5kg/m2. Uma bipartição de trânsito isolada laparoscópica foi realizada como o primeiro procedimento em uma nova abordagem em duas etapas. Perda de peso e complicações foram analisadas durante um ano de acompanhamento. RESULTADOS: todos os procedimentos foram completados por laparoscopia. Após seis meses, a perda média de excesso de peso percentual foi de 28%, permanecendo estável até o final do estudo. Não houve dificuldades intraoperatórias. Metade dos pacientes apresentou diarreia precoce e três tiveram úlceras marginais. Não houve complicações cirúrgicas maiores ou mortes. CONCLUSÃO: a bipartição de trânsito isolada laparoscópica é uma nova opção para uma abordagem em estágios na superobesidade, que pode permitir um segundo procedimento mais seguro após a perda de peso ao longo de seis meses. Pode ser útil, particularmente, para pacientes com obesidade grave.

CRITICAL ANALYSIS OF SURGICAL TREATMENT TECHNIQUES OF MORBID OBESITY.

INTRODUCTION: Obesity is a disease of high prevalence in Brazil and in the world, and bariatric surgery, with its different techniques, is an alternative treatment. OBJECTIVE: To compare techniques: adjustable gastric band (AGB), sleeve gastrectomy), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) analyzing leaks, bleeding, death, weight loss, resolution of type 2 diabetes, systemic arterial hypertension, dyslipidemia and obstructive sleep apnea. METHODS: Were selected studies in the PubMed database from 2003 to 2014 using the descriptors: obesity surgery; bariatric surgery; biliopancreatic diversion; sleeve gastrectomy; Roux-en-Y gastric bypass and adjustable gastric banding. Two hundred and forty-four articles were found with the search strategy of which there were selected 116 studies through the inclusion criteria. RESULTS: Excess weight loss (EWL) after five years in AGB was 48.35%; 52.7% in SG; 71.04% in RYGB and 77.90% in BPD. The postoperative mortality was 0.05% in the AGB; 0.16% on SG; 0.60% in RYGB and 2.52% in BPD. The occurrence of leak was 0.68% for GBA; 1.93% for SG; 2.18% for RYGB and 5.23% for BPD. The incidence of bleeding was 0.44% in AGB; 1.29% in SG; 0.81% in RYGB and 2.09% in BPD. The rate of DM2 resolved was 46.80% in AGB, 79.38% in SG, 79.86% in RYGB and 90.78% in BPD. The rate of dyslipidemia, apnea and hypertension resolved showed no statistical differences between the techniques. CONCLUSION: The AGB has the lowest morbidity and mortality and it is the worst in EWL and resolution of type 2 diabetes. The SG has low morbidity and mortality, good resolution of comorbidities and EWL lower than in RYGB and BPD. The RYGB has higher morbidity and mortality than AGB, good resolution of comorbidities and EWL similar to BPD. The BPD is the worst in mortality and bleeding and better in EWL and resolution of comorbidities.

Modificaciones anatómicas de la derivación biliopancreática con cruce duodenal: ¿tienen algún rol futuro en la cirugía bariátrica y metabólica? / Anatomical modifications of the biliopancreatic diversion with duodenal switch: do they have a future role in bariatric and metabolic surgery?

La derivación biliopancreática con cruce duodenal (BPD-DS) es el procedimiento bariátrico que ha mostrado los mejores resultados en cuanto a pérdida de peso y resolución de comorbilidades. Sin embargo, su adopción ha sido lenta, principalmente debido a sus complicaciones nutricionales y dificultad técnica. Dado esto, algunos autores han propuesto variaciones de este procedimiento. Estas están basadas en disminuir las anastomosis a solo una, y realizarla con un asa tipo loop (sin derivación biliopancreática). Estos cambios podrían reproducir las ventajas del BPD-DS, y eliminar algunas de sus desventajas. En este artículo, mostramos los resultados de estas variaciones comparadas con el BPD-DS, y cómo sus resultados prometedores pueden tener como consecuencia una nueva aproximación a la población que sufre de obesidad y sus comorbilidades

Biliopancreatic Diversion with duodenal switch (BPD-DS) is the bariatric surgery that has shown the better results regarding long-term weight loss and comorbidities resolution. Nevertheless, BPD-DS' adoption has been slow, mainly due to its nutritional complications, and technical complexity. Given this, some authors have proposed surgical variations of this effective procedure. These new procedures are based on reducing the anastomosis to only one, and doing it just a loop anastomosis (no biliopacreatic diversion). These changes might bring to us the advantages of BPD-DS, and eliminate some of its disadvantages. In this article, we show the results of these variations compared with BPD-DS, and how their promising results could be a new approach for obese population and bariatric surgery.

Critical analysis of surgical treatment techniques of morbid obesity / Análise crítica das técnicas de tratamento cirúrgico da obesidade mórbida

ABSTRACT Introduction: Obesity is a disease of high prevalence in Brazil and in the world, and bariatric surgery, with its different techniques, is an alternative treatment. Objective: To compare techniques: adjustable gastric band (AGB), sleeve gastrectomy), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) analyzing leaks, bleeding, death, weight loss, resolution of type 2 diabetes, systemic arterial hypertension, dyslipidemia and obstructive sleep apnea. Methods: Were selected studies in the PubMed database from 2003 to 2014 using the descriptors: obesity surgery; bariatric surgery; biliopancreatic diversion; sleeve gastrectomy; Roux-en-Y gastric bypass and adjustable gastric banding. Two hundred and forty-four articles were found with the search strategy of which there were selected 116 studies through the inclusion criteria. Results: Excess weight loss (EWL) after five years in AGB was 48.35%; 52.7% in SG; 71.04% in RYGB and 77.90% in BPD. The postoperative mortality was 0.05% in the AGB; 0.16% on SG; 0.60% in RYGB and 2.52% in BPD. The occurrence of leak was 0.68% for GBA; 1.93% for SG; 2.18% for RYGB and 5.23% for BPD. The incidence of bleeding was 0.44% in AGB; 1.29% in SG; 0.81% in RYGB and 2.09% in BPD. The rate of DM2 resolved was 46.80% in AGB, 79.38% in SG, 79.86% in RYGB and 90.78% in BPD. The rate of dyslipidemia, apnea and hypertension resolved showed no statistical differences between the techniques. Conclusion: The AGB has the lowest morbidity and mortality and it is the worst in EWL and resolution of type 2 diabetes. The SG has low morbidity and mortality, good resolution of comorbidities and EWL lower than in RYGB and BPD. The RYGB has higher morbidity and mortality than AGB, good resolution of comorbidities and EWL similar to BPD. The BPD is the worst in mortality and bleeding and better in EWL and resolution of comorbidities.

RESUMO Introdução: A obesidade é afecção de alta prevalência no Brasil e no mundo e a cirurgia bariátrica, com suas diferentes técnicas, é alternativa para o tratamento. Objetivo: Comparar as técnicas da banda gástrica ajustável (BGA), gastrectomia vertical (GV), gastroplastia com derivação em Y-de-Roux (GDYR) e derivação biliopancreática (DBP) focando fístula, sangramento, óbito, perda e reganho ponderal, e resolução das comorbidades diabete melito tipo 2 (DM2), hipertensão arterial sistêmica (HAS), dislipidemia e apneia obstrutiva do sono (AOS). Métodos: Buscou-se os estudos na base de dados PubMed de 2003 a 2014 usando os descritores: obesity surgery; bariatric surgery; biliopancreatic diversion; sleeve gastrectomy; Roux-en-Y gastric bypass e adjustable gastric banding. Dessa busca foram recuperadas 244 publicações sendo selecionados 116 após aplicar os critérios de inclusão/exclusão. Resultados: A perda de excesso de peso (PEP) após cinco anos foi 48,35% na BGA; 52,7% na GV; 71,04% na GDYR e 77,90% na DBP. A mortalidade pós-operatória foi 0,05% na BGA; 0,16% na GV; 0,60% na GDYR e 2,52% na DBP. A ocorrência de fístulas foi 0,68% para BGA; 1,93% para GV; 2,18% para GDYR e 5,23% para DBP. A ocorrência de sangramento foi 0,44% na BGA; 1,29% na GV; 0,81% na GDYR e 2,09% na DBP. A taxa do DM2 resolvida foi de 46,80% na BGA, 79,38% na GV, 79,86% na GDYR e 90,78% na DBP. A taxa de dislipidemia, apneia e hipertensão resolvidas não demonstraram diferenças estatísticas entre as técnicas. Conclusões: A BGA apresenta a menor morbimortalidade e é a pior em PEP e resolução do DM2. A GV apresenta baixa morbimortalidade, boa resolução das comorbidades e PEP inferior às GDYR e DBP. A GDYR apresenta morbimortalidade superior à BGA, boa resolução das comorbidades e PEP semelhante à DBP. A DBP é a pior em mortalidade e sangramento e melhor em PEP e resolução das comorbidades.

Bipartição de trânsito intestinal isolada: uma nova estratégia para cirurgia em estágios em superobesos / Isolated intestinal transit bipartition: a new strategy for staged surgery in superobesity

RESUMO Objetivo: o duodenal switch é um procedimento disabsortivo complexo, associado aos melhores resultados de perda de peso e controle metabólico. A cirurgia em etapas, com gastrectomia vertical como primeiro passo, é uma opção para reduzir complicações em pacientes superobesos. No entanto, alguns problemas persistem, como fígados grandes, que dificultam a abordagem cirúrgica, e complicações, como fístulas graves. A bipartição do trânsito intestinal é um modelo modificado e simplificado de desvio biliopancreático que complementa a gastrectomia vertical. É semelhante ao duodenal switch com menores complexidade e consequências nutricionais. Este estudo avaliou a viabilidade e a segurança da bipartição de trânsito isolada como o procedimento inicial para tratar a superobesidade. Métodos: foram incluídos 41 pacientes superobesos, com IMC médio de 54,5±3,5kg/m2. Uma bipartição de trânsito isolada laparoscópica foi realizada como o primeiro procedimento em uma nova abordagem em duas etapas. Perda de peso e complicações foram analisadas durante um ano de acompanhamento. Resultados: todos os procedimentos foram completados por laparoscopia. Após seis meses, a perda média de excesso de peso percentual foi de 28%, permanecendo estável até o final do estudo. Não houve dificuldades intraoperatórias. Metade dos pacientes apresentou diarreia precoce e três tiveram úlceras marginais. Não houve complicações cirúrgicas maiores ou mortes. Conclusão: a bipartição de trânsito isolada laparoscópica é uma nova opção para uma abordagem em estágios na superobesidade, que pode permitir um segundo procedimento mais seguro após a perda de peso ao longo de seis meses. Pode ser útil, particularmente, para pacientes com obesidade grave.

ABSTRACT Objective: biliopancreatic diversion with duodenal switch is a complex, malabsorptive procedure, associated with improved weight loss and metabolic control. Staged surgery with sleeve gastrectomy as the first stage is an option for reducing complications in superobese patients. However, some problems persist: large livers can hamper the surgical approach and complications such as leaks can be severe. Intestinal transit bipartition is a modified and simplified model of biliopancreatic diversion that complements sleeve gastrectomy. It is similar to the duodenal switch, but with less complexity and fewer nutritional consequences. This study assessed the feasibility and safety of isolated transit bipartition as the initial procedure in a two-step surgery to treat superobesity. Methods: this prospective study included 41 superobese patients, with mean BMI 54.5±3.5kg/m2. We performed a laparoscopic isolated transit bipartition as the first procedure in a new staged approach. We analyzed weight loss and complications during one year of follow-up. Results: we completed all the procedures by laparoscopy. After six months, the mean percent excess weight loss was 28%, remaining stable until the end of the study. There were no intraoperative difficulties. Half of the patients experienced early diarrhea, and three had marginal ulcers. There were no major surgical complications or deaths. Conclusion: isolated laparoscopic transit bipartition is a new option for a staged approach in superobesity, which can provide a safer second procedure after effective weight loss over six months. It may be useful particularly in the management of patients with severe obesity.

Revisional Malabsorptive Bariatric Surgery: 29-Year Follow-up in a Brazilian Public Hospital.

BACKGROUND: This study aimed to evaluate the outcomes of 67 patients who underwent revisional bariatric surgeries over a 29-year period in a Brazilian public hospital. METHODS: The records of all patients who underwent revisional bariatric surgery from January 1987 to December of 2016 at our hospital were analyzed for weight loss and complications. Descriptive statistics and paired t tests were computed. RESULTS: Sixty-seven patients were included in the study. The primary surgeries previously performed on these patients were biliopancreatic diversion with duodenal switch (BPD-DS) (37 cases, 55.2%), jejunoileal bypass (JIB) (24 cases, 35.8%), sleeve gastrectomy (4 cases, 5.9%), Roux-en-Y gastric bypass (RYGB) (1 case, 1.5%), and laparoscopic adjustable gastric band (1 case, 1.5%). The indications for revisional surgery were as follows: malnutrition in 29 cases (43.3%), failure to lose weight in 27 cases (40.3%), weight regain in 5 cases (7.5%), and untreatable diarrhea in 6 cases (9.2%). Most revisional surgeries were performed using JIB or BPD-DS. Operative mortality was higher after the revisional procedures compared with that following the primary bariatric surgeries. CONCLUSIONS: Most patients requiring a revisional surgery had undergone a primary BPD-DS or JIB. Severe and untreatable malnutrition and diarrhea were the main indications for the revisional procedures. RYGB produced significant and sustainable weight loss and exhibited a low risk of malnutrition or requiring revisional surgery.

Glucagon-Like Peptides 1 and 2 Are Involved in Satiety Modulation After Modified Biliopancreatic Diversion: Results of a Pilot Study.

BACKGROUND: This paper aimed to evaluate the influence of modified biliopancreatic diversion (BPD) on the levels of GLP-1 and GLP-2 and correlate them with satiety regulation. METHODS: This is a pilot prospective cohort study that evaluated six mildly obese individuals with type 2 diabetes mellitus, which underwent modified BPD and were followed-up for 12 months. Levels of GLP-1 and GLP-2 after a standard meal tolerance test were determined and correlated with satiety scores obtained by means of a visual analogue scale (VAS). RESULTS: There were significant changes in BMI (33 ± 2.2 versus 26.3 ± 2.2 kg/m2; p < 0.001), HbA1c (7.9 ± 1.6 versus 5.8 ± 1.2%; p = 0.026), total cholesterol (172.3 ± 11.1 versus 134.7 ± 16.1 mg/dL; p < 0.001), LDL-c (103.3 ± 13 versus 64.6 ± 12.2 mg/dL; p < 0.001), and postprandial GLP-2 (972.7 ± 326.2 versus 1993.2 ± 1024.7; p = 0. 044). None of the scores obtained in the VAS significantly changed after surgery. After surgery, there were significant correlations of VAS scores and GLP-1 levels in question 01 ("how hungry do you feel?"; R = -0.928; p = .008) and GLP-2 levels in questions 02 ("how full do you feel?" R = 0.943; p = 0.005) and 04 ("how much do you think you can eat now? R = -0.829; p = 0.042). CONCLUSIONS: Modified BPD does not lead to significant changes in satiety evaluated by the VAS; different aspects of satiety regulation are correlated with the postprandial levels of GLP-1 (hunger feeling) and GLP-2 (satiation feeling and desire to eat) 1 year after modified BPD, signaling a specific postoperative gut hormone-related modulation of appetite.

Effect of biliopancreatic diversion on sleep quality and daytime sleepiness in patients with obesity and type 2 diabetes

ABSTRACT Objective: The poor quality of sleep and the deprivation thereof have been associated with disruption of metabolic homeostasis, favoring the development of obesity and type 2 diabetes (T2DM). We aimed to evaluate the influence of biliopancreatic diversion (BPD) surgery on sleep quality and excessive daytime sleepiness of obese patients with T2DM, comparing them with two control groups consisting of obese and normal weight individuals, both normal glucose tolerant. Subjects and methods: Forty-two women were divided into three groups: LeanControl (n = 11), ObeseControl (n = 13), and ObeseT2DM (n = 18). The LeanC and ObeseC groups underwent all tests and evaluations once. The ObeseT2DM underwent BPD and were reassessed after 12 months. Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were applied before and 12 months after BPD. Results: Before surgery, there was less daytime sleepiness in LeanC group (p = 0.013) compared with ObeseC and T2DMObese groups. The two obese groups did not differ regarding daytime sleepiness, demonstrating that the presence of T2DM had no influence on daytime sleepiness. After surgery, the daytime sleepiness (p = 0.002) and the sleep quality (p = 0.033) improved. The score for daytime sleepiness of operated T2DMObese group became similar to LeanC and lower than ObeseC (p = 0.047). Conclusion: BPD surgery has positively influenced daytime sleepiness and sleep quality of obese patients with T2DM, leading to normalization of daytime sleepiness 12 months after surgery. These results reinforce previously identified associations between sleep, obesity and T2DM in view of the importance of sleep in metabolic homeostasis, quality of life and health.

Fístula biliopleurobronquial: reporte de un caso / Bronchobiliary fistula: Report of a case

La fístula biliopleurobronquial (FBB) es una comunicación anormal entre la vía biliar y el árbol bronquial. Es una condición infrecuente, generalmente secundaria a un proceso infeccioso local o a un evento traumático. La bilioptisis es patognomónica. Presentamos el caso de una mujer de 37 años con historia de cirrosis biliar secundaria, en lista para trasplante hepático, con múltiples episodios de colangitis previos y usuaria de derivación biliar externa, quien curso con bilioptisis y mediante gammagrafía HIDA con SPECT se confirmó fistula biliopleurobronquial. Éste caso se resolvió con derivación percutánea de la vía biliar

Bronchobiliary fistula (BBF) is an abnormal communication between the biliary tract and the bronchial tree. Is an infrequent condition, usually secondary to a local infectious process or a traumatic event. Bilioptisis is pathognomonic. We present the case of a 37 year old woman with secondary biliary cirrhosis, in list for liver transplantation, with several episodes of cholangitis and carrier of external biliary diverivation, who presented bilioptisis and HIDA scintigraphy with SPECT confirmed BBF. This case was resolved with percutaneous derivation of the biliary tract

Bone turnover after bariatric surgery

ABSTRACT Objective The aim of the present study was to evaluate parameters of bone and mineral metabolism after bariatric surgery. Subjects and methods This sectional study included data from medical records from 61 bariatric surgery (BS) patients (minimum period of 6 months after the procedure) and from 30 class II and III obese patients as a control group (Cont), consisting of daily dietary intake of macronutrients, calcium and sodium, serum 25(OH)D and parathyroid hormone (PTH) and other biochemical serum and urinary parameters. Bone alkaline phosphatase (BAP), leptin, fibroblast growth factor-23 (FGF-23) and deoxypyridinoline (DPYD) were determined from available banked serum and urinary samples. Results Mean body mass index (BMI), median energy, carbohydrate, protein and sodium chloride consumption were significantly lower in the BS versus Cont, but calcium and lipids were not. No significant differences were found in ionized calcium, 25(OH)D, PTH and fibroblast growth factor 23 (FGF-23) between groups. Mean serum BAP was significantly higher for BS versus Cont and had a positive correlation with time after the surgical procedure. Mean serum leptin was significantly lower and median urinary DPYD higher in BS versus Cont. Conclusion The present study showed an increase in bone markers of both bone formation and resorption among bariatric patients up to more than 7 years after the surgical procedure, suggesting that an increased bone turnover persists even at a very long-term follow-up in such patients.

Bone turnover after bariatric surgery.

OBJECTIVE: The aim of the present study was to evaluate parameters of bone and mineral metabolism after bariatric surgery. SUBJECTS AND METHODS: This sectional study included data from medical records from 61 bariatric surgery (BS) patients (minimum period of 6 months after the procedure) and from 30 class II and III obese patients as a control group (Cont), consisting of daily dietary intake of macronutrients, calcium and sodium, serum 25(OH)D and parathyroid hormone (PTH) and other biochemical serum and urinary parameters. Bone alkaline phosphatase (BAP), leptin, fibroblast growth factor-23 (FGF-23) and deoxypyridinoline (DPYD) were determined from available banked serum and urinary samples. RESULTS: Mean body mass index (BMI), median energy, carbohydrate, protein and sodium chloride consumption were significantly lower in the BS versus Cont, but calcium and lipids were not. No significant differences were found in ionized calcium, 25(OH)D, PTH and fibroblast growth factor 23 (FGF-23) between groups. Mean serum BAP was significantly higher for BS versus Cont and had a positive correlation with time after the surgical procedure. Mean serum leptin was significantly lower and median urinary DPYD higher in BS versus Cont. CONCLUSION: The present study showed an increase in bone markers of both bone formation and resorption among bariatric patients up to more than 7 years after the surgical procedure, suggesting that an increased bone turnover persists even at a very long-term follow-up in such patients.

Transenteric ERCP for Treatment of Choledocholithiasis After Duodenal Switch.

This article aims to describe step-by-step technique performed with the aid of a video. We report the performance of an endoscopic approach to the biliary tract on 2 patients who had previously undergone duodenal switch (DS). It was successfully performed a laparoscopic-assisted transenteric endoscopic retrograde cholangiopancreatography (ERCP) in both the patients. Although successful experiences with ERCP after Roux-en-Y gastric bypass have been found, few cases of ERCP after DS have been reported. Nevertheless, this is the first study to include a multimedia video with description of details and all technical steps of the transenteric ERCP performed on 2 patients who had previously undergone DS. Transenteric access is a feasible technique for reaching the biliary tract through endoscopy after DS. This technique could avoid most invasive and risky procedures. However, it requires a high level of therapeutic endoscopic training.

Liver failure following biliopancreatic diversions: a narrative review.

CONTEXT AND OBJECTIVE:: Occurrences of liver failure following jejunoileal bypass were extensively reported in the past and were one of the main factors that led to abandonment of this procedure. The newer predominantly malabsorptive procedures called biliopancreatic diversions (BPDs) have also been implicated in several cases of acute and subacute liver failure. The aim here was to review the current available evidence on occurrences of liver failure following BPDs. DESIGN AND SETTING:: Narrative review; bariatric surgery service of a public university hospital. METHODS:: A review of the literature was conducted through an online search of medical databases. RESULTS:: Associations between BPDs and liver failure have only infrequently been reported in the literature. However, they appear to be more than merely anecdotal. The pathophysiological mechanisms remain obscure, but they seem to be related to rapid weight loss, protein malnutrition, deficits of hepatotrophic factors, high circulating levels of free fatty acids and bacterial overgrowth in the bypassed bowel segments. Reversal of the BPD may ameliorate the liver impairment. CONCLUSIONS:: Although infrequent, liver failure remains a concern following BPDs. Careful follow-up is required in individuals who undergo any BPD.

Postprandial GLP-2 Levels Are Increased After Biliopancreatic Diversion in Diabetic Individuals with Class I Obesity: a Prospective Study.

BACKGROUND: Biliopancreatic diversion (BPD) is a predominantly malabsorptive procedure. Glucagon-like peptide 2 (GLP-2) plays predominantly trophic effects on the gut. A significant increase in GLP-2 after BPD in rats was previously observed, but there are no studies investigating the effect of BPD in GLP-2 levels in humans. OBJECTIVE: The aim of this study is to evaluate the influence of BPD on the release of GLP-2. METHODS: This is a prospective cohort study that evaluated diabetic individuals with class I obesity which underwent BPD (Scopinaro operation) and were followed up for 12 months. Of 12 individuals, four did not comply with the proposed follow-up and were excluded from the analysis. GLP-2 levels were determined by means of an enzyme-linked immunosorbent assay (ELISA), and we collected serial lab samples through a standard meal tolerance test (MTT) in the immediate preoperative period and 12 months after surgery. RESULTS: During standard MTT, we observed significant increases of GLP-2 levels from 15 to 60 min (respectively, at 15 min, 5.7 ± 3.4 versus 12.4 ± 4.3, p = 0.029; 30 min, 6 ± 3.5 versus 14.6 ± 3.9; p = 0.004; 45 min, 5.6 ± 4.1 versus 12.6 ± 5.2, p = 0.013; 60 min, 5.8 ± 2.9 versus 10.6 ± 5.6, p = 0.022); then it began to gradually decrease to levels close to the basal. DISCUSSION: Our findings have confirmed that there is a significant increase in GLP-2 levels after BPD in humans. GLP-2 plays a number of roles which may be adaptive, compensatory, and beneficial in the context of BPD. The clinical implications of this finding remain to be completely understood.

Liver failure following biliopancreatic diversions: a narrative review / Falência hepática após derivações biliopancreáticas: uma revisão narrativa

ABSTRACT CONTEXT AND OBJECTIVE: Occurrences of liver failure following jejunoileal bypass were extensively reported in the past and were one of the main factors that led to abandonment of this procedure. The newer predominantly malabsorptive procedures called biliopancreatic diversions (BPDs) have also been implicated in several cases of acute and subacute liver failure. The aim here was to review the current available evidence on occurrences of liver failure following BPDs. DESIGN AND SETTING: Narrative review; bariatric surgery service of a public university hospital. METHODS: A review of the literature was conducted through an online search of medical databases. RESULTS: Associations between BPDs and liver failure have only infrequently been reported in the literature. However, they appear to be more than merely anecdotal. The pathophysiological mechanisms remain obscure, but they seem to be related to rapid weight loss, protein malnutrition, deficits of hepatotrophic factors, high circulating levels of free fatty acids and bacterial overgrowth in the bypassed bowel segments. Reversal of the BPD may ameliorate the liver impairment. CONCLUSIONS: Although infrequent, liver failure remains a concern following BPDs. Careful follow-up is required in individuals who undergo any BPD.

RESUMO CONTEXTO E OBJETIVO: A ocorrência de falência hepática após a derivação jejunoileal foi extensivamente descrita no passado e foi um dos principais fatores que levaram ao abandono do procedimento. Os procedimentos predominantemente malabsortivos mais modernos, chamados de derivações biliopancreáticas, também já foram implicados em diversos casos de falência hepática aguda e subaguda. O objetivo foi revisar a atual evidência disponível sobre a ocorrência de insuficiência hepática após derivações biliopancreáticas. TIPO DE ESTUDO E LOCAL: Revisão narrativa; Serviço de Cirurgia Bariátrica de hospital universitário. MÉTODOS: Revisão da literatura conduzida por meio de pesquisa online de bancos de dados médicos. RESULTADOS: A associação entre derivações biliopancreáticas e falência hepática na literatura é infrequente. Entretanto, ela aparenta ser mais do que meramente anedótica. Os mecanismos fisiopatológicos continuam pouco compreendidos, mas parecem estar relacionados à rápida perda de peso, desnutrição proteica e déficit de fatores hepatotróficos, altos níveis circulantes de ácidos graxos livres e supercrescimento bacteriano em segmentos intestinais excluídos do trânsito. A reversão da cirurgia pode melhorar o comprometimento hepático. CONCLUSÕES: Embora infrequente, a falência hepática continua sendo preocupante após as derivações biliopancreáticas. Seguimento cuidadoso é mandatório em indivíduos submetidos a essas cirurgias.

Biliopancreatic Diversion Decreases Postprandial Apolipoprotein A-IV Levels in Mildly Obese Individuals with Type 2 Diabetes Mellitus: a Prospective Study.

BACKGROUND: Bariatric surgery usually leads to improvement on the general lipid profile, but its role in the levels of apolipoprotein A-IV (Apo-AIV) is not completely understood. Apo-AIV is a gut-released lipoprotein which is enrolled in satiety regulation and presents anti-inflammatory, anti-atherogenic, and anti-oxidative properties. The objective of this study was to determine the influence of biliopancreatic diversion (BPD) in the levels of Apo-AIV. METHODS: This is a prospective exploratory study which evaluated eight obese individuals with type 2 diabetes mellitus (T2DM) who underwent BPD (Scopinaro operation) and were followed-up for 12 months. Apo-AIV levels were determined by means of serial dosages through a standard meal tolerance test (MTT) in the immediate preoperative period and then 12 months later. RESULTS: There was a significant change in the Apo-AIV curve following MTT before and after surgery. At 0 and 45 min, the Apo-AIV levels did not significantly differ before and after surgery; at 120 and 180 min, Apo-AIV levels were significantly lower following BPD. CONCLUSIONS: We observed a decrease of postprandial levels of Apo-AIV following MTT in mildly obese individuals with T2DM. This finding appears to be related to the suppression in the Apo-AIV response that obese individuals tend to present. Weight reduction itself, endotoxemia, and the large segments of bypassed intestine may be enrolled in this impaired response.