Medication following bariatric surgery for type 2 diabetes mellitus (BY-PLUS) study: rationale and design of a randomised controlled study.

INTRODUCTION: Bariatric surgery is an effective method of controlling glycaemia in patients with type 2 diabetes mellitus (T2DM) and obesity. Long-term studies suggest that although glycaemic control remains good, only 20%-40% of patients will maintain remission according to the American Diabetes Association criteria. PURPOSE: This trial aims to examine the safety and efficacy of combining Roux-en-Y gastric bypass or sleeve gastrectomy with goal-directed medical therapy to improve long-term glycaemic control of T2DM. METHODS AND ANALYSIS: This prospective, open-label multicentre randomised controlled trial (RCT) will recruit 150 patients with obesity and T2DM from tertiary care obesity centres. Patients will be randomised 1:1 to receive either bariatric surgery and standard medical care or bariatric surgery and intensive goal-directed medical therapy, titrated to specific targets for glycated haemoglobin (HbA1c), blood pressure (BP) and low-density lipoproteins (LDL) cholesterol. The primary endpoints are the proportion of patients in each arm with an HbA1c<6.5% (48 mmol/mol) at 1 year and the proportion of patients in each arm achieving the composite endpoint of HbA1c<6.5% (48 mmol/mol), BP<130/80 mm Hg and LDL<2.6 mmol/L at 5 years. ETHICS AND DISSEMINATION: The local institutional review board approved this study. This study represents the first RCT to examine the safety and efficacy of combining bariatric surgery with intensive medical therapy compared with bariatric surgery and usual care for long-term diabetes control. TRIAL REGISTRATION NUMBER: NCT04432025.

Surgical Management of Obesity in Brazil: Proposal for a Value-Based Healthcare Model and Preliminary Results.

OBJECTIVES: To describe the implementation and 1-year results of a value-based bariatric surgery program in Brazil. METHODS: The study was conducted at a private hospital in São Paulo, Brazil (Hospital Alemão Oswaldo Cruz). A value-based healthcare program was implemented by designing an episode of care for eligible patients and developing a bundled payment model in which a single payment was made for the bariatric surgery covering the preoperative workup and ending 30 days after discharge. Assessment of outcomes included complication rate, hospital length of stay, intensive care admissions, reoperations, readmissions, and visits to the emergency department in the 30-day postoperative period. The results were compared with real-world evidence retrieved from a Brazilian private insurance database containing information on bariatric procedures performed in similar institutions (benchmark group). RESULTS: Eighty-three patients were enrolled in the value-based healthcare program (80.7% women; 18.0% with type 2 diabetes mellitus; 31.0% with high blood pressure). The mean age was 40.9 years, and body mass index was 42.1 kg/m2. The outcomes recorded in the benchmark group versus the value-based healthcare group involved complication rate, 2.6% versus 1.4% (P = 0.69); length of stay, 2.5 versus 2.0 days (P = 0.0001); intensive care admissions, 4.0% versus 1.2% (P = 0.31); emergency care visits, 15.0% versus 6.0% (P = 0.04); and readmissions, 2.3% versus 0 (P = 0.35), with an estimated cost reduction of 7.1%. CONCLUSIONS: These initial results showed favorable surgical and 30-day outcomes, demonstrating the benefits of a value-based approach for the surgical management of obesity and its comorbidities.

The recommendations of the Brazilian College of Surgeons and the Brazilian Bariatric and Metabolic Surgery Societies on the return of bariatric and metabolic operations in geographic regions of the country where the procedures have been allowed by local policies, in the period of COVID-19 pandemic.

Prioritizing surgical procedures aims at facilitating patient's access according to the clinical needs, maximizing access equity, and minimizing the damage from delayed access. Previous categorization of elective bariatric surgery have been adapted to define an objective prioritizing system that reflects those principles for bariatric and metabolic operations. Given the factors that contribute to the morbidity and mortality of obese and type 2 diabetes patients, surgical prioritization should be based on clinical risk stratification. For patients with type 2 diabetes, we suggest that the operation may be prioritized for those with a higher risk of morbidity and mortality in a relatively short term. Likewise, it is necessary to guide the surgical team regarding the necessary care both in the pre, per and postoperative periods of bariatric and metabolic surgery. These recommendations aim to reduce the risk of in-hospital contamination of the surgical team among health professionals and between health professionals and patients. In summary, these recommendations have been shaped after a thorough analysis of the available literature and are extremely important to mitigate the harm related to the clinical complications of obesity and its comorbidities while keeping healthcare providers' and patients' safety.

Elective surgeries in the "new normal" post-COVID-19 pandemic: to test or do not test?

The new coronavirus (SARS-CoV-2) pandemic has been wreaking havoc all over the planet. In a precautionary measure, populations have been forced and kept under quarantine to contain the outbreak of the COVID-19 disease. The quarantine primary goal is to avoid the overload to the hospitals, which should be available for the care of COVID-19 patients. However, the virus does not have a uniform spread throughout the planet, and Brazil is no different. Although all the world's attention is now on the COVID-19 pandemic, there is no similar pattern of spread, and other diseases are still a real problem. Given the risks of transmission between patients and healthcare providers, there is a great challenge for healthcare institutions who must balance resources to assure safe care to patients and professionals while they take care of other disease patients, and perform surgical procedures that need to be carried out. Under such circumstances, as COVID-19 can also present pre- or asymptomatic transmission, it can be challenging to identify patients who are carrying and spreading the virus. Studies and information on mandatory testing for who are candidates to undergo elective surgery are scarce. Thus, the authors have reviewed the literature, and discuss the need to test these patients under the current context.

Effect of Gastric Bypass vs Best Medical Treatment on Early-Stage Chronic Kidney Disease in Patients With Type 2 Diabetes and Obesity: A Randomized Clinical Trial.

Importance: Early-stage chronic kidney disease (CKD) characterized by microalbuminuria is associated with future cardiovascular events, progression toward end-stage renal disease, and early mortality in patients with type 2 diabetes. Objective: To compare the albuminuria-lowering effects of Roux-en-Y gastric bypass (RYGB) surgery vs best medical treatment in patients with early-stage CKD, type 2 diabetes, and obesity. Design, Setting, and Participants: For this randomized clinical trial, patients with established type 2 diabetes and microalbuminuria were recruited from a single center from April 1, 2013, through March 31, 2016, with a 5-year follow-up, including prespecified intermediate analysis at 24-month follow-up. Intervention: A total of 100 patients with type 2 diabetes, obesity (body mass indexes of 30 to 35 [calculated as weight in kilograms divided by height in meters squared]), and stage G1 to G3 and A2 to A3 CKD (urinary albumin-creatinine ratio [uACR] >30 mg/g and estimated glomerular filtration rate >30 mL/min) were randomized 1:1 to receive best medical treatment (n = 49) or RYGB (n = 51). Main Outcomes and Measures: The primary outcome was remission of albuminuria (uACR <30 mg/g). Secondary outcomes were CKD remission rate, absolute change in uACR, metabolic control, other microvascular complications, quality of life, and safety. Results: A total of 100 patients (mean [SD] age, 51.4 [7.6] years; 55 [55%] male) were randomized: 51 to RYGB and 49 to best medical care. Remission of albuminuria occurred in 55% of patients (95% CI, 39%-70%) after best medical treatment and 82% of patients (95% CI, 72%-93%) after RYGB (P = .006), resulting in CKD remission rates of 48% (95% CI, 32%-64%) after best medical treatment and 82% (95% CI, 72%-92%) after RYGB (P = .002). The geometric mean uACRs were 55% lower after RYGB (10.7 mg/g of creatinine) than after best medical treatment (23.6 mg/g of creatinine) (P < .001). No difference in the rate of serious adverse events was observed. Conclusions and Relevance: After 24 months, RYGB was more effective than best medical treatment for achieving remission of albuminuria and stage G1 to G3 and A2 to A3 CKD in patients with type 2 diabetes and obesity. Trial Registration: ClinicalTrials.gov Identifier: NCT01821508.

Elective surgeries in the new normal post-COVID-19 pandemic: to test or do not test? / Cirurgias eletivas no novo normal pós-pandemia da COVID-19: testar ou não testar?

ABSTRACT The new coronavirus (SARS-CoV-2) pandemic has been wreaking havoc all over the planet. In a precautionary measure, populations have been forced and kept under quarantine to contain the outbreak of the COVID-19 disease. The quarantine primary goal is to avoid the overload to the hospitals, which should be available for the care of COVID-19 patients. However, the virus does not have a uniform spread throughout the planet, and Brazil is no different. Although all the world's attention is now on the COVID-19 pandemic, there is no similar pattern of spread, and other diseases are still a real problem. Given the risks of transmission between patients and healthcare providers, there is a great challenge for healthcare institutions who must balance resources to assure safe care to patients and professionals while they take care of other disease patients, and perform surgical procedures that need to be carried out. Under such circumstances, as COVID-19 can also present pre- or asymptomatic transmission, it can be challenging to identify patients who are carrying and spreading the virus. Studies and information on mandatory testing for who are candidates to undergo elective surgery are scarce. Thus, the authors have reviewed the literature, and discuss the need to test these patients under the current context.

RESUMO A pandemia do novo coronavírus (SARS-CoV-2) vem causando estragos em todo o planeta. As populações estão sendo forçadas a quarentena - e assim mantidas - como medida de precaução para conter o surto da doença COVID-19. O principal objetivo da quarentena é evitar a sobrecarga dos hospitais, o que pode ser determinante para o atendimento aos pacientes COVID-19. O vírus não tem propagação uniforme pelo planeta, e no Brasil não é diferente. Contudo, as pessoas continuam a adoecer por outras causas não relacionadas ao SARS-CoV-2, demandando atendimento médico-hospitalar. Assim, os governos estão avaliando e liberando regiões para a realização de cirurgias eletivas em Estados e Municípios onde a COVID-19 está sob controle. Nesse contexto, há preocupação inerente à transmissão SARS-CoV-2 entre pacientes e prestadores de serviços de saúde, uma vez que há poucas informações sobre testes obrigatórios a serem realizados em pacientes com indicação cirúrgica. Esse problema é causado principalmente porque todos os pacientes durante o período de incubação são assintomáticos e, portanto, difíceis de serem avaliados. Assim sendo, os autores avaliam a literatura pertinente à microbiologia do SARS-CoV-2 e discutem a necessidade de testar esses pacientes com testes mais utilizados até o momento.

The recommendations of the Brazilian College of Surgeons and the Brazilian Bariatric and Metabolic Surgery Societies on the return of bariatric and metabolic operations in geographic regions of the country where the procedures have been allowed by local policies, in the period of COVID-19 pandemic / Recomendações do Colégio Brasileiro de Cirurgiões e da Sociedade Brasileira de Cirurgia Bariátrica e Metabólica para o retorno às cirurgias bariátricas e metabólicas em regiões epidemiológicas flexibilizadas, no período de pandemia COVID-19

ABSTRACT Prioritizing surgical procedures aims at facilitating patient's access according to the clinical needs, maximizing access equity, and minimizing the damage from delayed access. Previous categorization of elective bariatric surgery have been adapted to define an objective prioritizing system that reflects those principles for bariatric and metabolic operations. Given the factors that contribute to the morbidity and mortality of obese and type 2 diabetes patients, surgical prioritization should be based on clinical risk stratification. For patients with type 2 diabetes, we suggest that the operation may be prioritized for those with a higher risk of morbidity and mortality in a relatively short term. Likewise, it is necessary to guide the surgical team regarding the necessary care both in the pre, per and postoperative periods of bariatric and metabolic surgery. These recommendations aim to reduce the risk of in-hospital contamination of the surgical team among health professionals and between health professionals and patients. In summary, these recommendations have been shaped after a thorough analysis of the available literature and are extremely important to mitigate the harm related to the clinical complications of obesity and its comorbidities while keeping healthcare providers' and patients' safety.

RESUMO A priorização de qualquer operação eletiva visa facilitar o acesso do paciente de acordo com as necessidades clínicas, maximizando a equidade de acesso e minimizando os danos causados pelo atraso. As categorias de operações eletivas foram adaptadas para definir sistema de priorização objetiva que reflete esses princípios para operações bariátricas e metabólicas. Em razão dos fatores que contribuem para a morbidade e mortalidade da obesidade e do diabetes tipo 2, a priorização cirúrgica deve ser baseada na estratificação de risco clínico. Para pacientes com diabetes tipo 2, sugerimos que a operação possa ser priorizada para aqueles com maior risco de morbidade e mortalidade, em prazo relativamente curto. Da mesma forma, é necessário orientar a equipe cirúrgica quanto aos cuidados necessários tanto no pré, per e pós-operatório da cirurgia bariátrica e metabólica. As recomendações visam reduzir o risco de contágio hospitalar da equipe cirúrgica tanto entre profissionais de saúde quanto entre profissionais de saúde e pacientes. Em resumo, estas recomendações foram moldadas após análise minuciosa da literatura disponível e são extremamente importantes para mitigar os danos das complicações clínicas, sensíveis a doença obesidade e comorbidades, mantendo a segurança dos profissionais de saúde e dos pacientes.

Effects of Bariatric Surgery in Obese Patients With Hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension).

BACKGROUND: Recent research efforts on bariatric surgery have focused on metabolic and diabetes mellitus resolution. Randomized trials designed to assess the impact of bariatric surgery in patients with obesity and hypertension are needed. METHODS: In this randomized, single-center, nonblinded trial, we included patients with hypertension (using ≥2 medications at maximum doses or >2 at moderate doses) and a body mass index between 30.0 and 39.9 kg/m2. Patients were randomized to Roux-en-Y gastric bypass plus medical therapy or medical therapy alone. The primary end point was reduction of ≥30% of the total number of antihypertensive medications while maintaining systolic and diastolic blood pressure <140 mm Hg and 90 mm Hg, respectively, at 12 months. RESULTS: We included 100 patients (70% female, mean age 43.8±9.2 years, mean body mass index 36.9±2.7 kg/m2), and 96% completed follow-up. Reduction of ≥30% of the total number of antihypertensive medications while maintaining controlled blood pressure occurred in 41 of 49 patients from the gastric bypass group (83.7%) compared with 6 of 47 patients (12.8%) from the control group with a rate ratio of 6.6 (95% confidence interval, 3.1-14.0; P<0.001). Remission of hypertension was present in 25 of 49 (51%) and 22 of 48 (45.8%) patients randomized to gastric bypass, considering office and 24-hour ambulatory blood pressure monitoring, respectively, whereas no patient submitted to medical therapy was free of antihypertensive drugs at 12 months. A post hoc analysis for the primary end point considering the SPRINT (Systolic Blood Pressure Intervention Trial) target reached consistent results, with a rate ratio of 3.8 (95% confidence interval, 1.4-10.6; P=0.005). Eleven patients (22.4%) from the gastric bypass group and none in the control group were able to achieve SPRINT levels without antihypertensives. Waist circumference, body mass index, fasting plasma glucose, glycohemoglobin, low-density lipoprotein cholesterol, triglycerides, high-sensitivity C-reactive protein, and 10-year Framingham risk score were lower in the gastric bypass than in the control group. CONCLUSIONS: Bariatric surgery represents an effective strategy for blood pressure control in a broad population of patients with obesity and hypertension. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT01784848.

A Prospective Single-Arm Trial of Modified Long Biliopancreatic and Short Alimentary Limbs Roux-En-Y Gastric Bypass in Type 2 Diabetes Patients with Mild Obesity.

BACKGROUND: Type-2 diabetes (T2D) patients with body mass index (BMI) below 35 kg/m2 carry lower remission rates than severely obese T2D individuals submitted to "standard limb lengths" Roux-en-Y gastric bypass (RYGB). Mild-obese patients appear to have more severe forms of T2D, where the mechanisms of glycemic control after a standard-RYGB may be insufficient. The elongation of the biliopancreatic limb may lead to greater stimulation of the distal intestine, alterations in bile acids and intestinal microbiota, among other mechanisms, leading to better metabolic outcomes. The aim of this study is to evaluate the safety and efficacy of the RYGB with a biliopancreatic limb of 200 cm in the control of T2D in patients with BMI 30-35 kg/m2. METHODS: From January 2011 to May 2015, 102 T2D patients with BMI from 30 to 34.9 kg/m2 underwent laparoscopic RYGB with the biliopancreatic-limb of 200 cm and the alimentary-limb of 50 cm. RESULTS: There were no deaths or reoperations. The mean follow-up was 28.1 months. The mean BMI dropped from 32.5 to 25.1 kg/m2, while the mean fasting glucose decreased from 182.9 to 89.8 mg/dl and the mean glycated hemoglobin (HbA1c) went from 8.7 to 5.2%. During follow-up, 92.2% had their T2D under complete control (HbA1c < 6%, no anti-diabetic medications), while 7.8% were under partial control. Control of hypertension and dyslipidemia were 89.4 and 85.5%, respectively. No patient developed hypoalbuminemia, and there were mild micronutrient deficiencies. CONCLUSIONS: RYGB with long-biliopancreatic and short-alimentary limbs is safe and seems effective in achieving complete control of T2D in patients with BMIs between 30 and 35 kg/m2.

Effects of bariatric surgery in obese patients with hypertension: the GATEWAY randomized trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension)

BACKGROUND: Recent research efforts on bariatric surgery have focusedon metabolic and diabetes mellitus resolution. Randomized trials designedto assess the impact of bariatric surgery in patients with obesity andhypertension are needed.METHODS: In this randomized, single-center, nonblinded trial, we includedpatients with hypertension (using ≥2 medications at maximum doses or >2 atmoderate doses) and a body mass index between 30.0 and 39.9 kg/m2. Patientswere randomized to Roux-en-Y gastric bypass plus medical therapy or medicaltherapy alone. The primary end point was reduction of ≥30% of the totalnumber of antihypertensive medications while maintaining systolic and diastolicblood pressure <140 mmHg and 90 mmHg, respectively, at 12 months. RESULTS: We included 100 patients (70% female, mean age 43.8±9.2 years,mean body mass index 36.9±2.7 kg/m2), and 96% completed follow-up.Reduction of ≥30% of the total number of antihypertensive medicationswhile maintaining controlled blood pressure occurred in 41 of 49 patientsfrom the gastric bypass group (83.7%) compared with 6 of 47 patients(12.8%) from the control group with a rate ratio of 6.6 (95% confidenceinterval, 3.1–14.0; P<0.001). Remission of hypertension was present in 25of 49 (51%) and 22 of 48 (45.8%) patients randomized to gastric bypass,considering office and 24-hour ambulatory blood pressure monitoring...

Microvascular Outcomes after Metabolic Surgery (MOMS) in patients with type 2 diabetes mellitus and class I obesity: rationale and design for a randomised controlled trial.

INTRODUCTION: There are several randomised controlled trials (RCTs) that have already shown that metabolic/bariatric surgery achieves short-term and long-term glycaemic control while there are no level 1A of evidence data regarding the effects of surgery on the microvascular complications of type 2 diabetes mellitus (T2DM). PURPOSE: The aim of this trial is to investigate the long-term efficacy and safety of the Roux-en-Y gastric bypass (RYGB) plus the best medical treatment (BMT) versus the BMT alone to improve microvascular outcomes in patients with T2DM with a body mass index (BMI) of 30-34.9 kg/m2. METHODS AND ANALYSIS: This study design includes a unicentric randomised unblinded controlled trial. 100 patients (BMI from 30 to 34.9 kg/m2) will be randomly allocated to receive either RYGB plus BMT or BMT alone. The primary outcome is the change in the urine albumin-to-creatinine ratio (uACR) captured as the proportion of patients who achieved nephropathy remission (uACR<30 mg/g of albumin/mg of creatinine) in an isolated urine sample over 12, 24 and 60 months. ETHICS AND DISSEMINATION: The study was approved by the local Institutional Review Board. This study represents the first RCT comparing RYGB plus BMT versus BMT alone for patients with T2DM with a BMI below 35 kg/m2. TRIAL REGISTRATION NUMBER: NCT01821508; Pre-results.

The Role of Metabolic Surgery on Blood Pressure Control.

Obesity and hypertension are growing epidemics in the modern world. Lifestyle changes and medical treatment for obesity have disappointing long-term results and albeit drugs for hypertension are usually very effective, the necessity of multiple pills and frequent side effects make the adherence to treatment a huge challenge for healthcare systems. Bariatric/metabolic surgery is a very effective treatment and an exponential number of studies have been showing its positive impact beyond weight loss, mainly on type 2 diabetes. There is also growing evidence suggesting that bariatric/metabolic surgery is associated with reduced incidence of cardiovascular events, but the impact on hypertension and other components of metabolic syndrome usually derive from trials' secondary end points. Taking this limitation in mind, bariatric/metabolic surgery action on blood pressure is reaching a significant proportion of hypertension resolution or improvement. In this review, we discussed the current evidence on the impact of bariatric/metabolic surgery on blood pressure control and pointed out perspectives in this research area.

The Role of Metabolic Surgery on Blood Pressure Control

Obesity and hypertension are growing epidemics inthe modern world. Lifestyle changes and medical treatmentfor obesity have disappointing long-term results and albeitdrugs for hypertension are usually very effective, the necessityof multiple pills and frequent side effects make the adherenceto treatment a huge challenge for health care systems. Bariatric/metabolic surgery is a very effective treatment andan exponential number of studies have been showing its positiveimpact beyond weight loss, mainly on type 2 diabetes. There is also growing evidence suggesting that bariatric/metabolic surgery is associated with reduced incidence of cardiovascular events, but the impact on hypertension and other components of metabolic syndrome usually derive from trials’secondary end points. Taking this limitation in mind, bariatric/metabolic surgery action on blood pressure is reaching a significant proportion of hypertension resolution or improvement. In this review, we discussed the current evidence onthe impact of bariatric/metabolic surgery on blood pressurecontrol and pointed out perspectives in this research area...

Effects of gastric bypass surgery in patients with hypertension: rationale and design for a randomised controlled trial (GATEWAY study).

INTRODUCTION: Obesity and overweight are becoming progressively more prevalent worldwide and are independently associated with a significant increase in the risk of cardiovascular diseases. Systemic arterial hypertension is frequently found in association with obesity and contributes significantly to increased cardiovascular risk. We hypothesise that Roux-en-Y gastric bypass (RYGB) surgery, a procedure that effectively reduces body weight, can also positively impact blood pressure control in obese and hypertensive individuals. METHODS AND ANALYSIS: A unicentric, randomised, controlled, unblinded clinical trial. Sixty obese (body mass index between 30 and 39.9) and moderately well controlled hypertensive patients, in use of at least two antihypertensive medications at maximum doses or more than two in moderate doses, will be randomly allocated, using an online, electronic and concealed method, to receive either RYGB plus optimised clinical treatment (OCT) or OCT alone. The primary end point is the reduction of antihypertensive medication at 1 and 2 years of follow-up. Data analysis will primarily be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION: The study was approved by the local institutional review board that works in total compliance with the latest version of the Helsinki Declaration, the Good Clinical Practices (GCP), the 'America's Document' and the national regulatory laws. Before the beginning of any study-related activities, each study participant is asked to provide a signed informed consent. TRIAL REGISTRATION NUMBER: NCT01784848.

Effects of gastric bypass surgery inpatients with hypertension: rationaleand design for a randomised controlledtrial (GATEWAY study)

Obesity and overweight are becomingprogressively more prevalent worldwide and areindependently associated with a significant increase inthe risk of cardiovascular diseases. Systemic arterialhypertension is frequently found in association withobesity and contributes significantly to increasedcardiovascular risk. We hypothesise that Roux-en-Ygastric bypass (RYGB) surgery, a procedure thateffectively reduces body weight, can also positivelyimpact blood pressure control in obese andhypertensive individuals.Methods and analysis: A unicentric, randomised,controlled, unblinded clinical trial. Sixty obese (bodymass index between 30 and 39.9) and moderately wellcontrolled hypertensive patients, in use of at least twoantihypertensive medications at maximum doses ormore than two in moderate doses, will be randomlyallocated, using an online, electronic and concealedmethod, to receive either RYGB plus optimised clinicaltreatment (OCT) or OCT alone. The primary end pointis the reduction of antihypertensive medication at1 and 2 years of follow-up. Data analysis will primarilybe conducted on an intention-to-treat basis.Ethics and dissemination: The study was approvedby the local institutional review board that works intotal compliance with the latest version of the HelsinkiDeclaration, the Good Clinical Practices (GCP), the‘America’s Document’ and the national regulatory laws.Before the beginning of any study-related activities,each study participant is asked to provide a signedinformed consent.

A pilot study of the duodenal-jejunal bypass liner in low body mass index type 2 diabetes.

CONTEXT: The duodenal-jejunal bypass liner (DJBL) is a device that mimics the intestinal portion of gastric bypass surgery and has been shown to improve glucose metabolism rapidly in obese subjects with type 2 diabetes (T2DM). OBJECTIVE: To assess the safety of the DJBL and to evaluate its potential to affect glycemic control beneficially in subjects with T2DM who were not morbidly obese. PATIENTS AND DESIGN: Adult men and women with T2DM of ≤ 10 years' duration with hemoglobin A1c (HbA1c) ≥ 7.5% and ≤ 10% and having a body mass index ≥ 26 to ≤ 50 kg/m(2) were enrolled in this prospective, 52-week, single-center, open-label clinical study. MAIN OUTCOME MEASURES: Adverse events and changes in body weight, fasting plasma glucose (FPG) levels, and HbA1c levels. RESULTS: Sixteen of 20 subjects implanted with the DJBL completed the 1-year study (mean body mass index = 30.0 ± 3.6, mean ± SD). Gastrointestinal disorders were reported by 13 subjects, and metabolic or nutritional disorders occurred in 14 subjects. FPG levels dropped from 207 ± 61 mg/dL at baseline to 139 ± 37 mg/dL at 1 week and remained low throughout the study. Mean body weight also declined, but the change in body weight was not significantly associated with change in FPG at 52 weeks. HbA1c declined from 8.7 ± 0.9% at baseline to 7.5 ± 1.6% at week 52. CONCLUSIONS: The improvements in glycemic status were observed at 1 year in moderately obese subjects with T2DM, suggesting that the DJBL may represent an effective adjuvant to standard medical therapy of T2DM in this population.

Laparoscopic bariatric surgery: new technologies, trends and perspectives.

Obesity is an endemic disease. It was already proved that the clinical approach to morbid obesity fails in 95% of cases. Laparoscopy has shown that is related to a milder metabolic response and a smoother postoperative period. There is no doubt that the laparoscopic approach is not the future for the surgical treatment of morbid obesity, but the best present approach and with equally excellent results when compared to the traditional open operation. However, this challenging surgery requires masterful use of an array of specialized laparoscopic equipment and instrumentation. These include proper video monitors, cameras, visualization, peritoneal entrance, scopes, cutting/coagulation equipments, and staplers, suturing devices, graspers, dedicated endosurgery operating rooms, robotics and awareness of newer equipment. This paper covers the benefits of the laparoscopic access in bariatric surgery and reviews the cutting-edge in technology to drive surgeons and patients to a smoother intra and postoperative course.

Laparoscopic bariatric surgery: new technologies, trends and perspectives

Obesidade hoje é uma doença endêmica. Está comprovado que o tratamento clínico falha em 95% dos casos. A Cirurgia Laparoscópica já demonstrou ser menos agressiva do ponto de vista sistêmico e metabólico, levando a um pós-operatório mais confortável. Hoje, não existe dúvida que o acesso laparoscópico não é o futuro, mas sim o presente para o tratamento operatório da obesidade mórbida, tendo, pelo menos, os excelentes resultados em termos de perda ponderal e cura das co morbidades quando comparada às operações abertas. Porém, essas operações, por vezes, necessitam de um grande aparato tecnológico, como videocâmeras, monitores de alta resolução, laparoscópios, equipamentos para corte e coagulação eficientes e seguros e até mesmo salas cirúrgicas devotadas às operações minimamente invasivas. Esse artigo discorre sobre os benefícios do acesso laparoscópico, assim como revisa a tecnologia de ponta que pode ser utilizada pela equipe cirúrgica para a condução segura, rápida e eficiente das operações bariátricas por videolaparoscopia.

Abdome agudo no idoso / Acute abdome in the aged

Neste trabalho säo analisados restropectivamente 53 doentes idosos admitidos com o diagnóstico de abdome agudo. Considerou-se idoso, indivíduo com mais de 65 anos. Considerou-se idoso, indivíduo com mais de 65 anos, sendo que a faixa etária varia de 65 a 95 anos com média de idade de 74 anos. A obstruçäo intestinal foi a causa mais freqüente de abdome agudo, seguido pela doença inflamatória. Em até 50% dos casos dependendo da etiologia, a propedêutica abdominal näo foi täo exuberante e as alteraçöes laboratoriais eram pouco significativas. `A exceçäo de três doentes, todos foram tratados cirurgicamente. O índice de morbidade operatória foi de 30%, sendo que complicaçöes ocorreram em 14% dos casos. A mortalidade global foi de 41,5%, conseqüente a falência de órgäo ou descompensaçöes cardíacas. A diminuiçäo dos índices de morbidade e mortalidade operatórias, está na dependência de um diagnóstico precoce e da adoçäo de uma conduta