International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks.

Background and study aims A variety of endoscopic techniques are currently available for treatment of upper gastrointestinal (UGI) anastomotic leaks; however, no definite consensus exists on the most appropriate therapeutic approach. Our aim was to explore current management of UGI anastomotic leaks. Methods A survey questionnaire was distributed among international expert therapeutic endoscopists regarding management of UGI anastomotic leaks. Results A total of 44 % of 163 surveys were returned; 69 % were from gastroenterologists and 56 % had > 10 years of experience. A third of respondents treat between 10 and 19 patients annually. Fifty-six percent use fully-covered self-expandable metal stents as their usual first option; 80% use techniques to minimize migration; 4 weeks was the most common reported stent dwell time. Sixty percent perform epithelial ablation prior to over-the-scope-clip placement or suturing. Regarding endoscopic vacuum therapy (EVT), 56 % perform balloon dilation and intracavitary EVT in patients with large cavities but small leak defects. Regarding endoscopic septotomy, 56 % consider a minimal interval of 4 weeks from surgery and 90 % consider the need to perform further sessions. Regarding endoscopic internal drainage (EID), placement of two stents and shorter stents is preferred. Persistent inflammation with clinical sepsis was the definition most commonly reported for endoscopic failure. EVT/stent placement and EVT/EID were the therapeutic options most often chosen in patients with previous oncologic surgery and previous bariatric surgery, respectively. Conclusions There is a wide variation in the management of patients with UGI anastomotic leaks. Future prospective studies are needed to move from an expert- to evidence- and personalization-based care.

The Effect of Sleeve Gastrectomy on the Hormonal Profile of Patients with Polycystic Ovary Syndrome.

PURPOSE: To prospectively evaluate the hormonal profile and weight loss of women with obesity and PCOS submitted to sleeve gastrectomy (SG). METHODS: A Prospective study carried out at the Hospital das Clínicas, Federal University of Pernambuco, Recife, Brazil, in 2018, where 18 patients with PCOS, whose age varied from 18 to 40 years, with an indication for bariatric surgery were evaluated. Plasma estradiol (E2), fasting insulin, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were measured prior to bariatric surgery and 3 months after surgery. The LH/FSH ratio and BMI of the study participants were also calculated. RESULTS: Postoperative E2 levels were higher (preoperative mean of 63.4 pg/dL versus postoperative mean of 91.0 pg/dL), with no statistical significance then (p = 0.139). It was observed, at the postoperative period, statistically significant decreases in mean fasting insulin levels (24.4 mIU/mL vs. 9.0 mIU/mL; p < 0.001), LH levels (7.2 vs. 4.5; p = 0.047), and an inverted LH/FSH ratio (1.5 vs. 0.9; p = 0.008); relevant weight loss occurred (mean BMI, 40.5 kg/m2 vs. 33.4 kg/m2; p < 0.001). CONCLUSION: Relevant changes in the hormone profile and significant alterations in the gonadotropic and insulin patterns were seen. In addition to satisfactory weight loss, the observed endocrine alterations revealed an internal environment that was more homeostatic and conducive to reproduction, indicating that SG was able to produce attractive physiological outcomes for women with PCOS.

Roux-en-Y gastric bypass for nonobese patients with uncontrolled type 2 diabetes: a long-term evaluation.

BACKGROUND: There is growing evidence that the impact of Roux-en-Y gastric bypass (RYGB) on type 2 diabetes (T2D) occurs regardless of the amount of weight loss. Taking this background into consideration, it is plausible to study this procedure in individuals with lower body mass index (BMI) under clinical treatment failure for uncontrolled T2D. OBJECTIVES: To elucidate the long-term impact of RYGB on T2D regression in a non-obese population. SETTING: Hospital das Clínicas, Federal University of Pernambuco, Brazil. METHODS: Twelve patients with BMI 25 to 30 kg/m2 and inadequately controlled T2D underwent RYGB and were followed up for 6 years. Fasting plasma glucose, glycated hemoglobin, BMI, and the use of insulin and/or oral hypoglycemic agents were assessed. Each variable was analyzed in 3 distinct moments: preoperative evaluation, 2-year postoperative follow-up (2-PO), and 6-year postoperative follow-up (6-PO). RESULTS: There were no cases of early or late mortality. Mean BMI at preoperative evaluation, 2-PO, and 6-PO were 28.1 ± 1.2; 23.2 ± 2.4; and 24.7 ± 3.1, respectively. The lowest BMI at 6-PO was 19.1 kg/m2. Complete remission of T2D was achieved in 16.7%, partial remission in another 16.7%, glycemic control in 25%, and glycemic improvement in 25% of the sample at 6-PO; 16.7% did not present positive glycemic outcomes. Only 1 patient needed to resume insulin administration between 2-PO and 6-PO. CONCLUSIONS: RYGB was found to be safe and effective in treating uncontrolled T2D in non-obese patients, providing improvements in the glycemic patterns in 83.4% of our sample.

Omentopexy in Sleeve Gastrectomy Reduces Early Gastroesophageal Reflux Symptoms.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is one of the surgical procedures indicated in the treatment of obesity. The occurrence of gastroesophageal reflux (GER) in the postoperative period of this surgery is related to a reduction in the lower esophageal sphincter (LES) tone and the presence of gastric residual fundus (RF) associated with increased gastric intraluminal pressure. Fixation of the remaining gastric reservoir to the gastrosplenic and gastrocolic ligaments (omentopexy) has emerged as a technical option to avoid or decrease GER in the postoperative period of LSG. OBJECTIVE: To evaluate the presence of GER symptoms, alterations in LES tone, and the presence of RF in obese subjects submitted to LSG with omentopexy. METHODS: Twenty obese patients were submitted to LSG with omentopexy from July 2016 to July 2017 at the Hospital Unimed de Teresina, Brazil and was studied prospectively. Clinical evaluations, including a specific questionnaire (clinical score), upper digestive endoscopy and esophageal manometry, were performed preoperatively and on the 90th postoperative day. Contrast x-ray of the esophagus, stomach, and duodenum were performed after the 90th postoperative day. The Fischer exact test was used to evaluate the correlation between GER symptoms and changes in LES tone or the presence of RF. Analysis of variance was used to evaluate the correlation of GER symptoms with the 2 variables together. All analyses adopted a level of significance for α errors >5% (P-value <0.05). RESULTS: The mean clinical score of GER reduced from 6.7 in the preoperative period to 2.7 in the postoperative period. By manometry, there were no significant changes in the LES tone with mean values of 26.04 and 27.07 mm Hg before and after the procedure. RF was identified in 3 cases by contrast radiology. There was no statistical correlation between the changes in the LES tone or the presence of RF with the increase in the clinical score of GER (in cases where this occurred), even when the variables were evaluated together. CONCLUSIONS: LSG with omentopexy improved the clinical score of GER in most cases and did not cause significant changes in the LES tone. The presence of RF did not exacerbate the clinical score of GER.

Severe Dehiscence of Gastrojejunal Anastomosis after Gastric Bypass: Its Cure by Using Partially Covered Stent and Avoiding Migration.

BACKGROUND: Gastric leak is a severe complication of gastric bypass that is associated with significant morbidity and mortality. Anastomosis dehiscence usually occurs at gastrojejunal anastomosis and can appear simultaneously with gastric leak, for which treatment can be a challenge. Fistula may have several clinical impacts, depending on patient-related factors, fistula characteristics, onset time, and therapy proposal. Abdominal toilet, drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. Currently, endoscopic stents are gaining space, promoting fistula sealing, secretion deviation, treating gastric stricture, and allowing early oral diet. Herein, we present a case of severe gastrojejunal anastomosis dehiscence treated with partially covered stent. MATERIALS AND METHODS: We present a video of a 39-year-old man with a body mass index of 40 Kg/m2 who underwent a Roux-en-Y gastric bypass and presented fever and leukocytosis. Gastric leak was diagnosed 7 days after the bariatric surgery. At first, he was submitted to three reoperations: laparotomy with abdominal toilet, abdominal drain, and gastrostomy. Sepsis was controlled, but drain output maintained the same debit. On the 22nd POD, it was decided to place a metallic stent. As the first step, an endoscopist looked at the lesser curvature. There was no continuity to the alimentary limb, and the anastomosis was disrupted. Careful inflation and washing was done, allowing identification of the alimentary limb, followed by guidewire passage, with radioscopic control. Once the guidewire was positioned, stent placement was possible and safe. Upper edge of stent was placed in the lower third of the esophagus. RESULTS: Patient progressed uneventfully. After 4 weeks, stent removal was attempted. However, it was not possible due to endoluminal tissue hyperplasia. Argon plasma was used three times to promote proliferative mucosa ablation. Stent was removed after 53 days, with no migration. The abdominal drain was removed 1 week later. After 6-months follow-up, the patient remains asymptomatic. CONCLUSION: Early dehiscence closure was observed, without recurrence. The use of partially covered self-expandable metallic stent is associated with lower migration rates; however, removal can be technically difficult due to tissue hyperplasia.

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.

Endoscopic septotomy: an effective approach for internal drainage of sleeve gastrectomy-associated collections.

Background and study aims Staple-line leaks occur in 1 % - 7 % of patients who undergo sleeve gastrectomy, and can be challenging to treat. The success of endoscopic approaches decreases as leaks develop into chronic sinus tracts. Endoscopic septotomy has been used to facilitate healing of refractory leaks by incision and enlargement of the tract to allow direct communication with the gastric lumen and internal drainage. Patients and methods We reviewed the technique and outcomes among patients who underwent endoscopic septotomy at two centers for the management of sleeve gastrectomy-associated gastric fistulas and perigastric collections refractory to occlusive endoscopic therapies. Results Nine patients underwent endoscopic septotomy at a mean of 8.6 weeks after leak diagnosis, following failure of percutaneous and conventional endoscopic modalities. Perigastric collections ranged from 3 cm to 10 cm in size. The mean procedure time for endoscopic septotomy was 87.2 minutes. Multiple endoscopic septotomy procedures (mean 2.3, range 1 - 4) were required to achieve radiological resolution. The mean follow-up period was 21.2 weeks, and all nine patients achieved symptom resolution without the need for surgery. Bleeding at the time of endoscopic septotomy occurred in three patients, and was managed with endoscopic clips and did not require transfusion. No other adverse events or delayed complications were recorded. Conclusions Endoscopic septotomy appears to be a safe and effective technique for the management of sleeve gastrectomy-associated fistulae and collections, including those refractory to other endoscopic and percutaneous methods.

Morbidity Rates and Weight Loss After Roux-en-Y Gastric Bypass, Sleeve Gastrectomy, and Adjustable Gastric Banding in Patients Older Than 60 Years old: Which Procedure to Choose?

BACKGROUND: As life expectancy increases, more elderly patients fit into the criteria for bariatric procedures. The aim of our study is to evaluate and compare the safety and efficacy of Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB) in patients older than 60. MATERIAL AND METHODS: Between January 2005 and December 2013, 68 LAGB, 73 LSG, and 212 RYGB patients were 60 years or older at the time of primary procedure. A retrospective review was performed in these patients. RESULTS: Mean age and body mass index (BMI) was 62.7 ± 2.2, 64.1 ± 2.9, and 62.6 ± 2.3 years and 42.7 ± 5.6, 44.0 ± 7.0, and 45.2 ± 6.7 kg/m(2) for LAGB, LSG, and RYGB at the time of procedure, respectively. Seven (10.3%) patients from the LAGB, 3 (4.1%) from the LSG, and 29 (13.8%) from the RYGB group required readmissions. Reoperation rate was 10.3, 1.4, and 9.5% in LAGB, LSG, and RYGB, respectively. The difference in reoperation rates was statistically significant (p < 0.03) while that in readmission rates was not (p > 0.58). Procedure-related mortality rate was 1.4% in the RYGB group, while no mortality was observed in LSG and LAGB groups. At 6, 12, and 18 months postoperatively, mean percentage of excess weight loss were highest in the RYGB group, followed by LSG and LAGB group (p < 0.01). Mean number of comorbidities at the last follow-up significantly decreased in LSG and RYGB patients. CONCLUSIONS: LSG showed the lowest readmission and reoperation rate, and RYGB patients had the highest mortality rate. Weight loss and comorbidity resolution were effectively achieved in RYGB and LSG patients.

C-REACTIVE PROTEIN IN DIABETIC PATIENTS BEFORE GASTRIC BYPASS AS A POSSIBLE MARKER FOR POSTOPERATIVE COMPLICATION.

BACKGROUND: Obesity and type 2 diabetes mellitus are associated to inflammatory state, which can be set off by the adipose tissue, once it is a metabolically active organ that can cause a chronic mild inflammatory state. AIM: To evaluate the correlation between preoperative C-reactive protein and postoperative complications risk in obese patients (grades II and III) after Roux-en-Y gastric bypass, with and without type 2 diabetes mellitus. METHODS: Between 2008 and 2013 were analysed 209 patients (107 with diabetes), presenting body mass index >40 kg/m2 or >35 kg/m2 with comorbidities. During the postoperative period, two groups were evaluated: with and without complications. Preoperative ultra-sensitive C-reactive protein was measured by immunonephelometry method. RESULTS: Complications occurred in seven patients (pulmonary thromboembolism, fistula, two cases of suture leak, pancreatitis, evisceration and upper digestive hemorrhage). No statistical significance was found regarding lipid profile and C-reactive protein between patients with and without type 2 diabetes mellitus. When compared to each other, both groups (with and without complications) presented with statistical significance regarding C-reactive protein level (7,2 mg/dl vs 3,7 mg/dl, p=0,016) and had similar weight loss percentage after 3, 6 and 12 months follow-up. CONCLUSIONS: Preoperative C-reactive protein serum level was higher in the group which presented complications after Roux-en-Y gastric bypass when compared to the group without postoperative complications.

Endoscopic Management of Massive Hemorrhage 12 h Post Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: Acute (<24 h) staple line bleeding is not common but a known complication after bariatric surgery at a rate of 1-3%. In most cases, acute postoperative bleeding is mild and can be managed conservatively. Nonetheless, there are times when massive hemorrhage is encountered. Endoscopic treatment of these patients within 24 h of Roux-en-Y (RYGB) is controversial, due to fear of staple line dehiscence and/or perforation. Therefore, most surgeons prefer to undergo diagnostic laparoscopy for exploration and treatment. However, it has been reported that laparoscopic management of acute bleeding can be technically challenging with a high rate of morbidity as well as conversion to laparotomy. We herein present a multimedia video (6 min) demonstrating the management of acute massive hemorrhage after RYGB. METHODS: A 46-year-old female with hemodynamic instability after massive hematemesis and melena underwent endoscopy. An overtube was utilized to allow removal of large blood clots which obstructed endoscopic visualization. Two bleeding points were noted, and these were successfully treated with adrenaline and endoscopic clips. RESULTS: The patient rapidly improved during her hospital stay and commenced oral intake on day 1. A surveillance endoscopy was performed on day 5, and no stigmata of recent bleeding was noted. She was discharged home and is progressing well. CONCLUSIONS: We suggest endoscopy is an appropriate first step for the investigation and management of acute intraluminal bleeding post bariatric surgery.

Argon plasma coagulation of gastrojejunal anastomosis for weight regain after gastric bypass.

BACKGROUND: The failure of approximately 20 % of obese patients who undergo Roux-en-Y gastric bypass (RYGB) to maintain weight loss over the following 18-24 months is related to the surgical procedure, to the patient, or both. Although the underlying mechanisms are uncertain, one factor that has been postulated is the dilation of the gastrojejunal anastomosis. The objective was to evaluate the safety and efficacy of the serial use of argon plasma coagulation (APC) in reducing the diameter of the dilated gastrojejunal anastomosis and post-RYGB weight regain. METHODS: We carried out a prospective, nonrandomized study of 30 patients, with no control or sham group, monitoring RYGB weight regain associated with dilation of the gastrojejunal anastomosis over a postoperative period of 18 months. Each patient underwent three sessions of APC in the anastomosis separated by 8 weeks, with a final endoscopic examination 8 weeks after the last session. RESULTS: There was a loss of 15.48 kg (range = 8.0-16.0 kg) of the 19.6 kg (range = 7.0-39.0 kg) of regained weight after RYGB and a reduction of 66.89 % in the final anastomotic diameter, with statistically significant reductions between each APC session. Previous body mass index significantly decreased up to the final examination, and the final weight was close to but not at the same level as the nadir. CONCLUSIONS: Our study indicates that the use of APC to treat weight regain after RYGB is a safe and effective procedure and promotes a reduction in gastrojejunal anastomosis, final weight, and BMI, with a low rate of complications.

C-REACTIVE PROTEIN IN DIABETIC PATIENTS BEFORE GASTRIC BYPASS AS A POSSIBLE MARKER FOR POSTOPERATIVE COMPLICATION / PROTEÍNA C REATIVA EM DIABÉTICOS ANTES DO BYPASS GÁSTRICO COMO POSSÍVEL MARCADOR DE COMPLICAÇÃO PÓS-OPERATÓRIA

Background: Obesity and type 2 diabetes mellitus are associated to inflammatory state, which can be set off by the adipose tissue, once it is a metabolically active organ that can cause a chronic mild inflammatory state.Aim: To evaluate the correlation between preoperative C-reactive protein and postoperative complications risk in obese patients (grades II and III) after Roux-en-Y gastric bypass, with and without type 2 diabetes mellitus.Methods:Between 2008 and 2013 were analysed 209 patients (107 with diabetes), presenting body mass index >40 kg/m2or >35 kg/m2with comorbidities. During the postoperative period, two groups were evaluated: with and without complications. Preoperative ultra-sensitive C-reactive protein was measured by immunonephelometry method. Results: Complications occurred in seven patients (pulmonary thromboembolism, fistula, two cases of suture leak, pancreatitis, evisceration and upper digestive hemorrhage). No statistical significance was found regarding lipid profile and C-reactive protein between patients with and without type 2 diabetes mellitus. When compared to each other, both groups (with and without complications) presented with statistical significance regarding C-reactive protein level (7,2 mg/dl vs 3,7 mg/dl, p=0,016) and had similar weight loss percentage after 3, 6 and 12 months follow-up.Conclusions: Preoperative C-reactive protein serum level was higher in the group which presented complications after Roux-en-Y gastric bypass when compared to the group without postoperative complications.

Racional: Obesidade e diabete melito tipo 2 são associadas a estado inflamatório desencadeado pelo tecido adiposo, uma vez que é órgão metabolicamente ativo e que pode gerar estado de inflamação crônica leve.Objetivo: Avaliar a correlação entre os níveis de proteína C reativa pré-operatória e o risco de complicações pós-operatórias em obesos graus II e III após bypass gástrico em Y-de-Roux, em um grupo com e outro sem diabete melito tipo 2.Métodos: Entre 2008 e 2013 foram analisados 209 pacientes (107 diabéticos) com índice de massa corpórea acima de 40 kg/m2 ou maior que 35 kg/m2com comorbidades. No pós-operatório foi avaliado um grupo com e outro sem complicações. A proteína C reativa ultrassensível pré-operatória foi mensurada pela técnica de imunonefelometria.Resultados: Complicações ocorreram em sete pacientes (tromboembolismo pulmonar, fístula, dois casos de vazamento de sutura, pancreatite, evisceração e hemorragia digestiva alta). Não houve diferença estatística significativa em relação ao perfil lipídico e níveis séricos de proteína C reativa entre os grupos com e sem diabete. Quando comparados, os dois grupos (com e sem complicações) apresentaram significância estatística entre os níveis de proteína C reativa (7,2 mg/dl vs 3,7 mg/dl, p=0,016), sendo semelhantes em relação à percentagem de perda de peso após seguimento de 3, 6 e 12 meses.Conclusões: O nível sérico de proteína C reativa pré-operatória foi mais elevado no grupo com complicações após bypass gástrico em Y-de-Roux do que no grupo sem complicações.

Altered coronary artery calcium scores before bariatric surgery.

INTRODUCTION: Obesity is an important cause of cardiovascular disease, especially coronary artery disease. Severely obese patients are particularly prone to this risk. The coronary artery calcium (CAC) score is a strong predictor of coronary heart disease and provides incremental information beyond traditional risk factors. We sought to determine the prevalence of abnormally high CAC scores in the preoperative setting among patients undergoing bariatric surgery and to establish risk predictors for higher scores. METHODS: We performed an observational study of 202 patients free of known coronary artery disease who were referred for bariatric surgery. In each patient, the presence of CAC was detected with computed tomography, and coronary risk variables were either measured or determined via questionnaire. RESULTS: CAC was found in 14.4% of the overall population (26% of male and 10.5% of female patients). Participants with altered CAC scores were older (mean age, 46.8 years). The variables positively associated with an altered CAC score were older age, male sex, type 2 diabetes, hypertension, and hypercholesterolemia. Multivariate-adjusted analysis showed that age (OR, 1.11; 95% CI, 1.06-1.17; p = 0.001), male sex (OR, 4.17; 95% CI, 1.52-11.47; p = 0.006), and hypercholesterolemia (OR, 6.21; 95% CI, 1.81-21.29; p = 0.004) were most closely related to the presence of CAC. CONCLUSION: Obese patients in the preoperative bariatric surgery setting have a high prevalence of abnormal CAC scores. Traditional risk factors play a important role in this scenario.

Antibiotic prophylaxis in bariatric surgery with continuous infusion of cefazolin: determination of concentration in adipose tissue.

BACKGROUND: The aim of this study was to evaluate the concentration of cefazolin in adipose tissue of patients undergoing bariatric surgery. METHODS: Eighteen patients undergoing bariatric surgery were evaluated during the period from October 2011 to May 2012. All patients had a dosage schedule of antibiotic prophylaxis with cefazolin administered as follows: first, 2 g in anesthetic induction, followed by continuous infusion of 1 g diluted in 250 ml of saline solution. Adipose samples, collected soon after the incision (initial) and before the skin synthesis (final), were analyzed using reverse phase high-pressure liquid chromatography. The level of significance adopted was 5 %. RESULTS: The cefazolin concentration in the adipose tissue samples at the beginning of surgery was an average of 6.66 ± 2.56 ug/ml. The mean concentration before the skin synthesis was 7.93 ± 2.54 ug/ml. Patients with BMI < 40 kg/m(2) had higher initial and final sample concentrations of cefazolin than patients with BMI ≥ 40 kg/m(2). There was no surgical site infection (SSI) in any of the patients. CONCLUSIONS: In bariatric surgeries, addition of a 1 g increase of cefazolin, administered through continuous intravenous infusion, to the currently recommended dose of 2 g administered in anesthetic induction provided a concentration in the adipose tissue above the minimum inhibitory concentration (MIC) of the main causal agents of SSI. An inverse correlation between BMI and concentration of cefazolin in adipose tissue was observed.

Nonalcoholic steatohepatitis on preoperative period of gastric bypass: lack of correlation with degree of obesity.

BACKGROUND: Metabolic disorders have high correlation with severe forms of nonalcoholic fatty liver disease. However, there is no non-invasive method that promotes its proper stratification and biopsy remains the ideal diagnostic tool. AIM: To evaluate the prevalence of this disease in obese in preoperative period of Roux-en-Y gastric bypass and metabolic factors correlated with liver histopathology. METHODS: From a total of 47 patients, 35 were enrolled in the inclusion criteria and 12 excluded due to liver disease and alcohol intake >80 g/week. Were performed clinical and laboratory evaluation before the surgery and intraoperative liver biopsy . The intensity was ranked in grade of steatohepatitis: I (mild to moderate) and II (diffuse inflammation), III ( periportal fibrosis) and IV (cirrhosis). Were compared the following variables: duration of obesity, body mass index, waist-hip ratio, type 2 diabetes mellitus, hypertension and dyslipidemia. RESULTS: Thirty -five patients (68.6 % women , mean age 37 years) were evaluated. The mean body mass index preoperatively was 53.04 kg/m². Nonalcoholic steatohepatitis was found in 31 patients (88.6 %) and 32.2% were in grade I (n=10), grade II 45.2% (n=14), and 25.6% grade III (n=7). The waist-hip ratio was associated with hepatic steatosis; hypertriglyceridemia was the marker that had best correlation with higher grade; there was no correlation between aminotransferase and intensity of the disease; there was correlation of intensity with factors related to insulin resistance. CONCLUSION: Nonalcoholic steatohepatitis is highly prevalent in morbidly obese patients, but there was no positive correlation between aminotransferases and degree of obesity and liver histopathology. Hypertriglyceridemia and waist-hip ratio were positively correlated with the intensity of disease.

Metabolic surgery, weight regain and diabetes re-emergence.

INTRODUCTION: The poor success of clinical treatment of Type 2 Diabetes Mellitus (T2DM2) increased interest in metabolic surgery, which has been considered a promising alternative for the control of obese or non-obese diabetics. However, there is still no long-term follow-up to evaluate the duration of diabetes remission, and if weight regain would be associated to recurrence. AIM: 1) To describe the results of diabetic patients with a BMI < 30 and < 35 kg/m² submitted to the following types of metabolic surgery: ileal interposition and sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), adjustable gastric banding, duodeno-jejunal exclusion and duodeno-jejunal bypass; 2) to evaluate the possible relapse of diabetes after occurrence of weight regain on long-term after bariatric surgery. METHOD: An expositive and historical literature review about metabolic surgery in diabetic patients with BMI < 30 and < 35 kg/m² was conducted, and systematic review of the association between disease relapse and weight regain after bariatric surgery. RESULTS: After analysis of 188 published papers on Medline until 2010, three papers were selected, which included 269 patients who underwent RYGB. Pre-operatory BMI was between 37 and 60 kg/m² and follow-up of three to 16 years. CONCLUSIONS: 1) Two studies showed association between weight regain and recurrence of type 2 diabetes, while the third did not show this association when comparing groups with and without weight regain; 2) metabolic surgery has shown adequate control of T2DM2 in class I obese subjects; however, the non-obese group still need a long-term evaluation, considering the risk of diabetes recurrence when after weight regain.

Esteato-hepatite não-alcoólica em pré-operatório de bypass gástrico: ausência de correlação com grau de obesidade / Nonalcoholic steatohepatitis on preoperative period of gastric bypass: lack of correlation with degree of obesity

RACIONAL: Alterações metabólicas têm elevada correlação com formas graves da doença hepática gordurosa não-alcoólica. Todavia, ainda não há método não-invasivo que promova sua adequada estratificação sendo que a biópsia permanece como meio diagnóstico ideal. OBJETIVO: Avaliar a prevalência dessa doença em obesos no pré-operatório de bypass gástrico em Y-de-Roux e correlacionar fatores metabólicos com a histopatologia hepática. MÉTODOS: Do total de 47 pacientes, foram incluídos 35 em pré-operatório e excluídos 12 devido à doenças hepáticas e ingestão alcoólica >80 g/semana. Foi realizada avaliação clínico-laboratorial antes da operação e biópsia hepática transoperatória. A intensidade da esteatohepatite foi classificada nos graus: I (leve a moderada), II (difusa e inflamatória), III (fibrose periportal) e IV (cirrose). Foram comparadas as seguintes variáveis: tempo de obesidade, índice de massa corpórea, relação cintura-quadril, diabete melito tipo 2, hipertensão arterial e dislipidemia. RESULTADOS: Trinta e cinco pacientes (68,6% mulheres, média de idade de 37 anos) foram avaliados. O índice de massa corpórea médio pré-operatório foi de 53,04 kg/m2. Esteatohepatite não-alcoólica foi encontrada em 31 pacientes (88,6%), sendo grau I 32,2% (n=10), grau II 45,2% (n=14), e grau III 25,6% (n=7). A relação cintura-quadril mostrou associação com esteatose hepática; hipertrigliceridemia foi o marcador que melhor se correlacionou com maior grau; não houve correlação entre aminotransferase e a intensidade da doença; houve correlação da intensidade com fatores relacionados à resistência insulínica. CONCLUSÃO: Esteatohepatite não-alcoólica tem elevada prevalência em obesos graves, porém não foi observada correlação positiva entre aminotransferases e o grau de obesidade com histopatologia hepática. Hipertrigliceridemia e relação cintura-quadril correlacionaram-se positivamente com a intensidade de doença.

BACKGROUND: Metabolic disorders have high correlation with severe forms of nonalcoholic fatty liver disease. However, there is no non-invasive method that promotes its proper stratification and biopsy remains the ideal diagnostic tool. AIM: To evaluate the prevalence of this disease in obese in preoperative period of Roux-en-Y gastric bypass and metabolic factors correlated with liver histopathology. METHODS: From a total of 47 patients, 35 were enrolled in the inclusion criteria and 12 excluded due to liver disease and alcohol intake >80 g/week. Were performed clinical and laboratory evaluation before the surgery and intraoperative liver biopsy . The intensity was ranked in grade of steatohepatitis: I (mild to moderate) and II (diffuse inflammation), III ( periportal fibrosis) and IV (cirrhosis). Were compared the following variables: duration of obesity, body mass index, waist-hip ratio, type 2 diabetes mellitus, hypertension and dyslipidemia. RESULTS: Thirty -five patients (68.6 % women , mean age 37 years) were evaluated. The mean body mass index preoperatively was 53.04 kg/m². Nonalcoholic steatohepatitis was found in 31 patients (88.6 %) and 32.2% were in grade I (n=10), grade II 45.2% (n=14), and 25.6% grade III (n=7). The waist-hip ratio was associated with hepatic steatosis; hypertriglyceridemia was the marker that had best correlation with higher grade; there was no correlation between aminotransferase and intensity of the disease; there was correlation of intensity with factors related to insulin resistance. CONCLUSION: Nonalcoholic steatohepatitis is highly prevalent in morbidly obese patients, but there was no positive correlation between aminotransferases and degree of obesity and liver histopathology. Hypertriglyceridemia and waist-hip ratio were positively correlated with the intensity of disease.

Cirurgia metabólica, reganho de peso e recidiva do diabete / Metabolic surgery, weight regain and diabetes re-emergence

INTRODUÇÃO: O insucesso do tratamento clínico do diabete melito tipo 2 (DM2) aumentou o interesse em cirurgia metabólica, sendo considerada alternativa promissora no controle de diabéticos com ou sem obesidade. Todavia, ainda não há seguimento em longo prazo para se avaliar a duração da remissão da doença, cuja recidiva pode estar associada ao reganho de peso. OBJETIVOS: 1) Descrever os resultados de pacientes com DM2 e IMC <30 e <35 kg/m², submetidos aos seguintes tipos de operações metabólicas: interposição ileal e gastrectomia vertical, derivação gástrica em Y-de-Roux (DGYR), banda gástrica ajustável, exclusão duodeno-jejunal e bypass duodenojejunal; 2) avaliar a possível ocorrência de recidiva do diabete após reganho de peso em longo prazo. MÉTODO: Foi realizada revisão expositiva e histórica da literatura sobre cirurgia metabólica em pacientes com DM2 e IMC <30 e <35 kg/m², e revisão sistemática sobre a associação entre recidiva da doença e reganho de peso após cirurgia bariátrica. RESULTADO: Após análise de 188 artigos publicados no Medline até 2010, foram selecionados três estudos, com 269 pacientes submetidos à DGYR, com IMC pré-operatório entre 37 e 60 kg/m² e com seguimento de três a 16 anos. CONCLUSÕES: 1) Dois estudos mostraram que o reganho de peso está associado à recidiva do diabete, enquanto o terceiro não confirma este fato, na comparação entre o grupo com e sem reganho; 2) a cirurgia metabólica vem apresentando adequado controle do diabete em obesos grau I; todavia, o grupo não obeso ainda aguarda avaliação em longo prazo, considerando o risco de recidiva associado ao reganho de peso.

INTRODUCTION: The poor success of clinical treatment of Type 2 Diabetes Mellitus (T2DM2) increased interest in metabolic surgery, which has been considered a promising alternative for the control of obese or non-obese diabetics. However, there is still no long-term follow-up to evaluate the duration of diabetes remission, and if weight regain would be associated to recurrence. AIM: 1) To describe the results of diabetic patients with a BMI < 30 and < 35 kg/m² submitted to the following types of metabolic surgery: ileal interposition and sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), adjustable gastric banding, duodeno-jejunal exclusion and duodeno-jejunal bypass; 2) to evaluate the possible relapse of diabetes after occurrence of weight regain on long-term after bariatric surgery. METHOD: An expositive and historical literature review about metabolic surgery in diabetic patients with BMI < 30 and < 35 kg/m² was conducted, and systematic review of the association between disease relapse and weight regain after bariatric surgery. RESULTS: After analysis of 188 published papers on Medline until 2010, three papers were selected, which included 269 patients who underwent RYGB. Pre-operatory BMI was between 37 and 60 kg/m² and follow-up of three to 16 years. CONCLUSIONS: 1) Two studies showed association between weight regain and recurrence of type 2 diabetes, while the third did not show this association when comparing groups with and without weight regain; 2) metabolic surgery has shown adequate control of T2DM2 in class I obese subjects; however, the non-obese group still need a long-term evaluation, considering the risk of diabetes recurrence when after weight regain.

Colangiopancreatografía retrógrada endoscópica en pacientes con asa en Y-de-Roux / Endoscopic retrograde cholangiopancreatography in Roux-en-Y patients

The reconstruction of the digestive tract with a Roux-en-Y anastomosis has been performed more frequently in the last years mainly due to the overgrowth in the surgical treatment of obesity by gastric bypass in Roux-en-Y. The obesity pandemic is also associated with an increase in both the preoperative and postoperative diagnosis of gallstones in this population. Bearing in mind the greater complexity of endoscopic retrograde cholangiopancreatography in these circumstances, the authors have reviewed the various endoscopic approaches available, evaluating 249 articles published between 1990 and 2010 obtained from Medline, Cochrane and Scielo, excluding case reports and articles outside the specific scope of this study. Endoscopic techniques with high success rates include the use of enteroscope, colonoscope, enteral and transgastric access combined with surgery. Even with the technological progress already made, further development of the instruments used will be necessary if greater comfort and safety is to be achieved with this procedure.

La reconstrucción del trato digestivo con un asa en Y-de-Roux ha sido más empleada en los últimos años debido principalmente al aumento del tratamiento quirúrgico de la obesidad mediante el bypass gástrico en Y-de-Roux (BGYR). La pandemia de la obesidad se ha asociado a un aumento en la prevalencia de litiasis biliar en esta población, diagnosticada en el estudio preoperatorio y durante el seguimiento postoperatorio. La colangiopancreatografía endoscópica retrógrada (CPRE) posee una mayor complejidad en estas circunstancias donde existe una alteración anatómica que dificulta el acceso a la papila mayor. El objetivo de esta revisión es describir las alternativas de acceso al asa biliopancreática para realizar CPRE en pacientes con un asa en Y-de-Roux enfatizando la accesibilidad técnica, los resultados y complicaciones de los procedimientos. Se realizó una búsqueda y revisión de la literatura en las bases de datos: Medline, Cochrane y Scielo. Se evaluaron 249 publicaciones desde 1990 a 2010, en idioma español, inglés y portugués. Fueron excluidos de esta revisión los reportes de casos y publicaciones no atingentes. Las opciones endoscópicas para realizar CPRE en pacientes con reconstrucción con un asa en Y-de-Roux incluyen: el uso de enteroscopio, colonoscopio, acceso enteral y transgástrico combinado con cirugía. Todos las alternativas presentan una alta tasa de éxito, sin embargo, pese a los avances tecnológicos obtenidos en los últimos años en el instrumental utilizado aún se necesitan herramientas que permitan una mayor comodidad y seguridad para este procedimiento.