Outcomes in weight loss, fasting blood glucose and glycosylated hemoglobin in a sample of 415 obese patients, included in the database of the European accreditation council for excellence centers for bariatric surgery with laparoscopic one anastomosis gastric bypass.

BACKGROUND: Obesity is a risk factor for the development of diseases such as type 2 Diabetes Mellitus. Bariatric surgery with laparoscopic single anastomosis gastric bypass is an effective treatment for morbid obesity and diabetes type 2 complete remission, and it has been proven to generate an improvement in glycemic levels and glycosylated hemoglobin (HbA1c) keeping the weight loss for a long time. MATERIAL AND METHODS: In a period of time between June 2002 until May 2012, 2070 patients underwent surgery with LOAGB technique. Between January 2010 an May 2012, 415 patients were included in the European Accreditation Council for Excellence Centers for Bariatric Surgery (EAC-BS) database, from which 79 patients with a glycemic level disturbance in the preoperative blood sample where chosen. Of this group, 47 patients were pre-diabetic (fast plasma glucose ≥ 110 mg/dl ≤ 125 mg/dl) and glycosylated hemoglobin (HbA1c) levels between 5.7-6.4% and 32 were diabetic (fast plasma glucose ≥ 126 mg/dl) and glycosylated hemoglobin (HbA1c) levels ≥ 6.5%. We described the weight evolution, the excess body mass index lost percentage (%EBMIL) the glycemia and the glycosylated hemoglobin levels; and we reported regular laboratory controls during the first year after surgical intervention. RESULTS: Both patient groups achieved their lowest mean weight loss 12 months after surgery, being average weight in the pre-diabetic group 62,41 ± 10,93 and 68,36 ± 11,16 in the diabetic group. Since 3 months after surgery, pre-diabetic patients achieve a mean BMI < 30, according to the Spanish Society for Obesity Study (SEEDO 2007) this amount is outside of the definition of obesity. Not being the case of the diabetic patients who don´t achieve this result until 6 months after surgery. The weight loss was excellent in both study groups, achieving an excess body mass index loss percentage (% EBMIL) greater than 65%, since the first three-month postoperative control. Glycemia levels descend in both groups, achieving the pre-diabetic group a mean glycemia level of < 110 mg/ dl in the second day after LOAGB surgery. Pre-diabetic patients maintain more stable glycemia with better controls, and very favorable outcomes 12 months after surgery. The diabetic patients achieve the mean glycemia level of < 110 mg/dl at the first month after surgery and maintained it 12 months after surgery which is the time of this study. The glycosylated hemoglobin levels descended in both groups, achieving levels of 4% three months after surgery in the prediabetic group and 4.8% at six months in the diabetic group. CONCLUSION: LOAGB proved to be an efficient bariatric technique for complete remission of pre-diabetes and diabetes mellitus type 2 and also with the excess weight loss resolution. We showed that the excess weight loss, the glycemia and glycosylated hemoglobin levels continue being normal after one year of follow up after surgery. The best results are obtained in pre-diabetic patients who underwent LOAGB, this group is integrated with people who are at high risk of suffering a deterioration of their obesity and a rapid advance of the diabetes and the associated comorbidities, that's why surgery has to be performed as soon as possible when the medical exam continues being favorable.

Introducción: La obesidad es un factor de riesgo para el desarrollo de enfermedades tales como la diabetes mellitus tipo II. La cirugía bariátrica laparoscópica de una anastomosis también conocida como mini-bypass con las modificaciones del doctor Carbajo, es un tratamiento efectivo para el manejo de la obesidad mórbida y para obtener una completa remisión de la diabetes tipo II y se ha demostrado que se genera una mejoría de los niveles de glicemia y de hemoglobina glicosilada (HbA1c) manteniendo la pérdida de peso por un largo período de tiempo. Material y métodos: En un período de tiempo entre junio del 2002 hasta mayo de 2012, 2070 pacientes se intervinieron quirúrgicamente con la técnica bariátrica laparoscópica de una anastomosis gástrica (BAGUA). Entre enero de 2010 y mayo de 2012, 415 pacientes fueron incluidos en la base de datos del Consejo Europeo de acreditación para centros de excelencia de cirugía bariátrica, de los cuales se escogieron 79 pacientes que presentaban trastornos de los niveles de glicemia en sus pruebas sanguíneas preoperatorias. De este grupo 47 pacientes se clasificaron como pre-diabéticos con niveles de glucosa en sangre ≥110 mg/ dl ≤ 125 mg/dl y unos niveles de hemoglobina glicosilada ( HbA1C) entre 5.7-6.4% y 32 como diabéticos con niveles de glucosa en sangre ≥ 126 mg/dl y niveles de hemoglobina glicosilada (HbA1C) ≥ 6.5%. Nosotros describimos la evolución de los cambios en el peso, el porcentaje de pérdida del índice de masa corporal, los niveles de glicemia y de hemoglobina glicosilada de los pacientes estudiados y reportamos los resultados de los controles de laboratorio practicados regularmente durante el primer año postoperatorio. Resultados: ambos grupos de pacientes alcanzaron su máxima pérdida de peso a los 12 meses postoperatorios, siendo el peso promedio en el grupo de pre-diabéticos 62,41 ± 10,93 y 68,36 ± 11,16 en el grupo de diabéticos. Los pacientes pre-diabéticos alcanzaron desde los 3 meses de postoperatorio un índice de masa corporal (IMC) < 30, que de acuerdo con el estudio sobre Obesidad de la Sociedad Española (SEEDO 2007) esta cantidad se encuentra por fuera de la definición de obesidad, no siendo el caso del grupo de pacientes diabéticos que no alcanzaron este resultado hasta los 6 meses de postoperatorio. La pérdida de peso fue excelente en ambos grupos alcanzando un porcentaje de pérdida de índice de masa corporal mayor de 65% desde los primeros 3 meses de control postoperatorio. Los niveles de glicemia bajaron en ambos grupos, alcanzando el grupo de pre-diabéticos un nivel de glicemia < 110 mg/dl desde el segundo día postoperatorio de BAGUA. Los pacientes pre-diabéticos mantuvieron un nivel de glicemia estable con mejor control y una muy favorable evolución a los 12 meses de postoperatorio. Los pacientes diabéticos alcanzaron el nivel de glicemia < 110 mg/dl en el primer mes postoperatorio y lo mantuvieron así a los 12 meses de postoperatorio, tiempo en el que se elaboró este estudio. Los niveles de hemoglobina glicosilada descendieron en ambos grupos, alcanzando niveles de 4% a los 3 meses de postoperatorio en los pacientes prediabéticos y un 4,8% a los 6 meses en el grupo de los pacientes diabéticos. Conclusión: BAGUA mostró ser una técnica quirúrgica bariátrica eficiente para la remisión completa de la pre-diabetes y la diabetes tipo II así como de la pérdida del exceso de peso. Nosotros demostramos que la pérdida del exceso de peso, los niveles de glicemia y de hemoglobina glicosilada continuaron siendo normales al año de seguimiento postoperatorio. Los mejores resultados se obtuvieron en el grupo de pre-diabéticos a quienes se les practicó BAGUA. Este grupo está integrado por personas que se encuentran en riesgo de sufrir un deterioro de su obesidad y un rápido avance hacia diabetes y a las comorbilidades asociadas, está es la razón por la cual esta cirugía debe realizarse lo más pronto posible mientras las pruebas médicas de los pacientes sigan siendo favorables.

Effects of a balanced energy and high protein formula diet (Vegestart complet®) vs. low-calorie regular diet in morbid obese patients prior to bariatric surgery (laparoscopic single anastomosis gastric bypass): a prospective, double-blind randomized study.

OBJECTIVE: Bariatric surgery is considered the only therapeutic alternative for morbid obesity and its comorbidities. High risks factors are usually linked with this kind of surgery. In order to reduce it, we consider that losing at least 10% of overweight in Morbid Obese (MO) and a minimum of 20% in Super- Obese patients (SO) before surgery, may reduce the morbidity of the procedure. The aim of our study is to demonstrate the effectiveness and tolerance of a balanced energy formula diet at the preoperative stage, comparing it against a low calorie regular diet. METHOD: We studied 120 patients divided into two groups of 60 each, group A was treated 20 days prior to bariatric surgery with a balanced energy formula diet, based on 200 Kcal every 6 hours for 12 days and group B was treated with a low calorie regular diet with no carbs or fat. The last eight days prior to surgery both groups took only clear liquids. We studied the evolution of weight loss, the BMI, as well as behavior of co-morbidities as systolic blood pressure, diastolic blood pressure, glucose controls and tolerance at the protocol. RESULTS: The study shows that patients undergoing a balanced energy formula diet improved their comorbidities statistically significant in terms of decrease in weight and BMI loss, blood pressure and glucose, compared to the group that was treated before surgery with a low calorie regular diet. Nevertheless both groups improving the weight loss and co-morbidities with better surgical results and facilities. CONCLUSION: A correct preparation of the Morbid Obese patients prior of surgery can reduce the operative risks improving the results. Our study show that the preoperative treatment with a balanced energy formula diet as were included in our protocol in patients undergoing bariatric surgery improves statistical better their overall conditions, lowers cardiovascular risk and metabolic diseases that the patients with regular diet alone.

Gastric pouch carcinoma after gastric bypass for morbid obesity.

The relationship between bariatric surgery and gastric cancer is conjectural. We present a 52-year-old woman with BMI 45 operated initially by a Lap-Band procedure complicated by gastric wall erosion of the band 9 months later. She was re-operated and the band was removed. She subsequently underwent a Roux-en-Y gastric bypass. 5 years after, gastric carcinoma was discovered in the gastric pouch. Because of varied symptoms following bariatric surgery, patients may not present promptly with symptoms related to a gastric carcinoma.

Laparoscopic approach to incisional hernia.

BACKGROUND: After more than 8 years of working in the field, we thought it would be interesting to evaluate our experience in the laparoscopic repair of abdominal wall hernias, focusing attention on the lessons learned with time. METHODS: From January 1994 to November of 2000, a total of 270 patients with abdominal wall hernias were treated in our center using the laparoscopic approach. The data collected and analyzed were preoperative evaluation, operative findings, early and long-term complications, and recurrences. RESULTS: The mean follow-up time was 44 months, mean surgical time was 85 min, and mean hospital stay was 1.5 days. The average number of abdominal wall defects was 4.8 per patient. There were 9 (3.3%) small bowel perforations. Conversion to open surgery was required in 1 case (0.3%). Minor early postoperative complications occurred in 38 patients (14.07%). Twenty patients (7.4%) developed persistent postoperative abdominal pain. There was 1 case (0.3%) of small bowel incarceration through the mesh border and another case (0.3%) of small bowel leakage due to ischemia and subsequent peritonitis. The relapse rate was 4.4% (12 cases). CONCLUSION: The laparoscopic approach is a valuable option in the management of abdominal wall hernias, but it requires experience in laparoscopic surgery and there is a specific learning curve for the technique.

Laparoscopic intraperitoneal onlay polytetrafluoroethylene mesh repair (IPOM) for inguinal hernia during spinal anesthesia in patients with severe medical conditions.

In patients with severe pulmonary disease, laparoscopic techniques are not advised. The authors report their preliminary experience with laparoscopic intraperitoneal onlay polytetrafluoroethylene mesh repair for inguinal hernia during spinal anesthesia in patients with chronic obstructive pulmonary disease. Spinal anesthesia was performed using hyperbaric bupivacaine (3-3.5 mL) injected at L2-L3. If necessary, additive opioid therapy was administered. Under low-pressure pneumoperitoneum (10 mm Hg), polytetrafluoroethylene mesh was stapled securely on the posterior inguinal wall to spare epigastric and iliac vessels. Fifteen patients underwent surgery. Median age was 62 years. All patients were classified American Society of Anesthesiologists physical status III/IV. Mean forced expiratory volume in the first second was 1.1 L/s. Median operating time was 20 minutes. Postoperative recovery was uneventful for all patients. The average duration of hospital stay was 1.5 days. Seroma or hematoma was not noted. Six-month follow-up did not show recurrence or infection. This technique is an effective method of repair of inguinal hernia in patients with severe chronic obstructive pulmonary disease, and it provides a maximum of comfort.

Laparoscopic treatment of ventral abdominal wall hernias: preliminary results in 100 patients.

OBJECTIVE: The laparoscopic treatment of eventrations and ventral hernias has been little used, although these hernias are well suited to a laparoscopic approach. The objective of this study was to investigate the usefulness of a laparoscopic approach in the surgical treatment of ventral hernias. METHODS: Between January 1994 and July 1998, a series of 100 patients suffering from major abdominal wall defects were operated on by means of laparoscopic techniques, with a mean postoperative follow-up of 30 months. The mean number of defects was 2.7 per patient, the wall defect was 93 cm2 on average. There were 10 minor hernias (<5 cm), 52 medium-size hernias (5-10 cm), and 38 large hernia (>10 cm). The origin of the wall defect was primary in 21 cases and postsurgical in 79. Three access ports were used, and the defects were covered with PTFE Dual Mesh measuring 19 x 15 cm in 54 cases, 10 x 15 cm in 36 cases, and 12 x 8 cm in 10 cases. An additional mesh had to be added in 21 cases. In the last 30 cases, PTFE Dual Mesh Plus with holes was employed. RESULTS: Average surgery time was 62 minutes. One procedure was converted to open surgery, and only one patient required a second operation in the early postoperative period. Minor complications included 2 patients with abdominal wall edema, 10 seromas, and 3 subcutaneous hematomas. There were no trocar site infections. Two patients developed hernia relapse (2%) in the first month after surgery and were reoperated with a similar laparoscopic technique. Oral intake and mobilization began a few hours after surgery. The mean stay in hospital was 28 hours. CONCLUSIONS: Laparoscopic technique makes it possible to avoid large incisions, the placement of drains, and produces a lower number of seromas, infections and relapses. Laparoscopic access considerably shortens the time spent in the hospital.

Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh.

BACKGROUND: Despite being one of the most exact indications, laparoscopic treatment of eventrations and ventral hernias is barely known among the array of laparoscopic techniques. METHODS: A total of 60 patients were assigned at random over a 3-year period to two homogeneous groups to be operated on for major ventral hernias with mesh. Half of them were operated upon laparoscopically and the rest with open surgery. Early and longer-term complications were analyzed, as were operative time and postoperative hospital stays. RESULTS: The two groups were homogeneous in terms of demographic and clinical characteristics. The group that was operated on laparoscopically presented a lower rate of postoperative and longer-term complications; similarly, surgery time was significantly lower (p < 0.05). Hospitalization time was also significantly lower than in the group undergoing conventional open surgery (p < 0.05). CONCLUSIONS: Laparoscopic treatment of postoperative eventration and primary ventral hernia reduces complications and relapse rates, eliminates reintervention through mesh infection, reduces operative time, and considerably shortens the hospital stay.

Congenital malformations of the gallbladder and cystic duct diagnosed by laparoscopy: high surgical risk.

Congenital anomalies of the gallbladder are rare and can be accompanied by other malformations of the biliary or vascular tree. Being difficult to diagnose during routine preoperative studies, these anomalies can provide surgeons with an unusual surprise during laparoscopic surgery. The presence of any congenital anomaly or the mere suspicion of its existence demands that we exercise surgical prudence, limit the use of electrocoagulation, and ensure that no structure be divided until a clear picture of the bile ducts and blood vessels is obtained. If necessary, perform intraoperative cholangiography to further define the biliary system. However, if the case remains unclear, or if laparoscopy does not provide enough information, open surgery should be considered before undesirable complications occur.