Histologic and microbiological findings of the defunctionalized loop in sleeve gastrectomy with jejunal bypass.

BACKGROUND: Bariatric surgery produces anatomic changes in the digestive tract that can affect the intestinal microbiome and, in some cases, can cause small intestinal bacterial overgrowth. Since the inception of the sleeve gastrectomy with jejunal bypass (SGJB) in 2004, there has been discussion regarding the possible development of those complications associated with the now abandoned jejunoileal bypass (JIB) procedure. OBJECTIVES: The primary endpoint was to characterize the bacteriologic and histopathologic findings in the defunctionalized jejunal loop after the SGJB procedure and to analyze the liver profile. The secondary endpoint was to report SGJB conversions or reversions and to review the differences between SGJB and JIB. SETTING: Academic medical center. METHODS: We conducted a prospective study of patients who underwent laparoscopy for any reason, having previously had an SGJB. A 5-cm segment at the proximal end of the excluded limb was resected. Luminal liquid and tissue samples were taken from this segment for aerobic and anaerobic cultures, and pathologic examination of the bowel wall was performed to evaluate trophism and signs of chronic inflammation. Other variables were liver function and pre- and postoperative status. Finally, we retrospectively reviewed the causes of revisional surgery in the prospective database. RESULTS: Eleven patients underwent laparoscopy. The median time after SGJB was 14 months (range, 10-144 months). There were no complications from the procedure. Eight (72.7%) of the procedures were cholecystectomies. None of the patients showed histologic alterations or signs of chronic infection. The liquid and tissue cultures were negative. The liver tests and the laparoscopic morphology of the liver were normal in all patients, except in 1 with previously documented liver cirrhosis. The number of SGJB revisions was 19 of 1074 (1.8 %), and all of them were converted to Roux-en-Y gastric bypass for severe gastroesophageal reflux. CONCLUSIONS: In this study, we were unable to demonstrate the presence of symptoms or histologic alterations that would suggest that patients undergoing SGJB develop small intestinal bacterial overgrowth in the short- and medium-term follow-up, unlike those who have undergone JIB. The study constitutes an initial step toward establishing what happens to the defunctionalized jejunal limb as a result of this surgical technique.

Academic achievement and perception of two teaching methods in histology: light and digital microscopy: pilot study / Rendimiento académico y percepción de dos métodos de enseñanza en histología: microscopio de luz y microscopio digital: estudio piloto

With new digital systems, the role of the microscope as an irreplaceable instrument in the teaching of histology has been called into question. In this study academic performance and student perception for two learning methods were compared: digital and light microscopy, in the muscle tissue unit of the morphology course for first-year undergraduate dentistry at Universidad de los Andes, Santiago, Chile. 92 students were divided into 2 groups: Group 1: light microscopy and Group 2: digital microscope in a web application. All participants observed the same striate muscle, cardiac striated muscle, and smooth muscle samples. An academic performance test was applied (diagnostic and individual structures identify ability). A perception test was conducted after everyone had learned with both systems. For data analysis the T student test and central tendency with their standard deviation was used. In the cognitive evaluation, the median grades were 5.4 for group 1 and 5.7 for group 2. In the perception survey, 73.24 % considered the virtual microscope evaluation more fair. It was concluded that the use of virtual microscope tends to have better results than light microscopy. Further investigation is needed to evaluate this new teaching instrument.

Los sistemas digitales han puesto en tela de juicio el rol del microscopio óptico como instrumento insustituible para la enseñanza práctica de la histología. El objetivo de este estudio fue comparar el rendimiento académico y la percepción de los alumnos utilizando microscopía óptica y microscopía virtual en base a una aplicación web, utilizada por primera vez. Se dividieron 92 alumnos de primer año de Odontología en 2 grupos: 1: microscopía óptica, 2: microscopía digital. Todos observaron los mismos preparados de músculo estriado esquelético, estriado cardíaco y liso. Al finalizar, rindieron una evaluación formativa para medir conocimientos y luego se invertieron los grupos. Una vez que todos aprendieron con ambos sistemas se aplicó un test de percepción. Para el análisis de datos se utilizó el Test-t de student, medidas de tendencia central y desviación estandar. En la evaluación cognitiva se obtuvo un promedio de 5,4 en el grupo 1 y 5,7 el grupo 2. Respecto a la percepción, un 73,24 % consideró que la evaluación con microscopia virtual es más justa. La microscopía vitual tiene una mejor percepción por parte de los alumnos y tiende a mejorar el rendimiento académico. Nuevas investigaciones serán necesarias para evaluar esta herramienta de enseñanza.

Melatonin Decreases Pulmonary Vascular Remodeling and Oxygen Sensitivity in Pulmonary Hypertensive Newborn Lambs.

Background: Chronic hypoxia and oxidative stress during gestation lead to pulmonary hypertension of the neonate (PHN), a condition characterized by abnormal pulmonary arterial reactivity and remodeling. Melatonin has strong antioxidant properties and improves pulmonary vascular function. Here, we aimed to study the effects of melatonin on the function and structure of pulmonary arteries from PHN lambs. Methods: Twelve lambs (Ovis aries) gestated and born at highlands (3,600 m) were instrumented with systemic and pulmonary catheters. Six of them were assigned to the control group (CN, oral vehicle) and 6 were treated with melatonin (MN, 1 mg.kg-1.d-1) during 10 days. At the end of treatment, we performed a graded oxygenation protocol to assess cardiopulmonary responses to inspired oxygen variations. Further, we obtained lung and pulmonary trunk samples for histology, molecular biology, and immunohistochemistry determinations. Results: Melatonin reduced the in vivo pulmonary pressor response to oxygenation changes. In addition, melatonin decreased cellular density of the media and diminished the proliferation marker KI67 in resistance vessels and pulmonary trunk (p < 0.05). This was associated with a decreased in the remodeling markers α-actin (CN 1.28 ± 0.18 vs. MN 0.77 ± 0.04, p < 0.05) and smoothelin-B (CN 2.13 ± 0.31 vs. MN 0.88 ± 0.27, p < 0.05). Further, melatonin increased vascular density by 134% and vascular luminal surface by 173% (p < 0.05). Finally, melatonin decreased nitrotyrosine, an oxidative stress marker, in small pulmonary vessels (CN 5.12 ± 0.84 vs. MN 1.14 ± 0.34, p < 0.05). Conclusion: Postnatal administration of melatonin blunts the cardiopulmonary response to hypoxia, reduces the pathological vascular remodeling, and increases angiogenesis in pulmonary hypertensive neonatal lambs.These effects improve the pulmonary vascular structure and function in the neonatal period under chronic hypoxia.

Long-term weight loss in laparoscopic sleeve gastrectomy.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has become an option as a bariatric surgical technique. There is a lack of long-term results of this procedure in the literature. The aim of this study is to present weight loss results of LSG for up to 7 years of follow-up. METHODS: A retrospective series of patients who underwent LSG between 2008 and 2011 was examined. The primary endpoint was weight loss: percentage of excess weight loss (%EWL), percentage of total weight loss (%TWL), and body mass index (BMI) were reported. Failure was defined as %EWL<50%. Multivariate analysis for weight loss was performed. The complications rate was reported. RESULTS: A total of 148 patients met the inclusion criteria; 76.3% were female. Mean preoperative BMI was 36 ± 4 kg/m2. Mean operative time was 89.3 ± 3.2 minutes. Follow-up at 5, 6, and 7 years was 77.7%, 83.3%, and 82.2%, respectively. Mean %EWL and %TWL at 1, 3, 5, and 7 years was 93.2%, 80.7%, 70.6%, and 51.7%, and 27.2%, 23.3%, 20.4%, and 16.3%, respectively. The failure rate was 30.4% at the fifth year and 51.4% at the seventh year. High preoperative BMI was related to worse %EWL (P<0.001) but not to %TWL. Preoperative BMI<35 kg/m2 was associated with better %EWL but not with %TWL (P = 0.003). Four leaks (2.7%) and no mortalities were reported. CONCLUSIONS: LSG is an acceptable surgical technique for weight loss, but in this series, up to one third of the patients fail at the fifth year and half fail in the seventh year. %EWL is better in patients with BMI<35 kg/m2, but this difference disappears when we express outcomes with %TWL.

Staple Line Reinforcement in Laparoscopic SleeveGastrectomy: Experience in 1023 Consecutive Cases.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric procedures performed worldwide. However, staple line-related complications have become a major challenge for bariatric surgeons. The aim of this study was to evaluate the morbidity in a cohort of patients who underwent LSG with imbricated oversewing of the staple line at a single high-volume center. MATERIALS AND METHODS: We retrospectively reviewed prospectively collected data for all patients who underwent LSG to treat obesity at our institution from January 2010 to September 2016. All practitioners had undergone training with a single senior bariatric surgeon using oversewing as staple line reinforcement (SLR). RESULTS: In total, 1023 LSGs were performed (female, 67.3%; mean age, 40.6 ± 10.8 years; median preoperative body mass index, 37 ± 4.5 kg/m2). The mean operative time was 67.6 ± 23.4 min (range, 30-150 min). The rate of conversion to open surgery was 0.3%. Early complications were noted in 18 patients (1.8%), including 5 cases of bleeding (0.5%). No leaks, stenosis, or mortality occurred. CONCLUSIONS: LSG is a safe technique, but staple line-associated complications can be life-threatening. In this series, no leaks occurred from the very beginning of the surgeons' experience in LSG. Imbricated oversewing of the staple line, proper mentoring, and performance of surgery in appropriate settings are good approaches to decreasing complications.

Sleeve gastrectomy with jejunal bypass for the treatment of type 2 diabetes mellitus in patients with body mass index <35 kg/m2. A cohort study.

The objective of this study was to evaluate sleeve gastrectomy with jejunal bypass (SGJB) as a surgical treatment for type 2 diabetes mellitus (T2DM) in patients with a body mass index (BMI) <35 kg/m(2). This is a prospective cohort study. Patients with T2DM and BMI <35 kg/m(2) who underwent SGJB between January 2009 and June 2011 at DIPRECA Hospital, in Santiago, and Hospital Base, Osorno, Chile were included. SGJB consists of creating a gastric tube, which preserves the pylorus, and performing a jejunoileal anastomosis 300 cm distal to the angle of Treitz. Excess weight loss (EWL) and complete or partial remission of T2DM were reported. Forty-nine patients met the inclusion criteria. The mean age was 49 years (36-62), and 53 % of patients were female. Mean preoperative BMI was 31.6 kg/m(2) (25-34.9 kg/m(2)). Operation time was 123 ± 14 min, with 94.7 % of operations performed laparoscopically. Mean postoperative hospital stay was 2 days. Mean postoperative follow-up was 12 months. Median EWL at 1, 3, 6, 12, and 18 months postoperatively was 31.9 %, 56.9 %, 76.1 %, 81.5 %, and 76.1 %, respectively. Complete T2DM remission was achieved in 81.6 % of patients (40/49) and partial remission in 18.4 % (9/49). Forty of 41 patients (97.6 %) on oral hypoglycemic agents achieved complete T2DM remission, and 100 % of insulin-dependent patients stopped using insulin but were still being treated for T2DM. One patient experienced postoperative gastrointestinal bleeding. There were no deaths. SGJB is an effective treatment for T2DM in patients with BMI <35 kg/m(2).

Doble inervación del músculo braquial en la población chilena / Dual innervation of the brachialis muscle in the Chilean population

La doble inervación del músculo braquial está dada por el nervio musculocutáneo y por ramos provenientes del nervio radial según lo describen algunos textos anatómicos y numerosos trabajos científicos. Sin embargo, no existe consenso en la frecuencia con la que ésta se presenta. El objetivo de este estudio es verificar la presencia y determinar la frecuencia de la contribución del nervio radial en la inervación del músculo braquial. En el presente trabajo se utilizaron 30 miembros superiores previamente fijados con solución fijadora y conservadora. Se realizó disección de la región braquial para determinar la presencia de ramos del nervio radial inervando al músculo braquial, verificando la presencia de ramos que penetraban en el músculo y tomando muestras de estos ramos en el sitio donde perforaban al músculo para su estudio histológico. Fue posible observar la presencia de ramos del nervio radial que penetraban en el músculo braquial en un 90 porciento de los casos; en ellos el punto motor de estos ramos se ubicó siempre en el tercio distal del músculo. De acuerdo a los resultados obtenidos en el presente trabajo, la doble inervación del músculo braquial observada por autores clásicos y reportada en estudios en diversas poblaciones, está presente en alto porcentaje de la muestra. Estos hallazgos pueden servir de referencia para procedimientos quirúrgicos, estudios electromiográficos y sonográficos.

The dual innervation of the brachialis muscle by the musculocutaneos nerve and branches from the radial nerve has been described by some anatomical texts and several scientific papers; however, there is no consensus about the frequency with which this occurs. In this study we proposed to check the presence and determine the frequency of the contribution of radial nerve in the innervations of the brachialis muscle. In this study we used 30 upper limbs fixed in fixative and conservative solution. Dissection of the brachial region was carried out, checking the branches that penetrated the muscle and taking samples of these branches to histological study. It was possible to observe the presence of branches of the radial nerve innervating the brachialis muscle in a 90 percent of the sample used in this study; the motor point of these branches was always located in the distal third of this muscle. According with the results of this study, the dual innervations of the brachial muscles observed by classical authors and reported by several investigations is also present in a high percentage of the sample. These findings can serve as reference for surgical procedures, electromyographic and ultrasound studies.