Gut Microbiota Imbalance Can Be Associated with Non-malabsorptive Small Bowel Shortening Regardless of Blind Loop.

INTRODUCTION: Some traditional bariatric surgery procedures may lead to functional gut shortening, which may unsettle the fine-tuned gastrointestinal physiology and affect gut microbiota balance. PURPOSE: Evaluate the gut microbiota behavior in rat models facing gut shortening due to intestinal bypass. MATERIALS AND METHODS: Wistar rats (n = 17) were randomly distributed in three groups: (1) sham group (n = 5); (2) blind loop group (n = 6); and (3) resection group (n = 6). Intestinal samples and feces were analyzed to measure bacterial concentrations (small intestinal bacterial overgrowth-SIBO) 12 weeks after the experimental procedures. Bacterial translocation (BT) was investigated in the mesenteric lymph node (MLN), liver, spleen, and lung of the animals. In addition, inflammatory aspects were investigated in their liver and small bowel through histological analysis. RESULTS: Regardless of blind loop, gut shortening groups recorded similar high level of bacterial concentrations in intestine compartments, greater than that of the sham group (p ≤ 0.05). BT was only observed in the MLN of gut shortening models, with higher percentage in the blind loop group (p ≤ 0.05). The gut and liver histopathological analysis showed similar low-grade chronic inflammation in both gut shortening groups, likely associated with SIBO/BT events. CONCLUSION: Sustained SIBO/BT was associated with proximal gut shortening in half regardless of blind loop, whereas the GI tract's ability to restore gut microbiota balance after a surgical challenge on the small bowel appears to be linked to the functional remaining gut.

SADI-S WITH RIGHT GASTRIC ARTERY LIGATION: TECHNICAL SYSTEMATIZATION AND EARLY RESULTS.

Background: Bariatric surgery is performed all over the world with close to 500.000 procedures per year. The most performed techniques are Roux-en-Y gastric bypass and sleeve gastrectomy. Despite this data, the most effective procedure, biliopancreatic diversion with or without duodenal switch, represents only no more than 1.5% of the procedures. Technical complexity, morbidity, mortality, and severe nutritional adverse effects related to the procedure are the main fears that prevent most universal acceptance. Aim: To explain the technical aspects and the benefits of the SADI-S with right gastric artery ligation as an effective simplification from the original duodenal switch. Methods: Were included all patients undergoing this procedure from the November 2014 to May 2016, describing and analysing aspects of this technique, the systematization and early complications associated with the procedure. Results: A series of 67 patients were operated; 46 were women (68.7%); mean age of the group was 44 years old (33-56); and an average BMI of 53.5 kg/m2 (50-63.5). Surgical time was 115 min (80-180). A total of five patients (7.5%) had any complication and two (2.9%) had to be reoperated. There were two patients with leak, one at the duodenal stump and other at the esophagogastric angle. There was no mortality. Patients stayed at the hospital a median of 2.5 days (1-25). Conclusions: SADI-S with right gastric artery ligation is a safe procedure with few preliminary complications. The technical variations introduced to the classical duodenal switch are reproducible and may allow this procedure to be more popular. All the complications in this series were not related to the ligation of the right gastric artery.

Racional: Cerca de 500.000 cirurgias bariátricas são realizadas a cada ano em todo o mundo. As técnicas mais realizadas são o bypass gástrico em Y-de-Roux e a gastrectomia vertical. A derivação biliopancreática, com ou sem duodenal switch, é considerada técnica mais eficaz no tratamento cirúrgico do paciente obeso mórbido; entretanto, representa não mais do que 1,5% dos procedimentos na atualidade, pois sua complexidade técnica, morbimortalidade e graves efeitos adversos nutricionais impedem aceitação mais universal. Objetivo: Descrever os aspectos técnicos e os benefícios do SADI-S com ligadura da artéria gástrica direita como um modo simplificado do duodenal switch original. Métodos: Foram incluídos todos os pacientes submetidos a este procedimento entre novembro 2014 e maio de 2016. Além da descrição da sistematização da técnica operatória, foram analisadas as complicações precoces associadas ao procedimento. Resultados: Uma série de 67 pacientes foi operada no período analisado; 46 eram mulheres (68,7%) e a média de idade foi de 44 anos (33-56). O IMC médio foi de 53,5 kg/m2 (50-63,5). O tempo cirúrgico médio foi de 115 min (80-180) e a permanência hospitalar média foi de 2,5 dias (1-25). Complicações foram observadas em cinco pacientes (7,5%) e dois (2,9%) tiveram de ser reoperados. Duas pacientes evoluíram com fístula, uma no coto duodenal e outra na junção esofagogástrica. Não houve mortalidade. Conclusão: SADI-S com ligadura da artéria gástrica direita é procedimento seguro com poucas complicações precoces. A simplificação técnica em relação ao duodenal switch clássico pode permitir que este procedimento se torne mais popular. Todas as complicações observadas nesta série não estavam relacionadas com a ligadura da artéria gástrica direita.

SADI-S WITH RIGHT GASTRIC ARTERY LIGATION: TECHNICAL SYSTEMATIZATION AND EARLY RESULTS / SADI-S COM LIGADURA DA ARTÉRIA GÁSTRICA: SISTEMATIZAÇÃO TÉCNICA E OS PRIMEIROS RESULTADOS

ABSTRACT Background: Bariatric surgery is performed all over the world with close to 500.000 procedures per year. The most performed techniques are Roux-en-Y gastric bypass and sleeve gastrectomy. Despite this data, the most effective procedure, biliopancreatic diversion with or without duodenal switch, represents only no more than 1.5% of the procedures. Technical complexity, morbidity, mortality, and severe nutritional adverse effects related to the procedure are the main fears that prevent most universal acceptance. Aim: To explain the technical aspects and the benefits of the SADI-S with right gastric artery ligation as an effective simplification from the original duodenal switch. Methods: Were included all patients undergoing this procedure from the November 2014 to May 2016, describing and analysing aspects of this technique, the systematization and early complications associated with the procedure. Results: A series of 67 patients were operated; 46 were women (68.7%); mean age of the group was 44 years old (33-56); and an average BMI of 53.5 kg/m2 (50-63.5). Surgical time was 115 min (80-180). A total of five patients (7.5%) had any complication and two (2.9%) had to be reoperated. There were two patients with leak, one at the duodenal stump and other at the esophagogastric angle. There was no mortality. Patients stayed at the hospital a median of 2.5 days (1-25). Conclusions: SADI-S with right gastric artery ligation is a safe procedure with few preliminary complications. The technical variations introduced to the classical duodenal switch are reproducible and may allow this procedure to be more popular. All the complications in this series were not related to the ligation of the right gastric artery.

RESUMO Racional: Cerca de 500.000 cirurgias bariátricas são realizadas a cada ano em todo o mundo. As técnicas mais realizadas são o bypass gástrico em Y-de-Roux e a gastrectomia vertical. A derivação biliopancreática, com ou sem duodenal switch, é considerada técnica mais eficaz no tratamento cirúrgico do paciente obeso mórbido; entretanto, representa não mais do que 1,5% dos procedimentos na atualidade, pois sua complexidade técnica, morbimortalidade e graves efeitos adversos nutricionais impedem aceitação mais universal. Objetivo: Descrever os aspectos técnicos e os benefícios do SADI-S com ligadura da artéria gástrica direita como um modo simplificado do duodenal switch original. Métodos: Foram incluídos todos os pacientes submetidos a este procedimento entre novembro 2014 e maio de 2016. Além da descrição da sistematização da técnica operatória, foram analisadas as complicações precoces associadas ao procedimento. Resultados: Uma série de 67 pacientes foi operada no período analisado; 46 eram mulheres (68,7%) e a média de idade foi de 44 anos (33-56). O IMC médio foi de 53,5 kg/m2 (50-63,5). O tempo cirúrgico médio foi de 115 min (80-180) e a permanência hospitalar média foi de 2,5 dias (1-25). Complicações foram observadas em cinco pacientes (7,5%) e dois (2,9%) tiveram de ser reoperados. Duas pacientes evoluíram com fístula, uma no coto duodenal e outra na junção esofagogástrica. Não houve mortalidade. Conclusão: SADI-S com ligadura da artéria gástrica direita é procedimento seguro com poucas complicações precoces. A simplificação técnica em relação ao duodenal switch clássico pode permitir que este procedimento se torne mais popular. Todas as complicações observadas nesta série não estavam relacionadas com a ligadura da artéria gástrica direita.

MEDIUM-TERM FOLLOW-UP RESULTS WITH LAPAROSCOPIC SLEEVE GASTRECTOMY.

BACKGROUND: The indications for sleeve gastrectomy in the surgical treatment of morbid obesity have increased worldwide. Despite this, several aspects related to results at medium and long term remain in constant research. AIM: To present the experience of sleeve gastrectomy in a center of excellence in bariatric surgery by analyzing clinical outcomes, complications and follow-up in the medium term. METHODS: The study included 120 morbidly obese patients who underwent sleeve gastrectomy and who were followed for at least 24 months. Aspects related to surgical technique, surgical complications and clinical outcome were analyzed. RESULTS: Seventy-five patients were women (62.5%) and the average age was 36 years. The body mass index preoperatively ranged from 35.5 to 58 kg/m2(average of 40.2 kg/m2). The length of stay ranged from 1 to 4 days (mean 2.1 days). Comorbidities observed were hypertension (19%), type 2 diabetes mellitus (6.6%), dyslipidemia (7.5%), sleep apnea (16.6%), reflux esophagitis (10%) and orthopedic diseases (7.5%). The mean body mass index and total weight loss percentage with 3, 12, 18 and 24 months were 32.2 kg/m2-19,9%; 29.5 kg/m2-26,5%; 28.2 kg/m2-30,3% and 26.9 kg/m2-32,7%, respectively. Remission of diabetes and dyslipidemia occurred in all patients. In relation to hypertension, there was improvement or remission in 86%. There were only two complications (bronchial pneumonia and dehydration), with good response to clinical treatment. There was no evidence digestive fistula and mortality was zero. Eleven patients (9.1%) had regained weighing more than 5 kg. CONCLUSION: The sleeve gastrectomy is surgical technique that has proven safe and effective in the surgical treatment of obesity and control of their comorbidities in postoperative follow-up for two years.

TECHNICAL ASPECTS OF LAPAROSCOPIC SLEEVE GASTRECTOMY.

BACKGROUND: The vertical gastrectomy indications for surgical treatment of morbid obesity have increased worldwide. Despite this increase, many aspects of surgical technique still remains in controversy. AIM: To contribute presenting surgical details in order to better realize the vertical gastrectomy technique in bariatric surgery. METHODS: Technical systematization, patient preparation, positioning of the trocars, operative technique and postoperative care are presented in details. RESULTS: During 12 months were enrolled 120 patients undergoing GV according to the technique described herein. The results are published in another ABCD article (ABCD 2015;28(Supl.1):61-64) in this same volume and number. CONCLUSION: The surgical technique proposed here presented itself viable and facilitating the surgeon's work on difficult points of the vertical gastrectomy.

Laparoscopic total gastrectomy as an alternative treatment to postsleeve chronic fistula.

BACKGROUND: Sleeve gastrectomy (SG) has become a very common 1-stage procedure in bariatric surgery. Postsleeve chronic fistulas could be one of the possible complications and represent a true challenge for the surgeons. After the failure of more conservative treatments, including surgical and endoscopic approaches, laparoscopic total gastrectomy (LTG) could be an alternative treatment proposal. The objective of this study was to evaluate outcomes of patients who underwent laparoscopic total gastrectomy for the treatment of postsleeve chronic fistula. METHODS: Retrospectively review the data from patients after LTG for postsleeve chronic fistula who had failed in all previous treatment attempts with a combination of conservative, endoscopic, and/or surgical approach. RESULTS: From January 2008 to December 2012, 12 patients underwent LTG. Mean time from SG to LTG was 16 months (ranged from 6 to 30). All patients had undergone several previous treatment attempts, including endoscopic techniques (fibrin glue, clips, pneumatic dilation, and stents) and surgical procedures for abscess drainage. Surgical time ranged from 4 to 7 hours with a mean hospital stay of 6 days. Complications occurred in 2 patients (17%) with 1 revision as a result of an intestinal occlusion. There were no conversions to open surgery, anastomotic leaks, or deaths. CONCLUSIONS: LTG was feasible in the management of postsleeve chronic fistulas recalcitrant to other treatment approaches with a few complications and high rate of resolution.

Total clipless cholecystectomy by means of harmonic sealing.

BACKGROUND: In traditional laparoscopic cholecistectomy, the cystic duct and artery are commonly closed by metallic clips just before their division. Although the placement of these clips for occluding cystic artery and duct can be considered safe, biliary leaks and bleeding may occur especially by its dislodgement. AIM: To report a prospective case-series in total clipless cholecystectomy by means of harmonic shears for closure and division of the artery and cystic duct as well removal of the gallbladder from the liver. METHODS: Was evaluate a series of 125 patients who underwent laparoscopic cholecystectomy where the sealing and division of cystic artery and duct was carried out only by harmonic shears. The intact extracted gallbladder was submitted to a reverse pressure test for assessment of the technique safety by means of CO2 insuflation. RESULTS: The most common indication for surgery was gallstones. The mean operative time was 26 min and all gallbladders were dissected intact from the liver bed. There was no mortality and the overall morbidity rate was 0.8% with no hemorrhage or leaks. The reverse pressure test showed that all specimens support at least 36-mmHg of pressure without leaking. CONCLUSION: The harmonic shears is effective and safe in laparoscopic cholecystectomy as a sole instrument for sealing and division of the artery and cystic duct. The main advantages could be related to the safety and decreased operative time.

TECHNICAL ASPECTS OF LAPAROSCOPIC SLEEVE GASTRECTOMY / ASPECTOS TÉCNICOS DA GASTRECTOMIA VERTICAL LAPAROSCÓPICA

Background:The vertical gastrectomy indications for surgical treatment of morbid obesity have increased worldwide. Despite this increase, many aspects of surgical technique still remains in controversy.Aim:To contribute presenting surgical details in order to better realize the vertical gastrectomy technique in bariatric surgery.Methods:Technical systematization, patient preparation, positioning of the trocars, operative technique and postoperative care are presented in details.Results:During 12 months were enrolled 120 patients undergoing GV according to the technique described herein. The results are published in another ABCD article (ABCD 2015;28(Supl.1):61-64) in this same volume and number.Conclusion:The surgical technique proposed here presented itself viable and facilitating the surgeon's work on difficult points of the vertical gastrectomy.

Racional: As indicações da gastrectomia vertical no tratamento cirúrgico da obesidade mórbida têm aumentado no mundo todo. Apesar deste aumento, diversos aspectos relativos à técnica operatória têm sido controversos.Objetivo: Contribuir com detalhes cirúrgicos afim de melhor a técnica da gastrectomia vertical na cirurgia bariátrica.Métodos: A sistematização técnica, o preparo do paciente, o posicionamento dos trocárteres, a técnica operatória e cuidados do pós-operatório são apresentados em detalhes.Resultados: Durante 12 meses foram incluídos 120 pacientes submetidos à GV de acordo com a técnica aqui descrita. Os resultados estão publicados em outro artigo do ABCD (ABCD 2015;28(Supl.1):61-64) neste mesmo volume e número.Conclusão: A técnica cirúrgica aqui proposta apresentou-se viável facilitando o trabalho do cirurgião em pontos difíceis da gastrectomia vertical.

MEDIUM-TERM FOLLOW-UP RESULTS WITH LAPAROSCOPIC SLEEVE GASTRECTOMY / RESULTADOS A MÉDIO PRAZO COM A GASTRECTOMIA VERTICAL LAPAROSCÓPICA

Background: The indications for sleeve gastrectomy in the surgical treatment of morbid obesity have increased worldwide. Despite this, several aspects related to results at medium and long term remain in constant research.Aim: To present the experience of sleeve gastrectomy in a center of excellence in bariatric surgery by analyzing clinical outcomes, complications and follow-up in the medium term.Methods: The study included 120 morbidly obese patients who underwent sleeve gastrectomy and who were followed for at least 24 months. Aspects related to surgical technique, surgical complications and clinical outcome were analyzed.Results: Seventy-five patients were women (62.5%) and the average age was 36 years. The body mass index preoperatively ranged from 35.5 to 58 kg/m2(average of 40.2 kg/m2). The length of stay ranged from 1 to 4 days (mean 2.1 days). Comorbidities observed were hypertension (19%), type 2 diabetes mellitus (6.6%), dyslipidemia (7.5%), sleep apnea (16.6%), reflux esophagitis (10%) and orthopedic diseases (7.5%). The mean body mass index and total weight loss percentage with 3, 12, 18 and 24 months were 32.2 kg/m2-19,9%; 29.5 kg/m2-26,5%; 28.2 kg/m2-30,3% and 26.9 kg/m2-32,7%, respectively. Remission of diabetes and dyslipidemia occurred in all patients. In relation to hypertension, there was improvement or remission in 86%. There were only two complications (bronchial pneumonia and dehydration), with good response to clinical treatment. There was no evidence digestive fistula and mortality was zero. Eleven patients (9.1%) had regained weighing more than 5 kg.Conclusion: The sleeve gastrectomy is surgical technique that has proven safe and effective in the surgical treatment of obesity and control of their comorbidities in postoperative follow-up for two years.

Racional: As indicações da gastrectomia vertical no tratamento cirúrgico da obesidade mórbida têm aumentado no mundo todo. Apesar deste aumento, diversos aspectos relativos às indicações e aos resultados à médio e longo prazo permanecem em constante pesquisa.Objetivo: Apresentar a experiência da gastrectomia vertical de um centro de excelência em cirurgia bariátrica, analisando os resultados clínicos, complicações e seguimento a médio prazo.Métodos: Foram incluídos 120 pacientes obesos mórbidos submetidos à gastrectomia vertical e que foram acompanhados por no mínimo 24 meses. Foram analisados os aspectos relativos à técnica operatória, complicações cirúrgicas e evolução clínica.Resultados: Dos pacientes estudados 75 eram mulheres (62,5%) e a idade média foi de 36 anos. O índice de massa corpórea pré-operatório variou de 35,5 a 58 Kg/m2 (média de 40,2 kg/m2). O tempo de internação variou de 1 a 4 dias (média de 2,1 dias). As co-morbidades observadas foram a hipertensão arterial sistêmica (19%), diabete melito tipo 2 (6,6%), dislipidemia (7,5%), apneia do sono (16,6%), esofagite de refluxo (10%) e doenças ortopédicas (7,5%). A média do índice de massa corpórea e do percentual de peso total perdido com 3, 12, 18 e 24 meses foram 32,2 kg/m2-19,9%; 29,5 kg/m2-26,5%; 28,2 kg/m2-30,3% e 26,9 kg/m2-32,7%, respectivamente. Houve remissão do diabete e da dislipidemia em todos os pacientes. Já em relação à hipertensão arterial sistêmica, houve melhora ou remissão em 86% dos casos. Ocorreram apenas duas complicações (broncopneumonia e desidratação), com boa resposta ao tratamento clínico. Não se evidenciou fístula digestiva e a mortalidade foi zero. Onze pacientes (9,1%) apresentaram reganho de peso superior a 5 kg.Conclusão: A gastrectomia vertical é técnica operatória que se mostrou segura e eficaz no tratamento cirúrgico da obesidade e controle de suas co-morbidades em seguimento pós-operatório por dois anos.

Total clipless cholecystectomy by means of harmonic sealing / Colecistectomia laparoscópica totalmente ultrassônica sem uso de clipe metálico

BACKGROUND: In traditional laparoscopic cholecistectomy, the cystic duct and artery are commonly closed by metallic clips just before their division. Although the placement of these clips for occluding cystic artery and duct can be considered safe, biliary leaks and bleeding may occur especially by its dislodgement. AIM: To report a prospective case-series in total clipless cholecystectomy by means of harmonic shears for closure and division of the artery and cystic duct as well removal of the gallbladder from the liver. METHODS: Was evaluate a series of 125 patients who underwent laparoscopic cholecystectomy where the sealing and division of cystic artery and duct was carried out only by harmonic shears. The intact extracted gallbladder was submitted to a reverse pressure test for assessment of the technique safety by means of CO2 insuflation. RESULTS: The most common indication for surgery was gallstones. The mean operative time was 26 min and all gallbladders were dissected intact from the liver bed. There was no mortality and the overall morbidity rate was 0.8% with no hemorrhage or leaks. The reverse pressure test showed that all specimens support at least 36-mmHg of pressure without leaking. CONCLUSION: The harmonic shears is effective and safe in laparoscopic cholecystectomy as a sole instrument for sealing and division of the artery and cystic duct. The main advantages could be related to the safety and decreased operative time. .

RACIONAL: A colecistectomia laparoscópica na técnica tradicional oclui o ducto cístico e a artéria cística por clipes cirúrgicos, que podem se deslocar ou desprender no pós-operatório, possibilitando a ocorrência de fístula biliar ou hemorragia. OBJETIVO: Relato prospectivo de série de casos de colecistectomias laparoscópicas sem uso de clipe cirúrgico, sendo que a ligadura e secção da artéria cística e do ducto cístico foram realizadas por meio de bisturi ultrassônico. MÉTODO: Foram incluídos 125 pacientes submetidos à colecistectomia laparoscópica sem utilização de clipe cirúrgico metálico, onde a ligadura da artéria e do ducto cístico e também a remoção da vesícula biliar de seu leito hepático foram realizadas por meio de tesoura ultrassônica. Realizou-se teste de pressão reversa na vesícula biliar removida intacta do leito hepático para verificar a segurança da técnica. RESULTADOS: A principal indicação cirúrgica foi a colelitíase. O tempo cirúrgico médio foi de 26 min e todas as vesículas biliares foram retiradas intactas do leito hepático. Não houve mortalidade e a taxa global de morbidade foi de 0,8%, sem hemorragias ou fístulas. O teste de pressão reversa mostrou que o ducto cístico ocluído pelo bisturi harmônico suportou ao pelo menos 36 mmHg de pressão sem que ocorresse nenhum vazamento. CONCLUSÃO: O bisturi harmônico é eficaz e seguro em colecistectomias laparoscópicas eletivas como um instrumento único para ocluir e seccionar tanto a artéria cística quanto o ducto cístico. Vantagens podem ser apontadas ao método com relação a sua segurança e diminuição do tempo cirúrgico. .

Simplified gastric bypass: 13 years of experience and 12,000 patients operated.

BACKGROUND: Obesity is increasingly prevalent disease worldwide and bariatric surgery is the most effective treatment for the most severe cases. The Roux-en-Y gastric bypass is still the most used technique all over the world and the laparoscopic approach has been preferred by surgeons with different approaches, propositions and techniques in performing the procedure. AIM: To report the surgical aspects of the systematization and results of the simplified laparoscopic gastric bypass (Brazilian technique). METHODS: Were included all patients undergoing this procedure from January 2001 to July 2014; were described and analyzed aspects of this technique, the systematization and complications associated with the procedure. RESULTS: A total of 12,000 patients (72% women) were included, with a mean age of 43 years (14-76) and a mean BMI of 44.5 (35-90 kg/m2). Mean total operative time was 72 minutes (36-270) and the mean hospital stay was 36 hours. There were 303 cases of gastrojejunostomy stenosis (2.5%), 370 patients had gastrointestinal bleeding (3%) with only one lap revision due to a enteroanastomosis bleeding and six revisions related to intestinal obstruction caused by impacted clots in the jejunojenunostomy. Blood transfusion was needed in 32 patients (0.3%); Petersen hernia was diagnosed in 18 (0.15%) and digestive fistula in 54 (0.45%), which led to reoperation in 43 of them (67%). The overall mortality was 0.1% (fistula with sepsis=8, pulmonary thromboembolism=3; intestinal obstruction associated with sepsis=1). CONCLUSION: The simplified laparoscopic gastric bypass is a feasible and safe option with low complication rate and easy reproducibility for education and training in bariatric surgery.

Simplified gastric bypass: 13 years of experience and 12,000 patients operated / Bypass Gástrico Simplificado: 13 anos de experiência e 12.000 pacientes operados

BACKGROUND: Obesity is increasingly prevalent disease worldwide and bariatric surgery is the most effective treatment for the most severe cases. The Roux-en-Y gastric bypass is still the most used technique all over the world and the laparoscopic approach has been preferred by surgeons with different approaches, propositions and techniques in performing the procedure. AIM: To report the surgical aspects of the systematization and results of the simplified laparoscopic gastric bypass (Brazilian technique). METHODS: Were included all patients undergoing this procedure from January 2001 to July 2014; were described and analyzed aspects of this technique, the systematization and complications associated with the procedure. RESULTS: A total of 12,000 patients (72% women) were included, with a mean age of 43 years (14-76) and a mean BMI of 44.5 (35-90 kg/m2). Mean total operative time was 72 minutes (36-270) and the mean hospital stay was 36 hours. There were 303 cases of gastrojejunostomy stenosis (2.5%), 370 patients had gastrointestinal bleeding (3%) with only one lap revision due to a enteroanastomosis bleeding and six revisions related to intestinal obstruction caused by impacted clots in the jejunojenunostomy. Blood transfusion was needed in 32 patients (0.3%); Petersen hernia was diagnosed in 18 (0.15%) and digestive fistula in 54 (0.45%), which led to reoperation in 43 of them (67%). The overall mortality was 0.1% (fistula with sepsis=8, pulmonary thromboembolism=3; intestinal obstruction associated with sepsis=1). CONCLUSION: The simplified laparoscopic gastric bypass is a feasible and safe option with low complication rate and easy reproducibility for education and training in bariatric surgery. .

RACIONAL: A obesidade é doença de prevalência crescente no mundo todo e a cirurgia bariátrica é o tratamento mais eficaz para os graus mais severos. O bypass gástrico em Y-de-Roux ainda é a opção técnica mais utilizada no mundo e a via de acesso laparoscópica tornou-se rapidamente a opção preferencial dos cirurgiões, com diversas variações e proposições técnicas na execução do procedimento. OBJETIVO: Relatar os aspectos técnicos da sistematização cirúrgica e resultados do bypass gástrico laparoscópico simplificado (bypass brasileiro). MÉTODOS: Foram incluídos todos os pacientes submetidos a este procedimento entre janeiro de 2001 a julho de 2014. Foram descritos e analisados aspectos da sistematização técnica simplificada e as complicações associadas ao procedimento. RESULTADOS: No período, 12.000 pacientes (72% de mulheres) foram incluídos, com média de idade de 43 anos (14-76) e com IMC médio de 44,5 (35-90 kg/m2). O tempo operatório total médio foi de 72 minutos (36-270) e a permanência hospitalar média foi de 36 horas. Ocorreram 303 casos de estenose na gastroenteroanastomose (2,5%), 370 pacientes tiveram hemorragia digestiva (3%) com necessidade de reoperação de apenas um deles por sangramento da enteroanastomose e seis pacientes foram reoperados por obstrução na enteroanastomose causada por impactação de coágulos. Transfusão sanguínea foi necessária em 32 pacientes (0,3%); hérnia de Petersen foi diagnosticada em 18 (0,15%) e fístula digestiva em 54 (0,45%), o que levou à reoperação em 43 deles (67%). A mortalidade global foi de 0,1% (fístula com sepse=8; tromboembolismo pulmonar=3; obstrução intestinal com sepse associada=1). ...

Early outcomes of the first Brazilian experience in totally robotic bariatric surgery.

BACKGROUND: Currently, bariatric surgery is the most effective therapy for morbid obesity, and the laparoscopic approach is considered gold-standard for Roux-en-Y gastric bypass. Totally robotic Roux-en-Y gastric bypass has been proposed as a major evolution in minimally invasive bariatric surgery and its use is becoming more widespread. AIM: To provide an early report of the first Brazilian case-series of totally robotic gastric bypass and perioperative short-term outcomes. METHODS: All consecutive patients who underwent totally robotic gastric bypass at two recognized centers of bariatric surgery were included. Patient demographic data, body mass index, operative times, hospital stay, complications and mortality in the 30 postoperative days were recorded. The surgeons received the same training program before the clinical procedures and all the surgeries were performed under the supervision of an experienced robotic surgeon. RESULTS: The surgeries were performed by five surgeons and included 68 patients (52 women - 76.5%), with a mean age of 40.5 years (range 18 to 59) and mean BMI of 41.3 (35.2 - 59.2). Total mean operative time was 158 minutes (range 90 to 230) and mean overall hospital stay was 48 h. Postoperative surgical complication rate (30 day) was 5.9%, with three minor and one major complication. There was no mortality, leak or stricture. CONCLUSION: Even with surgeons in early learning curves, the robotic approach within a well-structured training model was safe and reproducible for the surgical treatment of the morbid obesity.

Resultados iniciais da primeira série de casos brasileira de cirurgia bariátrica totalmente robótica / Early outcomes of the first Brazilian experience in totally robotic bariatric surgery

RACIONAL: Atualmente a cirurgia bariátrica é o tratamento mais eficaz para a obesidade mórbida. Embora ainda tenha algumas dificuldades, a abordagem laparoscópica tem-se tornando o padrão-ouro para o by-pass gástrico em Y-de-Roux. O uso da robótica representa grande evolução no campo da cirurgia bariátrica minimamente invasiva e seu uso tem sido cada vez mais difundido. OBJETIVO: Relatar a primeira experiência brasileira em cirurgia bariátrica totalmente robótica. MÉTODOS: Foram avaliados todos os pacientes submetidos à cirurgia bariátrica totalmente robótica em dois centros de excelência em cirurgia bariátrica. Foram registrados a incidência demográfica, índice de massa corporal, tempos operatórios, duração da internação hospitalar, mortalidade e todas as complicações em até 30 dias. As equipes cirúrgicas receberam treinamento específico para aprendizagem da técnica robótica e todos os procedimentos foram feitos com supervisão. RESULTADOS: O procedimento foi realizado por cinco equipes cirúrgicas em 68 pacientes (52 mulheres - 76,5%), com idade média de 40,5 anos e IMC médio de 41,3. O tempo médio operatório total foi de 158 minutos e a média de permanência hospitalar foi de 48 h. O percentual de complicações perioperatórias foi de 5,9%. Não houve mortalidade, fístulas ou estenoses. CONCLUSÃO: Mesmo com cirurgiões em período inicial da curva de aprendizagem, o by-pass gástrico por abordagem totalmente robótica é opção técnica segura e reproduzível no tratamento cirúrgico da obesidade mórbida, desde que respeitado modelo de treinamento bem estruturado.

BACKGROUND: Currently, bariatric surgery is the most effective therapy for morbid obesity, and the laparoscopic approach is considered gold-standard for Roux-en-Y gastric bypass. Totally robotic Roux-en-Y gastric bypass has been proposed as a major evolution in minimally invasive bariatric surgery and its use is becoming more widespread. AIM: To provide an early report of the first Brazilian case-series of totally robotic gastric bypass and perioperative short-term outcomes. METHODS: All consecutive patients who underwent totally robotic gastric bypass at two recognized centers of bariatric surgery were included. Patient demographic data, body mass index, operative times, hospital stay, complications and mortality in the 30 postoperative days were recorded. The surgeons received the same training program before the clinical procedures and all the surgeries were performed under the supervision of an experienced robotic surgeon. RESULTS: The surgeries were performed by five surgeons and included 68 patients (52 women - 76.5%), with a mean age of 40.5 years (range 18 to 59) and mean BMI of 41.3 (35.2 - 59.2). Total mean operative time was 158 minutes (range 90 to 230) and mean overall hospital stay was 48 h. Postoperative surgical complication rate (30 day) was 5.9%, with three minor and one major complication. There was no mortality, leak or stricture. CONCLUSION: Even with surgeons in early learning curves, the robotic approach within a well-structured training model was safe and reproducible for the surgical treatment of the morbid obesity.

Associação entre a gastrite e a infecção gástrica pelo Helicobacter pylor / Association between gastritis and gastric infection caused by Helicobacter pylori

Introdução: Gastrite é qualquer processo inflamatório que envolve o estômago, sendo a infecção pelo Helicobacter pylori um importante fator etiológico. As informações sobre essa associação direta são escassas na literatura biomédica atual. Objetivo: Constatar a ocorrência de infecção gástrica pelo H. pylori nos casos de gastrite no Serviço de Endoscopia Digestiva da Faculdade de Medicina de Marília (FAMEMA). Métodos: Entre janeiro e maio de 2004, todos os pacientes submetidos ao exame de endoscopia digestiva alta (EDA) no Serviço de Endoscopia da FAMEMA que tinham indicação clínica de pesquisa de infecção gástrica pelo H. pylori e que assinaram o termo de consentimento foram in-cluídos no estudo, que foi aprovado pelo CEP (041/ 02). Nesses pacientes, foram coletados cinco frag-mentos de mucosa gástrica: um do antro para pesquisa do H. pylori por genotipagem através da técnica da polimerase chain reaction (PCR) e quatro fragmentos (dois do antro e dois do corpo) para análise histológica pelas colorações HE e Giemsa, que foram utilizados pelo patologista na busca da presença do H. pylori e determinação de reação inflamatória crônica na mucosa gástrica. Os dados encontrados na pesquisa de laboratório foram confrontados com o laudo endoscópico. Resultados:Das 251 endoscopias digestivas realizadas por ummesmo examinador, 88 pacientes foram incluídos no estudo. Nesses, a concordância do diagnóstico endoscópico e histológico de gastrite ocorreu em 50 casos, sendo 36 casos de gastrite associada ao H. pylori (casos "verdadeiro-positivos") e 14 casos de gastrite H. pylori negativo (gastrite não associada ao H. pylori). Conclusão: A ocorrência de infecção pelo H. pylori nos casos de gastrite no Serviço de Endoscopia Digestiva da FAMEMA é de 72.7.

The role of bovine preserved peritoneum in rats ventral hernia: a histological evaluation / Aspectos histológicos do uso do peritônio bovino conservado na correção de hérnia ventral em ratos

PURPOSE: To assess the role of preserved bovine parietal peritoneum as a material for hernia repair in a rat ventral hernia model. METHODS: An abdominal wall defect (15mm x 25mm) was created in Wistar male rats (n=40). Control animals (n=20) had the polypropylene (PP) mesh sutured into the defect, whereas bovine preserved peritoneum (BPP) was used in experimental group (n=20). After 7 and 28 days, the abdominal wall was taken off and histological studies of the amount of collagen by Sirius Red stain and morphometric evaluation consisted in quantitative analysis of the collagen by using specific software (Imagelab®). The Mann-Whitney, Kruskal-Wallis and ANOVA tests were applied for statistical analysis (pd"0.05). RESULTS: Histological examination revealed no difference between the BPP and PP groups (p = 0.55 NS). CONCLUSION: BPP is suitable for the closure of ventral hernias in rat model as shown by its morphological properties.

OBJETIVO: Estudar os aspectos histológicos do uso de uma prótese de peritônio bovino na correção de hérnia ventral em um modelo animal de doença. MÉTODOS: Utilizando 40 ratos machos Wistar, comparou-se o implante do peritônio bovino com a tela de polipropileno na correção de um defeito provocado na parede abdominal do animal. Após 7 (sub-grupo A) e 28 (sub-grupo B) dias de observação, as peças foram retiradas e procedeu-se o estudo histológico através da quantificação de colágeno pelo método de captação e processamento digital de imagens, sob a coloração do Sirius Red. Os testes de Mann-Whitney, de Kruskal-Wallis e ANOVA foram utilizados e estabeleceu-se em 0,05 o nível para rejeição da hipótese de nulidade (pd"0.05). RESULTADOS: A quantificação do colágeno na interface do implante mostrou equivalência entre os grupos Peritônio e Polipropileno (p=0,55 NS). CONCLUSÃO: O peritônio parietal bovino apresentou infiltração de tecido fibrocolágeno semelhante a da tela de polipropileno na correção de hérnia ventral em ratos.

The role of bovine preserved peritoneum in rats ventral hernia: a histological evaluation.

PURPOSE: To assess the role of preserved bovine parietal peritoneum as a material for hernia repair in a rat ventral hernia model. METHODS: An abdominal wall defect (15mm x 25mm) was created in Wistar male rats (n=40). Control animals (n=20) had the polypropylene (PP) mesh sutured into the defect, whereas bovine preserved peritoneum (BPP) was used in experimental group (n=20). After 7 and 28 days, the abdominal wall was taken off and histological studies of the amount of collagen by Sirius Red stain and morphometric evaluation consisted in quantitative analysis of the collagen by using specific software (Imagelab). The Mann-Whitney, Kruskal-Wallis and ANOVA tests were applied for statistical analysis (pd"0.05). RESULTS: Histological examination revealed no difference between the BPP and PP groups (p = 0.55 NS). CONCLUSION: BPP is suitable for the closure of ventral hernias in rat model as shown by its morphological properties.

Peritônio bovino conservado na correção de hérnia ventral em ratos: uma alternativa para tela cirúrgica biológica / Preserved bovine peritoneum for ventral hernia repair in rats: a biological surgical mesh alternative

OBJETIVO: Verificar a possibilidade de implantação e a capacidade de resistência tênsil do peritônio parietal bovino como tela cirúrgica na correção de hérnia ventral em um modelo animal de experimentação. MÉTODO: Utilizando 57 ratos machos Wistar, comparou-se o implante do peritônio bovino com a tela de polipropileno na correção de um defeito provocado na parede abdominal do animal. Após sete (sub-grupo A) e 28 (sub-grupo B) dias de observação, as peças foram retiradas e procedeu-se a avaliação da resistência à tração em Máquina Universal de Ensaios. Um grupo sem implante de material protético foi utilizado como controle nos testes de força tênsil. Os testes de Mann-Whitney e de Kruskal-Wallis foram utilizados e estabeleceu-se em 0,05 o nível para rejeição da hipótese de nulidade. RESULTADOS: Os testes de resistência à tração, com valores expressos em Newton, não mostraram diferenças estatísticas entre os grupos estudados, tanto no 7° quanto no 28° dia de pós-operatório, e ambos foram menos resistentes que a parede abdominal normal (p = 0,003). CONCLUSÃO: O peritônio parietal bovino apresentou resistência tênsil semelhante a da tela de polipropileno em um modelo de correção de hérnia ventral em ratos.

cagA vacA alelles and babA2 genotypes of Helicobacter pylori associated with gastric disease in Brazilian adult patients.

Helicobacter pylori is an important human pathogen that causes chronic gastritis and is associated with development of peptic ulcer disease and gastric malignancies. The vacuolating cytotoxin (vacA), cagA gene, and babA2 gene are important virulence factor involving gastric diseases. Eighty-nine Helicobacter pylori-positive gastric biopsies were analyzed by polymerase chain reaction and Southern blotting for H. pylori detection and genotyping with primer pairs from each virulence gene. Fifty-three strains (59%) were common vacA genotype s1/m1, and only 14 (16%) were s2/m2, 12% of strains was found to have multiple infection. The cagA presence was detected in 48% (43 strains) and babA2 gene was detected in 44% of our H. pylori strains. We observed high percentage of s1/m1 strains with chronic gastritis and peptic ulcer and a significant correlation between cagA presence with the s1 allele and babA2 gene with chronic gastritis.