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1.
J Gastrointest Surg ; 16(5): 967-76, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22350720

RESUMO

BACKGROUND: The objective of this study was to evaluate the mid-term outcomes of the laparoscopic ileal interposition into the jejunum (JII-SG) or into the duodenum (DII-SG) associated with sleeve gastrectomy for type 2 diabetes mellitus (T2DM) patients with BMI below 35. METHODS: The procedures were performed on 202 consecutive patients. Mean age was 52.2 ± 7.5. Mean duration of T2DM was 9.8 ± 5.2 years. Insulin therapy was used by 41.1%. Dyslipidemia was observed in 78.2%, hypertension in 67.3%, nephropathy in 49.5%, retinopathy in 31.2%, coronary heart disease in 11.9%, and other cardiovascular events in 12.9%. RESULTS: Mean follow-up was 39.1 months (range, 25-61). Early and late mortality was 0.99% and 1.0%, respectively. Early reoperation was performed in 2.5%. Early and late major complications were 8.4% and 3.5%. Early most frequent complications were pneumonia and ileus. Intestinal obstruction was diagnosed in 1.5%. Mean BMI decreased from 29.7 to 23.5 kg/m(2), mean fasting glucose from 202.1 to 112.2 mg/dl, and mean postprandial glucose from 263.3 to 130 mg/dl. Triglycerides diminished from a mean of 273.4 to 110.3 mg/dl and cholesterol from a mean of 204.7 to 160.1 mg/dl. Hypertension was resolved in 87.5%. Mean hemoglobin A(1c) (HbA(1c)) decreased from 8.7 to 6.2% after the JII-SG and to 5.9% following the DII-SG. HbA(1c) below 7% was seen in 89.9% of the patients and below 6.5% in 78.3%. Overall, 86.4% of patients were off antidiabetic medications. CONCLUSION: Both JII-SG and DII-SG demonstrated to be safe, effective, and long-lasting alternatives for the treatment of T2DM patients with BMI <35. Beyond glycemic control, other benefits were achieved.


Assuntos
Diabetes Mellitus Tipo 2/cirurgia , Gastrectomia/métodos , Laparoscopia/métodos , Obesidade/cirurgia , Adulto , Análise de Variância , Anastomose Cirúrgica/métodos , Índice de Massa Corporal , Estudos de Coortes , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/diagnóstico , Duodeno/cirurgia , Feminino , Seguimentos , Gastrectomia/efeitos adversos , Humanos , Íleo/cirurgia , Jejuno/cirurgia , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Obesidade/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
2.
Dig Surg ; 28(4): 293-8, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21894016

RESUMO

BACKGROUND: Laparoscopic ileal interposition associated with a sleeve gastrectomy (LII-SG) is a safe and effective operation for the treatment of type 2 diabetic (T2DM) patients with BMI below 35. The aim of this study was to evaluate insulin sensitivity (IS) and ß-cell function using the euglycemic hyperinsulinemic clamp (EHC) with the intravenous glucose tolerance test (IVGTT). METHODS: This was a prospective study of 24 T2DM patients submitted to a 3-hour EHC-IVGTT before and 1 month after LII-SG. Mean BMI was 29.0, mean age was 54.8 years and mean duration of T2DM was 10.2 years; insulin therapy was used by 62.5% of the patients. RESULTS: Mean BMI decreased from 29.0 to 25.8 (p < 0.001). Mean fasting plasma glucose and mean postprandial glucose were 202 and 251.3 mg/dl and dropped to 127.7 and 131.8 mg/dl (p < 0.001), respectively. Mean preoperative IS was 1.4 mmol·min(-1)·nmol(-1) and increased to 2.2 mmol· min(-1)·nmol(-1) postoperatively (p < 0.001). Mean C-peptide AUC was 488 pmol·nmol(-1) and increased to 777 pmol· nmol(-1) (p = 0.37). The disposition index increased from 9.4 to 36.4 postoperatively (p = 0.01). CONCLUSIONS: According to the clamp technique, II-SG significantly improved IS and ß-cell function as early as 30 days postoperatively in a T2DM population with a BMI of 21.9-33.8.


Assuntos
Glicemia/metabolismo , Diabetes Mellitus Tipo 2/fisiopatologia , Gastrectomia , Íleo/cirurgia , Resistência à Insulina/fisiologia , Células Secretoras de Insulina/fisiologia , Adulto , Área Sob a Curva , Cirurgia Bariátrica , Índice de Massa Corporal , Peptídeo C/sangue , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/cirurgia , Feminino , Técnica Clamp de Glucose , Teste de Tolerância a Glucose , Humanos , Insulina/sangue , Laparoscopia , Masculino , Pessoa de Meia-Idade , Obesidade/sangue , Obesidade/fisiopatologia , Obesidade/cirurgia , Período Pós-Operatório , Período Pré-Operatório , Estudos Prospectivos , Perda de Peso
3.
J Gastrointest Surg ; 15(8): 1344-53, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21557013

RESUMO

INTRODUCTION: Bariatric surgery in morbidly obese type 2 diabetic (T2DM) patients is associated with high rates of diabetes remission. We investigated the mechanisms of the anti-diabetic effect of the laparoscopic ileal interposition with sleeve gastrectomy (LII-SG) in normal weight (NW), overweight (OW) and obese (OB) T2DM patients. METHODS: Ninety-four patients (aged 54 ± 8 years) with long-standing (median 10 years), treated diabetes (median HbA(1c) = 8.6%), who were NW (15), OW (64) or OB (15) based on BMI, underwent LII-SG. Insulin sensitivity and parameters of ß-cell function were measured from an Oral Glycaemic Tolerance Test pre- and post-operatively. RESULTS: At a median of 13.4 months post-operatively, weight loss averaged 9.4 ± 1.3, 16.8 ± 0.8 and 23.2 ± 1.7 kg in NW, OW and OB subjects, respectively (p < 0.0001). Insulin sensitivity was fully restored (395 [108] vs 208 [99] ml min⁻¹ m⁻²), fasting insulin secretion rate decreased (68 [52] vs 146 [120] pmol min⁻¹ m⁻²) and total insulin output increased (52 [26] vs 39 [28] nmol m⁻², all p ≤ 0.001). ß-cell glucose sensitivity doubled (37 [33] vs 18 [24] mol min⁻¹ m⁻² mM⁻¹, p < 0.0001). The only parameter predicting remission of diabetes was a lower baseline insulin sensitivity (p = 0.005). CONCLUSIONS: LII-SG induced changes on T2DM by mechanisms in part distinct from weight loss, principally involving restoration of insulin sensitivity and improvement of ß-cell function.


Assuntos
Diabetes Mellitus Tipo 2/fisiopatologia , Diabetes Mellitus Tipo 2/cirurgia , Gastrectomia , Íleo/cirurgia , Resistência à Insulina/fisiologia , Células Secretoras de Insulina/fisiologia , Cirurgia Bariátrica/métodos , Glicemia/metabolismo , Índice de Massa Corporal , Diabetes Mellitus Tipo 2/sangue , Feminino , Teste de Tolerância a Glucose , Hemoglobina A Glicada/metabolismo , Humanos , Insulina/sangue , Masculino , Pessoa de Meia-Idade , Obesidade/sangue , Obesidade/fisiopatologia , Obesidade/cirurgia , Sobrepeso/sangue , Sobrepeso/fisiopatologia , Sobrepeso/cirurgia
4.
World J Surg ; 35(1): 102-8, 2011 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21052999

RESUMO

BACKGROUND: The objective of this study was to evaluate the early results of the laparoscopic interposition of a segment of ileum associated with a sleeve gastrectomy (LII-SG) in order to treat patients with type 2 diabetes mellitus (T2DM) and BMI <35. Data regarding morbidly obese diabetic patients subjected to surgery has consistently been validated. To date, there is scarce information about morbidity and mortality related to the surgical treatment of a "true" typical diabetic population with BMI <35. METHODS: The procedures were performed in 454 patients (322 male, 132 female). Mean age was 53.6 ± 8 years (range = 27-75). Mean BMI was 29.7 ± 3.6 kg/m(2) (range = 19-34.8). All patients had the diagnosis of T2DM for at least 3 years. Insulin therapy was used by 45.6% of patients. Mean duration of T2DM was 10.8 ± 5.9 years (range = 3-35). Mean hemoglobin A(1c) was 8.8 ± 1.9%. Dyslipidemia was observed in 78.4%, hypertension in 64.8%, nephropathy in 28.6%, retinopathy in 32.6%, neuropathy in 34.6%, and coronary heart disease in 13%. RESULTS: There was no conversion to open surgery. All patients were evaluated postoperatively. Mortality was 0.4%. There were 29 major complications (6.4%) in 22 patients (4.8%) and 51 minor complications (11.2%). Reoperations were performed on 8 patients (1.7%). Twenty patients (4.4%) were readmitted to the hospital. Mean postoperative BMI was 25.8 ± 3.5 kg/m(2). Mean fasting plasma glucose decreased from 198 ± 69 to 128 ± 67 mg/dl and mean postprandial plasma glucose decreased from 262 ± 101 to 136 ± 43 mg/dl. CONCLUSIONS: The laparoscopic ileal interposition associated with a sleeve gastrectomy was considered a safe operation with low rates of morbidity and mortality in a diabetic population with BMI < 35. An early control of postprandial glycemia was observed.


Assuntos
Diabetes Mellitus Tipo 2/cirurgia , Gastrectomia/métodos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Adulto , Idoso , Análise de Variância , Índice de Massa Corporal , Brasil/epidemiologia , Distribuição de Qui-Quadrado , Diabetes Mellitus Tipo 2/complicações , Feminino , Gastrectomia/mortalidade , Humanos , Íleo/cirurgia , Laparoscopia/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Complicações Pós-Operatórias/mortalidade , Reoperação , Resultado do Tratamento
5.
Obes Surg ; 21(5): 668-75, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-20652440

RESUMO

The aim of this study was to evaluate the mid-term outcomes of the laparoscopic ileal interposition associated to a sleeve gastrectomy (LII-SG) for the treatment of morbid obesity. The procedure was performed in 120 patients: 71 women and 49 men with mean age of 41.4 years. Mean body mass index (BMI) was 43.4 ± 4.2 kg/m². Patients had to meet requirements of the 1991 NIH conference criteria for bariatric operations. Associated comorbidities were observed in all patients, including dyslipidemia in 51.7%, hypertension in 35.8%, type 2 diabetes in 15.8%, degenerative joint disease in 55%, gastroesophageal reflux disease in 36.7%, sleep apnea in 10%, and cardiovascular problems in 5.8%. Mean follow-up was 38.4 ± 10.2 months, range 25.2-61.1. There was no conversion to open surgery nor operative mortality. Early major complications were diagnosed in five patients (4.2%). Postoperatively, 118 patients were evaluated. Late major complications were observed in seven patients (5.9%). Reoperations were performed in six (5.1%). Mean postoperative BMI was 25.7 ± 3.17 kg/m², and 86.4% were no longer obese. Mean %EWL was 84.5 ± 19.5%. Hypertension was resolved in 88.4% of the patients, dyslipidemia in 82.3%, and T2DM in 84.2%. The LII-SG provided an adequate weight loss and resolution of associated diseases during mid-term outcomes evaluation. There was an acceptable morbidity with no operative mortality. It seems that chronic ileal brake activation determined sustained reduced food intake and increased satiety over time. LII-SG could be regularly used as a surgical alternative for the treatment of morbid obesity.


Assuntos
Gastrectomia/métodos , Adulto , Feminino , Seguimentos , Humanos , Íleo/cirurgia , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Resultado do Tratamento
6.
J Gastrointest Surg ; 14(8): 1319-25, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20556664

RESUMO

BACKGROUND: Dyslipidemia is known to increase significantly the odds of major cardiovascular events in the general population. Its control becomes even more important in the type 2 diabetic (T2DM) population. Bariatric surgeries, especially gastric bypass, are effective in achieving long-term control of dyslipidemia in morbidly obese patients. OBJECTIVE: The objective of the study was to evaluate the control of dyslipidemia in patients with T2DM and BMI below 30 that were submitted to the laparoscopic ileal interposition associated to sleeve gastrectomy. METHODS: An observational transversal study was performed in a tertiary care hospital, between June 2005 and August 2007. Mean follow-up was 24.5 months (range 12-38). The procedure was performed in 72 patients: 51 were men and 21 were women. Mean age was 53.1 years (38-66). Mean BMI was 27 kg/m(2) (22.1-29.4). Mean duration of T2DM was 10.5 years (3-22). Mean HbA1c was 8.5%. Hypercholesterolemia was diagnosed in 68% of the patients and hypertriglyceridemia in 63.9%. RESULTS: Mean postoperative BMI was 21.2.kg/m(2) (17-26.7). Mean postoperative HbA1c was 6.1%, ranging 4.4% to 8.3%. Overall, 86.1% of the patients achieved an adequate glycemic control (HbA1c < 7) without anti-diabetic medication. HbA1c below 6 was achieved by 50%, 36.1% had HbA1c between 6 and 7, and 13.9% had HbA1c above 7. Total hypercholesterolemia was normalized in 91.8% and hypertriglyceridemia in 89.1% of patients. Low-density lipoprotein below 100 mg/dl was seen in 85.7%. CONCLUSIONS: The laparoscopic ileal interposition associated to sleeve gastrectomy was an effective operation for the regression of dyslipidemia and T2DM in a non-obese population.


Assuntos
Diabetes Mellitus Tipo 2/cirurgia , Duodeno/cirurgia , Dislipidemias/sangue , Gastrectomia/métodos , Íleo/cirurgia , Laparoscopia , Adulto , Idoso , Anastomose Cirúrgica , Glicemia/metabolismo , Índice de Massa Corporal , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Dislipidemias/complicações , Feminino , Seguimentos , Hemoglobina A Glicada/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
7.
Surg Obes Relat Dis ; 6(3): 296-304, 2010 May-Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20096647

RESUMO

BACKGROUND: The objective of the present study was to prospectively evaluate the results of 2 versions of laparoscopic ileal interposition (II) and sleeve gastrectomy (SG) for the treatment of patients with type 2 diabetes mellitus and body mass index of 21-34 kg/m(2). METHODS: The laparoscopic procedures were prospectively and randomly performed in 38 patients. Of the 38 patients, 18 underwent the first version (II-SG) and 20 underwent the second version in which a diversion of the second portion of the duodenum was applied (II-DSG) and a segment of ileum was interposed into the proximal duodenum. The groups were comparable regarding age (56 and 50 years); gender (13 men and 5 women and 14 men and 6 women); weight (78 and 86 kg); mean BMI (27 and 29 kg/m(2)); duration of type 2 diabetes mellitus (10.1 and 9.2 years); the presence of dyslipidemia (12 and 8 patients), micro- and macroalbuminuria (9 and 9 patients), hypertension (8 and 15 patients), and retinopathy (5 and 8 patients); and the use of antidiabetic medications and the hemoglobin A1c level (8.6% and 8.4%). All patients were followed up for >or=2 years. RESULTS: The mean hospital stay was 3.4 days for the II-SG and 3.5 days for the II-DSG group. No patient required reoperation. All patients in both groups achieved lower levels of hemoglobin A1c. In the II-SG group, the mean hemoglobin A1c level was 6.35% (range 4.9-8.1). In the II-DSG group, the mean hemoglobin A1c level was 5.39% (range 4.2-6.5%). The mean BMI decreased in both groups to 22.2 kg/m(2) in the II-SG group and 22.7 kg/m(2) in the II-DSG group. Normal cholesterol levels (<200 mg/dL) were observed in 95% of the II-SG group and 100% of the II-DSG group. The triglycerides were lower than 150 mg/dL in 73% of the II-SG group and 90% of the II-DSG group after 24 months. CONCLUSION: Laparoscopic II-SG and II-DSG were safe and effective operations for controlling type 2 diabetes mellitus in a nonobese (BMI 21-34 kg/m(2)) population.


Assuntos
Diabetes Mellitus Tipo 2/cirurgia , Gastrectomia/métodos , Íleo/cirurgia , Laparoscopia/métodos , Adulto , Idoso , Análise de Variância , Área Sob a Curva , Índice de Massa Corporal , Distribuição de Qui-Quadrado , Comorbidade , Duodeno/cirurgia , Feminino , Seguimentos , Humanos , Jejuno/cirurgia , Tempo de Internação/estatística & dados numéricos , Lipídeos/sangue , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reoperação , Resultado do Tratamento
8.
J Gastrointest Surg ; 11(6): 693-700, 2007 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-17562117

RESUMO

Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure since its introduction in 1991. There are few studies with greater than 5-year outcomes. Herein we report a series of 312 consecutive patients who underwent primary LNF before 1996. Follow-up of more than 6 years was available in 166 patients, and the mean follow-up was 11 years (median 11.1 years, range 6.1-13.3 years). Prospective data collection included preoperative and current symptom scores (scale 0 = none to 3 = severe), as well as the level of patient satisfaction and use of antireflux medications. Total symptom score for each patient was summed from seven symptoms for a maximum value of 21. Heartburn and regurgitation were the most improved symptoms; however, all symptoms were significantly improved (P < 0.01). The total symptom score at follow-up was 2.6 down from 7.5 at baseline, with a mean difference of -4.9 (range -12 to 3). The percentage of patients stating they would have the procedure again was 93.3%, and 70% were off daily antireflux medications. Outcomes at a mean of 11 years after LNF are excellent, and the majority of patients had their symptoms resolved or significantly improved and are satisfied with their results.


Assuntos
Fundoplicatura/métodos , Refluxo Gastroesofágico/cirurgia , Feminino , Seguimentos , Refluxo Gastroesofágico/tratamento farmacológico , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Recidiva , Resultado do Tratamento
9.
Ann Surg ; 243(5): 579-84; discussion 584-6, 2006 May.
Artigo em Inglês | MEDLINE | ID: mdl-16632991

RESUMO

OBJECTIVE: Heller myotomy has been shown to be an effective primary treatment of achalasia. However, many physicians treating patients with achalasia continue to offer endoscopic therapies before recommending operative myotomy. Herein we report outcomes in 209 patients undergoing Heller myotomy with the majority (74%) undergoing myotomy as secondary treatment of achalasia. METHODS: Data on all patients undergoing operative management of achalasia are collected prospectively. Over a 9-year period (1994-2003), 209 patients underwent Heller myotomy for achalasia. Of these, 154 had undergone either Botox injection and/or pneumatic dilation preoperatively. Preoperative, operative, and long-term outcome data were analyzed. Statistical analysis was performed with multiple chi and Mann-Whitney U analyses, as well as ANOVA. RESULTS: Among the 209 patients undergoing Heller myotomy for achalasia, 154 received endoscopic therapy before being referred for surgery (100 dilation only, 33 Botox only, 21 both). The groups were matched for preoperative demographics and symptom scores for dysphagia, regurgitation, and chest pain. Intraoperative complications were more common in the endoscopically treated group with GI perforations being the most common complication (9.7% versus 3.6%). Postoperative complications, primarily severe dysphagia, and pulmonary complications were more common after endoscopic treatment (10.4% versus 5.4%). Failure of myotomy as defined by persistent or recurrent severe symptoms, or need for additionally therapy including redo myotomy or esophagectomy was higher in the endoscopically treated group (19.5% versus 10.1%). CONCLUSION: Use of preoperative endoscopic therapy remains common and has resulted in more intraoperative complications, primarily perforation, more postoperative complications, and a higher rate of failure than when no preoperative therapy was used. Endoscopic therapy for achalasia should not be used unless patients are not candidates for surgery.


Assuntos
Acalasia Esofágica/cirurgia , Esofagectomia/métodos , Esofagoscopia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Músculo Liso/cirurgia , Cuidados Pré-Operatórios
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