Panlitiasis biliar en un paciente masculino de 60 años con anastomosis bilioentérica colecistectomizado hace 13 años. Reporte de caso / Biliary panlitiasis in a 60-year-old male patient who un-derwent a bilioenteric anastomosis and cholecystectomy 13 years ago. Case report

Introducción: La panlitiasis se define como la presencia de múltiples cálculos en el trayecto de la vía biliar. El manejo consiste en realizar una colangiopancreatografía retrógrada endoscópica (CPRE), la exploración de la vía biliar o la anastomosis biliodigestiva (ABD), ya sea coledocoduodenoanastomosis o hepaticoyeyunoanastomosis.Objetivo: Describir el caso clínico de un paciente con panlitiasis biliar, abordando la presentación clínica, los métodos diagnósticos, el tratamiento y la evolución, con el propósito de ofrecer un recurso sólido a la comunidad médica.Presentación del caso: Se presenta un paciente de 60 años colecistectomizado hace 13 años portador de anastomosis bilioentérica con panlitiasis recidivante, se realizó un lavado de la vía biliar con salida de cálculos y pus del interior, finalmente se colocó una sonda Kehr junto con tratamiento clínico. Presentó una evolución favorable. Discusión: Este caso reveló una panlitiasis a la exploración de las vías biliares bajo visión endoscópica, a pesar de que no se encontró obstrucción, el paciente tenía antecedente de colecistectomía y contaba con una derivación hepático-yeyunal por lesión iatrogénica. La decisión del tratamiento debe ser multidisciplinaria ya que cada caso es único y dependerá de las características del paciente y las condiciones clínicas individuales.Conclusiones: La panlitiasis coledociana recidivante requirió un control farmacológico estricto para evitar recurrencia y la subsecuente exploración de la vía biliar que incrementa la morbimortalidad del paciente. Es importante el seguimiento médico continuo del paciente y la predisposición con la que cuenta para la formación de litos, pudiendo ser prevenidos, identificados y tratados de manera oportuna

Introduction: Panlithiasis is define as the presence of multiple stones in the biliary tract that is classified as primary, secondary, or mixed according to the origin of the stones. Management consists of endoscopic retrograde cholangiopancreatography (ERCP), exploration of the biliary tract, or biliodigestive anastomosis (BDA), either choledochoduodenostomy or hepaticojejunostomy. Objective: Describe the clinical case of a patient with biliary panlithiasis, addressing the cli-nical presentation, diagnostic methods, treatment and evolution, with the purpose of offering a solid resource to the medical community.Case Presentation: We present a 60-year-old male patient who underwent cholecystectomy 13 years ago and has a bilioenteric anastomosis with recurrent panlithiasis. Biliary lavage was performed with the output of stones and pus from the inside. Finally, a Kehr tube was placed along with clinical treatment. The patient showed a favorable outcome.Discussion: This case revealed a panlithiasis upon exploration of the biliary tract under endoscopic vision. Despite finding no obstruction, the patient had a history of cholecystectomy and a hepatic-jejunal diversion due to iatrogenic injury. The treatment decision should be multidisciplinary, as each case is unique and depends on the patient's characteristics and individual clinical conditions.Conclusions: Recurrent choledocholithiasis required strict pharmacological control to prevent recurrence and subsequent exploration of the biliary tract, which increases patient morbidity and mortality. Continuous medical follow-up of the patient and the predisposition with which they have for the formation of stones is important. These can be prevented, identified, and treated in a timely manner.

Internal post-bariatric hernia due to hepatic adhesion: a case report

ABSTRACT Roux-en-Y gastric bypass, a procedure proven effective for treating morbid obesity and metabolic disorders, carries the risk of complications such as the formation of internal hernias. These hernias are often difficult to diagnose and can be potentially fatal because they can cause structural obstruction. Most internal hernias occur in the jejunojejunostomy mesentery space, followed by Petersen's space hernias, although herniation at other locations can also occur. Our case report presents an example of a rare internal hernia after laparoscopic Roux-en-Y gastric bypass. A 36-year-old woman presented with an uncommon internal hernia located between the liver and alimentary loop, resulting in the formation of a new space and consequently incarcerating the entire biliopancreatic loop. This type of internal hernia is rare and has not been reported in the literature, indicating that this is the first report of such a case. In this case, we realized that the diagnosis was challenging and imaging examinations could not help determine the etiology of the pain and obstruction. Therefore, videolaparoscopy revealed an uncommon hernia formed by firm adhesion between the hepatic segment III and the alimentary loop mesentery. Our case is an example of an internal hernia that was not detected with a normal computed tomography scan of the abdomen and pelvis. Only diagnostic laparoscopy revealed herniation, effectively preventing further complications for the patient.

Endoscopic negative pressure therapy for the closure of an esophagojejunal anastomosis fistula. Case report / Terapia endoscópica de presión negativa para cierre de fístula de la anastomosis esófago-yeyunal. Reporte de caso

Abstract Introduction: Post-surgical esophagojejunal anastomosis fistulas can be life-threatening. Currently, there are several treatment alternatives. In recent years, endoscopic negative pressure therapy has emerged as an innovative treatment for these fistulas, offering numerous benefits. Case presentation: A 72-year-old man diagnosed with gastric adenocarcinoma of the body and fundus underwent total gastrectomy with D2 lymphadenectomy and Roux-en-Y anastomosis with curative intent in a quaternary care hospital in Popayán, Colombia. However, in the postoperative period, he presented systemic inflammatory response syndrome and acute abdomen due to an esophagojejunal fistula. Initial management included a laparotomy, two peritoneal washings, and an abdominal drainage. Then the patient developed frozen abdomen, so it was not possible to access the esophagojejunal anastomosis. Fistula closure was attempted by inserting a self-expandable metallic stent, yet the procedure was not successful. Salvage therapy was started using an endoscopic vacuum-assisted closure (VAC) system. After 5 replacements of the VAC system, complete drainage of the intra-abdominal collection, complete closure of the peritoneal cavity, and closure of the esophagojejunal leak, with a small residual diverticular formation, were achieved. The patient's condition improved progressively, resuming oral intake 20 days after initiation of VAC therapy. In addition, no new abdominal complications were reported during the follow-up period (17 months). Conclusions: Endoscopic VAC therapy is a new safe and effective alternative to treat complex post-surgical fistulas caused by esophagojejunal anastomosis.

Resumen Introducción. Las fístulas de las anastomosis esófago-yeyunales postquirúrgicas pueden llegar a ser mortales. En la actualidad, existen varias alternativas de tratamiento, y en los últimos años la terapia endoscópica de presión negativa se ha convertido en un método innovador y con grandes ventajas para el manejo de estas fístulas. Presentación del caso. Hombre de 72 años diagnosticado con adenocarcinoma gástrico de cuerpo y fondo a quien se le realizó una gastrectomía total con linfadenectomía D2 y una anastomosis en Y de Roux con intención curativa en un hospital de cuarto nivel en Popayán, Colombia. Sin embargo, en el posoperatorio presentó síndrome de respuesta inflamatoria sistémica y abdomen agudo producto de fístula esófago-yeyunal. Se realizó manejo inicial con laparotomía, dos lavados de cavidad peritoneal y drenaje abdominal. Posteriormente, el paciente desarrolló abdomen congelado, por lo que no fue posible acceder a la anastomosis esófago-yeyunal. Se intentó cierre de fístula mediante la inserción de prótesis metálica autoexpandible, pero el procedimiento no fue exitoso. Se inició terapia de rescate mediante sistema de cierre asistido por vacío (VAC) por vía endoscópica. Luego de 5 recambios del sistema VAC, se logró el drenaje completo de la colección intraabdominal encontrada, el cierre completo de la cavidad peritoneal y el cierre de la fuga esófago-yeyunal, con una pequeña formación diverticular residual. La condición del paciente mejoró progresivamente, con reinicio de la vía oral a los 20 días del inicio de la terapia VAC. Además, no se reportaron nuevas complicaciones abdominales en el periodo de seguimiento (17 meses). Conclusión. La terapia endoscópica de VAC es una nueva alternativa segura y efectiva para el tratamiento de fístulas postquirúrgicas complejas producto de anastomosis esófago-yeyunales.

Safety and efficacy of roux-en-y gastric bypass in older aged patients / Segurança e eficácia do bypas gástrico em Y de Roux em pacientes idosos

ABSTRACT Introduction: laparoscopic Roux-en-Y Gastric Bypass (LRYGB) has been a revolutionary intervention for weight loss with reduction of up to 60-70% of excess body weight. However, these outcomes are not as well validated at the extremes of age, where the safety of the intervention still has some caveats. The aim of this study is to assess the efficacy and safety of primary LRYGB among different age groups. Methods: the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for patients who underwent primary LRYGB from January 2014 to December 2017 at a single institution. Four groups were created and compared by dividing our sample by age quartiles. The primary outcome was percent excess weight loss (%EWL) at 1 year. Additional operative outcomes and complications were also compared across groups. Results: a total of 1013 patients underwent non-revisional LRYGB during the study period. Mean %EWL at one year was 55%. When compared between quartiles, there was a statistically significant difference in %EWL: 1st 62%, 2nd 57%, 3rd 54% and 4th 47% (p=0.010). The differences in the secondary outcomes between age groups did not demonstrate statistical significance. Conclusions: though patients in the fourth age quartile (range) did not demonstrate a statistically significant increase in adverse outcomes, they did lose less weight compared to other cohorts. The %EWL at one year after RYGB varied by age in our cohort. Goals after bariatric surgery should be individualized as weight loss is less robust with aging.

RESUMO Introdução: o Bypass Gástrico Laparoscópico em Y de Roux (LRYGB) tem sido uma intervenção revolucionária para perda de peso com redução de até 60-70% do excesso de peso corporal. No entanto, esses resultados não são tão bem validados nos extremos de idade, onde a segurança da intervenção ainda possui algumas ressalvas. O objetivo deste estudo é avaliar a eficácia e segurança do LRYGB entre diferentes faixas etárias. Métodos: O banco de dados do Programa de Acreditação e Melhoria da Qualidade da Cirurgia Metabólica e Bariátrica (MBSAQIP) foi consultado para pacientes submetidos a LRYGB de janeiro de 2014 a dezembro de 2017 em uma única instituição. Quatro grupos foram criados e comparados dividindo a amostra por quartis de idade. O desfecho primário foi perda percentual de excesso de peso (%EWL) em 1 ano. Resultados: 1013 pacientes foram submetidos a LRYGB durante o período do estudo. A média de %EWL em um ano foi de 55%. Quando comparados entre os quartis, houve diferença significante no %EWL: 1º 62%, 2º 57%, 3º 54%, e 4º 47% (p=0,010). As diferenças nos desfechos secundários entre as faixas etárias não demonstraram significância estatística. Conclusões: embora os pacientes no quarto quartil de idade não tenham demonstrado um aumento estatisticamente significativo nos resultados adversos, eles perderam menos peso em comparação com outras coortes. O %EWL um ano após RYGB variou de acordo com a idade em nossa coorte. Os objetivos após a cirurgia bariátrica devem ser individualizados, pois a perda de peso é menos robusta com o envelhecimento.

Perda de peso e o comprimento do intestino delgado na cirurgia de fobi-capella: há relação? / Weight loss and the length of the small intestine in the fobi-capella surgery: is there a relationship?

RESUMO - RACIONAL: Os fatores relacionados à perda de peso nos pacientes obesos submetidos à cirurgia bariátrica sempre foram exaustivamente estudados na tentativa de propor a melhor técnica cirúrgica com maior perda de peso e resolução as comorbidades à longo prazo. Os pacientes apresentam variações anatômicas no que tange o comprimento do intestino delgado. Há estudos que demonstram alterações de peso nos pacientes que apresentam diferentes comprimentos das alças intestinais na técnica do by-pass em Y de Roux. O presente trabalho realizou um estudo entre a influência do IMC, a perda de peso e o comprimento da alça comum nos resultados cirúrgicos à longo prazo. MÉTODOS: Estudo transversal descritivo pela análise retrospectiva de 112 prontuários de pacientes submetidos à cirurgia bariátrica aberta pela técnica do bypass gástrico no Hospital de Clínicas -UFPR. Os dados foram correlacionados em programas estatísticos para este fim. RESULTADOS: Dos 112 pacientes, 83,03% eram do sexo feminino, média de idade de 41,52 anos. O comprimento médio do intestino delgado total dos pacientes foi de 5,02 metros. Houve uma relação diretamente proporcional entre o comprimento do intestino delgado e a perda de peso (p=0,0428). CONCLUSÃO: Há uma ampla gama de variáveis relacionadas à perda de peso nos pacientes submetidos à cirurgia bariátrica, tais como a técnica utilizada, o comprimento das alças no by-pass gástrico em Y de Roux e a rotina de acompanhamento nutricional e físico do paciente. É importante considerar os detalhes técnicos do procedimento cirúrgico, e verificar a perda de peso avaliando-se o paciente como um todo e outras variáveis.

ABSTRACT - BACKGROUND: Factors related to weight loss in obese patients undergoing bariatric surgery have always been exhaustively studied in an attempt to propose the best surgical technique with greater weight loss and long-term resolution of comorbidities. Patients present anatomical variations regarding the length of the small intestine. Some studies demonstrate weight changes in patients with different lengths of the intestinal loops in the Roux-en-Y bypass technique. The present work carried out a study on the influence of body mass index, weight loss, and common loop length on long-term surgical outcomes. METHODS: This is a descriptive cross-sectional study by retrospective analysis of 112 medical records of patients undergoing open bariatric surgery using the gastric bypass technique at University Hospital - UFPR. The data were correlated in statistical programs for this purpose. RESULTS: Out of 112 patients, 83.03% were women, with mean age of 41.52 years. The mean length of the total small bowel of the patients was 5.02 m. There was a directly proportional relationship between the length of the small intestine and weight loss (p=0.0428). CONCLUSION: There is a wide range of variables related to weight loss in patients undergoing bariatric surgery, such as the technique used, the length of the loops in the Roux-en-Y gastric bypass, and the routine of nutritional and physical monitoring of the patient. It is important to assess the technical details of the surgical procedure and to verify the weight loss by evaluating integrally the patient and other variables.

Is the waist/height ratio a better parameter than bmi in determining the cardiometabolic risk profile of obese people? / A razão cintura/estatura é melhor parâmetro que o imc na determinação do perfil de risco cardiometabólico dos obesos?

ABSTRACT Background: The increased prevalence of obesity has led to a significant increase in the occurrence of metabolic syndrome, a recognized risk factor for increased morbidity and mortality from cardiovascular diseases. Hyperglycemia or type 2 diabetes mellitus, dyslipidemia and arterial hypertension are its main components. Since 2015, international guidelines have recognized the benefits of bariatric surgery in each isolated factor of this syndrome. Aim: To evaluate the impact of Roux-en-Y gastric bypass in this syndrome comparing pre- and postoperative periods with laboratory analysis and to compare waist/height ratio and BMI in relation to the determination of the cardiometabolic risk profile. Methods: A retrospective study was carried out, selecting 80 patients undergoing Roux-en-Y gastric bypass. Total cholesterol, HDL, LDL, triglycerides, fasting glucose, glycated hemoglobin, insulin, body mass index (BMI), vitamin D, vitamin B12, waist circumference and waist/height ratio in three periods were analyzed: the preoperative period from 1 to 6 months, postoperative from 1 to 6 months and postoperative from 1 to 2 years. Results: There was an improvement in all parameters of the clinical analyses. The preoperative BMI had a mean value of 39.8, in the preoperative period from 1 to 6 months, the values ​​dropped to 33.2 and in the postoperative period of 1 year, the mean was 26. The perimeter mean values ​​of 118.5 preoperatively, 105.2 postoperatively from 1 to 6 months and 90.3 postoperatively from 1 to 2 years. Waist/height ratio was 0.73, 0.65 and 0.56 in pre, post 1 to 6 months and 1 to 2 years respectively. Conclusion: Roux-en-Y gastric bypass improves metabolic syndrome and waist-to-height ratio is superior to BMI in the assessment of the cardiometabolic risk profile.

RESUMO Racional: O aumento da prevalência da obesidade levou ao aumento significativo da ocorrência de síndrome metabólica, fator de risco reconhecido para aumento da morbimortalidade por doenças cardiovasculares. A hiperglicemia ou diabetes mellitus do tipo 2, dislipidemia e hipertensão arterial são seus principais componentes. Desde 2015, diretrizes internacionais reconheceram os benefícios da cirurgia bariátrica em cada fator isolado desta síndrome. Objetivos: Avaliar o impacto do bypass gástrico em Y-de-Roux nesta síndrome comparando períodos pré e pós-operatório com análise laboratorial, e comparar a razão cintura/estatura e o IMC em relação a determinação do perfil de risco cardiometabólico. Métodos: Realizou-se um estudo retrospectivo com base prospectiva selecionando 80 pacientes submetidos à bypass gástrico em Y-de-Roux. Foram analisados o colesterol total, HDL, LDL, triglicerídeos, glicemia de jejum, hemoglobina glicada, insulina, índice de massa corpórea (IMC), vitamina D, vitamina B12, perímetro abdominal e relação cintura/estatura em três períodos: o pré-operatório de 1 a 6 meses, pós-operatório de 1 a 6 meses e pós-operatório de 1 a 2 anos. Resultados: Houve melhora em todos os parâmetros das análises clínicas. O IMC, no pré-operatório, teve a média dos valores de 39,8, no pré-operatório de 1 a 6 meses, os valores caíram para 33,2 e no pós-operatório de 1 ano média foi de 26. O perímetro abdominal teve média dos valores de 118,5, no pré-operatório, 105,2 no pós-operatório de 1 a 6 meses e 90,3 no pós-operatório de 1 a 2 anos. A relação cintura/estatura teve 0,73, 0,65 e 0,56 no pré, pós 1 a 6 meses e 1 a 2 anos respectivamente. Conclusão: O bypass gástrico em Y-de-Roux melhora a síndrome metabólica e a relação cintura/estatura é superior ao IMC na avaliação do perfil do risco cardiometabólico.

Safety and effectiveness of laparoscopic Y-en-Roux gastric bypass surgery in obese elderly patients

Abstract Purpose To analyze, in aged obese patients, the weight loss, comorbidity control, and safety postoperative complications of bariatric surgery by Roux-en-Y gastric bypass technique. Methods Twenty-seven patients who underwent laparoscopic weight-reducing gastroplasty with Roux-en-Y gastric bypass to treat obesity were included. All patients were ≥ 60 years old at the time of surgery. The Wilcoxon test was used for statistical analysis, and a p-value ≤0.05it was considered significant. Results Ten (90.9%) patients with dyslipidemia were cured (p < 0.001). Nine (81.8%) patients with type 2 diabetes mellitus had total improvement and 2 (18.2%) had partial improvement (p = 0.003). In 23 patients with systemic arterial hypertension, 9 (39.1%) achieved total improvement and 14 (60.9%) partial improvement (p = 0.140). Five (71.4%) patients with obstructive sleep apnea syndrome were cured (p = <0.001). For other comorbidities, no partial improvement or cure was shown. Conclusions Roux-en-Y gastric bypass surgery in obese elderly patients can be performed safely and with low morbidity and mortality rates. The benefits of weight loss and reduced comorbidities are promising and like those of the younger population.

Safety and effectiveness of laparoscopic Y-en-Roux gastric bypass surgery in obese elderly patients

Purpose To analyze, in aged obese patients, the weight loss, comorbidity control, and safety postoperative complications of bariatric surgery by Roux-en-Y gastric bypass technique. Methods Twenty-seven patients who underwent laparoscopic weight-reducing gastroplasty with Roux-en-Y gastric bypass to treat obesity were included. All patients were 60 years old at the time of surgery. The Wilcoxon test was used for statistical analysis, and a p-value 0.05it was considered significant. Results Ten (90.9%) patients with dyslipidemia were cured (p 0.001). Nine (81.8%) patients with type 2 diabetes mellitus had total improvement and 2 (18.2%) had partial improvement (p = 0.003). In 23 patients with systemic arterial hypertension, 9 (39.1%) achieved total improvement and 14 (60.9%) partial improvement (p = 0.140). Five (71.4%) patients with obstructive sleep apnea syndrome were cured (p = 0.001). For other comorbidities, no partial improvement or cure was shown. Conclusions Roux-en-Y gastric bypass surgery in obese elderly patients can be performed safely and with low morbidity and mortality rates. The benefits of weight loss and reduced comorbidities are promising and like those of the younger population.(AU)

Detalles técnicos de la doble anastomosis hepático-yeyuno en Y de Roux, con base en la descripción de un caso / Technical details of double Roux-en-Y hepaticojejunostomy based on a clinical case description

La anastomosis hepático-yeyuno en Y de Roux se considera la técnica de elección para tratar lesiones quirúrgicas de la vía biliar, como su sección o resección. La pérdida de confluencia de los conductos hepáticos principales derecho e izquierdo es uno de los factores que incrementan la complejidad técnica durante el procedimiento y, en algunos de estos pacientes, se requiere una doble anastomosis hepático-yeyuno para garantizar resultados satisfactorios a largo plazo. Se describen los aspectos técnicos y los resultados posoperatorios del tratamiento quirúrgico empleado, con base en la intervención de una paciente con una lesión quirúrgica de la vía biliar y pérdida de la confluencia de los conductos hepáticos. La evolución de la paciente fue satisfactoria y se mantiene asintomática después de 12 meses de seguimiento. A pesar de ser una técnica compleja, la doble anastomosis hepático-yeyuno en Y de Roux resultó una opción segura de tratamiento en esta paciente

Roux-en-Y hepato-jejunostomy (RYHJ) is the technique of choice for the surgical treatment of bile duct injuries (BDI), such as section or resection. The loss of the hepatic confluence (LHC) increases the technical difficulties during the procedure and, in some of these patients, a doble-RYHJ is required to achieve a long term successful result. We report the technical aspects of the surgical technique as well as the results, based on the case of a young female patient with BDI and LHC. The patient shows a satisfactory evolution and remains asymptomatic during the 12 months of follow up. Double RYHJ, although technically demanding, resulted a safe option for treating this patient

Choledochal cyst in the pediatric population: experience of 13 laparoscopic procedures in two years at a single institution / Cisto de colédoco na população pediátrica: experiência de 13 procedimentos laparoscópicos em dois anos de uma única instituição

ABSTRACT Objective: to describe the first 13 cases of laparoscopic correction of common bile duct cyst in the Pequeno Príncipe Hospital, Curitiba, Paraná, Brazil. Methods: we performed a retrospective analysis of medical records of cases of choledochal cyst operated by laparoscopy between March 2014 and September 2016. Results: of the 13 patients, eight were female and the mean age at surgery was 7.8 years. The most common symptom was abdominal pain. The hepaticoduodenal anastomosis was the most used reconstruction technique, in 84.6% of the cases. There was no conversion to laparotomy or intraoperative complications. Only one patient presented anastomotic fistula and was reoperated by laparotomy. All patients were followed up in an outpatient clinic, were asymptomatic and had no episode of cholangitis after surgery, with a mean follow-up of 16 months. Conclusion: laparoscopy is a safe method to correct choledochal cysts, even in younger children, with low rates of complications and low rates of conversion to open surgery when performed by well trained surgeons.

RESUMO Objetivo: descrever os primeiros 13 casos de correção laparoscópica de cisto do ducto biliar comum no Hospital Pequeno Príncipe, Curitiba, Paraná, Brasil. Métodos: análise retrospectiva dos registros médicos em prontuário dos casos de cisto de colédoco operados por via laparoscópica entre março de 2014 e setembro de 2016. Resultados: dos 13 pacientes, oito eram do sexo feminino e a média de idade na ocasião da cirurgia foi de 7,8 anos. O sintoma mais comum foi dor abdominal. A anastomose hepático-duodenal foi a técnica de reconstrução mais utilizada, em 84,6% dos casos. Não houve conversão para laparotomia ou complicações intraoperatórias. Apenas um paciente apresentou fístula da anastomose e foi reoperado por laparotomia. Todos permanecem em acompanhamento ambulatorial, com tempo de seguimento médio de 16 meses, assintomáticos e não apresentaram episódio de colangite após a cirurgia. Conclusão: a laparoscopia é um método seguro para correção dos cistos de colédoco, mesmo em crianças mais jovens, com baixas taxas de complicações e baixas taxas de conversão para cirurgia aberta quando realizada por cirurgiões com bom treinamento.

Impact of bariatric surgery on the inflammatory state based on cpr value / Impacto da cirurgia bariátrica no estado inflamatório baseado no valor da pcr

ABSTRACT Background: PCR (C-reactive protein), produced in the liver after stimuli of inflammatory mediators, is determined as a marker of inflammatory activity (adipocytokines) and is present within adipocyte cells; besides being an inflammatory product, many studies have shown to be a predictor of complications. Aim: To determine if the inflammatory state of the obese patient decreases after bariatric surgery, based on pre and post-operative PCR. Methods: A prospective, observational study in patients undergoing Roux-en-Y gastric by-pass surgery followed up for three months after surgery, with serum preoperative CRP in 30, 60 and 90 days after surgery. Results: A total of 19 patients, who had a mean CRP value before the surgical procedure of 0.80(±0.54) mg/dl, were followed, and when compared to the CRP with 30 days of surgery, they presented a significant increase to 2.68 mg/dl (p=0.012). When compared with the PCR of 60 days after the surgical procedure, it was also higher with the value of 3.32 mg/dl (p=0.27). However, at three months after surgery, the CRP showed a decrease when compared to the preoperative mark, with value of 0.45 mg/dl (p=0.0042). Conclusion: Roux-en-Y gastric bypass was able to decrease the chronic inflammation status of these patients, based on the value of CRP, with three months of surgery.

RESUMO Racional: PCR (proteína C-reativa) produzida no fígado após estímulos de mediadores inflamatórios é determinada como um marcador de atividade inflamatória (adipocitocinas) e está presente nos adipócitos; além de ser um produto inflamatório, muitos estudos já mostraram ser ela um preditor de complicações. Objetivos: Determinar se o estado inflamatório do paciente obeso diminui após a realização de cirurgia bariátrica, com base na PCR do pré e pós-operatório. Métodos: Estudo prospectivo, observacional em pacientes submetidos à operação de by-pass gástrico em Y-de-Roux acompanhados por três meses após o procedimento com dosagem sérica da PCR no pré-operatório, 30, 60 e 90 dias após. Resultados: Foram acompanhados 19 pacientes, que apresentaram valor médio da PCR antes do procedimento cirúrgico de 0,80(±0,54) mg/dl e quando comparado à PCR com 30 dias de operados ela apresentou aumento significativo para 2,68 mg/dl (p=0,012). A análise da PCR de 60 dias após o procedimento cirúrgico mostrou-se maior também com o valor de 3,32 mg/dl (p=0,27). Entretanto no 3º mês após ela mostrou queda quando comparado ao pré-operatório (0,45 mg/dl (p=0,0042). Conclusão: O bypass gástrico em Y-de-Roux foi capaz de diminuir o estado de inflamação crônico desses pacientes com três meses de pós-operatório.

Caso Clínico: Quiste de Colédoco Tipo IA, Resolución Quirúrgica / Case Report: Type IA Choledochal Cyst, Surgical Resolution

INTRODUCCIÓN: El quiste del colédoco es una malformación congénita de etiología desconocida, caracterizada por diversos grados de dilatación del sistema biliar. El examen inicial para la valoración de la vía biliar debe ser una ecografía abdominal,sin embargo, la resonancia magnética con contraste es el estudio de elección para valorar estas estructuras. El tratamiento quirúrgico final depende del grado de dilatación quística y generalmente está basado en la escisión completa de la vía biliar extrahepática. CASO CLÍNICO: Paciente de sexo femenino de 27 años con dolor abdominal tipo cólico a nivel de epigastrio e hipocondrio derecho de 7 días de evolución. Se realizaron exámenes de Imagenología (ecografía­ TAC ­colangio RM)que reportaron colédoco con marcada dilatación fusiforme en toda su extensión, en relación a quiste de colédoco tipo IA. EVOLUCIÓN: Se planificó la exéresis del quiste de colédoco, anastomosis bilio-digestiva en «Y de Roux¼ y colecistectomía. El procedimiento quirúrgico no tuvo complicaciones. La paciente permaneció hospitalizada por 5 días con adecuada evolución y tolerancia a dieta. CONCLUSIÓN: El quiste de colédoco es una patología congénita infrecuente en la edad adulta generalmente diagnosticada como un hallazgo incidental. El diagnóstico y tratamiento oportuno aseguran el éxito del procedimiento quirúrgico y evita la aparición de complicaciones graves (colangiocarcinoma); con la escisión completa el pronóstico es excelente, la mortalidad posoperatoria es mínima. (au)

BACKGROUND: The choledochal cyst is a congenital malformation of unknown etiology characterized by different grades of dilatation of the biliary system. The first exam to evaluate the bile duct should be the abdominal ultrasound, which suggests the diagnosis of choledochal cyst. However, the magnetic resonance imagin with contrast is the gold standard to assess these structures. The final surgery treatment depends of the grade of cyst dilatation, the main procedure is based on the complete excision of the extrahepatic bile duct. CASE REPORT: A female 27-years old patient who reffered colic abdominal pain localized in epigastrium and right hypochondrium for 7 days. Imaging exams were performed (US­CT Scan­ choledochal MRI) which reported the bile duct with a severe fusiform dilatation, in complete extension related to type IA choledochal cyst. EVOLUTION: Choledocal cyst exeresis, «Roux-en-Y¼ bilio digestive anastomosis and cholecystectomy were planned. Surgical procedure had no complications. Patient was hospitalized for 5 days with proper evolution and oral diet tolerance. CONCLUSION: The choledochal cyst is a rare congenital disease in adult hood mostly diagnosed as an incidental finding. Early diagnosis and treatment ensure the success of the surgical procedure and prevents appearance of serious complications (cholangiocarcinoma).The prognosis after complete excision is excellent with minimal postoperative mortality(au)

Ruptura de estômago excluso em dilatação endoscópica de estenose de anastomose gastrojejunal em bypass gástrico / Rupture of bypassed stomach in endoscopic dilation of gastrojejunal anastomotic stricture in gastric bypass

Introdução: o Bypass Gástrico em Y de Roux (BGYR) é o procedimento mais realizado para o tratamento da obesidade no Brasil e no mundo. A anastomose gastrojejunal é confeccionada com diâmetro pequeno, sendo que, após procedimentos laparoscópicos, a taxa de estenose pode chegar a 27%. Relato do caso: relatamos um caso de estenose de anastomose gastrojejunal de BGYR laparoscópico que, após realização de dilatação endoscópica com balão, evoluiu com ruptura do estômago excluso durante o exame e necessidade de intervenção cirúrgica. Conclusão: a dilatação endoscópica é um procedimento seguro e eficaz para tratamento da estenose de anastomose gastrojejunal. A principal complicação é a perfuração da anastomose, entretanto não há relatos descritos de ruptura do estômago excluso durante o procedimento.

Background: gastric Bypass is the most performed procedure for treatment of obesity in Brazil and worldwide. Gastrojejunal anastomosis is made with small diameter, and after laparoscopic procedures the stricture rate can reach 27%. Case report: we report a case of gastrojejunal anastomotic stricture of laparoscopic Gastric Bypass that after performing endoscopic balloon dilation evoluted with rupture of bypassed stomach during the exam and need of surgical intervention. Conclusion: endoscopic dilation is safe and an effective procedure for treatment of gastrojejunal anastomotic stricture. The main complication is perforation of the anastomosis, however there is not described reports of rupture of bypassed stomach during the procedure.

COMPLICATIONS RELATED TO GASTRIC BYPASS PERFORMED WITH DIFFERENT GASTROJEJUNAL DIAMETERS / COMPLICAÇÕES RELACIONADAS AO BYPASS GÁSTRICO REALIZADO COM CALIBRES GASTROJEJUNAIS DIFERENTES

ABSTRACT Background: Among the options for surgical treatment of obesity, the most widely used has been the Roux-en-Y gastric bypass. The gastrojejunal anastomosis can be accomplished in two ways: handsewn or using circular and linear stapled. The complications can be divided in early and late. Aim: To compare the incidence of early complications related with the handsewn gastrojejunal anastomosis in gastric bypass using Fouchet catheter with different diameters. Method: The records of 732 consecutive patients who had undergone the bypass were retrospectively analyzed and divided in two groups, group 1 with 12 mm anastomosis (n=374), and group 2 with 15 mm (n=358). Results: The groups showed anastomotic stenosis with rates of 11% and 3.1% respectively, with p=0.05. Other variables related to the anastomosis were also analyzed, but without statistical significance (p>0.05). Conclusion: The diameter of the anastomosis of 15 mm was related with lower incidence of stenosis. It was found that these patients had major bleeding postoperatively and lower surgical site infection, and in none was observed presence of anastomotic leak.

RESUMO Racional: Entre as opções para o tratamento cirúrgico da obesidade, o mais utilizado é o bypass gástrico em Y-de-Roux. A anastomose gastrojejunal dele pode ser realizada de duas maneiras, manualmente ou utilizando grampeador linear e circular, e as complicações são dividas em precoces e tardias. Objetivo: Comparar a incidência de complicações precoces relacionadas com a confecção manual da anastomose gastrojejunal no bypass gástrico utilizando sonda de Fouchet com calibres diferentes. Métodos: Foi realizada análise retrospectiva transversal com 732 pacientes submetidos ao procedimento, divididos em dois grupos, grupo 1 com anastomose de 12 mm (n=374), e grupo 2 de 15 mm (n=358). Resultados: Os grupos apresentaram taxas de estenose de anastomose de 11% e 3,1% respectivamente, com p=0,05. Outras variáveis relacionadas à anastomose também foram analisadas, porém sem significância estatística (p>0,05). Conclusão: O diâmetro da anastomose de 15 mm esteve relacionado à menor ocorrência de estenoses. Verificou-se, contudo, que estes pacientes apresentaram maior sangramento no pós-operatório e menor infecção de sítio cirúrgico. Não ocorreram fístulas na presente casuística.

EFFECTS OF LONG-TERM ROUX-EN-Y GASTRIC BYPASS ON BODY WEIGHT AND CLINICAL METABOLIC COMORBIDITIES IN BARIATRIC SURGERY SERVICE OF A UNIVERSITY HOSPITAL / EFEITOS NO LONGO PRAZO DA GASTROPLASTIA REDUTORA EM Y-DE-ROUX SOBRE O PESO CORPORAL E COMORBIDADES CLÍNICO METABÓLICAS EM SERVIÇO DE CIRURGIA BARIÁTRICA DE UM HOSPITAL UNIVERSITÁRIO

ABSTRACT Background: Due to the high failure rate observed in the clinical treatment of morbid obesity an increase in bariatric surgery indications, as an alternative for the control of obesity and comorbidities, is noticeable. Aim: To evaluate the performance of type 2 diabetes mellitus, high blood pressure and dyslipidemia in patients submitted to Roux-en-Y gastric bypass in late follow-up. Methods: Retrospective analysis of 59 patients included in the bariatric surgery program. Anthropometric (height and body weight) and laboratory (LDLc, HDLc, VLDLc, triglyceride -TG - and glucose) data were collected on pre- and postoperative stages, through medical records. Results: Among the patients, 86% were female aged 43±11, of whom 52% had attended high school. The average postoperative time was 7±3 years. During the postoperative period, there were decreases of weight and body mass index, respectively (133±06 kg vs 91±04 kg p<0.05 e 49±74 kg/m2 vs 33±79 kg/m2, p<0.05). In comparison to the preoperative stage, lower concentrations of glucose (101.00±26.99 vs 89,11±15.19, p=0.014), total cholesterol rates (179.00±37,95 vs 167.48±28,50, p=0.016), LDLc (104.30±33.12 vs 91.46±24.58, p=0.016), VLDLc (25.40±11,12 vs 15.68±7.40, p<0.01), and TG (143.35±86.35 vs 82.45±37.39, p<0.01) and higher concentrations of HDLc (43.53±8.23 vs 57.90±15.60, p<0.01) were identified in the postoperative stage. 40% of hypertensive patients were still undergoing high blood pressure treatment during the postoperative stage. There was remission of type 2 diabetes mellitus and dyslipidemia on 81% and 94% of the cases, respectively. Conclusion: Roux-en-Y gastric bypass has proven itself to be an effective long term procedure, promoting weight loss, remission of DM2 and dyslipidemia.

RESUMO Racional: Em função do alto grau de falência que se observa no tratamento clínico da obesidade mórbida, observa-se um aumento da procura pela cirurgia bariátrica como alternativa para o controle da obesidade e comorbidades. Objetivo: Avaliar a evolução do diabete melito tipo 2, da hipertensão arterial sistêmica e da dislipidemia em pacientes submetidos à gastroplastia redutora em Y-de-Roux no período de pós-operatório tardio. Métodos: Análise retrospectiva de 59 pacientes inseridos em programa de cirurgia bariátrica. Foram coletados dados antropométricos (altura e peso corporal) e laboratoriais (LDLc, HDLc, VLDLc, triglicerídeo -TG - e glicose) nos períodos pré e pós-operatório por meio de prontuários médicos. Resultados: Entre os pacientes, 86% eram mulheres com idade de 43±11 anos e 52% tinham cursado o ensino médio. O tempo médio de pós-operatório foi de 7±3 anos. Houve redução no peso e no índice de massa corporal no pós-operatório, respectivamente (133±06 kg vs 91±04 kg p<0,05 e 49±74 kg/m2 vs 33±79 kg/m2, p<0,05). Observou-se concentrações inferiores no pós-operatório, comparado com o pré-operatório, da glicose (101,00±26,99 vs 89,11±15,19, p=0,014), colesterol total (179,00±37,95 vs 167,48±28,50, p=0,016), LDLc (104,30±33,12 vs 91,46±24,58, p=0,016), VLDLc (25,40±11,12 vs 15,68±7,40, p<0,01), e TG (143,35±86,35 vs 82,45±37,39, p<0,01) e maiores de HDLc (43,53±8,23 vs 57,90±15,60, p<0,01 ). No pós-operatório 40% dos pacientes hipertensos ainda estavam em tratamento para hipertensão arterial sistêmica. Houve remissão do diabete melito tipo 2 e da dislipidemia em 81% e 94% dos casos, respectivamente. Conclusão: A gastroplastia redutora em Y-de-Roux mostrou ser procedimento eficaz em longo prazo, com resultados persistentes na perda de peso, remissão do DM2 e da dislipidemia.

LINEA ALBA COLLAGEN ASSESSMENT IN MORBIDLY OBESE PATIENTS / AVALIAÇÃO DE COLÁGENO DA LINHA ALBA EM PACIENTES OBESOS MÓRBIDOS

ABSTRACT Background: The evaluation of collagen in the abdominal wall has been increasingly studied because of the relevance on collagen in the healing process after laparotomy. Aim: To evaluate the amount of collagen in the linea alba of patients undergoing laparotomic bariatric surgery and comparing with non-obese cadavers. Methods: Were evaluated 88 samples of aponeurosis from abdominal linea alba of 44 obese patients (obesity group) and 44 non-obese cadavers (control group). The samples were collected in 2013 and 2104, and were sorted according to age (18-30, 31-45 and 46-60), gender, BMI, waist and cervical circumference, and subcutaneous tissue thickness. Material for biopsy was collected from the supraumbilical region of the linea alba for immunohistochemical analysis differentiating collagen type 1 and type 3 and the 1/3 ratio. Image-Pro Plus pixel counting software was used to measure the amount of collagen. Results: The obesity group evidenced mean age 44.11±9.90 years; 18-30 age group had three (6.8%) obese individuals; 31-45 had 22 (50%) and 46-60 had 19 (43.1%). Females were present in 81.8% (n=36); BMI (kg/m²) was 48.81±6.5; waist circumference (cm) was 136.761±13.55; subcutaneous tissue thickness (cm) 4.873±0.916. Considering age groups, gender and BMI, there were statistical differences in all tests when compared with the cadavers. Conclusion: The amount of collagen in the linea alba above the umbilical region in the morbidly obese patients was smaller than in the non-obese cadavers in the same age group.

RESUMO Racional: A avaliação do colágeno na parede abdominal é cada vez mais estudada, em virtude da relevância dele no processo cicatricial após laparotomia. Objetivo: Avaliar a quantidade de colágeno na linha alba de pacientes submetidos à cirurgia bariátrica e compará-la com a de cadáveres não-obesos. Método: Foram avaliados dois grupos com total de 88 amostras da aponeurose da linha alba abdominal, divididas em 44 de pacientes obesos (grupo obesidade) com indicação de cirurgia bariátrica e 44 de cadáveres não-obesos (grupo controle). As amostras foram retiradas da linha alba abdominal no período de 2013 a 2014 e inicialmente foram separadas conforme faixas etárias (18-30, 31-45 e 46-60), gênero, medidas de IMC, circunferência abdominal e cervical e espessura do subcutâneo do indivíduo. Foi coletado material para biópsia da linha alba supraumbilical para análise imunoistoquímica, diferenciando o colágeno tipo I e III e sua relação de tipo I/III. Utilizou-se o programa de contagem de pixels Image-Pro Plus(r), que mensurou a quantidade do colágeno. Resultados: O grupo obesidade teve idade 44,11±9,90 anos, Na faixa etária de 18-30 anos foram incluídos três (6,8%) obesos; na de 31-45 anos 22 (50%) e na de 46-60 anos 19 (43,1%). O gênero feminino apresentou predomínio, com 36 (81,8%) pacientes. O IMC (kg/m²) foi de 48,81±6,5; a circunferência abdominal (cm) foi de 136,761±13,55; a espessura do subcutâneo (cm) foi de 4,873±0,916. A quantidade de colágeno tipo I foi de 134.683,3±206.657,4; a de colágeno tipo III foi de 413.137,2±283.656,1; a razão do colágeno tipo I/III foi 0,419±0,636. Considerando-se faixas de idade, gênero e IMC, foram constatadas diferenças estatísticas em todas as análises quando comparadas com às dos cadáveres. Conclusão: Os obesos mórbidos apresentaram quantidade de colágeno na linha alba supraumbilical menor que a do grupo controle de cadáveres não-obesos na mesma faixa etária.

Late surgical complications after gastric by-pass: a literature review / Complicações cirúrgicas tardias após bypass gástrico: revisão da literatura

INTRODUCTION: Gastric bypass is today the most frequently performed bariatric procedure, but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the late ones. METHOD: Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English. RESULTS: There were selected 35 studies that matched the headings. Late complications were considered as: anastomotic strictures, marginal ulceration and gastrogastric fistula. CONCLUSION: Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention. .

INTRODUÇÃO: O bypass gástrico é hoje o procedimento bariátrico mais realizado, mas, apesar disso, várias complicações podem ocorrer com variada morbimortalidade. Provavelmente todos os cirurgiões bariátricos conhecem essas complicações, mas como a cirurgia bariátrica continua a se espalhar, o cirurgião geral deve estar familiarizado com essas complicações e seu manuseio. As complicações do bypass gástrico podem ser divididas em dois grupos: as precoces e tardias, tendo em conta o período de duas semanas após a operação. Este artigo irá focar as tardias. MÉTODO: Foi realizada revisão da literatura utilizando as bases Medline/PubMed, Cochrane Library, SciELO, e informações adicionais sobre sites institucionais de interesse cruzando os descritores: bypass gástrico AND complicações; seguimento AND complicações; complicações pós-operatórias AND anastomose, Roux-en-Y; obesidade AND complicações pós-operatórias. A língua usada para a busca foi o inglês. RESULTADOS: Foram selecionados 35 estudos que combinavam com os descritores. As complicações tardias foram consideradas como: estenose de anastomose, ulceração marginal e fístula gastrogástrica. CONCLUSÃO: O conhecimento sobre as estratégias de como reduzir o risco e incidência das complicações deve ser adquirido ao longo do tempo, e cada cirurgião deve estar familiarizado com essas complicações, a fim de reconhecê-las precocemente e realizar a melhor intervenção. .

Early surgical complications after gastric by-pass: a literature review / Complicações cirúrgicas precoces após bypass gástrico: revisão da literatura

INTRODUCTION: Gastric bypass is today the most frequently performed bariatric procedure,but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the early ones. METHOD: Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English. RESULTS: There were selected 26 studies that matched the headings. Early complications included: anastomotic or staple line leaks, gastrointestinal bleeding, intestinal obstruction and incorrect Roux limb reconstruction. CONCLUSION: Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention. .

INTRODUÇÃO: O bypass gástrico é hoje o procedimento bariátrico mais realizado, mas, apesar disso, várias complicações podem ocorrer com variada morbimortalidade. Provavelmente todos os cirurgiões bariátricos conhecem essas complicações, mas como a cirurgia bariátrica continua a se espalhar, o cirurgião geral deve estar familiarizado com essas complicações e seu manuseio. As complicações do bypass gástrico podem ser divididas em dois grupos: as precoces e tardias, tendo em conta o período de duas semanas após a operação. Este artigo irá focar as precoces. MÉTODO: Foi realizada revisão da literatura utilizando as bases Medline/PubMed, Cochrane Library, SciELO, e informações adicionais sobre sites institucionais de interesse cruzando os descritores: bypass gástrico AND complicações; seguimento AND complicações; complicações pós-operatórias AND anastomose, Roux-en-Y; obesidade AND complicações pós-operatórias. A língua usada para a busca foi o inglês. RESULTADOS: Foram selecionados 26 artigos que combinavam com os descritores. As complicações imediatas foram: fístula na linha de grampeamento, sangramento gastrointestinal, obstrução intestinal e reconstrução incorreta da alça em Roux. CONCLUSÃO: O conhecimento sobre as estratégias de como reduzir o risco e incidência das complicações deve ser adquirido ao longo do tempo, e cada cirurgião deve estar familiarizado com essas complicações, a fim de reconhecê-las precocemente e realizar a melhor intervenção. .

Choledochal cyst in childhood: review of 30 cases / Cisto de colédoco na infância: revisão de 30 casos

Objective: To analyze and discuss the clinical data, diagnosis and treatment of a number of patients with cystic dilatation of the common bile duct of a Brazilian pediatric hospital. Methods: We analyzed 30 patients treated at the Martagão Gesteira Institute of Pediatrics and Child Care of the Federal University of Rio de Janeiro for 23 years ,with statistical analysis of epidemiological data, clinical manifestations, diagnosis, treatment and postoperative outcome. Results: We observed a marked female predominance (73.4% of cases), the diagnosis being made in the first decade of life in 90% of patients. The most prevalent clinical manifestation was jaundice (70% of cases) and the classic triad of choledochal cyst was not observed. Abdominal ultrasound was the first imaging examination performed, with a sensitivity of 56.6%, with diagnostic definition in 17 children. Two patients (6.6%) had prenatal diagnosis. All patients underwent surgical treatment, cyst resection with Roux-en-Y hepaticojejunostomy being performed in 80% of cases. The incidence of postoperative complications was 13.3% and the mortality rate was 6.6%, ie two patients were diagnosed with Caroli's disease. Conclusion: The non-observance of the classic triad of choledochal cyst suggests that its incidence is lower than that reported in the medical literature. The surgical treatment of choledochal cysts, with resection and bilioenteric anastomosis, is safe even for small children. .

Objetivo: analisar e discutir os dados clínicos, o diagnóstico e tratamento de uma série de pacientes portadores de dilatações císticas do colédoco de um hospital pediátrico brasileiro. Métodos: foram analisados 30 pacientes tratados no Instituto de Pediatria e Puericultura Martagão Gesteira da Universidade Federal do Rio de Janeiro durante 23 anos, com análise estatística de dados epidemiológicos, manifestações clínicas, diagnóstico, tratamento e evolução pós-operatória. Resultados: foi observada marcada predominância do sexo feminino (73,4% dos casos), sendo o diagnóstico feito na primeira década de vida em 90% dos pacientes. A manifestação clínica mais prevalente foi a icterícia (70% dos casos) e a tríade clássica do cisto de colédoco não foi observada. A ultrassonografia abdominal foi o primeiro exame de imagem realizado, demonstrando sensibilidade de 56,6%, com definição diagnóstica em 17 crianças. Dois pacientes (6,6%) tiveram diagnóstico pré-natal. Todos os pacientes foram submetidos a tratamento cirúrgico, sendo a ressecção do cisto com hepaticojejunostomia com Y de Roux realizada em 80% dos casos. A incidência de complicações pós-operatórias foi 13,3% e a taxa de mortalidade foi 6,6%, ou seja, dois pacientes com diagnóstico de doença de Caroli. Conclusão: a não observação da tríade clássica do cisto de colédoco nos pacientes avaliados sugere que a sua incidência seja menor que a relatada na literatura médica mundial. O tratamento cirúrgico dos cistos de colédoco, com sua ressecção e anastomose bíleodigestiva é seguro, mesmo em crianças pequenas. .

Impact of bariatric surgeries on diabetes outcomes / Impacto da cirurgia bariátrica no resultado do diabetes

Obesity and type 2-diabetes (T2D) are associated to dramatically high morbidity and mortality, and their incidence and prevalence are increasing rapidly. Bariatric surgeries, including a variety of gastrointestinal surgical procedures achieve substantial and sustained weight loss in morbidly obese patients, strongly improves diabetes and hypertension control or prevalence, quality of life, decreases incidence of stroke, myocardial infarction and obstructive sleep apnea among other favorable clinical outcomes. Most important, mortality rates decreases. The objectives of this narrative review were the effectiveness of bariatric procedures on diabetes remission or improvement and the implicated mechanisms. It was found that bariatric surgeries induce high rates of short and long-term diabetes remission (from 60 to 95% or improved control), according to the surgical intervention, with low frequency of perioperative and postoperative complications. Rates of diabetes recurrence are not well known, but the time free-of-disease should ameliorate diabetes complications and mortality. The mechanisms are still not completely understood; encompass improved insulin action, better b-cell function, higher adiponectin, lower inflammation and complex changes of hormones of the entero-insular axis, GLP-1 and glucose dependent insulinotropic polypeptide (GIP). Insulin action improves proportionally to weight loss (WL), in most types of surgery, but normalizes after Bilio-pancreatic diversion even in still obese people. b-cell function improves more after bypass than after restrictive surgeries, but does not normalize and baseline function predicts diabetes remission. Efforts to understand mechanisms and predictive factors for diabetes remission may optimize surgical interventions for metabolic disorders even in less obese patients. Finally and more important, they might drive the development of new clinical approaches for T2D...