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2.
Ann R Coll Surg Engl ; 102(1): e7-e11, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31530171

RESUMO

Ehlers-Danlos syndrome is a hereditary connective tissue disorder that has gastrointestinal manifestations in over 50% of its cases. We present the first case of bariatric surgery in a patient with Ehlers-Danlos syndrome and outline management challenges in the context of the relevant literature. A 56-year-old man with type IV Ehlers-Danlos syndrome and a body mass index of 41.8 kg/m2 was referred to the bariatric centre of the Churchill Hospital, Oxford, for consideration of surgery for morbid obesity. His comorbidity included type 2 diabetes, hypertension, dyslipidaemia and obstructive sleep apnoea. He underwent a laparoscopic Roux-en-Y gastric bypass. His initial recovery was uneventful and he was discharged on the first postoperative day. Six weeks later, he presented with 43.9% excess weight loss and improved glycaemic control. Three months postoperatively, however, he complained of dysphagia, regurgitation and postprandial pain. A barium meal and gastroscopy suggested the presence of a gastric diverticulum. A surgical exploration was planned. Intraoperative gastroscopy demonstrated an asymmetrical gastric pouch dilatation and the pouch was therefore refashioned laparoscopically. Despite the initial symptomatic relief, two months later he experienced retrosternal pain with progressive dysphagia. Since then, multiple endoscopic dilatations of the gastro-oesophageal junction have been performed for recurrence of symptoms. Finally, a laparoscopic hiatus hernia repair and adhesiolysis was performed resulting in complete relief of patient's symptoms. Bariatric management of patients with Ehlers-Danlos syndrome can prove challenging. The bariatric team must implement a careful management plan including a detailed consent process, a tailored surgical intervention and a follow-up focused on potential gastrointestinal manifestations.


Assuntos
Síndrome de Ehlers-Danlos/complicações , Obesidade Mórbida/cirurgia , Transtornos de Deglutição/etiologia , Diabetes Mellitus Tipo 2/complicações , Endoscopia do Sistema Digestório/métodos , Derivação Gástrica/métodos , Hérnia Hiatal/diagnóstico , Hérnia Hiatal/etiologia , Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Dor Pós-Operatória/etiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação
3.
Arq Bras Cir Dig ; 32(3): e1458, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31826085

RESUMO

BACKGROUND: Obesity and its surgical treatment have been related with oral diseases. Aim: To evaluate and compare dental wear and dental loss in eutrophic and morbidly obese patients submitted to Roux-en-Y gastric bypass. METHOD: Observational and analytical study with gender and age matching. The sample consisted of 240 patients, divided into four groups: eutrophic (GC=60), morbidly obese (GO=60), operated with up to 24 months (G24=60) and operated on for more than 36 months (G36=60). The following variables were analyzed: race, schooling, economic class, hypertension, diabetes, triglycerides, cholesterol, BMI, weight loss, waist-hip ratio, smoking, alcoholism, tooth loss and tooth wear. RESULTS: GO presented lower economic class (p=0.012), hypertension (p<0.001), diabetes (p<0.001), cholesterol (p=0.001), BMI (p<0.001), waist-hip ratio (p<0.001) and percentage of weight loss percent (p<0.001) than groups G24 and G36. Dental wear was higher among the II and V sextants. CONCLUSION: Individuals submitted to Roux-en-Y gastric bypass, regardless of the surgery period, presented more dental wear on the incisal/occlusal surfaces, and the anterior teeth were the most affected. Dental wear was associated with age and number of missing teeth.


Assuntos
Derivação Gástrica/efeitos adversos , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Perda de Dente/etiologia , Estudos Transversais , Feminino , Humanos , Masculino
4.
Arq Bras Cir Dig ; 32(4): e1482, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31859934

RESUMO

BACKGROUND: Obesity represents a growing threat to population health all over the world. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the lower esophageal sphincter after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure; that's why some patients have reflux after sleeve. AIM: To describe a technique and preliminary results of sleeve gastrectomy with a Nissen fundoplication, in order to decrease reflux after sleeve. METHOD: In the current article we describe the technique step by step mostly focused on the creation of the wrap and it care. RESULTS: This procedure was applied in a case of 45 BMI female of 53 years old, with GERD. An endoscopy was done demonstrating a hiatal hernia, and five benign polyps. A Nissen sleeve was performed due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure and was discharged home uneventfully 48 h after. CONCLUSION: N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when Roux-en-Y gastric bypass it is not indicated.


Assuntos
Gastrectomia/métodos , Refluxo Gastroesofágico/cirurgia , Hérnia Hiatal/cirurgia , Obesidade Mórbida/cirurgia , Feminino , Fundoplicatura , Refluxo Gastroesofágico/etiologia , Hérnia Hiatal/etiologia , Humanos , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Tomografia Computadorizada por Raios X , Resultado do Tratamento
6.
Am Surg ; 85(10): 1108-1112, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657304

RESUMO

In patients undergoing bariatric surgery, the presence of metabolic syndrome (MetS) contributes to perioperative morbidity. We aimed to evaluate the utilization and outcome of severely obese patients with MetS who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB). Using the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, data were obtained for patients with MetS undergoing LSG or LRYGB. There were 29,588 MetS patients (LSG: 58.7% vs LRYGB: 41.3%). There was no significant difference in 30-day mortality (0.1% for LSG vs 0.2% for LRYGB, adjusted odds ratio (AOR) 0.58, confidence interval (CI) 0.32-1.05, P = 0.07) or length of stay between groups (2 ± 2 for LSG vs 2.2 ± 2 days for LRYGB, P = 0.40). Compared with LRYGB, LSG was associated with significantly shorter operative time (78 ± 39 vs 122 ± 54 minutes, P < 0.01), lower overall morbidity (2.3% vs 4.4%, AOR 0.53, CI 0.46-0.60, P < 0.01), lower serious morbidity (1.5% vs 2.3%, AOR 0.64, CI 0.53-0.76, P < 0.01), lower 30-day reoperation (1.2% vs 2.3%, AOR 0.52, CI 0.43-0.63, P < 0.01), and lower 30-day readmission (4.2% vs 6.6%, AOR 0.62, CI 0.55-0.69, P < 0.01). In conclusion, LSG is the predominant operation being performed for severely obese patients with MetS, and its popularity may in part be related to its improved perioperative safety profile.


Assuntos
Gastrectomia/métodos , Derivação Gástrica/métodos , Síndrome Metabólica/cirurgia , Obesidade Mórbida/cirurgia , Intervalos de Confiança , Bases de Dados Factuais , Feminino , Gastrectomia/efeitos adversos , Gastrectomia/mortalidade , Derivação Gástrica/efeitos adversos , Derivação Gástrica/mortalidade , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Razão de Chances , Duração da Cirurgia , Complicações Pós-Operatórias , Análise de Regressão , Reoperação/estatística & dados numéricos
7.
BMC Health Serv Res ; 19(1): 748, 2019 Oct 24.
Artigo em Inglês | MEDLINE | ID: mdl-31651309

RESUMO

BACKGROUND: Despite the growing evidence base supporting intensive lifestyle and medical treatments for severe obesity, patient engagement in specialist obesity services is difficult to achieve and poorly understood. To address this knowledge gap, we aimed to develop a model for predicting non-completion of a specialist multidisciplinary service for clinically severe obesity, termed the Metabolic Rehabilitation Programme (MRP). METHOD: Using a case-control study design in a public hospital setting, we extracted data from medical records for all eligible patients with a body mass index (BMI) of ≥35 kg/m2 with either type 2 diabetes or fatty liver disease referred to the MRP from 2010 through 2015. Non-completion status (case definition) was coded for patients whom started but dropped-out of the MRP within 12 months. Using multivariable logistic regression, we tested the following baseline predictors hypothesised in previous research: age, gender, BMI, waist circumference, residential distance from the clinic, blood pressure, obstructive sleep apnoea (OSA), current continuous positive airway pressure (CPAP) therapy, current depression/anxiety, diabetes status, and medications. We used receiver operating characteristics and area under the curve to test the performance of models. RESULTS: Out of the 219 eligible patient records, 78 (35.6%) non-completion cases were identified. Significant differences between non-completers versus completers were: age (47.1 versus 54.5 years, p < 0.001); residential distance from the clinic (21.8 versus 17.1 km, p = 0.018); obstructive sleep apnoea (OSA) (42.9% versus 56.7%, p = 0.050) and CPAP therapy (11.7% versus 28.4%, p = 0.005). The probability of non-completion could be independently associated with age, residential distance, and either OSA or CPAP. There was no statistically significant difference in performance between the alternate models (69.5% versus 66.4%, p = 0.57). CONCLUSIONS: Non-completion of intensive specialist obesity management services is most common among younger patients, with fewer complex care needs, and those living further away from the clinic. Clinicians should be aware of these potential risk factors for dropping out early when managing outpatients with severe obesity, whereas policy makers might consider strategies for increasing access to specialist obesity management services.


Assuntos
Manejo da Obesidade/estatística & dados numéricos , Obesidade Mórbida/terapia , Cooperação do Paciente/estatística & dados numéricos , Ansiedade/etiologia , Pressão Sanguínea/fisiologia , Índice de Massa Corporal , Estudos de Casos e Controles , Pressão Positiva Contínua nas Vias Aéreas , Depressão/etiologia , Diabetes Mellitus Tipo 2/complicações , Feminino , Hospitalização/estatística & dados numéricos , Hospitais Públicos/estatística & dados numéricos , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Obesidade Mórbida/psicologia , Fatores de Risco , Apneia Obstrutiva do Sono/complicações
8.
Am J Case Rep ; 20: 1492-1496, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31597909

RESUMO

BACKGROUND First described in 1863 by French surgeon Victor-Auguste-François Morel-Lavallee, the Morel-Lavallee lesion (MLL) is a closed traumatic soft-tissue degloving injury. These lesions most commonly occur following motor vehicle collisions (MVCs). The pathophysiology stems from a shearing force that causes separation of the soft tissue from the fascia underneath, which disrupts the vasculature and lymphatic vessels that perforate between the tissue layers. Timely diagnosis and treatment are imperative, as a delayed diagnosis can lead to complications. However, at present there is no universally accepted treatment algorithm. CASE REPORT A 60-year-old morbidly obese woman presented after being involved in an MVC. She complained of abdominal tenderness in the right lower quadrant, with no evidence of peritonitis. Cross-sectional imaging revealed hemoperitoneum and a traumatic posterior abdominal wall/lumbar hernia on the right, with multiple contusions in the subcutaneous abdomen. The patient was taken to the operating room and underwent an exploratory laparotomy that revealed a large abdominal Morel-Lavallee lesion (MLL) along with a traumatic abdominal wall hernia (TAWH). There was also a mesenteric avulsion injury with an associated ileocecal injury. The patient underwent resection of the involved bowel, with primary anastomosis, debridement of the abdominal wall degloving injury, and expectant management for the hernia defect. She recovered from the injuries and was doing well when followed up in the clinic, with follow-up to repair the hernia in the near future. CONCLUSIONS More research is needed to provide surgeons with evidence-based standardized therapies for dealing with these rare pathologies to ensure optimal patient outcomes.


Assuntos
Traumatismos Abdominais/etiologia , Acidentes de Trânsito , Desenluvamentos Cutâneos/etiologia , Hérnia Ventral/etiologia , Traumatismos Abdominais/diagnóstico por imagem , Desenluvamentos Cutâneos/diagnóstico por imagem , Feminino , Hemoperitônio/diagnóstico por imagem , Hemoperitônio/etiologia , Hérnia Ventral/diagnóstico por imagem , Humanos , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Tomografia Computadorizada por Raios X
9.
Anesth Analg ; 129(4): 1130-1136, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31584919

RESUMO

BACKGROUND: Morbidly obese patients undergoing general anesthesia are at risk of hypoxemia during anesthesia induction. High-flow nasal oxygenation use during anesthesia induction prolongs safe apnea time in nonobese surgical patients. The primary objective of our study was to compare safe apnea time, between patients given high-flow nasal oxygenation or conventional facemask oxygenation during anesthesia induction, in morbidly obese surgical patients. METHODS: Research ethics board approval was obtained. Elective surgical patients ≥18 years with body mass index ≥40 kg·m were included. Patients with severe comorbidity, gastric reflux disease, known difficult airway, or nasal obstruction were excluded. After obtaining informed consent patients were randomized. In the intervention (high-flow nasal oxygenation) group, preoxygenation was provided by 100% nasal oxygen for 3 minutes at 40 L·minute; in the control group, preoxygenation was delivered using a facemask with 100% oxygen, targeting end-tidal O2 >85%. Anesthesia was induced with propofol, remifentanil, and rocuronium. Bag-mask ventilation was not performed. At 2 minutes after rocuronium, videolaryngoscopy was performed. If the laryngoscopy grade was I or II, laryngoscope was left in place and the study was continued; if grade III or IV was observed, the patient was excluded from the study. During the apnea period, high-flow nasal oxygenation patients received nasal oxygen at 60 L·minute; control group patients received no supplemental oxygen. The primary outcome, safe apnea time, was reached when oxygen saturation measured by pulse oximetry (SpO2) fell to 95% or maximum 6 minutes of apnea. The patient was then intubated. T tests and χ analyses were used to compare groups. P < .05 was considered significant. RESULTS: Forty patients completed the study. Baseline parameters were comparable between groups. Safe apnea time was significantly longer (261.4 ± 77.7 vs 185.5 ± 52.9 seconds; mean difference [95% CI], 75.9 [33.3-118.5]; P = .001) and the minimum peri-intubation SpO2 was higher (91.0 ± 3.5 vs 88.0 ± 4.8; mean difference [95% CI], 3.1 [0.4-5.7]; P = .026) in the high-flow nasal oxygenation group compared to the control group. CONCLUSIONS: High-flow nasal oxygenation, compared to conventional oxygenation, provided a longer safe apnea time by 76 seconds (40%) and higher minimum SpO2 in morbidly obese patients during anesthesia induction. High-flow oxygenation use should be considered in morbidly obese surgical patients.


Assuntos
Anestesia Geral , Apneia/fisiopatologia , Hipóxia/prevenção & controle , Obesidade Mórbida/fisiopatologia , Oxigenoterapia , Oxigênio/sangue , Administração Intranasal , Adulto , Anestesia Geral/efeitos adversos , Apneia/sangue , Biomarcadores/sangue , Índice de Massa Corporal , Feminino , Humanos , Hipóxia/sangue , Hipóxia/etiologia , Hipóxia/fisiopatologia , Intubação Intratraqueal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/sangue , Obesidade Mórbida/complicações , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
10.
Thorac Surg Clin ; 29(4): 379-386, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31564394

RESUMO

Gastroesophageal reflux disease (GERD) is common in the morbidly obese population, and hiatal hernias are encountered in 20% to 52% of patients. Primary surgical repair of hiatal hernias, in particular the paraesophageal type, is associated with a higher recurrence rate in obese patients. Concomitant weight loss surgery may be advisable. Combined sleeve gastrectomy and paraesophageal hiatal hernia repair is feasible but can induce or worsen preexisting GERD. A Roux-en-Y gastric bypass offers advantages of more pronounced excess weight loss and better symptom control, albeit with a potentially higher rate of morbidity compared with paraesophageal hernia repair alone or sleeve gastrectomy.


Assuntos
Cirurgia Bariátrica/métodos , Refluxo Gastroesofágico/cirurgia , Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Obesidade Mórbida/cirurgia , Gastrectomia/efeitos adversos , Derivação Gástrica , Hérnia Hiatal/complicações , Humanos , Laparoscopia , Obesidade Mórbida/complicações , Recidiva , Estudos Retrospectivos , Perda de Peso
11.
Am Surg ; 85(8): 923-926, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560313

RESUMO

The extended focused assessment with sonography for trauma (eFAST) ultrasound examination is an essential step in the initial assessment of trauma patients. Its accuracy depends on the ability to acquire high-quality ultrasound images, and we hypothesized that increasing BMI was associated with increased odds for incorrect eFAST. All adult blunt trauma activations at a high-volume urban trauma center in 2016 that underwent eFAST and CT chest, abdomen, and pelvis were included (n = 446). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the eFAST were calculated with CT results as reference. The association of BMI and eFAST accuracy was determined using univariate analyses. Sensitivity and specificity of the eFAST examination were 27.1 per cent and 91.7 per cent, respectively, with an overall 76.2 per cent accuracy. At BMI 36 kg/m², the odds of having incorrect eFAST results increased to odds ratio (OR) = 1.85 (95% confidence interval, 1.03-3.32; P = 0.05). For those with BMI > 40 kg/m², the OR increased to OR = 3.12 (95% confidence interval, 1.45-6.69; P = 0.01). One-third of patients in this study were obese or morbidly obese. The latter was associated with increased odds for incorrect eFAST results, particularly the abdominal examination component.


Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Obesidade Mórbida/complicações , Traumatismos Torácicos/diagnóstico por imagem , Ferimentos não Penetrantes/diagnóstico por imagem , Acidentes por Quedas , Acidentes de Trânsito , Adulto , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Sensibilidade e Especificidade , Centros de Traumatologia
12.
Ther Umsch ; 76(3): 133-137, 2019 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-31498050

RESUMO

Metabolic surgery in patients with poorly controlled type 2 diabetes and low BMI Abstract. Bariatric surgery has been established as an efficient therapy for morbid obesity. Metabolic surgery represents the operative treatment of type 2 diabetes and other metabolic disorders. Metabolic surgery does not focus on weight loss, as many mechanisms, which are responsible for the improvement of the glycemic control are independent from weight loss. There are many studies, which show the efficient effect of metabolic surgery in diabetic patients with class II obesity. Furthermore, there is growing evidence, that metabolic surgery does also work in patients with a BMI below 35 kg / m2. Multiple surgical and endocrinological associations have endorsed these facts and adopted their guidelines. In obese type 2 diabetics with a BMI below 35 kg / m2 and a poor glycemic control metabolic surgery should be considered as a therapeutic option.


Assuntos
Cirurgia Bariátrica , Diabetes Mellitus Tipo 2 , Obesidade Mórbida , Índice de Massa Corporal , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/cirurgia , Humanos , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Perda de Peso
13.
Nutr Metab Cardiovasc Dis ; 29(12): 1368-1381, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31383503

RESUMO

BACKGROUND AND AIMS: Resistant training (RT) improves health markers in obesity, but its effects in morbid obesity are unknown. We aimed to determine the effects of a RT-program in preventing/attenuating the metabolic syndrome (MetS) in patients with morbid obesity. A second aim was to report the interindividual variability in terms of improvements in MetS markers and other related co-variables. METHODS AND RESULTS: Twenty-one adults with obesity or morbid obesity were divided into two groups based on body mass index (BMI): a control obesity (CO, n = 7, BMI ≥35 < 40.0 kg/m2) and a morbid obese group (MO, n = 14, BMI ≥40 kg/m2). Participants completed a 20-week RT-program (3 sessions/week, 4-8 exercise) using free weights. Participants were assessed for MetS markers (waist circumference, systolic and diastolic blood pressure [BP], fasting glucose, high-density lipoproteins, and triglycerides) and other co-variables (total cholesterol, low-density lipoprotein, one-maximum repetition of biceps curl, and handgrip strength, 6 min walking test). Significant reductions in MetS markers were observed in both CO and MO groups (P < 0.05 to P < 0.0001), but significant reductions in diastolic BP and increases in HDL-C were noted only in the MO group (P < 0.0001). Changes in waist circumference, and systolic and diastolic BP were significantly greater only in the MO group (P < 0.001), but the CO group presented a greater fasting glucose decreases (P < 0.0001). The prevalence of non-responders between CO and MO groups was similar in the MetS outcomes. CONCLUSIONS: RT promotes greater improvements in overall MetS outcomes waist circumference, BP, and plasma triglycerides in patients with morbid obesity than in obese peers, with no overall differences in the prevalence of non-responders. CLINICAL TRIAL NUMBER: NCT03921853 at www.clinicaltrials.gov.


Assuntos
Variação Biológica Individual , Síndrome Metabólica/prevenção & controle , Obesidade Mórbida/terapia , Treinamento de Resistência , Perda de Peso , Adulto , Biomarcadores/sangue , Glicemia/metabolismo , Pressão Sanguínea , Índice de Massa Corporal , Aptidão Cardiorrespiratória , Chile , Tolerância ao Exercício , Feminino , Força da Mão , Humanos , Lipídeos/sangue , Masculino , Síndrome Metabólica/sangue , Síndrome Metabólica/etiologia , Síndrome Metabólica/fisiopatologia , Pessoa de Meia-Idade , Obesidade Mórbida/sangue , Obesidade Mórbida/complicações , Obesidade Mórbida/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Circunferência da Cintura
14.
BMJ Case Rep ; 12(8)2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31444260

RESUMO

A 57-year-old obese, diabetic woman, presented with 1 day history of purulent umbilical discharge. She was vitally stable and afebrile. Abdominal examination revealed a full abdomen with purulent discharge from the umbilicus, swelling with erythema and induration surrounding the umbilicus. Lab tests were normal. Initial impression was abdominal wall abscess. Ultrasound showed subcutaneous fluid collection. Non-contrast CT showed collection and abdominal wall defect at the umbilicus. On exploration of the abscess cavity, there were two defects (umbilical and supraumbilical) with appendix protruding through the umbilical defect and a part of a small bowel and omentum adherent to the other defect. Wash was given, bowel and omentum were released and appendectomy was performed. Histopathology showed mucinous cystadenoma with periappendicitis. We would like to highlight the rare occurrence of an appendiceal mucinous cystadenoma in such a clinical presentation.


Assuntos
Abscesso Abdominal/diagnóstico , Neoplasias do Apêndice/diagnóstico , Cistadenoma Mucinoso/diagnóstico , Hérnia Umbilical/diagnóstico , Infecções por Klebsiella/diagnóstico , Klebsiella pneumoniae/isolamento & purificação , Abscesso Abdominal/complicações , Abscesso Abdominal/cirurgia , Neoplasias do Apêndice/complicações , Neoplasias do Apêndice/cirurgia , Cistadenoma Mucinoso/complicações , Cistadenoma Mucinoso/cirurgia , Diabetes Mellitus Tipo 2/complicações , Diagnóstico Diferencial , Feminino , Hérnia Umbilical/complicações , Hérnia Umbilical/cirurgia , Humanos , Infecções por Klebsiella/complicações , Infecções por Klebsiella/cirurgia , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Umbigo/patologia
15.
J Bone Joint Surg Am ; 101(16): 1440-1450, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31436651

RESUMO

BACKGROUND: Many surgeons require or request weight loss among morbidly obese patients (those with a body mass index [BMI] of ≥40 kg/m) before undergoing total knee arthroplasty. We sought to determine how much weight reduction was necessary to improve operative time, length of stay, discharge to a facility, and physical function improvement. METHODS: Using a retrospective review of cohort data that were prospectively collected from 2011 to 2016 at 1 tertiary institution, we identified 203 patients who were morbidly obese at least 90 days before the surgical procedure and had their BMI measured again at the immediate preoperative visit. All heights and weights were clinically measured. We used logistic and linear regression models that adjusted for preoperative age, sex, year of the surgical procedure, bilateral status, physical function (Patient-Reported Outcomes Measurement Information System [PROMIS]-10 physical component score [PCS]), mental function (PROMIS-10 mental component score [MCS]), and the Charlson Comorbidity Index. RESULTS: Of the 203 patients in the study, 41% lost at least 5 pounds (2.27 kg) before the surgical procedure, 29% lost at least 10 pounds (4.54 kg), and 14% lost at least 20 pounds (9.07 kg). Among morbidly obese patients, losing 20 pounds before a total knee arthroplasty was associated with lower adjusted odds of discharge to a facility (odds ratio [OR], 0.28 [95% confidence interval (CI), 0.09 to 0.94]; p = 0.039), lower odds of extended length of stay of at least 4 days (OR, 0.24 [95% CI, 0.07 to 0.88]; p = 0.031), and an absolute shorter length of stay (mean difference, -0.87 day [95% CI, -1.39 to -0.36 days]; p = 0.001). There were no differences in operative time or PCS improvement. Losing 5 or 10 pounds was not associated with differences in any outcome. CONCLUSIONS: Losing at least 20 pounds before total knee arthroplasty was associated with shorter length of stay and lower odds of facility discharge for morbidly obese patients, even while most patients remained morbidly or severely obese. Although there were no differences in operative time or physical function improvement, this has considerable implications for patient burden and cost reduction. Patients and providers may want to focus on larger preoperative weight loss targets. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Artroplastia do Joelho/métodos , Índice de Massa Corporal , Obesidade Mórbida/complicações , Obesidade Mórbida/terapia , Aptidão Física , Perda de Peso , Idoso , Artroplastia do Joelho/efeitos adversos , Estudos de Coortes , Bases de Dados Factuais , Dieta Redutora/métodos , Exercício/fisiologia , Feminino , Humanos , Tempo de Internação , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Prognóstico , Estudos Retrospectivos , Medição de Risco , Centros de Atenção Terciária , Resultado do Tratamento
16.
Bone Joint J ; 101-B(7_Supple_C): 28-32, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31256642

RESUMO

AIMS: The aim of this study was to observe the implications of withholding total joint arthroplasty (TJA) in morbidly obese patients. PATIENTS AND METHODS: A total of 289 morbidly obese patients with end-stage osteoarthritis were prospectively followed. There were 218 women and 71 men, with a mean age of 56.3 years (26.7 to 79.1). At initial visit, patients were given information about the risks of TJA in the morbidly obese and were given referral information to a bariatric clinic. Patients were contacted at six, 12, 18, and 24 months from initial visit. RESULTS: The median body mass index (BMI) at initial visit was 46.9 kg/m2 (interquartile range (IQR) 44.6 to 51.3). A total of 82 patients (28.4%) refused to follow-up or answer phone surveys, and 149 of the remaining 207 (72.0%) did not have surgery. Initial median BMI of those 149 was 47.5 kg/m2 (IQR 44.6 to 52.5) and at last follow-up was 46.7 kg/m2 (IQR 43.4 to 51.2). Only 67 patients (23.2%) went to the bariatric clinic, of whom 14 (20.9%) had bariatric surgery. A total of 58 patients (20.1%) underwent TJA. For those 58, BMI at initial visit was 45.3 kg/m2 (IQR 43.7 to 47.2), and at surgery was 42.3 kg/m2 (IQR 38.1 to 46.5). Only 23 patients (39.7%) of those who had TJA successfully achieved BMI < 40 kg/m2 at surgery. CONCLUSION: Restricting TJA for morbidly obese patients does not incentivize weight loss prior to arthroplasty. Only 20.1% of patients ultimately underwent TJA and the majority of those remained morbidly obese. Better resources and coordinated care are required to optimize patients prior to surgery. Cite this article: Bone Joint J 2019;101-B(7 Supple C):28-32.


Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Obesidade Mórbida/complicações , Osteoartrite/cirurgia , Perda de Peso/fisiologia , Suspensão de Tratamento , Adulto , Idoso , Cirurgia Bariátrica , Índice de Massa Corporal , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Obesidade Mórbida/cirurgia , Osteoartrite/complicações , Estudos Prospectivos
17.
Laryngoscope ; 129(11): E407-E411, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31268557

RESUMO

Otologic manifestations are known to occur in patients with idiopathic intracranial hypertension (IIH), but the occurrence of sensorineural hearing loss, especially in pediatric populations, has been addressed in only a few reports. Here, we describe a pediatric patient who presented with IIH and severe bilateral hearing loss. The patient's hearing loss was diagnosed as a form of auditory neuropathy (AN) and resolved after prompt treatment of the increased intracranial pressure. This case points to a possible association between IIH and AN and suggests that IIH may potentially be a reversible cause of AN spectrum disorder. Laryngoscope, 129:E407-E411, 2019.


Assuntos
Perda Auditiva Central/etiologia , Obesidade Mórbida/complicações , Pseudotumor Cerebral/complicações , Adolescente , Humanos , Masculino
18.
Langenbecks Arch Surg ; 404(5): 615-620, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31300891

RESUMO

PURPOSE: The da Vinci Surgical System family remains the most widely used surgical robotic system for laparoscopy. Data about gastric bypass surgery with the Xi Surgical System are not available yet. We compared Roux-en-Y gastric bypass surgery performed at our institution with the da Vinci Xi and the da Vinci Si Surgical System. METHODS: All robotic gastric bypass procedures performed between January 2013 and September 2016 were analyzed retrospectively. Patient demographics and operative and postoperative outcomes up to 30 days were compared for the da Vinci Xi and Si Surgical System. Robotic costs per procedure were modeled including posts for a standard set of robotic instruments, capital investment, and yearly maintenance. RESULTS: One-hundred forty-four Xi Surgical System and 195 Si Surgical System procedures were identified. Mean age (p = 0.9), gender distribution (p = 0.8), BMI (p = 0.6), and ASA scores (p > 0.5) were similar in both cohorts. Operating room times were similar in both groups (219.4 ± 58.8 vs. 227.4 ± 60.5 min for Xi vs. Si, p = 0.22). Docking times were significantly longer with the Xi compared with the Si Surgical System (9 ± 4.8 vs. 5.8 ± 4 min, p < 0.0001). There was no difference in incidence of minor (13.9 vs. 10.3%, p = 0.3) and major complications (5.6 vs. 5.1%, p = 1 for Xi vs. Si). Costs were higher for the Xi Surgical System caused by higher capital investment and yearly maintenance. CONCLUSIONS: Roux-en-Y gastric bypass surgery can be safely performed with the Xi Surgical System, while drawbacks include longer docking times and higher costs.


Assuntos
Derivação Gástrica/instrumentação , Laparoscopia/instrumentação , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/instrumentação , Adulto , Feminino , Derivação Gástrica/efeitos adversos , Derivação Gástrica/economia , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/economia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Duração da Cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/economia , Resultado do Tratamento
19.
BMJ Case Rep ; 12(7)2019 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-31345831

RESUMO

Kartagener syndrome is a rare autosomal recessive condition. Approximately 25% of those with situs inversus totalis suffer the syndrome. With the rising overall number and indications for bariatric surgery, this condition will be increasingly recognised. We present a case of a 25-year-old woman with SIT and Kartagener syndrome who underwent a laparoscopic sleeve gastrectomy. As with all bariatric surgery, a multidisciplinary team approach was important in managing such a case. There were considerable cognitive challenges for the surgical team both preoperatively and during the procedure. The patient tolerated the operation well and was discharged 2 days after the surgery. At 12-months follow-up, the patient had achieved 125% excess weight loss. This case illustrates that an experienced surgeon can safely perform a laparoscopic sleeve gastrectomy on a patient with situs inversus totalis.


Assuntos
Gastrectomia , Síndrome de Kartagener/cirurgia , Laparoscopia , Obesidade Mórbida/cirurgia , Situs Inversus/cirurgia , Perda de Peso/fisiologia , Adulto , Feminino , Humanos , Síndrome de Kartagener/complicações , Síndrome de Kartagener/fisiopatologia , Obesidade Mórbida/complicações , Obesidade Mórbida/fisiopatologia , Situs Inversus/complicações , Situs Inversus/fisiopatologia , Resultado do Tratamento
20.
Tidsskr Nor Laegeforen ; 139(10)2019 06 25.
Artigo em Norueguês | MEDLINE | ID: mdl-31238674

RESUMO

BACKGROUND: Bariatric surgery has been performed at Oslo University Hospital since 2004. We wished to describe patient characteristics, use of surgical methods and perioperative complications in the period 2004-14. MATERIAL AND METHOD: We performed a retrospective analysis of prospective data collected for the period 2004-14. Complications include events during hospitalisation and up to 6-8 weeks postoperatively. RESULTS: Altogether 2 127 patients underwent surgery for morbid obesity, whereof 1 468 were women. Average age and body mass index were 42 years (range 17-73) and 46.2 kg/m2 (range 26-92). A total of 512 had a body mass index ≥ 50 kg/m2. Obesity-related sequelae were registered in 1 196 patients before surgery. Gastric bypass was performed in 1 966 patients, gastric sleeve resection in 122 (17 of these later underwent duodenal switch) and duodenal switch in 56 patients. All patients were operated laparoscopically, and four procedures were converted to laparotomy. Median hospitalisation time was two days (range 1-78). Complications were registered in 209 patients, 75 of whom had severe complications (grade ≥ IIIb on the Clavien-Dindo classification system). Patients with a body mass index ≥ 50 kg/m2 had a higher incidence of complications (12.5 % vs 8.9 %). Altogether 67 patients underwent further surgery. Six patients died, two of whom more than 30 days after the operation. The incidence of complications was reduced during the period. INTERPRETATION: Bariatric surgery may be performed laparoscopically with a low incidence of complications and short hospitalisation times. A large proportion of the patients who underwent surgery had obesity-related sequalae.


Assuntos
Cirurgia Bariátrica , Obesidade Mórbida/cirurgia , Adolescente , Adulto , Idoso , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Cirurgia Bariátrica/estatística & dados numéricos , Índice de Massa Corporal , Feminino , Gastrectomia/estatística & dados numéricos , Derivação Gástrica/estatística & dados numéricos , Hospitais Universitários/estatística & dados numéricos , Humanos , Laparoscopia/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Noruega , Obesidade Mórbida/complicações , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Adulto Jovem
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