Endoscopic sleeve gastroplasty in the management of weight regain after sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy is a well-standardized surgical treatment for obesity. However, rates of weight regain after sleeve gastrectomy in long-term follow-up are relatively high. This multicenter study is the first to evaluate the use of an endoscopic sleeve gastroplasty (ESG) technique for the management of this population. METHODS: This was a multicenter retrospective study, including patients with weight regain following sleeve gastrectomy who underwent ESG for weight loss. Primary outcomes included absolute weight loss, percent total weight loss (%TWL), change in body mass index (BMI), percent excess weight loss (%EWL) at 6 and 12 months, and safety profile. Clinical success was defined as achieving ≥ 25 % EWL at 1 year, ≤ 5 % serious adverse event (SAE) rate following society-recommended thresholds, and %TWL ≥ 10 %. RESULTS: 34 patients underwent ESG after sleeve gastrectomy. Technical success was 100 %. At 1 year, 82.4 % and 100 % of patients achieved ≥ 10 %TWL and ≥ 25 % EWL, respectively. Mean (SD) %TWL was 13.2 % (3.9) and 18.3 % (5.5), and %EWL was 51.9 % (19.1) and 69.9 % (29.9) at 6 months and 1 year, respectively. Mean (SD) %TWL was 14.2 % (12.5), 19.3 % (5.3), 17.5 % (5.2), and 20.4 % (3.3), and %EWL was 88.5 % (52.8), 84.4 % (22.4), 55.4 % (14.8), and 47.8 % (11.2) for BMI categories of overweight and obesity class I, II, and III, respectively, at 1 year. No predictors of success were identified in the multivariable regression analysis. No SAEs were reported. CONCLUSION: ESG appears to be safe and effective in the management of weight regain following sleeve gastrectomy.

Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study.

BACKGROUND AND AIMS: Obesity is a pandemic affecting approximately 700 million adults worldwide, with an additional 2 billion overweight. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric therapy that involves remodeling of the greater curvature in an effort to reduce gastric capacity and delay gastric emptying. A variety of ESG suture patterns has been reported. This study is the first to use a uniform "U" stitch pattern across all centers to simplify technical aspects of the procedure and limit cost. This also uniquely assessed outcomes in all body mass index (BMI) categories and changes in metabolic rate, lean body mass, and adipose tissue composition. METHODS: This is a multicenter analysis of prospectively collected data from 7 centers including patients with overweight and obesity who underwent ESG. Primary outcomes included absolute weight loss, percent total body weight loss (%TWL), change in BMI, and percent excess weight loss (%EWL) at 6 and 12 months in overweight and obese classes I, II, and III. Secondary outcomes included adipose tissue, lean body mass reduction, and metabolic rate analyzed by bioimpedance. Additionally, immediate or delayed adverse events (AEs) were analyzed. Clinical success was defined as achieving ≥25% EWL at 1 year with ≤5% serious AE (SAE) rate following the American Society for Gastrointestinal Endoscopy (ASGE)/American Society for Metabolic and Bariatric Surgery (ASMBS) threshold. RESULTS: A total of 193 patients underwent ESG during the study period. All groups had >10% TWL and >25% EWL at 6 months of follow-up. On average, %TWL was 14.25% ± 5.26% and 15.06% ± 5.22% and the %EWL 56.15% ± 22.93% and 59.41% ± 25.69% at 6 months and 1 year of follow-up, respectively. %TWL was 8.91% ± .3%, 13.92% ± 5.76%, 16.22% ± 7.69%, and 19.01% ± .95% and %EWL 56.21% ± 2.0%, 62.03% ± 27.63%, 54.13% ± 23.46%, and 46.78% ± 2.43% for overweight and obesity classes I, II, and III, respectively, at 1 year. Male sex, age <41 years, and higher BMI were predictors of achieving a TWL ≥10% at 1-year follow-up. There was a significant reduction in adipose tissue from baseline. SAEs occurred in 1.03%, including 2 perigastric collections needing surgery. CONCLUSIONS: ESG appears to be feasible, safe, and effective in the treatment of patients with overweight and obesity according to ASGE/ASMBS thresholds.

Bariatric postoperative fistula: a life-saving endoscopic procedure.

BACKGROUND: Gastric fistula after bariatric surgery has high morbi-mortality, and treatment is a challenge due to persistent abscess and/or distal stenosis. The present study evaluated the efficacy and safety of stricturotomy/internal drainage, a novel endoscopic procedure that can avoid re-operation and allow early oral feeding. METHODS: This prospective, non-randomized study, with no control or sham group, included 27 patients (74.07% were female), approved by the local IRB, who underwent the following bariatric surgeries: Roux-en-Y gastric bypass (RYGB; n = 14, 51.85%), laparoscopic sleeve gastrectomy (LSG; n = 9, 33.33%) and duodenal switch (DS; n = 4, 14.81%). The patients presented with gastric fistulas which were treated by internal drainage/stricturotomy. The mean patient age was 42.67 years, and the mean pre-operative BMI was 40.69 kg/m(2). Balloon dilation was performed if distal stenosis and/or axis deviation was present. The first endoscopic procedure was applied on the 15th day after RYGB and the 30th day after LSG and DS. RESULTS: All patients presented with His angle fistula. Eight patients (57.1%) had stenosis of the anastomosis after RYGB and were treated with balloon dilatation (20 mm). The patients submitted to LSG and DS had stenosis at the angularis incisure and were treated with achalasia balloon dilation (30 mm). The number of endoscopic sessions for stricturotomy ranged from 1 to 6. Two patients experienced bleeding after dilation, and one had perforation. The mean time to achieve fistula closure was 18.11 days (range, 1-72 days) without mortality. All the fistulas closed. CONCLUSIONS: This novel endoscopic procedure is safe, feasible, and effective, avoiding re-operation, allowing early oral feeding and discharge.

Comparison of respiratory muscle strength through manovacuometry in the early postoperative period of bariatric surgery by laparotomy and laparoscopy.

INTRODUCTION: surgical treatment of obesity causes important changes in respiratory mechanics. AIM: Comparatively analyze respiratory muscle strength in post bariatric patients underwent to gastric bypass by laparotomy and laparoscopy during hospital stay. METHODS: observational study with a non-randomized longitudinal design, of a quantitative character. Data were collected from 60 patients with BMI 40Kg/m2, divided in laparotomy group (n=30) and laparoscopy group (n=30). Smokers, patients with previous lung diseases and those unable to perform the exam correctly were excluded. Both groups were evaluated at immediate postoperative, first and second postoperative days with manovacuometry for respiratory muscle strength and visual analogue pain scale. RESULTS: the sample was homogeneous in age, sex and BMI. Reduction in maximal respiratory pressures was observed after surgery for those operated on by laparotomy, no return to baseline values on discharge day on the second postoperative day. This group had also more severe pain and longer operative time. There was no difference in respiratory pressure measurements after surgery in the laparoscopy group. CONCLUSION: conventional bariatric surgery reduces muscle strength in the postoperative period and leads to more intense pain during hospitalization when compared to the laparoscopy group.

DEVELOPMENT AND VALIDATION OF A PSYCHOLOGICAL SCALE FOR BARIATRIC SURGERY: THE BARITEST.

BACKGROUND: It is recommended that bariatric surgery candidates undergo psychological assessment. However, no specific instrument exists to assess the psychological well-being of bariatric patients, before and after surgery, and for which all constructs are valid for both genders. AIMS: This study aimed to develop and validate a new psychometric instrument to be used before and after bariatric surgery in order to assess psychological outcomes of patients. METHODS: This is a cross-sectional study that composed of 660 individuals from the community and bariatric patients. BariTest was developed on a Likert scale consisting of 59 items, distributed in 6 constructs, which assess the psychological well-being that influences bariatric surgery: emotional state, eating behavior, quality of life, relationship with body weight, alcohol consumption, and social support. Validation of BariTest was developed by the confirmatory factor analysis to check the content, criteria, and construct. The R statistical software version 3.5.0 was used in all analyses, and a significance level of 5% was used. RESULTS: Adjusted indices of the confirmatory factor analysis model indicate adequate adjustment. Cronbach's alpha of BariTest was 0.93, which indicates good internal consistency. The scores of the emotional state, eating behavior, and quality of life constructs were similar between the results obtained in the community and in the postoperative group, being higher than in the preoperative group. Alcohol consumption was similar in the preoperative and postoperative groups and was lower than the community group. CONCLUSIONS: BariTest is a reliable scale measuring the psychological well-being of patients either before or after bariatric surgery.

Multidisciplinary Approach for Weight Regain-how to Manage this Challenging Condition: an Expert Review.

Weight regain is a multifactorial condition that affects many patients following bariatric surgery. The purpose of the paper is to review the multidisciplinary approach for the management of weight regain. We performed a search in current clinical evidence regarding the causes, consequences, and treatments of weight regain. The multidisciplinary approach with periodic monitoring is of fundamental importance to prevent or treat weight regain. Several therapeutic options are ranging from nutritional to surgical options, which should be tailored according to patients' anatomy, lifestyle behavior, and compliance. Specialized multidisciplinary care is the key to achieve optimal long-term weight loss and maintenance goals following bariatric surgery.

[Effects of remifentanil on awakening of propofol sedated patients submitted to upper gastrointestinal endoscopy: a randomized clinical trial]. / Efeitos do remifentanil sobre despertar de pacientes sedados com propofol para endoscopia digestiva alta: estudo clínico randomizado.

BACKGROUND AND OBJECTIVES: Sedation for endoscopic procedures aims to provide high quality sedation, lower risks, short recovery time, superior recovery quality and absence of side effects, seeking high patient level of satisfaction. The goal of the study was to assess administration of remifentanil combined with propofol regarding the effects of the drug association during sedation and recovery for patients submitted to upper GI diagnostic endoscopy. METHOD: One hundred and five patients were assessed, randomly divided into three groups of 35 patients. The Control Group was sedated with propofol alone. Study Group 1 was sedated with a fixed dose of 0.2 µg.kg-1 remifentanil combined with propofol. Study Group 2 was sedated with 0.3 µg.kg-1 remifentanil combined with propofol. We assessed the quality of sedation, hemodynamic parameters, incidence of significant hypoxemia, time for spontaneous eye opening, post-anesthetic recovery time, quality of post-anesthetic recovery, presence of side effects and patient satisfaction. RESULTS: Study Group 1 showed better quality of sedation. The groups in which remifentanil was administered combined with propofol showed shorter eye-opening time and shorter post-anesthetic recovery time compared to the control group. The three groups presented hemodynamic changes at some of the moments assessed. The incidence of significant hypoxemia, the quality of post-anesthetic recovery, the incidence of side effects and patient satisfaction were similar in the three groups. CONCLUSIONS: The combination of propofol with remifentanil at a dose of 0.2 µg.kg-1 was effective in improving the quality of sedation, and at doses of 0.2 µg.kg-1 and 0.3 µg.kg-1 reduced the time to spontaneous eye opening and post-anesthetic recovery in comparison to sedation with propofol administered alone.

Laparoscopic Roux-en-Y Gastric Bypass After Gastroesophageal Reflux Disease Surgical Procedure: Analysis of 85 Consecutive Patients with Pre- and Post-Operative Endoscopy Control.

Background: Most of the obese patients undergoing an anti-reflux operation experience recurrence of gastroesophageal reflux disease (GERD). Laparoscopic Roux-en-Y gastric bypass (LRNYGB) has been accepted as the bariatric surgery of choice for a previous GERD-operated obese patients. Methods: We present 85 consecutive patients from a single institution, previously submitted to antireflux surgery and then to LRNYGB. Preoperative endoscopy was carried out in all patients; 49 (57.64%) patients had findings of fundoplication failure or signs of persistent GERD, of those 20 (40.81%) with esophagitis. Results: From the bypass, per or postoperative minor to moderate complications occurred in 12 patients (14.11%): 2 (2.35%) conversions to laparotomy, 1 (1.17%) melena, 8 (9.41%) stenosis of gastrojejunostomy, treated by a simple endoscopic dilatation with a balloon, and 1 (1.17%) gastrogastric fistula. A follow-up endoscopy of 79 of 85 (92.9%) patients was carried out after 6 months of LRNYGB. Eight of 79 (10.12%) patients had persistent esophagitis that represented 40% (8 of 20 patients) of persistent reflux esophagitis even after LRNYGB. All of them were men. Conclusion: LRNYGB after laparoscopic fundoplication is a feasible procedure with an excepted higher rate of complications because of the complexity of the procedure. Nevertheless esophagitis still persisted in many of those patients.

Influence of leukotriene inhibitor montelukast on wound contraction and cutaneous healing process in rats.

BACKGROUND: Wound contractures can cause severe deformities and disabilities. Recent studies have suggested that leukotriene receptor antagonists have an inhibitory effect on the healing contraction process. This study aimed to evaluate the influence of the leukotriene inhibitor montelukast on the cutaneous healing process and the wound contraction phenomenon in rats. METHODS: For this study, 60 male rats were randomly divided into four groups (MK-7d, SF-7d, MK-14d, and SF-14d) according to the drug given through a rigid orogastric tube (MK group: montelukast 10 mg/kg/day; SF group: normal saline solution) and the day the animals were killed (7d: postoperative day 7; 14d: postoperative day 14). An excisional wound (2 x 2 cm) was created on the dorsum of each rat. The wounds were left open to heal spontaneously and documented by standard digital photographs on different postoperative days. Wound contraction rates were calculated with specific software, and specimens were histologically evaluated using picrosirius red stain. Results were analyzed using the Aspin-Welch, Mann-Whitney, and t tests, assuming a significance level of 5%. RESULTS: The wound contraction rates were similar between the control and study groups (p > 0.05). On postoperative day 7, the wounds showed a marginally significant reduction in collagen maturation in the study group (40.1% +/- 6.88% vs 61.2% +/- 8.02%; p = 0.0607). On postoperative day 14, this reduction was statistically significant in the MK group (26% +/- 5.66% vs 68.3% +/- 7.76%; p = 0.0001). CONCLUSIONS: Montelukast does not alter the contraction rate of excisional wounds in rats but has a significant and progressive inhibitory effect on collagen maturation.

Systematization of Nutritional Care In Endoscopic Treatment for Obesity.

PURPOSE: Propose the systematization of nutritional care in the endoscopic treatment of obesity. METHOD: This is a bibliographical review, since the initial proposal was a systematic review. This method became unfeasible due to the inexistence of studies that address this theme. Thus, a bibliographic survey was carried out, considering the endoscopic treatment as a restrictive treatment, as well as the information referring to case reports and multicentric studies. RESULTS: Nutrition participation involves nutritional assessment and diagnosis, dietary planning pertinent to the adequate evolution of food consistency, as well as the use of food supplements compatible with the Gastric Sleeve due to food restriction. The Bariatric Plate Model (BPM) can be useful in the nutritional education of the patient after gastric endosuture, associated with water consumption and the performance of scheduled physical exercise, as well as periodic monitoring with the multiprofessional team. CONCLUSIONS: Specialized nutritional care is necessary, through a protocol of nutritional assistance defined after gastric endosuture, in order to achieve long-term weight loss and maintenance goals. The BPM can be an excellent form of nutritional education, observing protein intake as a macronutrient base.

Laparoscopic sleeve gastrectomy with NOTES visualization--a step toward NOTES procedures.

BACKGROUND: To demonstrate that bariatric procedures can be done with natural orifice visualization (NOTES) at 2 institutions (Nucleo Universitario de Estudos de Notes Centro de Cirurgia Experimental Vila do Conde-Junqueira, Vila do Conde, Portugal and Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, RS, Brasil). NOTES is a new surgical approach that is being developed. It consists of the use of a minimally invasive technique in which the surgical procedure is performed through natural orifices, thereby circumventing incisions through the skin. METHODS: We performed vertical gastrectomy or laparoscopic sleeve gastrectomy in a porcine model using vaginal route visualization. RESULTS: A laparoscopic vertical sleeve gastrectomy with NOTES visualization in a porcine model was performed with safety. CONCLUSION: Bariatric procedures can be done with NOTES with results as good as those using laparoscopic techniques.

BARIATRIC DIET GUIDE: PLATE MODEL TEMPLATE FOR BARIATRIC SURGERY PATIENTS.

BACKGROUND: The Bariatric Plate Model (BPM) may be an adequate form of nutritional guideline after obesity surgery. AIM: Create a food guide, based on the Plate Model for nutritional education of bariatric patients. METHOD: The Plate Model2 was revised from a model initially suggested for dyslipidemic and hypertensive patients to a new objective: adaptation to bariatric patient who needs effective long-term nutritional education. RESULTS: The adaptation of the Plate Model considered protein needs with high biological value, as it is the priority in the BPM, followed by vitamins and minerals and lastly the carbohydrates, especially the whole ones. CONCLUSION: The BPM is a tool that can be effectively used in nutritional education of bariatric patients.

BariMEP: uma ferramenta para treinar os pacientes de cirurgia bariátrica / Barimep: a tool for training bariatric surgery patients

ABSTRACT BACKGROUND Bariatric surgery patients have symptoms such as "plugging." Therefore, a possible good way to avoid these eating discomforts, typical of the early period after bariatric surgery, is to educate the patient. The Mindful Eating (ME) consists of paying attention to physical signs of hunger and satiety and developing awareness of emotional triggers related to food. In addition, conscious food choices reflect positively on the speed of chewing at mealtime. AIMS Due to the difficulties that patients reported during consultations to controlling their bad eating habits and the lack of tools to help the bariatric patient change eating habits, we elaborated "BariMEP: A Mindful Eating Placemat for bariatric surgery patients." METHODS The BariMEP was written by the multidisciplinary bariatric team based on a study by Russell et al. and ME principles in order to help bariatric patients pay attention to what and how they eat at each meal. RESULTS The BariMEP has some instructions based on Mindful Eating principles: get your seat at the table; do not distract yourself; before starting to eat, try breathing sometimes; recognize the internal hunger and satiety cues; let the fork rest at each bite and chew a lot; pay attention to the smell and taste; and be as present as possible at this time with nonjudgment. CONCLUSIONS For the first time, a tool has been developed with the aim of preparing the patient for bariatric surgery. Since the BariMEP is easy to teach and cheap, we suggest that the BariMEP be included in the bariatric surgery protocol.

RESUMO RACIONAL Pacientes operados de cirurgia bariátrica apresentam sintomas como "entalo". Portanto, uma possível maneira de evitar esses desconfortos alimentares, típicos do período inicial após a cirurgia bariátrica, é educar o paciente. O Mindful Eating (ME) consiste em avaliar aos sinais físicos de fome e saciedade e desenvolver a consciência dos gatilhos emocionais relacionados à alimentação. Além disso, as escolhas alimentares conscientes refletem positivamente na velocidade da mastigação durante as refeições. OBJETIVOS Devido às dificuldades, que os pacientes relataram durante as consultas, para controlar os maus hábitos alimentares e a falta de ferramentas para ajudar o paciente bariátrico na mudança, elaboramos o "BariMEP: um jogo americano de comer com atenção plena para pacientes de cirurgia bariátrica". MÉTODOS O BariMEP foi escrito pela equipe multidisciplinar bariátrica com base no estudo de Russell et al. e nos princípios do Mindful Eating, para ajudar os pacientes submetidos a cirurgia bariátrica a prestar atenção ao que e como comem em cada refeição. RESULTADOS O BariMEP possui algumas instruções baseadas nos princípios do Mindful Eating: Sente-se à mesa; não se distraia; antes de começar a comer, respire algumas vezes; reconheça os sinais de fome e saciedade; deixe o garfo descansar a cada mordida e mastigue bastante; preste atenção ao aroma e sabor; esteja o mais presente possível neste momento e sem julgamentos. CONCLUSÃO Pela primeira vez, foi desenvolvida uma ferramenta com o objetivo de preparar o paciente para a cirurgia bariátrica. Como o BariMEP é fácil de ensinar e barato, sugerimos que o BariMEP seja incluído no protocolo de cirurgia bariátrica.

Efficacy of Utilizing Argon Plasma Coagulation for Weight Regain in Roux-en-Y Gastric Bypass Patients: a Multi-center Study.

BACKGROUND: Endoscopic approaches exist for targeting weight regain after Roux-en-Y gastric bypass (RYGB), including endoscopic suturing, clipping, and sclerotherapy. Argon plasma coagulation (APC) is a noncontact electrocoagulation method, and when used in RYGB patients, it has shown reduction in the diameter of the gastrojejunal anastomosis. OBJECTIVES: To study the effectiveness of APC for weight regain in terms of weight loss for RYGB patients, from eight bariatric centers. METHODS: A retrospective chart review was performed for 558 patients at eight bariatric centers in the USA (1) and Brazil (7) who underwent APC procedure between 31st July 2009 and 29th March 2017. APC was performed on patients who regained weight after RYGB procedure. RESULTS: Upon exploratory analysis of the individual BMI data, the mean BMI decreased slightly during the first 24 months and increased slightly afterwards following the APC intervention. The mean weight was 94.5 ± 18.6 kg and the mean BMI was 34.0 kg/m2 at APC. Where data were available, the mean of lowest weight was 67.0 ± 23.0 kg and the mean of lowest BMI was 24.1 kg/m2 following gastric bypass. The mean weight loss was 6.5, 7.7, and 8.3 kg at 6, 12, and 24 months, respectively, and the changes in weight over time was statistically significant (p < 0.0001). Multi-level for change model showed the low body mass index (BMI) group (BMI < 30 kg/m2) to have greater TWL than the high BMI (BMI ≥ 30 kg/m2) group at 6, 12, and 24 months. In the low BMI group, the mean TWL was 4.7, 6.1, 6.9, and 2.4%, at 6, 12, and 24 months, respectively. In the high BMI group, the mean TWL was 7.5, 10.4, 13.4, and 3.7%, at 6, 12, 24, and 36 months, respectively. Of the 333 patients in four centers who provided complication information, complications after APC included stenosis (n = 9), GJ ulcer (n = 3), vomiting (n = 3), GJ leakage (n = 2), and melena (n = 1). CONCLUSION: APC can be useful in reducing the regained weight after RYGB, and patients showed 6-10% total weight loss at 12 months. Randomized trials would be needed to validate the findings.

[Selection and use of anti-infective agents for intra-abdominal infections]. / Seleção e uso de antibióticos em infecções intra-abdominais.

BACKGROUND: Intra-abdominal infections are common and are associated with elevated morbidity and mortality. The microorganisms that cause intra-abdominal infections are usually from the gastrointestinal flora, mainly E. coli and Bacteroides fragilis. AIM: To present a review of the selection and use of antibiotics in intra-abdominal infections. CONCLUSIONS: Appropriate use of antibiotics is essential to control infection and to reduce treatment failure. Antibiotics are initiated whenever intra-abdominal infection is suspected and the antimicrobial agents are selected based on the most common microorganisms involved. In addition, efficacy, cost, safety, and posologic regimen are considered for an appropriated selection. Antibiotic regimen is different whether the infection is acquired in the community or at hospital due to the more resistant flora in the latter.

NUTRITIONAL ASPECTS AND THE USE OF NUTRITIONAL SUPPLEMENTS BY WOMEN WHO UNDERWENT GASTRIC BYPASS.

Background: Bariatric surgery is deemed one of the most effective procedures for the treatment of obesity and it aims at the reduction and maintenance of weight loss in long term, as the control of the related comorbidities. Aim: Quantify the occurrence of alterations of the gastrointestinal tract, suggestive signs of nutritional deficiencies and the use of supplements in a group of women undergoing bariatric surgery. Methods: The sample consisted of women aged 20-65 years submitted to Roux-en-Y gastric bypass with monitoring equal to or higher than 24 months. For the qualitative analysis, the Feeding Frequency Questionnaire was used. Results: In the postoperative period, alopecia was the most reported (79.3%), followed by changes in the texture of the nails, both considered predictive of nutritional deficiencies. Changes in the gastrointestinal tract were described in 86.2%, and episodes of dumping were reported in 65.5%. Qualitative analysis has shown reduced daily consumption of sources of animal and plant proteins. Conclusion: After bariatric surgery can occur flatulence, vomiting and dumping syndrome as the most frequent representative symptoms of digestive functional disorders. Alopecia and nail changes are the most important signs of nutritional deficiency. The use of dietary supplements in the postoperative period is scarce and sporadic.

Racional: A cirurgia bariátrica é considerada um dos procedimentos mais eficazes para tratamento da obesidade e objetiva a redução e manutenção da perda de peso em longo prazo, assim como, o controle das comorbidades associadas. Objetivo: Quantificar a ocorrência de alterações funcionais do trato gastrointestinal, sinais sugestivos de carências nutricionais e o uso de suplementos em um grupo de mulheres submetidas à cirurgia bariátrica. Métodos: A amostra foi constituída por mulheres com idades entre 20-65 anos submetidas ao bypass gástrico em Y-de-Roux com seguimento igual ou superior a 24 meses. Para análise qualitativa foi utilizado o Questionário de Frequência Alimentar. Resultados: No período pós-operatório a alopecia foi a mais relatada (79,3%), seguida de alteração na textura das unhas, ambas consideradas preditivos de carências nutricionais. As alterações do trato gastrointestinal foram descritas por 86,2%, e os episódios de dumping foram relatados em 65,5%. Na análise qualitativa foi observado consumo diário reduzido de fontes de proteínas animal e vegetal. Conclusão: Após a cirurgia bariátrica pode ocorrer flatulência, vômitos e síndrome de dumping como sintomas representativos mais frequentes das alterações funcionais digestivas. Alopecia e alterações ungueais são os sinais mais relevantes de carência nutricional. O uso de suplementos alimentares no pós-operatório é escasso e esporádico.

Development and validation of a psychological scale for bariatric surgery: the baritest / Desenvolvimento e validação de escala psicométrica para os pacientes de cirurgia bariátrica: o baritest

ABSTRACT BACKGROUND: It is recommended that bariatric surgery candidates undergo psychological assessment. However, no specific instrument exists to assess the psychological well-being of bariatric patients, before and after surgery, and for which all constructs are valid for both genders. AIMS: This study aimed to develop and validate a new psychometric instrument to be used before and after bariatric surgery in order to assess psychological outcomes of patients. METHODS: This is a cross-sectional study that composed of 660 individuals from the community and bariatric patients. BariTest was developed on a Likert scale consisting of 59 items, distributed in 6 constructs, which assess the psychological well-being that influences bariatric surgery: emotional state, eating behavior, quality of life, relationship with body weight, alcohol consumption, and social support. Validation of BariTest was developed by the confirmatory factor analysis to check the content, criteria, and construct. The R statistical software version 3.5.0 was used in all analyses, and a significance level of 5% was used. RESULTS: Adjusted indices of the confirmatory factor analysis model indicate adequate adjustment. Cronbach's alpha of BariTest was 0.93, which indicates good internal consistency. The scores of the emotional state, eating behavior, and quality of life constructs were similar between the results obtained in the community and in the postoperative group, being higher than in the preoperative group. Alcohol consumption was similar in the preoperative and postoperative groups and was lower than the community group. CONCLUSIONS: BariTest is a reliable scale measuring the psychological well-being of patients either before or after bariatric surgery.

RESUMO RACIONAL: Recomenda-se que os candidatos à cirurgia bariátrica sejam submetidos a uma avaliação psicológica. Contudo, não existe nenhum instrumento específico para avaliar os pacientes bariátricos, e que todos os construtos sejam válidos para ambos os sexos. OBJETIVOS: Desenvolver e validar um novo instrumento psicométrico para avaliar o bem-estar psicológico dos pacientes antes e após a cirurgia bariátrica. MÉTODOS: O estudo foi transversal e composto por 660 indivíduos da comunidade e pacientes bariátricos. O BariTest foi desenvolvido numa escala Likert composta por 59 itens, distribuídos em seis construtos, que avaliam o bem-estar psicológico que influenciam a cirurgia bariátrica: estado emocional, comportamento alimentar, qualidade de vida, relação com o peso corporal, consumo de álcool, e suporte social. A validação do BariTest foi feita pela validação de conteúdo, critério e construto e utilizou-se análise fatorial confirmatória. O software estatístico R versão 3.5.0, foi utilizado em todas as análises, com um nível de significância de 5%. RESULTADOS: Os índices ajustados do modelo análise fatorial confirmatória indicam um ajustamento adequado. O alfa de Cronbach do BariTest foi 0,93, o que indica uma boa consistência interna. As pontuações de estado emocional, comportamento alimentar e qualidade de vida foram semelhantes na comunidade e no grupo pós-operatório, sendo mais elevados do que no grupo pré-operatório. O consumo de álcool foi semelhante nos grupos pré e pós-operatórios e foi inferior ao do grupo comunitário. CONCLUSÕES: O BariTest é uma escala confiável que mede o bem-estar psicológico dos pacientes antes e após a cirurgia bariátrica.

Comparison of respiratory muscle strength through manovacuometry in the early postoperative period of bariatric surgery by laparotomy and laparoscopy / Comparação da força muscular respiratória através da manovacuometria no pós-operatório precoce de cirurgia bariátrica por laparotomia e por videolaparoscopia

ABSTRACT Introduction: surgical treatment of obesity causes important changes in respiratory mechanics. Aim: Comparatively analyze respiratory muscle strength in post bariatric patients underwent to gastric bypass by laparotomy and laparoscopy during hospital stay. Methods: observational study with a non-randomized longitudinal design, of a quantitative character. Data were collected from 60 patients with BMI 40Kg/m2, divided in laparotomy group (n=30) and laparoscopy group (n=30). Smokers, patients with previous lung diseases and those unable to perform the exam correctly were excluded. Both groups were evaluated at immediate postoperative, first and second postoperative days with manovacuometry for respiratory muscle strength and visual analogue pain scale. Results: the sample was homogeneous in age, sex and BMI. Reduction in maximal respiratory pressures was observed after surgery for those operated on by laparotomy, no return to baseline values on discharge day on the second postoperative day. This group had also more severe pain and longer operative time. There was no difference in respiratory pressure measurements after surgery in the laparoscopy group. Conclusion: conventional bariatric surgery reduces muscle strength in the postoperative period and leads to more intense pain during hospitalization when compared to the laparoscopy group.

RESUMO Introdução: o tratamento cirúrgico da obesidade acarreta importantes alterações na mecânica respiratória. Objetivo: analisar comparativamente a força muscular respiratória em pacientes submetidos à cirurgia bariátrica do tipo bypass gástrico por laparotomia e por videolaparoscopia durante o internamento cirúrgico. Métodos: estudo observacional com delineamento longitudinal não-randomizado, de caráter quantitativo. Foram coletados dados de 60 pacientes com índice de massa corporal igual ou superior a 40Kg/m2, candidatos a cirurgia bariátrica e divididos em grupo 1, para os operados por laparotomia (n=30), e grupo 2, para os operados por videolaparoscopia (n=30). Foram excluídos os tabagistas, os pacientes incapazes de executar o exame de forma correta e os portadores de doenças pulmonares prévias. Ambos os grupos foram avaliados no pré-operatório imediato, no primeiro e no segundo dias de pós-operatório através do teste de manovacuometria para a força muscular respiratória e da escala visual analógica de dor. Resultados: a amostra foi homogênea em relação à idade, índice de massa corporal e sexo. Foi observado redução das pressões respiratórias máximas após a cirurgia para os operados por laparotomia, sem retorno aos valores basais no dia da alta hospitalar no segundo dia pósoperatório. Esse grupo também cursou com dor mais intensa e maior tempo cirúrgico. Não houve diferença das medidas de pressão respiratória após a cirurgia no grupo operado por laparoscopia. Conclusões: a cirurgia bariátrica pela via convencional reduz a força muscular respiratória no pós-operatório e cursa com dor mais intensa durante a internação cirúrgica em relação à via laparoscópica.

[Results of liver transplantation in patients with preoperative diagnosis of hepatocellular carcinoma]. / Resultados do transplante hepático em pacientes com diagnóstico pré-operatório de hepatocarcinoma.

BACKGROUND: [corrected] Hepatocellular carcinoma is the most frequent malignant hepatic tumor in humans, and its association with cirrhosis makes the therapeutic approach still a challenge. Liver transplantation is the treatment of choice for cirrhotic patients with unresectable early hepatocellular carcinoma AIM: To evaluate the post-transplant outcome of a cohort of 15 cirrhotic patients with preoperative diagnosis of unresectable early hepatocellular carcinoma according the Milan criteria who underwent liver transplantation between September 1991 and December 2003 METHODS: We retrospectively reviewed the clinical data from 15 liver transplant recipients and the explanted livers were assessed for the efficacy of preoperative therapy. Patient survival and tumor recurrence were evaluated as primary outcome measures RESULTS: The mean age of the patients was 49.2 +/- 14.3 years and hepatitis C was the etiology of the underlying liver disease in 60%. Preoperative therapy, either chemoembolization or percutaneous ethanol injection, was performed in 12 (86%) patients. Complete necrosis of all tumoral lesions were observed in 5 of 12 patients (44,66%); all others had variable amounts of viable tumor in the explanted liver. Only 4 of the 15 (26.6%) explanted livers had microscopic vascular invasion. The median post-transplant follow-up was 33 months (range: 8-71 months) and no tumor recurrence was detected during this period. The only death was an early event not related to the tumor. The recurrence-free survival rates at 1 and 3 years were 93% CONCLUSION: Liver transplantation has emerged as a good alternative for cirrhotic patients with early hepatocellular carcinoma not amenable to curative resection, offering excellent recurrence-free survival rates.

PRE- AND POSTOPERATIVE IN BARIATRIC SURGERY: SOME BIOCHEMICAL CHANGES.

Background: The bariatric surgery may cause some nutritional deficiencies. Aim: To compare the serum levels of biochemical markers, in iimmediate post-surgical patients who were submitted to bariatric surgery. Methods: Non-concurrent prospective cross-sectional study. The analysis investigated data in medical charts of pre-surgical and immediate post-surgical patients who were submitted to bariatric surgery, focusing total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, C reactive protein, vitamin B12 levels, folic acid, homocysteine values, iron and serum calcium at the referred period. Results: Twenty-nine patients of both genders were evaluated. It was observed weight loss from 108.53 kg to 78.69 kg after the procedure. The variable LDL-c had a significant difference, decreasing approximately 30.3 mg/dl after the surgery. The vitamin B12 serum average levels went from 341.9 pg/ml to 667.2 pg/ml. The triglycerides values were in a range of 129.6 mg/dl-173.3 mg/dl, and 81.9 mg/dl-105.3 mg/dl at the pre- and postoperative respectively. CRP levels fall demonstrated reduction of inflammatory activity. The variable homocysteine was tested in a paired manner and it did not show a significant changing before or after, although it showed a strong correlation with LDL cholesterol. Conclusion: Eligible patients to bariatric surgery frequently present pre-nutritional deficiencies, having increased post-surgical risks when they don´t follow an appropriate nutritional follow-up.

Racional: A cirurgia bariátrica pode causar deficiências nutricionais. Objetivo: Comparar os níveis séricos bioquímicos de pacientes submetidos à cirurgia bariátrica no pré e pós-operatório precoce. Métodos: Estudo transversal, retrospectivo não concorrente. A análise considerou a investigação de prontuários de pacientes submetidos à gastroplastia no período pré-operatório e pós-operatório precoce, analisando resultado bioquímicos de colesterol total, HDL colesterol, LDL colesterol, triglicérides, proteína C reativa, dosagens de vitamina B12, ácido fólico, valores de homocisteína, ferro e cálcio séricos, no referido período. Resultados: Compuseram a amostra 29 pacientes de ambos os sexos. Houve redução de peso após o procedimento cirúrgico com média de 108,53 kg para 78,69 kg. A variável LDL-c apresentou diferença significativa com diminuição de aproximadamente 30,3 mg/dl após a gastroplastia. Com relação à média de níveis séricos de vitamina B12 ela passou de 341,9 pg/ml para 667,2 pg/ml. Os valores de triglicérides encontravam-se na faixa de 129,6 mg/dl-173,3 mg/dl, e 81,9 mg/dl-105,3 mg/dl no pré e pós-cirúrgico, respectivamente. Foi evidenciada redução da atividade inflamatória verificada mediante queda dos níveis de PCR. A variável homocisteína foi avaliada de maneira pareada e não apresentou mudança significativa no antes e depois, havendo, contudo, forte correlação com o LDL-colesterol. Conclusão: Pacientes candidatos à cirurgia bariátrica frequentemente apresentam deficiências nutricionais anteriores ao procedimento com riscos aumentados no período pós-cirúrgico quando não aderem ao acompanhamento nutricional adequado.