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1.
Ann Surg ; 2024 Aug 05.
Artigo em Inglês | MEDLINE | ID: mdl-39101212

RESUMO

OBJECTIVE/BACKGROUND: Various anastomotic and reconstruction techniques are used for minimally invasive total (miTG) and distal gastrectomy (miDG). Their effects on postoperative morbidity have not been extensively studied. METHODS: MiTG and miDG patients were selected from 9356 oncological gastrectomies performed 2017-2021 in 44 centers. Endpoints included anastomotic leakage (AL) rate and postoperative morbidity tested by multivariable analysis. RESULTS: Three major anastomotic techniques (circular stapled (CS); linear stapled (LS); hand sewn (HS)), and three major bowel reconstruction types (Roux (RX); Billroth I (BI); Billroth II (BII)) were identified in miTG (n=878) and miDG (n=3334). Postoperative complications including AL (5.2% vs. 1.1%), overall (28.7% vs. 16.3%) and major morbidity (15.7% vs. 8.2%), as well as 90-day mortality (1.6% vs. 0.5%) were higher after miTG compared with miDG. After miTG, AL rate was higher after CS (4.3%) and HS (7.9%) compared with LS (3.4%). Similarly, major complications (LS: 9.7%, CS: 16.2%, HS: 12.7%) were lowest after LS. Multivariate analysis confirmed anastomotic technique as predictive factor for AL, overall and major complications. In miDG, AL rate (BI: 1.4%, BII 0.8%, RX 1.2%), overall (BI: 14.5%, BII: 15.0%, RX: 18.7%,) and major morbidity (BI: 7.9%, BII: 9.1%, RX: 7.2%), and mortality (BI: 0%, BII: 0.1%, RY: 1.1%%) were not affected by bowel reconstruction. CONCLUSION: In oncologically suitable situations, miDG should be preferred to miTG, as postoperative morbidity is significantly lower. LS should be a preferred anastomotic technique for miTG in Western Centers. Conversely, bowel reconstruction in DG may be chosen according to surgeon's preference.

2.
Br J Surg ; 111(1)2024 Jan 03.
Artigo em Inglês | MEDLINE | ID: mdl-37981863

RESUMO

BACKGROUND: Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks. METHODS: Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years. RESULTS: A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass. CONCLUSION: The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.


Assuntos
Cirurgia Bariátrica , Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Procedimentos Cirúrgicos Robóticos , Humanos , Feminino , Idoso , Adulto , Masculino , Derivação Gástrica/efeitos adversos , Obesidade Mórbida/cirurgia , Benchmarking , Estudos Retrospectivos , Cirurgia Bariátrica/efeitos adversos , Laparoscopia/efeitos adversos , Gastrectomia/efeitos adversos , Resultado do Tratamento
3.
Langenbecks Arch Surg ; 409(1): 120, 2024 Apr 11.
Artigo em Inglês | MEDLINE | ID: mdl-38602565

RESUMO

PURPOSE: The linear-stapled (LSA) and the circular-stapled anastomosis (CSA) are the two most commonly performed techniques for the gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (RYGB). This study compared the outcome after both techniques with special focus on postoperative morbidity using the comprehensive complication index (CCI). METHODS: Five hundred eighty-eight patients operated between 01/2010 and 12/2019 were included in the final analysis and divided in two cohorts according to the surgical technique of the GJ (LSA (n = 290) or CSA (n = 298)). Before 09/2016, the CSA was exclusively performed for the GJ, while after 09/2016, the LSA was solely used. RESULTS: The mean CCI for patients with Clavien-Dindo complication grade ≥ 2 within the first 90 days after RYGB was 31 ± 9.1 in the CSA and 25.7 ± 6.8 in the LSA group (p < 0.001), both values still below the previously published benchmark cutoff (≤ 33.73). The C-reactive Protein (CRP)-levels on postoperative days (POD) 1 and 3 as well as the use of opioids on POD 1 were significantly higher in the CSA- than in the LSA-group (all p < 0.001). There were significantly more internal herniations in the CSA group during the first 24 postoperative months (p < 0.001). CONCLUSION: Patients after RYGB with CSA were found to have higher CCI values during the first 90 PODs compared to patients in which the LSA was applied. To achieve optimal outcomes in terms of patient morbidity, the LSA seems to be the superior technique for GJ in RYGB.


Assuntos
Derivação Gástrica , Laparoscopia , Humanos , Derivação Gástrica/efeitos adversos , Laparoscopia/efeitos adversos , Morbidade , Período Pós-Operatório
4.
BMC Anesthesiol ; 24(1): 323, 2024 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-39261779

RESUMO

BACKGROUND: The perioperative management of patients with chronic cough or cough hypersensitivity syndrome and its sometimes severe effects is currently under-researched and under-reported. CASE PRESENTATION: A 46-year-old female patient with a history of chronic cough and Cough Hypersensitivity Syndrome. After laparoscopic hiatoplasty and anterior fundoplication under general anesthesia, experienced a pronounced exacerbation of coughing symptoms. Despite prompt and extensive treatment involving antitussives, inhalants, anxiolytics, and sedatives, the symptoms remained uncontrollable. Within a few hours, the patient developed a respiratory alkalosis with severe and life-threatening electrolyte shift (pH 7.705, pCO2 1.72 kPa, K+ 2.1 mmol/l). Lactatemia lasted for more than 12 hours with values up to 6.6 mmol/l. Acute bleeding, pneumothorax, and an acute cardiac event were ruled out. Deep analgosedation and inhalation of high-percentage local anesthetics were necessary to manage the clinical symptoms. CONCLUSIONS: This case highlights the challenging nature of chronic cough and hypersensitivity syndrome perioperatively. A tailored anesthesiologic approach, exclusion of other provoking medical problems, and knowledge of possible management and treatment options are key.


Assuntos
Alcalose Respiratória , Tosse , Complicações Pós-Operatórias , Humanos , Feminino , Pessoa de Meia-Idade , Desequilíbrio Hidroeletrolítico , Anestesia Geral/métodos , Anestesia Geral/efeitos adversos , Hiperlactatemia , Fundoplicatura/efeitos adversos , Síndrome , Doenças Respiratórias
5.
Ann Surg ; 275(1): 115-120, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-32398485

RESUMO

OBJECTIVE: To define a standardized methodology for establishing benchmarks for relevant outcomes in surgery. SUMMARY BACKGROUND DATA: Benchmarking is an established tool to improve quality in industry and economics, and is emerging in assessing outcome values in surgery. Despite a recent 10-step approach to identify such benchmark values, a standardized and more widely agreed-on approach is still lacking. METHODS: A multinational web-based Delphi survey with a focus on methodological requirements for establishing benchmarks for surgical outcomes was performed. Participants were selected among internationally renowned specialists in abdominal, vascular, and thoracic surgery. Consensus was defined as ≥70% agreement and results were used to develop a checklist to establish benchmarks in surgery. RESULTS: Forty-one surgical opinion leaders from 19 countries and 5 continents were involved. Experts' response rates were 98% and 80% in rounds 1 and 2, respectively. Upon completion of the final Delphi round, consensus was successfully achieved for 26 of 36 items covering the following areas: center eligibility, validation of databases, patient cohort selection, procedure selection, duration of follow-up, statistical analysis, and publication requirements regarding center-specific outcomes. CONCLUSIONS: This multinational Delphi survey represents the first expert-led process for developing a standardized approach for establishing benchmarks for relevant outcome measures in surgery. The provided consensual checklist customizes the methodology of outcome reporting in surgery and thus improves reproducibility and comparability of data and should ultimately serve to improve quality of care.


Assuntos
Benchmarking , Lista de Checagem , Avaliação de Resultados em Cuidados de Saúde/normas , Procedimentos Cirúrgicos Operatórios/economia , Competência Clínica , Técnica Delphi , Humanos
6.
Ann Surg ; 276(5): 860-867, 2022 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-35894428

RESUMO

OBJECTIVE: To define benchmark cutoffs for redo liver transplantation (redo-LT). BACKGROUND: In the era of organ shortage, redo-LT is frequently discussed in terms of expected poor outcome and wasteful resources. However, there is a lack of benchmark data to reliably evaluate outcomes after redo-LT. METHODS: We collected data on redo-LT between January 2010 and December 2018 from 22 high-volume transplant centers. Benchmark cases were defined as recipients with model of end stage liver disease (MELD) score ≤25, absence of portal vein thrombosis, no mechanical ventilation at the time of surgery, receiving a graft from a donor after brain death. Also, high-urgent priority and early redo-LT including those for primary nonfunction (PNF) or hepatic artery thrombosis were excluded. Benchmark cutoffs were derived from the 75th percentile of the medians of all benchmark centers. RESULTS: Of 1110 redo-LT, 373 (34%) cases qualified as benchmark cases. Among these cases, the rate of postoperative complications until discharge was 76%, and increased up to 87% at 1-year, respectively. One-year overall survival rate was excellent with 90%. Benchmark cutoffs included Comprehensive Complication Index CCI ® at 1-year of ≤72, and in-hospital and 1-year mortality rates of ≤13% and ≤15%, respectively. In contrast, patients who received a redo-LT for PNF showed worse outcomes with some values dramatically outside the redo-LT benchmarks. CONCLUSION: This study shows that redo-LT achieves good outcome when looking at benchmark scenarios. However, this figure changes in high-risk redo-LT, as for example in PNF. This analysis objectifies for the first-time results and efforts for redo-LT and can serve as a basis for discussion about the use of scarce resources.


Assuntos
Doença Hepática Terminal , Transplante de Fígado , Obtenção de Tecidos e Órgãos , Benchmarking , Doença Hepática Terminal/cirurgia , Sobrevivência de Enxerto , Humanos , Estudos Retrospectivos , Resultado do Tratamento
7.
Ann Surg ; 274(5): 821-828, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-34334637

RESUMO

OBJECTIVE: To define "best possible" outcomes for secondary bariatric surgery (BS). BACKGROUND: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. METHODS: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years. RESULTS: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ±â€Š10 years, 8.4 ±â€Š5.3 years after primary BS, with a BMI 35.2 ±â€Š7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. CONCLUSION: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.


Assuntos
Cirurgia Bariátrica/normas , Benchmarking/normas , Procedimentos Cirúrgicos Eletivos/normas , Laparoscopia/normas , Obesidade Mórbida/cirurgia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Estudos Prospectivos , Reoperação
8.
Surg Endosc ; 35(11): 6227-6243, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-33206242

RESUMO

BACKGROUND: Minimally invasive surgery (MIS) has profoundly changed standards of care and lowered perioperative morbidity, but its temporal implementation and factors favoring MIS access remain elusive. We aimed to comprehensibly investigate MIS adoption across different surgical procedures over 20 years, identify predictors for MIS amenability and compare propensity score-matched outcomes among MIS and open surgery. METHODS: Nationwide retrospective analysis of all hospitalizations in Switzerland between 1998 and 2017. Appendectomies (n = 186,929), cholecystectomies (n = 57,788), oncological right (n = 9138) and left hemicolectomies (n = 21,580), rectal resections (n = 13,989) and gastrectomies for carcinoma (n = 6606) were included. Endpoints were assessment of temporal MIS implementation, identification of predictors for MIS access and comparison of propensity score-matched outcomes among MIS and open surgery. RESULTS: The rates of MIS increased for all procedures during the study period (p ≤ 0.001). While half of all appendectomies were performed laparoscopically by 2005, minimally invasive oncological colorectal resections reached 50% only by 2016. Multivariate analyses identified older age (p ≤ 0.02, except gastrectomy), higher comorbidities (p ≤ 0.001, except rectal resections), lack of private insurance (p ≤ 0.01) as well as rural residence (p ≤ 0.01) with impaired access to MIS. Rural residence correlated with low income regions (p ≤ 0.001), which themselves were associated with decreased MIS access. Geographical mapping confirmed strong disparities for rural and low-income areas in MIS access. Matched outcome analyses revealed benefits of MIS for length of stay, decreased surgical site infection rates for MIS appendectomies and cholecystectomies and higher mortality for open cholecystectomies. No consistent morbidity or mortality benefit for MIS compared to open colorectal resections was observed. CONCLUSION: Unequal access to MIS exists in disfavor of older and more comorbid patients and those lacking private insurance, living in rural areas, and having lower income. Efforts should be made to ensure equal MIS access regardless of socioeconomic or geographical factors.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos , Protectomia , Idoso , Colectomia , Humanos , Pontuação de Propensão , Estudos Retrospectivos
9.
Am J Physiol Regul Integr Comp Physiol ; 318(5): R886-R893, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32189509

RESUMO

This minireview focuses on the interpretative value of ingestive microstructure by summarizing observations from both rodent and human studies. Preliminary data on the therapeutic manipulation of distinct microstructural components of eating are also outlined. In rodents, the interpretative framework of ingestive microstructure mainly concentrates on deprivation state, palatability, satiation, and the role of learning from previous experiences. In humans, however, the control of eating is further influenced by genetic, psychosocial, cultural, and environmental factors, which add complexity and challenges to the interpretation of the microstructure of meal intake. Nevertheless, the presented findings stress the importance of microstructural analyses of ingestion, as a method to investigate specific behavioral variables that underlie the regulation of appetite control.


Assuntos
Regulação do Apetite , Dieta , Ingestão de Alimentos , Comportamento Alimentar , Animais , Ingestão de Energia , Humanos , Estilo de Vida , Refeições , Valor Nutritivo , Tamanho da Porção , Fatores de Tempo
10.
Ann Surg ; 270(5): 859-867, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31592894

RESUMO

OBJECTIVE: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]). BACKGROUND: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix. METHODS: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50 kg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators. RESULTS: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ±â€Š5.8 kg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication. CONCLUSION: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.


Assuntos
Índice de Massa Corporal , Gastrectomia/métodos , Derivação Gástrica/métodos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Qualidade de Vida , Centros Médicos Acadêmicos , Adulto , Fatores Etários , Benchmarking , Estudos de Coortes , Feminino , Gastrectomia/efeitos adversos , Derivação Gástrica/efeitos adversos , Saúde Global , Hospitais com Alto Volume de Atendimentos , Humanos , Internacionalidade , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Obesidade Mórbida/diagnóstico , Obesidade Mórbida/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Redução de Peso
12.
Appetite ; 133: 47-60, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30179650

RESUMO

Microstructural analysis of ingestion provides valuable insight into the roles of chemosensory signals, nutritional content, postingestive events, and physiological state. Our aim was to develop a novel drinkometer for humans to measure detailed aspects of ingestion of an entire liquid meal or drinking session. The drinkometer records, in high definition (1 kHz), the weight of a fluid reservoir from which participants drink via a tube. An ultrasonic sensor measures the height of the fluid to derive density. Drinking speed over time can be displayed as a waveform. The smallest units of ingestion are sucks, which are organized in bursts. By applying probability density functions (PDF) on loge-transformed inter-suck intervals (ISI), an optimal burst-pause criterion (PC) can be identified. Information on ingestive volumes, rates, and durations can be then computed for the entire session, as well as for sucks and bursts. We performed a validation study on 12 healthy adults in overnight-fasted and in non-fasted states in 16 drinking sessions with 8 concentrations of sucrose (0-280 mM) presented in a blinded and random fashion. PDF determined PC = 2.9 s as optimal. Two-way RM-ANOVA revealed that total caloric intake during a drinking session depended on sucrose concentration (P < .001) and fasted state (P = .006); total drinking time (P < .001), total consumed volume (P = .003), number of sucks in total (P < .001), number of sucks per burst (P = .03), and burst duration (P = .02) were significantly influenced by fasting. In contrast, volume per suck (P = .002), suck speed (P < .001), and maximal speed per suck (P < .001) depended on sucrose concentration. We conclude that the novel drinkometer is able to detect differences in microstructural parameters of drinking behavior dependent on different motivational states, thus, adds to the technological toolbox used to explore human ingestive behavior.


Assuntos
Ingestão de Líquidos , Ingestão de Energia , Adulto , Algoritmos , Estudos Cross-Over , Sacarose Alimentar/administração & dosagem , Ingestão de Alimentos , Jejum , Feminino , Humanos , Masculino , Projetos Piloto , Estudo de Prova de Conceito , Comportamento de Sucção
13.
Curr Atheroscler Rep ; 20(8): 38, 2018 05 21.
Artigo em Inglês | MEDLINE | ID: mdl-29785493

RESUMO

PURPOSE OF REVIEW: Cumulating evidence is available to demonstrate the efficacy of bariatric surgery (BS) in achieving weight loss and optimizing comorbidities. However, currently, only a minority of eligible patients approaches bariatric centers. The underuse of BS can no longer be explained by the lack of evidence supporting its beneficial outcomes along with its favorable safety-profile, rather, by the supporting infrastructure, insurance coverage, and mindset of society, including potential patients and allied healthcare professionals. As a framework to approach mindset barriers in the diffusion of BS, we used the Rogers' levels of the innovation adoption process: (1) knowledge, (2) persuasion, (3) decision, (4) implementation, and (5) confirmation. RECENT FINDINGS: Knowledge: people tend to believe that obesity is a result of lack of willpower and they have difficulties in differentiating BS from cosmetic surgery. Eligible patients often do not assess themselves as being morbidly obese and are unaware that they would qualify for BS. Persuasion: majority of BS candidates search health information online, with the aim of getting information about surgical techniques and other patients' experiences. Decision: metabolically more compromised patients are more likely to opt for BS. IMPLEMENTATION: general practitioners who already referred patients for BS seem to be more confident to refer again, to tackle obesity and manage postoperative follow-up. Confirmation: postbariatric patients seem to be more self-confident and more productive at work; however, their stigmatization might prevail related to the way they have achieved weight loss. Dissemination of balanced and corroborative information seems to be the main instrument to combat mindset barriers. The integration of general practitioners under the umbrella of bariatric centers has a great potential to increase referrals. Social media may represent a helpful tool to be used by medical professionals and patient-role models to improve confident decision-making of bariatric candidates.


Assuntos
Cirurgia Bariátrica , Barreiras de Comunicação , Mau Uso de Serviços de Saúde/prevenção & controle , Obesidade Mórbida , Percepção Social , Cirurgia Bariátrica/educação , Cirurgia Bariátrica/métodos , Cirurgia Bariátrica/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Obesidade Mórbida/psicologia , Obesidade Mórbida/cirurgia , Estigma Social
14.
Curr Atheroscler Rep ; 19(9): 38, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28779431

RESUMO

PURPOSE OF REVIEW: Insights into physiological mechanisms responsible for weight loss after bariatric surgery (BS) have challenged the traditional view that mechanical restriction and caloric malabsorption are major drivers of weight loss and health benefits after BS. Altered diet selection with an increased postoperative preference for low-sugar and low-fat food has also been implicated as a potential mechanism beyond mere reduction of calorie intake. However, the empirical support for this phenomenon is not uniform and evidence is largely based on indirect measurements, such as self-reported food intake data, which are prone to inaccuracy due to their subjective character. RECENT FINDINGS: Most studies indicate that patients not only reduce their caloric intake after BS, but also show a reduced preference of food with high sugar and high fat content. So far, standard behavioral tests to directly measure changes in food intake behavior after BS have been mainly used in animal models. It remains unclear whether there are fundamental shifts in the palatability of high-fat and sugary foods after BS or simply a decrease in the appetitive drive to ingest them. Studies of appetitive behavior in humans after BS have produced equivocal results. Learning processes may play a role as changes in diet selection seem to progress with time after surgery. So far, direct measures of altered food selection in humans after BS are rare and the durability of altered food selection as well as the role of learning remains elusive.


Assuntos
Cirurgia Bariátrica/métodos , Preferências Alimentares , Obesidade Mórbida , Redução de Peso/fisiologia , Animais , Restrição Calórica/métodos , Restrição Calórica/psicologia , Dieta com Restrição de Gorduras/métodos , Dieta com Restrição de Gorduras/psicologia , Preferências Alimentares/fisiologia , Preferências Alimentares/psicologia , Humanos , Obesidade Mórbida/psicologia , Obesidade Mórbida/cirurgia , Período Pós-Operatório
15.
World J Surg ; 41(4): 1035-1039, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27896401

RESUMO

BACKGROUND: Our aim is to report our initial experience with a novel technique which addresses morbid obesity and gastro-esophageal reflux disease (GERD) simultaneously by combination of laparoscopic sleeve gastrectomy (LSG) and simplified laparoscopic Hill repair (sLHR). METHODS: Retrospective analysis of LSG+sLHR patients >5 months postoperatively includes demographics, GERD status, proton-pump inhibitor (PPI) use, body mass index (BMI), excess BMI loss (EBMIL), complications and GERD-Health Related Quality of Life (GERD-HRQL) questionnaire. LSG+sLHR surgical technique: posterior cruroplasty,  standard LSG, fixation of the esophagogastric junction to the median arcuate ligament. RESULTS: Fourteen patients underwent LSG+sLHR [12 women and 2 men, mean (range) age 47 years (27-57), BMI 41 kg/m2 (35-65)]. Five patients had previous gastric banding (GB). All had symptomatic GERD confirmed by gastroscopy and/or upper-gastrointestinal contrast study, two with chronic cough, 10 took PPI daily. Twelve had hiatus hernia and two patulous cardia at surgical exploration. Associated interventions were three GB removals and one cholecystectomy. Postoperative complication was one surgical site infection. Follow-up of all patients at median 12.5 months (5-17) is as follows: symptomatic GERD 3/14 patients, chronic cough 0/14, daily PPI use in 1/14, mean EBMIL 68% (17-120), satisfaction 93%, mean GERD-HRQL score 3,28/50 (0-15), with 4 patients 0/50, occasional bloatedness in 2 patients and dysphagia not reported. CONCLUSION: The novel technique which combines LSG with sLHR is feasible, safe and can be associated with GB removal. Preliminary results showed patient satisfaction, high remission rate of preexisting GERD, decrease in PPI use and unimpaired weight loss. Further evaluation is necessary in a controlled and staged manner to establish the technique's real effectiveness.


Assuntos
Gastrectomia/métodos , Refluxo Gastroesofágico/cirurgia , Laparoscopia , Obesidade Mórbida/cirurgia , Adulto , Uso de Medicamentos , Feminino , Refluxo Gastroesofágico/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Inibidores da Bomba de Prótons/uso terapêutico , Estudos Retrospectivos
16.
World J Surg ; 41(11): 2940-2948, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28634839

RESUMO

AIM: To evaluate outcomes and post-donation kidney function of older living kidney donors (LKD). METHODS: Retrospective analysis of prospective database including all consecutive LKD undergoing laparoscopic nephrectomy in a single center (09/1998-12/2013). LKD aged ≥60 years were compared to younger LKD. Renal function assessed by creatinine levels and estimated glomerular filtration rates (eGFR). Surgical complications classified according to the Clavien-Dindo classification. Bivariate and multivariate analyses using linear mixed effect models were performed to determine factors (age, gender, hypertension status, BMI, choice of better functioning kidney for donation) that might impinge on renal function after donation. RESULTS: 213 LKD were identified: 49 older (median age: 66 years, range: 60-79) and 164 younger (median age: 46, range: 25-59). Mean operative time (149 vs. 152 min, p = 0.69), conversion to laparotomy (n = 1 vs. 3, p = 0.92), grade III-IV complications (n = 4 vs. 2, p = 0.36) were similar. Older had more grade I-II complications (n = 18 vs. 4, p < 0.001). Despite similar pre-donation eGFR (80 vs. 84 ml/min/1.73 m2), older donors presented significantly lower eGFR during inpatient period (46 vs. 51 ml/min/1.73 m2, p = 0.0003), at 1 month (51 vs. 58 ml/min/1.73 m2, p = 0.002) and at 1 year (54 vs. 62 ml/min/1.73 m2, p = 0.001). Multivariate analysis adjusted to gender, hypertension status, BMI and choice of better functioning kidney for donation showed that at 1 year, age ≥60 affected renal function by a coefficient of 0.91 (p < 0.001). CONCLUSION: Despite renal function improvement after discharge, LKD ≥ 60 years presented lower eGFR than younger at one year and had more grade I-II surgical complications.


Assuntos
Transplante de Rim , Doadores Vivos , Idoso , Índice de Massa Corporal , Feminino , Taxa de Filtração Glomerular , Humanos , Hipertensão/complicações , Laparoscopia , Masculino , Pessoa de Meia-Idade , Nefrectomia , Estudos Prospectivos , Estudos Retrospectivos , Fatores Sexuais , Coleta de Tecidos e Órgãos
17.
Langenbecks Arch Surg ; 402(1): 149-158, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27488952

RESUMO

PURPOSE: Postoperative ileus (POI) is a frequent complication after abdominal surgery; nonetheless, it remains poorly defined. Our aim was to achieve an international consensus among leading colorectal surgeons on definition, prevention, and treatment of POI. METHODS: Thirty-five experts from five continents participated in a three-round Delphi process. Round 1 contained open-ended questions on POI and postoperative nausea and vomiting (PONV). Round 2 included closed-ended questions. Round 3 measured agreement on a 5-point Likert scale. Consensus was defined when items were rated as agree or strongly agree by at least 70 % of the experts. RESULTS: Experts reached following consensus: POI is a temporary inhibition (86 %) of gastrointestinal motility after surgical intervention due to non-mechanical causes (89 %) and prevents sufficient oral intake (96 %). Abdominal distension/tenderness are the most relevant clinical signs (71 %). Nasogastric tube placement is not mandatory (78 %) but can be removed without previous clamping (81 %)/gastrointestinal contrast study (100 %). Preventive measures are recommended to decrease the risk of POI (96 %): narcotic sparing analgesia (89 %) and fluid optimization (74 %). Treatment of POI should include stimulation of ambulation (96 %) and stop of opioids (74 %). Total parenteral nutrition is recommended from the 7th day without sufficient oral intake (81 %). There was no consensus on the ranking of POI's symptoms, on the imaging modality of choice for the diagnosis of POI, neither on the difference between POI and PONV. CONCLUSIONS: This Delphi study achieved consensus on the definition, relevant clinical signs, prevention, treatment, and supportive care of POI. Areas of non-consensus were identified (necessity and modality of radiologic imaging to establish the diagnosis, difference between POI and PONV), giving opportunity for further research.


Assuntos
Íleus/diagnóstico , Íleus/terapia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Analgésicos Opioides/uso terapêutico , Consenso , Técnica Delphi , Humanos , Íleus/etiologia , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/etiologia
18.
J Am Coll Surg ; 239(4): 375-386, 2024 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-38661176

RESUMO

BACKGROUND: In recent years, there has been growing interest in laparoscopic liver resection (LLR) and the audit of the results of surgical procedures. The aim of this study was to define reference values for LLR in segments 7 and 8. STUDY DESIGN: Data on LLR in segments 7 and 8 between January 2000 and December 2020 were collected from 19 expert centers. Reference cases were defined as no previous hepatectomy, American Society of Anesthesiologists score less than 3, BMI less than 35 kg/m 2 , no chronic kidney disease, no cirrhosis and portal hypertension, no COPD (forced expiratory volume 1 <80%), and no cardiac disease. Reference values were obtained from the 75th percentile of the medians of all reference centers. RESULTS: Of 585 patients, 461 (78.8%) met the reference criteria. The overall complication rate was 27.5% (6% were Clavien-Dindo 3a or more) with a mean Comprehensive Complication Index of 7.5 ± 16.5. At 90-day follow-up, the reference values for overall complication were 31%, Clavien-Dindo 3a or more was 7.4%, conversion was 4.4%, hospital stay was less than 6 days, and readmission rate was <8.33%. Patients from Eastern centers categorized as low risk had a lower rate of overall complication (20.9% vs 31.2%, p = 0.01) with similar Clavien-Dindo 3a or more (5.5% and 4.8%, p = 0.83) compared with patients from Western centers, respectively. CONCLUSIONS: This study shows the need to establish standards for the postoperative outcomes in LLR based on the complexity of the resection and the location of the lesions.


Assuntos
Benchmarking , Hepatectomia , Laparoscopia , Complicações Pós-Operatórias , Humanos , Hepatectomia/normas , Hepatectomia/métodos , Laparoscopia/normas , Masculino , Feminino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Idoso , Estudos Retrospectivos , Adulto , Resultado do Tratamento , Valores de Referência , Tempo de Internação/estatística & dados numéricos
19.
Physiol Behav ; 263: 114113, 2023 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-36764423

RESUMO

This invited review is based on a presentation given at the Annual Meeting of the Society for the Study of Ingestive Behavior in July 2022 and provides the summary of two recent studies on changes in ingestive behavior following bariatric surgery (BS). First, long-term changes in daily absolute and relative macronutrient intake are reported in a rodent model of Roux-en-Y gastric bypass (RYGB). Rats undergoing RYGB progressively decreased their daily calorie- and daily fat intake compared to their preoperative baseline and to the intake of sham operated animals. Second, postbariatric changes in the within-meal ingestive microstructure are portrayed, based on longitudinal data collected in RYGB patients using a drinkometer. The post-RYGB meal size showed a dynamic adjustment process, with the highest decrease in the early postoperative phase, followed by a steady convalescence up to 1-year, at which point the meal size of RYGB patients became comparable to the normal weight adults'. Results are contextualized and contrasted to recent reports on the effect of BS on taste and food choices and consumption. The showcased evidence supports the role of ingestive adaptation and learning in the achievement of reduced calorie intake after RYGB, both in humans and in rodents. The reorganized upper-gastrointestinal anatomy supposedly leads to increased postingestive caloric sensibility, which might be an important behavioral mediator of decreased postbariatric meal size and consequent weight loss.


Assuntos
Bariatria , Derivação Gástrica , Humanos , Adulto , Ratos , Animais , Comportamento Alimentar , Ingestão de Alimentos , Ingestão de Energia , Derivação Gástrica/métodos , Nutrientes
20.
Eur J Pediatr Surg ; 33(2): 120-128, 2023 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-36720250

RESUMO

Successful surgery combines quality (achievement of a positive outcome) with safety (avoidance of a negative outcome). Outcome assessment serves the purpose of quality improvement in health care by establishing performance indicators and allowing the identification of performance gaps. Novel surgical quality metric tools (benchmark cutoffs and textbook outcomes) provide procedure-specific ideal surgical outcomes in a subgroup of well-defined low-risk patients, with the aim of setting realistic and best achievable goals for surgeons and centers, as well as supporting unbiased comparison of surgical quality between centers and periods of time. Validated classification systems have been deployed to grade adverse events during the surgical journey: (1) the ClassIntra classification for the intraoperative period; (2) the Clavien-Dindo classification for the gravity of single adverse events; and the (3) Comprehensive Complication Index (CCI) for the sum of adverse events over a defined postoperative period. The failure to rescue rate refers to the death of a patient following one or more potentially treatable postoperative adverse event(s) and is a reliable proxy of the institutional safety culture and infrastructure. Complication assessment is undergoing digital transformation to decrease resource-intensity and provide surgeons with real-time pre- or intraoperative decision support. Standardized reporting of complications informs patients on their chances to realize favorable postoperative outcomes and assists surgical centers in the prioritization of quality improvement initiatives, multidisciplinary teamwork, surgical education, and ultimately, in the enhancement of clinical standards.


Assuntos
Complicações Pós-Operatórias , Cirurgiões , Humanos , Adulto , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Benchmarking , Melhoria de Qualidade , Índice de Gravidade de Doença
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