Revision/Conversion Surgeries After One Anastomosis Gastric Bypass-An Experts' Modified Delphi Consensus.

PURPOSE: There is a lack of evidence for treatment of some conditions including complication management, suboptimal initial weight loss, recurrent weight gain, or worsening of a significant obesity complication after one anastomosis gastric bypass (OAGB). This study was designed to respond to the existing lack of agreement and to provide a valuable resource for clinicians by employing an expert-modified Delphi consensus method. METHODS: Forty-eight recognized bariatric surgeons from 28 countries participated in the modified Delphi consensus to vote on 64 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus. RESULTS: A consensus was achieved for 46 statements. For recurrent weight gain or worsening of a significant obesity complication after OAGB, more than 85% of experts reached a consensus that elongation of the biliopancreatic limb (BPL) is an acceptable option and the total bowel length measurement is mandatory during BPL elongation to preserve at least 300-400 cm of common channel limb length to avoid nutritional deficiencies. Also, more than 85% of experts reached a consensus on conversion to Roux-en-Y gastric bypass (RYGB) with or without pouch downsizing as an acceptable option for the treatment of persistent bile reflux after OAGB and recommend detecting and repairing any size of hiatal hernia during conversion to RYGB. CONCLUSION: While the experts reached a consensus on several aspects regarding revision/conversion surgeries after OAGB, there are still lingering areas of disagreement. This highlights the importance of conducting further studies in the future to address these unresolved issues.

Comparison of Outcomes Between Banded and Non-banded Sleeve Gastrectomy: a Systematic Review and Meta-analysis.

BACKGROUND: Sleeve gastrectomy (SG) is the most common bariatric procedure performed worldwide. It accounts for more than 50% of primary bariatric surgeries performed each year. Recent long-term data has shown an alarming trend of weight recidivism. Some authors have proposed the concurrent use of a non-adjustable gastric band to decrease long-term sleeve failure. OBJECTIVE: To compare the outcomes (weight loss) and safety (rate of complication and presence of upper GI symptoms) between SG and BSG. METHODS: A systematic search with no language or time restrictions was performed to identify relevant observational studies and randomized controlled trials (RCT) evaluating people with morbid obesity undergoing SG or SGB for weight loss. An inverse-of-the-variance meta-analysis was performed by random effects model. Heterogeneity was assessed using Cochrane X2 and I2 analysis. RESULTS: A total of 7 observational studies and 3 RCT were included in the final analysis. There were 911 participants pooled from observational studies and 194 from RCT. BSG showed a significant higher excess of weight loss (% EWL). The difference among groups was clinically relevant after the third year where the weighted mean difference (SMD) was 16.8 (CI 95% 12.45, 21.15, p < 0.0001), while at 5 years, a SMD of 25.59 (16.31, 34.87, p < 0.0001) was noticed. No differences related to overall complications were noticed. Upper GI symptoms were up to three times more frequent in the BSG group (OR 3.26. CI 95% 1.96, 5.42, p < 0.0001). CONCLUSIONS: According to the results, BSG is superior to SG in weight loss at 5 years but is associated with a higher incidence of upper GI symptoms. However, these conclusions are based mainly on data obtained from observational studies. Further RCT are needed to evaluate the effect and safety of BSG.

Gastroesophageal reflux disease in children: efficacy of Nissen fundoplication in treating digestive and respiratory symptoms. Experience of a single center.

Fundoplication has been commonly performed in neurologically impaired and normal children with complicated gastroesophageal reflux disease. The relationship between gastroesophageal reflux disease and respiratory diseases is still unclear. We aimed to compare results of open and laparoscopic procedures, as well as the impact of fundoplication over digestive and respiratory symptoms. From January 2000 to June 2007, 151 children underwent Nissen fundoplication. Data were prospectively collected regarding age at surgery, presence of neurologic handicap, symptoms related to reflux (digestive or respiratory, including recurrent lung infections and reactive airways disease), surgical approach, concomitant procedures, complications, and results. Mean age was 6 years and 9 months. Eighty-two children (54.3%) had neurological handicaps. The surgical approach was laparoscopy in 118 cases and laparotomy in 33. Dysphagia occurred in 23 patients submitted to laparoscopic and none to open procedure (P = 0.01). A total of 86.6% of patients with digestive symptoms had complete resolution or significant improvement of the problems after the surgery. A total of 62.2% of children with recurrent lung infections showed any reduction in the frequency of pneumonias. Only 45.2% of patients with reactive airway disease had any relief from bronchospasm episodes after fundoplication. The comparisons demonstrated that Nissen fundoplication was more effective for the resolution of digestive symptoms than to respiratory manifestations (P = 0.04). Open or laparoscopic fundoplication are safe procedures with acceptable complication indices and the results of the surgery are better for digestive than for respiratory symptoms.

Placement of the GaBP ring system in the banded gastric bypass operation.

Currently, bariatric surgeons fashion the band or ring reinforcement prosthesis, to control the stoma in the vertical banded gastroplasty and gastric bypass operations for morbid obesity. To meet this need, the GaBP Ring system has been developed in various sizes, and consists of 4 main parts to provide a means for inserting a ring around the gastric pouch in the banded gastric bypass or the vertical banded gastroplasty. The pre-manufactured and sterilized device provides for better standardization and quality control than individually surgeon-fashioned devices. The GaBP Ring system is described, and the technique of placement and the pertinent initial clinical results are presented.

Choosing an operation for weight control, and the transected banded gastric bypass.

Obesity and particularly morbid obesity is a lifelong problem that currently cannot be cured but can be controlled. Attempted control of obesity non-surgically results in 98% recividism. Weight loss is readily attainable, but weight loss maintenance is recalcitrant. Surgery currently provides the only long-term control of obesity. Surgery at best is a tool that the patient can use to effect the weight loss and weight loss maintenance. We have celebrated the golden anniversary of bariatric surgery in 2004. Obesity surgery is thus a relatively young field which is evolving. Operations currently used for the treatment of obesity fall into 3 categories: 1) restrictive operations such as vertical banded gastroplasty, silastic ring gastroplasty and gastric banding; 2) malabsorptive operations which include all the variations of the intestinal bypass; and 3) combined operations which utilize both restriction and malabsorption which include all the variations of short-limb gastric bypass, long-limb or distal gastric bypass and biliopancreatic diversion. The choice of the operation will be guided by the extent of the patient's obesity, the age of the patient, other co-morbid conditions of the patient, the cost of the operation, the patient's choice, and the surgeon's choice based on training, experience and geographical location. First and foremost, the operation chosen should be effective in causing weight loss and providing long-term weight loss maintenance with acceptable morbidity and mortality. Recommendations are made for choosing an operation for weight control based on effectiveness and safety.

Fifty consecutive patients with the GaBP ring system used in the banded gastric bypass operation for obesity with follow up of at least 1 year.

BACKGROUND: The premanufactured GaBP ring system can be used in the banded gastric bypass operation instead of a surgeon-fashioned ring or band in current use. METHODS: The GaBP ring system was used in 50 consecutive patients, and the outcomes were reviewed after 1 year of follow-up. Data were kept prospectively. RESULTS: The GaBP ring system was used in 50 patients undergoing gastric bypass surgery, 9 with an open procedure and 41 with a laparoscopic approach. Placement took an average of < 5 minutes, and there were no GaBP ring system-related complications at the 1-year follow-up. The outcomes in terms of weight loss and resolution of comorbidities are similar to those previously reported for banded gastric bypass. CONCLUSION: The GaBP ring system provides a premanufactured standardized ring for use in the banded gastric bypass operation.

Characterization of residual lignin after SO(2)-catalyzed steam explosion and enzymatic hydrolysis of Eucalyptus viminalis wood chips.

The lignin component found in both water insoluble (WI) and water and alkali insoluble (WIA) fractions derived from SO(2)-impregnated steam-exploded eucalyptus chips (SEE) was isolated and characterized. Dioxane lignins with a sugar content lower than 2% (w/w) were obtained after each material was treated with commercial cellulases. The C9 formulas of both SEE-WI and SEE-WIA dioxane lignins were C(9)H(6.83)N(0.04)O(2.24)(OCH(3))(1.21)(OH(aro))(0.56)(OH(ali))(0. 77) and C(9)H(8.65)N(0.29)O(1.97)(OCH(3))(0.90)(OH(aro))(0. 46)(OH(ali))(1.02), respectively. The weight-average molecular weight (M(w)) of the SEE-WI lignin corresponded to 3.85 kDa, whereas the SEE-WIA lignin had an M(w) of 3.66 kDa for the same polydispersity of 2.4. The SEE-WIA lignin was shown to be more thermally stable than the SEE-WI lignin, requiring temperatures in the range of 520 degrees C for complete degradation. FTIR and (1)H NMR analyses of both untreated and peracetylated lignin fractions showed that (a) the alkali insoluble lignin contained a relatively higher degree of substitution in aromatic rings per C9 unit and that (b) alkaline extraction removed lignin fragments containing appreciable amounts of phenolic hydroxyl groups.

L-arabinose metabolism in Herbaspirillum seropedicae.

The pathway for L-arabinose metabolism in Herbaspirillum seropedicae was shown to involve nonphosphorylated intermediates and to produce alpha-ketoglutarate. The activities of the enzymes and the natures of several intermediates were determined. The pathway was inducible by L-arabinose, and two key enzymes, L-arabinose dehydrogenase and 2-keto-glutarate semialdehyde dehydrogenase, were present in all strains of H. seropedicae tested.

Pancreatite aguda associada a duplicacao gastrica em crianca. / Acute pancreatitis associated with gastric duplication in a child

Uma crianca do sexo feminino com dois anos e nove meses de idade, foi admitida com o diagnostico de crises recidivantes de pancreatite aguda. A pancreatografia endoscopica nada revelou de anormal. Um estudo radiologico do aparelho digestivo alto demonstrou a existencia de compressao extrinseca do antro gastrico cujas pregas mucosas se apresentavam finas e regulares.Fez-se suspeita diagnostica de duplicacao gastrica confirmada a cirurgia. O estudo radiologico intra-operatorio mostrou comunicacao com o ducto pancreatico. Optou-se por cistojejunostomia em Y de Roux com cura dos sintomas do doente

Atendimento miltiprofissional as criancas com incontinencia fecal pos-cirurgia colo-proctologica. / Multiprofessional assistance of children with fecal incontinence after colon-proctologic surgery

Os autores relatam a experiencia de uma equipe multiprofissional (pediatra, cirurgiao pediatra, assistente social, enfermeira e nutricionista) no atendimento a 17 criancas com incontinencia fecal pos-cirurgia colo-proctologica (9 por megacolo e 8 por anomalia anorretal). Foram realizados estudos morfofuncionais que revelaram somente alteracoes de absorcao de lactose e sacarose, o que motivou emprego de dietas especiais. O esquema basico de tratamento foi: a) diminuir o numero de evacuacoes e/ou aumentar a consistencia das fezes; b) promover disciplina da exoneracao intestinal; c) fortalecer a musculatura abdominoperineal; d) proporcionar apoio a crianca e e) orientar os familiares. Os resultados foram considerados muito satisfatorios