Predictive factors of insulin resistance resolution with adjustable gastric band surgery.

INTRODUCTION: The aim of the study was to evaluate preoperative factors associated with remission of diabetes and weight loss after laparoscopic gastric band surgery. MATERIAL AND METHODS: A retrospective cohort of 95 patients who had an adjustable gastric band placed were included. A preliminary descriptive study of prognostic factors was performed using the logistic regression model with SPSS 17.0. The independent variables were age, sex, body mass index (BMI), diabetes status and degree of obesity; dependent variables were the proportion of weight loss, change in diabetes status score and percent changes in fasting sugar and glycosylated hemoglobin. RESULTS: The variables that were significantly associated with the percentage of changes in fasting blood sugar and glycated hemoglobin were: the degree of obesity in the first year; preoperative and diabetes status respectively. The analysis of the need for antidiabetic treatment using the modified diabetes status score showed preoperative BMI, age and gender as significant predictors. CONCLUSIONS: In patients undergoing gastric band surgery, weight loss is the fundamental mechanism by which insulin sensitivity increases. This improvement in glucose metabolism is influenced by factors such as sex, age, insulin treatment, duration of diabetes and degree of preoperative obesity.

Obstrucción intestinal, complicación inusual por banda gástrica ajustable laparoscópica: reporte de caso / Small Bowel Obstruction as a Rare Complication After Laparoscopic Adjustable Gastric Banding: A Case Report

Resumen: Antecedentes: El objetivo principal de la cirugía bariátrica es la reducción del índice de masa corporal (IMC). La banda gástrica ajustable laparoscópica (BGAL) fue el método más popular por las relativas ventajas sobre otros. Caso clínico: Mujer de 44 años con dolor y distensión abdominal, con antecedente de colocación de una BGAL; se integró diagnóstico de oclusión intestinal secundario a un giro en el tubo del dispositivo, se dio manejo quirúrgico, la paciente presentó adecuada evolución. Conclusión: La oclusión del intestino delgado por el tubo del dispositivo es una complicación seria y poco común para tomarse en cuenta como diagnóstico diferencial en pacientes bariátricos.

Abstract: Background: The main goal of bariatric surgery is the reduction of Body mass index (BMI). Laparoscopic adjustable gastric band (LAGB) was the most popular method due to its relative advantages over others. Clinical case: A 44-year-old woman with abdominal pain and distension, with a history of LAGB placement had a diagnosis of intestinal occlusion secondary to a twist in the device tube, surgical management was given, the patient presented adequate evolution. Conclusion: The occlusion of the small intestine by the tube of the device is a serious and uncommon complication to be considered as a differential diagnosis in bariatric patients.

[Gastric band erosion: Alternative management]. / Banda gástrica penetrada. Una alternativa de tratamiento.

BACKGROUND: Obesity is a public health problem, for which the prevalence has increased worldwide at an alarming rate, affecting 1.7 billion people in the world. OBJECTIVE: To describe the technique employed in incomplete penetration of gastric band where endoscopic management and/or primary closure is not feasible. MATERIAL AND METHODS: Laparoscopic removal of gastric band was performed in five patients with incomplete penetrance using Foley catheterization in the perforation site that could lead to the development of a gastro-cutaneous fistula. CLINICAL CASES: The cases presented include a leak that required surgical lavage with satisfactory outcome, and one patient developed stenosis 3 years after surgical management, which was resolved endoscopically. In all cases, the penetration site closed spontaneously. DISCUSSION: Gastric band erosion has been reported in 3.4% of cases. The reason for inserting a catheter is to create a controlled gastro-cutaneous fistula, allowing spontaneous closure. CONCLUSIONS: Various techniques have been described: the totally endoscopic, hybrid techniques (endoscopic/laparoscopic) and completely laparoscopic. A technique is described here that is useful and successful in cases where the above-described treatments are not viable.

FROM COMPLEX EVOLVING TO SIMPLE: CURRENT REVISIONAL AND ENDOSCOPIC PROCEDURES FOLLOWING BARIATRIC SURGERY / EVOLUÇÃO DO COMPLEXO PARA O SIMPLES: PROCEDIMENTOS REVISIONAIS E ENDOSCÓPICOS APÓS CIRURGIA BARIÁTRICA

ABSTRACT Background: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled. Objective: The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice. Methods: Institutional experience and systematic review from the literature on revisional bariatric surgery. Results: Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained. Conclusion: Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions.

RESUMO Racional: Bypass gástrico em Y-de-Roux (BGYR) é procedimento padrão em cirurgia bariátrica. Gastrectomia vertical e banda gástrica, embora com bons resultados na literatura, estão mostrando taxas mais elevadas de insucesso no tratamento para reduzir a morbidade associada à obesidade e peso corporal. Outros problemas pós-operatórios podem ocorrer, como a erosão da banda, e doença do refluxo gastroesofágico refratária à medicação. Portanto, conversão laparoscópica para BGYR pode ser alternativa eficaz, desde que indicações específicas para a revisão sejam cumpridas. Objetivo: Analisar os nossos dados e os da literatura sobre procedimentos bariátricos revisionais para avaliar melhores alternativas para a prática atual. Métodos: Foram efetuados experiência institucional e revisão sistemática da literatura sobre cirurgia bariátrica revisional. Resultados: Procedimentos endoscópicos estão sendo aplicados recentemente para melhorar a falha e complicações de procedimentos bariátricos. Falha terapêutica após BGYR ocorre em até 20%. A redução transoral é atualmente um método alternativo para reduzir a anastomose gastrojejunal. A gastrectomia vertical pode apresentar aumento de volume e do diâmetro do pouch , o qual podem ser reduzidos por meio de sutura total endoscópica longitudinal. Síndrome de dumping e episódios de hipoglicemia grave (neuroglicopenia) podem estar presentes nos pacientes com BGYR. Os episódios hipoglicêmicos devem ser avaliados e geralmente podem ser tratados convencionalmente. Para evitar pancreatectomia parcial ou conversão à anatomia normal, uma nova abordagem laparoscópica com ressecção do remanescente gástrico e interposição de jejuno, pode ser aplicada como alternativa em não-respondedores. Episódios de hipoglicemia melhoram, enquanto a perda de peso é mantida. Conclusão: Procedimentos revisionais endoscópicos podem ser aplicados após cirurgia bariátrica em pacientes com sintomas colaterais ou na falha do tratamento. Abordagens convencionais não-cirúrgicas devem ser aplicadas intensivamente antes que uma operação revisional seja indicada. Antigos procedimentos cirúrgicos revisionais complexos estão evoluindo para soluções endoscópicas menos complicadas.

Complicaciones tardías en cirugía bariátrica / Late complications in bariatric surgery

La cirugía bariátrica denota complejidad y no está libre de complicaciones. Estas son de causa multfactorial y dependen de factores intrínsecos delpaciente o bien de habilidades técnicas y experiencia del cirujano. En general cualquier complicación puede catalogarse como temprana (< 30 días) otardía (> 30 días) según el tempo de aparición luego de la cirugía.La banda gástrica es uno de los procedimientos bariátricos mas realizados pero con un alto índice de complicaciones, entre las tardías destacan deslizamiento,migración y problemas del reservorio. El Bypass gástrico contnua teniendo mucha fabilidad en cuanto a control de la obesidad pero presentacomplicaciones como las hernias internas, estenosis y úlceras de anastomosis, y fstulas gastro gástricas entre otras, cuyo diagnóstco y manejo precozes importante.La gastrectomía vertcal en manga ha ganado terreno en los últmos años por sus buenos resultados pero también por su baja tasa de complicaciones amediano y largo plazo, dentro de sus problemas tardíos descritos están estenosis, dilatación gástrica y cierta relación con aparición o exacerbación derefujo gastroesofágico. Otro procedimiento bariátrico poco utlizado en la actualidad es la derivación biliopancreátca por su múltples complicacionestardías.La colelitasis es un problema comúnmente documentado luego de cirugía bariátrica en tasas de 30 a 52%, cuya resolución quirúrgica es importantepara evitar complicaciones mayores.

Bariatric surgery denotes complexity and is not free of complicatons. These are multfactorial and depend on intrinsic patent factors or technical skillsand experience of the surgeon. In general any complicatons can be classifed as early (<30 days) or late (> 30 days) as the tme of onset afer surgery.Gastric banding is one of the most performed bariatric procedures but with a high rate of complicatons; late complicatons as slipping, migraton andreservoir problems have been documented. Gastric bypass contnues to have much reliability as to control obesity but has complicatons such as internalhernias, anastomotc strictures and ulcers and gastro gastric fstulas among others, whose diagnosis and early management is important.Sleeve gastrectomy gained ground in recent years for its good results but also for its low complicaton rate in the medium and long term. The lateproblems described are stenosis, gastric dilataton and some relaton to onset or exacerbaton of gastro esophageal refux. Another bariatric procedureused actually is the biliopancreatc diversion but for his multple late complicatons it is less performed.Cholelithiasis is a problem commonly documented afer bariatric surgery rates from 30 to 52%, the surgical resoluton is important to prevent furthercomplicatons.

By pass gástrico laparoscópico como cirugía de rescate posterior a procedimientos restrictivos fallidos / Laparoscopic gastric bypass as rescue surgery when restrictive procedures failed

Objetivo:Exponer la experiencia en la cirugía de conversión a bypass gástrico por laparoscopia posterior a procedimientos restrictivos fallidos,en el servicio de Cirugía 2 del Hospital Universitario de Caracas.Pacientes y métodos:Se realizó un estudio retrospectivo y descriptivo incluyendo los pacientes a quienes se les realizó bypass gástrico por laparoscopia como cirugía de rescate posterior a un procedimiento bariátrico restrictivo fallido, en el período comprendido entre enero 2007 y diciembre 2010. Resultados:Entre 2007 y 2010 se intervinieron 12 pacientes con edad promedio de 46,4 años y predominio del sexo femenino (58 %). A 8 se les había colocado una banda gástrica ajustable por laparoscopia ya 4 se les había realizado una gastrectomía vertical laparoscópica. El peso promedio antes de la primera cirugía fue de 125,7 Kg y el IMC 46 kg/m2. Todos los pacientes presentaron pérdida inadecuada de peso con un promedio de 9,8% del exceso de peso perdido, motivo por el cual se decidió realizar cirugía de revisión y bypass gástrico por laparoscopia. La media de tiempo entre el primer procedimiento y el bypass gástrico fuede 47 meses. Sólo 1 paciente presentó complicaciones poso peratorias y se resolvió medicamente. Posterior a 6 meses la pérdida del exceso depeso fue 53,3% y después de un año 70,4% con un IMC de 29,6 kg/m2. Conclusión:El bypass gástrico por laparoscopia es seguro y efectivo como cirugía de rescate luego de procedimientos restrictivos fallido(AU)

Objective: To expose the experience in the conversion to laparoscopic gastric bypass when restrictive procedures failed, at Hospital Universitario de Caracas. Surgery II service. Patients and methods: A retrospective and descriptive study was conducted including patients who under going gastric bypass surgery as rescue procedure after a bariatricrestrictive procedure failed, from January 2007 toDecember 2010. Results: 12 patients with median age of46.4 years and predominance of female (58%) involved.Eight had placed an adjustable gastric band surgery and4 had made a laparoscopic vertical gastrectomy. The aver-age weight before the first surgery was 125,7 Kg and BMI46 kg/m2. All the patients had inadequate weight losswith an average of 9.8% of excess weight lost, reason bywhich it was decided to review and performe laparoscopygastric bypass. The average time from the first procedurewas 47 months. Only 1 patient developed postoperativecomplications and resolved medically. After 6 months, the loss of excess weight was 53.3% and after a year 70.4 percent with a BMI of 29.6 kg/m2. Conclusion: Gastric bypass surgery is safe and effective as surgery of rescue after failed restrictive procedures(AU)

Cirugía Bariátrica / Bariatric surgery

La cirugía de la obesidad ha tenido un impresionante desarrollo en los últimos 20 años, debido a la necesidad de tratamiento efectivo y duradero para esta enfermedad crónica epidémica. La introducción de la técnica laparoscópica a las cirugías bariátricas contribuyó en forma importante a disminuir sus complicaciones y mortalidad. Las operaciones más frecuentes en el mundo son el bypass gástrico, la gastrectomía vertical, la banda gástrica ajustable y la derivación biliopancreática, aunque en la actualidad en nuestro país se utilizan solo las dos primeras. Se describen estas cirugías bariátricas, su técnica, complicaciones y resultados. El tratamiento quirúrgico de la obesidad logra bajas de peso y control de las comorbilidades muy superiores a las logradas por el tratamiento médico y terapia farmacológica. Por ello, el tratamiento quirúrgico es la terapia estándar para pacientes con obesidad.

Obesity surgery has had an impressive development in the last 20 years, due to the need for effective and lasting treatment for this epidemic cronic disease. The introduction of laparoscopic technique in bariatric surgical interventions contributed significantly on reducing surgical complications and mortality. The most common operations in the world are gastric bypass, sleeve gastrectomy, gastric banding and biliopancreatic diversion, though only the first two mentioned are used in our country today. These bariatric surgery, their technique, complications and results are described. Surgical treatment of obesity achieves weight loss and comorbidities control far superior to those achieved by medical treatment and pharmacologic therapy. Therefore, surgical treatment is the standard therapy for obese patients.

Técnicas restrictivas en cirugía bariátrica: evolución y tendencias actuales / Restrictive bariatric surgery techniques: evolution and current trends

La cirugía bariátrica ha demostrado ser más efectiva que el tratamiento médico para el control del peso y las comorbilidades asociadas. Se han descrito múltiples técnicas, las cuales pueden ser divididas en tres grupos: cirugías restrictivas, en las que el objetivo principal es disminuir el volumen de la ingesta calórica; cirugías malabsortivas, en las que se limita la absorción a nivel intestinal; y una combinación de ambas. Dentro de las técnicas restrictivas, la gastroplastía fue uno de los primeros procedimientos descritos. Inicialmente horizontal y luego la gastroplastía vertical anillada, mostraban buenos resultados a corto plazo, pero con una importante tasa de fracaso a largo plazo, por lo que estas técnicas fueron abandonadas paulatinamente. La banda gástrica ajustable tiene la ventaja de ser mínimamente invasiva y reversible, la baja de peso es adecuada pero menos efectiva que en el bypass gástrico. Las complicaciones postoperatorias son pocas inicialmente, sin embargo aumentan con los años de seguimiento. La gastrectomía vertical tubular es un procedimiento efectivo para bajar de peso, que puede ser realizado en forma segura como procedimiento primario único o como primera etapa de otro procedimiento. Esto se refleja en una excelente baja de peso y control de las comorbilidades, lo cual la hace comparable a otros procedimientos bariátricos aceptados. Finalmente en los últimos años han aparecido reportes promisorios de una nueva técnica, la plicatura gástrica.

Bariatric surgery has proved to be more effective than medical therapy in the treatment for obesity. Multiple techniques have been described and can be divided into three main groups: Restrictive surgery, where the main objective is to decrease the volume of caloric intake; malabsortive surgery, where a portion of the absortive circuit is bypassed and thus limiting the caloric absortion; and a combination of both. Among the restrictive techniques, gastroplasty was one of the first procedures described. First horizontal gastroplasty and then vertical banded gastroplasty showed good short-term results but with poor long-term outcomes. These techniques have been gradually abandoned. Adjustable gastric banding is a minimally invasive technique and has the advantage of being reversible. Weight loss is adequate, but less effective than gastric bypass. Postoperative complications are low at short-term, but increase per year at long-term follow-up. Sleeve gastrectomy is an effective weight loss procedure that can be performed safely as a first stage or primary procedure. This results in excellent weight loss and co-morbidity reduction that exceeds, or is comparable to, that of other accepted bariatric procedures. Gastric plicature is a relatively new procedure and has reported good short-term outcomes in weight loss with few short-term complications. However, long-term outcomes are yet to be demonstrated.

Operação de Scopinaro modificado na falha da banda gástrica / Scopinaro modified operation for gastric banding failure

RACIONAL: A banda gástrica ajustável por videolaparoscopia é uma das técnicas cirúrgicas mais utilizadas na Europa e Austrália no tratamento da obesidade mórbida. É procedimento seguro, com muito baixa mortalidade, porém não é isento de complicações ou insucessos, com necessidade de re-operação em alguns casos. OBJETIVO: Avaliar os resultados da aplicação da técnica de Scopinaro modificada, na falha da aplicação da banda gástrica ajustável. MÉTODO: Utilizou-se a técnica de Scopinaro por videolaparoscopia sem ressecção do corpo e antro gástrico (técnica de Domene). Com este procedimento, foram operados 14 pacientes, sendo cinco do sexo feminino, com idade entre 24 e 68 anos, IMC (índice de massa corpórea) variando entre 35,3 a 55,2 kg/m². RESULTADOS: O tempo operatório médio foi de três horas. Não houve complicações durante a operação. No pós-operatório imediato, todos os pacientes foram realimentados no primeiro dia. A evolução em longo prazo, 18 meses após, mostrou perda de 68 por cento do excesso e resolução da diabetes tipo II e dislipidemia e melhora da hipertensão em todos os casos. CONCLUSÃO: A aplicação da operação de Scopinaro modificada por videolaparoscopia no resgate da banda gástrica ajustável é método que promove perda de peso satisfatória e persistente, através de pequena restrição alimentar, acompanhada de alto grau de satisfação com efeitos indesejáveis toleráveis.

BACKGROUND: The laparoscopic adjustable gastric band is one of the most used techniques in Europe and Australia in the treatment of morbid obesity. It is safe procedure with very low mortality, but is not free of complications or failure, requiring reoperation in some cases. AIM: To evaluate the results of applying the technique of modified Scopinaro, failure of the application of adjustable gastric band. METHOD: Was used the technique for laparoscopic Scopinaro without resection of the body and gastric antrum (Domene technique). With this procedure, 14 patients were operated, five females, aged between 24 and 68 years, BMI (body mass index) ranging from 35.3 to 55.2 kg/m². RESULTS: Mean operative time was three hours. There were no complications during the operation. In the immediate postoperative period, all patients were fed back into the first day. Over the long term, 18 months later, showed a 68 percent loss of excess and resolution of type II diabetes and dyslipidemia and hypertension improved in all cases. CONCLUSION: The application of modified Scopinaro operation by laparoscopy in the rescue of adjustable gastric banding is the method that promotes weight loss and persistent satisfactory, through a small food restriction, accompanied by a high degree of satisfaction with tolerable side effects.

Gastrectomía vertical posterior a retiro de banda gástrica / Sleeve gastrectomy performed simultaneously to extraction of a gastric band: experience in 10 patients

Background: Sleeve gastrectomy is replacing gastric banding in the management of morbid obesity. Aim: To report the results of sleeve gastrectomy performed simultaneously with the extraction of a gastric band. Material and Methods: We report ten patients aged 34 to 53 years (nine women) operated between 2008 and 2009. Results: The main indication for sleeve gastrectomy was the failure of the gastric band. No complications were recorded and patients were discharged 72 hours after the procedure. Conclusions: Sleeve gastrectomy can be carried out simultaneously with the extraction of a gastric band, without increasing operative complications.

Introducción: La Gastrectomía Vertical ha reemplazado a la banda gástrica en el manejo de un importante número de pacientes portadores de obesidad. El objetivo de este trabajo es mostrar los resultados de una serie de pacientes, en los que se realizó una Gastrectomía Vertical posterior a la extracción de una banda gástrica en un mismo tiempo operatorio. Método: La serie incluye a 10 pacientes operados entre Mayo de 2008 y Noviembre de 2009. La principal indicación de la Gastrectomía Vertical fue el fracaso de la banda como tratamiento de la obesidad. Resultados: En los 10 pacientes estudiados, la gastrectomía se pudo efectuar sin mayores dificultades ni diferencias con respecto al procedimiento habitual. No existieron complicaciones post operatorias, siendo la totalidad de los pacientes dados de alta dentro de las 72 horas. Conclusión: La Gastrectomía Vertical representa una alternativa de manejo en pacientes portadores de una banda gástrica con indicación de extracción de esta, ya sea por fracaso o por síntomas asociados a su presencia. El procedimiento puede efectuarse de manera segura en el mismo acto operatorio y sus resultados son comparables a los observados cuando la técnica se efectúa en pacientes que no han sido intervenidos previamente.