Evaluation of atopy schools for parents.

INTRODUCTION: Atopic dermatitis is a highly prevalent chronic disorder. Therapeutic education in diseases of this kind is essential in order to improve patient management and prognosis. A study was conducted regarding parent satisfaction following educational sessions in an Atopy School organized by a multidisciplinary team. MATERIAL AND METHODS: E-mail surveys with variables scored by means of a Likert scale were administered among the parents participating in the workshops organized by the Atopy School. The educational program comprised four sessions with a duration of 4 hours. RESULTS: Ninety-five percent of the parents were satisfied after participating in the workshops, and were of the opinion that the therapeutic education received was useful for improving control of the illness of their children. Likewise, 85% were satisfied or very satisfied with the help received in the sessions for control of the disease during flare-ups, and 90% considered the data and advice received in the sessions to be of use in improving quality of life of both the children and the family as a whole. CONCLUSIONS: The Atopy School afforded caregiver empowerment, and the parents were satisfied and felt more secure in dealing with the disease of their children-thereby improving the prognosis and quality of life.

LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION.

BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

Latest results (12-21 years) of a prospective randomized study comparing Billroth II and Roux-en-Y anastomosis after a partial gastrectomy plus vagotomy in patients with duodenal ulcers.

INTRODUCTION: After a partial resection of the stomach, the continuity of the gastrointestinal tract can be restored either by a Billroth II gastrojejunal anastomosis or a Roux-en-Y gastrojejunostomy. Each procedure has its advantages and disadvantages. OBJECTIVE: To determine through a prospective and random clinical trial, the clinical outcome and the endoscopic and histologic alterations of the distal esophagus and the gastric remnant in patients who received a partial distal gastrectomy due to duodenal ulcers and a Billroth II or Roux-en-Y reconstruction. MATERIAL AND METHODS: In this prospective random trial, a total of 75 patients with duodenal ulcers were included. A bilateral selective vagotomy and partial distal gastrectomy were performed in all patients. A Billroth II or Roux-en-Y 60-cm-long loop was randomly used for reconstruction of the gastrointestinal tract. During the latest follow-up clinical evaluation, upper endoscopy and biopsy samples from the distal esophagus and gastric remnant were obtained. RESULTS: There was 1 operative mortality and 6 patients had some morbidity. The average follow-up period was 15.5 years (range, 11-21). Patients with Roux-en-Y gastrojejunostomy were significantly more asymptomatic and had greater Visick I grading than patients with Billroth II reconstruction (P < 0.001). In the distal esophagus, endoscopic findings were normal in 90% of the Roux-en-Y group, but only in 51% of the Billroth II group (P < 0.0009). Nearly 25% of the latter group had the appearance of a short-segment Barrett esophagus compared with 3% of the Roux-en-Y group (P < 0.0001). The gastric remnant endoscopic findings were normal in 100% of the Roux-en-Y group and in 18% of the Billroth II group (P < 0.02). Histologic analyses showed similar proportions of normal fundic mucosa and chronic active fundic gastritis. However, chronic atrophic fundic gastritis and intestinal metaplasia were significantly more frequent after Billroth II reconstruction (P < 0.008). Helicobacter pylorus was present in a similar proportion of patients. CONCLUSIONS: This prospective and random study showed that Roux-en-Y gastrojejunostomy is significantly better than a Billroth II reconstruction in patients with duodenal ulcers, through subjective and objective endoscopic and histologic evaluations during the latest follow-up evaluation.

Incidence of anastomotic strictures after gastric bypass: a prospective consecutive routine endoscopic study 1 month and 17 months after surgery in 441 patients with morbid obesity.

BACKGROUND: Anastomotic stricture after gastric bypass for morbid obesity has been reported as the most frequent complication after surgery. The objective of this study is to determine in a prospective and consecutive endoscopic evaluation the true incidence of this complication early and late after gastric bypass. METHODS: A total of 441 morbidly obese patients were included in this prospective study. They were 358 women and 97 men, with a mean age of 41 years and a mean body mass index of 43 kg/m2. In all an endoscopic evaluation was performed 1 month after surgery, which was repeated in 315 patients (71.6%) 17 months after surgery, independent of the presence or not of symptoms. Anastomotic diameter was measured and strictures were classified as: (a) mild, with a diameter of 7 to 9 mm, (b) moderate with a diameter of 5 to 6 mm, and (c) difficult or critical with a diameter equal or less to 4 mm. Two methods of dilatation were employed: the endoscope itself or Savary-Gilliard dilators. Patients were submitted to laparotomic resectional gastric bypass in whom a circular stapler 25 was employed for gastrojejunal anastomosis or to laparoscopic gastric bypass, in whom hand-sewn one layer continuous suture was employed. RESULTS: One month after surgery, 23% of patients after open gastric bypass employing circular stapler 25 presented anastomotic stricture, being 22% of them critical. After laparoscopic gastric bypass employing hand-sewn anastomosis, 36% of the patients presented strictures, being critical 10% (p>0.17). Patients with mild or moderate strictures needed one or two dilatations. Patients with critical strictures needed three to five dilatations. There were no complications associated to dilatation. Moderate and severe strictures were symptomatic; however 29% of patients with mild strictures were asymptomatic. Endoscopy was repeated in 71% of the whole group 17 months after surgery, demonstrating normal anastomosis in all. CONCLUSIONS: Stricture at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Near 60% present a mild stricture (with a diameter between 7 and 9 mm), being 28% asymptomatic. This complication is easily treated by endoscopic procedure if it is diagnosed early (3 to 4 weeks) after surgery. Routine endoscopy 1 month after surgery is the only objective scientific way to determine the real true incidence of this complication.

A prospective randomized study comparing patients with morbid obesity submitted to laparotomic gastric bypass with or without omentectomy.

BACKGROUND: Visceral fat, especially the greater omentum, seems to be an important factor in the development of some metabolic disturbances such as insulin resistance, hyperglycemia, and dyslipidemia. Therefore, we wanted to evaluate the influence of resecting or leaving in situ the greater omentum in a group of patients with morbid obesity. METHODS: Seventy patients with morbid obesity were submitted to laparotomic resectional gastric bypass and an omentectomy was randomly performed in some patients. Body mass index (BMI), serum levels of sugar, insulin, total cholesterol, and triglycerides were determined prior to surgery and followed up on for 2 years afterwards. RESULTS: Two years after surgery, no differences were seen in BMI levels in either group. Blood sugar levels, serum insulin, total cholesterol levels, and serum triglycerides had similar values in both groups. Arterial hypertension had similar behavior. CONCLUSIONS: Based on these results, omentectomy is not justified as part of bariatric surgery. Its theoretical advantages are not reflected in this prospective random trial.

Incidence of marginal ulcer 1 month and 1 to 2 years after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients with morbid obesity.

BACKGROUND: Marginal ulcer (MU) is an occasional complication after gastric bypass. We studied the incidence of this complication by a prospective routine endoscopic evaluation. METHODS: 441 morbidly obese patients were studied prospectively. There were 358 women and 97 men, with mean age 41 years and mean BMI 43 kg/m(2). An endoscopic evaluation was performed in all 1 month after surgery, which was repeated in 315 patients (71%) 17 months after surgery, independent of the presence or absence of symptoms. Patients were submitted either to laparotomic resectional gastric bypass (360 patients), employing a circularstapler-25 or to laparoscopic gastric bypass (81 patients), in whom a hand-sewn anastomosis was performed. RESULTS: One month after surgery, 15 patients (4.1%) of the 360 laparotomic gastric bypass and 10 (12.3%) of the 81 laparoscopic gastric bypass presented an "early" marginal ulcer (p < 0.02). Seven patients among the 25 with MU were asymptomatic (28%). Endoscopy was repeated 17 months after surgery. Among 290 patients with no early MU, one patient (0.3%) presented a "late" MU 13 months after surgery. From the 25 patients with "early" MU, one patient (4%) presented a "late" MU. All these patients were treated with PPIs. CONCLUSION: By performing prospective routine endoscopic study 1 month and 17 months after gastric bypass, two different behaviors were seen regarding the appearance MU: (a) "early" MU, 1 month after surgery in mean 6% and (b) "late" MU, in a very small proportion of patients (0.6%). Among patients with "early" MU, those who had undergone resectional gastric bypass showed significantly less ulcers compared to those patients in whom the excluded distal gastric segment had been left in situ. The operative method may play a significant role in the pathogenesis of MU after gastric bypass.

Inflammatory response measured by body temperature, C-reactive protein and white blood cell count 1, 3, and 5 days after laparotomic or laparoscopic gastric bypass surgery.

BACKGROUND: Morbid obesity is a chronic inflammatory condition due to the production of several cytokines from the adipose tissue. However, what happens with some of these parameters the first days after surgery is unknown. Therefore, the objective of the present study was to determine, through a prospective and descriptive study, the behavior of the C-reactive protein (CRP), the white blood cell count, and the body temperature prior to a gastric bypass and for 5 days afterwards. METHODS: A total of 156 patients with morbid obesity were included in this prospective study. There were 120 women and 36 men, with a mean age of 41 years and a body mass index of 43 kg/m(2). They were submitted either to a laparotomic resectional gastric bypass or to a laparoscopic gastric bypass. Body temperature was measured every 8 h during 5 days. CPR and white blood cells were measured at the first, third, and fifth day after surgery. RESULTS: All patients had a normal postoperative course. Body temperature showed no change. White blood cells increased significantly at the first and third day after surgery but normalized by the fifth day. However, the third day after surgery, laparotomic gastric bypass patients showed a significantly greater increase in the total white blood cell count as well as in segmented neutrophil cells compared to laparoscopic surgery patients. CRP exhibited a similar increase and was more pronounced after a laparotomic approach. CONCLUSION: During the 5 days after gastric bypass, a significant increase in white blood cells and CRP was observed. The increase was significantly greater after a laparotomic bypass compared to the laparoscopic approach.

Clinical, Endoscopic, and Histologic Findings at the Distal Esophagus and Stomach Before and Late (10.5 Years) After Laparoscopic Sleeve Gastrectomy: Results of a Prospective Study with 93% Follow-Up.

OBJECTIVE: Perform a prospective study based on sequential clinical, endoscopic, and histologic evaluations of the foregut late after laparoscopic sleeve gastrectomy (LSG) in obese patients. After LSG, several studies have suggested an increase in the incidence of clinical gastroesophageal reflux (GERD) while others have reported an improvement but based mainly on clinical questionnaires. METHODS: Prospective study of 104 consecutive patients submitted to LSG. Several postoperative endoscopic and histologic evaluations of the esophagogastric junction (EGJ) and the gastric tube (GT) were performed and correlated with symptomatic findings. RESULTS: According to clinical preoperative findings, patients were divided into non-refluxers (Group I) and refluxers (Group II). Seven patients were unreachable, leaving 97 (93%) for late evaluation. Among Group I, 58.5% developed de novo GERD, while in Group II just 13.6% showed the disappearance of them. Endoscopic evaluations showed progressive deterioration of the EGJ in Group I, with the development of erosive esophagitis (EE), hiatal hernia (HH), and dilated cardia in a large proportion of them. In the GT, the presence of bile was seen in 40%, and an open immobile pylorus was detected in 82%. Short-segment Barrett's esophagus (BE) appeared in 4%. CONCLUSIONS: Patients submitted to LSG showed a significant and progressive increase in the presence of "de novo" GERD. Also, an increased duodenogastric reflux was seen through an open and immobile pylorus. Therefore, based on these results, it seems like LSG is a "pro-reflux" surgical procedure, which should be continuously evaluated late after surgery.

Loss and Regain of Weight After Laparoscopic Sleeve Gastrectomy According to Preoperative BMI : Late Results of a Prospective Study (78-138 months) with 93% of Follow-Up.

INTRODUCTION: The long-term results in sleeve gastrectomy (SG) have been reported in few publications. None of them has evaluated the importance of preoperative BMI (kg/m2) in the final results. OBJECTIVE: To determine the loss and regain of weight after SG, determining the influence of preoperative BMI in final results. MATERIAL AND METHODS: This prospective study included all patients operated between 2006 and 2010. Exclusion criteria corresponded to patients with Barrett's esophagus, type 2 diabetes, and hiatal hernia greater than 3 cm. Patients were followed and controlled "face to face" by the main author. RESULTS: From 109 original patients included in this study, 102 (93.5%) completed the late follow-up. Patients were divided into four groups: (a) I-29 patients with BMI 32.1-34.9; (b) II-56 patients with BMI 35-39.9; (c) III-20 patients with BMI 40-49.9; and (d) IV-4 patients with BMI > 50. There was a significant decrease in the BMI 12 to 24 months after surgery. At the late control, patients in groups III and IV regained weight in 85 and 100%, respectively. Patients in groups I and II had 3.6 and 38% of weight regain. CONCLUSION: The changes in weight after SG are directly related to preoperative BMI: the higher this value, the higher the percentage of failure and weight regain late after surgery. Besides, laparoscopic SG seems to be an adequate operation at late control in terms of loose of weight after surgery in patients with a BMI less than 40 kg/m2 before surgery.

Endoscopic and histologic findings of the foregut in 426 patients with morbid obesity.

BACKGROUND: Roux-en-Y gastric bypass is the most frequent bariatric operation. In this operation, the distal bypassed stomach is left in situ. We studied pre-operative clinical, endoscopic and histologic findings in a consecutive group of morbidly obese patients prior to bariatric surgery. METHODS: A prospective study was conducted from August 1999 until May 2004, which consisted of 426 patients with morbid obesity. There were 94 men and 332 women, with mean age 39.5 years. In all patients prior to surgery, upper endoscopy was performed and biopsy samples were taken distal to squamo-columnar junction (cardiac biopsies), and in 232 of them also in at the antrum. RESULTS: Pathological findings at the esophagus were seen in 55% of the patients, mainly related to reflux esophagitis. Barrett's esophagus was seen in 5.8%. In the stomach, pathological findings were seen in 32% of the patients. Active peptic ulcer was demonstrated in 2.6% of the cases. At the duodenum, pathologic findings were detected in 13.4% of the patients, showing an ulcer in 2.6%. At the stomach, chronic inactive gastritis and atrophic gastritis with intestinal metaplasia were found in 8.6% and 6.5% respectively. Antral adenoma with low-grade dysplasia was found in 1 patient, and 1 carcinoid tumor. H. pylori was present in 53% of the patients, mainly in the antrum. CONCLUSION: In candidates for bariatric surgery, upper endoscopy with biopsy samples and determination of H. pylori should be routinely performed. If present, H. pylori should be eradicated. After surgery, if Barrett's esophagus was present, endoscopic surveillance is recommended.

Laparoscopic sleeve gastrectomy: surgical technique, indications and clinical results.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been introduced as a multipurpose restrictive procedure for obese patients. Variations of the surgical technique may be important for the late results. METHODS: 50 patients submitted to LSG from January 2005 to December 2006 were studied. Mean age was 38.2 years, preoperative weight was 103.4 +/- 14.1 kg (78 to 146 kg), and preoperative BMI was 37.9 +/- 3.4 (32.9 to 46.8). Important co-morbidities were present in 39 patients (78%). RESULTS: Operative time was 110 +/- 15 min. Intraoperative difficulties were observed in 7 patients. Volume of the resected specimen was 760 +/- 55 ml and capacity of the gastric remnant was 108.5 +/- 25 ml. There was no conversion to open surgery. Histology of the resected stomach was normal in 8 patients, while chronic gastritis was found in 42 patients. At 6 and 12 months postoperatively, weight loss was 28.0 +/- 6.4 kg and 32.6 +/- 6.8 kg respectively. In the 18 patients who have reached 1 year follow-up, % excess BMI loss reached 85 +/- 0.7%. Most of the medical diseases associated with the obesity resolved after 6 to 12 months. CONCLUSION: LSG may be an acceptable operation. It is easy to perform, safe, and has a lower complication rate than other bariatric operations. Further studies are necessary for the clinical results at long-term follow-up.

Behavior of the common bile duct diameter before and 12 years after choledochostomy for cholecystolithiasis and choledocholithiasis. A prospective study.

INTRODUCTION: In patients with common bile duct (CBD) stones, the diameter of the CBD is usually dilated. After surgery, the behavior of CBD diameter is not clearly known. OBJECTIVE: To determine at a late follow-up the width of CBD before and after choledochostomy for CBD stones. MATERIAL AND METHODS: In this prospective study, 39 patients with gallstones and CBD stones were included. They were 30 women and 9 men with a mean age of 52.6 years. In all ultrasound, determination of the CBD caliber before and 12 years after surgery was performed. RESULTS: The mean value of the inner diameter of the CBD before surgery was 11.6 and 12.3 mm in patients below or above 60 years, respectively. Measurement 12 years after surgery showed a mean decrease of nearly 50% of preoperative values, which was highly significant (p < 0.0001). However, either below or above 60 years, only 75% of the patients showed this decrease, whereas 25% remained unchanged. CONCLUSION: The dilated preoperative CBD returns to normal or near normal values in 3/4 of the patients after surgical exploration of the CBD and extraction of the stones.

Laparoscopic redo fundoplication alone, redo nissen fundoplication, or toupet fundoplication combined with roux-en-y distal gastrectomy for treatment of failed nissen fundoplication / Refazer fundoplicatura laparoscópica, refazer fundoplicatura a nissen ou toupet combinada com gastrectomia distal em y-roux para tratamento de recidiva após fundoplicatura a nissen

ABSTRACT BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

RESUMO RACIONAL: A fundoplicatura de Nissen laparoscópica falha em controlar o refluxo gastroesofágico em quase 15% dos pacientes e a maioria deles deve ser reoperada devido aos sintomas. Diferentes técnicas cirúrgicas têm sido sugeridas. OBJETIVOS: Apresentar os resultados pós-operatórios de pacientes submetidos a 3 procedimentos diferentes: Reoperação e fundoplicatura de Nissen laparoscópica apenas (Grupo A), reoperação e fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal (Grupo B) ou reoperação e conversão para Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux (Grupo C). MÉTODOS: estudo prospectivo incluindo 77 pacientes submetidos inicialmente a fundoplicatura de Nissen laparoscópica que apresentaram recidiva do refluxo gastroesofágico após a operação. Eles foram avaliados antes e após a reoperação com questionário clínico e estudos funcionais específicos. Reestabelecida a anatomia da junção esôfago-gástrica, procedeu-se às referidas cirurgias. Nenhum paciente perdeu seguimento. RESULTADOS: Os sintomas persistentes foram observados com maior frequência nos pacientes dos Grupos A ou B, associados à estenose da fundoplicatura, fundoplicatura intratorácico ou fundoplicatura torcida. No Grupo C, os sintomas recorrentes associados a essa alteração anatômica foram observados com pouca frequência. Esfincter esofágico inferior incompetente foi confirmado em 57,7% dos pacientes pertencentes ao Grupo A em comparação com 17,2% após fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal, e 26% após a Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux. Nesse grupo, apesar do alto percentual de pacientes com esfincter esofágico inferior incompetente, 8,7% apresentaram refluxo ácido anormal após a cirurgia. CONCLUSÕES: As técnicas de Nissen ou Toupet combinados com a gastrectomia distal em Y de Roux são seguras e eficazes para o manejo da falha da fundoplicatura a Nissen. A técnica de Toupet é preferível para pacientes que sofrem principalmente com disfagia e dor.

Histological findings in the liver before and after gastric bypass.

BACKGROUND: Bariatric surgery results in massive loss of excess weight, changes in co-morbidities and improvement in quality of life. In these patients, liver histology taken before or during surgery reveals several histological abnormalities. In a prospective study of patients previously submitted to gastric bypass, we determined the changes in liver histology late after the surgery. METHODS: In 16 out of a total of 557 patients who were submitted to open gastric bypass, a second liver biopsy was taken during the repair of an incisional hernia, performed at a mean of 17 months after the gastric bypass. RESULTS: All patients had lost weight, now having a mean BMI of 28.6 kg/m(2) (which had been 44.3 kg/m(2) before gastric bypass). One patient with normal pre-operative liver histology remained normal at the second study. 11 out of 15 who had had liver abnormalities returned to a normal condition or had only minimal change (73.3%). 2 patients (13.3%) showed improvement, while 1 patient presented a slight worsening of liver condition. One patient who had had liver cirrhosis showed no change. CONCLUSION: Gastric bypass for morbid obesity is followed by a dramatic improvement or normalization of liver histological abnormalities in the great majority of the patients. Liver cirrhosis in the one patient remained unchanged.

Endoscopic and histologic findings in the gastric pouch and the Roux limb after gastric bypass.

BACKGROUND: Despite the large number of gastric bypasses performed for morbid obesity, very little is known about the endoscopic and histologic aspects of the gastric pouch and the Roux-limb late after surgery. We performed prospective routine endoscopic and histologic studies of the pouch and Roux-limb 2 years after gastric bypass. METHODS: The present study includes 227 patients submitted to resectional gastric bypass and followed for a mean of 27 months after surgery. Mean BMI before bypass was 44 kg/m2. In all patients, upper endoscopy of the pouch and of the jejunal limb was performed, taking 3 biopsy samples of the gastric pouch in 171 patients and 2 samples of the jejunum in 40 patients. RESULTS: Macroscopic appearance of the gastric pouch was normal in 99% of the patients and of the jejunal limb in 100%. Histologic analysis revealed normal fundic mucosa in 56%. Chronic active gastritis was the most frequent abnormal histologic finding. 7 patients (4.1%) showed intestinal metaplasia. H. pylori infection was present in the gastric pouch in 31% of the patients. CONCLUSIONS: The proximal gastric pouch after gastric bypass is endoscopically normal in 99% of patients 2 years after surgery, while the Roux-limb is normal in 100%. Histologic analysis of gastric mucosa revealed normal fundic mucosa in 56%. There are some chronic histologic changes, even intestinal metaplasia, whose behavior at late follow-up is not yet known. H. pylori is present in nearly (1/3) of the patients.

Effect of gastric bypass on Barrett's esophagus and intestinal metaplasia of the cardia in patients with morbid obesity.

Gastric bypass in patients with morbid obesity should be an excellent antireflux procedure, because no acid is produced at the small gastric pouch and no duodenal reflux is present, due to the long Roux-en-Y limb. Five hundred fifty-seven patients with morbid obesity submitted to resectional gastric bypass, and routine preoperative upper endoscopy with biopsy samples demonstrated 12 patients with Barrett's esophagus (2.1%) and three patients with intestinal metaplasia of the cardia (CIM). An endoscopic procedure was repeated twice after surgery, producing seven patients with short-segment Barrett's esophagus (BE) and five patients with long-segment BE. Body mass index (BMI) decreased significantly, from 43.2 kg/m(2) to 29.4 kg/m(2) 2 years after surgery. Symptoms of reflux esophagitis, which were present in 14 of the 15 patients, disappeared in all patients 1 year after surgery. Preoperative erosive esophagitis and peptic ulcer of the esophagus healed in all patients. There was regression from intestinal metaplasia to cardiac mucosa in four patients (57%) with short-segment BE, and in one patient (20%) with long-segment BE. Two (67%) of three cases with CIM had regression to cardiac mucosa. There was no progression to low- or high-grade dysplasia. Gastric bypass in patients with Barrett's esophagus and morbid obesity is an excellent antireflux operation, proved by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression to cardiac mucosa that is length-dependent and time-dependent.

Size, volume and weight of the stomach in patients with morbid obesity compared to controls.

BACKGROUND: There is no mention in surgical literature regarding anatomic measurements of the stomach in patients with morbid obesity. We investigated by a prospective study the length of the lesser and greater curvature, the volume or total capacity and the weight of the stomach in morbidly obese patients compared to controls. METHODS: 30 patients with different degrees of morbid obesity were compared to 20 controls. Measurements included length of both curvatures of the stomach, weight and total volume of saline needed to distend the stomach. Patients with morbid obesity were submitted to resectional gastric bypass. The stomach of controls was obtained from autopsy material during the first day after death. RESULTS: The length of the lesser curvature, total gastric capacity and weight of the stomach of morbidly obese patients were similar to control subjects. The length of greater curvature was significantly less in patients with morbid obesity. CONCLUSIONS: No significant differences were found in anatomic measurements of the stomach between control subjects and patients with morbid obesity.

Conservative management of anastomotic leaks after 557 open gastric bypasses.

BACKGROUND: One of the most serious complications after gastric bypass is an anastomotic leak. In a prospective surgical protocol for the management of this complication, the authors determined the incidence of anastomotic leaks. METHODS: From August 1999 to January 2005, 557 patients with morbid obesity were submitted to laparotomic resectional gastric bypass. In all patients a left drain was placed during surgery. All patients had a radiological study with liquid barium sulphate on the 5th postoperative day. After the occurrence of an anastomotic leak, the daily output of the leak was carefully measured. RESULTS: 12 patients developed an anastomotic leak at the gastrojejunostomy. All were managed medically, with antibiotics if necessary, enteral or parenteral feeding and frequent control by imaging procedures. In 8 patients, the left drain was maintained in situ up to 43 days after surgery. In 4 patients, the drain had been removed between the 5th and 8th days after surgery after a normal radiologic study, but had to be inserted under radiological control 2-3 weeks after the gastric bypass. Daily output increased significantly the second week after surgery, and the leak closed at a mean of 30 days after surgery. One patient of the 12 (8%) died 32 days after surgery from septic shock, without any abdominal collection secondary to the leak. CONCLUSION: The occurrence of an anastomotic leak is nearly 2% after gastric bypass. The majority of them can be managed medically, without the need for a reoperation, due to the fact that there is no acid production in the small gastric pouch and there is no intestinal reflux due to the long Roux loop.

Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients.

Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure. The objective of this study is to describe a series of patients who were subjected to LSG and then developed gastric stenosis, with an emphasis on their treatment and a discussion of the possible underlying mechanisms. From January 2006 to October 2012, 717 patients with morbid obesity underwent LSG in our institution. Out of 717 patients, 571 (79.6 %) were women. The mean age was 36.9 years with a BMI of 37.3 kg/m(2). Five patients (0.69 %) developed gastric stenosis. Treatment of the stenosis was endoscopic dilatations; however, one patient required a conversion to laparoscopic Roux-en-Y gastric bypass. Stenosis after LSG is rare but requires early diagnosis and treatment.

Classification and management of leaks after gastric bypass for patients with morbid obesity: a prospective study of 60 patients.

The most important and frequent major complication after gastric bypass is the appearance of a leak, which can result in death of a patient. The purpose of this prospective study was to determine the incidence of a postoperative leak, to propose a classification and to evaluate the results of conservative or surgical treatment. All patients submitted to gastric bypass either laparotomic or laparoscopic were included in a prospective protocol. In all radiological evaluation at 4(th) day after surgery was performed. The presence of a leak was evaluated according to the day of appearance, its location and its severity. Results of medical or surgical treatment were analyzed. From 1764 patients submitted to Roux-en-Y gastric bypass, 60 had a postoperative leak (3.4%). This leak appeared early after surgery (before 4 days) in 20%. It was a localized subclinical leak in 20% and clinical - septic in 80%. There were 7 possible anatomic location of a leak, being the gastrojejunal anastomosis the most frequent location (53%) followed by gastric pouch. The highest mortality was associated to the jejuno-jejunal anastomosis. Conservative treatment was employed in near 65% of the patients: The mean time of closure of a leak was 34 days. The appearance of a postoperative leak is a major and serious complication. It can be classified according to the day of appearance, its severity and its location. Conservative or surgical treatment can be employed properly if these 3 parameters are carefully evaluated.