Endoscopic treatment of food intolerance after a banded gastric bypass: inducing band erosion for removal using a plastic stent.

BACKGROUND AND STUDY AIMS: Ring complications after a banded Roux-en-Y gastric bypass (RYGB) are usually managed surgically. The aim of this study was to analyze the safety and effectiveness of endoscopic removal of noneroded rings after banded-RYGB, by inducing intragastric erosion of the ring using a self-expandable plastic stent (SEPS). PATIENTS AND METHODS: A total of 41 patients with banded RYGB who had noneroded rings and food intolerance were prospectively enrolled. Patients were treated with endoscopic SEPS placement and ring removal. Data from time of stenting, resolution of symptoms, need for endoscopic dilation, and complications were recorded. RESULTS: Successful ring removal was possible in all patients. In 21 cases, the SEPS induced complete erosion, and in 17 cases the ring was removed a month later because of incomplete erosion at the time of SEPS removal. Nine patients (22.0 %) needed endoscopic dilation after stent removal in order to treat fibrotic strictures. Food tolerance was observed in 32 patients (78.0 %) after the procedure. No patient needed surgery and there were no deaths. CONCLUSIONS: Endoscopic removal of the ring using SEPS appeared to be safe and effective after a banded RYGB.

Urolithiasis and sleeve gastrectomy: a prospective assessment of urinary biochemical variables.

INTRODUCTION: to evaluate urinary biochemical alterations related to urolithogenesis processes after sleeve gastrectomy (SG). MATERIALS AND METHODS: : prospective study with 32 individuals without previous diagnosis of urolithiasis who underwent SG. A 24-h urine test was collected seven days prior to surgery and at 6-month follow-up. The studied variables were urine volume, urinary pH, oxalate, calcium, citrate, and magnesium and calcium oxalate super saturation (CaOx SS). RESULTS: patients were mainly women (81.2%), with mean age of 40.6 years. Mean pre- and postoperative BMI were 47.1 ± 8.3 Kg/m2 and 35.5 ± 6.1 Kg/m2, respectively (p<0.001). Urine volume was significantly lower at the postoperative evaluation in absolute values (2,242.50 ± 798.26 mL x 1,240.94 ± 352.39 mL, p<0.001) and adjusted to body weight (18.58 ± 6.92 mL/kg x 13.92 ± 4.65 mL/kg, p<0.001). CaOx SS increased significantly after SG (0.11 ± 0.10 x 0.24 ± 0.18, p<0.001). Moreover, uric acid levels were significantly lower at the postoperative evaluation (482.34 ± 195.80 mg x 434.75 ± 158.38 mg, p=0.027). Urinary pH, oxalate, calcium, citrate, and magnesium did not present significant variations between the pre- and postoperative periods. CONCLUSION: SG may lead to important alterations in the urinary profile. However, it occurs in a much milder way than that of RYGB.

Treatment of ring slippage after gastric bypass: long-term results after endoscopic dilation with an achalasia balloon (with videos).

BACKGROUND: Silastic rings are used in gastric bypass procedures for the treatment of obesity, but ring slippage may lead to gastric pouch outlet stenosis (GPOS). Conventional management has been ring removal through abdominal surgery. OBJECTIVE: To describe a novel, safe, minimally invasive, endoscopic technique for the treatment of GPOS caused by ring slippage after gastric bypass. DESIGN: Case series. SETTING: Federal University of Pernambuco and São Paulo University. PATIENTS: This study involved 39 consecutive patients who were screened for inclusion. INTERVENTION: Endoscopic dilation with an achalasia balloon. MAIN OUTCOME MEASUREMENTS: Technical success and safety of the procedure. RESULTS: Among the 39 patients, 35 underwent endoscopic dilation at the ring slippage site for the relief of GPOS. The 4 patients who did not undergo endoscopic dilation underwent surgical removal of the ring, based on the exclusion criteria. The endoscopic approach was successful in 1 to 4 sessions in 100% of cases with radioscopic control (n = 12). The duration of the procedures ranged from 5 to 30 minutes, and the average internment was 14.4 hours. Dilation promoted either rupture (65.7%) or stretching (34.3%) of the thread within the ring, thereby increasing the luminal diameter of the GPOS. Complications included self-limited upper digestive tract hemorrhage (n = 1) and asymptomatic ring erosion (n = 4). There were no recurrences of obstructive symptoms during the follow-up period (mean of 33.3 months). LIMITATIONS: This was not a randomized, comparison study, and the number of patients was relatively small. CONCLUSION: The technique described promotes the relief of GPOS with low overall morbidity and avoids abdominal reoperation for ring removal.

Evaluation of splenomegaly in the hepatosplenic form of mansonic schistosomiasis.

This study was aimed to evaluate splenomegaly in patients with the hepatosplenic (HS) form of mansonic schistosomiasis (MS), analyzing the size and weight of the spleen and their relationships with patients' gender and age. Between October, 1993 to July, 1998, 78 patients with the HS form of MS had undergone splenectomy as treatment of choice for bleeding due to portal hypertension, at Hospital das Clínicas, Pernambuco, Brazil. By means of abdominal palpation, the excess spleen felt below the left costal edge was measured, and the weight was obtained after splenectomy along with the histopathological analysis. Liver biopsy was performed intraoperatively in order to confirm MS and to rule out other liver diseases. The mean age of the 78 patients were 45 years and 41 of them (53%) were female. The average spleen weight was 912g and the mean spleen size palpable below the left costal edge was 9.1cm. There was a positive relationship between size and weight (p<0.001). Spleen weight and size were larger in males (p=0.007 and p=0.001, respectively). An inverse correlation between age and spleen weight was observed (p<0.001). A classification based upon spleen weight showed 53% of patients presenting a moderate (501-1000g) and 33% a severe (>1001g) splenomegaly. As for the spleen size, the classification showed 64% of patients presenting moderate (4.1-10cm below the left costal edge) and 21% severe (>10cm) splenomegaly. In conclusion, splenomegaly may be considered a key physical finding in patients with HS form of MS, and we found a good correlation between the spleen sizes clinically evaluated with its weight. The majority of cases presents a moderate to severe splenomegaly and spleen size is larger in men and it seems to decrease with aging.

Hepatitis G virus infection in patients with hepatocellular carcinoma in Recife, Brazil.

The evidence of a higher incidence of hepatitis G virus (HGV) infection among patients with hepatocellular carcinoma (HCC) and the relatively high prevalence of patients with primary liver carcinoma without apparent risk factors in our country motivated the present study, the objective of which was to determine the frequency of HGV-ribonucleic acid (RNA) in a series of patients with HCC. The diagnosis of HCC was established based on alpha-fetoprotein levels (>400 ng/ml), a compatible image and/or biopsy of the hepatic nodules. Markers of hepatitis B virus (HBV) (HBsAg and anti-HBc), hepatitis C virus (HCV) (anti-HCV) and HGV (HGV-RNA) were investigated using MEIA and RT-PCR (reverse transcriptase polymerase chain reaction). There were 32 patients evaluated, including 20 males (63%), with a mean age of 58 years. Twenty-eight (88%) patients were cirrhotic (Child-Pugh: A = 8 patients, B = 14, and C = 6) and 50% reported alcohol consumption. Serological hepatitis markers were detected in 26 (81%) patients, including HBV in 19 (59%), HCV in 12 (38%) and HGV in 9 (28%). Only one (3%) patient was positive for HGV alone. The prevalence of HGV in blood donors from the same region is 10%. The findings suggest that, despite the frequent detection of HGV markers in patients with HCC, isolated infection with this agent does not seem to be a relevant factor in the etiology of this carcinoma.

Urolithiasis and sleeve gastrectomy: a prospective assessment of urinary biochemical variables / Urolitíase e gastrectomia vertical: uma avaliação prospectiva das variáveis bioquímicas urinárias

ABSTRACT Introduction: to evaluate urinary biochemical alterations related to urolithogenesis processes after sleeve gastrectomy (SG). Materials and methods : prospective study with 32 individuals without previous diagnosis of urolithiasis who underwent SG. A 24-h urine test was collected seven days prior to surgery and at 6-month follow-up. The studied variables were urine volume, urinary pH, oxalate, calcium, citrate, and magnesium and calcium oxalate super saturation (CaOx SS). Results: patients were mainly women (81.2%), with mean age of 40.6 years. Mean pre- and postoperative BMI were 47.1 ± 8.3 Kg/m2 and 35.5 ± 6.1 Kg/m2, respectively (p<0.001). Urine volume was significantly lower at the postoperative evaluation in absolute values (2,242.50 ± 798.26 mL x 1,240.94 ± 352.39 mL, p<0.001) and adjusted to body weight (18.58 ± 6.92 mL/kg x 13.92 ± 4.65 mL/kg, p<0.001). CaOx SS increased significantly after SG (0.11 ± 0.10 x 0.24 ± 0.18, p<0.001). Moreover, uric acid levels were significantly lower at the postoperative evaluation (482.34 ± 195.80 mg x 434.75 ± 158.38 mg, p=0.027). Urinary pH, oxalate, calcium, citrate, and magnesium did not present significant variations between the pre- and postoperative periods. Conclusion: SG may lead to important alterations in the urinary profile. However, it occurs in a much milder way than that of RYGB.

RESUMO Introdução: avaliar as alterações bioquímicas urinárias relacionadas aos processos de litíase urinária após gastrectomia vertical (GV). Método: estudo prospectivo, com 32 indivíduos submetidos a GV, sem diagnóstico prévio de urolitíase. Foi coletada urina de 24 horas, sete dias antes da operação e no retorno de 6 meses. As variáveis estudadas foram volume de urina, pH urinário, oxalato, cálcio, citrato e super saturação de oxalato e cálcio (SS CaOx). Resultados: os pacientes foram em sua maioria mulheres (81,2%), com idade média de 40,6 anos. O IMC médio pré e pós-operatório foi 47,1 ± 8,3 Kg/m2 e 35,5 ± 6,1 Kg/m2, respectivamente (p<0,001). O volume de urina foi significativamente baixo na avaliação pós-operatória em valores absolutos (2.242,50 ± 798,26 mL versus 1.240,94 ± 352,39 mL, p<0,001) e ajustado ao peso corporal (18,58 ± 6,92 mL/kg versus 13,92 ± 4,65 mL/kg, p<0,001). A SS CaOx aumentou significativamente após a GV (0,11 ± 0,10 versus 0,24 ± 0,18, p<0,001). Além disso, os níveis de ácido úrico apresentaram-se significativamente baixos na avaliação pós-operatória (482,34 ± 195,80 mg versus 434,75 ± 158,38 mg, p=0,027). PH urinário, oxalato, cálcio, citrato e magnésio não apresentaram variações significativas entre os períodos pré e pós-operatório. Conclusão: a GV pode levar a alterações importantes no perfil urinário. Entretanto, essas ocorrem de forma muito mais leve que na derivação gástrica em Y de Roux.

Metabolic and endocrinological factors related to nephrolithiasis pre and post multiple techniques of bariatric surgery: a sistematic review.

INTRODUCTION: Despite of benefits of bariatric surgery for obesity treatment, the procedure may be related to some complications. AIM: Analyze studies to address the relation between nephrolithiasis and bariatric surgery. METHODS: Ten papers about this theme were selected from 2005-2013 in Pubmed, describing the relation of nephrolithiasis or their risk factors with several types of bariatric surgery. RESULTS: Retrospective studies with minimal follow-up of three years demonstrated 7,65% in surgery patients and 4,63% non-surgery with nephrolithiasis (p<0,05). Prospective studies (8 of 10) revealed large percentage of calculi appearing and significant increase in oxaluria. CONCLUSION: There is correlation between obesity surgery and nephrolithiasis.

Association of human papillomavirus genomic sequences by polymerase chain reaction in gastric carcinomas in Brazil.

OBJECTIVE: To investigate the prevalence of human papillomavirus (HPV) in patients with gastric cancer and compare with a control group. STUDY DESIGN: Forty paraffin samples of gastric cancer and 40 endoscopic normal mucosa and peripheral blood controls were subjected to examination by polymerase chain reaction for the L1 gene of HPV. The extracted DNA was amplified in 2 reaction systems using 2 pairs of primers: MY09/MY11 and GP+5/GP+6. We used Milli-Q water as negative control and a mixture of 1 microL of human blood plus 0.25 microL of plasmid pBR322 (HPV-16) as positive control. RESULTS: HPV was found in 4 patients with gastric cancer and 10 patients without cancer. CONCLUSION: There was no statistically significant difference between the 2 samples (p = 0.077).

Small erosion of adjustable gastric band: endoscopic removal through incision in gastric wall.

The erosion of a laparoscopic adjustable gastric band (LAGB) can cause pain that is not controlled by analgesics. In such cases, early endoscopic removal may be indicated, but only when gastric penetration is greater than 50%. We report the case of a patient with severe shoulder pain due to a small area of LAGB erosion, which was treated with early endoscopic removal through an incision in the gastric wall. The pain worsened after eating and gastroscopy revealed slight gastric erosion of the band under the cardia. The gastric wall covering the LAGB was incised using an endoscopic needle knife. In a second upper endoscopy performed 7 days later at the endoscopy suite, endoscopic scissors were used to cut the thread and part of the band lock. The open band was then removed orally. This novel endoscopic incision in the gastric wall hastened band erosion and avoided abdominal reoperation.

Analysis of plasma citrulline and intestinal morphometry in mice with hepatosplenic schistosomiasis.

BACKGROUND: Portal hypertension in the mucosa of the intestine and the presence of granulomas in the wall of this organ can alter digestive function in patients with schistosomiasis. Citrulline is a potential marker of intestinal function in some diseases that affect the morphometry of the mucosa because of its close association with enterocytes. The aims of the present study were to determine serum citrulline concentrations in mice with hepatosplenic schistosomiasis, analyze the morphologic repercussions for the mucosa of the small intestine, correlate citrulline concentrations with morphometric changes in the intestinal mucosa, and evaluate the effect of splenectomy on citrulline concentration. METHODS: After approval from the local ethics committee, 46 adult female albino Swiss mice were divided into two groups: Control (23 healthy mice) and experimental (23 mice with hepatosplenic schistosomiasis). Blood samples were collected for the analysis of plasma citrulline before and after splenectomy. A segment of the jejunum was resected for morphometric analysis. RESULTS: The average body mass in the control group was greater than that in the experimental group (p = 0.00062). The average citrulline concentration in the control group was greater than that in the experimental group both before and after splenectomy (p < 0.001). In the experimental group, the villi had less height and area, and there was a smaller perimeter of the mucosal surface (p = 0.003, <0.001, and p = 0.001, respectively). There was a direct correlation between citrulline concentration and the height and area of the villi (p = 0.003 and 0.04, respectively). There was no correlation between citrulline concentration and the perimeter of the surface of the jejunal mucosa. After splenectomy, there was a reduction in the mean citrulline concentration in the experimental group (p = 0.009). CONCLUSIONS: Serum citrulline concentrations were reduced in mice with schistosomiasis, and a direct correlation was found between the citrulline concentration and the morphometry of the jejunal villi. Moreover, there was a reduction in the plasma concentration of citrulline after splenectomy.

Metabolic and endocrinological factors related to nephrolithiasis pre and post multiple techniques of bariatric surgery: a sistematic review / Fatores endócrinos e metabólicos relacionados à nefrolitíase pré e pós técnicas diversas de cirurgia bariátrica: uma revisão sistemática

INTRODUCTION: Despite of benefits of bariatric surgery for obesity treatment, the procedure may be related to some complications. AIM: Analyze studies to address the relation between nephrolithiasis and bariatric surgery. METHODS: Ten papers about this theme were selected from 2005-2013 in Pubmed, describing the relation of nephrolithiasis or their risk factors with several types of bariatric surgery. RESULTS: Retrospective studies with minimal follow-up of three years demonstrated 7,65% in surgery patients and 4,63% non-surgery with nephrolithiasis (p<0,05). Prospective studies (8 of 10) revealed large percentage of calculi appearing and significant increase in oxaluria. CONCLUSION: There is correlation between obesity surgery and nephrolithiasis. .

INTRODUÇÃO: Apesar dos benefícios das operações bariátricas para o tratamento da obesidade, elas podem acompanhar algumas complicações. OBJETIVO: Analisar estudos que enfoquem a relação entre nefrolitíase e procedimentos cirúrgicos bariátricos. MÉTODOS: Foram selecionados 10 estudos de 2005 a 2013 no PubMed que descreviam a relação de nefrolitíase ou seus fatores de risco com diversas técnicas de cirurgia bariátrica. RESULTADOS: Estudos retrospectivos, com seguimento por no mínimo três anos, demonstraram que 7,65% dos pacientes operados e 4,63% dos não operados apresentaram nefrolitíase (p<0,05). Estudos prospectivos (8 dos 10) verificaram grande porcentagem de aparecimento de nefrolitíase ou aumento significativo na oxalúria. CONCLUSÃO: Os estudos mostraram que há relação entre operações para obesidade e nefrolitíase. .

Resultados iniciais da oxigenoterapia hiperbárica empacientes em lista de espera para o transplante hepático / Preliminary results of hyperbaric oxygen therapy on patients on the waiting list for liver transplantation

RACIONAL: A função hepática é um processo complexo que envolve múltiplos eventos celulares. Ela, em pacientes cirróticos, pode se beneficiar da terapia com oxigênio hiperbárico. OBJETIVO: Avaliar, de forma preliminar, os dados clínicos e laboratoriais sobre a função hepática em pacientes cirróticos em lista de espera para transplante hepático, submetidos à oxigenoterapia hiperbárica. MÉTODO: Estudo prospectivo com intervenção, no qual 10 pacientes foram escolhidos aleatoriamente entre os pacientes cirróticos em lista de espera para transplante hepático. A idade variou de 20 a 65 anos, e todos apresentaram escore MELD maior que 15. Todos os pacientes foram submetidos a nove sessões de terapia com oxigênio hiperbárico, em dias alternados com a duração de 60 minutos por sessão, com atmosfera de oxigênio de 100 por cento e pressão de 2,8 ATM. As variáveis dependentes foram os valores laboratoriais bioquímicos e hematológicos, avaliados antes e após sessões de terapia hiperbárica de oxigênio, além de parâmetros clínicos, considerando-se também o Child-Turcotte-Pugh e o MELD. A análise estatística foi realizada com o SPSS (Statistcal Package for Social Sciences), e incluiu média com desvio-padrão. RESULTADOS: Trêspacientes (30 por cento) relataram diminuição no número e intensidade da encefalopatia. Não houve casos de peritonite bacteriana espontânea e sangramento gastrointestinal, e não houve aumento na gravidade da ascite. Dois pacientes relataram melhora no prurido, e quatro melhora no estado geral em poucas semanas após sessões de oxigenoterapia hiperbárica. CONCLUSÃO: A oxigenoterapia hiperbárica pode melhorar a função hepática na cirrose e ajudar a controlar as complicações relacionadas à insuficiência hepática na avaliação pré-operatória para transplante de fígado.

BACKGROUND: Hepatic function is a complex process which involves multiple celular events. Liver function in cirrhotic patients may be benefited with hyperbaric oxygen therapy. AIM: To evaluate clinical and laboratorial data regarding liver function in cirrhotic patients selected for liver transplantation, submitted to hyperbaric oxygen therapy. METHOD: A prospective interventional study was designed, wherein 10 patients were randomized amongst cirrhotic patients selected for liver transplantation. The ages ranged from 20 to 65 years, and all patients presented with a MELD score greater than 15. All patients were submitted to nine sessions of hyperbaric oxygen therapy, on alternated days with the duration of 60 minutes per session, with oxygen atmosphere of 100 percent and a 2,8 ATM pressure. Dependent parameters included were biochemical and hematologic laboratory values, evaluated before and after hyperbaric oxygen therapy sessions, besides clinical parameters, evaluated considering the Child-Turcotte-Pugh and the MELD scores. Statistical analysis was performed with SPSS (Statistcal Package for Social Sciences). RESULTS: Three patients (30 percent) reported decrease in the number and intensity of encephalopathy. There were no cases of spontaneous bacterial peritonitis and gastrointestinal bleeding, and there were no increases on the severity of ascitis. Two patients reported improvement on pruritus, and four improvement on the general status for few weeks following hyperbaric oxygen sessions. CONCLUSION: Hyperbaric oxygen therapy may improve liver function in cirrhosis, and may help to control complications related to liver failure on the preoperative evaluation for liver transplantation.

Desvios porta-jugular e cava-jugular passivos em cães: investigação de pressões sangüíneas / Passive porto-jugular and cava-jugular shunts in dogs: investigation on blood pressures

Os principais objetivos dos desvios veno-venosos durante o transplante ortotópico de fígado são: atenuação da estase venosa subdiafragmática, manutenção do retorno satisfatório de sangue ao coração e perfusão tissular eficiente. Investigações sobre PP, PVCIIH, PVC, PAM e PPR, bem como DPP e DPVCIIH foram conduzidas em seis cães, sob anestesia geral, com fígados perfundidos pela Artéria Hepática, submetidos a desvios porta-jugular e cava-jugular passivos durante 2 horas. Estes desvios não foram capazes de evitar estagnação de sangue na VP e VCIIH, acarretando estase e menor retorno sangüíneo ao coração, sugeridos por aumentos significativos de PP e PVCIIH e quedas significantes nos níveis de PVC. Os valores de PAM não apresentaram diferenças significativas em relação ao tempo T0, na maior parte dos tempos avaliados, enquanto que os valores de PPR foram significativamente menores que os verificados no tempo T0, na maioria dos tempos estudados. Tais pressões mantiveram-se, respectivamente, acima de 100 e 50 mm de Hg, atribuindo-se tais resultados, em parte, à vasoconstricção arteriolar generalizada. Incrementos de pressão na VP (DPP) foram significativamente menos elevados que aqueles verificados na VCIIH (DPVCIIH), atribuindo-se tal diferença à complacência esplâncnica. Decréscimos ulteriores dos níveis de PP e PVCIIH sugerem queda do fluxo arterial para os territórios esplâncnico e sistêmico, decorrente de diminuição do retorno sangüíneo ao coração. Determinações de PP, PVCIIH, PVC, PAM e PPR podem constituir meio prático de avaliação hemodinâmica do desvio veno-venoso.

Diclofenaco resinato no tratamento da hipertemia em crianças / Diclofenac resinate in the treatment of hyperthemia in children

Observou-se o efeito antitérmico do diclofenaco resinato em crianças, comparando-o com a dipirona magnesiana. Näo houve diferença entre as duas drogas empregadas

Estudo prospectivo e randomizado da utilizaçäo de sonda nasogastrica no pós-operatório imediato da cirurgia geral / Prospective randomized study of the nasogastric tube in the immediate postoperative period in general surgery

Bastante controversia existe sobre a validade da descompressao gastrica com o uso da sonda nasogastrica(SNG) de rotina e a incidencia de complicacoes no pos-operatorio de cirurgia geral. Para determinar o valor do seu uso avaliaram de forma prospectiva,randomizada, a necessidade da SNG, na descompressao gastrica em 149 pacientes submetidos a cirurgia, distribuidos em dois grupos, em funcao do uso ou nao da SNG. O uso da SNG em 86 pacientes (grupo A) nao contribuiu para uma menor incidencia de nauseas ou vomitos, quando comparados com o grupo B (63 pacientes), observando-se um maior tempo de permanencia hospitalar para o grupo A. O tempo de recuperacao da peristalse nao foi estatisticamente diferente entre os dois grupos. O estudo sugere que a descompressao profilatica com o uso da SNG nao e essencial no pos-operatorio da cirurgia geral