Gastric carcinoid tumor--incidental finding on endoscopy prior to bariatric surgery.

A 32-year-old female patient with morbid obesity (body mass index 44.4) was submitted to upper digestive endoscopy performed routinely as a preoperative procedure in bariatric surgery. The examination identified multiple small polypoid lesions in the upper portion of the gastric body, some with small ulcerations. Anatomo-pathological findings were compatible with carcinoid tumor of the stomach. The patient was submitted to extended subtotal gastrectomy with loco-regional lymphadenectomy. Upper digestive endoscopy is performed routinely in some services for bariatric surgery, but its value has been questioned by some authors. In this case, endoscopic examination was of great importance, being responsible for a change in the surgical procedure. We did not find any report in the literature of a carcinoid tumor of the stomach in morbidly obese patients.

Need for multivitamin use in the postoperative period of gastric bypass.

BACKGROUND: Based on the reduced gastric volume and the malabsorption produced by Roux-en-Y gastric bypass (RYGBP) and diet therapy, it is essential in the postoperative period to obtain and maintain an adequate nutritional state, with the aim of preventing malnutrition and seeking a healthy life. It is observed that patients have difficulty in understanding the new food choices that must considered, as they have eating habits that are very divergent from those currently proposed. There is often the need for vitamin and mineral replacement after laboratory tests. METHODS: This study calculated and evaluated the 24-h eating records of 210 patients, collected in the course of nutritional visits in follow-ups of the first, third, sixth, ninth, 12th, 18th, and 24th months postoperative. RESULTS: It was possible to observe an increase in the consumption of nutrients in the course of the study period, but it was not regular and significant for all the nutrients. Also, it is noted that the minimal requirements for vitamin A, vitamin C, calcium, iron and B-complex vitamins (except for cyanocobalamin and riboflavin) were not attained. The nutrients in which satisfactory results were obtained were total proteins of high biological value: cyanocobalamin and riboflavin. CONCLUSION: This study demonstrated the concern for nutrient supplementation in the postoperative period of RYGBP. Thus, the routine use of multivitamins is deemed necessary after the first month postoperatively, with its maintenance preferably for the rest of the patient's life, without abandoning periodic clinical and laboratory follow-up.

Laparoscopic sleeve gastrectomy with NOTES visualization--a step toward NOTES procedures.

BACKGROUND: To demonstrate that bariatric procedures can be done with natural orifice visualization (NOTES) at 2 institutions (Nucleo Universitario de Estudos de Notes Centro de Cirurgia Experimental Vila do Conde-Junqueira, Vila do Conde, Portugal and Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, RS, Brasil). NOTES is a new surgical approach that is being developed. It consists of the use of a minimally invasive technique in which the surgical procedure is performed through natural orifices, thereby circumventing incisions through the skin. METHODS: We performed vertical gastrectomy or laparoscopic sleeve gastrectomy in a porcine model using vaginal route visualization. RESULTS: A laparoscopic vertical sleeve gastrectomy with NOTES visualization in a porcine model was performed with safety. CONCLUSION: Bariatric procedures can be done with NOTES with results as good as those using laparoscopic techniques.

A comparison of wedge and needle hepatic biopsy in open bariatric surgery.

BACKGROUND: Morbidly obese patients, despite normal laboratory tests and no clinical evidence of liver disease, present a high prevalence of hepatic histological changes. Liver biopsy is able to provide the diagnosis, staging and assessment of follow-up of hepatic disease, thus helping to define clinical management. There is no agreement on which biopsy technique provides better material for analysis. Considering that subcapsular fibrosis is a common finding, sampling from deeper sites is necessary to achieve an adequate histological assessment. METHODS: A study was done in 264 consecutive morbidly obese patients who underwent open Roux-en-Y gastric bypass between July 2001 and Sept 2004, in whom an intraoperative liver biopsy was taken. The first 107 were wedge biopsies, and the last 157 were needle biopsies. The histological degree of steatosis, presence of fibrosis and adequacy of material from the 2 biopsy techniques were compared. RESULTS: Degree of steatosis in both sampling techniques showed no statistical difference (P=0.132). The presence of fibrosis in wedge biopsies (46.1% fibrosis, n 41) was significantly higher than in needle biopsies (13.7% fibrosis, n 20), P<0.001. As expected, sample size of needle biopsies was smaller than that obtained by the wedge technique (P<0.001), but there was no difference in the quality of material obtained (P=0.95). CONCLUSION: Needle biopsies were as effective as wedge biopsies in assessing the degree of steatosis in morbidly obese patients. More important, the presence of subcapsular fibrosis in needle biopsies was less than in wedge biopsies, suggesting an adequate tissue sample by the less invasive technique.

Histological behavior of hepatic steatosis in morbidly obese patients after weight loss induced by bariatric surgery.

BACKGROUND: Hepatic steatosis has a high prevalence among morbidly obese patients. Its relation to steatohepatitis and cirrhosis has been extensively studied among these patients. The aim of this study was to evaluate the behavior of hepatic steatosis with weight loss 1 year after bariatric surgery. METHODS: This study is a historical cohort that compared liver biopsies obtained from morbidly obese patients during the bariatric operation, with percutaneous biopsies taken from the same patient 1 year after surgery. The results were compared with weight loss, patients' profile (gender, age, body mass index (BMI) and waist/hip ratio), and with the presence of co-morbidities such as diabetes, hypertension, and dyslipidemia. RESULTS: 90 patients who had liver biopsies taken at the operation and postoperative period for bariatric surgery were included. The prevalence of hepatic steatosis was 87.6%. The average percent of excess weight loss was 81.4%. On the second biopsy, 16 patients (17.8%) of the total had the same degree of steatosis, 25 (27.8%) improved their steatosis pattern and 49 (54.4%) had normal hepatic tissue. There was no statistical difference regarding age, BMI, waist/hip ratio, and co-morbidities (P>0.05), but there was a difference in gender (P=0.044). CONCLUSION: Significant improvement in the hepatic histology of steatosis was observed after weight loss induced by bariatric surgery in most patients. There was no patient with a worsening in the histology.

Hepatic steatosis in patients undergoing bariatric surgery and its relationship to body mass index and co-morbidities.

BACKGROUND: Although non-alcoholic hepatitis usually is asymptomatic and benign, this condition may progress to cirrhosis and hepatic failure. Some findings are similar to alcoholic hepatitis, but there is no history of excessive alcohol consumption. Among the factors associated with non-alcoholic hepatitis, obesity, diabetes and dyslipidemia are the most important. METHODS: 77 consecutive patients undergoing bariatric surgery had their liver biopsy compared to the presence of co-morbidities and BMI. RESULTS: 67 patients (87.1%) had an abnormal liver biopsy, mostly due to steatosis (83.1%), but also steatohepatitis (2.6%) and cirrhosis (1.3%). The degree of liver damage was related to higher BMI scores. Co-morbidities were present in 46.9% of the patients with hepatic steatosis. CONCLUSIONS: The authors suggest that a liver biopsy should be performed in all patients at bariatric surgery, in order to evaluate possible liver damage and to assist postoperative care.

The role of ultrasound in the diagnosis of hepatic steatosis in morbidly obese patients.

BACKGROUND: Hepatic steatosis is prevalent in obese patients. Although it requires histology for diagnosis, ultrasound may indicate its presence. We evaluated the importance of ultrasound in the diagnosis of steatosis in morbidly obese patients, and considered its clinical relevance for patients with BMI of 35-40 kg/m(2) without co-morbidities. METHODS: 187 morbidly obese patients submitted to bariatric surgery were prospectively studied. All patients had ultrasound before the operation, and hepatic biopsies during the operation, which were compared. RESULTS: The prevalence of steatosis histologically was 91.4%. The sensitivity and specificity of ultrasound in diagnosing steatosis was 49.1% and 75%, respectively,with a positive predictive value of 95.4%. CONCLUSION: The biopsies found a very high prevalence of steatosis in the studied population. The ultrasound results yielded a high positive predictive value (95.4%), suggesting its use as a diagnostic tool for this co-morbidity in morbidly obese patients. The low sensitivity of the method could be related to the lack of objective criteria for the ultrasound diagnosis of steatosis, and probably, technical problems in performing ultrasound in such patients. We believe that in patients with a BMI of 35-40 kg/m(2) without other comorbidities, the ultrasound finding of steatosis could be of value as an indication for bariatric surgery.

Effect of bariatric surgery on liver fibrosis.

BACKGROUND: Although bariatric surgery has been shown to improve hepatic steatosis in morbidly obese patients, the effect of weight loss on hepatic fibrosis has not been determined. Since the prognosis of patients with nonalcoholic fatty liver disease is closely related to the development of hepatic fibrosis, it is important to determine the hepatic histology of these patients after weight loss. We therefore evaluated the prevalence of hepatic fibrosis in morbidly obese patients undergoing bariatric surgery and assessed the correlation of histologic changes with weight loss. METHODS: We retrospectively evaluated 78 morbidly obese patients who underwent gastric bypass. Liver biopsies were taken during surgery and after weight loss, and the correlations between histologic findings and hepatic fibrosis were determined. RESULTS: Of the 78 patients, 35 (44.8%) had fibrosis at first biopsy, and 24 (30.8%) had hepatic fibrosis after weight loss, including 19 of the 35 patients (54.3%) with fibrosis at first biopsy and 5 of the 43 (11.6%) without hepatic fibrosis at first biopsy (P = 0.027). CONCLUSIONS: Weight loss in morbidly obese patients was associated with a reduction in the prevalence of hepatic fibrosis.

Bone mineral density and nutritional profile in morbidly obese women.

BACKGROUND: Morbid obesity may be associated with malnutrition. Because it is important to assess the preoperative nutritional/metabolic status and bone mineral density of these patients, this study was designed aiming to evaluate bone metabolism/mineral density and nutritional profile in morbidly obese women. METHODS: Thirty-three morbidly obese women in preoperative care for obesity surgery were enrolled. Blood samples were drawn to determine nutritional and metabolic status, and dual-energy X-ray absorptiometry (DXA) was performed to evaluate bone mineral density; 24-h recall and food frequency questionnaire (FFQ) were also evaluated. RESULTS: Twenty-seven (81.8%) women were premenopausal and six (18.2%) were postmenopausal. The mean body mass index was 43.2 ± 4.8 kg/m(2), and 91% were Caucasian. Insulin-resistant subjects comprised 81.8% of the sample. The median (25-75 percentile) of the total intake of 24-h recall was 3,081 (2,718-3,737) and for FFQ 2,685 (2,284-4,400) calories. FFQ underestimated total energy value intake. The median of calcium was higher when evaluated by the FFQ as compared with the 24-h recall. Protein and lipid intakes were lower if evaluated by the FFQ as compared to the 24-h recall. Vitamin D levels were low in 18 (81.8%) patients. In one premenopausal woman, bone mineral density was low in the lumbar spine (L1-L4), and in one postmenopausal woman it was low in L1-L4, femoral neck and 1/3 proximal radius. CONCLUSIONS: In this study, the nutritional status of morbidly obese women was good, except for markers of bone metabolism, with no detectable differences between pre- and postmenopausal women.

Obese patients with type 2 diabetes submitted to banded gastric bypass: greater incidence of dumping syndrome.

BACKGROUND: Dumping syndrome is one of ten most common complications in morbidly obese patients operated. Recent studies in relation to type 2 diabetes mellitus (DM2) in patients submitted to gastric bypass led us to examine the different outcomes in this group of patients. Our objective was to determine the difference in the prevalence of dumping syndrome in patients with DM2 submitted to gastric bypass. METHODS: In this retrospective study, 49 diabetic and 54 non-diabetic morbidly obese patients were submitted to gastric bypass and followed up at 3, 6, and 12 months after surgery. The occurrence of dumping was determined by the patient's medical chart, where it was considered positive if recorded in at least one of three evaluations. RESULTS: The 103 patients evaluated had a mean BMI of 49.5 +/- 9.3 kg/m(2) and mean age of 38 +/- 9.7 years, with 75.7% being women. The prevalence of dumping syndrome in this population was 24.3%. The prevalence of dumping was greater in patients with DM2 (44.9%) when compared to the control group (5.6%; p < 0.001). Multivariate logistic regression analysis indicated the diagnosis of DM2 as the only variable associated with dumping syndrome. CONCLUSIONS: Dumping syndrome is a common postoperative complication in gastric bypass. Patients with DM2 show a greater postoperative prevalence of dumping.

Diagnostic and therapeutic ERCP in symptomatic choledocholithiasis, via laparoscopic transgastric access, after roux-en-y gastric bypass / CPER diagnóstica e terapêutica na coledocolitíase sintomática, via acesso transgástrico por videolaparoscopia, após bypass gástrico em y-de-roux

Treatment of choledocholithiasis is a challenge in patients previously submitted to gastric bypass and especially in those already cholecystectomized. We describe here the details of a technique that was shown to be safe, minimally invasive and effective in the treatment of a patient with a calculus of 1.8cm in the middle third of the common bile duct with various associated problems.

O tratamento da coledocolitíase é um desafio em pacientes previamente submetidos a bypass gástrico e especialmente naqueles que já colecistectomizados. Descrevemos aqui os detalhes de uma técnica que se mostrou segura, minimamente invasiva e eficaz no tratamento de um paciente com um cálculo de 1,8cm no terço médio do ducto biliar comum, com várias comorbidades associadas.

Doença hepática não-alcoólica gordurosa e risco de cirrose / Nonalcoholic fatty liver disease andrisk of cirrhosis

objetivos: destacar a doença hepática gordurosa não-alcoólica, seus diversos graus e suas possíveis conseqüências (cirrose e hepatocarcinoma) como uma comorbidez freqüentemente não diagnosticada da obesidade.Fonte de dados: os artigos selecionados para esta revisão foram obtidos em pesquisa no PUBMED. Os principais critérios de seleção foram publicações avaliadas por pares e autores de destaque na área de obesidade e hepatologia.Síntese dos dados: artigos recentes confirmam a relação entre obesidade e doença hepática gordurosa não-alcoólica. É de interesse a possível progressão da esteatose para cirrose e carcinoma hepatocelular.Conclusões: a obesidade mórbida está associada à doença hepática gordurosa não-alcoólica que, por sua vez, determina risco de cirrose e de carcinoma hepatocelular.

Aims: To highlight the non-alcoolic fatty liver disease, its different severities and possible consequences ? cirrhosis and hepatocellular carcinoma ? as an often underdiagnosed co-morbidity of obesity.Source of data: The review was based on a search in PUbMED. main criteria was peer-reviewed journals and well-known authors in the area of obesity and liver disease.Summary of the findings: Recent papers support the association of obesity with non-alcoolic fatty liver disease. It is of interest the possible progression of the steatosis process to cirrhosis and liver carcinoma.Conclusion: Morbid obesity is associated to non-alcoholic fatty liver disease, which, in turn, determines risk of cirrhosis and liver carcinoma.

Resultados iniciais do tratamento cirúrgico da obesidade mórbida em um centro multidisciplinar / Preliminary results of the surgical treatment for morbid obesity in a multi-disciplinary center

Objetivo: O objetivo principal deste artigo é descrever os resultados iniciais do tratamento cirúrgico da obesidade mórbida em um centro multidisciplinar. Métodos: Foram analisados os resultados de 252 pacientes submetidos ao tratamento cirúrgico da obesidade mórbida no período de março de 2000 a março de 2003. As principais variáveis em estudo foram idade, sexo, peso inicial, índice de massa corporal (IMC), presença de doenças associadas e sua melhora no seguimento pós-operatório, qualidade de vida, técnica cirúrgica empregada, presença de complicações e mortalidade. Resultados: A média de idade foi 37,2 anos. O predomínio foi do sexo feminino, com 186 (73,8%) pacientes. A técnica cirúrgica mais utilizada foi a gastroplastia vertical com reconstrução em Y-de Roux com anel restritivo em 250 pacientes. A mortalidade operatória foi de 1 (0,39%) caso. O tempo de seguimento variou de 1 a 36 meses, sendo que 229 (90,8%) pacientes tiveram seus resultados avaliados. A perda de peso média, expressa em percentual de perda do excesso de peso inicial no 2o ano foi de 85,5%. Houve melhora importante na qualidade de vida, e melhora ou resolução das principais doenças associadas. Conclusões: Os resultados encontrados neste estudo demonstram a segurança do procedimento e resultados excelentes em termos de melhora das doenças associadas e dos níveis de qualidade de vida em pacientes submetidos ao tratamento cirúrgico, com baixo índice de mortalidade e complicações operatórias (AU)

Objective: The aim of this study was to evaluate the preliminary results of bariatric surgery in a multi-disciplinary center. Methods: From March 2000 to March 2003, 252 patients underwent operations for morbid obesity and were evaluated prospectively. Study endpoints were surgical complications, operative mortality, percentage of excess body weight loss and impact in quality of life. Results: There were 186 (73.8%) women and 66 (26.2%) male with a mean age of 37.2 years. Roux-en-Y gastic bypass with a silastic ring was used in 250 patients. One (0.39%) operative death ocurred. Follow-up ranged from 1 to 36 months. Mean excess of body weight loss was 85.5% in the second year. Quality of life and comorbidities were significantly improved in the late follow-up. Conclusion: The results of this study show that bariatric operations can be safely performed by a specialized group. Improvement in quality of life and comorbidities, with a low operative mortality are achieved with the surgical treatment of this patients (AU)