Mil operaciones bariátricas

Diabetes remission after malabsorptive bariatric surgery

Obesity and diabetes are two closely related disorders. Lifestyle changes and drug treatment do not achieve successful diabetes remission. A treatment option for these patients is bariatric surgery (BS). The partial and complete remission rates vary, depending on the type of technique used (restrictive or malabsorptive), with malabsorptive surgery being more effective in terms of both weight reduction and diabetes remission (DR). Different scales (DiaRem, Ad-DiaRem or 5y-Ad-DiaRem) predict the probability of DR after BS, particularly after gastric bypass surgery. Some studies report higher DR rates in surgery with a greater malabsorptive component. Our aim was to study the benefits of BS at one year and 5 years in terms of the weight and blood glucose profile in patients with obesity and type 2 diabetes mellitus; assess percentage DR according to ADA criteria; determine the DR predictive capacity of different scores; and examine which variables predict DR at one and five years after biliopancreatic diversion (BPD). Percentage overweight reduction and the decrease in both blood glucose and HbA1c were greater with BPD. Complete diabetes remission was approximately 80% at one and 5 years after BS. In general, the scores that determine the probability of DR show poor discriminative capacity in malabsorptive surgery. Presurgery HbA1c predicts DR at one and 5 years after BPD. The type of surgery performed should be individualized, based on the severity of diabetes and the specific characteristics of each patient.

Diabetes remission after malabsorptive bariatric surgery

Obesity and diabetes are two closely related disorders. Lifestyle changes and drug treatment do not achieve successful diabetes remission. A treatment option for these patients is bariatric surgery (BS). The partial and complete remission rates vary, depending on the type of technique used (restrictive or malabsorptive), with malabsorptive surgery being more effective in terms of both weight reduction and diabetes remission (DR). Different scales (DiaRem, Ad-DiaRem or 5y-Ad-DiaRem) predict the probability of DR after BS, particularly after gastric bypass surgery. Some studies report higher DR rates in surgery with a greater malabsorptive component. Our aim was to study the benefits of BS at one year and 5 years in terms of the weight and blood glucose profile in patients with obesity and type 2 diabetes mellitus; assess percentage DR according to ADA criteria; determine the DR predictive capacity of different scores; and examine which variables predict DR at one and five years after biliopancreatic diversion (BPD). Percentage overweight reduction and the decrease in both blood glucose and HbA1c were greater with BPD. Complete diabetes remission was approximately 80% at one and 5 years after BS. In general, the scores that determine the probability of DR show poor discriminative capacity in malabsorptive surgery. Presurgery HbA1c predicts DR at one and 5 years after BPD. The type of surgery performed should be individualized, based on the severity of diabetes and the specific characteristics of each patient.

[Adjustable gastric band as surgical treatment for morbid obesity. Are worldwide results reproducibles in Spain?]

INTRODUCTION

Adjustable gastric banding is a surgical technique used all over the world for the treatment of morbid obesity. In Spain, the number of patients treated with adjustable gastric banding is far lower than the average worldwide average. A number of reasons have been put forward to explain this difference.

MATERIAL AND METHODS

A program of bariatric surgery by means of implantation of an adjustable gastric banding was started in 2001, together with a dedicated follow-up protocol in order to prevent complications and improve results.

RESULTS

A total of 132 patients were operated on between 2001 and 2011. The mean age of the 102 female and 30 male patients was 39 years, and the mean body mass index was 43. Follow-up was longer than 5 years in 61 patients, while the mean follow-up in the rest was 44.4 months. There was no mortality or severe morbidity. Eight patients (6.06%) underwent reoperation, 3 of them for complications related to the reservoir, 4 for slipping of the band, and one for erosion. One slipped band was removed, and a new one (of the Lap Band type) was inserted. Three slipping bands were converted to other techniques. The percentage excessive body weight loss was maintained in 54.8% of the patients followed-up for longer than 5 years.

CONCLUSIONS

The results of our series are comparable to those reported in the literature and show that, provided that a close follow-up, like that performed by most groups, is implemented, adjustable gastric banding can also be a safe and effective bariatric surgery technique in our country.

[Advances in bariatric surgery: from the open approach to the biliopancreatic bypass with laparoscopic gastric preservation. Twelve years of experience]

INTRODUCTION

An analysis is presented of the results in the treatment of morbid obesity after 12 years experience.

MATERIAL AND METHODS

A retrospective study of patients subjected to surgery for morbid obesity from July 1998 to April 2010. Open techniques were initially used, and from January 2005 using biliopancreatic bypass with gastric diversion by a laparoscopic approach.

RESULTS

A total of 165 patients have been subjected to surgery, 65 with open surgery (gastric bypass and Scopinaro), and 100 laparoscopic. The mean age was 40 years, with 74% females. The mean BMI was 48.6±6 kg/m(2), with 35% super-obese. The mean hospital stay was 7 days, with a morbidity of 26% (43 patients). Seven patients required further surgery, and 2 patients died. There was 99.4% follow-up during a median period of 46 months (1 to 141). There were complications of the gastro-jejunostomy in 17 patients. Seven patients required further surgery due to transmesenteric hernias. The rate of overweight lost was 67% (95% CI: 65-72%), 68% (95% CI: 65-72%) and 68% (95% CI: 63-73%) at 12, 36 and 60 months, respectively. The rate of excess BMI lost was 73% (95% CI: 70-76%), 74% (95% CI: 70-79%) and 74% (95% CI: 68-69%) at 12, 36 and 60 months, respectively. Comparing both approaches, there were more post-operative complications, longer hospital stays, and more incisional hernias in the open approach, with no significant differences found in the rest of the parameters analysed.

CONCLUSION

Our long-term results are within those classified as excellent, with acceptable morbidity and mortality. A great advance has been observed in the laparoscopic approach due to the less aggressive surgery, and maintaining an excellent weight loss.

Gastric leak after sleeve gastrectomy: analysis of its management

BACKGROUND

Bariatric surgery is increasingly being performed and sleeve gastrectomy (SG) has proved to be effective and safe. Among its complications, leaks are the most serious and life threatening.

METHODS

The focus of the study is nine patients who underwent a SG and developed a gastric leak after surgery. Our data were obtained from the clinical charts of the patients and through interviews with the surgeon who performed the index surgery.

RESULTS

Eight patients underwent SG at outside institutions while one was operated at Clinica Alemana. Three patients developed symptoms within 5 days after surgery, while the rest were diagnosed after 10 days from the surgery. A CT scan was the method used to confirm the diagnosis in all patients. The three patients who had a leak detected during the immediate postoperative period underwent laparoscopic reoperation. Among the rest of the patients, percutaneous drainage was employed in one patient as the primary procedure while the other underwent surgical drainage. An esophageal endoluminal stent was employed in four patients. The leak closed in all patients with the healing time ranging from 21 to 240 days.

CONCLUSIONS

Diagnosis of a leak after a SG required a greater index of suspicion in order to perform an early diagnosis. Sepsis control and nutritional support are the cornerstones of this treatment. Evolution is characterized by longer periods of time that are necessary in order to wait until the leak closes. Management must be tailored to each patient.

Complicações respiratórias pós-operatórias em cirurgia bariátrica: revisão da literatura

Obesidade é um problema de saúde pública mundial com altos índices de morbi-mortalidade. A cirurgia bariátrica tem sido o tratamento mais usado e desperta atenção para seu desenvolvimento e resultados. Porém, até o momento, não há revisão sobre a incidência de complicações respiratórias nesta população. O objetivo deste estudo foi revisar a literatura sobre as complicações respiratórias após cirurgias bariátricas convencionais com a utilização das bases de dados PubMed, Cochrane e Scielo buscando os termos: complicações, pulmonar, pós-operatório e cirurgia bariátrica. Os limites foram os últimos dez anos, adultos, inglês e espanhol. Encontramos 69 artigos e utilizamos 21. As complicações respiratórias mais observadas em cirurgia bariátrica são: embolia pulmonar, atelectasias e pneumonia, estando relacionadas à idade e à hipoventilação. A obesidade mórbida está associada a disfunções respiratórias, incluindo diminuição da resistência cardiorrespiratória e dispneia, sendo as alterações mais comuns: diminuição da ventilação e da complacência torácica, taquipneia e aumento do trabalho muscular respiratório, com altos índices de hipoxemia e fadiga respiratória. Nossos resultados mostram que embolia pulmonar, atelectasias e pneumonias são as complicações respiratórias mais incidentes em cirurgias bariátricas convencionais, sendo os idosos ou portadores de síndrome da hipoventilação e apneia obstrutiva do sono os que apresentam maior risco de desenvolvê-las.

Weight loss reporting: predicted body mass index after bariatric surgery

BMI and %EBMIL are the most accurate methods for comparing results of patients after bariatric surgery. %EBMIL is based on BMI 25 as a constant end-point for all patients, but BMI 25 is easily achieved by patients with BMI < 50, whereas it is not so feasible for patients with BMI > 50. We were prompted to obtain by statistical methods a mathematical formula able to calculate the final BMI (FBMI) 3 years after the operation, dependent on the initial or preoperative BMI (IBMI) of a multicenter group of morbid obese patients operated with different bariatric techniques. We also obtained a specific formula for each bariatric procedure of this group of patients. We propose the name Predicted BMI for the value obtained with these formulas and its application in the %EBMIL instead of the constant value of BMI 25. We have analyzed the IBMI and FBMI of a multicenter group of 7,410 patients, subjected to different bariatric procedures with a minimum follow-up of 36 months. Statistical methods with a linear regression model have been used to obtain the two types (global and specific) of Predicted BMI. We first obtained a general formula of PBMI = IBMI x 0.4 + 11.75 for the total population of patients, and a second specific formula for each bariatric technique: PBMI = IBMI x 0.43 + 13.25 + technique_correction_adjustment. Predicted BMI and its application to the %EBMIL may result in a more rational comparison of results of bariatric patients, bariatric techniques, and groups of bariatric surgeons. Predicted BMI may advance the BMI that each patient would probably achieve after surgery.

Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is a surgical procedure that is being increasingly performed on obese patients. The most frequent postoperative complication is the appearance of a gastric leak.

PURPOSE

To determine the main clinical features of a group of patients who developed a gastric leak after LSG.

MATERIAL

A total of 343 obese patients were submitted to LSG, two hundred and sixty-two women and 81 men with a mean age of 37.3 years and a BMI of 37.5 kg/m(2). Radiological evaluations were performed on all patients on the third day after surgery using liquid sulfate barium, as well as a close clinical control evaluation to monitor the appearance of epigastric pain, fever, tachycardia, C-reactive protein, and leukocytosis. Medical or surgical management of the leak were employed.

RESULTS

Fever was the earliest and most frequent symptom, followed by epigastric pain and tachycardia. Leaks were classified based on three parameters: severity or magnitude, location, and time of appearance after surgery. Leaks were classified as early if they appeared 1 to 4 days after surgery, intermediate if they appeared 5 to 9 days after surgery, and late 10 days after surgery. The diagnosis of a leak was confirmed with a barium liquid taken orally by six patients and with an abdominal CAT scan in ten. Surgical management was performed in eight patients, usually in those with early leaks (six patients). Early re-suturing in three patients was successful; however, re-suturing leaks after the third day resulted in failure. Medical management was performed mainly in patients with intermediate and late leaks, mainly through enteral nutrition and percutaneous drainage of the intra-abdominal fluid collection. There was no mortality. The mean healing days of these leaks was 45 days after surgery.

CONCLUSION

Close clinical observation detects gastric leaks early on inpatients who underwent LSG. We suggest evaluating these leaks based on three parameters: time of appearance, the location, and its severity, in order to propose the best medical or surgical treatment in these patients.

Gastric leak after laparoscopic-sleeve gastrectomy for obesity

BACKGROUND

One of the most serious complications after laparoscopic sleeve gastrectomy (LSG) is gastric leak. Few publications exist concerning the treatment of gastric leak. We sought to determine by way of a prospective study the clinical presentation, postoperative course, and treatment of gastric leak after LSG for obesity.

METHODS

From October 2005 to August 2008, 214 patients with different degrees of obesity underwent LSG. During surgery, each patient received saline with methylene blue by way of nasogastric tube and had a drain placed. All patients underwent radiologic study with liquid barium sulphate on postoperative day 3.

RESULTS

Seven patients developed gastric leak. Leak in two patients (28.6%) was diagnosed by upper gastrointestinal tract (UGI) study. Two patients had type I leak (28.6%), and five patients had type II leak (71.4%). Four patients underwent reoperation. Three patients were managed medically with enteral or parenteral feeding; the drain was maintained in situ; and collections were drained by percutaneous punctions guided by computed axial tomography. Mean hospital length of stay was 28.8 days, and time to leakage closure was 43 days after surgery.

CONCLUSION

Different ways exist to manage gastric leak, depending on the magnitude of the collection and the clinical repercussions. When treatment necessitates reintervention and is performed early, suture repair is more likely to be successful. Leakage closure time will vary.

[Expected body mass index after bariatric surgery]

INTRODUCTION

The body mass index (BMI) is the most practical method to measure and compare obesity between individuals. The Percentage of Excess BMI Loss (PEBMIL) is used to present results in operated patients and is based on the premise that a BMI-25 is the final aim, on being the upper limit in normal subjects. It is possible to achieve a BMI-25 in morbid obese (MO) patients with initial low BMIs (<50) but it is rare in overweight (OW) patients with a BMI>50. Expected BMI (EBMI) would be that which should be reached by all subjects depending on their initial BMI.

OBJECTIVE

The objective of this study is to search for, using statistical methods, a formula based on clinical evidence that can identify the EBMI depending on the initial BMI.

PATIENTS AND METHOD

We analysed the initial and final BMI in a group of 135 MO patients, operated on using the duodenal switch procedure and with a follow up of over 3 years. A linear regression method has been used to obtain a formula that could calculate the EBMI of each patient operated on.

RESULTS

We obtained an algorithm in which EBMI=Initial BMIx0.33+14. If we apply the individualised EBMI instead of the BMI-25, the median PEBMIL was 99.48 (range: 76.75-110.46).

CONCLUSION

This result suggests that the application of an individual EBMI is a more reliable estimate of the success or failure of bariatric operations.

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.

Treatment of gastric leaks with coated self-expanding stents after sleeve gastrectomy

BACKGROUND

Duodenal switch (DS) is one of the most effective techniques for the treatment of morbid obesity and its co-morbidities, with mortality rate <1%, but with 9.4% morbidity rates (6.5% due to leaks). In our experience, leaks of the staple-line after sleeve gastrectomy (SG) are the most frequent sites of fistula formation and conservative treatment usually takes a long time. We present our experience in the treatment of gastric leaks with coated self-expandable stents (CSES).

METHODS

6 patients had gastric leaks at the gastroesophageal (GE) junction after SG or DS. One patient had a symptomatic gastro-bronchial fistula. Stents were placed by the interventional radiologist under fluoroscopic control and removed endoscopically. In one case, we used an uncoated Wallstent. In two patients, percutaneous microcoil embolization of the fistula was added.

RESULTS

The patient treated with the Wallstent required a total gastrectomy 6 months after placement of the uncovered stent. In the other 5 patients, coated stents were successfully removed and the gastric leaks completely sealed.

CONCLUSIONS

CSES are proposed as an alternative therapeutic option for the management of GE junction leaks in bariatric surgery with good results in terms of morbidity and survival.

[Laparoscopic reoperative sleeve gastrectomy]

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) was developed after the laparoscopic duodenal switch (LDS) procedure and is increasingly indicated in the treatment of morbid obesity. The main indication for LSG is LDS in patients with superobesity.

MATERIAL AND METHOD

We describe the need to perform laparoscopic reoperative sleeve gastrectomy (LRSG) during LDS due to dilatation of the gastric remnant in two patients in our series. One of the patients had regained weight and the other showed insufficient final weight loss.

RESULTS

In both patients, LRSG was technically simple and without postoperative complications. Both patients began to lose weight again.

CONCLUSIONS

Gastric tube dilation is one of the causes of insufficient weight loss in LDS. To correct this dilatation, LRSG is sufficient, with excellent outcomes and low morbidity.