One stage laparoscopic left adrenalectomy and sleeve gastrectomy by direct supragastric approach

INTRODUCTION

The advances in laparoscopic surgical technique and the greater experience of surgical teams have enabled the combination of different surgical techniques in a single procedure. This paper presents a case of a sleeve gastrectomy and a left adrenalectomy by laparoscopy for a morbidly obese patient with Cushing's syndrome.

PRESENTATION OF CASE

A 52 year-old male patient with a BMI of 53kg/m(2) was diagnosed as having Cushing's syndrome caused by a left adrenal tumor. Sleeve gastrectomy was performed according to the usual technique. The adrenalectomy was performed at the same time by a left supragastric approach. The evolution was favorable, with 52% of excess weight loss observed after six months. Plasma and urinary cortisol at the 3- and 6-month follow-ups were under normal range and the patient required glucocorticoid therapy, confirming the cure of Cushing's syndrome.

DISCUSSION

Teams with experience of advanced laparoscopic surgery can successfully combine complex procedures in one surgical period. The approach we used for the adrenalectomy proved itself to be feasible after the sleeve gastrectomy.

CONCLUSION

Both procedures can be safely done in experience teams. Sleeve gastrectomy facilitates the direct supragastric approach.

Evaluation of bone disease in morbidly obese women after gastric bypass and risk factors implicated in bone loss

BACKGROUND

In patients undergoing gastric bypass, massive weight loss and impairment of calcium intake and absorption in the duodenum and proximal jejunum may increase the risk of bone mass loss and fractures. However, few data are available regarding the impact of this surgery on the skeleton. The aim of our study was to examine the skeletal changes in a cohort of morbidly obese Caucasian women during the first year after gastric bypass and to analyse the factors implicated in the development of bone loss.

METHODS

Sixty-two morbidly obese white women aged 45.3 +/- 8.9 years were studied. Anthropometric measurements, bone mineral density (BMD) screening using dual-energy X- ray absorptiometry and plasma determinations of calcium, phosphorus, parathyroid hormone (PTH), 25-hydroxyvitamin D [25(OH) D(3)] and insulin-like growth factor-I (IGF-I) were made prior to and 12 months after surgery.

RESULTS

A year after surgery, BMD significantly decreased at the femoral neck (10.2 +/- 5.7%) and at the lumbar spine (3.2 +/- 4.4%). In the follow-up, 16.1% of women had osteopenia at the femoral neck and 19.3% at the lumbar spine, and 1.6% developed osteoporosis at the lumbar spine. Patients with bone disease were significantly older; the percentage of women with menopause was greater in this group and had lower initial and final values of lean mass. However, no differences in body mass index, weight loss, fat mass, calcium, PTH, 25(OH) D(3) or IGF-I values were found between groups. In the logistic regression analysis, lean mass 12 months after surgery and menopause were found to be the main determinants of osteopenia after adjusting for age with odds ratios of 0.82 and 9.13, respectively.

CONCLUSIONS

There is a significant BMD loss at the femoral neck and lumbar spine a year after gastric bypass. Menopausal patients and those with greater lean mass loss are at greater risk and, consequently, should be closely followed up with periodic densitometries.

[Factors associated with morbidity and mortality after gastric bypass. Alternatives for risk reduction: sleeve gastrectomy]

INTRODUCTION

The aim of this study was to analyze factors related to morbidity and mortality after gastric bypass and to evaluate lower-risk alternatives in selected patients.

PATIENTS AND METHODS

A prospective cohort of 761 patients who underwent gastric bypass was included. Prognostic factors were studied using a logistic regression model with SPSS 11.0. Independent variables were age, sex, body mass index (BMI), comorbidities, and the laparoscopic approach. Dependent variables consisted of medical complications, surgical complications, and mortality. We performed a preliminary descriptive study of morbidity and weight loss at 3 months after sleeve gastrectomy.

RESULTS

In the postoperative period, 2.8% of patients presented medical complications and 5.4% presented surgical complications. Mortality was 0.52%. Surgical complications were significantly associated with age > 45 years (P = .04; OR = 2.00 [1.03-3.8]) and male sex (P = .041; OR = 2.40 [1.12-5.14]). Medical complications were significantly associated with a BMI of > 50 kg/m2 (P = .012; OR = 3.32 [1.23-8.98]), and mortality was significantly associated with a BMI of > 50 kg/m2 (P = .006) and male sex (P = .006). Sleeve gastrectomy was performed in eight patients with a BMI of > 60 kg/m2, in three patients with a BMI of > 50 kg/m2, cardiopulmonary disease and android fat distribution, and in four patients with a BMI of between 35 and 40 kg/m2 and major comorbidity. Morbidity consisted of self-limited febrile syndrome in one patient. There was no mortality. Weight loss at 3 months was 39.8 +/- 5.36% of excess BMI in superobese patients (n = 4) and was 50.2 +/- 11.05% of excess BMI in morbidly obese patients (n = 4).

CONCLUSIONS

Postoperative morbidity and mortality was significantly higher in male patients, in patients aged more than 45 years, and in those with a BMI of > 50 kg/m2. Sleeve gastrectomy in selected patients could be a lower-risk alternative.