Almino Cardoso Ramos

First human experience with endoscopically delivered and retrieved duodenal-jejunal bypass sleeve

BACKGROUNDnWe report the first human experience with an endoscopic duodenal-jejunal bypass sleeve (DJBS) in a community hospital.nnnMETHODSnThe DJBS is a 60-cm sleeve anchored in the duodenum to create a duodenal-jejunal bypass. In a 12-patient prospective, open-label, single-center, 12-week study, the device was endoscopically implanted, left in situ, and retrieved. The study included 5 men and 7 women, with a mean body mass index of 43 kg/m(2). Of the 12 patients, 4 had type 2 diabetes. The primary endpoints were the incidence and severity of adverse events. The secondary outcomes included the percentage of excess weight loss and changes in co-morbid status.nnnRESULTSnThe DJBS was endoscopically delivered and retrieved in all patients (mean implant/explant time of 26.6 and 43.3 min, respectively). Of the 12 patients, 10 were able to maintain the device for 12 weeks and 2 underwent explantation after 9 days secondary to poor device placement. Several self-limited adverse events were possibly or definitely related to the device, including 6 episodes of abdominal pain, 18 of nausea, and 16 of vomiting, mainly within 2 weeks of implantation. Two partial pharyngeal tears occurred during explantation. Implant site inflammation was encountered in all patients. No device-related event was considered severe. The average percentage of excess weight loss for the 10 patients with the device in place for 12 weeks was 23.6%, with all patients achieving at least 10% excess weight loss. All 4 diabetic patients had normal fasting plasma glucose levels without hypoglycemic medication for the entire 12 weeks. Of these 4 patients, 3 had decreased hemoglobin A(1c) of > or =.5% by week 12.nnnCONCLUSIONnThe DJBS can be safely delivered and removed endoscopically and left in situ for 12 weeks. The device had a favorable safety and encouraging efficacy profile. Randomized prospective trials are warranted.

Open label, prospective, randomized controlled trial of an endoscopic duodenal-jejunal bypass sleeve versus low calorie diet for pre-operative weight loss in bariatric surgery

BackgroundThe duodenal-jejunal bypass sleeve (DJBS) has been shown to achieve a completely endoscopic duodenal exclusion without the need for stapling. This report is the first randomized controlled trial for weight loss.MethodsIn a 12-week, prospective, randomized study, subjects received either a low fat diet and the DJBS or a low fat diet control (no device). Twenty-five patients were implanted with the device and 14 received the control. The groups were demographically similar. Both groups received counseling at baseline only, which consisted of a low calorie diet, and exercise/behavior modification advice. No additional counseling occurred in either group. Measurements included starting and monthly body weight and serum blood tests. The device group also had a plain abdominal film post implant, a monthly KUB and a 4-week post explant EGD.ResultsTwenty device (80%) subjects maintained the DJBS without a significant adverse event for the 12-week duration. At 12 weeks, the mean excess weight loss was 22% and 5% for the device and control groups, respectively (p < 0.001). Five subjects (20%) were endoscopically explanted early secondary to upper GI (UGI) bleeding (n = 3), anchor migration (n = 1) and sleeve obstruction (n = 1). The UGI bleeding occurred at a mean of 13.8 days post implant. EGD was performed in each of these cases with no distinct bleeding source identified. No blood transfusion was required. The migration occurred on day 47 and manifested as abdominal pain. The subject with the sleeve obstruction presented with abdominal pain and vomiting on day 30. Eight subjects (40%) underwent the 4 week post explant EGD at which time mild degrees of residual duodenal inflammation was noted.ConclusionThe DJBS achieves noninvasive duodenal exclusion and short term weight loss efficacy. Longer term randomized controlled sham trials for weight loss and treatment of T2DM are underway.

International multicenter study of safety and effectiveness of Swedish Adjustable Gastric Band in 1-, 3-, and 5-year follow-up cohorts

BACKGROUNDnNo long-term, international, multicenter studies of the effectiveness and safety of the SAGB in morbid obesity have been previously published. The objective of this study was to assess the effectiveness and safety of the Swedish Adjustable Gastric Band (SAGB) at 6 bariatric centers in Australia, Europe, and Brazil, with < or =5 years of follow-up; the effect on patient covariates; and changes in co-morbidity.nnnMETHODSnA 2-phase study design was used, involving both retrospective and prospective data. SAGB was implanted by way of the pars flaccida 1, 3, and 5 years previously. The retrospective phase entailed a review of the records. The prospective phase included a subset of eligible patients who agreed to undergo additional clinical assessments. The percentage of excess weight loss (%EWL), patient level predictors, change in co-morbidities, and complications were analyzed.nnnRESULTSnA total of 481 patients in 3 mutually exclusive follow-up cohorts (1 yr, n = 200; 3 yr, n = 184; 5 yr, n = 97) participated in the present study. Of these 481 patients, 339 (1 yr, n = 139; 3 yr, n = 131; 5 yr, n = 69) underwent prospective evaluations. The mean %EWL was 43.5% + or - 21.8%, 57.7% + or - 25.9%, and 49.8% + or - 27.6% and the mean change in body mass index was -7.64, -10.75, and -9.52 in the 1-, 3-, and 5-year cohorts, respectively (P <.001). Gender and age did not predict the %EWL; however, a greater preoperative body mass index was inversely related to the %EWL. Longer postimplantation times were associated with greater improvement in co-morbidities and with greater frequencies of reoperation. Fewer than 15% of the patients in the 5-year cohort had undergone band removal and 10% required band revisions. No fatal or life-threatening complications occurred.nnnCONCLUSIONnSAGB is safe and effective in inducing weight loss and improvement of co-morbidities in morbidly obese patients at international bariatric centers at 1, 3, and 5 years postoperatively.

Esofagogastrofundoplicatura videolaparoscópica por técnica mista

A doenca do refluxo gastroesofagico (DRGE) e uma patologia frequente, acometendo cerca de 10% da populacao geral. Esta incidencia tem se elevado nos ultimos anos. Tradicionalmente, sua abordagem terapeutica inicial e clinica, porem, o numero de indicacoes cirurgicas tem aumentado principalmente as custas das vantagens da videolaparoscopia. Durante o periodo de janeiro de 1993 a marco de 1998, 112 pacientes foram submetidos a fundoplicatura e hiatoplastia por videolaparoscopia para o tratamento da DRGE, sendo 62 (55,3%) do sexo masculino e 50 (44,7%) do sexo feminino. A idade variou de 20 a 90 anos, com media de 40 anos. As indicacoes cirurgicas foram doenca refrataria ao tratamento clinico (76,9%), seguido por esofago de Barrett (16,1 %), estenose esofagica (3,5%), hemorragia digestiva alta por ulcera esofagica (2,6%) e hernia hiatal paraesofagica (0,9%). Para o procedimento cirurgico foram utilizados cinco trocartes. A hiatoplastia foi realizada com pontos em X. Na fundoplicatura, apos a passagem do fundo gastrico por tras do esofago abdominal, inicialmente se realiza um ponto tomando as duas extremidades do fundo gastrico, porem sem fixar esta sutura ao esofago. A partir dai, mais quatro pontos sao realizados, sendo dois acima e dois abaixo deste ponto inicial, de maneira a envolver o esofago, de modo parcial (2700). O tempo medio de cirurgia foi de 80 minutos e o de internacao, de 1,8 dias. Ocorreram duas conversoes (1,7%). Nao houve mortalidade, e as complicacoes assinaladas foram pneumotorax (0,9%), enfisema subcutâneo (0,9%), disfagia transitoria (26%) e disfagia persistente (3,5%). A fundoplicatura mista laparoscopica tem se mostrado um procedimento seguro e eficaz para o tratamento definitivo da DRGE com baixo numero de complicacoes, reunindo as vantagens classicas da cirurgia laparoscopica: curto periodo de internacao, rapida recuperacao e bons resultados esteticos; e as de uma tecnica simplificada, visando facilitar as duas etapas mais complicadas da cirurgia: hiatoplastia e fundoplicatura.

Colecistectomia laparoscópica em regime ambulatorial

The arrival of cholecystectomy by minilaparotomy provided reduction of the hospitalar stay and the discharge on the same day began to be considered and applied with success to some patients. However, it was with the laparoscopic approach that the ambulatory surgery received strong stimulation. The feasibility of cholecystectomy for calculous chronic cholecystitis under laparoscopy in the outpatient ambulatory setting was evaluated in a prospective study. During the period between January 1994 to January 1997,120 patients were operated. Forty-two were male (35%) and 78 female (65%), aging from 16 to 60 at an average of 38. The patients were selected under the following criteria: no accute process, maximum age 60 years, no suspicion of choledocolithiasis and classification ASA I and 11. The surgery was performed in lithotomy position with three trocars. Cholangiography was routine. Surgical time ranged from 20 to 80 minutes with an average of 50. Cholangiography was done in 105 cases (87.5%) confirming choledocolithiasis in two (1.9%). There were no conversions. The most common complications in the imediate postoperative period were: nausea in eight patients (6.6%) with vomiting in two (1.6%). The abdominal pain was little and easily treated with dipiron and nonsteroidal antiinflammatory analgesics. Operatory wound infection was not observed but three patients (2.5%) showed hyperemia in the umbilical incision. All patients were discharged from ambulatory after an average hospitalar stay of ten hours. In conclusion, according to what this study has shown laparoscopic cholecystectomy can perfectly be done in the ambulatory setting without increasing on the complication rates.

The Role of Gastrojejunostomy Size on Gastric Bypass Weight Loss

BackgroundThe laparoscopic Roux-en-Y gastric bypass (LRYGB) has been considered a reference procedure in the bariatric surgery. The linear-stapled gastrojejunostomy (GJ) has proved to be safe and effective, but its optimal size referred to postoperative weight loss remains poorly understood.ObjectivesEvaluate the role of the linear-stapled GJ size in the mid-term post-LRYGB weight loss and occurrence of complications.Materials and MethodsFrom January to April 2014, 128 patients underwent LRYGB with linear-stapled GJ in a 2-year follow-up. The LRYGB were carried out with the same technical steps, except for the length of the GJ. In GJ-15-mm group (nxa0=xa064), the GJ was constructed with white 45-mm cartridge in an extension of only 15xa0mm whereas in GJ-45-mm group (nxa0=xa064), the GJ was achieved using full extension of the cartridge. The body mass index (BMI) reduction was recorded for 24xa0months after procedure.ResultsThe mean ages were 38xa0±xa010.6 and 41.3xa0±xa012.3xa0years, and there were 45 (70.3%) and 51 (79.7%) females in the GJ-15-mm and GJ-45-mm groups, respectively. The analysis on raw BMI data showed that both groups had significant reduction of BMI over time (pxa0≤xa00.05); however, reduction was greater in the GJ-15-mm group from 18xa0months onwards (pxa0≤xa00.05). The only complication observed was a case (1.56%) of stenosis in the group GJ-15xa0mm.ConclusionThe global analysis of BMI reduction indicated that the narrower GJ used (GJ-15-mm group) represented a favoring factor decreasing significantly more the BMI when compared to the wider one (GJ-45-mm group).

Esteato-hepatite não-alcoólica em pré-operatório de bypass gástrico: ausência de correlação com grau de obesidade

BACKGROUND: Metabolic disorders have high correlation with severe forms of nonalcoholic fatty liver disease. However, there is no non-invasive method that promotes its proper stratification and biopsy remains the ideal diagnostic tool. AIM: To evaluate the prevalence of this disease in obese in preoperative period of Roux-en-Y gastric bypass and metabolic factors correlated with liver histopathology. METHODS: From a total of 47 patients, 35 were enrolled in the inclusion criteria and 12 excluded due to liver disease and alcohol intake >80 g/week. Were performed clinical and laboratory evaluation before the surgery and intraoperative liver biopsy . The intensity was ranked in grade of steatohepatitis: I (mild to moderate) and II (diffuse inflammation), III ( periportal fibrosis) and IV (cirrhosis). Were compared the following variables: duration of obesity, body mass index, waist-hip ratio, type 2 diabetes mellitus, hypertension and dyslipidemia. RESULTS: Thirty -five patients (68.6 % women , mean age 37 years) were evaluated. The mean body mass index preoperatively was 53.04 kg/m2. Nonalcoholic steatohepatitis was found in 31 patients (88.6 %) and 32.2% were in grade I (n=10), grade II 45.2% (n=14), and 25.6% grade III (n=7). The waist-hip ratio was associated with hepatic steatosis; hypertriglyceridemia was the marker that had best correlation with higher grade; there was no correlation between aminotransferase and intensity of the disease; there was correlation of intensity with factors related to insulin resistance. CONCLUSION: Nonalcoholic steatohepatitis is highly prevalent in morbidly obese patients, but there was no positive correlation between aminotransferases and degree of obesity and liver histopathology. Hypertriglyceridemia and waist-hip ratio were positively correlated with the intensity of disease.

Laparoscopic cholecystectomy in children and adolescents

During the period between August 1991 and November 1995, seven patients under age 17 were submitted to videolaparoscopic cholecystectomy (LC). Two were males and five females with ages ranging from 12 to 16 years (mean 13.8 years). The diagnosis of chronic cholecystitis with gallstones was made by the clinical history and physical and ultrasonographic examinations. There was no evidence of an association with hemolytic diseases, familial hyperlipidemia or Glucose-6-phosphate dehydrogenase (G6PD) deficiency. The surgery was performed under general anesthesia and the abdomen approached by four ports: a 10 mm umbilical incision, a 5 mm cystic, a 5 mm one at the xiphoid appendix and a 10 mm one at the left lateral margin of the left rectus abdominal muscle between the umbilical scar and the xiphoid appendix. Operative time averaged 120 minutes (105-150 min). One case required conversion to laparotomic approach because of Mirizzis Syndrome, which was diagnosed by intraoperative cholangiography performed in all cases. There were no deaths or major postoperative complications. Hospital stays ranged from 1-3 days in the six patients submitted to LC. Thus LC in children can be considered a good method, requiring only more care regarding the use of proper equipment, complete and careful dissection of the biliary hilus, and intraoperative cholangiography. The latter is indispensable, as these children can present a higher rate of anatomic anomalies. The advantages of this techniques include a less painful postoperative period with a faster recovery, and it is especially recommended in children, who are less tolerant to physical restriction and pain than adults.

TEACHING MODEL FOR EVALUATION OF THE ABILITY AND COMPETENCE PROGRESS IN ENDOSUTURE IN SURGICAL SKILL LABORATORY

ABSTRACT nBackgroundn:n Laparoscopic manual suturing is probably the most difficult skill to be acquired in minimally invasive surgery. However, laparoscopic exercise endo-sutures can be learned with a simulator and are of great practical importance and clinical applicability, absorbing concepts that are immediately transferred to the operating room. nAimn:n To assess the progression of skills competence in endo-sutures through realistic simulation model of systematized education. nMethodn:n Evaluation of the progression of competence of students in three sequential stages of training in realistic simulation, pre-test (V.1), teaching concepts (V.2) and training station for absorption of video concepts in surgery - ergonomics, stereotaxia, ambidexterity, haptic touch, fucral effect, applied in the manufacture of points corresponding to a Nissen fundoplication, in endo-suture for realistic simulation. nResultsn:n All students who attended the course absorbed the video concepts in surgery; most participants showed steady and continued improvement and during the stages of training, obtained progression of appropriate skills, defining competence and validation of the teaching model to achieve proficiency. nConclusionsn:n The teaching model was adequate, safe, revealed the profile of the student, the evolutionary powers of the endo-sutures performance and critical analysis of the training to achieve proficiency in bariatric procedures.

Uso de anillo en bypass gástrico: Ventajas y desventajas

. Enseguida, otrosautores fueron incorporando y perfeccionando esteprincipio de contencion hasta alcanzar el formatodel procedimiento quirurgico actual.No hay uniformidad en el tipo de material em-pleado y ni en el tamano de la circunferencia de laprotesis, siendo descrito el uso de un anillo desilicona o de una cinta de Prolene® o de Goretex®,cuyo largo varia de 5,5 a 7 cm