Antonio Carlos Valezi

Rhabdomyolysis after Bariatric Surgery

Background: Rhabdomyolysis is a potential threat after bariatric surgey. The severity ranges from asymptomatic elevations of serum muscle enzyme levels to life-threatening cases associated with muscle necrosis, compartment syndrome, acute renal failure and cardiac arrest. Methods: We studied 98 consecutive obese patients who underwent primary uncomplicated bariatric surgery during a 1-year period. A database was created for all patients (sex, age, BMI, duration of the operation); serum creatinine phosphokinase (CPK) was systematically measured before surgery and on the first and second postoperative day. Results: The study sample consisted of 35 males (35.7%) and 63 females (64.3%) with preoperative CPK level 156.6 ± 41.1 U/L (40 to 220), 24 hours postoperatively 1,075.2 ± 596.5 U/L, (85 to 2,790 U/L) and 48 hours postoperatively 967.3 ± 545.3 U/L (79 to 2,630). There was no difference in mean BMI (P=0.1) and mean duration of operation (P=0.5) between males and females. However, a statistically significant difference in mean elevation of CPK between males and females (P=0.003) was found. The variables sex, age, weight and duration of surgery were analyzed by multivariate logistic regression, but did not show a statistically significant difference. Conclusion: Rhabdomyolysis is a potentially fatal complication of surgical procedures in obese patients, and can be minimized with simple measures such as additional padding, aggressive hydration and urine alkalinization. Diagnosis requires a high level of physician awareness.

Repercussão da perda de peso sobre parâmetros nutricionais e metabólicos de pacientes obesos graves após um ano de gastroplastia em Y-de-Roux

OBJECTIVE To assess nutritional and metabolic evolution and inflammatory activity in severe obese patients submitted to bariatric surgery. METHODS This prospective study evaluated 56 patients (50 female and 6 male), mean age 40 + or - 9,9 years, submitted to RYGB. Nutritional, metabolic, and inflammatory parameters were assessed prior to and 12 months postsurgery. RESULTS It was verified significant decreases in weight loss in relation to baseline values from 138 + or - 28,8 to 90 + or - 19,5 kg (p< 0,0001), glucose levels from 116 + or - 47,3 to 84 + or - 9,8 mg/dL (p< 0,0001), triacylglycerol levels from 137 + or - 61,4 to 84 + or - 38,6 mg/dL (p< 0,0001), and also in total cholesterol from 189 + or - 41,6 to 166 + or - 36,4 mg/dL (p< 0,0001) and LDL-cholesterol from 119 + or - 36,1 to 104 + or - 30,7 mg/dL (p< 0,0005). C-reactive protein levels reduced from 11,33 + or - 10,82 to 3,62 + or - 4,49 mg/dL (p< 0,0001). Although maintenance of iron levels was verified after one year, there was a significant decrease in hemoglobin from 13 + or - 1,3 to 12 + or - 1,4 g/dL (p< 0,01), and reduction in ferritin levels, especially in women who showed a decrease from 101,2 + or - 123,3 to 85,0 + or - 101,9 (p< 0,03). CONCLUSION Therefore, weigh loss in patients with severe obese after RYGB showed improvement in both metabolic and inflammatory status and may reduce substantially co-morbidities associated with increased cardiovascular risk.

Gastroplastia vertical com bandagem em y-de-roux: análise de resultados

BACKGROUND: To analyze prospectively the results of patients submitted to vertical banded gastroplasty-Roux-en-Y gastric bypass at the Hospital Universitario, Universidade Estadual de Londrina. METHODS: We analized mortality, morbidity and weight loss of 250 consecutive patients with no previous bariatric surgery who were submitted to a combination of vertical banded gastroplasty and Roux-en-Y gastric bypass. Patients were followed up at least for one year. They had a mean body mass index of 46 Kg/M2. RESULTS: The incidence of complications that required reoperation was 2%. No deaths ocurred in the present study. After a follow up of one to three years we noticed an average decrease of 37.5% in the pre-operative weight. In addition to the weight loss we detected a great improvement in the comorbidities and in some cases total control of the desease related to the obesity.CONCLUSIONS: Vertical banded gastroplastic Roux-en-Y gastric bypass is effective in promoting weight loss in morbid obese, and had a low mortality and morbidity.

Evolução ponderal oito anos após a derivação gástrica em Y-de-Roux

OBJECTIVE To evaluate the effectiveness of banded Roux-en-Y gastric bypass in promoting weight loss after an eight-year follow-up. METHODS Two hundred and eleven obese patients underwent Roux-en-Y gastric bypass with banding by the same surgical team. The study design was longitudinal, prospective and descriptive. The analysis of weight decrease in the postoperative period was based on the loss of excess weight in percentage and BMI. Failure was considered when patients lost <50% of excess weight. RESULTS The loss of follow-up was 36.5%, therefore, 134 patients were included in this study. The loss of excess weight in global average rate in the postoperative period was: 67.6 ± 14.9% in the first year, 72.6 ± 14.9% in the second year, 69.7 ± 15.1% in fifth year and 66.8 ± 7.6 in eight years. Surgical treatment failure occurred in 15 patients (7.1%) over the period. CONCLUSION Banded Roux-en-Y gastric bypass was effective in promoting and sustaining weight loss in the long term, with low failure rates.

A importância do anel de silicone na derivação gástrica em Y-de-ROUX para o tratamento da obesidade

BACKGROUND: The aim of the study is to state if the ring used in the Roux-en-Y gastric bypass is related to the weight loss after surgery. METHODS: The study has a 5 years follow up. After endoscopic examination the patientes were divided in two groups: internal diameter of the ring till 10mm (184 patients) and other group with internal diameter of the ring more than 10 mm (107 patients).The excess of weight loss were measured one, two and five years after surgery and compared one with each other. RESULTS: The excess of weight loss was higher for those patients with tighter ring. Statistc analysis was significant comparing the two groups one, two and five years after surgery, the excess of weight loss was higher in the tighter ring groups for each time after surgery. There were no difference related to sex, age and BMI. CONCLUSION: The restriction determined by ring increases the excess of weight loss in patients submitted to Roux-en-Y gastric bypass.

Estudo do padrão alimentar tardio em obesos submetidos à derivação gástrica com bandagem em Y- de- Roux: comparação entre homens e mulheres

BACKGROUND: To evaluate late meal patterns in patients after Roux-en-Y gastric bypass surgery and to compare sex gender differences. METHODS: From July 2006 to July 2007, patients from the outpatient Londrina Hospital State University - Digestive Surgery Section were evaluated after at least 12 months post-operatively. The patients were studied through a questionnaire, including demographic items about eating behavior, meal pattern, and frequency of vomiting and dumping symptoms. Statistical analysis was performed using Chi-square or Fischer test with significance requiring p<0.05. RESULTS: Data were collected from 116 patients, 95(78.4%) were women and 25(21.5%) were men. There were small differences when comparing women and men in eating behavior, meal pattern, frequency of vomiting and dumping symptoms and no statistical significance was found. Only the variables of fruits intake and somnolence were significantly more frequent in women. CONCLUSION: Applying the proposed questionnaire it was possible to know the late eating behavior and meal pattern of our patients. The intake of fruits was the unique item with statistical differences between genders.

Tratamento cirúrgico das estenoses da via biliar

BACKGROUND: Benign stricture of biliary tract (BSBT) are iatrogenic in about 95% of the cases. Although rare, its outcome is poor; therefore prevention is the best option. The objective of this study is to evaluate the surgical management and its results in BSBT. METHODS: We retrospectively analyzed 11 patients submitted to corrective surgery for BSBT at Hospital Universitario Regional do Norte do Parana, from July / 92 to December / 01. RESULTS: There were nine female patients and the mean age was 43.71 years old. Previous surgeries were classic cholecistectomies (81.8%) and videocholescistectomies (18.2%).The most frequent signs and symptoms were jaundice (64.3%), abdominal pain (64.3%) and fever (21.4). The diagnosis was confirmed by CPRE in 90.9% of the patients and CTP in 9.1%. According to Bismuth‘s classification, 18.2% of the patients were considered grade I, 45.4% grade II, 18.2% grade III and 18.2% grade IV. The corrective surgery for BSBT was choledochoduodenostomy in two cases of grade I, hepaticojejunostomy using a Roux-en-Y loop of jejunum in five cases of grade II, Hepp-Couinauds operations in two cases of grade III, hepaticojejunostomy with mucosal graft (Smiths technique) in two cases of grade IV. The postoperative complications were fistula (18.2%), death (18.2%), pneumonia (9.1%) and hemobilia (9.1%). CONCLUSION: Complexity of the surgical treatment requires prevention of injuries. Bile duct lesions repair should be considered as a specialists procedure and should be performed in a center with special interest in this disease.

Tratamento do megaesôfago chagásico grau II por laparoscopia: experiência em 12 casos

BACKGROUND: Various techniques have been used for the surgical treatment of esophageal achalasia, however, the best results for non - advanced esophageal achalasia has been achieved by miotomy. Laparoscopy for non advanced esophageal achalasia have been showing similar results than convencional surgery, with the benefits of a minimally invasive procedure. The aim of this study was to analyze the results of laparoscopy Heller miotomy and Dor fundoplication for non - advanced esophageal achalasia. METHODS: Twelve patients with non - advanced esophageal achalasia submitted to laparoscopic Heller miotomy and Dor fundoplication from Jan/99 to Dec/01 were prospectively analised. RESULTS: All surgeries were completed by laparoscopy with no conversion. Nine patients were assymptomatic and tree presented dysphagia, regurgitation and heartburn, respectively. These patients had a median follow-up of 13.2 months (9-39). There were two cases of gastric perfuration and one case of esophageal perfuration but no deaths occured in this series. CONCLUSION: Based in this study, we could conclude that the Heller miotomy associated to the Dor fundoplication by laparoscopy has a low complication rate. Its use was effective and safe for esophageal achalasia. The surgery is perfectively performed by laparoscopy, with results similar to those of laparotomy, added to the benefits of minimally invasive surgery.

Repercussões do pneumoperitônio sobre o sistema venoso dos membros inferiores-estudo em porcas

Deep venous thrombosis and pulmonary embolism are complications of surgical procedures, the most of times underdiagnosticated. ln laparoscopic surgery, the carbon dioxide insuflation into the peritoneal cavity is probably the cause of venous stasis of the lower limbs. The purpose of this study was to verify the effects of pneumoperitoneum in the blood circulation of the lower limbs. Thirty female pigs were divided in three groups: 1- without pneumoperitoneum; I - with 10 mmHg; and II - with 15 mmHg of abdominal pressure levels. Within the clinical parameters were analysed heart rate, cardiac output and mean arterial pressure to certify that the haemodynamic changes would not be gilty for the modifications of lower limbs circulation. This analysis did not find significant changes in the groups comparation. The results showed that were not found significant changes in the pressure, diameter and flow rate in the femoral artery in the presence of pneumoperitoneum. The average femoral venous pressure found in group I was 7.2 mmHg, in group II was 10.2 mmHg (p<0.05), and in group 11I was 14 mmHg (p<0.05). The average femoral venous flow rate was 9.8 cm/sec in group I; 6.8 cm/sec in group II (p<0.05) and 5.5 cm/sec in group 11I (p<0.05).The analisys of the femoral vein diameter found that the average value of group I was 4.2 cm; group II was 5 cm (p<0.05) and group III was 5.4 cm (p<0.05). The pneumoperitoneum was found to be associated with a significant increase of the pressure and diameter of the femoral vein, and a significant decrease of its flow rate. Every parameter analysed returned to the previous values after the peritoneal gas empting.

Preoperative progressive pneumoperitoneum in obese patients with loss of domain hernias

BACKGROUND Repair of hernias with loss of domain in obese patients can lead to acute respiratory failure. OBJECTIVES The objective of this study was to analyze preoperative progressive pneumoperitoneum (PPP) in increasing abdominal cavity volume and its impact on respiratory function. SETTING The study was conducted at the University Hospital, State University of Londrina, Brazil, which is a referral center for the treatment of obesity. The patients were hospitalized for the duration of the study. METHODS Sixteen obese patients were evaluated. Computed tomography was used to determine hernia sac volume (HSV) and abdominal cavity volume (ACV). Respiratory function was evaluated by measuring vital capacity and forced expiratory volume in the first second (FEV-1). All data were obtained before PPP, on the day before surgery, and on the second postoperative day. PPP was performed daily with insufflation of CO2. RESULTS The number of insufflations was 12. The average of total volume inflated was 5.7 L. The HSV was 2953 cm3 before PPP and 1935 cm3 after PPP. The average ACV increased from 8898 to 11,317 cm3 after PPP. The relationship between HSV and ACV was 38.2% before and 16.3% after PPP. There was a favorable improvement in respiratory function with an increase in vital capacity from 1875 to 2760 mL and an increase in FEV-1 from 1060 to 1670 mL after PPP. Respiratory function tests after surgery showed values of 2600 and 1560 mL, respectively, for cavity volume and FEV-1. There were no postoperative respiratory complications. CONCLUSIONS This technique can be used safely in the surgical preparation of obese patients with hernias with loss of domain, reducing the relation between HSV and ACV and avoiding pulmonary complications.