Attila Csendes J

Propuesta y fundamentos para una norma de manejo quirúrgico del paciente obeso: Año 2004

Obesity is a chronic disease with an increasing prevalence in all groups of age, and is associated to increased general mortality and cardiovascular risk. The multidisciplinary non surgical approach must be the treatment of choice for obese subjects. However, the results of such approach among subjects with severe or morbid obesity, are unsatisfactory. In this group of patients, bariatric surgery and specifically gastric bypass achieves good long term results, maintaining a low body mass index, reducing complications and improving quality of life. Considering the widespread practice of bariatric surgery in Chile, the Nutrition Unit of the Ministry of Health formed a task force to propose update guidelines for the surgical treatment of obesity. These guidelines were proposed after a thorough literature review and discussion with groups that practice bariatric surgery using defined protocols. This document provides a summarized version of the guidelines. The first section discusses the background for bariatric surgery and the second part give specific recommendations for patient management and the formation of reference centers for surgical management of obesity.

Evolución de comorbilidades metabólicas asociadas a obesidad después de cirugía bariátrica

Two hundred thirty two morbid obese patientssubjected to gastric bypass, were evaluated in the preoperative period and every three monthsafter surgery, during a minimum of 12 months. Clinical evolution, blood glucose, seruminsulin, insulin resistance measured with the homeostasis model assessment (HOMA) andserum lipid levels were analyzed.

Obesidad: factor de riesgo para esteatohepatitis y fibrosis hepática

Background: Nonalcoholic fatty liver (NAFL) has been recognized as a cause of chronic liver disease. Its main risk factor is obesity. Aim: To describe the clinical and liver pathological findings in a group of patients who underwent surgery as obesity treatment. Patients and Methods: Sixty eight patients with severe or morbid obesity were subjected to surgery as obesity treatment. Each patient was evaluated with a complete clinical and laboratory medical assessment. A wedge of liver was excised during surgery. Liver biopsies were analyzed without knowledge of clinical and laboratory findings. The presence of steatosis, inflammation (portal or lobular), fibrosis and cirrhosis were recorded in the pathological analysis. Age and body mass index (BMI) were correlated with pathological data. Significance was set at a p value of less than 0.05. Results: Ninety one percent of patients had steatosis, 45% inflammation and 47% fibrosis. One patient had cirrhosis (1,4%). There was a statistically significant association between BMI and moderate or severe steatosis (p <0.03). There was also an association between BMI and portal (p=0.017) and lobular inflammation (p=0.034). A BMI over 40 kg/m2 (morbid obesity) was significantly associated with the presence of fibrosis (p=0.032). Moreover, the presence of moderate or severe steatosis was a risk factor for the development of hepatic fibrosis (p=0.026). Conclusions: Obesity is a major and independent risk factor for steatohepatitis and fibrosis. The degree of steatosis in the liver biopsy, is a risk factor for the development of fibrosis (Rev Med Chile 2002; 130: 731-6)

Nutrición enteral precoz en pacientes con gastrectomía total por cáncer

BACKGROUND: Total parenteral nutrition has a high cost and frequency of complications. Enteral feeding is a feasible alternative that can be started early in the postoperative period. AIM: To assess digestive tolerance to early enteral feeding in cancer patients undergoing total gastrectomy and to compare early enteral feeding (EEF) with total parenteral nutrition plus enteral feeding (TPN + EF), initiated after overcoming postoperative ileus. PATIENTS AND METHODS: Subjects with a resectable gastric cancer were considered eligible for the study. During surgery a nasoenteral tube was placed and patients were prospectively randomized to EEF or TPN + EF. Digestive tolerance, effectiveness, complications and costs between both modalities of nutritional support were compared. RESULTS: Twenty eight patients (15 male, aged 63 +/- 14 years old) were studied. Fourteen patients were randomized to EEF and 14 to TPN + EF. Diarrhea occurred in 14 and 29% of EEF and TPN + EF patients respectively, (p: NS). Patients with TPN + EF received an average of 28 Cal/kg/day and 1.1 g/kg/day proteins. Patients with EEF received an average of 29 Cal/kg/day and 0.8 g/kg/day proteins. At the eighth postoperative day, serum albumin was 3.9 +/- 0.7 and 3.2 +/- 0.5 g/dl in EEF and TPN + EF patients respectively (p < 0.05), serum prealbumin was 16.9 +/- 5 and 12.3 +/- 4.3 mg/dl in EEF and TPN + EF patients respectively (p < 0.05) and nitrogen balance was +2.4 +/- 1.5 and -1.6 +/- 0.6 g/24 h in EEF and TPN + EF patients respectively (p < 0.05). Postoperative hyperglycemia was observed with a lower frequency and nutritional support costs and length of hospital stay were significantly lower in the EEF group. CONCLUSIONS: After total gastrectomy EEF is well tolerated, safe and effective, even during the early postoperative ileus. This therapeutic modality could be the first choice for nutritional support in these patients.

Resultados premilinares de la gastroplastia horizontal con anastomosis en Y de Roux como cirugía bariática en pacientes con obesidad severa y mórbida

Background: Morbidly obese subjects have a high incidence of complications. The poor results of dietary treatments, has prompted the search of new therapies for obesity and among these, surgical procedures. Aim: To report the long term results of horizontal gastroplasty with Roux en Y anastomosis in morbidly obese subjects. Patients and methods: Fifty patients with an initial body mass index of 41.3 ± 6 kg/m2 have been subjected to a horizontal gastroplasty with Roux en Y anastomosis. During the study period, surgical techniques were modified, reducing the gastric pouch size, adding a truncal vagotomy, cholecystectomy, and increasing the length of the Roux en Y loop from 70 to 100 cm. Twenty five patients have been followed for two years. Results: There was no operative mortality and one patient had an anastomotic leak that required 35 days of hospitalization. During follow up, in one patient, the stapled suture line loosened. After two years of follow up, weight decreased from 112 ± 19 to 77.2 ± 14 kg. Conclusions: Horizontal gastroplasty with Roux en Y anastomosis achieved an adequate weight loss with a low rate of complications in this group of morbidly obese subjects.

Manejo actual de la acalasia del esófago: revisión crítica y experiencia clínica

The therapeutic options for treatment of Achalasia of the esophagus include medical treatment, endoscopic and surgical procedures. The latter can be either conservative, such as cardiomyotomy or more aggressive, such as cardioplasty or esophageal resection. In this article, we discuss the early and long term results after the different therapeutic options. We also present the results of our recent surgical experience. The definitive results seem to be better after surgical treatment compared to medical management or endoscopic procedures (Rev Med Chile 2002; 130. 1055-66).

Reflujo gastroesofágico patológico en pacientes con obesidad severa, mórbida e hiper obesidad

Background: Overweight can be a risk factor for pathological gastroesophageal reflux or hiatal hernia. Aim: To study the prevalence of gastroesophageal reflux in patients with severe obesity. Patients and methods: Sixty seven patients, 51 female, aged 17 to 56 years old with a body mass index over 35 kg/m2, were studied. An upper gastrointestinal endoscopy was performed in all, esophageal manometry was done in 32 and 24 h pH monitoring was done in 32 patients. Results: Seventy nine percent of patients complained of heartburn and 66% of regurgitation. In 16 patients, endoscopy was normal. An erosive esophagitis was found in 33 patients, a short columnar epithelium in 12 and a Barret esophagus with intestinal metaplasia in six. Normal endoscopic findings and erosive esophagitis were present with a higher frequency in women. No association between the degree of obesity and esophageal lesions was observed. Lower esophageal sphincter pressure and abdominal length were significantly higher in subjects with a body mass index over 50 compared to those with a body mass index between 35 and 39.9 kg/m2. No differences were observed in 24 h pH monitoring. Conclusions: A high proportion of severely obese patients had symptoms and endoscopical findings of pathological gastroesophageal reflux (Rev Med Chile 2001; 129: 1038-43

Comparación del tratamiento médico y quirúrgico en pacientes con obesidad grado III (obesidad mórbida)

This is a review of publications comparing the results of medical and surgical treatment of morbid obesity. An overall conclusions is that the frequency of cardiovascular complications or cancer is higher among patients receiving medical treatment. Surgical treatment is associated with a better weight loss, reduction in complications and quality of life. Mortality risk decreases significantly after surgical treatment, when compared with patients receiving medical therapy Therefore, management of morbid obesity should be carried out by multidisciplinary teams with experience on gastrointestinal surgery. In this way the complications and mortality of bariatric surgery would be minimized.

Factores de riesgo del cáncer de mama en mujeres de Santiago

Background: Epidemiological studies suggest a relation between breast cancer, diet and life styles. Aim: To analyze the association between food patterns, obesity, smoking, alcohol consumption and breast cancer risk in women of Santiago. Patients and methods: A case-control study design (170 cases and 340 controls), matched by age and sex, was used. Through a food frequency questionnaire the average daily intake of vegetables, fruits, s-carotene, vitamin A, C, E and fiber was analyzed. Other exposures to non-nutritional risks (parity, smoking, cancer history) were also studied. Conditional logistic regression was calculated to determine the odds ratio associated with variations in food and nutrient intake and nonnutritional factors. Results: Cases had a greater BMI and a higher prevalence of obesity than controls (p< 0.02). No differences were observed in either group food patterns. The ORs for breast cancer associated with obesity and alcohol consumption were 1.65 (95% CI 1.06-2.64) and 1.61 (95% CI 1.06-2.54) respectively (p< 0.05). Multiparity had a protective effect with 0.66 less risk (95% CI 0.44-0.99). No protective effect associated to a greater intake of vegetables, fruits or natural antioxidants was observed. Multivariate analysis model disclosed obesity as a risk factor (OR 1.79, p< 0.02) and parity ³ 4 as protective (OR 0.62, p<0.02). Conclusions: This study does not support a protective role for natural antioxidants against breast cancer but indicate a weakassociation with obesity.

Programa de la especialidad Cirugía General: Definiciones y propuestas de la Sociedad de Cirujanos de Chile

El Directorio de la Sociedad de Cirujanos confecha 10 de Enero 2007 encargo al Dr. Juan HeppK. que coordinara el trabajo de una Comision inte-grada por los Drs. Attila Csendes J, FernandoIbanez, Osvaldo Llanos y Sergio San Martin, encar-gados de generar un documento que definiera losaspectos generales y contenidos de un “Programade Formacion de Postgrado en la especialidad deCirugia General”. Como resultado de dicho trabajose concluyo en los siguientes aspectos:INTRODUCCIONLa Cirugia General como especialidad se estaenfrentando en los ultimos anos, especialmente enEstados Unidos y Europa, a una crisis que se ma-nifiesta por los siguientes hechos: disminucion delos alumnos que la eligen como su primera priori-dad, aumento de las subespecialidades, lo quehace que la formacion de Cirugia General sea unpaso para alcanzar dicha especializacion; defini-cion demasiado amplia y difusa de los conocimien-tos y campo de accion del Cirujano General.Hay varios hechos que han ocurrido en losultimos 15 anos, que han cambiado el espectro delprograma de formacion de especialistas en cirugiageneral:- Cambios epidemiologicos de enfermedadestanto aumento como disminucion (obesidad y ulce-ra peptica por ejemplo).– Mayor dedicacion a areas mas especificasde la cirugia, lo que ha mejorado notablemente losresultados quirurgicos: cirujanos de “alto volumen”dedicados a temas mas especificos de la cirugia:esofagogastrica, mama, colorectal etc.–˜Desarrollo de nuevas tecnologias que noexistian hace 15 anos: cirugia laparoscopica yendoscopica, cirugia de trasplantes.– Incorporacion necesaria en la practica quirur-gica diaria de nuevos conocimientos como labioetica, la gestion clinica, la metodologia de lainvestigacion, conocimiento en computacion, etc.En Chile no hay una clara definicion de lascompetencias que debe tener el cirujano que nece-sita el pais. Tambien existe una discordancia entrelo que se aprende durante el programa de forma-cion de Cirugia General y lo que se hace en lapractica profesional. Esto se refiere basicamente alas tecnicas de especialidades como cirugia vas-cular, endocrinologica o torax.Dado que en hospitales de complejidad media-na no existe el superespecialista, y que por un ladola presion de la judicializacion de la medicina y porotro la evidencia de que cirugias complejas tienen