Carlos Eduardo Malzoni

Sleeve gastrectomy with transit bipartition: a potent intervention for metabolic syndrome and obesity.

Objective: To present 5-year results of sleeve gastrectomy (SG) with transit bipartition (TB) as a metabolic intervention for obesity. Background: Recent data suggest that high glycemic index foods may lead to a hormonally hyperactive proximal gut and a hypoactivate distal gut, which are linked to metabolic syndrome. TB was designed to counterbalance these effects. Methods: A total of 1020 obese patients with body mass index (BMI) ranging from 33 to 72 Kg/m2 underwent SG and TB (SG + TB). TB creates a gastroileal anastomosis in the antrum after the SG; nutrient transit is maintained in the duodenum, avoiding blind loops and minimizing malabsorption. The stomach retains 2 outflow pathways. A lateral enteroanastomosis connects both segments at 80 cm proximal to the cecum. Results: Adequate follow-up data were collected in 59.1% of patients from 4 months to 5 years. The average percent of excess BMI loss was 91%, 94%, 85%, 78%, and 74% in the first, second, third, fourth, and fifth year, respectively. Patients experienced early satiety and major improvement in presurgical comorbidities, including diabetes (86% in remission), following surgery. Two deaths occurred (0.2%). Other surgical complications occurred in 6% of patients. Signs of malabsorption were rare. Conclusions: SG + TB is a simple procedure that results in rapid weight loss and remission or major improvement of comorbidities. Strictly aiming at physiological correction, TB avoids prostheses, narrow anastomoses, excluded segments, and malabsorption. Weight and comorbidities are much improved. Diabetes is improved without duodenal exclusion. TB is an excellent complement to an SG.

Preliminary results from digestive adaptation: a new surgical proposal for treating obesity, based on physiology and evolution

CONTEXT AND OBJECTIVE Most bariatric surgical techniques include essentially non-physiological features like narrowing anastomoses or bands, or digestive segment exclusion, especially the duodenum. This potentially causes symptoms or complications. The aim here was to report on the preliminary results from a new surgical technique for treating morbid obesity that takes a physiological and evolutionary approach. DESIGN AND SETTING Case series description, in Hospital Israelita Albert Einstein and Hospital da Polícia Militar, São Paulo, and Hospital Vicentino, Ponta Grossa, Paraná. METHODS The technique included vertical (sleeve) gastrectomy, omentectomy and enterectomy that retained three meters of small bowel (initial jejunum and most of the ileum), i.e. the lower limit for normal adults. The operations on 100 patients are described. RESULTS The mean follow-up was nine months (range: one to 29 months). The mean reductions in body mass index were 4.3, 6.1, 8.1, 10.1 and 10.7 kg/m2, respectively at 1, 2, 4, 6 and 12 months. All patients reported early satiety. There was major improvement in comorbidities, especially diabetes. Operative complications occurred in 7% of patients, all of them resolved without sequelae. There was no mortality. CONCLUSIONS This procedure creates a proportionally reduced gastrointestinal tract, leaving its basic functions unharmed and producing adaptation of the gastric chamber size to hypercaloric diet. It removes the sources of ghrelin, plasminogen activator inhibitor-1 (PAI-1) and resistin production and leads more nutrients to the distal bowel, with desirable metabolic consequences. Patients do not need nutritional support or drug medication. The procedure is straightforward and safe.

Sleeve gastrectomy with anti-reflux procedures

Objective Sleeve gastrectomy is the fastest growing surgical procedure to treat obesity in the world but it may cause or worsen gastroesophageal reflux disease. This article originally aimed to describe the addition of anti-reflux procedures (removal of periesophageal fats pads, hiatoplasty, a small plication and fixation of the gastric remnant in position) to the usual sleeve gastrectomy and to report early and late results. Methods Eighty-eight obese patients that also presented symptoms of gastroesophageal reflux disease were submitted to sleeve gastrectomy with anti-reflux procedures. Fifty of them were also submitted to a transit bipartition. The weight loss of these patients was compared to consecutive 360 patients previously submitted to the usual sleeve gastrectomy and to 1,140 submitted to sleeve gastrectomy + transit bipartition. Gastroesophageal reflux disease symptoms were specifically inquired in all anti-reflux sleeve gastrectomy patients and compared to the results of the same questionnaire applied to 50 sleeve gastrectomy patients and 60 sleeve gastrectomy + transit bipartition patients that also presented preoperative symptoms of gastroesophageal reflux disease. Results In terms of weight loss, excess of body mass index loss percentage after anti-reflux sleeve gastrectomy is not inferior to the usual sleeve gastrectomy and anti-reflux sleeve gastrectomy + transit bipartition is not inferior to sleeve gastrectomy + transit bipartition. Anti-reflux sleeve gastrectomy did not add morbidity but significantly diminished gastroesophageal reflux disease symptoms and the use of proton pump inhibitors to treat this condition. Conclusion The addition of anti-reflux procedures, such as hiatoplasty and cardioplication, to the usual sleeve gastrectomy did not add morbidity neither worsened the weight loss but significantly reduced the occurrence of gastroesophageal reflux disease symptoms as well as the use of proton pump inhibitors.

Avaliaçäo da hernioplastia protética atensional no tratamento das hérnias inguinais

This is the inicial experience in Brazil with the routine use of prosthetic tensionless repair of common inguinal hernias. Before that many groups had been using prosthetic material in selected cases, mostly recurrences. Seventy six patients were operated on, 12 of them bilaterally so that there were 88 procedures over direct (26,1%), indirect (56,8%) and both direct and indirect hernias (17,1 %). The hernia sacs are reduced to the abdominal cavity and the abdominal wall is reinforced by the placement of a polipropilen mesh on the transversalis fascia. The technique is detailed described. Only minimal pain occurred in the postoperative period. There were no infeccion, no rejection, and until now (30 months of medium follow up), no signs of recurrences. Many aspects of the surgical treatment of inguinal hernias are discussed including results, feseability, risks and costs. It is concluded that prosthetic tensionless repair of inguinal hernias is easy, fast, safe and cheap. It does not require general anaesthesia neither complex material. It has excellent results and as it does not create tension sutures, it causes less pain and allows normal physical activity very soon. It suggests that, in common inguinal hernias, maybe we can spare the patient and community from the higher costs of laparoscopic surgery since we can obtain excellent results with an easier and cheaper method.

Gastrectomia vertical com medidas antirrefluxo

Objetivo A gastrectomia vertical e o procedimento cirurgico para tratamento da obesidade que mais cresce em indicacoes. No entanto, esse procedimento pode causar ou agravar a doenca do refluxo gastresofagico. Este artigo buscou descrever originalmente a adicao de procedimentos antirrefluxo (remocao de coxins gordurosos do hiato, hiatoplastia, pequena plicatura e fixacao do remanescente na posicao anatomica), alem de relatar seus resultados precoces e tardios.Metodos Foram submetidos a gastrectomia vertical com medidas antirrefluxo 88 oito pacientes obesos com sintomas de doenca [...]

Tratamento cirúrgico da doença pilonidal: meta-análise dos principais procedimentos adotados mundialmente

OBJETIVO: Analisar e comparar os diversos procedimentos cirurgicos descritos para o tratamento da doenca pilonidal. METODO: Foram selecionados 34 trabalhos publicados em revistas indexadas, totalizando 8698 doentes operados. Realizou-se meta-analise para comparacao das sete principais tecnicas cirurgicas descritas na literatura, quanto aos resultados em relacao a recidiva e ao tempo de cicatrizacao no pos-operatorio. RESULTADOS: Do total de doentes estudados, houve recidiva em 230 doentes (2,6%). O tempo de cicatrizacao no pos-operatorio foi significantemente maior no grupo de excisao sem sutura. As recidivas foram estatisticamente semelhantes nos metodos: excisao sem sutura, marsupializacao, incisao e curetagem, excisao e retalho e tecnica de Karidakys. Os metodos que apresentaram maior indice de recidiva (estatisticamente significante - p<0,001) foram: excisao e sutura primaria e o metodo de Bascom. CONCLUSOES: Conclui-se, por esse estudo, que os resultados em relacao a recidiva sao estatisticamente semelhantes em todos os metodos, com excecao da excisao e sutura primaria e da tecnica de Bascom, que apresentaram recidivas mais frequentes. O tempo de cicatrizacao foi maior nos individuos operados pela tecnica de excisao sem sutura primaria.