Edvaldo Fahel

Remission of Psoriasis after Open Gastric Bypass

Psoriasis is a frequent skin disease, affecting 2% of the worlds population. Stress, alcohol, smoking and obesity may be associated with psoriasis. A 56-year-old man with BMI 46.9 kg/m2, hypertension and gastroesophageal reflux, had severe psoriasis for the last 39 years, without any remission on multiple treatments. Psoriatic papules and plaques were noted on his face, dorsum of hands, buttocks, knees, and elbows. He underwent open Roux-en-Y gastric bypass. At 4-month follow-up, the patient had lost 23 kg or 34.8% of excess weight, and presented complete remission of the psoriasis without medications. Bariatric surgery for positive metabolic, psychological and lifestyle consequences should be considered a treatment of psoriasis. Long-term observation is necessary.

Prevention of Rhabdomyolysis in Bariatric Surgery

Background: Rhabdomyolysis (RML) is a clinical and biochemical syndrome caused by skeletal muscle necrosis that results in extravasation of toxic intracellular contents from the myocytes into the circulatory system. Postoperative RML in bariatric surgery occurs with various non-physiological surgical positions, with prolonged muscle compression. The potential consequences may lead to death. The purpose of this study is to review its pathophysiology and the best ways to prevent RML in bariatric surgery. Methods: We searched the literature and reviewed all relevant articles, by searching for the keywords: rhabdomyolysis, morbid obesity, prevention and bariatric surgery, giving a total of 39 articles. Results: Prevention may be enhanced by careful padding on the operative table at all pressure-points. Changing patient position, both intraoperatively and postoperatively, also reduces RML. A potential new solution to decrease the longer operative time and avoid RML is to perform the bariatric operation in two stages. Another way to limit the duration of surgery in high-risk patients is to alert surgeons not to select super-obese high-risk patients early in the learning curve. Conclusion: As RML is an important and potentially fatal complication of bariatric surgery, the best way to avoid it is effective prevention. More research on this subject is necessary.

Staplerless Laparoscopic Gastric Bypass: a New Option in Bariatric Surgery

The staplerless Roux-en-Y gastric bypass (RYGBP) is a new option in bariatric surgery. The first to describe it was Himpens (2004) utilizing the LigaSure Atlas™ (LSA) in a series of 10 patients. The laparoscopic RYGBP is performed utilizing the LSA for the gastric and jejunal partition; after that, an imbricating running suture is performed to ensure stomach and bowel hermetic closure. All anastomoses are hand-sewn. Technical disadvantages are: learning curve; complications related to suture failure; possible thermal/electricity related injuries; longer operating time. Advantages are: stapler-associated bleeding, leaks, staple-line disruption, and fistulas are avoided; cost reduction. The staplerless RYGBP is complex; the surgeon involved requires expertise and ability. This technique will evolve and will be used by more surgeons. It is a new option for the surgeon preoccupied with costs, which is particularly important in developing countries.

Laparoscopic gastric banding in the rat model as a means of videolaparoscopic training.

Background: The development of laparoscopy in bariatric surgery has attracted a large number of surgeons. Learning this method for future clinical practice requires intensive training with inert tissues, simulators and experimental surgery in animals. Performing these procedures in small animals, with the same equipment used in humans, is feasible, allowing familiarization with and comprehension of the basic techniques. Wistar rats weighing 300-600 g were used. The animals were kept in standard laboratory conditions. A laparoscopic video-system, Veress needle, three ports, a 0° optic, a laparoscopic needle-holder, two 5-mm graspers, a 5-mm dissection clamp and a 5-mm scissors were used. An orogastric catheter with three 4-0 nylon sutures and one 6-0 nylon suture were also utilized. For the gastric band, we used a plastic device similar to the human gastric band. The present study describes a simple, inexpensive and reproducible technique for laparoscopic gastric banding in a rat model utilizing the same instruments developed for humans. The experimental rat model is more motivating than simulators, requires less space, and has easier maintenance compared with bigger animals, and consequently allows the use of more animals for teaching, training and application in many scientific studies.

Critical Analysis of the Staged Laparoscopic Roux-en-Y: A Two-Stage Operation to Diminish the Size of the Liver in Super-Obese Patients

We read the interesting paper Staged Laparoscopic Roux-en-Y: A Novel Two-Stage Bariatric Operation as an Alternative in the Super-obese with Massively Enlarged Liver, by the renowned Ninh T. Nguyen, with M. Longoria, D.V. Gelfand, A. Sabio, and S.E. Wilson.1 The enlarged liver is a major concern for the bariatric surgeon. The effort to create alternatives to operate on patients with this problem is very important. The technique described is a very intelligent idea, but the pioneers have to overcome the uncertainty with this new procedure. Some points in this article are controversial. This new technique is not a simple and easy operation; severe complications can occur in super-obese patients submitted to this procedure. The first stage of the procedure consists of three main steps: 1) gastric partition; 2) entero-anastomosis; 3) gastrojejunostomy (Figure 1). The latter stage of the procedure is similar to the biliopancreatic diversion with gastric preservation as performed by Domene in Brazil,2 differing in the length of the alimentary and biliopancreatic limbs. The second stage of the procedure consists of a sleeve gastrectomy (Figures 2A-C) performed 6 to 12 months after the first stage. These several steps make this operation as complex as many bariatric operations. The laparoscopic RYGBP in the super-obese is associated with higher morbidity and mortality as demonstrated by Artuso et al,3 and the two-stage procedure probably has the same outcome. The operated individual may develop several complications in any of the three steps, e.g. 1) acute gastric dilatation, 2) bleeding in the staple-line, 3) intra-abdominal bleeding, 4) gastrojejunostomy and jejunojenunostomy dehiscence, 5) gastrojejunostomy fistula, 6) intestinal obstruction. If this technique is compared to the sleeve gastrectomy, the latter has less complications and is a faster procedure. Surgical time is very important in the super-obese, preventing complications related to longer operations such as rhabdomyolysis.4 The authors perform the gastrojejunal anastomosis low on the lesser curvature, and in doing that, they create a longer gastric pouch. In the future, lengthening can defeat the weight loss from the non-banded gastric bypass, so that the suggested first stage should have a smaller pouch. Another problem in the superobese is the thickened mesocolon and its weight during creation of the retrocolic tunnel;3 this difficult task can be solved if the gastrojejunostomy is performed ante-colic ante-gastric. The authors note that “the primary limiting factor making laparoscopic gastric bypass challenging in the super-obese is the volume of the left lobe of the liver”. Many surgeons have good results with a diet with a minimum amount of carbohydrates for 1-2 months before operation which diminishes the thickened lobe of the liver. Even if the liver is unexpectedly large when one passes the laparoscope, the Correspondence

Closure of the abdominal cavity after severe peritonitis in bariatric surgery utilizing a mesh and plastic device.

The major cause of peritonitis in bariatric surgery is leakage of GI contents, which can have a catastrophic outcome for the bariatric patient. To resolve this serious problem, the surgeon must act quickly. This paper describes a 27-year-old female after gastric bypass with disruption of the gastroenterostomy and severe contamination and peritonitis. Closure of the anastomotic leak, drainage, and gastrostomy in the bypassed stomach were performed, but the abdomen could not be closed, due to dilated bowel and the intra-abdominal edema with the sepsis. Temporary laparostomy closure was performed; a plastic sheet with an overlying mesh was sutured to the fascial margins. Planned multiple reoperations permitted removal of necrotic and infected debris, with progressive approximation and ultimate closure of the fascia. This treatment resulted in a successful outcome for the patient.

Hemangioma hepático gigante roto

INTRODUCAO: Ruptura por hemangioma hepatico e rara e ha somente 32 casos descritos na literatura. RELATO DO CASO: Homem com 39 anos foi admitido com dor abdominal em hipocondrio direito de inicio subito associado a lipotimia. A investigacao inicial demonstrou hemangioma hepatico gigante (7x13 cm) em lobo direito associado a sinais de sangramento recente. Com o intuito de minimizar possibilidade de sangramento no intra-operatorio, foi realizado embolizacao da arteria hepatica direita. A operacao transcorreu sem intercorrencias, sem necessidade de hemotransfusao no intra-operatorio. A transeccao foi realizada com grampeador linear cortante de 75 mm. O tempo de internacao foi de 13 dias. CONCLUSAO: Procedimento cirurgico e mandatorio para hemangioma hepatico roto, e a embolizacao e eficiente para controlar o sangramento e preparar melhor o paciente para a operacao.

Colangiopancreatografia endoscópica retrógrada (CPRE) intraoperatória como alternativa no tratamento de coledocolitíase

RACIONAL: O tratamento da coledocolitiase continua controverso, podendo ser realizado por pancreatocolangiografia retrograda endoscopica pre-operatoria seguida de videolaparocolecistectomia ou por videolaparocolecistectomia com exploracao de vias biliares. Ha relato na literatura de taxa de insucesso da pancreatocolangiografia retrograda endoscopica pre-operatoria em torno de 6%. OBJETIVO: Apresentar caso de uma paciente que necessitou da realizacao de CPRE intra-operatoria para resolucao de coledocolitiase tratada sem exito por CPRE. RELATO DO CASO: Paciente de 45 anos, admitida na emergencia com quadro de dor abdominal em epigastrio e hipocondrio direito. A ultra-sonografia da admissao evidenciou coledocolitiase, sendo ela encaminhada para pancreatocolangiografia retrograda endoscopica pre-operatoria onde nao houve sucesso na cateterizacao da papila. Foi optado entao pela realizacao de videolaparocolecistectomia com exploracao de via biliar por pancreatocolangiografia retrograda endoscopica pre-operatoria intra-operatoria com a cateterizacao da papila direcionada por fio guia passado pelo ducto cistico. Foi realizada duodenoscopia com captura do fio guia que serviu para a passagem do papilotomo dando sequencia a pancreatocolangiografia retrograda endoscopica pre-operatoria e retirada dos calculos. A paciente evoluiu satisfatoriamente tendo alta no 2o dia do pos-operatorio. CONCLUSAO: A abordagem da coledocolitiase por pancreatocolangiografia retrograda endoscopica intra-operatoria seguida de videolaparocolecistectomia, mostrou-se segura e eficaz.