Everton Cazzo

Comparison of Metabolic Effects of Surgical-Induced Massive Weight Loss in Patients with Long-Term Remission Versus Non-remission of Type 2 Diabetes

BackgroundThe aim of this study was to evaluate the pathophysiological mechanisms underlying the non-remission of type 2 diabetes in Roux-en-Y gastric bypass (RYGB) patients.MethodsA group of patients not in remission (NR) was formed (n = 13). A remission group (R) was composed of patients who had undergone normalization of fasting glycemia and A1c, without anti-diabetic drugs and matched for selected baseline characteristics (i.e., duration of disease, previous BMI, final BMI, fat distribution, and age; n = 15). A control group of lean subjects (n = 41) was formed.ResultsThe NR group had higher uric acid (5.1 vs. 3.9 mg/dL), number of leukocytes (6,866.9 vs. 5,423.6), hs-CRP (0.27 vs. 0.12 mg/dL), MCP-1 (118.4 vs. 64.4 ng/mL), HOMA-IR, and AUCglucose but lower adiponectin (9.4 vs. 15.4 ng/mL), leptin (12.7 vs. 20.7 ng/mL), and AUCGLP-1 in comparison to R group; the NR group also had lower leptin and higher adiponectin, HOMA-IR, AUCglucose, AUCC-peptide, AUCglucagon, and AUCGLP-1 than controls. The R group had lower MCP-1 and higher adiponectin compared to controls. Insulin sensitivity was significantly lower in the NR group than in the R and control groups. The insulin secretion index values were lower in the NR group than in the R and control groups.ConclusionsThis study found greater insulin resistance, lower insulin secretion, persistent adiposopathy and chronic subclinical inflammation, and less robust incretin response in the NR group despite a similar level of weight loss. Persistently altered pathophysiological mechanisms can be related to the lack of remission of type 2 diabetes after RYGB.

Surgical treatment of chronic pancreatitis using Frey's procedure: a Brazilian 16-year single-centre experience.

BACKGROUND Surgical treatment of chronic pancreatitis is indicated for intractable pain. Freys procedure is an accepted treatment for this disease. The aim of the present study was to describe a single-centre experience in the treatment of chronic pancreatitis using Freys procedure. METHODS A retrospective analysis of 73 patients who underwent a Freys procedure between 1991 to 2007 and had at least 1 year of follow-up. Demographics, indication for surgery, peri-operative complications and late outcomes were analysed. RESULTS The median age was 39.9 years. Seventy out of the 73 (95.8%) patients were male. The median pre-operative body mass index (BMI) was 19.1 kg/m(2). All patients had abdominal pain, 34 (46.6%) of them daily and 13 (17.8%) weekly, with moderate or severe intensity in 98.6% (n= 72). The aetiology was secondary to alcohol in 70 patients (95.9%), with a median consumption of 278 g per day. The surgical morbidity rate was 28.7%; there were no deaths. Median post-operative follow-up was 77.0 months; 64 patients (91.4%) had complete pain relief and post-operative BMI was 22.4 kg/m(2) (P<0.001). All patients with pre-operative endocrine and exocrine insufficiencies showed no reversal of the situation. New onset insufficiencies appeared late. CONCLUSIONS Freys procedure was a safe and effective therapeutic option for the surgical treatment of patients with intractable pain caused by chronic pancreatitis.

Apreensão de tópicos em ética médica no ensino-aprendizagem de pequenos grupos: comparando a aprendizagem baseada em problemas com o modelo tradicional

OBJETIVO: O presente estudo tem como objetivo avaliar o ensino de etica medica durante o curso de medicina e se houve mudanca na aquisicao de conhecimentos em etica medica com o redirecionamento do modelo pedagogico da Faculdade de Medicina de Marilia. METODOS: Foi realizado estudo prospectivo e analitico, baseado na aplicacao de questionarios sobre temas gerais em Etica, em dois periodos distintos. RESULTADOS: Observou-se nao haver diferencas significantes entre a aquisicao de conhecimentos entre os dois metodos. Verificou-se que os alunos de anos mais proximos do termino do curso apresentaram desempenho significativamente melhor que os ingressantes no curso. Os topicos que apresentaram menor indice de acerto compreendiam o sigilo medico, o consentimento do responsavel, a autonomia do paciente, a prescricao medica, o prontuario medico e o corporativismo em relacao ao erro medico. CONCLUSAO: A variavel mais importante nao foi o modelo pedagogico e sim o tempo de exposicao ao tema. O modelo ABP da chance de distribuir o tema em varios modulos e tutorias durante o curso medico ajudando a acelerar o processo de aquisicao de conhecimentos em etica medica. Conclui-se que e necessario uma revitalizacao do ensino da Etica Medica em nossa instituicao, visando a uma maior integracao com a conjuntura socioeconomica de nosso pais.

Impact of Roux-en-Y Gastric Bypass on Metabolic Syndrome and Insulin Resistance Parameters

BACKGROUND Metabolic syndrome (MetS) is a complex association of clustering metabolic factors that increase risk of type 2 diabetes mellitus (T2DM) and cardiovascular disease. Surgical treatment has become an important tool to achieve its control. The aim of this study was to evaluate the impact of Roux-en-Y gastric bypass (RYGB) on MetS and its individual components, clinical characteristics, and biochemical features. SUBJECTS AND METHODS The study is a retrospective cohort of 96 subjects with MetS who underwent RYGB and were evaluated at baseline and after surgery. Clinical and biochemical features were analyzed. RESULTS After surgery, significant rates of resolution for MetS (88.5%), T2DM (90.6%), hypertension (85.6%), and dyslipidemias (54.2%) were found. Significant decreases in levels of fasting glucose, fasting insulin, hemoglobin A1c, low-density lipoprotein, and triglycerides and an increase in high-density lipoprotein level were also shown. The decrease in insulin resistance evaluated by homeostasis model assessment (HOMA-IR) was consistent. MetS resolution was associated with postoperative glycemic control, decreases in levels of fasting glucose, hemoglobin A1c, HOMA-IR, and triglycerides and in antihypertensive usage, and percentage weight loss. CONCLUSIONS This study found high rates of resolution for MetS, T2DM, hypertension, and dyslipidemias after RYGB in obese patients. This finding was consistent with current literature. Hence RYGB should be largely indicated for this group of subjects as it is a safe and powerful tool to achieve MetS control.

GLP-2: A POORLY UNDERSTOOD MEDIATOR ENROLLED IN VARIOUS BARIATRIC/METABOLIC SURGERY-RELATED PATHOPHYSIOLOGIC MECHANISMS

ABSTRACT Introduction: Glucagon-like peptide-2 (GLP-2) is a gastrointestinal hormone whose effects are predominantly trophic on the intestinal mucosa. Aim: Critically evaluate the current literature on the influence of bariatric/metabolic surgery on the levels of GLP-2 and its potential clinical implications. Method s: Narrative review through online research on the databases Medline and Lilacs. There were six prospective human studies, two cross-sectional human studies, and three experimental animal studies selected. Results: There is evidence demonstrating significant increase in the levels of GLP-2 following gastric bypass, Scopinaro operation, and sleeve gastrectomy. There are no differences between gastric bypass and sleeve gastrectomy in regards to the increase in the GLP-2 levels. There is no correlation between the postoperative levels of GLP-2 and the occurrence of adequate or insufficient postoperative weight loss. Conclusion: GLP-2 plays significant roles on the regulation of nutrient absorption, permeability of gut mucosa, control of bone resorption, and regulation of satiety. The overall impact of these effects potentially exerts a significant adaptive or compensatory effect within the context of varied bariatric surgical techniques.

CONTROL OF HYPERTENSION AFTER ROUX-EN-Y GASTRIC BYPASS AMONG OBESE DIABETIC PATIENTS

CONTEXT Hypertension is a common disorder in general practice and has a widely known association with type 2 diabetes mellitus. Low adhesion to clinical treatment may lead to poor results. Obesity surgery can bring early and relevant resolution rates of both morbidities. OBJECTIVE To describe hypertension evolution after Roux-en-Y gastric bypass in patients with type 2 diabetes mellitus. METHOD Descriptive observational study designed as a historical cohort of 90 subjects with hypertension and diabetes who underwent Roux-en-Y gastric bypass and were evaluated before and after surgery. RESULTS It was observed a hypertension resolution rate of 85.6% along with markedly decrease in anti-hypertensive usage. Mean resolution time was 3.2 months. Resolution was associated with homeostasis model assessment - insulin resistance, preoperative fasting insulin, anti-hypertensive usage, hypertension time, body mass index and percentage of weight loss. Resolution of hypertension was not statistically associated with diabetes remission within this sample. CONCLUSION Roux-en-Y gastric bypass was a safe and effective therapeutic tool to achieve hypertension resolution in patients who also had diabetes mellitus.

Correlation Between Post Over Preoperative Surrogate Insulin Resistance Indexes’ Ratios and Reversal of Metabolic Syndrome After Roux-en-Y Gastric Bypass

Metabolic syndrome (MetS) is strongly linked to insulin resistance and has a high resolution rate after bariatric surgery. This study aims to determine whether post over preoperative ratios of surrogate insulin resistance markers (HOMA, TyG, and TG/HDL-c) are associated to postsurgical MetS reversal. This is a retrospective cohort study which involved 96 subjects with MetS who underwent Roux-en-Y gastric bypass (RYGB). Post over preoperative ratios of TyG and TG/HDL-c indexes were statistically associated to MetS resolution. The use of these ratios as a way to assess postsurgical insulin sensitivity response appears to be a simple and useful tool in clinical practice.

Mixed adenoneuroendocrine carcinoma of the gastric stump following Billroth II gastrectomy: case report and review of the literature

CONTEXT Gastric stump cancer after gastric resection is a well-known disease. It may be a newly developed cancer after resection due to benign disease, or recurrent or residual disease after oncological surgery. The predominant histological type is usually adenocarcinoma. This study aimed to report on a rare occurrence of a mixed adenoneuroendocrine carcinoma (MANEC) on the gastric stump. CASE REPORT The case of an 83-year-old female who presented a locally aggressive gastric stump MANEC, 35 years after Billroth II gastrectomy to treat a peptic ulcer, is reported. The patient underwent resection and adjuvant therapy. She has been followed up for one year without signs of recurrence. CONCLUSION MANEC is a rare type of gastrointestinal neoplasm. The classification, histopathology, clinical features, treatment issues and prognosis are discussed along with a brief review of the literature.

Influence of morbid obesity on physical capacity, knee-related symptoms and overall quality of life: A cross-sectional study

Objective: To evaluate the impact of morbid obesity on physical capacity, joint-related symptoms, and on the overall quality of life. Method: Cross-sectional study carried out at a university hospital, enrolling 39 individuals admitted to a bariatric surgery service. Physical capacity was assessed by Six-Minute Walk Test (SMWT) and the Borg rating of perceived exertion (RPE). Knee-related symptoms were evaluated by Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm Score. Quality of life was evaluated by Short Form 36 Health Questionnaire (SF-36). Results: On SMWT, the mean distance walked was 374.1±107.5 m. The mean Borg score was 12.9±2.4. KOOS questionnaire found the following scores: pain (64.3±24), other symptoms (67.2±25.5), function in daily living (60.4±26.8), function in sport and recreation (28.5±32.2), knee-related quality of life (35.9±33.5), mean Lysholm scale score (55.3±25.4). SF-36 provided the following scores: physical functioning (41±27.4), physical role functioning (34.6±39.2), bodily pain (45.7±23.6), general health perceptions (63.1±26.2), vitality (53.5±12.1), social role functioning (52.6±29.3), emotional role functioning (41±44.9), mental health (55±27.7). Conclusion: Obesity led to significant loss of physical capacity, gait impairment, knee-related symptoms, and a negative impact on the overall quality of life.

Influence of type 2 diabetes mellitus on liver histology among morbidly obese individuals. A cross-sectional study

CONTEXT AND OBJECTIVE Nonalcoholic fatty liver disease (NAFLD) has become a public health concern. It encompasses a wide spectrum of histological abnormalities and has close relationships with insulin resistance and type 2 diabetes mellitus (T2DM). This study sought to compare the histological alterations observed in morbidly obese individuals with and without T2DM who underwent Roux-en-Y gastric bypass. DESIGN AND SETTING Cross-sectional study in a tertiary-level public hospital. METHODS This was a cross-sectional study on 197 individuals who underwent gastric bypass surgery between 2011 and 2013. NAFLD was assessed through liver biopsies. T2DM was diagnosed through the International Diabetes Federation criteria. RESULTS Non-diabetics presented significantly more biopsies without any histological abnormalities, regarding steatosis (42.6% versus 25.5%; P = 0.0400), fibrosis (60.6% versus 36.2%; P = 0.0042) and steatohepatitis (27.3% versus 12.8%; P = 0.0495), while diabetics presented significantly higher frequency of moderate forms of steatosis (36.2% versus 20%; P = 0.0307) and fibrosis (23.4% versus 4%; P = 0.0002). DISCUSSION T2DM was associated with more advanced forms of NAFLD within the population studied. NAFLD has previously been correlated with severe forms of heart disease. CONCLUSION Screening for and early detecting of NAFLD in high-risk populations are important for avoiding further development of severe forms and the need for liver transplantation.