Francisco Callejas-Neto

Absolute ethanol and 5% ethanolamine oleate are comparable for sclerotherapy of esophageal varices

BACKGROUND Endoscopic sclerotherapy is widely accepted as an effective treatment for the eradication of esophageal varices in patients with portal hypertension and a history of upper gastrointestinal bleeding. The objective of this study was to assess the effectiveness and safety of absolute ethanol as an alternative sclerosing agent to the commonly used 5% ethanolamine oleate. METHODS One hundred fifty-seven patients with portal hypertension and a history of variceal bleeding were randomly assigned to sclerotherapy with absolute ethanol (n = 66) or 5% ethanolamine oleate (n = 91) between January 1992 and July 1994. Once eradication was achieved, these patients were prospectively followed until September 1998. RESULTS Sclerotherapy with both sclerosants resulted in similar eradication rates (approximately 90%), with comparable numbers of sessions required for eradication (5.4 and 5.9 sessions for absolute ethanol and 5% ethanolamine oleate, respectively). Similar complication and recurrent bleeding rates were observed among both groups. CONCLUSION Sclerotherapy with absolute ethanol is as effective as with 5% ethanolamine oleate in preventing further bleeding in patients with portal hypertension.

Gastroplastia redutora com bypass gastrojejunal em Y-de-Roux: conversão para bypass gastrointestinal distal por perda insuficiente de peso - experiência em 41 pacientes

BACKGROUND Surgery is the only effective treatment for morbid obesity. Gastric bypass could fail in up to 10% of the patients (excess weight loss under 50%). AIMS To evaluate the weight loss determined by reoperation performing disabsortive variation of gastric bypass. PATIENTS AND METHODS The records of 41 patients, in whom 32 were submitted to reoperation by one of three surgical techniques (Fobi, Brolin, distal gastrojejunoileal bypass) which consisted in increasing the disabsortive length of intestinal limb. RESULTS The patients submitted to distal gastrojejunoileal bypass showed the best results (69.7%). CONCLUSION The distal gastric bypass as a revisional procedure could be done in selected cases with the aim to improve the weight loss. It is advisable to refer these patients to selected centers (known as center of excellence) with experience in this area of bariatric surgery, in order to perform a very close follow-up.

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.

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.

Tratamento cirúrgico da pancreatite crônica com a técnica de F rey: panorama atual

INTRODUCTION: Chronic pancreatitis is a progressive inflammatory disorder characterized by irreversible destruction of pancreatic parenchyma and may be associated with disabling chronic pain and permanent loss of endocrine and exocrine function. Main indication for surgery is intractable abdominal pain and choosing the best technique to be used for a patient remains a challenge. The technique described by Frey combines the effectiveness of pain control characteristic of resection surgery with low mortality and morbidity of derivative procedures. AIM: To compare and discuss the results of surgical treatment of chronic pancreatitis with Frey procedure. METHODS: A literature review of scientific articles available in Medline/Pubmed database and the national theses descriptors with terms chronic pancreatitis, surgical treatment and Frey procedure. It was selected the most important articles and that reported more experience with this surgical option. CONCLUSIONS: Frey procedure proves to be an option with high effectiveness in controlling abdominal pain secondary to chronic pancreatitis in the long term in patients with abdominal pain and enlarged pancreatic head, with lower rates of morbidity and mortality. The studies showed little interference of technique in the deterioration of endocrine and exocrine pancreatic functions.

Polipose gastroduodenal em doentes com polipose adenomatosa familiar Pós-Retocolectomia

BACKGROUND The extra colonic manifestations, like upper gastrointestinal tract polyps and duodenal cancer are disorders that affect long-term morbidity and mortality of patients with familial adenomatous polyposis, after rectocolectomy. AIM To describe the frequency of those disorders in patients with familial adenomatous polyposis and to review efficacy of upper gastrointestinal endoscopic surveillance. METHODS Between 1984 and 2005, 62 patients with familial adenomatous polyposis after rectocolectomy, were studied retrospectively, by Coloproctology Group, Medical Sciences Faculty, State University of Campinas, SP, Brazil. It was possible to analyze 53 patients (85,5%) in this study. RESULTS Twenty seven (50,9%) of 53 patients in follow-up had upper gastrointestinal polyps. Eight (15,4%) had gastric adenomatous polyps, 14 (27%), duodenal polyps and 5 (9,6%) duodenal and gastric polyps. Two patients (3,8%) had adenomatous duodenal polyps with severe dysplasia, and one (1,9%) had adenocarcinoma of the duodenal papilla. CONCLUSION The upper gastrointestinal endoscopic surveillance has importance and the aim is to detect as early as possible the occurrence of duodenal adenocarcinoma and upper gastrointestinal polyps with severe dysplasia.

Long-term weight loss outcomes after banded Roux-en-Y gastric bypass: a prospective 10-year follow-up study

OBJECTIVE To evaluate the weight loss outcomes of banded Roux-en-Y gastric bypass (RYGB) during a 10-year follow-up. SETTING Private health-providing service, Brazil. METHODS A prospective study was conducted on 928 patients with obesity who underwent banded RYGB. Patients were divided into 2 groups according to their initial body mass index (BMI), morbid obesity (BMI 35-49.9 kg/m2) and super obesity (BMI ≥50 kg/m2). The percentages of excess weight loss (%EWL) and total weight loss (%TWL) at 18, 24, 36, 48, 60, 72, 84, 96, 108, and 120 months after surgery were assessed and compared, and the rates of surgical failure were also assessed. RESULTS There were individuals who were lost to follow-up at each year, including 423 (45.6%) at 18 months, 431 (46.4%) at 24 months, 482 (51.9%) at 36 months, 568 (61.2%) at 48 months, 658 (70.9%) at 60 months, 725 (78.1%) at 72 months, 781 (84.2%) at 84 months, 819 (88.3%) at 96 months, 838 (90.3%) at 108 months, and 819 (88.3%) at 120 months. The maximal %EWL was achieved at 18 months (P<.001). After 10 years, there was no significant change in mean BMI (28.7 ± 4.1 versus 28.5 ± 3.6 kg/m2; P = .07) or %EWL (80.4 ± 19.1 versus 79.7 ± 23.4; P = .065), but the mean %TWL was significantly lower at 10 years (30.8 ± 8.5 versus 32.5 ± 8.1; P = .035) in the morbid obesity group, compared with the values observed over 5 years. In the super obesity group, the %EWL significantly decreased from 77.7 ± 16.5 kg/m2 at 24 months to 71.3 ± 18.1 kg/m2 at 72 months (P = .008); at 5 years, mean BMI (33.1 ± 5.8 kg/m2) did not differ from the one observed at 10 years (36.4 ± 5 kg/m2; P = .21), as well as the mean %TWL (40.1 ± 8.5 versus 34.8 ± 8.9; P = .334). CONCLUSION Banded RYGB leads to significant and sustained weight loss in a 10-year follow-up. Despite a slight late weight regain evaluated by %TWL, RYGB leads to an optimal weight loss in the majority of the individuals.

MANAGEMENT OF PANCREATICOPLEURAL FISTULAS SECONDARY TO CHRONIC PANCREATITIS

ABSTRACT Introduction: Pancreaticopleural fistula is a rare complication of chronic pancreatitis. Objective: To describe pancreaticopleural fistula due to chronic pancreatitis and perform an extensive review of literature on this topic. Methods: Comprehensive narrative review through online research on the databases Medline and Lilacs for articles published over the last 20 years. There were 22 case reports and four case series selected. Results: The main indication for surgical treatment is the failure of clinical and/or endoscopic treatments. Surgery is based on internal pancreatic drainage, especially by means of pancreaticojejunostomy, and/or pancreatic resections. Conclusion: Pancreaticopleural fistula is a rare complication of chronic pancreatitis and the Frey procedure may be an appropriate therapeutic option in selected cases when clinical and endoscopic treatments are unsuccessful.

Gastric mesenchymal tumors as incidental findings during Roux-en-Y gastric bypass

BACKGROUND Occurrences of mesenchymal tumors have been more recognized in recent years, and the incidental diagnosis of these lesions during bariatric surgery has been previously reported. OBJECTIVE To describe the cases of incidentally diagnosed mesenchymal tumors during consecutive bariatric surgeries. SETTING Private health-providing service, Brazil. METHODS A retrospective population-based study, which enrolled individuals who consecutively underwent Roux-en-Y gastric bypass at a single center from January 2006 through July 2016. RESULTS Of 1502 individuals, there were 16 cases (1.1%) of confirmed mesenchymal tumors. Of these 16 cases, 14 (87.5%) were gastrointestinal stromal tumors and 2 (12.5%) were leiomyomas. The affected individuals were significantly older (aged 46.2 ± 6.3 versus 35.4 ± 7.2 yr; P = .00031), presented a lower body mass index (38.2 ± 5.1 versus 45.3 ± 8.1 kg/m2; P<.00001), and had a lower weight (102.1 ± 17.9 versus 121.1 ± 7.4 kg; P = .00321). None of the individuals presented reported relapses of the mesenchymal tumors. CONCLUSION The possibility of incidental gastric mesenchymal tumors during bariatric surgery should not be neglected; a careful inventory of the stomach at the beginning of the procedure and resection of lesions found are mandatory. (Surg Obes Relat Dis 2017;X:XXX-XXX.)

Intramural duodenal hematoma secondary to pancreatitis: case report and review of the literature

CONTEXT Spontaneous intramural duodenal hematoma is uncommon and is usually associated with coagulopathy, anticoagulant therapy and endoscopic procedures. The aim here was to describe a case of intramural duodenal hematoma caused by chronic exacerbation of pancreatitis. CASE REPORT A 46-year-old male with chronic alcoholic pancreatitis was admitted to hospital due to abdominal pain, melena and low hemoglobin. An intramural duodenal hematoma with active bleeding was detected and selective angioembolization was warranted. The patient evolved with a perforated duodenum and underwent laparotomy with exclusion of the pylorus and Roux-en-Y gastrojejunostomy. He was discharged nine days later. CONCLUSION Intramural duodenal hematoma is a rare complication of pancreatitis. Selective embolization is the preferred treatment for hemorrhagic complications of pancreatitis. However, the risk of visceral ischemia and perforation should be considered.