Joäo Batista Marchesini

Brazilian Multicenter Study of the Intragastric Balloon

Background: Intragastric balloons have been used in obese patients to provide early satiety and thereby induce weight loss. Several studies have reported promising results with a new balloon (BIB®) designed to overcome some of the technical pitfalls of earlier devices. We assessed both safety and effectiveness of the BIB®. Method: From November 2000 to February 2004, 483 overweight and obese patients were treated with the BIB®. 323 patients completed a 6-month follow-up, and 85 of them completed a 1-year follow-up. All patients took part in a multidisciplinary program involving clinical, psychiatric, physical training, and dietary approaches. Results: Compared to baseline values, after a 6-month follow-up subjects showed significant reductions in weight (15.2 ± 10.5 kg), percent excess weight loss (48.3 ± 28.1), and BMI (-5.3 ± 3.4 kg/m2) (P < 0.000). At 1-year follow-up, 85 patients have maintained more than 90% of their BMI reduction. The main side-effects were nausea/vomiting (40%), and epigastric pain (20%), requiring removal of the BIB ® in 11 patients (3.4%). Minor complications were reflux esophagitis (12%) and symptomatic gastric stasis (9%). Balloon impaction occurred in 2 cases (0.6%), and in 1 patient (0.3%) there was spontaneous deflation of the balloon leading to a small-bowel obstruction solved by a surgical approach. Conclusion: The BIB® has been effective to temporarily control obesity, inducing an excess weight loss of approximately 48%. It was not associated with mortality and showed minimal risk of major complications.

Recent advances in the placement of tubes for enteral nutrition.

Enteral nutrition is the preferred route for nutritional support compared with parenteral nutrition if the gastrointestinal tract is functionally preserved. Long-standing nasogastric or nasoenteric feeding tubes are not well tolerated. Alternative routes are gastrostomy and jejunostomy. Percutaneous endoscopic gastrostomy/jejunostomy or those guided by fluoroscopy, sonography or tomography should be the first choices. Laparoscopy or laparotomy gastrostomy/jejunostomy routes should be reserved for specific situations. Insufflation of the stomach with air or saline solution facilitates the placement of nasoenteric feeding tubes or percutaneous sonographic-guided gastrostomy. The gastrostomy button is a safe and aesthetic alternative, at least in children. Comparison between percutaneous endoscopic gastrostomy and surgical gastrostomy performed either via laparotomy or laparoscopy favours the first in terms of costs and risks. Whenever associated intra-abdominal procedures or anatomic difficulties arise, a laparoscopic or an open access becomes necessary. Complications with feeding tubes are not uncommon and should be promptly recognized and treated.

Anemia pós-cirurgia bariátrica: as causas nem sempre são relacionadas à cirurgia

RACIONAL: As anemias ferropriva, perniciosa e megaloblastica sao comuns apos procedimentos bariatricos como o bypass e as derivacoes biliopancreaticas. As principais causas devem-se ao desvio duodenal e do jejuno proximal do trânsito alimentar e, em menor grau, as ulceras anastomoticas. Entretanto a dieta pobre em nutrientes, a suplementacao vitaminica inadequada, medicamentos, uso de alcool e neoplasias devem ser lembrados. RELATO DOS CASOS: Os autores relatam dois casos de pacientes pos-procedimentos bariatricos com anemia severa sem controle clinico e cuja investigacao identificou melanoma metastatico em um caso e neoplasia colonica no segundo, ambos tratados cirurgicamente com bons resultados. CONCLUSAO: Anemias sao comuns apos procedimentos bariatricos, porem causas atipicas como neoplasias devem ser suspeitadas nos pacientes mais idosos e principalmente naqueles refratarios ao controle clinico.

Endoscopic plasma argon coagulation in treatment of weight regain after bariatric surgery: what does the patient think about this?

Background Bariatric surgery, especially Roux-en-Y gastric bypass is an effective treatment for refractory morbid obesity, causing the loss of 75% of initial excess weight. After the surgery, however, weight regain can occur in 10-20% of cases. To help, endoscopic argon plasma coagulation (APC) is used to reduce the anastomotic diameter. Many patients who undergo this treatment, are not always familiar with this procedure and its respective precautions. Aim The aim of this study was to determine how well the candidate for APC understands the procedure and absorbs the information provided by the multidisciplinary team. Method We prepared a questionnaire with 12 true/false questions to evaluate the knowledge of the patients about the procedure they were to undergo. The questionnaire was administered by the surgeon during consultation in the preoperative period. The patients were invited to fill out the questionnaire. Results We found out that the majority learned about the procedure through the internet. They knew it was an outpatient treatment, where the anesthesia was similar to that for endoscopy, and that they would have to follow a liquid diet. But none of them knew that the purpose of this diet was to improve local wound healing. Conclusion Bariatric patients who have a second chance to resume weight loss, need continuous guidance. The internet should be used by the multidisciplinary team to promote awareness that APC will not be sufficient for weight loss and weight-loss maintenance in the long term. Furthermore, there is a need to clarify again the harm of drinking alcohol in the process of weight loss, making its curse widely known.

Comparative study of five different surgical techniques for the treatment of morbid obesity using BAROS

Background The obesity is an universal disease of epidemic proportions and in a growing prevalence. It is one of the main public health problems and it will be inexorably the largest problem of the developing world. The morbid obesity is associated to serious diseases, reducing the life perspective, increasing the morbility and mortality. Several strategies of losing weight were proposed; however, the bariatric surgeries are today the most effective treatment for this disease. The BAROS is the most simple, practical and efficient method to evaluate the results in the bariatric surgeries. Aim To compare five surgical techniques for the treatment of morbid obesity using BAROS. Method The sample is constituted of 102 patients submitted to Fobi-Capella (23 patients), Scopinaro (21 patients), duodenal switch (20 patients), vertical banded gastroplasty of Mason (15 patients) and the adjustable gastric band (23 patients), evaluated 12 months after the surgeries using BAROS. Results The analysis of the final result of BAROS for the classification demonstrated that good, very good and excellent results were obtained in 100% of the patients in the group of duodenal switch; 91,3% in Fobi-Capella; 85,7% in Scopinaro; 60% in Mason; and 56,5% in adjustable gastric band. The final result of BAROS for the total score demonstrated that the group of duodenal switch obtained 6,3 points; the Fobi-Capella 5,1 points; the Scopinaro 4,8 points; the Mason 3,0 points; and the adjustable gastric band 2,9 points (p<0,0001). Conclusion The duodenal switch is the best technique for the surgical treatment of the morbid obesity, in the following 12 months post-surgical clinical procedures, according to BAROS.

Comparação de cinco técnicas para o tratamento cirúrgico da obesidade mórbida com o BAROS

RACIONAL: A obesidade e doenca universal de proporcoes epidemicas e com prevalencia crescente. E um dos principais problemas de saude publica da sociedade moderna e inexoravelmente sera o maior problema do mundo desenvolvido. Numerosas estrategias para emagrecer foram propostas nas ultimas decadas; porem, as operacoes bariatricas constituem, hoje, no tratamento mais eficaz desta doenca. Inumeros metodos sao usados para avaliar as operacoes bariatricas, mas o BAROS (Bariatric Analysis and Reporting Outcome System) e o mais simples, pratico e eficiente para avaliar os resultados das operacoes bariatricas. OBJETIVO: Comparar cinco tecnicas operatorias para o tratamento da obesidade morbida utilizando o BAROS e identificar qual delas e mais efetiva. METODOS: A amostra consistiu de 102 pacientes submetidos a um dos procedimentos: derivacao gastrojejunal de Fobi-Capella (23 pacientes), derivacao biliopancreatica de Scopinaro (21 pacientes), derivacao biliopancreatica com duodenal switch (20 pacientes), gastroplastia vertical com banda de Mason (15 pacientes) e banda gastrica ajustavel (23 pacientes). Foram avaliados 12 meses apos as operacoes utilizando o BAROS. RESULTADOS: Resultado bom, muito bom e excelente foi obtido em 100% dos pacientes no grupo duodenal switch; 91,3% no Fobi-Capella; 85,7% no Scopinaro; 60% no Mason; e 56,5% no banda. A analise do resultado final do BAROS pela pontuacao total demonstra que o grupo duodenal switch obteve 6,3 pontos; o Fobi-Capella 5,1 pontos; o Scopinaro 4,8 pontos; o Mason 3,0 pontos e o banda 2,9 pontos (p<0,0001). CONCLUSAO: A derivacao biliopancreatica com duodenal switch e a melhor tecnica para o tratamento cirurgico da obesidade morbida, no seguimento clinico pos-operatorio de 12 meses, segundo o BAROS.

SADI-S WITH RIGHT GASTRIC ARTERY LIGATION: TECHNICAL SYSTEMATIZATION AND EARLY RESULTS

ABSTRACT Background: Bariatric surgery is performed all over the world with close to 500.000 procedures per year. The most performed techniques are Roux-en-Y gastric bypass and sleeve gastrectomy. Despite this data, the most effective procedure, biliopancreatic diversion with or without duodenal switch, represents only no more than 1.5% of the procedures. Technical complexity, morbidity, mortality, and severe nutritional adverse effects related to the procedure are the main fears that prevent most universal acceptance. Aim: To explain the technical aspects and the benefits of the SADI-S with right gastric artery ligation as an effective simplification from the original duodenal switch. Methods: Were included all patients undergoing this procedure from the November 2014 to May 2016, describing and analysing aspects of this technique, the systematization and early complications associated with the procedure. Results: A series of 67 patients were operated; 46 were women (68.7%); mean age of the group was 44 years old (33-56); and an average BMI of 53.5 kg/m2 (50-63.5). Surgical time was 115 min (80-180). A total of five patients (7.5%) had any complication and two (2.9%) had to be reoperated. There were two patients with leak, one at the duodenal stump and other at the esophagogastric angle. There was no mortality. Patients stayed at the hospital a median of 2.5 days (1-25). Conclusions: SADI-S with right gastric artery ligation is a safe procedure with few preliminary complications. The technical variations introduced to the classical duodenal switch are reproducible and may allow this procedure to be more popular. All the complications in this series were not related to the ligation of the right gastric artery.

SADI-S COM LIGADURA DA ARTÉRIA GÁSTRICA: SISTEMATIZAÇÃO TÉCNICA E OS PRIMEIROS RESULTADOS

Racional: Cerca de 500.000 cirurgias bariatricas sao realizadas a cada ano em todo o mundo. As tecnicas mais realizadas sao o bypass gastrico em Y-de-Roux e a gastrectomia vertical. A derivacao biliopancreatica, com ou sem duodenal switch, e considerada tecnica mais eficaz no tratamento cirurgico do paciente obeso morbido; entretanto, representa nao mais do que 1,5% dos procedimentos na atualidade, pois sua complexidade tecnica, morbimortalidade e graves efeitos adversos nutricionais impedem aceitacao mais universal. Objetivo: Descrever os aspectos tecnicos e os beneficios do SADI-S com ligadura da arteria gastrica direita como um modo simplificado do duodenal switch original. Metodos: Foram incluidos todos os pacientes submetidos a este procedimento entre novembro 2014 e maio de 2016. Alem da descricao da sistematizacao da tecnica operatoria, foram analisadas as complicacoes precoces associadas ao procedimento. Resultados: Uma serie de 67 pacientes foi operada no periodo analisado; 46 eram mulheres (68,7%) e a media de idade foi de 44 anos (33-56). O IMC medio foi de 53,5 kg/m2 (50-63,5). O tempo cirurgico medio foi de 115 min (80-180) e a permanencia hospitalar media foi de 2,5 dias (1-25). Complicacoes foram observadas em cinco pacientes (7,5%) e dois (2,9%) tiveram de ser reoperados. Duas pacientes evoluiram com fistula, uma no coto duodenal e outra na juncao esofagogastrica. Nao houve mortalidade. Conclusao: SADI-S com ligadura da arteria gastrica direita e procedimento seguro com poucas complicacoes precoces. A simplificacao tecnica em relacao ao duodenal switch classico pode permitir que este procedimento se torne mais popular. Todas as complicacoes observadas nesta serie nao estavam relacionadas com a ligadura da arteria gastrica direita.

BAROS METHOD CRITICAL ANALYSIS (BARIATRIC ANALYSIS AND REPORTING SYSTEM)

Introduction : Although it has received several criticisms, which is considered to be the most effective method used for global assessment of morbid obesity surgical treatment, still needs to be updated. Objective : Critical analysis of BAROS constitution and method. Method : BAROS as headings was searched in literature review using data from the main bariatric surgery journals until 2009. Results : Where found and assessed 121 papers containing criticisms on BAROS constitution and methodology. It has some failures and few researches show results on the use of this instrument, although it is still considered a standard method. Several authors that used it found imperfections in its methodology and suggested some changes addressed to improving its acceptance, showing the need of developing new methods to qualify the bariatric surgery results. Conclusion: BAROS constitution has failures and its methodology needs to be updated.

Laparoscopic Roux-en-Y gastric bypass with single transumbilical incision - GelPoint®

The innumerable advantages of laparoscopic gastric bypass have stimulated the development of new and less invasive laparoscopic techniques, such as single-incision laparoscopic surgery (SILS). This novel approach provides the introduction of multiple laparoscopic instruments through a single incision at the umbilicus or at a place near the operated structure.1 SILS performed via an umbilical incision produces a better cosmetic outcome than does the traditional (five to seven ports) laparoscopic gastric bypass and probably improves postoperative outcome, because it may diminish trauma to the abdominal wall and peritoneum2,3. Recently, SILS has been gradually adopted in bariatric surgery. Saber et al. reported the first series of patients treated with single-incision laparoscopic sleeve gastrectomy. 4-6