João Eduardo Marques Tavares de Menezes Ettinger

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.

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.

Natural orifice transluminal endoscopic surgery: current situation

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. Natural orifice transluminal endoscopic surgery refers to the method of accessing the abdominal cavity through a natural orifice under endoscopic visualization. Since its introduction in 2004, numerous reports have been published describing different surgical interventions. Recently, a group of expert laparoscopic surgeons and endoscopists outlined the limitations of this approach and issued recommendations for progress toward human trials. Transluminal surgery is a new method for accessing the abdomen under direct endoscopic visualization. Preliminary studies have demonstrated the feasibility of this technique in animal models; however, further research is warranted to validate its safety in humans.

General anesthesia type does not influence serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in video laparoscopic bariatric surgery

OBJECTIVES: Video laparoscopic bariatric surgery is the preferred surgical technique for treating morbid obesity. However, pneumoperitoneum can pose risks to the kidneys by causing a decrease in renal blood flow. Furthermore, as in other surgical procedures, laparoscopic bariatric surgery triggers an acute inflammatory response. Neutrophil gelatinase-associated lipocalin is an early and accurate biomarker of renal injury, as well as of the inflammatory response. Anesthetic drugs could offer some protection for the kidneys and could attenuate the acute inflammatory response from surgical trauma. The objective of this study was to compare the effects of two types of anesthetics, propofol and sevoflurane, on the serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in laparoscopic bariatric surgery. METHODS: Sixty-four patients scheduled for laparoscopic bariatric surgery were randomized into two anesthesia groups and were administered either total intravenous anesthesia (propofol) or inhalation anesthesia (sevoflurane). In the perioperative period, blood samples were collected at three time points (before anesthesia, 6 hours after pneumoperitoneum and 24 hours after pneumoperitoneum) and urine output was measured for 24 hours. Acute kidney injuries were evaluated by examining both the clinical and laboratory parameters during the postoperative period. The differences between the groups were compared using non-parametric tests. ReBEC (http://www.ensaiosclinicos.gov.br/rg/recruiting/): RBR-8wt2fy RESULTS: None of the patients developed an acute kidney injury during the study and no significant differences were found between the serum neutrophil gelatinase-associated lipocalin levels of the groups during the perioperative period. CONCLUSION: The choice of anesthetic drug, either propofol or sevoflurane, did not affect the serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in laparoscopic bariatric surgery.