Luciana Teixeira de Siqueira

Fístula gastrobrônquica como complicação rara de gastroplastia para obesidade: relato de dois casos

Gastrobronchial fistula is a rare condition as a complication following bariatric surgery. The management of this condition requires the active participation of a pulmonologist, who should be familiar with aspects of the main types of bariatric surgery. Herein, we report the cases of two patients who presented recurrent subphrenic and lung abscess secondary to fistula at the angle of His for an average of 19.5 months. After relaparotomy was unsuccessful, cure was achieved by antibiotic therapy and, more importantly, by stenostomy and endoscopic dilatation, together with the use of clips and fibrin glue in the fistula. These pulmonary complications should not be treated in isolation without a gastrointestinal evaluation since this can result in worsening of the respiratory condition, thus making anesthetic management difficult during endoscopic procedures.

Analysis of Plasma Citrulline and Intestinal Morphometry in Mice with Hepatosplenic Schistosomiasis

BACKGROUND Portal hypertension in the mucosa of the intestine and the presence of granulomas in the wall of this organ can alter digestive function in patients with schistosomiasis. Citrulline is a potential marker of intestinal function in some diseases that affect the morphometry of the mucosa because of its close association with enterocytes. The aims of the present study were to determine serum citrulline concentrations in mice with hepatosplenic schistosomiasis, analyze the morphologic repercussions for the mucosa of the small intestine, correlate citrulline concentrations with morphometric changes in the intestinal mucosa, and evaluate the effect of splenectomy on citrulline concentration. METHODS After approval from the local ethics committee, 46 adult female albino Swiss mice were divided into two groups: Control (23 healthy mice) and experimental (23 mice with hepatosplenic schistosomiasis). Blood samples were collected for the analysis of plasma citrulline before and after splenectomy. A segment of the jejunum was resected for morphometric analysis. RESULTS The average body mass in the control group was greater than that in the experimental group (p = 0.00062). The average citrulline concentration in the control group was greater than that in the experimental group both before and after splenectomy (p < 0.001). In the experimental group, the villi had less height and area, and there was a smaller perimeter of the mucosal surface (p = 0.003, <0.001, and p = 0.001, respectively). There was a direct correlation between citrulline concentration and the height and area of the villi (p = 0.003 and 0.04, respectively). There was no correlation between citrulline concentration and the perimeter of the surface of the jejunal mucosa. After splenectomy, there was a reduction in the mean citrulline concentration in the experimental group (p = 0.009). CONCLUSIONS Serum citrulline concentrations were reduced in mice with schistosomiasis, and a direct correlation was found between the citrulline concentration and the morphometry of the jejunal villi. Moreover, there was a reduction in the plasma concentration of citrulline after splenectomy.

ANTIBIOTIC PROPHYLAXIS IN BARIATRIC SURGERY: a continuous infusion of cefazolin versus ampicillin/sulbactam and ertapenem

BACKGROUND The incidence of surgical site infection in bariatric patients is significant and the current recommendations for antibiotic prophylaxis are sometimes inadequate. Objective: The aim of this study was to analyze the effect of three prophylactic antibiotic regimens on the incidence of surgical site infection. METHODS A prospective, cross-sectional study was conducted between January 2009 and January 2013 in which 896 Roux-en-Y gastric bypasses were performed to treat obesity. The study compared three groups of patients according to the perioperative antibiotic prophylaxis administered intravenously and beginning at anesthesia induction: Group I consisting of 194 patients treated with two 3-g doses of ampicillin/sulbactam; Group II with 303 patients treated with a single 1-g dose of ertapenem; and Group III with 399 patients treated with a 2-g dose of cefazolin at anesthesia induction followed by a continuous infusion of cefazolin 1g throughout the surgical procedure. The rate of surgical site infection was analyzed, as well as its association with age, sex, preoperative weight, body mass index and comorbidities. RESULTS The rates of surgical site infection were 4.16% in the group treated prophylactically with ampicillin/sulbactam, 1.98% in the ertapenem group and 1.55% in the continuous cefazolin group. CONCLUSION The prophylactic use of continuous cefazolin in surgeries for morbid obesity shows very promising results. These findings suggest that some prophylactic regimens need to be reconsidered and even substituted by more effective therapies for the prevention of surgical site infections in bariatric patients.

SURGICAL TREATMENT OF SEVERE OBESITY IN TEENS: LATE RESULTS

Background : In children is estimated that the prevalence of overweight and obesity has increased up to five times in developed countries and up to four in developing countries. In Brazil, the proportion of children and adolescents who are overweight also increased from approximately 4.1% to 13.9%. Aim : To evaluate the surgical results of severe obesity in adolescents. Methods : Retrospective descriptive study of 2737 patients with severe obesity that underwent Roux-en-Y gastric bypass selecting from the total 44 patients with mean age of 18.1 years, 14 males and 30 females, most (37) operated by laparotomy. There was follow-up of 20 patients (45.45%). All were followed preoperatively by a multidisciplinary team and had indication confirmed for surgical unanimous approval of all team members. Results : Among the 20 adolescent, 14 were female. From five teenagers using anti-hypertension or hypoglycemic drugs before surgery, four (80%) had drug discontinuation and one (20%) reduced the dose in 50% postoperatively. The average weight loss was 45.4 kg after a mean follow up of 60 months. There were no deaths or severe postoperative complications. Among those who underwent postoperative follow-up with a multidisciplinary team, 18 were with BMI<30. Conclusions : Adolescents undergoing Roux-en-Y gastric bypass has good response in relation to weight loss and improvement of comorbidities. There was a low rate of complications and no deaths. All patients were satisfied with their personal results.

Bypass gástrico laparoscópico com uso reduzido de suturas mecânicas

BACKGROUND: To perform laparoscopic gastric bypass in public university hospital has been difficult due to the high cost of the surgical staplers. This fact induced to look for different technical options, with low cost, maintaining the efficacy. AIM: To present the viability of a new method with the use of a low number of stapler devices. METHODS: Sixty three patients were operated in two university hospitals, 12 men and 51 women (81%), with mean age of 33.5y and average BMI of 43. The surgical technique used followed this sequence: loop section with electrical scalpel 50 cm of the duodenojejunal angle; termino-lateral anastomosis; retrogastric-retrocolic passage of the Roux limb; construction of the lateral wall of the pouch using 1 blue load of 45 and other of 60 mm after horizontal section with electrical scalpel; suture of the excluded stomach and gastrojejunal anastomosis. The anastomoses were hand-sewn made and a single-layer continuous absorble suture was performed. RESULTS: The average surgical time was 5.5 hours. The early complications were: fistula in the esophago-gastric angle (1.6%), stenosis (1.6%); fistula in the gastro-jejunal anastomosis (1.6%); obstruction of the intestinal anastomosis (1.6%). The stenosis was treated by endoscopic dilation. The remaining complications, with 3 re-operations (2 with laparoscopic and 1 with laparotomic approaches). The length of hospital stay was in average 4 days. CONCLUSION: This method is viable with low cost; however, it is complex and requires ability mainly in laparoscopic handsewn sutures.

Diverticulite em adolescente com Síndrome de Williams: relato de caso

ABSTRACT: The Syndrome of Williams is a rare genetic illness, attributed the deletion of the gene of the elastin in chromosome7. It is characterized by aortic stenosis, bladder diverticula’s, constipation, light mental retardation, dysmorphic facies, we aknessof the wall of the bladder and colon that they lead to the sprouting of diverticula. A case of acute diverticulitis in patient of 18 yearsis told, the result of the clinical treatment during 5 years and the differential diagnosis of acute abdomen in this illness. Theindication of elective colectomy is argued, considering the unfamiliarity of the natural history of the diverticulitis in thesyndrome.Key words: Diverticulitis, acute abdomen, adolescent, Williams Syndrome. REFERENCIAS 1. Williams JC, Barratt-Boyes BG, Lowe JB. Supravalvular aorticstenosis. Circulation. 1961 Dec;24:1311-8.2. Morris CA, Demsey SA, Leonard CO, Dilts C, BlackburnBL. Natural history of Williams syndrome: physicalcharacteristics. J Pediatr. 1988 Aug;113(2):318-263. Ewart AK, Morris CA, Ensing GJ, Loker J, Moore C, LeppertM, Keating M. A human vascular disorder, supravalvular aorticstenosis, maps to chromosome 7. Proc Natl Acad Sci U S A.1993 Apr;90(8):3226-30.4. Nickerson E, Greenberg F, Keating MT, McCaskill C, ShafferLG. Deletions of the elastin gene at 7q11.23 occur inapproximately 90% of patients with Williams syndrome. AmJ Hum Genet. 1995 May;56(5):1156-61.5. Cagle AP, Waguespack SG, Buckingham BA, Shankar RR,Dimeglio LA. Severe infantile hypercalcemia associated withWilliams syndrome successfully treated with intravenouslyadministered pamidronate. Am J Med Genet A. 2005Aug;137(1):52-4.6. Afzal NA, Thomson M. Best Pract Res Clin Gastroenterol.2002 Aug;16(4):621-34.7. Deshpande AV, Oliver M, Yin M, Goh TH, Hutson JM. Severecolonic diverticulitis in an adolescent with Williams syndrome.J Paediatr Child Health. 2005 Dec;41(12):687-8.8. Nelson RS, Velasco A, Mukesh BN. Management ofdiverticulitis in younger patients. Dis Colon Rectum. 2006Sep;49(9):1341-5.9. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med.2007 Nov;357(20):2057-66.10. Guzzo J, Hyman N. Diverticulitis in young patients: isresection after a single attack always warranted? Dis ColonRectum. 2004 Jul;47(7):1187-90.11. Farmakis N, Tudor RG, Keighley MR. The 5-year naturalhistory of complicated diverticular disease. Br J Surg. 1994May;81(5):733-5.12. Biondo S, Pares D, Marti Rague J, Kreisler E, Fraccalvieri D,Jaurrieta E. Acute colonic diverticulitis in patients under 50years of age. Br J Surg. 2002 Sep;89(9):1137-4113. Partsch CJ, Siebert R, Caliebe A, Gosch A, Wessel A, PankauR. Sigmoid diverticulitis in patients with Williams-Beurensyndrome: relatively high prevalence and high complicationrate in young adults with the syndrome. Am J Med Genet A.2005 Aug;137(1):52-4.