Luis Fernando Evangelista

Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases

BACKGROUND One of the complications of laparoscopic adjustable gastric banding is intragastric erosion, leading to a revisional procedure to remove the band. Our aim was to present the procedure and results of endoscopic band removal in a 5-year multicenter experience from the Gastro Obeso Center and Universidade de São Paulo, São Paulo, and Universidade Federal de Pernambuco, Recife, Brazil. METHODS From 2003 to 2008, 82 patients were diagnosed with band erosion. The clinical data concerning the endoscopic procedure were prospectively recorded and retrospectively reviewed. RESULTS The average preoperative body mass index was 43.2 kg/m(2) (range 34-50). At the diagnosis of intragastric erosion, the body mass index was 24-41 kg/m(2) (average 31.8). The erosion occurred an average of 16.3 months (range 6-36) postoperatively. The symptoms included pain in 25 (31%), port infection in 21 patients (27%), and weight regain in 20 (25%), and 12 patients (15%) were asymptomatic. Endoscopic removal was possible for 78 patients (95%). In 85% of patients, the band was removed in the first session, with an average duration of 55 minutes (range 25-150). Five cases of pneumoperitoneum occurred after the procedure. Of these, 3 were treated conservatively, 1 was treated by laparoscopy, and 1 was treated by abdominal puncture using the Veress needle. CONCLUSION Endoscopic removal of eroded laparoscopic adjustable gastric banding is safe and effective. It can be used as a first choice procedure in clinical practice.

Treatment of ring slippage after gastric bypass: long-term results after endoscopic dilation with an achalasia balloon (with videos).

BACKGROUND Silastic rings are used in gastric bypass procedures for the treatment of obesity, but ring slippage may lead to gastric pouch outlet stenosis (GPOS). Conventional management has been ring removal through abdominal surgery. OBJECTIVE To describe a novel, safe, minimally invasive, endoscopic technique for the treatment of GPOS caused by ring slippage after gastric bypass. DESIGN Case series. SETTING Federal University of Pernambuco and São Paulo University. PATIENTS This study involved 39 consecutive patients who were screened for inclusion. INTERVENTION Endoscopic dilation with an achalasia balloon. MAIN OUTCOME MEASUREMENTS Technical success and safety of the procedure. RESULTS Among the 39 patients, 35 underwent endoscopic dilation at the ring slippage site for the relief of GPOS. The 4 patients who did not undergo endoscopic dilation underwent surgical removal of the ring, based on the exclusion criteria. The endoscopic approach was successful in 1 to 4 sessions in 100% of cases with radioscopic control (n = 12). The duration of the procedures ranged from 5 to 30 minutes, and the average internment was 14.4 hours. Dilation promoted either rupture (65.7%) or stretching (34.3%) of the thread within the ring, thereby increasing the luminal diameter of the GPOS. Complications included self-limited upper digestive tract hemorrhage (n = 1) and asymptomatic ring erosion (n = 4). There were no recurrences of obstructive symptoms during the follow-up period (mean of 33.3 months). LIMITATIONS This was not a randomized, comparison study, and the number of patients was relatively small. CONCLUSION The technique described promotes the relief of GPOS with low overall morbidity and avoids abdominal reoperation for ring removal.

Small erosion of adjustable gastric band: endoscopic removal through incision in gastric wall.

The erosion of a laparoscopic adjustable gastric band (LAGB) can cause pain that is not controlled by analgesics. In such cases, early endoscopic removal may be indicated, but only when gastric penetration is greater than 50%. We report the case of a patient with severe shoulder pain due to a small area of LAGB erosion, which was treated with early endoscopic removal through an incision in the gastric wall. The pain worsened after eating and gastroscopy revealed slight gastric erosion of the band under the cardia. The gastric wall covering the LAGB was incised using an endoscopic needle knife. In a second upper endoscopy performed 7 days later at the endoscopy suite, endoscopic scissors were used to cut the thread and part of the band lock. The open band was then removed orally. This novel endoscopic incision in the gastric wall hastened band erosion and avoided abdominal reoperation.

Uso de anillo en bypass gástrico: Ventajas y desventajas

. Enseguida, otrosautores fueron incorporando y perfeccionando esteprincipio de contencion hasta alcanzar el formatodel procedimiento quirurgico actual.No hay uniformidad en el tipo de material em-pleado y ni en el tamano de la circunferencia de laprotesis, siendo descrito el uso de un anillo desilicona o de una cinta de Prolene® o de Goretex®,cuyo largo varia de 5,5 a 7 cm

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.

Atividade mioelétrica do intestino delgado de cães submetidos à oclusão parcial da veia porta

BACKGROUND: Temporary occlusion of the portal vein causes splancnic venous stasis and intestinal disfunction, that can produce alterations in the motility, and this fact is not vastly known. AIM: To evaluate the small bowel myoelectric activity and histology in the six dogs, also covering mean arterial blood pressure (AP), pulse rate (PR), central venous pressure (CVP) e portal pressure (PP), in two phases: pre-occlusion and occlusion. METHODS: It was done general anesthesia, invasive monitorization of the AP, PR e CVP, laparotomy, measure of the PP, fixation of the three pairs of electrodes in the intestinal wall, jejunal biopsy and parcial occlusion of the portal vein, being programmed the increase of the PP between 2.5 and 3 times baseline. Electrodes were connected to a computer system that captured electrical signals from the intestine. The computer has a software of acquisition to store and analyse the myoelectric activity after registering, what happened in 30 minutes of the pre-occlusion phase and in 60 minutes of occlusion. The variance and the mean RMS(root mean square) of the myoeletric activity were determined. The statistical analysis was done with Friedman, Dunn, Cochran and Students t tests. RESULTS: Mean RMS of myoeletric activity showed significant decrease in the phase of portal occlusion, in comparison to preocclusion phase. The frequency of hemorrhage of the lamina propria was major during occlusion. It was proportional at stasis time, with significant difference between the preocclusion and the occlusion of 60 minutes. Inflammatory infiltration, vascular dilation and epithelial detachment did not show any differences between two phases. During the stasis, AP, PR and CVP decreased (p=0,326; 0,375 e 0,008, respectively), and PP increased(p=0,015). CONCLUSIONS: Parcial occlusion of the portal vein produced reduction of the myoeletric activity and elevation of the percentage frequency of hemorrhage in lamina propria, and a fall of CVP, with relative hemodynamic stabilization.

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.