Lyz Bezerra Silva

Cirurgia metabólica, reganho de peso e recidiva do diabete

INTRODUCTION The poor success of clinical treatment of Type 2 Diabetes Mellitus (T2DM2) increased interest in metabolic surgery, which has been considered a promising alternative for the control of obese or non-obese diabetics. However, there is still no long-term follow-up to evaluate the duration of diabetes remission, and if weight regain would be associated to recurrence. AIM 1) To describe the results of diabetic patients with a BMI < 30 and < 35 kg/m² submitted to the following types of metabolic surgery: ileal interposition and sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), adjustable gastric banding, duodeno-jejunal exclusion and duodeno-jejunal bypass; 2) to evaluate the possible relapse of diabetes after occurrence of weight regain on long-term after bariatric surgery. METHOD An expositive and historical literature review about metabolic surgery in diabetic patients with BMI < 30 and < 35 kg/m² was conducted, and systematic review of the association between disease relapse and weight regain after bariatric surgery. RESULTS After analysis of 188 published papers on Medline until 2010, three papers were selected, which included 269 patients who underwent RYGB. Pre-operatory BMI was between 37 and 60 kg/m² and follow-up of three to 16 years. CONCLUSIONS 1) Two studies showed association between weight regain and recurrence of type 2 diabetes, while the third did not show this association when comparing groups with and without weight regain; 2) metabolic surgery has shown adequate control of T2DM2 in class I obese subjects; however, the non-obese group still need a long-term evaluation, considering the risk of diabetes recurrence when after weight regain.

Endoscopic treatment of food intolerance after a banded gastric bypass: inducing band erosion for removal using a plastic stent.

BACKGROUND AND STUDY AIMS Ring complications after a banded Roux-en-Y gastric bypass (RYGB) are usually managed surgically. The aim of this study was to analyze the safety and effectiveness of endoscopic removal of noneroded rings after banded-RYGB, by inducing intragastric erosion of the ring using a self-expandable plastic stent (SEPS). PATIENTS AND METHODS A total of 41 patients with banded RYGB who had noneroded rings and food intolerance were prospectively enrolled. Patients were treated with endoscopic SEPS placement and ring removal. Data from time of stenting, resolution of symptoms, need for endoscopic dilation, and complications were recorded. RESULTS Successful ring removal was possible in all patients. In 21 cases, the SEPS induced complete erosion, and in 17 cases the ring was removed a month later because of incomplete erosion at the time of SEPS removal. Nine patients (22.0 %) needed endoscopic dilation after stent removal in order to treat fibrotic strictures. Food tolerance was observed in 32 patients (78.0 %) after the procedure. No patient needed surgery and there were no deaths. CONCLUSIONS Endoscopic removal of the ring using SEPS appeared to be safe and effective after a banded RYGB.

GASTROPLASTIA VERTICAL ENDOSCÓPICA - TERAPÊUTICA MINIMAMENTE INVASIVA PARA TRATAMENTO PRIMÁRIO DA OBESIDADE

Racional: Procedimentos menos invasivos e complexos tem sido desenvolvidos para o tratamento da obesidade. A gastroplastia vertical endoscopica com uso de OverStitch(r) (Apollo Endosurgery, Austin, TX, EUA) ja foi relatada com sucesso na literatura. Objetivo: Apresentar detalhes tecnicos do procedimento e seu resultado cirurgico/endoscopico preliminar. Metodo: O equipamento foi utilizado para realizar plicaturas ao longo da grande curvatura gastrica, objetivando tubulizacao do estomago semelhante a gastrectomia vertical. Resultado: O metodo foi aplicado em paciente com IMC 35,17 kg/m2, sendo realizadas quatro plicaturas, preservando o fundo gastrico. O procedimento foi realizado com sucesso em 50 min, sem sangramento ou outras complicacoes. O paciente evoluiu com dor abdominal leve, e teve boa aceitacao de dieta liquida. Conclusao: A realizacao da gastroplastia endoscopica foi segura, com viabilidade tecnica aceitavel e reprodutivel, com curto tempo de procedimento, sem complicacoes precoces.

ENDOSCOPIC SLEEVE GASTROPLASTY - MINIMALLY INVASIVE THERAPY FOR PRIMARY OBESITY TREATMENT

ABSTRACT Background: Less invasive and complex procedures have been developed to treat obesity. The successful use of Endoscopic Sleeve Gastroplasty using OverStitch(r) (Apollo Endosurgery, Austin, Texas, USA) has been reported in the literature. Aim: Present technical details of the procedure and its surgical/ endoscopic preliminary outcome. Method: The device was used to perform plications along the greater curvature of the stomach, creating a tubulization similar to a sleeve gastrectomy. Result: A male patient with a BMI of 35.17 kg/m2 underwent the procedure, with successful achievement of four plications, and preservation of gastric fundus. The procedure was successfully performed in 50 minutes, time without bleeding or other complications. The patient presented mild abdominal pain and good acceptance of liquid diet. Conclusions: The endoscopic gastroplasty procedure was safe, with acceptable technical viability, short in duration and without early complications.

Sleeve gastrectomy leak: endoscopic management through a customized long bariatric stent

re 1. A, Endoscopic view of perigastric cavity and septum below the GEJ. B, Radiographic view of stomach with flow of contrast medium through orifice. C, Totally covered nitinol stent, 200 mm 28 mm 30 mm. D, Radioscopic control: stent positioned 3 cm above GEJ, in a transpyloric er. E, Stent removal: proximal suture grasped by raptor forceps, with removal under radiologic control. F, Radiographic control after stent removal, ing resolution of axis deviation and closure of leak orifice. GEJ, gastroesophageal junction.

Brazilian Intragastric Balloon Consensus Statement (BIBC): practical guidelines based on experience of over 40,000 cases

BACKGROUND Intragastric balloons (IGBs) are a minimally invasive option for obesity treatment, acting as a space-occupying device and leading to weight loss through increased satiety. This device has been growing in popularity owing to its safety profile and good weight loss results. However, there are no published guidelines that standardize the technical aspects of the procedure. OBJECTIVES To create a practical guideline for intragastric balloon usage. SETTING Private and Academic Settings, Brazil. METHODS A consensus meeting was held in São Paulo, Brazil, in June 2016, bringing together 39 Brazilian endoscopists with extensive experience in IGBs from all regions of the country. Topics on patient selection, indications, contraindications, multidisciplinary follow-up, technique, and adverse events were discussed in the form of questions. After electronic voting, a consensus was defined when there was ≥70% agreement. Experts were also requested to provide data on their experience with IGBs. RESULTS The selected experts discussed and reached a consensus on 76 questions, mainly concerning specific indications and contraindications for the procedure; technical details, such as patient preparation, minimum balloon-filling volume, techniques for implant and explant; patient follow-up and recommended medication for the adaptation period; and adverse event management. The overall Brazilian expert data encompassed 41,863 IGBs, with a mean percentage total weight loss of 18.4% ± 2.9%. The adverse event rate after the adaptation period was 2.5%, the most common being hyperinflation (.9%) and spontaneous deflation (.8%) of the device. The early removal rate due to intolerance was 2.2%. CONCLUSIONS The present consensus represents practical recommendations for performing IGB procedures and reflects Brazils significant experience with this device. The experience of over 40,000 cases shows that the device leads to satisfactory weight loss with a low rate of adverse events.

Laparoscopic Gastric Plication

Bariatric operations classified as restrictive such as laparoscopic sleeve gastrectomy (LSG) and laparoscopic greater curvature plication (LGCP) are gaining more attention in bariatric surgery environment, as they are considered technically simpler since there are no anastomosis. However, in sleeve gastrectomy a significant portion of the stomach is resected resulting in impossibility to reversion of the procedure. LGCP is an alternative reversible bariatric procedure, which is similar to LSG, without the need of gastric resection, but it is still an experimental technique. The main advantages of this new procedure are: absence of foreign body (band or ring); no intestinal bypass; no gastric or intestinal resection; it can be augmented with more extensive procedures; no need for staples and the potential reversibility. However, hospital stay may be longer because of nausea and vomiting after the procedure that can interfere in diet acceptance, which can increase the costs. The outcomes in terms of weight loss are inferior than those achieved with LSG; percentage of excess weight loss (EWL) in LGCP is comparable to adjustable gastric band.

Cirurgia bariátrica robótico-assistida: análise de série de casos e comparação com via laparoscópica

OBJECTIVE to report a series of cases of robotic bariatric surgery in the treatment of obesity in Brazil. METHODS we evaluated patients undergoing robotic bariatric surgery at the Garrido Institute and compared them with a group submitted to conventional laparoscopic surgery. RESULTS we analyzed 45 patients, with a mean age of 39.44 years, of which 34 were female, with an initial mean BMI of 41.26kg/m2. Among the procedures performed, 91.11% were Roux-en-Y gastric bypass, while 8.89% were sleeve gastrectomy. The mean total surgery time was 158 (±56.54) minutes, with mean docking time of 7.93 (±3.9) minutes, and console time 113.0 (±41.4) minutes. The average pain presented in the post anesthetic recovery was 2.61 (±3.30) points on a scale of 0 to 10; four patients presented with mild signs of nausea, responding well to drug treatment. Only one patient needed ICU admission for a period of two days after surgery due to previous cardiopathy. In two cases, there was an incisional hernia at the trocar site, which were surgically treated without further complications. In the comparison between robotic versus laparoscopic surgery groups, 45 patients were selected for each group. Operative time was significantly longer in the robotic surgery group, with most other variables being equivalent, including postoperative control of comorbidities. CONCLUSION robotic bariatric surgery is a safe procedure, with results comparable to laparoscopic surgery.

Endoscopic Management of Complications

The treatment of bariatric surgery complications implies in early recognition of their signs and symptoms. Traditional surgical management options may be associated with increased morbidity and mortality. In this context, bariatric endoscopy aims to treat those complications with a less invasive nature and decreased morbidity.

Endoscopic Interventions for Complications in Bariatric Surgery

Bariatric endoscopy deals with treating bariatric surgery complications, postoperative weight loss failure and weight regain, and primary obesity itself. As the number of bariatric procedures done worldwide continues to grow, interest about bariatric endoscopy among surgeons and endoscopists is growing.