Marco Aurélio Santo

Metabolic Improvements in Obese Type 2 Diabetes Subjects Implanted for 1 Year with an Endoscopically Deployed Duodenal–Jejunal Bypass Liner

BACKGROUND The purpose of this study was to evaluate the effect of the duodenal-jejunal bypass liner (DJBL), a 60-cm, impermeable fluoropolymer liner anchored in the duodenum to create a duodenal-jejunal bypass, on metabolic parameters in obese subjects with type 2 diabetes. METHODS Twenty-two subjects (mean age, 46.2±10.5 years) with type 2 diabetes and a body mass index between 40 and 60 kg/m(2) (mean body mass index, 44.8±7.4 kg/m(2)) were enrolled in this 52-week, prospective, open-label clinical trial. Endoscopic device implantation was performed with the patient under general anesthesia, and the subjects were examined periodically during the next 52 weeks. Primary end points included changes in fasting blood glucose and insulin levels and changes in hemoglobin A1c (HbA1c). The DJBL was removed endoscopically at the end of the study. RESULTS Thirteen subjects completed the 52-week study, and the mean duration of the implant period for all subjects was 41.9±3.2 weeks. Reasons for early removal of the device included device migration (n=3), gastrointestinal bleeding (n=1), abdominal pain (n=2), principal investigator request (n=2), and discovery of an unrelated malignancy (n=1). Using last observation carried forward, statistically significant reductions in fasting blood glucose (-30.3±10.2 mg/dL), fasting insulin (-7.3±2.6 μU/mL), and HbA1c (-2.1±0.3%) were observed. At the end of the study, 16 of the 22 subjects had an HbA1c<7% compared with only one of 22 at baseline. Upper abdominal pain (n=11), back pain (n=5), nausea (n=7), and vomiting (n=7) were the most common device-related adverse events. CONCLUSIONS The DJBL improves glycemic status in obese subjects with diabetes and therefore represents a nonsurgical, reversible alternative to bariatric surgery.

Sleeve gastrectomy with transit bipartition: a potent intervention for metabolic syndrome and obesity.

Objective: To present 5-year results of sleeve gastrectomy (SG) with transit bipartition (TB) as a metabolic intervention for obesity. Background: Recent data suggest that high glycemic index foods may lead to a hormonally hyperactive proximal gut and a hypoactivate distal gut, which are linked to metabolic syndrome. TB was designed to counterbalance these effects. Methods: A total of 1020 obese patients with body mass index (BMI) ranging from 33 to 72 Kg/m2 underwent SG and TB (SG + TB). TB creates a gastroileal anastomosis in the antrum after the SG; nutrient transit is maintained in the duodenum, avoiding blind loops and minimizing malabsorption. The stomach retains 2 outflow pathways. A lateral enteroanastomosis connects both segments at 80 cm proximal to the cecum. Results: Adequate follow-up data were collected in 59.1% of patients from 4 months to 5 years. The average percent of excess BMI loss was 91%, 94%, 85%, 78%, and 74% in the first, second, third, fourth, and fifth year, respectively. Patients experienced early satiety and major improvement in presurgical comorbidities, including diabetes (86% in remission), following surgery. Two deaths occurred (0.2%). Other surgical complications occurred in 6% of patients. Signs of malabsorption were rare. Conclusions: SG + TB is a simple procedure that results in rapid weight loss and remission or major improvement of comorbidities. Strictly aiming at physiological correction, TB avoids prostheses, narrow anastomoses, excluded segments, and malabsorption. Weight and comorbidities are much improved. Diabetes is improved without duodenal exclusion. TB is an excellent complement to an SG.

Changes in Neuropsychological Tests and Brain Metabolism After Bariatric Surgery

CONTEXT The mechanisms by which obesity alters the cerebral function and the effect of weight loss on the brain have not been completely clarified. OBJECTIVE The objective of the study was to assess the effect of bariatric surgery on the cognitive function and cerebral metabolism. DESIGN Seventeen obese women were studied prior to and 24 weeks after bariatric surgery using neuropsychological tests and positron emission tomography. SETTING The study was conducted in a reference center for the treatment of obesity of a Brazilian public university. PARTICIPANTS Thirty-three women paired by age and level of education made up two groups: 17 severely obese patients and 16 lean patients. They did not have diabetes mellitus or a family history of dementia. MAIN OUTCOME MEASURES Comparison of performance in neuropsychological tests and cerebral metabolism of the obese women before and after bariatric surgery was measured. The results found at the two moments were compared with those of the women of normal weight. RESULTS Women with a mean age of 40.5 years and mean body mass index of 50.1 kg/m(2) when compared with women with mean body mass index of 22.3 kg/m(2) showed increased cerebral metabolism, especially in the posterior cingulate gyrus (P < .004). No difference was found between the groups for the neuropsychological tests. After 24 weeks the cerebral metabolism of the obese women was lower, similar to the lean women, and there was an improvement of executive function, accompanying changes of metabolic and inflammatory parameters. CONCLUSIONS Obese women may have increased cerebral metabolism when compared with women of normal weight, and this appears to reverse after weight loss induced by bariatric surgery, accompanied by improved executive function.

OUTCOMES ON QUALITY OF LIFE, WEIGHT LOSS, AND COMORBIDITIES AFTER ROUX-EN-Y GASTRIC BYPASS

CONTEXT Bariatric surgery has become the most effective method for producing weight loss in obese patients. The evaluation of improvement of comorbidities and changes in the quality of life are important outcome factors; however, it is necessary to investigate whether they persist over the long term. METHODS A cross-sectional study was conducted on 143 obese patients from our institution from February 2007 to February 2008. These patients were divided into five independent groups, one being a control group, plus four other groups with 1, 2, 3, 4 or more years following surgical Roux-en-Y gastric bypass with a silicon ring banded. quality of life forms and anthropometric measurements were performed and its scores correlated with social factors, weight loss success, and status of obesity-related conditions. RESULTS For the group that was 1 year postoperative, a significant percentage of excess body weight loss (EBWL%) of 81.7% was observed. The groups with 2, 3, 4 or more years of post-surgical follow-up showed a EBWL decline, but without significant difference. The main comorbidity percentages in all patients who had the surgery was as follows: 69.7% for hypertension; 88.2% for diabetes mellitus; and 27.5% for arthropathy. There was a significant decrease in the rate for diabetes resolution (P = 0.035) observed by evolutionary assessment of the comorbidity resolution. The results obtained by BAROS were good, very good, or excellent in more than 96% of patients in all evaluations that were performed. The use of the Moorehead-Ardelt Questionnaire (M/A) demonstrated improvement in the quality of life. Moreover, the quality of life, when evaluated through SF-36, also showed improvement in all related areas after 1 year; however, after 4 years, improvement remained elevated only in the areas of general state of health and functional capacity. CONCLUSIONS The Roux-en-Y gastric bypass procedure was able to achieve EBWL of 81.7% after 1 year following surgery, remaining steady with little decline after this period. Important resolution of comorbidities, such as hypertension and diabetes, was also seen. Immediate surgical outcomes assessed by SF-36 and M/A in the area of quality of life were satisfactory, but the general state of health and functional capacity areas were sustained satisfactory at a later time only.

Early complications in bariatric surgery: incidence, diagnosis and treatment.

CONTEXT Bariatric surgery has proven to be the most effective method of treating severe obesity. Nevertheless, the acceptance of bariatric surgery is still questioned. The surgical complications observed in the early postoperative period following surgeries performed to treat severe obesity are similar to those associated with other major surgeries of the gastrointestinal tract. However, given the more frequent occurrence of medical comorbidities, these patients require special attention in the early postoperative follow-up. Early diagnosis and appropriate treatment of these complications are directly associated with a greater probability of control. METHOD The medical records of 538 morbidly obese patients who underwent surgical treatment (Roux-en-Y gastric bypass surgery) were reviewed. Ninety-three (17.2%) patients were male and 445 (82.8%) were female. The ages of the patients ranged from 18 to 70 years (average = 46), and their body mass indices ranged from 34.6 to 77 kg/m2. RESULTS Early complications occurred in 9.6% and were distributed as follows: 2.6% presented bleeding, intestinal obstruction occurred in 1.1%, peritoneal infections occurred in 3.2%, and 2.2% developed abdominal wall infections that required hospitalization. Three (0.5%) patients experienced pulmonary thromboembolism. The mortality rate was 0,55%. CONCLUSION The incidence of early complications was low. The diagnosis of these complications was mostly clinical, based on the presence of signs and symptoms. The value of the clinical signs and early treatment, specially in cases of sepsis, were essential to the favorable surgical outcome. The mortality was mainly related to thromboembolism and advanced age, over 65 years.

Metabolic effects of an entero-omentectomy in mildly obese type 2 diabetes mellitus patients after three years

BACKGROUND: Various digestive tract procedures effectively improve metabolic syndrome, especially the control of type 2 diabetes mellitus. Very good metabolic results have been shown with vertical gastrectomy and entero-omentectomy; however, the metabolic effects of an isolated entero-omentectomy have not been previously studied. METHODS : Nine patients with type 2 diabetes mellitus and a body mass index ranging from 29 to 34.8 kg/m2 underwent an entero-omentectomy procedure that consisted of an enterectomy of the middle jejunum and exeresis of the major part of the omentum performed through a mini-laparotomy. Glucagon-like peptide-1 and peptide YY were measured preoperatively and three months following the operation. Fasting and postprandial variations in glycemia, insulinemia, triglyceridemia, hemoglobin A1c, and body mass index were determined in the preoperative period and 3, 18 and, 36 months after the operation. RESULTS : All patients significantly improved the control of their type 2 diabetes mellitus. Postprandial secretion of peptide YY and Glucagon-like peptide-1 were enhanced, whereas hemoglobin A1c, fasting and postprandial glucose, insulin, and triglyceride levels were significantly reduced. Mean body mass index was reduced from 31.1 to 27.3 kg/m2. No major surgical or nutritional complications occurred. CONCLUSIONS : Entero-omentectomy is easy and safe to perform. A simple reduction in jejunal extension and visceral fat causes important improvements in the metabolic profile.

Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery

INTRODUCTION Roux-en-Y gastric bypass is a commonly used technique of bariatric surgery. One of the most important complications is gastrojejunal anastomotic stricture. Endoscopic balloon dilation appears to be well tolerated and effective, but well-designed randomized, controlled trials have not yet been conducted. OBJECTIVE Identify factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. SETTING Gastrointestinal endoscopy service, university hospital, Brazil. METHODS The records of 64 patients with anastomotic stricture submitted to endoscopic dilation with hydrostatic balloon dilation were reviewed. Information was collected on gastric pouch length, anastomosis diameter before dilation, number of dilation sessions, balloon diameter at each session, anastomosis diameter after the last dilation session, presence of postsurgical complications, endoscopic complications, and outcome of dilation. Comparisons were made among postsurgical and endoscopic complications; number of dilations, balloon diameter; anastomosis diameter before dilation; and dilation outcome. RESULTS Success of dilation treatment was 95%. Perforation was positively and significantly associated with the number of dilation sessions (P = .03). Highly significant associations were found between ischemic segment and perforation (P<.001) and between ischemic segment and bleeding (P = .047). Ischemic segment (P = .02) and fistula (P = .032) were also associated with dilation failure. CONCLUSION Ischemic segment and fistula were found to be important risk factors for balloon dilation failure. The greater the number of dilation sessions, the greater the number of endoscopic complications.

Preoperative weight loss in super-obese patients: study of the rate of weight loss and its effects on surgical morbidity

OBJECTIVES: The incidence of obesity and particularly super obesity, has increased tremendously. At our institution, super obesity represents 30.1% of all severely obese individuals in the bariatric surgery program. In super obesity, surgical morbidity is higher and the results are worse compared with morbid obesity, independent of the surgical technique. The primary strategy for minimizing complications in these patients is to decrease the body mass index before surgery. Preoperative weight reduction can be achieved by a hypocaloric diet, drug therapy, an intragastric balloon, or hospitalization. The objective of this study was to analyze the results of a period of hospitalization for preoperative weight loss in a group of super-obese patients. METHODS: Twenty super-obese patients were submitted to a weight loss program between 2006 and 2010. The mean patient age was 46 years (range 21-59). The mean BMI was 66 kg/m2 (range 51-98) and 12 were women. The average hospital stay was 19.9 weeks and the average weight loss was 19% of the initial weight (7-37%). The average caloric intake was 5 kcal/kg/day. After the weight loss program, the patients underwent gastric bypass surgery. RESULTS: The statistical analysis revealed that after 14 weeks of treatment (15% loss of initial weight), the weight loss was not significant. All patients had satisfactory surgical recovery and were discharged after an average of 4.6 days. CONCLUSION: In super obesity, preoperative weight loss is an important method for reducing surgical risks. Hospitalization and a hypocaloric diet are safe and effective. After 14 weeks, the weight loss rate stabilized, signaling the time of surgical intervention in our study.

BARIATRIC SURGERY IN THE ELDERLY: RESULTS OF A MEAN FOLLOW-UP OF FIVE YEARS.

Background : Surgical treatment of obesity in the elderly, particularly over 65, remains controversial; it is explained by the increased surgical risk or the lack of data demonstrating its long-term benefit. Few studies have evaluated the clinical effects of bariatric surgery in this population. Aim : To evaluate the results of surgical treatment of obesity in patients over 60 years, followed for an average period of five years. Method : This was a retrospective study evaluating 46 patients, 60 years or older, who underwent surgical treatment of obesity, by conventional gastric bypass technique (laparotomy). The average age was 64 years (60-71), mean BMI of 49.6 kg/m2 (38-66), mean follow-up of 5.9 years; 91% of patients were hypertensive, 56% diabetics and 39% had dyslipidemia. Results : The incidence of complications (major and minor) in patients under 65 years was 26% and over 65 years 37% (p=0.002). There were no deaths in the group with less than 65 years and there were two deaths (12.5%) over 65 years. The average loss of overweight over 65 years or less was 72% vs 68% (p=0.56). There was total control of the diabetes mellitus in 77% and partial in 23%, with no difference between groups. There was improvement in arterial hypertension in 56% of patients, also no difference between groups. The average LDL levels did not differ between the pre and postoperative (106 mg/dl to 102 mg/dl), an increase of HDL (56 mg/dl to 68 mg/dL) and reduced triglyceride levels (136 mg/dl to 109 mg/dl). There was no statistical difference in the variation of the cholesterol fractions and triglycerides between the groups. Two patients in the group with less than 65 years died in late follow-up, of brain tumor and pneumonia, three and five years after bariatric surgery, respectively. Conclusions : Surgical morbidity and mortality were higher in patients over 65 years, and this group had the same benefits observed in patients lower 65 years for weight loss and comorbidities control.

Correlation between body composition and walking capacity in severe obesity

Background Obesity is associated with mobility reduction due to mechanical factors and excessive body fat. The six-minute walk test (6MWT) has been used to assess functional capacity in severe obesity. Objective To determine the association of BMI, total and segmental body composition with distance walked (6MWD) during the six-minute walk test (6MWT) according to gender and obesity grade. Setting University of São Paulo Medical School, Brazil; Public Practice. Methods Functional capacity was assessed by 6MWD and body composition (%) by bioelectrical impedance analysis in 90 patients. Results The mean 6MWD was 514.9 ± 50.3 m for both genders. The male group (M: 545.2 ± 46.9 m) showed a 6MWD higher (p = 0.002) than the female group (F: 505.6 ± 47.9 m). The morbid obese group (MO: 524.7 ± 44.0 m) also showed a 6MWD higher (p = 0.014) than the super obese group (SO: 494.2 ± 57.0 m). There was a positive relationship between 6MWD and fat free mass (FFM), FFM of upper limps (FFM_UL), trunk (FFM_TR) and lower limbs (FFM_LL). Female group presented a positive relationship between 6MWD and FFM, FFM_UL and FFM_LL and male group presented a positive relationship between 6MWD and FFM_TR. In morbid obese group there was a positive relationship between 6MWD with FFM, FFM_UL, FFM_TR and FFM_LL. The super obese group presented a positive relationship between 6MWD with FFM, FFM_TR and FFM_LL. Conclusions Total and segmental FFM is associated with a better walking capacity than BMI.