Sergio Santoro

Remaining small bowel length: association with catheter sepsis in patients receiving home total parenteral nutrition: evidence of bacterial translocation.

Patients with short bowel syndrome (SBS) receiving total parenteral nutrition (TPN) have a high incidence of catheter-related sepsis, one of its major complications. The aim of this study was to correlate the length of remaining small bowel (RSB) with septic episodes related to the central venous catheter in a group of patients with severe SBS with home TPN. The length of the RSB (<50 cm or ≥50 cm) was related to the frequency of catheter sepsis, time until the first episode, and the agents responsible in eight SBS patients receiving home TPN. There were 13 episodes of catheter infection (0.88 per patient-year). The group with a shorter RSB length (five patients) presented 1.3 to 2.76 infections/year and 2 to 9 months until the first episode, compared to 0 to 0.75 infections/year (p= 0.0357) and 11 to 65 months until the first episode (p= 0.0332) in the group with the longer RSB. In the first group, the agents isolated were Enterobacteriae (Enterobacter sp., Klebsiella sp., Pseudomonas sp., and Proteus sp.) in eight episodes and Candida sp. in one. In the latter sepsis was caused by Staphylococcus sp. in three episodes and Pseudomonas sp. in one. Therefore patients with remaining small bowel shorter than 50 cm have a higher frequency of catheter-related sepsis, particularly by enteric microorganisms. This might be an evidence of the occurrence of bacterial translocation and its role in the pathogenesis of catheter-related sepsis in patients with an extremely short RSB receiving home TPN.

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.

Preliminary results from digestive adaptation: a new surgical proposal for treating obesity, based on physiology and evolution

CONTEXT AND OBJECTIVE Most bariatric surgical techniques include essentially non-physiological features like narrowing anastomoses or bands, or digestive segment exclusion, especially the duodenum. This potentially causes symptoms or complications. The aim here was to report on the preliminary results from a new surgical technique for treating morbid obesity that takes a physiological and evolutionary approach. DESIGN AND SETTING Case series description, in Hospital Israelita Albert Einstein and Hospital da Polícia Militar, São Paulo, and Hospital Vicentino, Ponta Grossa, Paraná. METHODS The technique included vertical (sleeve) gastrectomy, omentectomy and enterectomy that retained three meters of small bowel (initial jejunum and most of the ileum), i.e. the lower limit for normal adults. The operations on 100 patients are described. RESULTS The mean follow-up was nine months (range: one to 29 months). The mean reductions in body mass index were 4.3, 6.1, 8.1, 10.1 and 10.7 kg/m2, respectively at 1, 2, 4, 6 and 12 months. All patients reported early satiety. There was major improvement in comorbidities, especially diabetes. Operative complications occurred in 7% of patients, all of them resolved without sequelae. There was no mortality. CONCLUSIONS This procedure creates a proportionally reduced gastrointestinal tract, leaving its basic functions unharmed and producing adaptation of the gastric chamber size to hypercaloric diet. It removes the sources of ghrelin, plasminogen activator inhibitor-1 (PAI-1) and resistin production and leads more nutrients to the distal bowel, with desirable metabolic consequences. Patients do not need nutritional support or drug medication. The procedure is straightforward and safe.

Adaptive and Neuroendocrine Procedures: A New Pathway in Bariatric and Metabolic Surgery

Obesity Surgery recently published an article [1] entitled “Bariatric Surgery: The Past, Present, and Future” written by Saber, Elgamal, and McLeod, from Michigan State University. It is an excellent article, as it is important to review the past periodically. However, our proposal, as discussed in the article, was incorrectly portrayed as a mix of restriction and malabsorption. Clearly, mechanical restriction, including a narrow anastomosis or a band, and malabsorption are not physiological and should be avoided. Nonetheless, both restriction and malabsorption were wisely used in a controlled manner to treat an uncontrolled condition, obesity. Thousands of patients have benefited greatly from these surgeries. Fortunately, our limited understanding of digestive physiology is now changing. The interacting neuroendocrine signals that control hunger, satiety, and energy expenditure were not known then, and indeed, they are only partially understood now. In spite of that, we have sufficient information for the proposal of new surgical strategies that aim exclusively at interfering with these signals, rather than mechanically impeding food consumption or causing intentional and nonspecific malabsorption. Mechanical restriction and malabsorption are responsible for the complications caused by traditional bariatric surgery, while the benefits were brought about mostly by unintentional metabolic and enterohormonal changes that could be neither predicted nor understood 20 years ago [2]. Physiological studies are reinforced by biological, anthropological, anatomical, epidemiological, clinical and evolutionary data providing evidence [3] that there must be a strict correlation between the species-specific digestive system and the diet for normal regulation of energy intake and expenditure. In nature, a change in the diet implies a digestive system adaptation; richer diets imply smaller and simpler digestive systems [4]. The human diet suffered a fast and profound change. Cooking and refining food produced an increase in caloric density and digestibility, representing a pre-digestion. These modern meals may be absorbed more in the first portions of the intestine. Distal gut signals thereby become attenuated, not reflecting the high caloric content of meals. To worsen matters, this modified diet became abundant. A possible hypertrophy of the proximal bowel, induced by overeating, may additionally diminish the amount of nutrients in the distal gut. What we proposed and began in 2002 is a strategy with graded procedures designed to produce an adaptation of the digestive tract to modulate the neuroendocrine response, avoiding (or minimizing) restriction and malabsorption. We, along with others [5], do not see the sleeve gastrectomy (SG) as a restriction in the usual sense. There is not a narrow anastomosis, a band or any sort of stenosis. Instead, we see it as an adaptation of the stomach size to the higher caloric density of modern food that, fortunately, also reduces ghrelin. We have used it for more than 5 years [6], and it is clear that it is not sufficient for all patients. For some patients, more powerful procedures are, unfortunately, needed. A jejunectomy [7] and transit bipartition [8] do not aim at malabsorption at all but in returning the site of major absorption to distal locations, as if a non-refined raw diet were consumed. Both procedures improve distal gut neuroendocrine response [7, 8], and these strategies may enhance the benefits of SG. OBES SURG (2008) 18:1343–1345 DOI 10.1007/s11695-008-9550-7

Sleeve gastrectomy with anti-reflux procedures

Objective Sleeve gastrectomy is the fastest growing surgical procedure to treat obesity in the world but it may cause or worsen gastroesophageal reflux disease. This article originally aimed to describe the addition of anti-reflux procedures (removal of periesophageal fats pads, hiatoplasty, a small plication and fixation of the gastric remnant in position) to the usual sleeve gastrectomy and to report early and late results. Methods Eighty-eight obese patients that also presented symptoms of gastroesophageal reflux disease were submitted to sleeve gastrectomy with anti-reflux procedures. Fifty of them were also submitted to a transit bipartition. The weight loss of these patients was compared to consecutive 360 patients previously submitted to the usual sleeve gastrectomy and to 1,140 submitted to sleeve gastrectomy + transit bipartition. Gastroesophageal reflux disease symptoms were specifically inquired in all anti-reflux sleeve gastrectomy patients and compared to the results of the same questionnaire applied to 50 sleeve gastrectomy patients and 60 sleeve gastrectomy + transit bipartition patients that also presented preoperative symptoms of gastroesophageal reflux disease. Results In terms of weight loss, excess of body mass index loss percentage after anti-reflux sleeve gastrectomy is not inferior to the usual sleeve gastrectomy and anti-reflux sleeve gastrectomy + transit bipartition is not inferior to sleeve gastrectomy + transit bipartition. Anti-reflux sleeve gastrectomy did not add morbidity but significantly diminished gastroesophageal reflux disease symptoms and the use of proton pump inhibitors to treat this condition. Conclusion The addition of anti-reflux procedures, such as hiatoplasty and cardioplication, to the usual sleeve gastrectomy did not add morbidity neither worsened the weight loss but significantly reduced the occurrence of gastroesophageal reflux disease symptoms as well as the use of proton pump inhibitors.

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.

Stomachs: does the size matter? Aspects of intestinal satiety, gastric satiety, hunger and gluttony

Many surgeons and most laypeople think that there is a strict correlation between the size of the stomach and the size of the meals. The term “stomach reduction” became a synonym for weight loss surgeries, as if by reducing the stomach, all meals would automatically be small.

Avaliaçäo da hernioplastia protética atensional no tratamento das hérnias inguinais

This is the inicial experience in Brazil with the routine use of prosthetic tensionless repair of common inguinal hernias. Before that many groups had been using prosthetic material in selected cases, mostly recurrences. Seventy six patients were operated on, 12 of them bilaterally so that there were 88 procedures over direct (26,1%), indirect (56,8%) and both direct and indirect hernias (17,1 %). The hernia sacs are reduced to the abdominal cavity and the abdominal wall is reinforced by the placement of a polipropilen mesh on the transversalis fascia. The technique is detailed described. Only minimal pain occurred in the postoperative period. There were no infeccion, no rejection, and until now (30 months of medium follow up), no signs of recurrences. Many aspects of the surgical treatment of inguinal hernias are discussed including results, feseability, risks and costs. It is concluded that prosthetic tensionless repair of inguinal hernias is easy, fast, safe and cheap. It does not require general anaesthesia neither complex material. It has excellent results and as it does not create tension sutures, it causes less pain and allows normal physical activity very soon. It suggests that, in common inguinal hernias, maybe we can spare the patient and community from the higher costs of laparoscopic surgery since we can obtain excellent results with an easier and cheaper method.

Sleeve Gastrectomy and Transit Bipartition

The modern techniques of food processing led to an increased consumption of high-glycemic index food. This leads to a hormonally hyperactive proximal gut and a hypoactive distal gut, which are linked to obesity and metabolic syndrome. Transit bipartition (TB) was designed to counterbalance these effects, by creating a gastroileal anastomosis in the antrum after the sleeve gastrectomy (SG). Unlike the previously designed malabsorptive surgical techniques, nutrient transit is maintained in the duodenum, avoiding blind loops and minimizing malabsorption. The stomach retains two outflow pathways. A lateral enteroanastomosis connects both segments at 80 t 120 cm proximal to the cecum. Distal gut hormone secretion is enhanced. SG + TB is a simple procedure that results in early satiety and rapid and maintained weight loss, with a low complication rate and rare signals of malabsorption. This strategy led to remission or major improvement of comorbidities, including diabetes, without duodenal exclusion. TB is an excellent complement to a SG.

Gastrectomia vertical com medidas antirrefluxo

Objetivo A gastrectomia vertical e o procedimento cirurgico para tratamento da obesidade que mais cresce em indicacoes. No entanto, esse procedimento pode causar ou agravar a doenca do refluxo gastresofagico. Este artigo buscou descrever originalmente a adicao de procedimentos antirrefluxo (remocao de coxins gordurosos do hiato, hiatoplastia, pequena plicatura e fixacao do remanescente na posicao anatomica), alem de relatar seus resultados precoces e tardios.Metodos Foram submetidos a gastrectomia vertical com medidas antirrefluxo 88 oito pacientes obesos com sintomas de doenca [...]