Victor Fernando Pilla

Ghrelin: A gut-brain hormone: Effect of gastric bypass surgery

Background: Ghrelin is a newly recognized gastric hormone with orexigenic and adipogenic properties, produced primarily by the stomach. Ghrelin is reduced in obesity.Weight loss is associated with an increase in fasting plasma ghrelin. We assessed the effect of massive weight loss on plasma ghrelin concentrations and its correlation with serum leptin levels and the presence of type 2 diabetes mellitus (DM) in severely obese patients. Methods: A prospective study was conducted on 28 morbidly obese women (BMI 56.3±10.2 kg/m2) who underwent gastric bypass, divided into 2 groups: 14 non-diabetics (NGT) and 14 type 2 diabetics (DM2). Ghrelin and leptin were evaluated before silastic ring transected vertical gastric bypass, and again 12 months postoperatively. Results: Fasting plasma ghrelin concentrations were 56% lower in NGT and 59% lower in DM2 compared with a lean control group (P<0.001). There was no difference in ghrelin levels between NGT and DM2 groups before and after surgery (P>0.05). Ghrelin was negatively correlated with leptin before gastric bypass surgery (r=0.51, P<0.01). The mean plasma ghrelin concentration decreased significantly after surgery in both groups (P<0.001). Conclusion: Ghrelin was inversely related to leptin concentrations. Presence of diabetes did not affect the ghrelin pattern. Reduced production of ghrelin after gastric bypass could be partly responsible for the lack of hyperphagia and thus for the weight loss.

The Incapacity of the Surgeon to Identify NASH in Bariatric Surgery Makes Biopsy Mandatory

BackgroundNonalcoholic steatohepatitis (NASH) is a morbid condition highly related to obesity. It is unclear if the macroscopic liver appearance correlates with the histopathologic findings. The goal of this prospective study was to determine the relationship between the intraoperative liver appearance and the histopathologic diagnosis of NASH in morbidly obese subjects undergoing bariatric surgery. We also aimed to determine variables that could predict NASH preoperatively.MethodsConsecutive 51 subjects undergoing bariatric surgery without evidence of other liver disease underwent intraoperative liver biopsy. An intraoperative liver visual (macroscopic and tactile examination) was recorded. The liver aspect was compared with the liver histologic findings. Histological assessment was categorized into two groups: NASH and non-NASH (including normal histology and simple steatosis). Clinical and biochemical parameters were obtained from the patient databases and were compared between groups to identify preoperatively predictive factors of NASH.ResultsFrom 51 patients, only one presented totally normal histology. Forty-three (86.2%) presented simple steatosis, and seven (13.7%) were classified as NASH. Clinical parameters were not different between groups. At biochemical analysis, only VLDL cholesterol level was significantly higher in the NASH group (p = 0.037) but yet within the normal range. Association between macroscopic liver appearance and the presence of histological NASH is poor (sensitivity of 14%, specificity of 56%, positive predictive value of 5%, and negative predictive value of 80%).ConclusionsNo predictor of NASH was found. Surgeons’ evaluation could not identify NASH individuals. Routine liver biopsy during bariatric operations is mandatory to differentiate NASH and nonalcoholic fatty liver disease.

Gastroplastia redutora com bypass gastrojejunal em Y-de-Roux: conversão para bypass gastrointestinal distal por perda insuficiente de peso - experiência em 41 pacientes

BACKGROUND Surgery is the only effective treatment for morbid obesity. Gastric bypass could fail in up to 10% of the patients (excess weight loss under 50%). AIMS To evaluate the weight loss determined by reoperation performing disabsortive variation of gastric bypass. PATIENTS AND METHODS The records of 41 patients, in whom 32 were submitted to reoperation by one of three surgical techniques (Fobi, Brolin, distal gastrojejunoileal bypass) which consisted in increasing the disabsortive length of intestinal limb. RESULTS The patients submitted to distal gastrojejunoileal bypass showed the best results (69.7%). CONCLUSION The distal gastric bypass as a revisional procedure could be done in selected cases with the aim to improve the weight loss. It is advisable to refer these patients to selected centers (known as center of excellence) with experience in this area of bariatric surgery, in order to perform a very close follow-up.

Intrahepatic Glissonian Approach for Laparoscopic Right Trisectionectomy

A 22-year-old woman with a giant angiomyolipoma was referred for surgical treatment. The patient was placedin aleft semilateral decubitus position with the surgeon between the patient’s legs. Five trocars (three 12 and two 5mm) were used. The pneumoperitoneum is established at a pressure of 12mm Hg. Round and falciform ligaments are taken down close to the abdominal wall in order to facilitate left-liver fixation at the end of the procedure. The falciform and coronary ligaments are divided by using laparoscopic coagulation shears (Harmonic Scalpel LCS; Ethicon Endo-Surgery Industries, Cincinnati, OH)toexpose thesuprahepaticinferiorvenacava. After cholecystectomy, the right hepatic artery is ligated, resulting in an ischemic delineation of the right liver. Due to previous right-portal-vein embolization in this patient, the hepatic pedicle was not fully dissected. The right liver is then fully mobilized, and the inferior vena cava is dissected. A large inferior right hepatic vein arising from segment 6 is ligated and divided between metallic clips. Another accessory right hepatic vein from segment 7 (middle-right hepatic vein) is divided with a vascular endoscopic stapler. The right hepatic vein is finally encircled, and downward retraction permits the safe application of a vascular endoscopic stapler. The stapler is fired, leaving three lines of metallic clips. With this maneuver, the anterior surface of the retrohepatic vena cava is completely exposed. The main trunk, including the middle and left hepatic veins, is now the only venous drainage of the liver. It is encircled and traction or temporary clamping permits complete outflow control of the liver, minimizing bleeding during liver transection. At this time, the intrahepatic access to the main right Glissonian pedicle is achieved with two small incisions: An incision is performed on the right portion of the caudate lobe and another anterior incisionismadeinfrontofthehilum.Anendoscopicvascular

A simple technique for large tumor removal during laparoscopic liver resection.

Experience with laparoscopic liver resections has increased in recent years, and so have the number of patients operated on by minimally invasive techniques. Specimen extraction is an important step of laparoscopic liver resection. The size of the specimen is usually a limitation for the use of laparoscopy. The aim of this paper is to describe a new technique combining Pfannenstiel suprapubic incision and obstetric forceps to remove a large specimen from laparoscopic liver resections. The present technique allows an expeditious extraction of intact specimens, even huge ones, through a standard suprapubic Pfannenstiel incision. This technique has additional functional and cosmetic advantages over other techniques of specimen retrieval. We believe that the described technique is feasible, can be easily and rapidly performed, and facilitates laparoscopic liver resection by reducing the technical difficulties for specimen removal and may also be used in other abdominal laparoscopic interventions that deal with large surgical specimens.