Food intake evaluation during the first year of postoperative of patients with type 2 diabetes mellitus or glycemic alteration submitted to roux-en-y gastric bypass / Avaliação da ingestão alimentar durante o primeiro ano de pós-operatório de pacientes com diabete melito tipo 2 ou alteração glicêmica submetidos ao bypass gástrico em y-de-roux

ABSTRACT Background : Obesity is one of the main causes of glycemic change. Failure of clinical obesity treatment may lead to an increase in bariatric surgery. Dietary guidance, in conjunction with disabsorptive and hormonal factors resulting from the anatomical and physiological changes provoked by the surgery, is associated with changes in food intake. Aim: To analyze food intake evolution during the first postoperative year of Roux-en-y gastric bypass in patients with type 2 diabetes mellitus or glycemic alteration. Methods : This was a longitudinal and retrospective observational study. For food intake evolution analysis, linear regression models with normal errors were adjusted for each of the nutrients. Results: At 12 months, all patients presented improvement in glycemic levels (p<0.05). During the first postoperative year, there was a reduction in energy intake, macronutrients, consumption of alcoholic beverages and soft drinks. Conversely, there was an increase in fiber intake and diet fractionation. It was observed that, despite gastric restrictions, the micronutrient intake specifically recommended for glycemic control was greater up to six months postoperatively. Conclusion: There was change in the quantity and quality of food intake. It was the most prevalent glycemic control contributor up to six months postoperatively. At the end of one year, the diet underwent a change, showing a similar tendency to the preoperative food intake pattern.

RESUMO Racional: Obesidade é uma das maiores causas de alteração glicêmica. O insucesso no seu tratamento clínico pode levar ao aumento de operações bariátricas. Orientação dietética, em conjunto com fatores disabsortivos e hormonais resultantes das alterações anatômicas e fisiológicas provocadas pela operação, está associada à mudanças na ingestão alimentar. Objetivo : Analisar a evolução da ingestão alimentar durante o primeiro ano pós-operatório de bypass gástrico em Y-de-Roux de pacientes com diabete melito tipo 2 ou alteração glicêmica no pré-operatório. Métodos : Estudo observacional longitudinal e retrospectivo. Para análise da evolução da ingestão alimentar, modelos de regressão linear com erros normais foram ajustados para cada nutriente. Resultados: Aos 12 meses, todos os pacientes apresentaram melhora nos níveis de glicemia (p<0,05). Durante o primeiro ano pós-operatório, houve redução na ingestão de energia, macronutrientes, consumo de bebidas alcoólicas e refrigerantes. Por outro lado, houve aumento na ingestão de fibras e fracionamento de dieta. Observou-se que, apesar das restrições gástricas, a ingestão de micronutrientes recomendados especificamente para o controle glicêmico foi maior até seis meses do pós-operatório. Conclusão: Houve mudança na quantidade e na qualidade da ingestão alimentar, sendo o consumo de alimentos que contribuem para o controle glicêmico mais prevalente até o sexto mês de pós-operatório. No pós-operatório em até um ano, a dieta sofre alteração, apresentando inadequações em relação à pirâmide específica, com tendência ao padrão alimentar do pré-operatório.

Laparoendoscopic pfannenstiel nephrectomy using conventional laparoscopic instruments - preliminary experience

PURPOSE: To confirm the feasibility of the laparoendoscopic Pfannenstiel nephrectomy using conventional laparoscopic instruments. MATERIALS AND METHODS: Since March 2009, laparoscopic nephrectomy through a Pfannenstiel incision has been performed in selected patients in our service. The Veress needle was placed through the umbilicus which allowed carbon dioxide inflow. One 5 mm (or 10 mm) trocar was placed at the umbilicus for the laparoscope, to guide the placement of three trocars over the Pfannenstiel incision. Additional trocars were placed as follows: a 10 mm in the midline, a 10 mm ipsilateral to the kidney to be removed (2 cm away from the middle one), and a 5 mm contralateral to the kidney to be removed (2 cm away from the middle one). The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed and all three incisions were united into a single Pfannenstiel incision for specimen retrieval. RESULTS: Five nephrectomies were performed following this technique: one atrophic kidney, one kidney donation, two renal cancers and one bilateral renal atrophy. Median operative time was 100 minutes and median intraoperative blood loss was 100 cc. No intraoperative complications occurred and no patients required blood transfusion. Median length of hospital stay was 1 day (range 1 to 2 days). CONCLUSIONS: The use of the Pfannenstiel incision for laparoscopic nephrectomy seems to be feasible even when using conventional laparoscopic instruments, and can be considered a potential alternative for traditional laparoscopic nephrectomy.

Laparoscopic live donor nephrectomy in patients surgically treated for morbid obesity

In the past, morbid obesity was considered a relative contraindication to renal donation; however, more recent publications have shown that laparoscopic renal surgery is safe and effective for obese donor nephrectomy. We report the performance of a bariatric surgery before the kidney donation in 2 patients in order to improve their medical condition and to reduce their surgical risk to the transplantation procedure. After bariatric surgery, both donors lost more than 30 percent of their initial corporal weight and their donation procedure was successfully performed, with uneventful postoperative courses.

Hand-assisted right laparoscopic live donor nephrectomy

PURPOSE: Laparoscopic live donor nephrectomy has acquired an important role in the era of minimally invasive surgery. Laparoscopic harvesting of the right kidney is technically more challenging than that of the left kidney because of the short right renal vein and the need to retract the liver away from the right kidney. The aim of this article is to report our experience with right laparoscopic live donor nephrectomies. MATERIALS AND METHODS: We performed a retrospective review of 28 patients who underwent right laparoscopic donor nephrectomies at our service. Operative data and postoperative outcomes were collected, including surgical time, estimated blood loss, warm ischemia time, length of hospital stay, conversion to laparotomy and complications. RESULTS: The procedure was performed successfully in all 28 patients. The mean operative time was 83.8 minutes (range 45 to 180 minutes), with an estimated blood loss of 111.4 mL (range 40 to 350 mL) and warm ischemia time of 3 minutes (range 1.5 to 8 minutes). No donor needed conversion to open surgery and all kidneys showed immediate function after implantation. The average time to initial fluid intake was 12 hours (range 8 to 24 hours). Two cases of postoperative ileus and a case of hematoma on the hand-port site were observed. The mean postoperative hospital stay was 3 days (range 1 to 7 days). CONCLUSIONS: Our data confirm the safety and feasibility of right laparoscopic donor nephrectomy and we believe that the right kidney should not be avoided for laparoscopic donor nephrectomy when indicated.

Laparocopic ureteral reimplantation in ureteral stenosis after gynecologic laparoscopic surgery

Pelvic surgery is the most common cause of iatrogenic ureteral injury, and traditionally repair of such injuries requires laparotomy. We report the case of a 48-year-old woman with an iatrogenic ureteral injury after laparoscopic ophorectomy which was laparoscopically reimplanted using the Lich-Gregoire technique. Total operating time was 150 minutes and estimated blood loss was 100 mL. Two months after surgery she is asymptomatic with normal renal function.

Maximizing the right renal vein length in laparoscopic live donor nephrectomy

Laparoscopic donor nephrectomy has become the standard of care at increasing numbers of renal transplant programs worldwide. The majority of laparoscopic living donor kidneys are procured from the left side because of the longer renal vein and improved transplantation. The aim of this article is to report a technique to maximize the right renal vein length by performing a hand-assisted cavotomy.