Hallazgos histológicos gástricos en obesos mórbidos sometidos a gastrectomía vertical laparoscópica / Pathological findings in resected gastric segments after laparoscopic sleeve gastrectomy

Background: Laparoscopic sleeve gastrectomy (LSG) is used for the treatment of obesity and may provide gastric tissue for pathological studies. The association of obesity with dyslipidemias, diabetes and cardiovascular disease is of common knowledge. However its association with gastrointestinal diseases and gastritis is less well known. Aim: To analyze the pathological findings of the resected gastric segment during LSG. Material and Methods: Two hundred fifty patients aged 37 +/- 12 years and with a body mass index of 37.7 +/- 3.1 kg/m² (189 women), subjected to LSG, were included in a prospective protocol. Resected gastric segments were sent for a pathological study. Results: A gastric disease was identified in 220 (88 percent) cases. Chronic follicular gastritis was diagnosed in 117 patients (46.8 percent), chronic superficial gastritis in 76 (30.4 percent), chronic nonspecific gastritis in 38 (15.2 percent), intestinal metaplasia in 14 percent (5.6 percent) and in one case (0.4 percent) an early gastric carcinoma. Helicobacterpylori was present in 34 (13.6 percent) patients. Conclusions: This study shows a high prevalence of histopathological gastric lesions detected after the LSG, reaffirming the need for detection of these lesions before surgery.

Introducción: La gastrectomía vertical laparoscópica (GVL) es un procedimiento quirúrgico efectivo en el tratamiento de la obesidad. La obesidad está asociada con algunas comorbilidades como diabetes, dislipidemia y enfermedad cardiovascular, pero también se ha demostrado que tiene efectos potenciales sobre la gastritis y diversas enfermedades gastrointestinales. El objetivo de este estudio es determinar los hallazgos histológicos del segmento gástrico resecado durante la GVL realizada en una serie de pacientes obesos. Material y Método: Entre enero de 2006 y diciembre de 2008, 250 pacientes consecutivos a los que se realizó GVL, fueron incluídos en un protocolo prospectivo. La serie consistió en 189 mujeres (75,6 por ciento) y 61 hombres (24,4 por ciento), con edad promedio de 37,5 +/- 12,1 años. El Índice de Masa Corporal (IMC) promedio fue 37,7 +/- 3,1 kg/m². Resultados: Los resultados histológicos identificaron 220 casos (88 por ciento) con patología gástrica. Se diagnosticó gastritis crónica folicular en 117 pacientes (46,8 por ciento), gastritis crónica superficial en 76 (30,4 por ciento), gastritis crónica inespecífica en 38 (15,2 por ciento), metaplasia intestinal en 14 percent (5,6 por ciento) y en un caso (0,4 por ciento) adenocarcinoma in situ. Helicobacter pylori (HP) estuvo presente en 34 pacientes (13,6 por ciento). Conclusiones: Los hallazgos de este estudio, muestran una prevalencia incrementada de lesiones gástricas histopatológicas detectadas posterior a la GVL, reafirmando la necesidad de una detección de estas lesiones antes de la cirugía.

Cirugía revisional por estenosis post gastrectomía vertical laparoscópica / Revisional surgery for stenosis following laparoscopic sleeve gastrectomy

Introducción: La cirugía bariátrica revisional se realiza para modificar o reparar alguno de los tipos de cirugía para perder peso, entre ellos la gastrectomía vertical laparoscópica (GVL). La revisión de procedimientos bariátricos se hace necesaria entre el 10 al 25 por ciento de los pacientes, ya sea por baja de peso insuficiente o por complicaciones, siendo la estenosis una de ellas. Posterior a una GVL, el bypass gástrico en Y de Roux (BPG) es la intervención quirúrgica más requerida para la conversión. El objetivo de este estudio fue describir una serie de 5 pacientes que tuvieron cirugía revisional por estenosis posterior a una GVL. Material y Métodos: Entre enero de 2006 y marzo de 2013, en 770 pacientes consecutivos se realizó GVL. Los pacientes fueron incluidos en un protocolo prospectivo. Cinco pacientes tuvieron cirugía revisional con conversión a BPG por estenosis posterior a la GVL. Tres pacientes fueron operados de GVL en nuestro hospital, los otros 2 provenían de otros centros hospitalarios. Resultados: En los 5 pacientes con cirugía revisional la edad promedio fue 39,8 +/- 15,7 años. Cuatro pacientes fueron mujeres (80 por ciento). El promedio IMC antes de GVL fue 37,0 +/- 2,1 kg/m² y del IMC antes del BPG fue 29,4 +/- 5,4 kg/m². El BPG fue laparoscópico en 3 casos y abierto en 2. No hubo complicaciones, ni mortalidad. Conclusiones: La conversión a bypass gástrico en Y de Roux es un tratamiento efectivo para la estenosis posterior a una GVL.

Introduction: Revisional bariatric surgery is performed to alter or repair one of the many types of weight loss surgery, including laparoscopic sleeve gastrectomy (LSG). The revision of bariatric procedures is required between 10 to 25% of patients operated, either by insufficient weight loss or complications, including stenosis. After a LSG, the Roux- en- Y gastric bypass (RYGBP) is the most requested surgery for conversion. The aim of this study was to describe a series of 5 patients who had revisional surgery for stenosis following LSG. Material and Method: Between January 2006 and March 2013, in 770 consecutive patients was performed LSG. Patients were included in a prospective protocol. Five patients had revisional surgery with conversion to RYGBP for stenosis following LSG. In three patients the initial LSG was performed in our hospital, the other 2 were from other hospitals. Results: In the 5 patients with revisional surgery mean age was 39.8 ± 15.7 years. Four patients were women (80%). The average BMI before LSG was 37.0 ± 2.1 kg/m2 and BMI before RYGBP was 29.4 ± 5.4 kg/m2. The RYGBP was laparoscopic in 3 cases and opened in two. There were no complications, and no mortality. Conclusions: Conversion to RYGBP is an effective treatment for stenosis following a LSG.

Síntomas, hallazgos radiológicos, endoscópicos y estudios funcionales del esófago en pacientes con hernia hiatal mayor a 5 cm / Clinical and functional features of patients with a hiatal hernia diagnosed during endoscopy

Background: the finding of a hiatal hernia is usual during upper gastrointestinal endoscopies. However the correlation of symptoms, manometric and radiological findings with the endoscopy report is far from clear. Aim: to assess radiological findings, 24 pH measurements, esophageal manometry and symptoms among patients in whom a hiatal hernia was found during an upper gastrointestinal endoscopy. Material and Methods: one hundred fifteen patients aged 23 to 82 years (77 women), with an endoscopic diagnosis of a hiatal hernia of more than 5 cm were studied. An esophageal manometry and 24 hour pH determination were carried out. Results: hiatal hernias type I, II, II and IV were found in 50, 12, 38 and 15 patients of similar age, respectively. Gastroesophageal reflux symptoms were more common among patients with hernias type I and III. Mechanical symptoms such as retrosternal pain were more common in type IV hernias. Manometry showed a hypotensive sphincter in 100 and 78 percent of patients with hernias type I and III, respectively. An abnormal 24 hour pH measurement was found in 95 and 85 percent of patients with hernias type I and III, respectively. Conclusions: functional studies show a high frequency of pathological acid reflux among patients with hiatal hernias type I and III.

El hallazgo de una hernia hiatal durante un estudio endoscópico se informa frecuentemente. Sin embargo, no hay referencias específicas acerca de los síntomas y los trastornos funcionales del esófago según el tipo de hernia hiatal. Objetivo: determinar los síntomas predominantes, los hallazgos radiológicos y endoscópicos y de los estudios funcionales en pacientes con los diferentes tipos de hernia hiatal. Método: se evaluaron 115 pacientes, todos con diagnóstico radiológico de hernia hiatal mayor a 5 cm, realizando estudios endoscópicos, histológicos y manometría esofágica, junto a pHmetría de 24 h. Resultados: la edad fue similar en los 4 tipos de hernia hiatal. Síntomas de reflujo gastroesofágico se presentaron con gran frecuencia en hernias tipo I y III, mientras que síntomas mecánicos se manifestaron en hernias tipo IV. El estudio manométrico mostró un esfínter hipotensivo junto con reflujo ácido patológico en casi 90 por ciento de las hernias tipo I y IIII. Conclusión: el estudio más útil para el diagnóstico de hernia hiatal es el radiológico. La endoscopia es necesaria para comprobar el daño de la mucosa esofágica. Los estudios funcionales muestran una alta prevalencia de reflujo ácido patológico en hernias hiatales tipo I y II.

Conducta frente a filtraciones post gastrectomía vertical / Manifestations and management of leaks after sleeve gastrectomy

Background: sleeve gastrectomy is one of the most commonly used bariatric surgical procedures. Aim: to analyze clinical and laboratory manifestations and management of leaks after sleeve gastrectomy. Material and Methods: analysis of 20 patients with leaks out of 785 operated subjects (2.5 percent). Symptoms and laboratory changes were analyzed. Leak was classified according to the postoperative day of appearance, its location and its severity. Results: fever, abdominal pain and tachycardia were the main clinical manifestations of the leak. Patients also had leukocytosis and an elevated C reactive protein. In 12 (60 percent) patients, the leak appeared within the first four postoperative days, in three, it appeared between the fifth and ninth postoperative day and in five, after the tenth postoperative day. In 90 percent, the leak was near the cardias. Eleven patients were reoperated and nine were managed conservatively. The leak closed 34 and 55 days after its appearance among patients managed conservatively or surgically, respectively. Conclusions: leaks are a serious complication of sleeve gastrectomy and require a close surveillance of patients.

Introducción: la gastrectomía vertical laparoscópica es una de las técnicas quirúrgicas más empleadas en pacientes con obesidad. El Objetivo de este trabajo es analizar los hallazgos clínicos y de laboratorio en pacientes con filtraciones post gastrectomía vertical, así como el tratamiento y la evolución clínica. Material y Método: el grupo estudiado comprende a 20 pacientes (2,5 por ciento) de un total de 785 operados. En todos se evaluó la presencia de síntomas y signos clínicos, así como el hemograma y PCR. La filtración se clasificó de acuerdo a 3 parámetros: a) día de aparición de la filtración; b) su localización; c) su gravedad. Resultados: la presencia de fiebre, dolor abdominal y taquicardia fueron los principales síntomas y signos. Leucocitosis con desviación a izquierda y PCR elevados fueron hallazgos importantes. Hubo 12 pacientes (60 por ciento) con filtración precoz, 3 pacientes (15 por ciento) con filtración de tipo intermedia y 5 pacientes (25 por ciento) con filtración tardía. El 90 por ciento era de localización alta. Se reoperaron 11 pacientes y se manejaron conservadoramente 9. El cierre de la filtración ocurrió en promedio 34 días después de la operación con manejo conservador y a los 55 días con manejo quirúrgico. No hubo mortalidad. Prótesis expansible se empleó en 4 pacientes. Conclusión: la filtración posterior a una gastrectomía vertical es un evento grave, que requiere una observación clínica muy cercana del paciente.

Efectos del bypass gástrico en el esófago de Barrett de pacientes con obesidad mórbida / Effects of gastric bypass for morbid obesity on Barrett esophagus

Background: Besides the weight reducing effects of gastric bypass, it is also a good antireflux procedure since there is no acid production by the gastric pouch and there is no duodenal reflux due to the presence of a Roux en Y. Aim: To describe the effect of gastric bypass on Barrett esophagus among patients with morbid obesity. Material and Methods: Among 896 patients subjected to gastric bypass, 14 patient with a Barrett esophagus diagnosed with endoscopy and biopsy, were followed. A new endoscopy was performed one to 30 months after the surgical procedure. Results: Short (< = 30 mm) and long segment (> = 31 mm) Barrett esophagi were present in eight and six patients, respectively. Gastroesophageal reflux symptoms relieved in 70 percent of these cases in a mean lapse of 6.5 months. There was regression from intestinal metaplasia to car-dial mucosa in six patients (75 percent) with short-segment, and in one patient (16 percent) with long-segment Barrett esophagus. Conclusions: Gastric bypass in patients with morbid obesity and Barrett esophagus is a very good antireflux operation. This was proved by the disappearance of symptoms in almost all patients and by the regression of the intestinal metaplasia which is time and length dependent.

Antecedentes: El bypass gástrico en obesos mórbidos, además de ser una alternativa de cirugía bariátrica, es un buen procedimiento antirreflujo dado que no hay producción de ácido en el reservorio gástrico y no existe reflujo duodenal debido a la Y de Roux. Objetivo: Describir el efecto que tiene el bypass gástrico sobre el esófago de Barrett (EB) de pacientes obesos mórbidos, además discutir nuevos mecanismos fisiopatológicos implicados. Población: De 896 obesos mórbidos operados mediante bypass gástrico resectivo abierto, se siguieron a los 14 pacientes diagnosticados con EB mediante endoscopia e histología. Resultados: De los 14 pacientes con diagnóstico de esófago de Barrett, ocho pacientes presentaban EB corto (< 30 mm) y seis EB largo (> 31 mm). Los síntomas de pirosis y/o regurgitación presentes se resolvieron en un 70 por ciento de los casos en una media de 6,5 meses. Hubo una regresión de la metaplasia intestinal a mucosa cardial normal en seis pacientes (75 por ciento) con EB corto y en un paciente (16 por ciento) con EB largo. Conclusiones: El bypass gástrico es una muy buena alternativa quirúrgica antirreflujo en obesos mórbidos con EB, demostrado por la desaparición de los síntomas en la mayoría de los pacientes y la regresión de la metaplasia intestinal en la mitad de ellos, dependiendo del tiempo y de la longitud. Lo anterior, postulamos, que no sería debido solamente a que no hay producción de ácido en el reservorio gástrico y a que no existe reflujo duodenal, sino que habrían otros mecanismos fisiopatológicos implicados.

Filtraciones en bypass gástrico resectivo por laparotomía en obesidad mórbida / Anastomotic leaks after roux-en Y gastric bypass for morbid obesity

Background: Obesity is a severe disease whose prevalence continues to increase. Resective gastric bypass is one of the surgical procedures used in our center in patients with obesity, but like other techniques is not without complications, and the leak is one of the most serious. Aim: To determine by a prospective study the incidence, clinical presentation, postoperative course and treatment of obese patients with leaks after open resective gastric bypass. Material and Methods: From August 1999 to December 2009, 900 morbidly obese patients underwent open resective Roux-en-Y gastric bypass at the Hospital of the University of Chile. The use of drains and leak test with methylene blue during surgery, such as barium x-ray were performed in all patients as part of a protocol. Clinical signs, development, testing and treatment were recorded. Results: 36 patients (4 percent developed leaks. Of the 900 patients died 3 (0.33 percent). Fever and tachycardia were the predominant symptoms. The diagnosis was made by imaging studies in 19 cases (52.7 percent). The leaks were mostly between 5 th and 9 th postoperative day. The most frequent location of the leak was at the gastrojejunal anastomosis (58.3 percent). Treatment was medical in 24 patients (66.7 percent), requiring re-operation only in 12 cases. The average time of closure of the leak was 35.5 days and the patients were hospitalized a total of 33.7 days on average. Conclusions: In the series studied after resective gastric bypass the leak is presented in 4 percent of patients. Fever and tachycardia are useful signs to suspect a leak. The early detection of leaks is determinant to reach the best evolution of the patient and success in the treatment.

Introducción: La obesidad es una enfermedad severa cuya prevalencia continúa en incremento. El bypass gástrico resectivo, es una intervención quirúrgica realizada en nuestro centro, para obesidad; al igual que otras técnicas no está exenta de complicaciones, siendo la filtración una de las más graves. Objetivos: Determinar mediante estudio prospectivo la incidencia, presentación clínica, evolución y tratamiento de pacientes obesos con filtraciones después de bypass gástrico resectivo vía abierta. Material y Método: Desde agosto de 1999 a diciembre de 2009, 900 obesos mórbidos fueron sometidos a bypass gástrico resectivo en Y de Roux vía abierta en el Hospital Clínico de la Universidad de Chile. Se realizó a los pacientes por protocolo, prueba con azul de metileno intraoperatoria y control radiológico con bario postoperatorio. Fue registrada la evolución, exámenes y tratamiento realizado. Resultados: 36 pacientes (4 por ciento) desarrollaron filtraciones. De 900 pacientes fallecieron 3 (0,33 por ciento). Fiebre y taquicardia fueron síntomas predominantes. El diagnóstico fue realizado por estudios radiológicos en 19 casos (52,7 por ciento). Las filtraciones se produjeron mayormente entre el 5° y 9° día postoperatorio. Localización más frecuente de filtración fue la anastomosis gastroyeyunal (58,3 por ciento). Tratamiento médico en 24 pacientes (66,7 por ciento) y reoperación en 12 casos. Tiempo promedio de cierre de filtración 35,5 días y hospitalización 33,7 días. Conclusiones: En la serie, la filtración post bypass gástrico resectivo se presentó en 4 por ciento de pacientes. Fiebre y taquicardia son signos útiles para sospechar filtración. El diagnóstico precoz de las filtraciones es determinante en la mejor evolución del paciente y éxito en el tratamiento.

Rol de las incretinas / Role of the incretins

Incretins are gut hormones that are released from gut endocrine cells following oral ingestion of nutrients. The incretin hormones include glucagon-like peptide-1 (GLP-1) and lucosedependentinsulinotropic polypeptide (GIP). GIP and GLP-1 are jointly responsible for the socalled “incretin effect”. That is, oral administration of an amount of glucose causes a greater stimulus of insulin secretion than the same amount of glucose administered by the intravenous route. Both incretins potentiate glucose-dependent insulin secretion and enhance beta-cell massthrough regulation of beta-cell proliferation, neogenesis and apoptosis. In contrast, GLP-1, but not GIP, inhibits gastric emptying, glucagon secretion, and food intake. The incretins share similar effects on the pancreatic beta cell; however, there are a number of differences in extrapancreatic actions. Both incretins are rapidly deactivated by an enzyme called dipeptidyl peptidase 4(DPP4). Type 2 diabetes mellitus (T2DM) is associated with abnormal incretin physiology, the incretin effect is severely reduced or absent. In patients with T2DM the secretion of GIP is nearnormal, but its effect on insulin secretion is severely impaired. GLP-1 secretion, on the other hand, is also impaired, but its insulinotropic action is preserved, although the potency of GLP-1 in this respect is decreased compared to healthy subjets.

Efecto del bypass gástrico a largo plazo (7 a 10 años) en pacientes con obesidad severa y mórbida sobre el peso corporal, diabetes, dislipidemia y desarrollo de anemia / Results of gastric bypass for morbid obesity after a follow up of seven to 10 years

weight and complications of obesity, seven to 10 years after gastric bypass surgery. Material and Methods: One hundred eighteen subjects with morbid obesity, aged 15 to 66years (103 women), were followed for a mean of 94 months after surgery. Body weight, fasting blood glucose, total cholesterol, triglycerides and hemoglobin were measured before surgery and during follow up. Results: At 24 months of follow up, all patients lost weight and there was a mild weight increase at 94 months, that paralleled the preo-perative body mass index. Diabetes, hypercholesterolemia and hypertriglyceridemia subsided in 95, 87 and 94% of cases, respectively. Twenty percent of patients had mild anemia and 11% moderate or severe anemia. No patient recovered the preoperative weight. Conclusions: Weight reducing effects of gastric bypass are maintained after 94 months of follow up with the expected health benefits.

Comparación del tratamiento médico y quirúrgico en pacientes con obesidad grado III (obesidad mórbida): [revisión] / Review of the results of medical and surgical treatment of morbid obesity: [revision]

This is a review of publications comparing the results of medical and surgical treatment of morbid obesity. An overall conclusions is that the frequency of cardiovascular complications or cancer is higher among patients receiving medical treatment. Surgical treatment is associated with a better weight loss, reduction in complications and quality of life. Mortality risk decreases significantly after surgical treatment, when compared with patients receiving medical therapy Therefore, management of morbid obesity should be carried out by multidisciplinary teams with experience on gastrointestinal surgery. In this way the complications and mortality of bariatric surgery would be minimized.

Función pulmonar pre y post operatoria en bypass gástrico laparotómico y laparoscópico por obesidad mórbida / Pulmonary function in the pre and immediate postoperative period after open and laparoscopic gastric bypass for morbid obesity

Introducción: La obesidad está asociada a múltiples comorbilidades, entre ellas la patología respiratoria, que puede verse incrementada después de realizar cirugía bariátrica. Objetivo: Evaluar en forma prospectiva las alteraciones en la función pulmonar pre y postoperatorias, de pacientes obesos mórbidos operados con bypass gástrico por vía laparotómica y laparoscópica. Material y Método: 39 pacientes consecutivos con obesidad mórbida sometidos a bypass gástrico, divididos en 2 grupos: el primero formado por 24 pacientes operados por vía laparotómica y el segundo por 15 pacientes operados por vía laparoscópica, con evaluación pre y postoperatorias de radiografía de tórax, espirometría y gases arteriales. Resultados: En el postoperatorio un incremento significativo de atelectasias, presentándose en el 1er grupo con cirugía abierta en 45,8 por ciento de casos y en el 2° grupo con cirugía laparoscópica en el 33,3 por ciento. Aumento del patrón restrictivo a 41,7 por ciento en el 1er grupo y 33,3 por ciento de casos en el 2° grupo. Una disminución en ambos grupos de la capacidad vital forzada (CVF) y alteraciones en los gases arteriales con descenso mantenido de PaC0(2) en 36,5 mmHg en el 1er grupo y 33,8 mmHg en el 2° grupo. Conclusiones: Con la cirugía del bypass gástrico en obesos mórbidos, por vía laparotómica o laparoscópica se producen cambios en la función pulmonar postoperatoria, presentándose atelectasia, patrones espirométricos restrictivos, capacidad vital forzada disminuida y alteraciones en la Pa0(2) y PaC0(2). Esta última tiene significación estadística.

Background: Hypoventilation and Pickwick syndrome are two respiratory problems observed in obese patients. Weight reduction achieved after bariatric surgery can correct these problems but an exacerbation of respiratory problems can be observed in the immediate postoperative period. Aim: To evaluate pulmonary function in patients subjected to open and laparoscopic gastric bypass, before and after surgery. Material and Methods: Thirty nine subjects with morbid obesity were studied. Twenty four patients aged 26 to 62 years (13 women) were subjected to an open bypass and 15 patients aged 22 to 55 years (12 women) were operated laparoscopically Chest X ray, spiromemetry and arterial gases were assessed in both groups in the preoperative period and during the fifth postoperative day. Results: The presence of atelectasis on Chest X rays in the open surgery group, increased from 8 percent in the preoperative period to 46 percent in the postoperative period. In the laparoscopic surgery group the figures changed from 0 to 33 percent. In the open surgery group a restrictive pattern in spirometry was observed in 13 and 42 percent in the pre and postoperative periods. In the laparoscopic group the figures were 13 and 33 percent. In both groups, a decrease in torced vital capacity (FVC) was observed in the postoperative period. Also a reduction in PaC0(2) after surgery, from 38.6 to 36.5 mm Hg and from 36.4 to 33.8 mmHg was observed in patients subjected to open and laparoscopic surgery, respectively. Conclusions: In the immediate period after gastric bypass, either open or laparoscopic, there is an increase in the frequency of atelectasis on Chest X rays, restrictive pattern and decreased torced vital capacity on spirometry and changes in blood gases.

Resultados del bypass gástrico resectivo en pacientes obesos mórbidos ≤ 18 años y ≥ 65 años / Resection gastric bypass in morbid obese patients aged less than 18 and over 65 years

Background: The incidence of morbid obesity is increasing and gastric bypass is the most effective surgical treatment. Aim: To assess the long term results of resection gastric bypass among morbidly obese patients aged less than 18 and over 65 years in terms of weight loss and correction comorbidities. Material and methods: From August 1999 to December 2006, 712 patients with morbid obesity were subjected to open resection gastric bypass. A group of 12 patients, aged less than 18 years and a second group of 8 patients aged more 65 years were selected to prospectively assess weight loss, complications and correction of associated comorbidities. Results: In the first group body mass índex (BMI) decreased from 45±6.7 kg/m² to 27.7±3.2 kg/m², in a follow-up períod of 22.9±8.4 months. All comorbidities disappeared or improved. A single patient (8.3 percent) had an incisional hernia. Among the second group, BMI decreased from 40.6±5.4 kg/m² to 28.4±4.4 kg/m², in a follow-up períod of 26.6±15.9 months. All obesity comorbidities disappeared. Three patients (37.5 percent) presented incisional hernias. No patient died or had postoperative complications. Conclusions: In both groups resection gastric bypass was safe, obtained an appropriate weight loss and corrected all associated comorbidities to obesity.

Estudio prospectivo del diámetro de la vía biliar principal antes y 12 años después de colecistectomía / Bile duct diameter before and 12 years after cholecystectomy

Background: Surgeons and radiologists commonly believe that common bile duct dilates after cholecystectomy. Aim: To measure common bile tract diameter before and 12 years after a cholecystectomy for cholelithiasis. Material and methods: Prospective study of 85 patients (aged 20 to 71 years, 68 fenmales) subjected to a cholecystectomy and followed for 12 years. AH were asymptomatic and had abdominal ultrasound to measure common bile duct diameter, seven days before and 12 years after the surgical procedure. Results: Common bile duct diameter before and 12 years after surgery was 4.6+0.9 and 5.0+1.8 cm respectively (p=NS) among 69 patients aged íess than 60 years. The figures for 16 patients aged more than 60 years were 5+0.8 and 6.7+1.9 (p <0.03). Conclusions: Among patients below 60 years of age there is no significant change in bile duct diameter 12 years after surgery. In subjects over 60 years of age there is a significant increase in this diameter.

Riesgo perioperatorio del bypass gástrico reseccional en pacientes con obesidad mórbida: Estudio prospectivo de 684 pacientes / Perioperative risk among morbid obese patients subjected to gastric bypass

Background: Bariatric surgery is a complex procedure not exempt of complications. Aim: To assess mortality and complications of excisional gastric bypass among morbidly obese subjects. Material and methods: Prospective analysis of 684 morbid obese patients (age range 14-70 years, 525 females) subjected to an excisional gastric bypass. Major postoperative complications and mortality were registered. Results: Mean body mass index (BMI) of the subjects was 43.7 kg/m2. One hundred sixty two patients had a BMI between 35 and 39.9 kg/m2, 419 had a BMI between 40 and 49.9 kg/m2 and 103 had a BMI over 50 kg/m2. Two patients with a BMI of 52 and 56 kg/m2 respectively, died in the postoperative period (0.3%). Thirty six patients had major complications. Anastomotic fistula was the most common complication in 12 patients (1.7%). Fourteen patients required a new operation due to complications. None of these died. The mean operative volume of the surgical team was 124 patients per year. Conclusions: Excisional gastric bypass has a low rate of mortality and complications, if the surgical team operates a large volume of patients.

Efecto del bypass en la esofagitis erosiva en pacientes con obesidad mórbida / Effects of gastric bypass on erosive esophagitis in obese subjects

Background: Obesity is an important risk for pathological gastroesophageal reflux. Aim: To assess the effects of gastric bypass on obese subjects with erosive esophagitis. Patients and methods: Sixty two morbid obese subjects (aged 16 to 70 years, 41 females) with erosive esophagitis at the moment of surgery were studied. These patients were subjected to a gastric bypass with gastric resection. They were followed with upper gastrointestinal endoscopy every one year, looking for the presence of erosions or ulcers in the distal esophagus. Results: The mean follow up period was 21 months. Prior to surgery all patients had heartburn or regurgitation and at two years after surgery, 97% were asymptomatic. Esophagitis was found in 97 and 6.5% before and after surgery, respectively. Two patients had an esophageal ulcer, that healed on follow up endoscopy. There was a 72% reduction of overweight on late follow up. Conclusions: Gastric bypass is effective to control pathological gastroesophageal reflux in patients with morbid obesity.

Reducción de peso a 2 años según índice de masa corporal preoperatoria en 286 pacientes con obesidad mórbida sometidos a bypass gástrico con resección del segmento gástrico distal / Weight loss two years after gastric bypass and gastrectomy in morbid obese patients

Introducción: La obesidad severa y mórbida ha aumentado en forma muy importante en Chile durante la última década. Objetivo: Evaluar los resultados del bypass gástrico con gastrectomía en cuanto al riesgo quirúrgico y los resultados de perdida de peso a 20 meses después de la cirugía. Material y Método: Es un estudio prospectivo descriptivo que incluye 286 pacientes consecutivos operados en un período de casi 4 años. Todos fueron sometidos a un bypass gástrico con asa en Y-de-Roux de 125 a 150 cm, resecando segmento distal excluido del estomago. Se realizó un seguimiento promedio de 20 meses, determinando la baja de peso, el índice de masa corporal (IMC) antes y después de la cirugía y la perdida del exceso de peso preoperatorio. Resultados: El grupo comprendió 233 mujeres y 51 hombres con una edad promedio de 39,9 años. Hubo 62 por ciento de los pacientes con IMC entre 40 y 49, 23 por ciento entre 35 y 39 y 11 por ciento con un IMC sobre 50 Kg/m². Se controló a todos los pacientes por 20 meses promedio, apreciando una significativa baja de peso y del IMC en todos los grupos. La baja del exceso de peso preoperatorio fue de 71 por ciento. Conclusiones: El bypass gástrico con gastrectomía puede ser una alternativa quirúrgica para pacientes con obesidad mórbida, especialmente en países con alta prevalencia de patología gastroduodenal.