The spectrum of non alcoholic fatty liver disease in morbidly obese patients: prevalence and associate risk factors

PURPOSE: To determine the prevalence of non alcoholic fatty liver disease (NAFLD) and non alcoholic steatohepatitis (NASH) in morbidly obese patients undergoing bariatric surgery and to identify risk factors associated with the disease spectrum. METHODS: Liver biopsy was performed in 60 patients who underwent bariatric surgery, after other causes of liver disease were excluded. Clinical, biochemical and histological features were evaluated. RESULTS: NAFLD was detected in fifty-seven patients (95%) of the sample and forty patients (66.7%) of the total sample met the criteria for NASH. Perisinusoidal fibrosis was only found in three (7.5%) patients with NASH. The γGT was an independent predictive factor associated with the degree of hepatic steatosis. The variables such as dyslipidemia and ALT were independently associated with the presence of Mallory's corpuscles with the following values, respectively, OR 0, 05, 95% CI 0.002 to 0.75, P = 0.031 and OR 10, 99, 95% CI 1.44 to 83.93, P = 0.021. CONCLUSIONS: Non alcoholic fatty liver disease seems to be an obese-related condition with approximately half of asymptomatic morbidly obese patients having histological NASH. The γGT was an independent predictor of the degree of steatosis.

Tratamento videoendoscópico do leiomioma de esôfago / Videoendoscopic surgery for the treatment of esophagus' leiomyoma

INTRODUÇÃO: Leiomiomas são as neoplasias esofagianas mais comuns. Seu tratamento de escolha é cirúrgico. A enucleação por toracotomia aberta é o procedimento padrão. Com o avanço das técnicas de cirurgia minimamente invasiva, novas alternativas se impõem. OBJETIVO: Apresentar técnica videoendoscópica para o tratamento desses miomas evitando-se toracotomia. TÉCNICA: Enucleação do leiomioma por: A) toracoscopia para tumores do esôfago torácico ou B) laparoscopia aos do esôfago abdominal. A) As operações são realizadas sob anestesia geral com entubação seletiva do pulmão esquerdo. Os pacientes são colocados em posição de decúbito lateral esquerdo e leve dorsoflexão. São utilizados quatro trocárteres de trabalho, dois de 11 mm e dois de 5 mm. Os de 11 mm, um no 6º espaço intercostal, na linha axilar posterior, para ótica de 30°; outro na mesma altura na linha hemi-clavicular para afastar o pulmão. Os outros dois trocárteres de 5 mm são instalados para dar passagem aos instrumentos de trabalho do cirurgião no 4º espaço, na linha axilar posterior, e no 7º, também na linha axilar posterior. As operações se iniciavam sempre pela abertura da pleura mediastinal, dissecção do tumor com abertura da parte muscular da parede esofágica, enucleação simples do tumor e fechamento da incisão muscular esofágica. B) As intervenções são feitas com os pacientes submetidos à anestesia geral e colocados em posição francesa. A abordagem é a mesma realizada para correção da hérnia hiatal e a enucleação é feita sem dificuldades. CONCLUSÃO: O acesso videocirúrgico é perfeitamente exequível para as ressecções de leiomiomas esofágicos e proporciona resultados satisfatórios muito semelhantes aos encontrados com aos procedimentos abertos.

INTRODUCTION: Leiomyomas are the commonest benign esophageal neoplasms. Surgical treatment is the therapy of choice for such tumors. Open enucleation via thoracotomy has long been the standard procedure. With the emergence of thoracoscopic and laparoscopic approaches, minimally invasive surgery represent interesting alternatives to open surgical procedures. AIM: To propose endoscopic technique for the treatment of these myomas avoiding thoracotomy. TECHNIQUE: Enucleation of leiomyoma by: A) thoracoscopy, for thoracic esophageal tumors, or B) laparoscopy to the ones located in abdominal esophagus. A) The operations are performed under general anesthesia with selective intubation of the left lung. Patients are placed in the left lateral decubitus position and mild dorsiflexion. Four work trocars are used, two of 11 mm and two of 5 mm. One of the 11 mm is put in the 6th intercostal space in the posterior axillary line to use the 30° endoscope; another, at the same hemi-clavicular line, to take the lung away off surgical site. Other two trocars of 5 mm are installed for working tools of the surgeon, one in the 4th space in the posterior axillary line, and another in the 7th, also in the posterior axillary line. Operations are always initiated by opening the mediastinal pleura, dissection of the tumor with opening the muscle of the esophageal wall, simple enucleation of the tumor and closure of esophageal parietal muscular layer. B) The interventions are done with patients undergoing general anesthesia and placed in the French position. The approach is the same performed to correct the hiatal hernia, and enucleation is done without difficulty. CONCLUSION: Videosurgery for leiomyomas resection is safe and feasible and provides results similar to open procedure, but with a significant reduction in morbidity.