Impact of pre-operative weight loss on non-alcoholic fatty liver disease histopathology and insulin resistance in individuals undergoing bariatric surgery: a propensity matched cross-sectional comparison

ABSTRACT BACKGROUND: The effect of weight loss (WL) on histopathological aspects of non-alcoholic fatty liver disease (NAFLD) may provide further insights into the dynamics of hepatic recovery after WL. OBJECTIVE: To analyze the effects of pre-operative WL on insulin resistance- and NAFLD-related histology in individuals undergoing bariatric surgery (BS) with or without pre-operative WL. DESIGN AND SETTING: A matched cross-sectional study was conducted at a public university hospital and a private clinic in Campinas, Brazil. METHODS: An analytical, observational, cross-sectional study was conducted using prospectively collected databases of individuals who underwent BS and liver biopsy at either a public tertiary university hospital (with pre-operative WL) or a private clinic (without pre-operative WL). Random electronic matching by gender, age, and body mass index (BMI) was performed and two paired groups of 24 individuals each were selected. RESULTS: Of the 48 participants, 75% were female. The mean age was 37.4 ± 9.6. The mean BMI was 38.9 ± 2.6 kg/m2. Fibrosis was the most common histopathological abnormality (91.7%). Glucose was significantly lower in the WL group (92 ± 19.1 versus 111.8 ± 35.4 mg/dL; P = 0.02). Significantly lower frequencies of macrovesicular steatosis (58.3% versus 95.8%; P = 0.004), microvesicular steatosis (12.5% versus 87.5%; P < 0.001), and portal inflammation (50% versus 87.5%; P = 0.011) were observed in the WL group. CONCLUSION: Pre-operative WL was significantly associated with lower frequencies of macro- and mi- crovesicular steatosis, portal inflammation, and lower glycemia, indicating an association between the recent trajectory of body weight and histological aspects of NAFLD.

Perda de peso e qualidade de vida após o Bypass Gástrico de Anastomose Única: resultados de um seguimento de 2 anos / Weight loss and quality of life after one anastomosis gastric bypass: a 2-year follow-up study

ABSTRACT Background: Studies assessing quality of life (QoL) after one anastomosis gastric bypass (OAGB) are currently scarce. Objective: To analyze the main weight loss outcomes and QoL in individuals undergoing OAGB during a 2-year follow-up. Methods: This is a retrospective study based on a prospectively collected database including individuals which underwent OAGB at a tertiary-level university hospital. After 2-years, excess weight loss was assessed, and post-surgical therapeutical success was determined using Reinhold's criteria. QoL was assessed through the Bariatric Analysis and Reporting Outcomes System (BAROS). Results: Out of 41 participants, 90.2% were female and the average age was 38±8.3 years old. The average body mass index significantly decreased from 37.1±5.6 kg/m2 to 27±4.5 kg/m2 after 2-years (P< 0.001). The mean percentage of excess weight loss was 84.6±32.5%. Regarding weight loss outcomes, 61% were considered "excellent", while 26.8% were "good" according to Reinhold's criteria. With regards to QoL assessed by BAROS, most individuals achieved a score classified as either "excellent" (26.8%), "very good" (36.6%), or "good" (31.7%). The highest degrees of satisfaction achieved were in the domains "self-esteem" and "work capacity", in which 75.6% and 61%, respectively, were classified as "much better". Conclusion: OAGB associated with significant weight loss and resolution of obesity-related medical conditions, as well as relevant QoL improvement assessed by the BAROS system.

RESUMO Contexto: Existem poucos estudos que analisaram a qualidade de vida (QV) após o bypass gástrico de anastomose única (BGAU). Objetivo: Analisar os principais resultados de perda de peso e QV em indivíduos submetidos ao BGAU ao longo de 2 anos de seguimento. Métodos: Este é um estudo retrospectivo baseado em um banco de dados coletado prospectivamente que incluiu indivíduos submetidos ao BGAU em um hospital universitário de nível terciário. Após 2 anos, foi analisado o percentual de perda do excesso de peso (%PEP) e o sucesso terapêutico pós-cirúrgico foi classificado através critérios de Reinhold. A qualidade de vida foi avaliada por meio do Bariatric Analysis and Reporting Outcomes System (BAROS). Resultados: Dos 41 participantes, 90,2% eram do sexo feminino e a idade média foi de 38±8,3 anos. O índice de massa corporal médio diminuiu significativamente de 37,1±5,6 kg/m2 para 27±4,5 kg/m2 após 2 anos (P<0,001). O %PEP médio foi de 84,6±32,5%. Quanto à avaliação dos resultados de perda de peso, 61% foram considerados "excelentes", enquanto 26,8% foram "bons" segundo os critérios de Reinhold. Com relação à QV avaliada pelo BAROS, a maioria dos indivíduos obteve escores classificados como "excelente" (26,8%), "muito bom" (36,6%) ou "bom" (31,7%). Os maiores graus de satisfação alcançados foram nos domínios "autoestima" e "capacidade para o trabalho", nos quais 75,6% e 61%, respectivamente, foram classificados como "muito melhor". Conclusão: O BGAU associou-se à significativa perda de peso e resolução de comorbidades, bem como melhora relevante da qualidade de vida avaliada pelo sistema BAROS.

A infecção por Helicobacter pylori e o resultado de seu tratamento de erradicação influenciam a perda de peso e achados endoscópicos após o bypass gástrico em Y de Roux? Um estudo de coorte histórica / Do helicobacter pylori infection and eradication therapy status influence weight loss outcomes and endoscopic findings after roux-en-y gastric bypass?a historical cohort study

ABSTRACT Background: Currently, there is conflicting evidence linking Helicobacter pylori (HP) infection with weight loss and endoscopic findings after Roux-en-Y gastric bypass (RYGB). Objective: To identify correlations between HP infection and its eradication with weight loss and endoscopic findings after RYGB. Methods: This is an observational retrospective cohort study based on a prospectively collected database of individuals who underwent RYGB from 2018-2019 at a tertiary university hospital. HP infection and the HP eradication therapy outcomes were correlated with post-operative weight loss and endoscopic findings. Individuals were classified according to the status of HP infection into four groups: no infection; successful eradication; refractory infection; and new-onset infection. Results: Of 65 individuals, 87% were female and the mean age was 39±11.2 years. Body mass index significantly decreased from 36.2±3.6 to 26.7±3.3 kg/m2 one year after RYGB (P<0.0001). The percentage of total weight loss (%TWL) was 25.9±7.2% and the percentage of excess weight loss was 89.4±31.7%. HP infection prevalence decreased from 55.4% to 27.7% (p=0.001); 33.8% never had HP infection, 38.5% were successfully treated, 16.9% had refractory infection and 10.8 % had new-onset HP infection. %TWL was 27.3±7.5% in individuals who never had HP, 25.4±8.1% in the successfully treated, 25.7±5.2% in those with refractory infection, and 23.4±6.4% in the new-onset HP infection group; there were no significant differences among the four groups (P=0.6). Pre-operative HP infection significantly associated with gastritis (P=0.048). New-onset HP infections significantly associated with a lower frequency of jejunal erosions after surgery (P=0.048). Conclusion: No effects of the HP infection on weight loss were identified in individuals undergoing RYGB. A higher prevalence of gastritis was observed in individuals with HP infection before RYGB. New-onset HP infection after RYGB was a protective factor for jejunal erosions.

RESUMO Contexto: Há evidências conflitantes na literatura atual ligando a infecção por Helicobacter pylori (HP) com a perda de peso e achados endoscópicos após o bypass gástrico em Y de Roux (BGYR). Objetivo: Identificar correlações entre infecção por Helicobacter pylori HP e seu tratamento de erradicação com perda de peso e achados endoscópicos após BGYR. Métodos: Trata-se de um estudo retrospectivo e observacional de coorte histórica, baseado em um banco de dados coletados prospectivamente de indivíduos submetidos ao BGYR de 2018 a 2019 em um hospital terciário universitário. A infecção pelo HP e os resultados da terapia de erradicação do HP foram correlacionados com a perda de peso pós-operatória e os achados endoscópicos. Os indivíduos foram classificados de acordo com o status de infecção pelo HP em quatro grupos: ausência de infecção; erradicação bem-sucedida; infecção refratária; e infecção nova. Resultados: Dos 65 indivíduos, 87% eram do sexo feminino e a média de idade foi de 39±11,2 anos. O índice de massa corporal diminuiu significativamente de 36,2±3,6 para 26,7±3,3 kg/m2 um ano após BGYR (P<0,0001). O percentual de perda de peso foi 25,9±7,2% e o percentual de perda do excesso de peso foi 89,4±31,7%. A prevalência de infecção por HP diminuiu de 55,4% para 27,7% após a cirurgia (P=0,001); 33,8% nunca tiveram infecção por HP, 38,5% tiveram um tratamento bem-sucedido, 16,9% tiveram infecção refratária e 10,8% tiveram nova infecção por HP. Infecção pré-operatória por HP associou-se significativamente à presença de gastrite (P=0,048). Infecções por HP de início recente associaram-se significativamente com menor frequência de erosões jejunais após a cirurgia (P=0,048). Conclusão: Não foram identificados efeitos da infecção por HP na perda de peso em indivíduos submetidos ao BGYR. Maior prevalência de gastrite foi observada em indivíduos com infecção por HP antes da cirurgia. A infecção por HP de início recente após BGYR foi um fator protetor para erosões jejunais.

GASTRIC PLICATION ASSOCIATED WITH FUNDOPLICATION IN INDIVIDUALS WITH CLASS I OBESITY AND GASTROESOPHAGEAL REFLUX DISEASE: WEIGHT LOSS OUTCOMES, REFLUX-RELATED SYMPTOMS, ENDOSCOPIC AND pH MONITORING FINDINGS / PLICATURA GÁSTRICA ASSOCIADA A FUNDOPLICATURA EM INDIVÍDUOS COM OBESIDADE GRAU I E DOENÇA DO REFLUXO GASTROESOFÁGICO: ANÁLISE DE PERDA DE PESO, SINTOMAS DE REFLUXO, ACHADOS ENDOSCÓPICOS E DE pHMETRIA

ABSTRACT BACKGROUND: The association of gastric plication with fundoplication is a reliable option for the treatment of individuals with obesity associated with gastroesophageal reflux disease. AIMS: To describe weight loss, endoscopic, and gastroesophageal reflux disease-related outcomes of gastric plication with fundoplication in individuals with mild obesity. METHODS: A retrospective cohort study was carried out, enrolling individuals who underwent gastric plication with fundoplication at a tertiary private hospital from 2015-2019. Data regarding perioperative and weight loss outcomes, endoscopic and 24-hour pH monitoring findings, and gastroesophageal reflux disease-related symptoms were analyzed. RESULTS: Of 98 individuals, 90.2% were female. The median age was 40.4 years (IQR 32.1-47.8). The median body mass index decreased from 32 kg/m2 (IQR 30,5-34) to 29.5 kg/m2 (IQR 26.7-33.9) at 1-2 years (p<0.05); and to 27.4 kg/m2 (IQR 24.1-30.6) at 2-4 years (p=0.059). The median percentage of total weight loss at 1-2 years was 7.8% (IQR −4.1-14.7) and at 2-4 years, it was 16.4% (IQR 4.3-24.1). Both esophageal and extra-esophageal symptoms showed a significant reduction (p<0.05). A significant decrease in the occurrence of esophagitis was observed (p<0.01). The median DeMeester score decreased from 30 (IQR 15.1-48.4) to 1.9 (IQR 0.93-5.4) (p<0.0001). CONCLUSIONS: The gastric plication with fundoplication proved to be an effective and safe technique, leading to a significant and sustained weight loss in addition to endoscopic and clinical improvement of gastroesophageal reflux disease.

RESUMO RACIONAL: A associação de plicatura gástrica com fundoplicatura é uma opção atrativa para o tratamento de indivíduos com obesidade associada à doença do refluxo gastroesofágico. OBJETIVOS: Descrever a evolução ponderal, clínica, endoscópica e de pHmetria após a gástrica com fundoplicatura em indivíduos com obesidade grau I e doença do refluxo gastroesofágico. MÉTODOS: Um estudo de coorte histórica foi realizado, incluindo indivíduos que realizaram gástrica com fundoplicatura em um hospital privado terciário de 2015 a 2019. Os dados sobre os resultados perioperatórios e de perda de peso, achados endoscópicos e de pHmetria de 24 horas e sintomas relacionados à doença do refluxo gastroesofágico foram analisados. RESULTADOS: Dos 98 indivíduos, 90,2% eram do sexo feminino. A idade mediana foi de 40,4 (IQR 32,1-47,8) anos. A mediana do índice de massa corporal diminuiu de 32 (IQR 30,5-34) kg/m2 para 29,5 (IQR 26,7-33,9) kg/m2 em 1-2 anos (p<0,05); de 2 a 4 anos, foi de 27,4 (IQR 24,1-30,6) kg/m2 (p=0,059). A mediana da porcentagem da perda total de peso em 1-2 anos foi de 7,8% (IQR −4,1-14,7) e em 2-4 anos, foi de 16,4% (IQR 4,3-24,1). Tanto os sintomas esofágicos quanto os extras esofágicos apresentaram redução significativa (p<0,05). Observou-se diminuição significativa na ocorrência de esofagite (p<0,01). A pontuação mediana do escore de DeMeester diminuiu de 30 (IQR 15,1-48,4) para 1,9 (IQR 0,93-5,4) (p<0,0001). CONCLUSÕES: A associação entre plicatura gástrica e fundoplicatura laparoscópica mostrou-se uma técnica eficaz e segura, levando a perda de peso significativa, bem como melhora endoscópica e clínica da doença do refluxo gastroesofágico.

Is Helicobacter pylori infection associated with non-alcoholic fatty liver disease in individuals undergoing bariatric surgery? Cross-sectional study

ABSTRACT BACKGROUND: A possible direct link between nonalcoholic fatty liver disease (NAFLD) and Helicobacter pylori (H. pylori) infection has recently emerged. OBJECTIVE: This study aimed to analyze associations between the presence of histologically demonstrated NAFLD aspects with H. pylori infection in individuals with obesity undergoing bariatric surgery. DESIGN AND SETTING: An observational analytical cross-sectional study was conducted based on data collected from the medical records of individuals undergoing bariatric surgery at a tertiary university hospital in 2019. METHODS: NAFLD was assessed through histological examination of wedge liver biopsies collected during the proceedings. H. pylori infection was analyzed through the association of the urease test and histological examination performed in biopsies routinely collected during preoperative esophagogastroduodenoscopy. RESULTS: Of the 88 participants, 85% were female, and the average age was 39.1 ± 8.4 years. H. pylori infection was present in 61.4% of the patients. The mean body mass index was 36.6 ± 3.4 kg/m2. The most prevalent histopathological aspects of NAFLD were macrovesicular steatosis (92%), hepatocellular ballooning (92%), lobular inflammation (93.2%), portal inflammation (96.6%), and fibrosis (93.2%). No histopathological aspect of NAFLD was found to be significantly associated with H. pylori infection. CONCLUSION: In this study population, H. pylori infection was not significantly associated with the histopathological aspects of NAFLD in individuals with obesity undergoing bariatric surgery.

Trajectory of NAFLD characteristics after Roux-en-Y gastric bypass: a five-year historical cohort study

Abstract BACKGROUND: The long-term effects of bariatric surgery on the course of non-alcoholic fatty hepatopathy (NAFLD) are not fully understood. OBJECTIVE: To analyze the evolution of NAFLD characteristics through noninvasive markers after Roux-en-Y gastric bypass (RYGB) over a five-year period. DESIGN AND SETTING: Historical cohort study; tertiary-level university hospital. METHODS: The evolution of NAFLD-related characteristics was evaluated among 49 individuals who underwent RYGB, with a five-year follow-up. Steatosis was evaluated through the hepatic steatosis index (HSI), steatohepatitis through the clinical score for non-alcoholic steatohepatitis (C-NASH) and fibrosis through the NAFLD fibrosis score (NFS). RESULTS: 91.8% of the individuals were female. The mean age was 38.3 ± 10 years and average body mass index (BMI), 37.4 ± 2.3 kg/m2. HSI significantly decreased from 47.15 ± 4.27 to 36.03 ± 3.72 at 12 months (P < 0.01), without other significant changes up to 60 months. C-NASH significantly decreased from 0.75 ± 1.25 to 0.29 ± 0.7 at 12 months (P < 0.01), without other significant changes up to 60 months. NFS decreased from 1.14 ± 1.23 to 0.27 ± 0.99 at 12 months (P < 0.01), and then followed a slightly ascending course, with a marked increase by 60 months (0.82 ± 0.89), but still lower than at baseline (P < 0.05). HSI variation strongly correlated with the five-year percentage total weight loss (R = 0.8; P < 0.0001). CONCLUSION: RYGB led to significant improvement of steatosis, steatohepatitis and fibrosis after five years. Fibrosis was the most refractory abnormality, with a slightly ascending trend after two years. Steatosis improvement directly correlated with weight loss.

Pesquisa pré-operatória de infecção por Helicobater pylori em pacientes bariátricos: a análise histopatológica é necessária? / Pre-operative screening of helicobacter pylori in bariatric patients: is histopathological analysis necessary?

ABSTRACT Background: Helicobacter pylori infection has been reported to lead to post-operative complications after bariatric surgery (BS), especially marginal ulcers. The optimal method for pre-operative screening is yet to be determined. Objective: To analyze the diagnostic accuracy of the endoscopic urease test for the detection of H. pylori in individuals undergoing BS and the main endoscopic and histological changes within this population. Methods: A cross-sectional study was carried out based on a database from medical records of 232 individuals who underwent BS between 2016 and 2019 at a tertiary university hospital. Clinical, anthropometric, and endoscopic data were analyzed. The gold-standard method considered to calculate diagnostic accuracy variables was histopathological examination through hematoxylin-eosin/Giemsa stains. Results: 87.5% of the participants were female; mean age was 38.5±9.5 years and average body mass index was 37.6±3.8 kg/m2. The commonest endoscopic finding was gastritis (50.9%) with a predominance of the mild erosive form (25%). Upon histological examination, 59.1% of the participants had confirmed H. pylori infection. H. pylori infection was associated with higher frequencies of endoscopic duodenitis (23.4% vs 12.6%; P=0.04), histological chronic gastritis (100% vs 56.8%; P<0.0001) and histological acute gastritis (58.4% vs 2.1%; P<0.0001). The urease test had a sensitivity of 79.6% and a specificity of 97.9%, leading to an overall accuracy of 87.1%. Conclusion The endoscopic urease test is highly accurate for pre-operative screening of H. pylori infection in individuals who undergo BS. H. pylori infection was significantly associated with endoscopic (duodenitis) and histopathological (chronic and active gastritis) changes.

RESUMO Contexto: A infecção por Helicobacter pylori tem sido descrita como causa de complicações pós-operatórias após cirurgia bariátrica (CB), especialmente úlceras marginais. O método ideal para a triagem pré-operatória ainda não foi determinado. Objetivo: Analisar a acurácia diagnóstica do teste endoscópico de urease para detecção de H. pylori em indivíduos submetidos à CB e as principais alterações endoscópicas e histológicas observadas nessa população. Métodos: Foi realizado um estudo transversal a partir de um banco de dados de prontuários de 232 indivíduos submetidos à CB entre 2016 e 2019 em um hospital universitário terciário. Dados clínicos, antropométricos e endoscópicos foram analisados. Foi considerado como método padrão-ouro para calcular as variáveis de acurácia diagnóstica o exame histopatológico por colorações de hematoxilina-eosina e Giemsa. Resultados: 87,5% dos participantes eram do sexo feminino; a média de idade foi de 38,5±9,5 anos e o índice de massa corporal médio foi de 37,6±3,8 kg/m2. O achado endoscópico mais comum foi gastrite (50,9%) com predomínio da forma erosiva leve (25%). Ao exame histológico, 59,1% dos participantes apresentaram infecção confirmada por H. pylori. A infecção por H. pylori foi associada a maiores frequências de duodenite endoscópica (23,4% vs 12,6%; P=0,04), gastrite crônica histológica (100% vs 56,8%; P<0,0001) e gastrite aguda histológica (58,4% vs 2,1%; P<0,0001). O teste de urease teve sensibilidade de 79,6% e especificidade de 97,9%, levando à acurácia global de 87,1%. Conclusão: O teste endoscópico de urease tem alta acurácia para triagem pré-operatória da infecção por H. pylori em candidatos à CB. A infecção por H. pylori foi significativamente associada a alterações endoscópicas (duodenite) e histopatológicas (gastrite crônica e ativa).

A realização sistemática de biópsia hepática deveria ser considerada na prática cirúrgica bariátrica? Uma análise das limitações de marcadores não-invasivos de DHGNA / Should routine liver biopsy be considered in bariatric surgical practice? an analysis of the limitations of non-invasive nafld markers

ABSTRACT Background Non-invasive markers are useful and practical tools for assessing non-alcoholic fatty liver disease (NAFLD), but liver biopsy remains the gold-standard method. Liver biopsy can be easily obtained on individuals undergoing bariatric surgery, but there is no ultimate evidence on the relationship between costs, risks and benefits of its systematic performance. Objective To compare the diagnostic accuracy of non-invasive methods with liver biopsy for detection and staging of NAFLD in obese individuals undergoing bariatric surgery. Methods This is a cross-sectional, observational and descriptive study which enrolled individuals who underwent bariatric surgery from 2018 through 2019 at a public tertiary university hospital. Ultrasound scan, hepatic steatosis index, Clinical Non-Alcoholic Steatohepatitis Score (C-NASH), hypertension, alanine aminotransferase (ALT) and insulin resistance (HAIR), aspartate aminotransferase (AST) to Platelet Ratio Index (APRI), NAFLD Fibrosis Score (NFS) and body mass index, AST/ALT ratio, and diabetes (BARD) were the methods compared with the histopathological examination of wedge liver biopsies collected during surgery. Results Of 104 individuals analyzed, 91 (87.5%) were female. The mean age was 34.9±9.7 years. There was no biopsy-related morbidity. The respective overall accuracies of each marker analyzed were: ultrasound scan (79.81% for steatosis), hepatic steatosis index (79.81% for steatosis), HAIR (40.23% for steatohepatitis), C-NASH (22.99% for steatohepatitis), APRI (94.23% for advanced fibrosis), NFS (94.23% for advanced fibrosis), and BARD (16.35% for advanced fibrosis). Discussion Given the high prevalence of liver disease within this population, even the most accurate markers did not present enough discretionary power to detect and/or rule out the NAFLD aspects they were designed to assess in comparison with liver biopsy, which is safe and easy to obtain in these patients. Conclusion Wedge liver biopsy during bariatric surgery helps to diagnose and stage NAFLD, presents low risks and acceptable costs; given the limitations of non-invasive methods, it is justifiable and should be considered in bariatric routine.

RESUMO Contexto Marcadores não-invasivos são ferramentas úteis e práticas para avaliar a doença hepática gordurosa não alcoólica (DHGNA), porém, a biópsia hepática continua sendo o método padrão-ouro. A biópsia pode ser facilmente obtida em indivíduos submetidos à cirurgia bariátrica, mas não há evidências definitivas acerca da relação entre custos, riscos e benefícios de sua realização sistemática. Objetivo Comparar a acurácia diagnóstica de métodos não-invasivos com a biópsia hepática para detecção e estadiamento da DHGNA em obesos submetidos à cirurgia bariátrica. Métodos Trata-se de um estudo transversal, observacional e descritivo que envolveu indivíduos que se submeteram à cirurgia bariátrica de 2018 a 2019 em um hospital universitário público terciário. Ultrassonografia (US), índice de esteatose hepática (HSI), Escore Clínico de Esteato-hepatite Não-Alcoólica (C-NASH), Índice de Hipertensão, alanina aminotransferase (ALT) e resistência à insulina (HAIR), Razão entre aspartato aminotransferase (AST) e plaquetas (APRI), Escore de Fibrose da DHGNA (NFS) e índice de massa corporal (IMC), relação AST/ALT e diabetes (BARD) foram os métodos comparados com o exame histopatológico de biópsias hepáticas em cunha coletadas durante a cirurgia. Resultados De 104 indivíduos analisados, 91 (87,5%) eram do sexo feminino. A média de idade foi de 34,9±9,7 anos. Não houve morbidade relacionada à biópsia. As respectivas acurácias globais de cada marcador analisado foram: US (79,81% para esteatose), HSI (79,81% para esteatose), HAIR (40,23% para esteato-hepatite), C-NASH (22,99% para esteato-hepatite), APRI (94,23% para fibrose avançada), NFS (94,23% para fibrose avançada) e BARD (16,35% para fibrose avançada). Discussão: Considerando a alta prevalência de doença hepática nesta população, mesmo os mais acurados destes marcadores não apresentaram poder discricionário suficiente para detectar e/ou descartar os aspectos da DHGNA que foram desenvolvidos para avaliar em comparação com a biópsia hepática, que é segura e de fácil obtenção nestes pacientes. Conclusão A biópsia hepática em cunha durante a cirurgia bariátrica auxilia no diagnóstico e estadiamento da DHGNA, apresenta baixo risco e custos aceitáveis e, dadas as limitações dos métodos não-invasivos, é justificável e deve ser considerada na rotina bariátrica.

Evolution of anthropometric data and quality of life in active bariatric individuals

SUMMARY Obesity is a disease characterized by the accumulation of abnormal or excessive fat that can damage health. Bariatric surgery, an effective and safe way to treat this disease, requires multidisciplinary monitoring with an educational nature to change lifestyle. Adherence to routine physical activity can be a part of adopting a healthier lifestyle and can assist in the treatment of this disease and its related comorbidities. OBJECTIVE: Thus, the aim of this study was to analyze the correlation between the evolution of anthropometric variables and the domains of quality of life at different times, including at one year after bariatric surgery in very active and irregularly active individuals. METHODS: This was a longitudinal, observational, prospective, and analytical study. The collected data included anamnesis, level of physical activity (International Physical Activity Questionnaire Short Form), height, weight, body mass index (BMI), average waist circumference, percentage of fat, and the World Health Organization Quality of Life Assessment Bref. RESULTS: Seven female individuals were evaluated and divided into two groups: a very active group and an irregularly active group. In the very active individuals, significant results were found in the evolutionary variables: weight (p<0.001); body mass index (p<0.001); average waist circumference (p<0.001); percentage of fat (p<0.001); and quality of life general (p=0.001). In the irregularly active individuals, a significant result was found only in one evolutionary variable: body mass index (p<0.001). CONCLUSION: Thus, it is evident that the improvement and maintenance of good health is more effective in bariatric individuals who maintain a routine with regular physical activity.

Effect of transient obstructive cholestasis on liver histology: a cross-sectional study

ABSTRACT BACKGROUND: The role of transient obstructive cholestasis on liver histology remains undetermined. OBJECTIVE: To investigate whether transient cholestasis impairs liver histology. DESIGN AND SETTING: Cross-sectional study at a public university hospital (UNICAMP), Brazil. METHODS: 169 individuals undergoing cholecystectomy, with or without cholestasis. were enrolled. Histopathological findings were correlated with clinical and biochemical characteristics. RESULTS: Biliary hepatopathy was more frequent in individuals with resolved cholestasis than in those with active obstruction or no jaundice (P < 0.01), as also were fibrosis and ductular proliferation (P = 0.02). Cholestasis was commoner in individuals with resolved obstruction than in those with no history (P < 0.01) or active cholestasis (P < 0.05). Biliary hepatopathy was associated with longer duration of cholestasis (P < 0.001) and higher bilirubin levels (P = 0.02) in individuals with active obstruction; with lower body mass index (P = 0.02) and longer cholestasis (P < 0.001) in individuals with resolved obstruction; and with longer cholestasis (P < 0.001) and longer interval between endoscopic retrograde cholangiopancreatography and surgery (P = 0.03) overall. In individuals with active obstruction, duration of cholestasis (R = 0.7; P < 0.001) and bilirubin levels (R = 0.6; P = 0.004) were independently correlated with cholestasis severity. Duration of cholestasis (R = 0.7; P < 0.001) was independently correlated with ductular proliferation severity. CONCLUSIONS: Transient cholestasis was associated with significant histopathological changes, even after its resolution. Longer duration of obstruction correlated with greater severity of histopathological changes, especially cholestasis and ductular proliferation. This emphasizes the need for early treatment of obstructive cholestasis.

Is there a link between non-alcoholic fatty liver disease aspects and pancreatic cancer? Results of a case-matched study / Existe ligação entre a doença hepática gordurosa não alcoólica e o câncer de pâncreas? Resultados de estudo caso-controle

ABSTRACT Background and Aims: An association between non-alcoholic fatty liver disease (NAFLD) and pancreatic ductal adenocarcinoma (PDAC) has been previously suggested. This study aims at investigating this association and at identifying potential links between variables of the NAFLD spectrum and PDAC. Methods: A cross-sectional case-matched analytical and comparative study was carried out to analyze patients undergoing surgical resection of PDAC and compare them to a control group of individuals undergoing cholecystectomy at a public tertiary teaching hospital, matched by sex, age and BMI. Hepatic histopathological examinations were compared between cases and controls. Results: Of 56 individuals, 36 were male (64.3%) and the median age was 61.5 years old (interquartile range: 57.5 - 70). The participants' median BMI was 24.3 kg/m2 (interquartile range: 22.1-26.2 kg/m2). Microvesicular steatosis (p=0.04), hepatocellular ballooning (p=0.02), fibrosis (p=0.0003) and steatohepatitis (p=0.03) were significantly more frequent in the group of cases. Odds ratios for hepatocellular ballooning (6.2; 95%CI: 1.2-31.8; p=0.03), fibrosis (9.3; 95%CI: 2.5-34.1; p=0.0008) and steatohepatitis (3.9; 95%CI: 1.1-14.3; p=0.04) were statistically significant in relation to the PDAC prevalence. Conclusions: Significant associations were identified between histopathological aspects of NAFLD (microvesicular steatosis, hepatocellular ballooning, fibrosis, and steatohepatitis) and PDAC.

RESUMO Histórico e objetivos: a associação entre a doença hepática gordurosa não alcoólica (DHGNA) e o adenocarcinoma ductal pancreático (ACDP) foi sugerida anteriormente. Este estudo visa investigar esta associação e identificar possíveis ligações entre as variáveis do espectro da DHGNA e o ACDP. Métodos: foi realizado estudo transversal caso-controle analítico e comparativo para analisar pacientes submetidos a ressecção cirúrgica de ACDP e compará-los a grupo controle de indivíduos submetidos a colecistectomia em hospital público terciário de ensino, pareados por sexo, idade e IMC. Os exames histopatológicos hepáticos foram comparados entre casos e controles. Resultados: dos 56 indivíduos, 36 eram do sexo masculino (64,3%) e a idade mediana era de 61,5 anos de idade (intervalo interquartil 57,5-70). A mediana do IMC dos participantes foi de 24,3 kg/m2 (intervalo interquartil 22,1 26,2). Esteatose microvesicular (p = 0,04), balonização hepatocelular (p = 0,02), fibrose (p = 0,0003) e esteato-hepatite (p = 0,03) foram significativamente mais frequentes no grupo de casos. As razões de chances para balonização hepatocelular (6,2; IC 95%: 1,2 - 31,8; p = 0,03), fibrose (9,3; IC 95%: 2,5 - 34,1; p = 0,0008) e esteato-hepatite (3,9; IC 95%: 1,1 - 14,3; p = 0,04) foram estatisticamente significativas em relação à prevalência de ACDP. Conclusões: houve associações significativas entre aspectos histopatológicos de DHGNA (esteatose microvesicular, balonização hepatocelular, fibrose e esteato-hepatite) e a ocorrência de ACDP.

Revisional surgery in severe nutritional complications after bariatric surgical procedures: report of four cases from a single institution and review of the literature / Cirurgia revisional em complicações nutricionais graves após cirurgia bariátrica: relato de 4 casos de uma única instituição e revisão da literatura

ABSTRACT Introduction: bariatric surgery is currently the only treatment that leads to long-term and sustained weight loss and decreased morbidity and mortality in morbidly obese individuals. Roux-en-Y bypass causes weight loss by restricting food intake associated with reduced intestinal absorption, in addition to multiple endocrine and satiogenic effects. Biliopancreatic diversion promotes weight loss mainly due to poor absorption of the nutrients ingested. Both procedures exclude parts of the gastrointestinal tract. Objective: to describe four cases of revisional surgery after primary bariatric surgery, due to serious nutritional complications, and to review the literature regarding this subject. Methods: a retrospective analysis of patients of Unicamps bariatric center database and review of the literatures were performed. Results: four patients were identified, 2 women and 2 men, with a mean age of 48 years. The mean body mass index before revisional surgery was 23.7 kg/m2. Three patients underwent Scopinaro biliopancreatic diversion, and onde patient underwent Roux-en-Y gastric bypass. The revisional surgeries were revision, conversion, and reversion. One patient died. For the review of the literature 12 articles remained (11 case reports and 1 case series). Another five important original articles were included. Conclusion: fortunately, revision surgery is rarely necessary, but when indicated it has increased morbidity, It can be revision, reverion or conversion according to the severity of the patient and the primary surgery performed.

RESUMO Introdução: atualmente, a cirurgia bariátrica é o único tratamento que leva à perda de peso prolongada e sustentada e diminuição da morbimortalidade em indivíduos obesos mórbidos. O bypass em Y-de-Roux causa perda de peso restringindo a ingestão de alimentos associada à redução da absorção intestinal, além de múltiplos efeitos endócrinos e sacietógenos. O desvio biliopancreático promove a perda de peso principalmente devido à diminuição da absorção dos nutrientes ingeridos. Ambos os procedimentos excluem partes do trato gastrointestinal. Objetivo: descrever 4 casos de cirurgia revisional após cirurgia bariátrica primária, devido a graves complicações nutricionais, bem como realizar uma revisão da literatura sobre esse assunto. Métodos: foi realizada uma análise retrospectiva dos pacientes do banco de dados do serviço de cirurgia bariátrica da Unicamp e revisão da literatura. Resultados: foram identificados 4 pacientes, 2 mulheres e 2 homens, com média de idade de 48 anos, o IMC antes da cirurgia revisional eram em média 23,7. Os pacientes haviam sido submetidos em 3 casos a cirurgia de Scopinaro e 1 caso ao bypass gástrico em Y-de-Roux. As cirurgias revisionais foram de revisão, conversão e reversão. Um paciente evoluiu a óbito. Em relação a revisão da literatura, foram selecionados 12 artigos (11 relatos de casos e 1 série de casos). Outros cinco artigos originais importantes foram incluídos. Conclusão: felizmente, a cirurgia revisional raramente é necessária, mas, quando indicada, apresenta alta morbidade. São cirurgias de revisão, reversão ou conversão, de acordo com a gravidade do paciente e a cirurgia primária realizada.

Ondas de choque eletromagnéticas na Dermatologia: análise microscópica de sua interação com a possível redução do tecido adiposo em indivíduos obesos / Electromagnetic shock wave therapy in dermatology: Microscopic analysis of its interaction with the possible reduction of adipose tissue in obese individuals

Introdução: a obesidade é uma doença que afeta a saúde pública em nível mundial devido a suas comorbidades e ao risco de morte prematura. Diante disso, a tecnologia de terapia de ondas de choque extracorpóreas (ESWT) pode ser útil em seu tratamento e na prevenção de suas comorbidades. Objetivos: o objetivo foi avaliar se a ESWT é capaz de estimular a lipólise e/ou apoptose da célula adiposa de indivíduos obesos. Métodos: trata-se de um estudo comparativo de intervenção baseado em análises imuno- -histoquímicas de um conjunto de amostras de tecido subcutâneo de mulheres com obesidade, submetidas ao tratamento ESWT. O material biológico foi coletado no momento da cirurgia bariátrica. Resultados: 14 mulheres obesas foram incluídas na pesquisa. Foi evidenciada positividade na expressão de Casp3 (p<0,0001), cCasp3 (p<0,0024), macrófagos CD68+ (p<0,0001), HSL (p<0,0001) e adipofilina (p<0,0013) na amostra intervenção quando comparada ao controle. Conclusões: a ESWT estimula a apoptose com consequente lipólise do tipo autofágica no tecido adiposo de mulheres obesas. Assim, a ESWT pode ser considerada uma terapia adjuvante útil, segura e promissora para redução do tecido adiposo e, consequentemente, para prevenção e/ou tratamento de obesidade

Introduction: Obesity is a disease that affects public health worldwide due to its comorbidities and premature death risk. Therefore, extracorporeal shock wave therapy (ESWT) technology can help treat and prevent its comorbidities. Objective: This study aims to assess whether ESWT can stimulate lipolysis and/or apoptosis of the fat cells of obese individuals. Methods: This is a comparative interventional study based on immunohistochemical analyzes of a set of subcutaneous tissue samples from women with obesity submitted to ESWT treatment. The biological material was collected at the time of bariatric surgery. Results: The survey included 14 obese women. Positivity was shown in the expression of Casp3 (p<0.0001), cCasp3 (p<0.0024), CD68+ macrophages (p<0.0001), HSL (p<0.0001), and adipophilin (p<0.0013) in the intervention sample compared to the control. Conclusions: We conclude that ESWT stimulates apoptosis with consequent autophagic lipolysis in the adipose tissue of obese women. Thus, ESWT can be considered useful, safe, and promising adjuvant therapy for reducing adipose tissue and, consequently, for preventing and/or treating obesity.

Tubulovillous adenoma of the duodenal papilla: radiological-endoscopic and anatomopathological correlation in the surgical proposal

SUMMARY Tubulovillous adenomas of the duodenal ampulla are rare neoplasms. The present report describes a case with radiological-endoscopic and pathological correlation in which the patient underwent duodenal pancreatectomy with good postoperative progression. With advanced imaging methods, especially magnetic resonance and endoscopic ultrasound, locoregional aspects and extraluminal, lymphovascular, and metastatic invasion have been increasingly discussed as contributors to therapeutic decision making. This progression improves lesion staging and is especially useful in selecting eligible candidates for endoscopic treatment.

RESUMO Os adenomas túbulo-vilosos da ampola duodenal são neoplasias raras. Neste trabalho apresentamos um caso com correlação radiológico-endoscópica e patológica, tendo a paciente sido submetida à duodenopancreatectomia com boa evolução pós-operatória. Com os avanços dos métodos de imagem, em especial da ressonância magnética e ultrassonografia endoscópica, aspectos locorregionais, além da invasão extraluminal, linfovascular e metastática, têm sido discutidos de maneira crescente como contribuintes na decisão terapêutica. Essa evolução contribui para o melhor estadiamento destas lesões e é especialmente útil para selecionar candidatos elegíveis ao tratamento endoscópico.

Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study

ABSTRACT BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

Duodenopancreatectomia com ressecção venosa: análise de morbidade e mortalidade em 30 dias / Pancreaticoduodenectomy with venous resection: an analysis of 30-day morbidity and mortality

ABSTRACT BACKGROUND: Pancreaticoduodenectomy (PD) with the resection of venous structures adjacent to the pancreatic head, even in cases of extensive invasion, has been practiced in recent years, but its perioperative morbidity and mortality are not completely determined. OBJECTIVE: To describe the perioperative outcomes of PD with venous resections performed at a tertiary university hospital. METHODS: A retrospective study was conducted, classified as a historical cohort, enrolling 39 individuals which underwent PD with venous resection from 2000 through 2016. Preoperative demographic, clinical and anthropometric variables were assessed and the main outcomes studied were 30-day morbidity and mortality. RESULTS: The median age was 62.5 years (IQ 54-68); 55% were male. The main etiology identified was ductal adenocarcinoma of the pancreas (82.1%). In 51.3% of cases, the portal vein was resected; in 35.9%, the superior mesenteric vein was resected and in the other 12.8%, the splenomesenteric junction. Regarding the complications, 48.7% of the patients presented some type of morbidity in 30 days. None of the variables analyzed was associated with higher morbidity. Perioperative mortality was 15.4% (six patients). The group of individuals who died within 30 days presented significantly higher values for both ASA (P=0.003) and ECOG (P=0.001) scores. CONCLUSION: PD with venous resection for advanced pancreatic neoplasms is a feasible procedure, but associated with high rates of morbidity and mortality; higher ASA e ECOG scores were significantly associated with a higher 30-day mortality.

RESUMO CONTEXTO: A duodenopancreatectomia (DP) com ressecção de estruturas venosas adjacentes à cabeça do pâncreas, mesmo em casos de invasão extensa, tem sido praticada nos últimos anos, mas sua morbidade e mortalidade perioperatórias não são completamente determinadas. OBJETIVO: Descrever os resultados perioperatórios de DP com ressecções venosas realizadas em um hospital terciário universitário. MÉTODOS: Foi realizado estudo retrospectivo, classificado como coorte histórica, envolvendo 39 indivíduos submetidos à DP com ressecção venosa entre 2000 e 2016. Foram estudadas variáveis demográficas, clínicas e antropométricas pré-operatórias e os desfechos principais foram a morbidade e mortalidade em 30 dias. RESULTADOS: A mediana de idade foi 62,5 anos (IQ 54-68), sendo 55% dos indivíduos do sexo masculino. A principal etiologia identificada foi o adenocarcinoma ductal de pâncreas (82,1%). Em 51,3% dos casos, a veia porta foi submetida à ressecção; em 35,9%, a veia mesentérica superior foi ressecada e nos outros 12,8%, a junção esplenomesentérica. Em relação às complicações, 48,7% dos pacientes apresentaram algum tipo de morbidade em 30 dias. Nenhuma das variáveis analisadas associou-se à maior morbidade. A mortalidade perioperatória foi 15,4% (seis pacientes). O grupo de indivíduos que cursou com mortalidade em 30 dias apresentou escores significativamente mais altos de ASA (P=0,003) e ECOG (P=0,001). CONCLUSÃO: A DP com ressecção venosa para neoplasias avançadas do pâncreas é um procedimento factível, porém que se acompanha de altos índices de morbidade e mortalidade; escores de ASA e ECOG altos são fatores significativamente associados à maior mortalidade.

Respiratory evaluation through volumetric capnography among grade III obese and eutrophic individuals: a comparative study

ABSTRACT BACKGROUND: Excess trunk body fat in obese individuals influences respiratory physiological function. The aims of this study were to compare volumetric capnography findings (VCap) between severely obese patients and normal-weight subjects and to assess whether there is any association between neck circumference (NC), waist-hip ratio (WHR) and VCap among grade III obese individuals. DESIGN AND SETTING: Analytical observational case-matched cross-sectional study, University of Campinas. METHODS: This cross-sectional study compared VCap variables between 60 stage III obese patients and 60 normal-weight individuals. RESULTS: In comparison with the normal-weight group, obese patients presented higher alveolar minute volume (8.92 ± 4.94 versus 6.09 ± 2.2; P = < 0.0001), CO2 production (278 ± 91.0 versus 209 ± 60.23; P < 0.0001), expiratory tidal volume (807 ± 365 versus 624 ± 202; P = 0.005), CO2 production per breath (21.1 ± 9.7 versus 16.7 ± 6.16; P = 0.010) and peak expiratory flow (30.9 ± 11.9 versus 25.5 ± 9.13; P = 0.004). The end-expiratory CO2 (PetCO2) concentration (33.5 ± 4.88 versus 35.9 ± 3.79; P = 0.013) and the phase 3 slope were normalized according to expired tidal volume (0.02 ± 0.05 versus 0.03 ± 0.01; P = 0.049) were lower in the obese group. CONCLUSIONS: The greater the NC was, the larger were the alveolar minute volume, anatomical dead space, CO2 production per minute and per breath and expiratory volume; whereas the smaller were the phase 2 slope (P2Slp), phase 3 slope (P3Slp) and pressure drop in the mouth during inspiration.

Efeitos precoces do bypass gástrico de anastomose única com e sem anel sobre a perda de peso e o metabolismo glicêmico: um estudo prospectivo randomizado / Early weight loss outcomes and glucose metabolism parameters after banded versus non-banded one anastomosis gastric bypass: a prospective randomized trial

ABSTRACT BACKGROUND: The influence of the placement of a band on the outcomes of one anastomosis gastric bypass (OAGB) has not been appropriately studied yet. OBJECTIVE: To compare early weight loss and glucose metabolism parameters following banded versus non-banded OAGB. METHODS: A prospective randomized study, which evaluated 20 morbidly obese individuals who underwent banded and non-banded OAGB and were followed-up for three months. Weight loss (percentage of excess weight loss - %EWL and percentage of body mass index loss - %BMIL) and glucose metabolism outcomes (glucose, insulin and homeostasis model assessment - HOMA) were compared. RESULTS: The banded group presented a significantly higher %EWL at one month (29.6±5.5% vs 17.2±3.4%; P<0.0001) and two months post-surgery (46±7% vs 34.2±9%; P=0.004544), as well as a significantly higher %BMIL at one month (9.7±1.1% vs 5.8±0.8%; P<0.0001), two months (15±1.4% vs 11.5±2.1; P=0.000248), and three months (18.8±1.8% vs 15.7±3.2%; P=0.016637). At three months, banded OAGB led to significant decreases of insulin (14.4±4.3 vs 7.6±1.9; P=0.00044) and HOMA (3.1±1.1 vs 1.5±0.4; P=0.00044), whereas non-banded OAGB also led to significant decreases of insulin (14.8±7.6 vs 7.8±3.1; P=0.006) and HOMA (3.2±1.9 vs 1.6±0.8; P=0.0041). The percent variation of HOMA did not significantly differ between banded and non-banded OAGB (P=0.62414); overall, the percent variation of HOMA was not correlated with %EWL (P=0.96988) or %BMIL (P=0.82299). CONCLUSION: Banded OAGB led to a higher early weight loss than the standard technique. Banded and non-banded OAGB led to improvements in insulin resistance regardless of weight loss.

RESUMO CONTEXTO: A influência da colocação de bandas sobre os resultados do bypass gástrico de anastomose única (BGAU) não foi profundamente estudada. OBJETIVO: Comparar a perda precoce de peso e os parâmetros do metabolismo da glicose após bypass gástrico de anastomose única (BGAU) com e sem anel. MÉTODOS: Estudo prospectivo randomizado que avaliou 20 obesos mórbidos submetidos ao BGAU com e sem anel e acompanhados por três meses. A perda de peso (percentual de perda do excesso de peso - %PEP e percentual de perda de peso - %PP) e parâmetros do metabolismo da glicose (glicemia, insulina e modelo homeostático de avaliação - HOMA) foram comparados. RESULTADOS: O grupo com anel apresentou %PEP significativamente maior em um mês (29,6±5,5% vs 17,2±3,4%; P<0,0001) e dois meses após a cirurgia (46±7% vs 34,2±9%; P=0,004544), bem como %PP significativamente maior em um mês (9,7±1,1% vs 5,8±0,8%; P<0,0001), dois meses (15±1,4% vs 11,5±2,1; P=0,000248) e três meses (18,8±1,8% vs 15,7±3,2%; P=0,016637). Aos três meses, o BGAU com anel resultou em reduções significativas de insulina (14,4±4,3 vs 7,6±1,9; P=0,00044) e HOMA (3,1±1,1 vs 1,5±0,4; P=0,00044), enquanto o BGAU sem anel também levou a reduções significativas de insulina (14,8±7,6 vs 7,8±3,1; P=0,006) e HOMA (3,2±1,9 vs 1,6±0,8; P=0,0041). A variação percentual de HOMA não diferiu significativamente entre BGAU com bandas ou sem anel (P=0,62414); no geral, a variação percentual do HOMA não foi correlacionada com %PEP (P=0,96988) ou %PP (P=0,82299). CONCLUSÃO: O BGAU com anel levou a uma maior perda de peso precoce do que a técnica padrão. O BGAU com ou sem anel levou à melhora precoce na resistência à insulina, independentemente da perda de peso.

Pancreaticoduodenectomy: impact of the technique on operative outcomes and surgical mortality / Duodenopancreatectomia: impacto da técnica nos resultados operatórios e mortalidade cirúrgica

ABSTRACT Background: Pancreaticoduodenectomy (PD) is a procedure associated with significant morbidity and mortality. Initially described as gastropancreaticoduodenectomy (GPD), the possibility of preservation of the gastric antrum and pylorus was described in the 1970s. Aim: To evaluate the mortality and operative variables of PD with or without pyloric preservation and to correlate them with the adopted technique and surgical indication. Method: Retrospective cohort on data analysis of medical records of individuals who underwent PD from 2012 through 2017. Demographic, anthropometric and operative variables were analyzed and correlated with the adopted technique (GPD vs. PD) and the surgical indication. Results: Of the 87 individuals evaluated, 38 (43.7%) underwent GPD and 49 (53.3%) were submitted to PD. The frequency of GPD (62.5%) was significantly higher among patients with pancreatic neoplasia (p=0.04). The hospital stay was significantly shorter among the individuals submitted to resection due to neoplasias of less aggressive behavior (p=0.04). Surgical mortality was 10.3%, with no difference between GPD and PD. Mortality was significantly higher among individuals undergoing resection for chronic pancreatitis (p=0.001). Conclusion: There were no differences in mortality, surgical time, bleeding or hospitalization time between GPD and PD. Pancreas head neoplasm was associated with a higher indication of GPD. Resection of less aggressive neoplasms was associated with lower morbidity and mortality.

RESUMO Racional : A duodenopancreatectomia (DP) é procedimento associado com significativa morbimortalidade. Inicialmente descrita como gastroduodenopancreatectomia (GDP), a possibilidade de preservação do antro gástrico e piloro foi descrita na década de 1970. Objetivo : Avaliar a mortalidade e variáveis operatórias da DP com ou sem preservação pilórica e correlacioná-las com a técnica adotada e indicação cirúrgica. Método: Estudo de coorte histórica, baseado em análise de dados de registros médicos de indivíduos submetidos à DP entre os anos de 2012 a 2017. Foram analisadas variáveis demográficas, antropométricas e operatórias e correlacionadas com a técnica adotada (GDP vs. DP) e a indicação cirúrgica. Resultados : Dos 87 indivíduos avaliados, 38 (43,7%) foram submetidos à GDP e 49 (53,3%) à DP. A frequência de realização da GDP (62,5%) foi significativamente maior entre os pacientes com neoplasia de pâncreas (p=0,04). O tempo de internação total foi significativamente menor entre os indivíduos submetidos à ressecção por neoplasias de comportamento menos agressivo (p=0,04). A mortalidade cirúrgica foi de 10,3%, não havendo diferença entre GDP e DP. A mortalidade foi significativamente maior entre os indivíduos submetidos à ressecção por pancreatite crônica (p=0,001). Conclusão : Não houve diferenças na morbimortalidade, tempo cirúrgico, sangramento ou tempo de internação entre GDP e DP. A neoplasia de cabeça de pâncreas associou-se mais com indicação de GDP. A ressecção de neoplasias menos agressivas associou-se a menor morbimortalidade.

Tratamento cirúrgico de lesões císticas do pâncreas: uma experiência unicêntrica / Surgical management of cystic lesions of the pancreas: a single-centre experience

ABSTRACT BACKGROUND: Cystic lesions of the pancreas represent a group of pancreatic diseases with great histological heterogeneity, varying from benign lesions, some of them with malignant potential, to overt malignant lesions. OBJECTIVE: To describe the cases of cystic lesions of the pancreas which underwent surgical intervention at a tertiary university hospital. METHODS: This is a retrospective population-based study (historical cohort) which was carried out enrolling individuals attended at the Outpatient service of Pancreas Surgery of the Hospital de Clínicas of Unicamp. The individuals underwent surgical procedures performed from January 2012 through December 2016. RESULTS: In the period evaluated, 39 cases of cystic lesions of the pancreas which underwent surgery were identified, 26 (66.6%) of which were female. The average age at diagnosis was 47.4±16.4 years (range, 18-73). In regards to symptoms, 35 (89.7%) were symptomatic. The average length of hospital stay was 10 days (range 4-76). Surgeries performed to treat the lesions depended on the localization and type of the lesions: cystojejunostomy (41%), distal pancreatectomy (36%), pancreaticoduodenectomy (15.4%), drainage of ruptured and/or infected pseudocyst (5.2%) and central pancreatectomy (2.6%). CONCLUSION: Cystic lesions of the pancreas are a group of lesions with a highly varying presentation and diagnostic approach and may require an also highly variable surgical treatment. An appropriate preoperative imaging diagnosis is essential for their management.

RESUMO CONTEXTO: As lesões císticas do pâncreas representam um grupo de doenças pancreáticas com grande heterogeneidade histológica, variando desde lesões benignas, algumas com potencial pré-maligno, até outras degeneradas para formas malignas. OBJETIVO: Descrever os casos de LCPs submetidos à intervenção cirúrgica em um hospital universitário terciário. MÉTODOS: Trata-se de um estudo retrospectivo populacional (coorte histórica) realizado com a participação de indivíduos atendidos no Ambulatório de Cirurgia do Pâncreas do Hospital de Clínicas da Unicamp. Os indivíduos foram submetidos a procedimentos cirúrgicos realizados no período de janeiro de 2012 a dezembro de 2016. RESULTADOS: No período avaliado, foram identificados 39 casos de lesões císticas do pâncreas operados, sendo 26 (66,6%) do sexo feminino. A idade média no diagnóstico foi de 47,4±16,4 anos. Em relação aos sintomas, 35 (89,7%) eram sintomáticos. O tempo médio de internação foi de 10 dias (variação de 4-76). As cirurgias realizadas para o tratamento das lesões dependeram da localização e do tipo das lesões: derivação pseudocisto-jejunal (41%), pancreatectomia distal (36%), pancreaticoduodenectomia (15,4%), drenagem de pseudocistos rotos e/ou infectados (5,2%) e pancreatectomia central (2,6%). CONCLUSÃO: As lesões císticas do pâncreas são um grupo de lesões cuja apresentação e abordagem diagnóstica são altamente heterogêneas e que podem requerer um tratamento cirúrgico altamente complexo e variável. Um diagnóstico pré-operatório adequado é essencial para definir o seu tratamento.