Nutrición perioperatoria en protocolos quirúrgicos para una mejor recuperación postoperatoria (Protocolo ERAS) / Perioperative nutrition in ERAS Protocols

The trauma involved in any surgical procedure, even if elective, causes a metabolic stress response characterized by postoperative insulin resistance (PIR). PIR is considered a surgical stress marker and is associated with increased morbidity and postoperative length of stay. PIR worsens when the patient is operated in a state of prolonged preoperative fasting or when postoperative feeding is delayed. The ERAS Protocols (Enhanced Recovery After Surgery) includes anesthetic, surgical, kinesiology, nutritional and nursing interventions aimed to modulate PIR. The nutritional perioperative interventions in the ERAS protocols, focus on avoiding prolonged preoperative fasting by oral carbohydrate loading up to two hours before surgery, accompanied by early postoperative feeding through the digestive tube. These nutritional perioperative interventions are safe and effective to reduce complications and postoperative stay, even in patients with well controlled type 2 diabetes. Nevertheless, their implementation and compliance are rather low, therefore, we must continue to make efforts in order to change perioperative nutritional management of our patients to achieve the best possible postoperative recovery.

Seguimiento y manejo de las complicaciones médicas tardías del obeso operado / Follow-up and treatment of late medical complications after bariatric surgery

Bariatric surgery is an effective treatment to reduce obesity by means of procedures aimed at restricting food intake and /or malabsorption. All procedures cause anatomic and functional changes that alter digestive physiology and reduce macro and micronutrients bioavailability. In the long run, surgical, metabolic and nutritional complications might occur. Anemia, vitamins and minerals deficiency are more frequent with malabsorption techniques, but they may also occur with restrictive techniques. Vitamin deficiency can cause neurological, hematologic and bone disorders, some of them with severe clinical manifestation. After bariatric surgery it is recommended to prescribe specific nutritional supplements and control patients periodically for prevention, early diagnosis and treatment of any complications.

La cirugía bariátrica es un efectivo tratamiento para reducir la obesidad mediante técnicas que sólo restringen la ingesta de alimentos y otras que además disminuyen la absorción intestinal. Todos los procedimientos causan cambios anatómicos y funcionales que alteran la fisiología digestiva y disminuyen la biodisponibilidad de macro y micronutrientes. En el largo plazo, pueden ocurrir complicaciones quirúrgicas, metabólicas y nutricionales, entre las que destacan anemia, deficiencia de vitaminas y minerales que son más frecuentes con las técnicas de mala absorción, pero también pueden ocurrir con técnicas restrictivas. La deficiencia de vitaminas produce alteraciones neurológicas, hematológicas y óseas que en algunos casos pueden ser severas. Después de la cirugía bariátrica se recomienda la administración de suplementos nutricionales específicos y controlar periódicamente a los pacientes para prevención, diagnóstico y tratamiento precoz de eventuales complicaciones.

Hiperobesidad y obesidad mórbida: estudio comparativo / Hiperobesity v/s morbid obesity: a comparative study

Introduction: Bariatric surgery is effective and safe in treating obese patients with BMI > 40, however, higher preoperative weight could increases morbidity and mortality. Aim: To describe and compare the perioperative and mid term outcomes between hiperobese and morbidly obese patients submitted to gastric bypass. Material and Method: A prospective study of hiperobese patients submitted to gastric bypass over the past 10 years. We analyzed clinical characteristics, perioperative morbimortality and resolution of comor-bidities. The results were compared with a group of morbidly obese patients matched by age and sex. Results: 146 hiperobese were operated and compared with 165 morbidly obese patients. 66.8 percent were female and the average age of the total group was 39.9 +/- 12.4 years, with no significant differences between groups by sex and age. The average BMI was 53 and 44.4 respectively. 21.5 percent had diabetes mellitus 2, 39.5 percent hypertension, 31 percent dislipidemia and 8.4 percent osteoarthritis, with no significant differences between groups except for a higher prevalence of dyslipidemia in the morbidly obeses (p = 0.001). 10.4 percent had surgical complications during the postoperative period, with no differences between both groups (p = 0.24). One year later all patients had a significant decrease in weight, however, hiperobeses showed a more pronounced decrease (p = 0.001). The fasting glucose, cholesterol and triglycerides levels also showed a significant decrease without reaching differences between the groups. Conclusions: The gastric bypass is effective in achieving weight loss and resolution of comorbidities in morbidly obese as well as hiperobese patients, with no significant differences in surgical complications and mortality.

Introducción: La cirugía bariátrica es efectiva y segura en el tratamiento de obesos con IMC > 40, sin embargo, a mayor peso preoperatorio podría aumentar la morbimortalidad. Objetivo: Describir y comparar los resultados perioperatorios y a mediano plazo entre hiperobesos y obesos mórbidos sometidos a bypass gástrico. Material y Método: Estudio prospectivo de pacientes hiperobesos operados de bypass gástrico los últimos 10 años. Se analizaron características clínicas, morbimortalidad perioperatoria y resolución de comorbilidades. Se compararon los resultados con un grupo de obesos mórbidos pareados por edad y sexo. Resultados: Se operaron 146 hiperobesos, que fueron comparados con 165 obesos mórbidos. El 66,8 por ciento fueron mujeres y el promedio de edad fue 39,9 +/- 12,4 años, no encontramos diferencias significativas entre ambos grupos por sexo y edad. El IMC promedio fue 53 y 44,4 respectivamente. El 21,5 por ciento tenía diabetes mellitus 2, el 39,5 por ciento hipertensión arterial, el 31 por ciento dislipidemia y el 8,4 por ciento artrosis, sin encontrar diferencias significativas, a excepción de una mayor prevalencia de dislipidemia en los obesos mórbidos (p = 0,001). Un 10,4 por ciento presentó complicaciones quirúrgicas durante el postoperatorio, no existiendo diferencias entre ambos grupos (p = 0,24). Al año todos los pacientes presentaban un descenso significativo del peso, sin embargo, los hiperobesos presentaban un descenso más acentuado (p = 0,001). Los niveles de glicemia en ayunas, colesterol y triglicéridos también presentaron un descenso significativo sin lograr diferencias entre ambos grupos. Conclusiones: El bypass gástrico es efectivo en la baja de peso y resolución de comorbilidades tanto en obesos mórbidos como hiperobesos, sin presentar diferencias significativas en las complicaciones quirúrgicas y mortalidad.

Cirugía para la obesidad: efectos generales, beneficios y riesgos / Obesity surgery: general effects, benefits and risks

El paciente obeso es difícil de tratar. La cirugía para la obesidad en pocos meses logra disminuir más del 20 por ciento del peso corporal. Las técnicas quirúrgicas actúan restringiendo la capacidad gástrica y/o produciendo malabsorción parcial de los alimentos. Todas han demostrado ser eficaces para el tratamiento de la obesidad y mejorar sus comorbilidades asociadas, destacando el alto porcentaje de remisión de la diabetes tipo 2, especialmente con las técnicas malabsortivas. El banding gástrico tienen la menor tasa de remisión de diabetes tipo2. La mayoría de los beneficios de la cirugía persisten más de 10 años, lo que ha permitido observar disminución del riesgo de aparición de enfermedades del ámbito metabólico, reducción del riesgo cardiovascular y de la mortalidad general de obesos mórbidos operados. Actualmente, las técnicas quirúrgicas más frecuentes son el bypass gástrico y la gastrectomía vertical (manga gástrica). La cirugía bariátrica tiene baja tasa de morbimortalidad en centros quirúrgicos expertos, sin embargo se pueden producir complicaciones nutricionales que se deben prevenir o tratar precozmente. La participación de un equipo multidisciplinario con expertos en nutrición, salud mental y actividad física aumenta las posibilidades de lograr una mejor reducción y mantención del peso, ya que con todas las técnicas se puede producir reganancia de peso en el largo plazo.

The obese patient is difficult to treat. Obesity surgery in a few months can accomplish more than 20 percent decrease in body weight. The techniques use in bariatric surgery, act through the restriction of gastric capacity or partial food malabsortion. All of them had demonstrated to be effective for obesity treatment and improve related co morbidities, highlighting a high percentage of remission of diabetes mellitus 2, specially in malaabsortion techniques. Gastric banding has the lowest rate of remission of type 2 diabetes. Most of the benefits of surgery, persist for more than 10 years. This characteristic had permitted to observe a decreased risk of metabolic disease, a reduction of cardiovascular risk and obese mortality rate. Currently the most frequent bariatric surgery techniques are gastric bypass and vertical gastrectomy (sleeve gastrectomy). Bariatric surgery has low morbidity and mortality rate in surgical bariatric centers. However nutritional complications may occur, so they should be prevent or early treat. A multidisciplinary team is demanded, with nutrition, mental health and physical activity experts, for an integrated management and follow up. Only with the integral therapy, it can increase the chances of achieving a better reduction and weight maintenance. If this conditions fail, the patient can regain weight, indepent of the type on bariatric surgery.

Reganancia de peso después de la cirugía bariátrica / Weight gain after bariatric surgery

Among obese subjects, bariatric surgery is very effective to achieve weight loss, to improve metabolic disturbances such as diabetes mellitus and to improve quality of live. However, long term follow up studies show that an important proportion of patients gain weight again. This phenomenon commonly occurs between the third and sixth postoperative year. The main risk factors for weight gain are behavioral and psychological issues, that can be detected in the preoperative assessment. This reinforces the concept that bariatric surgery must be managed by experienced multidisciplinary teams.

La cirugía para la obesidad ha probado ser el tratamiento más efectivo para reducir el exceso de peso de cualquier magnitud, lo que favorece la mejoría de las comorbilidades metabólicas, especialmente de la diabetes tipo 2 y de la calidad de vida. Los estudios con seguimiento de largo plazo muestran que un porcentaje importante de pacientes operados regana peso, lo que se observa más frecuentemente entre el tercer y sexto año postoperatorio. Existen cambios anatómicos y factores dependientes de la técnica quirúrgica que pueden explicar la reganancia de peso, pero son los aspectos conductuales y sicológicos, los principales factores de riesgo para que un paciente que ha reducido exitosamente su exceso de peso vuelva a engordar. Varios de estos aspectos, son detectables en la etapa preoperatoria, lo que confirma que la cirugía bariátrica debe ser realizada en centros de excelencia que cuenten con equipo multidisciplinario.

Equipo multidisciplinario en cirugía metabólica / Multidisciplinary team in metabolic surgery

Metabolic surgery may improve type 2 diabetes. However, diabetic patients have some pathophysiological characteristics that should be considered before facing a surgical treatment. Without an accurate selection and assessment of patients, surgical results may be limited and patients have risk of serious postoperative complications that may be nutritional and/or metabolic diseases. Clinical preoperative evaluations allow the analysis of the overall conditionof the diabetic patients, preparing them for surgery and especially reducing perioperative risks. Psychological, nutritional and physical preparation can improve success expectations.Multidisciplinary monitoring reduces the risk of nutritional complications, promotes lifestyle change optimize the results and the long-term maintenance as it is known that weight re-gain canreverse the good metabolic results achieved. There is international consensus recommending to perform surgeries in centers of excellence with a coordinated team of trained professionals developing comprehensive treatment protocols with early and late follow up of patients and reporting the outcomes.

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.

Estrategias de manejo nutricional en pancreatitis aguda / Nutritional management strategies in acute pancreatitis

Severe acute pancreatitis is a hypermetabolic and hypercatabolic condition that requires nutritional support. Enteral nutrition is the preferred type of nutritional support and the recommendation is to initiate treatment within the first 48 h. This treatment is safe and, compared to parenteral nutrition, patients develop less complications related to infections, and less mortality rates; probably because this treatment does not affect intestinal defensive and metabolic functions. There is no evidence supporting the use of special nutritional supplements or formulae; and probiotics have been considered dangerous. When enteral nutrition is not viable or deficient, parenteral nutrition shall be initiated in order to prevent cumulative nutritional deficit. However, calories overload and hyperglycemia must be avoided. Parenteral administration of lipids does not stimulate the pancreas. Parenteral nutrition supplemented with glutamine has shown beneficial effects. Nutritional therapy is an important therapeutic intervention that can affect the progression of the disease.

La pancreatitis aguda grave es una enfermedad hipermetabólica e hipercatabólica que necesita soporte nutricional. Nutrición enteral es el método de elección y se recomienda iniciar dentro de las primeras48 h de evolución. Es un tratamiento seguro y, en comparación con nutrición parenteral, los pacientes desarrollan menos complicaciones infecciosas y mortalidad, probablemente porque permite la mantención de las funciones defensivas y metabólicas del intestino. No hay evidencia que avale el uso de fórmulas o suplementos nutricionales especiales y los probióticos se han considerado peligrosos. Cuando la nutrición enteral es imposible o insuficiente se debe iniciar nutrición parenteral para prevenir un deficit nutricional acumulado, sin embargo, se debe evitar la sobrecarga de calorías y la hiperglicemia. Incluir lípidos vía parenteral no estimula el páncreas. Complementar la nutrición parenteral con glutamina ha mostrado efectos ventajosos. La terapia nutricional es una importante intervención terapéutica que puede modular la evolución de esta enfermedad.

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.

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.

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.

Propuesta y fundamentos para una norma de manejo quirúrgico del paciente obeso: Año 2004 / A proposal of guidelines for surgical management of obesity

Obesity is a chronic disease with an increasing prevalence in all groups of age, and is associated to increased general mortality and cardiovascular risk. The multidisciplinary non surgical approach must be the treatment of choice for obese subjects. However, the results of such approach among subjects with severe or morbid obesity, are unsatisfactory. In this group of patients, bariatric surgery and specifically gastric bypass achieves good long term results, maintaining a low body mass index, reducing complications and improving quality of life. Considering the widespread practice of bariatric surgery in Chile, the Nutrition Unit of the Ministry of Health formed a task force to propose update guidelines for the surgical treatment of obesity. These guidelines were proposed after a thorough literature review and discussion with groups that practice bariatric surgery using defined protocols. This document provides a summarized version of the guidelines. The first section discusses the background for bariatric surgery and the second part give specific recommendations for patient management and the formation of reference centers for surgical management of obesity.

Evolución de comorbilidades metabólicas asociadas a obesidad después de cirugía bariátrica / Effects of gastric bypass on weight, blood glucose, serum lipid levels and arterial blood pressure in obese patients

Background: Type 2 diabetes, hypertension and serum lipid abnormalities are common among obese people and they should improve with weight reduction. Aim: To study the outcome of these abnormalities after bariatric surgery in morbid obesity patients. Material and methods: Two hundred thirty two morbid obese patients subjected to gastric bypass, were evaluated in the preoperative period and every three months after surgery, during a minimum of 12 months. Clinical evolution, blood glucose, serum insulin, insulin resistance measured with the homeostasis model assessment (HOMA) and serum lipid levels were analyzed. Results: In the preoperative period, 17% had type 2 diabetes, 49% had abnormal serum lipid levels and 25% had high blood pressure. Sixty six percent had at least one of these abnormalities and 20% had more than one. During follow up, body mass index decreased from 44 to 29.3 kg/m2. Total and HDL cholesterol, blood glucose and insulin resistance significantly decreased from the third month after surgery. Diabetes disappeared in 97% of diabetic subjects, blood pressure normalized in 53% of subjects with hypertension and serum lipid levels returned to normal in 88% of subjects with dyslipidemia. Conclusions: Gastric bypass in morbid obese patients achieves a significant and important weight reduction that results in significant reductions in the frequency of diabetes, dyslipidemia and hypertension among operated obese subjects.

Evaluación del diagnóstico de insulino-resistencia durante el primer trimestre del embarazo como factor predictor de riesgo en el desarrollo de preeclampsia: estudio preliminar / Evaluation of diagnosis of insulin-resistance during the first trimester of the pregnancy like risk predicting factor in development of preeclampsia: preliminary study

La preeclampsia (PE) es una enfermedad de alto riesgo para el binomio madre-hijo. A pesar de lo anterior su etiología no está del todo aclarada. En el último tiempo la evidencia científica ha sugerido que la insulino-resistencia (IR) puede jugar un rol en la génesis de esta enfermedad. Objetivo: El propósito de este estudio es evaluar la relación del diagnóstico de la IR durante el primer trimestre del embarazo como factor predictor de riesgo de PE. Metodología: Estudio de cohorte prospectivo realizado en la unidad de Medicina Fetal del Hospital Clínico de la Universidad de Chile. Muestras sanguíneas maternas fueron tomadas y almacenadas a -80°C a mujeres no seleccionadas sometidas a examen ultrasonográfico de rutina entre las 11-14 semanas, posteriormente concentraciones plasmáticas maternas de biomarcadores de IR (Globulina Transportadora de Hormonas (SHBG), inhibidor del activador del plasminógeno 1 (PAl 1), Homocisteína (Hc), ácido fólico y vitamina B12) fueron medidas en pacientes que desarrollaron PE y en controles. Resultados: De un total de 53 pacientes reclutadas, seis desarrollaron PE (11,3 por ciento) y treinta y seis tuvieron una evolución fisiológica (67,9 por ciento). Las concentraciones plasmáticas maternas de los diferentes biomarcadores de IR en aquellas pacientes que desarrollaron PE no presentaron una diferencia significativa con las pacientes controles. SHBG (mediana 324,7 nmol/l vs 371,9 nmol/l, p=0,43), PAl 1 (mediana 26,5 ng/ml vs 37,9 ng/ml, p=0,07), homocisteína (mediana 4,45 umol/l vs 4,73 umol/l, p=0,59), ácido fólico (mediana 7,1 ng/ml vs 6,8 ng/ml, p=0,81), Vit B12 (mediana 346,7 pg/ml vs 368,7 pg/ml, p=0,77). Conclusión: Las concentraciones plasmática materna de los biomarcadores de IR durante el primer trimestre del embarazo no es predictor de riesgo de PE.

Síndrome Prader Willi asociado a obesidad mórbida: tratamiento quirúrgico / Surgical treatment of morbid obesity associated to Prader-Willi syndrome: report of 1 case

Prader-Willi Syndrome (PWS) is a multisystemic genetic disease characterized by hypothalamic hypogonadism, mental retardation and compulsive hyperphagia associated with early and severe obesity. Complications of overweight, such as type-2 diabetes Mellitus, dyslipidemia and diffuse atheromatosis are common. We report a 15 years old morbid obese male with PWS, with a body mass index of 57.7 kg/m2, refractory to weight-lowering treatments. He underwent preoperative evaluation and treatment by a multidisciplinary team, and subjected to a 95 percent gastrectomy, leaving a 50 ml remnant pouch and a long limb (120 cm) Y-Roux gastro-jejuno anastomosis. There were no surgical complications, oral feeding was initiated at the 5th day with an hypocaloric diet. During the first postoperative year, the patient lost 70 kg, achieving a body mass index of 30 kg/m2. Surgical treatment can become a therapeutic choice for obesity in PWS patients

Sonda nasoyeyunal larga: método endoscópico de colocación y su utilidad en el manejo nutricional de la pancreatitis aguda / Long nasojejunal feeding tube: an endoscopic method for its placement and its use in enteral nutrition for patients with acute pancreatitis

Background: Enteral nutrition can be useful for the feeding of patients with acute pancreatitis, specially in the later phases of the disease. Aim: To describe an endoscopic placement method for long nasojejunal tubes and assess its efficacy. To communicate a preliminary experience with enteral nutrition in patients with acute pancreatitis. Patients and methods: An endoscopic placement method for nasojejunal tubes is described. In 24 patients with acute pancreatitis, 28 tubes were placed using this method, after the second week of evolution. In 15 patients with brain damage, traditional nasojejunal feeding tubes were placed without endoscopy. The position of both types of tubes was determined by fluoroscopy with the aid of contrast media. Results: The endoscopic placement method was simple and the tube was placed beyond the ligament of Treitz in all patients. No traditional tube was placed in the jejunum and contrast media filled the duodenum in all cases. In patients with acute pancreatitis, enteral nutrition was well tolerated, 5 patients had a higher stool frequency and one, had an asymptomatic increase in serum amilase levels. Conclusions: Long nasojejunal tubes can be easily placed beyond the ligament of Treitz with endoscopic aid and can be used for enteral feeding in patients with acute pancreatitis