Seguridad y eficacia del bypass gástrico en Y de Roux asistido por robot versus abordaje laparoscópico convencional / Safety and efficacy of robot-assisted Roux-en-Y gastric bypass versus conventional laparoscopic approach

Resumen Introducción: La cirugía bariátrica se considera actualmente la opción de tratamiento más eficaz para la obesidad mórbida. El bypass gástrico laparoscópico en Y de Roux sigue siendo el estándar de oro en cirugía bariátrica. El advenimiento de la robótica quirúrgica ha llevado a una reducción de algunos de los desafíos más difíciles en la laparoscopia avanzada. Objetivo: Determinar la seguridad y eficacia del bypass gástrico en Y de Roux asistido por robot en comparación con el abordaje laparoscópico. Material y métodos: Se realizó un estudio retrospectivo que incluyo 50 pacientes con distintos grados de obesidad divididos en dos grupos de 25 cada uno. Se realizó una base de datos con las variables de acuerdo al tipo de abordaje quirúrgico (robótico y laparoscópico), registrando los días de estancia hospitalaria, sangrado, tiempo quirúrgico, complicaciones, reingresos hospitalarios, complicaciones y disminución del IMC. Resultados: En el grupo laparoscópico se observó un sangrado transoperatorio de 115.8+64 mililitros, en el grupo robótico solo fue de 59.6+45.8 mililitros (p<0.001). Un tiempo quirúrgico laparoscópico de 151.8+34.6 minutos, mientras que el grupo robótico fue de 216.4+50 minutos, los pacientes permanecieron hospitalizados 4.2+2.4 días en el grupo laparoscópico, los pacientes del grupo robótico 3.4+1 días, sin diferencia significativa (p=0.077). En ambos grupos no hubo reingresos hospitalarios. En el grupo laparoscópico la disminución de IMC fue de 8.9+2.5, mientras que para el grupo robótico fue de 13.7+2.3 con significancia estadística (p<0.001). Discusión: El bypass gástrico en Y de Roux asistido por robot es más seguro y eficaz en comparación con el abordaje laparoscópico. El abordaje robótico disminuye de forma significativa el sangrado transoperatorio, disminuye los días de estancia hospitalaria (sin diferencia significativa) y reduce de forma significativa la disminución del IMC, sin aumentar los reingresos hospitalarios a 30 días ni las complicaciones.

Abstract Introduction: Bariatric surgery is currently considered the most effective treatment option for morbid obesity. The laparoscopic Roux-en-Y gastric bypass remains the gold standard in bariatric surgery. The advent of surgical robotics has led to a reduction in some of the most difficult challenges in advanced laparoscopy. Objective: To determine the safety and efficacy of robot-assisted Roux-en-Y gastric bypass compared to the laparoscopic approach. Material and methods: A retrospective study was carried out that included 50 patients with different degrees of obesity divided into two groups of 25 patients each. A database was created with the variables according to the type of surgical approach (robotic and laparoscopic), recording the days of hospital stay, bleeding, surgical time, complications, hospital readmissions, complications, and BMI decrease. Results: In the laparoscopic group, intraoperative bleeding of 115.8+64 milliliters was observed, in the robotic group it was only 59.6+45.8 milliliters (p<0.001). A laparoscopic surgical time of 151.8+34.6 minutes, while the robotic group was of 216.4+50 minutes, the patients remained hospitalized 4.2+2.4 days in the laparoscopic group, the patients in the robotic group 3.4+1 days, with no significant difference (p=0.077). In both groups there were no hospital readmissions. In the laparoscopic group, the decrease in BMI was 8.9+2.5, while for the robotic group it was 13.7+2.3 with statistical significance (p<0.001). Discussion: Robot-assisted Roux-en-Y gastric bypass is more safe and effective compared to the laparoscopic approach. The robotic approach significantly reduces intraoperative bleeding, decreases the days of hospital stay (with no significant difference), and significantly reduces the decrease in BMI, without increasing 30-day hospital readmissions or complications.

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.

Regulation of intestinal microbiota by Roux-en-Y gastric bypass on patients with obesity or obesity combined with diabetes / 中华消化外科杂志

Objective:To investigate the regulation of intestinal microbiota by Roux-en-Y gastric bypass (RYGB) on patients with obesity or obesity combined with diabetes.Methods:The retrospective and descriptive study was conducted. The stool samples before and after surgery and clinical data of 20 patients with obesity, including 9 simple obesity cases and 11 obesity combined with diabetes cases, who underwent RYGB in the First Affiliated Hospital of Ji′nan University from July 2016 to August 2017 were collected. There were 11 males and 9 females, aged (33±11)years. Observation indicators: (1) changes in composition and structure of intestinal microflora; (2) changes of intestinal microflora in simple obesity patients after operation; (3) changes of intestinal microflora in obesity combined with diabetes patients after operation. Follow up was conducted using telephone interview or outpatient examinations to detect the body mass, the application of antimicrobial agent and the blood glucose control of patients. According to the unified training points, the stool samples were collected and stored into the DNA stabilizer, and then conducted to laboratory analysis within 45 hours. The follow up was up to November 2018. Measurement data with normal distribution were represented as Mean± SD, and independent-samples t test was used for inter-group comparison and paired-samples t test was used for intra-group comparison. Measurement data with skewed distribution were represented as M( Q1, Q3), and Wilcoxon signed rank test of two independent samples was used for inter-group comparison. Count data were described as absolute numbers, and the chi-square test, ANOSIM analysis, linear discriminant (LEfSe) analysis and the Metastats analysis were used for inter-group comparison. Results:(1) Changes in composition and structure of intestinal microflora. The Shannon index of α diversity of preoperative intestinal microflora in simple obesity patients and obesity combined with diabetes patients was 4.37±0.69 and 4.47±0.85, respectively, showing no significant difference between them ( t=0.28, P>0.05). Results of preoperative LEfSe analysis showed that there were differences in the bacterial abundance of Firmicutes and Bacteroidea between simple obesity patients and obesity combined with diabetes patients. The abundances of Parasutterella in simple obesity patients and obesity combined with diabetes patients was 0.000 113 0(0, 0.004 378 2) and 0.008 464 0(0.001 325 7, 0.034 983 1), respectively, showing a significant difference between them ( Z=2.12, P<0.05). Results of preoperative PCoA analysis showed that the contribution rates of principal component 1, principal component 2 and principal component 3 were 24.98%, 22.24% and 16.33% in simple obesity patients and obesity combined with diabetes patients and results of ANOSIM comparison showed that there was no significant difference in preoperative intestinal microflora between them ( r=?0.11, P>0.05). The Shannon index of α diversity of postoperative intestinal microflora in simple obesity patients and obesity combined with diabetes patients was 4.60±0.65 and 4.66±0.40, respectively, showing no significant difference between them ( t=0.24, P>0.05). Results of postoperative LEfSe analysis showed that there were differences in the bacterial abundance of Bacteroidea, Proteus and Firmicutes between simple obesity patients and obesity combined with diabetes patients. The abundances of Morganella and Coprococcus_2 in simple obesity patients and obesity combined with diabetes patients were 0.000 192 0(0.000 011 9,0.001 569 0), 0(0,0) and 0(0,0), 0.000 054 1(0,0.000 419 0), showing significant differences between them ( Z=2.70, 2.29, P<0.05). (2) Changes of intestinal microflora in simple obesity patients after operation. There were 10 genera of bacteria of intestinal bacteria changing after surgery, including 7 species of bacteria increasing in the Firmicutes and the Proteobacteria as Veillonella, Morganella, Granulicatella, Aeromonas, Streptococcus, Rothia and Megasphaera and the bacteria decreasing in the Firmicutes and the Actinobacteria as Ruminococcus_torques_group, Romboutsia and Erysipelo-trichaceae_UCG-003. Results of LEfSe analysis showed that the bacteria significantly enriched in simple obesity patients before surgery were Ruminococcus_torques_group, Romboutsia and Erysipelotri-chaceae_UCG-003, belonging to Firmicutes, and the bacteria significantly enriched in simple obesity patients after surgery were Rothia, Granulicatella, Enterococcus, Streptococcus, Megasphaera, Veillonella, A eromonas and Morganella, belonging to Actinobacteria, Firmicutes and Proteobacteria. (3) Changes of intestinal microflora in obesity combined with diabetes patients after operation. There were 16 bacteria of intestinal bacteria increasing after surgery, including Streptococcus, Veillonella, Haemophilus, Pluralibacter, Gemella, Lachnospiraceae_NC2004_group, Granulicatella,Aeromonas, uncultured_ bacterium_f_ Saccharimonadaceae, R uminiclostridium_9, Butyricicoccus, Fusobacterium, Anaerotruncus, Fusicateni-bacter, Klebsiella and E ubacterium_eligens_group, which belonged to the Firmicutes and the Proteo-bacteria. Results of LEfSe analysis showed that the bacteria significantly enriched in obesity combined with diabetes patients before surgery were Fusicatenibacter, Tyzzerella_3 and Butyricicoccus, belonging to the Firmicutes, and the bacteria significantly enriched in obesity combined with diabetes patients after surgery were Gemella, Granulicatella, Enterococcus, Streptococcus, Lachnospiraceae_NC2004_group, Eubacterium_eligens_group, Anaerotruncus, Ruminiclostridium_9, Anaeroglobus, Veillonella, Fusobacterium, uncultured_bacterium_f_Saccharimonadaceae, Aeromonas, Klebsiella, Pluralibacter, Proteus and Haemophilus, belonging to the Firmicutes and the Proteobacteria. Conclusions:RYGB can significantly increases the intestinal microflora abundance in simple obesity patients and obesity combined with diabetes patients. The two types of patients have specific changes in intestinal microflora at the genus level.

Estadía abreviada poscirugía bariátrica: una posibilidad real sin incrementar complicaciones ni readmisión de pacientes / Abbreviated Hospitalization after bariatric surgery

Resumen Introducción: Nuevas técnicas en cirugía bariátrica han permitido disminuir las complicaciones y la mortalidad quirúrgica. Estas mejoras han hecho posible disminuir la estadía hospitalaria y acelerar el proceso de recuperación permitiendo un potencial protocolo de alta temprana. Objetivos: Describir la experiencia en la utilización de un protocolo diseñado de estadía abreviada, en pacientes posoperados de cirugía bariátrica. Materiales y Método: Estudio analítico, retrospectivo de cohorte. Se consideró una cohorte de pacientes en que se realizó cirugía bariátrica, en Clínica Santa María, por un solo cirujano, entre julio de 2014 y abril de 2019, sometidos a un protocolo diseñado de alta temprana. Fueron registradas la morbilidad, la mortalidad, las readmisiones y reintervenciones en el periodo de tiempo registrado. Resultados: Se incluyeron un total de 775 pacientes, 654 pacientes sometidos a gastrectomía en manga laparoscópica (GEM) y 101 pacientes sometidos a bypass gástrico en Y de Roux (RYGB). Hubo 8 complicaciones, sin mortalidad registrada. La tasa de readmisión/reintervención fue de 4,13%/2,27% para GEM y 4,55%/3,53% para RYGB. Conclusiones: En este grupo de pacientes pudimos demostrar una baja tasa de complicaciones, lo que apoya la idea de que un protocolo de alta temprana en pacientes sometidos a cirugía bariátrica es una alternativa factible y segura.

Introduction: New techniques in bariatric surgery have allowed to reduce complications and surgical mortality. These improvements have made it possible to reduce the hospital stay and accelerate the recovery process, allowing a potential early discharge protocol. Aim: To describe the experience in the use of a protocol designed for an abbreviated stay, in post-operated bariatric surgery patients. Materials and Method: Analytical, retrospective cohort study. A cohort of patients who underwent bariatric surgery, at the Santa María Clinic, by a single surgeon, between July 2014 and April 2019 and submitted to a designed early discharge protocol was considered. Morbidity, mortality, readmissions, and reoperations were recorded in the established period of time. Results: A total of 775 patients were included, 654 patients undergoing laparoscopic sleeve gastrectomy (GEM) and 101 patients undergoing Roux-en-Y gastric bypass (RYGB). There were 8 complications, with no recorded mortality. The readmission/reoperation rate was 4.13%/2.27% for GEM and 4.55%/3.53% for RYGB. Conclusions: In this group of patients we were able to demonstrate a low rate of complications, which supports the idea that an early discharge protocol in patients undergoing bariatric surgery is a feasible and safe alternative.

Changes in serum albumin and liver enzymes following three different types of bariatric surgery: six-month follow-up. A retrospective cohort study

ABSTRACT BACKGROUND: Few reports have examined the effects of Roux-en-Y gastric bypass (RYGB), one-anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG) on changes to serum albumin (Alb) and liver enzyme levels. OBJECTIVE: To compare short-term post-surgery changes in serum Alb, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALKP) levels. Body composition changes were also measured and compared among three groups. DESIGN AND SETTING: Retrospective cohort study conducted in Tehran, Iran. METHODS: 151 OAGB, RYGB and SG patients referred to the obesity clinic of Hazrat-e Rasool General Hospital, Tehran, Iran, were evaluated. Physical characteristics and biochemical parameters were measured pre-surgery and then after three and six months. RESULTS: Through repeated measurements to determine intragroup changes, significant changes in serum AST (P = 0.003) and ALT (P < 0.001) were observed in follow-ups. However, Alb levels did not change (P = 0.413). Body fat, fat-free mass and muscle mass decreased significantly in each group (P < 0.05). In a univariate general linear model for determining intergroup changes, SG showed greater decreases in ALT and AST at three and six months (P < 0.05) and in ALKP at six months (P = 0.037), compared with OAGB. There were no significant differences in Alb levels. Also, RYGB had a greater effect on reducing fat percentage (three months, P = 0.011; six months, P = 0.059) and fat mass (three months, P = 0.042) than OAGB. CONCLUSION: SG and RYGB may be superior to OAGB in reducing liver enzymes and body fat, respectively. However, Alb levels showed no significant differences.

Atherogenic index of plasma is reduced during follow-up among Roux-in-Y gastric bypass patients

ABSTRACT Atherogenic index of plasma is a marker used to assess risk of cardiovascular diseases. The present study evaluated plasma atherogenic index in individuals before and after bariatric surgery. Individuals were evaluated at three time points: before surgery (T0), in the 2nd (T1) and 6th (T2) months post-surgery. Anthropometric (body mass index, waist circumference, fat and lean mass) and biochemical parameters (lipid profile, glucose and C-reactive protein), and atherogenic index of plasma, calculated by the formula [=log (serum triglycerides concentration/HDL cholesterol)], were evaluated. Data were analyzed using the repeated measures ANOVA or Friedman test according to data distribution. The level of significance was 5%. Thirty-four patients agreed to participate. A significant reduction was observed in all anthropometric parameters in women and men (p<0.05). Atherogenic index of plasma reduced significantly in all time points in women; there was a significant reduction only between periods T0 and T2 (p<0.05) in men. A reduction in the classification for risk in cardiovascular diseases, with high risk in T0 (0.441±0.13) to moderate risk at T1 (0.204±0.22) and low risk at T2 (0.041±0.16) was observed in men. In women, the risk remained low (<0.11) in all periods. Bariatric surgery reduced the atherogenic index of plasma during the 6-month follow-up, suggesting a reduction in cardiovascular risk.

RESUMEN El índice aterogénico plasmático es un marcador que se utiliza para evaluar el riesgo de enfermedades cardiovasculares. El presente trabajo evaluó el índice aterogénico plasmático de pacientes antes y después de la cirugía bariátrica. Los individuos fueron evaluados en tres momentos: antes de la cirugía (T0), el segundo (T1) y el sexto (T2) meses después de la cirugía. Se evaluaron parámetros antropométricos (índice de masa corporal, circunferencia de cintura, masa grasa y masa magra), parámetros bioquímicos (perfil lipídico, glucosa y proteína C reactiva) y el índice aterogénico plasmático, calculado mediante la fórmula [= log (concentración sérica de triglicéridos / colesterol HDL)]. Los datos se analizaron mediante el ANOVA de medidas repetidas o el Test de Friedman según la distribución de los datos. Nivel de significancia adoptado 5%. Treinta y cuatro pacientes aceptaron participar en el estudio. Se observó una reducción significativa en todos los parámetros antropométricos en ambos sexos (p<0.05). En las mujeres, el índice aterogénico plasmático disminuyó significativamente en todos los períodos. En los hombres, hubo una reducción significativa en el índice aterogénico plasmático solo entre T0 y T2 (p<0.05), aunque se observó una reducción en la clasificación de riesgo para enfermedades cardiovasculares de alto riesgo en T0 (0.441±0.13) para moderadas riesgo en T1 (0.204±0.22) y riesgo bajo en T2 (0.041±0.16). En las mujeres, el riesgo se mantuvo bajo (<0.11) en todos los períodos. La cirugía bariátrica redujo la PIA durante el seguimiento de 6 meses, lo que sugiere una reducción del riesgo cardiovascular.

Laparoscopic Roux / 中南大学学报(医学版)

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been proved to be a safe and effective treatment for Type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) >27.5 kg/m

Real-world evidence of health outcomes and medication use 24 months after bariatric surgery in the public healthcare system in Brazil: a retrospective, single-center study

OBJECTIVES: The number of bariatric procedures has significantly increased in Brazil, especially in the public Unified Health System. The present study describes health outcomes and medication use in obese patients treated in a major hospital that performs publicly funded surgery in Brazil. METHODS: A retrospective, single center study was conducted to collect real-world evidence of health outcomes and medication use in 247 obese patients (female, 82.2%) who underwent open Roux-en-Y gastric bypass. Changes in weight and body mass index (BMI), presence of apnea, hypertension, and type 2 diabetes (T2D), and medication use (hypertension, diabetes, and dyslipidemia) were assessed preoperatively and up to 24 months postoperatively. The mean cost of medications was calculated for the 12-month preoperative and 24-month postoperative periods. RESULTS: During the surgery, the mean age of patients was 43.42 years (standard deviation [SD], 10.9 years), and mean BMI was 46.7 kg/m2 (SD, 6.7 kg/m2). At 24 months, significant declines were noted in weight (mean, -37.6 kg), BMI (mean, -14.3 kg/m2); presence of T2D, hypertension, and apnea (-29.6%, -50.6%, and -20.9%, respectively); and number of patients using medications (-66.67% for diabetes, -41.86% for hypertension, and -55.26% for dyslipidemia). The mean cost of medications (total costs for all medications) decreased by >50% in 12-24 postoperative months compared to that in 12 preoperative months. CONCLUSION: Roux-en-Y gastric bypass successfully reduced weight, BMI, and comorbidities and medication use and cost at 24 months in Brazilian patients treated in the public Unified Health System.

Mesenteric desmoid tumor after Roux-en-Y gastric bypass: a case report

We report the case of a 37-year-old woman investigated for left flank pain 1 year after bariatric surgery (Roux-en-Y gastric bypass). Abdominal computed tomography (CT) revealed a solid intra-abdominal lesion measuring 9.3 × 9.4 × 10.4 cm, compressing adjacent structures with no signs of invasion. Ileocolectomy with partial mesenteric resection was performed. A histopathological and immunohistochemical analysis confirmed the diagnosis of mesenteric desmoid tumor.(AU)

Therapeutic effect of laparoscopic Roux-en-Y gastric bypass in non-obese patients with type 2 diabetes / 南方医科大学学报

OBJECTIVE@#To evaluate the effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery for treatment of type 2 diabetes (TD) in patients with a body mass index (BMI) < 27.5 kg/m.@*METHODS@#We retrospectively analyzed the data of patients who underwent LRYGB surgery from March, 2012 to June, 2018 in the General Hospital of Guangzhou Military Command and Jinshazhou Hospital of Guangzhou University of Chinese Medicine. The changes in the parameters of glucose metabolism and physical indicators of the patients in the first, second and third years after the surgery were analyzed in patients in low BMI group and high BMI group.@*RESULTS@#All the 74 patients underwent LRYGB successfully without conversion to open surgery. One year after the surgery, fasting blood glucose (FBG), HbA1c, postprandial blood glucose, fasting insulin, HOMA-IR, fasting C-peptide, BMI, body weight and waistline were significantly improved compared with their preoperative values in low BMI group ( < 0.05). At 2 years after the operation, FBG, HbA1c, postprandial blood glucose, HOMA-IR, BMI, body weight and waistline were significantly improved compared with the preoperative values in low BMI group ( < 0.05). In the third year, FBG, HOMA-IR, fasting C-peptide, body weight and waistline were significantly improved compared with the preoperative values in low BMI group ( < 0.05). There was no significant difference in the parameters of glucose metabolism and islet function between low BMI group and high BMI group at different stages. No serious complications occurred in these patients after the surgery.@*CONCLUSIONS@#LRYGB is effective for treatment of T2D in Chinese patients with a BMI < 27.5. After the surgery, the patient show reduced waistline without significant weight loss. The long-term results of the surgery still require further investigations with a larger samples and longer follow-up.

Obstrucción intestinal por fitobezoar en una paciente con bypass gástrico laparoscópico en Y de Roux: reporte de un caso / Intestinal obstruction due to phytobezoar in a patient with laparoscopic gastric bypass in Roux-en-Y: case report

INTRODUCCIÓN: Los bezoares son una etiología infrecuente de obstrucción intestinal (OI) posterior a un bypass gástrico laparoscópico en Y de Roux (BGLYR). OBJETIVO: Describir un caso clínico de OI debido a un fitobezoar en un sitio infrecuente, en una paciente 2 años después de un BGLYR. CASO CLÍNICO: Paciente de sexo femenino con antecedente de BGLYR hace 2 años y cuadro de obstrucción intestinal causado por fitobezoar. DISCUSIÓN: Se discuten los factores que pueden contribuir a la formación del bezoar en este caso y estrategias para su prevención. Se destaca la importancia del estudio imagenológico y de la exploración quirúrgica oportuna.

BACKGROUND: Bezoars are an infrequent aetiology of bowel obstruction after a laparoscopic Roux-en-Y gastric bypass (LRYGB). OBJECTIVE: To describe a clinical case of bowel obstruction due to a phytobezoar in an uncommon site, in a patient 2 years after a LRYGB. CASE REPORT: A female patient with a history of LRYGB 2 years ago and bowel obstruction due to phytobezoar. DISCUSSION: Factors that can contribute to the formation of bezoar in this case and strategies for its prevention are discussed. The importance of the imaging study and timely surgical exploration is emphasized.

Colangiopancreatografía retrógrada endoscópica (CPRE) transgástrica asistida por laparoscopia en un paciente con derivación gástrica en Y de Roux. Reporte de un caso y revisión de la literatura / Laparoscopic-assisted transgastric retrograde endoscopic cholangiopancreatography in a patient with a Roux-en-Y gastric bypass: Case report and literature review

Resumen La obesidad es un problema de salud pública. La cirugía bariátrica juega un papel importante en el manejo de estos pacientes. Con la llegada de estas técnicas quirúrgicas, los procedimientos endoscópicos digestivos y en especial la colangiopancreatografía retrógrada endoscópica (CPRE) se convierten en un desafío constante. Se describe un caso de CPRE transgástrica asistida por laparoscopia para el manejo de cálculos de la vía biliar principal en un paciente con antecedente de derivación gástrica en Y de Roux (BPGYR).

Abstract Obesity is a public health problem. Bariatric surgery plays an important role in the management of these patients. With the advent of bariatric surgical techniques, endoscopic digestive procedures, especially endoscopic retrograde cholangiopancreatography (ERCP), have become constant challenges. We describe a case of laparoscopic-assisted transgastric retrograde endoscopic cholangiopancreatography (ERCP) to treat calculi in the main bile duct of a patient with a history of a Roux-en-Y gastric bypass.

Cause analysis and treatment of reoperative metabolic and bariatric surgery:A report of 54 cases / 中国实用外科杂志

OBJECTIVE: To explore the cause and treatment of bariatric and metabolic surgery reoperation. METHODS: A retrospective analysis was conducted on the clinical data of 54 patients underwent reoperative metabolic and bariatric surgery in Department of Bariatric and Metabolic Surgery,the First Affiliated Hospital of Jinan University from November 2000 to December 2018, and the reasons and surgical techniques of reoperation were analyzed. RESULTS: Causes of reoperation included inadequate weight loss/weight regain in 22 cases(40.7%),adhesive intestinal obstruction in 5 cases(9.3%),mesenteric hernia in 5 cases(9.3%),gastroesophageal reflux in 4 cases(7.4%),anastomotic leakage4 cases(7.4%),anastomotic ulcer bleeding in 3 cases(5.6%),anastomotic stenosis in 3 cases(5.6%),postoperative intraabdominal bleeding in 3 cases(5.6%),recurrent diabetes in 2 cases(3.7%),severe dumping syndrome in 2 cases(3.7%),anastomotic error in 1 case(1.9%). Reoperation methods mainly included Roux-en-Y gastric bypass in 30 cases(55.6%),sleeve gastrostomy in 10 cases(18.5%),hernia repair in 5 cases(9.3%),exploratory laparotomy hemostasis in 4 cases(7.4%),gastroscopic balloon dilatation in 2 cases(3.7%),restoration surgery in 1 case(1.9%),revisional banded gastric bypass with GaBP ring in 1 case(1.9%), hiatal hernia repair in 1 case(1.9%). A total of 54 patients underwent reoperation with a follow-up period of 1 to 102 months. Among them, 42 patients were followed up,and 12 patients were lost to follow-up(follow-up rate of 77.8%). Among the 42 patients who were followed up, 41 of them achieved good results after surgery, and the symptoms and signs were relieved to various degrees. CONCLUSION: The most common cause of reoperative metabolic and bariatric surgery is inadequate weight loss/weight regain.The choice of reoperation method depends on the primary surgical procedure, the cause of failure, and the intraoperative condition.

Data analysis of bariatric & metabolic surgery quality control from 2012 to 2018 in Shanghai / 中国实用外科杂志

OBJECTIVE: To learn the latest developments of Shanghai's bariatric & metabolic surgery and the differences with east Asian countries according to the transverse and vertical comparison. METHODS: Through data reporting mechanism of the Shanghai Quality Control Center of General Surgery,the bariatric & metabolic surgery data were regularly collected and summarized. RESULTS: The number of hospitals developed from 11 in 2012 to 14 in 2018,and the overall surgery cases showed a progressive growth. In 2017, nineteen hospitals and 798 surgical cases had reached the highest level while decreased in 2018. The study showed that mean surgical time decreased to 112±14.8 min with no severe complication. The proportion of patients with type 2 diabetes pre-surgery decreased from 53.4% in 2014 to 30.9%in 2018. The proportion of sleeve gastrectomy(SG) increased from 68.4% in 2014 to 94.1% in 2018, which had become the most commonly bariatric surgical procedure. CONCLUSION: The amount of Shanghai metabolic and bariatric surgery increases year by year from 2012 to 2018, while increased little in 2017-2018,patients tend to be younger,mainly with obesity. The SG has become the main procedure performed in Shanghai.

Impact of Bariatric Surgery on Cardiovascular Risk Reduction in Korean Obese Patients

PURPOSE: Morbid obesity is a well-known risk factor for cardiovascular disease (CVD). This study aimed to quantitatively evaluate the effects of bariatric surgery on CVD risk reduction in Korean obese patients by using three CVD risk prediction models (Framingham General Cardiovascular Risk Score [FRS], Pooled Cohort Equation [PCE], and Korean Risk Prediction Model [KRPM]), and to investigate which procedure between laparoscopic Roux-en Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) is a better option for CVD risk reduction. MATERIALS AND METHODS: We retrospectively reviewed all obese patients who underwent bariatric surgery at a single institution from October 2009 to May 2016. Of the 1034 patients reviewed, 83 patients (6.5%) who met the criteria for calculating the FRS, PCE, and KRPM scores and had a follow-up of at least 1 year were included in this study. RESULTS: The FRS, PCE, and KRPM scores were significantly decreased at postoperative 1 year (10.47±7.30% to 6.33±4.59%, P=0.000; 5.45±6.25% to 2.75±2.75%, P=0.000; and 4.53±2.96% to 3.49±2.13%, P=0.000, respectively) in LRYGB. The PCE and KRPM scores were significantly decreased (4.13±3.63% to 2.42±2.45%, P=0.004 and 4.14±1.95% to 3.22±1.94%, P=0.000, respectively) in LSG, but not the FRS (9.43±3.58% to 5.63±3.24%, P=0.118). There was no difference in absolute risk reduction in FRS, PCE, and KRPM between LRYGB and LSG (4.13±5.08% and 3.80±3.50%, P=0.788; 2.70±0.52% and 1.72±0.49%, P=0.799; and 1.03±1.85% and 0.92±0.97%, P=0.776, respectively). CONCLUSION: LRYGB and LSG can equally significantly decrease the CVD risk in the Korean population, based on FRS, PCE, and KRPM.

Clinical application of laparoscopic Roux-en-Y gastric bypass in patients with type 2 diabetes mellitus / 中华内分泌外科杂志

Objective To evaluate the clinical effects of the laparoscopic Roux-en-Y gastric bypass (LRYGB) on patients with type 2 diabetes mellitus (T2DM).Methods From Dec.2013 to Dec.2015,83 cases with T2DM received LRYGB were enrolled to this study.They were divided into low body mass index group (LBMI,25≤BMI＜28),intermediate body mass index group (IBMI,28≤BMI＜32) and high body mass index group (HBMI,BMI≥33).Meanwhile,the clinical effects and side-effects were evaluated among three groups.The factors of adverse effects were evaluated by Cox multivariate analysis.Results Only one patient in HBMI was conversed to open surgery,all the others received LRYGB.The surgery time,intraoperative blood loss and complica tion were positively related to BMI,and the difference was statistically significant between the 3 groups(P＜0.05).The main side-effect of LRYGB was gastrointestinal reaction.The level of fasting blood-glucose,postprandial 2 hours blood sugar,HbA1c and cholesterol total in three groups were lower than baseline (P＜0.05),however,there was no significant difference among the three groups (P＞0.05).The rate of clinical effects in three groups was 89.5％,89.3％ and 91.7％.There was no significant difference among the three groups(P＞0.05);In Cox multivariate analysis,cholesterol total and BMI were independent prognostic indicator for LRGB adverse.Conclusions LRYGB is a safe and effective method for patients with T2DM,which can effectively improve glucose and lipid metabolism.The increased BMI can increase the incidence of LRYGB complications.Total cholesterol is an independent prognostic indicator for the adverse of LRYGB.

Therapeutic effects of laparoscopic Roux-en-Y gastric bypass on T2DM patients with different BMI / 中华内分泌外科杂志

Objective To investigate the clinical efficacy of laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus(T2DM) with different body mass index (BMI).Methods 62 T2DM patients were collected and divided into low BMI,medium BMI,and high BMI groups respectively according to BMI 25-28(kg/m2),28-33(kg/m2),≥33(kg/m2).All patients received laparoscopic Roux-en-Y gastric bypass and the clinical curative effects were monitored and analyzed subsequently.Results At 12 months postoperatively,the levels of total cholesterol(TC),triglyceride(TG) and BMI in medium and high BMI group were lower compared with those before surgery (P＜0.05).In low,medium BMI,and high BMI groups,the therapeutic effective rate was 81.8％(9/11),97.4％ (38/39),and 100％(12/12) respectively.The levels of fasting C-peptide and postprandial 1 h C-peptide were higher compared with those before surgery (P＜0.05).Conclusion Laparoscopic Roux-en-Y gastric bypass has good clinical curative effect for T2DM with different BMI,but for low BMI patients,the selection should be more cautious.

Reversión laparoscópica de bypass gástrico con Y de Roux a anatomía normal, en paciente con malnutrición severa y diarrea: reporte de un caso / Laparoscopic reversal of Roux-en-Y gastric bypass to normal anatomy in patient with severe malnutrition and diarrhea: case report

Introducción: El bypass gástrico (BG) es una de las técnicas más utilizadas y con mejores resultados a largo plazo en obesidad y control de enfermedades metabólicas. Cierto grupo de pacientes presentan complicaciones de difícil manejo como dumping severo, caquexia y malnutrición severa. Presentaremos un caso de malnutrición severa por déficit de nutrientes asociada a diarrea crónica, tratada exitosamente mediante reversión laparoscópica del BG. Caso clínico: Mujer de 43 años, que a los 6 meses post-BG presenta cólicos abdominales posprandiales y diarrea crónica. Al año presenta anemia, déficit de vitaminas B y D y desnutrición severa. Recibe evaluación interdisciplinaria, descartando patologías psiquiátrica y gastrointestinal. Se inicia tratamiento nutricional. Tres meses después se realiza conversión laparoscópica de BG a anatomía normal. Al seguimiento mejora los índices nutricionales y la calidad de vida. Discusión: La pérdida excesiva de peso post-BG es rara. Existe poca información de cuándo indicar una reversión de BG a anatomía normal. La evaluación debe ser realizada por un equipo multidisciplinario. La posibilidad de restituir a anatomía normal es plausible y bien tolerado por los pacientes. El abordaje laparoscópico es factible y seguro.

Introduction: Roux-en-Y Gastric Bypass is one of the most common techniques used to obtain better long term control in obesity and metabolic diseases. Certain group of patients have complications which are difficult to manage, such as dumping, cachexia and severe malnutrition. We present the case of severe malnutrition with deficiency of micro-nutrients associated with chronic diarrhea, which is successfully treated by laparoscopic reversal of BG. Case report: 43 year old woman. Six months after Roux-en-Y Gastric Bypass surgery she presents postprandial abdominal colic pain associated with chronic diarrhea. A year after surgery she presents anemia, vitamin deficiency and severe malnutrition. She underwent interdisciplinary team assessment, rouling out psychiatric and gastrointestinal pathology. Nutritional therapy is initiated and three months later we performed conversion to normal anatomy with laparoscopic technique. Patient presents nutritional and quality of life improvement. Discussion: Excessive weight loss due to Roux-en-Y Gastric Bypass is rare. There is little information on when to perform reversal surgery of Roux-en-Y Gastric Bypass to normal anatomy. The evaluation must be conducted by a multidisciplinary team. The possibility of restoring normal anatomy is plausible and well tolerated. The laparoscopic approach is feasible and safe.

Laparoscopic Adjustable Gastric Band as a Revision Surgery for Failed Vertical Gastric Sleeve or Roux-en-Y Gastric Bypass

Background: Bariatric surgery is seen as one of the most successful option for the control of morbid obesity and obesity related complications. Although, there are many surgical options available the Lincey Alexida, Xiaohua Qi, Patrick B. Asdell, José M. Martínez Landrón, Samarth B. Patel, Faustino Allongo. Frederick Tiesenga. Laparoscopic Adjustable Gastric Band as a Revision Surgery for Failed Vertical Gastric Sleeve or Roux-en-Y Gastric Bypass. IAIM, 2017; 4(12): 37-42. Page 38 laparoscopic vertical sleeve gastrectomy and the Roux-en-Y gastric bypass are among the most selected treatment methods. Even though the sleeve gastrectomy and the gastric bypass has proven to be efficacious in weight reduction in morbid obesity there are still some reported failures. Aim: This study main objective is to see if an adjustable gastric band can be offered as a sensible option for patients who have had a previously failed vertical sleeve gastrectomy or the Roux-en-Y gastric bypass surgery. The procedure will be classified as a revision surgery to increase the possibilities of additional weight loss not achieved with the sleeve gastrectomy or gastric bypass surgery alone. Method: A retrospective review of the charts for all the bariatric patients from April 2012 to April 2017 was conducted. The chart review yielded 12 patients who underwent either adjustable band over a previously failed vertical sleeve procedure or the adjustable band over a previously failed Roux-enY gastric bypass procedure. The patients were divided into two groups, group A and B. Group A is comprised of the 8 out 12 patients who had a previous failed gastric sleeve procedure. Group B has the remaining 4 patients who had a failed gastric bypass procedure. Observation: Both groups who underwent adjustable gastric band laparoscopically as a revision procedure after a two year follow up appointment showed Group A had a mean estimate weight loss of 30.75 lbs. (11%) with a mean Body Mass Index of 40.7 kg/m2 and Group B had a mean estimate weight loss of 42 lbs. (15%) with a mean Body Mass Index of 36.77 kg/m2 . Group A had an Excess Body Weight Loss of 27% at 1 month and 33% at the 2 year follow up and Group B had an Excess Body Weight Loss of 42.2%. Group B had an Excess Body Weight Loss of 15.1 % at 1 month and 42.2% at the 2 year follow up. Conclusion: Group A had an average of 27% Excess Body Weight Loss and Group B had an Excess Body Weight Loss of 15.1% after 1 month on follow up. Our study was limited by the small sample size. We suggest that further investigational studies, with greater and more diverse sample sizes, be conducted to assure the benefit of using the adjustable gastric band as a revision surgery. Based on our results we conclude that the adjustable gastric band as a revision surgery is a promising and sensible alternative treatment option for patients with a previously failed laparoscopic vertical sleeve gastrectomy or a failed Roux-en-Y gastric bypass.

Endoscopia preoperatoria en cirugía bariátrica: es realmente necesaria / Preoperative endoscopy in bariatric surgery: it is really necessary

Patologías esofagogástricas son reconocidas antes y después de procedimientos bariátricos, pero frecuentemente y severamente debatidos. Se realizó un estudio con la finalidad de comparar los hallazgos endoscópicos del aparato digestivo superior con los resultados de anatomía patológica en pacientes sometidos a bypass gástrico laparoscópico en Y de Roux y gastrectomía en manga por obesidad mórbida. Un total de 142 pacientes fueron incluidos en el estudio, todos bajo un régimen de seguimiento. Se hicieron análisis retrospectivos con hallazgos endoscópicos preoperatorios. Los reportes endoscópicos estuvieron disponibles para el total de los pacientes incluidos, asimismo los reportes de biopsias endoscópicas. El promedio de edad fue 34.7 años, 88 (61.9 por ciento) pacientes eran mujeres y 54 (38 por ciento) hombres. El hallazgo endoscópico patológico predominante fue gastritis erosiva 56.3 por ciento (80/142), seguida por gastritis nodular 17.6por ciento (25/142), hernia hiatal tipo I 3.5 por ciento (5/142), esofagitis 3.5 por ciento (5/142), duodenitis inespecífica 2.8 por ciento (4/142), pólipos gástricos 2,8 por ciento (4/142), y 18 estudios normales 12.6 por ciento. En cuanto a resultados de biopsias reportamos 243 hallazgos y el total no se corresponde con el número de casos en vista que algunos pacientes tenían más de una patología. El hallazgo más frecuente fue gastritis crónica 96.4% (137/142), infección por Helicobacter pylori 40.8 por ciento (58/142), hiperplasia foveolar difusa 14.7 por ciento (21/142), hiperplasia foveolar focal 15.4 por ciento (22/142), pólipos hiperplásicos 2.8 por ciento (4/142) y acantosis irregular 0.7 por ciento (1/142). Concluyendo de los 142 pacientes estudiados, solo 18 (12.6 por ciento) estudios resultaron normales, sin embargo, no se corresponden con biopsias indemnes, pero los hallazgos patológicos no tienen relevancia clínica, por lo que ni la endoscopia preoperato.(AU)

Esophagogastric diseases are recognized before and after bariatric procedures, but frequently and severely debated. A study with aim to compare the endoscopic findings of the upper digestive tract with the results of pathology in patients undergoing Roux en Y laparoscopic gastric bypass and sleeve gastrectomy for morbid obesity was performed. A total of 142 patients were included in the study, all under a monitoring regime. Retrospective analysis with preoperative endoscopic findings were made. Endoscopic reports were available for all patients included also reports of endoscopic biopsies. The average age was 34.7 years, 88 (61.9 percent) patients were female and 54 (38 percent) men. The predominant pathological endoscopic finding was erosive gastritis 56.3m percent (80/142), followed by nodular gastritis 17.6 percent (25/142), type I hiatal hernia 3.5 percent (5/142), esophagitis 3.5 percent (5/142), unspecific duodenitis 2.8 percent (4/142), gastric polyps 2.8 percent (4/142), and 18 normal studies 12.6 percent. As biopsy results we report total findings 243 does not correspond to the number of cases in view some patients had more than one pathology. The most common finding was chronic gastritis 96.4 percent(137/142), Helicobacter pyloriinfection 40.8 percent (58/142), foveal diffuse hyperplasia 14.7 percent (21/142), foveal focal hyperplasia 15.4 percent (22/142), hyperplastic polyps 2.8 percent (4/142) and irregular acanthosis 0.7 percent (1/142). In conclusion of the 142 patients studied, only 18 (12.6 percent) studies were normal, however the pathological findings have no clinical relevance, so neither preoperative endoscopy in the obese patient and the histological study of the stomach and duodenum appear to be justified in our population.(AU)