Clinical effect of minimally invasive duodenum preserving pancreatic head resection for benign and pre-malignant lesions of pancreatic head / 中华外科杂志

Objective: To examine the clinical effect of minimally invasive duodenum preserving pancreatic head resection(DPPHR) for benign and pre-malignant lesions of pancreatic head. Methods: The clinical data of patients with diagnosis of benign or pre-malignant pancreatic head tumor were retrospectively collected and analyzed,all of them underwent laparoscopic or robotic DPPHR between October 2015 and September 2021 at Division of Gastrointestinal and Pancreatic surgery,Zhejiang Provincial People's Hospital. Thirty-three patients were enrolled with 10 males and 23 females. The age(M(IQR)) was 54(32) years old(range: 11 to 77 years old) and the body mass index was 21.9(2.9)kg/m2(range: 18.1 to 30.1 kg/m2). The presenting symptoms included abdominal pain(n=12), Whipple triad(n=2), and asymptomatic(n=19). There were 7 patients with hypertension and 1 patient with diabetes mellitus. There were 19 patients who were diagnosed as American Society of Anesthesiologists class Ⅰ and 14 patients who were diagnosed as class Ⅱ. The student t test,U test, χ2 test or Fisher exact test was used to compare continuous data or categorized data,respectively. All the perioperative data and metabolic morbidity were analyzed and experiences on minimally invasive DPPHR were concluded. Results: Fourteen patients underwent laparoscopic DPPHR,while the rest of 19 patients received robotic DPPHR. Indocyanine green fluorescence imaging was used in 19 patients to guide operation. Five patients were performed pancreatico-gastrostomy and the rest 28 patients underwent pancreaticojejunostomy. Pathological outcomes confirmed 9 solid pseudo-papillary neoplasms, 9 intraductal papillary mucinous neoplasms, 7 serous cystic neoplasms, 6 pancreatic neuroendocrine tumors, 1 mucous cystic neoplasm, 1 chronic pancreatitis. The operative time was (309.4±50.3) minutes(range:180 to 420 minutes),and the blood loss was (97.9±48.3)ml(range:20 to 200 ml). Eighteen patients suffered from postoperative complications,including 3 patients experienced severe complications(Clavien-Dindo Grade ≥Ⅲ). Pancreatic fistula occurred in 16 patients,including 8 patients with biochemical leak,7 patients with grade B pancreatic fistula and 1 patient with grade C pancreatic fistula. No one suffered from the duodenal necrosis and none perioperative death was occurred. The length of hospital stay was 14(7) days (range:6 to 87 days). The follow-up was 22.6(24.5)months(range:2 to 74 months). None suffered from recurrence or metastasis. During the follow-up,all the patients were free of refractory cholangitis. Moreover,in the term of endocrine dysfunction,no postoperative new onset of diabetes mellitus were observed in the long-term follow-up. However,in the view of exocrine insufficiency,pancreatic exocrine insufficiency and non-alcoholic fatty liver disease (NAFLD) was complicated in 2 and 1 patient,respectively,with the supplement of pancreatic enzyme,steatorrhea and weight loss relieved,but NAFLD was awaited to be seen. Conclusions: Minimally invasive DPPHR is feasible and safe for benign or pre-malignant lesions of pancreatic head. Moreover,it is oncological equivalent to pancreaticoduodenectomy with preservation of metabolic function without refractory cholangitis.

Effect of duodenal stump reinforcement on postoperative complications in patients undergoing laparoscopic radical gastrectomy / 中华胃肠外科杂志

Objective: To evaluate the influence of duodenal stump reinforcing on the short-term complications after laparoscopic radical gastrectomy. Methods: A retrospective cohort study with propensity score matching (PSM) was conducted. Clinical data of 1204 patients with gastric cancer who underwent laparoscopic radical gastrectomy at the First Affiliated Hospital of Army Medical University from April 2009 to December 2018 were collected. The digestive tract reconstruction methods included Billroth II anastomosis, Roux-en-Y anastomosis and un-cut-Roux- en-Y anastomosis. A linear stapler was used to transected the stomach and the duodenum. Among 1204 patients, 838 were males and 366 were females with mean age of (57.0±16.0) years. Duodenal stump was reinforced in 792 cases (reinforcement group) and unreinforced in 412 cases (non-reinforcement group). There were significant differences in resection range and anastomotic methods between the two groups (both P<0.001). The two groups were matched by propensity score according to the ratio of 1∶1, and the reinforcement group was further divided into purse string group and non-purse string group. The primary outcome was short-term postoperative complications (within one month after operation). Complications with Clavien-Dindo grade ≥ III a were defined as severe complications, and the morbidity of complication between the reinforcement group and the non-reinforcement group, as well as between the purse string group and the non-purse string group was compared. Results: After PSM, 411 pairs were included in the reinforcement group and the non-reinforcement group, and there were no significant differences in baseline data between the two groups (all P>0.05). No perioperative death occurred in any patient.The short-term morbidity of postoperative complication was 7.4% (61/822), including 14 cases of anastomotic leakage (23.0%), 11 cases of abdominal hemorrhage (18.0%), 8 cases of duodenal stump leakage (13.1%), 2 cases of incision dehiscence (3.3%), 6 cases of incision infection (9.8%) and 20 cases of abdominal infection (32.8%). Short-term postoperative complications were found in 25 patients (6.1%) and 36 patients (8.8%) in the reinforcement group and the non-reinforcement group, respectively, without significant difference (χ2=2.142, P=0.143). Nineteen patients (2.3%) developed short-term severe complications (Clavien-Dindo grade ≥IIIa), while no significant difference in severe complications was found between the two groups (1.7% vs. 2.9%, χ2=1.347, P=0.246). Sub-group analysis showed that the morbidity of short-term postoperative complication of the purse string group was 2.6% (9/345), which was lower than 24.2% (16/66) of the non-purse string group (χ2=45.388, P<0.001). Conclusion: Conventional reinforcement of duodenal stump does not significantly reduce the incidence of duodenal stump leakage, so it is necessary to choose whether to reinforce the duodenal stump individually, and purse string suture should be the first choice when decided to reinforce.

Perforación duodenal por barotrauma durante colangiopancreatografía retrógrada endoscópica: caso clínico / Duodenal perforation due to barotrauma during endoscopic retrograde cholangiopancreatography: clinical case

Resumen Introducción: La perforación duodenal secundaria a la colangiopancreatografía retrógrada endoscópica (CPRE) es una complicación infrecuente y más aún cuando su mecanismo lesional es por barotrauma. La inyección de aire a alta presión produce un neumoretroperitoneo, cuya extensión y evolución lesional es incierta. Caso Clínico: Se comunica el caso de un hombre joven que sufrió una perforación duodenal durante una CPRE, su manejo quirúrgico y evolución. Discusión: El diagnóstico clínico-imagenológico suele ser precoz y claro si se detecta la lesión durante el procedimiento. El manejo terapéutico conservador o quirúrgico de esta entidad depende de varios factores que se analizan en el presente estudio.

Introduction: Duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication and even more if the mechanism of injury is secondary to barotrauma. The injection of high-pressure-air produces a pneumo-retroperitoneum, the extent and lesional evolution of which is uncertain. Clinical Case: We report the case of a young man who suffered a duodenal perforation during an ERCP, his surgical management and evolution. Discussion: The clinical-imaging diagnosis is usually early and clear if the lesion is detected during the procedure. Its conservative or surgical management will depends on several factors that are analyzed in the present study.

Robot-assisted single-anastomosis duodeno-ileal bypass with sleeve gastrectomy / 中华胃肠外科杂志

Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is simpler and has similar efficacy for obesity and obesity-associated metabolic diseases in comparison to biliopancreatic diversion with duodenal switch. We reported the first Da Vinci robot-assisted SADI-S in the treatment of severe obesity in China. This male patient was 27-year-old with height of 180 cm, body weight of 140 kg, waistline of 125 cm and body mass index of 43.2 kg/m(2). The diagnosis at admission was fatty liver, severe obesity, hypertriglyceridemia and hyperuricemia. The patient underwent Da Vinci robot-assisted SADI-S. The surgeon identified ileocecal part by appendix, then a common channel was measured retrogradely from the ileocecal valve, the distal ileum at 300 cm from the ileocecal part was marked and suspended. A sleeve gastrectomy was performed over a 34 Fr bougie tube. An end-to-side anastomosis between proximal duodenum and the pre-marked ileum was performed after duodenal bulb transection. Gastric incision was sutured with omentum reinforcement. No leakage was found after injecting methylene per os. Finally, a drainage tube was left in place under the anastomosis and close to the duodenal stump. The operation time was 244 minutes and the amount of bleeding during surgery was 50 ml. The patient recovered well with a postoperative hospital stay of 7 days and was followed up for six months. The percent of excess weight loss (EWL%) was 80.21% at 6 months after operation. The body weight, body mass index and waist circumference decreased significantly after operation. Complete remission was achieved for hypertriglyceridemia, hyperuricemia and insulin resistance. The patient suffered from cholestasis without serious complications at 6 months after operation. Our experience shows that Da Vinci robot-assisted SADI-S is safe and feasible in treating severe obesity.

Modificaciones anatómicas de la derivación biliopancreática con cruce duodenal: ¿tienen algún rol futuro en la cirugía bariátrica y metabólica? / Anatomical modifications of the biliopancreatic diversion with duodenal switch: do they have a future role in bariatric and metabolic surgery?

La derivación biliopancreática con cruce duodenal (BPD-DS) es el procedimiento bariátrico que ha mostrado los mejores resultados en cuanto a pérdida de peso y resolución de comorbilidades. Sin embargo, su adopción ha sido lenta, principalmente debido a sus complicaciones nutricionales y dificultad técnica. Dado esto, algunos autores han propuesto variaciones de este procedimiento. Estas están basadas en disminuir las anastomosis a solo una, y realizarla con un asa tipo loop (sin derivación biliopancreática). Estos cambios podrían reproducir las ventajas del BPD-DS, y eliminar algunas de sus desventajas. En este artículo, mostramos los resultados de estas variaciones comparadas con el BPD-DS, y cómo sus resultados prometedores pueden tener como consecuencia una nueva aproximación a la población que sufre de obesidad y sus comorbilidades

Biliopancreatic Diversion with duodenal switch (BPD-DS) is the bariatric surgery that has shown the better results regarding long-term weight loss and comorbidities resolution. Nevertheless, BPD-DS' adoption has been slow, mainly due to its nutritional complications, and technical complexity. Given this, some authors have proposed surgical variations of this effective procedure. These new procedures are based on reducing the anastomosis to only one, and doing it just a loop anastomosis (no biliopacreatic diversion). These changes might bring to us the advantages of BPD-DS, and eliminate some of its disadvantages. In this article, we show the results of these variations compared with BPD-DS, and how their promising results could be a new approach for obese population and bariatric surgery.

Bipartição de trânsito intestinal isolada: uma nova estratégia para cirurgia em estágios em superobesos / Isolated intestinal transit bipartition: a new strategy for staged surgery in superobesity

RESUMO Objetivo: o duodenal switch é um procedimento disabsortivo complexo, associado aos melhores resultados de perda de peso e controle metabólico. A cirurgia em etapas, com gastrectomia vertical como primeiro passo, é uma opção para reduzir complicações em pacientes superobesos. No entanto, alguns problemas persistem, como fígados grandes, que dificultam a abordagem cirúrgica, e complicações, como fístulas graves. A bipartição do trânsito intestinal é um modelo modificado e simplificado de desvio biliopancreático que complementa a gastrectomia vertical. É semelhante ao duodenal switch com menores complexidade e consequências nutricionais. Este estudo avaliou a viabilidade e a segurança da bipartição de trânsito isolada como o procedimento inicial para tratar a superobesidade. Métodos: foram incluídos 41 pacientes superobesos, com IMC médio de 54,5±3,5kg/m2. Uma bipartição de trânsito isolada laparoscópica foi realizada como o primeiro procedimento em uma nova abordagem em duas etapas. Perda de peso e complicações foram analisadas durante um ano de acompanhamento. Resultados: todos os procedimentos foram completados por laparoscopia. Após seis meses, a perda média de excesso de peso percentual foi de 28%, permanecendo estável até o final do estudo. Não houve dificuldades intraoperatórias. Metade dos pacientes apresentou diarreia precoce e três tiveram úlceras marginais. Não houve complicações cirúrgicas maiores ou mortes. Conclusão: a bipartição de trânsito isolada laparoscópica é uma nova opção para uma abordagem em estágios na superobesidade, que pode permitir um segundo procedimento mais seguro após a perda de peso ao longo de seis meses. Pode ser útil, particularmente, para pacientes com obesidade grave.

ABSTRACT Objective: biliopancreatic diversion with duodenal switch is a complex, malabsorptive procedure, associated with improved weight loss and metabolic control. Staged surgery with sleeve gastrectomy as the first stage is an option for reducing complications in superobese patients. However, some problems persist: large livers can hamper the surgical approach and complications such as leaks can be severe. Intestinal transit bipartition is a modified and simplified model of biliopancreatic diversion that complements sleeve gastrectomy. It is similar to the duodenal switch, but with less complexity and fewer nutritional consequences. This study assessed the feasibility and safety of isolated transit bipartition as the initial procedure in a two-step surgery to treat superobesity. Methods: this prospective study included 41 superobese patients, with mean BMI 54.5±3.5kg/m2. We performed a laparoscopic isolated transit bipartition as the first procedure in a new staged approach. We analyzed weight loss and complications during one year of follow-up. Results: we completed all the procedures by laparoscopy. After six months, the mean percent excess weight loss was 28%, remaining stable until the end of the study. There were no intraoperative difficulties. Half of the patients experienced early diarrhea, and three had marginal ulcers. There were no major surgical complications or deaths. Conclusion: isolated laparoscopic transit bipartition is a new option for a staged approach in superobesity, which can provide a safer second procedure after effective weight loss over six months. It may be useful particularly in the management of patients with severe obesity.

Parietal peritoneum graft for duodenum injuries in an animal model / Enxerto de peritônio parietal em lesão duodenal: modelo animal

ABSTRACT Background: Duodenal injuries and their surgical procedure cause a high morbidity and mortality. Aim: To assess the overall effectiveness of the auto-graft of peritoneum in the treatment of the perforation of the duodenum, aiming to reduce surgery time, costs, complexity and mortality. Methods: Twelve New Zealand rabbits, ages 4-6 months, both sexes, underwent designed surgical grade III duodenal injuries that were repaired 18 h after. Rabbits were surgically treated with the proposed auto-graft of peritoneum. Results: No postoperative deaths were observed; the animals presented corporal weight increase and were euthanized six months later. There was no significant difference between both groups relating to the postoperative evolution or in the histological changes. Conclusion: Auto-graft of the peritoneum and posterior fascia is a useful option for duodenal repair and that is worth of evaluation for humans.

RESUMO Racional: Lesões duodenais e seu procedimento cirúrgico causam alta morbimortalidade. Objetivo: Avaliar a eficácia geral de retalho peritoneal no tratamento da perfuração do duodeno, visando reduzir o tempo, os custos, a complexidade e a mortalidade cirúrgicas. Métodos: Doze coelhos da raça Nova Zelândia, com idades entre 4-6 meses, ambos os sexos, foram submetidos a lesões duodenais cirúrgicas de grau III, que foram reparadas 18 h depois. Coelhos foram tratados cirurgicamente com a proposta de auto-enxerto de peritônio. Resultados: Não foram observados óbitos pós-operatórios; os animais apresentaram aumento de peso corporal e foram eutanasiados seis meses depois. Não houve diferença significativa entre os dois grupos em relação à evolução pós-operatória ou nas alterações histológicas. Conclusão: A auto-enxertia do peritônio e da fáscia posterior é uma opção útil para o reparo duodenal e vale a pena ser avaliada em seres humanos.

Rotinas e condutas em cirurgias para as doenças malignas e benignas do esôfago, estômago e duodeno / Preoperative care in surgeries for the malignant and benign diseases of oesophagus, stomach and duodenum

Resumo: As doenças que acometem o trato digestivo alto, mais precisamente o esôfago, estômago e duodeno revestem-se de grande importância não só devido à relevância epidemiológica (com incidências elevadas e crescentes), mas também pela intensidade dos sintomas e a gravidade das complicações, comprometendo de forma significativa a qualidade de vida dos seus portadores. Nas últimas décadas, os avanços nos cuidados a pacientes portadores de doenças benignas e malignas do aparelho digestivo superior se manifestaram por meio da introdução de novos métodos de diagnóstico e estadiamento, mudanças no paradigma das estratégias perioperatórias e desenvolvimento de novos procedimentos, técnicas e vias de acesso cirúrgicos; ampliando ainda mais o espectro de opções diagnósticas e terapêuticas. Diante do amplo acesso a uma quantidade imensa de informações provida pela medicina atual, o desenvolvimento de protocolos de cuidados pré- e pós-operatórios baseados em evidências, resulta em auxílio na tomada de decisão e certamente também contribui para melhoria dos resultados cirúrgicos. Pela complexidade associada, é imperativo que o seguimento destes pacientes seja realizado em serviços terciários, muitos dos quais também se constituem em hospitais de ensino, com participação contínua de profissionais em treinamento e aprendizado. O presente projeto objetiva à elaboração de manual de rotinas e condutas específicas para o tratamento cirúrgico das doenças malignas e benignas do esôfago, estômago e duodeno; fundamentado em evidências clínicas e com aplicação em hospital de nível terciário. No contexto de hospitais universitários, de ensino e de referência ¿ que contem com equipes médicas, de enfermagem e multidisciplinares, além do envolvimento de alunos e médicos residentes em treinamento ¿ a implementação de protocolos de assistência possui relevância ainda maior, visto que não apenas diferencia e favorece melhores resultados operatórios, menor morbimortalidade e maior sobrevida em geral, mas também uniformiza condutas facilitando o processo de aprendizagem(AU)

Abstract: The diseases that affect the upper digestive tract, the esophagus, stomach and duodenum, are of great importance not only due to the epidemiological relevance (with high and increasing incidence), but also the intensity of the symptoms and the severity of the complications, compromising patients quality of life. Lately, the advances in patients care with benign and malignant diseases of the upper digestive system have consisted in the introduction of new diagnostic methods, changes in the paradigm of perioperative strategies and the development of new procedures, techniques and surgical access; expanding the spectrum of diagnostic and therapeutic options. Given the broad access to a vast amount of information provided by current medicine, the development of pre-and post-operative guidelines based on evidence, results in better decision making and certainly also contributes to improved surgical outcomes. Because of the associated complexity, it is imperative that the follow-up of these patients be performed in tertiary services, many of which also constitute teaching hospitals, with continuous participation of professionals in training and learning. The present project aims the elaboration of a guideline of specific routines and procedures for the surgical treatment of malignant and benign diseases of the esophagus, stomach and duodenum; based on clinical evidence. In the context of university, teaching and reference hospitals - which includes medical, nursing and multidisciplinary teams, as well as the involvement of students and physicians in training - the implementation of assistance protocols will have even greater influence, since it not only favors better overall survival, but also facilitates the learning process(AU)

Cirugía de supresión ácida y derivación duodenal laparoscópica vs abierta en esófago de Barrett extenso: resultados y complicaciones a corto y largo plazo / Laparoscopic versus open fundoplication with acid suppression/duodenal diversion technique for long segment Barrettís esophagus

Resumen Introducción: En pacientes con esófago de Barrett largo hemos sugerido efectuar fundoplicatura con antrectomía, vagotomía y derivación duodenal en Y de Roux que podría asociarse con complicaciones y efectos colaterales. Objetivo: El objetivo de este estudio es comparar la cirugía por vía abierta vs laparoscópica en cuanto a complicaciones postoperatorias precoces y alejadas, mortalidad y resultados alejados. Material y método: Se comparan 2 cohortes de pacientes, 73 pacientes con cirugía abierta y 53 pacientes operados con la misma técnica por vía laparoscópica por el mismo equipo. Solo se incluyeron los pacientes con Barret largo. Se controlan clínicamente en el postoperatorio inmediato y alejado, con endoscopia e histología anual, y se evalúan los resultados en cuanto a complicaciones precoces, alejadas y se analiza la calidad de vida y la satisfacción del paciente. Para el análisis se utilizó «t¼ de Student considerando un valor de p < 0,05 como significativo. Resultados: En cuanto a complicaciones precoces en ambos grupos no hubo diferencias significativas. No hubo mortalidad postoperatoria. En las complicaciones tardías las complicaciones totales no son significativamente diferentes entre ambos grupos (solo cambian sus causas y características) ni en cuanto a la clasificación de Visick y el puntaje de calidad de vida. Conclusión: La fundoplicatura con procedimiento de supresión ácida y derivación biliar por vía laparoscópica presenta similares resultados a corto y largo plazo que la cirugía abierta, pero con los beneficios de una cirugía mínimamente invasiva.

Abstract Introduction: In patients with long Barrett esophagus we have suggested to perform fundoplication with antrectomy, vagotomy and Roux-en-Y duodenal diversion however it could be associated with complications and side effects. Objective: The objective of this study is to compare open versus laparoscopic surgery for early and early postoperative complications, mortality and distant outcomes. Material and method: We compare 2 cohorts of patients, 73 patients with open surgery and 53 patients, who underwent laparoscopic surgery using the same technique. Only patients with Long Barrett were included. They are clinically monitored in the early and late postoperative period, with endoscopy and histology at long term follow-up (3-5 years). The results were evaluated in terms of early and late complications, the quality of life and patient satisfaction were analyzed. For the analysis we used t-student considering a P < .05 as significant. Results: As for early complications, there were no significant differences in both groups. There was no postoperative mortality. In the late complications, the total complications are not significantly different between the two groups (only their causes and characteristics changed) neither in terms of Visick's classification and the quality of life score Conclusion: The fundoplication, with laparoscopic acid suppression and duodenal diversion, presents similar short-term and long-term results than open surgery, with the benefits of a mini-invasive procedure.

Effects of duodenal-jejunal bypass on structure of diaphragm in western diet obese rats

Abstract Purpose: To evaluate the effects of duodenal-jejunal bypass (DJB) on the diaphragm muscle of obese rats fed on a western diet (WD) . Methods: Eighteen male Wistar rats were fed a standard rodent chow diet (CTL group) or WD ad libitum. After 10 weeks, WD rats were submitted to sham (WD SHAM) or duodenal-jejunal bypass (WD DJB). The structure, ultrastructure, collagen content and the morphometry of the neuromuscular junctions (NMJs) were analyzed two months after surgery. Results: WD SHAM rats displayed an increase in body weight, the Lee index and retroperitoneal and peri-epididymal fat pads compared to the CTL group. DJB did not alter these parameters. The muscle fiber structure and NMJs were similar in the WD SHAM and CTL groups. However, the WD SHAM group showed alterations in the fiber ultrastructure, such as loosely arranged myofibrils and Z line disorganization. In addition, WD SHAM animals presented a considerable amount of lipid droplets and a reduction in the percentage of collagen compared to the CTL group. DJB did not affect the structure or ultrastructure of the muscle fibers or the NMJs in the diaphragm of the WD DJB animals. Conclusion: Duodenal-jejunal bypass did not improve the alterations observed in the diaphragm of western diet obese-rats.

Duodenal-jejunal bypass normalizes pancreatic islet proliferation rate and function but not hepatic steatosis in hypothalamic obese rats

Modifications in life-style and/or pharmacotherapies contribute to weight loss and ameliorate the metabolic profile of diet-induced obese humans and rodents. Since these strategies fail to treat hypothalamic obesity, we have assessed the possible mechanisms by which duodenal-jejunal bypass (DJB) surgery regulates hepatic lipid metabolism and the morphophysiology of pancreatic islets, in hypothalamic obese (HyO) rats. During the first 5 days of life, male Wistar rats received subcutaneous injections of monosodium glutamate (4 g/kg body weight, HyO group), or saline (CTL). At 90 days of age, HyO rats were randomly subjected to DJB (HyO DJB group) or sham surgery (HyO Sham group). HyO Sham rats were morbidly obese, insulin resistant, hypertriglyceridemic and displayed higher serum concentrations of non-esterified fatty acids (NEFA) and hepatic triglyceride (TG). These effects were associated with higher expressions of the lipogenic genes and fatty acid synthase (FASN) protein content in the liver. Furthermore, hepatic genes involved in β-oxidation and TG export were down-regulated in HyO rats. In addition, these rats exhibited hyperinsulinemia, β-cell hypersecretion, a higher percentage of islets and β-cell area/pancreas section, and enhanced nuclear content of Ki67 protein in islet-cells. At 2 months after DJB surgery, serum concentrations of TG and NEFA, but not hepatic TG accumulation and gene and protein expressions, were normalized in HyO rats. Insulin release and Ki67 positive cells were also normalized in HyO DJB islets. In conclusion, DJB decreased islet-cell proliferation, normalized insulinemia, and ameliorated insulin sensitivity and plasma lipid profile, independently of changes in hepatic metabolism.

Preliminary analysis of interleukin-6 changes in pre- and postoperative in diabetic patients with bmi <35 submitted to partial duodenal switch / Análise preliminar da variação dos níveis de interleucina-6 no pré e pós-operatório de pacientes diabéticos com imc <35 submetidos ao desvio duodenal parcial

ABSTRACT Background: Studies related to obesity have shown association with metabolic syndrome. Data showing that obesity is capable to cause low grade chronic inflammation, without its classic signs and symptoms, call attention to researches to study different cells types and the mechanism of the inflammatory process. Aim: To evaluate the variation of glycated hemoglobin (HbA1c) and the pro-inflammatory cytokine interleukin-6 (IL6) in diabetic patients with BMI <35 kg/m2 in the pre and postoperative of partial duodenal switch. Method: Nine patients were studied before and one year after the operation and the variation of the serum IL6 was measured by Elisa. The changes of HbA1c were also registered. Results: The pre-operative IL6 levels reached 65,50436±2,911993 pg/ml and one year after de operation 39,47739±3,410057 and the HbA1c average of 10,67 and 5.8 in the same period. Conclusion: The partial duodenal switch was efficient to control one year after the procedure the chronic inflammatory process caused by the diabetes mellitus type 2 with BMI <35 by dropping the IL6 levels and bringing the HbA1c to normal.

RESUMO Racional: Os estudos relacionados à obesidade têm evidenciado sua associação com a síndrome metabólica. A descoberta que a obesidade é capaz de promover inflamação, sem os sinais clássicos, tem levado vários grupos de pesquisa a caracterizar os tipos celulares que agem e o mecanismo envolvido neste processo. Objetivo: Avaliar a variação da hemoglobina glicada e a secreção da citocina inflamatória, interleucina-6, em indivíduos diabéticos com IMC<35 kg/m² no pré e pós-operatório da técnica de desvio duodenal parcial. Métodos: Nove pacientes foram avaliados antes e um ano após a operação e a variação da concentração da interleucina-6 foi avaliada pela metodologia de Elisa. Também foi avaliada a variação da HbA1c. Resultados: A quantificação de interleucina-6 apresentou no pré-operatório valor de 65,50436±2,911993 pg/ml e de 39,47739+3,410057 pg/ml após um ano da operação e a hemoglobina glicada apresentou média de 10,67 no pré-operatório e de 5,8 após um ano da operação. Conclusão: O desvio duodenal parcial foi capaz de, um ano após o procedimento, diminuir os efeitos da inflamação crônica demonstrada pela diminuição da concentração da interleucina-6 plasmática e normalizar a hemoglobina glicada em pacientes diabéticos com IMC<35 kg/m2.

Critical analysis and systematization of rat pancreatectomy terminology

ABSTRACT PURPOSE: To critically analyze and standardize the rat pancreatectomy nomenclature variants. METHODS: It was performed a review of indexed manuscripts in PUBMED from 01/01/1945 to 31/12/2015 with the combined keywords "rat pancreatectomy" and "rat pancreas resection". The following parameters was considered: A. Frequency of publications; B. Purpose of the pancreatectomy in each article; C. Bibliographic references; D. Nomenclature of techniques according to the pancreatic parenchyma resection percentage RESULTS: Among the 468, the main objectives were to surgically induce diabetes and to study the genes regulations and expressions. Five rat pancreatectomy technique references received 15 or more citations. Twenty different terminologies were identified for the pancreas resection: according to the resected parenchyma percentage (30 to 95%); to the procedure type (total, subtotal and partial); or based on the selected anatomical region (distal, longitudinal and segmental). A nomenclature systematization was gathered by cross-checking information between the main surgical techniques, the anatomic parameters descriptions and the resected parenchyma percentages. CONCLUSION: The subtotal pancreatectomy nomenclature for parenchymal resection between 80 and 95% establishes a surgical parameter that also defines the total and partial pancreatectomy limits and standardizes these surgical procedures in rats.

ASSESSMENT OF THE GASTRO-JEJUNO-DUODENAL TRANSIT AFTER JEJUNAL POUCH INTERPOSITION / AVALIAÇÃO DO TRÂNSITO GASTROJEJUNODUODENAL APÓS INTERPOSIÇÃO DE ALÇA JEJUNAL

Background : The jejunal pouch interposition between the gastric body and the duodenum after the gastrectomy, although not frequent in the surgical practice today, has been successfully employed for the prevention and treatment of the postgastrectomy syndromes. In the latter, it is included the dumping syndrome, which affects 13-58% of the patients who undergo gastrectomy. Aim : Retrospective assessment of the results of this procedure for the prevention of the dumping syndrome. Methods : Fourty patients were selected and treatetd surgically for peptic ulcer, between 1965 and 1970. Of these, 29 underwent vagotomy, antrectomy, gastrojejunalduodenostomy at the lesser curvature level, and the 11 remaining were submitted to vagotomy, antrectomy, gastrojejunal-duodenostomy at the greater curvature level. The gastro-jejuno-duodenal transit was assessed in the immediate or late postoperative with the contrasted study of the esophagus, stomach and duodenum. The clinical evolution was assessed according to the Visick grade. Results : Of the 40 patients, 28 were followed with the contrast evaluation in the late postoperative. Among those who were followed until the first month (n=22), 20 (90%) had slow gastro-jejuno-duodenal transit and in two (10%) the transit was normal. Among those who were followed after the first month (n=16), three (19%) and 13 (81%) had slow and normal gastric emptying, respectively. None had the contrasted exam compatible with the dumping syndrome. Among the 40 patients, 22 underwent postoperative clinical evaluation. Of these, 19 (86,5%) had excellent and good results (Visick 1 and 2, respectively). Conclusions : The jejunal pouch interposition showed to be a very effective surgical procedure for the prevention of the dumping syndrome in gastrectomized patients.

Racional : A interposição de alça jejunal entre o corpo gástrico e o duodeno após a antrectomia, apesar de pouco frequente na prática cirúrgica atual, tem sido empregada com sucesso na prevenção e tratamento das síndromes pós-gastrectomias. Entre estas se inclui a síndrome de dumping, que acomete 13-58% dos pacientes gastrectomizados. Objetivo : Avaliação retrospectiva dos resultados desse procedimento na prevenção da síndrome de dumping. Métodos : Foram selecionados 40 pacientes todos encaminhados para tratamento cirúrgico de úlcera cloridropéptica entre 1965 e 1970. Destes, 29 foram submetidos à vagotomia, antrectomia, gastrojejunoduodenostomia no nível da pequena curvatura, e os 11 restantes à vagotomia, antrectomia, gastrojejunoduodenostomia no nível da grande curvatura. O trânsito gastrojejunoduodenal foi avaliado no pós-operatório imediato ou tardio por meio do estudo contrastado de esôfago, estômago e duodeno. A evolução clínica no pós-operatório foi avaliada segundo a classificação de Visick. Resultados : Dos 40 pacientes, 28 foram acompanhados com o estudo contrastado no pós-operatório tardio. Entre aqueles de até o 1º mês de pós-operatório (n=22), 20 (90%) apresentaram o trânsito gastrojejunoduodenal lento e dois (10%) tiveram o trânsito normal. Entre os que puderam ser acompanhados após o 1º mês (n=16), três (19%) e 13 (81%) mostraram o esvaziamento gástrico lento e normal, respectivamente. Nenhum apresentou o estudo contrastado compatível com a síndrome de dumping. Entre os 40 doentes, 22 foram submetidos à avaliação clínica pós-operatória. Destes, 19 (86,5%) apresentaram excelentes e bons resultados (Visick 1 e 2, respectivamente). Conclusões : A interposição de alça jejunal mostrou-se procedimento cirúrgico bastante eficaz na prevenção da síndrome de dumping em pacientes gastrectomizados.

Can Endoscopic Ultrasonography-guided Biliary Drainage Using Self-expandable Metal Stents in Malignant Distal Biliary Obstruction Be a Substitute When Endoscopic Retrograde Cholangiopancreatography Has Failed? / 대한소화기학회지

No abstract available.

Duodenal jejunal bypass attenuates non-alcoholic fatty liver disease in western diet-obese rats

PURPOSE: To evaluate the effects of duodenal-jejunal bypass (DJB) on serum and hepatic profiles of obese rats fed on a western diet (WD). METHODS: Twenty eight male Wistar rats were fed a standard rodent chow diet (CTL group) or WD ad libitum. After 10 weeks, WD rats were submitted to sham (WD SHAM) or duodenal-jejunal bypass (WD DJB). Body weight, fat pad depots, glycemia, insulinemia, HOMA-IR, TyG, lipids profile and hepatic analyses were evaluated two months after surgery. RESULTS: The WD SHAM group presented greater obesity, hyperglycemia, hyperinsulinemia, insulin resistance, hypertriglyceridemia and hepatic steatosis than the CTL group. WD DJB rats presented decreased serum glucose and insulin resistance, when compared to WD SHAM animals, without changes in insulinemia. In addition, DJB surgery normalized serum TG and attenuated TG accumulation and steatosis in the liver of the WD DJB group. Hepatic ACC and FAS protein expressions were similar in all groups. CONCLUSION: Duodenal-jejunal bypass attenuates hepatic parameters of non-alcoholic fatty liver disease in obese rats fed on a western diet. .

Is there a role for pyloric exclusion after severe duodenal trauma? / Existe lugar para a exclusão pilórica no trauma duodenal grave?

Duodenal trauma is an infrequent injury, but linked to high morbidity and mortality. Surgical management of duodenal injuries is dictated by: patient's hemodynamic status, injury severity, time of diagnosis, and presence of concomitant injuries. Even though most cases can be treated with primary repair, some experts advocate adjuvant procedures. Pyloric exclusion (PE) has emerged as an ancillary method to protect suture repair in more complex injuries. However, the effectiveness of this procedure is debatable. The "Evidence Based Telemedicine - Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical appraisal of the literature and selected three relevant publications on the indications for PE in duodenal trauma. The first study retrospectively compared 14 cases of duodenal injuries greater than grade II treated by PE, with 15 cases repaired primarily, all of which penetrating. Results showed that PE did not improve outcome. The second study, also retrospective, compared primary repair (34 cases) with PE (16 cases) in blunt and penetrating grade > II duodenal injuries. The authors concluded that PE was not necessary in all cases. The third was a literature review on the management of challenging duodenal traumas. The author of that study concluded that PE is indicated for anastomotic leak management after gastrojejunostomies. In conclusion, the choice of the surgical procedure to treat duodenal injuries should be individualized. Moreover, there is insufficient high quality scientific evidence to support the abandonment of PE in severe duodenal injuries with extensive tissue loss.

O trauma duodenal é incomum, mas possui alta morbimortalidade. As condições clínicas dos pacientes, gravidade das lesões, tempo de diagnóstico e lesões associadas influenciam na escolha do procedimento operatório. A maioria das lesões duodenais é tratada com reparo primário. Procedimentos adjuvantes para proteger a linha de sutura e evitar deiscência podem ser úteis em lesões complexas. Embora a exclusão pilórica (EP) seja utilizada em lesões duodenais graves, há controvérsia quanto a sua necessidade. A reunião "Telemedicina Baseada em Evidências - Cirurgia do Trauma e Emergência" (TBE-CiTE) revisou a literatura e selecionou três publicações relevantes sobre as indicações de EP no trauma duodenal. O primeiro estudo, retrospectivo, comparou 14 pacientes com ferimentos penetrantes duodenais grau > II, tratados com EP, com 15 pacientes semelhantes tratados com reparo primário; não houve diferença nos resultados. O segundo, também retrospectivo, comparou o reparo primário (34 casos) com EP (16 casos), em lesões duodenais contusas ou penetrantes grau > II. Os autores concluíram que a EP não é necessária para todos os pacientes, apesar de lesões duodenais graves. O terceiro estudo constituiu-se de revisão da literatura sobre os desafios do tratamento dos traumatismos duodenais. Na experiência do autor, a EP é útil nos casos de fístula de anastomoses gastrojejunais. Conclui-se que a escolha do procedimento operatório no tratamento das lesões duodenais deve ser individualizada. Não há evidência cientifica de boa qualidade para justificar o abandono da EP no tratamento das lesões duodenais graves com grande perda tecidual.

Efeitos do dispositivo temporário de exclusão duodenojejunal sobre o esvaziamento gástrico de pacientes obesos e diabéticos tipo 2 / Effects of temporary duodenojejunal exclusion device on Gastric Emptying of obese and type 2 diabetic patients

INTRODUÇÃO: Obesidade é, hoje, considerada uma pandemia, com cerca de 500 milhões de obesos no mundo, com cerca de 2,8 milhões de mortes por ano. A cirurgia de bypass gástrico é um importante tratamento para obesidade, porém, não é isenta de riscos. O dispositivo temporário de exclusão duodeno jejunal - DTED (EndoBarrier Gastrointestinal Liner® GIDynamics, Inc. Lexington, MA), apresenta-se como uma nova forma de tratamento endoscópico da obesidade. Apesar dos bons resultados, os mecanismos de ação do DTED ainda não foram estudados, podendo as alterações humorais e do esvaziamento gástrico promovidas, ser os principais responsáveis pelos resultados obtidos. OBJETIVO: Estudar as alterações promovidas pelo DTED no esvaziamento gástrico, e a relação destas alterações com os resultados clínicos de perda de peso e controle do diabetes tipo 2. MÉTODOS: Vinte e cinco obesos e com diabetes tipo 2, que fizeram uso do DTED por período mínimo de 16 semanas e máximo de 24 semanas, realizaram teste de esvaziamento gástrico cintilográfico, antes, durante a 16ª semana de uso e após 4 semanas de retirada do DTED. Foram obtidas medidas de peso e hemoglobina glicada. As médias e desvio-padrão de retenção gástricas foram obtidas e comparadas entre os três exames realizados, e, após, comparados entre os pacientes que obtiveram e os que não obtiveram melhora no parâmetro clínico selecionado (perda de peso maior que 10%, e hemoglobina glicada menor que 7%). Também se avaliou subjetivamente a sensação de saciedade e quantidade de alimento ingerido durante a 16ª semana de uso do dispositivo. RESULTADOS: Quando avaliadas médias de retenção, nota-se que, na 16ª semana de uso, há maior retenção para a primeira, segunda e quarta horas quando comparados ao baseline (1ª h 74 ± 16,3 % p=0,001, 2ª h 45 ± 25% p < 0,001; 4ª 15 ± 15,8% p < 0,001). Não há diferença estatística entre as retenções na 16ª semanas entre os pacientes que atingiram e os que não atingiram...

INTRODUCTION: Obesity is now considered a pandemic, with about 500 million obese worldwide, with about 2.8 million deaths per year. The gastric bypass surgery is an important treatment for obesity, however, not without risks. The temporary duodenal jejunal exclusion device - DTED (EndoBarrier ® Gastrointestinal Liner GIDynamics, Inc. Lexington, MA), presents itself as a new form of endoscopic treatment of obesity. Despite the good results, the mechanisms of action of DTED have not been studied, and the humoral changes and changes in gastric emptying promoted by the device maybe are the main mechanisms of action of the device. OBJECTIVE: To study the changes introduced by DTED in gastric emptying, and the relationship of these changes with clinical outcomes of weight loss and control of type 2 diabetes. METHODS: Twenty five obese patients with type 2 diabetes who used the DTED for a minimum of 16 weeks and maximum 24 weeks underwent a scintigraphic gastric emptying test, before, during the 16th week of treatment and after 4 weeks of withdrawal the DTED. Measurements of weight, glycated hemoglobin were obtained. The mean and standard deviation of gastric retention were obtained and compared between the three tests, and after, compared between patients who were and those who showed no improvement in selected clinical parameters (weight loss greater than 10%, and lower glycated hemoglobin 7%). Also, a subjective evaluation of the feeling of satiety and amount of food ingested during the 16 weeks of device use was done. RESULTS: When evaluated average retention , we note that in the 16th week of use there is greater retention for the first, second and fourth hour compared to baseline (1st h 74 ± 16.3 % p = 0.001, 2nd h 45 ± 25 % p < 0.001 4th 15.8 ± 15 %, p < 0.001). There is no statistical difference among patients who achieved and those who have not reached the control of diabetes (p = 0.73) or among those who lost more than 10 % by weight and not lost...

Síndrome pinzamiento mesentérico: a propósito de un caso de hiperemesis / Superior mesenteric aartery syndrome: in relation to a case of hypermesis

INTRODUCCIÓN: El Síndrome de Arteria Mesentérica (SAMS) o Pinzamiento Mesentérico es un trastorno adquirido poco frecuente. Su característica principal es la obstrucción de origen vascular de la tercera porción duodenal, entre la arteria mesentérica superior y la aorta abdominal. CASO CLÍNICO: Mujer de 42 años de edad con antecedentes de trastorno depresivo, colecistectomizada en 1994 y múltiples hospitalizaciones por hiperemesis desde 1995 con estudios no concluyentes. Ingresó en diciembre de 2011 por vómitos alimentarios, con gran compromiso nutricional. Se le realizaron múltiples estudios que descartaron enfermedades reumatológicas, hepáticas e infecciosas. Entre los estudios imagenológicos, la endoscopía digestiva alta mostró esofagitis congestiva leve y gastritis crónica antral, al igual que todas las endoscopias previas. En la radiografía seriada esófago-gastroduodenal se observa severo reflujo gastroesofágico,y compresión compatible con pinzamiento. La tomografía computarizada de abdomen y pelvis mostraba el estómago de mayor tamaño que lo habitual y el duodeno presentaba nuevamente esta compresión compatible con pinzamiento. En base a estos últimos hallazgos imagenológicos, y luego de descartar variados diagnósticos diferenciales se planteó un SAMS y se decidió realizar bypass duododenoyeyunal, con buena evolución posterior. DISCUSIÓN: El diagnostico de SAMS es muchas veces de exclusión, basado en la clínica y la imagenología abdominal que descarta otros cuadros clínicos. En este caso se tiene el antecedente de múltiples hospitalizaciones sin diagnóstico concluyente. Finalmente por la larga evolución del cuadro se decide una resolución quirúrgica.

INTRODUCTION: The Superior Mesenteric Artery Syndrome (SMAS) is an uncommon acquired disorder. The main characteristic is the obstruction due to compression of the third portion of the duodenum, between the superior mesenteric arthery and the abdominal aorta. CLINICAL CASE: 42-year-old female patient with a record of depressive disorder, cholecystectomyperformed in 1994 and multiple hospitalizations due to hyperemesissince 1995, with inconclusive studies. Was admitted to the hospital on December 2011 because to alimentary vomit associated with great nutritional compromise. Multiple exams were performed to discard rheumatologic, hepatic and infectious diseases. The imaging test showed high digestive endoscopy with mild esophagitis and antral chronic gastritis, as in previous endoscopies. Stomach-esophagus-duodenum radiography with gastroesophageal reflux and extrinsic compression of the duodenum. Abdominal and pelvic computed tomography revealed a larger than usual stomach’s size and a compression in the duodenum compatible with pinching. Based on these last results and after we discard other options, we diagnosed a superior mesenteric artery syndrome and it was decided to perform a duodenojejunal bypass, with favorable evolution. DISCUSSION: The diagnosis of SMAS many times is made by exclusion based on the clinic and the abdominal images, discarding other pathologies. In this case, multiple hospitalizations with inconclusive diagnostics led to performing several tests for a variety of illnesses. Finally, based on the large evolution of the case it was decided a surgical resolution.