Dermolipectomia trocantérica em paciente pós-cirurgia bariátrica: relato de caso / Trochanteric dermolipectomy in a patient after bariatric surgery: case report

Introdução: Atualmente com o aumento das gastroplastias redutoras (cirurgia bariátrica) e grande perda ponderal, há também um aumento na procura destes pacientes pela cirurgia plástica. Uma das características destes pacientes é o excesso de tecido dermogorduroso que causa deformidades, principalmente nos membros inferiores, acometendo a região trocantérica. Objetivo: Relatar um caso de dermolipectomia trocantérica em paciente pós-cirurgia bariátrica, onde a lipoaspiração por si só não resolveria a correção da deformidade. Relato de caso: IPMS, sexo feminino, 55 anos, histórico de gastroplastia redutora (cirurgia bariátrica) com grande perda ponderal. Relata desconforto importante com a lipodistrofia e extensa flacidez em região trocantérica bilateral. Após avaliação pela equipe, foi optado por realizar dermolipectomia trocantérica bilateral, em janeiro de 2019, no Serviço de Cirurgia Plástica Osvaldo Saldanha. Discussão: Nos casos de lipodistrofia trocantérica com deformidades graves, a cicatriz da dermolipectomia em relação à deformidade é favorável quanto a escolha desta técnica, pois a lipoaspiração poderá agravar ainda mais a deformidade, sendo mandatório utilizar a técnica de dermolipectomia trocantérica para corrigila. Quanto à lipodistrofia com deformidade moderada há dúvida entre a relação do benefício e a deformidade resultante, sendo aplicada a técnica de acordo com a necessidade do paciente e, por fim, nos casos de lipodistrofia com deformidade leve, opta-se pela lipoaspiração devido à correção ser realizada sem grandes cicatrizes aparentes. Conclusão: Portanto, a lipoaspiração tem benefício nos casos de adiposidade localizada, limitando as indicações da técnica de dermolipectomia, em especial na região trocantérica, sem invalidá-la para casos selecionados, como o descrito neste relato de caso.

Introduction: Currently, with the increase in reducing gastroplasty (bariatric surgery) and the great weight loss, there is also an increase in the demand of these patients for plastic surgery. One of the characteristics of these patients is the excess of dermal adipose tissue that causes deformities, especially in the lower limbs, affecting the trochanteric region. Objective: To report a case of trochanteric dermolipectomy in a patient after bariatric surgery, where liposuction alone would not solve the correction of the deformity. Case report: IPMS, female, 55 years old, history of reducing gastroplasty (bariatric surgery) with great weight loss. She reports significant discomfort with lipodystrophy and extensive flacidity in the bilateral trochanteric region. After the team's evaluation, it was decided to perform bilateral trochanteric dermolipectomy, in January 2019, at the Plastic Surgery Service Osvaldo Saldanha Discussion: In cases of trochanteric lipodystrophy with severe deformities, the scar of dermolipectomy in relation to the deformity is favorable in terms of the choice of this technique, since liposuction may further aggravate the deformity, and it is mandatory to use the trochanteric dermolipectomy technique to correct it. Conclusion: Therefore, liposuction is beneficial in cases of localized adiposity, limiting the indications for the dermolipectomy technique, especially in the trochanteric region, without invalidating it for selected cases, as described in this case report.

[Retracted Article] Gastric and jejunal histopathological changes in patients undergoing bariatric surgery / [Artigo Retratado] Alterações histopatológicas gástricas e jejunais em pacientes submetidos à cirurgia bariátrica

ABSTRACT BACKGROUND Morbid obesity is a multifactorial disease that is increasingly treated by surgery. OBJECTIVE To evaluate gastric histopathological changes in obese, and to compare with patients who underwent gastrojejunal bypass and the jejunal mucosa after the surgery. METHODS This is an observational study performed at a tertiary public hospital, evaluating endoscopic biopsies from 36 preoperative patients and 35 postoperative. RESULTS In the preoperative group, 80.6% had chronic gastritis, which was active in 38.9% (77.1% and 20.1%, respectively, in the postoperative). The postoperative group had a significant reduction in Helicobacter pylori infection (P=0.0001). A longer length of the gastric stump and a time since surgery of more than two years were associated with Helicobacter pylori infection. The jejunal mucosa was normal in 91.4% and showed slight nonspecific chronic inflammation in 8.6%. CONCLUSION There was a reduction in the incidence of Helicobacter pylori infection in the postoperative group. A longer length of the gastric stump and longer time elapsed since surgery were associated with Helicobacter pylori infection. The jejunal mucosa was considered normal in an absolute majority of patients.

RESUMO CONTEXTO A obesidade mórbida é doença multifatorial cujo tratamento cirúrgico é cada vez mais indicado. OBJETIVO Avaliar alterações histopatológicas gástricas em obesos e comparar com os submetidos à bypass gastrojejunal e a mucosa jejunal após a operação. MÉTODOS Estudo observacional realizado em hospital público terciário avaliando biópsias endoscópicas de 36 pacientes no pré-operatório e 35 no pós-operatório. RESULTADOS: No pré-operatório 80,6% apresentaram gastrite crônica, 38,9% em atividade (77,1% e 20,1%, respectivamente, no pós-operatório). O grupo pós-operatório apresentou diminuição significativa na infecção por Helicobacter pylory (P=0,0001). Maior comprimento do coto gástrico e tempo de operação superior a dois anos associaram-se a infecção por Helicobacter pylori. A mucosa jejunal foi normal em 91,4% e apresentava leve inflamação crônica inespecífica em 8,6%. CONCLUSÃO Houve diminuição da infecção por Helicobacter pylori após a operação. Maior comprimento do coto gástrico e do tempo de operação associaram-se à infecção por Helicobacter pylori. A mucosa jejunal foi considerada normal na maioria absoluta dos pacientes do grupo pós-operatório.

Mamoplastia pós-cirurgia bariátrica usando suporte protético complementar de contenção glandular / Breast augmentation after bariatric surgery by using complementary prosthetic support for glandular containment

INTRODUÇÃO: A pele de pacientes emagrecidas pós-cirurgia bariátrica apresenta alterações estruturais e proteômicas e não resiste ao peso das mamas, levando-as à flacidez residual precoce, exigindo suporte auxiliar. O objetivo é aplicar suporte auxiliar de lâmina de polipropileno não absorvível mais poliglecaprone absorvível ou lâmina de silicone de bustos, em forma de "soutien interno" como auxiliar de sustentação da pele, para manutenção da forma das mamas, e flacidez no mínimo comparável a outras pacientes sem emagrecimento pela cirurgia bariátrica. MÉTODOS: Nove pacientes foram submetidas à mamoplastia em T invertido com modelagem dos tecidos mamários, com redução do volume e envolvidos com lâmina de sustentação auxiliar. RESULTADOS: Não houve flacidez precoce e em observação de até 4 anos ela era aceitável. Uma delas apresentou seroma, drenado com boa resolução. Serão operadas outras 24 pacientes dentro do protocolo, acompanhadas e observadas por 2 anos com controle mamográfico, ultrassônico e ressonância magnética. CONCLUSÃO: A mamoplastia redutora pós-cirurgia bariátrica requer suporte extra à glândula mamária. A pele estruturalmente alterada não suporta o seu peso e haverá flacidez precoce.

INTRODUCTION: The skin presents structural and proteomic changes after bariatric surgery and cannot withstand the weight of the breasts, which leads to early residual flaccidity, requiring auxiliary support. The goal is to apply a nonabsorbable polypropylene-poliglecaprone absorbable auxiliary mesh support or Bustos silicone sheet, in the form of an "internal brassiere," to support the skin in order to maintain the shape and flaccidity of the breasts comparable with those of normal breasts. METHODS: Nine patients underwent mammoplasty in inverted T with modeling of tissue implants, reduction of breast volume, and wrapping with an auxiliary support mesh. RESULTS: Flaccidity was not observed at an early stage and the condition was acceptable for up to 4 years of follow-up. One of the patients had a seroma, which was drained with good resolution. Another 24 patients will be operated according to the protocol and observed for 2 years by using mammography, ultrasonography, and magnetic resonance imaging. CONCLUSION: Reduction mammoplasty after bariatric surgery requires additional support for the mammary gland. The structurally altered skin could not support the weight of the breasts, resulting in early flaccidity.

Considerações nutricionais para cirurgia plástica em paciente após cirurgia bariátrica / Nutritional considerations for plastic surgery in post-bariatric surgery patients

A cirurgia bariátrica continua a ser o tratamento mais efetivo para obesidade mórbida e a mais associada a outras condições metabólicas tais como diabetes tipo 2, doença refluxo gastroesofágico, e apneia do sono obstrutiva. Na população obesa, deficiências nutricionais comuns incluem vitaminas A, C, D, e B12, folato, tiamina, ferro, ferritina, zinco e selênio. Com a perda de peso ponderal, muitos pacientes podem utilizar o contorno corporal para deformidades. Após perda de peso ponderal seguida de cirurgia bariátrica, os pacientes geralmente desenvolvem deficiência nutricional significante que aumenta o risco de morbidade e mortalidade pós-operatória com quaisquer cirurgias subsequentes. Alguns pacientes requererem avaliação adicional durante a doença, ou quando candidatos eletivos pré-cirurgia, devido a alterações no trato alimentar com objetivo de melhorar os resultados e prevenir complicações devido a deficiências nutricionais.

Bariatric surgery continues to be the most effective treatment for morbid obesity and most other associated metabolic conditions such as type 2 diabetes mellitus, gastroesophageal reflux disease, and obstructive sleep apnea. In the obese population, common nutritional deficiencies include vitamins A, C, D, and B12, folate, thiamine, iron, ferritin, zinc, and selenium. With massive weight loss, many patients may utilize body contouring for deformities. After massive weight loss following bariatric surgery, patients often develop significant nutritional deficiencies that increase the risk of postoperative morbidity and mortality with any subsequent surgeries. Some unique patients will require additional evaluation during illness or when considering elective surgery due to alterations to the alimentary tract, in order to optimize outcomes and prevent complications from nutritional deficiencies.

Hallazgos histológicos gástricos en obesos mórbidos sometidos a gastrectomía vertical laparoscópica / Pathological findings in resected gastric segments after laparoscopic sleeve gastrectomy

Background: Laparoscopic sleeve gastrectomy (LSG) is used for the treatment of obesity and may provide gastric tissue for pathological studies. The association of obesity with dyslipidemias, diabetes and cardiovascular disease is of common knowledge. However its association with gastrointestinal diseases and gastritis is less well known. Aim: To analyze the pathological findings of the resected gastric segment during LSG. Material and Methods: Two hundred fifty patients aged 37 +/- 12 years and with a body mass index of 37.7 +/- 3.1 kg/m² (189 women), subjected to LSG, were included in a prospective protocol. Resected gastric segments were sent for a pathological study. Results: A gastric disease was identified in 220 (88 percent) cases. Chronic follicular gastritis was diagnosed in 117 patients (46.8 percent), chronic superficial gastritis in 76 (30.4 percent), chronic nonspecific gastritis in 38 (15.2 percent), intestinal metaplasia in 14 percent (5.6 percent) and in one case (0.4 percent) an early gastric carcinoma. Helicobacterpylori was present in 34 (13.6 percent) patients. Conclusions: This study shows a high prevalence of histopathological gastric lesions detected after the LSG, reaffirming the need for detection of these lesions before surgery.

Introducción: La gastrectomía vertical laparoscópica (GVL) es un procedimiento quirúrgico efectivo en el tratamiento de la obesidad. La obesidad está asociada con algunas comorbilidades como diabetes, dislipidemia y enfermedad cardiovascular, pero también se ha demostrado que tiene efectos potenciales sobre la gastritis y diversas enfermedades gastrointestinales. El objetivo de este estudio es determinar los hallazgos histológicos del segmento gástrico resecado durante la GVL realizada en una serie de pacientes obesos. Material y Método: Entre enero de 2006 y diciembre de 2008, 250 pacientes consecutivos a los que se realizó GVL, fueron incluídos en un protocolo prospectivo. La serie consistió en 189 mujeres (75,6 por ciento) y 61 hombres (24,4 por ciento), con edad promedio de 37,5 +/- 12,1 años. El Índice de Masa Corporal (IMC) promedio fue 37,7 +/- 3,1 kg/m². Resultados: Los resultados histológicos identificaron 220 casos (88 por ciento) con patología gástrica. Se diagnosticó gastritis crónica folicular en 117 pacientes (46,8 por ciento), gastritis crónica superficial en 76 (30,4 por ciento), gastritis crónica inespecífica en 38 (15,2 por ciento), metaplasia intestinal en 14 percent (5,6 por ciento) y en un caso (0,4 por ciento) adenocarcinoma in situ. Helicobacter pylori (HP) estuvo presente en 34 pacientes (13,6 por ciento). Conclusiones: Los hallazgos de este estudio, muestran una prevalencia incrementada de lesiones gástricas histopatológicas detectadas posterior a la GVL, reafirmando la necesidad de una detección de estas lesiones antes de la cirugía.

Argyrophil cell density in the oxyntic mucosa is higher in female than in male morbidly obese patients

Obesity is a multifactorial disorder often associated with many important diseases such as diabetes, hypertension and other metabolic syndrome conditions. Argyrophil cells represent almost the total population of endocrine cells of the human gastric mucosa and some reports have described changes of specific types of these cells in patients with obesity and metabolic syndrome. The present study was designed to evaluate the global population of argyrophil cells of the gastric mucosa of morbidly obese and dyspeptic non-obese patients. Gastric biopsies of antropyloric and oxyntic mucosa were obtained from 50 morbidly obese patients (BMI >40) and 50 non-obese patients (17 dyspeptic overweight and 33 lean individuals) and processed for histology and Grimelius staining for argyrophil cell demonstration. Argyrophil cell density in the oxyntic mucosa of morbidly obese patients was higher in female (238.68 ± 83.71 cells/mm2) than in male patients (179.31 ± 85.96 cells/mm2) and also higher in female (214.20 ± 50.38 cells/mm2) than in male (141.90 ± 61.22 cells/mm2) morbidly obese patients with metabolic syndrome (P = 0.01 and P = 0.02, respectively). In antropyloric mucosa, the main difference in argyrophil cell density was observed between female morbidly obese patients with (167.00 ± 69.30 cells/mm2) and without (234.00 ± 69.54 cells/mm2) metabolic syndrome (P = 0.001). In conclusion, the present results show that the number of gastric argyrophil cells could be under gender influence in patients with morbid obesity. In addition, gastric argyrophil cells seem to behave differently among female morbidly obese patients with and without metabolic syndrome.

Análise de pressão plantar de um indivíduo em pré e pós-operatório de cirurgia bariátrica / Analysis of one's plantar pressure in pre and post-operatory of bariatric surgery

O número de obesos no mundo cresce a cada ano. Muitos dos obesos que se encontram classificados como obesos mórbidos procuram a cirurgia bariátrica como forma de perder peso, e assim, evitar a piora das comorbidades. Sabe-se que estes indivíduos podem apresentar valores elevados de pressões plantares, que podem levar a prejuízos de locomoção e realização de atividades de vida diária (AVDs). Porém, não há estudos que comparem o comportamento da distribuição das pressões plantares médias e picos de pressão plantar no pré e pós-operatório de cirurgia bariátrica, objetivo deste estudo. Para esta análise utilizou-se um baropodômetro computadorizado, modelo Emed-at. Acoleta pré-operatória foi realizada no dia anterior à cirurgia bariátrica, e a coleta pós-operatória ocorreu 60 dias após a cirurgia. Os maiores valores de pressão plantar foram encontrados na região do hálux e cabeças dos metatarsos, em ambas as avaliações. Porém, ao compararem-se os dados de pré e pós-operatório, observou-se redução nos valores da pressão plantar no sujeito, após uma perda de peso de 13,8% do peso inicial. Configura-se a importância da redução de peso na população de obesos mórbidos, com o objetivo de reduzir a sobrecarga nos membros inferiores e evitar alterações funcionais e estruturais nos pés.

The number of obese people in the world grows each year. Many obese who are classified as morbid obese seek bariatric surgery as a way to lose weight, and thus preventing the worsening of comorbidities. It is known that these individuals may present high values for plantar pressures, which can lead to difficulties in mobility and in daily life activities. Although, there aren't any studies which compare the behavior of average plantar pressure and peaks of plantar pressure in the pre and post-operative for bariatric surgery, aim of this study. In order to perform this analysis, it was used a computerized baropometer, model Emed-at. The pre-operative evaluation was held the day before the bariatric surgery, and the post-operative evaluation took place 60 days after the surgery. The largest plantar pressure values were found in the region of the hallux and metatarsal heads in both evaluations. However, when comparing pre and post-operative data, it was noticed reduction in plantar pressure values in the subject, after a weight loss of 13.8% of the initial weight. It configures the importance of reducing the weight of morbid obese population, aiming to reduce the overload in lower limbs and to avoid strucutural and functional changes of the feet.

Manejo nutricional del niño obeso / Nutritional management of obese children

La obesidad constituye un problema grave de salud pública. La OMS la define como una acumulaciónanormal o excesiva de grasa que puede ser perjudicial para la salud. La prevalencia se ha incrementado.Enfermedad crónica, compleja y multifactorial, en la que interaccionan factores genéticos y ambientales. Elíndice de Quételet o índice de masa corporal (IMC), es usado para estimar la gravedad. La valoración inicialdebe incluir exploración física y valorar el desarrollo puberal. Se asocia, con complicaciones inmediatas,int e rmedi a s y t a rdí a s . El t r a t ami ento e s multidisciplinario e individualizado. La cirugía en la población pediátrica está limitada. No se debe perder de vista que la solución ideal a este problema es laprevención.

Obesity is a serious public health problema. WHO defines it as an accumulation of abnormal or excessive fat that can be harmful to health. The prevalence has increased. It's a chronic, complex and multifactorial patology, in which genetic and environmental factors interact. Quetelet index or body mass index is used to estímate the severity. The initial assessment should include physical examination and assess pubertal development. It is associated with immediate, intermédiate and late complications. The treatment is multidisciplinary and individualized. Surgery in the pediatric population is limited. Do not forget that the ideal solution to this problema is prevention.

Gastrectomía longitudinal en manga: abordaje laparoscópico a través de tres portales / Sleeve gastrectomy: laparoscopic approach three portals

El procedimiento bariátrico conocido como "manga gástrica" o gastrectomía longitudinal es una intervención que cada día gana más adeptos dentro del mundo quirúrgico bariátrico debido a su simplicidad técnica, ya que sólo involucra una resección subtotal del fundus y del cuerpo gástrico para crear un conducto gástrico de aspecto tubular a lo de la curva menor del estómago. La laparoscopia tradicional ha demostrado que disminuye el dolor postoperatorio, la estancia hospitalaria y el paciente reinicia más rápido de sus actividades laborales. Tradicionalmente la realización de la manga gástrica requiere la utilización de 5 a 6 portales A manera de puente entre la laparoscopia tradicional y el abordaje endoscópico con una sola incisión se plantea la realización esta operación a través de tres portales, con una incisión oculta en la cicatriz umbilical y dos incisiones de 5mm en el abdomen. Mostrar la técnica quirúrgica de las "gastrectomía longitudinal en manga" a través de tres portales. Un total de 5 pacientes (todos femeninos), con IMC promedio de 35,4, fueron intervenidos con esta técnica. Se usaron tres portales, uno de 12 mm colocado en la cicatriz umbilical y 2 de 5 mm en línea medio clavicular en ambos hipocondrios. Se utilizó una óptica de 5mm y 30° HD. La maquina de autosutura fue utilizada por el portal umbilical. El tiempo quirúrgico promedio fue de 43 minutos. En un caso hubo subengrapado, lo que conllevo a fuga de la línea de grapas. Fue diagnósticada precozmente y resuelta quirúrgicamente. Es factible reproducir esta técnica y se logran tiempos quirúrgicos equiparables a la laparoscopia tradicional y sustancialmente menor al abordaje endoscópico de una sola incisión.

Known as "gastric sleeve" or longitudinal gastrectomy bariatric procedure, is an intervention every day earning more adherents in the surgical bariatric world due to its technical simplicity, because it involves only the fundus and the gastric body subtotal resection to crease a gastric conduit of tubular appearance along the curve less tham the stomach. Traditional laparoscopy has show that it reduces postoperative pain, hospital stay and patients restarts faster their occupational activities. The realization of the gastric sleeve traditionally requires the use of 5 to 6 portals. A bridge the between the traditional laparoscopic and endoscopic approach with a single incision, arises the realization this operation through three portals with a hidden in the umbical scar incisión and two 5 mm abdominal incisions. Show the surgical technique of the "longitudinal sleeve gastrectomy" through three portals. A total of 5 patients (all female), with an average BMI of 35.4, were operated with this technique. Three portals, one of 12 mm placed in the umbilical SCAR and 2 of 5 mm on midclavicular line in both hypochondri were used. We used a lens of 5mm and 30° HD. The surgical stapler machine was used by the umbilical portal. The average surgical time was 43 minutes . In one case there was a sub stapled, which led to the staple line leak. It was diagnosed early and resolved surgically. It is possible to reproduce this technique and get surgical times comparable to traditional laparoscopy and substantially less that the endoscopic approach of a single incision.

Hernias internas luego de bypass gástrico en Y de roux por laparoscopia / Internal hernias following laparoscopic roux en Y gastric bypass

Presentamos nuestra experiencia en el diagnóstico y tratamiento de los pacientes con hernias luego de bypass gástrico en Y de Roux por laparoscopia (BGYRL) debido a obesidad mórbida. Se revisaron las historias de una serie`prospectiva de pacientes sometidos a BGYRL, incluyéndose para el análisis a aquellos casos con diagnóstico de hernia interna posoperatoria. Se determinó el tiempo de presentación, síntomas hallazgos radiológicos, abordaje quirúrgico, tipo de hernía, técnica quirúrgica, y morbilidad. Desde enero de 2004 a diciembre de 2009 intervenimos 512 pacientes con obesidad mórbida mediante BGYRL, utilizando una posición antecólica del asa alimentaria, sin cerrar los defectos mesentéricos. Se reoperaron 30 pacientes (5.8%) debido a hernia interna, de los cuales 27 (90%) se pudieron resolver mediante un abordaje laparoscópico. El tiempo promedo de presentación fue de 20 meses, y el principal síntoma dolor abdominal postprandial. La radiología simple de abdomen fue positiva sólo en 8 casos (26.6%). Una`paciente falleció debido a infarto intestinal masivo y sepsis intraabdominal para una mortalidad de 3.3%. Se concluye que las hernias internas constituyen la complicación tardia con mayor potencial de letalidad luego de BGYRL, por lo que es necesario un alto índice de sospecha clínico para un diagnóstico y tratamiento tempranos.

We present our experience in the diagnosis and treatment of patients with internal hernias following laparoscopic Roux en Y gastric bypass (LRYGB) for morbid obesity. The records of a prospective series of patients submitted to LRYGB were reviewed, including for the analysis those with diagnosis of postoperative internal hernia. Time of onset, symptoms, radiologic findines, surgical approach, type of hernia, surgical technique, and morbidity were determined. From January 2004 to December 2009, 512 morbidity obese patients were submitted to LRYGB, using an antecolic alimentary limb, without closing the mesentetic defects. Thirty patients (5.8%) were reoerated because an internal hernia, 27 of them (90%) solved by laparoscopic approach. Mean time of onset was 20 months, and postprandial abdominal pain was the main symptom. Plain abdominal x-ray was positive only in 8 cases (26.6%) One patient died because intestinal infarction and abdominal sepsis for a 3.3% mortality rate. We concluded that internal hernias are the late complication with most lethality potential after a LRYGB, a high index of clinical suspición is necessary for an early diagnosis and treatment.

Hernias internas luego de bypass gástrico en Y de Roux por laparoscopia / Internal hernias after gastric bypass laparoscopic Roux en Y

Presentamos nuestra experiencia en el diagnóstico y tratamiento de los pacientes con hernias internas luego de bypass gástrico en Y de Roux por laparoscopia debido a obesidad mórbida. Se revisaron las historias de una serie de pacientes sometidos a bypass gástrico en Y de Roux por laparoscopia, incluyéndose para el análisis a aquellos casos con diagnóstico de hernia interna posoperatoria. Se determinó el tiempo de presentación, síntomas, hallazgos radiológicos, abordaje quirúrgico, tipo de hernia, técnica quirúrgica, y morbilidad. Desde enero de 2004 a diciembre de 2009 intervenimos 512 pacientes con obesidad mórbida mediante bypass gástrico en Y de Roux por laparoscopia, utilizando una posición antecólica del asa alimentaria, sin cerrar los defectos mesentéricos. Se reoperaron 30 pacientes (5,8%) debido a hernia interna, de los cuales 27 (90%) se pudieron resolver mediante un abordaje laparoscópico. El tiempo promedio de presentación fue de 20 meses, y el principal síntoma dolor abdominal posprandial. La radiología simple de abdomen fue positiva solo en 8 casos (26,6%). Una paciente falleció debido a infarto intestinal masivo y sepsis intraabdominal para una mortalidad de 3,3%. Se concluye que las hernias internas constituyen la complicación tardía con mayor potencial de letalidad luego de bypass gástrico en Y de Roux por laparoscopia, por lo que es necesario un alto índice de sospecha clínico para un diagnóstico y tratamiento tempranos.

We present our experience in the diagnosis and treatment of patients with internal hernias following laparoscopic Roux Y gastric bypass for morbid obesity. The records of a series of patients submitedd to laparoscopic Roux Y gastric bypass were reviewed, including for the analysis those cases with diagnosis of postoperative internal hernia. Time of onset, symptoms, radiologic findings, surgical approach, type of hernia, surgical technique, and morbidity were determined. From January 2004 to December 2009, 512 morbidly obese patientes were submitted to laparoscopic Roux Y gastric bypass, using an antecolic alimentary limb, without closing the mesenteric defects. Thirty patients (5,8%) were reoperated because an internal hernia, 27 ofthem (90%) solved by laparoscopic approach. Mean time of onset was 20 months, and postprandial abdominal pain was the main symptom. Plain abdominal x-ray was positive only in 8 cases (26,6%). One patient died because intestinal infarction and abdominal sepsis for a 3,3% mortality rate. We concluded that internal hernias are late complication with most lethality potential after a laparoscopic Roux Y gastric bypass, a high index of clinical suspicion is necessary for an early diagnosis and treatment.

Bypass gástrico laparoscópico para el tratamiento de la obesidad mórbida: primeros 140 casos / Laparoscopic gastric bypass for treatment of morbid obesity: first 140 cases

La obesidad mórbida es una enfermedad crónica y degenerativa cuyo tratamiento médico no ha sido satisfactorio, siendo la cirugía bariátrica el tratamiento más efectivo actualmente. Caracterizar los resultados obtenidos con el bypass gástrico en Y de Roux para el tratameinto de la obesidad mórbida, en el Hospital General del Este Dr. Domingo Luciani, Caracas-Venezuela. Estudio descriptivo y observacional. 144 pacientes fueron intervenidos entre agosto 2008 y septiembre del 2010. La mayoría del sexo femenino, con edad de 35,7 ± 8,6 años e índice de Masa Corporal de 45,7 ± 6,3 kg/mt2 y al menos un comórbido asociado (67.4%). Se obtuvo una perdida del 71,5 ± 13,9% del exceso de peso al final del primer año, y de 72,5 ± 18,1% al final del segundo año. La curva de aprendizaje se superó con 80 casos aproximadamente. No hubo mortalidad operatoria, y la morbilidad fue de 9,72%, siendo las hemorragias postoperatorias las más frecuentes (4,16%). El bypass gástrico en Y de Roux es un procedimiento efectivo en el tratamiento de la obesidad mórbida, con morbilidad y mortalidad aceptables.

Morbid obesity is a chronic and degenerative disease, with an unsatisfactory medical treatment, being bariatric surgery the most effective actually. Characterize the results of gastric bypass surgery in morbid obesity treatment, at the Hospital General del Este Dr. Domingo Luciani, Caracas. Descriptive and observational study. 144 patients were operated between August 2008 and September 2010. Most were female, with 35,7 ± 8,6 years old, Body Mass Index 45,7 ± 6,3 Kg/mt" and at léast one comorbid associated (67,4%). The patients lost 71,5 ± 13,9% of excess weight at the first postoperative year, and 72,5 ± 18,1% at the end of the second year. There were no operative mortality, and morbidity was 9,72%, being postoperative bleeding, the most frequent (4,16%). Roux en-Y gastric bypas surgery is an effective treatment of morbid obesity, with acceptable mortality and morbidity rates.

Tratamiento quirúrgico de la obesidad mórbida / Evaluation of laparoscopic sleeve gastrectomy in the treatment of morbid obesity

Objetivo: determinar los resultados obtenidos en cuanto a la pérdida de peso, porcentaje de exceso de peso perdido (%EPP) y descenso del IMC a los 18 meses del postoperatorio de GML y resolución de las comorbilidades asociadas a la obesidad. Evaluar complicaciones postoperatorias. Material y método: estudio prospectivo desde el año 2004 al 2009. Se realizó GML según técnica estándard. Se evaluaron los resultados a 1,3, 6, 12 y 18 meses. Resultados: n = 65. El peso postoperatorio obtenido fue de 115,3, 102,1, 95,3, 89,5 y 80,03 kg al 1,3,6,12 y 18 meses respectivamente. El IMC fue de 38,89, 34,33, 31,5, 29,96 y 28,72 kg/m2 al 1, 3, 6, 12 y 18 meses respectivamente. El % de EPP fue de 30,62, 40,25, 51,36, 58,63 y 63,4% al 1, 3, 6, 12 y 18 meses respectivamente. El % de complicaciones postoperatorias fue de 4,6 %. El % de comorbilidades fue de 27,66 % se resolvieron en el 92 % de los pacientes. De los 65 pacientes estudiados 42 de ellos llegaron a ser controlados a los 18 meses. En estos pacientes no se consideró necesario un segundo procedimiento bariátrico. Conclusión: la GML es una técnica quirúrgica con buenos resultados en el descenso de peso y control de las comorbilidades en el período estudiado. Se deberían reevaluar los resultados a largo plazo para determinar la eficacia de la GML.

Objective: Determine the effectiveness of laparoscopic sleeve gastrectomy in terms of weihgt loss, percentage of excessive weight loss, rduction of BMI and comorbidities associated to obesity within 18 months of surgery. Evaluate postoperative complications. Material and method: Prospective study of 68 patients who underwent LSG performed according to standard technique from 2004 to 2009. Follow up was done by measuring the above mentioned variables 1, 3, 6, 12 and 18 months after surgery. Results: n = 65. The post operative weight obtained was 115.3, 102.1, 95.3, 89.5 and 80.03 kg to the 1, 3, 6, 12 and 18 months respectively. The BMI was 38.89, 34.33, 31.5, 29.96 and 28.72 kg/m2 to the 1, 3, 6, 12 and 18 months respectively. % EWL was 30.62, 40.25, 51.36, 58.63 and 63.4% to the 1, 3, 6, 12 and 18 months respectively. % of complications was 4.6%. % of comorbidities was 27.66 % and was resolved in 92 % of the patients. From 65 studied patients 42 of them arrived to be controlled to the 18 months. In these patients a second bariatric procedure was not considered necessary. Conclusion: The LSG is a surgery technique with good results in terms of weight reduction and controlled comorbidities in the time period evaluated. Further follow up is needed to prove LSG efficacy in the long term.

Caracterização da voz do indivíduo portador de obesidade mórbida / Morbid obesity and it´s relationship to voice alterations

RACIONAL: A obesidade é doença crônica e grave com crescimento alarmante em todo o mundo e de interesse na saúde pública. Existe alteração no comportamento vocal destes pacientes e ele é pouco estudado. OBJETIVO: Caracterizar prospectivamente a voz de indivíduos portadores de obesidade mórbida comparando-a com a de não obesos. MÉTODOS: Estudo prospectivo de 45 indivíduos adultos voluntários, 14 homens e 31 mulheres com idade média de 43 anos variando de 20 a 63 anos. Todos apresentavam IMC acima de 35 Kg/m2 constituindo o grupo em estudo (GO) Para cada indivíduo do GO foi selecionado também um indivíduo adulto voluntário, proveniente da população geral do ambulatório de otorrinolaringologia com IMC abaixo de 30 Kg/m2, constituindo o grupo controle (GN). Os critérios de exclusão foram diagnóstico de lesões neoplásicas malignas em cabeça e pescoço ou operações prévias da região orofaríngea. Fooram submetidos a exame laringológico e à gravação da voz. Também submeteram-se à avaliação subjetiva perceptivo-auditiva da qualidade vocal, através da escala GIRBAS e a aspereza, o estrangulamento no final das. A análise acústica foi realizada objetivamente utilizando os softwares Vox Metria versão 4.0.47 e PRAAT, fornecendo a frequência fundamenta, jitter, shimmer, ruído e tempo máximo fonatório. RESULTADOS: Observou-se que os grupos foram homogêneos em relação ao sexo, idade, tabagismo e altura, mas significativamente diferentes em relação ao peso e IMC (P<0,001). Os achados laringoscópicos em ambos os grupos mostraram que 26,7% dos obesos tinham laringoscopia alterada contra 13,3% dos não obesos. Sinais laríngeos sugestivos de RLF foram significativos para o GO (P<0,042). A análise perceptivo-auditiva revelou que o grau da disfonia, a instabilidade, a rouquidão, a soprosidade, a astenia, a tensão e a aspereza tiveram alterações altamente significantes para o GO (P=0,001 ou 002)...

BACKGROUND: Obesity is a chronic disease with public health interest. Voice disturbance is common in this group. AIM: To compare the voice between the morbid obese patients with the non obese. METHODS: Prospective trial with 45 adult volunteers with 43 years old median age with BMI>35 Kg/m2 as study group and a control group in the same number but with BMI<30 Kg/m2. Exclusion criteria were tumor in head and neck or previous operations in oropharynx. All had laryngoscopy and voice recording. They were submitted to GIRBAS score. Acoustic analysis was done based on Vox Metria software and PRAAT. RESULTS: Laryngoscopy showed alterations in 26,7% of the obese group and 13,3% in controls. The GIRBAS score was highly significant to the obese group. Acoustic alterations were also significant in the obese group. CONCLUSION: The patients with morbid obesity have significant alterations in voice caracteristics in comparison to the ones normal in weight.

Obesidad mórbida asociada a quiste broncogénico y leiomioma subcardial que simula GIST: caso clínico / Morbid obesity, esophageal bronchogenic cyst and subcardial leiomioma: report of one case

Gastric wall diseases are found in approximately of 1 percent of the patients submitted to bariatric surgery. Half of these are leiomiomas. Esophageal bronchogenic cysts are exceptional We report a 57 years old female with morbid obesity, a bronchogenic esophageal cyst and subcardial leiomioma. The preoperative study and intraoperative biopsy, suggested the presence of a gastrointestinal stromal tumor (GIST), but the definitive pathological study did not confirm its presence. A total gastrectomy was performed, with an uneventful postoperative course.

La patología intramural gástrica tiene una frecuencia menor al 1 por ciento, en cirugía gástrica. Alrededor del 50 por ciento corresponden a leiomiomas. Los quistes broncogénicos tienen origen embriológico y son excepcionales, y la mayor parte de los reportes corresponden a pacientes pediátricos. Se presenta un caso clínico de paciente portadora de Obesidad mórbida (IMC = 52), asociado a lesión subcardial que simula GIST, cuyo estudio histopatológico resultó ser un quiste esofágico de origen broncogénico de 40 mm, asociado a leiomioma subcardial de 10 mm. Fue sometida a gastrectomía total más anastomosis esófago-yeyunal en Y de Roux, con asa de 180 cm. No presentó morbi-mortalidad postoperatoria. Se discuten los métodos de estudio preoperatorio y las alternativas terapéuticas. No hemos encontrado en la literatura otro caso de asociación de estas raras patologías.

Tratamiento quirúrgico de la obesidad mórbida / Surgical treatment for morbid obesity

Since the realization in 1991 of the National Institutes of Health Consensus Development Conference Draft Statement on Gastrointestinal Surgery for Severe Obesity, the bariatric surgery become accepted by the medical community as the most long-term efficient procedure for the treatment of morbid obesity. The surgical suggestion is based mainly in the Body Mass Index of the patient wight/height (kg/m2). Bariatric surgical techniques can be classified according to their main mechanism of action in: restrictives (adjustable gastric banding, sleeve gastrectomy, open vertical banded gastroplasty), malabsorptives: biliopancreatic derivation Scopinaro type or biliopancreatic derivation with duodenal switch (Marceau) and finally the Roux-en-Y gastric bypass. All these aspects are treated in the article.

Abdominoplastia poscirugía bariátrica / Postsurgery bariatric abdominoplasty

En la evolución de la técnica de abdominoplatía, fueron muchas las descripciones que han sido comunicadas. Cada una de ellas ha generado una corriente quirúrgica o una nueva modalidad en la resección, conformando un grupo denominado demolipectomías clásicas. Con el advenimiento de la cirugía bariátrica, ha surgido un nuevo desafío en la especialidad: pacientes con obesidad mórbida que presentan descenso masivo de la masa corporal, que supera los 100 kg y se asocia a otras patologías. Esto determina una nueva terapéutica quirúrgica que va más allá de una simple abdominoplastía obligando al cirujano plástico a formar parte de un equipo médico multidisciplinario y a programar una técnica y táctica quirúrgica cuyas variables sean el tipo de cirugía utilizada para el descenso de peso, el estado nutricional, psicológico y metabólico actual, las patologías asociadas, etc. El objetivo de esta publicación es mostrar los resultados obtenidos a corto, mediano y largo plazo en relación con la reparación del abdomen de un paciente posbariátrico, de una serie de 10, en un período de 12 meses. El estudio es retrospectivo y cualitativo, en un paciente de sexo masculino de 62 años, con un descenso inicial de 95 kg de peso y luego otro de 35 kg, computando un descenso de más de 100 kg. Como patologías asociadas presentó hidrocele gigante y eventración mediana supraumbilical. Se le realizó tratamiento quirúrgico en 2 tiempos operatorios, con un lapso de 6 meses entre las intervenciones.

With the development reached of the abdominoplasty field, it was considerable the number of descriptions reported on it. Each one of them has generated a surgical current or modality on resections matter, conforming a group behind the name of Classic Dermolipectomies. With the advent of Bariatric Surgery, raised a brand new challenge in this particular field; patients that suffer morbid obesity showed massive decrease of body fat, in which results were higher than 100 kg and were connected to become a member of a medical support team that reaches all kinds of medical multidiscipline's and to be able to schedule and program a strategy and technique for surgery matters. Variables such as type of surgery envolved for the specific amount of weight it needs to be reduced, current nutritional, psychological and metabolic condition and finally associated pathologies, etc. The object of this publication its to show and demostrate short, not so short and long term ressults in regard of abdomen reconstruction on a post-bariatric patient in a row of 10 of them, in a 12 month period. Qualitative and retrospective study on a male with 62 years old, happened to show an initial weight loss of 95 kg plus other 35 kg after it, computating a total decrease over 100 kg. Regardin associated pathologies mayor Hidrocele and medium supraumbilical eventration, surgery treatment it's done in two surgeries with a space of time of six months between them.

Nonalcoholic fatty liver disease and obesity / Doença gordurosa não alcóolica do fígado e obesidade

PURPOSE: The aim of this review is to update concepts of the nonalcoholic fatty liver disease (NAFLD) and to establish a relationship between this condition and obesity. METHODS: By means of a comprehensive literature review where special attention was devoted to articles published in the last 5 years, NAFLD is discussed in view of new concepts, diagnosis, staging, and treatment. RESULTS: NAFLD is emerging as one of the main causes of chronic liver disease and it is believed to be the hepatic component of the metabolic syndrome, whose central features include obesity, hyperinsulinemia, peripheral insulin resistance, diabetes, dyslipidemia, and hypertension. The surgical treatment of morbid obesity is one of the options available for the treatment of NAFLD. CONCLUSION: Nonalcoholic fatty liver disease is strongly related with obesity.

OBJETIVO: O objetivo deste artigo foi atualizar conceitos com relação à doença gordurosa não alcoólica do fígado (DGNAF) e a sua intrínseca relação com a obesidade. MÉTODOS: Por meio de revisão bibliográfica, com atenção especial às publicações dos últimos 5 anos, o assunto foi abordado com relação à conceituação, ao diagnóstico, estadiamento e tratamento. RESULTADO: A DGNAF está emergindo como uma das maiores causas de doença crônica do fígado e representa o componente hepático da síndrome metabólica, caracterizada por obesidade, hiperinsulinemia, resistência periférica à insulina, diabete, hipertrigliceridemia e hipertensão. O tratamento cirúrgico da obesidade mórbida faz parte do arsenal terapêutico da DGNAF. CONCLUSÃO: O tema foi amplamente discutido, baseado em estudos recentes.