Laparoscopic ileal interposition associated to a diverted sleeve gastrectomy is an effective operation for the treatment of type 2 diabetes mellitus patients with BMI 21-29.

BACKGROUND: The objective of this study is to evaluate the clinical results of the laparoscopic interposition of a segment of ileum into the proximal duodenum associated to a sleeve gastrectomy (II-DSG) in order to treat patients with type 2 diabetes mellitus (T2DM) and body mass index (BMI) 21-29 kg/m2. PATIENTS AND METHODS: The laparoscopic procedure was performed in 69 patients, 22 female and 47 male. Mean age was 51 years (range 41-63 years). Mean BMI was 25.7 (21.8-29.2) kg/m2. All patients had the diagnosis of T2DM for at least 3 years and evidence of stable treatment with oral hypoglycemic agents and or insulin for at least 12 months. Insulin therapy was used by 44% of the patients. Mean duration of T2DM was 11 years (range 3-18 years). Dyslipidemia was diagnosed in 72.5% and hypertension in 66.7%. Nephropathy was characterized in 29% of the patients, retinopathy in 26.1%, and neuropathy in 24.6%. RESULTS: Overall, 95.7% of the patients achieved adequate glycemic control (Hb(A1c) < 7%) without antidiabetic medication. Hb(A1c) below 6% was achieved by 65.2%. Mean postoperative follow-up was 21.7 months (range 7-42 months). Mean postoperative BMI was 21.8 kg/m2. There was no conversion to open surgery. Median hospital stay was 3.4 days (range 2-58 days). Major postoperative complications were diagnosed in 7.3%. There was no mortality. Fasting glycemia decreased from a mean of 218 to 102 mg/dl, postprandial glycemia from 305 to 141 mg/dl, and homeostasis model assessment of insulin resistance (Homa-IR) from 5.2 to 0.77. All associated comorbidities and complications related to T2DM had significant improvement or control. Arterial hypertension was controlled in 91.3%. Macroalbuminuria was no longer observed. Microalbuminuria resolved in 87.5% of patients. Hypercholesterolemia was normalized in 95% and hypertriglyceridemia in 92% of patients. CONCLUSIONS: Laparoscopic II-DSG was an effective operation in controlling T2DM in a nonobese (BM < 30 kg/m2) population. Associated diseases and related complications were also improved. A longer follow-up period is needed.

Laparoscopic treatment of metabolic syndrome in patients with type 2 diabetes mellitus.

BACKGROUND: Metabolic syndrome refers to risk factors for cardiovascular disease. Hyperglycemia is a critical component contributing to the predictive power of the syndrome. This study aimed to evaluate the results from the laparoscopic interposition of an ileum segment into the proximal jejunum for the treatment of metabolic syndrome in patients with type 2 diabetes mellitus and a body mass index (BMI) lower than 35. METHODS: Laparoscopic procedures were performed for 60 patients (24 women and 36 men) with a mean age of 51.7 +/- 6.4 years (range, 27-66 years) and a mean BMI of 30.1 +/- 2.7 (range, 23.6-34.4). All the patients had a diagnosis of type 2 diabetes mellitus (T2DM) given at least 3 years previously and evidence of stable treatment using oral hypoglycemic agents, insulin, or both for at least 12 months. The mean duration of type 2 diabetes mellitus was 9.6 +/- 4.6 years (range, 3-22 years). Metabolic syndrome was diagnosed for all 60 patients. Arterial hypertension was diagnosed for 70% of the patients (mean number of drugs, 1.6) and hypertriglyceridemia for 70%. High-density lipoprotein was altered in 51.7% of the patients and the abdominal circumference in 68.3%. Two techniques were performed: ileal interposition (II) into the proximal jejunum and sleeve gastrectomy (II-SG) or ileal interposition associated with a diverted sleeve gastrectomy (II-DSG). RESULTS: The II-SG procedure was performed for 32 patients and the II-DSG procedure for 28 patients. The mean postoperative follow-up period was 7.4 months (range, 3-19 months). The mean BMI was 23.8 +/- 4.1 kg/m(2), and 52 patients (86.7%) achieved adequate glycemic control. Hypertriglyceridemia was normalized for 81.7% of the patients. An high-density lipoprotein level higher than 40 for the men and higher than 50 for the women was achieved by 90.3% of the patients. The abdominal circumference reached was less than 102 cm for the men and 88 cm for the women. Arterial hypertension was controlled in 90.5% of the patients. For the control of metabolic syndrome, II-DSG was the more effective procedure. CONCLUSIONS: Laparoscopic II-SG and II-DSG seem to be promising procedures for the control of the metabolic syndrome and type 2 diabetes mellitus. A longer follow-up period is needed.

Laparoscopic treatment of type 2 diabetes mellitus for patients with a body mass index less than 35.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a common disease with numerous complications. Bariatric surgery is an efficient procedure for controlling T2DM in morbidly obese patients. In T2DM, the incretin effect is either greatly impaired or absent. This study aimed to evaluate the preliminary results from interposing a segment of ileum into the proximal jejunum associated with a sleeve or diverted sleeve gastrectomy to control T2DM in patients with a body mass index (BMI) less than 35 kg/m(2). METHODS: For this study, 39 patients (16 women and 23 men) underwent two laparoscopic procedures comprising different combinations of ileal interposition into the proximal jejunum via a sleeve or diverted sleeve gastrectomy. The mean age of these patients was 50.3 years (range, 36-66 years). The mean BMI was 30.1 kg/m(2) (range, 23.4-34.9 kg/m(2)). All the patients had a diagnosis of T2DM that had persisted for at least 3 years and evidence of stable treatment with oral hypoglycemic agents or insulin for at least 12 months. The mean duration of T2DM was 9.3 years (range, 3-22 years). RESULTS: The mean operative time was 185 min, and the median hospital stay was 4.3 days. Four major complications occurred in the short term (30-days), and the mortality rate was 2.6%. The mean postoperative follow-up period was 7 months (range, 4-16 months), and the mean percentage of weight loss was 22%. The mean postoperative BMI was 24.9 kg/m(2) (range, 18.9-31.7 kg/m(2)). An adequate glycemic control was achieved for 86.9% of the patients, and 13.1% had important improvement. The patients whose glycemia was not normalized were using a single oral hypoglycemic agent. No patient needed insulin therapy postoperatively. All the patients except experienced normalization of their cholesterol levels. Targeted triglycerides levels were achieved by 71% of the patients, and hypertension was controlled for 95.8%. CONCLUSIONS: The laparoscopic ileal interposition via either a sleeve gastrectomy or diverted sleeve gastrectomy seems to be a promising procedure for the control of T2DM and the metabolic syndrome. A longer follow-up period is needed.

Results of the routine use of a modified endoprosthesis to drain the common bile duct after laparoscopic choledochotomy.

BACKGROUND: One hundred eighty-one patients were submitted to laparoscopic common bile duct exploration. METHODS: A transcystic approach was used in 147 patients, choledochotomy in 14, and both in 20. The indications to perform a choledochotomy included stones larger than 20 mm, stones proximal to the cystic duct entrance, and cases in which the transcystic duct approach proved impossible or unsuccessful. RESULTS: The common bile duct was drained by a T-tube in four patients, by laparoscopic sphincterotomy in one, by laparoscopic choledochoduodenostomy in one, and by a 10 Fr endoprosthesis in 28. The stent placement was technically feasible in all patients but one. The biliary drainage was adequate. Mean hospital stay was 2.1 days. Complication was limited to one umbilical infection and one self-limited biliary leak. CONCLUSIONS: The procedure proved to be technically simple, safe, and efficient, and resulted in a low morbidity rate and short hospital stay.

Laparoscopic reoperations after failed and complicated antireflux operations.

Nineteen patients underwent laparoscopic reoperations for failed or complicated antireflux operations from a total of 248 patients with gastroesophageal reflux disease who had been operated on by this approach. Sixteen had been submitted to open surgery and three to laparoscopic surgery over a period ranging from 5 days to 31 years before the study. Three patients had been submitted to two open antireflux surgeries previously. Seventeen patients had recurrent reflux esophagitis after different types of surgeries, and two patients presented with gastric strangulation after fundoplication. The causes of recurrence were: slipped total fundoplications (3), disruption of total and partial fundoplications (6), too-tight total fundoplication (1), too-low (gastric) partial fundoplication (1), Allison procedure (1), partial fundoplication and paraesophageal hernia (2), and unknown (3). The laparoscopic approach was used in 18 patients and a laparoscopic-thoracoscopic approach in 1. The procedures included laparoscopic total fundoplications (11), partial fundoplications (4), transhiatal esophagectomy (1), Collis-Nissen (1), Roux-en-Y gastrectomy and thoracoscopic vagotomy (1), and intrathoracic fundoplication (1). One patient was converted to open surgery. Intraoperative complications included 1 pneumothorax, 1 gastric perforation, and 1 esophageal perforation during the introduction of a Maloney dilator. Mean operative time was 210 min, ranging from 140 to 320 min. Mean hospital stay was 3.1 days after treatment of failed operations and 22 days after treatment of complications. Postoperative complications included subcutaneous infection (1), gastric fistula (1), and liver hematoma (1). The results have been excellent and good in 84.3% of the patients after a mean follow-up of 13 months. We concluded that laparoscopic reoperations are technically feasible with good preliminary results provided that the mandatory expertise is available.

Laparoscopic transhiatal esophagectomy with esophagogastroplasty.

Twelve patients with benign and malignant esophageal diseases were treated by transhiatal esophagectomy, without thoracotomy, using abdominal-mediastinal dissection conducted by videolaparoscopy. A cervical approach was used to retrieve the esophagus and to perform the esophagogastric anastomosis. The procedure was indicated in patients with advanced achalasia of the esophagus, severe reflux stenosis, squamous cell carcinoma, and adenocarcinoma of the esophagus. Three pleural perforations occurred during surgery. Blood loss was minimal. One patient required conversion to open surgery, two patients were submitted to chest drainage, and three had transitory dysphonia. One patient had an anastomotic leak with subsequent stenosis requiring endoscopic dilatation. No mortality occurred in this small series.

Laparoscopic management of choledocholithiasis.

The authors report on a group of 114 patients with common bile duct (CBD) stones who were treated by laparoscopic surgery. Management through the cystic duct was considered the first option. Choledochotomy was used for those patients in which the cystic approach was not possible or was unsuccessful. Transcystic lithotripsy was considered for patients with CBD stones in disproportion with the size of the cystic duct. Laparoscopic antegrade sphincterotomy was indicated as a drainage procedure. The transcystic approach was used in 89.5% of the patients; choledochotomy was used in 6.2%; and both ways were used in 4.3%. Different procedures were used, including mechanical and electrohydraulic lithotripsy, choledochotomy with T-tube or endoprostheses drainage, laparoscopic sphincterotomy, end-to-end common bile duct anastomosis, and choledochoduodenum anastomosis. One of the patients was in the 21st week of pregnancy. The laparoscopic approach to choledocholithiasis was successfully performed in 94.8% of the patients. Mean hospital stay was 1.7 days. There was a 6.2% incidence of complications and the mortality rate was 0.9%. In 84.3% of the patients, the transcystic approach was used successfully, with a complication rate of 4.9% and a mean hospital stay of 1.6 days. Three patients were converted to open surgery early in this series. Thus far, one patients has presented residual CBD stones. The results obtained suggest that laparoscopic common bile duct exploration is a technically feasible procedure, with low complication and mortality rates, although it requires adequate selection of patients and a variety of techniques and types of equipment.

Laparoscopic antegrade sphincterotomy.

The technique of laparoscopic antegrade sphincterotomy is described. This procedure was used to clear the common bile duct in 22 selected patients with documented choledocholithiasis. Indications for attempting laparoscopic antegrade sphincterotomy included multiple common bile duct stones, one or more common hepatic or intrahepatic stones, a dilated common bile duct requiring a drainage procedure, and suspicion of papillary stenosis. No major complications or mortality was observed. Mild hyperamylasemia was observed in two patients. However, both were asymptomatic, and serum amylase levels rapidly returned to normal. One patient was noted to have a drop in her hematocrit from a preoperative value of 39% to a postoperative value of 33%. Laparoscopic antegrade sphincterotomy added a mean of 17 min to the operative procedure. The mean postoperative stay was 1.4 days. The results of this study suggest that laparoscopic antegrade sphincterotomy may prove to be a useful modality in selected patients with complicated choledocholithiasis.