Hyperinsulinemic hypoglycemia in adults. Nesidioblastosis case report and review of the literature.

Hypoglycemia due to endogenous hyperinsulinism usually occurs in 2 pathological situations: the most frequent is insulinoma and, secondly, nesidioblastosis or also known as non-insulinoma pancreatic hypoglycemic syndrome. Nesidioblastosis is a rare cause of hyperinsulinic hypoglycemia in adults. We present the clinical case of an adult patient with recurrent hypoglycemia secondary to nesidioblastosis.

La hipoglucemia por hiperinsulinismo endógeno suele presentarse en dos situaciones patológicas: la más frecuente es el insulinoma y, en segundo lugar, la nesidioblastosis o síndrome hipoglucémico pancreático no insulinoma. La nesidioblastosis es una causa poco frecuente de hipoglucemia por hiperinsulinismo en adultos. Presentamos el caso de un paciente adulto con cuadros recurrentes de hipoglucemia secundarios a nesidioblastosis.

Remisión de síndrome metabólico con cirugía bariátrica / Remission of metabolic syndrome with bariatric surgery

Resumen: OBJETIVO Determinar el alivio de comorbilidades en pacientes a los que se les practicó cirugía bariátrica en el Hospital Regional de Alta Especialidad de la Península de Yucatán. MATERIAL Y MÉTODO Estudio retrospectivo observacional efectuado de 2011 a 2014, en el que se incluyeron pacientes con índice de masa corporal ≥ 40 kg/m2o ≥ 35 kg/m2 con comorbilidades a quienes se les efectuó cirugía bariátrica. Los criterios diagnósticos de síndrome metabólico fueron los de la Federación Internacional de Diabetes válidos para población mexicana. RESULTADOS Se incluyeron 67 pacientes a los que se les hizo cirugía bariátrica (bypass gástrico en Y de Roux por laparoscopia); 79% eran mujeres, el rango de edad fue de 19-55 años con media de 36.5 ± 8.2 años. El promedio de peso antes de la cirugía fue de 119.4±20 kg. El promedio del porcentaje de pérdida de peso posoperatorio fue de 19.8, 27.9 y 34.3% a 3, 6 y 12 meses. La media del peso, índice de masa corporal, presión arterial sistólica y diastólica, colesterol total, LDL, HDL y glucosa disminuyeron significativamente (p< 0.001) un año después de la intervención quirúrgica. Los porcentajes de remisión fueron: síndrome metabólico, diabetes mellitus y col-HDL bajo: 100%, hipertensión arterial: 94.1%, hipertrigliceridemia: 60.9%. CONCLUSIÓN A 12 meses de la intervención quirúrgica, las remisiones de síndrome metabólico, diabetes mellitus y HDL bajo fueron del 100% y mayores a 60% en los otros componentes del síndrome metabólico.

Abstract: OBJECTIVE To determine the relief of comorbidities in patients undergoing bariatric surgery of metabolic syndrome in the Regional Hospital of High Specialty of the Yucatan Peninsula, Mexico. MATERIAL AND METHOD A retrospective observational study was done from 2011 to 2014 in patients with a body mass index (BMI) ≥ 40 kg/m2 or ≥ 35 kg/m2 with comorbidities undergoing bariatric surgery. The diagnostic criteria of the metabolic syndrome were those of the International Diabetes Federation applied to the Mexican population. RESULTS A total of 67 patients undergoing bariatric surgery (laparoscopic Roux-en-Y gastric bypass) were included in the study; 79% were women, the age range was 19-55 years with an average of 36.5 ± 8.2 years. The average weight before surgery was 119.4 ± 20 kg. The average percentage of postoperative weight loss was 19.8%, 27.9% and 34.3% at 3, 6 and 12 months, respectively. The mean weight, BMI, systolic and dyastolic blood pressure, total cholesterol, LDL, HDL and glucose decreased significantly (p < 0.001) one year after surgery. The percentages of remission were: metabolic syndrome, diabetes mellitus and low HDL-cholesterol: 100%, arterial hypertension: 94.1%, hypertriglyceridemia: 60.9%. CONCLUSION At twelve months, the remissions of metabolic syndrome, diabetes mellitus and low HDL were 100%, being greater than 60% in the other components of the metabolic syndrome.

[Efectos metabólicos en pacientes obesos posoperados de bypass gástrico laparoscópico: 5 años de experiencia en un hospital de tercer nivel]. / Metabolic changes in obese patients after laparoscopic gastric bypass: five-year experience in a tertiary referral hospital.

INTRODUCCIÓN: La obesidad se define como una enfermedad caracterizada por una acumulación anormal o excesiva de grasa que puede ser perjudicial para la salud. La cirugía bariátrica es un método efectivo y seguro en el tratamiento de la obesidad extrema. MATERIALES Y MÉTODOS: Se realizó una revisión y análisis de 90 expedientes clínicos de pacientes post-operados de bypass gástrico laparoscópico. RESULTADOS: De los 38 pacientes incluidos para el presente análisis, 17 pacientes (43.6%), contaron con el diagnóstico de diabetes mellitus tipo 2 previo al procedimiento quirúrgico y 21 pacientes (56.4%), carecieron de este diagnóstico previo al procedimiento quirúrgico. En los pacientes no diabéticos, se encontraron diferencias estadísticamente significativas en los valores de índice de masa corporal en la comparación de medias entre el estado basal y a los 12 meses después de haber realizado el bypass gástrico, sin embargo, la hemoglobina glucosilada y la creatinina no mostraron diferencia significativa. En contraste, el grupo de pacientes diabéticos presentó diferencias estadísticamente significativas en las cifras de índice de masa corporal, hemoglobina glucosilada y ácido úrico. CONCLUSIONES: El bypass gástrico laparoscópico proporciona pérdida de peso y reducción del IMC satisfactoria, en específico, el porcentaje de exceso de IMC perdido, con la mejora simultánea de comorbilidades relacionadas con la obesidad. BACKGROUND: Obesity is defined as a disease characterized by an abnormal or excessive accumulation of adipose tissue that may be hazardous to the health. Bariatric surgery is an effective and safe treatment of morbid obesity. MATERIALS AND METHODS: A review and analysis of 90 clinical records of postoperative patients with laparoscopic gastric bypass was performed. RESULTS: 38 patients were included in the study; 17 (43.6%) of which were diagnosed with diabetes mellitus before the procedure and 21 patients (56.4%) without diabetes mellitus. In non-diabetic patients, it was found statistical differences in the value of body-mass index (BMI). In the group of diabetic patients, statistical differences were found in the value of BMI, glycated hemoglobin and uric acid. CONCLUSIONS: Laparoscopic gastric bypass (LRYGB) provides a satisfactory weight loss and BMI reduction, specifically, percent of excess BMI lost with the simultaneous improvement of comorbid disease.

[Laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity. Experience at the Nacional de Ciencias Médicas y Nutrición Salvador Zubirán]. / Bypass gástrico laparoscópico en Y de Roux y obesidad mórbida. Experiencia en el Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán.

INTRODUCTION: Morbid obesity is a serious health problem associated to a significant reduction in life expectancy. OBJECTIVE: To evaluate the anthropometric and metabolic changes observed in obese patients, 3, 6 and 12 months after laparoscopic Roux-en-Y gastric bypass surgery and the complications associated with the procedure. MATERIAL AND METHODS: Retrospective study that included 128 consecutive obese patients submitted for bariatric surgery at the INCMNSZ (2004-2006). RESULTS: Their mean age was 38 +/- 10 years, 83% were women with a BMI of 48 +/- 6 Kg/m2. 65% were hypertensives, 55% had hypertriglyceridemia and 34% diabetes. A year after surgery all patients had at least reduced 20% their body weight and the percentage of excess body weight loss was 73%. The prevalence of hypertension, hypertrigliceridemia and diabetes was reduced to 24%, 17% and 12%, respectively (p < 0.001). Four patients died (3%), all of them had a leak of the anastomosis and intra-abdominal abscess. One died because pulmonary embolism, another with a myocardial infarction (after surgical reinterventions) and the other two with sepsis. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass surgery in morbid obese patients favors significant reductions in body weight and associated co morbidities. This surgery is not free of complications and mortality, reason why it must be done only by surgical and interdisciplinary groups with experience in these procedures.

Intrahepatic repair of bile duct injuries. A comparative study.

INTRODUCTION: The frequency of bile duct injuries associated to cholecystectomy remains constant (0.3-0.6%). A multidisciplinary approach (endoscopical, radiological, and surgical) is necessary to optimize the outcome of the patient. Surgery is indicated when complete section of the duct is identified (Strasberg's E injuries) requiring a bilioenteric anastomosis as treatment. Nowadays, the most frequent technique used for reconstruction is a Roux-en-Y hepatojejunostomy. Long-term results of reconstruction are related to several technical and anatomic factors, but an ischemic duct (with subsequent scarring) plays a mayor role. In this paper, we report the results of biliary reconstructions comparing the extrahepatic-probably ischemic -- to intrahepatic -- non ischemic -- repairs. METHODS: We reviewed the files of patients referred to our hospital (third-level teaching hospital) for bile duct repair after iatrogenic injury from 1990 to July 2006. Injury classification, time lapse since injury, surgical repair technique, and long-term follow-up were noted. In all cases, a Roux-en-Y hepatojejunostomy was done. Partial resection of segment IV was performed in 136 patients to obtain noninflamed, nonscarred, nonischemic biliary ducts with the purpose of reaching the confluence and achieving a high-quality bilioenteric anastomosis. An anastomosis at the level of the confluence was attempted in 293 patients (in 198 the confluence was preserved and in 95 it was lost). In the remaining 80 patients, a low bilioenteric anastomosis was done at the level of the common hepatic duct. We compared intrahepatic (198) and extrahepatic (80) repairs. RESULTS: A total of 405 cases (88 males, 317 females) were identified, with a mean age of 42 years (range 17-75). All of the injuries were classified as Strasberg E1, E2, E3, E5 (less frequent); those with E4 classification (separated ducts) were excluded. In all cases, the confluence was preserved (N = 293). Thirty-two cases were repaired minutes to hours after the injury occurred. The remaining 373 patients arrived weeks after the injury. In 198 cases, an intrahepatic repair was done, including the 136 in which resection of segments IV and V was part of the surgery. In the remaining 80 cases (operated between 1990 and 1997), an extrahepatic repair was done at the level of the common hepatic duct where the surgeon found a healthy duct. Twelve (15%) of the 80 cases with extrahepatic anastomosis required a new intervention (surgical or radiological), compared to only 8 of the 198 (3%) that had an intrahepatic anastomosis (P = 0.00062). Good results were obtained in 85% and 97% of the cases with extrahepatic anastomosis and intrahepatic anastomosis, respectively. Both groups had a reintervention rate of 7% (20/278). CONCLUSIONS: An intrahepatic anastomosis requires finding nonscarred, nonischemic ducts, thus allowing a safe and high-quality anastomosis with significantly better results when compared to the low-level anastomosis group.