Conversion of Roux-en-Y gastric bypass to single anastomosis duodenal ileal bypass with sleeve gastrectomy with gastrogastric jejunal bridge.

Surgical conversion of Roux-en-Y gastric bypass (RYGB) to one anastomosis duodenal switch with sleeve gastrectomy (SADI-S), can be effective, when there is obesity recidivism, but surgically challenging. This case report video aims to detail the technical modifications that simplifies this conversion, in one stage. This video article demonstrates the conversion of RYGB to SADI-S using a jejunal bridge to facilitating the gastro-gastric reconnection. Surgical conversion was done laparoscopically, firstly removing the fundus, gastric body and the proximal part of the antrum. The gastrojejunal (GJ) anastomosis from the previous RYGB was preserved and the jejunal alimentary limb that follows was transected, 8cm distal to the GJ anastomosis, and anastomosed, at this level, with the antrum. The remaining alimentary limb was removed, until the jejuno-jejuno anastomosis, from the previous RYGB. The interposition of a segment of jejunal alimentary limb between the gastric bypass pouch and the antrum, has shown to be safe and feasible in RYGB conversion to SADI-S, without complications. Not reconnecting the remnant jejunal alimentary limb to the intestinal transit, but removing it, makes the procedure shorter and safer.

Mucinous cystic neoplasm of the liver

A 55-year-old woman was investigated for occasional epigastric pain and weight loss. T2-weighted abdominal magnetic resonance imaging and magnetic resonance cholangiography revealed a multilocular cyst with multiple septa and a solid component in the liver, measuring 6.1 × 4.8 × 6.5 cm. Given the patient's symptoms and malignant potential, a laparoscopic segmentectomy with partial resection of segments IV B and V was performed to completely remove the cystic lesion, associated with cholecystectomy. Histopathology demonstrated a cyst lined by columnar mucinous epithelium. Therefore, the diagnosis was mucinous cystic neoplasm of the liver. This article presents a case report and literature review of this entity.

Predictive Factors of Gastroesophageal Reflux Disease in Bariatric Surgery: a Controlled Trial Comparing Sleeve Gastrectomy with Gastric Bypass.

OBJECTIVE: To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) in patients with obesity. METHODS: Patients with class II or III obesity were treated with LSG or LRYGB. Procedure choice was based on patients and surgeon preferences. GERD symptoms, endoscopy, barium swallow X-ray, esophageal manometry, and 24-h pH monitoring were obtained before and 1 year after surgery. RESULTS: Seventy-five patients underwent surgery (83% female, 39.3 ± 12.1 years, BMI of 41.5 ± 5.1 kg/m2): 35 (46.7%) had LSG and 40 (53.3%) LRYGB. LSG patients had lower BMI (40.3 ± 4.0 kg/m2 vs. 42.7 ± 5.7 kg/m2; p = 0.041) and trend toward lower prevalence of GERD (20% vs. 40%; p = 0.061). One year after surgeries, GERD was more frequent in LSG patients (74% vs. 25%; p < 0.001) and all LSG patients with preoperative GERD continue to have GERD postoperatively. De novo GERD occurred in 19 of 28 (67.9%) of LSG patients and 4 of 24 (16.7%) patients treated with LRYGB (OR 10.6, 95%CI 2.78-40.1). Independent predictors for post-operative GERD were as follows: LSG (OR 12.3, 95%CI 2.9-52.5), preoperative esophagitis (OR 8.5, 95% CI 1.6-44.8), and age (OR 2.0, 95%CI 1.1-3.4). CONCLUSIONS: One year after surgery, persistent or de novo GERD were substantially more frequent in patients treated with LSG compared with LRYGB. LSG was the strongest predictor for GERD in our trial. Preoperative counseling and choice of bariatric surgical options must include a detailed assessment and discussion of GERD-related surgical outcomes.

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

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

Laparoscopic resection of gastrointestinal stromal tumors (GIST) of the small intestine: a case report

Although gastrointestinal stromal tumors (GISTs) are a rare type of cancer, they are the commonest mesenchymal tumors of the gastrointestinal tract (GIT). GISTs can affect any segment of the GIT, but the usual location is the stomach, followed by the small intestine. Surgical resection of the tumor is the gold standard treatment for localized GISTs, and in patients with inoperable and metastatic disease, imatinib mesylate is the standard treatment. Pathological diagnosis is based on morphology and immunohistochemical findings. We report the case of a 55-year-old man with jejunal GIST presenting with endophytic and exophytic growth, located in the proximal jejunum. He had history of melena, anemia and one episode of enterorrhagia, and was treated with surgical resection of the lesion. (AU)

Effect of Roux-en-Y gastric bypass in the control of erosive esophagitis

Introduction: Gastroesophageal reflux disease (GERD) is a multifactorial disease associated with environmental and genetic factors. Obesity is among the risk factors for its development, which also correlates with an increase in severity of clinical presentation and a higher incidence of complications associated with reflux. Methods: This historical cohort study included a sample of 249 patients who had undergone bariatric surgery using the Roux-en-Y gastric bypass technique at the Hospital São Vicente de Paulo, Passo Fundo, southern Brazil, from January 2014 to December 2015. Results: Of 249 patients, 77.9% (190 patients) were female and the mean age was 38 years. The occurrence of reflux esophagitis was 81.1% (196 patients) in the preoperative period and 31.3% (75 patients) in the postoperative period. With regard to bariatric treatment response to control moderate and severe esophagitis (grades B, C and D), there was a reduction in prevalence from 62 (25%) to 12 (5%) patients (p<0.05). Conclusions: Bariatric surgery using the Roux-en-Y gastric bypass technique is effective in the control of reflux esophagitis. Regression is observed mainly in cases of moderate and severe esophagitis. (AU)

Reported mortality for colorectal cancer in Brazil in the first 16 years of the 21st century

Introduction: Colorectal cancer (CRC) is a malignant neoplasm with major impact on health today. There is, however, an efficient method for prevention and screening, which varies in different protocols according to each institution or country. The objective is to evaluate the mortality rate and the economic cost of CRC in Brazil during the first 16 years of the 21st century. Method: A retrospective, temporal aggregation study was conducted with an exploratory, documentary quantitative approach on CRC mortality from 2000 to 2016, based on the Mortality Information System database provided by the Brazilian Ministry of Health. Results: In the study period, 218,000 deaths due to CRC were recorded. The CRC mortality rate was 6.2 (95% confidence interval, 5.59-6.81) per 100,000 population, with no significant difference between men and women. Of the 17 age subgroups analyzed, eight had a significant increase from 2000 to 2016, including all subgroups aged over 50 years. Conclusion: There was an increase in mortality due to CRC in the study period.

Innovative hybrid technique for bile duct exploration in the treatment of choledocholithiasis

Introduction: Common bile stone disease (CBDS) is frequent and has potentially severe complications, such as acute biliary pancreatitis and cholangitis. Unnecessary and unplanned procedures should be avoided, so before choosing the best treatment of common bile duct lithiasis it is essential to have a proper diagnose. CBDS is currently treated by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic bile duct exploration (LCBDE). Results: The aim of this article is to present an innovative hybrid technique for common bile duct exploration, as an option for cases where the laparoscopic approach is not resolutive, avoiding the need for conversion to open approach technique. Conclusions: The hybrid technique has the same benefits as open and laparoscopic techniques, but without increasing material costs and with good resolution in complex cases of common bile duct stones. (AU)

Epidemiological profile of esophageal cancer mortality in Rio Grande do Sul and its health regions

Introduction: Malignant esophageal neoplasia is a rare tumor, but it has high morbidity and mortality. Early diagnosis and intensive treatment associated with surgical approach remains the best treatment for the disease. Its epidemiology is extremely diverse in the world, even in the same country. Methods: This was a retrospective analysis made from 2000-2015, analyzing the mortality rates of malignant esophageal neoplasia in the state of Rio Grande do Sul (RS) in its 30 Health Regions and in Brazil. The mortality data were collected in the Mortality Information System (SIM) and the population data in the Brazilian Institute of Geography and Statistics (IBGE). Results: The esophageal cancer mortality rate was 8.61 (95% CI, 8.49-8.73) per 100,000 inhabitants in RS, while the national rate was 3.66 (95% CI, 3, 49-3.82), with a significant difference (p <0.0001). The regional distribution was variable, and the West Border region presented the highest rate, 12.91 (95% CI, 12.05-13.77). However, even regions with lower mortality presented twice as much deaths than the national rate. Mortality increased with aging, with the oldest age groups (≥80 years) presenting 69.62 (95% CI, 64.9-74) deaths per 100,000 inhabitants. Conclusion: Esophageal neoplasia is still a very serious condition in the state of RS, being associated with an almost 3-fold higher mortality rate compared to the national rate. Even within the state different epidemiological patterns are found. (AU)

Treatment of posterior gastric wall gastrointestinal stromal tumor with gastric sleeve: a case report

Gastrointestinal stromal tumors (GISTs) are the most common non-epithelial tumors of the gastrointestinal tract. The most usual location is the stomach, followed by the small intestine, where it may cause digestive bleeding and anemia. Surgical resection of the tumor is the gold standard treatment, and definitive diagnosis is based on immunohistochemical analysis of the surgical specimen. We report the case of a 53-year-old man with gastric GIST presenting with endophytic and exophytic growth, located at the posterior wall of the stomach, in the antrum-body transitional zone, treated with gastric sleeve. (AU)

Incarcerated right-sided diaphragmatic hernia in a patient undergoing Roux-en-Y gastric bypass

Bochdalek hernia is the most common congenital diaphragmatic hernia. Its symptoms are normally diagnosed and treated during the neonatal period. Conversely, in adults it is usually asymptomatic and, as a consequence, this group is misdiagnosed. A case of a 64-year-old female patient with an uncommon incarcerated right-sided diaphragmatic hernia formed three years after a Roux-en-Y gastric bypass and a significant weight loss is reported. The importance of this abnormality as a complication of the bariatric surgery should be considered(AU)

The Impact of Gastric Bypass on Gastroesophageal Reflux Disease in Morbidly Obese Patients.

OBJECTIVE: To assess the impact of Roux-en-Y gastric bypass (GBP) on gastroesophageal reflux disease (GERD) in morbidly obese patients. BACKGROUND: Recently, authors have reported that early results of GBP can control GERD. However, longer follow-ups based on objective parameters for GERD are missing. METHODS: Fifty-three patients [15 men (28%), 39 years old (range, 18-59), body mass index = 46 ± 7.7 kg/m2] were consecutively evaluated for GERD irrespectively of related symptoms, before the operation (E1) and at 6 (E2) and 39 ± 7 months postoperatively (E3). The end points were (1) esophageal syndromes based on the Montreal Consensus and (2) an esophageal acid exposure assessment. RESULTS: Body mass index dropped from 46 ± 7.7 kg/m2 at E1 to 30 ± 5.2 kg/m2 at E3. Typical reflux syndrome displayed a significant decrease from 31 (58%) at E1 to 8 (15%) at E2 and 5 (9%) at E3. Statistically significant differences occurred between E1 and both postoperative evaluations (P < 0.001). Reflux esophagitis was detected in 24 (45%), 17 (32%), and 10 patients (19%) at E1, E2, and E3, respectively (P = 0.002). The incidence of GERD decreased in 34 (64%) and 21 (40%) patients at E1 and E2, respectively, and then in 12 (23%) patients at E3. DeMeester scores reduced from 28.6 (E1) to 9.4 (E2) and 1.2 (E3) (P < 0.001). CONCLUSIONS: For most morbidly obese patients, in addition to causing significant weight loss, GBP reduces GERD symptoms, improves reflux esophagitis, and decreases esophageal acid exposure for longer than 3 years.

Mirizzi Syndrome Type IV: a challenging diagnosis

Mirizzi Syndrome type IV is an extremely rare condition, which is confused with the diagnosis of cholangiocarcinoma in many cases. This report describes a case of a forty-three-year old patient, who was forwarded to our department of general surgery with a high suspicion of a choledochal neoplasic lesion. During the hospitalization he was diagnosed with Mirizzi Syndrome type IV. We concisely describe the case and the literature review about this pathology

Epidermal growth factor receptor expression in esophageal adenocarcinoma: relationship with tumor stage and survival after esophagectomy.

Background and Aims. Esophageal adenocarcinoma (EA) is an aggressive tumor with increasing incidence in occidental countries. Several prognostic biomarkers have been proposed, including epidermal growth factor receptor (EGFR). The aim of this study was to assess whether EGFR expression predicts EA staging and patient survival. Methods. In this historical cohort, consecutive patients with EA managed between 2000 and 2010 were considered eligible for the study. Surgical specimens of patients treated with transhiatal esophagectomy were evaluated to establish EGFR expression and tumor differentiation. Staging was classified according with tumor-node-metastasis (TNM) system. Survival was determined according to either medical register or patient's family contact. Results. Thirty-seven patients who underwent esophagectomy without presurgical chemotherapy or radiotherapy were studied. EGFR expression was found in 16 patients (43%). EGFR expression was more frequent as higher was the TNM (I and II = 0% versus III = 47% versus IV = 100%; P < 0.001). Average survival in months was significantly shorter in the group of patients with EGFR expression (10.5 versus 21.7; P = 0.001). Conclusions. In patients with esophageal adenocarcinoma treated with transhiatal esophagectomy, EGFR expression was related to higher TNM staging and shorter survival. EGFR expression might be assumed as a prognostic marker for esophageal adenocarcinoma.

Gastroesophageal reflux disease is inversely related with glycemic control in morbidly obese patients.

BACKGROUND: The link between diabetes mellitus and gastroesophageal reflux disease (GERD) is controversial. We assessed the relationship between glycemic control (GC) and GERD in morbidly obese patients. METHODS: Consecutive patients with morbid obesity (n = 86) underwent manometry, pH-metry, endoscopy, and contrasted X-ray after responding to a GERD questionnaire and dosing fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c). Patients with poor GC (HbA1c, 6.1-10% and FPG < 140 mg/dl) and those with very poor GC (HbA1c > 10% or FPG > 140 mg/dl) were compared. RESULTS: There were 63 patients with poor GC and 17 with very poor GC. Compared to patients with very poor GC, patients with poor GC showed higher heartburn scores [8 (0-12) vs. 0 (0-4); P = 0.003]; higher total esophageal acid exposure [5.2% (2.5-10.5%) vs. 2.3% (0.8-7.5%); P = 0.041]; lower distal esophageal amplitude (105 ± 38 vs. 134 ± 63 mmHg; P = 0.019); higher expiratory gastroesophageal pressure gradient (GEPG, 7 ± 3.4 vs. 5.2 ± 3 mmHg; P = 0.050); lower ventilatory gradient (inspiratory-expiratory GEPG, 10.9 ± 3.8 vs. 13.6 ± 4.1 mmHg; P = 0.012); lower waist-to-hip ratio (0.95 vs. 1; P = 0.040); and more hiatal hernia (38% vs. 6%; P = 0.016). CONCLUSIONS: This study suggests an inverse relation between glycemic control and GERD in morbidly obese patients. This can be partially explained by a lower frequency of hiatal hernia in patients with very poor glycemic control.

Clinical utility of endoscopy and barium swallow X-ray in the diagnosis of sliding hiatal hernia in morbidly obese patients: a study before and after gastric bypass.

BACKGROUND: The main clinical consequence of sliding hiatal hernia (SHH) is gastroesophageal reflux disease (GERD). Endoscopy and barium swallow X-ray are commonly used to diagnose SHH. We aimed to assess the clinical utility of endoscopy and X-ray in the diagnosis of SHH in morbidly obese patients before and after gastric bypass (GBP). METHODS: Ninety-two patients underwent reflux symptoms evaluation, upper gastrointestinal endoscopy, and barium swallow X-ray before and 6 months after banded GBP. The performance of endoscopy in diagnosing SHH was assessed, taking X-ray as reference. Endoscopy and X-ray were tested as predictors of SHH with GERD. RESULTS: SHH was more prevalent when characterized by X-ray than endoscopy either before (33% vs. 17%; P = 0.017) or after GBP (26% vs. 7%; P = 0.001). Endoscopy showed low sensitivity (or=94%) in diagnosing SHH. Before GBP, more patients with SHH had GERD compared to patients without SHH using either X-ray (83% vs. 58%; P = 0.016) or endoscopy (94% vs. 61%; P = 0.009). After GBP, only patients with radiologic evidence of SHH showed higher prevalence of GERD compared to patients without SHH (50% vs. 26%; P = 0.037). SHH patients also reported weekly or daily vomit more often than patients without SHH (59% vs. 32%; P = 0.026). CONCLUSIONS: In morbidly obese patients, X-ray is superior to endoscopy in diagnosing SHH either before or after banded GBP. In patients treated with this technique, the utilization of X-ray may help in the management of reflux symptoms and frequent vomit.

Hospital discharge in the day following open Roux-en-Y gastric bypass: is it feasible and safe?

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) either laparoscopic or open has been increasingly employed in the treatment of patients with morbid obesity. Laparoscopic approach is believed to be superior over open approach in terms of shorter hospital stay and easier recovery. We aimed to assess feasibility and safety of open RYGBP with short stay in comparison with laparoscopic RYGBP. METHODS: One hundred and ninety consecutive patients were assigned to open (n=103) or laparoscopic (n=87) RYGBP. The first 20 patients of the laparoscopic arm were excluded due to procedure learning curve. Patients were treated by a multidisciplinary team focused on successfully RYGBP with short stay (1 day). RESULTS: Short stay was reached by 90% of patients operated with open approach and 81% by laparoscopy (P=0.070). Discharge in the second day was reached by 97% of patients in both groups. Procedure length [(median (IQR)] was faster for open RYGBP [103 (70-180 min) vs. 169 (105-248 min); P<0.0001]. Thirty-day readmission rate was similar between groups (3% vs. 7%; P=0.266). There was no death in either group. CONCLUSION: Short stay (1 day) following open gastric bypass was a feasible and safe procedure. This approach might have economic impact and might increase patient acceptance for open RYGBP.

Performance of the Montreal Consensus in the diagnosis of gastroesophageal reflux disease in morbidly obese patients.

BACKGROUND: Gastroesophageal reflux disease (GERD) has been increasingly recognized in patients with morbid obesity. A recent global evidence-based consensus on GERD has been proposed, but its performance in patients with morbid obesity is unknown. The aim of this study was to assess the performance of the Montreal Consensus in the diagnosis of GERD in morbidly obese patients. METHODS: Seventy-five consecutive morbidly obese patients underwent GERD symptoms assessment, upper gastrointestinal endoscopy, and ambulatory esophageal pH monitoring "off PPI". The performance of the Montreal Consensus was determined by comparing two diagnostic algorithms: 1. a gold standard approach in which any GERD symptom and findings from both endoscopy and pH monitoring were taken into account, and 2. the approach with the Montreal Consensus, in which troublesome GERD symptoms and endoscopic findings were considered. RESULTS: GERD was found present in 57 patients by applying the gold standard approach. The Montreal Consensus identified 41 of these patients, whereas the remaining 34 patients were classified as "no GERD". Of these, 16 (47%) showed reflux esophagitis and/or abnormal pH-metry. The Montreal Consensus had an accuracy of 78.7%, sensitivity of 72% (95% CI 59-82%), specificity of 100% (95% CI 82-100%) and negative predictive value of 47% (95% CI 37-57%). CONCLUSIONS: In morbidly obese patients, the approach with the Montreal Consensus has high specificity and suboptimal sensitivity in the diagnosis of GERD. Its intermediate negative predictive value suggests that complementary investigation might be routine in these patients, particularly in those who do not present with troublesome GERD symptoms.

Insuficiência renal aguda pós-operatória e icterícia obstrutiva / Post-operative acute renal failure and obstructive jaundice

Em análise retrospectiva de 213 doentes submetidos a cirurgia radical ou paliativa da via biliar principal , foi verificada uma taxa de mortalidade de 14 por cento. Insuficência renal aguda pós-operatória foi observada em 12 por cento dos casos, sendo a mortalidade específica desta complicaçäo de 88 por cento. Os resultados deste estudo demostraram haver correlaçäo significativa entre níveis elevados de bilirrubina total e doença maligna com o aumento de morbimortalidade pós-operatória