Incidence of de Novo Hiatal Hernia after Laparoscopic Sleeve Gastrectomy.

PURPOSE: After laparoscopic sleeve gastrectomy (LSG), several studies have reported an increase in the incidence of gastroesophageal reflux (GERD). The etiopathogenesis of GERD post-LSG is multifactorial, and hiatal hernia (HH) is one of them. The primary objective was to measure the incidence of de novo HH post-LSG. The secondary objectives were to relate the presence of HH with GERD, the chronic use of proton pump inhibitors (PPI), and the time elapsed from LSG. MATERIALS AND METHODS: A surgical evaluation of the crura after LSG was performed. A retrospective cohort study of 74 consecutive patients with history of LSG submitted to an intra-abdominal surgery that allowed the evaluation of the crura. RESULTS: Of a total of 74 patients, 51 were included. At the time of surgery, 37 patients (72.5%) had a HH; 24 patients (47.1%) had GERD, and 23 patients (45.1%) were frequently using PPI. When patients with HH and those without HH were compared, GERD was observed in 56.8% versus 21.4% (p = 0.01) and frequent consumption on PPI was found in 54.1% versus 21.4% (p = 0.02). According to the data of LSG, with a follow-up of < 18 months, 60% presented HH; meanwhile, with a follow-up of > 18 months, 84.6% presented HH (p = 0.02). CONCLUSIONS: Patients submitted to LSG showed a high incidence of de novo HH. HH was associated with a higher incidence of GERD and PPI dependence. The longer the time elapsed from the LSG, the greater the incidence of HH.

Long-term weight loss in laparoscopic sleeve gastrectomy.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has become an option as a bariatric surgical technique. There is a lack of long-term results of this procedure in the literature. The aim of this study is to present weight loss results of LSG for up to 7 years of follow-up. METHODS: A retrospective series of patients who underwent LSG between 2008 and 2011 was examined. The primary endpoint was weight loss: percentage of excess weight loss (%EWL), percentage of total weight loss (%TWL), and body mass index (BMI) were reported. Failure was defined as %EWL<50%. Multivariate analysis for weight loss was performed. The complications rate was reported. RESULTS: A total of 148 patients met the inclusion criteria; 76.3% were female. Mean preoperative BMI was 36 ± 4 kg/m2. Mean operative time was 89.3 ± 3.2 minutes. Follow-up at 5, 6, and 7 years was 77.7%, 83.3%, and 82.2%, respectively. Mean %EWL and %TWL at 1, 3, 5, and 7 years was 93.2%, 80.7%, 70.6%, and 51.7%, and 27.2%, 23.3%, 20.4%, and 16.3%, respectively. The failure rate was 30.4% at the fifth year and 51.4% at the seventh year. High preoperative BMI was related to worse %EWL (P<0.001) but not to %TWL. Preoperative BMI<35 kg/m2 was associated with better %EWL but not with %TWL (P = 0.003). Four leaks (2.7%) and no mortalities were reported. CONCLUSIONS: LSG is an acceptable surgical technique for weight loss, but in this series, up to one third of the patients fail at the fifth year and half fail in the seventh year. %EWL is better in patients with BMI<35 kg/m2, but this difference disappears when we express outcomes with %TWL.

Electrical stimulation therapy of the lower esophageal sphincter is successful in treating GERD: final results of open-label prospective trial.

BACKGROUND: Electrical stimulation of the lower esophageal sphincter (LES) improves LES pressure without interfering with LES relaxation. The aim of this open-label pilot trial was to evaluate the safety and efficacy of long-term LES stimulation using a permanently implanted LES stimulator in patients with gastroesophageal reflux disease (GERD). METHODS: GERD patients who were at least partially responsive to proton pump inhibitors (PPI) with abnormal esophageal pH, hiatal hernia ≤ 3 cm, and esophagitis ≤ LA grade C were included. Bipolar stitch electrodes were placed in the LES and an IPG was placed in a subcutaneous pocket. Electrical stimulation was delivered at 20 Hz, 215 µs, 3-8 mA in 30 min sessions. The number and timing of sessions was tailored to each patient's GERD profile. Patients were evaluated using GERD-HRQL, daily symptom and medication diaries, SF-12, esophageal pH, and high-resolution manometry. RESULTS: 24 patients (mean age = 53 years, SD = 12 years; 14 men) were implanted; 23 completed their 6-month evaluation. Median GERD-HRQL scores at 6 months was 2.0 (IQR = 0-5.5) and was significantly better than both baseline on-PPI [9.0 (range = 6.0-10.0); p < 0.001] and off-PPI [23 (21-25); p < 0.001] GERD-HRQL. Median% 24-h esophageal pH < 4.0 at baseline was 10.1 and improved to 5.1 at 6 months (p < 0.001). At their 6-month follow-up, 91 % (21/23) of the patients were off PPI and had significantly better median GERD-HRQL on LES stimulation compared to their on-PPI GERD-HRQL at baseline (9.0 vs. 2.0; p < 0.001). There were no unanticipated implantation- or stimulation-related adverse events or untoward sensation due to stimulation. There were no reports of treatment-related dysphagia, and manometric swallow was also unaffected. CONCLUSIONS: Electrical stimulation of the LES is safe and effective for treating GERD. There is a significant and sustained improvement in GERD symptoms, esophageal pH, and reduction in PPI usage without any side effects with the therapy. Furthermore, the therapy can be optimized to address an individual patient's disease.

Pilot clinical study of an endoscopic, removable duodenal-jejunal bypass liner for the treatment of type 2 diabetes.

BACKGROUND: Bariatric surgery is associated with the rapid improvement of type 2 diabetes (T2DM). Here we report an exploratory trial of a completely endoscopic, removable, duodenal-jejunal bypass liner (DJBL) intended to treat T2DM. METHODS: Obese T2DM subjects were randomized to receive a DJBL (n = 12) or sham endoscopy (n = 6) in a 24-week study, extended up to 52 weeks. Measurements included weights, hemoglobin A1c (HbA(1c)), meal tolerance testing, fasting glucose, and seven-point glucose profiles. Subjects' diets were adjusted in the first 2 weeks to obtain similar weight loss during this period. RESULTS: Subjects had baseline HbA(1c) of 9.1 +/- 1.7% and body mass index of 38.9 +/- 6.1 kg/m(2) (+/- SD). In the completer population by week 1, change in fasting glucose in the DJBL arm was -55 +/- 21 mg/dL versus +42 +/- 30 mg/dL in the sham arm (P < or = 0.05; +/- SE); the seven-point glucose profiles were reduced in the DJBL arm but not in the sham arm. Mean postprandial glucose area under the curve was reduced in the DJBL arm by 20% and increased 17% in the sham arm (P = 0.016). At week 12, HbA(1c) change was -1.3 +/- 0.9% in the DJBL arm and -0.7 +/- 0.4% in the sham arm (P > 0.05), and at 24 weeks, values were -2.4 +/- 0.7% in the DJBL arm and -0.8 +/- 0.4% in the sham arm (P > 0.05). Device migrations required endoscopic removal prior to reaching 52 weeks. CONCLUSIONS: The DJBL rapidly normalized glycemic control in obese T2DM subjects, a promising development in the search for novel therapies less invasive than bariatric surgery.

Utilización de la llamada medicina tradicional en distintos níveles socioeconómicos y educacionales / Use of the called tradicional medicine in different socioeconomic and educacional levels

Este estudio identificó el uso de la medicina tradicional (MT) en una población con diferentes niveles educacionales y socioeconómicos. Se describen los agentes informales de la salud utilizados. Una encuesta previamente validada escrutó a adultos de 280 hogares del territorio elegido. Para el análisis se consideró un nivel de significancia de p<0,01. Los resultados caracterizaron al grupo con edad promedio de 41 años (18 a 82 años), 60 por ciento de hombres y 40 por ciento de mujeres. El 45,4 por ciento pertenecían al nivel socioeconómico C2, 43,2 por ciento al nivel C3 y 11,4 por ciento al nivel D. Un 60,7 por ciento de los encuestados tenía educación escolar básica incompleta. Casi 3 de cada 4 pobladores tenía algún grado de confianza en la MT; un 47,5 por ciento ha utilizado o utiliza sus servicios. Los agentes más usados fueron homeópatas (39,8 por ciento) y yerbateros (37,6 por ciento). Un 56,4 por ciento asiste a éstos por tradición familiar. Se demostró uso de MT significativamente mayor en bajos niveles educacionales (p<0,001) y socioeconómico (p=0,005). El trabajo mostró que el uso de la MT es una realidad no despreciable en esta población, con una clara influencia cultural y de tradiciones familiares