Bile reflux after bariatric surgery.

The growing epidemic of obesity and the increase in weight loss surgery has led to a resurgence of interest in biliary reflux because anatomical alterations may be refluxogenic. HIDA scan is the least invasive scan with good patient tolerability, sensitivity and reproducibility for the diagnosis of biliary reflux. Patients with more advanced oesophageal lesions have a higher degree of duodenal reflux. It has been shown in animal models and in vitro that there is more Barrett's and dysplasia with duodenal reflux. There are two cases of post-OAGB malignancy reported in 20 years, both without correlation with a biliary aetiology, so the carcinogenic risk probably remains theoretical. Prospective trials on OAGB should include endoscopy preoperatively and at 5-year intervals, to have data on the real effects of bile exposure on the gastric reservoir and oesophagus.

Seguridad y eficacia del bypass gástrico en Y de Roux asistido por robot versus abordaje laparoscópico convencional / Safety and efficacy of robot-assisted Roux-en-Y gastric bypass versus conventional laparoscopic approach

Resumen Introducción: La cirugía bariátrica se considera actualmente la opción de tratamiento más eficaz para la obesidad mórbida. El bypass gástrico laparoscópico en Y de Roux sigue siendo el estándar de oro en cirugía bariátrica. El advenimiento de la robótica quirúrgica ha llevado a una reducción de algunos de los desafíos más difíciles en la laparoscopia avanzada. Objetivo: Determinar la seguridad y eficacia del bypass gástrico en Y de Roux asistido por robot en comparación con el abordaje laparoscópico. Material y métodos: Se realizó un estudio retrospectivo que incluyo 50 pacientes con distintos grados de obesidad divididos en dos grupos de 25 cada uno. Se realizó una base de datos con las variables de acuerdo al tipo de abordaje quirúrgico (robótico y laparoscópico), registrando los días de estancia hospitalaria, sangrado, tiempo quirúrgico, complicaciones, reingresos hospitalarios, complicaciones y disminución del IMC. Resultados: En el grupo laparoscópico se observó un sangrado transoperatorio de 115.8+64 mililitros, en el grupo robótico solo fue de 59.6+45.8 mililitros (p<0.001). Un tiempo quirúrgico laparoscópico de 151.8+34.6 minutos, mientras que el grupo robótico fue de 216.4+50 minutos, los pacientes permanecieron hospitalizados 4.2+2.4 días en el grupo laparoscópico, los pacientes del grupo robótico 3.4+1 días, sin diferencia significativa (p=0.077). En ambos grupos no hubo reingresos hospitalarios. En el grupo laparoscópico la disminución de IMC fue de 8.9+2.5, mientras que para el grupo robótico fue de 13.7+2.3 con significancia estadística (p<0.001). Discusión: El bypass gástrico en Y de Roux asistido por robot es más seguro y eficaz en comparación con el abordaje laparoscópico. El abordaje robótico disminuye de forma significativa el sangrado transoperatorio, disminuye los días de estancia hospitalaria (sin diferencia significativa) y reduce de forma significativa la disminución del IMC, sin aumentar los reingresos hospitalarios a 30 días ni las complicaciones.

Abstract Introduction: Bariatric surgery is currently considered the most effective treatment option for morbid obesity. The laparoscopic Roux-en-Y gastric bypass remains the gold standard in bariatric surgery. The advent of surgical robotics has led to a reduction in some of the most difficult challenges in advanced laparoscopy. Objective: To determine the safety and efficacy of robot-assisted Roux-en-Y gastric bypass compared to the laparoscopic approach. Material and methods: A retrospective study was carried out that included 50 patients with different degrees of obesity divided into two groups of 25 patients each. A database was created with the variables according to the type of surgical approach (robotic and laparoscopic), recording the days of hospital stay, bleeding, surgical time, complications, hospital readmissions, complications, and BMI decrease. Results: In the laparoscopic group, intraoperative bleeding of 115.8+64 milliliters was observed, in the robotic group it was only 59.6+45.8 milliliters (p<0.001). A laparoscopic surgical time of 151.8+34.6 minutes, while the robotic group was of 216.4+50 minutes, the patients remained hospitalized 4.2+2.4 days in the laparoscopic group, the patients in the robotic group 3.4+1 days, with no significant difference (p=0.077). In both groups there were no hospital readmissions. In the laparoscopic group, the decrease in BMI was 8.9+2.5, while for the robotic group it was 13.7+2.3 with statistical significance (p<0.001). Discussion: Robot-assisted Roux-en-Y gastric bypass is more safe and effective compared to the laparoscopic approach. The robotic approach significantly reduces intraoperative bleeding, decreases the days of hospital stay (with no significant difference), and significantly reduces the decrease in BMI, without increasing 30-day hospital readmissions or complications.

Causes of revisional surgery, reoperations, and readmissions after bariatric surgery.

INTRODUCTION AND OBJECTIVES: Bariatric surgery is the most effective treatment for weight loss, with comorbidity control. With low complication rates, the reasons for reoperation are major complications or weight loss failure/weight regain. Nonsurgical problems can also present, such as anemia, dehydration, chronic pain, and malnutrition, among others. Our aim was to analyze the main causes of revisional surgery, reoperation, and hospital readmission, at a specialized bariatric center. METHODS: A retrospective study was conducted on patients that underwent bariatric surgery within the time frame of 2012 and 2019. The baseline analysis included demographic, anthropometric, and perioperative data, as well as a sub-analysis of the main readmission causes and complications. RESULTS: A total of 776 primary surgeries were performed (649 RYGBP, 127 SG, and 10 revisional surgeries), and 99 patients were identified for the study: 10 revisional surgeries, 44 reoperations, and 45 readmissions. The incidence of revisional surgery was 1.2%, reoperation was 5.6%, and readmission 5.8%. Fifty percent of the revisional surgeries were performed due to insufficient weight loss or weight regain; the most frequent causes of reoperation were cholecystitis (38.6%) and internal hernias (9.1%); and the most common causes of readmission were nonspecific abdominal pain (35.5%) and dehydration (24.4%). CONCLUSION: The most frequent causes of postoperative readmission were nonsurgical events, followed by non-bariatric reoperations, and finally revisional surgeries. There was a low incidence of early reoperations. Knowledge of the abovementioned data is important for identifying higher-risk patients, to prevent major complications.

Consulta en servicio de urgencia y reingreso hospitalario después de una cirugía bariátrica primaria / Emergency department visit and Hospital Readmission after Primary Bariatric Surgery

Resumen Introducción: Las consultas en el servicio de urgencia (CU) y el reingreso (RI) hospitalario después de una cirugía bariátrica (CB) son importantes indicadores de calidad y seguridad. Sin embargo, existe escasa información de estos indicadores en nuestro medio nacional. En este trabajo analizamos las CU y RI de pacientes sometidos a una CB primaria en un centro universitario de alto volumen, y buscamos variables asociadas a estos indicadores. Materiales y Método: Estudio observacional retrospectivo que incluyó a todos los pacientes sometidos a bypass gástrico (BPG) o gastrectomía en manga (GM) laparoscópica primaria realizados de forma consecutiva en nuestra institución durante el período 2006-2007 y 2012-2013. Utilizando nuestros registros clínicos y base de seguimiento prospectivo, identificamos aquellos pacientes con CU o RI en nuestro hospital durante los primeros 30 días después del alta. Resultados: Se incluyeron 1.146 CB primarias, 53% (n = 613) fueron BPG y 47% (n = 533) GM. Un 8,03% (n = 92) de los pacientes tuvo al menos una CU y un 3,7% (n = 42) un RI. Las variables independientes asociadas tanto a CU como RI fueron el tiempo operatorio e índice de masa corporal (IMC) preoperatorio. No se encontró asociación estadística, en el periodo estudiado, para el tipo de CB realizada con la CU ni con el RI. Conclusión: Existe una baja proporción de pacientes que requieren CU y RI posterior a la CB, lo que demuestra la seguridad de estas intervenciones.

Introduction: Emergency department visits (EDV) and hospital readmission (HR) after bariatric surgery (BS) are important indicators of quality and safety in surgery, however there is little information on their characteristics in our national environment. Aim: In this work we analyze EDV and HR in patients undergoing a primary BS in a high-volume university center, and identify variables that could be associated with these indicators. Materials and Method: A retrospective observational study where we identified all patients undergoing Roux-in-Y gastric bypass (RYGBP) or primary laparoscopic sleeve gastrectomy (SG) performed consecutively at our institution during the period 2006-2007 and 2012-2013. Using our clinical records and prospective follow-up database, we identify those patients with EDV and/or HR in our hospital during the first 30 days after discharge. Results: 1146 primary BS were included, of these 53% (n = 613) were RYGBP and 47% (n = 533) SG. 8,03% (n = 92) of the patients had at least one EDV, of these 3,7% (n = 42) had an HR. The independent variables associated with EDV and HR were the operative time and preoperative body mass index (BMI). No statistical association was found, in the period studied, for the type of BS performed with EDV or HR. Conclusion: There is a low proportion of patients who require EDV and HR after BS, which demonstrates the safety of these interventions.

Estadía abreviada poscirugía bariátrica: una posibilidad real sin incrementar complicaciones ni readmisión de pacientes / Abbreviated Hospitalization after bariatric surgery

Resumen Introducción: Nuevas técnicas en cirugía bariátrica han permitido disminuir las complicaciones y la mortalidad quirúrgica. Estas mejoras han hecho posible disminuir la estadía hospitalaria y acelerar el proceso de recuperación permitiendo un potencial protocolo de alta temprana. Objetivos: Describir la experiencia en la utilización de un protocolo diseñado de estadía abreviada, en pacientes posoperados de cirugía bariátrica. Materiales y Método: Estudio analítico, retrospectivo de cohorte. Se consideró una cohorte de pacientes en que se realizó cirugía bariátrica, en Clínica Santa María, por un solo cirujano, entre julio de 2014 y abril de 2019, sometidos a un protocolo diseñado de alta temprana. Fueron registradas la morbilidad, la mortalidad, las readmisiones y reintervenciones en el periodo de tiempo registrado. Resultados: Se incluyeron un total de 775 pacientes, 654 pacientes sometidos a gastrectomía en manga laparoscópica (GEM) y 101 pacientes sometidos a bypass gástrico en Y de Roux (RYGB). Hubo 8 complicaciones, sin mortalidad registrada. La tasa de readmisión/reintervención fue de 4,13%/2,27% para GEM y 4,55%/3,53% para RYGB. Conclusiones: En este grupo de pacientes pudimos demostrar una baja tasa de complicaciones, lo que apoya la idea de que un protocolo de alta temprana en pacientes sometidos a cirugía bariátrica es una alternativa factible y segura.

Introduction: New techniques in bariatric surgery have allowed to reduce complications and surgical mortality. These improvements have made it possible to reduce the hospital stay and accelerate the recovery process, allowing a potential early discharge protocol. Aim: To describe the experience in the use of a protocol designed for an abbreviated stay, in post-operated bariatric surgery patients. Materials and Method: Analytical, retrospective cohort study. A cohort of patients who underwent bariatric surgery, at the Santa María Clinic, by a single surgeon, between July 2014 and April 2019 and submitted to a designed early discharge protocol was considered. Morbidity, mortality, readmissions, and reoperations were recorded in the established period of time. Results: A total of 775 patients were included, 654 patients undergoing laparoscopic sleeve gastrectomy (GEM) and 101 patients undergoing Roux-en-Y gastric bypass (RYGB). There were 8 complications, with no recorded mortality. The readmission/reoperation rate was 4.13%/2.27% for GEM and 4.55%/3.53% for RYGB. Conclusions: In this group of patients we were able to demonstrate a low rate of complications, which supports the idea that an early discharge protocol in patients undergoing bariatric surgery is a feasible and safe alternative.

Atherogenic index of plasma is reduced during follow-up among Roux-in-Y gastric bypass patients

ABSTRACT Atherogenic index of plasma is a marker used to assess risk of cardiovascular diseases. The present study evaluated plasma atherogenic index in individuals before and after bariatric surgery. Individuals were evaluated at three time points: before surgery (T0), in the 2nd (T1) and 6th (T2) months post-surgery. Anthropometric (body mass index, waist circumference, fat and lean mass) and biochemical parameters (lipid profile, glucose and C-reactive protein), and atherogenic index of plasma, calculated by the formula [=log (serum triglycerides concentration/HDL cholesterol)], were evaluated. Data were analyzed using the repeated measures ANOVA or Friedman test according to data distribution. The level of significance was 5%. Thirty-four patients agreed to participate. A significant reduction was observed in all anthropometric parameters in women and men (p<0.05). Atherogenic index of plasma reduced significantly in all time points in women; there was a significant reduction only between periods T0 and T2 (p<0.05) in men. A reduction in the classification for risk in cardiovascular diseases, with high risk in T0 (0.441±0.13) to moderate risk at T1 (0.204±0.22) and low risk at T2 (0.041±0.16) was observed in men. In women, the risk remained low (<0.11) in all periods. Bariatric surgery reduced the atherogenic index of plasma during the 6-month follow-up, suggesting a reduction in cardiovascular risk.

RESUMEN El índice aterogénico plasmático es un marcador que se utiliza para evaluar el riesgo de enfermedades cardiovasculares. El presente trabajo evaluó el índice aterogénico plasmático de pacientes antes y después de la cirugía bariátrica. Los individuos fueron evaluados en tres momentos: antes de la cirugía (T0), el segundo (T1) y el sexto (T2) meses después de la cirugía. Se evaluaron parámetros antropométricos (índice de masa corporal, circunferencia de cintura, masa grasa y masa magra), parámetros bioquímicos (perfil lipídico, glucosa y proteína C reactiva) y el índice aterogénico plasmático, calculado mediante la fórmula [= log (concentración sérica de triglicéridos / colesterol HDL)]. Los datos se analizaron mediante el ANOVA de medidas repetidas o el Test de Friedman según la distribución de los datos. Nivel de significancia adoptado 5%. Treinta y cuatro pacientes aceptaron participar en el estudio. Se observó una reducción significativa en todos los parámetros antropométricos en ambos sexos (p<0.05). En las mujeres, el índice aterogénico plasmático disminuyó significativamente en todos los períodos. En los hombres, hubo una reducción significativa en el índice aterogénico plasmático solo entre T0 y T2 (p<0.05), aunque se observó una reducción en la clasificación de riesgo para enfermedades cardiovasculares de alto riesgo en T0 (0.441±0.13) para moderadas riesgo en T1 (0.204±0.22) y riesgo bajo en T2 (0.041±0.16). En las mujeres, el riesgo se mantuvo bajo (<0.11) en todos los períodos. La cirugía bariátrica redujo la PIA durante el seguimiento de 6 meses, lo que sugiere una reducción del riesgo cardiovascular.

Conversion to Roux-en-Y gastric bypass surgery through a robotic-assisted hybrid technique after failed sleeve gastrectomy: Short-term results. / Conversión por técnica híbrida robótica a bypass gástrico en Y de Roux posterior a falla de manga gástrica: resultados a corto plazo.

INTRODUCTION AND AIMS: Laparoscopic sleeve gastrectomy (LSG) is the most widely performed bariatric surgery worldwide but complications and failed procedures are on the rise. AIMS: To determine the reasons for failed LSGs and report the results of conversion to gastric bypass surgery, comparing the outcomes with those of primary gastric bypass surgery. MATERIALS AND METHODS: Patients with failed LSG that underwent conversion to gastric bypass surgery through a robotic-assisted and laparoscopic (hybrid) technique were evaluated. Outcomes and follow-up related to weight loss failure (WLF) were compared with those in patients that underwent primary laparoscopic gastric bypass (pLGB) surgery. RESULTS: Revisional surgery was performed on 13 patients due to WLF, on 3 patients because of refractory gastroesophageal reflux disease (GERD), and on 2 patients due to gastric stricture. There were no differences between the preoperative characteristics of the patients with WLF before undergoing conversion to gastric bypass and the patients that underwent pLGB surgery. At postoperative month 36, the percentage of excess weight loss was greater in the patients that underwent pLGB surgery, than in those with WLF that underwent conversion to gastric bypass (69.17±23.73 vs. 54.17±12.48, respectively; P<0.05). Refractory GERD, symptoms due to gastric stricture, and comorbidities all improved after the revisional surgery. CONCLUSION: Revisional surgery resulted in acceptable weight loss at 36 months of follow-up and favored comorbidity remission. In addition, it resolved symptoms of refractory GERD and gastric stricture.

Obstrucción intestinal por fitobezoar en una paciente con bypass gástrico laparoscópico en Y de Roux: reporte de un caso / Intestinal obstruction due to phytobezoar in a patient with laparoscopic gastric bypass in Roux-en-Y: case report

INTRODUCCIÓN: Los bezoares son una etiología infrecuente de obstrucción intestinal (OI) posterior a un bypass gástrico laparoscópico en Y de Roux (BGLYR). OBJETIVO: Describir un caso clínico de OI debido a un fitobezoar en un sitio infrecuente, en una paciente 2 años después de un BGLYR. CASO CLÍNICO: Paciente de sexo femenino con antecedente de BGLYR hace 2 años y cuadro de obstrucción intestinal causado por fitobezoar. DISCUSIÓN: Se discuten los factores que pueden contribuir a la formación del bezoar en este caso y estrategias para su prevención. Se destaca la importancia del estudio imagenológico y de la exploración quirúrgica oportuna.

BACKGROUND: Bezoars are an infrequent aetiology of bowel obstruction after a laparoscopic Roux-en-Y gastric bypass (LRYGB). OBJECTIVE: To describe a clinical case of bowel obstruction due to a phytobezoar in an uncommon site, in a patient 2 years after a LRYGB. CASE REPORT: A female patient with a history of LRYGB 2 years ago and bowel obstruction due to phytobezoar. DISCUSSION: Factors that can contribute to the formation of bezoar in this case and strategies for its prevention are discussed. The importance of the imaging study and timely surgical exploration is emphasized.

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.