Efecto selectivo de bypass gástrico laparoscópico en Y de Roux sobre el metabolismo lipídico / Selective effect of laparoscopic Roux-en-Y gastric bypass on lipid metabolism

INTRODUCCIÓN: La cirugía bariátrica (CB) ha mostrado reducir la morbilidad y mortalidad cardiovascular en obesidad mórbida. La CB ha mejorado la dislipemia del paciente insulinorresistente (IR). El objetivo de nuestro trabajo fue evaluar si existe diferencia en el perfil lipídico entre la técnica de bypass gástrico laparoscópico en Y de Roux (BGYRL) vs. la técnica de la gastrectomía tubular laparoscópica (GTL) a 18 meses de seguimiento. MÉTODOS: Estudio observacional, abierto, prospectivo, de pacientes con obesidad mórbida sometidos que realizaron a cirugía bariátrica a 18 meses seguimiento. Se realizaron análisis antropométricos, composición corporal, gasto energético de reposo, de glucosa, insulina, hemoglobina glucosilada (HbA1c), lipoproteínas de baja densidad (LDL), lipoproteínas de alta densidad (HDL), triglicéridos (TG) y colesterol total (CT). RESULTADOS: No se encontraron diferencias basales de la proporción de pacientes con hipertensión arterial, diabetes de tipo 2, esteatosis y de sexo entre los grupos de BGYRL (91) vs. GTL (77). Se observo reducción de TG a los seis meses a favor de BGYRL vs. GTL: 108,60± 34,86 vs. 124,59±44,58; p = 0,044), en cambio se encontró disminución tanto de niveles de LDL a los 12 y 18 meses a favor del grupo BGYRL vs. GTL: 96,23±24,33 vs. 107,83±28,88, p = 0,025; 90,98±20,62 vs. 106,22±31,48, p = 0,003; la disminución de CT se observó solo a los 18 meses a favor del grupo BGYRL vs. GTL: 171,39±25,058 vs. 186,89±31,81, p = 0,005.ConclusiónEl BGYRL ha mostrado ser más eficaz para reducir LDL y CT en comparación con GTL, lo cual otorga un beneficio adicional del BGYRL en relación al perfil lipídico del paciente.

INTRODUCTION: Bariatric surgery (BS) has shown to reduce cardiovascular morbidity and mortality in obesity. The BS has improved the dyslipidemia of the insulin resistant patient, our objective was to evaluate if there was a difference in the lipid profile between the laparoscopic roux-en-Y gastric bypass (RYGB) technique vs. the sleeve gastrectomy (SG) technique at 18 months of follow-up. METHODS: An observational, open, prospective study of morbidly obese patients who underwent bariatric surgery at 18-month follow-up. Anthropometric analysis, body composition, energy expenditure at rest, glucose, insulin, HbA1c, LDL, HDL, TG and CT were performed. RESULTS: Absence baseline differences were found in the proportion of patients with hypertension, diabetes, steatosis, and sex between the RYGB vs SG groups. A reduction of TG was observed at 6 months in favor of RYGB vs SG: 108.60±34.86 vs. 124.59±44.58, P = 0.044), however, a decrease in both LDL levels was found at 12 and 18 months in favor of the RYGB vs. SG group: 96.23±24.33 vs. 107.83±28.88, P = 0.025; 90.98±20.62 vs 106.22±31.48, P = 0.003; the decrease in CT was observed only at 18 months in favor of the RYGB vs. SG group: 171.39±25.058 vs. 186.89±31.81, P = 0.005. CONCLUSIONS: RYBG has shown to be more effective in reducing LDL and CT levels compared to SG, which provides an additional benefit of RYGB in relation to the lipid profile of the patient.

Selective effect of laparoscopic Roux-en-Y gastric bypass on lipid metabolism. / Efecto selectivo de bypass gástrico laparoscópico en Y de Roux sobre el metabolismo lipídico.

INTRODUCTION: Bariatric surgery (BS) has shown to reduce cardiovascular morbidity and mortality in obesity. The BS has improved the dyslipidemia of the insulin resistant patient, our objective was to evaluate if there was a difference in the lipid profile between the laparoscopic roux-en-Y gastric bypass (RYGB) technique vs. the sleeve gastrectomy (SG) technique at 18 months of follow-up. METHODS: An observational, open, prospective study of morbidly obese patients who underwent bariatric surgery at 18-month follow-up. Anthropometric analysis, body composition, energy expenditure at rest, glucose, insulin, HbA1c, LDL, HDL, TG and CT were performed. RESULTS: Absence baseline differences were found in the proportion of patients with hypertension, diabetes, steatosis, and sex between the RYGB vs SG groups. A reduction of TG was observed at 6 months in favor of RYGB vs SG: 108.60±34.86 vs. 124.59±44.58, P = 0.044), however, a decrease in both LDL levels was found at 12 and 18 months in favor of the RYGB vs. SG group: 96.23±24.33 vs. 107.83±28.88, P = 0.025; 90.98±20.62 vs 106.22±31.48, P = 0.003; the decrease in CT was observed only at 18 months in favor of the RYGB vs. SG group: 171.39±25.058 vs. 186.89±31.81, P = 0.005. CONCLUSIóN: RYBG has shown to be more effective in reducing LDL and CT levels compared to SG, which provides an additional benefit of RYGB in relation to the lipid profile of the patient.

Chronic Gastric Dilation-Surgical Management.

Background: Chronic dilation of the gastric remnant is a rare complication, although it can be serious. It is due to an exaggerated distension of the gastric remnant after a Roux-en-Y gastric bypass (RYGB). Clinical suspicion and computed tomography (CT) are essential for its diagnosis. Its treatment is by means of a decompressive gastrostomy, which can be percutaneous or surgical, an option that can be carried out in certain patients. We present a clinical case of chronic dilation of the gastric remnant and its laparoscopic surgical resolution. Methods: We present a clinical case of a 67-year-old patient who underwent a RYGB. An abdominal CT scan showed chronic dilation of the gastric remnant. A laparoscopic biopsy and a laparoscopic-assisted percutaneous gastrostomy were performed. Conslusion: The combined percutaneous laparoscopic approach is a good option for cases of chronic gastric dilations of unknown origin, allowing to discover and treat its causes.

Image-Guided Surgical Simulation in Minimally Invasive Liver Procedures: Development of a Liver Tumor Porcine Model Using a Multimodality Imaging Assessment.

Background: Image-guided liver surgery and interventions are growing as part of the current trend to translate liver procedures into minimally invasive approaches. Hands-on surgical training in such techniques is required. Consequently, a meaningful and realistic liver tumor model using multi-imaging modalities, such as ultrasound (US), computed tomography (CT), magnetic resonance (MR), cone beam-CT (CBCT), is mandatory. The first aim of this study is to develop a novel tumor-mimic model and assess it with multi-imaging modalities. The second aim is to evaluate the usefulness of the model during image-guided liver procedures. Materials and Methods: The tumor-mimic model is made of a composition of hydrogel, smashed muscle, and gadolinium contrast solution. Five ex vivo livers and three pigs were included in the study. Procedures were performed in an experimental hybrid operating room. Under general anesthesia, US guidance was required to inject the biotumor formula into the pig's liver. US, CT, CBCT, and MR acquisitions were then performed after the initial injection. In vivo models were then used to perform liver procedures, including US-guided biopsy, radiofrequency ablation, and laparoscopic resection. Results: The formula developed is easily injected generating a tissue-like material. Visualization using multi-imaging modalities was appropriate, thereby allowing to perform image-guided techniques. Conclusion: A novel design of an in vivo and ex vivo tissue-like tumor liver model is presented. Due to the multimodality imaging appraisal, it may provide a realistic and meaningful model allowing to perform image-guided liver procedures.

Image-Guided Surgery for Common Bile Duct Stones After Roux-en-Y Gastric Bypass.

Background: The relationship between obesity with common bile duct stone (CBDS) is close and increases after a Roux-en-Y gastric bypass (RYGB). Due to the anatomical modification, direct endoscopic access is not always possible. For this reason, image-guided surgery (IGS) by percutaneous transhepatic biliary drainage (PTBD) of the common bile duct (CBD) could be a first-line approach for the treatment of post-RYGB choledocholithiasis. The aim of this study was to analyze the feasibility and safety of CBDS treatment after RYGB with IGS. Materials and Methods: We present a descriptive retrospective observational multicentric study on the treatment of choledocholithiasis in patients operated on for RYGB using IGS through a minimally invasive approach by PTBD. The diagnosis of CBDS was made according to the symptoms of the patients, supported by blood tests, and medical images. Treatment was planned in two stages: in the first step, a PTBD was performed, and in the second step the choledocholithiasis was removed. Results: Of a total of 1403 post-RYGB patients, 21 presented choledocholithiasis. Of these, n = 18 were included. Symptoms were reported in n = 15 (8 cholestatic jaundice, 7 cholangitis), whereas n = 3 were asymptomatic. Percutaneous treatment was performed in all these patients, treated with a balloon and stone basket. A hyperamylasemia without pancreatitis was observed in 3 patients. No complications or deaths associated with the procedure were reported. The average hospital stay was 8.6 days. Conclusion: IGS is an interesting option for the treatment CBDS after RYGB. For these patients, PTBD is feasible and safe.

Image-Guided Surgical Training in Percutaneous Hepatobiliary Procedures: Development of a Realistic and Meaningful Bile Duct Dilatation Porcine Model.

Background: Malignant or benign biliary obstructions can be successfully managed with minimally invasive percutaneous interventions. Since percutaneous approaches are challenging, extensive training using relevant models is fundamental to improve the proficiency of percutaneous physicians. The aim of this experimental study was to develop an in vivo training model in pigs to simulate bile duct dilatation to be used during percutaneous biliary interventions. Materials and Methods: Twenty-eight large white pigs were involved and procedures were performed in an experimental hybrid operating room. Under general anesthesia, animals underwent a preoperative magnetic resonance cholangiography (MRC). Afterward, the common bile duct was isolated and ligated laparoscopically. A postoperative MRC was performed 72 hours after the procedure to evaluate bile duct dilatation. The In vivo models presenting an effective dilatation model were included in the hands-on part of a percutaneous surgery training course. Animals were euthanized at the end of the training session. Results: Postoperative MRC confirmed the presence of bile duct dilatation in the survival pigs (n = 25). No intraoperative complications occurred and mean operative time was 15.8 ± 5.27 minutes. During the course, 27 trainees could effectively perform percutaneous transhepatic cholangiography, bile duct drainage, biliary duct dilatation, and stent placement, with a > 90% success rate, thereby validating the experimental model. All animals survived during the training procedures and complications occurred in 28.3% of cases. Conclusion: The creation of an in vivo bile duct dilatation animal model is feasible with a low short-term mortality. It provides a realistic and meaningful training model in percutaneous biliary procedures.

Acute Gastric Dilation of the Post-Roux-en-Y Gastric Bypass Remnant Stomach: Image-Guided Surgery Approach.

Background: Bariatric surgery is an effective treatment for obesity and its associated morbidities. They are safe surgeries, their general complication rate is 0%-10%. However, acute gastric dilation is an unusual complication. It requires rapid diagnosis and treatment to avoid major complications. Image-guided surgery represents a group of minimally invasive procedures. Acute gastric dilation is a complication that can benefit from the application of this type of procedure. We present a report of patients with acute gastric dilation of the remnant as a complication after bariatric surgery, its resolution through image-guided surgery, and updating. Materials and Methods: A retrospective review of patients who presented postoperative complications after bariatric surgery was carried out. The time period was 10 years. All patients were operated on in a single center by the same surgical team. Results: A total of 3507 bariatric procedures were analyzed (sleeve gastrectomy, 1929-55.1% ± 0.49%; Roux-en-Y gastric bypass [RYGB], 1403-40% ± 0.48%; other techniques, 175-4.9% ± 0.21%). The RYGB branch reported a total of 11 (0.78% ± 0.08%) complications, of which 2 (0.14% ± 0.03%) were reported as acute gastric dilation of the remnant. Conclusions: Acute gastric dilation of the post-RYGB remnant is a rare complication, but it can be serious. It is necessary to have a high suspicion to obtain an early diagnosis and treatment. Percutaneous gastrostomy is an image-guided procedure that can solve the problem temporarily or permanently.

Applications of Elastography in Ablation Therapies: An Animal Model In Vivo Study.

Background: Ablation therapies are one of the main local treatments for solid organ tumors. After applying any ablation therapy, few days should be waited to perform an imaging study and analyze the result. In this work, we analyzed the correlation between elastography monitoring after procedure and the result of ablation. The objective of this study is to determine tissue changes in vivo in short term after the application of ablation systems using different diagnostic imaging methods. Materials and Methods: Descriptive study in an in vivo swine model. Different types of ablation therapies (radiofrequency ablation, microwave ablation [MWA], and LASER ablation [LA]) were applied in the liver and kidneys. We compared their results by medical image monitoring (ultrasound, computed tomography, elastography) and macroscopic analysis. Results: All the animals survived the procedures. No major intraoperative complications were reported. We determined the characteristics of each procedure. MWA session was faster than the other types of ablation therapies. Regarding ablation area diameters, the largest was achieved with MWA and the smallest with LA. Macroscopically, we observed a central ablation zone, a peripheral ablation zone, and surrounding normal tissue. It was correlated with elastography images. Conclusion: Monitoring of the results of ablation therapies shortly after their application is possible through imaging studies. It allows determining the size of the ablation zone, its characteristics, ruling out complications, and its early results. Elastography could efficiently support this goal.

Percutaneous Image-Guided Surgery in Complications After Bariatric Surgery.

Background: Although bariatric surgery is a standardized procedure, it is not without complications. Image-guided surgery allows minimally invasive resolution of complications, making it ideal for bariatric patients. The objective of this work was to analyze the image-guided surgery approach to postoperative complications of bariatric surgery. Materials and Methods: Retrospective comparative study in patients with complications after bariatric surgery. Patients were included consecutively according to selection criteria. All the patients were treated by the same surgical team. Results: n = 58 patients were recruited. The average age was 47.3 (range 16-62) years; the distribution by sex was male 52% and female 48%. Average body mass index was 42% (±1.26). The associated comorbidities were diabetes mellitus 41% (±0.49), dyslipidemia 41% (±0.49), and high blood pressure 39% (±0.48). Of the total, 39 (67.2%) underwent laparoscopic sleeve gastrectomy (LSG) and 19 (32.8%) under Roux-en-Y Gastric Bypass (RYGB) (P ≥ .05). Complications reported were leaks/fistulas (with/without abdominal collections) in 94.8% (±0.22), gallstones 3.5% (±0.18), and hemorrhage 1.7% (±0.13). There was no statistically significant difference between the type of bariatric surgery (LSG versus RYGB) and the complications found (P ≥ .005). There were no intestinal obstructions, strictures or acute gastric dilations, or deaths. The treatment of complications was approached percutaneously (56.9%), endoscopically (29.4%), reoperation laparoscopically (12%), and clinical control (1.7%). Conclusion: The image-guided surgery approach to postoperative complications of bariatric surgery is feasible and safe. Good results are obtained with a decrease in the surgical comorbidities associated with the procedure.

Revisional Surgery: Aphagia After Gastric Bypass.

Background: Gastric bypass is one of the most widely performed bariatric procedures worldwide and continues to be the gold standard in obese patients with metabolic disorders.1 Regarding the complications, these can appear early or late, the most frequent of the latter being anastomosis stenosis, especially the gastrojejunal (G-J) stenosis. The first treatment option in stenosis is the endoscopic approach, but in cases wherein it fails or the diagnosis is kinking, revisional surgery should be performed. Methods: We describe the technique, step by step, we use to perform a very complex revisional surgery in a patient with aphagia after gastric bypass. Results: This is the case of a 38-year-old female patient who underwent laparoscopic adjustable gastric band in 2011; due to her poor tolerance, a laparoscopic gastric bypass was done. She began with vomiting and gastroesophageal reflux with remarkable symptoms. Diagnosis of stenosis of the jejunojejunal anastomosis of the Roux-en-Y was made and two surgeries were done to treat it. Later the patient referred aphagia and a kink of the gastrojejunal (G-J) anastomosis were observed in the gastrointestinal series. We decided to do a revisional surgery and we describe it step by step in this article. Conclusion: The G-J anastomosis stenosis is the most frequent late complication. Also kinking has to be considered strongly when aphagia or symptoms of obstruction are present. If endoscopic treatment for stenosis or cases of kinking is unsuccessful and fails, then revisional surgery should be considered.

Definitions of Computer-Assisted Surgery and Intervention, Image-Guided Surgery and Intervention, Hybrid Operating Room, and Guidance Systems: Strasbourg International Consensus Study.

OBJECTIVE: To develop consensus definitions of image-guided surgery, computer-assisted surgery, hybrid operating room, and surgical navigation systems. SUMMARY BACKGROUND DATA: The use of minimally invasive procedures has increased tremendously over the past 2 decades, but terminology related to image-guided minimally invasive procedures has not been standardized, which is a barrier to clear communication. METHODS: Experts in image-guided techniques and specialized engineers were invited to engage in a systematic process to develop consensus definitions of the key terms listed above. The process was designed following review of common consensus-development methodologies and included participation in 4 online surveys and a post-surveys face-to-face panel meeting held in Strasbourg, France. RESULTS: The experts settled on the terms computer-assisted surgery and intervention, image-guided surgery and intervention, hybrid operating room, and guidance systems and agreed-upon definitions of these terms, with rates of consensus of more than 80% for each term. The methodology used proved to be a compelling strategy to overcome the current difficulties related to data growth rates and technological convergence in this field. CONCLUSIONS: Our multidisciplinary collaborative approach resulted in consensus definitions that may improve communication, knowledge transfer, collaboration, and research in the rapidly changing field of image-guided minimally invasive techniques.

Laparoscopic Sleeve Gastrectomy: How Do I Do It.

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world. LSG is a safe and effective primary bariatric procedure with durable weight loss. We believe LSG should not be called "easy" and should be performed only by surgeons trained in bariatric surgery. Method: We describe the technique, step by step, we use to perform a sleeve gastrectomy (SG). Results: The highlights of a safer SG systematization are based on minimum 36Fr bougie calibration, starting 4-5 cm from the pylorus, keeping ∼1 cm distance from esophagus. We routinely use staple line reinforcement by continuous suture. Conclusions: LSG is a safe and effective primary bariatric procedure with durable weight loss. It should be performed only by surgeons trained in bariatric surgery.

Mixed reality navigation system for ultrasound-guided percutaneous punctures: a pre-clinical evaluation.

Image-guided surgery is growing in importance with each year. Various imaging technologies are used. The objective of this study was to test whether a new mixed reality navigation system (MRNS) improved percutaneous punctures. This system allowed to clearly visualize the needle tip, needle orientation, US probe and puncture target simultaneously with an interactive 3D computer user inferface. Prospective pre-clinical comparative study. An opaque ballistic gel phantom containing grapes of different sizes was used to simulate puncture targets. The evaluation consisted of ultrasound-guided (US-guided) needle punctures divided into two groups, standard group consisted of punctures using the standard approach (US-guided), and assisted navigation group consisted of punctures using MRNS. Once a puncture was completed, a computed tomography scan was made of the phantom and needle. The distance between the needle tip and the center of the target was measured. The time required to complete the puncture and puncture attempts was also calculated. Total participants was n = 23, between surgeons, medical technicians and radiologist. The participants were divided into novices (without experience, 69.6%) and experienced (with experience > 25 procedures, 30.4%). Each participant performed the puncture of six targets. For puncture completion time, the assisted navigation group was faster (42.1%) compared to the standard group (57.9%) (28.3 s ± 24.7 vs. 39.3 s ± 46.3-p 0.775). The total punctures attempts was lower in the assisted navigation group (35.4%) compared to the standard group (64.6%) (1.0 mm ± 0.2 vs. 1.8 mm ± 1.1-p 0.000). The assisted navigation group was more accurate than the standard group (4.2 ± 2.9 vs. 6.5 ± 4.7-p 0.003), observed in both novices and experienced groups. The use of MRNS improved ultrasound-guided percutaneous punctures parameters compared to the standard approach.

N-SLEEVE GASTRECTOMY: AN OPTION FOR OBESITY AND GERD.

BACKGROUND: Obesity represents a growing threat to population health all over the world. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the lower esophageal sphincter after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure; that's why some patients have reflux after sleeve. AIM: To describe a technique and preliminary results of sleeve gastrectomy with a Nissen fundoplication, in order to decrease reflux after sleeve. METHOD: In the current article we describe the technique step by step mostly focused on the creation of the wrap and it care. RESULTS: This procedure was applied in a case of 45 BMI female of 53 years old, with GERD. An endoscopy was done demonstrating a hiatal hernia, and five benign polyps. A Nissen sleeve was performed due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure and was discharged home uneventfully 48 h after. CONCLUSION: N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when Roux-en-Y gastric bypass it is not indicated.

Percutaneous Image-Guided Abdominal Interventions for Leaks and Fistulas Following Sleeve Gastrectomy and Roux-en-Y Gastric Bypass.

BACKGROUND: Bariatric surgery offers the only effective long-term weight loss therapy for morbidly obese patients. Numerous studies have demonstrated a mortality and morbidity reduction associated with weight loss surgery, but these interventions also have significant rates of complications. It is important for the bariatric surgeons to recognize these complications and acknowledge which of them can be solved in a minimally invasive manner in order to offer to patients the best treatment. The aim of this article was to review factors and success rates associated with percutaneous image guide abdominal interventions to treat the complications of bariatric surgery. MATERIALS AND METHODS: Retrospective descriptive study. Eighty-two patients with complications after bariatric surgery were included. Of these, 56 presented fistula with or without abdominal collection. RESULTS: Of the total patients, 54% are male and 46% female. The average age was 49.4 (range 16-62). Of the 56 cases, 37 (66.1%) occurred after laparoscopic sleeve gastrectomy, and 19 (33.9%) post-Roux-en-Y gastric bypass. The fistula was resolved by percutaneous image guide abdominal interventions in 49 opportunities, of which 67% required only conservative treatment afterwards, the remaining 33% required endoscopic treatment with prostheses, fibrin sealants, and/or clips. No mortality was reported in the series. CONCLUSION: Percutaneous image-guided abdominal interventions play a significant role in the treatment of complications following bariatric surgery. The minimally invasive treatment of fistula after bariatric surgery is safe and effective.

STAGES AND FACTORS OF THE "PERIOPERATIVE PROCESS": POINTS IN COMMON WITH THE AERONAUTICAL INDUSTRY.

BACKGROUND: The aeronautical industry is one of the disciplines that most use control systems. Its purpose is to avoid accidents and return safer flights. The flight of an airplane, from its takeoff to its landing is a process divided into stages under strict control. A surgical procedure has the same characteristics. We try to identify and develop the stages of the surgical process using the experience of the aviation industry in order to optimize the results and reduce surgical complications. AIM: To identify and develop the stages of the surgical process so that they could be applied to surgery departments. METHODS: A search, review and bibliographic analysis of the application of aeronautical control and safety to medical practice in general and to surgery, in particular, were carried out. RESULTS: Surgical process comprises the perioperative period. It is composed of Preoperative Stage (it is divided into 2 "sub-steps": hospital admission and control of preoperative studies) Operative Stage (it is divided into 3 "sub-steps": anesthetic induction, surgery, and anesthetic recovery) and Postoperative Stage (it is divided into 2 "sub-steps": control during hospitalization and ambulatory control). Two checkpoints must be developed. Checkpoint #1 would be located between the preoperative and operative stages, and checkpoint #2 would be located between the operative and postoperative stages. Surgical factors are surgeons, instrumental and technology, anesthesiology and operating room environment. CONCLUSION: It is possible and necessary to develop a systematic surgical procedure. Its application in the department of surgery could optimize the results and reduce the complications and errors related to daily practice.

N-sleeve gastrectomy: an option for obesity and gerd / N-gastrectomia vertical: uma opção para obesidade associada à doença do refluxo gastroesofágico

ABSTRACT Background: Obesity represents a growing threat to population health all over the world. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the lower esophageal sphincter after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure; that's why some patients have reflux after sleeve. Aim: To describe a technique and preliminary results of sleeve gastrectomy with a Nissen fundoplication, in order to decrease reflux after sleeve. Method: In the current article we describe the technique step by step mostly focused on the creation of the wrap and it care. Results: This procedure was applied in a case of 45 BMI female of 53 years old, with GERD. An endoscopy was done demonstrating a hiatal hernia, and five benign polyps. A Nissen sleeve was performed due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure and was discharged home uneventfully 48 h after. Conclusion: N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when Roux-en-Y gastric bypass it is not indicated.

RESUMO Racional: A obesidade representa ameaça crescente à saúde da população em todo o mundo. A gastrectomia por laparoscopia induz alteração do ângulo esofagogástrico devido à própria técnica, hipotonia do esfíncter esofágico inferior após secção de fibras musculares da junção, diminuição do volume gástrico e, consequentemente, aumento da pressão intragástrica; é por isso que alguns pacientes têm refluxo após a gastrectomia vertical. Objetivo: Descrever uma técnica e resultados preliminares da gastrectomia vertical com fundoplicatura a Nissen, a fim de diminuir o refluxo após ela. Método: No artigo atual, descrevemos a técnica passo a passo, principalmente focada na criação da válvula e seu cuidado. Resultados: Este procedimento foi aplicado em um caso de mulher com IMC 45 de 53 anos com DRGE. Foi realizada endoscopia demonstrando hérnia hiatal e cinco pólipos benignos. A gastrectomia vertical com Nissen foi realizada devido à DRGE, à hérnia hiatal e aos múltiplos pólipos no estômago. Ela tolerou bem o procedimento e recebeu alta sem intercorrências 48 h depois. Conclusão: A N-gastrectomia vertical (N-sleeve) é alternativa viável e segura em pacientes obesos com refluxo e hérnia hiatal quando não é indicado o desvio gástrico em Y-de-Roux.

Stages and factors of the "perioperative process": points in common with the aeronautical industry / Etapas e fatores do "processo perioperatório": pontos em comum com a indústria aeronáutica

ABSTRACT Background: The aeronautical industry is one of the disciplines that most use control systems. Its purpose is to avoid accidents and return safer flights. The flight of an airplane, from its takeoff to its landing is a process divided into stages under strict control. A surgical procedure has the same characteristics. We try to identify and develop the stages of the surgical process using the experience of the aviation industry in order to optimize the results and reduce surgical complications. Aim: To identify and develop the stages of the surgical process so that they could be applied to surgery departments. Methods: A search, review and bibliographic analysis of the application of aeronautical control and safety to medical practice in general and to surgery, in particular, were carried out. Results: Surgical process comprises the perioperative period. It is composed of Preoperative Stage (it is divided into 2 "sub-steps": hospital admission and control of preoperative studies) Operative Stage (it is divided into 3 "sub-steps": anesthetic induction, surgery, and anesthetic recovery) and Postoperative Stage (it is divided into 2 "sub-steps": control during hospitalization and ambulatory control). Two checkpoints must be developed. Checkpoint #1 would be located between the preoperative and operative stages, and checkpoint #2 would be located between the operative and postoperative stages. Surgical factors are surgeons, instrumental and technology, anesthesiology and operating room environment. Conclusion: It is possible and necessary to develop a systematic surgical procedure. Its application in the department of surgery could optimize the results and reduce the complications and errors related to daily practice.

RESUMO Racional: A indústria aeronáutica é uma das disciplinas que mais utiliza sistemas de controle. Sua finalidade é evitar acidentes e retornar voos mais seguros. O voo de um avião, desde a decolagem até a aterrissagem, é processo dividido em etapas com estrito controle. Um procedimento cirúrgico tem as mesmas características. Tentar identificar e desenvolver etapas no processo cirúrgico, utilizando a experiência da indústria aeronáutica, poderá otimizar os resultados e reduzir as complicações cirúrgicas. Objetivo: Identificar e desenvolver etapas no processo cirúrgico para que possam ser aplicadas nos serviços de cirurgia. Métodos: Foram realizadas pesquisas, revisão e análise bibliográfica sobre o controle e segurança aeronáutica e aplicando-as na prática médica em geral e à cirurgia em particular. Resultados: O processo cirúrgico compreende o período perioperatório. É composto de pré-operatório (dividido em duas sub-etapas: admissão hospitalar e controle de estudos pré-operatórios); fase operatória (dividida em três sub-etapas: indução anestésica, operação e recuperação anestésica) e fase pós-operatória (dividida em duas "sub-etapas": controle durante a hospitalização e controle ambulatorial). Dois pontos de verificação devem ser desenvolvidos. O ponto de checagem nº 1 estaria localizado entre os estágios pré-operatório e operatório, e o ponto de checagem nº 2 entre os estágios operatório e pós-operatório. Fatores cirúrgicos são cirurgiões, instrumental e tecnologia, anestesiologia e ambiente de sala de cirurgia. Conclusão: É possível e necessário desenvolver um procedimento cirúrgico sistemático. Sua aplicação no departamento de cirurgia poderia otimizar os resultados e reduzir as complicações e erros relacionados à prática diária.

THE CRITICAL VIEW OF SAFETY PREVENTS THE APPEARANCE OF BILIARY INJURIES? ANALYSIS OF A SURVEY.

BACKGROUND: The risk of bile duct injury (BDI) during cholecystectomy remains a concern, despite efforts proposed for increasing safety. The Critical View of Safety (CVS) has been adopted promoting to reduce its risk. AIM: To perform a survey to assess the awareness of the CVS, estimating the proportion of surgeons that correctly identified its elements and its relationship with BDI. METHODS: An anonymous online survey was sent to 2096 surgeons inquiring on their common practices during cholecystectomy and their knowledge of the CVS. RESULTS: A total of 446 surgeons responded the survey (21%). The percentage of surgeons that correctly identified the elements of CVS was 21.8% and 24.8% among surgeons claiming to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS (p=0.03). In the multivariate analysis, career length was the most significant factor related to BDI (p=0.002). CONCLUSIONS: The percentage of surgeons that correctly identified the Critical View of Safety was low, even among those who claimed to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS.