Copper deficiency related myelopathy 40 years following a jejunoileal bypass.

Introduction: Acquired copper deficiency myelopathy is a rare disorder associated with hematologic abnormalities, peripheral neuropathy, and sensory ataxia. Although its clinical presentation and radiographic findings are similar to other nutrient deficiencies, practitioners often fail to diagnose copper deficiency. This report describes a case of copper deficiency decades after a jejunoileal bypass (JIB) to draw attention to potential long-term sequelae associated with this now abandoned procedure. Case presentation: A 67-year-old female presented with bilateral paresthesias of her hands and legs, accompanied by gait instability and frequent falls. The individual had a significant history of malabsorption and malnutrition related to a 40 years prior JIB for weight loss. MRI demonstrated T2 hyperintense signal in the dorsal spinal cord between C3 and C5. She was found to have copper deficiency, underwent IV repletion, prescribed oral repletion, and was discharged home. She subsequently developed progressive symptoms over the following year and remained unable to function at home. Treatment required inpatient copper repletion followed by inpatient rehabilitation. Following rehabilitation, the individual demonstrated significant improved independence. Discussion: Although JIB surgery is not currently performed, it is important to recognize the metabolic consequences of nutrient deficiencies related to this procedure and the potential for the development of neurological sequelae including myelopathy. Furthermore, additional causes of copper deficiency to consider in cases of undifferentiated myelopathy include congenital metabolic syndromes, zinc toxicity, and malabsorption. This case demonstrates the potential of intensive physical and occupational therapy regimens, along with symptomatic treatment and nutrient repletion, to help an individual regain independence and improve activities of daily living.

Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Experiencia en una serie de 280 casos en 8 años / Gastrojejunal anastomotic stenosis after laparoscopic gastric bypass. Experience in 280 cases in 8 years

INTRODUCCIÓN: La estenosis de la anastomosis gastroyeyunal (GY) representa la complicación más frecuente en la cirugía de derivación gástrica por laparoscopia, llegando en algunas series a alcanzar el 15%. Presentamos nuestra incidencia de estenosis de la anastomosis GY en el bypass gástrico laparoscópico, su forma de presentación y su manejo a largo plazo. MATERIAL Y MÉTODO: Desde enero del 2004 hasta diciembre del 2012 se han realizado 280 bypass gástricos por la laparoscopia, según la técnica de Wittgrove modificada. La anastomosis GY circular se practicó con material de autosutura tipo CEAA n° 21 en 265 casos, en los restantes se realizó con una anastomosis longitudinal con grapadora lineal de 45 mm. A todos los pacientes con intolerancia persistente a la alimentación se les realizó tránsito baritado o gastroscopia. Cuando se evidenció estenosis GY (diámetro <10 mm), se procedió a dilatación neumática endoscópica. RESULTADOS: En 20 casos (7,1%) se desarrolló una estenosis GY, en 4 de ellos el diagnóstico inicial fue con tránsito baritado. Todos los casos fueron confirmados por gastroscopia. De ellos, 5 pacientes tenían antecedentes de hemorragia digestiva alta que precisaron esclerosis endoscópica de la línea de sutura de la anastomosis GY. Todos los casos se han resuelto mediante dilatación endoscópica, precisando en un caso 2 sesiones de dilatación, en otro caso 3 sesiones y el resto, una. No se han detectado reestenosis. Uno de los pacientes sufrió una perforación de úlcera postanastomótica. CONCLUSIONES: La estenosis de la anastomosis GY es una complicación frecuente tras el bypass gástrico en Y de Roux. Favorecida por anastomosis de pequeño calibre. La endoscopia es la piedra angular para el diagnóstico y tratamiento, pues resuelve la mayoría de casos, siendo rara la revisión quirúrgica

OBJETIVE: Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass, but its frequency is about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass. PATIENTS AND METHOD: From January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis is performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation. RESULTS: Twenty cases (7.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and all case were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up has not been detected re-stricture. CONCLUSION: Structure at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy

Endoscopic treatment of obesity.

BACKGROUND: The increasing incidence of obesity and overweight among children and adolescents will be reflected by the imminent increase in the number of obese patients who require more definitive methods of treatment. There is great interest in new, safe, simple, nonsurgical procedures for weight loss. OBJECTIVE: To provide an overview of new endoscopic methods for the treatment of obesity. METHODS: An English-language literature search on endoscopic interventions, endoscopically placed devices and patient safety was performed in the MEDLINE and Cochrane Library databases. RESULTS: The literature search yielded the following weight loss methods: space-occupying devices (widely used), gastric capacity reduction, modifying gastric motor function and malabsorptive procedures. A commercially available intragastric balloon was the most commonly used device for weight loss. In specific subgroups of patients, it improved quality of life, decreased comorbidities and served as a bridge to surgery. More evidence regarding the potential benefits and safety of other commercially available intragastric balloons is needed to clarify whether they are superior to the most commonly used one. Moreover, early experiences with transoral gastroplasty, the duodenal-jejunal bypass sleeve and an adjustable, totally implantable intragastric prosthesis, indicate that they may be viable options for obesity treatment. Other agents, such as botulinum toxin and a device known as the 'butterfly', are currently at the experimental stage. CONCLUSION: New endoscopic methods for weight loss may be valuable in the treatment of obesity; however, more clinical experience and technical improvements are necessary before implementing their widespread use.

Antiobesity surgery in Sweden from 1980 to 2005: a population-based study with a focus on mortality.

BACKGROUND: Antiobesity surgery reduces mortality, but this reduction is dependent to a great extent on surgical perioperative mortality. Population-based perioperative mortality after antiobesity surgery is not well known. OBJECTIVE: To evaluate mortality after antiobesity surgery in Sweden. DESIGN: Retrospective cohort study. SETTING: All patients who underwent antiobesity surgery in Sweden between 1980 and 2005. MAIN OUTCOME MEASURES: All-cause mortality after antiobesity surgery. RESULTS: A total of 12,379 patients (9,614 women) with mean age (+/-SD) of 39.5 +/- 10.4 years underwent 14,768 antiobesity procedures. Mean follow-up time was 10.9 +/- 6.3 years. A total of 751 (6.1%) patients died during the follow-up period and the cumulative 30-day, 90-day, and 1-year mortality was 0.2, 0.3, and 0.5%, respectively. Early cumulative mortality was higher for men and patients older than 50 years of age. Long-term mortality was higher in men than in women (90 vs. 50 per 10,000 person years when excluding early deaths, mortality rate ratio 1.8 (95% CI, 1.5-2.1)). There was no difference in the rates of early mortality when primary procedures were compared with reoperations. Myocardial infarction and malignancy were the most common late causes of death after surgery. CONCLUSIONS: Antiobesity surgery can be performed safely in unselected populations of obese patients with low rates of early mortality. Men are at a higher risk of early death, which is carried through over long-term follow-up, and that is why a future specific study of the effect of antiobesity surgery on mortality in men is warranted.

Time trends in obesity surgery 1987 through 1996 in Sweden--a population-based study.

BACKGROUND: The Swedish health-care system is well suited for surveys of incidence of surgical procedures including those for morbid obesity, since almost all hospital care is provided by public hospitals funded by a public health-care insurance system. The National Board of Health and Welfare keeps a nation-wide registry of all in-patient hospital care. In order to describe the practice of obesity surgery, we extracted data for all patients who had undergone obesity surgery between 1987 and 1996. MATERIAL: 6,339 patients had at least one obesity surgery procedure between Jan. 1987 and Dec. 1996. A total of 7,176 procedures were identified. 77.2% were women, and the mean age was 39 years. Hospital stay averaged 8 days. RESULTS: There was a 3-fold increase in the annual incidence from 312 procedures/year in 1987 to 952 in 1996. 14% of the patients operated in1996 had previously undergone obesity surgery during the study period. The hospital mortality was 0.4%. Simple gastric restrictive procedures dominated (76%), and gastric bypass and jejuno-ileal bypass were performed in 7.5% and 5%, respectively. There was a trend that gastric bypass was performed more frequently towards the end of the study period. An increased number of procedures were performed in smaller hospitals during 1994-96, and there were obvious geographical variations. CONCLUSION: There has been 3-fold increase in obesity surgery in Sweden between 1987 and 1996, accounted for by increased performance of simple gastric restrictive procedures. The operative mortality is low, but the incidence of a second obesity surgery procedure is high.

Derivación bilioentérica convergente con mecanismo antireflujo: estudio experimental / Biliary-enteric derivation with antirefluz technic: an experimental study

Con el objeto de evitar reflujo en las derivaciones bilio-entéricas y las complicaciones que se derivan de este fenómeno: se puso a prueba una nueva técnica de derivación, denominada convergente con plicatura entero-entérica. Dicho procedimiento se llevó a cabo en un grupo de perros mestizos recién destetados. Los resultados mostraron que la nueva técnica presentó un menor número de complicaciones, comparada con las que se observaron en sujetos con la derivación "habitual en Y de Roux. No obstante, no suprime los efectos iniciales de la contaminación bilio-hepática