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Introduction : Obesity is related with higher incidence of gastroesophageal reflux disease. Antireflux surgery has inadequate results when associated with obesity, due to migration and/or subsequent disruption of antireflux wrap. Gastric bypass, meanwhile, provides good control of gastroesophageal reflux. Objective: To evaluate the technical difficulty in performing gastric bypass in patients previously submitted to antireflux surgery, and its effectiveness in controlling gastroesophageal reflux. Methods: Literature review was conducted between July to October 2016 in Medline database, using the following search strategy: (“Gastric bypass” OR “Roux-en-Y”) AND (“Fundoplication” OR “Nissen ‘) AND (“Reoperation” OR “Reoperative” OR “Revisional” OR “Revision” OR “Complications”). Results: Were initially classified 102 articles; from them at the end only six were selected by exclusion criteria. A total of 121 patients were included, 68 women. The mean preoperative body mass index was 37.17 kg/m² and age of 52.60 years. Laparoscopic Nissen fundoplication was the main prior antireflux surgery (70.58%). The most common findings on esophagogastroduodenoscopy were esophagitis (n=7) and Barrett’s esophagus (n=6); the most common early complication was gastric perforation (n=7), and most common late complication was stricture of gastrojejunostomy (n=9). Laparoscopic gastric bypass was performed in 99 patients, with an average time of 331 min. Most patients had complete remission of symptoms and efficient excess weight loss. Conclusion: Although technically more difficult, with higher incidence of complications, gastric bypass is a safe and effective option for controlling gastroesophageal reflux in obese patients previously submitted to antireflux surgery, with the added benefit of excess weight loss.

Obesity is a pandemic associated with significant comorbidities such as type 2 diabetes (T2DM). RYGB is an effective treatment modality for obesity and T2DM. However, bariatric surgery is currently limited to a relatively small population of patients. The duodenal-jejunal bypass sleeve (DJBS) has recently emerged as a promising therapy for obesity and T2DM by providing similar physiological effects to RYGB. We describe a case of a patient with a previously placed DJBS presenting with abdominal pain from anchor erosion managed with an endoscopic approach. A 58-year-old man with obesity and T2DM who had failed prior medical therapy for obesity was referred for DJBS placement. This was placed without complications. At 8 weeks follow-up, he developed abdominal pain and vomiting prompting immediate endoscopic evaluation. EGD revealed an anchor erosion resulting in mild stenosis of the pylorus. Additionally, hyperplastic tissue was found to be adhered to the device in the duodenal bulb. Endoscopic removal with balloon dilation was unsuccessful, and a stent was placed in a “stent-in-stent” fashion through the sleeve to compress the area of tissue ingrowth encouraging local tissue necrosis and device extraction. At 15 days follow-up, the stent was removed; however, the DJBS remained adhered and immobile. Next, the ingrowing hyperplastic tissue was resected in a piecemeal fashion. This resulted in mobilization of the sleeve anchors in the duodenal bulb and successful removal of the DJBS. DJBS endoscopic removal is safe and effective even in challenging cases, thus preventing the need for surgical intervention.

BACKGROUND: In traditional laparoscopic cholecistectomy, the cystic duct and artery are commonly closed by metallic clips just before their division. Although the placement of these clips for occluding cystic artery and duct can be considered safe, biliary leaks and bleeding may occur especially by its dislodgement. AIM: To report a prospective case-series in total clipless cholecystectomy by means of harmonic shears for closure and division of the artery and cystic duct as well removal of the gallbladder from the liver. METHODS: Was evaluate a series of 125 patients who underwent laparoscopic cholecystectomy where the sealing and division of cystic artery and duct was carried out only by harmonic shears. The intact extracted gallbladder was submitted to a reverse pressure test for assessment of the technique safety by means of CO2 insuflation. RESULTS: The most common indication for surgery was gallstones. The mean operative time was 26 min and all gallbladders were dissected intact from the liver bed. There was no mortality and the overall morbidity rate was 0.8% with no hemorrhage or leaks. The reverse pressure test showed that all specimens support at least 36-mmHg of pressure without leaking. CONCLUSION: The harmonic shears is effective and safe in laparoscopic cholecystectomy as a sole instrument for sealing and division of the artery and cystic duct. The main advantages could be related to the safety and decreased operative time.

Less invasive and complex procedures have been developed to treat obesity. The successful use of Endoscopic Sleeve Gastroplasty using OverStitch(r) (Apollo Endosurgery, Austin, Texas, USA) has been reported in the literature.Present technical details of the procedure and its surgical/ endoscopic preliminary outcome.The device was used to perform plications along the greater curvature of the stomach, creating a tubulization similar to a sleeve gastrectomy.A male patient with a BMI of 35.17 kg/m2 underwent the procedure, with successful achievement of four plications, and preservation of gastric fundus. The procedure was successfully performed in 50 minutes, time without bleeding or other complications. The patient presented mild abdominal pain and good acceptance of liquid diet.The endoscopic gastroplasty procedure was safe, with acceptable technical viability, short in duration and without early complications.Procedimentos menos invasivos e complexos têm sido desenvolvidos para o tratamento da obesidade. A gastroplastia vertical endoscópica com uso de OverStitch(r) (Apollo Endosurgery, Austin, TX, EUA) já foi relatada com sucesso na literatura.Apresentar detalhes técnicos do procedimento e seu resultado cirúrgico/endoscópico preliminar.O equipamento foi utilizado para realizar plicaturas ao longo da grande curvatura gástrica, objetivando tubulização do estômago semelhante a gastrectomia vertical.O método foi aplicado em paciente com IMC 35,17 kg/m2, sendo realizadas quatro plicaturas, preservando o fundo gástrico. O procedimento foi realizado com sucesso em 50 min, sem sangramento ou outras complicações. O paciente evoluiu com dor abdominal leve, e teve boa aceitação de dieta líquida.A realização da gastroplastia endoscópica foi segura, com viabilidade técnica aceitável e reprodutível, com curto tempo de procedimento, sem complicações precoces.

Background: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled. Objective: The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice. Methods: Institutional experience and systematic review from the literature on revisional bariatric surgery. Results: Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained. Conclusion: Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions. RESUMO Racional: Bypass gástrico em Y-de-Roux (BGYR) é procedimento padrão em cirurgia bariátrica. Gastrectomia vertical e banda gástrica, embora com bons resultados na literatura, estão mostrando taxas mais elevadas de insucesso no tratamento para reduzir a morbidade associada à obesidade e peso corporal. Outros problemas pós-operatórios podem ocorrer, como a erosão da banda, e doença do refluxo gastroesofágico refratária à medicação. Portanto, conversão laparoscópica para BGYR pode ser alternativa eficaz, desde que indicações específicas para a revisão sejam cumpridas. Objetivo: Analisar os nossos dados e os da literatura sobre procedimentos bariátricos revisionais para avaliar melhores alternativas para a prática atual. Métodos: Foram efetuados experiência institucional e revisão sistemática da literatura sobre cirurgia bariátrica revisional. Resultados: Procedimentos endoscópicos estão sendo aplicados recentemente para melhorar a falha e complicações de procedimentos bariátricos. Falha terapêutica após BGYR ocorre em até 20%. A redução transoral é atualmente um método alternativo para reduzir a anastomose gastrojejunal. A gastrectomia vertical pode apresentar aumento de volume e do diâmetro do pouch , o qual podem ser reduzidos por meio de sutura total endoscópica longitudinal. Síndrome de dumping e episódios de hipoglicemia grave (neuroglicopenia) podem estar presentes nos pacientes com BGYR. Os episódios hipoglicêmicos devem ser avaliados e geralmente podem ser tratados convencionalmente. Para evitar pancreatectomia parcial ou conversão à anatomia normal, uma nova abordagem laparoscópica com ressecção do remanescente gástrico e interposição de jejuno, pode ser aplicada como alternativa em não-respondedores. Episódios de hipoglicemia melhoram, enquanto a perda de peso é mantida. Conclusão: Procedimentos revisionais endoscópicos podem ser aplicados após cirurgia bariátrica em pacientes com sintomas colaterais ou na falha do tratamento. Abordagens convencionais não-cirúrgicas devem ser aplicadas intensivamente antes que uma operação revisional seja indicada. Antigos procedimentos cirúrgicos revisionais complexos estão evoluindo para soluções endoscópicas menos complicadas.

The duodenal-jejunal bypass liner (DJBL) is a promising technique for treating obesity and type 2 diabetes mellitus (T2DM). However, despite promising results, its mechanism of action has not been elucidated. It is thought to promote changes in gastric emptying owing to the neuro-endocrine axis. The aim of this paper was to study DJBL-induced changes in gastric emptying and the relationship of those changes with weight loss and T2DM. Twenty-five patients with obesity and T2DM met inclusion criteria. Scintigraphic gastric emptying testing was performed prior to implantation, 16 weeks after implantation, and 4 weeks after removal. The average gastric retention was compared between tests, to examine the relationship between gastric emptying and those who lost more than 10 % of total body weight. Similarly, we compared average gastric retention between those who achieved a glycated hemoglobin target lower than 7 %. Average gastric retention was greater after DJBL implantation compared with the baseline (first hour, 74 ± 16.3 %, p = 0.001; second hour, 45 ± 25 %, p

Background : Obesity and type 2 diabetes mellitus are associated to inflammatory state, which can be set off by the adipose tissue, once it is a metabolically active organ that can cause a chronic mild inflammatory state. Aim : To evaluate the correlation between preoperative C-reactive protein and postoperative complications risk in obese patients (grades II and III) after Roux-en-Y gastric bypass, with and without type 2 diabetes mellitus. Methods : Between 2008 and 2013 were analysed 209 patients (107 with diabetes), presenting body mass index >40 kg/m2or >35 kg/m2with comorbidities. During the postoperative period, two groups were evaluated: with and without complications. Preoperative ultra-sensitive C-reactive protein was measured by immunonephelometry method. Results : Complications occurred in seven patients (pulmonary thromboembolism, fistula, two cases of suture leak, pancreatitis, evisceration and upper digestive hemorrhage). No statistical significance was found regarding lipid profile and C-reactive protein between patients with and without type 2 diabetes mellitus. When compared to each other, both groups (with and without complications) presented with statistical significance regarding C-reactive protein level (7,2 mg/dl vs 3,7 mg/dl, p=0,016) and had similar weight loss percentage after 3, 6 and 12 months follow-up. Conclusions : Preoperative C-reactive protein serum level was higher in the group which presented complications after Roux-en-Y gastric bypass when compared to the group without postoperative complications. Racional : Obesidade e diabete melito tipo 2 são associadas a estado inflamatório desencadeado pelo tecido adiposo, uma vez que é órgão metabolicamente ativo e que pode gerar estado de inflamação crônica leve. Objetivo : Avaliar a correlação entre os níveis de proteína C reativa pré-operatória e o risco de complicações pós-operatórias em obesos graus II e III após bypass gástrico em Y-de-Roux, em um grupo com e outro sem diabete melito tipo 2. Métodos : Entre 2008 e 2013 foram analisados 209 pacientes (107 diabéticos) com índice de massa corpórea acima de 40 kg/m2 ou maior que 35 kg/m2com comorbidades. No pós-operatório foi avaliado um grupo com e outro sem complicações. A proteína C reativa ultrassensível pré-operatória foi mensurada pela técnica de imunonefelometria. Resultados : Complicações ocorreram em sete pacientes (tromboembolismo pulmonar, fístula, dois casos de vazamento de sutura, pancreatite, evisceração e hemorragia digestiva alta). Não houve diferença estatística significativa em relação ao perfil lipídico e níveis séricos de proteína C reativa entre os grupos com e sem diabete. Quando comparados, os dois grupos (com e sem complicações) apresentaram significância estatística entre os níveis de proteína C reativa (7,2 mg/dl vs 3,7 mg/dl, p=0,016), sendo semelhantes em relação à percentagem de perda de peso após seguimento de 3, 6 e 12 meses. Conclusões : O nível sérico de proteína C reativa pré-operatória foi mais elevado no grupo com complicações após bypass gástrico em Y-de-Roux do que no grupo sem complicações.