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Diabetes Mellitus (DM) and obesity are a public health problem in Chile. Bariatric surgery is the most effective treatment alternative to achieve a significant and sustained weight reduction in patients with morbid obesity. The results of controlled clinical trials indicate that, compared to medical treatment, surgery for obese patients with DM2 allows a better control of blood glucose and cardiovascular risk factors, reduces the need for medications and increases the likelihood for remission. Consensus conferences and clinical practice guidelines support bariatric surgery as an option to treat DM2 in Class III Obesity (Body Mass Index (BMI) > 40) regardless of the glycemic control and the complexity of pharmacological treatment and in Class II Obesity (BMI 35-39,9) with inadequate glycemic control despite optimal pharmacological treatment and lifestyle. However, surgical indication for patients with DM2 and BMI between 30-34.9, the most prevalent sub-group, is only suggested. The Chilean Societies of Endocrinology and Diabetes and of Bariatric and Metabolic Surgery decided to generate a consensus regarding the importance of other factors related to DM2 that would allow a better selection of candidates for surgery, particularly when weight does not constitute an indication. Considering the national reality, we also need a statement regarding the selection and characteristics of the surgical procedure as well as the role of the diabetologist in the multidisciplinary team.

Deep venous thrombosis (DVT) and pulmonary thromboembolism (PE) are known and severe postoperative complications and major causes of morbidity and mortality up to 1 year after bariatric surgery. Patients undergoing bariatric surgery should be considered at least at moderate risk for DVT and PE, and pharmacologic prophylaxis reduces the incidence of these thrombotic complications. Portomesenteric vein thrombosis (PVT) is a rare and potentially life-threatening postoperative complication in bariatric surgery with a higher incidence after LSG compared with other bariatric procedures. Extended postoperative pharmacologic prophylaxis reduces the incidence of DVT and PE, may also reduce the incidence of PVT, and should be considered in patients after LSG.

The duodenal–jejunal bypass liner (DJBL) is an endoscopic device that mimics the duodenal–jejunal exclusion component of the Roux-en-Y gastric bypass. Previous studies assessing the efficacy of the DJBL have shown 10-40% excess weight loss (%EWL) and improvements in obesity-associated comorbidities. The aim of this study was to evaluate the safety and efficacy of a new DJBL prototype over a 3-year period. Morbidly obese subjects were enrolled in a single-arm, open-label, prospective trial. The subjects were offered the opportunity to continue with the trial annually and signed a new consent form. The primary endpoint was safety. The secondary endpoints were changes in weight and biochemical parameters from baseline. The DJBL was implanted endoscopically in 80 subjects (age: 35±10 years; 69% female; weight: 109±17 kg; BMI: 42±5.4 kg/m2). Seventy-two severe adverse events (AEs) were observed in 55 patients (68%), of which nine subjects required a prolonged hospital stay and three subjects required major interventions. Overall, 23 subjects (29%) underwent early device removal due to AEs. Additionally, 95% of the patients experienced mild AEs that mainly consisted of abdominal pain. The severe AEs included a liver abscess (3), upper GI bleeding (4), cholangitis (1), and acute pancreatitis (1) and mostly occurred after 12 months of follow-up. Two patients presented a short esophageal perforation during explantation. These perforations were successfully managed with endoscopic closure in one subject and medical treatment in the other subject. In the completer population at 52 weeks (71 patients), 104 weeks (40 patients), and 156 weeks (11 patients), the mean %EWL were 44 ± 16, 40 ± 22, and 39 ± 20, respectively (p

Introducción: La perforación de una úlcera marginal es un evento grave que suele requerir una reoperación y se asocia a morbimortalidad. El manejo de estos pacientes es debatido y complejo. Objetivo: Describir una serie de pacientes operados de bypass gástrico laparoscópico (BPGLP) que evolucionaron con una úlcera marginal perforada. Material y Método: Se revisaron retrospectivamente las fichas de pacientes operados de BPGL los últimos 10 años y que evolucionaron con una úlcera marginal perforada. Se analizaron las características clínicas, de tratamiento y morbimortalidad perioperatoria. Resultados: Durante este período se operaron 2.095 pacientes de BPGLP, 12 de los cuales presentaron una úlcera marginal perforada, correspondientes a 10 mujeres y 2 hombres. El promedio de edad fue 39 años (21-60) y el índice de masa corporal (IMC) promedio al momento de la primera cirugía fue 34 (29,3-38,6). Diez pacientes tenían hábito tabáquico activo al momento de la perforación. La ocurrencia de esta sucedió en promedio a los 27 meses (rango 3-54, mediana 23,5) de la cirugía. En 11 casos la resolución fue quirúrgica, mediante abordaje laparoscópico en 9 y laparotomía en 2. En todos los casos se encontró una úlcera perforada en la vertiente yeyunal de la gastro-yeyuno anastomosis. No hubo mortalidad ni morbilidad asociada a la cirugía. Conclusiones: En nuestra experiencia la ocurrencia de úlcera marginal perforada post BPGLP se desarrolla en un bajo porcentaje de pacientes. El abordaje laparoscópico es de elección, presentando una baja morbimortalidad. El hábito tabáquico estuvo presente en la mayoría de los pacientes.

Internal hernias (IH) after Roux-en-Y gastric bypass (RYGB) are a serious concern among surgeons and are often under-diagnosed due to heterogeneity of clinical manifestations. Our aim is to assess the frequency of IH after a RYGB in symptomatic and asymptomatic patients. Retrospective analysis of our bariatric surgery unit’s database between 2001 and 2013 is obtained. Patients are surgically explored after RYGB due to acute bowel obstruction (ABO), intermittent abdominal pain (IAP), or being asymptomatic (during an elective cholecystectomy) in whom anatomical presence of IH was established. Also, we compared patients with retrocolic and antecolic technique. Statistical analysis with non-parametric tests and chi-square are used. Of the patients, 3,656 submitted to RYGB during this period, 81.9 % (2,993) by laparoscopy and 26.3 % (963) with retrocolic technique. Of the patients, 130 (3.5 %) were surgically explored due to ABO, 27 patients (0.7 %) due to IAP, and 93 patients (2.5 %) submitted to an elective cholecystectomy with exploration for IH. IH was present in 75 % of the obstructed patients, and in 69 %, it was the cause of obstruction. Patients with IAP showed 59 % of IH, but only 15 % have herniated bowel. In asymptomatic patients, 25 % showed IH and none of them have herniated bowel. Retrocolic technique showed a higher risk of whole causes of ABO and IH than the antecolic technique, with a relative risk of 1.53 (1.07–2.17) and 1.62 (1.06–2.47), respectively. A high frequency of IH exists in all operated patients of this series. All members of the bariatric team should be aware of the symptoms related to IH and actively pursue it during follow-up.

La recurrencia peritoneal en el cáncer gástrico avanzado, luego de una cirugía con intención curativa es un problema que debe ser considerado una prioridad en nuestro país, debido a la alta proporción de pacientes con compromiso de la serosa gástrica al momento del diagnóstico, siendo el peritoneo el principal sitio de recurrencia luego de una cirugía con intención curativa en este grupo. Luego de la recurrencia peritoneal, los pacientes presentan un deterioro importante de la calidad de vida, principalmente por episodios de obstrucción intestinal, deshidratación y rehospitalizaciones. Se han realizado múltiples estudios en el extranjero de potenciales medidas que se pueden realizar durante la cirugía inicial con intención curativa que previenen la recurrencia. Algunas de estas medidas han disminuido la recurrencia peritoneal y aumentado la sobrevida a 5 años, como son la quimioterapia hipertérmica intraoperatoria, el lavado peritoneal extensivo y la bursectomía rutinaria, en pacientes seleccionados. El objetivo de la presente revisión es mostrar los resultados oncológicos de la cirugía curativa, los patrones de falla luego de una cirugía curativa, los factores de riesgo para una recurrencia peritoneal y los estudios que se han realizado en relación a la prevención de la carcinomatosis peritoneal.

Endoscopic treatment with the duodenal-jejunal bypass liner (DJBL) leads to significant weight loss in obese patients. We sought to identify clinical factors associated with weight loss in obese patients treated with the DJBL for 1 year. Subjects with morbid obesity were enrolled in a single-arm, open-label, prospective trial and implanted with the DJBL. Patient demographics along with baseline comorbidities, anthropometrics, and biochemical variables were selected for univariate and multivariate analysis. The DJBL was implanted in 79 subjects and 61 completed 12 months of follow-up. There were 18 early removals. Baseline mean age and body mass index (BMI) were 35.4 ± 9.7 years and 43 ± 5.6 kg/m2, respectively. Forty-four (72 %) were women. This population included 22 subjects with type 2 diabetes (T2DM). Twelve months after treatment, patients had a mean excess body weight loss (%EBWL) of 46 ± 18 %. Univariate analysis identified that fasting glycemia (r 2 = −0.303, p

Bariatric surgery has experienced a dramatic evolution over the last years. The search for less invasive procedures to improve the benefit/risk ratio and to expand the benefits of these interventions to a larger group of patients has led to the development of primary endoscopic procedures for the treatment of obesity and its associated diseases. The duodenal-jejunal bypass liner (DJBL) is a highly flexible and impermeable tube that can be endoscopically implanted and explanted. It is specifically designed to create a duodenal-jejunal exclusion. The DJBL treatment has now become a primary intervention for the treatment of morbid obesity and to improve glycemic control in obese patients with type 2 diabetes mellitus (T2DM). Available evidence supports the role of DJBL in treating obesity and improving glycemic control in a significant proportion of severely obese diabetic patients. Early removal and a higher rate of serious adverse events in clinical practice are the most important limitations in terms of safety. Randomized clinical trials are needed to evaluate the safety/efficacy ratio of the procedure and its clinical use in future.

La reconstrucción del trato digestivo con un asa en Y-de-Roux ha sido más empleada en los últimos años debido principalmente al aumento del tratamiento quirúrgico de la obesidad mediante el bypass gástrico en Y-de-Roux (BGYR). La pandemia de la obesidad se ha asociado a un aumento en la prevalencia de litiasis biliar en esta población, diagnosticada en el estudio preoperatorio y durante el seguimiento postoperatorio. La colangiopancreatografía endoscópica retrógrada (CPRE) posee una mayor complejidad en estas circunstancias donde existe una alteración anatómica que dificulta el acceso a la papila mayor. El objetivo de esta revisión es describir las alternativas de acceso al asa biliopancreática para realizar CPRE en pacientes con un asa en Y-de-Roux enfatizando la accesibilidad técnica, los resultados y complicaciones de los procedimientos. Se realizó una búsqueda y revisión de la literatura en las bases de datos: Medline, Cochrane y Scielo. Se evaluaron 249 publicaciones desde 1990 a 2010, en idioma español, inglés y portugués. Fueron excluidos de esta revisión los reportes de casos y publicaciones no atingentes. Las opciones endoscópicas para realizar CPRE en pacientes con reconstrucción con un asa en Y-de-Roux incluyen: el uso de enteroscopio, colonoscopio, acceso enteral y transgástrico combinado con cirugía. Todos las alternativas presentan una alta tasa de éxito, sin embargo, pese a los avances tecnológicos obtenidos en los últimos años en el instrumental utilizado aún se necesitan herramientas que permitan una mayor comodidad y seguridad para este procedimiento.

11-β-Hydroxysteroid dehydrogenase type 1 (11β-HSD1) converts cortisone to cortisol, mainly in the liver and visceral adipose tissue (VAT), and has been implicated in several metabolic disorders. The absence of systemic hypercortisolism in central obesity could be due to increased inactivation of cortisol to its tetrahydrometabolites by the hepatic enzymes 5α- and 5β-reductases. Our aim was to assess the expression of the reductases in the liver and of 11β-HSD1 in the liver and VAT in morbidly obese patients and to analyze their association with clinical, anthropometric, and biochemical parameters. Hepatic and VAT samples were obtained during bariatric surgery. 5α- and 5β-reductases, 11β-HSD1, and 18S expression was measured using real-time polymerase chain reaction. Anthropometric and biochemical variables were analyzed. Forty-one patients were recruited (age, 41.8 ± 10.6 years; body mass index, 42.1 ± 6.6 kg/m(2); 71% women). The expression of hepatic 5α- and 5β-reductases was positively correlated (r = +0.53, P = .004), and their expression levels were correlated with hepatic 11β-HSD1 expression (r = +0.61, P < .001 for 5α-reductase and r = +0.50, P < .001 for 5β-reductase). Hepatic 5α-reductase was associated with insulin (r = +0.34, P = .015). Visceral adipose tissue 11β-HSD1 expression was associated with glucose (r = +0.37, P = .025) and insulin (r = +0.54, P = .002). Our results showed that 5α-reductase and VAT 11β-HSD1 expressions were associated with insulinemia. These findings suggest that overexpression of 5α-reductase, through a higher inactivation of cortisol in the liver, could have a protective role in preserving hepatic sensitivity to insulin. The overexpression of liver reductases in obesity could be an adaptive response to an increase in cortisol production by the liver and visceral 11β-HSD1 to avoid systemic hypercortisolism.

Background One of the complications of laparoscopic adjustable gastric banding is intragastric erosion, leading to a revisional procedure to remove the band. Our aim was to present the procedure and results of endoscopic band removal in a 5-year multicenter experience from the Gastro Obeso Center and Universidade de Sao Paulo, Sao Paulo, and Universidade Federal de Pernambuco, Recife, Brazil. Methods From 2003 to 2008, 82 patients were diagnosed with band erosion. The clinical data concerning the endoscopic procedure were prospectively recorded and retrospectively reviewed. Results The average preoperative body mass index was 43.2 kg/m 2 (range 34–50). At the diagnosis of intragastric erosion, the body mass index was 24–41 kg/m 2 (average 31.8). The erosion occurred an average of 16.3 months (range 6–36) postoperatively. The symptoms included pain in 25 (31%), port infection in 21 patients (27%), and weight regain in 20 (25%), and 12 patients (15%) were asymptomatic. Endoscopic removal was possible for 78 patients (95%). In 85% of patients, the band was removed in the first session, with an average duration of 55 minutes (range 25–150). Five cases of pneumoperitoneum occurred after the procedure. Of these, 3 were treated conservatively, 1 was treated by laparoscopy, and 1 was treated by abdominal puncture using the Veress needle. Conclusion Endoscopic removal of eroded laparoscopic adjustable gastric banding is safe and effective. It can be used as a first choice procedure in clinical practice.

The duodenal-jejunal bypass sleeve (DJBS) has been shown to achieve a completely endoscopic duodenal exclusion without the need for stapling. This report is the first randomized controlled trial for weight loss. In a 12-week, prospective, randomized study, subjects received either a low fat diet and the DJBS or a low fat diet control (no device). Twenty-five patients were implanted with the device and 14 received the control. The groups were demographically similar. Both groups received counseling at baseline only, which consisted of a low calorie diet, and exercise/behavior modification advice. No additional counseling occurred in either group. Measurements included starting and monthly body weight and serum blood tests. The device group also had a plain abdominal film post implant, a monthly KUB and a 4-week post explant EGD. Twenty device (80%) subjects maintained the DJBS without a significant adverse event for the 12-week duration. At 12 weeks, the mean excess weight loss was 22% and 5% for the device and control groups, respectively (p < 0.001). Five subjects (20%) were endoscopically explanted early secondary to upper GI (UGI) bleeding (n = 3), anchor migration (n = 1) and sleeve obstruction (n = 1). The UGI bleeding occurred at a mean of 13.8 days post implant. EGD was performed in each of these cases with no distinct bleeding source identified. No blood transfusion was required. The migration occurred on day 47 and manifested as abdominal pain. The subject with the sleeve obstruction presented with abdominal pain and vomiting on day 30. Eight subjects (40%) underwent the 4 week post explant EGD at which time mild degrees of residual duodenal inflammation was noted. The DJBS achieves noninvasive duodenal exclusion and short term weight loss efficacy. Longer term randomized controlled sham trials for weight loss and treatment of T2DM are underway.

11β-Hydroxysteroid dehydrogenase type 1 (11β-HSD1) enzyme catalyzes interconversion of inactive cortisone to active cortisol. Its expression in adipose tissue has been associated with obesity and some of its metabolic disorders. Controversies regarding which fat depots [subcutaneous adipose tissue (SAT) or visceral adipose tissue (VAT)] have higher expression still remain. The aim of this work was to evaluate 11β-HSD1 expression in SAT and VAT of obese patients and evaluate its association to metabolic features of metabolic syndrome. In 32 morbidly obese patients, paired samples of SAT and VAT were collected. All patients, 40.2 ± 12.3 years and 36.7 ± 3.8 body mass index (BMI), underwent sleeve gastrectomy or laparoscopic gastric bypass. Gene expression of 11β-HSD1 in adipose tissue samples were determined by real-time reverse transcriptase polymerase chain reaction. Spearman correlation test was used to evaluate relationships between 11β-HSD1 levels and clinical and biochemical parameters. 11β-HSD1 mRNA levels were higher in SAT than in VAT, with median expression levels of 11.4 arbitrary units (AU) and 7.8 AU, respectively (p = 0.03). SAT 11β-HSD1 mRNA were correlated with VAT mRNA levels (r = −0.6, p = 0.018) and hip circumference (r = 0.66, p = 0.018). SAT 11β-HSD1 levels increase parallel according to BMI category. We did not find a correlation between SAT or VAT with fasting glucose (r = 0.15, p = NS), total cholesterol (r = 0.13, p = NS), triglycerides (r = 0.04, p = NS), and high-density lipoprotein (r = −0.16, p = NS). However, SAT expression in patients with features of MS was higher than those without features of MS. Our results demonstrate that SATs express higher 11β-HSD1 mRNA levels than VAT. This finding highlights the importance of SAT in obesity and its possible role on metabolic disorders associated with obesity.

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high. The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

Background: The laparoscopic approach for the treatment of gastric tumors has many advantages. Aim: To evaluate the results of a laparoscopic gastrectomy program developed in a public hospital. Patients and Methods: Retrospective review of epidemiological, perioperative and follow-up data of patients who were treated with a laparoscopic gastrectomy due to gastric tumors between 2006 and 2013. A totally laparoscopic technique was used for all cases. Complications were evaluated according to the Clavien-Dindo classification. Results: Fifty one patients, aged 65 (36-85) years, underwent a laparoscopic gastrectomy. In 22 patients a total gastrectomy was performed. Conversion rate to open surgery was 8%. Operative time was 330 (90-500) min and bleeding was 200 (20-500) ml. Median hospital stay was 7 (3-37) days. Postoperative morbidity was present in 17 (33%) patients, 3 (6%) patients had complications grade 3 or higher and one patient died (1.9%). Tumor pathology was adenocarcinoma in 39 patients. A complete resection was achieved in 97%. Twenty nine patients (74%) with gastric adenocarcinoma had early gastric cancer and 84% of patients were in stage one. Median lymph node count was 24. Median follow-up was 26 (1-91) months. There was no cancer related mortality among patients subjected to a curative resection. Overall survival for patients with adenocarcinoma was 92% at 3 years. Conclusions: This study supports the feasibility and safety of a laparoscopic gastrectomy program in a public hospital; with low morbidity, adequate lymph node dissection and long-term survival. This approach must be considered an option for selected patients with gastric cancer.

Item does not contain fulltext BACKGROUND: A previous single-centre study showed that lower oesophageal sphincter electrical stimulation therapy (LES-EST) in gastro-oesophageal reflux disease (GERD) patients improves reflux symptoms and decreases oesophageal acid exposure. AIM: To evaluate safety and efficacy of LES-EST in GERD patients with incomplete response to proton pump inhibitors (PPIs) in a prospective, international, multicentre, open-label study. METHODS: GERD patients, partially responsive to PPIs, received LES-EST. GERD health-related quality of life (GERD-HRQL), daily symptom diaries, quality of life scores, oesophageal acid exposure, and LES resting and residual pressure were measured before and after initiation of LES-EST. Stimulation sessions were optimised based on residual symptoms and oesophageal acid exposure. RESULTS: Forty-four patients were enrolled and 6-month data from 41 patients are available. Hiatal repair was performed in 16 patients. One device-related, one procedure-related and one unrelated severe adverse event were reported. GERD-HRQL improved from 31.0 (IQR 26.2-36.8) off-PPI and 16.5 (IQR 9.0-22.8) on-PPI to 4 (IQR 1-8) at 3-month and 5 (IQR 3-9) at 6-month follow-up (P < 0.0001 vs. on- and off-PPI). Oesophageal acid exposure (pH < 4.0) improved from 10.0% (IQR 7.5-12.9) to 3.8% (IQR 1.9-12.3) at 3 months (P = 0.0027) and 4.4% (IQR 2.2-7.2) at 6 months (P < 0.0001). CONCLUSIONS: These interim results show an acceptable safety record of LES-EST to date, combined with good short-term efficacy in GERD patients who are partially responsive to PPI therapy. A remarkable reduction in regurgitation symptoms, without the risk of intervention-requiring dysphagia may prove to be an advantage compared with other anti-reflux procedures. ClinicalTrials.gov Identifier: NCT01574339.

Epidemiological studies have proven that obesity is a significant risk factor for type 2 diabetes. Long-term progression of diabetes leads to various microvascular complications, of which diabetic nephropathy has become of increasing importance, and is the main cause of end-stage renal failure in occidental countries. Microalbuminuria is the first marker of incipient diabetic nephropathy, an early stage glomerulopathy which can progress to renal failure and which historically has been treated with angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists. We report a severely obese diabetic patient on treatment for diabetic nephropathy with ACE-inhibitors and poor results, which resolved after Roux-en-Y gastric bypass.

The T-tube has been the alternative of choice for decompression following common bile duct (CBD) exploration. The development of laparoscopic surgery has suggested using a biliary stent as an alternative to the T-tube following choledochotomy. The purpose of this prospective randomized study was to compare clinical results obtained from patients who underwent open CBD exploration using a biliary stent versus those from patients with a T-tube for decompression. Between September 2000 and June 2002 a total of 81 patients were randomly assigned to a biliary stent or a T-tube as the decompression method following choledochotomy. An open CBD exploration was performed when CBD stones were suspected, in both elective and emergency settings. The length of the postoperative hospital stay was 6.8 +/- 4.7 days for patients with the T-tube and of 5.2 +/- 3.3 days for, patients with the biliary stent (p = 0.19). Postoperative complications were observed in 13 patients (30%) with the T-tube and in 4 patients (11%) with the biliary stent (p = 0.03). One patient with a biliary stent was reoperated because of an intraabdominal abscess, and another patient was reoperated because of biliary peritonitis following T-tube removal. Three patients (7%) with a biliary stent and one patient (3%) with a T-tube were rehospitalized. There were no deaths. The T-tube and biliary stent were removed 27.1 +/- 10.8 days and 34.9 +/- 12.9 days after surgery, respectively (p = 0.24). The biliary stent is a safe alternative to the T-tube as a biliary decompression method following an open CBD exploration.

Implantation of the duodenal-jejunal bypass sleeve under conscious sedation: a case series Rodrigo Montana, M.D., Milenko Slako, M.D., Alex Escalona, M.D.* Department of Anesthesiology, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile Received June 29, 2011; accepted June 30, 2011 Surgery for Obesity and Related Diseases 8 (2012) e63–e65

Endoscopic placement of the duodenal-jejunal bypass liner (DJBL) in morbidly obese patients induces significant weight loss. Additionally, early studies reported significant improvements in several parameters of glucose homeostasis in morbidly obese patients with T2DM. The observed glycemic control occurred soon after device placement, after a minimal weight loss, suggesting the activation of weight loss-independent anti-diabetic mechanisms of glucose normalization. This effect is associated with favorable changes in hormones involved in glucose level regulation. Recently, larger clinical studies, focused primarily on the effect of the DJBL on T2DM treatment, have corroborated initial observations not only in morbidly obese patients but in non-morbidly obese diabetic patients as well. In this article we review the evidence from preclinical animal and clinical human studies that support the efficacy of DJBL to treat T2DM in obese patients.

The laparoscopic approach for the treatment of gastric tumors has many advantages.To evaluate the results of a laparoscopic gastrectomy program developed in a public hospital.Retrospective review of epidemiological, perioperative and follow-up data of patients who were treated with a laparoscopic gastrectomy due to gastric tumors between 2006 and 2013. A totally laparoscopic technique was used for all cases. Complications were evaluated according to the Clavien-Dindo classification.Fifty one patients, aged 65 (36-85) years, underwent a laparoscopic gastrectomy. In 22 patients a total gastrectomy was performed. Conversion rate to open surgery was 8%. Operative time was 330 (90-500) min and bleeding was 200 (20-500) ml. Median hospital stay was 7 (3-37) days. Postoperative morbidity was present in 17 (33%) patients, 3 (6%) patients had complications grade 3 or higher and one patient died (1.9%). Tumor pathology was adenocarcinoma in 39 patients. A complete resection was achieved in 97%. Twenty nine patients (74%) with gastric adenocarcinoma had early gastric cancer and 84% of patients were in stage one. Median lymph node count was 24. Median follow-up was 26 (1-91) months. There was no cancer related mortality among patients subjected to a curative resection. Overall survival for patients with adenocarcinoma was 92% at 3 years.This study supports the feasibility and safety of a laparoscopic gastrectomy program in a public hospital; with low morbidity, adequate lymph node dissection and long-term survival. This approach must be considered an option for selected patients with gastric cancer.

Background: Bariatric surgery is the gold-standard treatment for morbid obesity because it has low morbidity rates in high-volume centers and generates long term sustained weight loss. Aim: To describe our experience in bariatric surgery since the creation of our bariatric program in 1992. Material and Methods: Retrospective analysis of all patients subjected to bariatric surgery from 1992 to December 2010. Data was obtained from the electronic institutional registry. The Procedures per-formed were open and laparoscopic Roux-en-Ygastric bypass (BPGA and BPGL, respectively), laparoscopic adjustable gastric band (BGAL) and laparoscopic sleeve gastrectomy (GML). Results: A total of 4943 procedures were performed, 768 (16%) BPGA, 2558 (52%) BPGL, 199 (4%) BGAL and 1418 (29%) GML. The number of procedures progressively increased, from 100 cases in 2000 to over 700 cases in 2008. Proportion of femóles and preoperative mean body mass Índex fluctuated between 69 and 79% and 35 and 43 kg/m², respectively, among the different procedures. Early and late complications fluctuated between Oto 1% (higher on BPGA) and 3 to 32.7% (higher on BGAL), respectively. The excess weight lost atfiveyears was 76.1 % in BPGA, 92.5%o in BPGL and 53.7% in BGAL. The figure for GML at three years was 73.7%. Conclusions: The complication rates ofthis series of patients are similar to those reported in large series abroad. BPGL is still the most effective procedure; however GML is an attractive alternative for less obese patients.

To evaluate safety, weight loss, and cardiometabolic changes in obese subjects implanted with the duodenal-jejunal bypass liner (DJBL) for 1 year.The DJBL is an endoscopic implant that mimics the duodenal-jejunal bypass component of the Roux-en-Y gastric bypass. Previous reports have shown significant weight loss and improvement in type 2 diabetes for up to 6 months.Morbidly obese subjects were enrolled in a single arm, open label, prospective trial and implanted with the DJBL. Primary endpoints included safety and weight change from baseline to week 52. Secondary endpoints included changes in waist circumference, blood pressure, lipids, glycemic control, and metabolic syndrome.The DJBL was implanted endoscopically in 39 of 42 subjects (age: 36 ± 10 years; 80% female; weight: 109 ± 18 kg; BMI: 43.7 ± 5.9 kg/m); 24 completed 52 weeks of follow-up. Three subjects could not be implanted due to short duodenal bulb. Implantation time was 24 ± 2 minutes. There were no procedure-related complications and there were 15 early endoscopic removals. In the 52-week completer population, total body weight change from baseline was -22.1 ± 2.1 kg (P0.0001) corresponding to 19.9 ± 1.8% of total body weight and 47.0 ± 4.4% excess of weight loss. There were also significant improvements in waist circumference, blood pressure, total and low-density lipoprotein cholesterol, triglycerides, and fasting glucose.The DJBL is safe when implanted for 1 year, and results in significant weight loss and improvements in cardiometabolic risk factors. These results suggest that this device may be suitable for the treatment of morbid obesity and its related comorbidities. This study was registered at www.clinicaltrials.gov (NCT00985491).

Bariatric surgery is the gold-standard treatment for morbid obesity because it has low morbidity rates in high-volume centers and generates long term sustained weight loss.To describe our experience in bariatric surgery since the creation of our bariatric program in 1992.Retrospective analysis of all patients subjected to bariatric surgery from 1992 to December 2010. Data was obtained from the electronic institutional registry. The Procedures per-formed were open and laparoscopic Roux-en-Y gastric bypass (BPGA and BPGL, respectively), laparoscopic adjustable gastric band (BGAL) and laparoscopic sleeve gastrectomy (GML).A total of 4943 procedures were performed, 768 (16%) BPGA, 2558 (52%) BPGL, 199 (4%) BGAL and 1418 (29%) GML. The number of procedures progressively increased, from 100 cases in 2000 to over 700 cases in 2008. Proportion of femóles and preoperative mean body mass Índex fluctuated between 69 and 79% and 35 and 43 kg/m², respectively, among the different procedures. Early and late complications fluctuated between Oto 1% (higher on BPGA) and 3 to 32.7% (higher on BGAL), respectively. The excess weight lost at five years was 76.1% in BPGA, 92.5% in BPGL and 53.7% in BGAL. The figure for GML at three years was 73.7%.The complication rates of this series of patients are similar to those reported in large series abroad. BPGL is still the most effective procedure; however GML is an attractive alternative for less obese patients.

Background The enzyme 11β-hydroxysteroid-dehydrogenase type 1 (11β-HSD1) catalyses the reactivation of intracellular cortisol. We explored the potential role of 11β-HSD1 overexpression in visceral adipose tissue (VAT) in non-alcoholic fatty liver disease (NAFLD) assessing sequential changes of enzyme expression, in hepatic and adipose tissue, and the occurrence of portal hypercortisolism in obese mice. 11β-HSD1 expression was also assessed in tissues from obese patients undergoing bariatric surgery. Methods Peripheral and portal corticosterone levels and liver histology were assessed in ob/ob mice at two time points (8–12 weeks of age). 11β-HSD1 tissue expression was assessed in by RT-pcr in ob/ob mice and in 49 morbidly obese patients. Results Portal corticosterone serum levels were higher in obese mice with a 26% decrease between 8 and 12 weeks of age (controls: 78.3 ± 19.7 ng/ml, 8-week-old ob/ob: 167.5 ± 14.5 ng/ml and 12-week-old ob/ob: 124.3 ± 28 ng/ml, P

The efficacy of Roux-en-Y gastric bypass (RYGB) to control type 2 diabetes mellitus (T2DM) has been demonstrated in morbidly obese patients. Surgical procedures primarily focused on T2DM control in patients with body mass index (BMI) 35 kg/m(2) have shown to effectively induce remission of T2DM. However, only few reports have evaluated the safety and efficacy of RYGB in this group of patients. The aim of this study is to assess the safety and efficacy of RYGB in TD2M patients with BMI 35 kg/m(2). All T2DM patients with BMI 35 kg/m(2) and at least 12 months of follow-up who underwent laparoscopic RYGB were included. Safety of the procedure was evaluated according to mortality, need of reoperation/conversion, and complication rates. Metabolic parameters were evaluated at baseline and 6, 12, and 24 months after surgery. Thirty patients were included. Seventeen (56.6%) were women. Age, BMI, and duration of diabetes were 48 ± 9 years, 33.7 ± 1.2 kg/m(2), 4 ± 2.9 years, respectively. No mortality was observed. No conversion/reoperation was needed. Average length of stay was 3.2 ± 0.9 days. Early and late postoperative complications were observed in five (16.6%) and five (16.6%) patients, respectively. Twelve months after surgery, remission was observed in 25 of 30 patients (83.3%). After 2 years, remission was achieved in 13 of 20 patients (65%), and hemoglobin A1c decreased from 8.1 ± 1.8% to 5.9 ± 1.1% and homeostasis model assessment of insulin resistance from 5.7 ± 3.2 to 1.9 ± 0.8 after 12 months. RYGB is a safe and effective procedure to induce T2DM remission in otherwise not eligible patients for bariatric surgery. Evidence from prospective studies is needed to validate this approach.

The application of laparoscopic gastric surgery has rapidly increased for the treatment of early gastric cancer. However, laparoscopic gastrectomy for advanced tumor remains controversial, particularly in terms of oncologic outcomes. This study was designed to compare 3-year survival of laparoscopic versus open curative gastrectomy in early and advanced gastric cancer.This was a retrospective matched cohort study. We included patients between 2003 and 2010 with an R0 resection. A totally laparoscopic technique was used and D2 lymph node dissection was practiced routinely. We performed an intracorporeal hand-sewn esophagojejunostomy in all laparoscopic total gastrectomy cases. We matched all laparoscopic cases 1:1 with open cases according to TNM AJCC seventh edition. We used Mann-Whitney or t test and Chi-square test to compare both groups. Kaplan-Meier analysis with log-rank test was performed to compare survival.We included 31 open and 31 laparoscopic cases (mean age 63 ± 14 years; 66% males). Both groups were identical in type of gastrectomy (71% total and 29% subtotal). There were no statistical difference between laparoscopic and open groups in age, sex, N category, tumor location and size, histological differentiation, and T category (48% T1, 13% T2, 16% T3, and 23% T4 in both groups), with 48% early and 52% advanced tumors. The median number of resected lymph nodes was similar: 35 (23-53) for laparoscopic and 39 (23-45) for open cases (P = 0.81). The median follow-up was 50 months. The overall 3-year survival was 82% for laparoscopic surgery and 87% for the open surgery group (P = 0.56). There were no difference in 3-year survival for the laparoscopic versus the open surgery groups for advanced tumors (74 vs. 75%, P = 0.88), N+ tumors (73 vs. 73%, P = 0.99) and for the different AJCC stages (stage 1: 94 vs. 100%, stage 2: 89 vs. 82%, and stage 3: 50 vs. 50%, P = 0.32, 0.83, and 0.98 respectively).In this preliminary report, with 52% of advanced tumor, the 3-year overall and stage-by-stage survival was comparable for laparoscopic and open curative gastrectomy.

The plasminogen activator inhibitor type-1 (PAI-1) has been implicated in the regulation of fibrinolysis and extracellular matrix components. The single base pair guanine insertion/deletion polymorphism (4G/5G) within the promoter region of the PAI-1 gene influences PAI-1 synthesis and may modulate hepatic fibrogenesis.To evaluate the influence of PAI-1 serum levels and 4G/5G polymorphism on the risk of liver fibrosis associated to non-alcoholic fatty liver disease (NAFLD) in morbidly obese patients.Case-control study of 50 obese patients undergoing bariatric surgery and 71 non-obese subjects matched by age and sex. Anthropometric and biochemical measurements were performed, including PAI-1 serum levels. Genomic DNA was obtained to assess the presence of 4G/5G polymorphism.BMI, insulinemia, triglycerides, HOMA-IR, hypertension and diabetes were significantly higher in obese patients compared to control subjects. PAI-1 serum levels observed in obese patients were significantly lower (10.63 ± 4.82) compared to controls (14.26 ± 11.4; p0.05). No differences were observed in the PAI-1 4G/5G promoter genotypes frequencies (p = 0.12). No differences were observed in PAI-1 plasma levels among obese patients with liver fibrosis (10.64 ± 4.35) compared to patients without liver fibrosis (10.61 ± 5.2; p = 0.985). PAI-1 4G/5G promoter genotypes frequencies were similar in patients with or without liver fibrosis associated to NASH (p = 0.6).Morbidly obese patients had significantly lower PAI-1 serum levels with similar PAI-1 4G/5G genotypes frequencies compared to non-obese subjects. The frequency of 4G/5G genotypes in Chilean Hispanic healthy subjects was similar to that described in other populations. No association was found between PAI-1 serum levels or 4G/5G genotype with liver fibrosis in obese patients.

Initial human experience with a restrictive, duodenal-jejunal by-pass liner for the treatment of morbid obesity Background: The EndoBarrier TM Gastrointestinal Liner creates an endoscopic duodenal-jejunal bypass leading to weight loss in morbidly obese patients. Aim: To evaluate the safety and effi cacy of the EndoBarri- er TM with a 4 mm restrictor in morbidly obese patients. Material and Methods: Ten obese patients aged 18 to 54 years (eight women) with a body mass index (BMI) ranging from 35.8 to 45 kg/m 2 were enrolled. Patients were followed for 12 weeks after the placement of the device, when it was removed. Outcomes measured were percent excess weight loss (%EWL), minor and major adverse events. Results: The mean implant time was 33 ± 4 minutes with a mean fl uoroscopy time of 14.8 ± 3 minutes. There were no major adverse events. Periodic episodes of nausea and vomiting lead to the endoscopic dilation of the restrictor hole with a 6 mm balloon between 2nd and 8th weeks in seven patients (70%). One subject required a second dilation with a 10 mm balloon. The device was endoscopically removed at the 12 th week in all patients. The mean removal time was 47 ± 53.8 minutes (range 10-155 minutes). At week 12, BMI decreased from 40 ± 3.9 to 34.5 ± 3.1 kg/m 2 , and %EWL was 39.8% (range, 21.7% - 65.3%). The mean total weight loss was 16.7 ± 4.4 kg. Conclusions: The EndoBarrier TM Gastrointestinal Liner with the addition of a duodenal restrictor is a safe

The enzyme 11-beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) catalyzes intracellular glucocorticoid reactivation by conversion of cortisone to cortisol in different tissues and have been implicated in several metabolic disorders associated with obesity. The aim of this study was to evaluate the 11beta-HSD1 expression in liver, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) in morbidly obese patients undergoing bariatric surgery and its correlations with clinical, anthropometric, and biochemical variables.A prospective study was conducted over a 27-month period. Hepatic, VAT, and SAT samples were obtained at the time of surgery. 11beta-HSD1 and 18S gene expression was measured using real-time quantitative reverse transcriptase-polymerase chain reaction.Forty nine patients met the inclusion criteria [mean age: 42.2 +/- 10 years, body mass index (BMI): 42 +/- 6 kg/m(2), 71% women and 63% with metabolic syndrome (MS)]. 11beta-HSD1 mRNA levels were higher in liver than fat tissue (p0.001), being higher in SAT than in VAT (p0.001) without gender-specific differences. Hepatic expression of 11beta-HSD1 correlated positively with SAT and VAT, alanine aminotransferase (ALT), and serum glucose and was inversely associated with BMI. 11beta-HSD1 mRNA in VAT correlated positively with insulinemia, ALT, and LDL cholesterol. There were no associations between 11beta-HSD1 mRNA in SAT and the variables analyzed.11beta-HSD1 expression is higher in liver in comparison to adipose tissue in obese patients. The observed correlations between hepatic and VAT 11beta-HSD1 expression with dyslipidemia and insulin resistance suggest that this enzyme might have a pathogenic role in obesity and related metabolic disorders.

Enseguida, otrosautores fueron incorporando y perfeccionando esteprincipio de contencion hasta alcanzar el formatodel procedimiento quirurgico actual.No hay uniformidad en el tipo de material em-pleado y ni en el tamano de la circunferencia de laprotesis, siendo descrito el uso de un anillo desilicona o de una cinta de Prolene® o de Goretex®,cuyo largo varia de 5,5 a 7 cm

Reduced serum levels of adiponectin have been associated with insulin resistance and non-alcoholic fatty liver disease (NAFLD). However, the relationship between serum adiponectin levels and hepatic histology in NAFLD is controversial. The aim of this study was to explore associations between plasma adiponectin concentrations and liver histology in morbidly obese patients. We conducted a case–control study including obese patients undergoing bariatric surgery and normal controls. Anthropometric, standard biochemical variables as well as plasma adiponectin and leptin levels were determined. Liver biopsy was performed in all patients at the time of surgery. Seventy morbidly obese patients (mean BMI, 40.6 ± 5.6 kg/m2) met the inclusion criteria and were compared with 69 controls (mean BMI, 22.8 ± 1.6 kg/m2, p = 0.0001). Thirty patients (43%) had NAFLD and 20 (28%) of them fulfilled the histological criteria for steatohepatitis. Obesity was associated with increased leptin and decreased adiponectin levels. NAFLD patients exhibited decreased levels of serum adiponectin compared with matched controls [median (Q1–Q3), 3.9 (3.2–4.3) vs. 8.6 (6.5–9.2) μg/mL, p

LAGB is a technique increasingly used in the USA. The aim of this study is to analyze the 5-year outcome in terms of weight loss and complications. We reviewed our prospective electronic database for all patients undergoing LAGB between 2002 and 2007. We assessed weight progression, complications, and reoperations. We performed 199 cases during this period (70.4% females). Mean age was 37.8 ± 12.4 years. Preoperative body mass index (BMI) was 36.0 ± 3.8 kg/m2. Preoperative comorbidities were dyslipidemia in 52.3%, insulin resistance in 30.7%, arterial hypertension in 24.6%, and type 2 diabetes in 5.5%. There were no conversions to open technique. Early complications were observed in two patients (1%): one hemoperitoneum and one ileitis. Mortality was 0%. Late complication rate was 33.6% (18.0% related to the band). Reoperation was required in 40 patients (20.1%). Laparoscopic repositioning was done in seven patients, and port/reservoir revision was done in five patients. Band removal was required in 28 patients, due to inadequate weight loss in 9, slippage in 9, gastric erosion in 1, bowel obstruction in 1, acute stomach dilatation in 1, and food intolerance in 7. Twenty of these patients underwent revisional surgery: sleeve gastrectomy in 12 and laparoscopic Roux-en-Y gastric bypass in 8 cases. Unrelated band complication was seen in 15.6%, mainly due to anemia (7.5%), alopecia (4.5%), and cholelithiasis (3.5%). With a median follow-up of 48 months (1–72 months), 75, 60, and 95% of patients were available for follow-up at 1, 3, and 5 years, respectively. Mean percent excess weight loss (%EWL) at 1, 3, and 5 years was 58.8 ± 30.0%, 56.8 ± 35.0%, and 58.4 ± 46.6%, respectively. However, failure rate (%EWL

The effects of Roux-en-Y Gastric Bypass (RYGB) on bone in the long-term remains unclear. We assessed bone metabolism and bone mineral density (BMD) 1 to 5 years after RYGB.We designed a retrospective cohort study in 26 postmenopausal women (58.0+/-3.9 years old) with RYGB 3.5+/-1.1 years before (body mass index (BMI) 29.5+/-3.8 kg/m2, presurgery 43.6+/-5.5 kg/m2) and 26 nonoperated women (57.5+/-4.7 years old, BMI 29.2+/-4.1 kg/m2) matched by age and BMI. The main measures were BMD, serum carboxy telopeptide (CTx), total alkaline phosphatases (ALP), parathyroid hormone (PTH), 25-hydroxyvitamin D (25OHD), and ghrelin.RYGB group, compared to nonoperated women, had higher CTx (0.71+/-0.21 vs. 0.43+/-0.15 ng/ml; P0.01) and PTH (68.3+/-35 vs. 49.4+/-16 pg/ml; P=0.02). There were no differences between RYGB and nonoperated women in: calcium and vitamin D intake (759+/-457 vs. 705+/-460 mg/day; 176+/-160 vs. 111+/-86 UI/day), ghrelin (763+/-336 vs. 621+/-274 pg/ml), ALP (101+/-22 vs. 94+/-25 UI/l), 25OHD (18.8+/-7.6 vs. 17.4 +/- 5.9 ng/ml), lumbar spine BMD (1.059+/-0.32 vs. 1.071+/-0.207 g/cm2), or femoral neck BMD (0.892+/-0.109 vs. 0.934+/-1.1 g/cm2).RYGB is associated to high bone resorption and hyperparathyroidism prevalence in postmenopausal women in the long-term. This occurs independently of the intake of calcium, vitamin D status, or ghrelin and does not seem to affect BMD after RYGB.

Morbid obesity is associated with different gastrointestinal alterations and diseases. Surgically induced weight loss has become the best treatment for morbidly obese patients. Roux-en-Y gastric bypass is the most common procedure performed worldwide. Concerns regarding difficulties in further evaluation of stomach remnant for early detection of gastric cancer, however, have emphasized the routine use of preoperative upper endoscopy, even in asymptomatic patients, to detect upper gastrointestinal abnormalities. The main outcome of this study was to identify the most common preoperative endoscopic findings.Data was collected from a prospective database and medical records of patients with available endoscopic reports, who underwent Roux-en-Y gastric bypass from February 1999 to June 2006. Logistic regression analysis was performed to detect preoperative clinical variables that might be associated with abnormal endoscopy.Six hundred twenty-six patients were identified. Four hundred fifty-two (72%) were female; age and body mass index were 38.5 +/- 11.3 years and 42 +/- 6.5 kg/m(2), respectively. Abnormalities were found in 288 (46%) patients. The age of patients with abnormal and normal endoscopy was 40 +/- 11 and 36.8 +/- 11 years, respectively (p0.001). The most common findings were gastritis 21% (n = 132), esophagitis 16% (n = 100), and hiatal hernia 10.7% (n = 67). Duodenitis has a frequency of 7.8% (n = 49), gastric ulcers of 2.7%(n = 17), duodenal ulcers of 2.6% (n = 16), gastric polyps of 1.3% (n = 8), Barrett's esophagus of 0.16% (n = 1), and gastric cancer of 0.16% (n = 1). Age was the only clinical variable associated to abnormal endoscopy (odds ratio = 1.03; 95% confidence interval, 1.02-1.05).Routine preoperative endoscopy detects different abnormalities which need specific approach prior to surgery. Preoperative endoscopy should be performed to all patients prior to surgery.

Introducción: La cirugía laparoscópica ha sido incorporada como una alternativa de tratamiento curativo en cancer gástrico. El objetivo de este estudio es evaluar los resultados quirúrgicos inmediatos de pacientes sometidos a gastrectomía laparoscópica por cancer gástrico incipiente e intermedio en el Hospital Clínico de la Pontificia Universidad Católica de Chile y en el Hospital Dr. Sótero del Río. Material y método: Se incluyen todos los pacientes sometidos a gastrectomía laparoscópica por cancer gástrico incipiente e intermedio (T1 - T2) en ambas instituciones. Resultados: Desde Mayo de 2005 a Diciembre del 2006, 13 pacientes fueron sometidos a gastrectomía laparoscópica, 9 hombres (70 %). Edad promedio 62+ 12 años. El tiempo operatorio promedio fue 293 + 51 minutos, la estadía hospitalaria 7,3 + 2,8 días. No hubo complicaciones quirúrgicas. El promedio de ganglios resecados fue de 27 + 18. De acuerdo a la clasificación TNM-AJCC, 9 pacientes se encontraban en etapa IA y 4 en etapa IB. Discusión: La gastrectomía laparoscópica es una alternativa segura en el tratamiento quirúrgico del cancer gástrico incipiente e intermedio

The development of the laparoscopic surgery has allowed its incorporation to the surgical treatment of gastric cancer.To evaluate the feasibility and safety of laparoscopic gastrectomy in gastric cancer in our institution.Prospective data in four patients who underwent laparoscopic gastrectomy for gastric cancer from May to August of 2005 was reviewed. Demographic data, clinical characteristics and postoperative results were registered. Patients were staged according to TNM-AJJC staging system.Four patients aged 48 to 80 years (three males), underwent a completely laparoscopic R0 gastrectomy with lymph node dissection. Two patients underwent total gastrectomy. A subtotal Billroth II gastrectomy was performed in the other two patients. The mean operative time was 260 minutes (Range 180-330). There were no conversions to open surgery. The mean postoperative hospital stay was 6.5 days (Range 6-7 days). There were no complications. According to pathology, one patient presented carcinoma in stage IA, two patients in stage IB and one patient in stage IIIB. The mean number of lymph nodes dissected was 40 (Range 35-54).Laparoscopic gastrectomy is a feasible procedure with good postoperative results in this preliminary experience.

Achalasia is characterized by an incomplete relaxation of the lower esophageal sphincter. The best treatment is surgical and the laparoscopic approach may have good results.To assess the results of laparoscopic Heller myotomy among patients with achalasia.Prospective study of patients subjected to a laparoscopic Heller myotomy between 1995 and 2004. Clinical features, early and late operative results were assessed.Twenty seven patients aged 12 to 74 years (12 females) were operated. All had disphagia lasting for a mean of 32 months. Mean lower esophageal sphincter pressure ranged from 18 to 85 mmHg. Eight patients received other treatments prior to surgery but symptoms persisted or reappeared. The preoperative clinical score was 7. No patient died and no procedure had to be converted to open surgery. In a follow up of 21 to 131 months, all patients are satisfied with the surgical results and the postoperative clinical score is 1. Only one patient with a mega esophagus maintained a clinical score of six.In this series of patients, laparoscopic Heller myotomy was an effective and safe treatment for esophageal achalasia.