Preoperative weight loss in super-obese patients: study of the rate of weight loss and its effects on surgical morbidity

OBJECTIVES: The incidence of obesity and particularly super obesity, has increased tremendously. At our institution, super obesity represents 30.1% of all severely obese individuals in the bariatric surgery program. In super obesity, surgical morbidity is higher and the results are worse compared with morbid obesity, independent of the surgical technique. The primary strategy for minimizing complications in these patients is to decrease the body mass index before surgery. Preoperative weight reduction can be achieved by a hypocaloric diet, drug therapy, an intragastric balloon, or hospitalization. The objective of this study was to analyze the results of a period of hospitalization for preoperative weight loss in a group of super-obese patients. METHODS: Twenty super-obese patients were submitted to a weight loss program between 2006 and 2010. The mean patient age was 46 years (range 21-59). The mean BMI was 66 kg/m2 (range 51-98) and 12 were women. The average hospital stay was 19.9 weeks and the average weight loss was 19% of the initial weight (7-37%). The average caloric intake was 5 kcal/kg/day. After the weight loss program, the patients underwent gastric bypass surgery. RESULTS: The statistical analysis revealed that after 14 weeks of treatment (15% loss of initial weight), the weight loss was not significant. All patients had satisfactory surgical recovery and were discharged after an average of 4.6 days. CONCLUSION: In super obesity, preoperative weight loss is an important method for reducing surgical risks. Hospitalization and a hypocaloric diet are safe and effective. After 14 weeks, the weight loss rate stabilized, signaling the time of surgical intervention in our study

Changes in the intestinal microbiota of superobese patients after bariatric surgery

OBJECTIVES: The gut microbiota is associated with obesity and weight loss after bariatric surgery and has been related to its changing pattern. Exactly how the bacterial population affects weight loss and the results of surgery remain controversial. This study aimed to evaluate the intestinal microbiota of superobese patients before and after gastric bypass surgery (RYGB). METHOD: DNA fragments for the microbiota obtained from stool samples collected from nine superobese patients before and after bariatric surgery were sequenced using Ion Torrent. RESULTS: We observed that with a mean follow-up of 15 months, patients achieved 55.9% excess weight loss (EWL). A significant population reduction in the Proteobacteria phylum (11 to 2%, p=0.0025) was observed after surgery, while no difference was seen in Firmicutes and Bacteroidetes. Further analyses performed with two specific individuals with divergent clinical outcomes showed a change in the pattern between them, with a significant increase in Firmicutes and a decrease in Bacteroidetes in the patient with less weight loss (%EWL 50.79 vs. 61.85). CONCLUSIONS: RYGB affects the microbiota of superobese patients, with a significant reduction in Proteobacteria in patients with different weight loss, showing that different bacteria may contribute to the process

Real-world evidence of health outcomes and medication use 24 months after bariatric surgery in the public healthcare system in Brazil: a retrospective, single-center study

OBJECTIVES: The number of bariatric procedures has significantly increased in Brazil, especially in the public Unified Health System. The present study describes health outcomes and medication use in obese patients treated in a major hospital that performs publicly funded surgery in Brazil. METHODS: A retrospective, single center study was conducted to collect real-world evidence of health outcomes and medication use in 247 obese patients (female, 82.2%) who underwent open Roux-en-Y gastric bypass. Changes in weight and body mass index (BMI), presence of apnea, hypertension, and type 2 diabetes (T2D), and medication use (hypertension, diabetes, and dyslipidemia) were assessed preoperatively and up to 24 months postoperatively. The mean cost of medications was calculated for the 12-month preoperative and 24-month postoperative periods. RESULTS: During the surgery, the mean age of patients was 43.42 years (standard deviation [SD], 10.9 years), and mean BMI was 46.7 kg/m2 (SD, 6.7 kg/m2 ). At 24 months, significant declines were noted in weight (mean, -37.6 kg), BMI (mean, -14.3 kg/m2 ); presence of T2D, hypertension, and apnea (-29.6%, -50.6%, and -20.9%, respectively); and number of patients using medications (-66.67% for diabetes, -41.86% for hypertension, and -55.26% for dyslipidemia). The mean cost of medications (total costs for all medications) decreased by 450% in 12–24 postoperative months compared to that in 12 preoperative months. CONCLUSION: Roux-en-Y gastric bypass successfully reduced weight, BMI, and comorbidities and medication use and cost at 24 months in Brazilian patients treated in the public Unified Health System

Microbiota no trato digestivo em voluntários saudáveis

PURPOSE: The aim of this study was to standardize the methods of sample collection of mucus from the digestive tract and to determine the microbiota in healthy volunteers from Brazil, collecting samples from the mouth, esophagus, stomach, duodenum, jejunum, ileum, colon, and rectum. METHODS: Microbiota of selected healthy volunteers from the oral cavity (n=10), the esophagus (n=10), the upper digestive tract (n=20), and the lower digestive tract (n=24) were evaluated through distinct collection methods. Collection methods took into account the different sites, using basic scraping and swabbing techniques, stimulated saliva from the oral cavity, irrigation-aspiration with sterile catheters especially designed for the esophagus, a probe especially designed for upper digestive tract, and a special catheter for the lower digestive tract. RESULTS: (i) Mixed microbiota were identified in the oral cavity, predominantly Gram-positive aerobic and anaerobic cocci; (ii) transitional flora mainly in the esophagus; (iii) Veillonella sp, Lactobacillus sp, and Clostridium sp in the stomach and duodenum; (iv) in the jejunum and upper ileum, we observed Bacteroides sp, Proteus sp, and Staphylococcus sp, in addition to Veillonella sp; (v) in the colon, the presence of "nonpathogenic" anaerobic bacteria Veillonella sp (average 10(5) UFC) indicates the existence of a low oxidation-reduction potential environment, which suggests the possibility of adoption of these bacteria as biological markers of total digestive tract health. CONCLUSIONS: The collection methods were efficient in obtaining adequate samples from each segment of the total digestive tract to reveal the normal microbiota. These procedures are safe and easily reproducible for microbiological studies.OBJETIVO: Padronizar os métodos de coleta do muco do trato digestivo e determinar a microbiota, em voluntários saudáveis no Brasil, coletando amostras da boca, esôfago, estômago, duodeno, jejunos e íleo, cólons e reto. MÉTODOS: A microbiota de voluntários saudáveis foi avaliada através de diferentes métodos de coleta: cavidade oral (n=10 voluntários), do esôfago (n=10), do trato digestivo alto (n=20) e do trato digestivo baixo (n=24). Métodos de coleta foram adotados em cada sítio restrito, usando derramar saliva, técnica de esfregar a mucosa e saliva estimulada da cavidade oral, irrigação-aspiração, cateteres específicos designados para o esôfago, sonda especial para o trato digestivo alto e cateteres especiais para o trato digestivo baixo. RESULTADOS: Identificados: (i) na cavidade oral, microbiota mista, predominando cocos aeróbios e anaeróbios Gram positivos; (ii) no esôfago, flora transitória; (iii) no estômago e duodeno, Veillonella sp, Lactobacillus sp and Clostridium sp; (iv) no jejuno e íleo proximal, Bacteróides sp, Proteus sp and Staphilococcus sp, além da Veillonella sp ; (v) no colon, foi revelada a presença "não patogênica" da bactéria anaeróbica Veillonella sp numa concentração média de 10(5) unidades formadoras de colônia, indicando um meio de baixo potencial de oxido-redução e a possibilidade de se conceituar esta bactéria como um marcador biológico do trato digestivo total em sadios. CONCLUSÃO: Estes métodos de coleta foram considerados eficientes para obtenção adequada de amostra em cada segmento do trato digestivo total para caracterizar a microbiota normal. Estes procedimentos são seguros e facilmente reprodutível para estudo microbiológico

Microbiota in chagasic megaesophagus

A estase de secreção salivar e alimentos deglutidos na luz esofágica de pacientes com megaesôfago chagásico traz como consequências: (1) supercrescimento bacteriano na luz do órgão, (2) episódios de aspiração pulmonar e infecções respiratórias de repetição, (3) aumento do risco dos procedimentos terapêuticos cirúrgicos ou endoscópicos em caso de perfuração pela maior possibilidade de contaminação, (4) desenvolvimento de processos inflamatórios crônicos na mucosa esofágica, que podem predispor ao aparecimento de displasia e câncer. Apesar disto, a microbita esofágica no megaesôfago nunca foi estudado. Esse estudo teve o objetivo de analisar qualitativa e quantitativamente a microbiota presente no líquido de estase esofágico de pacientes portadores de megaesôfago chagásico, comparando-a com a existente em indivíduos sadios. Foram estudados prospectivamente 25 pacientes (10 homens e 15 mulheres) com idades variando de 24 a 74 anos ( &#61507; = 49,1a). Quinze pacientes eram portadores de esofagopatia chagásica, sendo 5 portadores de mega grau I (MG1), 5 portadores de mega grau II (MG2) e 5 portadores de mega grau III (MG3), segundo a classificação de Rezende; e 10 indivíduos sadios, agrupados no Grupo Controle (GC). Utilizou-se método de coleta que permitia aspiração de líquido através de sonda de Levine diretamente da luz esofágica, evitando-se a contaminação com microrganismos da orofaringe. Após análise microbiológica qualitativa e quantitativa, foi feita a descrição dos microrganismos encontrados nos vários grupos e sua classificação em aeróbios Gram positivos, aeróbios Gram negativos, anaeróbios e fungos. A análise estatística visou avaliar diferenças quantitativas entre os microrganismos nos diferentes grupos, sendo para tanto utilizado o teste não paramétrico de Kruskal-Wallis, com nível de rejeição menor 0,05 (5%). A positividade das culturas no Grupo Controle foi 40%, com predomínio do gênero Streptococcus sp, em concentrações que variaram de 101 a 102 ufc/ml. No Grupo Megaesôfago 93,3% da culturas foram positivas, com grande variedade de bactérias, mas predomínio de aeróbios Gram positivos (Streptococcus sp. foi o mais comum) e anaeróbios (Veillonella sp foi a mais freqüente) em concentrações que variaram de 101 a 105 ufc/ml. As concentrações foram geralmente mais elevadas em MG3, quando comparado com MG1, MG2 e GC (p<0,05). Concluiu-se que no megoesôfago, diferentemente dos indivíduos sadios, existe a presença de rica microflora bacteriana, constituída principalmente por aeróbios Gram positivos e anaeróbios, em concentrações tanto maiores quanto maior o seu grau de dilatação. Parte desta microbiota tem capacidade de metabolizar nitratos, etapa importante na formação de nitrosaminas.The stasis of saliva and swallowed food in the esophageal lumen of patients with chagasic megaesophagus causes: (1) bacterial overgrowth in the esophageal lumen, (2) recurring pulmonary aspirations and respiratory infections, (3) increased risk of surgical or endoscopic procedures if perforation occurs by the major possibility of contamination, and (4) the development of chronic inflammatory process in esophageal mucosa, that can predispose to the development of dysplasia and cancer. In spite of this, esophageal microbiota in the megaesophagus has never been studied. The aim of this study was to analyze qualitatively and quantitatively the microbiota in chagasic megaesophagus in comparison to the normal esophagus. Twenty-five patients (10 men and 15 women) were prospectively studied, with ages varying from 24 to 74 years (&#61507;=49,1), from March to September 2000. Fifteen patients with chagasic megaesophagus (MG), were divided into three sub- groups according to the grade of esophageal dilation: MG1 5 patients with megaesophagus grade I; MG2- 5 patients with megaesophagus grade II; MG3- 5 patients with megaesophagus grade III. Another group of ten patients without any esophageal disease was constituted in the Control Group (CG). The sample collection was performed using a method specially developed to avoid contamination with microorganisms of the oral cavity and oropharynx. After qualitative and quantitative analysis, the microorganisms found were described and classified as Gram positive aerobes, Gram negative aerobes, anaerobes and fungus. Statistical analysis using Kruskal-Wallis non-parametric test was performed in order to find quantitative differences of microorganisms in the different groups. In CG 40% of the cultures were positive with predominance of the genus Streptococcus sp, in concentrations that varied from 101 to 102 cfu/ml. In MG, 93,3% of the cultures were positive, with great bacterial variability and predominance of a variety of aerobic Gram-positive (Streptococcus sp was the most common) and anaerobic bacteria (Veillonella sp was the most frequent), in concentrations that varied from 101 to 105 cfu/ml. The bacterial concentrations were generally more elevated in MG3 in comparison to MG1, MG2 and CG (p<0,05). It was concluded that patients with megaesophagus present a varied microbiota constituted mostly of aerobic Gram positive and anaerobic bacteria, in concentrations that vary with the megaesophagus dilatation degree. Some of the bacteria found in MG are able to metabolize nitrates intro nitrites, an important step in the formation of nitrosamines

Microbiota in chagasic megaesophagus

A estase de secreção salivar e alimentos deglutidos na luz esofágica de pacientes com megaesôfago chagásico traz como consequências: (1) supercrescimento bacteriano na luz do órgão, (2) episódios de aspiração pulmonar e infecções respiratórias de repetição, (3) aumento do risco dos procedimentos terapêuticos cirúrgicos ou endoscópicos em caso de perfuração pela maior possibilidade de contaminação, (4) desenvolvimento de processos inflamatórios crônicos na mucosa esofágica, que podem predispor ao aparecimento de displasia e câncer. Apesar disto, a microbita esofágica no megaesôfago nunca foi estudado. Esse estudo teve o objetivo de analisar qualitativa e quantitativamente a microbiota presente no líquido de estase esofágico de pacientes portadores de megaesôfago chagásico, comparando-a com a existente em indivíduos sadios. Foram estudados prospectivamente 25 pacientes (10 homens e 15 mulheres) com idades variando de 24 a 74 anos ( &#61507; = 49,1a). Quinze pacientes eram portadores de esofagopatia chagásica, sendo 5 portadores de mega grau I (MG1), 5 portadores de mega grau II (MG2) e 5 portadores de mega grau III (MG3), segundo a classificação de Rezende; e 10 indivíduos sadios, agrupados no Grupo Controle (GC). Utilizou-se método de coleta que permitia aspiração de líquido através de sonda de Levine diretamente da luz esofágica, evitando-se a contaminação com microrganismos da orofaringe. Após análise microbiológica qualitativa e quantitativa, foi feita a descrição dos microrganismos encontrados nos vários grupos e sua classificação em aeróbios Gram positivos, aeróbios Gram negativos, anaeróbios e fungos. A análise estatística visou avaliar diferenças quantitativas entre os microrganismos nos diferentes grupos, sendo para tanto utilizado o teste não paramétrico de Kruskal-Wallis, com nível de rejeição menor 0,05 (5%). A positividade das culturas no Grupo Controle foi 40%, com predomínio do gênero Streptococcus sp, em concentrações que variaram de 101 a 102 ufc/ml. No Grupo Megaesôfago 93,3% da culturas foram positivas, com grande variedade de bactérias, mas predomínio de aeróbios Gram positivos (Streptococcus sp. foi o mais comum) e anaeróbios (Veillonella sp foi a mais freqüente) em concentrações que variaram de 101 a 105 ufc/ml. As concentrações foram geralmente mais elevadas em MG3, quando comparado com MG1, MG2 e GC (p<0,05). Concluiu-se que no megoesôfago, diferentemente dos indivíduos sadios, existe a presença de rica microflora bacteriana, constituída principalmente por aeróbios Gram positivos e anaeróbios, em concentrações tanto maiores quanto maior o seu grau de dilatação. Parte desta microbiota tem capacidade de metabolizar nitratos, etapa importante na formação de nitrosaminas.The stasis of saliva and swallowed food in the esophageal lumen of patients with chagasic megaesophagus causes: (1) bacterial overgrowth in the esophageal lumen, (2) recurring pulmonary aspirations and respiratory infections, (3) increased risk of surgical or endoscopic procedures if perforation occurs by the major possibility of contamination, and (4) the development of chronic inflammatory process in esophageal mucosa, that can predispose to the development of dysplasia and cancer. In spite of this, esophageal microbiota in the megaesophagus has never been studied. The aim of this study was to analyze qualitatively and quantitatively the microbiota in chagasic megaesophagus in comparison to the normal esophagus. Twenty-five patients (10 men and 15 women) were prospectively studied, with ages varying from 24 to 74 years (&#61507;=49,1), from March to September 2000. Fifteen patients with chagasic megaesophagus (MG), were divided into three sub- groups according to the grade of esophageal dilation: MG1 – 5 patients with megaesophagus grade I; MG2- 5 patients with megaesophagus grade II; MG3- 5 patients with megaesophagus grade III. Another group of ten patients without any esophageal disease was constituted in the Control Group (CG). The sample collection was performed using a method specially developed to avoid contamination with microorganisms of the oral cavity and oropharynx. After qualitative and quantitative analysis, the microorganisms found were described and classified as Gram positive aerobes, Gram negative aerobes, anaerobes and fungus. Statistical analysis using Kruskal-Wallis non-parametric test was performed in order to find quantitative differences of microorganisms in the different groups. In CG 40% of the cultures were positive with predominance of the genus Streptococcus sp, in concentrations that varied from 101 to 102 cfu/ml. In MG, 93,3% of the cultures were positive, with great bacterial variability and predominance of a variety of aerobic Gram-positive (Streptococcus sp was the most common) and anaerobic bacteria (Veillonella sp was the most frequent), in concentrations that varied from 101 to 105 cfu/ml. The bacterial concentrations were generally more elevated in MG3 in comparison to MG1, MG2 and CG (p<0,05). It was concluded that patients with megaesophagus present a varied microbiota constituted mostly of aerobic Gram positive and anaerobic bacteria, in concentrations that vary with the megaesophagus dilatation degree. Some of the bacteria found in MG are able to metabolize nitrates intro nitrites, an important step in the formation of nitrosamines

BARIATRIC SURGERY AND BINGE EATING DISORDER: SHOULD SURGEONS CARE ABOUT IT? A LITERATURE REVIEW OF PREVALENCE AND ASSESSMENT TOOLS

ABSTRACT BACKGROUND: Eating pathologies among bariatric surgery candidates are common and associated with adverse surgical outcomes, including weight regain and low quality of life. However, their assessment is made difficult by the great variety and inconsistent use of standardized measures. OBJECTIVE: The purpose of this review was to synthesize current knowledge on the prevalence of binge eating disorder (BED) in presurgical patients and to make a critical appraisal of assessment tools for BED. METHODS: A search was conducted on PubMed, Scopus, and Web of Science databases from January 1994 to March 2017. Data were extracted, tabulated and summarized using a narrative approach. RESULTS: A total of 21 observational studies were reviewed for data extraction and analysis. Prevalence of BED in bariatric populations ranged from 2% to 53%. Considerable variation in patient characteristics and in BED assessment measures was evident among the studies. In addition, several methodological weaknesses were recognized in most of the studies. Ten different psychometric instruments were used to assess BED. Clinical interviews were used in only 12 studies, though this is the preferred tool to diagnose BED. CONCLUSION: Study heterogeneity accounted for the variability of the results from different centers and methodological flaws such as insufficient sample size and selection bias impaired the evidence on the magnitude of BED in surgical settings. For the sake of comparability and generalizability of the findings in future studies, researchers must recruit representative samples of treatment-seeking candidates for bariatric surgery and systematically apply standard instruments for the assessment of BED

EARLY COMPLICATIONS IN BARIATRIC SURGERY:

ContextBariatric surgery has proven to be the most effective method of treating severe obesity. Nevertheless, the acceptance of bariatric surgery is still questioned. The surgical complications observed in the early postoperative period following surgeries performed to treat severe obesity are similar to those associated with other major surgeries of the gastrointestinal tract. However, given the more frequent occurrence of medical comorbidities, these patients require special attention in the early postoperative follow-up. Early diagnosis and appropriate treatment of these complications are directly associated with a greater probability of control.MethodThe medical records of 538 morbidly obese patients who underwent surgical treatment (Roux-en-Y gastric bypass surgery) were reviewed. Ninety-three (17.2%) patients were male and 445 (82.8%) were female. The ages of the patients ranged from 18 to 70 years (average = 46), and their body mass indices ranged from 34.6 to 77 kg/m2.ResultsEarly complications occurred in 9.6% and were distributed as follows: 2.6% presented bleeding, intestinal obstruction occurred in 1.1%, peritoneal infections occurred in 3.2%, and 2.2% developed abdominal wall infections that required hospitalization. Three (0.5%) patients experienced pulmonary thromboembolism. The mortality rate was 0,55%.ConclusionThe incidence of early complications was low. The diagnosis of these complications was mostly clinical, based on the presence of signs and symptoms. The value of the clinical signs and early treatment, specially in cases of sepsis, were essential to the favorable surgical outcome. The mortality was mainly related to thromboembolism and advanced age, over 65 years