Sleeve Gastrectomy Associated with Antral Lesion Resection and Roux-en-Y Antrojejunal Reconstruction

Obesity has been growing worldwide, reaching epidemic proportions. Bariatric surgery is the most effective and durable treatment for severe obesity and related diseases. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are the most frequently performed bariatric operations, with long-term good results, in terms of weight loss and comorbidities control. Gastroesophageal Reflux Disease (GERD) is commonly associated with obesity. In general, it precludes the indication of sleeve gastrectomy, since this technique has a refluxogenic potential, as shown in many studies. In such cases, RYGB is considered the best surgery, reaching good weight loss and gastroesophageal reflux disease control. The drawback of this technique is that it leaves the remnant stomach, the duodenum, and the proximal part of the jejunum inaccessible. Besides, RYGB makes transoral endoscopic access to the biliary tree impossible. For all these reasons, this bariatric technique is not indicated in cases of gastric polyposis, gastric dysplasia, or strong family history of cancer, among others. We report a case of a morbidly obese patient with intense GERD, for whom a RYGB was precluded due to her strong family history of cancer, even knowing that it would be the best choice for reflux disease control. Instead, SG was chosen, even knowing it could worsen the gastroesophageal reflux disease. The patient signed an informed consent, after being fully enlightened about the risks. During the surgery, a small subserosal whitish lesion was detected, near the pylorus, on the anterior wall of the antrum. Thinking in a Gastrointestinal Stromal Tumor (GIST), it was resected, with a 2 cm safety margin, leaving a 4 to 5 cm hole on the gastric wall. The decision to maintain the proposed sleeve gastrectomy was made, to avoid leaving a remnant stomach, in a patient with such a strong family history of cancer. In the area of the resected lesion, an intraoperative decision was made not to just close the big gastric hole, being afraid of causing some anatomic or functional disturbance in gastric emptying. Instead, we decided to use the gastric opening to construct a Roux-en-Y antrotrojejunal anastomosis, with a 50 cm alimentary limb and a 200 cm biliopancreatic limb. Accordingly, it was performed a sleeve gastrectomy, associated with an antrojejunostomy in a Roux-en-Y fashion. The patient had an uneventful postoperative course. In the second year, she achieved normal weight and good nutritional status, without gastroesophageal reflux symptoms complaints. Seriography study shows that most of the contrast material passes through the antrojejunal anastomosis, instead of the pylorus, while the duodenum is endoscopically patent. This case report shows an unexpected surgical finding that led to a tactic of adding a Roux-en-Y gastric bypass in the antrum, associated with a sleeve gastrectomy, a strategy that may be adopted in cases of morbidly obese patients with important GERD, for whom gastrointestinal exclusions are contraindicated. To confirm this hypothesis, controlled studies are needed.info:eu-repo/semantics/publishedVersio

Evaluation of the Scopinaro Modified Technique in the Surgical Treatment of Obesity Compared to the Classic Scopinaro Surgery – Results after an 18-Month Randomized Clinical Trial

Objective: To assess whether the modified Scopinaro surgery is as effective and safe as the classic Scopinaro surgery to reduce excess weight, control the comorbidities, and evaluate the onset of clinical and nutritional intercurrences, if any. Methods: The study sample was composed of 28 participants who were randomized to undergo one of the surgical procedures, and who were monitored by a multiprofessional health team to evaluate the impact of the surgery in the treatment of obesity. We assessed the following variables: comorbidities, clinical and nutritional intercurrences and quality of life. The research protocol was approved by the Ethics in Research Committee of Faculdades Integradas de Pitágoras de Montes Claros (under CAAE 26919414.9.0000.5109). All of the participants signed the informed consent form (ICF). Results: The mean pre-surgery body mass index (BMI) for the classic Scopinaro group and the modified Scopinaro group was of 46.89 kg/m2 and 43.22 kg/m2 respectively. After 540 days of the surgery, these values dropped to 32.16 kg/m2 and 28.79 kg/m2. The evaluation of the percentage of excess BMI lost (%EBL) in the period proved the surgical success, with values of 67.33%% for the classic Scopinaro surgery, and of 80.37% for the modified Scopinaro surgery. Control of the comorbidities, as well as a general improvement in the laboratory test results, was achieved by most of the participants subjected to either one of the techniques. Flatulence and diarrhea were the clinical intercurrencesfound as a result of both procedures. Conclusion: We concluded that the modified Scopinaro surgery is as effective and safe as the classic Scopinaro surgery in reducing weight and in the control of comorbidities, and it also presents the possibility of endoscopic access of all of the stomach and duodenum, surgical reversibility, and conversion into another surgical procedure

Triglyceride-to-High-Density-Lipoprotein-Cholesterol Ratio as a Predictor of Metabolic Syndrome According to Stage of Life at Obesity Onset in Women with Severe Obesity—A Pilot Study

The triglyceride-to-high-density lipoprotein-cholesterol (TG/HDL-c) ratio is a simple but effective indicator of metabolic imbalance that characterizes metabolic syndrome (MetS) and can consequently indicate a higher cardiovascular risk. It may, therefore, be useful in identifying a high risk for cardiometabolic diseases according to the onset of obesity. The aim of this study was to evaluate the association between MetS and the stage of life at obesity onset and to establish the cutoff point for the TG/HDL-c ratio as a marker of MetS in women with severe obesity. Forty-seven women who were to undergo bariatric surgery were evaluated. Anthropometric and metabolic parameters were measured, and the TG/HDL-c ratio was calculated. The volunteers were grouped according to their stage of life at obesity onset. A receiver operating characteristic (ROC) curve was constructed to define cutoff points for the TG/HDL-c ratio as predictors of MetS. Women who developed obesity early (during infancy/adolescence) had higher weight (p = 0.008), body mass index (p = 0.031), and hip circumference (p = 0.036) than those who developed obesity later (in adulthood); however, no association was found between obesity onset and MetS. The cutoff points for the TG/HDL-c ratio that were established for those who developed early or late obesity were 2.30 and 2.19, respectively. Although the stage of life at the onset of obesity was not related to MetS, different cutoff points for the TG/HDL-c ratio were observed