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Pyloric Sympathectomy: A Novel Way to Get Pylorus Relaxation? Report of Two Bariatric Cases

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Surgical Science 2024年第6期15卷 381-395页

作者： Victor Ramos Mussa Dib Carlos Augusto Scussel Madalosso Rui Ribeiro paulo Reis Esselin de Melo Fernando Fornari Victor Dib Institute Manaus Brazil Gastrobese Clinic Passo Fundo Brazil Lusadas Amadora Hospital Lisboa Portugal paulo Reis Institute Goinia Brazil Alfredo nasser University Center (UNIFAN) Goinia Brazil Faculdade de Medicina Universidade de Passo Fundo Passo Fundo Brazil Faculdade de Medicina Universidade Federal da Fronteira do Sul Chapec Brazil

Objective: This case report aimed to demonstrate a possible neuromuscular effect of pyloric sympathectomy on the pylorus motility, leading to its permanent relaxation, observed in two bariatric surgical cases, one primary and the other, revisional. Background: Pyloric sphincter is a physiological barrier to free gastric emptying. In sleeve gastrectomy and in Roux-en-Y gastric bypass revisions, that put the remnant stomach in transit, the pylorus can contribute to generate a high intragastric pressure, which could lead to acute gastric fistulas and/or chronic gastroesophageal reflux disease. The possibility of functionally relaxing the pylorus, promoting intragastric pressure reduction, could represent a protective maneuver against these complications. Methods: We describe herein a surgical maneuver applied in two cases of bariatric surgeries, with the intention of facilitating antrum-duodenal region exposure, in a sleeve gastrectomy and in a Roux-en-Y gastric bypass conversion to SADI-S. For this, a ligation of terminal peripyloric vessels was done, allowing a passage of a tape, which surrounded the pylorus, for its traction. In both cases, 30-day and 1-year endoscopic evaluations were done, to assess esophagitis signs, anastomosis healing and anatomical pouch aspect. A clinical evaluation was also done, to assess gastroesophageal symptoms (validated questionnaire). Results: In the postoperative endoscopic evaluations, no esophagitis were observed in any case and the gastric pouches had normal aspect, with the expected anatomical findings, compatible with the surgeries performed. The anastomosis healed without problems, in the revisional case. Interestingly, in both cases, it was observed a complete pyloric sphincter relaxation, which lasted until 1-year endoscopic evaluation. There were no fistulas, nor esophagitis in any of these cases. Clinically, there were no symptoms of gastroesophageal reflux disease (validated questionnaire). Conclusion: The observation of a

关键词： Roux-en-Y Gastric Bypass Sleeve Gastrectomy Sympathectomy Bariatric Surgery

Functional Roux-en-Y Gastric Bypass (F-RYGB), with Preservation of Duodenal Access: Report of Two Revisional Cases of Sleeve Gastrectomy

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Surgical Science 2024年第3期15卷 135-158页

作者： Victor Ramos Mussa Dib Carlos Augusto Scussel Madalosso paulo Reis Esselin de Melo Rui Ribeiro Paula Volpe Carlos Eduardo Domene Victor Dib Institute Manaus Brazil Gastrobese Clinic Passo Fundo Brazil paulo Reis Institute of Bariatric Surgery Goi&#226nia Brazil Alfredo nasser University Center (UNIFAN) Goi&#226nia Brazil Lusíadas Amadora Hospital Lisboa Portugal Integrated Center for Advanced Medicine (CIMAMED) S&#227o Paulo Brazil

Objective: This case report aimed to demonstrate a possible neuromuscular effect of Latarjet nerves transection or truncal vagotomy, in association with sleeve gastrectomy plus antrojejunostomy, in order to reproduce a Roux-en-Y gastric bypass (RYGB) mechanistic principles, in patients with previous Sleeve Gastrectomy (SG) who had had weight regain, with or without concomitant gastroesophageal reflux disease (GERD). Background: Sleeve gastrectomy (SG) is one of the most frequently performed bariatric operations worldwide. Nevertheless, weight regain and gastroesophageal reflux disease (GERD) have been consistently demonstrated, in association with this technique, which may require a revisional procedure. RYGB is an option in such a situation but, implies in gastrointestinal exclusions, which represents a shortcoming of this revision. Surpassing this inconvenient would be of great value for the patients. Methods: We describe herein two cases of SG revision for weight regain and GERD, with a follow-up of one year. Gastroesophageal reflux disease was evaluated by validated questionnaire, upper endoscopy, seriography, high resolution manometry (HRM) and impedance pHmetry (I-pHmetry), in the pre and postoperative periods. A re-Sleeve Gastrectomy with antrojejunal anastomosis was done in both cases, after informed consents. The Latarjet nerves were transected in one case, due to a bleeding in the left gastric vessels and a truncal vagotomy was required in the other, to appropriately treat an associated hiatal hernia. Results: In the postoperative evaluation it was observed a pyloric spasm in both cases, during seriography and endoscopy, kept until the one-year follow-up. There was unidirectional contrast flow to the gastrointestinal anastomosis, filling the jejunal limb, in radiologic contrast study. No contrast passed through the pylorus. Nonetheless, the duodenum was kept endoscopically accessible. In the one-year evaluation, weight loss was adequate and GERD resolution

关键词： Roux-en-Y Gastric Bypass Sleeve Gastrectomy Jejuno Gastric Bypass Vagus Nerve Vagotomy Bariatric Surgery

Sleeve Gastrectomy with Duodenal Transit Bipartition (S-DTB): Preliminary Results and Technical Aspects of Its Metabolic Structure

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Surgical Science 2024年第4期15卷 244-264页

作者： paulo Reis Esselin de Melo Ricardo Zorron Victor Ramos Mussa Dib Carlos Augusto Scussel Madalosso Rui Ribeiro Thonya Cruz Braga Paula Volpe Carlos Eduardo Domene paulo Reis Institute Goiania GO Brazil Alfredo nasser University Center (UNIFAN) Goiania GO Brazil Department of Bariatric and Metabolic Surgery CUF Descobertas Hospital Lisbon Portugal Victor Dib Institute Manaus AM Brazil Gastrobese Clinic Passo Fundo RS Brazil Lusiadas Amadora Hospital Lisbon Portugal Clianest Group Renaissance Hospital Goiania GO Brazil Integrated Center for Advanced Medicine (CIMAMED) Sao Paulo Brazil

Obesity is a significant and escalating health issue both in Brazil and globally, with over 650 million overweight adults worldwide. The treatment of obesity can be performed clinically, endoscopically or surgically;surgical treatment proves to be safe and more effective in terms of weight loss and long-term maintenance. Objective: This study aimed to monitor the progress of weight loss and comorbidity control in patients undergoing sleeve gastrectomy with duodenal bipartition. Methods: This pilot project involved 8 patients divided into 2 arms. In the first arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenoileal transit bipartition (S-RYDITB), while in the second arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenojejunal transit bipartition (S-RYDJTB). Both procedures involved Roux-en-Y reconstruction without duodenal exclusion. In S-RYDITB, the duodenal-ileal anastomosis was performed 300 cm from the ileocecal valve (ICV), creating a 250 cm common channel and a 50 cm alimentary channel. In S-RYDJTB, a biliopancreatic loop was created 200 cm from the angle of Treitz, with a 1 m alimentary channel. Results: Five patients underwent the procedures, with one undergoing S-RYDITB and four undergoing S-RYDJTB. No adverse events such as hospitalizations, readmissions, reoperations, fistulas, bleeding, pulmonary embolism, diarrhea, dumping syndrome, or hypoglycemia occurred during the study period. The mean length of hospital stay was 2 days. The average BMI decreased from 37.27 kg/m2 preoperatively to 29.48 kg/m2 after 6 months. The significant percentage of weight loss was 21.22%, with excess weight loss of 63.6%. Ninety-five percent remission of comorbidities, including hypercholesterolemia, hypertriglyceridemia, diabetes, hypertension, steatosis, and pre-diabetes. Two patients underwent sleeve gastrectomy with duodenal bipartition using a single anastomosis. Conclusion: Duodenal switch surgery has gained worldwide recog

关键词： Obesity Bariatric Surgery Metabolic Surgery Duodenal Switch

Transit Bipartition with Duodeno-Ileal Anastomosis, without Duodenal Exclusion, as a First Stage of Bariatric Surgery in Severely Obese Patients: Case Report

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Surgical Science 2022年第11期13卷 497-505页

作者： paulo Reis Esselin de Melo Thonya Cruz Braga Danilo Fossalussa Minari José Humberto Cardoso Resende Instituto paulo Reis Goi&#226nia Brazil UNIFAN-Centro Universitário Alfredo nasser Aparecida de Goi&#226nia Goi&#225s Brazil

Obesity is a difficult disease to control;bariatric surgery is one of the tools used to treat obesity and its comorbidities. The present case was chosen because it concerns a very obese patient whose proposed surgery—duodenal switch—resulted in traoperatively difficult to the medical team because the esophagogastric junction could not be reached due to the presence of hepatomegaly. Due to this unfavorable condition, we decided to perform a duodeno-ileal anastomosis with gastric preservation and without duodenal exclusion. The patient has been under follow-up for 14 years. She has lost 55 kg and maintains the comorbidities controlled to date.

关键词： Bariatric Surgery Biliopancreatic Diversion Gastric Bypass Duodenal Switch

SADI-S with Extended Duodeno-Bulb Preservation: Case Report

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Surgical Science 2023年第2期14卷 131-142页

作者： Victor Ramos Mussa Dib Carlos Augusto Scussel Madalosso paulo Reis Esselin de Melo Rui Ribeiro Gabriela Trentin Scortegagna Elinton Adami Chaim Victor Dib Institute Manaus Brazil Gastrobese Clinic Passo Fundo Brazil paulo Reis Institute of Bariatric Surgery Goi&#226nia Brazil Alfredo nasser University Center (UNIFAN) Goi&#226nia Brazil Luziadas Hospital Lisboa Portugal Faculdade de Ciências Médicas (FCM) da Unicamp Campinas S&#227o Paulo Brazil

Obesity has been growing in Brazil and in the world. It is reaching epidemic proportions, and bariatric surgery is the most effective treatment for patients with this disease. Among the procedures described in the literature, ileal surgeries such as biliopancreatic diversion with duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) present better long-term results in terms of weight loss and comorbidities control. However, there are concerns regarding long term nutritional problems with these procedures. In this case report the aim is to demonstrate the technical feasibility of preserving an extended duodenal bulb segment, in the SADIS-S procedure, when there are difficulties in dissecting the retrobulbar region, as occurred here, due to fibrosis in this area. This assures the maintenance of the proposed surgical technique, in such a situation. The dissection and transection of the duodenum was done 7 cm distally to the pylorus, under endoscopic view, proximally to the papillae, where the tissue was normal. Additionally, due the importance of the duodenal mucosa on minerals and trace elements absorption and the release of important hormones in this region, this case report elicits the evaluation of the impact of this technical modification, which occurred casually, in the nutritional, hormonal and metabolic results, long term. In this case report, the extended duodenal length has demonstrated reasonable weight loss, adequate comorbidities control and good nutritional status, so far. These aspects must be evaluated in the long term, by clinical trials.

关键词： Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy Obesity Bulb Preservation Bariatric Surgery Metabolic Surgery

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

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Surgical Science 2023年第5期14卷 360-376页

作者： Victor Ramos Mussa Dib Carlos Augusto Scussel Madalosso Carlos Eduardo Domene paulo Reis Esselin de Melo Rui Ribeiro Gabriela Trentin Scortegagna Elinton Adami Chaim Victor Dib Institute Manaus Brazil Gastrobese Clinic Passo Fundo Brazil Integrated Center for Advanced Medicine (CIMA) S&#227o Paulo Brazil paulo Reis Institute of Bariatric Surgery Goi&#226nia Brazil General Surgery Unit Alfredo Nasser University Center (UNIFAN) Goi&#226nia Brazil Luziadas Hospital Lisboa Portugal Department of Surgery Faculty of Medical Sciences (FCM) at UNICAMP Campinas Brazil

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 ga

关键词： Roux-en-Y Gastric Bypass Sleeve Gastrectomy Jejunum Gastric Bypass Bariatric Surgery

Long-term outcomes of hepatocellular carcinoma that underwent chemoembolization for bridging or downstaging

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World Journal of Gastroenterology 2019年第37期25卷 5687-5701页

作者： Breno Boueri Affonso Francisco Leonardo Galastri Joaquim Mauricio da Motta Leal Filho Felipe nasser Priscila Mina Falsarella Rafael Noronha Cavalcante Marcio Dias de Almeida Guilherme Eduardo Goncalves Felga Leonardo Guedes Moreira Valle Nelson Wolosker Department of Interventional Radiology Hospital Israelita Albert EinsteinSao Paulo 05651-901Sao PauloBrazil Department of Liver Transplant Hospital Israelita Albert EinsteinSao Paulo 05651-901Sao PauloBrazil Department of Vascular Surgery Hospital Israelita Albert EinsteinSao Paulo 05651-901Sao PauloBrazil

BACKGROUND Prospective study of 200 patients with hepatocellular carcinoma(HCC)that underwent liver transplant(LT)after drug-eluting beads transarterial chemoembolization(DEB-TACE)for downstaging versus *** survival and tumor recurrence rates were calculated,eligibility for LT,time on the waiting list and radiological response were *** TACE,only patients within Milan Criteria(MC)were *** patients underwent LT in bridging ***-year post-transplant overall survival,recurrence-free survival has no difference between the *** response was observed more frequently in bridging *** in DS group can achieve posttransplant survival and HCC recurrence-free probability,at five years,just like patients within MC in patients undergoing *** To determine long-term outcomes of patients with HCC that underwent LT after DEB-TACE for downstaging vs *** Prospective cohort study of 200 patients included from April 2011 through June *** group included patients within *** group(out of MC)was divided in 5 subgroups(G1 to G5).Total tumor diameter was≤8 cm for G1,2,3,4(n=42)and was>8 cm for G5(n=22).Downstaging(n=64)and bridging(n=136)populations were not significantly *** survival and tumor recurrence rates were calculated by the Kaplan-Meier ***,eligibility for LT,time on the waiting list until LT and radiological response were *** After TACE,only patients within MC were *** patients underwent LT in bridging group 65.9%(P=0.001).Downstaging population presented:higher number of nodules 2.81(P=0.001);larger total tumor diameter 8.09(P=0.001);multifocal HCC 78%(P=0.001);more post-transplantation recurrence 25%(P=0.02).Patients with maximal tumor diameter up to 7.05 cm were more likely to receive LT(P=0.005).Median time on the waiting list was significantly longer in downstaging group 10.6 mo(P=0.028).Five-year posttransplant over

关键词： Hepatocellular carcinoma Down-staging Liver transplantation Localregional therapy Bridging

Imaging response predictors following drug eluting beads chemoembolization in the neoadjuvant liver transplant treatment of hepatocellular carcinoma

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World Journal of Hepatology 2020年第1期12卷 21-33页

作者： Francisco Leonardo Galastri Felipe nasser Breno Boueri Affonso Leonardo Guedes Moreira Valle Bruno Calazans Odísio Joaquim Mauricio Motta-Leal Filho Paolo Rogério Salvalaggio Rodrigo Gobbo Garcia Márcio Dias de Almeida Ronaldo Hueb Baroni Nelson Wolosker Department of Interventional Radiology Hospital Israelita Albert EinsteinSão Paulo 05652-000Brazil Department of Diagnostic Radiology The University of Texas MD Anderson Cancer CenterHoustonTX 77230United States Radiology Department Radiology DepartmentHeart Institute(InCor)University of São PauloSão Paulo 05403-900Brazil Teaching and Research Institute São PauloBrazilHospital Israelita Albert EinsteinSão Paulo 05652-000Brazil Department of Liver Transplant Hospital Israelita Albert EinsteinSão Paulo 05652-900Brazil Department of Radiology Hospital Israelita Albert EinsteinSão Paulo 05652-000Brazil Department of Vascular Surgery Hospital Israelita Albert EinsteinSão Paulo 05652-000Brazil

BACKGROUND Drug-eluting bead transarterial chemoembolization(DEB-TACE)is an endovascular treatment to release chemotherapeutic agents within a target lesion,minimizing systemic exposure and adverse effects to ***,identifying which patient characteristics may predict imaging response to DEB-TACE can improve treatment results while selecting the best *** of the response after DEB-TACE still have not been fully *** is the first prospective study performed with standardized DEBTACE technique that aim to identify predictors of radiological response,assessing patients clinical and laboratory characteristics,diagnostic imaging and intraprocedure data of the hepatocellular carcinoma treated in the neoadjuvant context for liver *** To identify pre-and intraoperative clinical and imaging predictors of the radiological response of drug-eluting bead transarterial chemoembolization(DEB-TACE)for the neoadjuvant treatment of hepatocellular carcinoma(HCC).METHODS This is prospective,cohort study,performed in a single transplant center,from 2011 to *** patients with HCC considered for liver transplant who underwent DEB-TACE in the first session for downstaging or bridging purposes were *** and post-chemoembolization imaging studies were performed by computed tomography or magnetic *** radiological response of each individual HCC was evaluated by objective response using mRECIST and the percentage of *** Two hundred patients with 380 HCCs were *** of the objective response(nodule-based analysis)demonstrated that HCC with pseudocapsules had a 2.01 times greater chance of being responders than those without pseudocapsules(P=0.01),and the addition of every 1mg of chemoembolic agent increased the chance of therapeutic response in 4%(P<0.001).Analysis of the percentage of necrosis through multiple linear regression revealed that the addition of each 1mg of the

关键词： Hepatocellular carcinoma Liver transplantation Response evaluation criteria in solid tumors Neoadjuvant therapy Liver neoplasms

Diagnosis and management of hepatic artery in-stent restenosis after liver transplantation by optical coherence tomography:A case report

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World Journal of Hepatology 2020年第7期12卷 399-405页

作者： Francisco Leonardo Galastri Guilherme Moratti Gilberto Breno Boueri Affonso Leonardo Guedes Moreira Valle Priscila Mina Falsarella Adriano Mendes Caixeta Camila Antunes Lima Marcela Juliano Silva Lucas Lembrança Pinheiro Conrado Dias Pacheco Annicchino Baptistella Márcio Dias de Almeida Rodrigo Gobbo Garcia Nelson Wolosker Felipe nasser Hospital Israelita Albert Einstein Department of Interventional RadiologySão Paulo 05652900Brazil Hospital Israelita Albert Einstein Department of Interventional CardiologySão Paulo 0562900Brazil Hospital Israelita Albert Einstein Department of Liver TransplantSão Paulo 05652900Brazil Hospital Israelita Albert Einstein Department of Vascular SurgerySão Paulo 05652-000Brazil

BACKGROUNDPercutaneous transluminal angioplasty and stenting represent an effectivetreatment for hepatic artery stenosis after liver transplantation. In the first yearafter stenting, approximately 22% of patients experience in-stent restenosis,increasing the risk of artery thrombosis and related complications, and 50%experience liver failure. Although angiography is an important tool for diagnosisand the planning of therapeutic interventions, it may raise doubts, especially insmall-diameter arteries, and it provides low resolution rates compared withnewer intravascular imaging methods, such as optical coherence tomography(OCT).CASE SUMMARYA 64-year-old male developed hepatic artery stenosis one year after orthotropicliver transplantation and was successfully treated with percutaneous transluminalangioplasty with stenting. Five months later, the Doppler ultrasound resultsindicated restenosis. Visceral arteriography confirmed hepatic artery tortuositybut was doubtful for significant in-stent restenosis (ISR) and intrahepatic flowreduction. To confirm ISR, identify the etiology and guide treatment, OCT wasperformed. OCT showed severe stenosis due to four mechanisms: Focal andpartial stent fracture, late stent malapposition, in-stent neointimal hyperplasia,and *** diagnostic methods can be useful in evaluating cases in which initialangiography results are not sufficient to provide a proper diagnosis of significantstenosis, especially with regard to ISR. A wide range of diagnoses are provided byOCT, resulting in different treatment options. Interventional radiologists shouldconsider intravascular diagnostic methods as additional tools for evaluatingpatients when visceral angiography results are unclear.

关键词： Liver transplantation Hepatic artery restenosis Tomography Optical coherence Case report Endovascular procedures Angiography