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BACKGROUND: Roux-en-Y gastric bypass patients can experience changes in calcium metabolism and hyperparathyroidism secondary to vitamin D deficiency. AIM: To evaluate nutritional deficiencies related to the calcium metabolism of patients undergoing gastric bypass with a 10-year follow-up. METHOD: This is a longitudinal retrospective study of patients submitted to Roux-en-Y gastric bypass at a multidisciplinary clinic located in the Brazilian southeast region. The study investigated the results of the following biochemical tests: serum calcium, ionized calcium, vitamin D, and parathormone (PTH). The generalized estimating equations (GEE) determined the nutritional deficiencies using a significance level of 5%. RESULTS: Among the patients who finished the study (120 months), 82.86% (n=29) had vitamin D deficiency, and 41.94% (n=13) had high PTH. Postoperative time had a significant effect on PTH (p=0.0059). The percentages of patients with vitamin D, serum calcium, and ionized calcium deficiencies did not change significantly over time. CONCLUSION: One of the outcomes was vitamin D deficiency associated with secondary hyperparathyroidism. These findings reaffirm the importance of monitoring the bone metabolism of patients submitted to Roux-en-Y gastric bypass. HEADINGS: Calcium deficiency. Vitamin D deficiency. Secondary hyperparathyroidism.

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OBJECTIVE: The aim of this study was to investigate the lipid and glycemic profiles of patients up to 10 years after Roux-en-Y gastric bypass. METHOD: A retrospective, longitudinal study was conducted at a multidisciplinary center for the treatment of obesity in the state of São Paulo, Brazil. The study included 150 patients submitted to unbanded laparoscopic Roux-en-Y gastric bypass. The metabolic profile included total cholesterol and fractions, triglycerides, and fasting glucose. The patients were examined before and 3, 6, 12, 24, 48, 72, 96, and 120 months after surgery. Statistical analyses included the generalized estimating equations (GEE) and the Wilcoxon test at a significance level of 5%. RESULTS: All postoperative fasting glucose, total cholesterol, and triglyceride (p < 0.0001) test results were significantly lower than the preoperative test results. Low-density lipoprotein cholesterol (LDL-c) differed significantly in all but the 120-month follow-up (p = 0.0129). High-density lipoprotein cholesterol (HDL-c) was significantly higher 12, 24, 48, and 72 months after surgery (p < 0.001) and also 120 months after surgery (p = 0.0002). CONCLUSION: Gastric bypass promoted the control of metabolic diseases inherent to obesity as long as 10 years after surgery.

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ABSTRACT Background : Roux-en-Y gastric bypass patients can experience changes in calcium metabolism and hyperparathyroidism secondary to vitamin D deficiency. Aim : To evaluate nutritional deficiencies related to the calcium metabolism of patients undergoing gastric bypass with a 10-year follow-up. Method : This is a longitudinal retrospective study of patients submitted to Roux-en-Y gastric bypass at a multidisciplinary clinic located in the Brazilian southeast region. The study investigated the results of the following biochemical tests: serum calcium, ionized calcium, vitamin D, and parathormone (PTH). The generalized estimating equations (GEE) determined the nutritional deficiencies using a significance level of 5%. Results : Among the patients who finished the study (120 months), 82.86% (n=29) had vitamin D deficiency, and 41.94% (n=13) had high PTH. Postoperative time had a significant effect on PTH (p=0.0059). The percentages of patients with vitamin D, serum calcium, and ionized calcium deficiencies did not change significantly over time. Conclusion : One of the outcomes was vitamin D deficiency associated with secondary hyperparathyroidism. These findings reaffirm the importance of monitoring the bone metabolism of patients submitted to Roux-en-Y gastric bypass. HEADINGS: Calcium deficiency. Vitamin D deficiency. Secondary hyperparathyroidism.

Resumo Racional: Pacientes submetidos ao bypass gástrico em Y-de-Roux, podem apresentar alterações do metabolismo do cálcio e hiperparatireoidismo secundário à deficiência de vitamina D. Objetivo: Avaliar as deficiências nutricionais relacionadas ao metabolismo do cálcio de pacientes submetidos à bypass gástrico em Y-de-Roux, com seguimento de 10 anos. Método: Um estudo retrospectivo longitudinal foi conduzido com pacientes submetidos à bypass gástrico em Y-de-Roux, em uma Clínica Multidisciplinar no Sudeste do Brasil. Investigou-se a frequência do acompanhamento médico e nutricional e os exames bioquímicos de cálcio sérico, cálcio iônico, vitamina D e paratormônio (PTH). Para a análise das deficiências nutricionais, foram utilizadas as Equações de Estimativas Generalizadas (EEG), com nível de significância de 5%. Resultados: Dos pacientes que permaneceram no estudo até o final (120 meses), 82,86% (29), apresentaram níveis de deficiência de vitamina D e 41,94% (13) apresentaram PTH elevado. O efeito do tempo foi significativo para o PTH (p=0,0059). Para a vitamina D, cálcio sérico e cálcio iônico, o percentual de deficiência manteve-se constante ao longo do tempo, sem diferença significativa entre os tempos. Conclusão: A deficiência de vitamina D, associada ao hiperparatireoidismo secundário, foi um desfecho encontrado. Tais achados reafirmam a importância do cuidado com o metabolismo ósseo, em pacientes submetidos à bypass gástrico em Y-de-Roux.

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RACIONAL: A cirurgia minimamente invasiva ganhou rapidamente papel fundamental no tratamento da doença do refluxo gastroesofágico. Entretanto, o melhor método para as grandes hérnias paraesofágicas (tipos III e IV) ainda está em discussão. O uso de próteses para reforço da hiatoplastia tem sido proposto por diversos autores, no intuito de diminuir as altas taxas de recidivas encontradas nesses pacientes. Riscos de estenose e erosão da prótese são as complicações mais preocupantes quando se pensa em aplicar uma prótese no hiato esofágico. OBJETIVO: Demonstrar a técnica cirúrgica e resultados do uso de um modelo de tela idealizado no serviço dos autores para reforçar a hiatoplastia em grandes hérnias de hiato. MÉTODOS: Uma prótese de polipropileno foi aplicada para reforço da hiatoplastia em pacientes com grandes hérnias de hiato (Tipos II a IV de Hill). A prótese era cortada em forma de U, com sutura de cateter de silicone na borda côncava que ficaria em contato com o esôfago. Após sua fixação sobre a hiatoplastia, toda prótese era recoberta por gordura do omento maior, impedindo contato com o fundo gástrico ou fundoplicatura. RESULTADOS: De 1999 a 2012, esta técnica foi utilizada em 70 pacientes. Eram 52 do sexo feminino e 18 do sexo masculino, com idades variando de 32 a 83 anos (média de 63 anos). Em 48 (68,6%) pacientes, tratava-se de hérnias primárias e em 22 (31,4%) era recidivada após operação antirrefluxo. O único óbito ocorreu por sepse (1,4%) no 22o dia pós-operatório em caso com laceração da sutura da fundoplicatura causando fístula gastropleural. Não houve relação direta com o uso da prótese. Seguimento de seis meses ou mais foi obtido em 60 pacientes (85,7%), variando de seis a 146 meses (média de 49 meses). Todos os pacientes foram submetidos à entrevista clínica e pelo menos uma endoscopia e/ou radiografia contrastada no período de acompanhamento. Durante o seguimento, não foram observadas complicações (estenose ou erosão) relacionadas com a prótese. CONCLUSÃO: O uso do modelo de prótese de polipropileno descrito é seguro, desde que observados os aspectos técnicos de sua implantação.

BACKGROUND: The minimally invasive surgery has gained rapidly important role in the treatment of gastroesophageal reflux disease. However, the best method to treat large paraesophageal hernias (type III and IV) is still under discussion. The use of prosthetics for enhancing the crural repair has been proposed by several authors in order to reduce the high relapse rates found in these patients. AIM: To demonstrate the technique and surgical results in using an idealized polypropylene mesh for the strengthening of the cruroraphy in large hiatal hernias. METHODS: Was applied the polypropylene mesh to reinforce the hiatal closure in large hernias - types II to IV in Hill's classification - with a primary or recurrent hiatal defect greater than 5 cm, in a series of 70 patients. The prosthesis was done cutting a polypropylene mesh in a U-shape, adapted to the dimensions found in the intraoperative field and coating the inner edge (which will have direct contact with the esophagus) with a silicon catheter. This was achieved by removing a small longitudinal segment of the catheter and then inserting the edge of the cut mesh, fixing with running nylon 5-0 suture. RESULTS: From 1999 to 2012, this technique was used in 70 patients. There were 52 females and 18 males, aged 32-83 years (mean 63 years). In 48 (68.6%) patients, paraesophageal hernia was primary and in 22 (31.4%), it was relapse after antireflux surgery. The only case of death in this series (1.4%) occurred on 22nd postoperative day in one patient (74 y) that had a laceration of the sutures on the fundoplication, causing gastropleural fistula and death. There was no relationship with the use of the prosthesis. A follow-up of six months or more was achieved in 60 patients (85.7%), ranging from six to 146 months (mean 49 months). All patients have at least one follow-up endoscopy or esophageal contrast examination, and a clinical interview. In this follow-up period, no cases of complications related to the prosthesis (stenosis or erosion) were observed. CONCLUSION: The use of this model of polypropylene mesh is safe if the technical aspects of its placement are followed carefully.

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BACKGROUND: The minimally invasive surgery has gained rapidly important role in the treatment of gastroesophageal reflux disease. However, the best method to treat large paraesophageal hernias (type III and IV) is still under discussion. The use of prosthetics for enhancing the crural repair has been proposed by several authors in order to reduce the high relapse rates found in these patients. AIM: To demonstrate the technique and surgical results in using an idealized polypropylene mesh for the strengthening of the cruroraphy in large hiatal hernias. METHODS: Was applied the polypropylene mesh to reinforce the hiatal closure in large hernias--types II to IV in Hill's classification--with a primary or recurrent hiatal defect greater than 5 cm, in a series of 70 patients. The prosthesis was done cutting a polypropylene mesh in a U-shape, adapted to the dimensions found in the intraoperative field and coating the inner edge (which will have direct contact with the esophagus) with a silicon catheter. This was achieved by removing a small longitudinal segment of the catheter and then inserting the edge of the cut mesh, fixing with running nylon 5-0 suture. RESULTS: From 1999 to 2012, this technique was used in 70 patients. There were 52 females and 18 males, aged 32-83 years (mean 63 years). In 48 (68.6%) patients, paraesophageal hernia was primary and in 22 (31.4%), it was relapse after antireflux surgery. The only case of death in this series (1.4%) occurred on 22nd postoperative day in one patient (74 y) that had a laceration of the sutures on the fundoplication, causing gastropleural fistula and death. There was no relationship with the use of the prosthesis. A follow-up of six months or more was achieved in 60 patients (85.7%), ranging from six to 146 months (mean 49 months). All patients have at least one follow-up endoscopy or esophageal contrast examination, and a clinical interview. In this follow-up period, no cases of complications related to the prosthesis (stenosis or erosion) were observed. CONCLUSION: The use of this model of polypropylene mesh is safe if the technical aspects of its placement are followed carefully.

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Apresentam-se resultados iniciais com a aplicaçao clínica, em 41 pacientes, de técnica operatória de esofagogastrofundoplicatura laparoscópica, a técnica "mista". Considerada como variante da fundoplicatura total, permite bons resultados na contençao do refluxo gastresofagiano. Todos os pacientes foram reavaliados após período que variou de um a 12 meses, demostrando que a queixa original de azia desapareceu em todos os casos e que 87,8 por cento encontravam-se satisfeitos com os resultados obtidos. Os 12,2 por cento restantes apresentavam queixas leves, que apesar de investigadas nao exigiram qualquer tratamento complementar.

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O tratamento cirúrgico da colecistite aguda sempre foi motivo de preocupaçao, dadas as dificuldades técnicas impostas pela doença. O surgimento da cirurgia videolaparoscópica reacendeu as discussoes quanto ao método ideal a ser empregado na atualidade. Os autores analisam os resultados obtidos na realizaçao de 25 colecistectomias videolaparoscópicas em pacientes portadores de colecistites agudas, sem critérios de exclusao e independentemente do tempo de evoluçao; classificadas, segundo aspecto operatório, em edematosas (14), empiematosas (8) e necróticas (3). A cirurgia foi possível em todos os casos sem necessidade de conversao a laparotomia; o tempo médio operatório foi de 125 minutos e o período de internaçao hospitalar, 1,8 dia, em média. As intercorrências peroperatórias foram sempre controladas e a morbidade pós-operatória restringiu-se a dois casos de infecçao e um de hérnia incisional, todos na cicatriz umbilical. Os autores concluem ser o método factível, seguro, de baixa morbidade e curta permanência hospitalar. No entanto, é indispensável experiência com a técnica, treinamento em grupo e equipamentos adequados, para a obtençao de bons resultados.

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