INTRODUÇÃO: Não obstante os bons resultados e reprodutibilidade da derivação gástrica em Y de Roux (DGYR), discutem-se ainda aspectos técnicos que podem influenciar tanto o resultado na perda de peso, como a qualidade de vida pós-operatória (PO). Atribui-se hoje a efeitos restritivos, como volume da bolsa gástrica e sua velocidade de esvaziamento, assim como a fatores metabólicos, o resultado da cirurgia. As influências morfofuncionais não são totalmente compreendidas. OBJETIVO: Avaliar a influência do volume da bolsa gástrica e sua velocidade de esvaziamento sobre a perda de peso e a tolerância alimentar no PO de DGYR. MÉTODO: Pacientes em PO tardio de DGYR; foram avaliados a percentagem de perda de excesso de peso (%PEP), reganho de peso (%PEPreganho), tolerância alimentar por questionário de tolerância (ES), volume da bolsa (V) por tomografia computadorizada tridimensional (TC3D) e velocidade de esvaziamento da bolsa por cintilografia, avaliada por percentual de retenção (%Ret) em 1, 2 e 4 horas. Foram identificados pontos de corte para V e %Ret em 1 hora (%Ret1). A partir destes parâmetros a amostra foi categorizada por V e %Ret1, e os dados correlacionados com resultados em perda de peso e tolerância alimentar. RESULTADOS: Foram estudados 67 pacientes. A idade mediana foi 51 anos, 91,04% sexo feminino, e IMC mediano inicial de 51,44 kg/m2. O tempo de seguimento PO mediano foi de 47 meses. A amostra apresentou 60,27%PEPnadir como mediana da maior perda de peso PO e 16,13%PEPreganho. A mediana de V foi de 28mL; a %Ret em 1, 2, 4 horas foras foram 8%, 2%, 1%, respectivamente. A pontuação mediana do ES foi 21. Os pontos de corte considerados foram V=40mL, e %Ret1 de 12% e 25%. Foram comparados subgrupos por V (V <= 40mL, V > 40mL) e por %Ret1 (%Ret1 <= 12%, 12%<%Ret1 < 25%, e %Ret1>=25%). Na análise categorizada por V, houve associação entre V <= 40mL e maior velocidade de esvaziamento até 2 horas (V <= 40mL: %Ret1=6, %Ret2=2, p=0,009; V > 40mL: %Ret1=44, %Ret2=13,5, p=0,045). Na análise categorizada por %Ret1, observou-se associação entre maior velocidade de esvaziamento em 1 hora e melhor evolução ponderal tardia, representada por menor %PEPreganho (p=0,036), e maior %PEPatual (p=0,033) no grupo com %Ret1 <= 12%. Na avaliação do ES, associou-se melhor tolerância alimentar (ES > 24) e menor %Ret1 (p=0,003). CONCLUSÕES: Houve associação do volume da bolsa gástrica com a velocidade de esvaziamento. O esvaziamento mais rápido correlacionou-se com maior %PEP tardia, menor reganho de peso e melhor tolerância alimentar. Estes dados sugeriram que a presença de bolsa gástrica pequena, com menos de 40 mL, e com rápido esvaziamento, são parâmetros importantes para adequado resultado tardio na DGYR. O uso da TC3D e da cintilografia para avaliação morfofuncional da DGYR podem contribuir para investigação do reganho de peso e intolerância alimentar PO / INTRODUCTION: Despite the good results and good reproducibility of the Roux-en-Y gastric bypass (GBP), discussions about technical aspects still remain. Postoperative anatomy can influence the result in weight loss, as the postoperative (PO) quality-of-life. Surgical results are nowadays attributed to restriction, promoted by the small neo-stomach volume and its emptying, as well as metabolic factors. These anatomical and functional influences on surgical results are often poorly evaluated, and yet not fully understood. OBJECTIVE: To evaluate the influence of the gastric pouch volume and its emptying rate on weight loss, and food tolerance, in the late PO of GBP. METHOD: Patients followed-up at HC-FMUSP in late PO of GBP; percentage of excess weight loss (%EWL), weight regained (%EWLregain), food tolerance with specific questionnaire (Suter Score, SS), gastric pouch volumetry (V) by three-dimensional computed tomography (CT3D), and pouch emptying rate by scintigraphy, evaluated by retention percentage (%Ret) in 1, 2, 4 hours, were assessed. Cutoffs were identified for %Ret at 1 hour (%Ret1) and V. From these parameters the sample was categorized by V and %Ret1, looking for associations between V and %Ret and results in weight loss and food tolerance. RESULTS: Eighty patients were enrolled and 67 completed the study. The median age was 51 years, 91.04% were female, with initial median BMI of 51.44 kg/m2. The PO median follow-up time was 47 months. The sample showed median of 60.27% as EWLnadir as PO better weight loss, with 16.13% of EWLregain. The median V was 28mL; %Ret at 1, 2, 4 hours were 8%, 2%, 1%, respectively. The median score of SS was 21. The cutoff points considered were V=40mL, and %Ret1=12% and 25%. Subgroups were compared by V (V <= 40mL, V > 40mL) and Ret1% (%Ret1 <= 12%, 12% < %Ret1 < 25%, and %Ret1 >= 25%). The categorized analysis by V found associations between V<=40mL and higher emptying speeds up to 2 hours (V <= 40mL: %Ret1=6, %Ret2=2, p=0.009; V > 40mL: %Ret1=44, %Ret2=13.5, p=0.045). In the categorized analysis by %Ret1, it was found association between higher emptying speed in 1 hour and higher late PO weight loss, represented by lower %EWLregain (p=0.036), and higher late %EWL (p=0.033) in the group with %Ret1<=12%, compared to the group %Ret1 >= 25%. Better food tolerance, assessed by Suter questionnaire (SS > 24), was associated with lower %Ret1 (p=0.003). CONCLUSIONS: There was an association between gastric pouch volume and emptying rate. Smaller gastric pouch have shown faster gastric emptying. The fastest gastric emptying was correlated with higher late %EWL, less weight regain and better PO food tolerance. These data suggest that the construction of small gastric pouch, with less than 40 mL, and with rapid emptying rate, are important parameters for good outcomes in late postoperative in GBP. The use of CT3D and scintigraphy for morphological and functional assessment of GBP can contribute in the evaluation of possible causes of late postoperative weight regain and food intolerance

The meaning of loss is love. I know this through attention to experience. Whether loss or love is experienced in abundance or in absence, the meaning is mystical with an opening of body, mind, heart and soul to spirit. And so, in the style of a memoir, in the way of contemplative prayer, I contemplate and share my soul as a promise kept in the mystical reach through loss. With the first, initiating loss, the loss of my nine-year-old nephew, Caleb, I experience an epiphany that gives me spiritual instructions that will not be ignored. I experience loss as an abundance of meaning that comes to me as gnosis, as “knowledge of the heart” according to Elaine Pagels or divine revelation in what Evelyn Underhill calls mystical illumination in the experience of “losing-to-find” in union with the divine. Then, with gnostic import, in leaving the ordinary for the extraordinary, I enter the empty room in the painful yet liberating experience of the loss of my self. In the embrace of emptiness, I proceed to the first wall, the second wall, the third wall, the dark corner of denial, the return to centre, and, finally, to breaking the fourth wall in the empty room so as to keep my promise to you. Who are “you”? You are God. You are Caleb. You are spirit. You are my higher soul or self. And, you are the reader. You are my dear companion in silence. And then, through a series of broken promises and more loss, within what John of the Cross calls, “the dark night of the soul,” I am stopped by the ineffability of the dark corner of denial, the horror of separation and the absence of meaning, which is depicted as the grueling gap between the spiritual abyss and the breakthrough. What does it mean to keep going through a solemn succession of losses? I don’t know. In going into the empty room, I simply put pain to work in order to reach you. Through loss, though there are infinite manifestations, there is only one way: keep going. And so, in a triumph of the spirit, I keep going so as to be: a promise kept in the mystical reach through loss. As for you, through my illumined and dark experiences of loss, what is my promise to you? I keep going to reach the unreachable you. In the loss of self, with embodied emptiness, in going into the dark corner of denial, with a return to the divine centre of my emptied self, in an invitation to you, I give my soul to you in union with you. / Graduate / 2020-06-25