NTRODUÇÃO: A maioria dos nomogramas para o câncer gástrico (CG) foi desenvolvida para prever a sobrevida global dos pacientes após ressecção curativa. O sistema de pontuação prognóstico (SPP) do Grupo Italiano de Pesquisa do Câncer Gástrico (GIRCG) foi projetado para prever o risco de recorrência após tratamento curativo baseado no estadiamento patológico do tumor e do tratamento realizado (linfadenectomia D1- D2/D3). Este estudo foi elaborado para avaliar a reprodutibilidade do SPP do GIRCG. PACIENTES E MÉTODO: Para validação do SPP preconizado pelo GIRCG, foram utilizados 185 pacientes operados no Serviço de Cirurgia de Estômago, Duodeno e Intestino Delgado do HCFMUSP, no período de janeiro de 2001 a dezembro de 2007, que preencheram os mesmo critérios utilizados pelo grupo italiano para construção e validação interna do SPP, ou seja, pacientes submetidos a cirurgias potencialmente curativas com ressecções R0, com linfadenectomia a D2 conforme preconizado pela Escola Japonesa. Os pacientes que apresentaram doença disseminada ou metástases a distância, mesmo sendo submetidos a ressecções paliativas, foram excluídos do estudo; assim como pacientes com menos de cinco anos de seguimento, pacientes que faleceram por complicações perioperatórias (até 30 dias) ou que, eventualmente, foram a óbito por outras causas não relacionadas ao CG. Tumores da transição esofagogástrica (TEG) e Linitis plastica também foram excluídos. O tempo mediano de seguimento foi de 77,8 meses (mínimo de 5,9 e máximo de 150,8) para todos os pacientes e de 102,5 meses (mínimo de 60,9 e máximo de 150,8) para os pacientes livres de doença. Foi utilizado modelo de regressão logística múltipla para comparar o SPP com o sistema de estadiamento TNM. RESULTADOS: A recorrência do CG ocorreu em 70 (37,8%) dos 185 pacientes. A média de idade foi de 59,7 anos (± 12,8; SE 0,94, amplitude de 22 a 88). O tempo mediano de recorrência foi de 22,2 meses (mínimo de 5,9 e máximo de 98,1). A pontuação média dos pacientes com recidiva e livres de doença foram, respectivamente, 68,2 (± 29,7 amplitude de 2,57 a 99,7) e 30,5 (± 29 amplitude de 3,6 a 97,7). A maioria dos pacientes obteve pontuações altas ou baixas, ou seja, situaram-se nos extremos da curva de distribuição da pontuação. Oito (4,3%) pacientes com pontuação maior que 90 não apresentaram recorrência e quatro (2,1%) pacientes com pontuação inferior a 10 apresentaram recidiva da doença. O SPP previu corretamente recorrência em 50 dos 70 pacientes (sensibilidade de 71,4% - IC 95% 0,61 a 0,82), enquanto a ausência de recorrência foi prevista em 88 dos 115 pacientes (especificidade de 75,6% - IC95% 0,69 a 0,84), sendo a acurácia global de 74,6% (IC95% 0,68 a 0,81). Em consonância com os resultados obtidos pelo GIRCG, apenas os valores do SPP provaram ser uma variável de previsão significante (P < 0,001), enquanto o estadio do tumor não mostrou a mesma significância (p=0,416). CONCLUSÃO: Este estudo validou o SPP do GIRCG que prevê recorrência após tratamento cirúrgico radical para CG. Este nomograma é simples, facilmente reproduzível e possui boa aplicabilidade clínica / BACKGROUND: Most nomograms for Gastric Cancer (GC) were developed to predict overall survival after curative resection. The Italian Research Group for Gastric Cancer (GIRCG) prognostic scoring system was designed to predict the risk of recurrence after curative treatment based on pathologic tumor stage and treatment performed (D1- D2/D3 lymphadenectomy). We carried out this study to externally validate the GIRCG\'s prognostic scoring system. PATIENTS AND METHODS: In order to validate the prognostic scoring system recommended by GIRCG, 185 patients operated at the Department of Surgery of Stomach, Duodenum and Small Intestine at HCFMUSP from January 2001 to December 2007 who met the same criteria used by the Italian Group for construction and internal validation have been used, that is, patients who underwent potentially curative surgery with R0 resection, with D2 lymphadenectomy as recommended by the Japanese School. Patients with disseminated disease or distant metastases, even if undergoing palliative resections were excluded from the study. As well as patients with less than five years of follow up, patients who died of perioperative complications (within 30 days) or who eventually died of other causes unrelated to the GC. Tumors of the esophagogastric junction and Linitis plastica were also excluded. The median follow-up period was 77,8 months (range 5,9 - 150,8) for all patients and 102,5 months (range 60,9 - 150,8) for patients free of disease. A multiple logistic regression model was used to compare the scoring system with TNM stage system. RESULTS: CG recurrence occurred in 70 (37.8%) of 185 patients. The mean age was 59.7 years (± 12.8; SE 0.94, range 22 to 88). The median time to recurrence was 22.2 months (range 5,9 - 98,1). The average values of the scores of patients with recurrence and disease-free were, respectively, 68.2 (± 29.7 range 3.77 to 99.7) and 30.5 (± 29.4 range 2,57 to 97.7). Most patients had high or low scores, ie, stood at the extremes of the range. Eight (4,3%) patients with score higher than 90 showed no recurrence and only four (2,1%) patients with score lower than 10 recurred. The prognostic scoring system correctly predicted recurrence in 50 of 70 patients (sensitivity71.4% - CI 95% 0.61 to 0.82), while the absence of recurrence was predicted in 88 of 115 patients (specificity of 75.6% - CI 95% 0.69 to 0.84%) with an overall accuracy of 74.6% (CI 67.8% to 80.3%). In consonance with the results obtained by GIRCG only score level proved to be a significant predictive variable (P < 0.001), while the stage of the tumor did not showed the same significance (P=0.416). CONCLUSION: This study has validated the GIRCG prognostic scoring system that predicts recurrence after radical surgical treatment for CG. This nomogram is simple, easily reproducible and has good clinical applicability

A obesidade e o Diabetes mellitus tipo 2 se tornaram importantes problemas de saúde pública nos últimos anos. O aumento da prevalência do diabetes está intimamente relacionado ao aumento da prevalência da obesidade. As cirurgias bariátricas surgiram nos últimos cinqüenta anos e vêm se popularizando como uma opção terapêutica efetiva para a redução do peso e controle ou reversão do diabetes no paciente obeso. Dentre as técnicas cirúrgicas disponíveis, o Sleeve gástrico, que era utilizado como parte integrante da técnica de derivação bílio-pancreática ou como primeiro estágio, em pacientes de alto risco, a fim de prepará-los para a cirurgia definitiva, tem sido adotado, por alguns grupos de cirurgiões, como técnica definitiva. Como é recente sua utilização como procedimento bariátrico definitivo, faltam estudos que avaliem sua efetividade. O presente estudo teve por objetivo avaliar o Sleeve gástrico, para o controle ou reversão do Diabetes mellitus tipo 2, no paciente obeso. Para tanto, foi realizada uma revisão sistemática. A busca na literatura resultou em 698 títulos e resumos. Após aplicação dos critérios de inclusão foram recuperados 96 textos completos e incluídos, na revisão sistemática, sete artigos com ensaios clínicos controlados. Foi possível realizar metanálise entre estudos comparando o Sleeve gástrico à derivação gástrica com Y de Roux e com a bandagem gástrica. Foram avaliados os desfechos glicemia de jejum e hemoglobina glicosilada. O resultado da metanálise foi favorável ao Sleeve gástrico, em comparação ao Y de Roux, para o desfecho redução pós-operatória da hemoglobina glicosilada. O Sleeve gástrico se apresenta como mais uma opção terapêutica para a obesidade e correção das co-morbidades associadas. Porém, os resultados são bastante preliminares, e ensaios clínicos controlados, de boa qualidade metodológica, são necessários para melhor avaliação. / Obesity and type 2 diabetes mellitus have become lately important public health problems. The increase of diabetes is closely related to the increase of obesity. The bariatric surgeries appeared in the last fifty years, and have become popular as an effective therapeutic option for reducing weight and for controlling or even reverting diabetes in obese patients. Among the available surgery techniques the sleeve gastrectomy, which was used as an inner part of the bilio-pancreatic diversion technique or as first step in high risk patients in order to prepare them for the final surgery, has been used by some surgeons groups as a definitive technique. As its use as a definitive bariatric procedure is quite recent, there are still not enough studies to evaluate its effectiveness. The present study aims at evaluating the sleeve gastrectomy as a technique for the control or reversion of the type 2 diabetes mellitus in obese patients. Therefore, a systematic review was done. A research in the existing literature presented 698 titles and summaries. After applying the inclusion criteria, 96 complete texts were considered; seven papers with controlled clinic tests were included in the systematic review. This allowed to perform a metanalysis between studies, comparing the sleeve gastrectomy with the Roux-en-Y gastric bypass and with the adjustable gastric band. The comparison was based on the evaluation of the outcome of fast glycemia and glucosided hemoglobin. The result of the metanalysis was favorable to the sleeve gastrectomy, in comparison to the Roux-en-Y gastric bypass, for the closing of the post-surgery reduction of the glycoside hemoglobin. The sleeve gastrectomy thus appears as another therapeutic option towards obesity and correction of the related co-morbidities. But the results are still at an early stage, and so controlled clinical tests with high quality methodology are required in order to achieve a better evaluation.

Obesity is the fifth leading cause of global deaths. The efficacy and safety of obesity treatment is still controversial. The objective of the thesis is to evaluate the efficacy and safety of bariatric surgery, through a systematic review of the current evidence and meta- analysis of important outcomes. Nineteen (19) randomized controlled trials (RCTs) with 1346 participants were included. Bariatric surgery resulted in greater weight loss when compared to non-surgical treatment. Weight loss was also associated with resolution and/or improvement of obesity related comorbidites such as diabetes, hypertension, hyperlipidemia, and sleep apnea. Weight loss and safety varied across the surgical procedures. Biliopancreatic diversion/duodenal switch had the greatest weight loss, followed by sleeve gastrectomy and Roux-en-Y gastric bypass, purely restrictive procedures such as vertical banded gastroplasty and adjustable gastric banding resulted in the least weight loss. Long term, high quality, and adequately powered trials are still needed to support the available evidence

Προσχεδιασμένη συγκριτική διπλή τυφλή μελέτη της αποτελεσματικότητας της επιμήκους γαστρεκτομής (LSG) και της μερικής γαστρικής παράκαμψης Roux-en-Y (LRYGB) σε ασθενείς με κλινικά σοβαρή παχυσαρκία (BMI 35-49,9) Η λαπαροσκοπική γαστρική παράκαμψη (LRYGB) αποτελεί στις μέρες μας το χρυσό κανόνα για τη χειρουργική αντιμετώπιση της κλινικά σοβαρής παχυσαρκίας. Η λαπαροσκοπική επιμήκης γαστρεκτομή (LSG) είναι μία σχετικώς νέα επέμβαση περιοριστικού τύπου η οποία τελευταία έχει αρχίσει να εφαρμόζεται ως μοναδική επέμβαση για την κλινικά σοβαρή παχυσαρκία. Η παρούσα προοπτική διπλή τυφλή μελέτη έχει σκοπό να διερευνήσει την ασφάλεια των παραπάνω επεμβάσεων καθώς και την αποτελεσματικότητα τους σε χρονικό ορίζοντα τριών χρόνων. Μέθοδος: Εξήντα ασθενείς με δείκτη σωματικής μάζας <50 Kg/m2 μετά από τυχαιοποίηση υπεβλήθησαν τριάντα σε LSG και τριάντα σε LRYGB. Οι ασθενείς παρακολουθήθηκαν μετεγχειρητικά για τρία χρόνια. Στο διάστημα αυτό καταγράφηκε η απώλεια βάρους, η πρώιμη και όψιμη νοσηρότητα και θνητότητα, η ίαση των συνοδών της παχυσαρκίας νόσων και η ανάπτυξη μικροθρεπτικών ανεπαρκειών μετά τους δύο τύπους χειρουργείων. Αποτελέσματα: Η θνητότητα ήταν μηδενική και στους δύο τύπους επεμβάσεων. Δεν καταγράφηκε σημαντική διαφορά στην πρώιμη (10% μετά από LRYGBP και 13.3% μετά από LSG, P>0.05) και όψιμη νοσηρότητα (10% σε κάθε ομάδα) μετά και τους δύο τύπους χειρουργείων. Η απώλεια βάρους ήταν στατιστικώς μεγαλύτερη μετά από LSG καθόλη τη διάρκεια της μελέτης. Τον τρίτο μετεγχειρητικό χρόνο η επί τις εκατό απώλεια του υπερβάλλοντος βάρους κυμαίνονταν στο 62.09% μετά από LRYGBP και στο 68.46% μετά από LSG (p=0.02). Δεν παρατηρήθηκε σημαντική διαφορά ως προς την ίαση των συνοδών της παχυσαρκίας νόσων, εκτός από τη δυσλιπιδαιμία η οποία βελτιώθηκε σε σημαντικότερο βαθμό μετά από LRYGB και την υπέρταση η οποία βελτιώθηκε σε σημαντικότερο βαθμό μετά από LSG. Ανεπάρκεια μικροθρεπτικών συστατικών παρατηρήθηκε σε ανάλογο βαθμό μετά τις δύο επεμβάσεις εκτός από την έλλειψη βιταμίνης Β12 η οποία παρατηρήθηκε σε μεγαλύτερο βαθμό μετά από LRYGB (P<0.001). Συμπεράσματα: Και οι δύο επεμβάσεις είναι ασφαλείς και αποτελεσματικές ως προς την απώλεια βάρους και την ίαση των συνοδών της παχυσαρκίας νόσων. Η LSG συνοδεύεται από λιγότερες μεταβολικές ανεπάρκειες και δεν απαιτεί τη χορήγηση συμπληρωμάτων εφ’ όρου ζωής. Η LSG φαίνεται ότι είναι μία υποσχόμενη επέμβαση για την κλινικά σοβαρή παχυσαρκία η οποία στα τρία χρόνια μετεγχειρητικής παρακολούθησης επιτυγχάνει μεγαλύτερη απώλεια βάρους από την LRYGB. / The efficacy of sleeve gastrectomy (LSG) and Roux en Y gastric bypass (LRYGB) in patients with morbid obesity (BMI 35-49,9). A comparative double-blind randomized trial Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently the gold standard bariatric procedure for the treatment of morbid obesity. Laparoscopic sleeve gastrectomy (LSG) is an innovative restrictive procedure which has been increasingly applied as a sole bariatric procedure. A randomized trial was conducted to evaluate perioperative safety (30-day) and 3-years results. Methods: Sixty patients with body mass index (BMI) ≤ 50 Kg/m2 were randomized to LRYGB or LSG. Patients were monitored for 3 years after operation and throughout the study period weight loss, early and late complications, improvement of obesity related comorbidities and nutritional deficiencies were compared between studied groups. Results: There was no death in either group and no significant difference in early (10% after LRYGBP and 13.3% after LSG, P>0.05) and late morbidity (10% in each group). Weight loss was significantly better after LSG throughout the study period. At 3 years %EWL reached 62.09% after LRYGBP and 68.46% after LSG (p=0.02). There was no significant difference in the overall improvement of comorbidities but dyslipidemia improved more after LRYGB, whereas hypertension resolved more after LSG. Nutritional deficiencies occurred at same rate in the two groups except to vitamin B12 deficiency which was more common after LRYGB (P<0.001). Conclusion: In conclusion, LSG and LRYGBP are equally safe and effective in the amelioration of comorbidities, while LSG is associated with fewer postoperative metabolic deficiencies, without the need of supplementation. Furthermore, LSG is a promising bariatric procedure, since it seems to be superior to LRYGB at 3 years follow up on weight reduction.

Η χολοπαγκρεατική εκτροπή αποτελεί την πιο αποτελεσματική μέθοδο της βαριατρικής χειρουργικής όσο αφορά την απώλεια του βάρους και την υποχώρηση του σακχαρώδους διαβήτη τύπου 2, συνοδεύεται όμως συχνά από σημαντική έλλειψη θρεπτικών συστατικών. Η επιμήκης γαστρεκτομή είναι μια σχετικά νέα επέμβαση, η οποία σύμφωνα με μελέτες προκαλεί σημαντικού βαθμού απώλεια βάρους και υποχώρηση του σακχαρώδους διαβήτη τύπου 2. Σκοπός: Η προοπτική εκτίμηση και σύγκριση της επίδρασης της χολοπαγκρεατικής εκτροπής μακρών ελίκων και της λαπαροσκοπικής επιμήκους γαστρεκτομής στην υποχώρηση του σακχαρώδους διαβήτη τύπου 2, της υπέρτασης και της δυσλιπιδαιμίας, καθώς επίσης και στα επίπεδα ινσουλίνης, γλυκαγόνης, γκρελίνης, PYY και GLP-1( σε νηστεία αλλά και μετά από τη λήψη γλυκόζης ) σε ασθενείς με κλινικά σοβαρή παχυσαρκία και σακχαρώδη διαβήτη τύπου2. Μέθοδος: Δώδεκα ασθενείς (ΔΜΣ 57.6±9.9 kg/m2) υποβλήθηκαν σε χολοπαγκρεατική εκτροπή μακρών ελίκων και δώδεκα (ΔΜΣ 43.7±2.1 kg/m2 ) σε λαπαροσκοπική επιμήκη γαστρεκτομή. Όλοι οι ασθενείς παρουσίαζαν σακχαρώδη διαβήτη τύπου 2 και μελετήθηκαν προεγχειρητικά και σε 1, 3 και 12 μήνες μετά το χειρουργείο. Σε όλους τους χρόνους υποβλήθηκαν σε από του στόματος δοκιμασία ανοχής γλυκόζης. Αποτελέσματα: Το σωματικό βάρος σημείωσε σημαντική και αναλόγου μεγέθους μείωση και στις δύο ομάδες (Ρ<0.001). Στους 12 μήνες η ποσοστιαία απώλεια του υπερβάλλοντος σωματικού βάρους ήταν παρόμοια στις δύο ομάδες (Ρ=0.8) και ο σακχαρώδης διαβήτης είχε υποχωρήσει σε όλους τους ασθενείς. Η γλυκόζη, η ινσουλίνη και η αντίσταση στη δράση της παρουσίαζαν σημαντική μείωση έπειτα και από τις δύο επεμβάσεις, όμως η ευαισθησία στην ινσουλίνη ενισχύθηκε περισσότερο έπειτα από τη χολοπαγκρεατική εκτροπή (Ρ=0.003). Η αρτηριακή πίεση, η ολική και η LDL χοληστερόλη μειώθηκαν σημαντικά έπειτα από τη χολοπαγκρεατική εκτροπή (Ρ<0.001), όχι όμως και μετά την επιμήκη γαστρεκτομή. Τα τριγλυκερίδια μειώθηκαν σημαντικά και στις δύο ομάδες, ενώ η HDL χοληστερόλη παρουσίασε σημαντική αύξηση μόνο μετά την επιμήκη γαστρεκτομή (Ρ<0.001). Τα επίπεδα γκρελίνης νηστείας δεν μεταβλήθηκαν σημαντικά μετά τη χολοπαγκρεατική εκτροπή (Ρ=0.2), ενώ σημείωσαν σημαντική μείωση μετά την επιμήκη γαστρεκτομή (Ρ<0.001). Η απόκριση των ΡΥΥ και GLP-1 ενισχύθηκε σημαντικά και στις δύο ομάδες ασθενών (Ρ=0.001). Συμπεράσματα: Η λαπαροσκοπική επιμήκης γαστρεκτομή οδήγησε σε αναλόγου βαθμού απώλεια σωματικού βάρους και υποχώρηση του σακχαρώδη διαβήτη τύπου 2 με τη χολοπαγκρεατική εκτροπή μακρών ελίκων. Η χολοπαγκρεατική εκτροπή όμως ήταν περισσότερο αποτελεσματική όσο αφορά τη βελτίωση της ευαισθησίας στην ινσουλίνη, της δυσλιπιδαιμίας και της αρτηριακής υπέρτασης. / Biliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss and remission of diabetes type 2 (DM2) but it is accompanied by nutrient deficiencies. Sleeve gastrectomy (SG) is a relatively new restrictive operation that has shown promising results concerning DM2 resolution and weight loss. Objective: To evaluate and compare prospectively the effects of BPD long limb (BPDLL) and SG on remission of DM2, hypertension and dyslipidemia and also on fasting, and glucose-stimulated insulin, glucose, glucagon, ghrelin, PYY and glucagon-like peptide-1 (GLP-1) levels in morbidly obese patients with DM2. Methods: Twelve patients (BMI 57.6±9.9 kg/m2) underwent BPDLL and 12 (BMI 43.7±2.1 kg/m2) underwent SG. All patients had DM2 and were evaluated before and 1, 3 and 12 months after surgery. Oral glucose tolerance test and blood sampling were carried out after an overnight fast and 30, 60 and 120 minutes after glucose ingestion. Results: Body weight decreased markedly in both groups (P<0.001); excess weight loss was similar in both groups at 12 months (P=0.08) and DM2 resolved in all patients. Glucose, insulin and insulin resistance decreased significantly after both procedures, but the BPDLL group had higher insulin sensitivity than the SG group at 1 year (P=0.003). Blood pressure, total and LDL cholesterol decreased markedly after BPDLL (P<0.001) but not after SG. Triglycerides decreased significantly after both operations but HDL increased significantly after SG only (p<0.001). Fasting ghrelin did not change significantly after BPDLL (P=0.2), but decreased markedly after SG (P<0.001). Fasting GLP-1 and PYY increased significantly after BPDLL only (P=0.01), however GLP-1 and PYY responses to glucose were significantly enhanced in both groups (P=0.001). Conclusion: SG results in weight loss and resolution of DM2 comparable to BPDLL, but BPDLL is more effective in terms of dyslipidemia resolution and blood pressure reduction.

A obesidade e o Diabetes mellitus tipo 2 se tornaram importantes problemas de saúde pública nos últimos anos. O aumento da prevalência do diabetes está intimamente relacionado ao aumento da prevalência da obesidade. As cirurgias bariátricas surgiram nos últimos cinqüenta anos e vêm se popularizando como uma opção terapêutica efetiva para a redução do peso e controle ou reversão do diabetes no paciente obeso. Dentre as técnicas cirúrgicas disponíveis, o Sleeve gástrico, que era utilizado como parte integrante da técnica de derivação bílio-pancreática ou como primeiro estágio, em pacientes de alto risco, a fim de prepará-los para a cirurgia definitiva, tem sido adotado, por alguns grupos de cirurgiões, como técnica definitiva. Como é recente sua utilização como procedimento bariátrico definitivo, faltam estudos que avaliem sua efetividade. O presente estudo teve por objetivo avaliar o Sleeve gástrico, para o controle ou reversão do Diabetes mellitus tipo 2, no paciente obeso. Para tanto, foi realizada uma revisão sistemática. A busca na literatura resultou em 698 títulos e resumos. Após aplicação dos critérios de inclusão foram recuperados 96 textos completos e incluídos, na revisão sistemática, sete artigos com ensaios clínicos controlados. Foi possível realizar metanálise entre estudos comparando o Sleeve gástrico à derivação gástrica com Y de Roux e com a bandagem gástrica. Foram avaliados os desfechos glicemia de jejum e hemoglobina glicosilada. O resultado da metanálise foi favorável ao Sleeve gástrico, em comparação ao Y de Roux, para o desfecho redução pós-operatória da hemoglobina glicosilada. O Sleeve gástrico se apresenta como mais uma opção terapêutica para a obesidade e correção das co-morbidades associadas. Porém, os resultados são bastante preliminares, e ensaios clínicos controlados, de boa qualidade metodológica, são necessários para melhor avaliação. / Obesity and type 2 diabetes mellitus have become lately important public health problems. The increase of diabetes is closely related to the increase of obesity. The bariatric surgeries appeared in the last fifty years, and have become popular as an effective therapeutic option for reducing weight and for controlling or even reverting diabetes in obese patients. Among the available surgery techniques the sleeve gastrectomy, which was used as an inner part of the bilio-pancreatic diversion technique or as first step in high risk patients in order to prepare them for the final surgery, has been used by some surgeons groups as a definitive technique. As its use as a definitive bariatric procedure is quite recent, there are still not enough studies to evaluate its effectiveness. The present study aims at evaluating the sleeve gastrectomy as a technique for the control or reversion of the type 2 diabetes mellitus in obese patients. Therefore, a systematic review was done. A research in the existing literature presented 698 titles and summaries. After applying the inclusion criteria, 96 complete texts were considered; seven papers with controlled clinic tests were included in the systematic review. This allowed to perform a metanalysis between studies, comparing the sleeve gastrectomy with the Roux-en-Y gastric bypass and with the adjustable gastric band. The comparison was based on the evaluation of the outcome of fast glycemia and glucosided hemoglobin. The result of the metanalysis was favorable to the sleeve gastrectomy, in comparison to the Roux-en-Y gastric bypass, for the closing of the post-surgery reduction of the glycoside hemoglobin. The sleeve gastrectomy thus appears as another therapeutic option towards obesity and correction of the related co-morbidities. But the results are still at an early stage, and so controlled clinical tests with high quality methodology are required in order to achieve a better evaluation.

NTRODUÇÃO: A maioria dos nomogramas para o câncer gástrico (CG) foi desenvolvida para prever a sobrevida global dos pacientes após ressecção curativa. O sistema de pontuação prognóstico (SPP) do Grupo Italiano de Pesquisa do Câncer Gástrico (GIRCG) foi projetado para prever o risco de recorrência após tratamento curativo baseado no estadiamento patológico do tumor e do tratamento realizado (linfadenectomia D1- D2/D3). Este estudo foi elaborado para avaliar a reprodutibilidade do SPP do GIRCG. PACIENTES E MÉTODO: Para validação do SPP preconizado pelo GIRCG, foram utilizados 185 pacientes operados no Serviço de Cirurgia de Estômago, Duodeno e Intestino Delgado do HCFMUSP, no período de janeiro de 2001 a dezembro de 2007, que preencheram os mesmo critérios utilizados pelo grupo italiano para construção e validação interna do SPP, ou seja, pacientes submetidos a cirurgias potencialmente curativas com ressecções R0, com linfadenectomia a D2 conforme preconizado pela Escola Japonesa. Os pacientes que apresentaram doença disseminada ou metástases a distância, mesmo sendo submetidos a ressecções paliativas, foram excluídos do estudo; assim como pacientes com menos de cinco anos de seguimento, pacientes que faleceram por complicações perioperatórias (até 30 dias) ou que, eventualmente, foram a óbito por outras causas não relacionadas ao CG. Tumores da transição esofagogástrica (TEG) e Linitis plastica também foram excluídos. O tempo mediano de seguimento foi de 77,8 meses (mínimo de 5,9 e máximo de 150,8) para todos os pacientes e de 102,5 meses (mínimo de 60,9 e máximo de 150,8) para os pacientes livres de doença. Foi utilizado modelo de regressão logística múltipla para comparar o SPP com o sistema de estadiamento TNM. RESULTADOS: A recorrência do CG ocorreu em 70 (37,8%) dos 185 pacientes. A média de idade foi de 59,7 anos (± 12,8; SE 0,94, amplitude de 22 a 88). O tempo mediano de recorrência foi de 22,2 meses (mínimo de 5,9 e máximo de 98,1). A pontuação média dos pacientes com recidiva e livres de doença foram, respectivamente, 68,2 (± 29,7 amplitude de 2,57 a 99,7) e 30,5 (± 29 amplitude de 3,6 a 97,7). A maioria dos pacientes obteve pontuações altas ou baixas, ou seja, situaram-se nos extremos da curva de distribuição da pontuação. Oito (4,3%) pacientes com pontuação maior que 90 não apresentaram recorrência e quatro (2,1%) pacientes com pontuação inferior a 10 apresentaram recidiva da doença. O SPP previu corretamente recorrência em 50 dos 70 pacientes (sensibilidade de 71,4% - IC 95% 0,61 a 0,82), enquanto a ausência de recorrência foi prevista em 88 dos 115 pacientes (especificidade de 75,6% - IC95% 0,69 a 0,84), sendo a acurácia global de 74,6% (IC95% 0,68 a 0,81). Em consonância com os resultados obtidos pelo GIRCG, apenas os valores do SPP provaram ser uma variável de previsão significante (P < 0,001), enquanto o estadio do tumor não mostrou a mesma significância (p=0,416). CONCLUSÃO: Este estudo validou o SPP do GIRCG que prevê recorrência após tratamento cirúrgico radical para CG. Este nomograma é simples, facilmente reproduzível e possui boa aplicabilidade clínica / BACKGROUND: Most nomograms for Gastric Cancer (GC) were developed to predict overall survival after curative resection. The Italian Research Group for Gastric Cancer (GIRCG) prognostic scoring system was designed to predict the risk of recurrence after curative treatment based on pathologic tumor stage and treatment performed (D1- D2/D3 lymphadenectomy). We carried out this study to externally validate the GIRCG\'s prognostic scoring system. PATIENTS AND METHODS: In order to validate the prognostic scoring system recommended by GIRCG, 185 patients operated at the Department of Surgery of Stomach, Duodenum and Small Intestine at HCFMUSP from January 2001 to December 2007 who met the same criteria used by the Italian Group for construction and internal validation have been used, that is, patients who underwent potentially curative surgery with R0 resection, with D2 lymphadenectomy as recommended by the Japanese School. Patients with disseminated disease or distant metastases, even if undergoing palliative resections were excluded from the study. As well as patients with less than five years of follow up, patients who died of perioperative complications (within 30 days) or who eventually died of other causes unrelated to the GC. Tumors of the esophagogastric junction and Linitis plastica were also excluded. The median follow-up period was 77,8 months (range 5,9 - 150,8) for all patients and 102,5 months (range 60,9 - 150,8) for patients free of disease. A multiple logistic regression model was used to compare the scoring system with TNM stage system. RESULTS: CG recurrence occurred in 70 (37.8%) of 185 patients. The mean age was 59.7 years (± 12.8; SE 0.94, range 22 to 88). The median time to recurrence was 22.2 months (range 5,9 - 98,1). The average values of the scores of patients with recurrence and disease-free were, respectively, 68.2 (± 29.7 range 3.77 to 99.7) and 30.5 (± 29.4 range 2,57 to 97.7). Most patients had high or low scores, ie, stood at the extremes of the range. Eight (4,3%) patients with score higher than 90 showed no recurrence and only four (2,1%) patients with score lower than 10 recurred. The prognostic scoring system correctly predicted recurrence in 50 of 70 patients (sensitivity71.4% - CI 95% 0.61 to 0.82), while the absence of recurrence was predicted in 88 of 115 patients (specificity of 75.6% - CI 95% 0.69 to 0.84%) with an overall accuracy of 74.6% (CI 67.8% to 80.3%). In consonance with the results obtained by GIRCG only score level proved to be a significant predictive variable (P < 0.001), while the stage of the tumor did not showed the same significance (P=0.416). CONCLUSION: This study has validated the GIRCG prognostic scoring system that predicts recurrence after radical surgical treatment for CG. This nomogram is simple, easily reproducible and has good clinical applicability

(EN) Obesity and type 2 diabetes mellitus (T2DM) are among metabolic disease with increasing incidence and prevalence. Last decade has been devoted to intensive research focused on pathophysiological mechanisms underlying development of these diseases. Besides environmental factors, lifestyle and amount and composition of food, adipose tissue is a key player in the pathogenesis of obesity and its metabolic complications including insulin resistance (IR) and T2DM. Primary aim of our work was to evaluate the role of recently discovered adipokine omentin and the role of mitochondrial dysfunction in subcutaneous adipose tissue (SCAT) and in peripheral monocytes (PM) in patients with obesity and T2DM with respect to the development of insulin resistance and diabetes. A total number of 118 subjects enrolled in the study were divided into three groups: patients with obesity and T2DM (T2DM group), obese non-diabetics (OB) and healthy lean subjects as a control group (KO). Study subjects underwent several types of interventions - 2 to 3 weeks of very-low calorie diet (VLCD, energy intake 600 kcal per day), regular physical activity program or bariatric surgery (laparoscopic sleeve gastrectomy, LSG). Results indicate that low serum omentin concentrations may contribute to development of obesity-associated...

Obesity is the fifth leading cause of global deaths. The efficacy and safety of obesity treatment is still controversial. The objective of the thesis is to evaluate the efficacy and safety of bariatric surgery, through a systematic review of the current evidence and meta- analysis of important outcomes. Nineteen (19) randomized controlled trials (RCTs) with 1346 participants were included. Bariatric surgery resulted in greater weight loss when compared to non-surgical treatment. Weight loss was also associated with resolution and/or improvement of obesity related comorbidites such as diabetes, hypertension, hyperlipidemia, and sleep apnea. Weight loss and safety varied across the surgical procedures. Biliopancreatic diversion/duodenal switch had the greatest weight loss, followed by sleeve gastrectomy and Roux-en-Y gastric bypass, purely restrictive procedures such as vertical banded gastroplasty and adjustable gastric banding resulted in the least weight loss. Long term, high quality, and adequately powered trials are still needed to support the available evidence

Bakgrund: Fetma är ett allvarligt folkhälsoproblem då fetma ökar risken att drabbas av följdsjukdomar, samt att patienter med fetma visat sig ha lägre genomsnittlig hälsorelaterad livskvalitet (HRQoL) jämfört med befolkningen i allmänhet. Syfte: med denna litteraturöversikt var att beskriva hälsorelaterad livskvalitet bland personer som genomgått fetmakirurgi. Metod: Litteraturöversikt baserad på 8 kvantitativa interventionsstudier med uppföljningar mellan 9 månader - 10 år efter genomförd behandling. Litteratursökning skedde i databaserna PubMed och Cinahl. Analys av studierna skedde genom att studierna sammanställdes baserat på redovisning av frågeformulär SF-36 för index fysisk och mental hälsa och dess åtta dimensioner. Resultat: Samtliga studier indikerar att den fysiska hälsan i genomsnitt ökar efter fetmakirurgi. Samtliga utom en studie indikerar att hälsoindex för mental hälsa i genomsnitt ökar efter fetmakirurgi. Studier som sträcker sig över flera uppföljningsperioder visar att den initiala ökningen av hälsoindex minskar med tiden och effekten är som högst 1–2 år efter fetmakirurgi. Konklusion: Resultaten pekar på att fetmakirurgi initialt leder till en förbättring av fysisk och mental HRQoL med en tydlig topp efter 1–2 år. Studier med högt deltagande och uppföljning över tid är för få för att dra slutsatser kring effekten av fetmakirurgi på HRQoL på längre sikt. Utbildning av vårdpersonal och uppföljningsprogram kan bidra till ökat uppföljningsdeltagande, och minska risken för bortfall till följd av brister i vårdpersonalens bemötande. / Background: Obesity is a serious public health problem as it increases the risk of secondary diseases. Patients with obesity have been shown to have lower average health-related quality of life (HRQoL) compared to the general population. Aim: of this literature review was to describe health-related quality of life among people who have undergone bariatric surgery. Methods: Literature review of eight quantitative intervention studies with follow-ups between 9 months to 10 years. Literature search took place in the databases PuBMed and Cinahl. Analysis of the studies was done by summarizing the studies based on the reported result of the SF-36 questionnaire for physical and mental health and its eight dimensions. Results: All studies indicate that physical health increases on average after bariatric surgery. All but one study indicate that the mental health index increases, on average, after bariatric surgery. Studies that extend over several follow-up periods show that the initial increase in mental health decreases over time and the effect is highest 1–2 years after bariatric surgery. Conclusion: The results indicate that bariatric surgery initially leads to an improvement in physical and mental HRQoL with a clear peak after 1–2 years. Studies with high participation and follow-up over time are too few to draw conclusions about the effect of bariatric surgery on HRQoL in the longer term. Training of healthcare professionals and follow-up programs can contribute to increased follow-up participation, and reduce the risk of non-response.