RESUMEN

Metabolic surgery has been studied in the last decades as an effective and safe treatment for type 2 diabetes (T2D), and randomized controlled trials generally found surgery superior when compared with medical treatment. In 2016, the DSS-II Joint Statement recognized the importance of metabolic surgery in the treatment of T2D and urged clinicians to discuss, recommend, or at least consider this procedure for their patients. Diabetes societies also cogitate metabolic surgery as an option for T2D patients in their guidelines. However, there are some differences in recommendations that could lead a careful reader to some confusion. This was potentialized in a recent document published by the same DSS-II group concerning prioritization for surgery after the COVID-19 pandemic, in which the criteria suggested for an expedited recommendation that is not exactly evidence-based, and collided substantially with several clinical guidelines worldwide, especially with regard to secondary prevention of cardiovascular disease. A more harmonious discussion and unified guidelines between clinicians and surgeons are needed in order to provide the same message for those who read different articles.

Asunto(s)

RESUMEN

Según la Organización Mundial de la Salud, la obesidad se define como una acumulación excesiva de grasa corporal (1), que tiene una estrecha relación con la aparición o complicación de enfermedades crónicas como la diabetes, enfermedades cardiovasculares, y el cáncer (2). En la actualidad, la obesidad es considerada como una pandemia a nivel mundial (3) que afecta a más de 650 millones de adultos, con una prevalencia de 13% para el 2016, y una tendencia al alza (2). En países con altas prevalencias de obesidad, como México, se ha estimado un costo de la obesidad equivalente al 0.5% del producto bruto interno, que constituye el 9% del gasto en salud, y un costo por mortalidad prematura asociada a obesidad de 1390 millones de dólares (3). Frente a esto se han priorizado las estrategias de prevención y manejo de la obesidad. Sin embargo, en ciertas personas con obesidad, los cambios en los estilos de vida y el tratamiento farmacológico no es suficiente para el manejo de esta condición, sobre todo en aquellos que presentan un estadio severo (4). Por lo cual se han propuesto alternativas de tratamiento para la obesidad como la cirugía bariátrica/metabólica. La cirugía bariátrica corresponde al conjunto de intervenciones quirúrgicas cuyo objetivo es la reducción de peso en pacientes con obesidad severa, mientras que la cirugía metabólica es el término que se aplica cuando el objetivo de la intervención es el control de la comorbilidad adyacente a la obesidad severa (5, 6). El Seguro Social de Salud (EsSalud) priorizó la realización de la presente guía de práctica clínica (GPC) para establecer lineamientos basados en evidencia para el manejo quirúrgico de la obesidad en adultos.

Asunto(s)

RESUMEN

Resumen: En los últimos años, la obesidad severa en adolescentes ha aumentado a nivel mundial y Chile no es la excepción a este fenómeno. Es conocido que esta condición aumenta exponencialmente los riesgos para la salud y se asocia a mortalidad prematura. Desde el año 2008, diversas guías de tratamiento de obesidad pediátrica han incluido a la cirugía bariátrica como una estrategia de tratamiento para adolescentes obesos severos seleccionados. Estos procedimientos han mostrado ser seguros y eficaces en adultos. Un cuerpo emergente de evidencia demuestra que, en centros especializados, en el corto y mediano plazo se obtendrían resultados similares en adolescentes. Sin embargo, en este grupo de pacientes, la cirugía bariátrica tiene implícitos otros riesgos inherentes a la etapa de desarrollo en que se encuentran, y los resultados y complicaciones especialmente de largo plazo en gran medida son aún desconocidos. Por lo anterior y para el logro de los resultados esperados, es muy importante que la selección de pacientes, la cirugía y el seguimiento, sean realizados por equipos multidisciplinarios calificados, en centros hospitalarios que cuenten con la infraestructura adecuada, siendo imprescin dible la adherencia de por vida al seguimiento médico y nutricional. El objetivo de este documento es presentar la postura de la Rama de Nutrición de la Sociedad Chilena de Pediatría (SOCHIPE) frente a las diversas aristas a considerar para la adecuada indicación de estos procedimientos en adolescentes obesos severos.

Abstract: In recent years, severe obesity in adolescents has been rising worldwide, and Chile is no exception to this phenomenon. This condition exponentially increases health risks and it is associated with prema ture mortality. Since 2008, several guidelines on pediatric obesity treatment have included bariatric surgery as a treatment strategy for certain severely obese adolescents. These procedures have proven to be safe and efficient in adults. Recent evidence shows that, when done in specialized centers, the re sults would be similar in adolescents in the short and medium term. Nonetheless, in this group of pa tients, bariatric surgery has risks related to their stage of development, and data on long-term results and complications are still lacking. Therefore, to achieve the expected results, the patient selection, surgery, and follow-up must be carried out by qualified multidisciplinary teams, in hospitals centers that have the appropriate infrastructure, It is essential for the patients a life-long adherence to medi cal and nutritional monitoring. The objective of this document is to present the position statement of the Nutrition Branch of the Chilean Society of Pediatrics on the different issues to be considered for the adequate indication of these procedures in severely obese adolescents.

Asunto(s)

RESUMEN

Prioritizing surgical procedures aims at facilitating patient's access according to the clinical needs, maximizing access equity, and minimizing the damage from delayed access. Previous categorization of elective bariatric surgery have been adapted to define an objective prioritizing system that reflects those principles for bariatric and metabolic operations. Given the factors that contribute to the morbidity and mortality of obese and type 2 diabetes patients, surgical prioritization should be based on clinical risk stratification. For patients with type 2 diabetes, we suggest that the operation may be prioritized for those with a higher risk of morbidity and mortality in a relatively short term. Likewise, it is necessary to guide the surgical team regarding the necessary care both in the pre, per and postoperative periods of bariatric and metabolic surgery. These recommendations aim to reduce the risk of in-hospital contamination of the surgical team among health professionals and between health professionals and patients. In summary, these recommendations have been shaped after a thorough analysis of the available literature and are extremely important to mitigate the harm related to the clinical complications of obesity and its comorbidities while keeping healthcare providers' and patients' safety.

Asunto(s)

Asunto(s)

RESUMEN

In recent years, severe obesity in adolescents has been rising worldwide, and Chile is no exception to this phenomenon. This condition exponentially increases health risks and it is associated with prema ture mortality. Since 2008, several guidelines on pediatric obesity treatment have included bariatric surgery as a treatment strategy for certain severely obese adolescents. These procedures have proven to be safe and efficient in adults. Recent evidence shows that, when done in specialized centers, the re sults would be similar in adolescents in the short and medium term. Nonetheless, in this group of pa tients, bariatric surgery has risks related to their stage of development, and data on long-term results and complications are still lacking. Therefore, to achieve the expected results, the patient selection, surgery, and follow-up must be carried out by qualified multidisciplinary teams, in hospitals centers that have the appropriate infrastructure, It is essential for the patients a life-long adherence to medi cal and nutritional monitoring. The objective of this document is to present the position statement of the Nutrition Branch of the Chilean Society of Pediatrics on the different issues to be considered for the adequate indication of these procedures in severely obese adolescents.

Asunto(s)

RESUMEN

ABSTRACT Prioritizing surgical procedures aims at facilitating patient's access according to the clinical needs, maximizing access equity, and minimizing the damage from delayed access. Previous categorization of elective bariatric surgery have been adapted to define an objective prioritizing system that reflects those principles for bariatric and metabolic operations. Given the factors that contribute to the morbidity and mortality of obese and type 2 diabetes patients, surgical prioritization should be based on clinical risk stratification. For patients with type 2 diabetes, we suggest that the operation may be prioritized for those with a higher risk of morbidity and mortality in a relatively short term. Likewise, it is necessary to guide the surgical team regarding the necessary care both in the pre, per and postoperative periods of bariatric and metabolic surgery. These recommendations aim to reduce the risk of in-hospital contamination of the surgical team among health professionals and between health professionals and patients. In summary, these recommendations have been shaped after a thorough analysis of the available literature and are extremely important to mitigate the harm related to the clinical complications of obesity and its comorbidities while keeping healthcare providers' and patients' safety.

RESUMO A priorização de qualquer operação eletiva visa facilitar o acesso do paciente de acordo com as necessidades clínicas, maximizando a equidade de acesso e minimizando os danos causados pelo atraso. As categorias de operações eletivas foram adaptadas para definir sistema de priorização objetiva que reflete esses princípios para operações bariátricas e metabólicas. Em razão dos fatores que contribuem para a morbidade e mortalidade da obesidade e do diabetes tipo 2, a priorização cirúrgica deve ser baseada na estratificação de risco clínico. Para pacientes com diabetes tipo 2, sugerimos que a operação possa ser priorizada para aqueles com maior risco de morbidade e mortalidade, em prazo relativamente curto. Da mesma forma, é necessário orientar a equipe cirúrgica quanto aos cuidados necessários tanto no pré, per e pós-operatório da cirurgia bariátrica e metabólica. As recomendações visam reduzir o risco de contágio hospitalar da equipe cirúrgica tanto entre profissionais de saúde quanto entre profissionais de saúde e pacientes. Em resumo, estas recomendações foram moldadas após análise minuciosa da literatura disponível e são extremamente importantes para mitigar os danos das complicações clínicas, sensíveis a doença obesidade e comorbidades, mantendo a segurança dos profissionais de saúde e dos pacientes.

Asunto(s)

RESUMEN

PURPOSE: Propose the systematization of nutritional care in the endoscopic treatment of obesity. METHOD: This is a bibliographical review, since the initial proposal was a systematic review. This method became unfeasible due to the inexistence of studies that address this theme. Thus, a bibliographic survey was carried out, considering the endoscopic treatment as a restrictive treatment, as well as the information referring to case reports and multicentric studies. RESULTS: Nutrition participation involves nutritional assessment and diagnosis, dietary planning pertinent to the adequate evolution of food consistency, as well as the use of food supplements compatible with the Gastric Sleeve due to food restriction. The Bariatric Plate Model (BPM) can be useful in the nutritional education of the patient after gastric endosuture, associated with water consumption and the performance of scheduled physical exercise, as well as periodic monitoring with the multiprofessional team. CONCLUSIONS: Specialized nutritional care is necessary, through a protocol of nutritional assistance defined after gastric endosuture, in order to achieve long-term weight loss and maintenance goals. The BPM can be an excellent form of nutritional education, observing protein intake as a macronutrient base.

Asunto(s)

RESUMEN

Non-alcoholic fatty liver disease (NAFLD) is characterized by hepatic accumulation of lipid in patients who do not consume alcohol in amounts generally considered harmful to the liver. NAFLD is becoming a major liver disease in Eastern countries and it is related to insulin resistance and metabolic syndrome. Treatment has focused on improving insulin sensitivity, protecting the liver from oxidative stress, decreasing obesity and improving diabetes mellitus, dyslipidemia, hepatic inflammation and fibrosis. Lifestyle modification involving diet and enhanced physical activity associated with the treatment of underlying metabolic are the main stain in the current management of NAFLD. Insulin-sensitizing agents and antioxidants, especially thiazolidinediones and vitamin E, seem to be the most promising pharmacologic treatment for non-alcoholic steatohepatitis, but further long-term multicenter studies to assess safety are recommended.

Asunto(s)

RESUMEN

SUMMARY Non-alcoholic fatty liver disease (NAFLD) is characterized by hepatic accumulation of lipid in patients who do not consume alcohol in amounts generally considered harmful to the liver. NAFLD is becoming a major liver disease in Eastern countries and it is related to insulin resistance and metabolic syndrome. Treatment has focused on improving insulin sensitivity, protecting the liver from oxidative stress, decreasing obesity and improving diabetes mellitus, dyslipidemia, hepatic inflammation and fibrosis. Lifestyle modification involving diet and enhanced physical activity associated with the treatment of underlying metabolic are the main stain in the current management of NAFLD. Insulin-sensitizing agents and antioxidants, especially thiazolidinediones and vitamin E, seem to be the most promising pharmacologic treatment for non-alcoholic steatohepatitis, but further long-term multicenter studies to assess safety are recommended.

RESUMO A doença hepática gordurosa não alcoólica (DHGNA) é caracterizada pela deposição significativa de lipídios nos hepatócitos de pacientes que não apresentam história de ingestão alcoólica significativa. É a doença do fígado mais prevalente em populações ocidentais e existe forte associação da DHGNA com a resistência à insulina (RI) e com a síndrome metabólica. O tratamento objetiva reduzir a RI, o estresse oxidativo, a obesidade, a dislipidemia bem como a inflamação e a fibrose hepáticas. O tratamento atual baseia-se principalmente em modificações do estilo de vida, que incluem dieta e prática regular de exercícios físicos, associadas ao tratamento de todos os componentes da síndrome metabólica. Quanto ao tratamento medicamentoso da esteato-hepatite não alcoólica, os agentes insulino-sensibilizantes e os antioxidantes parecem os mais promissores, especialmente as tiazolidinodionas e a vitamina E, mas faltam estudos multicêntricos avaliando sua segurança a longo prazo.

Asunto(s)

RESUMEN

There is mounting evidence, derived from mechanistic studies, RCTs, and other high-quality studies that there are weight loss independent antidiabetic effects of gastrointestinal surgery. Additionally, there appears to be no relation between the positive metabolic outcomes to baseline BMI. The outdated US National Health Institutes guidelines from 1991 were centered on BMI only criterion and often misleading. The Second Diabetes Surgery Summit held in collaboration with leading diabetes organizations and endorsed by a large group of international Professional Societies developed guidelines that defined eligibility based on the severity and degree of T2D medical control while referring to obesity as a qualifier and not the sole criterion. That is the first time that guidelines are provided to put metabolic surgery into the T2D treatment algorithms.

Asunto(s)

Asunto(s)

RESUMEN

Currently there is little doubt that the body mass index ( BMI) is not an appropriate tool to grant access to metabolic surgery, especially in type 2 diabetics (T2D). Several studies are pointing towards other parameters that should go along with BMI in the treatment decision tree in non morbidly obese diabetics. Insulin resistance, fat distribution among others are considered good tools to predict favorable outcomes in medically non controlled diabetics if sent to surgery. The bottom line in good T2D control is to decrease cardiovascular mortality. Using adequate tools to screen patients to the appropriate surgical treatment may favour patients that are not under control after lifestyle changes and best medical treatment, thus decreasing longterm cardiovascular mortality secondary to type 2 diabetes.

En la actualidad, existe poca duda de que el índice de masa corporal (IMC) no es una herramienta apropiada para garantizar el acceso a la cirugía metabólica, especialmente en los diabéticos tipo 2 (DT2). Diversos estudios apuntan a que otros parámetros deberían considerarse junto con el IMC en el árbol de decisión terapéutica de los diabéticos sin obesidad mórbida. La resistencia a la insulina y la distribución de la grasa, entre otros, se consideran buenas herramientas para predecir unos resultados favorables en pacientes diabéticos no controlados médicamente si se les deriva para cirugía. La idea de base en la DT2 bien controlada es disminuir la mortalidad cardiovascular. Utilizando las herramientas adecuadas para cribar a los pacientes para el tratamiento quirúrgico apropiado puede favorecer a los pacientes que no se controlan después de los cambios en el estilo de vida y el mejor tratamiento médico, disminuyendo así la mortalidad cardiovascular a largo plazo secundaria a la diabetes tipo 2.

Asunto(s)

RESUMEN

BACKGROUND: There is a controversy about the best way to report results after bariatric surgery. Several indices have been proposed over the years such as percentage of total weight loss (%TWL), percentage of excess weight loss (%EWL), and percentage of excess body mass index loss (%EBMIL). More recently, it has been suggested to individualize the body mass index (BMI) goal to be achieved by the patients (predicted BMI-PBMI). The objective was to assess the reproducibility of this PBMI in our service. METHODS: In this retrospective study, we assessed the %TWL, %EWL, %EBMIL (with expected BMI of 25 kg/m2), and %EBMIL (with PBMI) over 4 years of observation in two groups of patients: BMI <50 kg/m2 and BMI ≥50 kg/m2. RESULTS: The medical records of 403 patients were studied. From 18 to 42 months after surgery, %TWL was higher in the superobese group, whereas %EWL was similar for the two groups. %EBMIL was higher in less obese patients up to 24 months and similar thereafter. In contrast, %EBMIL with PBMI was greater in the superobese group, although it never reached the 100% goal. CONCLUSIONS: We conclude that %EBMIL results according to PBMI were not reproducible in our institution. There is a need to elaborate a new easy-to-obtain and reproducible index.

Asunto(s)

RESUMEN

We analyzed the Mexican legal framework, identifying the vectors that characterize quality and control in gastrointestinal surgery. Quality is contemplated in the health protection rights determined according to the Mexican Constitution, established in the general health law and included as a specific goal in the actual National Development Plan and Health Sector Plan. Quality control implies planning, verification and application of corrective measures. Mexico has implemented several quality strategies such as certification of hospitals and regulatory agreements by the General Salubrity Council, creation of the National Health Quality Committee, generation of Clinical Practice Guidelines and the Certification of Medical Specialties, among others. Quality control in gastrointestinal surgery must begin at the time of medical education and continue during professional activities of surgeons, encouraging multidisciplinary teamwork, knowledge, abilities, attitudes, values and skills that promote homogeneous, safe and quality health services for the Mexican population.

Asunto(s)

Asunto(s)

RESUMEN

The International Diabetes Federation Taskforce on Epidemiology and Prevention of Diabetes convened a consensus working group of diabetologists, endocrinologists, surgeons and public health experts to review the appropriate role of surgery and other gastrointestinal interventions in the treatment and prevention of Type 2 diabetes. The specific goals were: to develop practical recommendations for clinicians on patient selection; to identify barriers to surgical access and suggest interventions for health policy changes that ensure equitable access to surgery when indicated; and to identify priorities for research. Bariatric surgery can significantly improve glycaemic control in severely obese patients with Type 2 diabetes. It is an effective, safe and cost-effective therapy for obese Type 2 diabetes. Surgery can be considered an appropriate treatment for people with Type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially in the presence of other major co-morbidities. The procedures must be performed within accepted guidelines and require appropriate multidisciplinary assessment for the procedure, comprehensive patient education and ongoing care, as well as safe and standardized surgical procedures. National guidelines for bariatric surgery need to be developed for people with Type 2 diabetes and a BMI of 35 kg/m² or more.

Asunto(s)

Asunto(s)

RESUMEN

The International Diabetes Federation Taskforce on Epidemiology and Prevention of Diabetes convened a consensus working group of diabetologists, endocrinologists, surgeons and public health experts to review the appropriate role of surgery and other gastrointestinal interventions in the treatment and prevention of Type 2 diabetes. The specific goals were: to develop practical recommendations for clinicians on patient selection; to identify barriers to surgical access and suggest interventions for health policy changes that ensure equitable access to surgery when indicated; and to identify priorities for research. Bariatric surgery can significantly improve glycaemic control in severely obese patients with Type 2 diabetes. It is an effective, safe and cost-effective therapy for obese Type 2 diabetes. Surgery can be considered an appropriate treatment for people with Type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially in the presence of other major co-morbidities. The procedures must be performed within accepted guidelines and require appropriate multidisciplinary assessment for the procedure, comprehensive patient education and ongoing care, as well as safe and standardized surgical procedures. National guidelines for bariatric surgery need to be developed for people with Type 2 diabetes and a BMI of 35 kg/m² or more.

A Força-Tarefa para Epidemiologia e Prevenção da International Diabetes Federation reuniu um grupo de trabalho com diabetologistas, endocrinologistas, cirurgiões e especialistas em saúde pública para revisar o papel correto da cirurgia e outras intervenções gastrointestinais no tratamento e prevenção do diabetes tipo 2 em obesos. Os objetivos específicos foram: desenvolver recomendações práticas para a seleção dos pacientes; identificar barreiras ao acesso à cirurgia e sugerir intervenções para mudanças das políticas de saúde que garantam equidade de acesso à cirurgia, quando indicada, e identificar prioridades para a pesquisa. A cirurgia bariátrica pode gerar uma melhora significativa no controle glicêmico em pacientes com obesidade grave e diabetes tipo 2. Ela é um tratamento efetivo, seguro e de bom custo-benefício para pacientes obesos com diabetes tipo 2. A cirurgia pode ser considerada um tratamento apropriado para pessoas com diabetes tipo 2 e obesidade que não consigam atingir as metas recomendadas de tratamento com terapias medicamentosas, especialmente na presença de outras comorbidades maiores. Os procedimentos devem ser executados por meio de diretrizes aceitas e requerem uma avaliação multidisciplinar, um processo amplo de educação do paciente e cuidados contínuos, além de procedimentos cirúrgicos seguros e padronizados. As diretrizes nacionais para a cirurgia bariátrica devem ser desenvolvidas para pacientes com diabetes tipo 2 e IMC de 35 kg/m² ou mais.

Asunto(s)

RESUMEN

Surgical procedures for treatment of morbid obesity have increased in recent years exponentially. It states that these procedures are not under the current paradigm that underlies surgical practice. The widespread use of some of these procedures has not been preceded by pilot studies and the vast majority of relevant publications have methodological shortcomings. This has led to not have optimal results on efficacy and safety. Until they have clearly the efficacy and safety of these procedures should be practiced strictly according to the mandates of ethics in clinical research.

Asunto(s)