MARCO AURELIO SANTO
Projetos de Pesquisa
Unidades Organizacionais
Departamento de Gastroenterologia, Faculdade de Medicina - Docente
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
LIM/35 - Laboratório de Nutrição e Cirurgia Metabólica do Aparelho Digestivo, Hospital das Clínicas, Faculdade de Medicina
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
LIM/35 - Laboratório de Nutrição e Cirurgia Metabólica do Aparelho Digestivo, Hospital das Clínicas, Faculdade de Medicina
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- Early glycemic control and incretin improvement after gastric bypass: the role of oral and gastrostomy route(2019) FERNANDES, Gustavo; SANTO, Marco Aurelio; CRESPO, Andrea de Fatima Crispino Bastos; BIANCARDI, Gabriel Barbosa; MOTA, Filippe Camarotto; ANTONANGELO, Leila; CLEVA, Roberto deBackground: Patients with obesity have a suppressed incretin effect and a consequent imbalance of glycemic homeostasis. Several studies have shown improved type 2 diabetes after Roux-en-Y gastric bypass (RYGB). The mechanisms of early action are linked to caloric restriction, improvement of insulin resistance, pancreatic beta cell function, and the incretin effect of glycogen-like protein 1 and gastric inhibitory polypeptide, but reported data are conflicting. Objective: The objective of this study was to evaluate glycemic metabolism, including the oral glucose tolerance test and enterohormonal profile in the early postoperative period in severely obese patients who underwent RYGB with gastrostomy, comparing the preoperative supply of a standard bolus of nutrient against the postoperative administration through an oral and a gastrostomy route. Setting: Clinics Hospital of University of Sao Paulo, Brazil. Methods: Eleven patients with obesity and diabetes underwent RYGB with a gastrostomy performed in the excluded gastric remnant. Patients were given preoperative assessments of glycemic and enterohormone profiles and an oral glucose tolerance test; these were compared with early postoperative assessments after oral and gastrostomy route administrations. Results: The mean preoperative body mass index of the group was 44.1 +/- 6.6 kg/m(2), mean fasting blood glucose of 194.5 +/- 62.4 mg/dL, and glycated hemoglobin 8.7 +/- 1.6%. In 77.7% of the patients, there was normalization of the glycemic curve in the early postoperative period as evaluated by the oral glucose tolerance test. Significant decreases in glycemia, insulinemia, and homeostatic model assessment-insulin resistance were also observed, regardless of the route of administration. There was significant increase in glycogen-like protein 1 by the postoperative oral route and reduction of gastric inhibitory polypeptide in both routes. Ghrelin did not change. Conclusion: Glycemia and peripheral insulin resistance reductions were observed in early postoperative RYGB, independent of the oral or gastrostomy route. Incretin improvement, mediated by glycogen-like protein 1 increased was observed only in the postoperative oral route, while GIP reduced for both routes.
- Comment on: Sleeve gastrectomy versus Roux-En-Y gastric bypass in patients aged >= 65 years: a comparison of short-term outcomes(2021) DANTAS, Anna Carolina Batista; PAJECKI, Denis; SANTO, Marco Aurelio
- The Edmonton Obesity Staging System: assessing a potential tool to improve the management of obesity surgery in the Brazilian public health services(2020) OGASSAVARA, Nicolas Chiu; DIAS, Joao Gabriel Magalhaes; PAJECKI, Denis; SIQUEIRA, Jose de Oliveira; SANTO, Marco Aurelio; TESS, Beatriz HelenaBackground: Limited access to publicly funded, insurance-covered, and self-paid obesity surgery is a reality worldwide. Waiting lists for procedures are usually based on chronologic criteria and body mass index (BMI)-defined obesity categorization. Obesity classification systems assess overall health and have been proposed as an alternative. Objective: To investigate the correlation between BMI-based classification and the Edmonton Obesity Staging System (EOSS) to support current evidence that the assessment of the clinical severity of obesity could be a helpful tool to maximize access to surgery. Setting: University hospital, Brazil. Methods: Retrospective analysis of all 2011 to 2014 adult patients who underwent obesity surgery under the public health system. Data on sex, age, presurgical BMI, and co-morbidities were extracted from hospital records. Spearman correlation coefficients were used to assess the strength and direction of the relationship between BMI classification and EOSS. Results: Of 565 patients, 79% were female, mean age 44.1 +/- 10.9 years and mean BMI 46.9 +/- 6.2 kg/m(2). The most common EOSS stage was 2 (86.5%), followed by stages 3 (8.5%) and 1 (4.9%). There was no correlation between the severity of obesity measured by BMI and EOSS (p = - .030, P = .475). Older patients had higher Edmonton scores (p = .308, P < .001). No difference was observed regarding sex. Conclusions: No correlation was found between EOSS and BMI and between these and sex. Age correlated with both obesity indicators. EOSS was reproducible in Brazilian surgical patients and may be an important tool from a health services perspective contributing to the more efficient use of limited resources for obesity surgery.
- Pharmacokinetics of oral levonorgestrel and ethinylestradiol in women after Roux-en-Y gastric bypass surgery(2021) BRITO, Claudia Moreira de; MELO, Maria Edna de; MANCINI, Marcio C.; SANTO, Marco Aurelio; CERCATO, CintiaBackground: Most patients undergoing Roux-en-Y gastric bypass (RYGB) are women in reproductive age. It is not known if bariatric surgery affects the pharmacokinetics of oral contraceptives. Objectives: The primary objective was to evaluate ethinylestradiol (EE) and levonorgestrel (LNG) absorption in women undergoing RYGB, compared with nonoperated controls matched by age and body mass index (BMI). A secondary objective was to assess whether the time since surgery and BMI in the postoperative period influenced the absorption parameters. Setting: University hospital, Brazil. Methods: This study was designed to compare the maximum plasma concentration (C-max), the time to the peak plasma level (T-max), the area under the curve (AUC(0-8) and AUC(0-infinity)) after a single dose of a combined oral contraceptive with 0.03 mg EE and 0.15 mg LNG among 20 women after RYGB and 20 controls. Blood samples were obtained for 8 hours. Results: The mean LNG AUC(0-8) and LNG AUC(0-infinity) were higher in RYGB group (P = .048 and P = .004, respectively). We found a positive correlation for LNG AUC(0-8) (P = .045) and AUC(0-infinity) (P = .004) and the time since surgery, and we found a negative correlation for LNG Cmax (P = .018), AUC(0-8) (P = .003), and AUC(0-infinity) (P = .001) and BMI. Conclusion: No significant differences were found in oral EE pharmacokinetics. The operated group showed higher mean LNG AUC(0-8) and AUC(0-infinity) but it was not considered clinically significant. The present study suggests that RYGB may not affect EE and LNG absorption.
- Bariatric surgery in the elderly: a randomized prospective study comparing safety of sleeve gastrectomy and Roux-en-Y gastric bypass (BASE Trial)(2020) PAJECKI, Denis; DANTAS, Anna Carolina Batista; KANAJI, Ana Lumi; OLIVEIRA, Daniel Riccioppo Cerqueira Ferreira de; CLEVA, Roberto de; SANTO, Marco AurelioBackground: The aging population along with the obesity epidemic has increased the number of older patients undergoing bariatric surgery. Nevertheless, there is still conflicting data regarding surgical safety in this population. Objectives: The aim of this study was to compare the surgical morbidity of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) for older patients. Setting: University hospital, Sao Paulo, Brazil. Methods: We performed a prospective randomized clinical trial from September 2017 to May 2019. Obese patients aged >= 65 years were randomized to LSG or LRYGB. Data collection included demographic information, body mass index (BMI), and co-morbidities. We assessed readmission, postoperative complications, and mortality. Complications were scored according to Clavien-Dindo classification. Results: A total of 36 patients, with a BMI between 35.5 and 52.8 kg/m(2) were randomized to either LSG (18 patients) or LRYGB (18 patients). The overall complication rate was similar between LSG and LRYGB (3 versus 7, P=.13). Severe complication was more prevalent in LRYGB patients but had no statistically significant difference (0 versus 3, P=.07). Each group had 1 readmission and there was no mortality in 90-day follow-up. Conclusions: Morbidity and mortality rates of bariatric surgery are low in elderly obese patients. Despite not statistically significant, LSG had a lower rate of severe complications compared with LRYGBin this population setting.
- Use of noninvasive markers to predict advanced fibrosis/cirrhosis in severe obesity(2016) CLEVA, Roberto de; DUARTE, Livio Fiolo; CRENITTE, Milton Roberto Furst; OLIVEIRA, Claudia Pinto Marques de; PAJECKI, Denis; SANTO, Marco AurelioBackground: Nonalcoholic steatohepatitis is observed in 25%-55% of patients with severe obesity and in 2%-12% with bridging fibrosis or cirrhosis. There is currently no noninvasive test for the diagnosis of severe liver fibrosis before bariatric surgery. Objectives: To determine the best noninvasive test for predicting advanced liver disease in patients with severe obesity. Setting: University tertiary care hospital, Brazil. Methods: A cross-sectional retrospective study was conducted with 699 patients with severe obesity undergoing bariatric surgery: 568 without a biopsy (nonbiopsy cohort) and 131 patients who had undergone an intraoperative liver biopsy. The tissues were subjected to histologic diagnosis (Brunt criteria) and classified as advanced fibrosis (stages 3 and 4) or no significant fibrosis (absence of nonalcoholic steatohepatitis and stages 1 or 2). The following predictive indices of cirrhosis were calculated in all patients: aspartate aminotransferase/alanine aminotransferase ratio (AAR), age platelet (AP) index, aminotransferase-to-platelet ratio index (APRI), cirrhosis discriminant score (CDS), and hepatitis C antiviral long-term treatment against cirrhosis (HALT-C). The cutoff values, sensitivity, specificity, and areas under the receiver operating characteristic curves (AUROCs) were calculated for patients with biopsies. Results: The AUROC of the AAR, AP, APRI, CDS, and HALT-C model for predicting advanced fibrosis or cirrhosis were, respectively, .522, .88, .99, .905, and .921. The calculated cutoff values, sensitivity, and specificity, respectively, were as follows: AAR: .94, .7, .45; AP 5, .7, .93; APRI .44, 1.0, .97; CDS 6, .7, .97; and HALT-C: .76, 1.0, .77. Conclusion: APRI index was the best predictor of advanced liver disease in patients with severe obesity. (Surg Obes Relat Dis 2016;12:862-867.) (C) 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.
- Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery(2016) MOURA, Eduardo G. H. de; ORSO, Ivan R. B.; AURELIO, Eduardo F.; MOURA, Eduardo T. H. de; MOURA, Diogo T. H. de; SANTO, Marco A.Introduction: Roux-en-Y gastric bypass is a commonly used technique of bariatric surgery. One of the most important complications is gastrojejunal anastomotic stricture. Endoscopic balloon dilation appears to be well tolerated and effective, but well-designed randomized, controlled trials have not yet been conducted. Objective: Identify factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. Setting: Gastrointestinal endoscopy service, university hospital, Brazil. Methods: The records of 64 patients with anastomotic stricture submitted to endoscopic dilation with hydrostatic balloon dilation were reviewed. Information was collected on gastric pouch length, anastomosis diameter before dilation, number of dilation sessions, balloon diameter at each session, anastomosis diameter after the last dilation session, presence of postsurgical complications, endoscopic complications, and outcome of dilation. Comparisons were made among postsurgical and endoscopic complications; number of dilations, balloon diameter; anastomosis diameter before dilation; and dilation outcome. Results: Success of dilation treatment was 95%. Perforation was positively and significantly associated with the number of dilation sessions (P =.03). Highly significant associations were found between ischemic segment and perforation (P <.001) and between ischemic segment and bleeding (P =.047). Ischemic segment (P =.02) and fistula (P =.032) were also associated with dilation failure. Conclusion: Ischemic segment and fistula were found to be important risk factors for balloon dilation failure. The greater the number of dilation sessions, the greater the number of endoscopic complications.
- Resting metabolic rate and weight loss after bariatric surgery(2018) CLEVA, Roberto de; MOTA, Filippe Camarotto; GADDUCCI, Alexandre Vieira; CARDIA, Lilian; GREVE, Julia Maria D'Andrea; SANTO, Marco AurelioBackground: There is an increased interest in understanding how variation in body composition (BC) and energy expenditure is related to successful weight loss after surgery. It has been suggested that low resting metabolic rate (RMR) could be associated with poor weight loss. Objectives: To determine the relation among changes in BC, RMR, and weight loss after bariatric surgery. Setting: University tertiary care hospital, Brazil. Methods: A cohort of 45 patients submitted to bariatric surgery was prospectively studied. BC was evaluated by bioelectrical impedance analysis and RMR by indirect calorimetry before and 6 months after surgery. The RMR value was adjusted per kilogram of weight (RMR/kg). The patients were divided in 4 groups, based on patterns of change in the RMR/kg after surgery. The RMR/kg could decrease (group 1), remain stable (group 2), have a small increase (group 3), or have a major increase (group 4). Results: A significant relation between fat-free mass and RMR for both pre- (P <.01) and postoperative periods (P <.01) was observed. Excess weight loss had a significantly correlation only with post-RMR/kg (P <.01). The pattern of change in RMR/kg was strongly correlated with weight loss, considering an excess weight loss >50% a successful weight loss: No patients achieved success in group 1; 61% of patients did in group 2; 80% di in group 3; and all patients in group 4 had successful weight loss. Conclusions: We demonstrate a clearly correlation between the postoperative RMR and weight loss. The increase in RMR/kg after surgery is a major factor related to a satisfactory excess weight loss after surgery.