Mapping of ghrelin gene expression and cell distribution in the stomach of morbidly obese patients--a possible guide for efficient sleeve gastrectomy construction. Obes Surg. 2012;22:617-622. [PMID: 22231739 DOI: 10.1007/s11695-011-0585-9]

Analysis of the Immunohistochemical Expression of Ghrelin in the Gastric Mucosa and Correlation with Weight Loss After Sleeve Gastrectomy

INTRODUCTION

Sleeve gastrectomy is one of the main techniques used to treat severe obesity. The study of the immunohistochemical expression of ghrelin in the gastric mucosa has already been related to weight loss and can be a promising method to predict the surgical outcome.

PURPOSE

To analyze the immunohistochemical expression of ghrelin in the gastric mucosa and its correlation with weight loss, comorbidities, and inflammatory changes after sleeve gastrectomy.

METHODS

Thirty-five patients submitted to sleeve gastrectomy were evaluated, 29 of whom were female (82.9%), with a mean age of 35.2 years and an average body mass index of 38.1 kg/m². Endoscopic samples of the mucosa were collected, whose ghrelin expression was evaluated in a semi-quantitative way through the stained antibody area. These data were correlated with weight loss at 3, 6, and 12 months and with the control of comorbidities, and inflammatory alterations.

RESULTS

The average total weight loss (TWL%) was 17.7, 26.4, and 32.1%, respectively, at 3, 6, and 12 months. A negative correlation was found between the immunohistochemical expression of ghrelin in the endoscopic biopsy of the fundus and weight loss at 3 (s =  - 0.536; p = 0.001) and 6 months (s =  - 0.339; p = 0.047).

CONCLUSION

The immunohistochemical expression of ghrelin in the mucosa of the gastric fundus was negatively correlated with early weight loss after sleeve gastrectomy.

Histopathologic findings on removed stomach after sleeve gastrectomy. Do they influence the outcome?

Little is known about the role of chronic gastritis on weight loss after laparoscopic sleeve gastrectomy (LSG). This study aims to investigate the relationship between histopathologic findings of gastric specimens, excess weight loss (% EWL), and excess BMI loss (% EBL) at 6 and 12 months follow up after LSG. We retrospectively reviewed the clinical records of 95 patients who had undergone LSG between January 2017 and December 2019. Based on the histopathological findings of gastric resection specimens, patients were divided into those with chronic gastritis (CG) and those without chronic gastritis (NoCG) and compared for their % EWL and % EBL at 6 and 12 months. The mean BMI was 44.74 kg/m² in the CG group and 44.14 kg/m² in the NoCG group. At 6 months follow up, the CG group had a mean % EWL of 45.7 and % EBL of 40.5, while NoCG had a mean % EWL of 51.1 and % EBL of 46.7. After 1-year follow-up, the CG group had a mean % EWL of 53.1 and a % EBL of 44.8, while the NoCG group had a % EWL of 54.1 and % EBL of 44. This observational study does not support the hypothesis that the occurrence of chronic gastritis can affect postoperative % EWL and % EBL.

Endoscopic Procedures for Weight Loss

PURPOSE OF REVIEW

To provide updated evidence on the endoscopic procedures for weight loss and to bring personal insights on the future of endobariatrics.

RECENT FINDINGS

Intragastric balloons promote significant improvement in histologic and radiologic aspects of non-alcoholic steatohepatitis; the endoscopic sleeve gastroplasty is effective up to 5 years and seems particularly beneficial to patients with BMI≤40kg/m²; distal POSE is a promising technique but still lacks adequate clinical data; aspiration therapy triggers remarkable weight loss, but data on weight trends after removal of the device are still lacking; the satiety-inducing device, the sleeveballoon, the gastric mucosal devitalization, and the endoscopic magnetic partial jejunal diversion are promising procedures still under study and refinements. Several therapeutic options are necessary during obesity's natural history. Therefore, endobariatrics should act in harmony with lifestyle interventions, diet modification, psychological treatment, pharmacotherapy, and bariatric surgery seeking the best outcome in the long term.

Intragastric satiety-inducing device reduces food intake and suppresses body weight gain in a rodent model

BACKGROUND

An intragastric satiety-inducing device (ISD) (Full Sense Device; Baker, Foote, Kemmeter, Walburn, LLC, Grand Rapids, MI) is a novel weight-loss device, which may induce satiety by applying continuous pressure on the gastric cardia. This study investigated the effect of the ISD on food intake and body weight gain in a rodent model.

METHODS

Thirty-two male Sprague-Dawley rats (weight, 250-300 g) were randomly divided into four groups of eight individuals. Single-disk (SD) and double-disk (DD) group animals underwent peroral placement of a single- or double-disk ISD, respectively, under fluoroscopic guidance. The ISD comprised a 4 mm × 1.5 cm nitinol stent placed in the lower esophagus and one (single-disk) or two (double-disk) 2.5-cm-diameter star-shaped nitinol disks placed in the gastric fundus. Esophageal stent (ES) and sham-operated (SO) group animals underwent peroral placement of the ES part of the ISD and a sham operation, respectively.

RESULTS

Food intake was significantly different among the four groups over the 4-week study period (P < 0.001); food intake was significantly lower in the SD and DD groups than in the SO group (P = 0.016 and P = 0.002, respectively) but was not significantly different between the SD and DD groups (P > 0.999) and between the ES and SO groups (P = 0.677). Body weight was significantly different among the four groups by the end of the study period (P < 0.001); body weight was significantly lower in the DD group than in the SD, ES, and SO groups (P = 0.010, P < 0.001, and P < 0.001, respectively) and in the SD group than in the SO group (P = 0.001), but it was not significantly different between the ES and SO groups (P = 0.344).

CONCLUSION

ISD reduced food intake and suppressed body weight gain in a rodent model.

Weight loss with or without intragastric balloon causes divergent effects on ghrelin cell expression

Objective

The mechanism of action of intragastric balloons in the treatment of obesity is not fully understood. One of the hypotheses is that balloons might have an effect on the fundus, the area of ghrelin production.

Methods

Participants were randomized to a 13‐week period of sham or balloon treatment followed by a 13‐week period of balloon therapy in everyone. Blood samples for ghrelin levels were taken in the fasting state and after a breakfast at the start, after 13 and 26 weeks. Biopsies for ghrelin cell immunohistochemistry were taken from the fundus at endoscopy.

Results

Seven participants entered the balloon–balloon (BB) group and 11 the sham–balloon (SB) group. Despite a considerable weight loss, a median −17.9 kg (interquartile ranges −23.8 to −0.5) in the BB group and −18.3 kg (−22.7 to −14.7) in the SB group, fasting ghrelin and meal‐induced ghrelin response did not change. In the SB group, the number of ghrelin cells increased significantly (p 0.001) from 110.6 (83.6–118.9) to 160.2 (128.5–223.0) while on sham treatment and returned to initial levels, 116.3 (91.7–146.9) (p 0.001), when they received their first balloon. No significant changes in ghrelin cell numbers were observed in the BB group.

Conclusion

In participants without a balloon, weight loss induced an increase in ghrelin cell numbers in the fundus, which was annulled by the subsequent placement of a balloon. The effect of a balloon might be explained by effects on ghrelin cell numbers or ghrelin cell activity.

Gastric ghrelin cells in obese patients are hyperactive

BACKGROUND/OBJECTIVES

Distribution and activity of ghrelin cells in the stomach of obese subjects are controversial.

SUBJECTS/METHODS

We examined samples from stomachs removed by sleeve gastrectomy in 49 obese subjects (normoglycemic, hyperglycemic and diabetic) and quantified the density of ghrelin/chromogranin endocrine cells by immunohistochemistry. Data were compared with those from 13 lean subjects evaluated by gastroscopy. In 44 cases (11 controls and 33 obese patients) a gene expression analysis of ghrelin and its activating enzyme ghrelin O-acyl transferase (GOAT) was performed. In 21 cases (4 controls and 17 obese patients) the protein levels of unacylated and acylated-ghrelin were measured by ELISA tests. In 18 cases (4 controls and 14 obese patients) the morphology of ghrelin-producing cells was evaluated by electron microscopy.

RESULTS

The obese group, either considered as total population or divided into subgroups, did not show any significant difference in ghrelin cell density when compared with control subjects. Inter-glandular smooth muscle fibres were increased in obese patients. In line with a positive trend of the desacylated form found by ELISA, Ghrelin and GOAT mRNA expression in obese patients was significantly increased. The unique ghrelin cell ultrastructure was maintained in all obese groups. In the hyperglycemic obese patients, the higher ghrelin expression matched with ultrastructural signs of endocrine hyperactivity, including expanded rough endoplasmic reticulum and reduced density, size and electron-density of endocrine granules. A positive correlation between ghrelin gene expression and glycemic values, body mass index and GOAT was also found. All obese patients with type 2 diabetes recovered from diabetes at follow-up after 5 months with a 16.5% of weight loss.

CONCLUSIONS

Given the known inhibitory role on insulin secretion of ghrelin, these results suggest a possible role for gastric ghrelin overproduction in the complex architecture that takes part in the pathogenesis of type 2 diabetes.

Effect of Sleeve Gastrectomy on Ghrelin, GLP-1, PYY, and GIP Gut Hormones: A Systematic Review and Meta-analysis

OBJECTIVE

To perform a structured systematic review and meta-analysis to evaluate changes in ghrelin, glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and gastric inhibitory peptide (GIP) gut hormone levels in patients after sleeve gastrectomy.

BACKGROUND

Despite sleeve gastrectomy becoming the most common surgical weight loss procedure, weight loss mechanisms remain less clear.

METHODS

Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed through April 1, 2019, in accordance with PRISMA and MOOSE guidelines. Randomized controlled trials and prospective observational studies evaluating pre and post-procedure hormones fasting ghrelin, postprandial GLP-1, postprandial PYY, and fasting GIP levels were included. Hedge g with random-effects models were used to determine pooled effect size and corresponding 95% confidence intervals (CIs).

RESULTS

A total of 28 studies (n = 653; 29.56% male) were included. Mean age was 42.00 ± 5.48 years, with average follow-up of 11.70 ± 11.38 months. Pre-procedure body mass index (BMI) was 46.01 ± 4.07 kg/m with a postsleeve gastrectomy BMI of 34.07 ± 3.73 kg/m, representing total body weight loss of 25.13 ± 4.44% and excess weight loss of 57.48 ± 9.64% (P < 0.001). Ghrelin decreased (Hedge g -1.486, 95% CI -1.884 to -1.089, I = 91.95%), whereas GLP-1 and PYY increased post-procedure (Hedge g 1.095, 95% CI 0.509 to 1.642, I = 84.38%; and Hedge g 1.396, 95% CI 0.781 to 2.011, I = 84.02%, respectively). GIP did not significantly change (Hedge g -0.213, 95% CI -1.019 to 0.592, I = 79.65%).

CONCLUSIONS

Fasting ghrelin levels decreased, whereas postprandial GLP-1 and PYY increased after sleeve gastrectomy. Fasting GIP levels remained unchanged. Future studies are needed to assess the role of these gut hormones and relationship to weight loss and metabolic outcomes.

Correlation Between the Number of Ghrelin-Secreting Cells in the Gastric Fundus and Excess Weight Loss after Sleeve Gastrectomy

BACKGROUND

Weight loss after laparoscopic sleeve gastrectomy (LSG) has been mainly attributed to the restriction of gastric volume; however; other factors may contribute to weight loss after LSG. This study aimed to investigate the correlation between the number of ghrelin-secreting cells in the gastric fundus and excess weight loss (EWL) at 12 months after LSG.

METHODS

The surface area of the gastric fundus was measured postoperatively in square centimeter. Histopathologic examination of the gastric fundus was made to estimate the number of ghrelin-secreting cells per square centimeter then was multiplied by the surface area of the fundus to calculate the total number of ghrelin-secreting cells in the fundus. The number of ghrelin-secreting cells was correlated with EWL and BMI at 12 months postoperatively.

RESULTS

The present study included 39 patients of a mean age of 33.7 years. The mean %EWL at 12 months was 59.7 ± 12.7. The mean total number of ghrelin-producing cells in the gastric fundus was 26,228.4 ± 16,995.3. The total number of ghrelin-secreting cells had a weak positive correlation with BMI at 12 months (r = 0.2891, p = 0.07), and weak negative correlation with %EWL (r = - 0.1592, p = 0.33).

CONCLUSION

There was a weak correlation between the total number of ghrelin-producing cells in the gastric fundus and plasma ghrelin levels with EWL after LSG.

Quantitative and Topographic Analysis by Immunohistochemical Expression of Ghrelin Gastric Cells in Patients with Morbid Obesity

PURPOSE

The cellular distribution of ghrelin positive cells is not well defined. The aim of the study is to quantify and determine the distribution of ghrelin cells in gastric mucosa in patients with morbid obesity and relate this finding to gender, comorbidities, gastritis, and plasmatic levels of acyl and desacylghrelin before and after laparoscopic sleeve gastrectomy.

PATIENT AND METHODS

We performed a study on 61 patients with BMI≥50 kg/m² operated by laparoscopic sleeve gastrectomy. Three gastric regions were analyzed by histopathology and immunohistology. Blood sample was taken before surgery, and at 6 and 12 months post-surgery, to study the plasma levels of ghrelin isoforms.

RESULTS

Ghrelin cells are present in all regions of the gastric mucosa, with a greater number in the body and the fundus. Difference was found in the antrum between male and female patients (p=0.018). Patients with arterial hypertension also showed a lower level of cells in antrum (p<0.05). Acylghrelin levels after surgery were significantly lower (32.83+5.6 pg/mL to 10.09+11.8 pg/mL, p<0.05). Values of desacylghrelin tended to decrease but no significant variation was observed (207.4+39.3 pg/mL to 188.84+52.3 pg/mL).

CONCLUSION

Our patients show ghrelin cells in all areas of the stomach. Gender, comorbidities, and gastritis are determinant on gastric ghrelin-producing cells distribution.

Bariatric Arterial Embolization: Effect of Microsphere Size on the Suppression of Fundal Ghrelin Expression and Weight Change in a Swine Model

Purpose To determine whether microsphere size effects ghrelin expression and weight gain after selective bariatric arterial embolization (BAE) in swine. Materials and Methods BAE was performed in 10 swine by using smaller (100-300 μm; n = 5) or larger (300-500 μm; n = 5) calibrated microspheres into gastric arteries. Nine control pigs underwent a sham procedure. Weight and fasting plasma ghrelin levels were measured at baseline and weekly for 16 weeks. Ghrelin-expressing cells (GECs) in the stomach were assessed by using immunohistochemical staining and analyzed by using the Wilcoxon rank-sum test. Results In pigs treated with smaller microspheres, mean weight gain at 16 weeks (106.9% ± 15.0) was less than in control pigs (131.9% ± 11.6) (P < .001). Mean GEC density was lower in the gastric fundus (14.8 ± 6.3 vs 25.0 ± 6.9, P < .001) and body (27.5 ± 12.3 vs 37.9 ± 11.8, P = .004) but was not significantly different in the gastric antrum (28.2 ± 16.3 vs 24.3 ± 11.6, P = .84) and duodenum (9.2 ± 3.8 vs 8.7 ± 2.9, P = .66) versus in control pigs. BAE with larger microspheres failed to suppress weight gain or GECs in any stomach part compared with results in control swine. Plasma ghrelin levels were similar between BAE pigs and control pigs, regardless of microsphere size. Week 1 endoscopic evaluation for gastric ulcers revealed none in control pigs, five ulcers in five pigs embolized by using smaller microspheres, and three ulcers in five pigs embolized by using larger microspheres. Conclusion In bariatric arterial embolization, smaller microspheres rather than larger microspheres showed greater weight gain suppression and fundal ghrelin expression with more gastric ulceration in a swine model. © RSNA, 2018.

Intestinal peptide changes after bariatric and minimally invasive surgery: Relation to diabetes remission

Bariatric surgery is very effective in achieving and maintaining weight loss but it is also associated with improvement of obesity metabolic complications, primarily type 2 diabetes (T2D). Remission of T2D or at least a net improvement of glycemic control persists for at least 5 years. The bypass of duodenum and of the first portion of the jejunum up to the Treitz ligament as in Roux-en-Y Gastric Bypass (RYGB), or the bypass of the duodenum, the entire jejunum and the first tract of the ileum, such as in Bilio-Pancreatic Diversion (BPD), achieve different results on insulin sensitivity. Insulin resistance is the major driver of T2D manifesting long before insulin secretion failure. In fact, T2D development can be prevented by treatment with insulin sensitizing agents. Interestingly, RYGB improves hepatic insulin sensitivity while BPD ameliorates whole-body insulin sensitivity. Two major theories have been advocated to explain the early remission of T2D following RYGB or BPD before a meaningful weight loss takes place, the foregut and the hindgut hypotheses. The former holds that the bypass of the proximal intestine, i.e. duodenum and jejunum, prevents the secretion of signals - including nervous transmitters and hormones - promoting insulin resistance, the latter instead states that the delivery of nutrients directly into the ileum stimulates the secretion of hormones improving glucose disposal. The most studied candidate is Glucagon Like Peptide 1 (GLP1). However, while there is unambiguous evidence that GLP-1 stimulates insulin secretion, its direct action in lowering insulin resistance, independently of the effect on weight loss secondary to its satiety action, is utterly controversial. In this review we examine the effects on T2D and gastrointestinal peptide secretion produced by different types of metabolic surgery and by minimally invasive endoscopic surgery, whose utilization for the treatment of obesity and T2D is gaining wider interest and acceptance.

Intestinal Adaptations after Bariatric Surgery: Consequences on Glucose Homeostasis

The gastrointestinal (GI) tract can play a direct role in glucose homeostasis by modulating the digestion and absorption of carbohydrates and by producing the incretin hormones. In recent years, numerous studies have focused on intestinal adaptation following bariatric surgeries. Changes in the number of incretin (glucagon-like peptide 1 and glucose-dependent insulinotropic polypeptide) producing cells have been reported, which could result in the modified hormonal response seen after surgery. In addition, the rate of absorption and the intestinal regions exposed to sugars may affect the time course of appearance of glucose in the blood. This review gives new insights into the direct role of the GI tract in the metabolic outcomes of bariatric surgery, in the context of glucose homeostasis.

Comparison of Weight Loss, Ghrelin, and Leptin Hormones After Ligation of Left Gastric Artery and Sleeve Gastrectomy in a Rat Model

Background

Ligation of the left gastric artery (LLGA), which supplies the fundus of the stomach, may reduce the appetite hormone ghrelin, resulting in weight control. The aim of this study was to compare LLGA and sleeve gastrectomy (SG) in terms of postoperative outcomes in a rat model.

Material/Methods

Fifteen male Wistar albino rats, weighing >350 grams (range 350–525 grams), were enrolled in LLGA (N=5), SG (N=5), and control (N=5) groups. Blood samples were drawn preoperatively and also during the first and fourth week postoperatively to assay ghrelin and leptin hormone levels. Body weight was measured in each group.

Results

The maximum reduction in ghrelin level (41.5%) was found in the LLGA group. Considerable% total weight loss (TWL) (mean 24.1%) was observed in the SG group, and slight%TWL was noted in the control and LLGA groups (means of 0.1% and 2.1%, respectively). There was no significant difference in mean percent weight change between the LLGA and the SG groups (p=0.08). Blood sample analysis revealed no statistically significant changes in ghrelin or leptin levels between the groups (p=0.9 and p=0.3, respectively).

Conclusions

We present evidence that LLGA causes the same reduction in ghrelin hormone levels as SG at 4 weeks after surgery in a rat model. However, LLGA did not cause the same%TWL as SG. The mechanism of weight loss in SG is most likely due to restriction and to the effects of the procedure, rather than due to neurohormonal changes.

Efficacy of laparoscopic sleeve gastrectomy for the treatment of obesity in a non-Western society

PURPOSE

The objective of this study was to analyze the mid-term outcomes of sleeve gastrectomy in a cohort of obese patients.

METHODS

We analyzed the outcomes of 159 adult patients who had laparoscopic sleeve gastrectomy between January 2011 and January 2015 in our center. Data collected included patient demographics, presence of comorbid diseases, preoperative body mass index, percent excess weight loss, resolution of comorbid diseases, morbidity and in-hospital mortality.

RESULTS

We achieved a 24th month percent excess weight loss of 75.1 ± 10.5. Remission of diabetes mellitus, hypertension, hyperlipidemia and obstructive sleep apnea syndrome after sleeve gastrectomy was as high as 84, 63.9, 75.8 and 93 %, respectively, in different studies. Our results in diabetes mellitus, hypertension and hyperlipidemia are comparable with other data on the improvement of comorbidites after sleeve gastrectomy. We found less improvement in obstructive sleep apnea syndrome in our cohort when compared to other reports.

CONCLUSIONS

Sleeve gastrectomy is an efficient, durable technique for the treatment of obesity and associated comorbidities in all body mass index subgroups of obese population. For better outcomes, strategies for proper education and certification are needed.

Bariatric Left Gastric Artery Embolization for the Treatment of Obesity: A Review of Gut Hormone Involvement in Energy Homeostasis

OBJECTIVE

The global population is becoming more overweight and obese, leading to increases in associated morbidity and mortality rates. Advances in catheter-directed embolotherapy offer the potential for the interventional radiologist to make a contribution to weight loss. Left gastric artery embolization reduces the supply of blood to the gastric fundus and decreases serum levels of ghrelin. Early evidence suggests that this alteration in gut hormone balance leads to changes in energy homeostasis and weight reduction. The pathophysiologic findings and current evidence associated with the use of left gastric artery embolization are reviewed.

CONCLUSION

The prevalence of obesity continues to increase at an alarming rate, and, thus far, advances in medical management have been relatively ineffective in slowing this trend. Lifestyle modifications such as diet and exercise are effective initially, but most patients regain the weight in the long term. Bariatric surgery is the most effective strategy for achieving long-term weight loss; however, as with all surgical procedures, it has potential complications.

Impact of sleeve gastrectomy volumes on weight loss results: a prospective study

BACKGROUND

Causes of weight loss failure after sleeve gastrectomy (SG) are still controversial. The impact of the size of the sleeve continues to be debated.

OBJECTIVE

The aim of our study was to determine the impact of sleeve volumes assessed at 3 months using gastric computed tomography (CT) on weight loss at 18 months.

SETTING

University Hospital, France.

METHODS

Sixty-seven obese patients eligible for SG were prospectively evaluated. Sleeve volumes were assessed postsurgery using 3-dimensional gastric CT with gas at 3 months and weight loss outcomes recorded up to 18 months. The population was divided into 2 groups: the first tertile (n = 22) with the smallest gastric volume was defined as the "small sleeve" group (SSG) and the rest of the population (n = 45) was defined as the "without small sleeve" group (WSSG).

RESULTS

No patients were lost to follow-up. In the SSG, overall gastric volume was 133±7 mL versus 264±11 mL for the WSSG (P<.0001). Percentage excess body mass index loss (%EBMIL) during the first postoperative 18 months was significantly greater in the SSG compared with the WSSG (P = .04). Although the volume of the gastric tube was not correlated with weight loss (r =-.04, P = .78), there was a negative linear correlation between the volume of the antrum and the %EBMIL at 18 months (r =-.39, P = .005). A narrow gastric tube was also associated with a high digestive intolerance and reflux.

CONCLUSION

Our data suggest that performing the sleeve with a not-too-small bougie size and a radical antrectomy could improve weight loss and digestive tolerance.

Laparoscopic sleeve gastrectomy: More than a restrictive bariatric surgery procedure?

Sleeve gastrectomy (SG) is a restrictive bariatric surgery technique that was first used as part of restrictive horizontal gastrectomy in the original Scopinaro type biliopancreatic diversion. Its good results as a single technique have led to a rise in its use, and it is currently the second most performed technique worldwide. SG achieves clearly better results than other restrictive techniques and is comparable in some aspects to the Roux-en-Y gastric bypass, the current gold standard in bariatric surgery. These benefits have been associated with different pathophysiologic mechanisms unrelated to weight loss such as increased gastric emptying and intestinal transit, and activation of hormonal mechanisms such as increased GLP-1 hormone and decreased ghrelin. The aim of this review was to highlight the salient aspects of SG regarding its historical evolution, pathophysiologic mechanisms, main results, clinical applications and perioperative complications.

Gastric Supply Manipulation to Modulate Ghrelin Production and Enhance Vascularization to the Cardia

Introduction. Selective embolization of the left-gastric artery (LGA) reduces levels of ghrelin and achieves significant short-term weight loss. However, embolization of the LGA would prevent the performance of bariatric procedures because the high-risk leakage area (gastroesophageal junction [GEJ]) would be devascularized. Aim. To assess an alternative vascular approach to the modulation of ghrelin levels and generate a blood flow manipulation, consequently increasing the vascular supply to the GEJ. Materials and methods. A total of 6 pigs underwent a laparoscopic clipping of the left gastroepiploic artery. Preoperative and postoperative CT angiographies were performed. Ghrelin levels were assessed perioperatively and then once per week for 3 weeks. Reactive oxygen species (ROS; expressed as ROS/mg of dry weight [DW]), mitochondria respiratory rate, and capillary lactates were assessed before and 1 hour after clipping (T0 and T1) and after 3 weeks of survival (T2), on seromuscular biopsies. A celiac trunk angiography was performed at 3 weeks. Results. Mean (±standard deviation) ghrelin levels were significantly reduced 1 hour after clipping (1902 ± 307.8 pg/mL vs 1084 ± 680.0; P = .04) and at 3 weeks (954.5 ± 473.2 pg/mL; P = .01). Mean ROS levels were statistically significantly decreased at the cardia at T2 when compared with T0 (0.018 ± 0.006 mg/DW vs 0.02957 ± 0.0096 mg/DW; P = .01) and T1 (0.0376 ± 0.008mg/DW; P = .007). Capillary lactates were significantly decreased after 3 weeks, and the mitochondria respiratory rate remained constant over time at the cardia and pylorus, showing significant regional differences. Conclusions. Manipulation of the gastric flow targeting the gastroepiploic arcade induces ghrelin reduction. An endovascular approach is currently under evaluation.

The role of bariatric surgery in the treatment of diabetes

The obesity epidemic contributes to approximately 44% of the world's type 2 diabetes burden. Bariatric surgery is an effective treatment for type 2 diabetes mellitus in patients with morbid obesity as it improves glycaemia, blood pressure, lipids and inflammation. This review describes the evidence supporting the addition of bariatric surgery to the treatment algorithms used by diabetologists. We emphasize the need to view bariatric surgery as an adjuvant therapy which should not be used instead of but rather together with best medical therapy.

The impact of laparoscopic sleeve gastrectomy on plasma ghrelin levels: a systematic review

Within the last decade, several authors have proposed laparoscopic sleeve gastrectomy (LSG) as a potential definitive treatment for morbid obesity. While initially perceived as being a solely restrictive procedure, it is now theorized to have additional hormonal effects (primarily the reduction of circulating levels of plasma ghrelin). However, there is limited supporting evidence for this claim. Therefore, the purpose of our study is to conduct a systematic review of the literature to clarify the effects of LSG on modulation of postoperative ghrelin concentrations. A comprehensive literature search for published or unpublished studies of sleeve gastrectomy (SG) and ghrelin written in English prior to February 2013 was performed using Pubmed, EMBASE, the Cochrane database, and Scopus. Gray literature was also searched through Google. Inclusion criteria for searches were: randomized controlled trials, non-randomized clinical trials, retrospective and prospective cohort studies, or case series. Seven studies were deemed suitable for analysis. The mean patient age was 43 ± 8.8 years and female percentage was 74.4 ± 15.3 %. The mean initial BMI was 46.2 ± 7.8 and mean follow-up time was 9.5 ± 15 months. The mean postoperative BMI was 37.3 ± 5.8 over the same follow-up period. Pooled mean preoperative ghrelin levels were 698.4 ± 312.4 pg/ml and postoperative levels were 414.1 ± 226.3 pg/ml (P < 0.0001). Pooled analysis of ghrelin levels at 3, 6, and 12 months showed a significant reduction in circulating levels. Our systematic review shows that LSG has a significant effect on ghrelin levels, leading to considerable reduction in circulation levels following surgery. Further research and standardization is necessary to clearly establish a causative relationship between LSG and reduction of circulating ghrelin levels.