Surgical treatment of obesity

Rerouting cardiovascular management following gastric bypass surgery: Dose optimization of carvedilol using population-based analysis

AIMS

A population-based pharmacokinetic (PK) modeling approach (PopPK) was used to investigate the impact of Roux-en-Y gastric bypass (RYGB) on the PK of (R)- and (S)-carvedilol. We aimed to optimize carvedilol dosing for these patients utilizing a pharmacokinetic/pharmacodynamic (PK/PD) link model.

METHODS

PopPK models were developed utilizing data from 52 subjects, including nonobese, obese, and post- RYGB patients who received rac- carvedilol orally. Covariate analysis included anthropometric and laboratory data, history of RYGB surgery, CYP2D6 and CYP3A4 in vivo activity, and relative intestinal abundance of major drug- metabolizing enzymes and transporters. A direct effect inhibitory Emax pharmacodynamic model was linked to the PK model of (S)- carvedilol to simulate the changes in exercise- induced heart rate.

RESULTS

A 2-compartmental model with linear elimination and parallel first-order absorptions best described (S)-carvedilol PK. RYGB led to a twofold reduction in relative oral bioavailability compared to nonoperated subjects, along with delayed absorption of both enantiomers. The intestinal ABCC2 mRNA expression increases the time to reach the maximum plasma concentration. The reduced exposure (AUC) of (S)-carvedilol post-RYGB corresponded to a 33% decrease in the predicted area under the effect curve (AUEC) for the 24-hour β-blocker response. Simulation results suggested that a 50-mg daily dose in post-RYGB patients achieved comparable AUC and AUEC to 25-mg dose in nonoperated subjects.

CONCLUSION

Integrated PK/PD modeling indicated that standard dosage regimens for nonoperated subjects do not provide equivalent β-blocking activity in RYGB patients. This study highlights the importance of personalized dosing strategies to attain desired therapeutic outcomes in this patient cohort.

Impact of obesity and roux-en-Y gastric bypass on the pharmacokinetics of (R)- and (S)-omeprazole and intragastric pH

This study employed physiologically-based pharmacokinetic-pharmacodynamics (PBPK/PD) modeling to predict the effect of obesity and gastric bypass surgery on the pharmacokinetics and intragastric pH following omeprazole treatment. The simulated plasma concentrations closely matched the observed data from non-obese, morbidly obese, and post-gastric bypass populations. Obesity significantly reduces CYP3A4 and CYP2C19 activities, as reflected by the metabolic ratio [omeprazole sulphone]/[omeprazole] and [5-hydroxy-omeprazole]/[omeprazole]. The morbidly obese model accounted for the down-regulation of CYP2C19 and CYP3A4 to recapitulate the observed data. Sensitivity analysis showed that intestinal CYP3A4, gastric pH, small intestine bypass, and the delay in bile release do not have a major influence on omeprazole exposure. Hepatic CYP3A4 had a significant impact on the AUC of (S)-omeprazole, while hepatic CYP2C19 affected both (R)- and (S)-omeprazole AUC. After gastric bypass surgery, the activity of CYP3A4 and CYP2C19 is restored. The PBPK model was linked to a mechanism-based PD model to assess the effect of omeprazole on intragastric pH. Following 40 mg omeprazole, the mean intragastric pH was 4.3, 4.6, and 6.6 in non-obese, obese, and post-gastric bypass populations, and the daily time with pH >4 was 14.7, 16.4, and 24 h. Our PBPK/PD approach provides a comprehensive understating of the impact of obesity and weight loss on CYP3A4 and CYP2C19 activity and omeprazole pharmacokinetics. Given that simulated intragastric pH is relatively high in post-RYGB patients, irrespective of the dose of omeprazole, additional clinical outcomes are imperative to assess the effect of proton pump inhibitor in preventing marginal ulcers in this population.

Which nutritional prognosis is better? comparison of the three most commonly performed bariatric surgeries: A systematic review and network meta-analysis

Background

Obesity is one of the most important public health conditions in the world, and surgical intervention is the only medical treatment recognized by the medical community as a complete and permanent cure for morbid obesity and its complications. The choice of surgical modality is also based more on the experience of the physician or the requirements of people with obesity, rather than on scientific data. In this issue, a thorough comparison of the nutritional deficiencies caused by the three most commonly used surgical modalities is needed.

Objectives

We aimed to use the network meta-analysis to compare the nutritional deficiencies caused by the three most common BS procedures in many subjects who underwent BS to help physicians determine the best BS surgical approach to apply to their clinical people with obesity.

Setting

A systematic review and network meta-analysis of world literature.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, systematically reviewed the literature, and conducted a network meta-analysis using R Studio.

Results

For the four vitamins calcium, vitamin B12, iron and vitamin D, the micronutrient deficiency caused by RYGB is the most serious.

Conclusions

RYGB causes slightly higher nutritional deficiencies in Bariatric surgery, but RYGB remains the most commonly used modality for Bariatric surgery.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022351956, identifier: CRD42022351956.

Low-frequency Coding Variants Associated With Body Mass Index Affect the Success of Bariatric Surgery

CONTEXT

A recent study identified 14 low-frequency coding variants associated with body mass index (BMI) in 718 734 individuals predominantly of European ancestry.

OBJECTIVE

We investigated the association of 2 genetic scores (GS) with i) the risk of severe/morbid obesity, ii) BMI variation before weight-loss intervention, iii) BMI change in response to an 18-month lifestyle/behavioral intervention program, and iv) BMI change up to 24 months after bariatric surgery.

METHODS

The 14 low-frequency coding variants were genotyped or sequenced in 342 French adults with severe/morbid obesity and 574 French adult controls from the general population. We built risk and protective GS based on 6 BMI-increasing and 5 BMI-decreasing low-frequency coding variants that were polymorphic in our study.

RESULTS

While the risk GS was not associated with severe/morbid obesity status, BMI-decreasing low-frequency coding variants were significantly less frequent in patients with severe/morbid obesity than in French adults from the general population. Neither the risk nor the protective GS was associated with BMI before intervention in patients with severe/morbid obesity, nor did they affect BMI change in response to a lifestyle/behavioral modification program. The protective GS was associated with a greater BMI decrease following bariatric surgery. The risk and protective GS were associated with a higher and lower risk of BMI regain after bariatric surgery.

CONCLUSION

Our data indicate that in populations of European descent, low-frequency coding variants associated with BMI in the general population also affect the outcomes of bariatric surgery in patients with severe/morbid obesity.

Bariatric Surgery in NAFLD

Currently, there are no approved medications to treat patients with nonalcoholic steatohepatitis (NASH) with fibrosis or cirrhosis. Although the management goal in these patients is weight reduction by 7-10% with lifestyle modifications, only less than 10% of patients achieve this target at 1-year, and fewer maintain the weight loss at 5 years. Bariatric surgery is an option that may be considered in those who fail to lose weight by lifestyle changes. Bariatric surgery has been shown to improve liver histology including fibrosis secondary to NASH, in addition to other benefits including an improvement or resolution of type 2 diabetes mellitus, dyslipidemia, and hypertension, and a reduction of cardiovascular morbidity or mortality. There are no guidelines of bariatric surgery indications for the management of NASH. The purpose of this review is to critically appraise the current knowledge of the role of bariatric surgery and the potential mechanisms for its perceived benefits in the management of patients with NASH-related liver disease.

The risk of inflammatory bowel disease after bariatric surgery

BACKGROUND

The association between bariatric surgery and new onset of inflammatory bowel disease has so far only been sparsely studied and with conflicting results.

OBJECTIVES

To investigate the association between bariatric surgery and inflammatory bowel disease in a large population-based cohort.

SETTING

Nationwide in Sweden.

METHODS

This population-based retrospective cohort study included Swedish individuals registered in the Scandinavian Obesity Surgery Registry who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy during 2007-2018. Ten control individuals from the general population were matched according to age, sex, and region of residence at time of exposure. The study population was followed until 2019 with regard to the development of inflammatory bowel disease. Cox proportional hazards models were used to compare disease-free survival time between subgroups and control individuals for each outcome.

RESULTS

The final cohort consisted of 64,188 exposed individuals with a total follow-up of 346,860 person-years and 634,530 controls with total follow-up of 3,444,186 person-years. Individuals who underwent Roux-en-Y-gastric bypass had an increased risk of later development of Crohn's disease (hazard ratio [HR] 1.8, 95% CI 1.5-2.2) and unclassified inflammatory bowel disease (HR 2.7, 95% CI 2.0-3.7) but not ulcerative colitis (HR .9, 95% CI .8-1.1) compared with control individuals, whereas individuals who underwent sleeve gastrectomy had an increased risk of ulcerative colitis (HR 1.8, 95% CI 1.1-3.1) but not Crohn's disease (HR .8, 95% CI .3-2.1) and unclassified inflammatory bowel disease (HR 2.5, 95% CI .8-7.8).

CONCLUSIONS

Roux-en-Y gastric bypass was associated with increased risk of Crohn's disease and unclassified inflammatory bowel disease, whereas sleeve gastrectomy was associated with increased risk of ulcerative colitis only.

White adipocyte-targeted dual gene silencing of FABP4/5 for anti-obesity, anti-inflammation and reversal of insulin resistance: Efficacy and comparison of administration routes

Obesity is a serious health problem with tremendous economic and social consequences, which is associated with metabolic diseases and cancer. Currently available anti-obesity drugs acting in the gastrointestinal tract, or the central nervous system have shown limited efficacy in the reduction of obesity, accompanied by severe side effects. Therefore, a novel therapeutic delivery targeting adipocytes and normalizing excess fat transport and accumulation is necessary to maximize efficacy and reduce side effects for long-term treatment. Fatty acid binding protein 4 (FABP4) is an adipokine that coordinates lipid transport in mature adipocyte and its inhibition in obesity model showed weight loss and normalized insulin response. Reduction of FABP4 level in adipocytes was compensated by fatty acid binding protein 5 (FABP5), which resulted in reduction of recovery of obesity and co-morbidities related to obesity by FABP4 knock-down alone. In this study, we developed a non-viral gene delivery system, sh (FABP4/5)/ATS9R, that silences FABP4 and FABP5 simultaneously with oligopeptide (ATS9R) that can selectively target mature adipocyte. For future clinical application to increase patient compliance, sh (FABP4/5)/ATS9R was administered subcutaneously and intraperitoneally to obese animal model and both routes demonstrated startling dual gene efficacy in visceral adipose tissues. Furthermore, dual gene silencing efficiently alleviated obesity, improved insulin sensitivity and restored hepatic metabolism in high fat diet-induced type 2 diabetes mouse model. Targeted-dual gene silencing of sh (FABP4/5)/ATS9R in adipose tissues demonstrated synergistic effects to overcome obesity and obesity-induced metabolic diseases and beneficial effects against liraglutide, providing a great potential for future translational research.

Short- and long-term effects of body weight loss following calorie restriction and gastric bypass on CYP3A-activity - a non-randomized three-armed controlled trial

It remains uncertain whether pharmacokinetic changes following Roux-en-Y gastric bypass (RYGB) can be attributed to surgery-induced gastrointestinal alterations per se and/or the subsequent weight loss. The aim was to compare short- and long-term effects of RYGB and calorie restriction on CYP3A-activity, and cross-sectionally compare CYP3A-activity with normal weight to overweight controls using midazolam as probe drug. This three-armed controlled trial included patients with severe obesity preparing for RYGB (n = 41) or diet-induced (n = 41) weight-loss, and controls (n = 18). Both weight-loss groups underwent a 3-week low-energy-diet (<1200 kcal/day) followed by a 6-week very-low-energy-diet or RYGB (both <800 kcal/day). Patients were followed for 2 years, with four pharmacokinetic investigations using semisimultaneous oral and intravenous dosing to determine changes in midazolam absolute bioavailability and clearance, within and between groups. The RYGB and diet groups showed similar weight-loss at week 9 (13 ± 2.4% vs. 11 ± 3.6%), but differed substantially after 2 years (-30 ± 7.0% vs. -3.1 ± 6.3%). At baseline, mean absolute bioavailability and clearance of midazolam were similar in the RYGB and diet groups, but higher compared with controls. On average, absolute bioavailability was unaltered at week 9, but decreased by 40 ± 7.5% in the RYGB group and 32 ± 6.1% in the diet group at year 2 compared with baseline, with no between-group difference. No difference in clearance was observed over time, nor between groups. In conclusion, neither RYGB per se nor weight loss impacted absolute bioavailability or clearance of midazolam short term. Long term, absolute bioavailability was similarly decreased in both groups despite different weight loss, suggesting that the recovered CYP3A-activity is not only dependent on weight-loss through RYGB.

Metabolic alterations in plasma after laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is an important therapeutic option for morbidly obese patients. Although LSG promotes sufficient weight loss, how LSG changes plasma metabolites remains unclear. We assessed changes in plasma metabolite levels after LSG. We collected plasma samples from 15 morbidly obese Japanese patients before and 3 months after LSG. A total of 48 metabolites were quantified using capillary electrophoresis time-of-flight mass spectrometry-based metabolomic profiling. Branched chain amino acids, several essential amino acids, choline, 2-hydroxybutyric acid, 2-oxoisovaleric acid and hypoxanthine were significantly decreased after LSG. Tricarboxylic acid cycle metabolites, including citric acid, succinic acid and malic acid, were significantly elevated after LSG. This is the first report to show dynamic alterations in plasma metabolite concentrations, as assessed using capillary electrophoresis time-of-flight mass spectrometry, in morbidly obese patients after LSG. Our results might show how LSG helps improve obesity, in part through metabolic status changes, and propose novel therapeutic targets to ameliorate obesity.

Zinc Supplementation and Body Weight: A Systematic Review and Dose-Response Meta-analysis of Randomized Controlled Trials

The aim of this study was to determine the effect of zinc supplementation on anthropometric measures. In this systematic review and dose-response meta-analysis, we searched PubMed, Scopus, ISI Web of Science, and the Cochrane Library from database inception to August 2018 for relevant randomized controlled trials. Mean differences and SDs for each outcome were pooled using a random-effects model. Furthermore, a dose-response analysis for zinc dosage was performed using a fractional polynomial model. Quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Twenty-seven trials (n = 1438 participants) were included in the meta-analysis. There were no significant changes in anthropometric measures after zinc supplementation in the overall analysis. However, subgroup analyses revealed that zinc supplementation increased body weight in individuals undergoing hemodialysis (HD) [3 trials, n = 154 participants; weighted mean difference (WMD) = 1.02 kg; 95% CI: 0.38, 1.65 kg; P = 0.002; I2 = 11.4%] and decreased body weight in subjects who are overweight/obese but otherwise healthy (5 trials, n = 245 participants; WMD = -0.55 kg; 95% CI: -1.06, -0.04 kg; P = 0.03; I2 = 31.5%). Dose-response analyses revealed a significant nonlinear effect of supplementation dosage on BMI (P = 0.001). Our data suggest that zinc supplementation increases body weight in patients undergoing HD and decreases body weight in individuals who are overweight/obese but otherwise healthy, although after normalization for study duration, the association observed in subjects who are overweight/obese disappeared. Although more high-quality studies are needed to reach a definitive conclusion, our study supports the view that zinc may be associated with body weight.

Loss-of-function mutations in the melanocortin-3 receptor gene confer risk for human obesity: A systematic review and meta-analysis

The association between rare coding loss-of-function (LOF) mutations in the melanocortin receptor 3 (MC3R) gene and human obesity is controversial. To fill this gap of knowledge, we performed a systematic review and meta-analysis of genetic association studies in all ages and ethnicities. Two reviewers independently performed risk of bias assessment and extracted data. We searched Medline, Embase, Web of Science Core Collection, BIOSIS Preview, CINAHL, ProQuest Dissertations & Theses, and reference lists of relevant studies. All case-control, cross-sectional, prospective, and retrospective studies that evaluated prevalence of rare (less than 1% frequency) coding partial/complete LOF mutations in MC3R among individuals with obesity and normal weight were included. Our systematic search identified 1925 references relevant to the present review. Six studies were deemed eligible. Meta-analysis of 2969 individuals with obesity and 2572 with normal weight showed a positive association between rare heterozygous coding partial/complete LOF mutations in MC3R and obesity in children and adults of European, North African, and Asian ancestries (odds ratio = 3.07; 95% CI, 1.48-7.00; P = 4.2 × 10^-3 ). Our data demonstrates that rare partial/complete LOF mutations in the coding region of MC3R confer three-time increased risk of obesity in humans, and implies that rare genetic variants with intermediate effects contribute to the missing heritability of obesity.

Laparoscopic sleeve gastrectomy: a study of efficiency in treatment of metabolic syndrome components, comorbidities and influence on certain biochemical markers

Introduction

The worldwide outbreak of morbid obesity forced contemporary medicine to adopt a multidisciplinary approach, which led to the description of metabolic syndrome (MS): a disease with self-aggravating components and one of the most important causes of morbidity and mortality. The need for therapeutic methods provoked development of metabolic surgery, which nowadays give possibilities for safe and effective treatment of all MS aspects simultaneously and improves many obesity-related comorbidities.

Aim

To assess the laparoscopic sleeve gastrectomy (LSG) procedure's efficiency in resolving MS components, treating comorbidities and to analyze the influence on certain biochemical markers in 1-year follow-up.

Material and methods

The retrospective cohort study of 211 patients after an LSG operation relied on statistical analysis of clinical data collected prospectively in follow-up visits. All applicable guidelines and bioethical recommendations were respected in this study.

Results

Assessment of bariatric efficiency proved the LSG operation to be effective in inducing significant weight loss and treating obesity. Analysis on the influence on MS components, such as non-insulin dependent diabetes (NIDDM), arterial hypertension (AH) and dyslipidemia, showed substantial improvement in all observed cases of these diseases. In the present study, follow-up also proved a partial remission inducing effect of this bariatric operation in many comorbidities, especially in chronic obstructive pulmonary disease, obstructive sleep apnea, peptic ulcer disease and depression. A desirable reduction in creatinine, C-reactive protein, uric acid, alanine aminotransferase, asparagine aminotransferase, γ-glutamyltransferase serum levels has also been observed during the follow-up.

Conclusions

The LSG is an effective method of treatment in all areas of metabolic syndrome, provides a significant positive clinical outcome in obesity-related comorbidities and induces desirable changes in inflammatory, kidney and liver related biomarkers.

Gold nanoparticles as cell regulators: beneficial effects of gold nanoparticles on the metabolic profile of mice with pre-existing obesity

Background

We have previously shown that intraperitoneal injection of gold nanoparticles (AuNPs, 20–30 nm) into mice, decreases high-fat diet (HFD) induced weight gain and glucose intolerance, via suppression of inflammatory responses in both fat and liver tissues. This study investigates whether AuNPs provide similar benefit to mice with pre-existing obesity. Male C57BL/6 mice were fed a HFD for 15 weeks. AuNPs (OB-EAu 0.0785 μg/g/day, OB-LAu 0.785 μg/g/day, OB-HAu7.85 μg/g/day, ip) were administered to subgroups of HFD-fed mice over the last 5 weeks. Control group was fed standard chow and administered vehicle injection.

Results

Only the OB-LAu group demonstrated significant weight loss (12%), while all AuNP treated groups showed improved glycaemic control and reduced blood lipid levels. In the fat tissue, mRNA expression of pro-inflammatory markers were unchanged following AuNP treatment, while glucose and lipid metabolic markers were improved in OB-LAu and OB-HAu mice. In the liver, AuNP treatment downregulated inflammatory markers and improved lipid metabolic markers, with marked effects in OB-EAu and OB-LAu groups.

Conclusions

AuNP treatment can improve glucose and fat metabolism in mice with long-term obesity, however weight loss was only observed in a single specific dose regime. AuNP therapy is a promising new technology for managing metabolic disorders in the obese.

Electronic supplementary material

The online version of this article (10.1186/s12951-018-0414-6) contains supplementary material, which is available to authorized users.

Supplementation with Oligonol, Prevents Weight Gain and Improves Lipid Profile in Overweight and Obese Saudi Females

Background:

Obesity is a global health problem, increasing susceptibility to Type 2 Diabetes (T2DM) and Cardiovascular Disease (CVD). Varieties of products have been proposed for treatment with varying degrees of success. Recent studies, suggested Oligonol; an optimized phenolic product mixture from Lychee Fruit Polyphenols (LFP); as such treatment in Japanese population.

Objectives:

We aimed to investigate the effect of oligonol on weight, insulin resistance by (HOMA-IR), lipids profile, leptin, Adiponectin, and resistin in healthy overweight and obese Saudi females.

Subjects and Methods:

60 Saudi healthy overweight and obese females were enrolled in a double blind case/control study to take either Oligonol or placebo for 12 weeks without dietary or lifestyle re-strictions. Weight, height, Waist Circumference (WC), hip circumference (HC), and blood pressure were measured, and fasting blood samples of participants were taken before, and at the end of study. Total cholesterol, HDL-cholesterol, triglycerides, glucose, insulin, leptin, adiponectin, and resistin were meas-ured. LDL- cholesterol, HOMA-IR were calculated by equation.

Results:

47 subjects completed the study, 25 in placebo group, and 22 in Oligonol group. No ill effects were noted in any participant. Oligonol reduced means of serum triglycerides (P=0.008), and resistin (P=0.045) significantly. In addition, no weight gain was noted in oligonol group, unlike placebo group which exhibited significant increase in mean weight (P= 0.036), WC (P=0.027), HC (P= 0.047), and leptin (P <0.001).

Conclusion:

Oligonol could be suggested as future hypolipidemic and weight controlling agent for overweight and obese Saudi females.

The role of bariatric surgery in nonalcoholic fatty liver disease and nonalcoholic steatohepatitis

Nonalcoholic fatty liver disease (NAFLD) affects between 25% and 33% of the population, is more common in obese individuals, and is the most common cause of chronic liver disease in the United States. However, despite rising prevalence, effective treatments remain limited. Areas covered: We performed a literature search across multiple databases (Pubmed, Medline, etc.) to identify significant original research and review articles to provide an up-to-date and concise overview of disease pathogenesis and diagnostic evaluation and to expand on available treatment options with a specific focus on the potential role of bariatric surgery. Here we provide the most comprehensive review of bariatric surgery for the management of NAFLD, noting benefits from different procedures and multiple reports showing improvements in steatosis, inflammation and fibrosis over the duration of follow-up. Expert commentary: The morbidity of NAFLD is significant as it may become the most common indication for liver transplantation within the next 5 years. In addition to known benefits of weight loss and diabetes resolution, bariatric surgery has the potential to halt and reverse disease progression and future controlled trials should be performed to further define its benefit in the treatment of NAFLD in morbidly obese patients.

Comparison of Early Results and Complications between Multi-and Single-Port Sleeve Gastrectomy: A Randomized Clinical Study

BACKGROUND

In recent years, laparoscopic sleeve gastrectomy (LSG) has become more acceptable for obese patients. Single-port sleeve gastrectomy (SPSG) is more popular since each abdominal incision carries the risk of bleeding, hernia, and internal organ injury as well as exponentially affecting cosmesis. This cross-sectional study aimed at comparing multi-port sleeve gastrectomy (MPSG) and SPSG in terms of their early results and complications.

METHODS

Out of129 obese patients candidated for LSG, 102 patients were assigned to 2 groups of SPSG and MPSG. Complications and demographic data such as body mass index (BMI), age, gender, operation time, and hospital stay were measured. All surgeries were carried out between2013 and 2015 in Shiraz, Iran. Data analysis was performed using SPSS, version 16 for Windows (SPSS Inc., Chicago, IL). The continuous and categorical variables were compared using the Student t-test and the Chi-square test or the Fisher exact test, respectively.

RESULTS

The patients' data from both groups were similar in terms of age, intraoperative and postoperative bleeding volume, and length of hospital stay. Mean BMI was 42.8±0.7 in the SPSG group and 45.3±1.2 in the MPSG group. Duration of surgery was significantly lower in the SPSG group (P<0.001). Only 1 patient from the SPSG group and 5 patients from the MPSG group had bleeding as an early complication.

CONCLUSION

The differences in each complication between the groups were not statistically significant. SPSG seems to be safe and is the same as MPSG in terms of major postoperative complications.

TRIAL REGISTRATION NUMBER

IRCT201512229936N12 The abstract was presented in the 4^th International Congress of Minimally Invasive Surgery, Iran, as a poster and published in Iran J Med Sci Journal as a supplement (May 2015; Vol. 40, No. 3).

Health-Related Fitness Improvements in Morbid Obese Patients After Laparoscopic Sleeve Gastrectomy: a Cohort Study

OBJECTIVE

Laparoscopic sleeve gastrectomy (LSG) has demonstrated high long-term effectiveness and major advantages over other techniques. The objective of this study was to analyze changes in physical fitness parameters in morbidly obese patients during 6 months after LSG.

METHODOLOGY

We conducted a descriptive observational study with 6-month follow-up in 72 LSG patients, evaluating changes in body mass index (BMI), functional capacity (6-min walking test), hand grip strength (manual dynamometry), flexibility (fingertip-to-floor test), balance (Flamingo test), physical activity level (International Physical Activity Questionnaire, IPAQ), and perception of general physical fitness (International Fitness Scale [IFIS] questionnaire).

RESULTS

The ANOVA revealed significant improvements in BMI, functional capacity, flexibility, balance, and physical activity level (P < 0.001) at 6 months, with an improvement in the perception of physical fitness in most cases. No significant changes were found in dominant hand (P = 0.676) or non-dominant hand (P = 0.222) dynamometry. General physical fitness was positively correlated with BMI and distance in the 6-min test, and was negatively correlated with fingertip-to-floor distance.

CONCLUSION

Morbidly obese patients showed major improvements at 6 months after LSG in functional capacity, balance, mobility, and physical activity, with no change in grip strength. These improvements were related to a better self-perception of general physical fitness.

Perfil farmacoterapêutico de pacientes obesos no pós-operatório de cirurgia bariátrica

Contexto

A obesidade pode estar relacionada a doenças como diabetes, hipertensão arterial e dislipidemia. A cirurgia bariátrica é um dos tratamentos mais eficazes, levando à diminuição de peso e comorbidades.

Objetivo

Avaliar o perfil metabólico e farmacoterapêutico de pacientes obesos após cirurgia bariátrica.

Métodos

Trata-se de um estudo observacional transversal retrospectivo, realizado em um hospital localizado na cidade de Porto Alegre, RS, Brasil. Foram avaliados 70 prontuários de pacientes que realizaram cirurgia bariátrica, nos períodos de antes de 2 meses e mais de 6 meses após a cirurgia bariátrica. A análise estatística foi realizada no programa SPSS 17.0®.

Resultados

A pressão arterial inicial foi de 130/85 mmHg, passando para 120/80 mmHg (p < 0,01). Com relação ao perfil metabólico antes de dois meses, o HDL foi de 34 mg/dL, o colesterol total foi de 195,07 ± 40,17 mg/dL, o LDL foi de 118,22 ± 41,28 mg/dL, os triglicerídeos foram de 141,09 ± 43,39 mg/dL, e a glicemia de jejum foi de 90 mg/dL. Após 6 meses de cirurgia, os valores passaram para 43 mg/dL, 133,67 ± 28,14 mg/dL, 65,53 ± 24,3 mg/dL, 104,41 ± 29,6 mg/dL, e 77 mg/dL, respectivamente (p < 0,01). Com relação ao uso de medicamentos, 41% utilizaram anti-hipertensivos, 39% utilizaram hipolipemiantes, 10% utilizaram hipoglicemiantes orais e 97% utilizaram suplementos antes dos 2 meses de cirurgia. Após os 6 meses, os percentuais foram alterados para 21%, 19%, 9% e 99%, respectivamente.

Conclusões

O estudo mostra o sucesso da cirurgia bariátrica em pacientes obesos com comorbidades, revelando melhora no perfil metabólico e redução na utilização de medicamentos para tratamento de comorbidades.

Semiphysiologically based pharmacokinetic model for midazolam and CYP3A mediated metabolite 1-OH-midazolam in morbidly obese and weight loss surgery patients

This study aimed to describe the pharmacokinetics of midazolam and its cytochrome P450 3A (CYP3A) mediated metabolite 1‐OH‐midazolam in morbidly obese patients receiving oral and i.v. midazolam before (n = 20) and one year after weight loss surgery (n = 18), thereby providing insight into the influence of weight loss surgery on CYP3A activity in the gut wall and liver. In a semiphysiologically based pharmacokinetic (semi‐PBPK) model in which different blood flow scenarios were evaluated, intrinsic hepatic clearance of midazolam (CL_int,H) was 2 (95% CI 1.40–1.64) times higher compared to morbidly obese patients before surgery (P < 0.01). Midazolam gut wall clearance (CL_int,G) was slightly lower in patients after surgery (P > 0.05), with low values for both groups. The results of the semi‐PBPK model suggest that, in patients after weight loss surgery, CYP3A hepatic metabolizing capacity seems to recover compared to morbidly obese patients, whereas CYP3A mediated CL_int,G was low for both populations and showed large interindividual variability.

Pharmacotherapy for the treatment of obesity

The recognition of the complex counter-regulatory hormonal, metabolic and neurochemical mechanisms that promote weight regain following weight loss and the conceptualisation of obesity as a chronic disease requiring long-term management has led to increasing focus on the role of adjunctive therapies for obesity, particularly pharmacotherapy. Currently available pharmacotherapy achieves a weight loss intermediate between that commonly attained by lifestyle intervention and bariatric surgery, however its accessibility, compared to bariatric surgery increases its appeal. Despite the poor history of obesity pharmacotherapy, novel agents that are in development appear to have several advantages over predecessors. They are generally more selective in their mechanism of action, thereby potentially minimising adverse sequelae and improving the risk-benefit ratio of pharmacotherapy. Another approach has been to use combined pharmacotherapy to better counteract the multiple counter-regulatory neuroendocrine mechanisms which promote weight regain, as well as allowing lower constituent doses of the combined monotherapy agents, which improves the safety and tolerability of these agents that are usually required long-term for chronic weight maintenance. This review will provide an overview of past, present and future pharmacotherapy for obesity. The efficacy and safety profile of currently available pharmacotherapy will be discussed in the setting of stringent regulatory review processes now in place given the fraught history of pharmacological interventions for obesity. Potential novel therapies that seek to better target the multiple complex counter-regulatory mechanisms promoting weight regain while improving the efficacy/safety profile, will also be examined.

The Pharmacokinetics of the CYP3A Substrate Midazolam in Morbidly Obese Patients Before and One Year After Bariatric Surgery

PURPOSE

Bariatric surgery is nowadays commonly applied as treatment for morbid obesity (BMI > 40 kg/m(2)). As information about the effects of this procedure on a drug's pharmacokinetics is limited, we aimed to evaluate the pharmacokinetics of CYP3A probe substrate midazolam after oral and intravenous administration in a cohort of morbidly obese patients that was studied before and 1 year post bariatric surgery.

METHODS

Twenty morbidly obese patients (aged 26-58 years) undergoing bariatric surgery participated in the study of which 18 patients returned 1 year after surgery. At both occasions, patients received 7.5 mg oral and 5 mg intravenous midazolam separated by 160 ± 48 min. Per patient and occasion, a mean of 22 blood samples were collected. Midazolam concentrations were analyzed using population pharmacokinetic modeling.

RESULTS

One year after bariatric surgery, systemic clearance of midazolam was higher [0.65 (7%) versus 0.39 (11%) L/min, mean ± RSE (P < 0.01), respectively] and mean oral transit time (MTT) was faster [23 (20%) versus 51 (15%) minutes (P < 0.01)], while oral bioavailability was unchanged (0.54 (9%)). Central and peripheral volumes of distribution were overall lower (P < 0.05).

CONCLUSIONS

In this cohort study in morbidly obese patients, systemic clearance was 1.7 times higher 1 year after bariatric surgery, which may potentially result from an increase in hepatic CYP3A activity per unit of liver weight. Although MTT was found to be faster, oral bioavailability remained unchanged, which considering the increased systemic clearance implies an increase in the fraction escaping intestinal first pass metabolism.

Long-term virologic outcomes following bariatric surgery in patients with HIV

The management of morbid obesity and its metabolic complications among HIV-infected patients requires a multi-disciplinary approach, with surgical interventions as one option. We sought to assess the long-term durability of ART among HIV-infected patients undergoing bariatric procedures for the management of morbid obesity. During the study period, 7 patients underwent a bariatric surgery procedure for the management of morbid obesity: 3 patients underwent sleeve gastrectomy, 2 patients underwent laparoscopic banding, and 2 patients underwent Roux-en-Y gastric bypass surgery. Overall, the proportion of undetectable HIV viral load levels did not change after the bariatric procedures, although 2 patients did require temporary cessation of medications due to procedure-related complications. Sleeve gastrectomy and Roux-en-Y gastric bypass were safe and effective among morbidly obese HIV-infected patients in our clinic population.

Lipidomic profiling at the interface of metabolic surgery and cardiovascular disease

Bariatric surgery has helped patients attain not only significant and sustained weight loss but has also proved to be an effective means of mitigating or reversing various obesity-related comorbidities. The impressive rates of remission or resolution of type 2 diabetes mellitus (T2D) following bariatric surgery are well documented and have rightly received great attention. Less understood are the effects of bariatric surgery on cardiovascular disease (CVD) and its underlying risk factors. Thanks to the availability of increasingly sensitive laboratory tools, the emerging science of lipidomics and metagenomics is poised to offer significant contributions to our understanding of metabolically induced vascular diseases. They are set to identify novel mechanisms explaining how the varied approaches of bariatric surgery produce the remarkable improvements in multiple organs observed during patient follow-up. This article reviews recent and novel findings in patients through the lens of lipidomics with an emphasis on CVD.

Bari-Active: a randomized controlled trial of a preoperative intervention to increase physical activity in bariatric surgery patients

BACKGROUND

Habitual physical activity (PA) may help to optimize bariatric surgery outcomes; however, objective PA measures show that most patients have low PA preoperatively and make only modest PA changes postoperatively. Patients require additional support to adopt habitual PA. The objective of this study was to test the efficacy of a preoperative PA intervention (PAI) versus standard presurgical care (SC) for increasing daily moderate-to-vigorous PA (MVPA) in bariatric surgery patients.

METHODS

Outcomes analysis included 75 participants (86.7% women; 46.0±8.9 years; body mass index [BMI]=45.0±6.5 kg/m2) who were randomly assigned preoperatively to 6 weeks of PAI (n=40) or SC (n=35). PAI received weekly individual face-to-face sessions with tailored instruction in behavioral strategies (e.g., self-monitoring, goal-setting) to increase home-based walking exercise. The primary outcome, pre- to postintervention change in daily bout-related (≥10 min bouts) and total (≥1 min bouts) MVPA minutes, was assessed objectively via a multisensor monitor worn for 7 days at baseline- and postintervention.

RESULTS

Retention was 84% at the postintervention primary endpoint. In intent-to-treat analyses with baseline value carried forward for missing data and adjusted for baseline MVPA, PAI achieved a mean increase of 16.6±20.6 min/d in bout-related MVPA (baseline: 4.4±5.5 to postintervention: 21.0±21.4 min/d) compared to no change (-0.3±12.7 min/d; baseline: 7.9±16.6 to postintervention: 7.6±11.5 min/d) for SC (P=.001). Similarly, PAI achieved a mean increase of 21.0±26.9 min/d in total MVPA (baseline: 30.9±21.2 to postintervention: 51.9±30.0 min/d), whereas SC demonstrated no change (-0.1±16.3 min/d; baseline: 33.7±33.2 to postintervention: 33.6±28.5 minutes/d) (P=.001).

CONCLUSION

With behavioral intervention, patients can significantly increase MVPA before bariatric surgery compared to SC. Future studies should determine whether preoperative increases in PA can be maintained postoperatively and contribute to improved surgical outcomes.

Duodenal-jejunal bypass with sleeve gastrectomy versus the sleeve gastrectomy procedure alone: the role of duodenal exclusion

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) has become accepted as a stand-alone procedure as a less complex operation than laparoscopic duodenojejunal bypass with sleeve gastrectomy (DJB-SG).

OBJECTIVES

The aim of this study was to compare one-year results between DJB-SG and SG.

SETTING

University hospital.

METHODS

A total of 89 patients who received a DJB-SG surgery were matched with a group of SG that were equal in age, sex, and body mass index (BMI). Complication rates, weight loss, and remission of co-morbidities were evaluated after 12 months.

RESULTS

The mean preoperative patient BMI in the DJB-SG and SG groups was similar. There were more patients with type 2 diabetes mellitus (T2DM) in the DJB-SG group than in the SG group. The mean operative time and length of hospital stay (LOS) were significantly longer in the DJB-SG group than in the SG group. At 12 months after surgery, the BMI was lower and excess weight loss higher in DJB-SG than SG. Remission of T2DM was greater in the DJB-SG group. Low-density lipoprotein, total cholesterol, and metabolic syndrome (MS) improved after operation in both groups.

CONCLUSIONS

In this study DJB-SG was superior to SG in T2DM remission, triglyceride improvement, excess weight loss, and lower BMI at 1 year after surgery. Adding duodenal switch to sleeve gastrectomy increases the effect of diabetic control and MS resolution.

Drug development strategies for the treatment of obesity: how to ensure efficacy, safety, and sustainable weight loss

The prevalence of obesity has increased worldwide, and approximately 25%-35% of the adult population is obese in some countries. The excess of body fat is associated with adverse health consequences. Considering the limited efficacy of diet and exercise in the current obese population and the use of bariatric surgery only for morbid obesity, it appears that drug therapy is the only available method to address the problem on a large scale. Currently, pharmacological obesity treatment options are limited. However, new antiobesity drugs acting through central nervous system pathways or the peripheral adiposity signals and gastrointestinal tract are under clinical development. One of the most promising approaches is the use of peptides that influence the peripheral satiety signals and brain-gut axis such as GLP-1 analogs. However, considering that any antiobesity drug may affect one or several of the systems that control food intake and energy expenditure, it is unlikely that a single pharmacological agent will be effective as a striking obesity treatment. Thus, future strategies to treat obesity will need to be directed at sustainable weight loss to ensure maximal safety. This strategy will probably require the coadministration of medications that act through different mechanisms.

Striatal dopamine homeostasis is altered in mice following Roux-en-Y gastric bypass surgery

Roux-en-Y gastric bypass (RYGB) is an effective treatment for obesity. Importantly, weight loss following RYGB is thought to result in part from changes in brain-mediated regulation of appetite and food intake. Dopamine (DA) within the dorsal striatum plays an important role in feeding behavior; we therefore hypothesized that RYGB alters DA homeostasis in this subcortical region. In the current study, obese RYGB-operated mice consumed significantly less of a high-fat diet, weighed less by the end of the study, and exhibited lower adiposity than obese sham-operated mice. Interestingly, both RYGB and caloric restriction (pair feeding) resulted in elevated DA and reduced norepinephrine (NE) tissue levels compared with ad libitum fed sham animals. Consequently, the ratio of NE to DA, a measure of DA turnover, was significantly reduced in both of these groups. The RYGB mice additionally exhibited a significant increase in phosphorylation of tyrosine hydroxylase at position Ser31, a key regulatory site of DA synthesis. This increase was associated with augmented expression of extracellular-signal-regulated kinases ERK1/2, the kinase targeting Ser31. Additionally, RYGB has been shown in animal models and humans to improve insulin sensitivity and glycemic control. Curiously, we noted a significant increase in the expression of insulin receptor-β in RYGB animals in striatum (a glucosensing brain region) compared to sham ad libitum fed mice. These data demonstrate that RYGB surgery is associated with altered monoamine homeostasis at the level of the dorsal striatum, thus providing a critical foundation for future studies exploring central mechanisms of weight loss in RYGB.

Global methylation in the placenta and umbilical cord blood from pregnancies with maternal gestational diabetes, preeclampsia, and obesity

Emerging evidence indicates that maternal medical risk during pregnancy, such as gestational diabetes mellitus (GDM), preeclampsia, and obesity, predisposes the offspring to suboptimal development. However, the underlying biological/epigenetic mechanism in utero is still unknown. The current pilot study (N = 50) compared the levels of global methylation in the placenta and umbilical cord blood among women with and without each risk condition (GDM, preeclampsia, and obesity) and explored whether the levels of global methylation were associated with fetal/infant growth. Results show that global methylation levels in the placenta were lower in patients with gestational diabetes (P = .003) and preeclampsia (P = .05) but higher with obesity (P = .01). Suggestive negative associations were found between global methylation level in the placenta and infant body length and head circumference. While preliminary, it is possible that the placenta tissue, but not umbilical cord blood, may be epigenetically programmed by maternal GDM, preeclampsia, and obesity to carry out its own specific functions that influence fetal growth.

Weight loss after gastric bypass surgery in human obesity remodels promoter methylation

DNA methylation provides a mechanism by which environmental factors can control insulin sensitivity in obesity. Here, we assessed DNA methylation in skeletal muscle from obese people before and after Roux-en-Y gastric bypass (RYGB). Obesity was associated with altered expression of a subset of genes enriched in metabolic process and mitochondrial function. After weight loss, the expression of the majority of the identified genes was normalized to levels observed in normal-weight, healthy controls. Among the 14 metabolic genes analyzed, promoter methylation of 11 genes was normalized to levels observed in the normal-weight, healthy subjects. Using bisulfite sequencing, we show that promoter methylation of PGC-1α and PDK4 is altered with obesity and restored to nonobese levels after RYGB-induced weight loss. A genome-wide DNA methylation analysis of skeletal muscle revealed that obesity is associated with hypermethylation at CpG shores and exonic regions close to transcription start sites. Our results provide evidence that obesity and RYGB-induced weight loss have a dynamic effect on the epigenome.

Satiety signals and obesity

PURPOSE OF REVIEW

The obesity epidemic over the world has called to attention different ways to manage this development. As bariatric surgery today is the only manner by which rapid and sustained weight control can be achieved, new ways of treating obesity are under investigation. This review focuses on today's knowledge on satiety signaling as a means to combat obesity.

RECENT FINDINGS

The combined knowledge achieved from obesity surgery with gastric bypass and duodenal switch together with the pharmacological treatment of type 2 diabetes have given us some clues of how to manage obesity. The basis for our understanding is the present research focusing on the gut peptide hormones that are released in response to food intake, and the paucity of satiety signaling seems to prevail in obesity. This means that obese patients experience less activation of higher brain centers in association with a meal and therefore compensate with increased meal size or frequent food intake.

SUMMARY

Altered satiety signaling primarily emanating from the gastrointestinal tract seems to lead to the development of obesity and type 2 diabetes. Pharmacological tools that enhance the gut hormone signaling are in focus for the upcoming venues of treatment.

Mouse Models of Bariatric Surgery

Morbid obesity is linked to increased incidences of glucose intolerance, Type 2 diabetes mellitus, cardiovascular diseases, various forms of liver disease, and specific forms of cancer. Treatment of obesity by lifestyle modifications (i.e. changes in diet and exercise) and drug therapy is generally ineffective. Bariatric surgery is currently the most effective means of treating obesity and related disorders. We as well as others have developed surgical procedures for application to genetic mouse models that mimic an array of human bariatric surgical procedures used in the treatment of obesity. The application of bariatric surgery to genetic mouse models will broaden our understanding of the role of the gut in metabolic disease. Models that have been developed include gastric banding, sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) with a complete exclusion of the stomach, duodenal-jejunal bypass (DJB) and biliopancreatic diversion (BPD). The detailed methods of these procedures are provided.

Anti-obesity drugs: past, present and future

The ideal anti-obesity drug would produce sustained weight loss with minimal side effects. The mechanisms that regulate energy balance have substantial built-in redundancy, overlap considerably with other physiological functions, and are influenced by social, hedonic and psychological factors that limit the effectiveness of pharmacological interventions. It is therefore unsurprising that anti-obesity drug discovery programmes have been littered with false starts, failures in clinical development, and withdrawals due to adverse effects that were not fully appreciated at the time of launch. Drugs that target pathways in metabolic tissues, such as adipocytes, liver and skeletal muscle, have shown potential in preclinical studies but none has yet reached clinical development. Recent improvements in the understanding of peptidergic signalling of hunger and satiety from the gastrointestinal tract mediated by ghrelin, cholecystokinin (CCK), peptide YY (PYY) and glucagon-like peptide-1 (GLP-1), and of homeostatic mechanisms related to leptin and its upstream pathways in the hypothalamus, have opened up new possibilities. Although some have now reached clinical development, it is uncertain whether they will meet the strict regulatory hurdles required for licensing of an anti-obesity drug. However, GLP-1 receptor agonists have already succeeded in diabetes treatment and, owing to their attractive body-weight-lowering effects in humans, will perhaps also pave the way for other anti-obesity agents. To succeed in developing drugs that control body weight to the extent seen following surgical intervention, it seems obvious that a new paradigm is needed. In other therapeutic arenas, such as diabetes and hypertension, lower doses of multiple agents targeting different pathways often yield better results than strategies that modify one pathway alone. Some combination approaches using peptides and small molecules have now reached clinical trials, although recent regulatory experience suggests that large challenges lie ahead. In future, this polytherapeutic strategy could possibly rival surgery in terms of efficacy, safety and sustainability of weight loss.

The influence of laparoscopic sleeve gastrectomy on metabolic syndrome parameters in obese patients in own material

Popularity of laparoscopic sleeve gastrectomy (LSG) has been growing gradually. The aim of this study was to determine changes in metabolic syndrome parameters as well as insulin, total cholesterol, and LDL cholesterol, and to describe the influence of body weight loss on co-morbidities in obese patients after LSG with 1-year follow-up. The material consists of 130 patients who underwent LSG (2007–2010) in order to treat morbid obesity and who had met before the surgery at least three criteria necessary for the diagnosis of metabolic syndrome according to the International Diabetes Federation. The influence of LSG on co-morbidities was also analyzed. During 1-year follow-up after LSG, we obtained a statistically significant decrease in BMI (from 53.18 ± 7.5 kg/m² to 31.4 ± 3.75 kg/m², p < 0.00001) and a reduction in waist circumference. Twelve months after the surgery, excess weight loss (EWL) was 59.42 ± 7.21% and excess body mass index loss (EBL) was 61.03 ± 6.50%. One year after LSG, the amount of patients with diagnosed metabolic syndrome decreased in 61 patients (53.08%). After 1 year, none of the patients met five criteria of metabolic syndrome. According to efficiency in body mass loss presented by %EWL and %EBL, LSG is gaining approval as a method of obesity and metabolic syndrome treatment, although it is a relatively new procedure. LSG is rather an easy procedure; the time of performance and hospitalization are shorter which entails normalization in all parameters of metabolic syndrome and decreases the percentage of obese patients with metabolic syndrome.

Pregnancy and foetal outcome after bariatric surgery: a review of recent studies

It is well known that maternal obesity has adverse effects on the health of offspring, causing immediate and long-term morbidities. The various types of procedure coming under the heading of bariatric surgery have proved effective in preventing some maternal and foetal complications in morbidly obese pregnant women. This review aims to assess the role, the risks and the benefits of bariatric surgery for mothers and offspring. According to recent findings, pregnancy and neonatal outcomes in morbidly obese women who have undergone bariatric surgery depend to some extent on the type of surgery used. Maternal complications, nutritional defects and intestinal obstruction are more frequently reported after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) than after laparoscopic adjustable gastric banding (LAGB) procedures, whereas caesarean section, preterm delivery and neonatal death are more commonly reported after RYGB than after LAGB. The authors of the only long-term follow-up study conducted on this subject reported that the rate of obesity in the children dropped by 52% after bariatric surgery for the mother, and the cases of severe obesity decreased by 45%. Data on pregnancy and bariatric surgery confirm that the procedure is more effective than dietary measures alone in morbidly obese women, and that pregnancy outcome is generally favorable after surgery. Some studies have indicated, nonetheless, that pregnancies after bariatric surgery are at higher risk: the women affected require special medical attention, particularly as concerns gastrointestinal symptoms and vitamin deficiencies, warranting nutritional/dietary counselling by a multidisciplinary team before, during and after pregnancy.

A modified laparoscopic sleeve gastrectomy for the treatment of diabetes mellitus type 2 and metabolic syndrome in obesity

BACKGROUND

Ghrelin is a gastrointestinal peptide hormone (a 28-amino acid peptide) produced primarily by X/A cells in the oxyntic glands of the stomach fundus and cells lining the duodenum cavern. It suppresses insulin secretion and action and commands a significant role in regulating food intake. The aim of the present study was to show that modified laparoscopic sleeve gastrectomy (MLSG), in which a significant part of the gastric fundus and body of the stomach is removed up to 1 inch from the pylorus vein, may contribute to decreasing circulating ghrelin levels.

METHODS

A study population consisting of 150 individuals was monitored after undergoing a MLSG, with individuals chosen based on a documented history of diabetes mellitus type 2 and metabolic syndrome, clinical results determining a body mass index (BMI) of 35 to 60 kg/m(2), peptide C level greater than 1, negative anti-glutamic acid decarboxylase, negative anti-insulin, and confirmed stability of drug/insulin treatment and glycosylated hemoglobin greater than 6.5% for at least 24 and 3 months, respectively, before enrollment.

RESULTS

Twenty-four months after surgery, 150 patients (86.6%) presented with normal glycemic levels between 77 and 99 mg/dL. All patients improved average serum insulin levels by 9 mU/L and average glycosylated hemoglobin levels by 5.1% (normal range, 4%-6%). All patients tested negative for Helicobacter pylori and stopped using insulin, with 3 patients prescribed twice-daily use of an oral hypoglycemiant. In 14% of cases, patients experienced partial hair loss with low serum zinc levels and were prescribed oral zinc reposition and topical hair stimulants. The average weight loss recorded was 44.6% for patients with a BMI less than 45 kg/m(2) and 58% for patients with a BMI greater than 50 kg/m(2).

CONCLUSIONS

The MLSG is a safe procedure with a low morbidity rate (2.7%) (4 cases of fistula and 2 of bleeding) and no surgical mortality in this study. This surgery can promote control of diabetes mellitus type 2 and aid the treatment of exogenous overweight and morbidly obese individuals. The results of this study show that only through resection of the ghrelin-producing gastric area can most obesity cases and diabetes type II conditions be reverted to nonobese and controlled diabetes.

Evaluation of quality of life in severely obese patients after bariatric surgery carried out in the public healthcare system

OBJECTIVES: To assess QoL of obese patients in the Brazilian public healthcare system, before and after bariatric surgery, and to determine the appropriateness of the Moorehead-Ardelt Questionnaire II (M-A-QoLQII) compared with the Short-Form Health Survey (SF-36). SUBJECTS AND METHODS: Forty-one severe obese patients in a waiting-list, and 84 patients who underwent bariatric surgery were included. Correlations were tested and reliability determined by the Cronbach's coefficient. RESULTS: BMI differed between the pre- and post-surgery groups (52.3 ± 8.3 kg/m² vs. 32.5 ± 6.4 kg/m², p < 0.001). The latter showed better scores in the SF-36 domains than in the pre-surgery. SF-36 and M-A-QoLQII categories were correlated (r = 0.53, 0.49 and 0.47, for vitality, mental health, and general health domains, p < 0.001). In the logistic regression, age, previous BMI, and loss of excess weight were associated with functional capacity. CONCLUSIONS: The outcomes of bariatric surgery obtained in a Brazilian public healthcare center were successful. M-A-QoLII represents a useful tool to assess surgery outcomes, including QoL.

What are obese patients able to eat after Roux-en-Y gastric bypass?

BACKGROUND/AIMS

The goal of this study was to analyze the likelihood of patients undergoing Roux-en-Y gastric bypass (RYGB) to recover a normal daily food intake, and the possible influence of dietary and exercise habits on long-term weight loss.

METHODS

The sample included 107 morbidly obese postoperative patients with at least 1 year of follow-up. The data collected included anthropometry, dietary and exercise habits, and information on ingested food. The unpaired Student's t test and the multivariate step-by-step regression were used in the analysis.

RESULTS

The mean preoperative BMI was 50.7 ± 11.8 kg/m(2), which had decreased at the moment of survey to 31.7 ± 5.4 kg/m(2). The mean % Excess of BMI Lost (%EBMIL) was 77.4 ± 23.7%. The nutritional components of diet were similar to those for the nonobese population. There were no significant differences in %EBMIL regarding number of meals, social habits, components of diet, or amount of exercise. The daily mean caloric intake (1,364 ± 293 kcal) was the only parameter significantly related to the %EBMIL outcome. More than 30% of the patients had intolerance to certain foods.

CONCLUSION

Obese patients undergoing RYGB can establish a postoperative lifestyle and diet similar to the ideal. Only the daily amount of ingested calories demonstrated a statistically significant influence on weight loss over time.

The effects of weight loss strategies on gastric emptying and appetite control

The gastrointestinal tract plays an important role in the improved appetite control and weight loss in response to bariatric surgery. Other strategies which similarly alter gastrointestinal responses to food intake could contribute to successful weight management. The aim of this review is to discuss the effects of surgical, pharmacological and behavioural weight loss interventions on gastrointestinal targets of appetite control, including gastric emptying. Gastrointestinal peptides are also discussed because of their integrative relationship in appetite control. This review shows that different strategies exert diverse effects and there is no consensus on the optimal strategy for manipulating gastric emptying to improve appetite control. Emerging evidence from surgical procedures (e.g. sleeve gastrectomy and Roux-en-Y gastric bypass) suggests a faster emptying rate and earlier delivery of nutrients to the distal small intestine may improve appetite control. Energy restriction slows gastric emptying, while the effect of exercise-induced weight loss on gastric emptying remains to be established. The limited evidence suggests that chronic exercise is associated with faster gastric emptying, which we hypothesize will impact on appetite control and energy balance. Understanding how behavioural weight loss interventions (e.g. diet and exercise) alter gastrointestinal targets of appetite control may be important to improve their success in weight management.

Technology for behavioral assessment and intervention in bariatric surgery

Patients' behaviors have a substantial effect on postoperative outcomes after bariatric surgery. Thus, studying patients' behaviors is essential to learning how to optimize postoperative outcomes. To be most effective, this research should use the best tools available for assessing patient behavior. However, the traditional methods of behavioral assessment (e.g., questionnaires and clinical interviews) rely primarily on patients' retrospective self-report, which is often inaccurate. Despite their significant shortcomings, these types of assessments continue to predominate. However, technological advances now allow for much greater accuracy in the assessment of patient behaviors by way of devices, such as accelerometers and palmtop computers. Accelerometers allow for patients' physical activity to be measured objectively in great detail, in real-time, in the patients' natural environment. Ecologic momentary assessment using a palmtop computer or mobile telephone allows the assessment of important behaviors, such as eating and activity behaviors, to be measured, with many of the same advantages. Furthermore, new computer-assisted technologies are in development that will further facilitate behavioral assessment. Technology also has the potential to play an important role in the delivery of behavioral interventions aimed at bariatric surgery patients, given that Internet-based treatments have already proved effective for nonoperative weight loss and are often highly cost-effective and easily disseminable. Future research should evaluate the efficacy of these programs for bariatric patients.

Changes in headache frequency in premenopausal obese women with migraine after bariatric surgery: A case series

Background: The association between migraine and obesity gives the clinician with an exciting possibility to alleviate migraine suffering through weight-reduction gastric-restrictive operations. We hypothesized that bariatric weight-reduction intervention (gastric banding) will be associated with reduction of migraine burden in this population.

Methods: A total of 105 women between 18 and 50 years of age, admitted for bariatric surgery between April 2006 and February 2007, were screened for migraine. Twenty-nine with diagnosis of migraine were enrolled into the prospective phase. We followed the migraine pattern of these patients for 6 months post bariatric surgery.

Results: Baseline median migraine frequency was six headache days a month. Post bariatric surgery, the migraine-suffering women reported of a lower frequency of migraine attacks ( p < 0.001), shorter duration of the attacks ( p = 0.02), lower medication use during the attack ( p = 0.005), less non-migraine pain (44.8 vs. 33%, p = 0.05), and post-bariatric surgery reduction in headache-related disability assessed by the MIDAS and HIT-6 scores. There was a reduction in migraine frequency among both episodic (from four to one episodes a month) and chronic (from 16.8 to 8.5 episodes per month) migraine patient cohorts separately and combined.

Conclusions: Among migraine-suffering premenopausal obese women, we found a reduced frequency of migraine attacks and improvement of headache-related disability post bariatric surgery. Our findings should be interpreted cautiously. The absence of a control group and the non-blinded nature of our small study make it difficult to draw firm conclusions about the causal nature of the headache changes observed in this population. Further study is needed to evaluate the possible specific effects of surgical weight loss on migraine in obese women.

Pregnancy outcome in morbidly obese women before and after laparoscopic gastric banding

BACKGROUND

Increasing numbers of pregnancies are seen in obese women treated surgically with laparoscopic adjustable gastric banding (LAGB). We compared their maternal and fetal outcomes with obese women without LAGB and normal-weight controls.

METHODS

Sixty-nine obese women with LAGB (83 pregnancies) were compared with 120 obese women without LAGB and 858 controls.

RESULTS

By comparison with normal controls, post-LAGB pregnancies had higher rates of gestational hypertension (9.6% vs 2.4%, p < 0.05), preeclampsia/eclampsia (12.0% vs 2.3%, p < 0.001), abortion (10.8% vs 0.3%, p < 0.001), cesarean section (45.9% vs 28.2%, p < 0.01), preterm delivery (17.6% vs 3.6%, p < 0.001), and babies needing neonatal intensive care (20.3% vs 9.0%, p < 0.01). Compared with the no-LAGB obese group, the post-LAGB pregnancies had lower rates of gestational hypertension (9.6% vs 23.5%, p < 0.05), preeclampsia/eclampsia (12.0% vs 20.8%, p < 0.05), and cesarean section (45.9% vs 65.8%, p < 0.01). The post-LAGB obese women gained less weight during the pregnancy (6.6 +/- 7.9 vs 14.8 +/- 10.1 kg, p < 0.001) and experienced less gestational hypertension (14.8% vs 33%), preeclampsia/eclampsia (7.4% vs 14.8%), and macrosomia (4.2% vs 16%) than in pregnancies before LAGB. No significant differences in maternal and fetal outcomes emerged between post-LAGB pregnant women who lost versus those who gained weight during pregnancy. Compared with those no longer morbidly obese, women still morbidly obese after LAGB had a lower weight gain (2.8 +/- 11.8 vs 8.6 +/- 9.5 kg, p < 0.05) and a higher gestational hypertension rate (29.4% vs 8.9%, p < 0.05).

CONCLUSION

The risks of negative maternal and fetal outcomes for obese women can be reduced by LAGB if the women are closely followed up.

Comparison of the effects of Roux-en-Y gastric bypass and ileal transposition surgeries on food intake, body weight, and circulating peptide YY concentrations in rats

BACKGROUND

Roux-en-Y gastric bypass (RYGB) surgery is one of the most effective treatments for obesity producing long-term weight loss. The anorexia and weight loss from RYGB could be due to gastric restriction, malabsorption, enhanced lower gut stimulation, increased energy expenditure, and/or other metabolic adaptations. In ileal transposition (IT) surgery, a segment of the ileum is transposed to the upper jejunum with no gastric restriction or malabsorption. Our objective is to compare the effects of RYGB and IT surgeries on food intake, body weight, and plasma concentrations of the anorexigenic lower gut hormone Peptide YY (PYY) in rats.

METHODS

Adult male Sprague-Dawley rats were subjected to either RYGB (n = 9), IT (n = 9) or sham surgeries (n = 16). A subset of sham animals were either pair-fed to RYGB (n = 9) or ad lib fed (n = 7) on a highly palatable mixed nutrient liquid food (Ensure). Food intake, body weight and plasma PYY concentrations were measured.

RESULTS

The data demonstrate that (1) RYGB produces a sustained reduction in food intake and weight gain, (2) the anorexic effects of IT are relatively transient lasting for 5 weeks, (3) the reduction in weight gain resulting from IT is similar to that of animals pair-fed to RYGB, and (4) RYGB and IT surgeries are associated with elevated postprandial plasma PYY concentrations.

CONCLUSIONS

We demonstrate in our rat models that RYGB surgery produces a greater reduction in food intake and weight gain than IT surgery, and that both surgeries are associated with enhanced plasma concentrations of Peptide YY.