Bariatric surgery in liver cirrhosis

Introduction

Obesity is frequently associated with its hepatic manifestation, the nonalcoholic fatty liver disease (NAFLD). The most effective treatment for morbid obesity is bariatric surgery (BS) also improving NAFLD and liver function. In patients where NAFLD has already progressed to liver cirrhosis, BS can be considered a high-risk procedure. Hence, consideration of the procedure and the most appropriate timing is crucial.

Material and Methods

Obese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed.

Results

Twenty-seven patients underwent BS. Most common procedures were laparoscopic Roux-en-Y-gastric (RYGB) and laparoscopic sleeve gastrectomy (SG). All patients suffered from liver cirrhosis Child A. A preoperative transjugular portosystemic shunt (TIPS) was established in three patients and failed in another patient. Postoperative complications consisted of wound healing disorders (n = 2), anastomotic bleeding (n = 1), and leak from the staple line (n = 1). This patient suffered from intraoperatively detected macroscopic liver cirrhosis. Excess weight loss was 73% and 85% after 1 and 2 years, respectively. Two patients suffered from postoperative aggravation of their liver function, resulting in a higher Child-Pugh score, while three could be removed from the waiting list for a liver transplantation.

Conclusion

BS leads to weight loss, both after SG and RYGB, and potential improvement of liver function in liver cirrhosis. These patients need to be considered with care when evaluated for BS. Preoperative TIPS implantation may reduce the perioperative risk in selected patients.

Laparoscopic conversion of omega loop gastric bypass to Roux-en-Y gastric bypass for Barrett's esophagus: case report

BACKGROUND

The number of mini gastric bypass / one anastomosis bypass (MGB-OAGB) procedures in bariatric patients that have been performed world-wide has drastically increased during the past decade. Nevertheless, due to the risk of subsequent biliary reflux and development of ulcer and neoplastic (pre)lesions caused by long-time bile exposure, the procedure is still controversially discussed. In here presented case report, we could endoscopically demonstrate a transformation from reflux oesophagitis to Barrett's metaplasia most likely caused by bile reflux after mini-gastric bypass. To our knowledge, this is a first case study that shows development of Barrett's metaplasia after MGB-OAGB.

CASE PRESENTATION

We present the case of a 50-year-old female which received a mini-gastric bypass due to morbid obesity (body mass index (BMI) 42.4 kg/m²). Because of history gastroesophageal reflux disease (GERD), a fundoplication had been performed earlier. Preoperative gastroscopy showed reflux esophagitis (Los Angeles classification grade B) with no signs of Barrett's metaplasia. Three months post mini-gastric bypass, the patient complained about severe bile reflux under 40 mg pantoprazole daily. Six months postoperative, Endoscopically Barrett's epithelium was detected and histopathologically confirmed (C1M0 after Prague classification). A conversion into Roux-en-Y gastric bypass was performed. The postoperative course was without complications. In a follow up after 6 months the patient denied reflux and showed no signs of malnutrition.

CONCLUSIONS

The rapid progress from inflammatory changes of the distal esophagus towards Barrett's metaplasia under bile reflux in our case is most likely a result of previous reflux disease. Nevertheless, bile reflux appears to be a potential decisive factor. Study results regarding presence of bile reflux or development of endoscopically de-novo findings after MGB-OAGB are widely non-conclusive. Long-term prospective studies with regular endoscopic surveillance independent of clinical symptoms are needed.

SP3.1.14 NELA; what happens after discharge?

Aims

NELA has been instrumental at improving perioperative care and 30–day mortality following emergency laparotomy (EmLap); long-term outcomes and follow-up are less well reported. This study aims to establish the unscheduled and scheduled service use of EmLap patients after discharge.

Methods

This is a single-centre service evaluation. Patients were included if they had an EmLap recorded from 2016-2019 at our local institute and were alive on discharge. Outcomes were 30-day readmission rate and outpatient follow-up.

Results

944 patients were included. 11.9% re-presented to the surgical department within 30-days; 58.0% of these needed readmissions. The most common causes for re-presentation (n = 112) were management of a wound issue (15.2%), ongoing pain without evidence of complication (10.7%) and ongoing intra-abdominal sepsis (9.8%).

1-year survival was 81.4%. Of these (n = 856); 74.3% were invited to outpatients; DNA rate was 8.8%, with only 67.8% of patients having a follow-up review. Median time to follow up was 9 weeks. Patients were more likely to be invited for outpatient review if they had a new stoma (OR 2.56, 95% CI 1.81 – 3.56), and less likely if adhesiolysis was the primary procedure (OR 0.55, 95% 0.39-0.76).

Patients who failed to attend an appointment were significantly younger (median age 53 vs. 60 years, p = 0.0033) and from more deprived areas (average WIMD 673.6 vs 977.3, p = 0.002).

Conclusion

This study demonstrates higher levels of unscheduled care and lower levels of scheduled care than expected. Care standards should be extended beyond the 30-day milestone to fully appreciate the morbidity associated from EmLap.

Childhood maltreatment in bariatric patients and its association with postoperative weight, depressive, and eating disorder symptoms

PURPOSE

The present study aimed to compare prevalence rates of childhood maltreatment between patients with severe obesity undergoing bariatric surgery and patients without a surgical procedure. Second purpose was to calculate the association between childhood maltreatment and outcomes 6 and 12 months after a bariatric procedure.

METHODS

Childhood maltreatment was assessed using the Childhood Trauma Questionnaire (CTQ) and compared between 120 bariatric surgery patients and 346 non-surgery patients with severe obesity. For the bariatric surgery subgroup, linear mixed models with repeated measures were used to analyze the predictive value of childhood maltreatment on weight outcomes and psychopathology. Additionally, between- and within-group comparisons were calculated to compare patients with and without childhood maltreatment regarding BMI and weight loss (%TWL, %EWL), depression severity (BDI-II), eating disorder psychopathology (EDE-Q), and suicidal ideation (BSS), at baseline, 6- and 12-month assessment.

RESULTS

Prevalence rates for childhood maltreatment, depression and suicidal ideation were significantly higher in non-surgery compared to bariatric surgery patients. Within the surgery group, no significant interaction effect between childhood maltreatment and time was found. Hence, childhood maltreatment did not impact the course of body weight, depression and eating disorder psychopathology from pre- to post-surgery.

CONCLUSIONS

Significantly higher rates of childhood maltreatment were found within non-surgery patients with obesity in comparison to bariatric surgery patients. Childhood maltreatment did not predict poorer outcomes after surgery. Since history of childhood maltreatment may increase the risk for psychological disturbances, regular screening and, if necessary, psychological support should be offered to both groups.

LEVEL OF EVIDENCE

Evidence obtained from well-designed cohort or case-control analytic studies, Level III.

CLINICAL TRIAL REGISTRATION

Deutsches Register Klinischer Studien-German Clinical Trials Register: DRKS00003976.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Perceived Barriers in the Decision for Bariatric and Metabolic Surgery: Results from a Representative Study in Germany

BACKGROUND

Attitudes of the general public may be an influencing factor for low surgery rates: When skepticism is high, support for individuals wanting or needing to undergo surgery may diminish. This study assesses the relevance of barriers to metabolic surgery.

METHODS

The study was conducted using a representative sample of the German population (n = 1007). Participants were asked to imagine that they would have to decide for or against metabolic surgery and rate how this decision would be influenced by a number of reasons given to them (Likert scale). Results are presented by weight status.

RESULTS

The barrier found most irrelevant is that surgery could be considered cheating across all weight groups. About a fourth of the sample state that not knowing enough about surgery (28.5%), being afraid of surgery (28.3%), and potential negative consequences after surgery (24.5%) are reasons against metabolic surgery that were rated extremely relevant. Having obesity was a significant predictor of endorsement in two variables: feeling like cheating (lower probability for relevance, OR = 0.58, p = 0.025) and a lack of knowledge (lower probability for relevance, OR = 0.59, p = 0.031).

CONCLUSIONS

In summary, the public's view of weight loss surgery lacks information about post-surgical consequences. It is important to address these points in the public and in social networks of patients as they may be pre- or antecedent of surgery stigma.

Measurement of soft tissue drug concentrations in morbidly obese and non-obese patients - A prospective, parallel group, open-labeled, controlled, phase IV, single center clinical trial

Background

Pharmacokinetic (PK) and pharmacodynamic (PD) data on perioperative antibiotic prophylaxis or antibiotic therapy are rare in patients suffering from morbid obesity. Furthermore, dosing regimens should be based on PK/PD models that ensure effective antibiotic exposure not in plasma, but primarily at the site of infection, mostly in the interstitial fluid (ISF). The aim of this trial is to investigate whether current dosing regimens of various antibiotics lead to effective concentrations in the ISF of morbidly obese patients.

Methods

We designed a prospective, parallel group, open-labeled, controlled single center trial to investigate the plasma and tissue pharmacokinetics of the antibiotics linezolid, meropenem, tigecycline, piperacillin/tazobactam, fosfomcyine, cefazolin, metronidazole and as secondary aim the analgesics metamizole and acetaminophen. Inclusion criteria comprise body mass index ≥35 kg/m² for obese or between 18.5 and 30 kg/m² for non-obese patients scheduled for elective abdominal surgery. For PK analysis, blood and microdialysate samples of subcutaneous tissue were collected 0–8 h after study drug administration. The primary endpoint is to investigate a possible dependency of the area-under-the-curve (AUC_0-8) in the interstitial fluid on body weight and obesity with population based pharmacokinetic analysis.

Discussion

Inadequate dosing regimes of antibiotics may be a relevant factor for morbidity and mortality of patients, as well as for the development of bacterial antibiotic resistance. The measurement of plasma and tissue concentrations will provide information necessary for PK/PD-modelling. These data about antibiotic PK/PDcharacteristics in soft tissue and their dependence on weight should help to develop weight-dependent models for calculation of patient's individual doses of different antibiotics.

Trial registration

EU clinical trials register (EudraCT-No. 2012-004383-22) and German Clinical trials Register (DRKS00004776);

Individualized positive end-expiratory pressure in obese patients during general anaesthesia: a randomized controlled clinical trial using electrical impedance tomography

Background

General anaesthesia leads to atelectasis, reduced end-expiratory lung volume (EELV), and diminished arterial oxygenation in obese patients. We hypothesized that a combination of a recruitment manoeuvre (RM) and individualized positive end-expiratory pressure (PEEP) can avoid these effects.

Methods

Patients with a BMI ≥35 kg m -2 undergoing elective laparoscopic surgery were randomly allocated to mechanical ventilation with a tidal volume of 8 ml kg -1 predicted body weight and (i) an RM followed by individualized PEEP titrated using electrical impedance tomography (PEEP IND ) or (ii) no RM and PEEP of 5 cm H 2 O (PEEP 5 ). Gas exchange, regional ventilation distribution, and EELV (multiple breath nitrogen washout method) were determined before, during, and after anaesthesia. The primary end point was the ratio of arterial partial pressure of oxygen to inspiratory oxygen fraction ( P aO 2 / F iO 2 ).

Results

For PEEP IND ( n =25) and PEEP 5 ( n =25) arms together, P aO 2 / F iO 2 and EELV decreased by 15 kPa [95% confidence interval (CI) 11-20 kPa, P <0.001] and 1.2 litres (95% CI 0.9-1.6 litres, P <0.001), respectively, after intubation. Mean ( sd ) PEEP IND was 18.5 (5.6) cm H 2 O. In the PEEP IND arm, P aO 2 / F iO 2 before extubation was 23 kPa higher (95% CI 16-29 kPa; P <0.001), EELV was 1.8 litres larger (95% CI 1.5-2.2 litres; P <0.001), driving pressure was 6.7 cm H 2 O lower (95% CI 5.4-7.9 cm H 2 O; P <0.001), and regional ventilation was more equally distributed than for PEEP 5 . After extubation, however, these differences between the arms vanished.

Conclusions

In obese patients, an RM and higher PEEP IND restored EELV, regional ventilation distribution, and oxygenation during anaesthesia, but these differences did not persist after extubation. Therefore, lung protection strategies should include the postoperative period.

Clinical trial registration

German clinical trials register DRKS00004199, www.who.int/ictrp/network/drks2/en/ .

Evaluation of applying statistical process control techniques to daily average feeding behaviors to detect disease in automatically fed group-housed preweaned dairy calves

Group housing and computerized feeding of preweaned dairy calves are gaining in popularity among dairy producers, yet disease detection remains a challenge for this management system. The aim of this study was to investigate the application of statistical process control charting techniques to daily average feeding behavior to predict and detect illness and to describe the diagnostic test characteristics of using this technique to find a sick calf compared with detection by calf personnel. This prospective cross-sectional study was conducted on 10 farms in Minnesota (n = 4) and Virginia (n = 6) utilizing group housing and computerized feeding from February until October 2014. Calves were enrolled upon entrance to the group pen. Calf personnel recorded morbidity and mortality events. Farms were visited either every week (MN) or every other week (VA) to collect calf enrollment data, computer-derived feeding behavior data, and calf personnel-recorded calf morbidity and mortality. Standardized self-starting cumulative sum (CUSUM) charts were generated for each calf for each daily average feeding behavior, including drinking speed (mL/min), milk consumption (L/d), and visits to the feeder without a milk meal (no.). A testing subset of 352 calves (176 treated, 176 healthy) was first used to find CUSUM chart parameters that provided the highest diagnostic test sensitivity and best signal timing, which were then applied to all calves (n = 1,052). Generalized estimating equations were used to estimate the diagnostic test characteristics of a single negative mean CUSUM chart signal to detect a sick calf for a single feeding behavior. Combinations of feeding behavior signals were also explored. Single signals and combinations of signals that included drinking speed provided the most sensitive and timely signal, finding a sick calf up to an average (±SE) of 3.1 ± 8.8 d before calf personnel. However, there was no clear advantage to using CUSUM charting over calf observation for any one feeding behavior or combination of feeding behaviors when predictive values were considered. The results of this study suggest that, for the feeding behaviors monitored, the use of CUSUM control charts does not provide sufficient sensitivity or predictive values to detect a sick calf in a timely manner compared with calf personnel. This approach to examining daily average feeding behaviors cannot take the place of careful daily observation.

[Will laparoscopic sleeve gastrectomy continue to exist as a stand-alone procedure? : A procedure critical perspective]

BACKGROUND

Sleeve gastrectomy is currently the most frequently performed bariatric procedure worldwide; however, with respect to a certain need for revisional surgery (due to reflux disease or weight regain) there is an ongoing discussion about the value of sleeve gastrectomy in terms of a stand-alone procedure.

OBJECTIVE

The aim of this article is to critically discuss whether sleeve gastrectomy can still be considered a stand-alone procedure.

MATERIAL AND METHODS

The current literature was searched for results after sleeve gastrectomy and the recommendations regarding this procedure are discussed.

RESULTS

Currently approximately 50% of primary bariatric procedures are sleeve gastrectomies, which has become a well-established stand-alone procedure. Sleeve gastrectomy leads to good mid-term results; however, the results of the Roux-en-Y gastric bypass are comparatively superior in terms of type 2 diabetes remission, control of preexisting or de novo reflux disease and weight loss. The mortality is comparable; however, the morbidity is lower after sleeve gastrectomy but there is a relevant rate of fistulas of the stapler suture.

CONCLUSION

Patients considered for sleeve gastrectomy must be informed of the procedure-specific risks, including the unforeseeable need for revision or redo surgery firstly due to weight regain or failing to reach the individual therapy target and secondly for worsening of a preexisting or de novo reflux disease.

Integrative network analysis highlights biological processes underlying GLP-1 stimulated insulin secretion: A DIRECT study

Glucagon-like peptide 1 (GLP-1) stimulated insulin secretion has a considerable heritable component as estimated from twin studies, yet few genetic variants influencing this phenotype have been identified. We performed the first genome-wide association study (GWAS) of GLP-1 stimulated insulin secretion in non-diabetic individuals from the Netherlands Twin register (n = 126). This GWAS was enhanced using a tissue-specific protein-protein interaction network approach. We identified a beta-cell protein-protein interaction module that was significantly enriched for low gene scores based on the GWAS P-values and found support at the network level in an independent cohort from Tübingen, Germany (n = 100). Additionally, a polygenic risk score based on SNPs prioritized from the network was associated (P < 0.05) with glucose-stimulated insulin secretion phenotypes in up to 5,318 individuals in MAGIC cohorts. The network contains both known and novel genes in the context of insulin secretion and is enriched for members of the focal adhesion, extracellular-matrix receptor interaction, actin cytoskeleton regulation, Rap1 and PI3K-Akt signaling pathways. Adipose tissue is, like the beta-cell, one of the target tissues of GLP-1 and we thus hypothesized that similar networks might be functional in both tissues. In order to verify peripheral effects of GLP-1 stimulation, we compared the transcriptome profiling of ob/ob mice treated with liraglutide, a clinically used GLP-1 receptor agonist, versus baseline controls. Some of the upstream regulators of differentially expressed genes in the white adipose tissue of ob/ob mice were also detected in the human beta-cell network of genes associated with GLP-1 stimulated insulin secretion. The findings provide biological insight into the mechanisms through which the effects of GLP-1 may be modulated and highlight a potential role of the beta-cell expressed genes RYR2, GDI2, KIAA0232, COL4A1 and COL4A2 in GLP-1 stimulated insulin secretion.

Hyperglycaemic memory affects the neurovascular unit of the retina in a diabetic mouse model

AIMS/HYPOTHESIS

The aim of this study was to evaluate damage to the neurovascular unit in a mouse model of hyperglycaemic memory.

METHODS

A streptozotocin-induced mouse model of diabetes (C57BL/6J background) received insulin-releasing pellets and pancreatic islet-cell transplantation. Damage to the neurovascular unit was studied by quantitative retinal morphometry for microvascular changes and microarray analysis, with subsequent functional annotation clustering, for changes of the retinal genome.

RESULTS

Sustained microvascular damage was confirmed by persistent loss of pericytes in the retinal vasculature (PC/mm²): compared with healthy controls (1981 ± 404 PC/mm²), the pericyte coverage of the retinal vasculature was significantly reduced in diabetic mice (1571 ± 383 PC/mm², p < 0.001) and transplanted mice (1606 ± 268 PC/mm², p < 0.001). Genes meeting the criteria for hyperglycaemic memory were attributed to the cytoskeletal and nuclear cell compartments of the neurovascular unit. The most prominent regulated genes in the cytoskeletal compartment were Ddx51, Fgd4, Pdlim7, Utp23, Cep57, Csrp3, Eml5, Fhl3, Map1a, Mapk1ip1, Mnda, Neil2, Parp2, Myl12b, Dynll1, Stag3 and Sntg2, and in the nuclear compartment were Ddx51, Utp23, Mnda, Kmt2e, Nr6a1, Parp2, Cdk8, Srsf1 and Zfp326.

CONCLUSIONS/INTERPRETATION

We demonstrated that changes in gene expression and microvascular damage persist after euglycaemic re-entry, indicating memory.

DATA AVAILABILITY

The datasets generated during and/or analysed during the current study are available in the GEO repository, GSE87433, www.ncbi.nlm.nih.gov/geo/query/acc.cgi?token=idmbysgctluxviv&acc=GSE87433 .

The role of insulin resistance in experimental diabetic retinopathy-Genetic and molecular aspects

BACKGROUND

Diabetic retinopathy is characterized by defects in the retinal neurovascular unit. The underlying mechanisms of impairment-including reactive intermediates and growth-factor dependent signalling pathways and their possible interplay are incompletely understood. This study aims to assess the relative role of hyperglycemia and hyperinsulinemia alone or in combination on the gene expression patterning in the retina of animal models of diabetes.

MATERIAL AND METHODS

As insulinopenic, hyperglycemic model reflecting type 1 diabetes, male STZ-Wistar rats (60mg/kg BW; i.p. injection at life age week 7) were used. Male obese ZDF rats (fa/fa) were used as type-2 diabetes model characterized by persisting hyperglycemia and transient hyperinsulinemia. Male obese ZF rats (fa/fa) were used reflecting euglycemia and severe insulin resistance. All groups were kept till an age of 20 weeks on respective conditions together with appropriate age-matched controls. Unbiased gene expression analysis was performed per group using Affymetrix gene arrays. Bioinformatics analysis included analysis for clustering and differential gene expression, and pathway and upstream activator analysis. Gene expression differences were confirmed by microfluidic card PCR technology.

RESULTS

The most complex genetic regulation in the retina was observed in ZDF rats with a strong overlap to STZ-Wistar rats. Surprisingly, systemic insulin resistance alone in ZF rats without concomitant hyperglycemia did not induce any significant change in retinal gene expression pattern. Pathway analysis indicate an overlap between ZDF rats and STZ-treated rats in pathways like complement system activation, acute phase response signalling, and oncostatin-M signalling. Major array gene expression changes could be confirmed by subsequent PCR. An analysis of upstream transcriptional regulators revealed interferon-γ, interleukin-6 and oncostatin-M in STZ and ZDF rats. CONCLUSIONS: Systemic hyperinsulinaemia without hyperglycemia does not result in significant gene expression changes in retina. In contrast, persistent systemic hyperglycemia boosts much stronger expression changes with a limited number of known and new key regulators.

Factors associated with non-participation and dropout among cancer patients in a cluster-randomised controlled trial

We investigated the impact of demographic and disease related factors on non-participation and dropout in a cluster-randomised behavioural trial in cancer patients with measurements taken between hospitalisation and 6 months thereafter. The percentages of non-participation and dropout were documented at each time point. Factors considered to be potentially related with non-participation and dropout were as follows: age, sex, marital status, education, income, employment status, tumour site and stage of disease. Of 1,338 eligible patients, 24% declined participation at baseline. Non-participation was higher in older patients (Odds Ratio [OR] 2.1, CI: 0.6-0.9) and those with advanced disease (OR 2.0, CI: 0.1-1.3). Dropout by 6 months was 25%. Dropout was more frequent with increased age (OR 2.8, CI: 0.8-1.2), advanced disease (OR 3.0, CI: 1.0-1.2), being married (OR 2.4, CI 0.7-1.1) and less frequent with university education (OR 0.4, CI -1.3 to -0.8) and middle income (OR 0.4, CI -0.9 to -0.7). When planning clinical trials, it is important to be aware of patient groups at high risk of non-participation or dropout, for example older patients or those with advanced disease. Trial designs should consider their special needs to increase their rate of participation.

Insulin-Like Peptide 5 Interacts with Sex Hormones and Metabolic Parameters in a Gender and Adiposity Dependent Manner in Humans

Insulin-like peptide 5 (INSL5) is a gut hormone produced by L-cells in the colorectal epithelium and may play a role in the regulation of metabolic processes. The biological role of INSL5 is poorly investigated and nothing is known about the role of this hormone in obese and lean humans. Two cohorts were analyzed in the study. In the first cohort (n=76) the relationship between serum levels of INSL5 and different metabolic and hormonal parameters in obese and lean men and women were investigated. In the second cohort 14 male subjects underwent bariatric surgery. Circulating levels of INSL5 were then measured before and after interventions.We report for the first time that circulating INSL5 interacts with multiple metabolic and hormonal variables in lean and obese men and women and is affected by bariatric surgery. Serum levels of INSL5 negatively correlated with testosterone and blood lipids but positively with cortisol in obese men. In contrast to males, obese women had a strong negative correlation of plasma levels of INSL5 with C-reactive protein (CRP). We observed that adipose tissue loss after bariatric surgery significantly reduced serum levels of INSL5 in obese men with and without Type 2 Diabetes Mellitus (T2DM) that was associated with the restoration of circulating levels of testosterone. All together, our data demonstrated that INSL5 may interact with some metabolic parameters in obese humans and this process is dependent of gender and obesity state.

Brain regulation of food craving: relationships with weight status and eating behavior

OBJECTIVES

Food craving is a driving force for overeating and obesity. However, the relationship between brain mechanisms involved in its regulation and weight status is still an open issue. Gaps in the studied body mass index (BMI) distributions and focusing on linear analyses might have contributed to this lack of knowledge. Here, we investigated brain mechanisms of craving regulation using functional magnetic resonance imaging in a balanced sample including normal-weight, overweight and obese participants. We investigated associations between characteristics of obesity, eating behavior and regulatory brain function focusing on nonlinear relationships.

SUBJECTS/METHODS

Forty-three hungry female volunteers (BMI: 19.4-38.8 kg m(-2), mean: 27.5±5.3 s.d.) were presented with visual food stimuli individually pre-rated according to tastiness and healthiness. The participants were instructed to either admit to the upcoming craving or regulate it. We analyzed the relationships between regulatory brain activity as well as functional connectivity and BMI or eating behavior (Three-Factor Eating Questionnaire, scales: Cognitive Restraint, Disinhibition).

RESULTS

During regulation, BMI correlated with brain activity in the left putamen, amygdala and insula in an inverted U-shaped manner. Functional connectivity between the putamen and the dorsolateral prefrontal cortex (dlPFC) correlated positively with BMI, whereas that of amygdala with pallidum and lingual gyrus was nonlinearly (U-shaped) associated with BMI. Disinhibition correlated negatively with the strength of functional connectivity between amygdala and dorsomedial prefrontal (dmPFC) cortex as well as caudate.

CONCLUSIONS

This study is the first to reveal quadratic relationships of food-related brain processes and BMI. Reported nonlinear associations indicate inverse relationships between regulation-related motivational processing in the range of normal weight/overweight compared with the obese range. Connectivity analyses suggest that the need for top-down (dlPFC) adjustment of striatal value representations increases with BMI, whereas the interplay of self-monitoring (dmPFC) or eating-related strategic action planning (caudate) and salience processing (amygdala) might be hampered with high Disinhibition.

Tumour-adapted Reduction Mammoplasty - a New (Old) Breast Conserving Strategy: Review

Today over 70 % of patients treated for primary breast carcinoma in certified breast centres are managed with breast conserving surgery. The classical semicircular incision directly above the tumour, though in many cases easily carried out and associated with good cosmetic results, does have limitations. Unsatisfactory aesthetic results often occur when tumour location is unfavourable or when there is unfavourable tumour size relative to breast size. Distortion of the nipple, changes to breast shape and retraction of skin overlying surgical defects can occur. Tumour-adapted reduction mammoplasty/mastopexy or the "modified B technique" offer excellent chances of combining the oncological demands of breast surgery with satisfactory symmetrical cosmetic results. This article reviews a traditional, old operative technique that has been re-embraced in various new forms.

Obesogenic memory can confer long-term increases in adipose tissue but not liver inflammation and insulin resistance after weight loss

Objective

Obesity represents a major risk factor for the development of type 2 diabetes mellitus, atherosclerosis and certain cancer entities. Treatment of obesity is hindered by the long-term maintenance of initially reduced body weight, and it remains unclear whether all pathologies associated with obesity are fully reversible even upon successfully maintained weight loss.

Methods

We compared high fat diet-fed, weight reduced and lean mice in terms of body weight development, adipose tissue and liver insulin sensitivity as well as inflammatory gene expression. Moreover, we assessed similar parameters in a human cohort before and after bariatric surgery.

Results

Compared to lean animals, mice that demonstrated successful weight reduction showed increased weight gain following exposure to ad libitum control diet. However, pair-feeding weight-reduced mice with lean controls efficiently stabilized body weight, indicating that hyperphagia was the predominant cause for the observed weight regain. Additionally, whereas glucose tolerance improved rapidly after weight loss, systemic insulin resistance was retained and ameliorated only upon prolonged pair-feeding. Weight loss enhanced insulin action and resolved pro-inflammatory gene expression exclusively in the liver, whereas visceral adipose tissue displayed no significant improvement of metabolic and inflammatory parameters compared to obese mice. Similarly, bariatric surgery in humans (n = 55) resulted in massive weight reduction, improved hepatic inflammation and systemic glucose homeostasis, while adipose tissue inflammation remained unaffected and adipocyte-autonomous insulin action only exhibit minor improvements in a subgroup of patients (42%).

Conclusions

These results demonstrate that although sustained weight loss improves systemic glucose homeostasis, primarily through improved inflammation and insulin action in liver, a remarkable obesogenic memory can confer long-term increases in adipose tissue inflammation and insulin resistance in mice as well as in a significant subpopulation of obese patients.

•

Upon weight loss in mice liver insulin sensitivity rapidly improves.

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Upon weight loss in mice fat retains metabolic inflammation and insulin resistance.

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Weight gain upon successful weight reduction in mice is driven by increased food intake.

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A proportion of human subjects undergoing bariatric surgery retain AT-inflammation.

Human papillomavirus status, anal cytology and histopathological outcome in HIV-positive patients

BACKGROUND

Human papillomavirus (HPV) are responsible for a broad spectrum of mucocutaneous infections and may cause squamous cell carcinoma following long-standing infection . Oncogenic HPV, most commonly HPV 16, are detectable in over 90% of cervical intraepithelial neoplasia and anal intraepithelial neoplasia (AIN). Human immunodeficiency virus (HIV) infection is strongly associated with a higher prevalence of chronic HPV infection, a higher incidence of AIN and an increased risk for anal cancer (AC). In September 2013, guidelines concerning prevention, screening and treatment of AIN for patients affected by HIV were issued by the German AIDS society.

OBJECTIVE

In order to validate the suggested screening procedure, we analysed data from 123 male and female patients with HIV infection that regularly present in our outpatient clinic.

METHODS

Anal cytology, HPV typing and high-resolution anoscopy (HRA) were performed.

RESULTS

Our results show that screening by anal cytology only identifies a minority of patients with high grade AIN (AIN 3) histology. Patients with normal cytology (NILM, cytology graded negative for intraepithelial lesion or malignancy; n = 5, 29.4%), atypical squamous cells of undetermined significance (ASCUS; n = 5, 71.4%) and low grade squamous intraepithelial lesion (LSIL; n = 8, 44.5%) showed highly dysplastic lesions (AIN 2 and 3) in the histological workup more frequently than expected. Additionally, high-grade squamous intraepithelial lesion (HSIL) was strongly associated with detection of high-risk oncogenic HPV.

CONCLUSION

Anal cytology as the solitary screening tool for anal cancer fails to detect anal dysplasia in a considerable number of patients. Additionally, HPV typing and possibly further biomarkers might be applied to identify those patients with a higher risk of developing anal carcinoma, in order to monitor them more closely or directly transfer them to HRA.

Improving external beam radiotherapy by combination with internal irradiation

The efficacy of external beam radiotherapy (EBRT) is dose dependent, but the dose that can be applied to solid tumour lesions is limited by the sensitivity of the surrounding tissue. The combination of EBRT with systemically applied radioimmunotherapy (RIT) is a promising approach to increase efficacy of radiotherapy. Toxicities of both treatment modalities of this combination of internal and external radiotherapy (CIERT) are not additive, as different organs at risk are in target. However, advantages of both single treatments are combined, for example, precise high dose delivery to the bulk tumour via standard EBRT, which can be increased by addition of RIT, and potential targeting of micrometastases by RIT. Eventually, theragnostic radionuclide pairs can be used to predict uptake of the radiotherapeutic drug prior to and during therapy and find individual patients who may benefit from this treatment. This review aims to highlight the outcome of pre-clinical studies on CIERT and resultant questions for translation into the clinic. Few clinical data are available until now and reasons as well as challenges for clinical implementation are discussed.

Obesity-related immune responses and their impact on surgical outcomes

The obesity epidemic represents a critical disease burden with broad clinical consequences. At the same time, obesity has been linked to inferior surgical outcomes and considered a contraindication for some elective surgical procedures. A growing body of mechanistic evidence has accumulated linking obesity to changes of metabolism and immune responses. This concept provides an integrated inflammatory network based on the perception of obesity as a state of chronic low-grade inflammation. With a more detailed understanding of this dynamic network and mechanistic insights, novel treatment and management strategies may be developed with the goal to optimize surgical outcomes in obese patients.

[New impulses for tic research through international collaboration]

BACKGROUND

A section of the UMCG Child and Adolescent Psychiatry Department is currently focusing much of its research on tic disorders.

AIM

To provide an overview of the research projects on tic disorders being currently undertaken at our center.

METHOD

We discuss our research projects giving particular attention to factors that are restricting current research.

RESULTS

The first project is TIC Genetics, a project involving international collaboration. The researchers are looking for rare genetic variants in several family members who have tics and for new gene mutations in children who have tics but no family history of tics. TIC Genetics also investigates the interactions between genes and the environment. A second large-scale longitudinal project, the European Multicentre Tics in Children Study (EMTICS), is focusing on the interplay between genetics, auto-immunity, and environmental factors as a possible cause for the onset and exacerbation of tics. Finally, TS-EUROTRAIN is a European collaboration that concentrates on genetics, neuro-imaging and animal models.

CONCLUSION

International collaborations are essential if we are to acquire a deeper understanding of the etiology of tic disorders.

Obesity and co-morbid psychiatric disorders as contraindications for bariatric surgery?-A case study

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Current or past psychiatric disorders are not uncommon in patients undergoing bariatric surgery.

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Bariatric surgery contributes to weight loss, improvement of physical disorders and well-being but psychiatric disorders may remain.

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Adequate post-operative support is inevitable.

INTRODUCTION

Many patients undergoing bariatric surgery report current or past psychiatric disorders and controversy exists regarding their outcome after bariatric surgery.

PRESENTATION OF CASE

We present a case of an obese patient with a borderline personality disorder, a recurrent depressive disorder, post-traumatic stress symptoms and binge eating episodes who underwent bariatric surgery.

DISCUSSION

Although the psychiatric disorders remained, the procedure contributed to an improvement of the health status and well-being of the patient. Adequate psychological care after the surgical procedure is necessary to enable a long-term stabilization of patients with mental co-morbidities.

CONCLUSION

Patients with psychiatric co-morbidities should not be excluded from the procedure if adequate post-operative support is provided.