[Nutrition, metabolic syndrome and morbid obesity]. / Nutrición, síndrome metabólico y obesidad mórbida.

INTRODUCTION: Obesity, and specifically morbid obesity (MO), is a chronic disease with serious health consequences related to the associated comorbidities and constitutes a leading risk factor for the metabolic syndrome (MS) and cardiovascular disease (CVD). In the present study we analyze the abnormalities related to MO in the plasmatic levels of nutrients (both macro and micronutrients). METHODS: We retrospectively evaluated data of 497 patients, 369 women and 128 men diagnosed of MO. The average age of the patients was 40.07 (rank: 16-62). Previous to the study anthropometric measures, blood pressure (BP) and plasma levels of insulin and macronutrients and micronutrients were measured. RESULTS: The higher body mass index (BMI) in women and the waist circumference (WC) in both sexes demonstrates the existence of visceral obesity. Hypertensive disease (HD) was found in 18.6% of men and 33.5% of women. 55.1% of the men and 42.3% of the women had three or more criteria defining the risk of developing MetS. We found hyperglycemia, insulinemia and dyslipemia. We did not find protein malnutrition, but there were elevated values of reactive C-protein. Biochemical indicators of macro and micronutrients were not altered. DISCUSSION AND CONCLUSIONS: The high incidence of patients with HD, carriers of three or more criteria that defines the metabolic syndrome (SM), suggests that a very significant part of our patients suffered the metabolic syndrome (MS). The term metabolic syndrome defines the group of factors of metabolic risk of CVD, which is confirmed by the elevated levels of reactive C-protein. We did not find abnormalities in the plasmatic levels of biochemical markers of nutrients.

[Morbid obesity, non-alcoholic fatty liver disease, metabolic syndrome and bariatric surgery]. / Obesidad mórbida, enfermedad de hígado graso no alcohólico, síndrome metabólico y cirugía bariátrica.

OBJECTIVES: The objectives of the present study are: 1) to assess protein changes in patients diagnosed with morbid obesity (MO) and non-alcoholic fatty liver disease (NAFLD) or steatohepatitis (NASH); 2) to assess the likely reversibility of these entities after bariatric surgery, and 3) to analyze their progression seven years after the gastric bypass. MATERIAL AND METHODS: We retrospectively analyzed the data from 190 patients, 150 women (79%) and 40 men (21%) diagnosed with MO and surgically treated at our Hospital (Capella's gastric bypass). Mean age of the patients was 36.5 years (range: 18.5-54.5). Anthropometric values are gathered: body mass index (BMI), waist circumference (WC) and biochemistry: insulin (INS), glucose (GLU), total proteins (TP), albumin (ALB), transferrin (TRF), ferritin (FER), prealbumin (PBA), retinol binding protein (RBP) and C reactive protein (CRP). The HOMA index was calculated before the bypass and at the following follow-up periods after bypass: 6, 12, 60 and 84 months. RESULTS: Abdominal ultrasound suggesting NAFLD or NASH was found in 34.7% (n = 66; 52 women and 14 men) of MO patients surgically treated. Ninety patients (47.3%; 67 women and 23 men) presented risk factors for metabolic syndrome (MS). All patients with possible liver dysfunction had MS. Before the bypass, we found increased levels of: BMI, WC, CRP, GLU, INS and HOMA index and changes in TP, ALB, PBA, RBP, FER and TRF levels. The first set of parameters start to decrease within 6 months after surgical bypass and at the same time the changes in protein levels start to face off and remain stable at 84 months. CONCLUSIONS: Weight loss due to bariatric surgery represents an effective method of fighting MO and its associated comorbidities (NAFLD, NASH, hyperinsulinemia, hyperglycemia, dyslipidemia and components of the metabolic syndrome).

HOMA, QUICKI and MFfm to measure insulin resistance in morbid obesity.

BACKGROUND: The relationship between morbid obesity (MO) and insulin resistance (IR) has been widely demonstrated. The euglycemic-hyperglycemic clamp method for diagnosis of IR is neither practical nor cost-effective for population-based studies. However, the application of mathematical models (HOMA, QUICKI and Mf(fm) indices) can be useful. METHODS: The data from 171 patients were retrospectively evaluated. We recorded general anthropometric parameters and the basal levels of glucose, triglycerides and insulin and calculated the metabolic indexes both before surgery (Capella gastric bypass) and 6, 12, 24, 36 and 48 months after the operation. RESULTS: Before surgery, patients could be classified according to their waist-hip ratio (WHR) into 2 groups. Group A (n = 131, 108 females and 23 males) with WHR values 1.10 +/- 0.1 SD for males and 0.94 +/- 0.1 for females (central obesity); and Group B (n = 40, 34 females and 6 males) with WHR values 0.90 +/- 0.1 for males and 0.84 +/- 0.1 for females (peripheral obesity). Group A patients showed elevated serum levels of glucose, triglycerides and insulin and high values of the HOMA index with low values of QUICKI and Mf(fm). Group B patients showed lower levels of glucose, triglycerides, insulin and HOMA index and higher values of QUICKI and Mf(fm). These abnormal levels began to decrease 6 months after bypass and the QUICKI and Mf(fm) began to increase. CONCLUSIONS: The high baseline levels of insulin and the high prevalence of hypertension, diabetes or both conditions in patients with central obesity confirm that they suffer a metabolic syndrome, Meanwhile, patients with peripheral obesity with lower levels of chemical parameters and of the metabolic indices suffer peripheral resistance against insulin. Clinical application of these mathematical indices can be useful in patients with MO; they are easily performed and lack the high costs and risks associated with the clamp technique.

Morbid obesity, hypertensive disease and the renin-angiotensin-aldosterone axis.

BACKGROUND: Resistance to insulin and secondary hyperinsulinemia seem to be the putative link between morbid obesity (MO) and hypertensive disease (HD). Adipose tissue can secrete leptin and angiotensinogen, among other substances. Leptin activates the sympathetic nervous system, leading to HD. Angiotensinogen is a substrate for renin, therefore taking part in the renin-angiotensin-aldosterone axis and the regulation of blood pressure. In MO, both hypertrophy and hyperplasia of the adipocytes lead to an increase in the secretion of both substances, leading to loss of the equilibrium between the levels of both hormones. The aim of the present study was to evaluate these abnormalities and their potential reversibility following bariatric surgery. METHODS: Data from 100 patients with MO was retrospectively evaluated. Anthropometric data, the plasma renin activity (PRA), plasma levels of aldosterone, ACE, potassium and sodium were collected both prior to surgery and 6, 12, 24 and 36 months after surgery. RESULTS: The waist-hip ratio (WHR) before surgery allowed classification of our patients in two groups: central obesity (WHR > or =0.90 in men and > or =0.85 in women); peripheral obesity (WHR <0.90 in men and <0.85 in women). In patients with central obesity, high levels of PRA, aldosterone and ACE with sodium retention and potassium loss and high insulin levels, were found. These changes were not found in patients with peripheral obesity. After gastric bypass, these abnormalities tended to disappear, mainly in the first 6 months. CONCLUSIONS: The reduction of BMI and WHR after gastric bypass confirmed this operation to be effective against MO. The high basal levels of insulin and the high rate of HD and diabetes in patients with central obesity seem to indicate that they suffer a metabolic syndrome with significant hormonal imbalances and sodium retention. Patients with peripheral obesity only showed a peripheral resistance against insulin, probably with a shorter duration of the hormonal action, but they did not show hormonal abnormalities or sodium retention. After gastric bypass these abnormal hormone levels tended to normalize.

Morbid obesity and gastric bypass surgery: biochemical profile.

BACKGROUND: Morbid obesity (MO) and the pathologies associated with it constitute an important public health problem, accounting for 7% of the health expenditure in industrialized countries. An important percentage of this expense is attributed to the different biochemical tests performed in these patients, who suffer from several metabolic derangements. We evaluated the basic biochemical abnormalities in MO patients and their reversibility by weight loss after gastric bypass, to standardize the surveillance of the different metabolic abnormalities in obese patients. METHODS: By a retrospective analysis on 125 patients operated in our hospital, we evaluated anthropometric and biochemical data before and 1, 3, 6, 12 and 24 months after gastric bypass. RESULTS: Preoperatively hyperinsulinemia, hyperglycemia, dyslipidemia and hypertensive disease were present, and began to improve 1 and 3 months after surgery (although not significantly) and significantly at 6, 12 and 24 months after it. We also observed deficient protein nutrition and a deficiency of micronutrients both before bypass and during the follow-up. CONCLUSION: After gastric bypass, a marked decrease in insulin occurred, with normalization of blood pressure and the biochemical parameters associated with the metabolic syndrome. We propose a biochemical follow-up protocol for MO patients.

Gastric actinomycosis: a rare complication after gastric bypass for morbid obesity.

A 41-year-old woman in November 2002 underwent a gastric bypass by the Capella technique for morbid obesity. Almost 1 year after the surgery, she developed severe vomiting. Radiological studies confirmed a severe stenosis of the gastrojejunal anastomosis. Two pneumatic dilatations of the stenosis failed. In February 2004, she underwent resection of the stenotic anastomosis. Histology showed an intact mucosa and beneath it an abscess filled with numerous filamentous microorganisms, with typical features of Actinomyces. With the diagnosis of gastric actinomycosis, she received a postoperative course of antibiotherapy with imipenem and was discharged after an uneventful recovery. Gastric actinomycosis is a rare infection, of which only 19 additional cases have been reported in the literature. To our knowledge, this is the first case to affect a patient following batriatric surgery. The reported cases of this entity are reviewed, and the diagnostic criteria that could avoid surgery in these cases are discussed.

Choledochal cyst resection and reconstruction by biliary-jejuno-duodenal diversion.

From January, 1983 to December, 1986, a total of 9 patients, ranging in age from 2 years and 4 months to 36 years, with choledochal cysts were treated. Symptoms were right upper quadrant pain (n = 9), ascending cholangitis (n = 7), and jaundice (n = 6). A right upper quadrant mass was palpable in 7 patients and gallstones were present in 5 patients. Diagnosis was established by intravenous cholangiogram and ultrasound. The operation was performed through a right subcostal laparotomy. The choledochal cyst diameter ranged from 4.5 to 7 cm. The cyst and the common duct were dissected from the hepatic artery and portal vein. The choledochus was sectioned above the duodenum and the distal end was closed by interrupted sutures. The common duct was divided below the hepatic confluence and the diameter enlarged by longitudinal section of the left hepatic duct. A 30-cm-long segment of isolated jejunum was passed through the transverse mesocolon to the right of the middle colic vessels and behind the duodenum and then interposed between the hepatic confluence and the second portion of the duodenum. Biliary-jejunal anastomosis was performed in 1 layer with interrupted absorbable stitches. No mortality or serious complications occurred during follow-up (1-4 years). No cholangitis, fever, or pain have developed. All patients were studied postoperatively by biochemical test, ultrasonography, Tc 99m DISIDA, and barium meal swallow. Good liver function and biliary excretion, and absence of duodeno-jejuno biliary reflux were demonstrated.

Unselective end-to-side proximal left-gastric-caval shunt without splenectomy. Indications and technique.

From 1976 to 1982, 104 patients with bleeding esophageal varices were treated surgically. In three patients a wide left gastric vein without portal flow was demonstrated by means of arterial splenoportography. Ascites estimated at between 4-to-6 liters was observed in two patients. Anemia, leukopenia and platelet counts below 85 X 10(9)/l were shown in all of three. Liver panangiography was performed on all three patients. Given the absence of portal flow, the presence of intractable ascites and the demonstration of a wide left gastric vein, we dissect this vein disconnecting it from the stomach, and performing the anastomosis between the proximal end of this vessel and the inferior vena cava (proximal unselective left gastric caval shunt). Ascites and esophageal varices disappeared in our three patients between one and three weeks after the operation. The shunts were patent between eight months to eight and a half years after the operation. All three patients are still living.

[A nonselective proximal end-to-side shunt between the gastric vein and the inferior vena cava (coronario-caval shunt). Indication, technic and results]. / Ein nicht-selektiver proximaler End-zu-Seit-Shunt zwischen Vena coronaria ventriculi und Vena cava inferior (coronario-cavaler Shunt). Indikation, Technik und Ergebnisse.

From 1976 to 1982, 104 patients with bleeding esophageal varices were treated surgically. In three patients a wide left gastric vein without portal flow was demonstrated by means of arterial splenoportography. Ascites estimated between 4 to 61 was observed in two patients. Anemia, leukopenia, platelet counts inferior to 85 X 10(9)/l were shown in all of them. Liver panangiography was done in the three patients. According to the absence of portal flow, the presence of intractable ascites and the demonstration of a wide left gastric vein, we dissect this vein disconnecting it from the stomach, and performing the anastomosis between the proximal end of this vessel and the inferior caval vena (proximal unselective left gastric caval shunt). Ascites and esophageal varices disappeared in the three patients between 1 and 3 weeks after the operation. The shunts were confirmed open between eight months to eight and a half years after operation. All the three patients are still living.

Results of fundic patch operation for severe stricture of the esophagus.

Eighteen patients ranging in age from 32-82 years with benign distal esophageal stricture underwent and survived fundic patch operation. Twelve of these patients had undergone esophageal dilatation but without success. Five had had surgery for hiatal hernia using Hill, Belsey or Lortat-Jacob techniques. Middle laparotomy was done in five and left thoracotomy in thirteen. A fundic patch with a 270 degrees fundoplication was performed in seven and a fundic patch with 360 degrees fundoplication in the remaining eleven. The average hospital stay was 12.3 days. Dysphagia disappeared in seventeen and persisted for eight months in one patient. Three patients required instrumental dilatation for a few months. Endoscopic examination, pH study and X-ray fluoroscopy were done. Gastroesophageal reflux was nil in patients treated with Nissen's 360 degrees fundoplication and three of these 7 patients without Nissen's fundoplication had gastroesophageal reflux. Epithelialization of the patched esophageal wound was evident 6 months after the operation.

Left gastric arteriovenous fistula after selective distal splenorenal shunt.

We present the case of a 64-year-old alcoholic who had suffered two episodes of hemorrhage from esophageal varices. For control of variceal hemorrhage, he underwent a distal splenorenal shunt. His immediate postoperative course was complicated by the development of marked ascites and intermittent episodes of encephalopathy. Routine postoperative angiography was performed after 4 months and demonstrated a fistula between the left gastric artery and vein. Patency of the shunt was demonstrated by direct percutaneous splenoportography. Two months after this admission, the patient was readmitted with the complaints of anorexia and nausea. Marked encephalopathy was noted. Eight hours following admission, he developed acute abdominal distention and hypotension. An abdominal tap revealed bloody fluid, and the patient was immediately prepared for transport to the operating room. He suffered cardiac arrest during transport, and all efforts at resuscitation were unsuccessful. Although a postmortem examination was not performed, it is suspected the arteriovenous fistula resulted in severe portal venous hypertension leading to intraperitoneal rupture of one of the affected veins, producing a massive hemoperitoneum.

Pancreato-biliary-duodenal interposition of isolated jejunal loop in the surgical treatment of selected cases of chronic pancreatitis.

Eight patients suffering from symptoms of chronic pancreatitis with dilation of Wirsung's and common bile ducts were selected for a double biliary and pancreatic diversion by interposition of two jejunal loops between these ducts and the duodenum. In three patients a single loop was used, performing an anastomosis on the proximal end to the Wirsung duct about 45 centimeters below the anastomosis between the common duct and the jejunum. The distal end of this loop was anastomosed end-to-side to the duodenum. In five patients two different jejunal loop were used. While the proximal end of one loop was anastomosed to the Wirsung duct, the proximal end of the second loop was anastomosed to the common bile duct. End-to-side anastomosis was then performed between the distal end of both loops and the duodenum. There were no deaths or serious complications. The minimum follow-up was twelve months and the maximum three and half years, all the patients being without symptoms and with normalization of the laboratory tests three months after operation.

Biliary and pancreatoduodenal diversion by means of an isolated jejunal loop.

Seven patients suffering from chronic pancreatitis, with dilatation of the duct of Wirsung and obstruction of the intrapancreatic segment of the choledochus, underwent a pancreatic and biliary jejunoduodenal diversion. An isolated jejunal loop was used as a conduit between the bile and pancreatic ducts and duodenum in 3 patients, while in 4 patients separate isolated loops between the duct and duodenum were fashioned. The postoperative period passed without incident. All the patients were symptom free 3 months after operation.

Treatment of splenic artery aneurysm after distal splenorenal shunt. A case report.

A patient with splenic artery aneurysm which developed after creation of selective distal spleno-renal shunt for hepatic cirrhosis and portal hypertension was presented. Three months after operation, an aneurysm of the splenic artery with a diameter of about 20 mm was detected. This aneurysm reached 4 cm three months later, and a resection was carried out. An arterial continuity was established by means of end-to-end anastomosis of the sectioned arterial ends. Because the flow through the splenic artery was about 60% of the total flow of the selective distal spleno-renal shunt, it is important to maintain continuity in order to avoid thrombosis of the shunt.