CTRP7 deletion attenuates obesity-linked glucose intolerance, adipose tissue inflammation, and hepatic stress.

Chronic low-grade inflammation and cellular stress are important contributors to obesity-linked metabolic dysfunction. Here, we uncover an immune-metabolic role for C1q/TNF-related protein 7 (CTRP7), a secretory protein of the C1q family with previously unknown function. In obese humans, circulating CTRP7 levels were markedly elevated and positively correlated with body mass index, glucose, insulin, insulin resistance index, hemoglobin A1c, and triglyceride levels. Expression of CTRP7 in liver was also significantly upregulated in obese humans and positively correlated with gluconeogenic genes. In mice, Ctrp7 expression was differentially modulated in various tissues by fasting and refeeding and by diet-induced obesity. A genetic loss-of-function mouse model was used to determine the requirement of CTRP7 for metabolic homeostasis. When fed a control low-fat diet, male or female mice lacking CTRP7 were indistinguishable from wild-type littermates. In obese male mice consuming a high-fat diet, however, CTRP7 deficiency attenuated insulin resistance and enhanced glucose tolerance, effects that were independent of body weight, metabolic rate, and physical activity level. Improved glucose metabolism in CTRP7-deficient mice was associated with reduced adipose tissue inflammation, as well as decreased liver fibrosis and cellular oxidative and endoplasmic reticulum stress. These results provide a link between elevated CTRP7 levels and impaired glucose metabolism, frequently associated with obesity. Inhibiting CTRP7 action may confer beneficial metabolic outcomes in the setting of obesity and diabetes.

Early hospital readmission after bariatric surgery.

BACKGROUND: With the rise in bariatric procedures being performed nationwide and the growing focus on quality and outcome measures, reducing early hospital readmission (EHR) rates has garnered great clinical interest. The aim of this study was to identify the incidence, reasons, and risk factors for EHR after bariatric surgery. METHODS: Using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset (2012-2013), patients with a diagnosis of obesity and body mass index ≥35 who underwent bariatric surgery were identified. EHR was defined as at least one hospitalization within 30 days of bariatric procedure. The association between readmission and patient factors was assessed using multivariable logistic regression analysis. In addition, reasons for readmission were sought. RESULTS: A total of 36,042 patients were identified. The overall EHR rate was 4.70 % [laparoscopic (lap) adjustable band 1.87 %, lap gastric bypass (GBP) 5.94 %, open GBP 7.86 %, and sleeve gastrectomy 3.73 %], and it occurred at the median of 11 days postoperatively. The rate of EHR significantly decreased from 2012 to 2013 (5.15 vs. 4.32 %, p < 0.001). The median age and BMI were 44 years and 44.7 kg/m(2), respectively, 78.99 % were female, and 70.78 % were white. The most common reason for readmission was nausea/vomiting (12.95 %), followed by abdominal pain (11.75 %) and dehydration (10.54 %). On multivariable analysis, factors most strongly associated with readmission were procedure type (lap band: reference; open GBP: OR 3.78, 95 % CI 2.47-5.80; lap GBP 3.18, 2.39-4.22; sleeve gastrectomy: 2.03, 1.52-2.71; all p < 0.001), steroid use (1.82, 1.33-2.48, p < 0.001), pre-discharge complication (1.64, 1.20-2.24, p < 0.001), and black population (1.51, 1.34-1.71, p < 0.001). CONCLUSIONS: Bariatric centers should consider implementing standardized protocols for outpatient monitoring of patients identified to be at high risk of experiencing early readmission, which in turn would decrease overall costs and improve quality of care.

Decreased Escitalopram Concentrations Post-Roux-en-Y Gastric Bypass Surgery.

BACKGROUND: There is a high coincidence between obesity and psychiatric disorders including depression. Depressive disorders are commonly treated with antidepressants, including the selective serotonin reuptake inhibitor Lexapro (escitalopram). Although candidates for elective Roux-en-Y gastric bypass (RYGB) surgery may be treated with escitalopram, drug dosing strategies are typically not adjusted postoperatively. Therefore, studies are needed to better characterize escitalopram drug concentrations in a postsurgical setting. METHODS: Turbulent flow-liquid chromatographic-tandem mass spectrometric methods were used to quantify escitalopram concentrations in serum in study participants approved for RYGB. Blood was collected from study subjects 2 weeks before surgery, and 2 and 6 weeks postoperatively, to assess the impact of RYGB on systemic drug concentrations. RESULTS: Twelve samples from 4 study participants were collected and analyzed for serum escitalopram concentrations. Two weeks post-RYGB, although there were minimal changes in each participant's body mass index (<5%), drug concentrations were 33% (4%-71%) decreased as compared with presurgical serum concentrations. There were further decreases in drug concentrations 6 weeks postsurgery. All clinical laboratory values were within normal reference intervals. CONCLUSIONS: RYGB significantly alters the gastrointestinal tract and impacts escitalopram drug concentrations, even shortly after surgery.

The effect of warm-up on surgical performance: a systematic review.

BACKGROUND: The concept of warming-up before a performance has been accepted across many disciplines including sports and music. In contrast, it is uncommon for a surgeon to "warm-up" prior to operating. OBJECTIVE: To date, few studies from various specialties have attempted to answer this question whether warm-up improved the intraoperative performance of the surgeon. However, there has not been a systematic review of these studies. The aim of our systematic review is to assess the effect of warming-up preoperatively on the laparoscopic performance of the surgeon. METHODS: Pubmed and scopus were searched to identify all published prospective observational studies, which involved either residents, fellows or attending surgeons. We excluded case reports, reviews, non-English studies, and medical student participation. Study risk of bias were assessed regarding sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases, using a validated Cochrane Collaboration's tool. RESULTS: Out of 241 studies, 6 met the inclusion criteria. All included studies were randomized with half of them being randomized controlled studies and the rest randomized crossover studies. The total number of operative cases was 196, including 98 warm-up and 98 non warm-up. The total number of participants was 87, with the largest number in a single study being 38 and the average sample size of all studies was 14. All six studies assessed various aspects of laparoscopic surgical performances. Significant improvement in the intraoperative laparoscopic performance was observed with warming-up preoperatively in five out of six studies (p < 0.05). The sixth study failed to reach statistical significance (p > 0.05). CONCLUSION: Warming-up before an operative procedure improve a trainee's technical, cognitive, and psychomotor performance. Further studies are necessary to assess the ways in which warm-up could impact a surgeon's performance, and to identify the optimal timing and duration of warm-up prior to operating.

Preoperative warm-up the key to improved resident technique: a randomized study.

BACKGROUND: The ACGME has required that a skills lab be incorporated into the surgical residency curriculum. While the value of warm-up is generally accepted in other areas requiring complex motor skills, there is little evidence to support the benefits of warm-up prior to performing surgery. We are conducting this study in an attempt to identify whether a warm-up period prior to operating impacts operative technique. METHODS: All general surgery residents and MIS fellows were included in this IRB-approved randomized study. Participants were randomized to either warm-up or no warm-up groups. Participants randomized to the warm-up group completed a 10 min practice session in the simulation lab within 1 h of starting the case, using an FLS training box. At the conclusion of the operation, the participant was evaluated by the attending surgeon using the validated global rating scales of Reznick and Vassiliou. The attending surgeons were blinded to the use of pre-procedure warm-up. The results of the questionnaire were analyzed using student's t test with p < 0.05 for significance. RESULTS: Pilot data were obtained after completing 40 cases that were randomized to warm-up (19) or no warm-up (21). There was a statistically significant improvement in depth perception (p = 0.02), bimanual dexterity (p = 0.01), and efficiency of movements (p = 0.03) for those randomized to warm-up. There was statistical improvement when we preformed a composite scoring of the attending evaluations for each of the Reznick (p = 0.008) and the Vassiliou (p = 0.01) global rating scales. CONCLUSIONS: Preoperative warm-up significantly improves depth perception, bimanual dexterity, and efficiency of movements, as well as improvement in composite scores as judged by the attending surgeon. The lack of self-perceived improvement by the residents may be a reflection of the high standards and intense self-critique that is common among surgical trainees. We believe that our findings, while preliminary, reflect that surgical performance can be enhanced through structured warm-up activities.

Hospital-acquired conditions after bariatric surgery: we can predict, but can we prevent?

BACKGROUND: Centers for Medicare and Medicaid Services initiated a non-payment policy for certain hospital-acquired conditions (HACs) in 2008. This study aimed to determine the rate of the three most common HACs (surgical site infection (SSI), urinary tract infection (UTI), and venous thromboembolism (VTE)) among bariatric surgery patients. Additionally, the association of HACs with patient factors and the effect of HACs on post-operative outcomes were investigated. METHODS: Patients over 18 years with a body mass index (BMI) ≥ 35 who underwent bariatric surgery were identified using the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012). Patients were grouped into two categories: HAC versus no HAC patients and baseline characteristics and outcomes, including 30-day mortality, reoperation, and mean length of stay (LOS) were compared. Multivariable logistic regression analysis was performed to identify the risk factors for developing a HAC. RESULTS: 98,553 patients were identified, 2,809 (2.9%) developed at least one HACs. SSI was the most common HAC (1.8%), followed by UTI (0.7%) and VTE (0.4%). The rate of these HACs significantly decreased from 4.6% in 2005-2006 to 2.5% in 2012 (p < 0.001). Laparoscopic gastric banding was associated with the lowest rates of HAC (1.3%) and open gastric bypass with the highest (8.0%). HAC patients had significantly higher rates of in-hospital mortality (0.8 vs. 0.1%, p < 0.001) and LOS (3.9 vs. 2.1 days, p < 0.001). On adjusted analysis, open GBP patients had 5.36-fold higher odds of developing a HAC. Interestingly, the presence of a resident surgeon 7-11 years post graduation was associated with significantly increased odds of HACs (1.86, 1.50-2.31, p < 0.001). CONCLUSION: Our data demonstrate a strong correlation between these three HACs following bariatric surgery and factors intrinsic to the bariatric patient population. This calls into question the non-payment policy for inherent patient factors on which they cannot have impact. These findings are important to help inform health care policy decisions regarding access to care for bariatric surgery patients.

A single institutional comparison of endoscopic and open abdominal component separation.

BACKGROUND: The authors analyzed surgical factors and outcomes data in the largest single institutional study comparing endoscopic (ECS) and open component separation (OCS) in ventral hernia repairs (VHR). METHODS: A prospectively maintained database was reviewed, identifying 76 patients who underwent component separation for VHR with mesh from 2010 to 2013: 34 OCS and 42 ECS. Comparisons were made for demographics, surgical risk factors, and peri-operative outcomes. Wound complications and hernia occurrence post-operatively were reviewed. Risk analyses were performed to determine the association of pre-operative risk factors with surgical site occurrences. RESULTS: Twenty-five ECS patients underwent subsequent laparoscopic hernia repair, and 17 underwent open repair. Operative time for ECS was longer than OCS (334 vs. 239 min; P < 0.001); however, there was no difference in length of stay (4 days in both groups, P = 0.64) and estimated blood loss (ECS: 97 vs. OCS: 93 cc, P = 0.847). In a sub-analysis of ECS patients, those who underwent laparoscopic hernia repair had a 96 min shorter operative time (P < 0.001) and lower EBL (63 vs. 147 cc, P < 0.001) than open repair. Wound complications were 24% in the ECS (n = 10) and 32% in OCS group (n = 11). There was one midline hernia recurrence in the ECS group (mean follow-up of 8 months, range 0.5-34.5 months) and no hernia recurrences in the OCS group (mean follow-up 10 months, range 0.5-30 months). Three of the patients in the ECS group developed new lateral abdominal wall hernias post-operatively. CONCLUSIONS: The ECS group had a significantly longer operative time than the OCS group. Post-operative wound complications were similar between ECS and OCS groups. Patients in the ECS group who underwent subsequent laparoscopic VHR had a shorter operative time and blood loss than open repair.

Sleep apnea predicts distinct alterations in glucose homeostasis and biomarkers in obese adults with normal and impaired glucose metabolism.

BACKGROUND: Notwithstanding previous studies supporting independent associations between obstructive sleep apnea (OSA) and prevalence of diabetes, the underlying pathogenesis of impaired glucose regulation in OSA remains unclear. We explored mechanisms linking OSA with prediabetes/diabetes and associated biomarker profiles. We hypothesized that OSA is associated with distinct alterations in glucose homeostasis and biomarker profiles in subjects with normal (NGM) and impaired glucose metabolism (IGM). METHODS: Forty-five severely obese adults (36 women) without certain comorbidities/medications underwent anthropometric measurements, polysomnography, and blood tests. We measured fasting serum glucose, insulin, selected cytokines, and calculated homeostasis model assessment estimates of insulin sensitivity (HOMA-IS) and pancreatic beta-cell function (HOMA-B). RESULTS: Both increases in apnea-hypopnea index (AHI) and the presence of prediabetes/diabetes were associated with reductions in HOMA-IS in the entire cohort even after adjustment for sex, race, age, and BMI (P = 0.003). In subjects with NGM (n = 30), OSA severity was associated with significantly increased HOMA-B (a trend towards decreased HOMA-IS) independent of sex and adiposity. OSA-related oxyhemoglobin desaturations correlated with TNF-α (r=-0.76; P = 0.001) in women with NGM and with IL-6 (rho=-0.55; P = 0.035) in women with IGM (n = 15) matched individually for age, adiposity, and AHI. CONCLUSIONS: OSA is independently associated with altered glucose homeostasis and increased basal beta-cell function in severely obese adults with NGM. The findings suggest that moderate to severe OSA imposes an excessive functional demand on pancreatic beta-cells, which may lead to their exhaustion and impaired secretory capacity over time. The two distinct biomarker profiles linking sleep apnea with NGM and IGM via TNF-α and IL-6 have been discerned in our study to suggest that sleep apnea and particularly nocturnal oxyhemoglobin desaturations are associated with chronic metabolic fluxes and specific cytokine stressors that reflect links between sleep apnea and glucose metabolism. The study may help illuminate potential mechanisms for glucose dysregulation in OSA, and resolve some controversy over the associations of OSA with TNF-α and IL-6 in previous studies.

Cytokine, Chemokine, and Cytokine Receptor Changes Are Associated With Metabolic Improvements After Bariatric Surgery.

Context: Altered cytokine levels and chronic low-grade inflammation contribute to metabolic dysfunction in obesity. The extent of cytokine changes and their impact on metabolic improvements after bariatric surgery have not been fully explored. Objective: To compare 76 circulating cytokines, chemokines, and secreted cytokine receptors in subjects with obesity and lean subjects and determine how these cytokines are altered by bariatric surgery. Design, Setting, and Participants: A total of 37 patients with obesity and 37 lean patients in a cross-sectional study at an academic medical center. We also investigated cytokine changes in 25 patients with obesity after bariatric surgery. Intervention: Bariatric surgery (Roux-en-Y gastric bypass and vertical sleeve gastrectomy). Main Outcome Measures: Quantification of 76 circulating cytokines, chemokines, and secreted cytokine receptors. Results: A total of 13 cytokines were significantly higher, and 4 lower, in patients with obesity relative to lean controls. Soluble vascular endothelial growth factor receptor 2 (sVEGFR2), soluble TNF receptor (sTNFR) 1, and sTNFR2 were positively correlated, and soluble receptor for advanced glycation end-products was inversely correlated, with weight and body mass index. sTNFR2 was positively correlated with fasting glucose, homeostatic model assessment of insulin resistance, and hemoglobin A1c. After bariatric surgery, adiponectin increased, and leptin decreased. Elevated sVEGFR2 levels in patients with obesity were decreased (P = 0.01), whereas reduced chemokine (C-X-C motif) ligand (CXCL) 12 levels in patients with obesity increased (P = 0.03) after surgery. Patients with higher soluble interleukin receptor (sIL) 1R2 and sIL-6R levels before surgery had greater weight loss after surgery (P < 0.05). Conclusions: We demonstrate that chemokine (C-C motif) ligand (CCL) 14, sVEGFR2, and platelet-derived growth factor BB are elevated in obesity, and CXCL12, CCL11, and CCL27 are lower in obesity. We found clinically concordant directionality between lean and patients with obesity and before vs after surgery for six cytokines, suggesting that bariatric surgery shifted the cytokine profiles of patients with obesity toward that of lean controls.

Obesity is associated with copper elevation in serum and tissues.

Copper misbalance has been linked to fat accumulation in animals and experimental systems; however, information about copper homeostasis in human obesity is limited. In this study, the copper status of obese individuals was evaluated by measuring their levels of copper and cuproproteins in serum, adipose and hepatic tissues. The analysis of serum trace elements showed significant positive and element-specific correlation between copper and BMI after controlling for gender, age, and ethnicity. Serum copper also positively correlated with leptin, insulin, and the leptin/BMI ratio. When compared to lean controls, obese patients had elevated circulating cuproproteins, such as semucarbazide-sensitive amine oxidase (SSAO) and ceruloplasmin, and higher SSAO activity and copper levels in visceral fat. Although hepatic steatosis reduces copper levels in the liver, obese patients with no or mild steatosis have higher copper content in the liver compared to lean controls. In conclusion, obese patients evaluated in this study had altered copper status. Strong positive correlations of copper levels with BMI and leptin suggest that copper and/or cuproproteins may be functionally linked to fat accumulation.

Suboptimal weight loss after gastric bypass surgery: correlation of demographics, comorbidities, and insurance status with outcomes.

Although Roux-en-Y gastric bypass surgery (RYGBP) is safe and effective at achieving weight loss in the majority of severely obese patients, a subset fails to achieve expected weight loss outcomes. Factors associated with poor weight loss are not well defined. Patients undergoing open RYGBP using a standardized surgical technique and clinical pathway by a single surgeon at a dedicated bariatric center were reviewed. Suboptimal weight loss was defined as failure to lose at least 40% excess body weight by 12 months postoperatively. Of 555 consecutive patients who underwent RYGBP from 1999 to 2004, a 12-month follow-up was available for the 495 (89%). Suboptimal weight loss occurred in 55 (11%) and was associated on unadjusted bivariate analysis with increased body mass index (BMI; p = 0.0002), diabetes mellitus (p = 0.0002), Medicaid insurance (p = 0.04), and male sex (p = 0.01). On adjusted multivariate analysis, increased BMI (p = 0.003), diabetes (p = 0.002), and male gender (p = 0.04) were associated with suboptimal weight loss, but type of insurance (p = 0.11) was not. Medicaid patients were younger (p = 0.01) and had higher BMI (p = 0.0002). Suboptimal weight loss after RYGBP appears to be associated with greater BMI, male sex, and diabetes but not type of insurance. This study may help identify patients who could benefit from increased perioperative education and counseling or selection of procedures with greater malabsorption.

The Role of Laboratory Testing in Differentiating Type 1 Diabetes from Type 2 Diabetes in Patients Undergoing Bariatric Surgery.

BACKGROUND: It may be difficult to distinguish between adults with type 1 diabetes and type 2 diabetes by clinical assessment. In patients undergoing bariatric surgery, it is critical to correctly classify diabetes subtype to prevent adverse perioperative outcomes including diabetic ketoacidosis. This study aimed to determine whether testing for C-peptide and islet cell antibodies during preoperative evaluation for bariatric surgery could improve the classification of type 1 versus type 2 diabetes compared to clinical assessment alone. METHODS: This is a retrospective analysis of the Improving Diabetes through Lifestyle and Surgery trial, which randomized patients with clinically diagnosed type 2 diabetes and BMI 30-40 kg/m2 to medical weight loss or bariatric surgery; one participant was discovered to have type 1 diabetes after experiencing postoperative diabetic ketoacidosis. Using blood samples collected prior to study interventions, we measured islet cell antibodies and fasting/meal-stimulated C-peptide in all participants. RESULTS: The participant with type 1 diabetes was similar to the 11 participants with type 2 diabetes in age at diagnosis, adiposity, and glycemic control but had the lowest C-peptide levels. Among insulin-treated participants, fasting and stimulated C-peptide correlated strongly with the C-peptide area-under-the-curve on mixed meal tolerance testing (R = 0.86 and 0.88, respectively). Three participants, including the one with type 1 diabetes, were islet cell antibody positive. CONCLUSIONS: Clinical characteristics did not correctly identify type 1 diabetes in this study. Preoperative C-peptide testing may improve diabetes classification in patients undergoing bariatric surgery; further research is needed to define the optimal C-peptide thresholds.

Inversion Technique for the Removal of Partially Covered Self-Expandable Metallic Stents.

BACKGROUND AND AIMS: Partially covered self-expandable metallic stents (PCSEMS), although an effective treatment for anastomotic/staple line leaks and strictures, can be difficult to remove. This study examines the effectiveness of the inversion technique for the removal of PCSEMS in the treatment of leaks and strictures that occurred post-sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). METHODS: Consecutive patients who underwent PCSEMS removal for a leak and/or stricture post-SG or RYGB between July 2013 and December 2016 at the Johns Hopkins Medical Institutions were reviewed. All PCSEMS removals were first attempted via the inversion technique, which involves grasping the distal end of the stent and inverting it through itself. RESULTS: Fourteen patients (four males) underwent PCSEMS removal via the inversion technique for an anastomotic/staple line leak (50%), stricture (29%) or both (21%) post-SG (79%) or RYGB (21%). Technical success (successful removal of the stent) was achieved in one endoscopic session for 13 of the 14 PCSEMS (93%). One PCSEMS required the use of the stent-in-stent technique for removal. The median dwell time was 47 days (range 5-72). A distal partial occlusion developed in five patients (35%) due to tissue overgrowth and one PCSEMS (7%) migrated, necessitating premature removal. Eight patients (57%) experienced clinical success at follow-up, and six patients (43%) required subsequent treatment due to persistence or recurrence of the pathology. CONCLUSIONS: The inversion technique is a safe, effective, and efficient method of removing PCSEMS placed to correct anastomotic/staple line leaks and strictures post-SG and RYGB.

A zero leak rate in 251 consecutive laparoscopic gastric bypass operations using a two-layer gastrojejunostomy technique.

PURPOSE: Laparoscopic Roux-en-Y gastric bypass is quickly replacing open techniques in the morbidly obese patient who presents for surgical treatment. Safety concerns about the laparoscopic technique have arisen in the literature with gastrojejunostomy leak rates of 5% or greater reported in several series. MATERIALS AND METHODS: A total of 251 consecutive gastric bypass operations were performed from August 2001 to January 2004 by a single surgeon with over 6 years' experience. A double layer technique was used for every gastrojejunostomy anastomosis. This consisted of end-to-side stapled anastomosis using only 30 mm of a 45 mm blue (3.5 mm) staple cartridge that was fired inside the gastric pouch and Roux limb. A posterior running suture was then used to reinforce the back wall. An intraluminal 32F bougie was placed before the stapler opening was closed. Finally, 2 running sutures were used to reinforce the anterior and lateral sides of the anastomosis. RESULTS: The average patient age was 43 years (range, 18-67 years), 89% were female, average preoperative weight was 137 kg (range, 89.5-214.5 kg), and average body mass index of 49 kg/m2 (range, 35-75). One hundred forty-two cases were performed with the Ethicon endoscopic linear stapler and 109 with the United States Surgical endoscopic linear stapler. There were no anastomotic leaks, staple line leaks, pulmonary emboli, or in-hospital deaths recorded. Endoscopic dilation successfully treated 10 (4%) cases of stomal stenosis. Eleven (4%) patients developed marginal ulcers that were easily treated with a proton pump inhibitor. Average excess weight loss at 12 months and 18 months was 63% and 71%, respectively. CONCLUSIONS: Laparoscopic results are as good as or better than open surgery in the morbidly obese patient. The learning curve for this operation is steep and this may be reflected in the higher leak rates reported in earlier series. However, the technique used to create the gastrojejunostomy anastomosis may also account for a lower leak rate. The two-layer gastrojejunostomy anastomotic technique combines an inner stapled layer and outer sutured layer that yields excellent results.

Treatment for Vitamin D Deficiency Prior to Bariatric Surgery: a Prospective Cohort Study.

BACKGROUND: Since obesity increases vitamin D deficiency (VDD) risk, bariatric surgery candidates are high-risk. Previously, we documented 71.4% VDD at our center. OBJECTIVES: To investigate diagnosis and treatment for VDD in our bariatric candidates. METHODS: 25(OH)D, if pending, and supplementation (form, dosing, frequency) were prospectively documented in 265 candidates. RESULTS: Candidates were 83.0% female, 48.9% white, age 43 ± 13 years and BMI 46.3 ± 10.5 kg/m(2). 25(OH)D was available for 18.5%: 35.7% VDD 39.3% insufficiency. VDD history did not differ by demographics or procedure, as with those tested versus not. CONCLUSION: VDD testing was lower than clinically-indicated. Of those tested, 35.7% were deficient and 39.3% insufficient. We previously reported higher rates: 71.4% deficiency, 92.9% insufficiency. Thus, many candidates are untested but high-risk.

Malnutrition in Bariatric Surgery Candidates: Multiple Micronutrient Deficiencies Prior to Surgery.

BACKGROUND: Over 78 million American adults have obesity. Bariatric surgery is the leading means of durable weight loss. Nutritional deficiencies are commonly treated post-operatively but are often undiagnosed pre-operatively. Malnutrition is correlated with adverse surgical outcomes. OBJECTIVES: The aim of this study is to assess pre-operative nutritional status in our bariatric surgery candidates in a cross-sectional study. METHODS: We recruited 58 bariatric candidates approved to undergo the Roux-en Y gastric bypass. Nutritional status was determined for vitamins A, B12, D, E-α, and E-ß/γ as well as thiamine, folate, and iron. We used clinical as well as frank deficiency cut-offs based on the Institute of Medicine and the World Health Organization guidelines. RESULTS: This cohort was largely female (77.6%) and white (63.8%). Median age was 42.2 years. Median body mass index (BMI) was 46.3 kg/m(2). Multiple comorbidities (MCM) were present in 41.4%, 54.0% hypertension, 42.0% diabetic, 34.0% sleep apnea. Men had more comorbidities, 69.2 % with MCM. Folate and iron saturation varied significantly by sex. Vitamins A, D, E-α, and thiamine significantly varied by race. Vitamin D negatively correlated with BMI (p = 0.003) and age (p = 0.030). Vitamin A negatively correlated with age (p = 0.001) and number of comorbidities (p = 0.003). These pre-operative bariatric candidates had significant malnutrition, particularly in vitamin D (92.9%) and iron (36.2 to 56.9 %). Multiple micronutrient deficiency (MMND) was more common in blacks (50.0 versus 39.7% overall). Number of comorbidities did not correlate with MMND. CONCLUSIONS: Malnutrition in one or multiple micronutrients is pervasive in this pre-operative bariatric cohort. The effect of pre-operative supplementation, especially vitamin D and iron, should be explored.

C1q/TNF-Related Protein-9 (CTRP9) Levels Are Associated With Obesity and Decrease Following Weight Loss Surgery.

CONTEXT: C1q/TNF-related protein-9 (CTRP9) is a novel adipokine that has beneficial metabolic and cardiovascular effects in various animal models. Alterations in circulating CTRP9 have also been observed in patients with cardiovascular disease and diabetes, but little is known about the impact of obesity and bariatric surgery on CTRP9 concentrations. OBJECTIVE: The aim of this study was to compare CTRP9 levels in obese and lean subjects and to determine whether circulating CTRP9 levels in morbidly obese patients are altered by bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS: Fifty-nine obese bariatric surgical patients and 62 lean controls were recruited to participate in a cross-sectional study at an academic medical center. The obese patients were further invited to participate in a cohort study, and 21 returned for analysis at 3 and 6 months postsurgery. INTERVENTION: Bariatric surgery (Roux-en-Y gastric bypass and vertical sleeve gastrectomy) was the intervention for this study. MAIN OUTCOME MEASURES: Fasting serum was obtained from all subjects on entry to the study and was analyzed in the core laboratory for hemoglobin A1c, glucose, aspartate aminotransferase, alanine aminotransferase, total cholesterol, high- and low-density lipoprotein cholesterol, and triglycerides; CTRP9, insulin, adiponectin, and leptin were measured by ELISA. Serum from the patients in the cohort study was also analyzed at 3 and 6 months. RESULTS: Serum CTRP9 was significantly higher in the obese group compared to the lean group. CTRP9 was associated with obesity, even after controlling for age, gender, and ethnicity. Following bariatric surgery, there was a significant decrease in weight at 3 and 6 months postprocedure, accompanied by decreases in CTRP9, hemoglobin A1c and leptin, and an increase in serum adiponectin. CONCLUSIONS: CTRP9 levels are elevated in obesity and significantly decrease following weight loss surgery. Our data suggest that CTRP9 may play a compensatory role in obesity, similar to that of insulin, and is down-regulated following weight loss surgery.

Vitamin D status and supplementation before and after bariatric surgery: a comprehensive literature review.

BACKGROUND: Bariatric surgery is the most effective long-term weight loss method. The most common procedures are Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG). Bariatric patients are at high risk of vitamin D deficiency (VDD) and insufficiency (VDI), which are associated with skeletal and nonskeletal ailments. There is no consensus regarding the optimal treatment for VDD/VDI in bariatric patients. OBJECTIVES: To critically examine the literature on vitamin D status (serum 25[OH]D concentrations) pre- and postbariatric surgery as well as supplementation regimens currently used. METHODS: We searched PubMed, Embase, and Cochrane from inception to May 2015 for articles relating to vitamin D, RYGB, and VSG. Of 208 citations retrieved, 30 were included. RESULTS: Preoperative VDD (<20 ng/mL) ranged from 13% to 90%, while VDI (<30 ng/mL) was found in up to 98%. Prevalence remained similar postoperatively and was highest after RYGB. Most studies found dosages<800 IU daily insufficient postbariatric surgery. Other studies examined the effectiveness of dosages between 1000 and 5000 IU daily, reaching similar conclusions. Several studies suggested using 50,000 IU weekly plus a daily dose. No studies reported optimization. CONCLUSIONS: It is widely accepted that serum 25(OH)D concentrations above 30 ng/mL are optimal; however, current postbariatric vitamin D supplementation fails to raise 25(OH)D above that level universally. This review highlights both the great need and the lack of consensus on the optimal supplementation regimen (dosage and frequency) for pre- and postbariatric patients. Future studies should investigate multiple regimens and attempt to identify methods for personalizing these regimens if found necessary.

Race and comorbid factors predict nonalcoholic fatty liver disease histopathology in severely obese patients.

PURPOSE: Nonalcoholic fatty liver disease (NAFLD) is a common and potentially serious form of chronic liver disease. Although NAFLD is known to be associated with obesity and some comorbid conditions, less is known about the severity of NAFLD among different racial groups. METHODS: We prospectively studied 237 consecutive morbidly obese patients presenting for bariatric surgery. All patients underwent intraoperative liver biopsy and chart review. After excluding subjects who reported alcohol use (n = 37) or who had missing biopsy data (n = 11), 189 patients were available for analysis. Clinical and laboratory associations with each of the histological components of NAFLD were assessed using multiple logistic regression analysis. RESULTS: The mean age was 43.1 years, 84% were female, and 13% were African American. It was found that 88% had steatosis, including 35% with moderate to severe steatosis (> 33% of hepatocytes involved). Of these patients, 67% had inflammation, 46% had fibrosis, and 45% met Brunt's criteria for NASH. Compared with Caucasians and after adjustment, African Americans had significantly lower odds of severe hepatic pathology, with adjusted odds ratios of 0.1 (P = .02) for the presence of moderate or severe steatosis, 0.2 for inflammation (P = .006), 0.3 for fibrosis (P = .05), and 0.2 for NASH (P = .02). In addition, participants with one or more features of the metabolic syndrome (ie, diabetes, hypertension, or dyslipidemia) or elevated aminotransferase levels had significantly higher odds of severe hepatic histopathology. CONCLUSION: Among obese patients presenting for bariatric surgery, NAFLD is more common in Caucasians, patients with features of the metabolic syndrome, and those with elevated aminotransferase levels.

Assessment of postdischarge complications after bariatric surgery: A National Surgical Quality Improvement Program analysis.

BACKGROUND: Little is reported about postdischarge complications after bariatric surgery. We sought to identify the rates of postdischarge complications, associated risk factors, and their influence on early hospital readmission. METHODS: Using the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) (2005-2013), we identified patients ≥18 years of age who underwent a bariatric operation with a primary diagnosis of morbid/severe obesity and a body mass index ≥35. The incidence of postdischarge complication was the primary outcome, and hospital readmission was the secondary outcome. The association between postdischarge complications and various patient factors was explored by the use of multivariable logistic regression. RESULTS: A total of 113,898 patients were identified with an overall postdischarge complication rate of 3.2% within 30 days of operation. The rates decreased from 2005 to 2006 (4.6%) to 2013 (3.0%) (P < .001). On average, postdischarge complications occurred 10 days postoperatively, with wound infection (49.4%), reoperation (30.7%), urinary tract infection (16.9%), shock/sepsis (12.4%), and organ space surgical-site infection (11.0%) being the most common. Patients undergoing open gastric bypass had the greatest postdischarge complication rate of 8.5%. Of those patients experiencing postdischarge complications, 51.6% were readmitted. The overall readmission rate was 4.9%. The factors associated most strongly with increased odds of postdischarge complications were body mass index ≥ 50, use of steroids, procedure type, predischarge complication, prolonged duration of stay, and prolonged operative time. CONCLUSION: Postdischarge complications after bariatric surgery represent a substantial source of patient morbidity and hospital readmissions. The majority of postdischarge complications are infection-related, including surgical-site infections and catheter-associated urinary tract infections. Adopting and implementing standardized pre- and postoperative strategies to decrease perioperative infection may help to decrease the rate of postdischarge complications and associated readmissions and enhance overall quality of care.