Adolescents' views and experiences of treatments for Type 2 diabetes: a qualitative study.

AIM: To explore adolescents' views and experiences of different treatments for Type 2 diabetes, in order to improve treatment concordance and consider how the current treatment pathway for adolescent Type 2 diabetes could be improved. METHODS: In-depth interviews were held with 12 adolescents who had been diagnosed with Type 2 diabetes. Adolescents were sampled from a UK cohort study. Data were analysed thematically. RESULTS: Interviewees struggled to maintain lifestyle changes. Insulin, metformin and liraglutide were described as effective but, in some cases, as resulting in side effects. Injected treatments were viewed less favourably than oral medications. Weight loss surgery was considered an acceptable treatment for obese adolescents who had tried other treatments for their diabetes. It was apparent that some adolescents had not been surprised by their diagnosis and did not fully appreciate the implications of having diabetes. It was also evident that some individuals had not told peers about their diagnosis due to fearing how they would react. Factors identified as improving treatment concordance included reminders and viewing treatment as effective and easy to take. CONCLUSIONS: Adolescents want treatments that are effective, discrete, easy to take and do not make them different from their peers. As liraglutide was described as effective, and surgery viewed as acceptable in certain circumstances, greater consideration should be given to their potential role in treating adolescent Type 2 diabetes. Practitioners need to ensure that adolescents appreciate the implications of having diabetes and may want to address adolescents' concerns regarding how others view this condition.

Bone mineral density and expression of vitamin D receptor-dependent calcium uptake mechanisms in the proximal small intestine after bariatric surgery.

BACKGROUND: Roux-en-Y gastric bypass may lead to impaired calcium uptake. Therefore, operation-specific effects of gastric bypass and vertical banded gastroplasty on bone mineral density (BMD) were examined in a randomized clinical trial. Bone resorption markers and mechanisms of decreased calcium uptake after gastric bypass were investigated using blood and endoscopic samples from two additional patient cohorts. METHODS: Total BMD and non-weight-bearing skull BMD were measured by dual-energy X-ray absorptiometry at baseline, and 1 and 6 years after gastric bypass or vertical banded gastroplasty in patients who were not receiving calcium supplements. Bone resorption markers in serum and calcium uptake mechanisms in jejunal mucosa biopsies were analysed after gastric bypass by proteomics including radioimmunoassay, gel electrophoresis and mass spectrometry. RESULTS: One year after surgery, weight loss was similar after gastric bypass and vertical banded gastroplasty. There was a moderate decrease in skull BMD after gastric bypass, but not after vertical banded gastroplasty (P < 0·001). Between 1 and 6 years after gastric bypass, skull BMD and total BMD continued to decrease (P = 0·001). C-terminal telopeptide levels in serum had increased twofold by 18 months after gastric bypass. Proteomic analysis of the jejunal mucosa revealed decreased levels of heat-shock protein 90ß, a co-activator of the vitamin D receptor, after gastric bypass. Despite increased vitamin D receptor levels, expression of the vitamin D receptor-regulated calcium transporter protein TRPV6 decreased. CONCLUSION: BMD decreases independently of weight after gastric bypass. Bone loss might be attributed to impaired calcium absorption caused by decreased activation of vitamin D-dependent calcium absorption mechanisms mediated by heat-shock protein 90ß and TRPV6.

Application of the International Diabetes Federation and American Diabetes Association criteria in the assessment of metabolic control after bariatric surgery.

The International Diabetes Federation (IDF) and the American Diabetes Association (ADA) have introduced specific criteria to define the 'optimization' of the metabolic state and glycaemic 'remission' of type 2 diabetes mellitus (T2DM) after bariatric surgery, respectively. Our objective was to assess the percentage of patients achieving these criteria. Data were collected for body mass index, glycaemic markers, lipids, blood pressure, hypoglycaemia and medication usage from 396 morbidly obese T2DM patients who underwent bariatric surgery in two centres and followed up for 2 years. At year 1, 14% of patients achieved the IDF criteria and 38% the ADA criteria, whereas at 2 years 8 and 9% satisfied these criteria, respectively. A relatively low proportion of patients achieved optimization of the metabolic state and T2DM remission. These patients may potentially benefit from the combination of bariatric surgery and adjuvant medical therapy to achieve optimal metabolic outcomes.

Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes.

Obesity is recognized as a global health crisis. Bariatric surgery offers a treatment that can reduce weight, induce remission of obesity-related diseases, and improve the quality of life. In this article, we outline the different options in bariatric surgery and summarize the recommendations for selecting and assessing potential candidates before proceeding to surgery. We present current data on post-surgical outcomes and evaluate the psychosocial and economic effects of bariatric surgery. Finally, we evaluate the complication rates and present recommendations for post-operative care.

Long-term results of a randomized clinical trial comparing Roux-en-Y gastric bypass with vertical banded gastroplasty.

BACKGROUND: The long-term results of Roux-en-$\hbox{Y}$ gastric bypass (gastric bypass) and vertical banded gastroplasty (VBG) from randomized studies have not been described in detail. METHODS: Patients were randomized to gastric bypass or VBG. Body mass index (BMI), body composition, eating habits and gastrointestinal hormones were reviewed after 6 years. The frequency of reoperation was assessed up to 10 years after surgery. RESULTS: Sixty-six (80 per cent) of the 82 subjects randomized were assessed for weight and BMI 6 years after surgery, 30 (81 per cent) in the gastric bypass group and 36 (80 per cent) in the VBG group. Intention-to-treat analysis demonstrated greater weight loss after gastric bypass compared with VBG, 6 years after surgery: BMI reduced from 41·8 (95 per cent confidence interval 41·3 to 42·3) to 30·3 (28·6 to 32·0) kg/m(2) for gastric bypass and from 42·3 (42·8 to 44·8) to 32·9 (31·3 to 34·5) kg/m(2) for VBG (P = 0·036). Gastric bypass caused a larger loss of fat mass (P = 0·026) and better preservation of lean tissue (P = 0·009). Patients having a gastric bypass had greater postprandial responses to the satiety hormones glucagon-like peptide 1 and peptide YY (P = 0·003 and P = 0·004 respectively). Ghrelin levels did not differ between the groups. Patients with a gastric bypass maintained a lower intake of fat compared with those having VBG (P = 0·013). Some 89 per cent of patients who initially had VBG had undergone, or were scheduled for, conversion to gastric bypass at latest follow-up. CONCLUSION: Gastric bypass was superior to VBG regarding weight loss, body composition, dietary composition and postprandial satiety hormone responses.

Changes in eating behaviour and meal pattern following Roux-en-Y gastric bypass.

BACKGROUND: Little is known about eating behaviour and meal pattern subsequent to Roux-en-Y gastric bypass (RYGB), knowledge important for the nutritional care process. The objective of the study was to obtain basic information of how meal size, eating rate, meal frequency and eating behaviour change upon the RYGB surgery. MATERIALS AND METHODS: Voluntary chosen meal size and eating rate were measured in a longitudinal, within subject, cohort study of 43 patients, 31 women and 12 men, age 42.6 (s.d. 9.7) years, body mass index (BMI) 44.5 (4.9) kg m(-2). Thirty-one non-obese subjects, 37.8 (13.6) years, BMI 23.7 (2.7) kg m(-2) served as a reference group. All subjects completed a meal pattern questionnaire and the Three-Factor Eating Questionnaire (TFEQ-R21). RESULTS: Six weeks postoperatively meal size was 42% of the preoperative meal size, (P<0.001). After 1 and 2 years, meal size increased but was still lower than preoperative size 57% (P<0.001) and 66% (P<0.001), respectively. Mean meal duration was constant before and after surgery. Mean eating rate measured as amount consumed food per minute was 45% of preoperative eating rate 6 weeks postoperatively (P<0.001). After 1 and 2 years, eating rate increased to 65% (P<0.001) and 72% (P<0.001), respectively, of preoperative rate. Number of meals per day increased from 4.9 (95% confidence interval, 4.4,5.4) preoperatively to 6 weeks: 5.2 (4.9,5.6), (not significant), 1 year 5.8 (5.5,6.1), (P=0.003), and 2 years 5.4 (5.1,5.7), (not significant). Emotional and uncontrolled eating were significantly decreased postoperatively, (both P<0.001 at all-time points), while cognitive restraint was only transiently increased 6 weeks postoperatively (P=0.011). CONCLUSIONS: Subsequent to RYGB, patients display markedly changed eating behaviour and meal patterns, which may lead to sustained weight loss.

Two-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS).

CONTEXT: The prevalence of obesity among adolescents has increased and we lack effective treatments. OBJECTIVE: To determine if gastric bypass is safe and effective for an unselected cohort of adolescents with morbid obesity in specialized health care. DESIGN, SETTING AND PATIENTS: Intervention study for 81 adolescents (13-18 years) with a body mass index (BMI) range 36-69 kg m(-2) undergoing laparoscopic gastric bypass surgery in a university hospital setting in Sweden between April 2006 and May 2009. For weight change comparisons, we identified an adult group undergoing gastric bypass surgery (n=81) and an adolescent group (n=81) receiving conventional care. MAIN OUTCOME MEASUREMENTS: Two-year outcome regarding BMI in all groups, and metabolic risk factors and quality of life in the adolescent surgery group. RESULTS: Two-year follow-up rate was 100% in both surgery groups and 73% in the adolescent comparison group. In adolescents undergoing surgery, BMI was 45.5 ± 6.1 (mean ± s.d.) at baseline and 30.2 (confidence interval 29.1-31.3) after 2 years (P<0.001) corresponding to a 32% weight loss and a 76% loss of excess BMI. The 2-year weight loss was 31% in adult surgery patients, whereas 3% weight gain was seen in conventionally treated adolescents. At baseline, hyperinsulinemia (>20 mU l(-1)) was present in 70% of the adolescent surgery patients, which was reduced to 0% at 1 year and 3% at 2 years. Other cardiovascular risk factors were also improved. Two-thirds of adolescents undergoing surgery had a history of psychopathology. Nevertheless, the treatment was generally well tolerated and, overall, quality of life increased significantly. Adverse events were seen in 33% of patients. CONCLUSIONS: Adolescents with severe obesity demonstrated similar weight loss as adults following gastric bypass surgery yet demonstrating high prevalence of psychopathology at baseline. There were associated benefits for health and quality of life. Surgical and psychological challenges during follow-up require careful attention.

Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders.

BACKGROUND: The American Diabetes Association recently defined remission of type II diabetes as a return to normal measures of glucose metabolism (haemoglobin (Hb) A1c below 6 per cent, fasting glucose less than 5·6 mmol/l) at least 1 year after bariatric surgery without hypoglycaemic medication. A previously used common definition was: being off diabetes medication with normal fasting blood glucose level or HbA1c below 6 per cent. This study evaluated the proportion of patients achieving complete remission of type II diabetes following bariatric surgery according to these definitions. METHODS: This was a retrospective review of data collected prospectively in three bariatric centres on patients undergoing gastric bypass, sleeve gastrectomy and gastric banding. RESULTS: Some 1006 patients underwent surgery, of whom 209 had type II diabetes. Median follow-up was 23 (range 12-75) months. HbA1c was reduced after operation in all three surgical groups (P < 0·001). A total of 72 (34·4 per cent) of 209 patients had complete remission of diabetes, according to the new definition; the remission rates were 40·6 per cent (65 of 160) after gastric bypass, 26 per cent (5 of 19) after sleeve gastrectomy and 7 per cent (2 of 30) after gastric banding (P < 0·001 between groups). The remission rate for gastric bypass was significantly lower with the new definition than with the previously used definition (40·6 versus 57·5 per cent; P = 0·003). CONCLUSION: Expectations of patients and clinicians may have to be adjusted as regards remission of type II diabetes after bariatric surgery. Focusing on improved glycaemic control rather than remission may better reflect the benefit of this type of surgery and facilitate improved glycaemic control after surgery.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results. METHODS: Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups. RESULTS: Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001). CONCLUSION: LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.

Body composition and bone health in adolescents after Roux-en-Y gastric bypass for severe obesity.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) causes changes in body composition and bone metabolism, yet little is known about effects in adolescents. OBJECTIVES: The objective of this study was to report dual-energy X-ray absorptiometry measures and serum bone markers, hypothesizing that bone turnover increases after surgery. METHODS: Inclusion criteria included the following: age 13-18 years and body mass index (BMI) >35 kg/m2 . Seventy-two adolescents (22 boys; mean age 16.5 years; BMI 44.8 kg/m2 ) undergoing RYGB underwent dual-energy X-ray absorptiometry and serum bone marker analyses preoperatively and annually for 2 years. RESULTS: Mean BMI reduction at 2 years was 15.1 kg/m2 . Body composition changes included a reduction in fat mass (51.8% to 39.6%, p < 0.001) and relative increase in lean mass (47.0% to 58.1%, p < 0.001). In contrast to previous studies in adults, adolescent boys lost a greater percentage of their body fat than girls (-17.3% vs. -9.5%, p < 0.001). Individual bone mineral density Z-scores (BMD-Z) at baseline were within or above the normal range. The mean (SD) BMD-Z was 2.02 (1.2) at baseline, decreasing to 0.52 (1.19) at 2 years. Higher concentrations of serum CTX (p < 0.001) and osteocalcin (p < 0.001) were observed in boys throughout the study period. Levels rose in the first year, before decreasing modestly in the second. Levels of serum markers of bone synthesis and resorption were higher in boys, whose skeletal maturity occurs later than girls'. CONCLUSIONS: Differences in body fat and lean mass proportions were observed according to sex following RYGB. Bone turnover increased, and BMD decreased to levels approaching a norm for age. Long-term outcome will determine the clinical relevance.

Self-Reported Eating Disorder Symptoms Before and After Gastric Bypass and Duodenal Switch for Super Obesity--a 5-Year Follow-Up Study.

BACKGROUND: This study assessed eating disorder pathology in persons with obesity before and after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (DS), in a 5-year follow-up study. METHODS: Sixty participants with BMI 50-60 kg/m(2) were randomly assigned to RYGB (n = 31) or DS (n = 29). The participants completed the Eating Disorder Examination-Questionnaire (EDE-Q) before and 6 months, 1 year, 2 years, and 5 years after surgery. RESULTS: Before surgery, the prevalence of objective bulimic episodes was 29 % in the RYGB group and 32 % in the DS group. The prevalence improved during the first 12 months after surgery in both groups. After 5 years, the prevalence of objective bulimic episodes was 22 % in the RYGB group and 7 % in the DS group. The difference between groups throughout follow-up was non-significant (logistic regression model). A linear mixed model showed that global EDE-Q score was not a significant predictor for weight loss after surgery, but participants reporting objective bulimic episodes before surgery had significantly lower BMI than those with no episodes after 2 years (p = 0.042) and 5 years (p = 0.013). Global EDE-Q score was significantly lower in the DS group after 5 years (p = 0.009) (linear mixed model). CONCLUSIONS: Objective bulimic episodes but not global EDE-Q score before surgery predicted greater weight loss after RYGB and DS. The DS group had a significantly lower global EDE-Q score than the RYGB group 5 years after surgery.

Bariatric surgery in adolescents: what do we know so far?

INTRODUCTION: Obesity represents a vast and rapidly increasing global burden. Bariatric surgery is the only intervention achieving sustained weight loss, among its wide-ranging benefits. METHODS: In this article, we describe the growing challenges presented by adolescents with severe obesity and review the literature on surgical and other treatment options. RESULTS: Outcomes in terms of weight loss, metabolic and quality of life improvement, reversal of obstructive sleep apnea, insulin resistance, type II diabetes mellitus, hypertension, and dyslipidemia appear comparable to those seen in adults. However, long-term data on safety and sustainability are lacking. There is a growing acceptance of the need for surgery as a treatment for the morbidly obese adolescent population, and the number of studies reporting outcomes after adolescent bariatric surgery is increasing. CONCLUSION: Accumulating evidence suggests that the benefits seen in adult bariatric surgery can be reproduced in adolescents. Thus, adolescent bariatric surgery appears to be safe and effective in achieving benefits desired in terms of weight control and improvements in metabolic health and quality of life. However, particular care must be taken when treating a young population, and long-term outcomes are awaited to properly define indications and limitations.

Formation of the Scandinavian Obesity Surgery Registry, SOReg.

BACKGROUND: Obesity surgery is expanding, the quality of care is ever more important, and learning curve assessment should be established. A large registry cohort can show long-term effects on obesity and its comorbidities, complications, and long-term side effects of surgery, as well as changes in health-related quality of life (QoL). Sweden is ideally suited to the task of data collection and audit, with universal use of personal identification numbers, nation-wide registries permitting cross-matching to analyze causes of death, in-hospital care, and health-related absenteeism. METHOD: In 2004, the Scandinavian Obesity Surgery Registry (SOReg) was initiated and government financing secured. A project group created a national database covering all public as well as private hospitals. Data entry was to be made online, operative definitions of comorbidity were formed, and complication severity scored. Several forms of audit were devised. RESULTS: After pilot studies, the system has been running in its present form since 2007. Since 15 January 2013, SOReg covers all bariatric surgery centers in Sweden. The number of operations in the database exceeded 40,000 (March 2014), with a median follow-up of 2.94 years. Audit shows that >98% of data are correct. All results are publicized annually on the Internet. COMMENTS: Using this systematic approach, it has been possible to cover >99% of all bariatric surgery, cross-matching our data with nation-wide registries for in-hospital care, cause of death, and permitting regular nation-wide audit. Several scientific studies have used, or are using, what seems to be the most comprehensive database in obesity surgery.

Laparoscopic vertical banded gastroplasty--an effective long-term therapy for morbidly obese patients?

BACKGROUND: Vertical banded gastroplasty (VBG) has previously been documented as an effective treatment for morbid obesity. We have described a laparoscopic technique to perform this operation. Follow-up data are now presented. METHODS: A consecutive series of 139 morbidly obese patients were operated on with laparoscopic VBG. The patients were assessed with respect to peri- and postoperative morbidity, postoperative recovery and weight reduction up to 5 years thereafter. RESULTS: Conversions to an open operation (n = 6) and early reoperations (n = 3) occurred in the early part of the series. Late complications were observed in 8 patients. The average weight reduction after 1 year was 50% of excess body weight, which remained also after 2 years. The continued follow-up covering 3 to 5 years postoperatively revealed a moderate weight gain in about 20% of patients. CONCLUSION: VBG can be safely performed by use of the laparoscopic technique. The average weight reduction after 1 and 2 years was 50% of excess body weight, whereafter tendency to partial weight gain was noted, suggesting an outcome comparable to that documented after the open surgical approach.

Decreased energy density and changes in food selection following Roux-en-Y gastric bypass.

BACKGROUND/OBJECTIVES: The main objective was to test the hypothesis that dietary energy density (DED) decreases after Roux-en-Y gastric bypass (gastric bypass). SUBJECTS/METHODS: A total of 43 patients (31 women and 12 men) aged 43 (s.d. 10) years, with body mass index (BMI) 44.3 kg/m(2) (4.9), were assessed preoperatively at 6 weeks and 1 and 2 years after gastric bypass. Self-reported energy intake (EI), food weight (FW) and food choice were assessed using a dietary questionnaire. DED was calculated by dividing EI by FW (kcal/g). Number of dropouts was 4 of 203 visits. RESULTS: Percent weight loss (%WL) was 13.5% at 6 weeks, 30.7% at 1 year and 31.8% at 2 years post surgery (P<0.001 for all). EI decreased from 2990 to 1774, 2131 and 2425 kcal after 6 weeks and 1 and 2 years postoperatively, respectively (P<0.001 at all time points). FW changed from 2844 to 1870 g/day at 6 weeks (P<0.001) and 2416 g/day after 1 year (P<0.05), but was not significantly different from baseline 2 years postoperatively (2602 g/day, P=0.105). DED decreased from 1.07 to 0.78 kcal/g at 6 weeks (P<0.001) and 0.90 kcal/g (P<0.001) and 0.96 kcal/g (P=0.001) after 1 and 2 years, respectively. All statistical comparisons were made from baseline. There was no correlation between changes in DED and %WL, neither after 1 year (r=-0.215; P=0.183) nor after 2 years (r=-0.046; P=0.775) post surgery. CONCLUSIONS: Besides substantial reduction in EI and large variation in FW, patients reported decreased DED over 2 years following gastric bypass. Despite lack of association between the reduction in DED and percentage weight loss, changes in food choice were overall nutritionally beneficial.

Roux-en-Y gastric bypass in mice--surgical technique and characterisation.

BACKGROUND: A reproducible Roux-en-Y gastric bypass (RYGB) model in mice is needed to study the physiological alterations after surgery. METHODS: Male C57BL6 mice weighing 29.0 ± 0.8 g underwent either RYGB (n = 14) or sham operations (n = 6). RYGB surgery consisted of a small gastric pouch (~2 % of the initial stomach size), a biliopancreatic and alimentary limb of 10 cm each and a common channel of 15 cm. Animals had free access to standard chow in the postoperative period. Body mass and food intake were recorded for 60 days. Bomb calorimetry was used for faecal analysis. Anatomical rearrangement was assessed using planar X-ray fluoroscopy and computed tomography (CT) after oral Gastrografin® injection. RESULTS: RYGB surgery led to a sustained reduction in body weight compared to sham-operated mice (postoperative week 1: sham 27.8 ± 0.7 g vs. RYGB 26.5 ± 1.0 g, p = 0.008; postoperative week 8: sham 30.7 ± 0.8 g vs. RYGB 28.4 ± 1.1 g, p = 0.003). RYGB mice ate less compared to shams (sham 4.6 ± 0.2 g/day vs. RYGB 4.3 ± 0.4 g/day, p < 0.001). There were no differences in faecal mass (p = 0.13) and faecal energy content (p = 0.44) between RYGB and shams. CT scan demonstrated the expected anatomical rearrangement without leakage or stenosis. Fluoroscopy revealed rapid pouch emptying. CONCLUSIONS: RYGB with a small gastric pouch is technically feasible in mice. With this model in place, genetically manipulated mouse models could be used to study the physiological mechanisms involved with metabolic changes after gastric bypass.

Assessment of obesity beyond body mass index to determine benefit of treatment.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: • Weight or weight loss per se may not indicate health status or health benefit. • There is no gold standard for assessing which patients would benefit most from weight-loss interventions. • The King's Criteria is one of several recently proposed obesity classification systems. WHAT THIS STUDY ADDS: • The King's Criteria can capture health problems related to obesity and health benefits after weight loss. • The King's Criteria is a reproducible scoring system. • Using the King's Criteria may help shift the focus of patients and clinicians from weight loss to health gain. SUMMARY: Body mass index (BMI) alone does not reflect health status in individuals. The King's Obesity Staging Criteria is a clinical tool for the assessment of patients with complex obesity. We assessed the performance of a modified version of the King's Criteria by scoring 144 obese patients before and 1 year after bariatric surgery. We also evaluated inter-observer variability by having 11 clinicians score the same 12 patients. The King's Obesity Staging Criteria comprise nine health domains: Airways, Body mass index, Cardiovascular disease, Diabetes, Economic complications, Functional limitations, Gonadal axis, Health status (perceived), and body Image. For each domain, a person's health is assigned a score of 0 ('normal health'), 1 ('at risk'), 2 ('established disease') or 3 ('advanced disease'). The patient's mean BMI decreased from 48 ± 7 to 37 ± 7 kg m(-2) post surgery. Before surgery, 84% of patients were either in stage 2 ('established disease') or stage 3 ('advanced disease') for one or more domains other than BMI. The modified King's Criteria showed significant health improvements after surgery, with a higher proportion of patients scored in stage 0 ('normal health') within each health domain (P < 0.001 for all). Observers assigned the same score in >75% of cases for all domains except Health status perceived (71%) and body Image (65%). In conclusion the King's Criteria captured morbidity in obese patients and health gains after weight loss. Different clinicians mostly assigned similar scores. The King's Criteria is a clinical tool that may help shift the focus of patients and clinicians towards improving health and not only losing weight. REGISTRATION NUMBER: NCT01112228 (http://www.clinicaltrials.gov).

Patulous eustachian tube complicating gastric bypass surgery.

OBJECTIVE: We report the first case in the English literature of a patulous eustachian tube occurring after laparoscopic Roux-en-Y gastric bypass surgery for obesity. METHOD: Case report of a 44-year-old woman who was referred to our ENT clinic complaining of autophonia and bilateral aural fullness. The patient had noticed these symptoms after she had undergone a laparoscopic Roux-en-Y gastric bypass surgery to aid weight loss. RESULT: On the basis of the medical history, clinical examination and immittance measurement (revealing a change in acoustic immittance synchronous with normal breathing in the right ear), a diagnosis of patulous eustachian tube was made, more severe in the right ear than the left. CONCLUSION: We report a case of patulous eustachian tube occurring after laparoscopic gastric bypass surgery for weight loss, which could be considered as one of the possible complications of this surgery. Our patient began to notice the symptoms of patulous eustachian tube after a 20 kg weight loss.

Angiotensin II-induced contractions in human jejunal wall musculature in vitro.

AIM: Angiotensin II is well known for its contractile effects on smooth muscle cells. This effect is also present in the gut previously shown in animal models. The aim of this study was to clarify expression and localization of angiotensin II receptors in the human small intestine and to explore the pharmacological profile of angiotensin II effects in vitro. METHODS: Strips of jejunal muscle wall from 32 patients undergoing bariatric surgery were used to record isometric tension in vitro in response to angiotensin II (10(-10)-10(-5) M) alone and in the presence of PD123319 (10(-7) M), losartan (10(-7) M), PD123319 (10(-7) M) and losartan (10(-7) M) in combination, tetrodotoxin (TTX) (10(-6) M), atropine (10(-6) M) and guanethidine (3 x 10(-6) M). Western blot, immunohistochemistry and RT-PCR were performed on corresponding muscle samples to identify expression and localization of key components of the renin-angiotensin system. RESULTS: Angiotensin II elicited concentration-dependent contraction in both longitudinal and circular jejunal muscle wall strips; neither TTX, atropine nor guanethidine affected this action. Losartan alone and in combination with PD123319 shifted the concentration-response curve to the right. Transcription of angiotensinogen, ACE and angiotensin II types 1 and 2 receptor RNA was detected in all patients. Immunohistochemistry detected angiotensin II type 1 receptors in the musculature; both angiotensin II types 1 and type 2 receptors were found in the myenteric plexus. CONCLUSION: This pharmacological analysis indicates that the contractile action elicited by angiotensin II on jejunal wall musculature is primarily mediated through the angiotensin II type 1 receptor located on the musculature.

Angiotensin II induced contraction of rat and human small intestinal wall musculature in vitro.

BACKGROUND: Angiotensin II (Ang II) is a well-known activator of smooth muscle in the vasculature but has been little explored with regard to intestinal wall muscular activity. This study investigates pharmacological properties of Ang II and expression of its receptors in small-intestinal smooth muscle from rats and humans. METHODS: Isometric recordings were performed in vitro on small intestinal longitudinal muscle strips. Protein expressions of Ang II typ 1 (AT1R) and typ 2 (AT2R) receptors were assessed by Western blot. RESULTS: Ang II elicited concentration-dependent contractions of rat jejunal and ileal muscle preparations. The concentration-response curve (rat ileum, EC(50): 1.5 +/- 0.9 x 10(-8) M) was shifted to the right by the AT1R receptor antagonist losartan (10(-7) M) but was unaffected by the AT2R antagonist PD123319 (10(-7) M) as well as by the adrenolytic guanethidine (3 x 10(-6) M) and the anticholinergic atropine (10(-6) M). Human duodenal, jejunal and ileal longitudinal muscle preparations all contracted concentration-dependently in response to Ang II. The concentration-response curve (human jejunum, EC(50): 1.5 +/- 0.8 x 10(-8) M) was shifted to the right by losartan (10(-7) M) but was unaffected by PD123319 (10(-7) M). Both AT1R and AT2R were detected in all segments of the rat small intestinal wall musculature, whereas only AT1R was readily detectable in the human samples. CONCLUSION: Ang II elicits contractions of small-intestinal longitudinal muscle preparations from the small intestine of rats and man. The pharmacological pattern and protein expression analyses indicate mediation via the AT1R.