Upper gut heat shock proteins HSP70 and GRP78 promote insulin resistance, hyperglycemia, and non-alcoholic steatohepatitis.

A high-fat diet increases the risk of insulin resistance, type-2 diabetes, and non-alcoholic steato-hepatitis. Here we identified two heat-shock proteins, Heat-Shock-Protein70 and Glucose-Regulated Protein78, which are increased in the jejunum of rats on a high-fat diet. We demonstrated a causal link between these proteins and hepatic and whole-body insulin-resistance, as well as the metabolic response to bariatric/metabolic surgery. Long-term continuous infusion of Heat-Shock-Protein70 and Glucose-Regulated Protein78 caused insulin-resistance, hyperglycemia, and non-alcoholic steato-hepatitis in rats on a chow diet, while in rats on a high-fat diet continuous infusion of monoclonal antibodies reversed these phenotypes, mimicking metabolic surgery. Infusion of these proteins or their antibodies was also associated with shifts in fecal microbiota composition. Serum levels of Heat-Shock-Protein70 and Glucose-Regulated Protein78were elevated in patients with non-alcoholic steato-hepatitis, but decreased following metabolic surgery. Understanding the intestinal regulation of metabolism may provide options to reverse metabolic diseases.

The early reduction of left ventricular mass after sleeve gastrectomy depends on the fall of branched-chain amino acid circulating levels.

INTRODUCTION: Body-mass index is a major determinant of left-ventricular-mass (LVM). Bariatric-metabolic surgery (BMS) reduces cardiovascular mortality. Its mechanism of action, however, often encompasses a weight-dependent effect. In this translational study, we aimed at investigating the mechanisms by which BMS leads to LVM reduction and functional improvement. METHODS: Twenty patients (45.2 ± 8.5years) were studied with echocardiography at baseline and at 1,6,12 and 48 months after sleeve-gastrectomy (SG). Ten Wistar rats aged 10-weeks received high-fat diet ad libitum for 10 weeks before and 4 weeks after SG or sham-operation. An oral-glucose-tolerance-test was performed to measure whole-body insulin-sensitivity. Plasma metabolomics was analysed in both human and rodent samples. RNA quantitative Real-Time PCR and western blots were performed in rodent heart biopsies. The best-fitted partial-least-square discriminant-analysis model was used to explore the variable importance in the projection score of all metabolites. FINDINGS: Echocardiographic LVM (-12%,-23%,-28% and -43% at 1,6,12 and 48 months, respectively) and epicardial fat decreased overtime after SG in humans while insulin-sensitivity improved. In rats, SG significantly reduced LVM and epicardial fat, enhanced ejection-fraction and improved insulin-sensitivity compared to sham-operation. Metabolomics showed a progressive decline of plasma branched-chain amino-acids (BCAA), alanine, lactate, 3-OH-butyrate, acetoacetate, creatine and creatinine levels in both humans and rodents. Hearts of SG rats had a more efficient BCAA, glucose and fatty-acid metabolism and insulin signaling than sham-operation. BCAAs in cardiomyocyte culture-medium stimulated lipogenic gene transcription and reduced mRNA levels of key mitochondrial ß-oxidation enzymes promoting lipid droplet accumulation and glycolysis. INTERPRETATION: After SG a prompt and sustained decrease of the LVM, epicardial fat and insulin resistance was found. Animal and in vitro studies showed that SG improves cardiac BCAA metabolism with consequent amelioration of fat oxidation and insulin signaling translating into decreased intra-myocytic fat accumulation and reduced lipotoxicity. FUNDING: This work was supported by the University of Rome Sapienza.

Publisher Correction: New insight into the mechanisms of ectopic fat deposition improvement after bariatric surgery.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

New insight into the mechanisms of ectopic fat deposition improvement after bariatric surgery.

Non-alcoholic fatty-liver disease (NAFLD) is frequent in obese patients and represents a major risk factor for the development of diabetes and its complications. Bariatric surgery reverses the hepatic features of NAFLD. However, its mechanism of action remains elusive. We performed a comprehensive analysis of the mechanism leading to the improvement of NAFLD and insulin resistance in both obese rodents and humans following sleeve-gastrectomy (SG). SG improved insulin sensitivity and reduced hepatic and monocyte fat accumulation. Importantly, fat accumulation in monocytes was well comparable to that in hepatocytes, suggesting that Plin2 levels in monocytes might be a non-invasive marker for the diagnosis of NAFLD. Both in vitro and in vivo studies demonstrated an effective metabolic regeneration of liver function and insulin sensitivity. Specifically, SG improved NAFLD significantly by enhancing AMP-activated protein kinase (AMPK) phosphorylation and chaperone-mediated autophagy (CMA) that translate into the removal of Plin2 coating lipid droplets. This led to an increase in lipolysis and specific amelioration of hepatic insulin resistance. Elucidating the mechanism of impaired liver metabolism in obese subjects will help to design new strategies for the prevention and treatment of NAFLD.

10-year follow-up after laparoscopic sleeve gastrectomy: Outcomes in a monocentric series.

BACKGROUND: Sleeve gastrectomy (SG) has grown into the most popular bariatric operation. Nevertheless, a scarcity of long-term outcomes are available. OBJECTIVES: This study aims at evaluating the long-term percent weight loss (%WL), excess weight loss (%EWL), weight regain (WR), and co-morbidity resolution rates in a single-center cohort undergoing SG as a primary procedure, with a minimum 10-year follow-up. SETTING: University hospital, Italy. METHODS: One hundred eighty-two morbidly obese patients with body mass index (BMI) 46.6 ± 7.3 kg/m2 underwent SG. Obesity-related co-morbidities (type 2 diabetes, hypertension, sleep apnea, gastroesophageal reflux disease) were investigated. Predictors of dichotomous dependent-variable diabetes remission were computed using a binomial logistic regression. RESULTS: Patient retention rate was 77%. Mean %WL was 30.9, %EWL was 52.5%, and WR (≥25% maximum WL) occurred in 10.4%. Baseline BMI significantly (P = .001) and linearly predicted %EWL (10 yr %EWL = 18.951 + initial BMI × .74); the super-obese subgroup generated substantially greater WL compared with those with BMI <50 kg/m2 (%EWL 48.0 ± 18.5 versus 61.5 ± 23.2; P < .001). Type 2 diabetes remission occurred in 64.7%; 42.9% patients developed de novo gastroesophageal reflux disease symptoms postoperatively (P < .0001). CONCLUSIONS: SG generates sustained WL and co-morbidity resolution up to 10 years postoperatively. Although a notable portion of patients experience WR, mean %WL persists to exceed 30%, translating in adequate WL also in the long term. Additionally, WR does not seem to impact negatively on co-morbidity resolution. SG represents a safe and effective bariatric operation, which easily grants the possibility to proceed to revisional bariatric surgery in patients with WR or failure to WL.

Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication.

BACKGROUND: Morbidly obese patients are affected by gastroesophageal reflux disease (GERD) and hiatal hernia (HH) more frequently than lean patients. Because of conflicting results, the indication to sleeve gastrectomy (SG) in patients with GERD is still debated. OBJECTIVES: To evaluate the incidence of GERD on the basis of clinical, endoscopic, and histologic data in patients undergoing SG. SETTINGS: University hospital, Rome, Italy. METHODS: From July 2007 to January 2010, 162 patients underwent primary SG. Preoperatively all patients underwent visual analogue scale (VAS) evaluation of GERD symptoms, proton pump inhibitors (PPIs) consumption recording, and esophagogastroduodenoscopy (EGD). Stomach resection started 6 cm from pylorus on a 48Fr bougie. Staple line was reinforced by an oversewing suture. A postoperative clinical control with VAS evaluation, PPI consumption, and EGD was proposed to all patients. Three patients were excluded because of the occurrence of major postoperative complications. RESULTS: A total of 110 patients accepted to take part in the study (follow-up rate: 69.1%). At a mean 58 months of follow-up, incidence of GERD symptoms, VAS mean score, and PPI intake significantly increased compared with preoperative values (68.1% versus 33.6%: P<.0001; 3 versus 1.8: P = .018; 57.2% versus 19.1%: P<.0001) At EGD, an upward migration of the "Z" line and a biliary-like esophageal reflux was found in 73.6% and 74.5% of cases, respectively. A significant increase in the incidence and in the severity of erosive esophagitis (EE) was evidenced, whereas nondysplastic Barrett's esophagus (BE) was newly diagnosed in 19 patients (17.2%). No significant correlations were found between GERD symptoms and endoscopic findings. CONCLUSION: In the present series the incidence of EE and of BE in SG patients was considerably higher than that reported in the current literature, and it was not related to GERD symptoms. Endoscopic surveillance after SG should be advocated irrespective of the presence of GERD symptoms.

Insulin Resistance, Microbiota, and Fat Distribution Changes by a New Model of Vertical Sleeve Gastrectomy in Obese Rats.

Metabolic surgery improves insulin resistance and type 2 diabetes possibly because of weight loss. We performed a novel sleeve gastrectomy in rats that resects ∼80% of the glandular portion, leaving the forestomach almost intact (glandular gastrectomy [GG]) and compared subsequent metabolic remodeling with a sham operation. GG did not affect body weight, at least after 10 weeks; improved hepatic and peripheral insulin sensitivity likely through increased Akt, glycogen synthase kinase 3, and AMPK phosphorylation; and reduced ectopic fat deposition and hepatic glycogen overaccumulation. Body adipose tissue was redistributed, with reduction of intraabdominal fat. We found a reduction of circulating ghrelin levels, increased GLP-1 plasma concentration, and remodeling of gut microbiome diversity characterized by a lower relative abundance of Ruminococcus and a higher relative abundance of Lactobacillus and Collinsella These data suggest that at least in rat, the glandular stomach plays a central role in the improvement of insulin resistance, even if obesity persists. GG provides a new model of the metabolically healthy obese phenotype.

Long-term results after laparoscopic sleeve gastrectomy in a large monocentric series.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has gained great popularity as a stand-alone bariatric procedure because short- and mid-term outcomes in terms of weight loss and resolution of co-morbidities have been very positive. However, long-term results from large series still are sparse. OBJECTIVES: To evaluate the long-term clinical outcomes of SG in a large series of patients undergoing SG as a stand-alone procedure. SETTING: University hospital in Italy. METHODS: A retrospective analysis of prospectively collected data from 182 patients undergoing SG between 2006 and 2008 in the authors' institution. Long-term outcomes at 6 and 7 years were analyzed in terms of weight loss and co-morbidities resolution. RESULTS: Mean initial body mass index (BMI) was 45.9±7.3 kg/m(2). Major postoperative complications occurred in 8 patients (5.4%): 4 leaks, 2 bleeding, 1 abdominal collection, and 1 dysphagia. All complications were managed conservatively. One hundred forty-eight patients (81.4%) completed the 72-month (6-year) follow-up. Thirty-seven patients (25%) reached a follow-up of 84 months. At year 6 follow-up the mean BMI and the mean percentage of excess weight loss (%EWL) were 30.2 kg/m(2) and 67.3%, respectively. Mean total body weight loss was 44.9 kg, while a %EWL >50 was registered in 123 patients (83.1%). Preoperative BMI did not significantly influence postoperative %EWL. Remission of type 2 diabetes mellitus, arterial hypertension, obstructive sleep apnea syndrome, and gastroesophageal reflux disease symptoms occurred in 83.8%, 59.7%, 75.6%, and 64.7% of patients, respectively. CONCLUSION: %EWL and resolution of co-morbidities appear to be sustained 6 and 7 years after SG. Preoperative BMI is not predictive for weight loss outcomes.

Learning curve for laparoscopic sleeve gastrectomy: role of training in a high-volume bariatric center.

BACKGROUND: Since the great diffusion of laparoscopic treatment of obesity, there is a growing interest concerning the learning process for those surgeons who undertake the bariatric activity. However, papers analyzing the learning curve (LC) for sleeve gastrectomy (SG) are still scarce. This study aims to investigate whether the LC for SG of a novice bariatric surgeon might be positively influenced by the training in a high-volume bariatric center (HVBC). METHODS: Between October 2010 and January 2014, 128 patients underwent SG by the same young surgeon who previously attended a 2-year training in a HVBC. His LC has been divided into three consecutive periods: in the first period (1st-47th SGs) he operated in the HVBC, while in the second (48th-88th SGs) and third period (89th-128th SGs) he moved to a novel department where surgical and ancillary staff were initially not confident with bariatric procedures but progressively owned the proper experience. Preoperative characteristics, operative data, complications and postoperative results of the three periods were compared. RESULTS: Mean follow-up was 1 year. Preoperative patients' characteristics were homogeneous. No significant differences have been registered among the three periods concerning operative data, mortality, intra- and post-operative complications, weight loss outcomes and comorbidities' resolution. Post-operative follow-up rates at 6 and 12 months were 98.4 and 92.1 %, respectively. CONCLUSIONS: Long-lasting fellowship in a HVBC might allow the novel bariatric surgeon to safely and proficiently overcome the LC for SG, even in a new established bariatric setting.

Use of platelet-rich plasma to reinforce the staple line during laparoscopic sleeve gastrectomy: feasibility study and preliminary outcome.

AIMS: Reinforcement of the staple line is one of the most debated technical aspects concerning laparoscopic sleeve gastrectomy (LSG). Different buttressing methods have been proposed and demonstrated to be effective in reducing the incidence of staple line bleeding, although data concerning their effort on staple line leakage are not consistent. The aim of this study was to ascertain the technical feasibility and to report the preliminary outcomes of laparoscopic use of platelet-rich plasma (PRP) to reinforce the staple line during sleeve gastrectomy. PATIENTS AND METHODS: From March 2012 to May 2012, 20 patients were prospectively enrolled (10 females; mean age, 44.6 ± 11 years; mean body mass index, 42.3 ± 5.45 kg/m(2)). Type 2 diabetes mellitus was present in 4 patients, obstructive sleep apnea syndrome in 3, and hypertension in 6. LSG was performed using a 48-French bougie and gold cartridges; reinforcement of the staple lines with buttressed materials or oversewing the suture was performed excluding the last cranial cartridge. PRP was prepared by separating the platelets from autologous blood withdrawn on the same day of surgery, in order to obtain a membrane with cylindrical shape (2×5 cm) formed by fibrin and active platelets. The membrane is introduced through the 10-mm trocar and placed at the upper portion of the staple line. The overall cost for the preparation of PRP is about €15. RESULTS: No intraoperative complications and conversions have been recorded during the surgical procedures. No deaths occurred. The mean operative time was 85 ± 31 minutes, which was not significantly increased compared with the operative time of the surgeon's overall personal series (750 cases). At 12 months of follow-up the abdominal ultrasound was negative for collections, and upper contrast showed no images indicating gastric leaks. In no case did PRP induce symptoms of rejection, infection, or adverse events. CONCLUSIONS: The use of PRP during LSG is feasible, does not increase significantly the operative time, does not require any special devices, and is cost effective. A larger cohort of patients is needed to ascertain the potential effectiveness of PRP in the prevention of postoperative staple line complications.

Comparative use of different techniques for leak and bleeding prevention during laparoscopic sleeve gastrectomy: a multicenter study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an approved primary procedure for morbid obesity, but it is associated with serious complications, such as staple line leaks and bleeding. The objective of this study was to assess the effectiveness of staple line reinforcement (SLR) in reducing leaks and bleeding after LSG. METHODS: A total of 1162 patients underwent LSG (305 males, 857 females). The mean age was 43.7 years and the mean body mass index was 48 kg/m(2). The patients were divided into 6 groups based on the type of SLR, including a no-SLR control group, with evaluation of leaking and bleeding risk and correlation of patients' characteristics with complications. RESULTS: A total of 189 patients underwent LSG without reinforcement. The SLR method was oversewing in 476 patients, bovine pericardium in 312, synthetic polyester in 76, glycolide/trimethylene copolymer in 63, and thrombin matrix in 46. The overall leak frequency was 2.8%; higher with synthetic polyester (7.8%), 4.8% with no reinforcement, and lower with bovine pericardium strips (.3%; P<.01). Postoperative hemorrhage occurred in 35 patients (3%), with a higher frequency being observed without SLR (13.7%; P = .02). Only diabetes was a risk-factor for a leak (P< .01). CONCLUSION: SLR with bovine pericardium strips significantly reduced the leak risk. Postoperative bleeding was significantly lower with all SLR-methods, although there was no significant difference among the various techniques. Patients with type II diabetes had a higher risk of staple line leak after LSG. Further randomized, controlled studies are needed to improve our understanding of the efficacy of SLR during LSG.

Effect of consecutive intragastric balloon (BIB®) plus diet versus single BIB® plus diet on eating disorders not otherwise specified (EDNOS) in obese patients.

BACKGROUND: Eating disorders are a group of conditions characterised by abnormal eating habits. Greater than 50 % of patients with eating disorders have an 'eating disorder not otherwise specified' (EDNOS). No specific tools exist to evaluate EDNOS, and patients are identified only with a diagnosis of exclusion from the other eating disorders. The BioEnterics® Intragastric Balloon (BIB®) is used worldwide as a short-term treatment option in obese patients. A new frequency score was used to evaluate the influence of double consecutive BIB® treatment compared with single BIB® treatment followed by diet on four categories of EDNOS (grazing, emotional eating, sweet-eating and after-dinner grazing). METHODS: A prospective study allocated 50 obese patients (age range 25-35, BMI range 40.0-44.9) into two groups: BIB® (6 months) followed by diet therapy (7 months; group A (N = 25)) and BIB® placement for 6 months followed by another BIB® for 6 months, with a 1-month interval between placement (group B (N = 25)). Baseline demographics were similar across both groups. RESULTS: At the time of removal of the first BIB® device, EDNOS scores in both groups were not significantly different, but decreased significantly from baseline. By the end of the study, all EDNOS scores were significantly lower in patients undergoing consecutive BIB®, compared with single BIB® followed by diet therapy. CONCLUSIONS: The placement of an intragastric balloon in obese patients allows for a reduction in the intensity of grazing, emotional eating, sweet-eating and after-dinner grazing. A more significant reduction in the EDNOS score was observed with two consecutive BIBs®.

Adjustable intragastric balloon vs non-adjustable intragastric balloon: case-control study on complications, tolerance, and efficacy.

BACKGROUND: The objective of this study is the comparison of a new intragastric balloon recently introduced, the Adjustable Balloon System (ABS), with the BioEnterics intragastric balloon (BIB) in terms of tolerance, safety, and weight loss parameters. METHODS: A case-control study was done: 40 patients were matched with 80 controls. To achieve the same duration therapy (12 months), a single ABS positioning was compared with a BIB followed by another BIB (6 + 6 months). Length of procedure, hospital stay, complications, and weight loss parameters after 6 months (time of first BIB removal) and after 12 months from baseline (time of Spatz and second BIB removal) were considered. Statistical analysis was done by means of Student's t test, χ2 test, or Fisher's test. P < 0.05 was considered significant. RESULTS: Mortality, positioning, and extraction complications were absent. Both the devices were well tolerated with slight duration of post placement symptoms. During this study, the Spatz balloon was adjusted with inflation of 200 cm(3) of saline (total, 800 cm(3)) in 9/40 (22.5 %) patients, for poor weight loss after first 6-months treatment. In the Spatz group, there occurred 7/40 complications linked to the device and in 6/7 patients the balloon was removed. At the end of the study, the weight loss parameters were similar between groups: BMI 31.0 ± 11.8 (Spatz group) vs 31.3 ± 12.3 (BIB group) (p = Ns). CONCLUSIONS: The idea of dynamic balloon therapy needs to be confirmed with wider series. The rate of complication reported is very high, and several studies regarding safety and efficacy are needed.

Long-term remission of type 2 diabetes in morbidly obese patients after sleeve gastrectomy.

BACKGROUND: The aim of this study was to evaluate the long-term effects of laparoscopic sleeve gastrectomy (LSG) on type 2 diabetes mellitus (T2DM) and other related co-morbidities in severely obese patients. METHODS: From May 2003 to July 2008, 33 morbidly obese diabetic patients (20 with body mass index [BMI]>50 kg/m(2)) underwent LSG. A total of 23 females and 10 males participated, with a mean age of 49.3±8 years, mean preoperative BMI of 52.1±8.5 kg/m(2), mean fasting plasma glucose (FPG) of 143.2±47.9 mg/dL, mean glycosylated hemoglobin (HbA1c) of 7.3%±1.4%, and a mean T2DM duration of 7 years. All patients had a 36-month follow-up, and 13 had a 60-month follow-up. RESULTS: Twenty-nine patients (87.8%) discontinued antidiabetic medications 3 months after LSG, (mean BMI of 42.8±7.8 kg/m(2); FPG of 104.5±22.1 mg/dL; HbA1c of 5.3%±.4%). At 36 months, 22 of 26 LSG patients (84.6%) had normal FPG and HbA1c values without antidiabetic therapy. At the 60-month follow-up, 10 of 13 patients (76.9%) had normal FPG and HbA1c values without antidiabetic therapy. The Framingham risk score decreased significantly from 9.7% preoperatively to 4.7% postoperatively. No new diabetic retinopathy occurred during the whole period of observation. CONCLUSIONS: This study confirms the efficacy of LSG in the treatment of T2DM and indicates that, at both 36- and 60-month follow-ups, LSG can provide a significant percentage of treated patients with a prolonged remission of T2DM, with diminished cardiac risk factors and no development of diabetic retinopathy. These results compare favorably with those reported after standard medical therapy.

Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia.

BACKGROUND: Gastroesophageal reflux disease (GERD) with or without hiatal hernia (HH) is now recognized as an obesity-related co-morbidity. Roux-en-Y gastric bypass has been proved to be the most effective bariatric procedure for the treatment of morbidly obese patients with GERD and/or HH. In contrast, the indication for laparoscopic sleeve gastrectomy (SG) in these patients is still debated. Our objective was to report our experience with 97 patients who underwent SG and HH repair (HHR). The setting was a university hospital in Italy. METHODS: From July 2009 to December 2011, 378 patients underwent a preoperative workup for SG. In 97 patients, SG was performed with HHR. The clinical outcome was evaluated considering GERD symptom resolution or improvement, interruption of antireflux medications, and radiographic evidence of HH recurrence. RESULTS: Before surgery, symptomatic GERD was present in 60 patients (15.8%), and HH was diagnosed in 42 patients (11.1%). In 55 patients (14.5%), HH was diagnosed intraoperatively. The mean follow-up was 18 months. GERD remission occurred in 44 patients (73.3%). In the remaining 16 patients, antireflux medications were diminished, with complete control of symptoms in 5 patients. No HH recurrences developed. "De novo" GERD symptoms developed in 22.9% of the patients undergoing SG alone compared with 0% of patients undergoing SG plus HHR. CONCLUSION: SG with HHR is feasible and safe, providing good management of GERD in obese patients with reflux symptoms. Small hiatal defects could be underdiagnosed at preoperative endoscopy and/or upper gastrointestinal contrast study. Thus, a careful examination of the crura is always recommended intraoperatively.

Cardiac remodeling in obese patients after laparoscopic sleeve gastrectomy.

BACKGROUND: Obesity is associated with high morbidity and represents an increasing health care problem worldwide. Laparoscopic sleeve gastrectomy (LSG) has been used effectively for weight loss and co-morbidity remission. In this retrospective study, we evaluated cardiac reverse remodeling at medium-term follow-up by echocardiography, the amount of cardiovascular medications, and the impact of co-morbidities after sleeve gastrectomy. METHODS: Altogether, 16 obese patients (4 men, 12 women; 46.4 ± 10.3 years) underwent complete clinical evaluation, laboratory tests, and color Doppler/tissue Doppler imaging echocardiography preoperatively and 12-20 months after bariatric surgery. RESULTS: Body weight (mean body mass index) was significantly reduced (from 44.8 ± 8.0 to 31.2 ± 7.8 kg/m2; p = 0.001). Lipid profile significantly improved: total cholesterol and triglycerides decreased (respectively: 215.5 ± 53.8 vs. 205.3 ± 46.6 mg/dl and 184.9 ± 109.3 vs. 116.1 ± 49.9 mg/dl, both p ≤ 0.05), and high-density lipoprotein increased (43.1 ± 10.9 vs. 51.4 ± 12.8 mg/dl, p = 0.005). Systolic blood pressure significantly decreased (from 133.0 ± 17.1 to 120.6 ± 13.7 mmHg; p = 0.04). Diabetes remission was complete in five of six patients (83%) and sleep apnea in four of five (80 %). Echocardiography showed significantly reduced interventricular septum and posterior wall thickness (11.3 ± 1.8 to 9.4 ± 2.1 mm and 10.4 ± 1.7 to 8.6 ± 1.9 mm, respectively; both p < 0.007) and reduced left ventricular mass (absolute value and indexed by height, respectively: 222.41 ± 78.2 to 172.75 ± 66.3 g (p = 0.003) and 55.9 ± 14.3 to 43.8 ± 17.2 g/m(2.7) (p = 0.0004). Antihypertensive drug intake was significantly reduced (p = 0.03), as shown by the 10-year Framingham Risk Score (from 14.2 ± 9.3 to 8.3 ± 9.5%, p = 0.003). CONCLUSIONS: Sleeve gastrectomy is associated with marked improvement in terms of weight loss, lipid profile, type 2 diabetes, sleep apnea, hypertension, and left ventricular hypertrophy, with a significantly reduced Framingham Risk Score.

Obesity, type 2 diabetes mellitus, and other comorbidities: a prospective cohort study of laparoscopic sleeve gastrectomy vs medical treatment.

OBJECTIVE: To compare the effect of sleeve gastrectomy vs medical therapy on type 2 diabetes mellitus and other obesity-related comorbidities (obstructive sleep apnea syndrome, hypertension, and dyslipidemia) in prospectively enrolled and matched obese patients with type 2 diabetes. DESIGN: A prospective cohort study. Morbidly obese patients with type 2 diabetes who either underwent sleeve gastrectomy or conventional therapy were followed up and assessed for their diabetic state and other comorbidities every 3 months for 18 months. SETTING: Centre for the Surgical-Medical Treatment of Morbid Obesity, Policlinico "Umberto I," University of Rome "Sapienza," Italy. PATIENTS: A total of 30 morbidly obese patients with type 2 diabetes who underwent sleeve gastrectomy (group A) and a total of 30 morbidly obese patients with type 2 diabetes who underwent conventional therapy (group B). RESULTS: In group A, the preoperative mean (SD) body mass index, fasting plasma glucose level, and hemoglobin A1c level were 41.3 (6.0), 166.6 (68.1) mg/dL, and 7.9% (2.1%), respectively, and, at 18 months, these values were 28.3 (5.4), 96.2 (29.4) mg/dL, and 6.0% (1.5%), respectively. For 80% of patients, diabetes was resolved. With regard to other comorbidities, the prevalence of obstructive sleep apnea syndrome dropped from 50% to 10%, and patients reduced significantly their use of medication for hypertension and dyslipidemia. In group B, the preoperative mean (SD) body mass index, fasting plasma glucose level, and hemoglobin A1c level were 39.0 (5.5), 183.7 (63.5) mg/dL, and 8.1% (1.7%), respectively, and, at 18 months, these values were 39.8 (5.0), 150 (48) mg/dL, and 7.1% (1.3%), respectively. All patients remained diabetic and continued or increased their level of hypoglycemic therapy. With regard to other comorbidities, we observed an increase in the use of medication for hypertension and dyslipidemia, and the prevalence of obstructive sleep apnea syndrome did not change. CONCLUSIONS: This study confirms the efficacy of sleeve gastrectomy in the treatment of morbidly obese type 2 diabetic patients when compared with conventional medical treatment.

International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida. METHODS: Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). RESULTS: Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions. CONCLUSION: The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.

Type 2 diabetes in obese patients with body mass index of 30-35 kg/m2: sleeve gastrectomy versus medical treatment.

BACKGROUND: Type 2 diabetes mellitus (T2DM) and obesity are diseases of epidemic proportions. Long-term realistic weight loss by nonsurgical methods has a variable effect on glycemic control, and only a proportion of patients with T2DM have a worthwhile response. Laparoscopic sleeve gastrectomy (LSG) has been proposed as an advantageous bariatric procedure for patients with a lower body mass index (BMI). Our objective was to compare the effects of LSG and medical therapy on patients with T2DM and a BMI of <35 kg/m(2). METHODS: A total of 18 nonmorbidly obese patients with T2DM, diagnosed according to the American Diabetes Association guidelines, were consecutively enrolled. Of these patients, 9 underwent LSG (group A) and 9 underwent conventional medical therapy (group B). The 2 groups were matched for BMI, glycated hemoglobin (HbA1c) and C-peptide levels, pretrial therapy type, and number of patients with a T2DM duration of >10 years. RESULTS: In group A, T2DM resolution was achieved in 8 (88.8%) of the 9 patients (T2DM duration 5.2 yr). Hypertension was controlled in all 8 of 9 patients. Dyslipidemia was corrected. In 1 patient, obstructive sleep apnea syndrome improved. In group B, all 9 patients continued to have T2DM and required hypertensive and hypolipemic therapies throughout the observation period. At baseline, 3 patients were affected by obstructive sleep apnea syndrome and remained affected 1 year later. CONCLUSION: The results of the present study have confirmed the efficacy of LSG in the treatment of nonmorbidly obese T2DM patients, with a remission rate of 88.8% without undesirable excessive weight loss. The results in this group of patients add to those obtained by us in patients with a BMI >35 kg/m(2).

Ten-year duration of type 2 diabetes as prognostic factor for remission after sleeve gastrectomy.

BACKGROUND: Several studies have demonstrated a high rate of type 2 diabetes mellitus (T2DM) resolution after sleeve gastrectomy. Different prognostic factors have been hypothesized for T2DM remission after bariatric surgery. Our objectives were to analyze the role of T2DM duration as an independent prognostic factor for remission. METHODS: From January 2008 to September 2010, 56 obese patients with T2DM underwent sleeve gastrectomy. Group A consisted of 16 patients who had lived with T2DM for >10 years (12 women and 4 men, mean body mass index 42.7 kg/m2). Group B included 40 obese patients who had lived with T2DM for <10 years (29 women and 11 men, mean body mass index 44.9 kg/m2). RESULTS: In group A, 43.7% were treated with oral hypoglycemics, 6.3% with insulin, and 50% with oral hypoglycemics and insulin. In group B, 87.5% were treated with oral hypoglycemics, 5% with dietary therapy, and 7.5% with insulin. The preoperative average glycemia, glycosylated hemoglobin, and C-peptide value was 206.2 mg/dL, 9.5%, and 2.8 µg/L in group A and 134 mg/dL, 7.1%, and 4.5 µg/L in group B, respectively (P < .05 for all). The T2DM remission rate in all 56 patients was 80.3%. However, in group B, the resolution rate was 100%, but in group A, the resolution rate was 31%. Patients without complete remission were more sensitive to lower doses of antidiabetic drugs. CONCLUSION: Sleeve gastrectomy is effective in the treatment of obese patients with T2DM. The duration of T2DM seems to be of paramount importance as a prognostic factor, with 10 years representing a cutoff between a 100% rate of remission and significantly lower rates of remission.