Outcomes of totally robotic Roux-en-Y gastric bypass in patients with BMI ≥ 50 kg/m2: can the robot level out "traditional" risk factors?

Roux-en-Y gastric bypass (RYGB) in patients with body mass index (BMI) ≥ 50 kg/m2 is a challenging procedure and BMI ≥ 50 kg/m2 has been identified as independent risk factor for postoperative complications and increased morbidity in previous studies. The objective of the present study was to assess whether a BMI ≥ 50 kg/m2 and various established risk factors maintain their significance in patients undergoing fully robotic RYGB (rRYGB). A single-center analysis of prospectively collected data of 113 consecutive patients undergoing standardized rRYGB with robotic stapling technique and hand-sewn gastrojejunostomy using the daVinci Xi system. Surgical outcomes were analyzed considering a number of individual perioperative risk factors including BMI ≥ 50 kg/m2. The mean BMI of the total cohort was 50.6 ± 5.5 kg/m2 and 63.7% of patients had a BMI ≥ 50 kg/m2. There were no major surgical and perioperative complications in patients with BMI ≥ 50 kg/m2 as well as in those with BMI < 50 kg/m2 after rRYGB. We identified female sex and surgeon experience but neither body weight, BMI, metabolic disorders, ASA nor EOSS scores as independent factors for shorter operation times (OT) in multivariate analyses. Complication rates and length of hospital stay (LOS) did not significantly differ between patients with potential risk factors and those without. rRYGB is a safe procedure in both, patients with BMI ≥ 50 kg/m2 and with BMI < 50 kg/m2. Higher body weight and BMI did affect neither OT nor LOS. A fully robotic approach for RYGB might help to overcome "traditional" risk factors identified in conventional laparoscopic bariatric surgery. However, larger and prospective studies are necessary to confirm these results.

Progranulin serum levels and gene expression in subcutaneous vs visceral adipose tissue of severely obese patients undergoing bariatric surgery.

BACKGROUND: Progranulin represents an adipokine putatively mediating insulin resistance and inflammation. Data in humans are sparse, and the source of circulating progranulin in obesity is unknown. OBJECTIVES: Serum progranulin concentrations and subcutaneous (sc) as well as visceral (vis) adipose tissue (AT) progranulin expression were quantified in a large cohort of patients with obesity undergoing bariatric surgery (BS) (n = 153) or a low-calorie diet (LCD) (n = 121). COHORTS AND METHODS: Paired serum and AT mRNA samples were obtained from patients with severe obesity undergoing BS (ROBS cohort; Research in Obesity and Bariatric Surgery). Serum progranulin was measured by ELISA in both cohorts, and AT mRNA expression was analysed by quantitative real-time PCR in bariatric patients. RESULTS: There was no gender-specific effect in serum progranulin or AT progranulin expression. Importantly, circulating progranulin was independent from adipose tissue gene expression in paired samples. sc AT progranulin expression was higher than in vis AT (P = 0.027), and there was a positive correlation between sc AT and vis AT gene expression (P < 0.001; r = +0.34). Serum progranulin strongly and rapidly increased after BS within 3 days and remained elevated up to 12 months. Serum progranulin was strongly correlated with serum CTRP-3 levels. CONCLUSIONS: The present study provides detailed progranulin gene expression data in sc and vis AT in a large, prospective and observational cohort of patients with severe obesity. Serum progranulin concentrations are not predicted by sc or vis AT progranulin gene expression. Thus, AT seems not to be the main source of circulating progranulin levels in obesity.

Successful treatment of severe hypertriglyceridemia with a formula diet rich in omega-3 fatty acids and medium-chain triglycerides.

BACKGROUND: Patients with highly increased plasma triglyceride levels are at risk of developing serious complications such as pancreatitis, coronary heart disease and stroke. Therefore it is important to rapidly decrease plasma triglyceride levels. A sufficient control of triglyceride levels with drugs like fibrates, statins or nicotinic acid can usually only be attained after a couple of weeks. Plasma exchange appears to be a fast but expensive method to reduce triglyceride levels. In this study we describe the use of a new omega-3 fatty acid and medium-chain triglyceride-rich formula diet as a therapeutic concept to reduce plasma triglyceride levels fast and effectively. METHODS: Thirty-two patients with severe hypertriglyceridemia were treated with the especially composed formula diet for a period of 7 days. RESULTS: Within this period of time, plasma triglycerides decreased from 1,601 (402-4,555) to 554 (142-2,382) mg/dl (p < 0.05). Total cholesterol levels were reduced from 417 (211-841) to 287 (165-457) mg/dl (p < 0.001). Fasting glucose and uric acid levels also slightly decreased (-8%; -12%). The formula diet as a 1-week treatment was well tolerated and accepted by the patients. CONCLUSION: This diet was successfully used as an acute treatment in severe hypertriglyceridemia and showed effectiveness in rapidly and safely lowering plasma triglyceride levels.

Royal jelly reduces the serum glucose levels in healthy subjects.

Earlier biological investigations have shown that royal jelly has insulin-like activity. However, there have so far been no clinical trials to support these findings. The objective of the present study was to study the effect of royal jelly ingestion on the glucose metabolism of healthy humans. Twenty volunteers underwent the standardized oral glucose tolerance test (OGTT) and afterwards a second OGTT after ingestion of 20 g of royal jelly. Serum glucose levels after 2 hours and the area under the curve for glucose were significantly lower (P = .041) after royal jelly administration. Substances originating from the pharyngeal glands of the honey bee with insulin-like activity are likely to have caused this effect and may thus be, at least partially, responsible for the lowering impact of honey on blood glucose levels. The identification of the substances that seem to act even after passage through the human stomach could lead to the development of new concepts in diabetology.

Parenteral and enteral nutrition in the management of neurosurgical patients in the intensive care unit.

The iatrogenic malnutrition of neurosurgical patients in intensive care units (ICU) is an underestimated problem. It may cause a decrease in plasma albumin and oncotic pressure, leading to an increase in the amount of water entering the brain and increased intracranial pressure (ICP). This study was conducted to test the hypothesis that combined high-protein parenteral and enteral nutrition is beneficial for neurosurgical patients in ICU. A total of 202 neurosurgical patients in ICU (mean age+/-standard deviation, 56 years+/-16 years; male:female=1.2:1) were studied. Two consecutive 1-year time periods were compared, during which two different nutritional regimens were followed. In the first time period (Y1) patients were given a low-protein/high-fat formulation parenterally, followed by a standard enteral regimen. In the second time period (Y2) a protein-rich, combined parenteral and enteral diet was prospectively administered. The Glasgow Outcome Score was measured at 3-6 months after discharge. The following clinical parameters were recorded during the first 2 weeks after admission: ICP; albumin; cholinesterase (CHE); daily hours of ICP > 20 mmHg and cerebral perfusion pressure<70 mmHg; and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. It was found that overall albumin (32.4 g/L+/-4.1g/L vs. 27.5 g/L+/-3.6g/L) and CHE was higher during Y2, although the total energy supply, glucose and fat intake was lower. Higher GOS scores were seen when patients had lower APACHE II scores and received the Y2 nutritional regimen. During Y2, the total hours of ICP > 20 mmHg were fewer. With the Y2 nutrition, maintenance of adequate cerebral perfusion required less catecholamine medication and colloidal fluid replacement. Therefore, adequate nutrition is an important parameter in the management of neurosurgical patients in ICU.

Effect of honey on serum cholesterol and lipid values.

Small studies have suggested that honey benefits patients with high cholesterol concentrations. The present study aimed to confirm this finding in a larger group of subjects. Sixty volunteers with high cholesterol, stratified according to gender and hydroxymethylglutaryl-coenzyme A reductase inhibitor (statin) treatment (yes/no), were randomized to receive 75 g of honey solution or a honey-comparable sugar solution once daily over a period of 14 days. Baseline measurements, including body mass index (BMI) and lipid profile, were obtained, and subjects also completed dietary questionnaires and the Inventory for the Assessment of Negative Bodily Affect-Trait form (INKA-h) questionnaire. Measurements were repeated 2 weeks later. BMI and high-density lipoprotein (HDL) cholesterol values were significantly correlated (r = -0.487; P < .001) as were BMI and a lower ratio of low-density lipoprotein (LDL) cholesterol to HDL cholesterol (r = 0.420; P < .001), meaning that subjects with a high BMI had a lower HDL cholesterol value. INKA-h scores and LDL cholesterol values were also significantly correlated (r = 0.273, P = .042). Neither solution influenced significantly cholesterol or triglyceride values in the total group; in women, however, the LDL cholesterol value increased in the sugar solution subgroup but not in the women taking honey. Although ingesting honey did not reduce LDL cholesterol values in general, women may benefit from substituting honey for sugar in their diet. Reducing the BMI lowers the LDL cholesterol value, and psychological interventions also seem important and merit further investigation.

Effects of basswood honey, honey-comparable glucose-fructose solution, and oral glucose tolerance test solution on serum insulin, glucose, and C-peptide concentrations in healthy subjects.

Studies suggest that honey has less influence on serum glucose concentrations than monosaccharides and disaccharides. This study aimed to confirm these findings conclusively by comparing directly the effects of honey, an identical sugar solution, and oral glucose tolerance (OGT) test solution on serum glucose, insulin, and C-peptide values in healthy subjects. Twelve healthy men with a mean age of 27.7 years, a mean body mass index of 23.2 kg/m(2), and no history of metabolic disorders participated in the study. Subjects underwent OGT testing to establish values and exclude preclinical diabetes. One week later they were randomly assigned to basswood honey or a glucose-fructose solution (honey-comparable glucose-fructose solution). The following week subjects were given the other solution. All solutions contained 75 g of glucose. Serum glucose was measured before drinking test solutions and every 10 minutes for 120 minutes afterwards. C-peptide and insulin were measured at 60 and 120 minutes. Serum insulin and C-peptide values at 60 minutes were significantly lower for honey. The mean serum glucose concentration was also lower for honey, but direct comparisons at the various times showed no statistically significant differences between solutions. However, the area under the concentration-time profile for glucose response was lower for the honey than the honey-comparable glucose-fructose solution. Honey had less effect on serum glucose, C-peptide, and insulin values than the honey-comparable glucose-fructose solution. Further study to elucidate underlying mechanisms may be worthwhile, as may investigation of the implications of these findings for diabetic patients.

Successful long-term treatment of severe hypertriglyceridemia by feedback control with lipid self-monitoring.

BACKGROUND/AIMS: Successful treatment of severe hypertriglyceridemia is difficult. Besides therapy with different drugs, dietary intervention is an important approach. However, compliance with dietary recommendations is usually bad. Lipid self-monitoring in patients might improve dietary compliance and control of lipid parameters. METHODS: Thirty-two patients with severe hypertriglyceridemia (>750 mg/dl) were primarily treated with a formula diet reducing the triglyceride levels <600 mg/dl. After this acute treatment, self-monitoring of lipid parameters was performed for 48 weeks. Twenty-five patients completed the whole study. The participants measured their lipid parameters with Accutrend GCT dry chemistry strips. Dietary records were taken and measurements of body composition, BMI, triglycerides, total cholesterol and glucose were performed. RESULTS: Triglycerides remained stable in patients with levels <300 mg/dl at the beginning of the protocol. There was a significant decline in triglycerides in those who started with levels >300 mg/dl. No severe hypertriglyceridemia (>750 mg/dl) could be observed. The energy intake decreased in all patients due to a reduction in total fat and carbohydrate consumption. The relation between carbohydrates and protein remained unchanged. Self-measurement was well tolerated and an improvement in controlling the diet was reported. CONCLUSIONS: Self-control of lipid parameters can improve the dietary compliance of patients with hypertriglyceridemia and is well tolerated.

Effect of liquid pancreatic enzymes on the assimilation of fat in different liquid formula diets.

BACKGROUND: In some diseases, patients require high-calorie tube feeding with standard enteral formulas usually administered via temporal feeding tubes. One frequent pathophysiological condition in a relevant number of these patients is exocrine pancreatic insufficiency. Patients unable to swallow capsules might benefit from a liquid pancreatic enzyme (LPE) preparation. METHODS: LPEs were prepared and mixed with different commercially available formula diets produced for enteral feeding. Lipolysis was then measured by fatty acid titration. RESULTS: Complete lipolysis by liquid enzyme preparations was observed in diverse formula diets. Fat assimilation was even complete when LPE had been prepared 3.5 hours before the experiments, showing that the enzymes had been stable up to that time. CONCLUSIONS: The use of LPEs seems to be a good therapeutic option in patients with exocrine pancreatic insufficiency and the need for permanent high-calorie enteral feeding. Pharmaceutical companies should therefore be further encouraged to develop and distribute liquid enzyme preparations.

High prevalence of exocrine pancreatic insufficiency in diabetes mellitus. A multicenter study screening fecal elastase 1 concentrations in 1,021 diabetic patients.

BACKGROUND: There have been numerous reports on pancreatic exocrine dysfunction in diabetes mellitus using either direct or indirect function tests. The measurement of fecal elastase 1 concentrations (FEC) has been used as a screening tool for exocrine pancreatic disease in different patient groups indicating a high prevalence of exocrine dysfunction in diabetic populations. In this study we had the opportunity to study more than 1,000 diabetic patients to confirm recent observations in smaller populations. METHODS: FEC were measured by ELISA in 323 patients with type 1 and 697 type 2 diabetes mellitus. Subjects with a history of alcohol abuse, gastrointestinal surgery, cancer or inflammatory diseases were not included. Diabetes history and clinical data were recorded using a standard case report form. FINDINGS: 1,021 patients (334 female, 687 male; mean age 50 years; mean diabetes duration 11 years; mean age at onset of diabetes 39 years) were studied. FEC was normal (>200 microg/g) in 59.3% and severely reduced (<100 microg/g) in 22.9%. There were significant differences between type 1 and type 2 patients as well as between insulin-treated and non-insulin-treated patients. Furthermore, there were weak associations between FEC and diabetes duration, age at onset of diabetes and body mass index, respectively. INTERPRETATION: We could confirm that both type 1 and type 2 diabetic patients show pathological exocrine function in high prevalence. Exocrine insufficiency seems to be correlated to early onset of endocrine failure, long-lasting diabetes mellitus and low body mass index levels.

High prevalence of steatorrhea in 101 diabetic patients likely to suffer from exocrine pancreatic insufficiency according to low fecal elastase 1 concentrations: a prospective multicenter study.

Impaired exocrine pancreatic secretion has been frequently observed in diabetic patients by different methods, including direct function tests. However, the clinical importance remained unclear. In the present study, the fecal fat excretion in patients with type 1 or type 2 diabetes mellitus and exocrine dysfunction according to fecal elastase 1 concentrations <100 microg/g was investigated. Subjects with a history of gastrointestinal cancer, gastrointestinal surgery, alcohol abuse, or inflammatory diseases were excluded. In 101 patients the mean (+/- SD) fat excretion was 9.19 +/- 5.39 g. Only 41 patients (40.6%) had normal fat excretion <7 g/day. In 40 patients (39.6%), it was higher than 10 g/day, indicating relevant steatorrhea. The fat excretion did not correlate with diabetes type, duration, or clinical symptoms. This finding is of some clinical importance and might influence pathophysiological concepts and the management of diabetic patients.