Small Intestinal Perforation after 360-Degree Liposuction: A Case Report.

OBJECTIVE: As one of the most commonly performed cosmetic procedures, liposuction is relatively safe. Bowel injury following liposuction is a rare but devastating complication, which necessitates hospital admission and surgical intervention. The authors highlight a case report describing the presentation, diagnosis, and management of a patient with bowel injury following liposuction. CASE: A 58-year-old woman presented with abdominal pain, erythema, and discharge three days after 360-degree abdominal liposuction with concomitant fat grafting to bilateral buttocks at an outpatient surgery center. Bowel perforation was suspected after CT-scan revealed extraluminal gas in the abdomen and communication that traversed the peritoneum. Exploratory laparotomy was performed which demonstrated at least one site of distinct perforation of the small bowel and an area omentum noted to be inflamed, thickened and with a purulent rind. The patient underwent 20-cm small bowel resection and partial omentectomy temporarily closed with negative pressure wound therapy. After subsequent abdominal wall debridements the patient received ventral hernia repair with bridging mesh and abdominal closure. CONCLUSIONS: While safe, elective cosmetic procedures are not without risk of serious and even fatal complications. Providers must be familiar with the presentation of bowel injury following abdominal liposuction to prevent delays in appropriate surgical and medical care. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Safety of Breast Liposuction and Oncologic Considerations.

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lipectomy as an alternative for superficialization of autologous AVF in obese patients: experience of a referral center in Amazon.

Background: The preferred vascular access for hemodialysis is a native arteriovenous fistula (AVF) because it offers the best results in the short and long terms, lower morbidity and mortality, and has additional advantages in relation to central venous catheters or arteriovenous grafts. However, obesity can present an additional challenge because of the barrier of subcutaneous cellular tissue covering the surface of the vein to be punctured. Objectives: The authors review their experience with excision of subcutaneous tissue (lipectomy) overlying upper arm cephalic vein arteriovenous fistulas in obese patients. Methods: Consecutive vascular access patients undergoing lipectomy for cannulation with difficult access because of vein depth were reviewed. Cephalic vein depth was measured by ultrasound in all cases. Results: Twenty-two patients were reviewed (15 men and 7 women), with a mean body mass index of 34.0 kg/m2 (range: 28-40 kg/m2). Mean age was 58.4 years. The mean preoperative vein depth of 7.9 mm (range: 7.0-10.0 mm) was reduced to 4.7 mm (range: 3.0-6.0 mm) (P 0.01). The mean follow-up period for patients was 13.2 months. Four patients were lost to follow-up and four died during the period due to causes unrelated to vascular access. Conclusions: Obesity should not be a limiting factor to creation of a native AVF, since lipectomy is a relatively simple option for superficialization, enabling functioning native and deep arteriovenous fistulas in obese patients.

Gonadal white adipose tissue is important for gametogenesis in mice through maintenance of local metabolic and immune niches.

Gonadal white adipose tissue (gWAT) can regulate gametogenesis via modulation of neuroendocrine signaling. However, the effect of gWAT on the local microenvironment of the gonad was largely unknown. Herein, we ruled out that gWAT had a neuroendocrine effect on gonad function through a unilateral lipectomy strategy, in which cutting off epididymal white adipose tissue could reduce seminiferous tubule thickness and decrease sperm counts only in the adjacent testis and epididymis of the affected gonad. Consistent with the results in males, in females, ovary mass was similarly decreased by lipectomy. We determined that the defects in spermatogenesis were mainly caused by augmented apoptosis and decreased proliferation of germ cells. Transcriptome analysis suggested that lipectomy could disrupt immune privilege and activate immune responses in both the testis and ovary on the side of the lipectomy. In addition, lipidomics analysis in the testis showed that the levels of lipid metabolites such as free carnitine were elevated, whereas the levels of glycerophospholipids such as phosphatidylcholines and phosphatidylethanolamines were decreased, which indicated that the metabolic niche was also altered. Finally, we show that supplementation of phosphatidylcholine and phosphatidylethanolamine could partially rescue the observed phenotype. Collectively, our findings suggest that gWAT is important for gonad function by not only affecting whole-body homeostasis but also via maintaining local metabolic and immune niches.

The Safety and Effects of Pregnancy after Abdominoplasty: A Systematic Review of the Literature.

BACKGROUND: As advanced maternal age and bariatric procedures have become more common, the number of women seeking pregnancy after having abdominoplasty has increased. This has traditionally been a relative contraindication and counselled against, though there are little data in the literature regarding the potential effects to mother and baby. METHODS: A systematic review of Medline and Embase databases was performed to identify cases of pregnancy occurring after abdominoplasty. Data were extracted and analysed for presentation. RESULTS: 17 studies encompassing 237 patients met inclusion. Mean age was 33.08 years. Mean parity prior to first pregnancy after abdominoplasty 2.13. Previous bariatric surgery was reported in 31.75%. Body contouring procedure was abdominoplasty (94.51%), body lift (3.80%) and other (1.69%). Rectus plication was performed in 89.74%, where reported. Mean time between abdominoplasty and pregnancy was 3.75 years. Method of delivery was Caesarean section in 43.63%, and vaginal delivery in 56.37%. Mean gestational age at delivery was 38.90 weeks. Preterm delivery (<37 weeks) was reported in 9.85%, and low birthweight (<2500 g) was reported in 7.22%. Diagnoses or complications were documented in 14 studies (136 patients). These were grouped as foetal/neonatal (n = 21), maternal (n = 104) or abdominal wall/aesthetic (n = 96); and are detailed within. There were no neonatal or maternal mortalities in any study. A lower-than-expected spinal anaesthetic block was stated in 3 cases. Mean follow-up was 8.5 months. CONCLUSION: Pregnancy should not be contraindicated after abdominoplasty. The data presented allow clinicians to have an evidence-based discussion and provide information for shared decision-making. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Aesthetic Evaluation of Breast Reconstruction with Autologous Fat Transfer vs. Implants.

BACKGROUND: Autologous fat transfer (AFT) seems to be a new minimal invasive method for total breast reconstruction, yet how patients, surgeons, and laymen evaluate cosmesis is lacking. The aim of this study was to evaluate the aesthetic outcome of AFT (intervention group) for total breast reconstruction post-mastectomy, as compared to implant-based reconstruction (IBR) (control group). METHODS: A random and blinded 3D photographic aesthetic outcome study was performed on a selection of 50 patients, scored by three panels: plastic surgeons, breast cancer patients, and laymen. Secondary outcomes included agreement within groups and possible patient characteristics influencing scoring. RESULTS: Breast cancer patients and plastic surgeons did not differ in the aesthetic scores between the treatment groups. In contrast, the laymen group scored AFT patients lower than IBR patients (- 1.04, p < 0.001). Remarkably, mean given scores were low for all groups and overall agreement within groups was poor (ICC < 0.50). Higher scores were given when subjects underwent a bilateral reconstruction and if a mamilla was present. CONCLUSION: Evaluation of aesthetic outcomes varies greatly. Hence, aesthetic outcome remains a very personal measure and this emphasizes the importance of thorough patient counseling including information on achievable aesthetic results before starting a reconstructive procedure. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Efficacy of Suspensory Ligament Release and Pubic Lipectomy Via Penopubic Z Plasty During Penile Prosthesis Implantation in Improving Sexual Satisfaction: A Prospective Randomized Controlled Trial.

BACKGROUND: The utility of penile suspensory ligament release (SLR) in the setting of penile prosthesis implantation (PPI) has received limited attention in the literature. AIM: To assess the efficacy and safety of penile SLR release, pubic lipectomy (PL), and the utility of penopubic Z-plasty (ZP) during malleable PPI in improving sexual satisfaction compared to that achieved with the conventional method. METHODS: Between August 2018 and April 2020, 61 patients with refractory erectile dysfunction were prospectively randomized into 2 groups; group A included 31 patients who underwent PPI with SLR and PL via ZP, and group B included 30 patients who underwent conventional PPI via a penoscrotal incision. OUTCOMES: Penile length was assessed at 3 months, and sexual satisfaction was assessed up to 1 year after PPI using both validated and non-validated tools. RESULTS: The median operative time was higher in group A than in group B (170 min; interquartile range [IQR] [160-190] vs 97.5 min; IQR [90-110] P < .001).The median pre- to postoperative differences in functional and visible penile lengths for group A were 1.5 cm; IQR [0-2] and 2.5 cm; IQR [1-3.5], respectively, while those in group B were both 0 cm; IQR [-1 to 0] P < .001). Group A patients reported higher scores in the International Index of Erectile Function satisfaction domains than the group B patients did (13; IQR [12-14] and 9; IQR [8-10] vs 11; IQR [9.5-12] and 8; IQR [6.5-8.5], respectively, P < .001). Moreover, the postoperative Erectile Dysfunction Inventory of Treatment Satisfaction score was higher in group A than that in group B (95.40; IQR [91-97.7] vs 85.20; IQR [72.7-91], respectively, P < .001). Common complications in group A were penile edema (77.4%), penile instability (9.7%) and glans numbness (9.7%). CLINICAL IMPLICATIONS: The benefit in patient satisfaction following SLR and PL via ZP during PPI may outweigh the incremental increase in complications. STRENGTH & LIMITATIONS: To our knowledge, this is the first prospective randomized controlled study to evaluate the efficacy and safety of SLR, PL, and ZP during PPI. However, because an optimal tool for assessing sexual satisfaction after PPI is lacking at this time, we alternatively adopted the most used assessment tools. Further, our data applies only to malleable penile prosthesis. CONCLUSION: SLR and PL via ZP during PPI resulted in a substantial improvement of the patients' sexual satisfaction without serious complications. Fotouh El Gharably MA, Ghoneima W, Lotfi MR, et al. The Efficacy of Suspensory Ligament Release and Pubic Lipectomy Via Penopubic Z Plasty During Penile Prosthesis Implantation in Improving Sexual Satisfaction: A Prospective Randomized Controlled Trial. J Sex Med 2022;19:852-863.

Safety and Efficacy of Third-Generation Ultrasound-Assisted Liposuction: A Series of 261 Cases.

BACKGROUND: The introduction of third-generation ultrasound-assisted liposuction (3rd UAL) allows for a less invasive modality of both deep and superficial lipectomy while offering improved skin retraction and reduced rate of complications. This study examined the efficacy and safety profile of this technology over 15 years of clinical experience. METHODS: A consecutive series of patients treated from 2005-2020 by the senior author were reviewed for demographic and anthropometric measurements, intraoperative settings, surgical outcomes, and complications via retrospective chart review. Body-Q survey was used to assess patient satisfaction. RESULTS: A total of 261 patients underwent 3rd UAL in 783 areas. There were 238 female and 23 male patients with an average age of 43.5 years and BMI of 27.4 kg/m2. The most frequently treated areas were the trunk and lower limbs. An average of 2840 mL of wetting solution was used with an average of 2284 mL of lipocrit aspirate. About 65% of the cases were done in conjunction with another procedure. Overall complication rate was 4.6%, contour irregularity (1.9%), seroma (0.8%), cellulitis (0.8%), pigmentation changes (0.4%), and electrolyte imbalance (0.4%), with a minimum follow-up of 6 months. 78% of patient would undergo the procedure again and 86% would recommend it. CONCLUSION: Third-generation ultrasound-assisted liposuction can be used effectively and safely, either alone, or in conjunction with other plastic surgery procedures. VASER liposuction allows surgeons to address superficial fat plane and enhanced skin tightening. Rate of complications are lower than that of traditional liposuction with equivalent or higher patient satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of Diameter and Fenestration Area of the Liposuction Cannula on the Viability of the Adipocytes.

BACKGROUND: Loss of volume is perhaps the most frustrating problem of fat grafting. The process of fat grafting depends on different variables such as harvesting, processing, and injection techniques. Results between studies that evaluate the effect of the cannula size on fat graft survival have been controversial. However, the role of the fenestration area of the cannula has not been described. METHODS: Four custom-made cannulas with a single fenestration were used for this study. Cannulas vary in diameter and area of the fenestration. Healthy patients seeking primary liposuction of the abdomen for aesthetic reasons were included. Lipoaspiration was performed in a clockwise pattern, and the order of the cannulas was rotated. Negative pressure was maintained at 0.8 atm at all times. Ten ml of fat, obtained from the suction tube, was poured into 20-ml conical centrifugal tubes for further processing. One gram of lipoaspirate was extracted from each sample, and acridine orange stain was added. Adipocytes were extracted, extended in a frotis, and observed by a histologist (masked fashion) under fluorescence microscopy. Viability was reported in percentages per sample. RESULTS: The overall viability was 64.75% ± 18.58. The viability of the obtained samples ranged from 66.51± 20.66 % to 62.83 ± 18.1. In further analysis, comparing the viability according to the shaft diameter and fenestration area, there was no significant difference among groups. CONCLUSIONS: Neither the diameter of the cannula nor the size of the fenestrations are determining factors to affect the viability of the adipocytes. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Effect of Ultrasonic Liposuction Energy Levels on Fat Graft Viability.

BACKGROUND: The use of fat obtained from ultrasound-assisted liposuction is popular. However, no study has considered the effect of different energy levels on fat grafts. OBJECTIVES: We hypothesized that different ultrasonic energy levels could change the fat graft viability. METHODS: Both flanks of 15 CD1 nude mice (30 experimental areas) were used, with experimental areas randomly distributed into five groups. Using different energy settings, fat grafts were obtained from a patient's abdominoplasty material and applied to the mouse flank regions. Device settings were intermittent mode with 50% vibration amplitude in group 1, continuous mode with 50% vibration amplitude in group 2, intermittent mode with 90% vibration amplitude in group 3, and continuous mode with 90% vibration amplitude in group 4. The control group was grafted with fat obtained via the conventional method. After 6 weeks, all mice were sacrificed, and fat grafts were excised. Sections were stained with hematoxylin-eosin, Masson's trichrome, and anti-perilipin A antibody. RESULTS: The perilipin A immunostaining result was lowest in group 4, indicating the lowest viable cell count (p < 0.01). There was no significant difference between groups for the other parameters (p > 0.05). CONCLUSION: High ultrasonic energy may affect fat graft survival. If fat injection is planned, avoiding high energy settings (our recommendation is not to exceed 16 Watts.) should be considered. We also recommend increasing the vibration amplitude rather than switching from intermittent to continuous mode in body parts that are relatively resistant to liposuction. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

TULUA: Effects of Flap Undermining and Type of Wall Plicature in a Rat Model Abdominoplasty.

BACKGROUND: TULUA, a transverse plication lipoabdominoplasty, which excludes elevation of the supraumbilical flap and includes a skin graft neoumbilicoplasty, claims greater safety and better results. An animal study was designed to compare it, with two current techniques. MATERIALS AND METHODS: Three matched groups of 12 rats had combined liposuction and abdominoplasty. Liposuction was extensive and unrestricted. Groups 1 and 2 had vertical plication and transposition umbilicoplasty, and group 3 had transverse plication and neoumbilicoplasty. Flap elevation in the epigastrium was wide to costal margins in group 1, limited to a tunnel in group 2, and no dissection in group 3. The animals were observed for 21 days and then euthanized. Intraoperative, postoperative, and postmortem variables and findings were measured and analyzed to find differences between groups. RESULTS: Transverse lipoabdominoplasty demonstrated a wider wall plication area, as well as a decrease in tension to close the wound, causing the horizontal scar to remain in a low position. In vertical plication lipoabdominoplasty groups, flap necrosis and seromas were more frequent, and the umbilical position descended due to secondary healing and scar contraction. The scar's scores were better in the transverse group and were confirmed when evaluated by external observers.In postmortem examination, horizontal plication presented less widening; perforator vessels were preserved when surgical undermining of the upper abdomen was not performed, and there were fewer seromas. CONCLUSION: In a rat model, TULUA demonstrates superior results and a decrease in complications when compared to lipoabdominoplasties with vertical plication and wide or tunneled dissection in the upper abdomen. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Treatment and prognosis of retroperitoneal liposarcoma with multiple primary tumor].

Objective: To investigate the multiple origin of retroperitoneal liposarcoma and its postoperative prognosis. Methods: A total of 49 retroperitoneal liposarcoma patients underwent total (ipsilateral) retroperitoneal lipectomy in our center from May 2017 to December 2019 were recruited. Clinical data and the follow-up information were reviewed and the origin and prognosis were analyzed. Results: A total of 15 patients were pathologically diagnosed as multiple primary cancer (MPC), the incidence rate of retroperitoneal liposarcoma with MPC was 30.6% (15/49), while other 34 cases was non-MPC. The postoperative recurrence rates of patients with high differentiation and de-differentiation retroperitoneal liposarcoma were 31.8% and 44.4%, without significant difference (P>0.05). The postoperative recurrence rates of MPC and non-MPC were 40.0% and 38.2%, without significant difference (P>0.05). Five cases died within the follow-up. Conclusion: Retroperitoneal liposarcoma might origin form MPC, and total (ipsilateral) retroperitoneal lipectomy is recommended to reduce the recurrence rate.

Surgical treatment of Milroy disease.

BACKGROUND AND OBJECTIVES: Milroy disease is a form of congenital primary lymphedema affecting the lower limbs. When conservative management is ineffective, surgical treatment becomes necessary. The purpose of this study was to investigate the efficacy of vascularized lymph node transfer (VLNT) associated with extensive therapeutic lipectomy in the treatment of these patients. METHODS: In China Medical University Hospital, four patients have been diagnosed with Milroy disease and treated over an 8 year-period time. All patients presented with hereditary bilateral legs swelling since birth. All patients were treated with VLNT from the gastroepiploic region bilaterally associated with extensive therapeutic lipectomy. RESULTS: All procedures have been executed bilaterally and have been successful, without complications. The average follow-up of the patients was 20.2 ± 2.8 months. The limbs treated presented an average circumference reduction of a 4.0 ± 2.1 cm and patients did not experience cellulitis during follow-up. Patients expressed satisfaction with the procedure. CONCLUSIONS: VLNT together with therapeutic lipectomy proved to be a reliable technique in moderate cases of Milroy disease, providing an alternative path for lymph drainage, and reducing the lymph load and the excess of subcutaneous adipose tissues, thus improving patients' quality of life.

Surgical Approach to Lymphedema Reduction.

PURPOSE OF REVIEW: For patients who have or may develop lymphedema due to oncologic resection, surgical options are available to prevent and treat this chronic disease. Here, we review the current pathophysiology, classification systems, surgical preventive techniques, and treatment options for lymphedema reduction. RECENT FINDINGS: Preventive surgical techniques, including de-escalation of axillary surgery, sentinel lymph node biopsy (SLNB), axillary reverse mapping (ARM), and lymphedema microsurgical preventive healing approach (LYMPHA), have been shown to reduce the incidence of lymphedema. Water displacement remains the gold standard for measuring limb volume and classification of lymphedema; however, lymphoscintigraphy and ICG lymphography are two novel imaging techniques that are now utilized to characterize lymphedema and guide management. Complete decongestive therapy (CDT) remains the mainstay of treatment. Vascularized lymph node transfer (VLNT) and lymphovenous bypass have shown promising results, particularly in advanced lymphedema stages. Combination therapy, incorporating both surgical and non-surgical approaches to lymphedema, yields best patient outcomes. Lymphedema is a chronic disease wherein management requires a combination of surgical and conservative treatments. Standardization in lymphedema staging, key outcome indicators, and quantitative data will be critical to establish the absolute best practices in lymphedema diagnosis and treatment.

Evaluation of the Effect of Erector Spinae Plane Block in Patients Undergoing Belt Lipectomy Surgery.

BACKGROUND: The interest in and demand for post-bariatric surgery have increased along with the increase in obesity surgery. Belt lipectomy, during which a circular correction is made in the center of the trunk, is the most commonly performed among these surgical techniques. Postoperative pain is an important problem due to the size of the surgical site and stretched closure. In this study, it was aimed to evaluate the intraoperative and postoperative narcotic analgesic consumption, postoperative analgesic requirement, postoperative visual analog scale (VAS) scores, postoperative nausea and vomiting (PONV), and the first mobilization time in patients with and without erector spinae plane block (ESPB). METHODS: The files of patients who had undergone belt lipectomy between 2016 and 2019 in our hospital were retrospectively reviewed. Patients who received ESPB were called group 1, and those who did not undergo ESPB were called group 2. Their demographic characteristics, intraoperative and postoperative narcotic and non-narcotic analgesic consumption, VAS scores, PONV, and the first mobilization times were recorded. RESULTS: The files of a total of 51 patients, including 23 patients in group 1 and 28 patients in group 2, were reviewed. It was determined that intraoperative and postoperative narcotic analgesic consumption (p < 0.005), PONV (p < 0.005), and the first mobilization time (p < 0.005) were significantly lower in group 1 compared with group 2. CONCLUSION: The use of the ESP block in belt lipectomy surgeries significantly reduces intraoperative and postoperative narcotic analgesic consumption and pain scores. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lower Body Lift After Bariatric Surgery: 323 Consecutive Cases Over 10-Year Experience.

BACKGROUND: Lower body lift is a widespread procedure for massive weight loss patients aimed to improve the contour of the lower trunk, gluteal region and proximal lower extremity. The data about complications are confusing, and there is a lack of uniform studies for massive weight loss patients. A simple formula to carry out a reliable procedure in a short time with a low complication rate should be advocated. METHODS: This retrospective study analyzed data of 323 patients undergoing lower body lift after bariatric surgery over a 10-year period. Selection criteria, careful preoperative marking, reliable intra- and postoperative care and a few surgical tips are discussed. All the complications (both major and minor) and the aesthetic satisfaction were evaluated. Risk factors assessed were patient age, tobacco consumption, current BMI, operative time and combined surgery. RESULTS: The overall complication rate was 42%. We recorded a lower rate of major complications and skin dehiscence; no infection and no skin necrosis were observed. The most frequent complication was seroma (35%). A complication development was straight related to age (p = 0.0177) and tobacco use (p = 0.0336). Patients' satisfaction about overall aesthetic was high. CONCLUSIONS: We present our case load and describe an easy recipe to perform a safe surgery without undermining and liposuction in short operative times. The reasonable overall complication rate and the surprisingly lower rate of dehiscence and skin necrosis combined with a pleasant aesthetic result make the lower body lift an easy and safe procedure, when applied to the appropriate patient population. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Impaired metabolic and hepatic functions following subcutaneous lipectomy in adult obese rats.

NEW FINDINGS: What is the central question of this study? What is the impact and drawbacks of subcutaneous lipectomy on body metabolism? What is the main finding and its importance? Subcutaneous lipectomy resulted in deterioration of hepatic functions, atherosclerotic lipid profile and disturbed redox state. While the results support lipectomy as an effective treatment for obesity, lipectomy induces unfavourable changes in health. ABSTRACT: The number of obese older adults is on the rise, but data about proper treatment of obesity in the elderly is controversial. The present study was designed to investigate the effectiveness and consequences of partial subcutaneous lipectomy, as a rapid medical intervention against increased accumulation of body fat, in adult obese rats. The study was conducted on adult (9-12 months) female rats, in which obesity was induced by bilateral surgical ovariectomy. They were randomized into two main groups: short term (5 weeks) and long term (10 weeks). Both groups were subdivided into control, ovariectomized (OVX) and ovariectomized lipectomized groups. Body weight (BW) was measured and body mass index (BMI) calculated. Fasting blood glucose, lipid profile and plasma levels of total proteins, albumin, liver enzymes, malondialdehyde (MDA), leptin and adiponectin were determined. The content of both blood and hepatic tissue of reduced glutathione was estimated. In addition, histological study of the liver, aorta and peri-renal fat was performed. Compared to controls, OVX rats showed significant increase in BW, BMI and plasma levels of liver enzymes, MDA and leptin. Histological study revealed vacuolated ballooned hepatocytes and enlarged irregular visceral adipocytes with atherosclerotic changes in the wall of aorta. Following subcutaneous lipectomy, rats exhibited significant fasting hyperglycaemia, dyslipidaemia, lowered plasma albumin and disturbed redox state with aggravation of the histological changes. The findings indicate that although subcutaneous lipectomy appears to be effective in combating obesity in older females, it has unfavourable effects on both metabolic and hepatic functions.

Up-regulation of PCSK9 gene expression and diminished level of LDL-receptor in rat liver as a potential cause of post-lipectomy hypercholesterolemia.

Studies designed to examine effects of fat mass reduction (including lipodystrophy and lipectomy) on human serum total and LDL-cholesterol concentrations are inconsistent. The purpose of this study was to examine effect of partial lipectomy in rats (as an experimental model of fat mass reduction in humans) on (1) circulating total cholesterol, LDL-cholesterol + VLDL-cholesterol and HDL-cholesterol concentrations, and (2) factors which may affect serum cholesterol concentrations such as: (a) liver LDL-receptor level, (b) expression of liver PCSK9 and (c) circulating PCSK9 concentration. Reduction of rat adipose tissue mass resulted in an increase in circulating total and LDL + VLDL-cholesterol concentrations, which was associated with (a) decrease in liver LDL-R level, (b) increase in liver PCSK9 expression, and (c) increase in circulating PCSK9 concentration as compared with sham controls. These changes were accompanied by elevated liver HNF1α (and HNF4α) mRNA levels. Silencing HNF1α in HepG2 cells by siRNA led to decrease in PCSK9 mRNA levels. This suggests that overexpression of HNF1α gene in liver of lipectomized rats can lead to overproduction of PCSK9. In conclusion, up-regulation of PCSK9, due to overexpression of HNF1α gene in liver of lipectomized rats and subsequently increase in circulating PCSK9 concentration lead to decrease in liver LDL-R level. This may contribute, at least in part, to an increase in the concentration of circulating cholesterol in rats with reduced fat mass. These findings provide a possible explanation for the molecular mechanism of hypercholesterolemia observed sometimes after reduction of fat mass in human.

Comparison of Cardiovascular Benefits of Bariatric Surgery and Abdominal Lipectomy.

PURPOSE OF REVIEW: The purpose of this review is to examine recent evidence supporting effectiveness of bariatric surgery and abdominal lipectomy as interventional strategies aimed at reduction in incidence of cardiovascular disease (CVD) and related morbidity and mortality in obese and metabolic syndrome patients. RECENT FINDINGS: While several studies show reduction in CVD risk factors in patients who have undergone both the Roux-en-Y gastric bypass and sleeve gastrectomy, very few demonstrate actual improvements in cardiovascular function, or a decrease in CVD events or CVD-related mortality. Consequently, the cardiovascular benefits of the less invasive sleeve gastrectomy in comparison to the gastric bypass are also unclear. Striking new data on large patient samples demonstrate significant positive correlation between gastric bypass and CVD risk factor reduction only in patients who are diabetic or > 50 years of age at the time of surgery, with no significant differences in non-diabetic and younger patients and with significant side effects. On the other hand, a markedly less invasive removal of abdominal subcutaneous adipose tissue via lipectomy consistently and significantly improved CVD risk factors as well as cardiovascular function in the very few studies available. Overall, neither the potential nor the definitive cardiovascular benefits of either of the commonly used bariatric surgical or the various lipectomy procedures have been adequately explored. Future basic science and clinical studies have the opportunity to understand the mechanisms and long-term consequences of both approaches and develop personalized approaches with higher benefit to side effect ratios.

Endoscopic Superficialisation of Haemodialysis Arteriovenous Fistulas in Obese Patients - Safety, Feasibility, and Outcomes.

OBJECTIVE: The aim was to evaluate the safety and feasibility of endoscopic superficialisation (ES) in patients with deeply located cephalic veins in well matured arteriovenous fistulae (AVF) and to present functional outcomes. METHODS: All patients with cannulation difficulties due to a deep lying cephalic vein of more than 6 mm but with an otherwise matured AVF with a straight needle access segment of at least 6 cm were included in this retrospective study. Procedure related safety, defined as completion of ES with no need for conversion to open surgery, and feasibility in terms of cephalic vein depth reduction were assessed. The primary endpoint was three successfully performed haemodialysis sessions using the endoscopically superficialised AVF during a minimum follow up of 12 months. RESULTS: From June 2013 to August 2017, 12 patients with a mean body mass index of 33.5 ± 3.9 kg/m2 underwent ES as a second stage procedure following radiocephalic (n = 5) or brachiocephalic AVF (n = 7) creation. All procedures were conducted endoscopically. Ultrasound imaging 12 weeks post-operatively documented a reduction in the depth of the cephalic vein from a mean of 10.1 ± 1.4 mm to 4.3 ± 0.8 mm. The mean duration of the ES was 69 ± 26.0 min with 67% performed under locoregional anaesthesia. In all but one patient with a cephalic vein of poor wall quality leading to recurrent haematoma, haemodialysis was performed successfully following ES. CONCLUSIONS: Endoscopic superficialisation of the cephalic vein is a safe and effective technique. Providing good functional results, ES represents an alternative approach for second stage superficialisation in obese patients.