Timing of enteral nutrition in acute pancreatitis: meta-analysis of individuals using a single-arm of randomised trials.

INTRODUCTION: In acute pancreatitis, enteral nutrition (EN) reduces the rate of complications, such as infected pancreatic necrosis, organ failure, and mortality, as compared to parenteral nutrition (PN). Starting EN within 24 h of admission might further reduce complications. METHODS: A literature search for trials of EN in acute pancreatitis was performed. Authors of eligible trials were requested to provide the data of all patients in the EN-arm of their trials. A meta-analysis of individual patient data was performed. The cohort of patients with EN was divided into patients receiving EN within 24 h or after 24 h of admission. Multivariable logistic regression, adjusting for predicted disease severity and trial, was used to study the effect of timing of EN on a composite endpoint of infected pancreatic necrosis, organ failure, or mortality. RESULTS: Observational data from 165 individuals from 8 randomised trials were obtained; 100 patients with EN within 24 h and 65 patients with EN after 24 h of admission. In the multivariable model, EN started within 24 h of admission compared to EN started after 24 h of admission, reduced the composite endpoint from 45% to 19% (adjusted odds ratio [OR] of 0.44; 95% confidence interval [CI] 0.20-0.96). Within the composite endpoint, organ failure was reduced from 42% to 16% (adjusted OR 0.42; 95% CI 0.19-0.94). CONCLUSIONS: In this meta-analysis of observational data from individuals with acute pancreatitis, starting EN within 24 h after hospital admission, compared with after 24 h, was associated with a reduction in complications.

Benefits and drawbacks of SILS cholecystectomy: a report of 60 SILS cholecystectomies with conventional instrumentation from an academic center.

BACKGROUND: Single-incision laparoscopic surgery is a rapidly emerging approach to gallbladder disease. METHODS: From February 2009 to September 2010, 60 patients were subjected to single-incision laparoscopic cholecystectomy. In all the patients, a 12-mm incision was made in the umbilicus and a 2-trocar technique was applied. Gallbladder was suspended with 2 sutures and the procedure was accomplished with standard partly reusable laparoscopic instruments. RESULTS: In all, 41 women (68.3%) and 19 men (31.7%) were enrolled in this study. Mean age was 50.7 years (range = 17-72 years), mean body mass index was 26.2 kg/m(2) (range = 18.3-37.7 kg/m(2)) and mean operative time was 52.6 minutes (range = 30-120 minutes). No mortality or morbidity was recorded and hospital stay was less than 24 hours. At follow-up visits, no complications were recorded and cosmesis was excellent. CONCLUSION: Single-incision laparoscopic cholecystectomy can be safely performed with conventional instrumentation with minimal cost.

Comparison of one anastomosis gastric bypass versus standard Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion, in a case-matched, non-superobese population: 6 years of follow-up.

INTRODUCTION: One anastomosis gastric bypass (OAGB) is gaining increasing acceptance as a simple, safe, and effective operation for treating morbid obesity. Data comparing this procedure with the most effective biliopancreatic diversions (BPD) remain scarce, and most studies evaluate OAGB against standard Roux-en-Y gastric bypass (RYGB). AIM: To present the mid-term results of a comparison of RYGB, OAGB, and our modification of BPD in an exclusively non-superobese population, regarding safety, efficacy, preservation of weight loss, as well as late postoperative metabolic and non-metabolic complications. MATERIAL AND METHODS: From our cohorts of patients treated for morbid obesity with OAGB, RYGB, and BPD at Patras University Hospital, we identified patients who had case-matched preoperative profiles regarding age, preoperative body mass index (BMI), and obesity-related comorbidities (diabetes mellitus, hypertension, and dyslipidaemia). Thirty-four patients from each group were included in the study. Bariatric outcomes, non-metabolic complications, and postoperative metabolic parameters were followed until the 6th postoperative year. RESULTS: The average patient age was 37.4 years (range: 19-57), 85.3% were female and 14.7% were male, with a mean BMI of 46.3 kg/m2 (range: 38.3-49.7). Regarding weight loss and glycaemic control, OAGB had comparable results to BPD and was significantly better than RYGB. The safety profile was analogous to RYGB, with the exception of calcium levels, which, even though they were within normal range, were significantly lower than those in RYGB. Comorbidities were successfully treated with all operations at comparable rates. In this cohort, no other major complications were observed. CONCLUSIONS: OAGB offered mid-term results comparable to BPD while being safe and with minimal impact on the patient's nutritional state. It is an effective procedure for treating morbid obesity, which results in sustained weight loss and a high rate of resolution of comorbidities.

Comparison of early and late complications after various bariatric procedures: incidence and treatment during 15 years at a single institution.

BACKGROUND: Bariatric procedures are effective in the life-long treatment of clinically severe obesity, but they are technically demanding and have known complications. The present study presents mortality and morbidity with different procedures from the prospective 15-year bariatric database of the University Hospital of Patras in Greece. METHODS: From June 1994 through December 2008, 1,162 morbidly obese patients underwent various bariatric procedures at our institution (35 vertical banded gastroplasties, 151 laparoscopic sleeve gastrectomies, 90 open and 137 laparoscopic Roux-en-Y gastric bypasses, 699 biliopancreatic diversions with long limbs, and 50 reoperations). Postoperative metabolic deficiencies and causes of early and late morbidity for various bariatric procedures were compared by using the z-test for the comparison of proportions. Logistic regression analysis was used to model the occurrence of early and late death and complications. RESULTS: Total mortality was 1.81% (early 0.6%, intermediate 0.26%, late 0.95%). No significant predictors for early death were found, but age (odds ratio (OR), 1.077; 95% confidence interval (CI), 1.024-1.133; P = 0.004) and BMI (OR, 1.156; 95% CI, 1.023-1.306; P = 0.02) were predictors for late death. Early and late morbidity were 8% and 27.71%, respectively. The total leakage incidence was 1.98% and was significantly higher (P < 0.05) after reoperation. Fifteen of the 23 leaks were successfully treated conservatively. Most late complications were incisional hernias (18.85%)--almost all after open procedures. Hypoalbuminemia incidence was significantly higher after biliopancreatic diversion with long limbs (3.58%) and reoperation (8%). CONCLUSIONS: Bariatric procedures, even in specialized centers, may have serious complications because of their technical complexity in a high-risk population. Almost all can be managed successfully.

Adequate vitamin D supplementation does not ameliorate bone loss following long limb-biliopancreatic diversion in morbidly obese women.

OBJECTIVES: The objective of this study is to investigate the effect of adequate vitamin D supplementation on bone mineral density (BMD) following long limb-biliopancreatic diversion (LL-BPD), a malabsorptive bariatric operation. BACKGROUND: Marked weight loss following bariatric surgery is associated with significant decrease in BMD, attributed to the weight loss and to nutritional, mineral, and vitamin D deficiencies resulting in secondary hyperparathyroidism. METHODS: Two groups, of 35 and 37 healthy, obese (BMI, 50.4 + 6.6 and 46.5 + 4.8 g/cm2), premenopausal, normally menstruating women underwent LL-BPD. Both groups received high-calcium diets, 600 IU of vitamin D, and 1000 mg elemental calcium daily, while group B received an extra dose of vitamin D (10,000 IU/day) during the first postoperative month, followed by dose adjustment in order to maintain 25OHD concentration higher than 30 µg/L. Areal BMD (aBMD) was measured at the lumbar spine preoperatively and 1 year postoperatively. RESULTS: One year postoperatively, BMI decreased by approximately 19 kg/m2 in both groups, while 25-OH-vitamin D levels did not change in group A (18.7 + 9.1 to 20.2 + 13.0 µg/L, (p = 0.57)) and increased in group B (15.58 ± 5.73 to 52.97 ± 15.46 µg/L, (p = < 0.001). PTH levels increased in group A (from 38.5 ± 12.2 to 51.2 ± 32.8 pg/ml) (p = 0.047) and decreased in group B (from 51.61 ± 18.7 to 45.1 ± 17.8 pg/ml) (p = 0.042). Lumbar spine aBMD decreased similarly in both groups (p = 0.311, for the comparison between groups) from 1.198 + 0.14 to 1.103 + 0.15 g/cm2 in group A (p < 0.001) and from 1.157 + 0.14 to 1.076 + 0.14 g/cm2 in group B (p < 0.001) and Z-score from 0.93 + 0.97 to 0.19 + 1.02, (p < 0.001) and from 1.15 + 1.29 to 0.419 + 1.28, (p < 0.001), respectively. CONCLUSIONS: LL-BPD leads to similar and significant bone mass reduction 1 year postoperatively, irrespective of adequate vitamin D replacement and in the absence of secondary hyperparathyroidism.

Adipokine serum levels are related to liver histology in severely obese patients undergoing bariatric surgery.

BACKGROUND: Leptin, adiponectin, and resistin are adipokines linked to the development of insulin resistance, which plays a central role in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). We aimed to define adipokine serum levels in severely obese patients undergoing bariatric surgery and to correlate these with anthropometric and metabolic variables, liver function tests, and histopathological parameters of NAFLD and nonalcoholic steatohepatitis (NASH). METHODS: Surgical liver biopsies were obtained from 50 bariatric patients with no history of liver disease or significant alcohol consumption. Serum leptin, adiponectin, and resistin levels were measured, and histology was assessed using Brunt's and Kleiner's scoring systems. RESULTS: Waist/hip ratio was significantly higher in men (p = 0.0001), and leptin (p = 0.036) and adiponectin (p = 0.0001) serum levels were higher in women. Forty-one of 50 patients (82%) had histological NAFLD, including 10 (20%) with NASH. Nine patients (18%) had normal liver histology (obese control subgroup). In NAFLD patients, serum adiponectin was negatively correlated with activity grade and fibrosis stage, resistin was negatively correlated with steatosis grade (p = 0.033), while leptin was not related to histology. Leptin/adiponectin ratio showed positive association with stage (p = 0.044). In the subgroup of NASH patients, adiponectin was negatively correlated only with stage (p = 0.01), while there was no correlation between leptin, resistin, or leptin/adiponectin and histology. CONCLUSIONS: Serum adiponectin and resistin levels are related to liver histology in bariatric patients and may be indicative of the histological severity of NAFLD and the extent of hepatic steatosis, respectively. Serum leptin levels are not informative of underlying liver histology in severely obese patients.

Decreased adipocyte glucose transporter 4 (GLUT4) and aquaglyceroporin-7 (AQP7) in adults with morbid obesity: possible early markers of metabolic dysfunction.

PURPOSE: Morbid obesity (BMI > 40) is often accompanied by metabolic disorders. In adipose tissue, serine/threonine kinase PKBß/AktΙΙ plays a role in glucose uptake, mediated by glucose transporter 4 (GLUT4). The insulin pathway also affects aquaglyceroporin-7 (AQP7), which mediates lipolysis-derived glycerol efflux into the bloodstream. The aim of our study was to investigate the molecular mechanisms in adipocytes of adults with morbid obesity that may lead to insulin resistance (IR) and diabetes mellitus type 2 (DM2) in morbid obesity. METHODS: Primary in vitro adipocyte cultures were developed from surgical biopsies from visceral (Visc), abdominal (Sub), and gluteal subcutaneous (Glut) fat depots, from 20 lean adults and 36 adults with morbid obesity (OB), divided into two groups: 20 without (MOW) and 16 with DM2 (MODM). mRNA and protein expression (PE) of AktΙΙ, AQP7, and GLUT4 were studied with RT-PCR and Western immunoblotting (WI), respectively. RESULTS: The PE of (1) AktII and basal phosphorylated AktII (pAktII) showed no difference within the groups, (2) the 37 kDa and 34 kDa isoforms of AQP7 were decreased in Visc/Sub from OB/MOW/MODM, (3) GLUT4 was decreased in Visc/Sub from OB/MOW/MODM, and (4) the 34 kDa isoform of AQP7 was decreased in Sub of MODM compared with MOW. CONCLUSIONS: Decreased 37 kDa (presented in this study as a novel isoform) and 34 kDa isoforms of AQP7 in MOW and MODM may cause reduced lipolysis, enhancement of adipocyte hypertrophy, and impairment of insulin, signaling possibly reflected by low GLUT4 expression. This may potentially cause systemic IR, since decreased adipose GLUT4 expression may affect whole-body insulin sensitivity, increasing the risk for DM2. Furthermore, decreased subcutaneous AQP7 34 kDa could represent an early marker of IR.

A prospective evaluation of a variant of biliopancreatic diversion with Roux-en-Y reconstruction in mega-obese patients (BMI > or = 70 kg/m(2)).

BACKGROUND: Super-obese patients with BMI > or = 70 kg/m(2) present a special subgroup among the obese population due to the higher incidence of severe comorbidities and increased technical difficulties in perioperative management. The optimal surgical approach still remains controversial. METHODS: From January 2002 to October 2007, 68 super-obese patients with BMI > or = 70 kg/m(2) (75.7 +/- 5.61) and various comorbidities (mean 1.45 +/- 1, range 0-5), underwent a variant of biliopancreatic diversion with Roux-en-Y reconstruction (BPD-RYGBP) at our institution. The mean age was 39.6 +/- 9.5 years, and the excess weight was 146.1 +/- 24.5 kg. The safety and the effectiveness of the procedure were prospectively evaluated. RESULTS: Thirty-one patients have completed their second postoperative year. Mean BMI after 2 years follow-up was 35 +/- 5.33 kg/m(2) (p < 0.001) and mean %EWL was 79.9% (range 57.17-149.89). Significant improvement in preexisting comorbidities was also observed (mean 0.95 +/- 0.1, range 0-2; p < 0.001). Early major postoperative complications included one case of acute renal failure (1.47%), three anastomotic leaks (4.41%), four pulmonary embolisms (5.88%), one hemorrhage requiring reoperation (1.47%), and three cases of pneumonia (4.41%), resulting in a total morbidity rate of 8.82% and a mortality rate of 8.82%. Late complications included small bowel obstruction in four patients (5.88%), pulmonary embolism in one patient (1.47%), severe hypoalbuminemia requiring artificial nutrition support in six patients (8.82%), and incisional hernia in 23 patients (33.8%). Late morbidity was 41.1%, and there was no late mortality. CONCLUSION: BPD-RYGBP appears to be an effective procedure in patients with BMI > or = 70 kg/m(2) providing adequate weight loss and improvement of co-existing comorbidies after 2 years. Nevertheless, it is associated with higher morbidity and mortality rates compared to patients with BMI < 70 kg/m(2) undergoing the same surgical procedure.

Glucose levels and insulin secretion in surgery-induced hyperglycemia in normoglycemic obese patients.

BACKGROUND: Transient hyperglycemia is commonly observed in non-diabetic subjects during surgery. We undertook this study to investigate (1) insulin secretion pattern and glucose levels during elective surgery, and (2) the role of pre-operative fasting in the development of surgery-induced hyperglycemia. METHODS: We examined 21 severely obese normal glucose tolerant patients, who underwent bariatric surgery. From the 21 operated subjects, 14 remained fasted while seven patients received 75 g glucose the preoperative night. They sampled at baseline and from the onset of operation frequently for 9 h thereafter, for measuring serum insulin and glucose. RESULTS: Hyperglycemia developed within 1 h from the onset of operation and lasted 9 h. The administration of 75 g glucose the preoperative night prevented surgery-induced hyperglycemia. Insulin profile analyzed by deconvolution analysis was similar between fasted patients and those who received 75 g glucose. Serum insulin was suppressed at the beginning of the surgery and reached baseline values 4 h thereafter. CONCLUSION: Hyperglycemia occurred within 1 h from the beginning of surgery and sustained for at least 9 h while insulin levels are suppressed or unaltered compared to baseline values in euglycemia. The administration of 75 g glucose the preoperative night prevents surgery-induced hyperglycemia without altering the profile of insulin secretion.

Prospective evaluation of laparoscopic Roux en Y gastric bypass in patients with clinically severe obesity.

AIM: To evaluate and present our experience with laparoscopic Roux en Y gastric bypass (RYGB) in a selected patient population. METHODS: A cohort of 130 patients with a body mass index (BMI) between 35 and 50 kg/m(2) were evaluated in relation to postoperative morbidity, weight loss and resolution of co-morbidities for a period of 4 years following laparoscopic RYGB. RESULTS: Early morbidity was 10.0%, including 1 patient with peritonitis who was admitted to Intensive Care Unit (ICU) and 1 conversion to open RYGB early in the series. There was no early or late mortality. Maximum weight loss was achieved at 12 mo postoperatively, with mean BMI 30 kg/m(2), mean percentage of excess weight loss (EWL%) 66.4% and mean percentage of initial weight loss (IWL%) 34.3% throughout the follow-up period. The majority of preexisting comorbidities were resolved after weight loss and no major metabolic disturbances or nutritional deficiencies were observed. CONCLUSION: Laparoscopic RYGB appears to be a safe and effective procedure for patients with BMI 35-50 kg/m(2) with results that are comparable to previously published data mostly from the USA but from Europe as well.

Laparoscopic versus open appendectomy: which way to go?

AIM: To compare the outcome of laparoscopic versus open appendectomy. METHODS: Prospectively collected data from 293 consecutive patients with acute appendicitis were studied. These comprised of 165 patients who underwent conventional appendectomy and 128 patients treated laparoscopically. The two groups were compared with respect to operative time, length of hospital stay, postoperative pain, complication rate and cost. RESULTS: There were no statistical differences regarding patient characteristics between the two groups. Conversion to laparotomy was necessary in 2 patients (1.5%). Laparoscopic appendectomy was associated with a shorter hospital stay (2.2 d vs 3.1 d, P = 0.04), and lower incidence of wound infection (5.3% vs 12.8%, P = 0.03). However, in patients with complicated disease, intra-abdominal abscess formation was more common after laparoscopic appendectomy (5.3% vs 2.1%, P = 0.002). The operative time and analgesia requirements were similar in the two groups. The cost of treatment was higher by 370 EUR in the laparoscopic group. CONCLUSION: Laparoscopic appendectomy is as safe and efficient as open appendectomy, provided surgical experience and equipment are available.

Weight loss after bariatric surgery improves aortic elastic properties and left ventricular function in individuals with morbid obesity: a 3-year follow-up study.

OBJECTIVE: To investigate whether weight loss after bariatric surgery (gastric bypass) is associated with changes in aortic function (an important determinant of left ventricular function) and in left ventricular function, in morbidly obese individuals 3 and 36 months after surgery. METHODS: We used echocardiography to evaluate 60 obese individuals [body mass index (BMI) > 40 kg/m2] who underwent surgery and 20 obese individuals who neither underwent surgery nor lost weight, at baseline and at 3 and 36 months of follow-up, and 40 lean individuals (BMI < 25 kg/m2) of similar age, sex and risk factors, at baseline. We measured aortic strain, distensibility, stiffness index, pressure-strain modulus and Doppler indices of left ventricular diastolic dysfunction (ratio of peak early to peak atrial flow velocities, isovolumic relaxation time and deceleration time). RESULTS: Baseline aortic function and Doppler diastolic indices were impaired in obese individuals compared with those who were lean (P < 0.05). During 3 and 36 months of follow-up, BMI and left ventricular diastolic diameter, volume, mass and wall thickness were reduced, and indices of aortic function and left ventricular diastolic function were normalized, in obese individuals after surgery [aortic distensibility (cm2 x dyn(-1) x 10(-6)): 1.9 before surgery, 3.4 at 3 months after surgery and 4.3 at 3 years after surgery, compared with 3.36 in lean controls; P < 0.01], but not in those who did not lose weight. The reduction in BMI after surgery was related to the concomitant improvement in indices of aortic function (P < 0.01) and isovolumic relaxation time (P < 0.05) after adjustment for age, sex and concomitant reduction in blood pressure, lipids and glucose concentrations. CONCLUSION: Weight reduction after bariatric surgery normalizes aortic function, reduces left ventricular hypertrophy and, thus, improves left ventricular diastolic function in morbidly obese individuals over a 3-year period of follow-up.

Resolution of diabetes mellitus and metabolic syndrome following Roux-en-Y gastric bypass and a variant of biliopancreatic diversion in patients with morbid obesity.

BACKGROUND: Obesity is associated with increased prevalence of type 2 diabetes mellitus (DM2) and metabolic syndrome and increased morbidity and mortality. Bariatric surgery results in significant and long-term weight loss. Two of the most effective and popular bariatric procedures are Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD). The objective of this study was to investigate the effects of RYGBP and BPD-RYGBP, a variant of BPD with a lower rate of metabolic deficiencies than BPD, on DM2 and the major components of metabolic syndrome in patients with morbid obesity and DM2. METHODS: The prospective database of our unit, from June 1994 until May 2006, was analyzed and 137 patients with DM2 were found. 26 underwent RYGBP (BMI 46.1 +/- 2.9 kg/m2) and 111 BPD-RYGBP (BMI 59.7 +/- 10.6 kg/m2). 7 of the patients were on insulin (4.90%) and 37 on oral hypoglycemic agents (25.87%). Pre- and postoperative medications, and clinical and biochemical parameters were considered in the analysis. The mean follow-up was 26.39 +/- 21.17 months. RESULTS: Excess weight loss was approximately 70% after either procedure. DM2 resolved in 89% and 99% of the cases following RYGBP and BPD-RYGBP, respectively. 2 years after BPD-RYGBP all the patients had blood glucose < 110 mg/dl, 95% had normal cholesterol, 92% normal triglycerides and 82% normal blood pressure. The respective values following RYGBP were 66%, 33%, 78% and 44%. Uric acid decreased significantly only after BPD-RYGBP. Liver enzymes improved in both groups. CONCLUSIONS: RYGBP and BPD-RYGBP are safe and lead to normalization of blood glucose, lipids, uric acid, liver enzymes and arterial pressure in the majority of patients, although this variant of BPD was more effective than RYGBP. We suggest that further studies should also investigate its usefulness in patients with milder degrees of obesity, DM2 and metabolic syndrome.

Intragastric balloon for high-risk super-obese patients: a prospective analysis of efficacy.

BACKGROUND: Super-obese patients with many co-morbidities present a challenge in bariatric surgery because of the high perioperative morbidity and mortality. The BioEnterics intragastric balloon (BIB) is an endoscopic device used preoperatively to induce weight loss to reduce the risk of surgery for morbid obesity. METHODS: From November 2003 to April 2006, the BIB was endoscopically placed in 26 high-risk super-obese patients with a mean body mass index of 65.3 +/- 9.8 kg/m(2) and severe co-morbidities (mean 4.33 +/- 1.12, range 3-7). The BIB was endoscopically removed 6 months later, at which time the patients were evaluated in terms of weight loss and improvement of co-morbid conditions. RESULTS: BIB placement was uneventful in all patients. The major side effect related to the procedure was occasional vomiting during the first 2 days (65%). One patient died (3.8%) of cardiac arrest after aspiration on the first postinsertion day as a direct result of BIB placement. The mean weight loss was 28.5 +/- 19.6 kg, and clinical re-evaluation revealed significant improvement in patient co-morbidity status (mean 2.23 +/- .7, range 1-3; P = .024). Twenty patients underwent a primary bariatric surgical procedure the day after BIB removal; 2 patients were rejected for surgery because of inadequate weight loss. CONCLUSIONS: BIB placement can be considered an effective first-stage treatment of high-risk super-obese patients in need of surgical intervention. Although not without risk, it is generally a simple procedure leading to satisfactory weight loss, improvement in co-morbidities, and consequent reduction of the perioperative mortality and morbidity rates associated with surgery.

Ghrelin and peptide YY levels after a variant of biliopancreatic diversion with Roux-en-Y gastric bypass versus after colectomy: a prospective comparative study.

BACKGROUND: The gastrointestinal peptide hormones ghrelin and PYY have been shown to play a role in the regulation of metabolism and appetite. We investigate the effect of Biliopancreatic diversion with Roux-en-Y gastric bypass (BPD-RYGBP) on the circulating levels of ghrelin and peptide YY during the first 3 months postoperatively as compared to the effects of colectomy, an abdominal operation of similar severity. METHODS: Fasting plasma levels of ghrelin and PYY were determined in 20 super-obese patients (BMI> or =50) who underwent BPD-RYGBP and in 13 patients who underwent colectomy for large bowel cancer. Fasting plasma ghrelin and PYY levels were measured preoperatively and during the postoperative period on days 1, 3, 7, 30 and 90 in all patients of both groups, and at 1 year for 10 of the patients who had attained 1-year follow up. RESULTS: Preoperatively, both plasma ghrelin and PYY levels were lower in the BPD-RYGBP group of patients. A temporary decrease in plasma ghrelin levels was observed in both groups of patients during the immediate postoperative period, with a gradual return to preoperative levels by the 3rd month. In addition, ghrelin concentrations increased at 1 year to levels 40% higher than those at baseline, in 10 of the BPD-RYGBP patients who had completed the 1-year follow-up (P=0.004). Plasma PYY levels in the colectomy group decreased in the first 3 postoperative days and then returned to baseline. In contrast, PYY levels in the BPD-RYGBP group did not change during the early postoperative period but increased to levels 50% higher at 3 months (P<0.001) and 170% higher at 1 year (P<0.001) than the baseline. CONCLUSIONS: The great postoperative increase in the levels of the anorexigenic peptide PYY following BPD-RYGBP may contribute to the reduced appetite observed after this type of bariatric surgery. The changes in ghrelin levels postoperatively make its contribution to the appetite suppression less likely.

Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion in a non-superobese population: prospective comparison of the efficacy and the incidence of metabolic deficiencies.

BACKGROUND: In the non-superobese population, an agreement has not been made as to the optimal bariatric operation. The present study reports the results of a prospective comparison of Roux-en-Y gastric bypass (RYGBP) and a variant of biliopancreatic diversion (BPD) in a non-superobese population. METHODS: From a cohort of 130 patients with BMI 35 to 50 kg/m(2), 65 patients were randomly selected to undergo RYGBP and 65 to undergo BPD. All patients underwent complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. RESULTS: Patients in both groups have completed their second postoperative year. Mean % excess weight loss (%EWL) was significantly better after BPD at all time periods (12 months, P=0.0001 and 24 months, P=0.0003), and the %EWL was >50% in all BPD patients compared to 88.7% in the RYGBP patients at 2-year follow-up. No statistically significant differences were observed between the 2 groups in early and late non-metabolic complications. Hypoalbuminemia occurred in only 1 patient (1.5%) after RYGBP and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at the second year follow-up (t-test, P<0.0001). Diabetes completely resolved in all BPD patients and in 7 of the 10 diabetic RYGBP patients. CONCLUSION: Both RYGBP and BPD were safe and effective procedures when offered to non-superobese patients. Weight loss after BPD was consistently better than that after RYGBP, as was the resolution of diabetes and hypercholesterolemia. Because the nutritional deficiencies that occurred following this type of BPD were not severe and were not significantly different between the 2 operations, both may be offered to non-superobese patients, keeping in mind the severity and type of preoperative co-morbidities as well as the desired weight loss.

A prospective comparison of vertical banded gastroplasty and Roux-en-Y gastric bypass in a non-superobese population.

BACKGROUND: In the non-superobese population, consensus is currently unavailable in bariatric surgery. We report the results of a prospective comparison of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP) in a non-superobese population. METHODS: From 1994 to 2000, 179 patients with clinically severe obesity underwent various surgical procedures in our department. During this time a prospective study was undertaken in order to compare VBG with RYGBP in morbidly obese patients with a BMI <50 kg/m2. Based on specific criteria including eating behavior, 68 patients were selected to undergo RYGBP and 35 VBG. All patients have undergone complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. RESULTS: All patients have now completed their 5th postoperative year. Mean follow-up period to date is 96.5+/-12.2 months for VBG and 67.6+/-11.3 months for RYGBP. 3 patients (8.6%) in the VBG group and 9 patients (13.2%) in the RYGBP group are lost to follow-up. Mean excess weight loss (EWL) was always better in the RYGBP group (P=0.0013). The percentage of failure, defined as EWL <25%, was not significantly different between the two procedures. No statistically significant differences were observed between the 2 groups in the total number of non-metabolic complications, and the only statistically significant difference observed in metabolic complications was vitamin B12 deficiency after RYGBP. Frequency of vomiting was significantly less and quality of eating significantly better in RYGBP than in VBG patients. CONCLUSION: This prospective long-term study, with nearly complete follow-up, suggests that in the non-superobese population, preoperative eating habits may play a role in choosing the most appropriate bariatric operation for each patient. Although RYGBP is associated with better mean weight loss outcomes, the percentage of patients who achieved and maintained > or = 50% EWL after VBG in this pre-selected patient population was not significantly different. Each type of operation has advantages and disadvantages, and, if properly chosen, a purely restrictive procedure can be successful for some patients. Therefore, it can be said that the decision regarding which bariatric procedure to perform in non-superobese patients must be based on in-depth preoperative evaluation as well as the patients' own preferences and outcome expectations.

Assessing sexual function in obese women preparing for bariatric surgery.

BACKGROUND: Obesity has become a modern epidemic, increasingly affecting the general population worldwide. Obese people are vulnerable to a variety of co-morbidities, including cardiovascular and pulmonary disease, osteoarthritis, diabetes, cancer and psychiatric conditions, that not only diminish life expectancy but also impair quality of life. Research has shown that obesity is further linked to sexual dysfunction, although relevant studies are limited and further investigation is needed. METHODS: We assessed the sexual function of 60 obese women scheduled to undergo bariatric surgery and 50 healthy controls matched by age, education and marital status. All participants were administered the Female Sexual Function Index (FSFI). Additionally, participants completed the Hospital Anxiety and Depression Scale (HADS). RESULTS: Obese women reported significant impairment on most domains of sexual function, including sexual desire, arousal, lubrication, orgasm, and satisfaction, compared to healthy controls. The observed sexual impairment was associated with BMI but was not entirely attributed to the presence of anxiety or depression. CONCLUSION: Obese women complain of significant sexual impairment. Obesity-related sexual dysfunction appears to be a complex condition linked to a range of social, psychological and biological factors. Clinicians are encouraged to evaluate routinely sexual function in this patient population in order to detect those who are in need of intervention.

Thyroid function in humans with morbid obesity.

Morbidly obese subjects may present with abnormal thyroid function tests but the reported data are scarce. Therefore, we studied the thyroid parameters in 144 morbidly obese patients, 110 females and 34 males, to assess the prevalence of hypothyroidism. Eleven percent (11.8%) carried the diagnosis of hypothyroidism and were undergoing levothyroxine (LT4) replacement therapy, 7.7% had newly diagnosed subclinical hypothyroidism, 0.7% had subclinical hyperthyroidism and 7.7% were euthyroid with positive antibodies (anti-thyroid peroxidase antibodies [TPOAb]). From the 144 subjects, we selected a cohort of 78 euthyroid subjects with negative TPOAb, who did not receive LT4 replacement or suppression therapy (the experimental group) and compared them to 77 normal-weight euthyroid subjects, TPOA-negative, matched for age and gender who served as controls. The experimental group had higher serum levels of triiodothyronine (T3), thyroxine (T4), free triiodothyronine (FT3), and thyrotropin (TSH) compared to the control group. Serum TSH concentration was associated with fasting serum insulin levels and insulin resistance but not with serum leptin levels, body mass index (BMI), fat mass, and lean body mass. In conclusion, in morbidly obese individuals, the prevalence of overt and subclinical hypothyroidism was high (19.5%). The morbidly obese subjects have higher levels of T3, FT3, T4, and TSH, probably the result of the reset of their central thyrostat at higher level.

Restoration of high-frequency glucose-entrained insulin oscillations in obese subjects with type 2 diabetes after biliopancreatic diversion.

BACKGROUND: Minimal glucose infusions are known to entrain insulin oscillations in patients with normal glucose tolerance (NGT) but not in patients with type 2 diabetes (T2D). OBJECTIVES: To investigate whether weight loss after a version of biliopancreatic diversion (BPD) can restore the glucose entrainment of high-frequency insulin oscillations in morbidly obese NGT or T2D patients. SETTING: University Hospital, Greece. METHODS: We prospectively studied 9 NGT controls (body mass index [BMI] 23.3±1.6 kg/m2), 9 obese NGT patients (BMI 51.1±12.7 kg/m2), and 9 obese T2D patients (BMI 56.8±11.6 kg/m2). Patients were studied before and 1.5 years after BPD. Insulin was sampled every minute for 90 minutes. Glucose (6 mg/kg weight) was infused every 10 minutes for 1 minute. Regularity of insulin pulses was estimated by autocorrelation analysis, spectral analysis, approximate entropy/sample entropy (ApEn/SampEn), and insulin pulsatility by deconvolution analysis. RESULTS: Postoperatively, glucose and insulin concentrations of NGT and T2D patients decreased to control levels and BMI to 31.3±6.3 for NGT patients and 34.9±9.9 kg/m2 for T2D patients. Preoperatively, glucose entrainment was absent in all T2D and in 4 NGT patients as assessed with spectral analysis and in 8 and 4, respectively, as assessed with autocorrelation and deconvolution analysis. Postoperatively, it was restored to normal in all patients. ApEn/SampEn decreased significantly only in the T2D group postoperatively. CONCLUSION: BPD restores the glucose entrainment of high-frequency insulin oscillations in obese NGT and T2D patients after marked weight loss and normalizes glucose levels and insulin sensitivity, thus demonstrating recovery of ß-cell glucose sensing.