The Role of FTO and Vitamin D for the Weight Loss Effect of Roux-en-Y Gastric Bypass Surgery in Obese Patients.

BACKGROUND: A recent study in children demonstrated that the rs9939609 single-nucleotide polymorphism in the fat mass and obesity (FTO) gene influences prospective weight gain, however, only in those who were vitamin D-deficient. If this might also be the case for Roux-en-Y gastric bypass (RYGB), surgery-induced weight loss is however unknown. The objective of this study is to examine if the magnitude of RYGB surgery-induced weight loss after 2 years depends on patients' FTO rs9939609 genotype (i.e., TT, AT, and AA) and presurgery vitamin D status (<50 nmol/L equals deficiency). METHODS: Before and at 24 months after RYGB surgery, BMI was measured in 210 obese patients (mean BMI 45 kg/m(2), 72 % females). Serum 25-hydroxyvitamin D3 levels were also repeatedly measured. Following surgery, vitamin D was supplemented. Possible weight loss differences between genotypes were tested with multiple linear regressions. RESULTS: The per-allele effect of each FTO A-allele on excessive BMI loss (EBMIL) was 3 % (P = 0.02). When split by baseline status, the EBMIL of vitamin D-deficient patients carrying AA exceeded that of vitamin D-deficient patients carrying TT by ~14 % (P = 0.03). No such genotypic differences were found in patients without presurgery vitamin D deficiency. Post-surgery serum levels of vitamin D did not differ between groups. CONCLUSIONS: Our data suggest that presurgery vitamin D levels influence the size of genotype effects of FTO rs9939609 on RYGB surgery-induced weight loss in obese patients.

Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

OBJECTIVE: Laparoscopic sleeve gastrectomy (LSG) has been proposed as an effective alternative to the current standard procedure, laparoscopic Roux-en-Y gastric bypass (LRYGB). Prospective data comparing both procedures are rare. Therefore, we performed a randomized clinical trial assessing the effectiveness and safety of these 2 operative techniques. METHODS: Two hundred seventeen patients were randomized at 4 bariatric centers in Switzerland. One hundred seven patients underwent LSG using a 35-F bougie with suturing of the stapler line, and 110 patients underwent LRYGB with a 150-cm antecolic alimentary and a 50-cm biliopancreatic limb. The mean body mass index of all patients was 44 ± 11.1 kg/m, the mean age was 43 ± 5.3 years, and 72% were female. RESULTS: The 2 groups were similar in terms of body mass index, age, sex, comorbidities, and eating behavior. The mean operative time was less for LSG than for LRYGB (87 ± 52.3 minutes vs 108 ± 42.3 minutes; P = 0.003). The conversion rate was 0.9% in both groups. Complications (<30 days) occurred more often in LRYGB than in LSG (17.2% vs 8.4%; P = 0.067). However, the difference in severe complications did not reach statistical significance (4.5% for LRYGB vs 1% for LSG; P = 0.21). Excessive body mass index loss 1 year after the operation was similar between the 2 groups (72.3% ± 22% for LSG and 76.6% ± 21% for LRYGB; P = 0.2). Except for gastroesophageal reflux disease, which showed a higher resolution rate after LRYGB, the comorbidities and quality of life were significantly improved after both procedures. CONCLUSIONS: LSG was associated with shorter operation time and a trend toward fewer complications than with LRYGB. Both procedures were almost equally efficient regarding weight loss, improvement of comorbidities, and quality of life 1 year after surgery. Long-term follow-up data are needed to confirm these facts.

A novel distal very long Roux-en Y gastric bypass (DVLRYGB) as a primary bariatric procedure--complication rates, weight loss, and nutritional/metabolic changes in the first 355 patients.

Proximal Roux-en Y gastric bypass (RYGB) representing the most frequently performed bariatric procedure yields a weight loss failure rate of around 20 %. In order to reduce failure rates, we established a novel distal RYGB variant characterized by a very long alimentary (Roux) limb and a short common channel. Up to 5 years, follow-up data (complication rates, weight loss, nutritional/metabolic changes) of the first 355 patients (mean ± SD preoperative age, 41.4 ± 10.8 years; BMI, 48.5 ± 11.5 kg/m(2)) who underwent the novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) were analysed. Overall follow-up rate was 98.9 %, mean follow-up time 1.6 ± 1.4 years. Limb lengths were as follows: common channel 76 ± 7 cm, biliopancreatic limb 79 ± 14 cm, and alimentary (Roux) limb 604 ± 99 cm. The operation was performed laparoscopically in 95.2 % of the cases. Thirty-day mortality was zero; major and minor complication rate was 4.5 % and 10.4 %, respectively. Average excess weight loss (EWL) was >74 % 3, 4, and 5 years after the operation and failure rate defined by an EWL < 50 % remained < 6 %. Annually blood measurements revealed a relatively low incidence rate of severe nutritional deficiencies, but mild anaemia and hypoproteinemia were frequently observed. Laparoscopic revision with a proximalization of the lower anastomosis was required in 4 (1.1 %) patients. Data indicate that our DVLRYGB leads to excellent weight loss results. Furthermore, within the setting of a structured multidisciplinary follow-up program, the incidence of severe malnutrition states was relatively low.

Distal gastric bypass surgery for the treatment of hypothalamic obesity after childhood craniopharyngioma.

CONTEXT: Obesity resulting from damage to the hypothalamus, i.e. hypothalamic obesity, is a severe condition that currently lacks any effective evidence-based therapy. OBJECTIVE: Our goal was to describe the course of hypothalamic obesity in a craniopharyngioma patient treated with distal gastric bypass surgery and to outline distinct aspects of multidisciplinary case management. PATIENT AND METHODS: A 29-year-old man, who had undergone craniopharyngioma resection at the age of 8, was referred to our Interdisciplinary Obesity Centre with a body mass index (BMI) of 52.0 kg/m(2), type 2 diabetes and obstructive sleep apnoea syndrome (OSAS). After careful preoperative preparation, including the adjustment of hormone substitution therapy for panhypopituitarism, nutritional counselling and a supervised exercise program, he underwent a distal gastric bypass operation. RESULTS: Eighteen months after the operation the patient's BMI had decreased to 31.9 kg/m(2), type 2 diabetes was in complete remission, and OSAS appeared to be improved. Also, feelings of hunger were markedly reduced after the operation. A standard regimen of supplements successfully prevented any severe nutritional deficiencies. After weight loss, the dose of hydrocortisone could be distinctly reduced without any signs of adrenal insufficiency while GH substitution had to be markedly increased to achieve normal IGF1 levels. CONCLUSIONS: Our case demonstrates that within a multidisciplinary team approach, a distal gastric bypass operation can be a safe and highly effective therapy for patients with hypothalamic obesity. Also, our findings hint at an effect of gastric bypass surgery on hunger and eating behaviour that may not essentially rely on hypothalamic mechanisms.

Gut protein uptake and mechanisms of meal-induced cortisol release.

The enhanced cortisol release after protein-rich meals might represent a neuroendocrine response to food allergens. We tested whether the antigenicity of proteins contributes to this effect. Twelve healthy men nasogastrically received casein, its less allergenic hydrolysate, and placebo. Contrary to expectations, secretion of cortisol (area under the curve, 742.70 +/- 73.48 vs. 542.95 +/- 70.31 micromol/liter.min, P < 0.03) and ACTH (2020.21 +/- 251.10 vs. 1649.82 +/- 241.23 micromol/liter.min, P < 0.05) was stronger on casein-hydrolysate than casein. Systemic immune activity remained unaffected as indicated by unchanged IL-6 plasma concentrations. This finding indicates that the grade of hydrolysis of a protein and the presence of particular amino acids, rather than its antigenicity, are crucial for the pituitary-adrenal response to nutrients. To further examine whether this response is triggered at the gastrointestinal mucosa or after the substance has reached the circulation, in a supplementary experiment, amino acids were given either nasogastrically or iv to healthy men (n = 4). Only the nasogastric infusion of amino acids induced a significant rise in cortisol concentrations. Serum concentrations of tryptophan, which is known to directly excite the hypothalamo-pituitary-adrenal axis, were comparable for both conditions. We conclude that the meal-related hypothalamo-pituitary-adrenal axis response to amino acids results from a signal that rather acts at the gastrointestinal mucosa than directly via the circulating blood.