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BACKGROUND: There has been a substantial increase in the use of laparoscopic sleeve gastrectomy (SG) to treat morbid obesity despite observational evidence demonstrating the superiority of Roux-en-Y gastric bypass (RYGB) for reducing low-density lipoprotein (LDL) cholesterol. The main aim was to ascertain whether high LDL cholesterol levels should be considered when selecting the most appropriate surgical procedure for each patient (RYGB or SG). METHODS: In this single-center, randomized clinical trial using intention-to-treat analysis, 38 patients with severe obesity and elevated levels of LDL cholesterol were randomly assigned to undergo RYGB or SG. The primary outcome was LDL cholesterol remission at 12 months, defined as LDL cholesterol < 3.36 nmol/l without lipid-lowering medications. Secondary outcomes included changes in weight, other comorbidities, qualitative lipoprotein traits, cholesterol esters, glycoproteins, cholesterol absorption and synthesis metabolites and complications. RESULTS: Intention-to-treat analysis revealed that LDL cholesterol remission occurred in 66.6% of RYGB patients compared to 27.8% of SG patients (p = 0.019). Among patients completing follow-up, RYGB demonstrated superior remission (80.0% vs. 29.4%, p = 0.005). Exclusive benefits of RYGB included a reduction in large, medium, and small LDL particles. Cholesterol absorption markers showed differential behavior after both techniques: campesterol (Δ -15.2 µg/mg, 95% CI -30.2 to -0.1) decreased after RYGB, and sitosterol (Δ 21.1 µg/mg, 95% CI 0.9 to 41.2), cholestanol (Δ 30.6 µg/mg, 95% CI 14.8 to 57.9) and campesterol (Δ 18.4 µg/mg, 95% CI 4.4 to 32.3) increased after SG. No differences in weight loss, cholesterol esters, glycoproteins, cholesterol synthesis metabolites or postoperative complications were observed between techniques. CONCLUSION: In conclusion, RYGB is superior to SG in terms of short-term of high LDL cholesterol remission. Furthermore, RYGB also led to a greater improvement in lipoprotein parameters that confer an atherogenic profile. Therefore, the presence of elevated levels of LDL cholesterol should be considered when determining the optimal bariatric surgery procedure for each patient. TRIAL REGISTRATION: Clinicaltrials.gov number, NCT03975478).
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Biomarcadores , LDL-Colesterol , Gastrectomía , Derivación Gástrica , Obesidad Mórbida , Humanos , Masculino , Femenino , Derivación Gástrica/efectos adversos , Gastrectomía/efectos adversos , Adulto , Persona de Mediana Edad , LDL-Colesterol/sangre , Resultado del Tratamiento , Obesidad Mórbida/cirugía , Obesidad Mórbida/sangre , Obesidad Mórbida/diagnóstico , Factores de Tiempo , Biomarcadores/sangre , Pérdida de Peso , Inducción de Remisión , Laparoscopía/efectos adversos , Hipercolesterolemia/sangre , Hipercolesterolemia/diagnóstico , Hipercolesterolemia/tratamiento farmacológico , Sitoesteroles/sangreRESUMEN
PURPOSE: To assess the effects of Helicobacter pylori (HP) eradication with an omeprazole, clarithromycin, amoxicillin, and metronidazole (OCAM) regimen on the metabolic profile and weight loss 12 months after bariatric surgery (BS). METHODS: Retrospective analysis of a prospective cohort of patients with morbid obesity undergoing BS. HP presence was tested preoperatively by gastric biopsy and treated with OCAM when positive. Short-term metabolic outcomes and weight loss were evaluated. RESULTS: HP infection was detected in 75 (45.7%) of the 164 patients included. OCAM effectiveness was 90.1%. HP-negative patients had a greater reduction in glucose levels at 3 (-14.6 ± 27.5 mg/dL HP-treated vs -22.0 ± 37.1 mg/dL HP-negative, p=0.045) and 6 months (-13.7 ± 29.4 mg/dL HP-treated vs -26.4 ± 42.6 mg/dL HP-negative, p= 0.021) and greater total weight loss (%TWL) at 6 (28.7 ± 6.7% HP-treated vs 30.45 ± 6.48% HP-negative, p= 0.04) and 12 months (32.21 ± 8.11% HP-treated vs 35.14 ± 8.63% HP-negative, p= 0.023). CONCLUSIONS: Preoperative treatment with OCAM has been associated to poorer glycemic and weight loss outcomes after BS. More research is needed on the influence of OCAM on gut microbiota, and in turn, the effect of the latter on metabolic and weight loss outcomes after BS.
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Cirugía Bariátrica , Infecciones por Helicobacter , Helicobacter pylori , Obesidad Mórbida , Humanos , Estudios Retrospectivos , Estudios Prospectivos , Obesidad Mórbida/cirugía , Infecciones por Helicobacter/tratamiento farmacológico , Amoxicilina/uso terapéutico , Claritromicina/uso terapéutico , Omeprazol/uso terapéutico , Metronidazol/farmacología , Metronidazol/uso terapéutico , Pérdida de Peso , Quimioterapia Combinada , Antibacterianos/uso terapéuticoRESUMEN
INTRODUCTION: A small bowel gastrointestinal stromal tumor (GIST) is a rare neoplasm of the gastrointestinal tract. The manifestation of bleeding is a diagnostic challenge and could present as a life-threatening situation that needs urgent intervention. PRESENTATION OF CASE: 64-year-old woman consulted for episodes of melena and anemia. The upper and lower endoscopies were not diagnostic. Capsule endoscopy (CE) revealed a probable jejunal hemangioma, however double-balloon enteroscopy and magnetic resonance imaging (MRI) did not show any intestinal nodule but MRI show a pelvic mass apparently related to the uterus confirmed by a gynecologist. Even so, the patient returned with melena, and a contrast-enhanced computed tomography (CT) scan again identified a pelvic mass, highlighting that its vascularization drained into the superior mesenteric territory and seemed to invade the jejunum, with active bleeding, suspicious for jejunal GIST. A laparotomy was performed to remove the jejunal mass. Histopathology and immunohistochemical studies confirmed the diagnosis. DISCUSSION: Bleeding is a common symptom in small bowel GISTs but its diagnoses could be difficult because its location. In most cases, gastroscopy and colonoscopy are not useful and CE or imaging studies are necessary to find the cause of bleeding. Moreover, it has recently proved that bleeding is a prognostic risk factor because it is related to tumor rupture and tumor invasion of blood vessels. CONCLUSION: In this case, bleeding caused by small bowel GIST was misdiagnosed in endoscopic procedures and the clinical management was delayed. CT angiography was the most effective investigation to detect the source of bleeding.
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INTRODUCTION: Duodenal switch (DS) is considered one of the most effective techniques to achieve weight loss and reduce comorbidities in patients with morbidly obesity. MATERIAL AND METHODS: Descriptive single-center study. 224 patients were analyzed who underwent direct laparoscopic DS in our center. The objective was to describe the results of weight, resolution of comorbidities, nutritional supplementation and postoperative complications at 2, 5 and 10 years. RESULTS: The mean age of the cohort was 49.3 [23-65] years and the mean weight and BMI were 131.8 [20] kg and 49.8 [5] kg/m2. The excess weight lost percentage at 2, 5 and 10 years was 80.6[15]%, 69.3[18]%, 67.4[18]%, respectively. Complete remission of diabetes was evidenced at 2 and 5 years in 35 (85.4%) and 27 (70.4%) patients. In the immediate postoperative period, the complication rate for Clavien-Dindo ≥ III was 15 patients (6.7%) and mortality at 30 and 90 days was 1 (0.4%) and 2 (0.9%) patients. Revisional surgery was performed in 2 patients (0.9%). 80% of the patients required an extra nutritional supplement up to 10 years after surgery. CONCLUSIONS: Direct DS is a safe and effective technique in patients with a BMI between 45 and 55 kg/m2. Weight loss is maintained with a low rate of revision surgery. It is a metabolically effective technique that entails the need for a close postoperative follow-up to assess nutritional supplementation.
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Desviación Biliopancreática , Obesidad Mórbida , Adulto , Anciano , Anastomosis Quirúrgica , Desviación Biliopancreática/métodos , Duodeno/cirugía , Humanos , Persona de Mediana Edad , Obesidad Mórbida/cirugía , Pérdida de Peso , Adulto JovenRESUMEN
BACKGROUND: No studies have evaluated the effect of metabolic and bariatric surgery (MBS) on nonalcoholic fatty liver disease (NAFLD) and cardiometabolic markers in metabolically healthy patients with morbid obesity (MHMO) at midterm. OBJECTIVES: To assess the effect of MBS on NAFLD and cardiometabolic markers in MHMO patients and ascertain whether metabolically unhealthy patients with morbid obesity (MUMO) remain metabolically healthy at 5 years after MBS. SETTING: University hospital. METHODS: A total of 191 patients with a body mass index >40 kg/m2 and at least 5 years of follow-up were retrospectively analyzed. Lost to follow-up were 37.6% (151 of 401 patients). Patients were classified as MHMO if 1 or 0 of the cardiometabolic markers were present using the Wildman criteria. The degree of liver fibrosis was assessed using the NAFLD fibrosis score (NFS). RESULTS: Forty-one patients (21.5%) fulfilled the criteria for MHMO. They showed significant improvements in blood pressure (from 135.1 ± 22.1 and 84.2 ± 14.3 mm Hg to 117.7 ± 19.2 and 73.0 ± 10.9 mm Hg), plasma glucose (from 91.0 ± 5.6 mg/dL to 87.2 ± 5.2 mg/dL), homeostatic model assessment for insulin resistance (from 2.2 ± .9 to 1.0 ± .8), triglycerides (from 88.0 [range, 79.5-103.5] mg/dL to 61.0 [range, 2.0-76.5] mg/dL), alanine aminotransferase, gamma-glutamyl transpeptidase NFS (from -1.0 ± 1.0 to -1.9 ± 1.2), and high-density lipoprotein cholesterol (from 56.9 ± 10.5 mg/dL to 77.9 ± 17.4 mg/dL) at 5 years after surgery. A total of 108 MUMO patients (84.4%) who became metabolically healthy after 1 year stayed healthy at 5 years. CONCLUSIONS: MBS induced a midterm improvement in cardiometabolic and NAFLD markers in MHMO patients. Seventy-six percent of MUMO patients became metabolically healthy at 5 years after MBS.
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Cirugía Bariátrica , Resistencia a la Insulina , Enfermedad del Hígado Graso no Alcohólico , Obesidad Mórbida , Índice de Masa Corporal , Humanos , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Enfermedad del Hígado Graso no Alcohólico/cirugía , Obesidad Mórbida/complicaciones , Obesidad Mórbida/metabolismo , Obesidad Mórbida/cirugía , Estudios RetrospectivosRESUMEN
INTRODUCTION: The "Single Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy" (SADI-S) is a bariatric surgery conceived to simplify the duodenal switch in order to reduce its postoperative complications. The objective of this study is to assess the safety and efficacy of SADI-S, comparing its results in both direct and two-step procedure. METHODS: Unicentric cohort study that includes patients submitted to SADI-S, both direct or in two-step, between 2014 and 2019. RESULTS: Two hundred thirty-two patients were included, 192 were submitted to direct SADI-S and 40 had previously undergone a sleeve gastrectomy. The severe complications rate (Clavien-Dindoâ¯≥â¯IIIA) was 7.8%, being hemoperitoneum and duodenal stump leak the most frequent ones. One patient was exitus between the first 90 days after surgery (0.4%). Patients submitted to direct SADI-S had an initial body mass index (BMI) of 49.6â¯kg/m2 in comparison of 56.2â¯kg/m2 in the two-step SADI-S (Pâ¯<â¯.001). The mean excess weight loss (EWL) at two years was higher in direct SADI-S (77.3 vs. 59.3%, Pâ¯<â¯.05). Rate of comorbidities resolution was 88.5% for diabetes, 73.0% for hypertension, 77.0% for dyslipidemia and 85.7% for sleep apnea, with no differences between both techniques. CONCLUSION: In medium term, SADI-S is a safe and effective technique that offers a satisfactory weight loss and remission of comorbidities. Patients submitted to two-step SADI-S had a higher initial BMI and presented a lower EWL than direct SADI-S.
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Obesidad Mórbida , Anastomosis Quirúrgica/efectos adversos , Estudios de Cohortes , Gastrectomía/efectos adversos , Humanos , Obesidad Mórbida/cirugía , Estudios RetrospectivosRESUMEN
INTRODUCTION: Duodenal switch (DS) is considered one of the most effective techniques to achieve weight loss and reduce comorbidities in patients with morbidly obesity. MATERIAL AND METHODS: Descriptive single-center study. 224 patients were analyzed who underwent direct laparoscopic DS in our center. The objective was to describe the results of weight, resolution of comorbidities, nutritional supplementation and postoperative complications at 2, 5 and 10 years. RESULTS: The mean age of the cohort was 49.3 [23-65] years and the mean weight and BMI were 131.8 [20]kg and 49.8 [5]kg/m2. The excess weight lost percentage at 2, 5 and 10 years was 80.6[15]%, 69.3[18]%, 67.4[18]%, respectively. Complete remission of diabetes was evidenced at 2 and 5 years in 35 (85.4%) and 27 (70.4%) patients. In the immediate postoperative period, the complication rate for Clavien-Dindo ≥ III was 15 patients (6.7%) and mortality at 30 and 90 days was 1 (0.4%) and 2 (0.9%) patients. Revisional surgery was performed in 2 patients (0.9%). 80% of the patients required an extra nutritional supplement up to 10 years after surgery. CONCLUSIONS: Direct DS is a safe and effective technique in patients with a BMI between 45 and 55 kg/m2. Weight loss is maintained with a low rate of revision surgery. It is a metabolically effective technique that entails the need for a close postoperative follow-up to assess nutritional supplementation.
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PURPOSE: Long-term studies comparing the mechanisms of different bariatric techniques for T2DM remission are scarce. We aimed to compare type 2 diabetes (T2DM) remission after a gastric bypass with a 200-cm biliopancreatic limb (mRYGB), sleeve gastrectomy (SG), and greater curvature plication (GCP), and to assess if the initial secretion of gastrointestinal hormones may predict metabolic outcomes at 5 years. MATERIAL AND METHODS: Forty-five patients with mean BMI of 39.4(1.9)kg/m2 and T2DM with HbA1c of 7.7(1.9)% were randomized to mRYGB, SG, or GCP. Anthropometric and biochemical parameters, fasting concentrations of PYY, ghrelin, glucagon, and AUC of GLP-1 after SMT were determined prior to and at months 1 and 12 after surgery. At 5-year follow-up, anthropometrical and biochemical parameters were determined. RESULTS: Total weight loss percentage (TWL%) at year 1 and GLP-1 AUC at months 1 and 12 were higher in the mRYGB than in the SG and GCP. TWL% remained greater at 5 years in mRYGB group - 27.32 (7.8) vs. SG - 18.00 (10.6) and GCP - 14.83 (7.8), p = 0.001. At 5 years, complete T2DM remission was observed in 46.7% after mRYGB vs. 20.0% after SG and 6.6% after GCP, p < 0.001. In the multivariate analysis, shorter T2DM duration (OR 0.186), p = 0.008, and the GLP-1 AUC at 1 month (OR 7.229), p = 0.023, were prognostic factors for complete T2DM remission at 5-year follow-up. CONCLUSIONS: Long-term T2DM remission is mostly achieved with hypoabsortive techniques such as mRYGB. Increased secretion of GLP-1 after surgery and shorter disease duration were the main predictors of T2DM remission at 5 years.
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Diabetes Mellitus Tipo 2 , Derivación Gástrica , Hormonas Gastrointestinales , Obesidad Mórbida , Diabetes Mellitus Tipo 2/cirugía , Gastrectomía , Humanos , Obesidad Mórbida/cirugía , Resultado del TratamientoRESUMEN
AIMS/HYPOTHESIS: Midlife obesity is a risk factor for dementia. We investigated the impact of obesity on brain structure, metabolism, and cerebrospinal fluid (CSF) core Alzheimer's disease (AD) biomarkers in healthy elderly. METHODS: We selected controls from ADNI2 with CSF AD biomarkers and/or fluorodeoxyglucose positron emission tomography (FDG-PET) and 3T-MRI. We measured cortical thickness, FDG uptake, and CSF amyloid beta (Aß)1-42, p-tau, and t-tau levels. We performed regression analyses between these biomarkers and body mass index (BMI). RESULTS: We included 201 individuals (mean age 73.5 years, mean BMI 27.4 kg/m2). Higher BMI was related to less cortical thickness and higher metabolism in brain areas typically not involved in AD (family-wise error [FWE] <0.05), but not to AD CSF biomarkers. It is notable that the impact of obesity on brain metabolism and structure was also found in amyloid negative individuals. CONCLUSIONS/INTERPRETATION: In the cognitively unimpaired elderly, obesity has differential effects on brain metabolism and structure independent of an underlying AD pathophysiology.
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OBJECTIVE: To explore the meal response of circulating succinate in patients with obesity and type 2 diabetes undergoing bariatric surgery and to examine the role of gastrointestinal glucose sensing in succinate dynamics in healthy subjects. RESEARCH DESIGN AND METHODS: Cohort I comprised 45 patients with morbid obesity and type 2 diabetes (BMI 39.4 ± 1.9 kg/m2) undergoing metabolic surgery. Cohort II was a confirmatory cohort of 13 patients (BMI 39.3 ± 1.4 kg/m2) undergoing gastric bypass surgery. Cohort III comprised 15 healthy subjects (BMI 26.4 ± 0.5 kg/m2). Cohorts I and II completed a 2-h mixed-meal tolerance test (MTT) before the intervention and at 1 year of follow-up, and cohort II also completed a 3-h lipid test (LT). Cohort III underwent a 3-h oral glucose tolerance test (OGTT) and an isoglycemic intravenous glucose infusion (IIGI) study. RESULTS: In cohort I, succinate response to MTT at follow-up was greater than before the intervention (P < 0.0001). This response was confirmed in cohort II with a greater increase after 1 year of surgery (P = 0.009). By contrast, LT did not elicit a succinate response. Changes in succinate response were associated with changes in the area under the curve of glucose (r = 0.417, P < 0.0001) and insulin (r = 0.204, P = 0.002). In cohort III, glycemia, per se, stimulated a plasma succinate response (P = 0.0004), but its response was greater in the OGTT (P = 0.02; OGTT versus IIGI). CONCLUSIONS: The meal-related response of circulating succinate in patients with obesity and type 2 diabetes is recovered after metabolic surgery.
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Cirugía Bariátrica , Diabetes Mellitus Tipo 2/cirugía , Ingestión de Alimentos/fisiología , Obesidad Mórbida/cirugía , Ácido Succínico/sangre , Adulto , Anciano , Glucemia/metabolismo , Estudios de Cohortes , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/complicaciones , Técnicas de Diagnóstico Endocrino/normas , Femenino , Estudios de Seguimiento , Prueba de Tolerancia a la Glucosa , Humanos , Insulina/sangre , Masculino , Comidas , Persona de Mediana Edad , Obesidad Mórbida/sangre , Obesidad Mórbida/complicaciones , Valores de Referencia , Ácido Succínico/normas , Adulto JovenRESUMEN
There is scant evidence of the long-term effects of bariatric surgery on bone mineral density (BMD). We compared BMD changes in patients with severe obesity and type 2 diabetes (T2D) 5 years after randomization to metabolic gastric bypass (mRYGB), sleeve gastrectomy (SG) and greater curvature plication (GCP). We studied the influence of first year gastrointestinal hormone changes on final bone outcomes. Forty-five patients, averaging 49.4 (7.8) years old and body mass index (BMI) 39.4 (1.9) kg/m2, were included. BMD at lumbar spine (LS) was lower after mRYGB compared to SG and GCP: 0.89 [0.82;0.94] vs. 1.04 [0.91;1.16] vs. 0.99 [0.89;1.12], p = 0.020. A higher percentage of LS osteopenia was present after mRYGB 78.6% vs. 33.3% vs. 50.0%, respectively. BMD reduction was greater in T2D remitters vs. non-remitters. Weight at fifth year predicted BMD changes at the femoral neck (FN) (adjusted R2: 0.3218; p = 0.002), and type of surgery (mRYGB) and menopause predicted BMD changes at LS (adjusted R2: 0.2507; p < 0.015). In conclusion, mRYGB produces higher deleterious effects on bone at LS compared to SG and GCP in the long-term. Women in menopause undergoing mRYGB are at highest risk of bone deterioration. Gastrointestinal hormone changes after surgery do not play a major role in BMD outcomes.
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PURPOSE: To study weight loss, comorbidity remission, complications, and nutritional deficits after duodenal switch (DS) and single-anastomosis DS with sleeve gastrectomy (SADI-S). MATERIAL AND METHODS: Retrospective review of patients submitted to DS or SADI-S for morbid obesity in a single university hospital. RESULTS: Four hundred forty patients underwent DS (n = 259) or SADI-S (n = 181). Mean preoperative body mass index (BMI) was 50.8 ± 6.4Kg/m2. Mean follow-up was 56.1 ± 37.2 months for DS and 27.2 ± 18.9 months for SADI-S. Global mean excess weight loss was 77.4% at 2 years similar for SADI-S and DS, and 72.1% at 10 years after DS. Although early complications were similar in SADI-S and DS (13.3% vs. 18.9%, p = n.s.), long-term complications and vitamin and micronutrient deficiencies were superior after DS. Rate of comorbidities remission was 85.2% for diabetes, 63.9% for hypertension, 77.6% for dyslipidemia, and 82.1% for sleep apnea, with no differences between both techniques. In patients with initial BMI > 55 kg/m2 (n = 91), DS achieved higher percentage of BMI < 35 kg/m2 (80% vs. 50%, p = 0.025) and higher rate of diabetes remission (100% vs. 75%, p = 0050). CONCLUSIONS: DS and SADI-S showed similar weight loss and comorbidity remission rates at 2 years. In patients with initial BMI > 55 kg/m2, DS obtained better BMI control at 2 years and better diabetes remission, but more long-term complications and supplementation needs.
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Desviación Biliopancreática , Obesidad Mórbida , Anastomosis Quirúrgica , Estudios de Cohortes , Duodeno/cirugía , Gastrectomía , Humanos , Obesidad Mórbida/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: To compare changes in bone mineral density (BMD) in patients with morbid obesity and type 2 diabetes (T2D) a year after being randomized to metabolic gastric bypass (mRYGB), sleeve gastrectomy (SG), and greater curvature plication (GCP). We also analyzed the association of gastrointestinal hormones with skeletal metabolism. METHODS: Forty-five patients with T2D (mean BMI 39.4 ± 1.9 kg/m2) were randomly assigned to mRYGB, SG, or GCP. Before and 12 months after surgery, anthropometric, body composition, biochemical parameters, fasting plasma glucagon, ghrelin, and PYY as well as GLP-1, GLP-2, and insulin after a standard meal were determined. RESULTS: After surgery, the decrease at femoral neck (FN) was similar but at lumbar spine (LS), it was greater in the mRYGB group compared with SG and GCP - 7.29 (4.6) vs. - 0.48 (3.9) vs. - 1.2 (2.7)%, p < 0.001. Osteocalcin and alkaline phosphatase increased more after mRYGB. Bone mineral content (BMC) at the LS after surgery correlated with fasting ghrelin (r = - 0.412, p = 0.01) and AUC for GLP-1 (r = - 0.402, p = 0.017). FN BMD at 12 months correlated with post-surgical fasting glucagon (r = 0.498, p = 0.04) and insulin AUC (r = 0.384, p = 0.030) and at LS with the AUC for GLP-1 in the same time period (r = - 0.335, p = 0.049). However, in the multiple regression analysis after adjusting for age, sex, and BMI, the type of surgery (mRYGB) remained the only factor associated with BMD reduction at LS and FN. CONCLUSIONS: mRYGB induces greater deleterious effects on the bone at LS compared with SG and GCP, and gastrointestinal hormones do not play a major role in bone changes.
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Cirugía Bariátrica , Densidad Ósea/fisiología , Remodelación Ósea , Diabetes Mellitus Tipo 2/cirugía , Hormonas Gastrointestinales/fisiología , Obesidad Mórbida/cirugía , Adulto , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/métodos , Huesos/metabolismo , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/metabolismo , Femenino , Cuello Femoral , Estudios de Seguimiento , Hormonas Gastrointestinales/sangre , Ghrelina/sangre , Glucagón/sangre , Péptido 1 Similar al Glucagón/sangre , Humanos , Insulina/sangre , Masculino , Persona de Mediana Edad , Obesidad Mórbida/complicaciones , Obesidad Mórbida/metabolismo , Resultado del TratamientoRESUMEN
BACKGROUND: The surgical management of weight regain following RYGB remains controversial. Simpler modifications such as endoscopic suturing and banding the bypass have had variable efficacy. Distalization of the bypass has resulted in a high risk of malabsorption-related complications as reported by Amor et al. (Obes Surg. 27(1):273-274, 2017); Borbély et al. (Obes Surg. 27(2):439-444, 2017); Thomopoulos et al. (Surg Laparosc Endosc Percutan Tech. 0(0):1, 2018); and Tran et al. (Obes Surg. 26(7):1627-1634, 2016). Conversion to a procedure such as duodenal switch (DS) or SADS with greater average weight loss would be logical but is technically challenging and is related to a high complication rate especially with the reformation of the stomach. In this video, we present the technique that we have adapted to make this complex case reproducible minimizing operative risk. METHODS: A 49-year-old female weighing 154 kg (BMI 57 kg/m2) with sleep apnea disease underwent a laparoscopic RYGB in 2009. She had an initial weight loss of 47 kg but had complete recidivism with a weight of 151 kg (BMI 56 kg/m2). Upper gastrointestinal (barium swallow study) and esophagogastroduodenoscopy showed no evidence of fistula, with a normal pouch diameter and length with stoma size of 2 cm. Blood test showed no significant micro/macronutrient deficiencies. With super morbid obesity refractory to RYGB, it was our belief that conversion to SADS was the best alternative. RESULTS: We introduced a subcostal camera trocar with Optiview and we observed epiploic adherences to the previous anastomosis. We placed an additional trocar to remove adhesions in the re-operative field. We measured the 300 cm of the small bowel proximal to the ileocecal valve. We next divided the antecolic Roux limb from the gastric remnant preserving the left gastric artery and divided the pouch proximal to the gastrojejunal anastomosis. We identified and mobilized the remnant stomach preserving the 8 lowest branches of the right gastroepiploic artery. After reaching the angle of His, we were able to separate the remnant and the pouch. The pouch was reshaped using a 42Fr bougie for guidance. A gastrostomy was made and a matching opening was created near the lesser curvature on the remnant. We then began gastrogastric anastomosis. First, the posterior layer was done and then the bougie was placed through into the remnant. The sleeve and fundic resection was done. The bougie was replaced by an oral gastric tube and the anterior layer of the anastomosis completed. This was tested with methylene blue. We next divided the duodenum postpylorus, preserving the right gastric artery. We performed and tested a hand-sewn duodeno-ileal anastomosis with a common limb length of 300 cm. There were no intra- or postoperative complications and the patient was discharged after 2 days. CONCLUSIONS: We believe that this video shows a reproducible technique for this complex anastomosis. Preservation of the distal epiploics makes the gastro-gastric anastomosis safer but requires direct dissection of the duodenum.
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Duodeno/cirugía , Derivación Gástrica , Laparoscopía , Obesidad Mórbida/cirugía , Pared Abdominal/cirugía , Femenino , Humanos , Persona de Mediana Edad , Pérdida de PesoRESUMEN
We aimed to explore the relationship between GLP-1 receptor (GLP-1R) expression in adipose tissue (AT) and incretin secretion, glucose homeostasis and weight loss, in patients with morbid obesity and type 2 diabetes undergoing bariatric surgery. RNA was extracted from subcutaneous (SAT) and visceral (VAT) AT biopsies from 40 patients randomized to metabolic gastric bypass, sleeve gastrectomy or greater curvature plication. Biochemical parameters, fasting plasma insulin, glucagon and area under the curve (AUC) of GLP-1 following a standard meal test were determined before and 1 year after bariatric surgery. GLP-1R expression was higher in VAT than in SAT. GLP-1R expression in VAT correlated with weight (r = -0.453, p = 0.008), waist circumference (r = -0.494, p = 0.004), plasma insulin (r = -0.466, p = 0.007), and systolic blood pressure (BP) (r = -0.410, p = 0.018). At 1 year, GLP-1R expression in VAT was negatively associated with diastolic BP (r = -0.361, p = 0.039) and, following metabolic gastric bypass, with the increase of GLP-1 AUC, (R2 = 0.46, p = 0.038). Finally, GLP-1R in AT was similar independently of diabetes outcomes and was not associated with weight loss after surgery. Thus, GLP-1R expression in AT is of limited value to predict incretin response and does not play a role in metabolic outcomes after bariatric surgery.
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Diabetes Mellitus Tipo 2/cirugía , Receptor del Péptido 1 Similar al Glucagón/genética , Incretinas/genética , Obesidad Mórbida/cirugía , Tejido Adiposo/metabolismo , Tejido Adiposo/cirugía , Adolescente , Adulto , Cirugía Bariátrica , Glucemia/genética , Diabetes Mellitus Tipo 2/genética , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/fisiopatología , Ayuno , Femenino , Gastrectomía , Derivación Gástrica/métodos , Humanos , Incretinas/biosíntesis , Masculino , Persona de Mediana Edad , Obesidad Mórbida/genética , Obesidad Mórbida/metabolismo , Obesidad Mórbida/fisiopatología , Estómago/fisiopatología , Estómago/cirugía , Pérdida de Peso/genética , Adulto JovenRESUMEN
Mid-life obesity is an established risk factor for Alzheimer's disease (AD) dementia, whereas late-life obesity has been proposed as a protective state. Weight loss, which predates cognitive decline, might explain this obesity paradox on AD risk. We aimed to assess the impact of late life obesity on brain structure taking into account weight loss as a potential confounder. We included 162 elderly controls of the Alzheimer's Disease Neuroimaging Initiative (ADNI) with available 3T MRI scan. Significant weight loss was defined as relative weight loss ≥5% between the baseline and last follow-up visit. To be able to capture weight loss, only subjects with a minimum clinical and anthropometrical follow-up of 12 months were included. Individuals were categorized into three groups according to body mass index (BMI) at baseline: normal-weight (BMI<25 Kg/m2), overweight (BMI 25-30 Kg/m2) and obese (BMI>30 Kg/m2). We performed both an interaction analysis between obesity and weight loss, and stratified group analyses in the weight-stable and weigh-loss groups. We found a significant interaction between BMI and weight loss affecting brain structure in widespread cortical areas. The stratified analyses showed atrophy in occipital, inferior temporal, precuneus and frontal regions in the weight stable group, but increased cortical thickness in the weight-loss group. In conclusion, our data support that weight loss negatively confounds the association between late-life obesity and brain atrophy. The obesity paradox on AD risk might be explained by reverse causation.
RESUMEN
Endobarrier® is a minimally invasive, reversible endoscopic treatment for obesity. It provokes malabsorption along 60 cm of the small intestine, which can contribute to the development of vitamin deficiencies and to changes in bone mineral density (BMD). To determine the prevalence of nutrient deficiencies, changes in body composition and BMD during the first year after Endobarrier® placement. Twenty-one patients with type 2 diabetes met inclusion criteria. Levels of vitamins, micro and macronutrients were assessed prior and at 1, 3 and 12 months post-operatively. DEXA was performed before and 12 months after implant. Nineteen patients completed the 12 months follow-up. Vitamin D deficiency was the most prevalent finding before Endobarrier® implant. The percentage of patients with severe deficiency decreased from 19 to 5% at 12 months after supplementation. Microcytic anaemia was initially present in 9.5% of patients and increased to 26.3% at 12 months. Low ferritin and vitamin B12 levels were observed in 14.2 and 4.8% of patients before the implant and worsened to 42 and 10.5%. Low concentrations of magnesium and phosphorus were also common but improved along the study. A significant but not clinically relevant decrease in BMD of 4.14 ± 4.0% at the femoral neck was observed at 12 months without changes in osteocalcin levels. Vitamin deficiencies are common after Endobarrier® implant. It is therefore important to screen patients prior to and at regular intervals after the implant, and to encourage adherence to diet counselling and supplementation.
Asunto(s)
Densidad Ósea , Enfermedades Carenciales/etiología , Diabetes Mellitus Tipo 2/complicaciones , Absorción Intestinal , Intestino Delgado , Obesidad/terapia , Prótesis e Implantes/efectos adversos , Anemia/etiología , Avitaminosis/etiología , Enfermedades Carenciales/sangre , Femenino , Cuello Femoral , Ferritinas/sangre , Humanos , Magnesio/sangre , Masculino , Persona de Mediana Edad , Obesidad/complicaciones , Fósforo/sangre , Vitamina B 12/sangre , Deficiencia de Vitamina B 12/etiología , Deficiencia de Vitamina D/etiologíaRESUMEN
INTRODUCTION: The effects of bariatric surgery on skeletal health raise many concerns. Trabecular bone score (TBS) is obtained through the analysis of lumbar spine dual X-ray absorptiometry (DXA) images and allows an indirect assessment of skeletal microarchitecture (MA). The aim of our study was to evaluate the changes in bone mineral density (BMD) and alterations in bone microarchitecture assessed by TBS in morbidly obese women undergoing Roux-en-Y gastric bypass (RYGB), over a three-year follow-up. MATERIAL/METHODS: A prospective study of 38 morbidly obese white women, aged 46.3 ± 8.2 years, undergoing RYGB was conducted. Biochemical analyses and DXA scans with TBS evaluation were performed before and at one year and three years after surgery. RESULTS: Patients showed normal calcium and phosphorus plasma concentrations throughout the study. However, 25-hydroxyvitamin D (25(OH)D3) decreased, and 71% of patients had a vitamin D deficiency at three years. BMD at femoral neck and lumbar spine (LSBMD) significantly decreased 13.53 ± 5.42% and 6.03 ± 6.79%, respectively, during the three-year follow-up; however Z-score values remained above those for women of the same age. TBS was within normal ranges at one and three years (1.431 ± 106 and 1.413 ± 85, respectively), and at the end of the study, 73.7% of patients had normal bone MA. TBS at three years correlated inversely with age (r = -0.41, p = 0.010), body fat (r = -0.465, p = 0.004) and greater body fat deposited in trunk (r = -0.48, p = 0.004), and positively with LSBMD (r = 0.433, p = 0.007), fat mass loss (r = 0.438, p = 0.007) and lean mass loss (r = 0.432, p = 0.008). In the regression analysis, TBS remained associated with body fat (ß = -0.625, p = 0.031; R² = 0.47). The fracture risk, calculated by FRAX® (University of Sheffield, Sheffield, UK), with and without adjustment by TBS, was low. CONCLUSION: Women undergoing RYGB in the mid-term have a preserved bone MA, assessed by TBS.
Asunto(s)
Densidad Ósea/fisiología , Huesos/ultraestructura , Derivación Gástrica/efectos adversos , Obesidad Mórbida , Adulto , Femenino , Fracturas de Cadera , Humanos , Obesidad Mórbida/cirugía , Osteoporosis , Factores de Riesgo , Adulto JovenRESUMEN
Weight loss has been proposed as a sign of pre-clinical Alzheimer Disease (AD). To test this hypothesis, we have evaluated the association between longitudinal changes in weight trajectories, cognitive performance, AD biomarker profiles and brain structure in 363 healthy controls from the Alzheimer´s Disease Neuroimaging Initiative (mean follow-up 50.5±30.5 months). Subjects were classified according to body weight trajectory into a weight loss group (WLG; relative weight loss ≥ 5%) and a non-weight loss group (non-WLG; relative weight loss < 5%). Linear mixed effects models were used to estimate the effect of body weight changes on ADAS-Cognitive score across time. Baseline CSF tau/AΔ42 ratio and AV45 PET uptake were compared between WLG and non-WLG by analysis of covariance. Atrophy maps were compared between groups at baseline and longitudinally at a 2-year follow-up using Freesurfer. WLG showed increased baseline levels of cerebrospinal fluid tau/AΔ42 ratio, increased PET amyloid uptake and diminished cortical thickness at baseline. WLG also showed faster cognitive decline and faster longitudinal atrophy. Our data support weight loss as a non-cognitive manifestation of pre-clinical AD.