Outcomes of in-vitro fertilization after bariatric surgery: a national register-based case-control study.

STUDY QUESTION: Does previous bariatric surgery (BS) in women affect cumulative live birth rate in IVF? SUMMARY ANSWER: Women having had BS seem to have the same cumulative live birth rate as non-operated women of the same BMI at IVF treatment. WHAT IS KNOWN ALREADY: Because of the perinatal risks of obesity to mother and infant as well as impaired outcomes of IVF, obese women are advised to reduce their weight, but it is not clear whether previous BS could affect IVF results. STUDY DESIGN, SIZE, DURATION: This national register-based case-control study included all cases of BS (n = 30 436) undergoing IVF (n = 153) from 2007 until 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS: Swedish women between 18 and 45 years operated with BS, with at least one first started cycle of IVF after surgery, were included. For each woman having IVF after BS (n = 153), up to five non-operated control women (n = 744) starting their first IVF cycle during the study period were matched for age, parity and BMI at treatment. The primary outcome in this study was the cumulative live birth rate (CLBR) after the first IVF cycle, defined as all live births after the first cycle including fresh and frozen embryo transfers. MAIN RESULTS AND THE ROLE OF CHANCE: There was no significant difference in CLBR between the BS group and the matched controls (29.4% compared to 33.1%), even though the number of retrieved oocytes (7.6 vs 8.9, P = 0.005) and frozen embryos (1.0 vs 1.5, P = 0.041) were significantly fewer in the BS group. There was no association between cumulative live birth and BS, adjusted odds ratio 1.04, 95% CI (0.73, 1.51). However, the birth weight was significantly lower in the children born to mothers with previous BS, mean (SD) 3190 (690) vs 3478 (729) g, P = 0.037. LIMITATIONS, REASONS FOR CAUTION: Confounders such as age, BMI and previous childbirth were accounted for by the matching design of the study, but there were no data on indication for IVF, anti-Müllerian hormone, smoking or previous comorbidities. The study was exploratory and did not reach sufficient power to detect potential smaller differences in live birth rates. WIDER IMPLICATIONS OF THE FINDINGS: The findings concur with those in previously published smaller studies and provide somewhat reassuring results considering IVF outcomes after BS with a CLBR comparable to that of controls, despite a lower mean birth weight. STUDY FUNDING/COMPETING INTEREST(S): This research was funded by grants from the Southern Health Care Region of Sweden. The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER: N/A.

Effect of different limb lengths on quality of life, eating patterns and gastrointestinal symptoms after Roux-en-Y gastric bypass in superobese patients: randomized study.

BACKGROUND: Distal Roux-en-Y gastrojejunal bypass (DRYGJB) gives better weight reduction than standard Roux-en-Y gastric bypass (RYGB) but at the risk of increased malnutrition side-effects. This study compared the effects of RYGB and DRYGJB on gastrointestinal symptoms, eating patterns and health-related quality of life (QoL). METHODS: This was a single-blind RCT from a university-affiliated obesity centre. Patients with a BMI of 50 kg/m2 or above were invited to participate. Treatment arms were standard gastric bypass with an alimentary limb of 150 cm and a biliopancreatic limb of 60 cm, with a variable common channel length, or DRYGJB with biliopancreatic limb of 200 cm, common channel limb of 150 cm and variable alimentary limb length. Baseline and follow-up data to 5 years on quality of life, obesity-related problems and gastrointestinal symptoms were collected using prospectively created and validated questionnaires. RESULTS: Some 140 patients were included. Those with a DRYGJB had better weight loss at 5 years (mean(s.d.) 68·3(21·8) kg versus 55·7(19·8) kg for standard RYGB; P = 0·011). Eating patterns improved, with no difference between the groups. Gastrointestinal symptoms (diarrhoea, indigestion) worsened significantly in both groups, but only patients with DRYGJB had significantly worse diarrhoea at the end of the study than at baseline (P = 0·006). Both groups had improved perceived generic QoL over baseline, and obesity-related problems were markedly reduced. CONCLUSION: Standard RYGB and both improved generic and disease-specific QoL and eating behavioural pattern. Diarrhoea was increased more following DRYGJB than after RYGB. Registration number: NCT01514799 (https://clinicaltrials.gov).

ANTECEDENTES: El bypass gastroyeyunal distal (distal gastrojejunal bypass, DRYGB) proporciona una mejor pérdida de peso que el RYGB estándar, pero con el riesgo de aumentar los efectos secundarios de malnutrición. El presente estudio comparó los efectos de RYGB y DRYGJB en los síntomas gastrointestinales, patrón alimentario y calidad de vida relacionada con la salud. MÉTODOS: Estudio aleatorizado simple-ciego y controlado efectuado en un centro de obesidad con afiliación universitaria. Se invitó a participar a pacientes con un IMC de ≥ 50 kg/m2 . Las ramas del tratamiento fueron el bypass gástrico estándar con asa alimentaria (alimentary lim, AL) de 150 cm y asa biliopancreática (biliopancreatic, BP) de 60 cm, con asa común (common cannel, CC) de longitud variable, o DRYGJB con asa BP de 200 cm, asa CC de 150 cm y AL variable. Se recogieron datos basales y de seguimiento a los 5 años respecto a la calidad de vida, problemas relacionados con la obesidad y síntomas gastrointestinales utilizando cuestionarios prospectivos creados y validados. RESULTADOS: Se incluyeron un total de 140 pacientes. Los pacientes con DRYGJB tuvieron una mayor pérdida de peso a los 5 años (media (DE) 68,3 kg (21,9) versus 55,7 (19,8); P = 0,011)). Los patrones alimentarios mejoraron sin diferencia entre grupos. Los síntomas gastrointestinales (diarrea, indigestión) empeoraron significativamente en ambos grupos, pero solo los pacientes con DRYGJB presentaron diarrea al final del estudio significativamente peor en comparación con la situación basal (P = 0,006). Ambos grupos presentaron una mejor percepción de la QoL genérica en comparación con el estado basal, y los problemas relacionados con la obesidad se redujeron considerablemente. CONCLUSIÓN: El bypass gástrico estándar (RYGB) y el bypass gastroyeyunal distal (DRYGJB) mejoraron la QoL, tanto genérica como la específica de la enfermedad, así como el patrón de comportamiento alimentario. El DRYGJB aumentó la diarrea más que el RYGJB.

Ghrelin suppresses insulin secretion in human islets and type 2 diabetes patients have diminished islet ghrelin cell number and lower plasma ghrelin levels.

It is not known how ghrelin affects insulin secretion in human islets from patients with type 2 diabetes (T2D) or whether islet ghrelin expression or circulating ghrelin levels are altered in T2D. Here we sought out to identify the effect of ghrelin on insulin secretion in human islets and the impact of T2D on circulating ghrelin levels and on islet ghrelin cells. The effect of ghrelin on insulin secretion was assessed in human T2D and non-T2D islets. Ghrelin expression was assessed with RNA-sequencing (n = 191) and immunohistochemistry (n = 21). Plasma ghrelin was measured with ELISA in 40 T2D and 40 non-T2D subjects. Ghrelin exerted a glucose-dependent insulin-suppressing effect in islets from both T2D and non-T2D donors. Compared with non-T2D donors, T2D donors had reduced ghrelin mRNA expression and 75% less islet ghrelin cells, and ghrelin mRNA expression correlated negatively with HbA1c. T2D subjects had 25% lower fasting plasma ghrelin levels than matched controls. Thus, ghrelin has direct insulin-suppressing effects in human islets and T2D patients have lower fasting ghrelin levels, likely as a result of reduced number of islet ghrelin cells. These findings support inhibition of ghrelin signaling as a potential therapeutic avenue for stimulation of insulin secretion in T2D patients.

Impact of diet and bariatric surgery on anti-Müllerian hormone levels.

STUDY QUESTION: Do serum levels of anti-Müllerian hormone (AMH) change in women of reproductive age following dietary and surgery-induced weight loss? SUMMARY ANSWER: AMH levels increased after very low-calorie diet (VLCD) before surgery and decreased at 6 and 12 months after Roux-en-Y gastric bypass (RYGB), beyond expected normal age-related decline. WHAT IS KNOWN ALREADY: Obesity has negative effects on fertility and IVF outcomes, and possibly also on AMH levels. AMH correlates to the number of growing follicles and is used to predict the response to IVF treatment. However, AMH might decrease after bariatric surgery. STUDY DESIGN, SIZE, DURATION: A prospective cohort study of 48 women followed first for 8 weeks preoperatively, then operated with RYGB and followed postoperatively for 1 additional year. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women aged 18-35 years with a mean (SD) BMI 40.9 (3.6) kg/m2 were included at baseline (BL). After the VLCD, a RYGB was performed. Body weight and height were measured at BL and 1 year postoperatively. Hormones were analysed at BL, after VLCD on the day before surgery, and at 6 and 12 months postoperatively. MAIN RESULTS AND THE ROLE OF CHANCE: Median AMH levels were 30.0 pmol/L at BL and rose significantly after VLCD (median: 35.0 pmol/L; P = 0.014). Median AMH at 6 and 12 months postoperatively were significantly lower (19.5 and 18.0 pmol/L, respectively; P = 0.001). Free androgen index (FAI) was significantly lower after 12 months, compared to BL (1.2 vs 3.5, P < 0.0005). LIMITATIONS REASONS FOR CAUTION: Ultrasound for PCOS diagnosis was not performed. The change in laboratory methods for AMH analysis during the study might be a limitation. WIDER IMPLICATIONS OF THE FINDINGS: Obese young women might choose bariatric surgery also for fertility reasons, and the observed decrease in FAI is in line with improved fertility. More research is needed to evaluate the clinical effects of the decrease of AMH, and the effect of bariatric surgery prior to IVF treatment. STUDY FUNDING/COMPETING INTEREST(S): Study-specific laboratory analyses were funded by the Swedish Regional Research Fund (ALF). Authors declare no competing interests. TRIAL REGISTRATION NUMBER: N/A.

Diabetes Resolution and Work Absenteeism After Gastric Bypass: a 6-Year Study.

BACKGROUND: Obesity-related diseases cause costs to society. We studied the cost of work absenteeism before and after gastric bypass and the effects of postoperative diabetes resolution. PATIENTS AND METHODS: Data were obtained from the Scandinavian Obesity Surgery Registry (SOReg) (national coverage >98%) and cross-matched with data from the Social insurance Agency (coverage 100%) for the period ±3 years from operation. In 2010, a total of 7454 bariatric surgeries were performed; the study group is 4971 unique individuals with an annual income of >10,750 Euros and complete data sets. A sex-, age-, and income-matched reference population was identified for comparison. RESULTS: Patients with obesity had preoperatively a 3.5-fold higher absenteeism. During follow-up (FU), the ratio relative to the reference population remained constant. An increase of 12-14 net absenteeism days was observed in the first 3 months after surgery. Female sex (OR 1.5, CI 1.13-1.8), preoperative anti-depressant use (OR 1.5, CI 1.3-1.9), low income (OR 1.4, CI 1.2-1.8), and a history of sick leave (OR 1.004, CI 1.003-1.004) were associated with increased absenteeism during FU. Diabetes resolution did not decrease absenteeism from preoperative values. CONCLUSIONS: Patients with obesity have higher preoperative absenteeism than the reference population. Operation caused an increase the first 90 days after surgery of 12-13 days. There were no relative increases in absenteeism in the next 3 years; patients did not deviate from preoperative patterns but followed the trend of the reference population. Preoperative diabetes did not elevate that level during FU; diabetes resolution did not lower absenteeism.

Systematic review of risk prediction models for diabetes after bariatric surgery.

BACKGROUND: Diabetes remission is an important outcome after bariatric surgery. The purpose of this study was to identify risk prediction models of diabetes remission after bariatric surgery. METHODS: A systematic literature review was performed in MEDLINE, MEDLINE-In-Process, Embase and the Cochrane Central Register of Controlled Trials databases in April 2015. All English-language full-text published derivation and validation studies for risk prediction models on diabetic outcomes after bariatric surgery were included. Data extraction included population, outcomes, variables, intervention, model discrimination and calibration. RESULTS: Of 2330 studies retrieved, eight met the inclusion criteria. Of these, six presented development of risk prediction models and two reported validation of existing models. All included models were developed to predict diabetes remission. Internal validation using tenfold validation was reported for one model. Two models (ABCD score and DiaRem score) had external validation using independent patient cohorts with diabetes remission assessed at 12 and 14 months respectively. Of the 11 cohorts included in the eight studies, calibration was not reported in any cohort, and discrimination was reported in two. CONCLUSION: A variety of models are available for predicting risk of diabetes following bariatric surgery, but only two have undergone external validation.

Corticosteroids or Not for Postoperative Nausea: A Double-Blinded Randomized Study.

BACKGROUND: Postoperative nausea and vomiting (PONV) is common after general anaesthesia, and corticosteroids are used in many protocols for enhanced recovery after surgery (ERAS). However, surgical techniques are developing, and ERAS protocols need to be reevaluated from time to time. PATIENTS AND METHOD: In this study, we compared the effects of oral vs. parenteral corticosteroid administration on postoperative nausea. Elective Roux-y-gastric bypass (RYGB) patients were randomly assigned to either 8 mg betamethasone orally (n = 50) or parentally (n = 25) or as controls (n = 25), in a double-blind design. PONV risk factors were noted. All patients had the same anaesthetic technique. Data were collected at baseline, on arrival to the recovery room (RR) and at five more time points during the first 24 h. Nausea and tiredness were patient assessed using visual analogue scales; rescue drug consumption was recorded. RESULTS: Operation time was 30-40 min. Neither demographics nor risk factors for nausea differed between groups. Neither peak values for nor total amount of nausea differed between groups. The number of supplemental injections was the same for all groups. COMMENTS: In a setting of modern laparoscopic RYGB, the value of betamethasone in preventing PONV seems to be limited. ERAS protocols may need re-evaluation.

Intraabdominal Pressure and Postoperative Discomfort in Laparoscopic Roux-en-Y Gastric Bypass (RYGB) Surgery: a Randomized Study.

BACKGROUND: High intraabdominal pressure (IAP) during laparoscopic surgery has been associated with postoperative discomfort. Effects on nausea and access have not been subjected to randomized studies. In cholecystectomy, lower IAP may cause less pain, but nausea and surgical access in RYGB surgery have not been investigated. We studied the influence of two IAP levels on surgical access, operation time, postoperative pain, and nausea. METHODS: Fifty consecutive female gastric bypass patients were randomized to intraabdominal pressure of 12 (IAP12) or 18 (IAP18) mm Hg. Surgeons and personnel were blinded to randomization; study groups were well matched for age and BMI. Operative time was noted in minutes. Visual analogue scales were used for assessing access and for patients assessing pain (abdomen-shoulder) and nausea (supine-standing) at six time points during the first 16 postoperative hours. Rescue medication was recorded. RESULTS: In 3/25 patients in the IAP12 group, the code was broken due to access problems vs. 0/25 in the IAP18 group (p = 0.1398). Operative time did not differ. Access was significantly better for IAP18 (92.2 ± 2.3 vs. 69.3 ± 4.2; p = 0.0001). Postoperative shoulder pain was maximal after 6 h but throughout less than in the abdomen (p < 0.0001); there were no differences in pain between IAP18 and IAP12 (p = 0.7408). Postoperative nausea was significantly greater standing than supine but without differences between groups. CONCLUSION: Higher IAP gives better surgical access in laparoscopic Roux-en-Y gastric bypass with no negative effect on pain or nausea.

Preoperative Nutrition and Postoperative Discomfort in an ERAS Setting: A Randomized Study in Gastric Bypass Surgery.

BACKGROUND: Many patients experience postoperative nausea and vomiting (PONV). Preoperative treatment with carbohydrate solutions seems to improve the course after different types of surgery. This study was undertaken to investigate the potential value of different models for preoperative hydration/nutrition, in addition to our ERAS (enhanced recovery after surgery) protocol. METHODS: Ninety non-diabetic women planned for elective laparoscopic gastric bypass and aged 18-65 years were included. All were on preoperative low-calorie diet (LCD). They were randomized into three arms, either a carbohydrate-rich drink, a protein-enriched drink, or tap water and instructed to drink 800 and 200 mL 16 and 2 h, respectively, prior to operation. Risk factors for PONV were recorded preoperatively. All patients were operated before lunch and received 1500-2000 mL of Ringer-Acetate solution during the 24-30-h postoperative hospital time. Four variables (nausea, pain, tiredness, and headache) were registered on 100-mm visual analog scales six times over 22 h. The need for additional medication was registered. RESULTS: Out of 90 patients, 73 complete datasets were obtained. Nausea peaked at 7 p.m. but with no statistically significant differences between groups for any of the variables. Pain peaked the first 2 h postoperatively, remained longer, and had not returned to baseline values at 6 a.m. the morning after surgery but with no difference between groups. CONCLUSIONS: Inside our ERAS protocol, additional preoperative carbohydrate- or protein-enriched fluid treatment did not further reduce immediate patient discomfort in laparoscopic gastric bypass surgery.

Formation of the Scandinavian Obesity Surgery Registry, SOReg.

BACKGROUND: Obesity surgery is expanding, the quality of care is ever more important, and learning curve assessment should be established. A large registry cohort can show long-term effects on obesity and its comorbidities, complications, and long-term side effects of surgery, as well as changes in health-related quality of life (QoL). Sweden is ideally suited to the task of data collection and audit, with universal use of personal identification numbers, nation-wide registries permitting cross-matching to analyze causes of death, in-hospital care, and health-related absenteeism. METHOD: In 2004, the Scandinavian Obesity Surgery Registry (SOReg) was initiated and government financing secured. A project group created a national database covering all public as well as private hospitals. Data entry was to be made online, operative definitions of comorbidity were formed, and complication severity scored. Several forms of audit were devised. RESULTS: After pilot studies, the system has been running in its present form since 2007. Since 15 January 2013, SOReg covers all bariatric surgery centers in Sweden. The number of operations in the database exceeded 40,000 (March 2014), with a median follow-up of 2.94 years. Audit shows that >98% of data are correct. All results are publicized annually on the Internet. COMMENTS: Using this systematic approach, it has been possible to cover >99% of all bariatric surgery, cross-matching our data with nation-wide registries for in-hospital care, cause of death, and permitting regular nation-wide audit. Several scientific studies have used, or are using, what seems to be the most comprehensive database in obesity surgery.

Water with food intake does not influence caloric intake after gastric bypass (GBP): a cross-over trial.

BACKGROUND: Bariatric patients seeking information meet very different recommendations on postoperative diet and eating behaviour. A reason for variability may be lack of hard evidence. A national survey on current dietary advice was conducted to serve as background for the present study on how drinking during a meal influenced caloric consumption. METHODS: A standardised questionnaire was sent to all units in the Scandinavian Obesity surgery registry (SOReg) in order to obtain information regarding current diet advice after gastric bypass. Twenty-eight patients, 14 in each group, were studied either 2 months or 1 year after a standard gastric bypass (GBP). A standardised lunch was served on two separate days with or without water in randomised order. Meal and water weights were measured before and after. Hunger/satiety scores were obtained using visual analogue scales. RESULTS: Response rate for surgeons was low, for dieticians 75 %. No clear consensus for liquid intake during meals was found; few surgeons advised patients whether or not to drink with meals. All patients ate to full satiety. Two months post-GBP, 7/14 patients consumed more solid food when allowed drinking water; the increase in caloric consumption was not significant. One year post-GBP, 5/14 patients consumed more solid food when allowed drinking water, the difference not reaching statistical significance. CONCLUSION: Our study does not indicate that patients should refrain from drinking during meals the first year after a GBP, at least not from a caloric intake point of view.

Management of suspected anastomotic leak after bariatric laparoscopic Roux-en-y gastric bypass.

BACKGROUND: Anastomotic leak is one of the most serious complications following bariatric laparoscopic Roux-en-Y gastric bypass (LRYGB), and associated with high morbidity rates and prolonged hospital stay. Timely management is of utmost importance for the clinical outcome. This study evaluated the approach to suspected leakage in a high-volume bariatric surgery unit. METHODS: All consecutive patients who underwent LRYGB performed by the same team of surgeons were registered prospectively in a clinical database from September 2005 to June 2012. Suspected leaks were identified based on either clinical suspicion and/or associated laboratory values, or by a complication severity grade of at least II using the Clavien-Dindo score. RESULTS: A total of 6030 patients underwent LRYGB during the study period. The leakage rate was 1·1 per cent (64 patients). Forty-five leaks (70 per cent) were treated surgically and 19 (30 per cent) conservatively. Eight (13 per cent) of 64 patients needed intensive care and the mortality rate was 3 per cent (2 of 64). Early leaks (developing in 5 days or fewer after LRYGB) were treated by suture of the defect in 20 of 22 patients and/or operative drainage in 13. Late leaks (after 5 days) were managed with operative drainage in 19 of 23 patients and insertion of a gastrostomy tube in 15. Patients who underwent surgical treatment early after the symptoms of leakage developed had a shorter hospital stay than those who had symptoms for more than 24 h before reoperation (12·5 versus 24·4 days respectively; P < 0·001). CONCLUSION: Clinical suspicion of an anastomotic leak should prompt an aggressive surgical approach without undue delay. Early operative treatment was associated with shorter hospital stay. Delays in treatment, including patient delay, after symptom development were associated with adverse outcomes.

Gastroesophageal reflux after vertical banded gastroplasty is alleviated by conversion to gastric bypass.

BACKGROUND: Conversion operations after vertical banded gastroplasty (VBG) are sometimes performed because of vomiting and/or acid regurgitation. Primary operation with gastric bypass (GBP) is known to reduce gastroesophageal reflux (GERD). Previous studies have not been designed to differentiate between the effects of the altered anatomy and of the ensuing weight loss. No series has reported data on acid reflux before and after conversion from VBG to GBP. METHODS: We invited eight VBG patients with current symptoms of GERD. All had intact staple lines as assessed by barium meal and gastroscopy. Acid reflux was quantified using 48-h Bravo capsule measurements. Conversion operations were performed creating an isolated 15-20-ml pouch; the previously banded part of gastric wall was excised. Gastrojejunostomy was made end to end with a 28-mm circular stapler. The study is based on five patients consenting to early postoperative endoscopy and pH measurement. RESULTS: All patients were women with a mean age of 49.5 years and BMI of 36.3. Time since VBG was 132.1 months. Time from conversion to second measurement was 46.6 days and BMI at that time 32.7. There was no mortality and no serious morbidity. All patients improved clinically and no patient had to go back on proton pump inhibition or antacids. Total time with pH < 4.0 was reduced from 18.4% to 3.3% (p < 0.05). DeMeester score was reduced from 58.1 to 15.9 (p < 0.05). CONCLUSIONS: The effect of converting VBG-operated patients to GBP results in a near-normalisation of acid reflux parameters and a discontinuation of proton pump inhibitor medication.

Pro-opiomelanocortin gene is associated with serum leptin levels in lean but not in obese individuals.

OBJECTIVE: Mutations in the pro-opiomelanocortin and melanocortin 4 receptor genes (POMC and MC4R) cause monogenic obesity, and the POMC locus (2p21) has been linked to leptin levels and body mass index (BMI). We searched for monogenic obesity due to mutations in POMC and MC4R among morbidly obese Swedes and studied the association of POMC variants with BMI and serum leptin levels. DESIGN: MC4R and POMC were screened for mutations in 102 obese Swedish subjects (40+/-11 y, 41.3+/-5.0 kg/m(2)) using the single-strand conformation polymorphism technique. The detected polymorphisms were genotyped in 118 lean control subjects (56+/-11 y, 22.6+/-1.3 kg/m(2)) and studied for association with BMI and serum leptin levels. RESULTS: No cases of monogenic obesity due to mutations in POMC or MC4R were identified and none of the four common POMC polymorphisms (RsaI, ins56, Glu188Gly and C8246T) were associated with obesity. Lean carriers of the C8246T CC-genotype had higher serum leptin levels compared to CT or TT carriers (9.7+/-6.6 vs 6.7+/-4.4 microg/l, P=0.003 for leptin levels adjusted for age, sex and BMI in regression analysis), especially lean females (P=0.004) and lean female carriers with the C8246T(CC)/RsaI(--or +-) genotype combinations (P<0.0005). Neither the C8246T CC-genotype nor the C8246T(CC)/RsaI(--or +-) were associated with serum leptin levels in obese subjects. CONCLUSIONS: Monogenic forms of obesity due to mutations in POMC and MC4R are rare in Swedish obese patients. Polymorphisms in POMC are associated with variation in serum leptin levels within the normal range in healthy lean but not in obese individuals.

Fully stapled gastric bypass with isolated pouch and terminal anastomosis: 1-3 year results.

BACKGROUND: Roux-en-Y gastric bypass is a bariatric procedure of choice. There is evidence supporting a small isolated pouch and a wide anastomosis. Gastric vascular anatomy renders the ventral aspect less suited for anastomotic construction. The lesser curvature has abundant blood supply that should preferably not be interfered with. Terminal anastomosis is a logical choice. METHODS: We devised a way of making a fully stapled gastric bypass with complete separation of a pouch that empties dependently. The technique obviates the oral passage of the stapler anvil. Such a procedure facilitates the creation of an "end-of-pouch to end-of-jejunal limb" wide-diameter anastomosis and precludes the risk of staple-line disruption. RESULTS: Since October 1997 we have performed 227 such anastomoses (146 primary, 81 reoperative procedures) in consecutive patients with no leaks, no gastro-gastric fistulas and no mortality. The postoperative hospital time was 3.6 (3-8) days (median, range). In primary operations baseline BMI was 47.5, 1-yr 29.7 and 3-yr 29.2. Corresponding values for reoperations were 39.3, 30.8 and 31.5. Weight loss was adequate, and complications were limited to three anastomotic ulcers and two narrow stomas without visible ulcers but necessitating endoscopic dilatation. CONCLUSION: The technique confers distinctive advantages.

Common variants in the beta2-(Gln27Glu) and beta3-(Trp64Arg)--adrenoceptor genes are associated with elevated serum NEFA concentrations and type II diabetes.

AIMS/HYPOTHESIS: Higher NEFA concentrations predict Type II (non-insulin-dependent) diabetes mellitus but it is not known whether higher NEFA concentrations are genetically determined or reflect coexisting obesity. To address this question we studied whether common variants in two genes encoding for key regulators of lipolysis, the beta2- and beta3- adrenoceptors (B2AR and B3AR) are associated with NEFA concentrations and Type II diabetes. METHODS: A total of 1054 Swedish subjects with varying degrees of glucose tolerance were genotyped for the Gln27Glu variant in the B2AR and for the Trp64Arg variant in the B3AR genes using PCR-RFLP. RESULTS: The B2AR Gln27 allele was more frequent in 219 Type II diabetic patients than in 237 non-diabetic subjects (59.8 % vs 52.3 %; OR = 1.72, p = 0.02) while there was no significant difference in the frequency of the B3AR Arg64 allele. Subjects homozygous for the protective alleles (Glu27 and Trp64) had, however, a lower prevalence of diabetes than subjects with other genotype combinations (OR = 0.58, p = 0.03). Among sibling pairs discordant for the B2AR Gln27Glu polymorphism, siblings with an excess of the Gln27 allele had higher fasting insulin (n = 217; p = 0.02) and NEFA concentrations (107 sex-matched pairs; p = 0.01) than siblings with an excess of the Glu27 allele. Among sibling pairs discordant for the B3AR Trp64Arg variant, siblings with the Arg64 allele had higher 2 h glucose (n = 48; p = 0.01) and NEFA concentrations (16 pairs matched for sex; p < 0.04) than siblings with the Trp64Trp64 genotype. CONCLUSIONS/INTERPRETATION: Common variants in the beta2- and beta3- adrenoceptor genes are associated with increased fasting insulin and NEFA concentrations and could increase susceptibility to Type II diabetes.

Energy expenditure during treadmill walking before and after vertical banded gastroplasty: a one-year follow-up study in 11 obese women.

OBJECTIVE: To find out whether weight reduction induced by vertical banded gastroplasty (VBG) alters the energy expenditure in severely obese women during treadmill walking. DESIGN: A prospective one year follow-up study, patients being their own controls. SETTING: University hospital, Sweden. SUBJECTS: A consecutive series of 11 women who had VBG. MAIN OUTCOME MEASURES: Indirect calorimetry, body mass index (BMI), preset and comfortable walking speeds, heart rate, perceived exertion, and quality of life. RESULTS: 11 patients were evaluated. Mean BMI (kg/ml) decreased from 41 (range 36-46) before to 32 (range 25-37) 12 months postoperatively. The energy expenditure decreased significantly both at comfortable and preset walking speeds. The comfortable walking speed increased from 2.7 km x h(-1) (range 1.3-3.4) before operation to 3.8 (range 2.0-4.2) one year postoperatively (p = 0.003). All bodily variables in the SF-36 questionnaire showed improvement from 6 months onwards. CONCLUSION: Weight reduction in women reduces the energy expenditure during walking both at comfortable and preset speeds. The comfortable walking speed is increased. The improvements are reflected in the patients' own assessment.

The T 54 allele of the intestinal fatty acid-binding protein 2 is associated with a parental history of stroke.

To test the hypothesis that the A/T polymorphism of the fatty acid-binding protein 2 gene (FABP2) is associated with impaired lipid metabolism and cardiovascular disease, we compared clinical characteristics and a parental history of cardiovascular disease between 213 sibling pairs discordant for the polymorphism. Siblings with an excess of the T54 allele had higher triglyceride (P = 0.002) and cholesterol (P = 0.019) concentrations than siblings with the A54 allele. Parents of offspring with the T54T and T54A genotypes reported an increased prevalence of stroke compared to parents of offspring with the A54A genotype (P = 0.007). In summary, we have confirmed the association of the FABP2 T54 allele with increased concentrations of cholesterol and triglycerides in genotype-discordant sibling pairs. We also present novel evidence that genetic variation in the FABP2 gene may increase susceptibility to stroke.

Neither low-calorie diet nor vertical banded gastroplasty influence gastro-oesophageal reflux in morbidly obese patients.

OBJECTIVE: Investigate the effect of a liquid diet, and of vertical banded gastroplasty, on gastro-oesophageal reflux in morbidly obese patients. DESIGN: Prospective study, patients being their own controls. SETTING: University hospital, Sweden. SUBJECTS: 25 morbidly obese patients, listed for vertical banded gastroplasty. INTERVENTIONS: 24 hour ambulatory intra-oesophageal pH-monitoring three weeks before operation and repeated after 10-14 days on a liquid very low calorie diet, and finally three weeks after operation, while still on a liquid very low calorie diet. MAIN OUTCOME MEASURES: Percentage of time that pH in the oesophagus was < or =4. RESULTS: There were no changes in the amount of reflux, either after a liquid diet or after vertical banded gastroplasty. CONCLUSIONS: Neither the liquid diet nor vertical banded gastroplasty alone had any appreciable effect on gastro-oesophageal reflux.