Effects of Morbid Obesity and Metabolic Syndrome on the Composition of Circulating Immune Subsets.

Morbid obesity is characterized by chronic, low-grade inflammation, which is associated with 'inflamm-aging'. The presence of metabolic syndrome (MetS) might accelerate this phenomenon of metaflammation. In this study, we assessed the effects of morbid obesity and MetS on the composition of a broad spectrum of immune cells present within the circulation. A total of 117 morbidly obese patients (MOP) without MetS (MetS-), 127 MOP with MetS (MetS+) and 55 lean controls (LC) were included in this study. Absolute numbers of T cell, B cell, NK cell and monocyte subsets were assessed within peripheral blood using flow cytometry. Both absolute cell numbers and proportion of cells were evaluated correcting for covariates age, body mass index and cytomegalovirus serostatus. Although the absolute number of circulating CD4+ T cells was increased in the MetS+ group, the CD4+ T cell composition was not influenced by MetS. The CD8+ T cell and B cell compartment contained more differentiated cells in the MOP, but was not affected by MetS. Even though the absolute numbers of NK cells and monocytes were increased in the MOP as compared to LC, there was no difference in proportions of NK and monocyte subsets between the three study groups. In conclusion, although absolute numbers of CD4+ and CD8+ T cells, B cells, NK cells and monocytes are increased in MOP, obesity-induced effects of the composition of the immune system are confined to a more differentiated phenotype of CD8+ T cells and B cells. These results were not affected by MetS.

Improvement of Cardiac Function After Roux-en-Y Gastric Bypass in Morbidly Obese Patients Without Cardiac History Measured by Cardiac MRI.

PURPOSE: Metabolic syndrome in patients with morbid obesity causes a higher cardiovascular morbidity, eventually leading to left ventricular hypertrophy and decreased left ventricular ejection fraction (LVEF). Roux-en-Y gastric bypass (RYGB) is considered the gold standard modality for treatment of morbid obesity and might even lead to improved cardiac function. Our objective is to investigate whether cardiac function in patients with morbid obesity improves after RYGB. MATERIALS AND METHODS: In this single center pilot study, 15 patients with an uneventful cardiac history who underwent RYGB were included from May 2015 to March 2016. Cardiac function was measured by cardiac magnetic resonance imaging (CMRI), performed preoperatively and 3, 6, and 12 months postoperative. LVEF and myocardial mass and cardiac output were measured. RESULTS: A total of 13 patients without decreased LVEF preoperative completed follow-up (mean age 37, 48.0 ± 8.8). There was a significant decrease of cardiac output 12 months postoperative (8.3 ± 1.8 preoperative vs. 6.8 ± 1.8 after 12 months, P = 0.001). Average myocardial mass declined by 15.2% (P < 0.001). After correction for body surface area (BSA), this appeared to be non-significant (P = 0.36). There was a significant improvement of LVEF/BSA at 6 and 12 months postoperative (26.2 ± 4.1 preoperative vs. 28.4 ± 3.4 and 29.2 ± 3.6 respectively, both P = 0.002). Additionally, there was a significant improvement of stroke volume/BSA 12 months after surgery (45.8 ± 8.0 vs. 51.9 ± 10.7, P = 0.033). CONCLUSION: RYGB in patients with morbid obesity with uneventful history of cardiac disease leads to improvement of cardiac function.

Predicting Symptom Relief After Reoperation for Suspected Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: Internal herniation (IH) is one of the most common long-term complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Diagnosis of IH may be difficult, and not all patients with suspected IH will have full relief of symptoms after closure of both mesenteric defects. OBJECTIVES: To investigate possible predictive factors for relief of symptoms in patients with suspected IH. METHODS: All patients that underwent reoperation for (suspected) IH after LRYGB from June 2009 to December 2016 were retrospectively evaluated in this multicentre cohort study. Logistic regression analysis was used to identify predictive factors for pain relief after closure of the mesenteric defects. RESULTS: A total of 193 patients underwent laparoscopy for (suspected) IH during the study period. The median interval between LRYGB and reoperation was 18.3 ± 19.0 months. In 40.2% of cases, IH was identified on computed tomography (CT), and IH was objectified during surgery in 61.1%. Postoperative symptom relief was observed in 146 patients (77.2%). For patients in which IH was present during surgery, 82.8% had relief of pain postoperatively, as compared to 68.5% for those procedures in which no IH was found. The only significant predictor for postoperative pain relief was a swirl sign on CT (OR 4.24, 95%CI 1.63-11.05). CONCLUSIONS: Pain relief after closure of the mesenteric defects for IH remains unpredictable. A positive CT for IH was a predictive factor for symptom relief after reoperation for (suspected) IH after LRYGB. However, many patients benefit from closure of the mesenteric defects, irrespective of perioperative presence of IH.

Correction to: Age-Related Effects of Bariatric Surgery on Early Atherosclerosis and Cardiovascular Risk Reduction.

Frederik H. W. Jonker and Vera A. A. van Houten contributed equally to this work.

Age-Related Effects of Bariatric Surgery on Early Atherosclerosis and Cardiovascular Risk Reduction.

BACKGROUND: Carotid intima-media thickness (CIMT) is increasingly used as a prognostic indicator for early atherosclerosis and the development of cardiovascular disease. The objective of this study is to assess the exact effects of bariatric surgery on CIMT reduction in different age groups. METHODS: CIMT was measured just proximal to the bifurcation of the carotid artery in 166 patients with mean body mass index of 43.4 kg/m2 before and at 6 and 12 months after bariatric surgery. Preoperative CIMT and Framingham Risk Score (FRS) were compared to measurements at 6 and 12 months, postoperatively. Impact of age on CIMT change and cardiovascular risk reduction was analyzed. RESULTS: Median follow-up was 12 months; 12% were lost to follow-up. Mean CIMT values at 12 months after bariatric surgery were significantly lower compared to baseline (0.619 vs. 0.587 mm, p = 0.005 in women and 0.675 vs. 0.622 mm, p = 0.037 in men, respectively), and these effects were statistically significant in all age groups. The mean reduction of CIMT for patients < 50 years at 12 months was 0.043 mm (- 7.0%), while CIMT was reduced with 0.013 mm for patients ≥ 50 years (- 1.9%, p = 0.022). At 12 months after bariatric surgery, FRS had decreased with 52% in patients < 50 years as compared with 35% in patients ≥ 50 years (p = 0.025). CONCLUSIONS: Bariatric surgery resulted in a significant CIMT decrease in patients with morbid obesity in all evaluated age categories. These beneficial effects of bariatric surgery were more pronounced in younger patients, while cardiovascular risk reduction by bariatric surgery appeared inferior in patients of 50 years and older.

Impact of initial response of laparoscopic adjustable gastric banding on outcomes of revisional laparoscopic Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: Failed laparoscopic adjustable gastric banding (LAGB) can be converted to laparoscopic Roux-and-Y gastric bypass (LRYGB), which is currently the gold standard for bariatric surgery. Revisional LRYGB (rLRYGB) is associated with inferior results compared with primary LRYGB (pLRYGB), but the exact influence of the initial response to LAGB is unclear. OBJECTIVES: To compare follow-up outcomes after pLRYGB with rLRYGB in nonresponders of LAGB and rLRYGB in responders of LAGB. SETTING: General-community teaching hospital, Rotterdam, the Netherlands. METHODS: All patients who underwent pLRYGB and rLRYGB after LAGB were reviewed in an observational study. Postoperative outcomes, excess weight loss, total weight loss, and success and failure rate were compared in patients after pLRYGB and rLRYGB (both responders and nonresponders of LAGB) at 12, 24, and 36 months. RESULTS: A total of 1285 primary patients, 96 nonresponders, and 120 responders were included. The median follow-up was 33.9±18.0 months. After 36 months, the mean percentage excess weight loss was significantly lower in the nonresponding group compared with the responding and primary groups (48.1% versus 58.2% versus 72.8%, P<.001); the total weight loss showed the same trend. The success rate was 38.2% versus 61.0% versus 81.6% respectively, P<.001. The failure rate was significantly higher after rLRYGB compared with pLRYGB (10.9% nonresponders, 8.5% responders, and 2.5% primary, P = .001). CONCLUSION: Nonresponders of LAGB show inferior weight loss results after rLRYGB compared with responders of LAGB and pLRYGB at all moments of follow-up.