Reduced Need for In-hospital Care After Sleeve Gastrectomy: a Single Center Observational Study.

SETTING: Private clinic, Stockholm, and nation-wide in-hospital care, Sweden. OBJECTIVES: The use of sleeve gastrectomy (SG) for treatment of morbid obesity has increased worldwide, but information about long-term outcome is still limited. Our objective was to evaluate the need for additional in-hospital care after SG for obesity (body mass index [BMI] > 30) in 862 patients, all operated at a single center. METHODS: Two national registries, the Inpatient Registry and the Death Registry, were used to collect long-term data on in-hospital care, grouped by the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and mortality, respectively. RESULTS: In-hospital care for SG-operated females was decreased for four groups of obesity-related ICD-10 diagnoses: endocrine and metabolic diseases and circulatory, digestive, and genitourinary diseases, as well as injuries and poisoning (p < 0.001 for all). However, female SG patients still required in-hospital care above the national level for women of corresponding ages. CONCLUSIONS: Although a significant reduction in in-hospital care was observed, SG patients did not reach national levels.

Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT.

SUMMARY: Bariatric surgery (BS) is rated as the best evidence based treatment for obesity with regard to weight loss and maintenance of weight loss evaluated to date. Although BS interventions are effective, 20-30% of BS patients start to regain weight within 24 months. Emotional eating is a behavior pattern which has been found to predict poor outcome. The aim of this study is to evaluate the effects of acceptance and commitment therapy (ACT) for patients who underwent BS, with regard to emotional eating, body dissatisfaction and quality of life. This study is a randomized controlled trial (n = 39) with two conditions (1) ACT including two face-to-face sessions and support via an Internet application and (2) treatment as usual (TAU) comprising the standard follow-up used by the BS team. Results show that participants in the ACT condition significantly improve on eating disordered behaviors, body dissatisfaction, quality of life and acceptance for weight related thoughts and feelings, as compared to those in the TAU group. This study shows that it is possible to improve effects of BS by specifically targeting emotional eating behavior.:

Initial results with sleeve gastrectomy for patients with class I obesity (BMI 30-35 kg/m2).

BACKGROUND: To investigate the role of sleeve gastrectomy for patients with class I obesity (body mass index 30-35 kg/m(2)) at a private hospital with self-paying patients. Randomized trials have shown a benefit for bariatric surgery compared with conservative treatment in patients with class I obesity. Sleeve gastrectomy is a relatively new method that has not been previously evaluated in this group of patients. METHODS: We performed a prospective, consecutive, nonrandomized trial of 79 patients. This is the initial report of the first 23 patients with > or =6 months of follow-up. RESULTS: The patients lost, on average, 100% of their excess body mass index in the first 6 months for an average body mass index of 25 kg/m(2). Most co-morbidities had resolved or improved. Their quality of life was regarded as excellent or very good by most patients. Some complications occurred in the early phase of our series, but after adjusting our operative technique and the routines for venous thromboembolic prophylaxis, the complications were reduced. CONCLUSION: Sleeve gastrectomy results in a promising early weight loss and quality of life improvement in patients with class I obesity. However, additional studies of larger numbers of patients with longer follow-up are necessary before any firm conclusions can be drawn.

The acute and delayed effects of hydrostatic dilation on rat femoral arteries.

The technique of intraoperative vessel dilation is sometimes used to facilitate microvascular anastomosis and prevent vasospasm. Although this technique is not new, its application has not gained widespread acceptance mainly due to concerns raised about potential damage to the vessels acutely and during the postoperative period, leading to decreased vessel patency. The goal of this study was to determine the acute and delayed histologic effects of hydrostatic dilation on rat femoral arteries and to compare the response of dilated arteries to vasodilating and vasoconstricting agents. The femoral arteries in 22 rats were used in 2 experimental groups; 9 in the acute group and 13 in the delayed group. Six animals served as controls. After the vessels were exposed, a microcatheter was inserted into a segment of the vessel that had been isolated between 2 vessel clamps. Saline was infused into the artery until a pressure of 300 mm Hg was attained and then maintained for 60 seconds. In the acute group, the animals were euthanized at the end of the dilation, while in the delayed group the animals were euthanized 24 hours later. Hydrostatic dilation of rat femoral arteries was found to increased vessel diameter acutely, with subsequent relief and prevention of vasospasm during the ensuing 24 hours. Histologically, there was no increased damage of the vessel walls in the dilated vessels compared with control vessels. Based on the data reported in this study, hydrostatic dilation of rat microvessels appears to be safe and may be used to technically facilitate microanastomoses and decrease vasospasm.

Chronic heart allograft rejection in rats demonstrates a dynamic interplay between IFN-gamma and IL-10 producing T cells.

The relative roles of different types of T cells and their modes of alloantigen recognition and cytokine production in chronic rejection have been controversial. This may be due to the use of models involving various immune interventions. We recently reported a rat heart allograft model (PVG.1U-to-PVG.R8) that consistently develops chronic rejection without any immune manipulations. Using this model, we investigated the frequency of indirectly activated alloreactive CD4+ T cells and directly/indirectly induced CD8+ T cells and characterized their cytokine profiles at various times posttransplantation. In vitro quantitative-proliferative and intracellular cytokine assays were performed using recipient lymphocytes as responders against donor and third party stimulator cells. Intragraft transcript levels for IFN-gamma were measured using competitive RT-PCR. We observed a steady increase in the frequency of donor reactive CD4+ T cells, peaking on day 18-22 posttransplantation, followed by a decline to background levels on day 60. These cells produced high levels of IL-10 that steadily increased throughout the 100-day experimental period. In contrast, the frequency of donor reactive CD8+ T cells was similar to that of naïve cells and remained unchanged throughout the study. CD8+ T cells produced high amounts of IFN-gamma only on days 39-45 posttransplantation when chronic rejection was apparent. There was a sharp increase in intragraft IFN-gamma transcripts on days 8-12 that peaked on days 39-45 followed by a steady decrease thereafter. Our results demonstrate that chronic rejection in this model involves a dynamic interplay between alloreactive CD8+IFN-gamma+ and CD4+IL-10+ T cells, both of which may have differential effects on the pathogenesis of the disease.

Prevention of chronic rejection with immunoregulatory cells induced by intrathymic immune modulation with class I allopeptides.

Intrathymic immune modulation with RT1.Aa allopeptides in the PVG.R8-to-PVG.1 U rat strain combination leads to long-term survival of cardiac allografts. This regimen, however, does not induce transplantation tolerance, since most long-surviving allografts undergo chronic rejection. We investigated recipients with chronic rejection for donor-specific immune nonresponsiveness and immunoregulatory cells as possible mechanisms responsible for long-term graft survival. There was a significant reduction in the proliferative response of T cells from long-term allograft recipients to donor alloantigens as compared with that of naïve T cells. Adoptive transfer of splenocytes from intrathymically manipulated primary long-term graft survivors into minimally irradiated secondary hosts resulted in indefinite survival of > 80% of allografts, providing evidence for immunoregulatory cells. Secondary recipients had total absence of donor-reactive cellular and humoral responses. Immunoregulation was also transferable from secondary to tertiary graft recipients. More importantly, there was a significant reduction in the incidence of chronic rejection in secondary hosts (> 85%) and complete prevention of acute and chronic rejection in tertiary hosts. This study demonstrates that intrathymic immunomodulation with class I allopeptides results in the generation of immunoregulatory cells that do not block chronic rejection in primary hosts where they develop, but prevent both acute and chronic allograft rejection when adoptively transferred into secondary and tertiary recipients.

Composite tissue allotransplantation in chimeric hosts: part I. Prevention of graft-versus-host disease.

BACKGROUND: Mixed allogeneic chimerism (MAC) has been shown to induce tolerance to composite tissue allografts (CTA). However, transplantation of unmanipulated donor-specific limbs results in severe graft-versus-host disease (GVHD). This suggests that nontolerant mature donor-derived cells in the CTA may affect the stability of chimerism, potentially resulting in GVHD. The aim of this study was to develop an approach to study and prevent GVHD in a mixed chimeric-rat hind-limb transplantation model. METHODS: [ACI-->WF] chimeras received a limb from Wistar Furth (WF) (syngeneic), Fisher (third-party), or ACI (irradiated [1,050 cGy] or nonirradiated) rats. In vitro tolerance was assessed using mixed lymphocyte reactivity (MLR) assays at the time the animals were killed. RESULTS: [ACI-->WF] chimeras with greater than 85% chimerism exhibited rejection-free survival of donor-specific hind limbs. However, 100% of these animals developed lethal GVHD 22.4+/-2.8 days after limb transplantation. [ACI-->WF] chimeras that underwent transplantation with irradiated ACI or syngeneic WF limbs showed no signs of rejection or GVHD at 5 months. Nonchimeric and third-party controls rejected limbs within 10 days. CONCLUSIONS: Conditioning of the host WF rats with 950 cGy of irradiation (sublethal, myeloablative) led to high levels of MAC without GVHD. The mature T-cell content of nonirradiated donor (ACI) limbs was sufficient to induce lethal GVHD in 100% of tolerant mixed chimeric [ACI-->WF] hosts. Irradiation of donor limbs before transplantation resulted in long-term donor-specific tolerance and prevented GVHD. These data demonstrate that (1) established chimeras could be susceptible to GVHD caused by immunocompetent donor cells transferred with the hind limb, and (2) inactivating these cells with irradiation prevents GVHD and destabilization of chimerism, and permits rejection-free graft acceptance.

Predominant expression of the Th2 response in chronic cardiac allograft rejection.

Chronic rejection is the main cause of late allograft failure in patients. CD4+ T cells activated by indirect recognition of alloantigens are implicated in this rejection reaction. However, the type of T cell response (Th1 vs Th2) that contributes to chronic rejection has not been fully investigated. The purpose of this study is to examine whether chronic rejection is associated with a polarized T-cell response in a rat cardiac allograft model, where long-term graft survival is achieved by intrathymic immunomodulation with donor class I, RT1.Aa, allopeptides. All long-surviving allografts showed histological evidence of chronic rejection. Chronic rejection was associated with high levels of intragraft Th2 cytokines and the Th2-regulated alloantibodies. The Th2 response was systemic, since long-surviving allografts with chronic rejection had high levels of serum IL-10. The predominance of the Th2 cytokines demonstrates that the Th2 response was not sufficient for the prevention of chronic rejection in this model. The predominant expression of Th2 cytokines, together with the presence of Th2-regulated alloantibodies, suggests that the Th2 response may play a role in the development of chronic rejection.