Metabolic effects and outcomes of sleeve gastrectomy and gastric bypass: a cohort study.

BACKGROUND: The outcomes of bariatric surgery should not be evaluated only for weight loss purposes but from a wider point of view that is closer to the reality of morbidly obese patients. The study of the influence of bariatric surgery over obesity-related diseases in bariatric patients is worthwhile. METHODS: We present a cohort study of 329 patients who underwent either laparoscopic sleeve gastrectomy (LSG: 165 patients) or laparoscopic gastric bypass (LRYGBP: 164). We analyzed complication rate, comorbidities and weight loss evolution. RESULTS: Both groups were comparable in demographic characteristics at baseline. Significant statistical differences were found in length of hospital stay and operative time (both were lower in the LSG group). Bleeding and wound infection were higher in the LRYGBP group, as it happened with intestinal occlusion as a late complication (p < 0.05). After a 5-year follow-up, the percentage of excess weight loss (%EWL) was higher in gastric bypass than sleeve gastrectomy (p = 0.01) but there was no statistical difference in percentage of total weight loss (%TWL) (p = 0.2). The resolution of comorbidities was similar in both groups except for dyslipidemia, which resolution was significantly higher in the gastric bypass group (p = 0.005). Metabolic syndrome (MeTS) resolution was similar in both groups. CONCLUSIONS: Sleeve gastrectomy and gastric bypass achieve similar outcomes in hypertension, type 2 diabetes, obstructive sleep apnea and MeTS resolution even when there is weight regain. Although gastric bypass achieves higher weight loss in morbid obese patients, complication rates are also higher compared to those of sleeve gastrectomy. Thus, the appropriate procedure should be tailored based on patient factors and comorbidities, but also on surgeon comfort level and experience.

Metabolic syndrome after bariatric surgery. Results depending on the technique performed.

BACKGROUND: There is a lack of long-term studies for metabolic syndrome after bariatric surgery. Our aim is to show the evolution of the parameters that define the metabolic syndrome after bariatric surgery, up to 10 years of follow-up, in order to clarify what technique gets better results with fewer complications. METHODS: The IDF definition of the metabolic syndrome was used for this study. One hundred twenty-five morbid obese and superobese patients underwent vertical banded gastroplasty. Two hundred sixty-five morbid obese and superobese patients had biliopancreatic diversion (Scopinaro and modified biliopancreatic diversions), and 152 morbid obese patients underwent laparoscopic gastric bypass. A mean follow-up of up to 7 years was done in all groups. RESULTS: Prior to surgery, metabolic syndrome was diagnosed in 114 patients of Scopinaro group (76%), in 85 patients of modified biliopancreatic diversion group (73.9%), in 81 patients of laparoscopic gastric bypass (53.4%), and in 98 patients of vertical banded gastroplasty (78.4%). When metabolic syndrome parameters were evaluated at 7 years of follow-up, owing to weight gain, these results changed nearby to preoperative values in both laparoscopic gastric bypass and vertical banded gastroplasty groups. CONCLUSION: According to our results, the best technique to resolve metabolic syndrome is the modified biliopancreatic diversion. Due to its high morbidity, it only must be considered in superobese patients. In obese patients, the laparoscopic gastric bypass may be a less agressive choice, but it should be coupled with lifestyle changes to keep away from the weight gain in the long run. Restrictive procedures may be indicated only in a few well-selected cases.

Obesity surgery results depending on technique performed: long-term outcome.

BACKGROUND: Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. METHODS: This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). RESULTS: One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. CONCLUSIONS: The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75-225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m(2)), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.

Circannual variation in human semen parameters.

The aim of the present study was to determine whether there were significant monthly variations in the semen parameters (i.e. volume, sperm count, total sperm count, motile and normal sperm count) of men living in a Mediterranean climate area. A total of 10 877 semen analysis results were included. Semen samples were obtained as a part of an initial screening of male partners from couples with infertility problems who were attending our laboratory from 1970 to 2000. Log transformation and cubic root transformation were used to test the sample distribution. Statistical significance was adjusted by year of examination, patient's age and sexual abstinence period by performing covariance analyses. Differences between months were assessed with the Bonferroni post-hoc test. There was an increase in March and a decrease in September in the adjusted mean sperm count (p < 0.0005), total sperm count (p < 0.0005), motile sperm count (p=0.01) and normal sperm count (p=0.002). There were no variations in semen volume in the study period. Monthly changes in semen quality are confirmed in this population.

Evolution of semen quality in North-eastern Spain: a study in 22,759 infertile men over a 36 year period.

A retrospective study was conducted in a large population to determine whether sperm quality has changed in Northeastern Spain between 1960 and 1996. From a total initial population of 22,759 men, two separate groups were studied: men with spermatozoa (n = 20,411) and those with azoospermia (n = 1364). After adjustment for age and sexual abstinence, multiple linear regression analyses were used to assess changes in semen parameters over time. A 0.2% decline was observed in semen volume in the spermatozoa group (P < 0.001). No significant increase (0.04%) in sperm count (x 10(6)/ml) was observed in the spermatozoa group. There was a 0.4% increase in motile spermatozoa in the spermatozoa group (P < 0.001). There was a statistically significant decline in normal spermatozoa (3.6%) in the spermatozoa group (P < 0.001). Of the total population, 1364 men had azoospermia (6.0%). The changes observed in the semen parameters analysed in this large population showed no evidence of a deteriorating sperm quality, although a statistically significant decline was observed in the percentage of normal spermatozoa.

Effect of oocyte-sperm co-incubation on acrosome reaction in the goat.

The induction of acrosome reaction of goat spermatozoa was investigated. The acrosomal status of spermatozoa was determined by a triple-staining technique. The effect of the presence of goat oocytes on the proportion of acrosome-reacted spermatozoa was also determined. Ovulated oocytes were obtained from superstimulated adult goats. Other sources of oocytes were adult and prepubertal goats; oocytes from both sources were maturated in vitro. There was an increase in the percentage of acrosome-reacted spermatozoa from 4% +/- 0.98 to 9% +/- 1.41 when oocytes from adult females were used. Similar induction rates were measured with prepubertal and adult oocytes maturated in vitro (10.4% +/- 2.06 and 8.75% +/- 1.06, respectively). The influence of several qualities of cumulus oophorus as well as the presence of zona pellucida was also investigated. No significant differences were obtained with any cumulus oophorus or zona pellucida oocyte complexes. Although oocyte quality is important for high fertilization rates, it does not seem to be crucial for the induction of acrosome reaction.

Which semen parameters have a predictive value for pregnancy in infertile couples?

A prospective study was carried out in 156 couples attending an infertility clinic. To assess the predictive value of semen parameters in relation to pregnancy, we defined a group of 16 couples (group II) in whom the female became pregnant by intra-uterine insemination (IUI), and therefore in whom a female factor could be ruled out. Studies of semen parameters before and after capacitation were carried out in the first trimester of pregnancy (< 12 weeks). The same studies were done in the remaining 140 men (group III) with primary infertility and then all results were compared with a control group of 27 healthy, fertile men (group I), with normal semen parameters. Our results showed that progressive motility and straight line velocity were significantly lower in group III compared with group II: 33.4 and 45.2% respectively (P < 0.001) for progressive motility, and 25.7 and 32.8% respectively (P < 0.005) for straight line velocity. Acrosome alterations, on the other hand, were significantly more frequent in group III compared with group II: 21.4 +/- 0.7 and 5.9 +/- 1.7 respectively (P < 0.003). After capacitation, the recovery in terms of numbers of motile spermatozoa, spermatozoa with normal morphology and acrosome-reacted spermatozoa could be a predictive parameter of fertilization, because all were significantly decreased in group III compared with group II (P < 0.01).

Characterization of monoclonal antibodies specific for human sperm: effect of CRL-10 on acrosome reaction.

Monoclonal antibodies to human sperm were obtained from hyperimmunized BALB/c mouse spleen cells fused with myeloma NS-1 cells. Each antibody recognized definite regions in fresh unfixed sperm: equatorial region, acrosome, postacrosome, midpiece, tail. All the antibodies were specific for sperm. We selected CRL-10 monoclonal antibody, specific for acrosome, for a detailed study. The expression of the CRL-10 antibody-bound antigen was detected in other mammalian species. When CRL-10 antibody was added prior to sperm incubation in a capacitating medium, promotion of the acrosome reaction was observed.

Detection of induced anti-sperm antibodies by an improved enzyme-linked immunosorbent assay.

The enzyme-linked immunosorbent assay (ELISA) has been adapted for the detection of human anti-sperm antibodies (ASA). The use of peroxidase in the enzyme-anti-immunoglobulin conjugate, together with a nontoxic chromogenic substrate (MBTH-DMAB), renders the assay highly sensitive for detection of sperm surface antigens. This ELISA is highly reproducible, not only intra-assay (94% to 97%) but also interassay (80% to 96%). A great advantage of this ELISA is that microplates can be kept at -20 degrees C for months without any decrease in the response. New Zealand white rabbits showed a significant response to human sperm and tail fractions obtained by sonication. The sperm were extremely immunogenic, reaching titers of antisera of 1/10,000 or more. The results show that this ELISA is a good tool for the objective measurement of the anti-sperm response, and is significantly more sensitive than other techniques for anti-sperm antibody analysis.

Detection of anti-sperm antibodies in serum, seminal plasma and cervical mucus by the immunobead test.

Anti-sperm antibodies in serum and seminal plasma were detected by means of an indirect immunobead test (IBT). Immunobeads with separate specificites for each immunoglobulin class (IBT-IgG, IBT-IgM, and IBT-IgA) were used. Semen parameters were controlled in all sperm donors and Biggers-Whitten-Whittingham (BWW) medium supplemented with human serum albumin (HSA) was used to increase sperm motility. This technique was tested with high titre anti-human sperm sera induced in rabbits. Sperm tails showed a good response by IBT. We included in this study 178 men and 35 women evaluated for infertility and the sera were also tested by the Tray Agglutination Test (TAT). Although the presence of semen markers such as agglutination or trembling of spermatozoa is meaningful even by itself, the percentage of anti-sperm antibodies was increased in the patients with markers, both using IBT (21.4%) and using TAT (35.7%). At high titres of specific immunoglobulins (rabbit antisera and vasectomized men), the correlation between IBT and TAT techniques was better than in sera with very low titres, in which more positive TAT's were detected.

Improvement of sperm quality in abnormal semen samples using a modified swim-up procedure.

A modified swim-up procedure for the selection of motile and morphologically normal spermatozoa is described. Applied to abnormal (astheno and asthenoterato) semen samples, the recovery figures are comparable to those obtained by other authors in normal samples. The elimination of seminal plasma from the beginning of the procedure avoids contact of spermatozoa with decapacitating factors.