Predictors of weight loss after bariatric surgery-a cross-disciplinary approach combining physiological, social, and psychological measures.

BACKGROUND: Bariatric surgery leads to a substantial weight loss (WL), however, a subset of patients undergoing surgery fails to achieve adequate WL. The reason for the individual variation in WL remains unexplained. Using an exploratory cross-disciplinary approach, we aimed to identify preoperative and early postoperative factors explaining the variation in WL after bariatric surgery. METHODS: Sixty-one subjects were recruited. Eighteen subjects did not receive surgery and three subjects dropped out, leaving a total sample of 40 subjects. Physiological, social, and psychological data were collected before and 6 months after surgery. All variables were analyzed in combination using a least absolute shrinkage and selection operator (LASSO) regression to explain the variation in WL 18 months after Roux-en-Y gastric bypass (n = 30) and sleeve gastrectomy (n = 10). RESULTS: Mean WL was 31% (range: 10-52%). The following preoperative factors predicted 59% of the variation in WL: type of surgery (14%), diabetes status (12%), economic resources (9%), sex (7%), binge eating disorder (7%), degree of depression (5%), household type (3%), and physical activity (1%). Including information on early responses after surgery increased the ability to predict WL to 78% and was explained by early WL (47%), changes in energy density of food consumed from a buffet meal (9%), changes in glicentin (5%), degree of depression (5%), sex (5%), type of surgery (2%), economic resources (2%), and changes in drive for thinness (1%). CONCLUSIONS: Using a cross-disciplinary approach, a substantial part of the individual variation in WL was explained by a combination of basic patient characteristics, psychological profile, and social conditions as well as physiological, psychological and behavioral responses to surgery. These results suggest that patient characteristics collected in a cross-disciplinary approach may help determine predictors for less successful WL after bariatric surgery. If verified in larger cohorts this may form the basis for individualized postoperative support to optimize WL outcome.

Patient profiling for success after weight loss surgery (GO Bypass study): An interdisciplinary study protocol.

Despite substantial research efforts, the mechanisms proposed to explain weight loss after gastric bypass (RYGB) and sleeve gastrectomy (SL) do not explain the large individual variation seen after these treatments. A complex set of factors are involved in the onset and development of obesity and these may also be relevant for the understanding of why success with treatments vary considerably between individuals. This calls for explanatory models that take into account not only biological determinants but also behavioral, affective and contextual factors. In this prospective study, we recruited 47 women and 8 men, aged 25-56 years old, with a BMI of 45.8 ±â€¯7.1 kg/m2 from the waiting list for RYGB and SL at Køge hospital, Denmark. Pre-surgery and 1.5, 6 and 18 months after surgery we assessed various endpoints spanning multiple domains. Endpoints were selected on basis of previous studies and include: physiological measures: anthropometrics, vital signs, biochemical measures and appetite hormones, genetics, gut microbiota, appetite sensation, food and taste preferences, neural sensitivity, sensory perception and movement behaviors; psychological measures: general psychiatric symptom-load, depression, eating disorders, ADHD, personality disorder, impulsivity, emotion regulation, attachment pattern, general self-efficacy, alexithymia, internalization of weight bias, addiction, quality of life and trauma; and sociological and anthropological measures: sociodemographic measures, eating behavior, weight control practices and psycho-social factors.Joining these many endpoints and methodologies from different scientific disciplines and creating a multi-dimensional predictive model has not previously been attempted. Data on the primary endpoint are expected to be published in 2018. TRIAL REGISTRATION: Clinicaltrials. gov ID NCT02070081.

The IGF-Axis and Diabetic Retinopathy Before and After Gastric Bypass Surgery.

BACKGROUND: Laparoscopic gastric bypass (LGB) abruptly causes remission of type 2 diabetes (T2D). Such dramatic metabolic changes have previously been found to cause worsening of diabetic retinopathy (DR) and circulating insulin-like growth factor I (IGF-I) has been suggested as a causal mediator. We aimed to evaluate baseline imbalances in the circulating IGF-system and changes after LGB in patients with T2D. METHODS: Prospective ocular examinations and measurement of the IGF-axis before and 3 and 12 months after LGB. IGF-bioactivity was measured by cell-based IGF-I receptor (IGF-IR) kinase activation assay (bioactive IGF). Total IGF-I, IGF-II and IGF binding protein (IGFBP) 1 and 3 were determined by immunoassays. RESULTS: At baseline, 18 of 36 patients presented with DR. These patients had higher levels of bioactive IGF (p = 0.03) than patients without DR and this association was strengthened in multivariate analysis (p = 0.006). Three patients had worsening of DR, unrelated to other markers. In univariate analysis, bioactive IGF increased at 3 months (p = 0.05) but this change became insignificant in multivariate analysis (p = 0.11). IGFBP-1 increased whereas IGFBP-3 and total IGF-II decreased at the two postoperative visits (p ≤ 0.001). Total IGF-I showed no significant changes. HbA1c, glucose, HOMA-IR and lipids improved after surgery. Two patients did not complete the 12-month visit. CONCLUSIONS: In obese T2D patients, bioactive IGF is a potential biomarker for DR and levels tended to increase 3 months after bariatric surgery. IGFBP-1 increased while IGFBP-3 and total IGF-II decreased postoperatively, but these changes were unassociated with the development of DR. Markers of the metabolic syndrome improved.

Hepatic mitochondrial oxidative phosphorylation is normal in obese patients with and without type 2 diabetes.

KEY POINTS: Hepatic insulin resistance in patients with obesity or type 2 diabetes has been suggested to result from hepatic mitochondrial dysfunction. High-resolution respirometry (HRR) can be used to assess oxidative phosphorylation by measuring the mitochondrial oxygen consumption rate in the individual complexes of the mitochondria. By using HRR, the present study demonstrates no difference in hepatic mitochondrial oxidative phosphorylation among subjects with obesity with or without type 2 diabetes and non-obese controls. Furthermore, the amount of mitochondria, assessed by the citrate synthase activity, is not different between the three groups. Together the present findings indicate that hepatic mitochondrial oxidative phosphorylation capacity is not impaired in patients with obesity or type 2 diabetes. ABSTRACT: Obese patients with type 2 diabetes (T2DM) and without type 2 diabetes (OB) are characterized by high hepatic lipid content and hepatic insulin resistance. This may be linked to impaired hepatic mitochondrial oxidative phosphorylation (OXPHOS) capacity. The aim of the present study was to investigate and compare hepatic mitochondrial OXPHOS capacity in T2DM, OB and non-obese controls (CON). Seventeen obese patients (nine OB and eight T2DM) and six CON patients had perioperative liver biopsies taken. Samples were divided into three parts to measure (1) complex I, II and IV linked respiration, (2) citrate synthase (CS) activity and (3) lipid droplet (LD) size and area (% of total tissue area filled by LDs). State 3 respiration of complex I, II and IV and the CS activity did not differ in OB, T2DM and CON. LD size was significantly higher in T2DM compared with CON, and LD area tended (P = 0.10) to be higher in T2DM and OB compared with CON. The present findings indicate that hepatic OXPHOS capacity is not different in patients with markedly different weight and glycaemic control. Furthermore, the results do not support impaired hepatic mitochondrial respiratory capacity playing a major role in the development of obesity-induced type 2 diabetes.

Internal herniation after laparoscopic antecolic Roux-en-Y gastric bypass: a nationwide Danish study based on the Danish National Patient Register.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most common surgical treatment for morbid obesity in Denmark. Internal herniation (IH) or intermittent internal herniation (IIH) is a major late complication after LRYGB due to persistent mesenteric defects. However, the incidence of IH/IIH is still not known in Denmark. OBJECTIVES: The primary aim of the study was to assess the incidence of IH/IIH after LRYGB performed in the period between 2006 and 2011 with a follow-up until 2013, where mesenteric defects were not routinely closed during the primary operation. SETTING: Department of Bariatric Surgery, Koege University Hospital, Denmark METHODS: We performed a retrospective nationwide analysis of prospectively collected data from all patients with LRYGB performed in Denmark from 2006 to 2011 based on the Danish National Patient Registry (NPR). From January 2006 to December 2011, 12,221 patients underwent an LRYGB procedure in Denmark. Relevant data from all 12,221 patients were retrieved from the NPR during the follow-up period from January 2006 to May 2013; we registered possible subsequent abdominal operations in these patients. RESULTS: Operations were performed on 398 patients because of suspected IH/IIH; 383 of these patients had IH/IIH (3.1%; 95% CI 2.8-3.5). The estimate for the 5-year cumulative incidence of clinically significant cases with IH/IIH was 4%. The median time interval until the onset of IH/IIH after LRYGB was 15 months (range 0-67 months) in a follow-up period with a median of 38 months (range 16-87 months). CONCLUSION: In the period from 2006 to 2011, mesenteric defects were not routinely closed during LRYGB in Denmark. The cumulative 5-year incidence of IH/IIH after LRYGB was 4% in a median follow-up period of 38 months (range 16-87) in Denmark when data was retrieved from the NPR.

Monitoring of Diabetic Retinopathy in relation to Bariatric Surgery: a Prospective Observational Study.

BACKGROUND: To investigate the need for closer perioperative monitoring of diabetic retinopathy in patients with type 2 diabetes undergoing bariatric surgery. METHODS: Prospective observational clinical study of 56 patients with type 2 diabetes undergoing bariatric surgery. The patients were examined with 7-field fundus images and optical coherence tomography scans 2 weeks before and 1, 3, 6 and 12 months after bariatric surgery. Worsening was defined as a two-step change in the Wisconsin Epidemiologic Study of Diabetic Retinopathy scale or appearance or worsening of macular edema. Postoperative changes were analyzed in a mixed model. RESULTS: Six patients (11 %) had any worsening at any visit, and three (5 %) persisted at 1 year. Of the 24 patients with preoperative retinopathy, 4-13 % worsened and 9-22 % improved, with significant overall improvement at 6 months (p = 0.01). Only one (3%) of the 32 patients without preoperative diabetic retinopathy had a transient worsening at 6 months. No patients developed macular edema, but the whole cohort had a minor increase in center point foveal thickness that peaked 6 months postoperatively. The patients were required to have good glucose control preoperatively where HbA1c was 6.4 ± 1.9 %. CONCLUSIONS: Diabetic retinopathy was clinically stable after bariatric surgery, and none of the observed changes would have resulted in a changed screening interval at our center. This supports adherence to regular diabetic retinopathy screening guidelines following bariatric surgery in well-controlled patients. A clinically negligible but statistically significant foveal thickening 6 months postoperatively warrants further study.

Preoperative ß-cell function in patients with type 2 diabetes is important for the outcome of Roux-en-Y gastric bypass surgery.

The majority of the patients with type 2 diabetes (T2DM) show remission after Roux-en-Y gastric bypass (RYGB). This is the result of increased postoperative insulin sensitivity and ß-cell secretion. The aim of the present study was to elucidate the importance of the preoperative ß-cell function in T2DM for the chance of remission after RYGB. Fifteen patients with and 18 without T2DM had 25 g oral (OGTT) and intravenous (IVGTT) glucose tolerance tests performed at inclusion, after a diet-induced weight loss, and 4 and 18 months after RYGB. Postoperative first phase insulin secretion rate (ISR) during the IVGTT and ß-cell glucose sensitivity during the OGTT increased in T2DM. Postoperative insulin sensitivity and the disposition index (DI) markedly increased in both groups. By stratifying the T2DM into two groups according to highest (T2DMhigh ) and lowest (T2DMlow ) baseline DI, a restoration of first phase ISR and ß-cell glucose sensitivity were seen only in T2DMhigh . Remission of type 2 diabetes was 71 and 38% in T2DMhigh and T2DMlow , respectively. Postoperative postprandial GLP-1 concentrations increased markedly, but did not differ between the groups. Our findings emphasize the importance of the preoperative of ß-cell function for remission of diabetes after RYGB.

Does the closure of mesenteric defects during laparoscopic gastric bypass surgery cause complications?

BACKGROUND: A well-known complication of laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) is bowel obstruction due to internal herniation (IH). Evidence suggests that mesenteric defects should be closed during LRYGB to reduce the risk of IH. Therefore, surgeons are now closing mesenteric defects during LRYGB using sutures, clips, or fibrin glue. However, it has been reported that complications may arise due to the closure of mesenteric defects. The aim of this review was to summarize the reported possible complications associated with the closure of mesenteric defects during LRYGB. METHODS: A literature search of PubMed and EMBASE was performed to identify studies related to the closure of mesenteric defects during LRYGB. The studies were screened for the listing of possible complications associated with the closure of mesenteric defects. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. RESULTS: Thirty studies complied with the inclusion criteria for our analysis, which included 21,789 patients. Reported complications related to closure of the mesenteric defects were: small bowel obstruction because of IH, kinking, and adhesions. IH occurred because of incomplete closure of the mesenteric defects in 1.4% of all patients, 1.2% by the antecolic approach, and 1.9% by the retrocolic approach, respectively. Kinking of the small bowel occurred in .2% of 1630 patients after closure of the mesenteric defects with clips and adhesion formation was found among 4.6% of 152 patients after closure of the mesenteric defects with nonabsorbable sutures. CONCLUSIONS: The reported risk of complications caused by closure of the mesenteric defects during LRYGB seems low.

Effect of closure of the mesenteric defect during laparoscopic gastric bypass and prevention of internal hernia.

INTRODUCTION: The aim of this study is to evaluate the benefits and disadvantages of closing the mesenteric defects during gastric bypass to avoid internal herniation (IH). MATERIAL AND METHODS: The study is performed as a single-centre, randomised, controlled, blinded trial. Patients are randomly assigned to either conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) without closing the mesenteric defects (n = 250) or RYGB with closing of the defects with hernia clips (n = 250). Follow-up is conducted at six months, one year, two years and five years after RYGB. The primary endpoint is the incidence of IH. CONCLUSION: This study will be the first Danish, randomised, controlled study comparing conventional LRYGB with and without closure of the mesenteric defects. The results will contribute to evidence-based recommendations for the prevention of IH. FUNDING: not relevant. TRIAL REGISTRATION: The study was registered with the Danish Data Protection Agency (SN-10-2012) and The Central Denmark Regional Committees on Biomedical Research Ethics (1-01-83-0209-12, SJ-284). The study is registered with clinicaltrials.gov: NCT01595230.

The clinical value of procalcitonin in early assessment of acute pancreatitis.

OBJECTIVES: Early assessment of the severity and the etiology is crucial in the management of acute pancreatitis. To determine the value of procalcitonin (PCT) as a prognostic marker and as an indicator of biliary etiology in the early phase of acute pancreatitis. METHODS: In a prospective study, 75 consecutive patients were included (severe pancreatitis in 12 patients, biliary etiology in 42 cases). The value of PCT as a prognostic marker was compared to C-reactive protein (CRP), hematocrit (HCT), acute physiology and chronic health evaluation (APACHE) II score, and Ranson score. The value of PCT as an indicator of biliary etiology was compared to alanine aminotransferase (ALT) and alkaline phosphatase (AP). The area under the receiver operating characteristic curve (AUC) was applied as a measure of the overall accuracy of the single markers and multiple scoring systems. RESULTS: The most accurate prediction of severe disease was provided by the APACHE II score on the day of admission (AUC: APACHE II, 0.78; CRP, 0.73; HCT, 0.73; and PCT, 0.61), and by CRP after 48 h (AUC: CRP, 0.94; Ranson score, 0.81; PCT, 0.71; APACHE II score, 0.69; and HCT, 0.46). ALT was the most accurate indicator of biliary pancreatitis (AUC: ALT, 0.83; AP, 0.81; and PCT, 0.68). CONCLUSIONS: PCT is of limited additional value for early assessment of severity and etiology in acute pancreatitis. CRP is found to be a reliable prognostic marker with a delay of 48 h, while ALT is validated as the best indicator of biliary etiology.