Partial remission of Type 2 diabetes and changes in quality of life after gastric bypass.

INTRODUCTION: The prevalence of severe obesity is increasing and highly associated with co-morbidities such as Type 2 diabetes (T2D). Furthermore, quality of life (QoL) is negatively affected among patients with severe obesity and T2D. Studies have found that gastric bypass surgery may lead to remission of T2D and improved QoL. The aim of this study was to investigate the association between partial remission of T2D and change in QoL from baseline to a one-year follow-up in severely obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: This cohort study was based on data from patients with T2D undergoing LRYGB at a private hospital in Denmark and included 704 patients among whom 337 (48%) patients with T2D contributed with data in the analysis. Data were collected preoperatively and at a one-year follow-up. Preoperative T2D status was patient-reported and validated through the patient's medical record. At the one-year follow-up, partial remission was defined as an HbA1c concentration less than 7.3% with no use of antidiabetics. Continued T2D was defined as intake of diabetic medication or an HbA1c concentration > 7.3%. QoL was measured by the Moorehead-Ardelt QoL Questionnaire. Multiple linear regression was applied. RESULTS: At the one-year follow-up, the prevalence of partial remission of T2D was 72.7%. No significant association was seen between partial remission of T2D after LRYGB and change in QoL one year later. Loss to follow-up was 35.8%. CONCLUSIONS: The majority of patients with T2D experienced partial remission one year after undergoing LRYGB surgery. However, partial remission of T2D was not associated with an improved QoL. FUNDING: none. TRIAL REGISTRATION: not relevant.

The Association Between Weight Loss and Quality of Life 1 and 5 Years After Laparoscopic Roux-en-Y Gastric Bypass in Danish Bariatric Patients.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is effective to achieve significant weight loss, as well as improvement of comorbidity and quality of life (QoL) in obese patients. Several studies have examined whether weight loss can predict the change in QoL after LRYGB but results vary and follow-up is short. The aim of this study was to examine the association between weight loss and change in QoL at 1- and 5-year follow-up after LRYGB. METHODS: The study was a cohort study with 1- and 5-year follow-up, based on data consecutively recorded at the Private Hospital Mølholm, Denmark. Before LRYGB (baseline), 3371 severely obese patients filled in the questionnaire that included information on weight and QoL. The patients were invited to fill in a similar questionnaire at 1- and at 5-year follow-up. The response rate at 1 and 5 years was 71 and 63%, respectively. RESULTS: Among the respondents, there was a positive, significant association between weight loss and change in QoL at both 1- and 5-year follow-up after LRYGB. Weight loss and change in QoL peaked after 1 year but remained significantly different from baseline at 5-year follow-up. CONCLUSION: This study showed that weight loss after LRYGB predicts the change in QoL of patients 1 and 5 years after surgery. Furthermore, both weight loss and change in QoL peaked after 1 year but remained significant at 5-year follow-up.

Difficult Tracheal Intubation in Obese Gastric Bypass patients.

BACKGROUND: Endotracheal intubation is commonly perceived to be more difficult in obese patients than in lean patients. Primarily, we investigated the association between difficult tracheal intubation (DTI) and obesity, and secondarily, the association between DTI and validated scoring systems used to assess the airways, the association between DTI and quantities of anesthetics used to induce general anesthesia, and the association between DTI and difficulties with venous and arterial cannulation. METHODS: This is a monocentric prospective observational clinical study of a consecutive series of 539 obese patients undergoing gastric bypass. Tracheal intubation was done preoperatively together with scoring of Intubation Score (IS), Mallampati (MLP), and Cormack-Lehane classification (CLC) and registration of the quantities of anesthetics and total attempts on cannulation. RESULTS: The overall proportion of patients with DTI was 3.5 % and the patients with DTI were more frequently males, had higher CLC, higher American Society of Anesthesiologists physical status classification (ASA), and noticeably, a lower BMI compared to the patients with easy tracheal intubation. After adjustment with multivariable analyses body mass index (BMI) <40, CLC >2, ASA scores >2, and male gender were risk factors of DTI. Males generally had higher CLC, MLP, and ASA scores compared to females, but no difference in BMI. There was no difference in quantities of anesthetics used between the two groups with or without DTI. Intra-venous and intra-arterial cannulation was succeeded in first attempt in 85 and 86 % of the patients, respectively, and there were no association between BMI and difficult vascular access. CONCLUSIONS: We found no association between increasing BMI and DTI.

The Association Between Preoperative Symptoms of Obesity in Knee and Hip Joints and the Change in Quality of Life After Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: Weight loss after bariatric surgery is shown to reduce knee and hip pain in the majority of the severely obese. Studies indicate that with a reduction in musculoskeletal symptoms, quality of life (QoL) will improve. The group of severely obese with knee and hip symptoms might therefore have potential for a large improvement in QoL after a bariatric surgery. This study aimed therefore to assess the association between the degree of knee and hip symptoms before a laparoscopic Roux-en-Y gastric bypass (LRYGB) and the improvement of QoL, 1 year after the surgery, in severely obese. METHODS: This study is a historical cohort study based on data collected consecutively at the private hospital Mølholm, Denmark. Before LRYGB surgery, 4548 severely obese completed a questionnaire on knee and hip symptoms of obesity and QoL. One year after surgery, 2862 (62.9 %) of the participants answered the same questionnaire again. RESULTS: Participants with moderate or severe knee or hip symptoms, before the surgery, experienced a statistically significantly larger improvement of their QoL, compared to participants without symptoms before the surgery. Furthermore, an association between the reduction of knee and hip symptoms and the improvement in QoL was found. CONCLUSIONS: Severely obese with moderate or severe preoperative knee and hip symptoms experienced a larger improvement of their QoL after a LRYGB compared to participants without symptoms before the operation.

Eliminating learning curve-related morbidity in fast track laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is associated with a significant learning curve. We report the results of a systematic training program from a high-volume bariatric center measuring the outcome by comparing the results with data from a consecutive series of 1000 fast-track LRYGB. METHODS: Using a stepwise training program, the Roux-en-Y gastric bypass operation was divided into an upper and lower procedure and subdivided into 11 well-defined steps. A laparoscopic surgeon without experience in upper-gastrointestinal surgery was mentored by an experienced bariatric surgeon. During 6-month full-time fellowship, 300 operations were performed. RESULTS: The trainee surgeon performed 61 upper procedures and 121 lower procedures in which the mentor surgeon did the other part of the operation. In 110 patients, the trainee performed both procedures. Two percent had perioperative complications compared with 1% of 1000 patients. All were repaired and had an uneventful recovery. Two percent had postoperative complications <30 days compared with 2.8% in the clinic. In the trainees series, there were no leaks compared with 1% in 1000 patients. Operative time was 56/55/70 minutes for operation 0-100/100-200/200-300 compared with an average of 47 minutes registered in the clinic. Concerning time to discharge, there was no difference between patients operated by the trainee and the standard of the clinic. CONCLUSION: Using a systematic training program in LRYGB surgery eliminates morbidity of the learning curve without affecting the volume.

Circulating levels of insulin-like growth factor-II/mannose-6-phosphate receptor in obesity and type 2 diabetes.

OBJECTIVE: The extracellular domain of the insulin-like growth factor II/mannose-6-phosphate receptor (IGF-II/M6P-R) is present in the circulation, but its relationship with plasma IGF-II is largely unknown. As IGF-II appears to be nutritionally regulated, we studied the impact of obesity, type 2 diabetes (T2D) and weight loss on circulating levels of IGF-II and its soluble receptor. METHODS: Twenty-three morbidly obese non-diabetic subjects were studied before and after gastric banding (GB), reducing their BMI from 59.3+/-1.8 to 52.7+/-1.6 kg/m(2). Lean controls (n=10, BMI 24.2+/-0.5 kg/m(2)), moderately obese controls (n=21, BMI 31.8+/-1.0 kg/m(2)) and obese T2D patients (n=20, BMI 32.3+/-0.8 kg/m(2)) were studied before and after a hyperinsulinaemic euglycaemic clamp. RESULTS: Morbidly obese subjects had elevated IGF-II/M6P-R and IGF-II levels, which both decreased following GB (IGF-II/M6P-R: from 0.97+/-0.038 to 0.87+/-0.030 nmol/l, P=0.001; IGF-II: from 134+/-7 to 125+/-6 nmol/l, P=0.01), as did fasting plasma glucose and insulin (P<0.05). However, the metabolic parameters correlated with neither IGF-II nor IGF-II/M6P-R. Obese diabetics had increased IGF-II/M6P-R as compared with lean and obese controls (0.82+/-0.031 vs. 0.70+/-0.033 vs. 0.74+/-0.026 nmol/l; P<0.03) and levels were unaffected by clamp. In the latter cohort, IGF-II/M6P-R but not IGF-II correlated with HbA1c, and fasting plasma C-peptide, insulin and glucose (0.34

Weight loss after gastric banding is associated with pouch pressure and not pouch emptying rate.

BACKGROUND: Morbid obesity defined as BMI > 40 is a growing problem. It is primarily treated with diet, lifestyle changes, and medicine. However, at present, surgery remains the only effective option for the management. METHODS: Seventeen patients were studied 2 months after laparoscopic gastric banding. The aims were to evaluate the association between (1) the extent of pouch filling and satiety, (2) gastric emptying and weight loss, and (3) the pouch pressure during a meal and the sensation of satiety and weight loss. RESULTS: The preoperative weight was 146 kg (range 108-202 kg). The average weight loss was 21 kg between the banding and the examination. The half time (T (50%)) for the pouch emptying was 3 min (quartiles 3-12.5) and the time to 90% of pouch emptying (T (90%)) was 40 min (24.5-60). The sensation of satiety lasted 75 min (57.5-105), and the feeling of hunger started after 90 min (40-90). Neither T (50%) nor T (90%) correlated to the weight loss (R = 0.006, P > 0.5 and R = 0.1, P > 0.5). The sensation of satiety did not correlate to T (50%) or T (90%) (R = 0.6, P = 0.12 and R = 0.5, P = 0.15). No association was found between the sensory data and the pressure decline. Significant association was found between the load of the meal expressed as the area under the pouch pressure curve and the weight loss (R = 0.786, P = 0.015). CONCLUSION: The satiety sensation lasted much longer than the pouch emptying and the pressure increase. The pressure load correlated to the weight loss. This indicates that neuroendocrine mechanisms caused by the accumulated mechanical load are most important for maintaining satiety.

The effect of weight loss after gastric banding on the molecular distribution of serum adiponectin.

The above article has been retracted by the authors, as they have withdrawn the data upon which it was based. The retraction was made before the article reached its final form in the publication process. However, the authors' manuscript, prior to copy editing, page layout and proofing, was initially made available online upon acceptance as an Accepted Preprint.

[Lifestyle intervention in the treatment of severe obesity]. / Livsstilsintervention i behandlingen af svaer fedme.

INTRODUCTION: The prevalence of overweight and obesity is escalating globally, and in Denmark more than 10% of the population are now severely overweight. The aim of this study was to estimate the short-term health effects of 15 weeks of intensive lifestyle intervention composed of physical activity, dietary changes and personal development in severely obese subjects of both sexes. MATERIALS AND METHODS: The 27 subjects were weighed weekly. Fat percentage, abdominal circumference, maximum oxygen uptake, heart rate, oral glucose tolerance and blood lipids were measured at baseline and in week 15. The intensive lifestyle intervention was completed under supervision at a stay at Ebeltoft Kurcenter, and the goal was a weight loss of approximately 1% per week. RESULTS: At baseline, the participants' average body mass index (BMI: kg/m2) was 44 +- 1; the BMI was reduced by 11% after the stay (p<0.001). Body weight was reduced by 14 +- 4 kg (p<0.001), corresponding to 76% of the desired weight loss. The subjects' fat mass was reduced by 4% (p<0.001), and their maximal oxygen uptake was enhanced by 25% (p<0.001). Concerning the blood lipids, total cholesterol was reduced by 8% (p = 0.03); there was no significant change in LDL level and a reduction of 15% (p<0.05) in HDL level. After the intervention, oral glucose tolerance was significantly improved (p<0.001). CONCLUSION: After 15 weeks of intensive lifestyle intervention, there were significant improvements in aerobic fitness and metabolic risk parameters, and the observed weight loss was equivalent to that obtained by surgical treatment. Decisive in the choice of obesity treatment will continue to be the extent of success in permanent weight loss.

Comparison of gene expression in intra-abdominal and subcutaneous fat: a study of men with morbid obesity and nonobese men using microarray and proteomics.

Extent of intra-abdominal fat had significant linear relations with six metabolic coronary risk factors: systolic and diastolic blood pressure, fasting blood concentrations of glucose, high density lipoprotein (HDL) cholesterol, triglyceride, and plasminogen activator inhibitor-1. Tumor necrosis factor-alpha and adiponectin can be biological mediators from the intra-abdominal fat to the metabolic coronary risk factors. Complementarily, we describe a new study that will analyze the gene expression in intra-abdominal and subcutaneous fat on mRNA and protein level using high throughput methods. The study will elucidate further whether intra-abdominal obesity is the common denominator for the different components of the metabolic syndrome.

Detection of intestinal ischemia using a microdialysis technique in an animal model.

The purpose of this study was to use a microdialysis technique to demonstrate the metabolic changes that occur in the intestinal wall during ischemia in vivo. Continuous monitoring of glucose, lactate, and glycerol using a microdialysis technique was performed in the jejunal wall of 10 pigs during steady-state and occlusive ischemia. The microdialysis catheters were introduced 50, 80, and 110 cm from the ligament of Treitz. Occlusive ischemia was established to two segments after steady state was reached. Microdialysate samples were collected from ischemic/nonischemic intestinal segments simultaneously every 20 minutes. For comparison with the microdialysis measurements, systemic blood samples were drawn from the cannulated femoral artery and analyzed consecutively. A significant increase of microdialysate lactate and a significant decrease of microdialysate glucose were found during occlusive ischemia as compared to the preischemic samples and samples from the nonischemic control catheters. The microdialysate glycerol increased during ischemia, but later than the lactate. No changes were observed in systemic serum lactate, serum glucose, pH, p co(2), and p o(2), but serum potassium increased by 1.1 mmole (median) during ischemia. Microdialysis measured in the intestinal wall identifies local ischemia and may be a new method for the monitoring of intestinal perfusion.

Systemic response in patients undergoing laparoscopic cholecystectomy using gasless or carbon dioxide pneumoperitoneum: a randomized study.

In general, laparoscopic cholecystectomy produces a surgical stress response very similar to which occurs after open cholecystectomy. The question is whether the pneumoperitoneum constitutes a significant pathophysiologic trauma, which might be followed by profound changes in the stress response. We conducted a prospective, randomized trial involving 50 consecutive patients scheduled for laparoscopic cholecystectomy, who had a body mass index equal to or less than 30 kg/m(2) with no acute cholecystitis, pancreatitis, or liver or renal disease. These patients were randomized to undergo either the gasless (GLC, n = 24) or the carbon dioxide pneumoperitoneum (CLC, n = 26) procedure. Perioperative assessment of cortisol, insulin, glucose, and C-reactive protein levels was the main determinant of outcome. During the operative procedure, significantly higher levels of serum cortisol and insulin were found in the CLC group than in the GLC group (P < 0.05). No difference in glucose levels was observed between the two groups. The inflammatory response was moderate in both groups. However, on postoperative day 1 the median C-reactive protein level was significantly higher in the GLC group than that in the CLC group (P < 0.05). Carbon dioxide and the positive intra-abdominal pressure during conventional laparoscopy may contribute to the activation of the surgical stress response.

[Gasless versus conventional laparoscopic cholecystectomy. A randomized trial with regard to technical problems, postoperative course and convalescence]. / Gasløs versus konventionel laparoskopisk kolecystektomi. En randomiseret undersøgelse omhandlende teknik, postoperativt forløb og rekonvalescens.

INTRODUCTION: The positive CO2 pneumoperitoneum needed to create the working space for laparoscopic surgery may induce pathophysiological changes. Concern about these changes has led to the introduction of a gasless technique. The aim of the present study was to compare the gasless CLC and GLC with regard to exposure, technical problems, operation time, postoperative pain, clinical course, and convalescence. MATERIAL AND METHODS: Fifty consecutive patients with symptomatic gallstones were randomised to conventional (CLC) or gasless laparoscopic cholecystectomy (GLC), with special reference to overall patient satisfaction, technical difficulties, duration of surgery, postoperative pain, and recovery. RESULTS: The overall exposure of the operative field was poorer in the GLC group, whereas the duration of surgery, steps involved in the cholecystectomy technique, length of hospital stay, and postoperative pain score did not differ significantly. The period to return to normal activity was significantly shorter in the GLC group, six days compared to 8.5 days in the CLC group (p < 0.05). No differences were found in terms of fatigue, dizziness and nausea, and overall satisfaction with the outcome. DISCUSSION: This study shows that convalescence is significantly shorter after laparoscopic cholecystectomy by the gasless technique than by the conventional CO2 technique. However, exposure of the operative field was less than optimal with the gasless technique.