Effect of bariatric surgery on cardiac structure and function in obese patients: Role of the renin-angiotensin system.

Echocardiographic alterations have been described in obesity, but their modifications after bariatric surgery (BS) and mechanisms are little known, mostly in normotensive patients. We aimed to analyze cardiac changes 1 year post-BS and to explore possible mechanisms. A cohort of patients with severe obesity (58% normotensives) were prospectively recruited and examined before surgery and after 12 months. Clinical and echocardiographic data, 24 h BP, renin-angiotensin-aldosterone system (RAAS) components, cytokines, and inflammatory markers were analyzed at these two time points. Overall reduction in body weight was mean (IQR) = 30.0% (25.9-33.8). There were statistically significant decreases in left ventricle mass index2.7 (LVMI)2.7 , septum thickness (ST), posterior wall thickness (PWT), relative wall thickness (RWT), and E/e', both in the whole cohort and in patients without RAAS blockers (p ≤ .04 for all). Plasma renin activity (PRA) decreased from (median, IQR) = 0.8 (0.3;1.35) to 0.4 (0.2;0.93) ng/ml/h, plasma aldosterone from 92 (58.6;126) to 68.1 (56.2;83.4) ng/dl, and angiotensin-converting enzyme (ACE)-2 activity from 7.7 (5.7;11.8) to 6.8 (5.3;11.2) RFU/µl/h, p < .05. The body weight loss correlated with a decrease in both 24 h SBP and 24 h DBP (Pearson's coefficient 0.353, p = .022 and 0.384, p = .012, respectively). Variation (Δ) of body weight correlated with ΔE/e' (Pearson's coeff. 0.414, p = .008) and with Δ lateral e' (Pearson's coeff. = -0.363, p = .018). Generalized linear models showed that ΔPRA was an independent variable for the final (12-months post-BS) LVMI2.7 (p = .028). No other changes in cardiac parameters correlated with ΔBP. In addition to the respective baseline value, final values of PWT and RWT were dependent on 12-month Δ of PRA, ACE, and ACE/ACE2 (p < .03 for all). We conclude that there are cardiac changes post-BS in patients with severe obesity, normotensives included. Structural changes appear to be related to modifications in the renin-angiotensin axis.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for 5-year hypertension remission in obese patients: a systematic review and meta-analysis.

: Controversial results exist on mid-term effects of Roux-en-Y gastric bypass and sleeve gastrectomy on hypertension remission. The aim of the present systematic review was to study 5-year hypertension remission after both procedures. One-year hypertension remission and SBP and DBP pressure change at 1 and 5 years after both surgical techniques were also evaluated. We searched MEDLINE, EMBASE and The Cochrane Central Register of Controlled Trials (CENTRAL). Thirty-two articles were included (six randomized controlled trials, 18 cohort and eight case-control studies). The proportion of patients with hypertension remission was greater for those treated with gastric bypass compared with sleeve gastrectomy at 5 years (RR = 1.26, 95% CI = 1.07-1.48) and 1 year (RR = 1.14, 95% CI = 1.06-1.21). Gastric bypass and sleeve gastrectomy did not differ in terms of SBP or DBP change. Patients treated with gastric bypass present a higher hypertension remission rate at 1 and 5 years.

Changes in Central 24-h Ambulatory Blood Pressure and Hemodynamics 12 Months After Bariatric Surgery: the BARIHTA Study.

BACKGROUND: Weight loss is associated to blood pressure (BP) reduction in obese patients. There is no information on central 24-h BP changes after bariatric surgery (BS). METHODS AND RESULTS: In this study, we analyzed changes in 24-h BP 12 months following BS, with intermediate evaluations at 1, 3, and 6 months, in severely obese adults. The primary endpoint was aortic (central) 24-h systolic BP changes. Circadian BP patterns and hypertension resolution were also assessed. As secondary endpoints, we analyze changes in central 24-h diastolic BP as well as in all office and ambulatory peripheral BP parameters. Obese adults scheduled for BS as routine clinical care were recruited. We included 62 patients (39% with hypertension, 77% women, body mass index, 42.6 ± 5.5 kg/m2). Reduction in body weight was mean (IQR) 30.5% (26.2-34.4) 1 year after BS. Mean (95% CI) change in central 24-h systolic BP was - 3.1 mmHg (- 5.5 to - 0.7), p = 0.01 after adjustment for age, sex, and baseline hypertensive status. BP parameter changes were different between normotensives and hypertensives. Mean (95% CI) change in central 24-h systolic BP was - 5.2 mmHg (- 7.7 to - 2.7), p < 0.001, in normotensives and - 0.5 mmHg (- 5.1 to 4.0), p = 0.818, in hypertensives. There was a remission of hypertension in 48% of patients. Most patients had a reduced dipping pattern, similarly at baseline and 12 months after BS. CONCLUSIONS: Among patients with severe obesity, there was a substantial central 24-h systolic BP decrease 12 months following BS. Importantly, this change was observed in those patients with normal BP at baseline. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03115502.

Characterization of the pattern of food consumption in severely obese patients prior to bariatric surgery.

INTRODUCTION: Introduction: severe obesity is increasing rapidly in several countries, as well as the number of bariatric surgeries performed. However, the pattern of food consumption of the population is not well defined. Objectives: the aim of the present study was to describe the food consumption pattern (comparing men and women) of severely obese patient candidates to bariatric surgery and to determine the promoting and protecting factors. Methods: food consumption and nutrient intake were measured by a validated food frequency questionnaire (FFQ), including food and beverages. Multivariate principal component analysis (PCA) was done to analyze the component that best relates to the food pattern consumption dividing the different food groups in promotors and protectors. Results: significant differences in the food consumption pattern of men and women with severe obesity addressed for bariatric surgery were found. A positive correlation was found between the food groups that are protective factors for obesity such as the fiber (r = 0.84), vegetables (r = 0.767) and fruits (r = 0.83), whereas a negative correlation was found with those factors that are promotors of obesity such as fats (r = -0.341), saturated fats (r = -0.411), soft drinks (r = -0.386), and fast food (r = -0.17).Multivariate analysis of principal components revealed that calorie consumption is the component that correlates better with the pattern. Conclusions: there are significant differences in the food consumption pattern of men and women with severe obesity addressed for bariatric surgery and these differences should be taken into account when planning nutritional intervention. Therefore, a healthy lifestyle behaviour should be highly encouraged among the severe obese population.

INTRODUCCIÓN: Introducción: la obesidad mórbida así como el número de cirugías bariátricas que se practican van en aumento en varios países. Sin embargo, el patrón de consumo alimentario de estos pacientes no está bien definido. Objetivos: describir el patrón de consumo de alimentos (comparando hombres y mujeres) de pacientes con obesidad severa candidatos a cirugía bariátrica y determinar los factores promotores y protectores de la obesidad. Métodos: el consumo de alimentos y la ingesta de nutrientes se midieron mediante un cuestionario de frecuencia de consumo de alimentos validado que incluye alimentos y bebidas. Se realizó un análisis multivariado de componentes principales para determinar qué componente se relaciona mejor con el consumo de patrones alimentarios promotores y protectores de obesidad. Resultados: el estudio mostró diferencias significativas en el patrón de consumo de alimentos entre hombres y mujeres. Se encontró una correlación positiva entre los grupos de alimentos considerados factores de protección para la obesidad, como la fibra (r = 0,84), las verduras (r = 0,767) y las frutas (r = 0,83), mientras que la correla-ción fue negativa con los factores promotores de la obesidad como las grasas (r = -0,341), las grasas saturadas (r = -0,411), los refrescos (r = -0,386) y la comida rápida (r = -0,17). El análisis multivariado de los componentes principales reveló que el consumo de calorías es el componente que se correlaciona mejor con el patrón. Conclusiones: existen diferencias significativas en el patrón de consumo de alimentos entre hombres y mujeres con obesidad severa y estas deben tenerse en cuenta al planificar la intervención nutricional. Asimismo, un consumo alimentario saludable debe promocionarse en la población obesa.

Short- and medium-term impact of bariatric surgery on the activities of CYP2D6, CYP3A4, CYP2C9, and CYP1A2 in morbid obesity.

Morbid obesity and bariatric surgery induce anatomical, physiological and metabolic alterations that may alter the body's disposition of drugs. Current literature on this topic is limited and sometimes inconsistent. Cytochrome P450 (CYP) is a superfamily of enzymes that metabolize around 75% of all marketed drugs. The purpose of this study was to evaluate the impact of body mass index and bariatric surgery on CYP activities. Firstly, we evaluated the in vivo activity of 4 major CYP isoenzymes (CYP2D6, CYP3A4, CYP2C9, and CYP1A2) in normal weight, overweight, and morbidly obese individuals. Secondly, we assessed the short- (1 month) and medium-term (6 month) effects of the most commonly employed bariatric surgery techniques (laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass) on the activity of these enzymes. CYP3A4 activity was lower in morbidly obese individuals, compared to normal-weight controls. Interestingly, bariatric surgery normalized CYP3A4 activity. In comparison with normal-weight controls, morbidly obese individuals had higher CYP2D6 activity, which was only observed in individuals with two functional alleles for this isoenzyme. Neither body mass index nor surgery had significant effects on CYP2C9 and CYP1A2 activities. Overall, no relevant differences in CYP activities were found between surgical techniques. In conclusion, further studies should evaluate whether the observed alterations in CYP3A4 activity will require dose adjustments for CYP3A4 substrates especially in morbidly obese individuals before and after bariatric surgery.

High-Dose Vitamin D Supplementation is Necessary After Bariatric Surgery: A Prospective 2-Year Follow-up Study.

BACKGROUND: We assessed the need of vitamin D supplementation to achieve normal 25-hydroxyvitamin D (25[OH]D) levels after bariatric surgery and whether there were differences between laparoscopy sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: A total of 164 morbid obese patients undergoing bariatric surgery from January 2008 to June 2011 were followed for 2 years. Serum levels of 25(OH)D and intact parathyroid hormone (iPTH) were measured preoperatively and at 3, 6, 9, 12, 18, and 24 months after operation. All patients received 400 IU/day of 25(OH)D. Patients received additional supplementation with 16,000 IU of vitamin D3 (calcifediol) every 2 weeks if 25(OH)D serum levels were < 30 ng/mL (intervention group). RESULTS: Ninety-six (58.5 %) patients underwent LSG and 68 (41.5 %) LRYGB. A total of 106 (64.6 %) patients received calcifediol supplementation (62 in the LSG group and 44 in the LRYGB group). Normal 25(OH)D levels at 24 months were recorded in 69 % of patients in the intervention group and in 48.3 % in the non-intervention group. At 24 months, mean 25(OH)D levels in the non-intervention group were significantly lower among LRYGB patients than among LSG patients (P = 0.009). In the intervention group, normal 25(OH)D levels were achieved in 60 % of patients treated with LSG and in 22.2 % of those treated with LRYGB. Secondary hyperparathyroidism was presented in 49 (29.9 %) patients preoperatively but without significant differences in iPTH levels between the two surgical procedures. CONCLUSION: Patients undergoing bariatric surgery should receive high-dose vitamin D supplementation independently of the surgical technique.

Obesity surgery mortality risk score for the prediction of complications after laparoscopic bariatric surgery.

INTRODUCTION: Morbimortality after bariatric surgery varies according to patient characteristics and associated comorbidities. The aim of this study was to evaluate the usefulness of the Obesity sugery mortality risk score scale (OS-MRS) to predict the risk of postoperative complications after bariatric surgery. METHODS: A retrospective study was performed of a prospective series of patients undergoing bariatric surgery in which the OS-MRS scale was applied preoperatively. Postoperative complications were classified as proposed by Dindo-Clavien. We analyzed the relationship between the categories of OS-MRS scale: A) low risk, B) intermediate risk, and C) high risk and the presence of complications. RESULTS: Between May 2008 and June 2012, 198 patients were included (85 [42.9%] after gastric bypass and 113 [57.1%] after sleeve gastrectomy). Using the OS-MRS scale, 124 patients were classified as class A (62.6%), 70 as class B (35.4%) and 4 as class C (2%). The overall morbidity rate was 12.6% (25 patients). A significant association between OS-MRS scale and rate of complications (7.3, 20 and 50%, respectively, P=.004) was demonstrated. The gastric bypass was associated with a higher complication rate than sleeve gastrectomy (P=.007). In multivariate analysis, OS-MRS scale and surgical technique were the only significant predictive factors. CONCLUSIONS: The OS-MRS scale is a useful tool to predict the risk of complications and can be used as a guide when choosing the type of bariatric surgery.

Lack of adherence to follow-up visits after bariatric surgery: reasons and outcome.

BACKGROUND: A substantial number of patients undergoing bariatric surgery are lost to follow-up for unknown reasons, which may cause an overestimation of the benefits of operation. The aim of this study was to identify the reasons of failure to attend controls after bariatric surgery and the relationship with poor weight loss. METHODS: A retrospective analysis of a prospective database including all patients undergoing bariatric surgery from January 2004 to February 2012 was performed. Nonadherence was defined as missing any scheduled control visit for more than 6 months. Contact was attempted (mail, telephone, and e-mail), and responders were requested to complete a questionnaire. RESULTS: Forty-six (17.5%) out of 263 patients were considered nonadherent. Thirty-three (71.7%) of these patients completed the questionnaire. The main reasons for nonadherence were work- (36.4%) and family-related (18.2%) problems or having moved outside the city or to the country (15.2%). The percentage of nonadherent patients aged ≤45 years was greater as compared with those aged >45 years [28 (60.1%) vs 18 (42.2%), respectively, P = 0.034]. Likewise, of the 30 patients with unsuccessful weight loss (<50% EWL), seven (30.4%) were in the nonadherent group while 23 (10.6%) in the adherent group (P = 0.046). Finally, 96.9% of patients were completely satisfied with surgery and would recommend the procedure to other morbid obese patients. CONCLUSION: The nonadherence rate to follow-up visits after bariatric surgery was 17.5%, mainly associated with work-related problems. Nonadherence was greater in patients aged ≤45 years and in those with poor weight loss.

Residual gastric volume estimated with a new radiological volumetric model: relationship with weight loss after laparoscopic sleeve gastrectomy.

BACKGROUND: The volume of the gastric reservoir appears crucial to explain the success of laparoscopic sleeve gastrectomy (LSG) in the treatment of morbid obesity. The aims of this study were to describe a new, easy model to estimate gastric reservoir volume after LSG; to evaluate the volumetric changes 1 year after surgery; and to analyze their relationship with weight loss. METHODS: This is a prospective observational study of all patients undergoing LSG in the Department of Surgery at our institution. The gastric reservoir was evaluated radiologically considering the image as a complex geometrical shape with two components: a cylinder (gastric body) and a truncated cone (antrum). Radiologic assessment using this new model was performed at 1 and 12 months after surgery. Moreover, body mass index and percentage of excess weight loss (%EWL) were evaluated at 3, 6, 12, and 18 months after LSG. RESULTS: Forty-five patients (34 F/11 M) with a mean age of 46.9 years were included. A significant increase in total gastric reservoir volume (124.8 ± 58.7 and 188.6 ± 76.4 mL at 1 and 12 months, respectively; p = 0.001) was observed. No statistically significant differences were observed comparing volume of the two components at the two time points. The %EWL at 18 months was inversely correlated with reservoir volume changes at 12 months after LSG (p = 0.006). CONCLUSIONS: We describe an easy volumetric model to estimate the size of the gastric reservoir after LSG. Moreover, a direct relationship between an increase in gastric reservoir volume and a lower weight loss after surgery was documented.

Simultaneous SERS detection of copper and cobalt at ultratrace levels.

We report a SERS-based method for the simultaneous and independent determination of two environmental metallic pollutants, Cu(ii) and Co(ii). This was achieved by exploiting the coordination-sensitive Raman bands of a terpyridine (TPY) derivative for detecting transition metal ions. Changes in the vibrational SERS spectra of dithiocarbamate anchored terpyridine (TPY-DTC) were correlated as a function of each metal ion concentration, with limits of detection comparable to those of several conventional analytical methods. Simultaneous detection of ultratrace levels of Co(ii) in the presence of high Cu(ii) concentration was also demonstrated, supporting the potential of this sensing strategy for monitoring potable water supplies.