Search

One anastomosis gastric bypass (OAGB) is gaining increasing acceptance as a simple, safe, and effective operation for treating morbid obesity. Data comparing this procedure with the most effective biliopancreatic diversions (BPD) remain scarce, and most studies evaluate OAGB against standard Roux-en-Y gastric bypass (RYGB).To present the mid-term results of a comparison of RYGB, OAGB, and our modification of BPD in an exclusively non-superobese population, regarding safety, efficacy, preservation of weight loss, as well as late postoperative metabolic and non-metabolic complications.From our cohorts of patients treated for morbid obesity with OAGB, RYGB, and BPD at Patras University Hospital, we identified patients who had case-matched preoperative profiles regarding age, preoperative body mass index (BMI), and obesity-related comorbidities (diabetes mellitus, hypertension, and dyslipidaemia). Thirty-four patients from each group were included in the study. Bariatric outcomes, non-metabolic complications, and postoperative metabolic parameters were followed until the 6The average patient age was 37.4 years (range: 19-57), 85.3% were female and 14.7% were male, with a mean BMI of 46.3 kg/mOAGB offered mid-term results comparable to BPD while being safe and with minimal impact on the patient's nutritional state. It is an effective procedure for treating morbid obesity, which results in sustained weight loss and a high rate of resolution of comorbidities.

The objective of this study is to investigate the effect of adequate vitamin D supplementation on bone mineral density (BMD) following long limb-biliopancreatic diversion (LL-BPD), a malabsorptive bariatric operation. Marked weight loss following bariatric surgery is associated with significant decrease in BMD, attributed to the weight loss and to nutritional, mineral, and vitamin D deficiencies resulting in secondary hyperparathyroidism. Two groups, of 35 and 37 healthy, obese (BMI, 50.4 + 6.6 and 46.5 + 4.8 g/cm2), premenopausal, normally menstruating women underwent LL-BPD. Both groups received high-calcium diets, 600 IU of vitamin D, and 1000 mg elemental calcium daily, while group B received an extra dose of vitamin D (10,000 IU/day) during the first postoperative month, followed by dose adjustment in order to maintain 25OHD concentration higher than 30 μg/L. Areal BMD (aBMD) was measured at the lumbar spine preoperatively and 1 year postoperatively. One year postoperatively, BMI decreased by approximately 19 kg/m2 in both groups, while 25-OH-vitamin D levels did not change in group A (18.7 + 9.1 to 20.2 + 13.0 μg/L, (p = 0.57)) and increased in group B (15.58 ± 5.73 to 52.97 ± 15.46 μg/L, (p =

Morbid obesity (BMI > 40) is often accompanied by metabolic disorders. In adipose tissue, serine/threonine kinase PKBβ/AktΙΙ plays a role in glucose uptake, mediated by glucose transporter 4 (GLUT4). The insulin pathway also affects aquaglyceroporin-7 (AQP7), which mediates lipolysis-derived glycerol efflux into the bloodstream. The aim of our study was to investigate the molecular mechanisms in adipocytes of adults with morbid obesity that may lead to insulin resistance (IR) and diabetes mellitus type 2 (DM2) in morbid obesity. Primary in vitro adipocyte cultures were developed from surgical biopsies from visceral (Visc), abdominal (Sub), and gluteal subcutaneous (Glut) fat depots, from 20 lean adults and 36 adults with morbid obesity (OB), divided into two groups: 20 without (MOW) and 16 with DM2 (MODM). mRNA and protein expression (PE) of AktΙΙ, AQP7, and GLUT4 were studied with RT-PCR and Western immunoblotting (WI), respectively. The PE of (1) AktII and basal phosphorylated AktII (pAktII) showed no difference within the groups, (2) the 37 kDa and 34 kDa isoforms of AQP7 were decreased in Visc/Sub from OB/MOW/MODM, (3) GLUT4 was decreased in Visc/Sub from OB/MOW/MODM, and (4) the 34 kDa isoform of AQP7 was decreased in Sub of MODM compared with MOW. Decreased 37 kDa (presented in this study as a novel isoform) and 34 kDa isoforms of AQP7 in MOW and MODM may cause reduced lipolysis, enhancement of adipocyte hypertrophy, and impairment of insulin, signaling possibly reflected by low GLUT4 expression. This may potentially cause systemic IR, since decreased adipose GLUT4 expression may affect whole-body insulin sensitivity, increasing the risk for DM2. Furthermore, decreased subcutaneous AQP7 34 kDa could represent an early marker of IR.

Surgery stimulates an intense systemic inflammatory response which might increase postoperative morbidity. Corticosteroids may reduce this inflammatory reaction. The purpose of this study was to investigate any possible effect on postoperative morbidity and recovery after administrating methylprednisolone in super-obese patients undergoing open surgery. Sixty super-obese patients with BMI ≥50 kg/m2 (mean 57.48 ± 7.33), mean age of 39 ± 9 years, who underwent an open bariatric procedure, were enrolled. Thirty patients (group A) were allocated to a preoperative single dose of 30 mg/kg (ideal body weight) methylprednisolone versus placebo (group B, 30 patients). Endpoints included assessment of IL-6 and CRP; evaluation of postoperative pulmonary function, pain management, nausea, and vomiting; and documentation of postoperative complications. Significant improvement in spirometry parameters and arterial blood gas analysis, in the first and third postoperative days, was observed in the methylprednisolone group. IL-6 and CRP levels were significantly lower in that group. Administration of methylprednisolone was associated with less postoperative pain, nausea, and vomiting, with no statistical difference in septic complications. Preoperative administration of a single high dose of methylprednisolone in super-obese patients undergoing open surgery inhibits the inflammatory signaling cascade, lessens the systemic inflammatory response, and results in fewer pulmonary complications and better patient recovery.

Background Minimal glucose infusions are known to entrain insulin oscillations in patients with normal glucose tolerance (NGT) but not in patients with type 2 diabetes (T2D). Objectives To investigate whether weight loss after a version of biliopancreatic diversion (BPD) can restore the glucose entrainment of high-frequency insulin oscillations in morbidly obese NGT or T2D patients. Setting University Hospital, Greece. Methods We prospectively studied 9 NGT controls (body mass index [BMI] 23.3±1.6 kg/m 2 ), 9 obese NGT patients (BMI 51.1±12.7 kg/m 2 ), and 9 obese T2D patients (BMI 56.8±11.6 kg/m 2 ). Patients were studied before and 1.5 years after BPD. Insulin was sampled every minute for 90 minutes. Glucose (6 mg/kg weight) was infused every 10 minutes for 1 minute. Regularity of insulin pulses was estimated by autocorrelation analysis, spectral analysis, approximate entropy/sample entropy (ApEn/SampEn), and insulin pulsatility by deconvolution analysis. Results Postoperatively, glucose and insulin concentrations of NGT and T2D patients decreased to control levels and BMI to 31.3±6.3 for NGT patients and 34.9±9.9 kg/m 2 for T2D patients. Preoperatively, glucose entrainment was absent in all T2D and in 4 NGT patients as assessed with spectral analysis and in 8 and 4, respectively, as assessed with autocorrelation and deconvolution analysis. Postoperatively, it was restored to normal in all patients. ApEn/SampEn decreased significantly only in the T2D group postoperatively. Conclusion BPD restores the glucose entrainment of high-frequency insulin oscillations in obese NGT and T2D patients after marked weight loss and normalizes glucose levels and insulin sensitivity, thus demonstrating recovery of β-cell glucose sensing.

Insufficient data exist regarding postoperative thoracic epidural analgesia for morbidly obese patients undergoing open bariatric surgery. This study evaluated the effectiveness of morphine loading in a postoperative thoracic epidural analgesic regimen of patient-controlled epidural analgesia (PCEA) with levobupivacaine combined with continuously administered epidural morphine in this patient group. In this prospective randomized controlled trial, 48 superobese patients (body mass index of ≥50 kg/m2) undergoing open bariatric surgery were randomly allocated to three groups of 16 patients each. Postoperatively, all groups received a continuous epidural morphine infusion of 0.2 mg/h with 0.1 % levobupivacaine via PCEA. Group A did not receive intraoperative epidural morphine loading, while groups B and C received an intraoperative 1- and 2-mg morphine bolus, respectively. Levobupivacaine consumption via PCEA (primary outcome), pain scores at rest and on cough, the time to return of bowel function and ambulation, and arterial blood gas levels (secondary outcomes) were recorded. The increase in perioperative morphine administration (groups B and C) led to a significantly prolonged return to normal bowel function and delayed ambulation (P

This study presents late results of a previously published 2-year prospective comparison between Roux-en-Y gastric bypass (RYGBP) versus biliopancreatic diversion with Roux-en-Y gastric bypass (BPD-RYGBP) in an exclusively non-superobese population. From a cohort of 130 patients with a BMI of 35–50 kg/m2, 65 were randomly selected to undergo RYGBP and 65 to BPD-RYGBP. All underwent follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Follow-up at the eighth year was achieved in 60 % of the BPD-RYGBP and in 58 % of the RYGBP group (p = 1.00). Mean excess weight loss (EWL%), was significantly higher following BPD-RYGBP (76.89 ± 1.53) as compared to RYGBP (67.17 ± 1.43) (p = 0.0004). The mean success rate (percentage of patients with EWL% ≥50 %) was significantly higher after BPD-RYGBP (95.85 ± 1.01) than RYGBP (75.91 ± 3.58) (p = 0.0001). No significant differences were observed for late non-metabolic complications. The incidence of anemia, iron deficiency, B12 deficiency, and low-ferritin levels was relatively high in both groups with not always significant differences. Severe protein malnutrition occurred in four patients (three BPD-RYGBP and one RYGBP) (p = 0.37). In only one BPD-RYGBP patient (1.54 %) was revision surgery to RYGBP necessary, due to recurrent episodes of hypoproteinemia. The remaining patients were treated successfully with total parenteral nutrition and nutritional counseling. Late results presented in this paper agree with the previously published 2-year results of the same patient cohort. Although both procedures are safe and effective, BPD-RYGBP seems to prevail in terms of successful weight loss without a significantly higher incidence of metabolic and non-metabolic complications.

Background Sleeve gastrectomy (SG) is increasingly indicated as a stand-alone procedure for the treatment of clinically severe obesity. Our objective was to present the outcomes of SG in relation to weight loss, resolution of co-morbidities, and procedural morbidity/mortality for ≤5 years postoperatively. The study was conducted at a university hospital, bariatric referral center. Methods From January 2005 to December 2010, 208 patients underwent SG at our institution. Per standard protocol, SG was the sole surgery indicated for weight reduction in patients with a body mass index of ≤50 kg/m2 who were not “sweet-eaters” and had no symptoms of gastroesophageal reflux disease. The study endpoints were weight loss, perioperative and late morbidity/mortality, and clinical improvement in co-morbidities and consequential nutritional deficiencies. Results SG was performed laparoscopically in 203 of the patients. The mean age and body mass index was 34.3 ± 10.3 years and 43.2 ± 2.8 kg/m2, respectively. No deaths were recorded. Early morbidity (≤30 d) was 9.6%, chiefly owing to staple line closure leaks, and late morbidity was 4.8%. A mean excess weight loss of 71.1% was documented in 90 (89.4%) of 106 patients, available for follow-up after 3 years. The excess weight loss slowly declined to 57.6% in 21 (77.7%) of 27 patients at 5 years of follow-up. No major metabolic deficiencies were apparent. Statistically significant improvements in pre-existing hypertension, diabetes mellitus, and dyslipidemia were achieved. After laparoscopic SG, gastroesophageal reflux disease symptoms developed in 9.8% of patients within the first postoperative year but lessened over time to 7.4% at the 5-year mark. Conclusions SG is a reproducible procedure associated with significant weight reduction, resolution of obesity-related co-morbidities, and minor nutritional deficits at 5 years of follow-up. Laparoscopic SG can thus be safely used as the sole surgical treatment of clinically severe obesity (body mass index ≤50 kg/m2). The chief complication of postoperative leakage can be managed nonoperatively in most patients.

Increased visceral adipose tissue is a risk factor for the metabolic complications associated with obesity and promotes a low-grade chronic inflammatory process. Resection of the great omentum in patients submitted to a bariatric procedure has been proposed for the amelioration of metabolic alterations and the maximization of weight loss. The aim of the present study was to investigate the impact of omentectomy performed in patients with morbid obesity undergoing sleeve gastrectomy (SG) on metabolic profile, adipokine secretion, inflammatory status, and weight loss. Thirty-one obese patients were randomized into two groups: SG alone or with omentectomy. Adiponectin, omentin, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), high-sensitivity C-reactive protein (hs-CRP), blood lipids, fasting glucose, insulin, and insulin resistance were measured before surgery and at 7 days, and 1, 3 and 12 months after surgery. During the 1-year follow-up, body mass index (BMI) decreased markedly and comparably in both groups (p

Over the past 14 years, we have used different malabsorptive bariatric operations to treat super-obesity. We compared the efficacy and safety of our preferred procedure for the last 8 years with previous methods used in super-obese. Our first procedure was distal Roux-en-Y gastric bypass (distal RYGBP) (gastric pouch 15 ± 5 mL, 80 cm biliopancreatic limb, 100 cm common limb [CL]). The second was distal RYGBP with short alimentary limb (distal RYGBP-sAL) (gastric pouch 15 ± 10 mL, alimentary limb [AL] 250 cm, CL 100 cm). Our preferred procedure for the past 8 years has been biliopancreatic diversion with RYGB and long limbs (BPD-RYGB-LL) (gastric pouch 40 ± 10 mL, AL 400 cm, CL 100 cm). Seventy-five patients underwent distal RYGBP, 44 distal RYGBP-sAL, and 841 BPD-RYGB-LL. Eight years postoperatively, the mean BMIs were 39.0, 29.4, and 29.2, respectively. The greatest reduction of 47.6% was achieved with BPD-RYGB-LL (distal RYGBP 30.6%; distal RYGBP-sAL 43.1%). Mean excess weight loss was 51.3% for distal RYGBP, 76.5% for distal RYGBP-sAL, and 80.9% for BPD-RYGB-LL. Six patients died at the early postoperative period. Sixteen patients died during the first eight postoperative years, of whom significantly more were after distal RYGBP-sAL (P = 0.0003). Complications were significantly more frequent after distal RYGBP-sAL (P = 0.001). All procedures led to rapid and sustained resolution of major comorbidities in almost all patients affected. Metabolic and nutritional deficiencies were similar and manageable. Our variant of biliopancreatic diversion (BPD-RYGB-LL) results in substantial and sustained weight loss in super-obese, without compromising safety.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently the gold standard bariatric procedure for the treatment of morbid obesity. Laparoscopic sleeve gastrectomy (LSG) is a relatively innovative procedure which has been increasingly applied lately as a sole bariatric procedure. A randomized trial was conducted in a Greek population to evaluate perioperative safety and 3-years results.Sixty patients with body mass index (BMI) ≤ 50 Kg/m(2) were randomized to LRYGB or LSG. Patients were monitored for 3 years postoperatively and throughout the study period weight loss, in terms of percent excess weight loss (%EWL), early and late complications, improvement of obesity related comorbidities and nutritional deficiencies were compared between groups.There was no death in either group and there was no significant difference in early (10% after LRYGB and 13% after LSG, P 0.05) and late morbidity (10% in each group). Weight loss was significantly better after LSG in the first years of the study and at 3 years %EWL reached 62% after LRYGB and 68% after LSG (p = 0.13). There was no significant difference in the overall improvement of comorbidities. Nutritional deficiencies occurred at the same rate in the two groups except to vitamin B(12) deficiency which was more common after LRYGB (P = 0.05).LSG and LRYGB are equally safe and effective in the amelioration of comorbidities, while LSG is associated with fewer postoperative metabolic deficiencies, without the need of supplementation. Furthermore, LSG is a promising bariatric procedure, equally effective to LRYGB at 3 years follow up on weight reduction.

Bariatric surgery is an effective treatment for obesity; few studies, however, have investigated its impact on patients' sexuality. We aimed to determine bariatric surgery's effect on female patients' body mass index (BMI), anxiety and depressive symptoms, and sexual function and delineate predictors of treatment outcomes. Fifty-nine obese female bariatric candidates were administered the Hospital Anxiety and Depression Scale and the Female Sexual Function Index 1 week before surgery (T1) and 1 year after (T2). Statistical analysis revealed significant reductions in BMI (p < 0.001), depression (p < 0.001), and sexual pain levels (p = 0.014) and significant improvements in sexual desire (p = 0.005), arousal (p = 0.001), lubrication (p = 0.003), satisfaction (p = 0.012), and total sexual function (p = 0.003) postoperatively. Postoperative total sexual function was independently predicted by baseline sexual function and low baseline BMI. Bariatric surgery is an effective way to reduce weight, manage depression, and improve sexual function in female obese patients. Obes Surg

Purpose To retrospectively evaluate the efficacy and safety of computed tomography (CT)-guided percutaneous gastrostomy in patients presenting with complications after bariatric surgery. Materials and Methods From January 2003 up to today, 25 patients (20 women), formerly operated for severe obesity, were referred for gastrostomy, after presenting with a complication. The mean age and body mass index were 38±9.3 years and 46±7.1 kg/m2, respectively. A gastrostomy tube was placed under CT in all patients. Results The procedure's technical success rate was 96%, with mean interventional time of 80±42 minutes. In 14 of 25 (56%) cases submucosal spread of air was noticed during air insufflation into the stomach. No major complications were recorded. There was a statistically significant improvement of both albumin and prealbumin values compared with the initial ones (P Conclusions CT-guided gastrostomy in patients with complications after bariatric surgery, provides a reliable alternative for nutritional support. It restores the normal absorption route, reversing metabolic deficiencies.

To investigate the effect of marked weight loss after long limb-biliopancreatic diversion (BPD-LL) on bone mass and serum calcium, 25-OH-vitamin D, and PTH levels in relation to calcium supplementation.BPD is the most effective type of bariatric surgery, but it is followed by bone mass loss, mainly attributed to calcium and vitamin D malabsorption leading to secondary hyperparathyroidism.Two groups, each consisting of 26 healthy, morbidly obese, premenopausal women, underwent BPD-LL. Both groups received high-calcium diets, 200 IU of vitamin D and 100 mg elemental calcium daily and group B, in addition to an extra 2 g of calcium. Bone density and biochemical markers were measured before and 12 months after BPD-LL.One year after surgery, both groups had lost an average of 55 kg of body weight; albumin-corrected calcium concentration did not change. 25-OH-vitamin D levels in group A were 17.34 +/- 8.90 pre- and 20.51 +/- 14.71 microg/L postoperatively (p = 0.058), and in group B, 15.70 +/- 9.46 and 13.52 +/- 8.16 microg/L (p = 0.489), respectively. PTH levels in group A were 38.5 +/- 12.2 before and 51.2 +/- 32.8 pg/ml after surgery (p = 0.08), and in group B, 48.1 +/- 26.3 and 52.9 +/- 29.2 pg/ml (p = 0.147), respectively. Bone formation markers (alkaline phosphatase, osteocalcin and procollagen type 1), as well as the bone resorption marker CTx, increased significantly in both groups. Bone mineral density T score was 0.862 +/- 0.988 in group A and 0.851 +/- 1.44 in group B and declined postoperatively to -0.123 +/- 1.082 and 0.181 +/- 1.285, respectively.Marked weight loss after BPD-LL leads to increased bone turnover and normalization of the increased bone mass without calcium or vitamin D malabsorption and without the appearance of secondary hyperparathyroidism. We conclude that the bone mass reduction is a normal adaptation to the decreased loading of the bone following weight loss.

Leptin, adiponectin, and resistin are adipokines linked to the development of insulin resistance, which plays a central role in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). We aimed to define adipokine serum levels in severely obese patients undergoing bariatric surgery and to correlate these with anthropometric and metabolic variables, liver function tests, and histopathological parameters of NAFLD and nonalcoholic steatohepatitis (NASH). Surgical liver biopsies were obtained from 50 bariatric patients with no history of liver disease or significant alcohol consumption. Serum leptin, adiponectin, and resistin levels were measured, and histology was assessed using Brunt’s and Kleiner’s scoring systems. Waist/hip ratio was significantly higher in men (p = 0.0001), and leptin (p = 0.036) and adiponectin (p = 0.0001) serum levels were higher in women. Forty-one of 50 patients (82%) had histological NAFLD, including 10 (20%) with NASH. Nine patients (18%) had normal liver histology (obese control subgroup). In NAFLD patients, serum adiponectin was negatively correlated with activity grade and fibrosis stage, resistin was negatively correlated with steatosis grade (p = 0.033), while leptin was not related to histology. Leptin/adiponectin ratio showed positive association with stage (p = 0.044). In the subgroup of NASH patients, adiponectin was negatively correlated only with stage (p = 0.01), while there was no correlation between leptin, resistin, or leptin/adiponectin and histology. Serum adiponectin and resistin levels are related to liver histology in bariatric patients and may be indicative of the histological severity of NAFLD and the extent of hepatic steatosis, respectively. Serum leptin levels are not informative of underlying liver histology in severely obese patients.

Transient hyperglycemia is commonly observed in non-diabetic subjects during surgery. We undertook this study to investigate (1) insulin secretion pattern and glucose levels during elective surgery, and (2) the role of pre-operative fasting in the development of surgery-induced hyperglycemia.We examined 21 severely obese normal glucose tolerant patients, who underwent bariatric surgery. From the 21 operated subjects, 14 remained fasted while seven patients received 75 g glucose the preoperative night. They sampled at baseline and from the onset of operation frequently for 9 h thereafter, for measuring serum insulin and glucose.Hyperglycemia developed within 1 h from the onset of operation and lasted 9 h. The administration of 75 g glucose the preoperative night prevented surgery-induced hyperglycemia. Insulin profile analyzed by deconvolution analysis was similar between fasted patients and those who received 75 g glucose. Serum insulin was suppressed at the beginning of the surgery and reached baseline values 4 h thereafter.Hyperglycemia occurred within 1 h from the beginning of surgery and sustained for at least 9 h while insulin levels are suppressed or unaltered compared to baseline values in euglycemia. The administration of 75 g glucose the preoperative night prevents surgery-induced hyperglycemia without altering the profile of insulin secretion.

Obesity is associated with increased prevalence of type 2 diabetes mellitus (DM2) and metabolic syndrome and increased morbidity and mortality. Bariatric surgery results in significant and long-term weight loss. Two of the most effective and popular bariatric procedures are Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD). The objective of this study was to investigate the effects of RYGBP and BPD-RYGBP, a variant of BPD with a lower rate of metabolic deficiencies than BPD, on DM2 and the major components of metabolic syndrome in patients with morbid obesity and DM2.The prospective database of our unit, from June 1994 until May 2006, was analyzed and 137 patients with DM2 were found. 26 underwent RYGBP (BMI 46.1 +/- 2.9 kg/m2) and 111 BPD-RYGBP (BMI 59.7 +/- 10.6 kg/m2). 7 of the patients were on insulin (4.90%) and 37 on oral hypoglycemic agents (25.87%). Pre- and postoperative medications, and clinical and biochemical parameters were considered in the analysis. The mean follow-up was 26.39 +/- 21.17 months.Excess weight loss was approximately 70% after either procedure. DM2 resolved in 89% and 99% of the cases following RYGBP and BPD-RYGBP, respectively. 2 years after BPD-RYGBP all the patients had blood glucose110 mg/dl, 95% had normal cholesterol, 92% normal triglycerides and 82% normal blood pressure. The respective values following RYGBP were 66%, 33%, 78% and 44%. Uric acid decreased significantly only after BPD-RYGBP. Liver enzymes improved in both groups.RYGBP and BPD-RYGBP are safe and lead to normalization of blood glucose, lipids, uric acid, liver enzymes and arterial pressure in the majority of patients, although this variant of BPD was more effective than RYGBP. We suggest that further studies should also investigate its usefulness in patients with milder degrees of obesity, DM2 and metabolic syndrome.

Background: Obesity has become a modern epidemic, increasingly affecting the general population worldwide. Obese people are vulnerable to a variety of co-morbidities, including cardiovascular and pulmonary disease, osteoarthritis, diabetes, cancer and psychiatric conditions, that not only diminish life expectancy but also impair quality of life. Research has shown that obesity is further linked to sexual dysfunction, although relevant studies are limited and further investigation is needed. Methods: We assessed the sexual function of 60 obese women scheduled to undergo bariatric surgery and 50 healthy controls matched by age, education and marital status. All participants were administered the Female Sexual Function Index (FSFI). Additionally, participants completed the Hospital Anxiety and Depression Scale (HADS). Results: Obese women reported significant impairment on most domains of sexual function, including sexual desire, arousal, lubrication, orgasm, and satisfaction, compared to healthy controls. The observed sexual impairment was associated with BMI but was not entirely attributed to the presence of anxiety or depression. Conclusion: Obese women complain of significant sexual impairment. Obesity-related sexual dysfunction appears to be a complex condition linked to a range of social, psychological and biological factors. Clinicians are encouraged to evaluate routinely sexual function in this patient population in order to detect those who are in need of intervention.

Background: In the non-superobese population, consensus is currently unavailable in bariatric surgery. We report the results of a prospective comparison of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP) in a non-superobese population. Methods: From 1994 to 2000,179 patients with clinically severe obesity underwent various surgical procedures in our department. During this time a prospective study was undertaken in order to compare VBG with RYGBP in morbidly obese patients with a BMI

Morbidly obese subjects may present with abnormal thyroid function tests but the reported data are scarce. Therefore, we studied the thyroid parameters in 144 morbidly obese patients, 110 females and 34 males, to assess the prevalence of hypothyroidism. Eleven percent (11.8%) carried the diagnosis of hypothyroidism and were undergoing levothyroxine (LT4) replacement therapy, 7.7% had newly diagnosed subclinical hypothyroidism, 0.7% had subclinical hyperthyroidism and 7.7% were euthyroid with positive antibodies (anti-thyroid peroxidase antibodies [TPOAb]). From the 144 subjects, we selected a cohort of 78 euthyroid subjects with negative TPOAb, who did not receive LT4 replacement or suppression therapy (the experimental group) and compared them to 77 normal-weight euthyroid subjects, TPOA-negative, matched for age and gender who served as controls. The experimental group had higher serum levels of triiodothyronine (T3), thyroxine (T4), free triiodothyronine (FT3), and thyrotropin (TSH) compared to the control group. Serum TSH concentration was associated with fasting serum insulin levels and insulin resistance but not with serum leptin levels, body mass index (BMI), fat mass, and lean body mass. In conclusion, in morbidly obese individuals, the prevalence of overt and subclinical hypothyroidism was high (19.5%). The morbidly obese subjects have higher levels of T3, FT3, T4, and TSH, probably the result of the reset of their central thyrostat at higher level.

The aim of this study was to determine prospectively the efficacy and safety of the biliopancreatic diversion with Roux-en-Y gastric bypass (BPD with RYGBP) procedure used as the primary bariatric procedure in super obese patients. The main characteristics of the BPD with RYGBP procedure were a gastric pouch of 15 +/- 5 ml, biliopancreatic limb of 200 cm, common limb of 100 cm, and alimentary limb of the remainder of the small intestine. From June 1994 through July 2003, 132 super obese patients (body mass index [BMI]: 57 +/- 7), with an incidence of comorbidities 6 +/- 2 per patient, underwent BPD with RYGBP and subsequent follow-up. Mean follow-up time was 29 +/- 14 months. Maximum weight loss was achieved at 18 months postoperative with average excess weight loss (EWL) 65%, average initial weight loss (IWL) 39%, and average BMI 35 kg/m(2). Thereafter, a decline was observed with EWL stabilizing at around 50%, IWL at around 30%, and BMI at around 40 kg/m(2), respectively, by the end of the study period. The majority of preexisting comorbidities were permanently resolved by the 6-month follow-up visit. Early mortality was 1% and early morbidity was 11%. Late morbidity was 27%, half of which was due to incisional hernia. Deficiencies of microelements were mild and successfully treated with additional oral supplementation. The incidence of hypoalbuminemia was 3% and there were no hepatic complications. We conclude that BPD with RYGBP is a safe and effective procedure for the super obese with few metabolic complications.

This study was performed to evaluate the impact of pro- and anti-inflammatory molecules and human leukocyte antigen DR (HLA-DR) expression as markers of immune status for the final outcome of septic patients. The study included 30 patients with severe sepsis due to community-acquired infections. Concentrations of tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), IL-8, IL-10, and transforming growth factor β1 (TGF-β1) in serum, as well as monocyte HLA-DR expression, were determined on admission and on days 3, 10, 13, and 17 during hospitalization. Of the 30 patients enrolled, 13 survived, while 17 died during their hospital stay. All patients had significantly lower HLA-DR expression and higher pro- and anti-inflammatory cytokine levels than healthy individuals. HLA-DR expression was significantly decreased in nonsurvivors at almost all time points. In nonsurvivors, higher levels in serum of TNF-α on days 13 and 17; IL-6 levels on day 3; and IL-10 on days 3, 10, and 13 were found. Baseline levels of TGF-β1 were significantly higher in survivors. Independent risk factors of mortality were IL-10 levels on days 3 and 10, while monocyte HLA-DR expression on admission was a good predictor for survival. Several pro- and anti-inflammatory cytokines are oversynthesized during severe infections, especially in patients with a poor outcome. Monocyte HLA-DR expression is an early and constant predictive marker for survival in severe sepsis, while serum IL-10 levels on days 3 and 10 have negative prognostic value for the final outcome.

The purpose of the present study was to investigate the prognostic role of severe hypoxemia on admission as an independent risk factor of pulmonary complications and mortality in patients with acute pancreatitis. Pulmonary complications were studied in 166 previously healthy patients with acute pancreatitis. Forty-eight patients (28.9%) developed one or more pulmonary complications, including pleural effusion, atelectasis, pulmonary consolidations, and acute respiratory distress syndrome (ARDS). Pulmonary consolidations (odds ratio = 7.25) and, especially, ARDS (odds ratio = 22.9) were significantly associated with severe baseline hypoxemia (PaO2

Item does not contain fulltext INTRODUCTION: In acute pancreatitis, enteral nutrition (EN) reduces the rate of complications, such as infected pancreatic necrosis, organ failure, and mortality, as compared to parenteral nutrition (PN). Starting EN within 24 h of admission might further reduce complications. METHODS: A literature search for trials of EN in acute pancreatitis was performed. Authors of eligible trials were requested to provide the data of all patients in the EN-arm of their trials. A meta-analysis of individual patient data was performed. The cohort of patients with EN was divided into patients receiving EN within 24 h or after 24 h of admission. Multivariable logistic regression, adjusting for predicted disease severity and trial, was used to study the effect of timing of EN on a composite endpoint of infected pancreatic necrosis, organ failure, or mortality. RESULTS: Observational data from 165 individuals from 8 randomised trials were obtained; 100 patients with EN within 24 h and 65 patients with EN after 24 h of admission. In the multivariable model, EN started within 24 h of admission compared to EN started after 24 h of admission, reduced the composite endpoint from 45% to 19% (adjusted odds ratio [OR] of 0.44; 95% confidence interval [CI] 0.20-0.96). Within the composite endpoint, organ failure was reduced from 42% to 16% (adjusted OR 0.42; 95% CI 0.19-0.94). CONCLUSIONS: In this meta-analysis of observational data from individuals with acute pancreatitis, starting EN within 24 h after hospital admission, compared with after 24 h, was associated with a reduction in complications.

We studied whether programmed cell death (or apoptosis) is the predominant mechanism in radiation-induced cell damage to rat intestinal mucosa and investigated the mechanism of the protective effect of GH and IGF-I in the same model. Male albino Wistar rats were divided into four groups: controls, radiation, radiation plus GH and radiation plus IGF-I. Radiation was administered on the first day and on day 4. All animals were sacrificed and segments of the terminal ileum were stained with hematoxylin–eosin. Apoptosis of the epithelial cells was identified at the cellular level by the TUNEL stain and was distinguished from necrosis by the characteristic morphology of the cells (cytoplasmic shrinkage, marginal chromatin condensation and generation of nuclear apoptotic bodies). Apoptotic cells in the control animals were few and detected only at the tips of the villi while in the irradiated animals almost all the epithelial cells were apoptotic, distributed from the crypts to the tips of the villi and the mucosa showed severe epithelial atrophy and ulceration. The histologic picture of the mucosa in the GH and IGF-I treated animals was similar to normal controls and apoptotic cells were restricted only at the tips of the villi. DNA and RNA from the mucosa cells were isolated and analyzed by electrophoresis. DNA fragmentation and RNA 28s band ribonuclease cleavage was observed only in the irradiated animals. We have shown that abdominal radiation causes intestinal epithelial cell damage mainly through the induction of apoptosis and the treatment with GH and IGF-I inhibits apoptosis of the cells and preserves the mucosal integrity.

Background Predicting successful outcomes after bariatric surgical procedures has been difficult, and the establishment of specific selection criteria has been a subject of ongoing research. In an effort to choose the most appropriate surgical procedure for each patient, we have established a specific set of selection criteria for each procedure based on degree of obesity, preoperative dietary habits, eating behavior, and various metabolic features. Methods From June 1994 to December 1998, 90 bariatric surgical procedures were performed at the authors' institution by a single surgeon (F.K.) based on specific selection criteria. Vertical banded gastroplasty (VBG) was performed in 35 patients, standard Roux-en-Y gastric bypass (RYGB) in 38 patients, and distal RYGB in 17 patients. All patients were monitored postoperatively 1, 3, 6, and 12 months and once per year thereafter, with an additional visit at 18 months in distal RYGB patients. Results Early postoperative morbidity ( 30 days) included 9 incisional hernias (2 in the VBG group, 5 after RYGB, and 2 in the distal RYGB group). There were 6 cases of staple-line disruption, 4 after VBG and 2 after standard RYGB, 1 of which resulted in stomal ulcer. Early postoperative mortality was 0%, and long-term mortality was 1.1%, which was due to pulmonary embolism in 1 standard RYGB patient on the 65th postoperative day. Average percentage of excess weight loss (%EWL) was 62% the first year, 61% the second year, and 50% the third year in VBG patients, and 63.6%, 65%, and 63.3%, respectively, in standard RYGB patients. In distal RYGB patients, where the patient number was significantly smaller, the %EWL at 1 and 2 years, respectively, was 51% and 53%. The most significant metabolic/nutritional complication was the appearance of hypoproteinemia (hypoalbuminemia) in 1 distal RYGB patient 20 months after surgery, which was corrected by total parenteral nutrition and subsequent increase in dietary protein intake. Significant improvement or resolution of preexisting comorbid conditions was observed in all patient groups. The postoperative quality of eating, as evaluated by variety of food intake and frequency of vomiting, was significantly better in RYGB patients. Conclusions These results show that selection of the bariatric surgical procedure to be performed in each patient based on specific criteria leads to acceptable weight loss, improvement in preexisting comorbid conditions, and a high degree of patient satisfaction in most patients. On the basis of our own observations as well as those of others, our selection criteria have become more strict over time and our selection of VBG as the operation of choice increasingly infrequent.

The effect of growth hormone (GH) and insulin-like growth factor-I (IGF-I) on intestinal mucosal integrity and bacterial translocation after abdominal radiation was studied in rats. Animals were divided into the following groups: I (control), II (radiation), III (radiation plus GH) and IV (radiation plus IGF-I). Radiation (1,100 cGy) was administered on the 1st day to groups II, III and IV. GH [0.25 mg/kg body weight (BW) s.c. once daily] was administered on days 1, 2 and 3 to group III, and IGF-I (0.1 mg/kg BW s.c. twice daily) was given on days 1, 2 and 3 to group IV. On day 4, animals were sacrificed. Cultures of the mesenteric lymph nodes (MLN) and blood cultures from aorta and portal vein were performed. The number of villi per centimeter (V/cm), the villus height (Vh), mitoses per crypt (M/C) and protein and DNA contents of the mucosa were evaluated in samples from the terminal ileum. Radiation increased the number of positive MLN cultures, while treatment with GH and IGF-I reduced them significantly. V/cm, Vh, M/C, protein and DNA contents were significantly increased in all irradiated animals treated with GH and IGF-I. In conclusion both GH and IGF-I are not only capable of improving the mucosal integrity but also to reduce the bacterial translocation that follows intestinal radiation. In small doses IGF-I could reproduce the effects of GH and in some parameters the effects were more pronounced, although not statistically significant. This suggests that the effects of GH on intestine could be mediated through the local and systemic generation of IGF-I.

Background Parenteral nutrition is well established for providing nutritional support in acute pancreatitis while avoiding pancreatic stimulation. However, it is associated with complications and high cost. Benefits of enteral feeding in other disease states prompted a comparison of early enteral feeding with total parenteral nutrition in this clinical setting. Methods Thirty-eight patients with acute severe pancreatitis were randomized into two groups. The first (n = 18) received enteral nutrition through a nasoenteric tube with a semi-elemental diet, while the second group (it = 20) received parenteral nutrition through a central venous catheter. Safety was assessed by clinical course of disease, laboratory findings and incidence of complications. Efficacy was determined by nitrogen balance. The cost of nutritional support was calculated. Results Enteral feeding was well tolerated without adverse effects on the course of the disease. Patients who received enteral feeding experienced fewer total complications (P < 0-05) and were at lower risk of developing septic complications (P < 0-01) than those receiving parenteral nutrition. The cost of nutritional support was three times higher in patients who received parenteral nutrition. Conclusion This study suggests that early enteral nutrition should be used preferentially in patients with severe acute pancreatitis. Severe acute pancreatitis is accompanied by increased resting energy requirements and loss of protein mass resulting from the inflammatory response following necrosis or inflammation of the pancreas and retroperitoneal tissues 1 . This, combined with the absence of oral intake, leads to a persistently negative nitrogen balance that appears to be associated with a higher mortality rate as a result of the loss of function and structural integrity of vital organs 2-4 . Thus, the provision of early aggressive nutritional support is of utmost importance in this clinical setting. Total parenteral nutrition (TPN) has been the standard practice for providing exogenous nutrients to patients with acute pancreatitis in order to improve nutritional status and at the same time to avoid pancreatic stimulation 5-8 . Howcver, TPN is associated with certain disadvantages. In particular, there is an increased risk of central catheter infection, severe hyperglycaemia, and other metabolic and clectrolyte disturbances 5-8 . TPN may also promote gut barrier alterations due to increased intestinal permeability 9-10 . The use of early enteral feeding (EF) for nutritional support in patients with acute pancreatitis has not been evaluated systematically. The commonly encountered problems of gastric atony and outlet obstruction have limited the successful delivery of enteral formulas to patients with severe acute pancreatitis. However, these problems may be overcome if enteral nutrition were to be delivered to the small intestine distal to the ligament of Treitz using elemental or semi-elemental low-fat diets 1,11,12 . The efficacy, tolerance. clinical outcome and cost of EF and TPN have been evaluated in patients with severe acutc pancreatitis.

Objecti6e: The palliation of dysphagia caused by esophageal carcinoma and other inoperable tumours obstructing the esophagus presents a challenge for the thoracic surgeon, in particularly when associated with fistula (F). In a prospective study over the last 5 years, we have evaluated the effectiveness of different approaches and types of prostheses to solve the above problem. Method: Thirty three patients (mean age: 63.5 years, range 42‐76, M:F:24:9) with inoperable tumours obstructing the esophagus underwent intubation and:or palliative surgery according to the following protocol: (1) Preoperative esophagography; (2) endoscopy and biopsy; (3) dilatation and insertion of prosthesis usually under general anaesthesia; and (4) re-evaluation the following day, in 30 days and as required thereafter. Prosthesis used were: Atkinson 3, Wilson-Cook (plain) 12, Wilson-Cook (cuffed) 4, Strecker (metallic self-expandable) 13. The patients were divided in three groups according to the extension of the disease: group A (n19) plain malignant strictures, group B (n 5) strictures with respiratory Fs, group C (n 9) strictures with mediastinal or pleural Fs. Results: All patients of group A had successful palliation irrespectively of prosthesis used and site of obstruction. One patient required two stents. There was no death and 50% survival at 6 months was 70%. In group B, a cuffed prosthesis successfully closed two bronchoesophageal Fs, while three patients underwent retrosternal bypass surgery. There was one death on the 26th postoperative day. In group C, one Strecker, two plain Wilson-Cook and two cuffed Wilson-Cook stents, although initially succeeded, in due course, failed to block the Fs in five patients who subsequently underwent bypass surgery with one death. With four patients both leak and dysphagia were significantly improved with the use of self-expandable stents therefore, not requiring surgery. Overall, there were two deaths but no failure in palliating dysphagia. Longer survival was 20 months. Patients with fistulae had poorer prognosis as compared to those suffering from plain malignant stricture (P0.01). Conclusions: Plain malignant inoperable oesophageal strictures can be successfully palliated with intubation. Complicated with fistula strictures, however, are difficult to manage and have a poor prognosis. Due to the fact that bypass surgery is associated with an increased mortality, it should be kept for those with late stent failures and fistula recurrences. Copyright © 1997 Elsevier Science B.V.

Major surgical trauma has been considered as a cause of immunosuppression mainly through the production of prostaglandin E2 from activated monocytes/macrophages. In the present study we investigated the effect of parenteral indomethacin--a cyclo-oxygenase inhibitor--on T-lymphocyte subsets and cytokine production in patients under major operations. We studied 20 patients undergoing major surgical procedures, 10 of whom were randomly treated pre- and post-operatively with indomethacin (group 2) and 10 were not (group 2). We measured total T-cells, T-helper, T-suppressor, T-helper/T-suppressor (Th/Ts) cell ratio, NK-cells and interleukin (IL-1) and tumor necrosis factor production by endotoxin- or phytohemagglutinin-stimulated peripheral blood mononuclear cells, before operation and at days 1, 3 and 7 postoperatively. We detected a significant increase in Th/Ts cell ratio and an improvement in delayed type hypersensitivity response in the treated group at day 3. We believe that the above immunomodulating effect of in vivo cyclo-oxygenase inhibition may be beneficial in patients under major surgical procedures with a high susceptibility to postoperative infections.

Laparoscopic Roux-en Y-Gastric bypass (LRYGBP) is the commonest available option for the surgical treatment of morbid obesity. Weight loss following bariatric surgery has been linked to changes of gastrointestinal peptides, shown to be implicated also in metabolic effects and appetite control. The purpose of this study was to evaluate whether gastric fundus resection in patients undergoing LRYGBP enhances the efficacy of the procedure in terms of weight loss, glucose levels, and hormonal secretion. Twelve patients underwent LRYGBP and 12 patients LRYGBP plus gastric fundus resection (LRYGBP+FR). All patients were evaluated before and at 3, 6, and 12 months postoperatively. Blood samples were collected after an overnight fast and 30, 60, and 120 min after a standard 300-kcal mixed meal. Body weight and body mass index decreased markedly and comparably after both procedures. Fasting ghrelin decreased 3 months after LRYGBP, but increased at 12 months to levels higher than baseline while after LRYGBP+FR was markedly and persistently decreased. Postprandial GLP-1, PYY, and insulin responses were enhanced more and postprandial glucose levels were lower after LRYGBP+FR compared to LRYGBP. Postoperatively, ghrelin changes correlated negatively with GLP-1 changes. Resection of the gastric fundus in patients undergoing LRYGBP was associated with persistently lower fasting ghrelin levels; higher postprandial PYY, GLP-1, and insulin responses; and lower postprandial glucose levels compared to LRYGBP. These findings suggest that fundus resection in the setting of LRYGBP may be more effective than RYGBP for the management of morbid obesity and diabetes type 2.

Biliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss and remission of diabetes type 2 (T2DM), but it is accompanied by nutrient deficiencies. Sleeve gastrectomy (SG) is a relatively new operation that has shown promising results concerning T2DM resolution and weight loss. The objective of this study was to evaluate and compare prospectively the effects of BPD long limb (BPD) and laparoscopic SG on fasting, and glucose-stimulated insulin, glucagon, ghrelin, peptide YY (PYY), and glucagon-like peptide-1 (GLP-1) secretion and also on remission of T2DM, hypertension, and dyslipidemia in morbidly obese patients with T2DM.Twelve patients (body mass index [BMI] 57.6 ± 9.9 kg/m(2)) underwent BPD and 12 (BMI 43.7 ± 2.1 kg/m(2)) underwent SG. All patients had T2DM and underwent an oral glucose tolerance test (OGTT) before and 1, 3, and 12 months after surgery.BMI decreased more after BPD, but percent excess weight loss (%EWL) was similar in both groups (P = .8) and T2DM resolved in all patients at 12 months. Insulin sensitivity improved more after BPD than after SG (P = .003). Blood pressure, total and LDL cholesterol decreased only after BPD (P.001). Triglycerides decreased after either operation, but HDL increased only after SG (P.001). Fasting ghrelin did not change after BPD (P = .2), but decreased markedly after SG (P.001). GLP-1 and PYY responses during OGTT were dramatically enhanced after either procedure (P = .001).SG was comparable to BPD in T2DM resolution but inferior in improving dyslipidemia and blood pressure. SG and BPD enhanced markedly PYY and GLP-1 responses but only SG suppressed ghrelin levels.

Background. Single-incision laparoscopic surgery is a rapidly emerging approach to gallbladder disease. Methods. From February 2009 to September 2010, 60 patients were subjected to single-incision laparoscopic cholecystectomy. In all the patients, a 12-mm incision was made in the umbilicus and a 2-trocar technique was applied. Gallbladder was suspended with 2 sutures and the procedure was accomplished with standard partly reusable laparoscopic instruments. Results. In all, 41 women (68.3%) and 19 men (31.7%) were enrolled in this study. Mean age was 50.7 years (range = 17-72 years), mean body mass index was 26.2 kg/m2 (range = 18.3-37.7 kg/m2) and mean operative time was 52.6 minutes (range = 30-120 minutes). No mortality or morbidity was recorded and hospital stay was less than 24 hours. At follow-up visits, no complications were recorded and cosmesis was excellent. Conclusion. Single-incision laparoscopic cholecystectomy can be safely performed with conventional instrumentation with minimal cost.

Objective: Plasma cortisol in obese subjects does not differ from that in normoweight subjects. Extra-adrenal cortisol production by 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) can result in local hypercortisolemia. The aim of the present study was to examine the role of visceral hypercortisolemia in the development of metabolic syndrome in severe obesity. Methods: Eight lean women during hysterectomy (controls) and 19 severely obese women during bariatric surgery were studied, 8 without metabolic syndrome (OM– group) and 11 with it (OM+ group). Biopsies of omental and subcutaneous fat were performed in the severely obese women during surgery, but only omental biopsies in the controls. Expression of 11β-HSD1, glucocorticoid receptor α (GRα) and glucocorticoid receptor β (GRβ) was evaluated using real-time PCR.Results: Omental 11β-HSD1 expression was different between groups (one-way ANOVA, p < 0.01). Post-hoc analysis revealed that mean omental 11β-HSD1 mRNA levels were higher in the OM– group compared to controls, whereas they were similar when comparing the OM+ group with lean controls. Expression of 11β-HSD1 in subcutaneous fat was not different between OM+ and OM– groups. GRα expression in omental fat did not differ among groups or between omental and subcutaneous fat in severely obese patients. An expression of GRβ was not detected.Conclusion: Contrary to our original hypothesis, omental 11β-HSD1 expression is not increased in the OM+ group.

Background Gastrointestinal leaks after bariatric surgery are the primary cause of serious morbidity and mortality nationwide. Enteric leaks can differ in severity, presentation, and management, depending on the type of bariatric surgery performed. Our objective was to describe the clinical presentation and treatment outcomes in patients who developed postoperative leaks at a university hospital bariatric referral center. Methods A retrospective observational study using descriptive statistics was conducted on data from 1499 bariatric operations performed at our institution from 1994 to 2010. The procedures included a variant of biliopancreatic diversion with long limb reconstruction (BPD-LL) in 820 patients (791 open and 29 laparoscopic), Roux-en-Y gastric bypass (RYGB) in 301 patients (105 open and 196 laparoscopic), and sleeve gastrectomy (SG) in 208 patients (5 open and 203 laparoscopic). Results Of these patients, 30 (2%) developed a postoperative leak at a median of 18 days (range 2–32) postoperatively. The primary procedure was laparoscopic SG in 12 patients (5.8%), laparoscopic RYGB in 5 patients (1.6%), and BPD-LL (12 open and 1 laparoscopic) in 13 patients (1.6%). In all patients who underwent laparoscopic SG, the leak site was along the staple line. The gastrojejunal anastomosis was leaking in 4 (80%) and 12 (92.3%) patients in the RYGB and BPD-LL group, respectively. The enteroenteral anastomosis was leaking in 1 patient each in the RYGB and BPD-LL groups (20% and 7.7%, respectively). Three patients (10%; 2 from the BPD-LL group and 1 from the RYGB group) presented with generalized peritonitis and underwent emergency re-exploration; nonoperative treatment was successful in the remaining 27 patients (90%). Stent placement for persistent gastrocutaneous fistula was used in 9 patients (30%; 8 from the SG cohort and 1 from the BPD-LL group). The overall mortality rate was 3.3%. Conclusion In our experience, most leaks resulting from antiobesity surgery were successfully managed using nonoperative methods. Rapid management of gastrointestinal leaks using computed tomography-guided drainage and/or intraluminal stent placement could be the treatment of choice in selected patients.

Bariatric procedures are effective in the life-long treatment of clinically severe obesity, but they are technically demanding and have known complications. The present study presents mortality and morbidity with different procedures from the prospective 15-year bariatric database of the University Hospital of Patras in Greece. From June 1994 through December 2008, 1,162 morbidly obese patients underwent various bariatric procedures at our institution (35 vertical banded gastroplasties, 151 laparoscopic sleeve gastrectomies, 90 open and 137 laparoscopic Roux-en-Y gastric bypasses, 699 biliopancreatic diversions with long limbs, and 50 reoperations). Postoperative metabolic deficiencies and causes of early and late morbidity for various bariatric procedures were compared by using the z-test for the comparison of proportions. Logistic regression analysis was used to model the occurrence of early and late death and complications. Total mortality was 1.81% (early 0.6%, intermediate 0.26%, late 0.95%). No significant predictors for early death were found, but age (odds ratio (OR), 1.077; 95% confidence interval (CI), 1.024–1.133; P = 0.004) and BMI (OR, 1.156; 95% CI, 1.023–1.306; P = 0.02) were predictors for late death. Early and late morbidity were 8% and 27.71%, respectively. The total leakage incidence was 1.98% and was significantly higher (P

Objective To evaluate the safety and effectiveness of revisional bariatric surgery at a tertiary institution. Revisional bariatric operations for unsuccessful weight loss or intolerable complications following the primary intervention are increasing. Design Case series from a prospective database. Setting Tertiary bariatric referral center. Patients From 1995 to 2008, 56 patients who had been formerly operated on for clinically severe obesity underwent a revisional procedure at our institution. Their mean (SD) age and body mass index were 39.6 (9.6) years and 46.9 (16.4), respectively. They were divided into 3 groups according to the indications for reoperation: (1) unsatisfactory weight loss (n = 39), (2) severe nutritional complications (n = 15), and (3) intolerable adverse effects (n = 2). Main Outcome Measures Effectiveness of the procedures according to the indication of revision and overall morbidity and mortality rates. Results Mean (SD) follow-up was 102 (8) months. There was no mortality but there was an early morbidity rate of 33.9% due to postoperative complications, including 2 cases of acute renal failure (3.6%), 5 anastomotic leaks (13.1%), 8 cases of pneumonia (14.3%), and 1 case each of wound infection, incisional dehiscence, bile leak, and small-bowel obstruction (1.8%). Late complications included stenosis of the gastrojejunal anastomosis in 2 patients (3.6%), hypoalbuminemia in 2 patients (3.6%), and incisional herniation in 9 patients (16.1%). Late morbidity was 23.2%. Conclusion Although revisional bariatric surgery is associated with higher risk of perioperative complications compared with the primary procedures, it appears to be safe and effective when performed in experienced centers.

Total parenteral nutrition (TPN) induces biliary dilatation, sludge and formation of gallstones. Cholecystokinin (CCK) induces gallbladder (GB) contraction. During thyrotropin-releasing hormone (TRH) testing for thyroid function, we observed that patients felt a strong micturition reflex attributable to smooth muscle contraction of the bladder. The possibility of GB contraction after TRH administration was studied compared to cholecystokinin-octapeptide (CCK-OP) and/or fatty meal administration. The effect of intravenous (IV) CCK-OP, TRH and a combination of the two on GB volume was studied in normal volunteers without GB or liver disease and in patients receiving TPN for greater than 2 weeks. Subjects included six normal volunteers who received an oral fatty meal only, 18 other normal volunteers (Group A) and 18 TPN patients (Group B). Gallbladder contraction was estimated by ultrasound prior to and after administration of the fatty meal; in the other 36 subjects, GB contraction was calculated prior to and after administration of CCK-OP, TRH, or both. Results are expressed as a percentage of the GB basal volume using each subject as his or her own control. Group A and Group B were each divided into three equal subgroups receiving IV CCK-OP (A1, B1), TRH (A2, B2), or both (A3, B3).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of neurotensin (NTN) on preventing microbial translocation and preserving intestinal mucosal integrity after abdominal radiation was studied in rats. Animals were divided into the following groups: I (control), II (radiation control) and III (radiation and NTN). Radiation (1,100 cGy) was administered on the 1st day to groups II and III. NTN (300 micrograms/kg) was given intraperitoneally to group III animals, once daily for 3 days. On the 4th day, mesenteric lymph nodes (MLN) were obtained and cultured. Villi per centimeter (V/cm), villus height (Vh) and mitoses per crypt (M/c) were evaluated from ileal mucosa. Radiation increased positive MLN cultures, while treatment with NTN reduced them significantly. V/cm and Vh also returned to normal levels after NTN treatment, while M/c were increased in all irradiated animals. It was shown that NTN reduces bacterial translocation after abdominal radiation. Examination of ileal mucosa indicates that this can be attributed to the improvement of the mucosal integrity, due to the trophic effect of the hormone on the gut.

During illness, thyroid parameters undergo acute changes, which are known as non-thyroidal illness syndrome, the cause of which has not been elucidated. In vitro and in vivo data demonstrate that leptin regulates the expression of thyrotropin-releasing hormone (TRH)-mRNA in the paraventricular nucleus as well as the secretion of thyrotropin (TSH) in response to fasting in humans and animals. Moreover, in healthy adults, TSH and leptin have almost identical circadian rhythms. Our aim was to investigate the secretion of leptin and TSH, and their probable interaction, during the acute stress that is induced by surgery.We studied 18 severely obese but otherwise healthy men. All participants were admitted to the hospital in the morning after an overnight fast. On the following day, 14 of the participants underwent bariatric surgery at 0900. The remaining four participants did not undergo surgery and served as controls. Serum samples to measure the levels of TSH and leptin were collected from all participants, as follows: upon admission to the hospital (baseline values) and on the following day at 0900 and every 10 min, thereafter for 9 h.The serum TSH increased during the first hour after skin incision (si) and then decreased gradually throughout the rest of the observation period. In contrast, during the first hour after si, the leptin levels remained unaltered. The leptin levels then decreased and reached a nadir at 4 h and 10 min post si after which they remained constant for approximately 1 h. Thereafter, while TSH continued to decrease, leptin started to increase and reached baseline values at 9 h post si. In control subjects, the TSH and leptin profiles seemed parallel each other.During acute surgical stress, the secretion of TSH and leptin in severely obese men is asynchronous and causality could not be proven.

Bariatric surgery is currently the most effective treatment in morbidly obese patients, leading to durable weight loss.In this prospective double blind study, we aim to evaluate and compare the effects of laparoscopic Roux-en-Y gastric bypass (LRYGBP) with laparoscopic sleeve gastrectomy (LSG) on body weight, appetite, fasting, and postprandial ghrelin and peptide-YY (PYY) levels.After randomization, 16 patients were assigned to LRYGBP and 16 patients to LSG. Patients were reevaluated on the 1st, 3rd, 6th, and 12th postoperative month. Blood samples were collected after an overnight fast and in 6 patients in each group after a standard 420 kcal mixed meal.Body weight and body mass index (BMI) decreased markedly (P0.0001) and comparably after either procedure. Excess weight loss was greater after LSG at 6 months (55.5% +/- 7.6% vs. 50.2% +/- 6.5%, P = 0.04) and 12 months (69.7% +/- 14.6% vs. 60.5% +/- 10.7%, [P = 0.05]). After LRYGBP fasting ghrelin levels did not change significantly compared with baseline (P = 0.19) and did not decrease significantly after the test meal. On the other hand, LSG was followed by a marked reduction in fasting ghrelin levels (P0.0001) and a significant suppression after the meal. Fasting PYY levels increased after either surgical procedure (Por = 0.001). Appetite decreased in both groups but to a greater extend after LSG.PYY levels increased similarly after either procedure. The markedly reduced ghrelin levels in addition to increased PYY levels after LSG, are associated with greater appetite suppression and excess weight loss compared with LRYGBP.

Long-chain triglycerides (LCTs) contained in total parenteral nutrition (TPN) regimens provide a considerable energy substrate in malnourished patients. Their effect on the immune system is controversial, however. In this randomized, prospective study we investigated the possible differences between the effect of TPN with LCTs or medium-chain triglycerides (MCTs) on T-lymphocyte subpopulations. Our study included 15 normal subjects, 20 patients receiving glucose-based TPN, and 40 patients receiving glucose-fat-based TPN. In the last group 20 patients received TPN that included LCTs and 20 received 50% MCTs and 50% LCTs. T-lymphocyte subpopulations, including total T cells and T-helper, T-suppressor, and NK cells, as well as the ratio of helper to suppressor T cells were determined before and 10 d after initiation of TPN. We found a significant decrease in the ratio of helper to suppressor T cells in the LCT group although no such difference was detected in the MCT-LCT group. No difference whatever was found in total T cells and helper, suppressor, and NK cells.

Super-obese patients with BMIor = 70 kg/m(2) present a special subgroup among the obese population due to the higher incidence of severe comorbidities and increased technical difficulties in perioperative management. The optimal surgical approach still remains controversial.From January 2002 to October 2007, 68 super-obese patients with BMIor = 70 kg/m(2) (75.7 +/- 5.61) and various comorbidities (mean 1.45 +/- 1, range 0-5), underwent a variant of biliopancreatic diversion with Roux-en-Y reconstruction (BPD-RYGBP) at our institution. The mean age was 39.6 +/- 9.5 years, and the excess weight was 146.1 +/- 24.5 kg. The safety and the effectiveness of the procedure were prospectively evaluated.Thirty-one patients have completed their second postoperative year. Mean BMI after 2 years follow-up was 35 +/- 5.33 kg/m(2) (p0.001) and mean %EWL was 79.9% (range 57.17-149.89). Significant improvement in preexisting comorbidities was also observed (mean 0.95 +/- 0.1, range 0-2; p0.001). Early major postoperative complications included one case of acute renal failure (1.47%), three anastomotic leaks (4.41%), four pulmonary embolisms (5.88%), one hemorrhage requiring reoperation (1.47%), and three cases of pneumonia (4.41%), resulting in a total morbidity rate of 8.82% and a mortality rate of 8.82%. Late complications included small bowel obstruction in four patients (5.88%), pulmonary embolism in one patient (1.47%), severe hypoalbuminemia requiring artificial nutrition support in six patients (8.82%), and incisional hernia in 23 patients (33.8%). Late morbidity was 41.1%, and there was no late mortality.BPD-RYGBP appears to be an effective procedure in patients with BMIor = 70 kg/m(2) providing adequate weight loss and improvement of co-existing comorbidies after 2 years. Nevertheless, it is associated with higher morbidity and mortality rates compared to patients with BMI70 kg/m(2) undergoing the same surgical procedure.

To investigate whether weight loss after bariatric surgery (gastric bypass) is associated with changes in aortic function (an important determinant of left ventricular function) and in left ventricular function, in morbidly obese individuals 3 and 36 months after surgery.We used echocardiography to evaluate 60 obese individuals [body mass index (BMI)40 kg/m2] who underwent surgery and 20 obese individuals who neither underwent surgery nor lost weight, at baseline and at 3 and 36 months of follow-up, and 40 lean individuals (BMI25 kg/m2) of similar age, sex and risk factors, at baseline. We measured aortic strain, distensibility, stiffness index, pressure-strain modulus and Doppler indices of left ventricular diastolic dysfunction (ratio of peak early to peak atrial flow velocities, isovolumic relaxation time and deceleration time).Baseline aortic function and Doppler diastolic indices were impaired in obese individuals compared with those who were lean (P0.05). During 3 and 36 months of follow-up, BMI and left ventricular diastolic diameter, volume, mass and wall thickness were reduced, and indices of aortic function and left ventricular diastolic function were normalized, in obese individuals after surgery [aortic distensibility (cm2 x dyn(-1) x 10(-6)): 1.9 before surgery, 3.4 at 3 months after surgery and 4.3 at 3 years after surgery, compared with 3.36 in lean controls; P0.01], but not in those who did not lose weight. The reduction in BMI after surgery was related to the concomitant improvement in indices of aortic function (P0.01) and isovolumic relaxation time (P0.05) after adjustment for age, sex and concomitant reduction in blood pressure, lipids and glucose concentrations.Weight reduction after bariatric surgery normalizes aortic function, reduces left ventricular hypertrophy and, thus, improves left ventricular diastolic function in morbidly obese individuals over a 3-year period of follow-up.

Background: The gastrointestinal peptide hormones ghrelin and PYY have been shown to play a role in the regulation of metabolism and appetite. We investigate the effect of Biliopancreatic diversion with Roux-en-Y gastric bypass (BPD-RYGBP) on the circulating levels of ghrelin and peptide YY during the first 3 months postoperatively as compared to the effects of colectomy, an abdominal operation of similar severity. Methods: Fasting plasma levels of ghrelin and PYY were determined in 20 super-obese patients (BMI≥50) who underwent BPD-RYGBP and in 13 patients who underwent colectomy for large bowel cancer. Fasting plasma ghrelin and PYY levels were measured preoperatively and during the postoperative period on days 1, 3, 7, 30 and 90 in all patients of both groups, and at 1 year for 10 of the patients who had attained 1-year follow up. Results: Preoperatively, both plasma ghrelin and PYY levels were lower in the BPD-RYGBP group of patients. A temporary decrease in plasma ghrelin levels was observed in both groups of patients during the immediate postoperative period, with a gradual return to preoperative levels by the 3rd month. In addition, ghrelin concentrations increased at 1 year to levels 40% higher than those at baseline, in 10 of the BPD-RYGBP patients who had completed the 1-year follow-up (P=0.004). Plasma PYY levels in the colectomy group decreased in the first 3 postoperative days and then returned to baseline. In contrast, PYY levels in the BPD-RYGBP group did not change during the early postoperative period but increased to levels 50% higher at 3 months (P

Background: In the non-superobese population, an agreement has not been made as to the optimal bariatric operation. The present study reports the results of a prospective comparison of Roux-en-Y gastric bypass (RYGBP) and a variant of biliopancreatic diversion (BPD) in a non-superobese population. Methods: From a cohort of 130 patients with BMI 35 to 50 kg/m2, 65 patients were randomly selected to undergo RYGBP and 65 to undergo BPD. All patients underwent complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Results: Patients in both groups have completed their second postoperative year. Mean % excess weight loss (%EWL) was significantly better after BPD at all time periods (12 months, P=0.0001 and 24 months, P=0.0003), and the %EWL was >50% in all BPD patients compared to 88.7% in the RYGBP patients at 2-year follow-up. No statistically significant differences were observed between the 2 groups in early and late non-metabolic complications. Hypoalbuminemia occurred in only 1 patient (1.5%) after RYGBP and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at the second year follow-up (t-test, P

Background: Patients undergoing either Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) with RYGBP are at risk of developing metabolic sequelae secondary to malabsorption.We compared the differences in nutritional complications between these two bariatric operations. Methods: A retrospective analysis of a prospective database was done. From June 1994 to December 2001, 243 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 79 (BMI 45.6 ± SD=4.9) who underwent RYGBP (gastric pouch 15 ± 5ml, biliopancreatic limb 60-80 cm, alimentary limb 80-100 cm and common limb the remainder of the small intestine), and 95 super obese (BMI 57.2 ± 6.1) who underwent a BPD (gastric pouch 15 ± 5ml, biliopancreatic limb 150-200 cm, common limb 100 cm and alimentary limb the remainder of the small intestine), were selected and studied for the incidence of micronutrient deficiencies and level of serum albumin at yearly intervals postoperatively. A variety of nutritional parameters including Hb, Fe, ferritin, folic acid, vitamin B12 and serum albumin were measured preoperatively and compared postoperatively at 1, 3, 6, 12, 18 and 24 months, and yearly thereafter. Results: Nutritional parameters were compared preoperatively and at similar periods postoperatively. No statistically significant (P

Background: Obese patients undergoing bariatric surgery are at a high risk of developing fatal pulmonary embolism or post-thrombotic syndrome.The prophylactic use of low molecular weight heparins (LMWHs) is correlated with a significant reduction in post-operative venous thrombosis in patients undergoing orthopedic or general surgery. In morbidity obese patients, the limited number of comparative trials are too sparse to allow a consensus on the effective dose and dosing schedule. Methods: In a prospective study to evaluate the effect of two doses of nadroparin as prophylaxis for venous thromboembolism following bariatric surgery, 60 consecutive patients undergoing Rouxen-Y gastric bypass were randomized to receive either 0.6 ml (5700 IU) or 1.0 ml (9500 IU) of nadroparin started pre-operatively and then given once daily post-operatively until discharge. Results: No statistically significant differences between the two groups were detected in any of the measured coagulation parameters either preoperatively or at days 1, 3 and 5 postoperatively.No thrombotic events were observed pre- or post- operatively, and no patient developed meta-thrombotic syndrome at the 3 and 6 months follow-up. No bleeding events occurred in the patients given the lower dose compared with two major hemorrhages in those given the higher dose. Conclusion: Our results indicate that 0.6 ml (5700 IU) of nadroparin once daily is safe and well-tolerated, and it is as effective in prophylaxis of venous thromboembolism as the higher dose of 1 ml (9500 IU), in such high risk patients.

Background: Morbidly obese patients who undergo purely restrictive bariatric operations may fail to maintain satisfactory long-term results. In an attempt to achieve the best possible outcome after restrictive procedures, we have employed preoperative selection criteria and are following this selected patient group over time in order to evaluate longterm success. Materials and Methods: From June 1994 through August 2000, 166 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 35 underwent vertical banded gastroplasty (VBG) based on selection criteria, including degree of obesity and dietary habits and eating behavior. All patients were seen at 1, 3, 6, 9, and 12 months postoperatively and yearly thereafter. Average follow-up time now is 4.1 years (29-75 mos.), and follow-up is 100%. A multivitamin and mineral supplement is administered to all patients for at least 6 months. Radiology examination is performed in all patients on the 4th postoperative day and at each yearly visit, in order to check for staple-line disruption and stomal stenosis. Results: Early postoperative morbidity was 5.7%. Late postoperative morbidity was 22.8%. A significant number of patients had some degree of stomal stenosis as shown by radiology examination, but to date there has been no need for surgical revision. There has been no early or late mortality.Weight loss results expressed as average percent excess weight loss (% EWL) were as follows: 61% (28-90) at 1 year, 61% (20-90) at 2 years, 57% (13-91) at 3 years, 56% (25-87) at 4 years and 37% (24-59) at 5 years following surgery. A significant number of patients with excellent weight loss had a high frequency of vomiting. Evaluation by BAROS showed that 25% of patients had an overall unsatisfactory outcome. Anemia and iron deficiency were found in 46% and 32% ofVBG patients respectively.Recurrence of preexisting comorbidities was significant if lost weight was regained. Conclusions: In spite of preoperative selection of patients for VBG, a significant percentage of patients had poor overall results in terms of weight loss, quality of life, and resolution of preexisting comorbidities. For these reasons and based on the long-term results published by others, VBG is no longer our preferred surgical option in morbidly obese patients.