Age as a Predictive Factor of Testosterone Improvement in Male Patients After Bariatric Surgery: Preliminary Results of a Monocentric Prospective Study

Background

Male obesity can be associated with symptomatic alterations in sex hormones resulting in hypogonadism and impaired fertility. Surgical-induced weight loss can improve the sex hormone profile in men. The aim of the present study is to evaluate the levels of sex hormones in obese males before and after 6 months from bariatric surgery. Possible mechanisms and clinical implications are also discussed.

Methods

We evaluated levels of serum total testosterone (TT), sex hormone-binding globulin (SHBG), calculated free testosterone (cFT), follicular-stimulating hormone (FSH), luteinizing hormone (LH), and total estradiol (E2) in 20 male patients at the baseline and 6 months after bariatric surgery.

Results

Median [interquartile range] age at the time of surgery was 40.5 [27.2–46.7] years with a median [interquartile range] BMI of 43.6 [40.9–48.7] kg/m². The median baseline levels of TT, SHBG, cFT, LH, and FSH were reduced; levels of E2 were elevated. At 6 months from surgery, the median BMI dropped to 34.8 [31.7–40.5]?kg/m², TT, SHBG, cFT, LH, and FSH increased, while levels of E2 decreased. The improvement in the sex hormone profile was more evident in younger patients, with a statistically significant difference in cFT following surgery and in the raise of TT and cFT between the groups of patients below and above 35 years. At multivariate analysis, the age was the best predictive factor of the postoperative variations of TT.

Conclusions

These preliminary results confirm the general improvement in sex hormone profile in obese men after bariatric surgery and introduce the age as a possible contributing factor to this improvement.     

Long-term Changes in Leptin, Chemerin and Ghrelin Levels Following Different Bariatric Surgery Procedures: Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Background

Different studies have evaluated changes in adipo/cytokine levels after bariatric surgery and have given conflicting results. The adipo/cytokines, leptin and chemerin, and the orexigenic hormone, ghrelin, have been shown to play a role in the regulation of metabolism and appetite. The aims of our study were to test the levels of these molecules after bariatric surgery and to compare the results between Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.

Methods

We analysed circulating levels of chemerin, ghrelin and leptin in 30 morbidly obese women (body mass index of >40 kg/m²). Subjects were studied at three time points: baseline (before the surgery started), and after 6 and 12 months.

Results

After surgery, chemerin (baseline, 95.03?±?23.79; after 12 months, 76.80?±?21.51; p?=?0.034) and leptin levels (baseline, 248.17?±?89.16; after 12 months, 63.85?±?33.48; p?<?0.001) were significantly lower than their baseline levels, whereas ghrelin was higher (baseline, 0.87?±?0.38; after 12 months, 1.08?±?0.31; p?=?0.010). Fasting glucose, insulin and homeostasis model assessment of insulin resistance levels were markedly lower postoperatively. High-density lipoprotein levels moderately increased and triglyceride levels sharply decreased. There were no differences between the types of bariatric surgery in terms of weight reduction, general metabolic state or adipo/cytokine levels after surgery.

Conclusions

Our study demonstrates a marked decrease in fasting leptin and chemerin levels, and an increase in ghrelin levels, after bariatric surgery-induced weight loss, independently of the type of surgery performed. Further studies are needed on the interrelation between the changes in the circulating levels of these molecules and the efficacy of the bariatric surgery procedures to induce the beneficial metabolic changes and to sustain body weight loss.     

Greater Short-Term Weight Loss in Women 20–45 versus 55–65 Years of Age Following Bariatric Surgery

Background

Whether and how sex and age affect bariatric-surgery outcome is poorly understood. Estrogens regulate body composition in women and animals, and increase weight loss in a rodent model of gastric bypass, suggesting that premenopausal women may lose more weight following bariatric surgery.

Methods

One thousand three hundred fifty-six female gastric-bypass or gastric-banding patients were retrospectively grouped as 20–45 years old (presumptively premenopausal; n?=?1,199) and 55–65 years old (presumptively postmenopausal; n?=?157). Mixed-model ANCOVA followed by Bonferroni-corrected t tests were used to categorically test the effect of age on percent excess body weight loss (%EBWL) at 1 and 2 years post-surgery, controlling for preoperative EBW and surgery type. Age effects were also tested dimensionally in all women and in 289 male patients.

Results

Twenty- to forty-five-year-old women showed greater %EBWL 1 and 2 years post-surgery than 55–65-year-old women (p’s?<?0.0005). No age effect was detected in 20–25- vs. 30–35-, 30–35- vs. 40–45-, or 20–25- vs. 40–45-year-old women (p’s?>?0.2) This age effect was detected only after gastric banding, with 20–45-year-old women losing ～7 kg more than 55–65-year-old women after 2 years. Dimensional analysis confirmed a significant inverse effect of age on bariatric surgery outcome in women, but did not detect any effect in men.

Conclusions

Results indicate that 55–65-year-old women lose less weight than 20–45-year-old women in the initial 2 years after bariatric surgery, especially gastric banding; this may be mediated by age- or menopause-associated changes in physical activity, energy expenditure, or energy intake.     

Serum SPARC and Matrix Metalloproteinase-2 and Metalloproteinase-9 Concentrations after Bariatric Surgery in Obese Adults

Background

Remodeling of the extracellular matrix (ECM) of adipose tissue is regarded as part of the pathophysiology of obesity. Secreted protein acidic and rich in cysteine (SPARC) was the first ECM protein described in adipose tissue. Matrix metalloproteinases (MMPs) also play a role in ECM remodeling, and MMP-2 and MMP-9 may be associated with abnormal ECM metabolism. Here, we investigated changes in serum SPARC, MMP-2, and MMP-9 concentrations after bariatric surgery in obese adults.

Methods

We recruited 34 obese patients who were scheduled to undergo bariatric surgery for weight loss. We analyzed changes in serum SPARC, MMP-2, and MMP-9 concentrations before and 9 months after bariatric surgery and any associations between changes in SPARC, MMP-2, and MMP-9 concentrations and obesity-related parameters.

Results

Serum leptin levels significantly decreased, and the serum adiponectin level significantly increased after bariatric surgery. The serum SPARC concentration decreased significantly from 165.0?±?18.2 to 68.7?±?6.7 ng/mL (p?<?0.001), and the MMP-2 concentration also decreased significantly from 262.2?±?15.2 to 235.9?±?10.5 ng/mL (p?<?0.001). Changes in the serum SPARC concentration were significantly correlated with HOMA-IR changes, and changes in the serum MMP-9 concentration were found to inversely correlate with serum adiponectin changes.

Conclusion

These findings show that significant decreases in serum SPARC and MMP-2 concentrations occur after bariatric surgery. Our results thus suggest that weight loss via bariatric surgery could alter the ECM environment, and that these changes are related to certain metabolic changes.     

Improvement of Type 2 Diabetes Mellitus (T2DM) After Bariatric Surgery—Who Fails in the Early Postoperative Course?

Backround

Diabetes surgery in nonobese or moderately obese patients is an emerging topic. The identification of preoperative factors predicting diabetes outcome following bariatric surgery, especially for metabolic nonresponders, is imperative.

Methods

Between 2005 and 2011, 235 patients underwent bariatric surgery for morbid obesity. Eighty-two of 235 patients had type 2 diabetes mellitus (T2DM). Data from this subgroup were investigated with univariate and multivariate analyses to identify predictors for metabolic nonresponse after surgery.

Results

Diabetes did not improve in 17/82 patients within 3?months after surgery. No correlation between excess body weight loss and metabolic response was detected. In univariate analysis, preoperative duration of diabetes was significantly longer in the nonresponder group (9.146 vs. 6.270?years; *p?=?0.016), preoperative HbA1c levels were significantly higher among the nonresponders than among the responders (8.341 vs. 7.781?%; *p?=?0.033), and more patients in the nonresponder group were reliant on a multi-drug approach preoperatively (*p?=?0.045). In multivariate analysis, age, preoperative doses of insulin, and preoperative oral antidiabetics showed positive correlation to metabolic nonresponse after surgery (*p?=?0.04; *p?=?0.021; *p?=?0.021). Metabolic failure rate was lower after Roux-en-Y gastric bypass compared to other bariatric procedures (**p?=?0.008).

Conclusions

A long history of preoperative T2DM, high preoperative HbA1c levels, and a preoperative therapy consisting of diverse approaches to diabetes treatment may be factors predicting failure of diabetes improvement in the early postoperative course after bariatric surgery. Age, preoperative insulin, and oral antidiabetic medication can be regarded as independent, significant predictors for metabolic outcome after bariatric surgery.     

Bariatric Surgery Patients Exhibit Improved Memory Function 12 Months Postoperatively

Background

Previous work from our group demonstrated improved memory function in bariatric surgery patients at 12 weeks postoperatively relative to controls. However, no study has examined longer-term changes in cognitive functioning following bariatric surgery.

Methods

A total of 137 individuals (95 bariatric surgery patients and 42 obese controls) were followed prospectively to determine whether postsurgery cognitive improvements persist. Potential mechanisms of change were also examined. Bariatric surgery participants completed self-report measurements and a computerized cognitive test battery prior to surgery and at 12-week and 12-month follow-up; obese controls completed measures at equivalent time points.

Results

Bariatric surgery patients exhibited cognitive deficits relative to well-established standardized normative data prior to surgery, and obese controls demonstrated similar deficits. Analyses of longitudinal change indicated an interactive effect on memory indices, with bariatric surgery patients demonstrating better performance postoperatively than obese controls.

Conclusions

While memory performance was improved 12 months postbariatric surgery, the mechanisms underlying these improvements were unclear and did not appear attributable to obvious postsurgical changes, such as reductions in body mass index or comorbid medical conditions. Future studies employing neuroimaging, metabolic biomarkers, and more precise physiological measurements are needed to determine the mechanisms underlying memory improvements following bariatric surgery.     

Maternal Ileal Interposition Surgery Confers Metabolic Improvements to Offspring Independent of Effects on Maternal Body Weight in UCD-T2DM Rats

Background

Increasing numbers of people are undergoing bariatric surgery, of which approximately half are women in their childbearing years. However, information on the long-term effects of maternal bariatric surgery in their children is lacking. Furthermore, since bariatric surgery is performed to reduce body weight, clinical studies have not been able to differentiate between benefits to the child due to maternal body weight loss versus other maternal postoperative metabolic changes. Therefore, we used the University of California, Davis, type 2 diabetes mellitus (UCD-T2DM) rat model to test the hypothesis that maternal ileal interposition (IT) surgery would confer beneficial metabolic effects in offspring, independent of effects on maternal body weight.

Methods

IT surgery was performed on 2-month-old prediabetic female UCD-T2DM rats. Females were bred 3 weeks after surgery, and male pups were studied longitudinally.

Results

Maternal IT surgery resulted in decreased body weight in offspring compared with sham offspring (P?<?0.05). IT offspring exhibited improvements of glucose-stimulated insulin secretion and nutrient-stimulated glucagon-like peptide-2 (GLP-2) secretion (P?<?0.05). Fasting plasma unconjugated bile acid concentrations were 4-fold lower in IT offspring compared with sham offspring at two months of age (P?<?0.001).

Conclusions

Overall, maternal IT surgery confers modest improvements of body weight and improves insulin secretion and nutrient-stimulated GLP-2 secretion in offspring in the UCD-T2DM rat model of type 2 diabetes, indicating that this is a useful model for investigating the weight-independent metabolic effects of maternal bariatric surgery.     

Bone loss in relation to serum levels of osteoprotegerin and nuclear factor-κB ligand: the Tromsø Study

Summary

In this longitudinal study of 4,137 persons, bone mineral density was negatively associated with osteoprotegerin at baseline in both genders. In postmenopausal women not using hormone replacement therapy (HRT), bone-loss increased with increasing osteoprotegerin levels, whereas no relationship was found in men, premenopausal women, or postmenopausal women taking HRT.

Introduction

In a population-based study of 2,003 men and 2,134 women, the relationship between the osteoprotegerin (OPG)/factor-κB ligand (RANKL) system and bone mineral density (BMD) and changes in BMD was examined.

Methods

Baseline measurements included height, weight, BMD of the forearm, OPG, RANKL, vitamin D, and serum parathyroid hormone (PTH) and information about lifestyle, prevalent diseases, and use of medication. BMD was remeasured at follow-up 6 years later.

Results

BMD was negatively associated with OPG at baseline in both men and women (p trend over OPG levels?=?0.01 and 0.007, respectively, after adjustments for age, and other confounders). In postmenopausal women not on hormone replacement therapy, bone loss increased with increasing OPG (p?=?0.005), whereas no relationship was found in men, premenopausal women, or postmenopausal women on HRT (p?≥?0.28). BMD at baseline and BMD changes were not related to RANKL levels in any of the groups (p?≥?0.14).

Conclusions

In postmenopausal women not using HRT, bone loss associated positively with OPG. The results indicate that in women deficient in sex steroids, the OPG/RANKL system may play an important counter regulatory role in order to avoid bone loss and maintain BMD. In men and women replete in sex steroids, the OPG/RANKL system was not associated with BMD.     

Five-Year Changes in Psychiatric Treatment Status and Weight-Related Comorbidities Following Bariatric Surgery in a Veteran Population

Background

Although bariatric surgery is an established treatment for obesity, less is known regarding the long-term effects of surgery on psychiatric function. This paper reports changes in psychiatric treatment status, weight, and weight-related comorbidities over 5?years of follow-up among a population of veterans completing bariatric surgery.

Methods

We assessed 55 veterans undergoing bariatric surgery at a single Veteran Affairs medical center for 5?years post-surgery. Patients completed a pre-surgery clinical interview with a licensed psychologist. Using computerized medical records, we tracked pre- to post-surgery involvement with antidepressants, anxiolytics, psychotherapies, and overall psychiatric treatment visits along with changes in weight and metabolic function.

Results

Rates of antidepressant use and/or involvement with psychotherapy for depression declined from 56.4?% at pre-surgery to 34.6?% at 5?years post-surgery, p?=?0.01. Anxiolytic use and/or involvement with psychotherapy for anxiety, however, increased from 23.6 to 32.7?% pre- to 5?years post-surgery. Average psychiatric treatment volume remained similar to pre-surgery status across follow-up. These mixed indicators of psychiatric improvement occurred despite marked metabolic improvements from surgery. Mean percent excess weight loss?=?51.7 and 41.3 (1 and 5?years post-surgery, respectively), systolic blood pressure (?6.8?mmHg (14.3)/?6.1?mmHg (12.8), respectively), glucose levels (?18.6?mg/dL (30.2)/?10.0?mg/dL (25.9), respectively), triglycerides (?78.2?mg/dL (96.7)/?69.1?mg/dL (102.2), respectively) and high-density lipoproteins (+7.1 (9.9)/+11.3 (11.3), respectively) levels each improved.

Conclusions

We report evidence of decreased antidepressant use and depression therapies following bariatric surgery, but no improvements on rates of anxiolytic use and anxiety therapies or on overall psychiatric treatment involvement. Despite metabolic improvements, bariatric patients with psychiatric histories may warrant ongoing attention to mental health.     

Excess Body Weight Loss is Associated with Nonpathological Gait Patterns in Women 4 to 5 Years After Bariatric Surgery

Background

This study examined relationships between excess body weight (EBW) loss and current gait and functional status in women 5 years after Roux-en-Y gastric bypass surgery.

Methods

Gait data were analyzed in nine female bariatric patients for relationships with longitudinal changes in weight, body composition, and physical function assessed by the Short Musculoskeletal Functional Assessment (SMFA) questionnaire and the timed “get-up-and-go” (TGUG) test. Gait characteristics in the bariatric sample were also compared to an age- and BMI-matched nonsurgical reference sample from the Fels Longitudinal Study.

Results

Bariatric patients lost an average of 36.4 kg (61.1 %) of EBW between preoperative and 5-year follow-up visits (P?<?0.01); SMFA function index scores and TGUG times also decreased (both P?<?0.01). Degree of EBW loss was correlated with less time spent in initial double support and more time in single support (both P?=?0.02), and for all gait variables, the bariatric sample fell within the 95 % confidence intervals of gait/EBW relationships in the reference sample.

Conclusions

Gait and function 5 years after bariatric surgery were characteristic of current weight, not preoperative obesity, suggesting that substantial, sustained recovery of physical function is possible with rapid surgical weight loss.     

Body Image After Sleeve Gastrectomy: Reduced Dissatisfaction and Increased Dynamics

Background

Individuals with severe obesity commonly report poor body image. Improvement in body image has been found after conservative weight reduction programs as well as after bariatric surgery (gastric bypass, biliopancreatic diversion, or gastric banding). However, no studies investigating body image after laparoscopic sleeve gastrectomy (LSG) are available.

Methods

Of 70 consecutive patients who planned to undergo LSG at a comprehensive obesity center, 62 patients were included in the study and evaluated before surgery. Their mean body mass index (BMI) was 51.3?kg/m² and the patients?? mean age before surgery was 43.8?years. One-year follow-up data were obtained for 51 patients (82.3?%). Body image was assessed using the body image questionnaire (BIQ-20), and depression was assessed using the Patient Health Questionnaire (PHQ-9).

Results

Patients reported poor body image before surgery. One year after LSG, negative evaluations of the body and perceptions of body dynamics and vitality had markedly improved, without reaching healthy levels. No correlations between body image and weight-related parameters (BMI, percentage of excess weight loss) or mood after 1?year were found.

Conclusions

Body image improves after LSG. This improvement might reflect changes to patients?? attitudes, beliefs, and thoughts rather than real weight lost. Further studies should investigate the factors that mediate improvement of body image after bariatric surgery.     

Gastric Bypass and Sleeve Gastrectomy: the Same Impact on IL-6 and TNF-α. Prospective Clinical Trial

Background

Due to the association between the quantity of adipose tissue and concentrations of interleukin-6 (IL-6) and tumor necrosis factor (TNF-α), this work aimed to assess the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures on serum IL-6 and TNF-α concentrations.

Methods

This study evaluated serum IL-6 and TNF-α levels, as well as routine anthropometric and biochemical values, before and 1 year post-bariatric surgery. Fifty percent of patients (n?=?24) underwent RYGB, and 50 % (n?=?24) underwent SG. Prior to bariatric surgery, IL-6 and TNF-α mRNA expression levels in subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) were investigated in obese women.

Results

There was a significant reduction (p?<?0.05) in all anthropometric and routine biochemical measurements in patients in the RYGB and SG groups 1 year post-surgery. The serum concentrations of IL-6 and TNF-α were reduced following surgery in both groups (p?<?0.05). No differences in the relative expression levels of IL-6 and TNF-α were found between SAT and VAT prior to bariatric surgery.

Conclusions

RYGB and SG procedures demonstrated a similar impact on adipokine levels in women 1 year post-surgery. Both techniques may improve the course of chronic diseases and the state of inflammation associated with obesity.     

Changes in Metabolic Profile and Adipoinsular Axis in Morbidly Obese Premenopausal Females Treated with Restrictive Bariatric Surgery

Background

The aim of the present study was to evaluate the effects of surgically induced weight loss on the metabolic profile and adipocytokine levels in premenopausal morbidly obese females.

Methods

Twenty premenopausal morbidly obese (MO) women with a median age of 34?years (range: 24?C48?years) and a median body mass index (BMI) of 41.47?kg/m² (range: 38.0?C56.73?kg/m²) were studied (13 women underwent gastric banding and 7 women underwent sleeve gastrectomy). In addition, 20 lean premenopausal women with a median age of 32?years (range: 22?C44?years) and a median BMI of 20.0?kg/m² (range: 18.5?C24.7?kg/m²) were also studied. Anthropometric measurements and metabolic parameters were analyzed in each patient, along with changes in leptin, adiponectin, resistin, and interleukin-6 (IL-6) before surgery, 6?months after surgery, and 12?months after surgery. Comparisons with the reference normal-weight subjects were also performed.

Results

Both weight and BMI were found to be significantly decreased postoperatively. A 54.5% loss of excess BMI was observed 12?months after surgery, and was associated with significant improvement in all anthropometric and metabolic parameters. Twelve months after surgery we also observed decreased levels of serum leptin, resistin, and IL-6; increased levels of serum adiponectin; and a remarkable improvement in metabolic syndrome markers. Furthermore, postoperative serum resistin and IL-6 levels were found to reach those of normal-weight volunteers.

Conclusions

The results of this study suggest that weight loss through restrictive bariatric surgery results in a significant reduction in leptin, resistin, and IL-6 levels, and an increase in adiponectin levels, in addition to improving insulin sensitivity and glucose and lipid homeostasis in young morbidly obese female patients. These changes were significantly correlated with the magnitude of weight loss.     

Impact of Weight-Loss Surgery and Diabetes Status on Serum ALT Levels

Background

Alanine aminotransferase (ALT) is used to detect non-alcoholic fatty liver disease and has been associated with increased risk of metabolic syndrome and type II diabetes mellitus (T2DM). Bariatric procedures result in significant weight loss and a rapid resolution of T2DM. We aimed to study the impact of bariatric interventions on ALT levels in patients with or without T2DM and compare this effect between different types of weight-loss procedures.

Methods

We reviewed 756 patients undergoing bariatric surgery. Demographics, co-morbidities, baseline and post-operative ALT and HbA1C levels, weight-loss data, and diabetes status were recorded. ALT levels were compared between different procedures and between diabetic and non-diabetic patients. Chi-square test, ANOVA, and t test were used to evaluate outcomes.

Results

Males and diabetics had significantly higher ALT at baseline. Both Roux-en-Y gastric bypass surgery (RYGB) and laparoscopic adjustable gastric banding (LAGB) resulted in significant reduction in ALT levels beginning at the third post-operative month (20 and 17?%, respectively, compared to baseline, p?Conclusions RYGB and LAGB decrease ALT levels to the same degree and independent of weight loss. Our data confirm higher ALT in diabetics and demonstrate a rapid normalization after bariatric surgery with a simultaneous decrease in HbA1C. These results suggest that ALT may be used as a marker of metabolic improvement after bariatric surgery.     

Bariatric Surgery Improves Urinary Incontinence but Not Anorectal Function in Obese Women

Background

While the association between obesity and urinary incontinence (UI) in women has been clearly documented, the relationship with anal incontinence (AI) is less well defined; moreover, while bariatric surgery has been shown to improve UI, its effect on AI is still unclear.

Methods

A total of 32 obese women were studied by means of PFDI-20 and PFIQ-7 questionnaires and anorectal manometry before and after bariatric surgery and compared with 71 non-obese women.

Results

Obese women showed worse overall questionnaire results (OR 5.18 for PFDI-20 and 2.66 for PFIQ-7). Whereas obese women showed worse results for urinary sub-items and a higher urge UI incidence (43.8 vs 18.3 %, p?=?0.013), they did not show worsening in colorecto-anal symptoms. Post-operatively, median PFDI-20 total score did not change (24.2 vs 26.6, p?=?ns), while there was an improvement in urinary score (14.6 vs 8.3, p?<?0.001); median PFIQ-7 improved (4.8 vs 0.0, p?=?0.044), but while the urinary score improved (2.4 vs 0.0, p?=?0.033), the colorecto-anal score did not change significantly. Although after surgery urge UI decreased from 43.8 to 15.6 % (p?=?0.029), the incidence of any AI increased from 28.1 to 40.6 % (p?=?ns) and flatus incontinence increased from 18.8 to 37.5 % (p?=?ns). Anorectal manometry did not show significant changes after surgery.

Conclusions

Obese women had worse questionnaire results, but while showing a higher incidence of UI, they did not experience anorectal function worsening. After bariatric surgery, there was a slight improvement in PFD symptoms related to UI, but anorectal function did not change significantly and flatus incontinence increased.     

Effects of Obesity on Posture and Walking: Study Prior to and Following Surgically Induced Weight Loss

Background

We investigate whether in severely obese people a marked weight loss may influence individual postural control and motor activities and then reverse the alterations caused by the extra load of body mass. Recent studies have shown that most severely obese patients have various degrees of impairment of postural control, but only a few studies considered those subjects before and after a marked weight loss.

Methods

Ten obese and ten subjects of average weight took part in our experiment. The subjects were requested to perform four different tasks. All obese patients repeated the tasks 1 year after undergoing bariatric surgery.

Results

We have found differences between obese and normal-weight people in the execution of all four work tasks. However, a year after surgery, obese patients showed a change in the execution of only two tasks, keeping the same performance in the other two.

Conclusions

The excess of fat mass alters the execution of some tasks, as confirmed by the improvement obtained after weight loss. For other work tasks, we can hypothesize that the neurophysiological plasticity of the neuro-muscular system would require more time to adapt.     

Patientenselektion als Schlüssel zum Erfolg der metabolischen Chirurgie

Background

The indications for bariatric interventions consist of the objectives to improve the quality of life and to prolong survival by remission of obesity-associated comorbidities. Until now the selection criteria for patients to undergo surgery which allow a prediction of therapeutic success are obscure.

Objective

The aim of the study was to identify the prerequisites for selection of overweight and obese patients to undergo bariatric surgery.

Results

Obesity per se is a proven indication for bariatric surgery due to the associated increase in mortality; however, not all obese patients can be considered for weight reduction surgery. A decisive factor for patient selection is the evidence of behavioral change regarding nutrition, composition and frequency of meals as well as increased ambulation. In patients with psychiatric diseases and behavioral disorders responsible for obesity a specific therapy is mandatory as well as intensive counseling and adherence to a lifelong follow-up.

Discussion

It seems that therapeutic success on a long-term basis is only guaranteed by behavioral changes. Preoperative multimodal therapy does not influence the outcome but it seems possible that such treatment may contribute to increased adherence to the behavior necessary for therapeutic success. Nevertheless, such treatment must not constitute a barrier against bariatric surgery. However, patients who are not willing to change their pathological behavior do not qualify for weight-reducing surgery because otherwise therapeutic success is questioned.     

Lifestyle After Bariatric Surgery: a Multicenter, Prospective Cohort Study in Pregnant Women

Background

To ensure a good pregnancy outcome after bariatric surgery, a healthy life-style and a multidisciplinary prenatal follow-up is recommended. The aim of this prospective multicenter trial was to compare diet quality and physical activity (PA) of pregnant women with bariatric surgery with current lifestyle recommendations.

Methods

Pregnant women (>18?years, prepregnancy BMI 28?±?6?kg/m2, 39?% nulliparae, 25?% smokers) with a history of bariatric surgery were recruited and allocated to two groups according to surgery type: restrictive (N?=?18) and bypass group (N?=?31). One 7-day dietary record and one Kaiser questionnaire on PA were collected during the first and second trimester. Dietary quality was assessed using the Healthy Eating Index.

Results

The diet quality did not change during pregnancy (restrictive group p?=?0.050; bypass group p?=?0.975) and was comparable between groups (first trimester p?=?0.426; second trimester p?=?0.937). During the first trimester, 15?% of the pregnant women had a healthy diet quality, 82?% had a diet that needed improvement, and 3?% had a poor diet quality. This was independent of surgery type and was comparable in the second trimester (p?=?0.525). No difference between groups was observed for the PA level, but the PA level in the bypass group significantly decreased from the first to the second trimester (p?=?0.033).

Conclusions

Nutritional advice and lifestyle coaching in this high-risk population seems recommendable since only 15?% of the pregnant women had a healthy diet quality, 25?% was smoking at the beginning of pregnancy, and the reported PA levels were low.     

SHBG levels are associated with bone loss and vertebral fractures in patients with prostate cancer

Summary

Fractures are increased among prostate cancer patients. No data have been reported in patients with prostate cancer about the relation between serum sex hormone-binding globulin (SHBG) and bone metabolism. We found that SHBG levels were inversely related to bone mass and vertebral fractures in this population.

Introduction

Fractures are increased among prostate cancer patients, especially those on androgen deprivation therapy (ADT), but few data are available on the role of SHBG in their bone status. Our objective was to analyze the relation between serum SHBG and bone metabolism in prostate cancer patients.

Methods

This is a cross-sectional study including 91 subjects with prostate cancer (54 % with ADT). We measured serum levels of SHBG and sex steroids, bone mineral density (BMD) by dual-energy X-ray absorptiometry, and prevalent radiographic vertebral fractures.

Results

SHBG levels were inversely related to BMD (femoral neck: r?=??0.299, p?=?0.00; total hip: r?=??0.259, p?=?0.019). Subjects with osteoporosis had higher SHBG concentrations than patients without osteoporosis (60.97?±?39.56 vs 44.45?±?23.32 nmol/l, p?=?0.022). Patients with SHBG levels in the first quartile (>57.6 nmol/l) had an odds ratio (OR) for osteoporosis of 2.59 (95 % CI, 1.30–5.12; p?=?0.009) compared with patients with lower SHBG levels. In patients with SHBG >57.6 nmol/l, the OR for vertebral fractures was 2.34 (95 % CI, 1.15–4.78; p?=?0.034). The calculated OR was higher after adjustment for age (OR, 5.16; 95 % CI, 1.09–24.49; p?=?0.039), estrogens (OR, 6.45; 95 % CI, 1.44–28.95; p?=?0.023), and androgens (OR, 5.51; 95 % CI, 1.36–22.37; p?=?0.017).

Conclusions

In prostate cancer patients, SHBG levels were inversely related to bone mass and vertebral fractures. Determination of the serum SHBG level may constitute a useful and straightforward marker for predicting the severity of osteoporosis in these patients.     

Incidence of Venous Thromboembolism After Bariatric Surgery: A Population-Based Cohort Study

Background

The incidence of venous thromboembolism (VTE) after bariatric surgery is uncertain.

Methods

Using the resources of the Rochester Epidemiology Project and the Mayo Bariatric Surgery Registry, we identified all residents of Olmsted County, Minnesota, with incident VTE after undergoing bariatric surgery from 1987 through 2005. Using the dates of bariatric surgery and VTE events, we determined the cumulative incidence of VTE after bariatric surgery by using the Kaplan–Meier estimator. Cox proportional hazards modeling was used to assess patient age, sex, weight, and body mass index as potential predictors of VTE after bariatric surgery.

Results

We identified 396 residents who underwent 402 bariatric operations. The most common operation was an open Roux-en-Y gastric bypass (n?=?228). Eight patients had VTE that developed within 6 months (7 within 1 month) after surgery; five events occurred after hospital discharge but within 1 month after bariatric surgery. The cumulative incidence of VTE at 7, 30, 90, and 180 days was 0.3, 1.9, 2.1, and 2.1 %, respectively (180-day 95 % confidence interval (CI), 0.7–3.6 %). Patient age was a predictor of postoperative VTE (hazard ratio, 1.89 per 10-year increase in age; 95 % CI, 1.01–3.55; P?=?0.05).

Conclusions

In our population-based study, bariatric surgery had a high risk of VTE, especially for older patients. Because most VTE events occurred after hospital discharge, a randomized controlled trial of extended outpatient thromboprophylaxis is warranted in patients undergoing open Roux-en-Y gastric bypass for medically complicated obesity.