Increased Expression and Activity of Hepatic Lipase in the Liver of Morbidly Obese Adult Patients in Relation to Lipid Content

Background  The types and sources of lipid deposition in the liver of most patients with morbid obesity, as well as the effects of bariatric surgery, are discussed. Methods  In 26 patients with morbid obesity who underwent bariatric surgery, we analyzed different kinds of lipids and hepatic lipase (HL) from both plasma and liver biopsies performed 12–18 months after surgery. Results  The HL activity and HL-mRNA in morbidly obese (MO) livers were high (258 ± 17 mU/g, and 4.5-fold, respectively); after surgery, the activity decreased (137 ± 15 mU/g, p < 0.001) but not the levels of HL-mRNA (4.3-fold). Plasma HL activity was also high (4.31 ± 0.94 mU/mL plasma), and it decreased during weight loss (2.01 ± 0.29 mU/mL, p < 0.01); moreover, it correlated (r = 0.3694, p < 0.05) with decreased liver HL activity. Adrenocorticotropic hormone in MO was higher (27 ± 3 pg/mL) than after surgery (13 ± 1 pg/mL, p < 0.001). All hepatic and plasma lipids were significantly increased in MO patients, but, after bariatric surgery, most of those parameters recovered or normalized. Liver HL activity correlated with total and esterified cholesterol (r = 0.4399, p < 0.001 and r = 0.4395, p < 0.01, respectively). Conclusion  High HL in MO patients could allow for liver intake of cholesterol that could be re-exported to steroidogenic organs to synthesize steroidal hormones. A decrease of plasma HL during weight loss could be a good index for improvement of liver disease.     

Negative-pressure sternal wound closure with interrupted subcuticular suturing and a subcutaneous drain tube reduces the incidence of poststernotomy wound infection after coronary artery bypass grafting surgery

To retrospectively evaluate the effect of negative-pressure sternal wound closure (NPSWC) with a subcutaneous closed drain tube on the sternal surgical site infection (SSI) incidence. After propensity score matching of 231 patients undergoing coronary artery bypass grafting (CABG), we compared 104 pairs in the NPSWC and historical control groups. In the molecular analysis, the interleukin-6 (IL-6), basic fibroblast growth factor (b-FGF), and transforming growth factor β1 (TGF-β1) levels in the wound fluid were measured using two different reservoir types at postoperative days 2 and 7. NPSWC significantly reduced the SSI incidence from 10.6 to 2.9%. No mediastinitis occurred in the NPSWC group. A multivariate logistic regression analysis identified female sex (p = 0.0040) and no NPSWC (p = 0.0084) as significant risk factors for sternal SSI development. The Negative-pressure value was 49.4 ± 4.1 and 115.5 ± 15.2 mmHg in the standard-type (SSR) and bulb-type suction reservoirs (BSR), respectively. Given that growth factors were affected by the difference in negative pressure, the IL-6, b-FGF, and TGF-β1 levels were significantly higher in the BSR than in the SSR. NPSWC using a subcutaneous closed drain tube was effective in preventing sternal SSI after CABG and may accelerate wound healing even when both internal thoracic arteries are harvested. University Hospital Medical Information Network Clinical Trials Registry, registration number: UMIN000037060.     

How to define anemia in children with chronic kidney disease?

In a cross-sectional study, we compared the prevalence of anemia based on age- and gender-specific reference intervals for hemoglobin (Hgb) and hematocrit (Hct) with the Kidney Disease Outcomes Quality Initiative (KDOQI) anemia definition (Hgb < 110 g/L) in 351 children with chronic kidney disease (CKD) stages I–V. Cystatin C-based GFRs were 122 ± 36 mL/min/1.73 m² in patients with stage I CKD (n = 196), 76 ± 8 mL/min/1.73 m² for stage II (n = 104), 45 ± 9 mL/min/1.73 m² for stage III (n = 36), and 22 ± 5 mL/min/1.73 m² in patients with stage IV+V CKD (n = 15). Fifty-nine patients received iron therapy and 32 patients were treated with Darbepoetin. For Hgb, a total of 90 patients fit the age and gender derived criteria, compared to only 54 patients identified by the KDOQI guidelines (p = 0.0010). Similarly, for Hct, a total of 78 patients fit the age and gender derived criteria, which was a significantly higher proportion than the 56 identified by the KDOQI guidelines (r = 0.22, p = 0.0435). There was a significant correlation between the GFR and both the Hgb Z-score (p = 0.0068) and the Hct Z-score (p = 0.0128). There was poor agreement between conventional and KDOQI definitions of anemia in children with CKD.     

Baroreceptor-heart rate reflex sensitivity enhancement after urinary bladder distention in essential hypertensives

Our objective was to determine if urinary bladder distention modifies the sensitivity of the baroreceptor-heart rate reflex in hypertensive and control subjects. The baroreceptor-heart rate reflex sensitivity was measured in 15 male patients (mean age 37 ± 8 years) with mild untreated hypertension (mean 163 ± 8/95 ± 12 mmHg) and 17 age- and sex-matched control subjects before and after urinary bladder distention. Bladder filling was performed infusing saline heated to 37°C via a urinary catheter; the volume infused in each patient corresponded to that which caused the urge to void without reaching the pain threshold. The baroreceptor-heart rate reflex sensitivity was determined correlating the variations of the systolic pressure and of the peak blood flow velocity in the common carotid artery with the variations of the ECG RR′ interval of the following heart beat, both during spontaneous and phenylephrine-induced fluctuations of the haemodynamic variables. After bladder distention the diastolic pressure of the hypertensive subjects increased significantly (95 ± 12 vs. 100 ± 12 mmHg; P < 0.02), whereas the heart rate decreased (RR=873 ± 70 vs. 926 ± 80 ms; P < 0.005). These parameters were unchanged in the normotensive subjects (84 ± 9 vs. 83 ± 8 mmHg and 914 ± 158 vs. 913±140 ms, respectively). The baroreceptor-heart rate reflex sensitivity, measured on the basis of spontaneous pressure and carotid blood flow velocity fluctuations in relationship to RR changes, decreased in the normotensive subjects after bladder distention (10.7 ± 4.6 vs. 9.4 ± 2.7 ms/mmHg; P < 0.05 and 423 ± 99 vs. 356 ± 102 ms/kHz; P < 0.01, respectively), whereas it increased in the hypertensive patients (6.9 ± 3.6 vs. 8.3 ± 2.8 ms/mmHg; P < 0.03, and 332 ± 86 vs. 381 ± 97 ms/kHz; P < 0.03 respectively). After bladder distention and phenylephrine administration the baroreceptor-heart rate reflex sensitivity, measured by the correlation between systolic pressure and RR interval, increased only in the hypertensive group (10.2 ± 5.4 vs. 15.2 ± 7.7 ms/mmHg; P < 0.005). In conclusion urinary bladder distention provokes in hypertensives but not normotensive controls a brisk parasympathetic response of the component of the baroreceptor-heart rate reflex which controls heart rate. Received: 17 June 1998 / Accepted: 20 October 1998     

Gastroesophageal Reflux Disease in Morbid Obesity: The Effect of Roux-en-Y Gastric Bypass

Background  Gastroesophageal reflux disease (GERD) is a common condition in obesity. The impact of Roux-en-Y gastric bypass (RYGBP) on GERD is poorly known. We studied the effect of the RYGBP on GERD in patients with morbid obesity (MO). Methods  Twenty consecutive patients with MO (BMI > 40 kg/m²) were studied before and 6 months after RYGBP. GERD symptoms were evaluated with Carlsson–Dent questionnaire (CDQ). All the patients underwent esophageal manometry and ambulatory 24-h pH-metry. Chi-square test was used to compare categorical variables, and Wilcoxon test was used for numerical variables. A p value under 0.05 was considered significant. Results  There were 16 women (80%) and 4 men (20%) with mean age 38.9 ± 6.9 years included in this study. BMI was 48.5 ± 6.2 kg/m² and 33.2 ± 4.5 kg/m² before and after RYGBP, respectively. Mean weight reduction was 42.5 ± 9.7 kg (p < 0.001). Reflux symptoms measured by CDQ and esophageal acid exposure improved significantly after RYGBP. The percentage of time of pH < 4 was 10.7 ± 6.7 before and 1.6 ± 1.2 after the surgical procedure (p < 0.001). LES basal pressure before and after the RYGBP was 18 ± 11 and 20.1 ± 5.6 mmHg (p = 0.372), and the esophageal body amplitude was 104.2 ± 47.2 and 75.1 ± 36.2 mmHg, respectively (p = 0.005). Conclusion  RYGBP improves GERD symptoms and reduces esophageal acid exposure in patients with MO.     

Reconstructive Procedures after Massive Weight Loss

Background Following excess weight loss in many patients, a dermolipectomy of the abdomen, arms and thighs becomes necessary. This kind of operation was offered to 88 former morbidly obese patients after having lost between 50% and 75% of their excess weight. Methods and Results Abdomen: Because of a distinct pannus, a dermolipectomy was performed in 66 females and 16 males. An average of 2800 ± 1381 g of tissue was removed from the females and 3116 ± 2195 g from the males. Operative time was 166 ± 35 and 177 ± 46 minutes for the female and male patients, respectively. Minor and major wound healing disorders occurred in 23% and 19% of the patients. In two females, a panniculectomy (12.4/13.5 kg) was performed after they had reached 150 kg of body weight. Thighs: A medial thigh lift was performed in 19 females (excision of varicose veins was included in 9 patients). In patients receiving a dermolipectomy only, 1212 g of tissue was removed in 172 ± 81 minutes. Five patients had complications (wound infection, lymphatic fistula). With both dermolipectomy and varicectomy, 1358 g of tissue were removed in 294 ± 80 minutes. Four patients developed a wound infection. Arms: 7 female patients had brachioplasty performed, with an average of 410 g of tissue removed from both arms over a period of 161 ± 64 minutes. In one patient, a neurolysis of the ulnar nerve became necessary due to postoperative edema. Conclusions Dermolipectomy and/or panniculectomy should be offered to bariatric patients who have lost massive amounts of weight.     

Limberg flap procedure for pilonidal sinus disease: results of 353 patients

Purpose Pilonidal sinus disease is common especially in young adult males. Many surgical and nonsurgical methods have been described. Some surgical techniques for the treatment still have high recurrence rate. The aim of this study was to evaluate advantages and long term results of Limberg flap surgical technique. Methods From November 2001 to December 2004, 353 patients [335 male, 18 female; average age = 24.65 ± 4.2 (range, 15–53) years] with primary or recurrent pilonidal sinus disease were operated on under spinal anesthesia by rhomboid excision and Limberg flap. Follow-up examinations were made at the end of the 4 weeks and 3, 6, 12, 18, and 24 months after surgery. Results The mean duration of symptoms was 23.28 ± 16.09 (range, 2–140) months. The mean duration of hospital stay was 4.51 ± 2.85 (range, 2–19) days. Thirty nine patients (11%) had recurrent disease. Total wound dehiscence and flap necrosis did not occur in any patient. Recurrences were observed in 11 patients (3.1%) at the end of the follow up period. Conclusion Quick healing time, short hospital stay, early return to daily life, low complication and recurrence rate are the important advantages of the Limberg flap procedure. We think using closed suction drain in Limberg flap operation is not necessary. In the light of this study results, Limberg flap surgical technique may be an ideal operation for pilonidal sinus disease.     

The Relationship Between Esophageal Peristalsis and In Vivo Intraband Pressure Measurements in Gastric Banding Patients

Intraband pressure (IBP) measurement may be a less invasive method to assess esophageal motility response to band adjustment and restrictive integrity of the device in Swedish adjustable gastric band (SAGB) patients. However, the relationship between IBP and esophageal function is not yet established. Our aim was to characterize in vivo IBP–peristalsis associations in SAGB patients. Ten patients in their second postoperative year were prospectively recruited. IBP was measured via percutaneous port, and concurrent esophageal manometry was performed using an 8-channel catheter. Contraction length and amplitude were measured with both methods. The IBP–peristalsis correlation was computed using the R-square of the regression analysis (R ²) for band volumes ranging from 4 to 9 mL. One hundred ten swallows were studied. Excellent IBP–peristalsis correlation was observed in 6 of 10 patients (267 contractions): contraction length R ² = 0.8537 and amplitude R ² = 0.7365 (p-value of slope < 0.001). Mean contraction length was 17 ± 7 (4–42) s for manometry and 18 ± 7 (5–43) s for IBP. Mean amplitude was 55 ± 55 (9–209) mm Hg for manometry and 67 ± 47 (7–190) mm Hg for IBP. A weak IBP–peristalsis correlation was observed in the remaining four patients: two had impaired lower sphincter relaxation, one had band slippage, and one had disruption of the port needle connection. In vivo IBP measurement may be reliable in the assessment of esophageal peristalsis in response to band adjustments and the restrictive integrity of the device in patients with intact esophageal function. More studies are warranted to completely assess the potential for IBP to be indicative of the presence of band-related complications.     

Cadherin 5 and Annexin V as Circulating Endothelial Microparticles: Markers for Atherosclerotic Vascular Lesions in Patients with Chronic Renal Failure

Cardiovascular disease is the leading cause of death in Chronic kidney disease patients. This study tries to identify circulating endothelial microparticles {MPs} [such as Cadherin 5 and Anexin V] in CKD patients with and without IHD as potential new risk factors of atherosclerotic vascular disease. This study was carried out in Theodor Bilharz Research Institute [TBRI] on 60 patients with chronic kidney disease on maintenance hemodialysis. They were 41 male and 19 females selected from hemodialysis unit in TBRI. They were further subclassified into the following two groups according to the Echocardiography and Electrocardiogram (ECG) to 25 patients of chronic kidney disease without cardiac complications (17 males, 8 females and ages were 53.5 ± 9.9 years) and 35 patients of chronic kidney disease with cardiac complications (24 males, 11 females and ages were 57.5 ± 7.4 years). Twenty healthy subjects were selected as healthy control, their age 50 ± 9 years. Cadherin 5 & Annexin V Were done by enzyme linked immunosorbant assay (ELISA). The mean cadherin 5 levels in CKD with ischemic HD, CKD without ischemic HD and control group were 86.99 ± 21.51, 33.21 ± 8.65 and 2.63 ± 1.47 respectively which significantly higher in CKD with ischemic HD and CKD without ischemic HD than control group (p < 0.01) and significantly higher in CKD with ischemic HD than CKD without ischemic HD (p < 0.01). As regard to the mean annexin v levels in CKD with ischemic HD, CKD without ischemic HD and control group were 83.73 ± 22.64, 28.51 ± 9.73 and 0.47 ± 0.36 respectively which significantly higher in CKD with ischemic HD and CKD without ischemic HD than control group (p < 0.01) and significantly higher in CKD with ischemic HD than CKD without ischemic HD (p < 0.01). Endothelial dysfunction leading to atherosclerotic vascular disease in patients with CKD can be assessed quantitatively by measurement of plasma levels of endothelial microparticles such as CD144-EMP (Cadherin 5) and Annexin V.     

Hemorrhage-Induced Hepatic Injury and Hypoperfusion can be Prevented by Direct Peritoneal Resuscitation

Background  Crystalloid fluid resuscitation after hemorrhagic shock (HS) that restores/maintains central hemodynamics often culminates in multi-system organ failure and death due to persistent/progressive splanchnic hypoperfusion and end-organ damage. Adjunctive direct peritoneal resuscitation (DPR) using peritoneal dialysis solution reverses HS-induced splanchnic hypoperfusion and improves survival. We examined HS-mediated hepatic perfusion (galactose clearance), tissue injury (histopathology), and dysfunction (liver enzymes). Methods  Anesthetized rats were randomly assigned (n = 8/group): (1) sham (no HS); (2) HS (40% mean arterial pressure for 60 min) plus conventional i.v. fluid resuscitation (CR; shed blood + 2 volumes saline); (3) HS + CR + 30 mL intraperitoneal (IP) DPR; or (4) HS + CR + 30 mL IP saline. Hemodynamics and hepatic blood flow were measured for 2 h after CR completion. In duplicate animals, liver and splanchnic tissues were harvested for histopathology (blinded, graded), hepatocellular function (liver enzymes), and tissue edema (wet–dry ratio). Results  Group 2 decreased liver blood flow, caused liver injuries (focal to submassive necrosis, zones 2 and 3) and tissue edema, and elevated liver enzymes (alanine aminotransferase (ALT), 149 ± 28 μg/mL and aspartate aminotransferase (AST), 234 ± 24 μg/mL; p < 0.05) compared to group 1 (73 ± 9 and 119 ± 10 μg/mL, respectively). Minimal/no injuries were observed in group 3; enzymes were normalized (ALT 89 ± 9 μg/mL and AST 150 ± 17 μg/mL), and tissue edema was similar to sham. Conclusions  CR from HS restored and maintained central hemodynamics but did not restore or maintain liver perfusion and was associated with significant hepatocellular injury and dysfunction. DPR added to conventional resuscitation (blood and crystalloid) restored and maintained liver perfusion, prevented hepatocellular injury and edema, and preserved liver function. Presented at the Digestive Disease Week, American Association for the Study of Liver Diseases, Los Angeles, CA, USA, May 2006. No conflicts of interest exist. Grant support: This project was supported by a VA Merit Review grant and by NIH research Grant # 5R01 HL076160-03, funded by the National Heart, Lung, and Blood Institute and the United States Army Medical Resources and Material Command.     

Safety and efficacy of a biliary-excreted angiotensin converting enzyme (ACE) inhibitor,temocapril, in combination with amlodipine in advanced diabetic nephropathy

Background. Diabetic patients with moderate to advanced renal failure have severe hypertension and often require multiple antihypertensive agents to control it. Nevertheless, no standardized therapy has been established. This study was designed to examine the safety and efficacy of the biliary-excreted angiotensin converting enzyme inhibitor temocapril in those patients whose blood pressure was not adequately decreased by calcium channel blocker monotherapy. Methods. Twenty-seven patients who did not reach the therapeutic goal of blood pressure (140/90 mm Hg) with amlodipine monotherapy were assigned to receive temocapril (2 mg) and amlodipine (5 mg) for 3 months. Blood samples for hematological and biochemical examinations were taken every month during treatment. Twenty-four-hour urine was collected to measure urinary protein excretion. Trough plasma concentrations and pharmacokinetics were measured during temocapril treatment. Results. Blood pressure was significantly decreased (P < 0.05) from 158 ± 14/91 ± 9 to 148 ± 15/83 ± 8 mm Hg by the addition of temocapril. The peak serum concentration (Cmax) was 86.3 ± 22.7 μg/l at 3.9 ± 1.6 h (Tmax) after administration. Mean area under curve for 0 to 24 h (AUC_0–24 h) was 1179 ± 273 μg/l · h. Trough levels showed a steady state. After temocapril therapy, the slope of the reciprocal of creatinine decreased compared with that before the addition of temocapril. Urinary protein excretion significantly decreased from 3100 ± 1100 to 2300 ± 1100 mg/day. There was no significant change in hematological and biochemical data. Conclusions. The present findings suggest that temocapril can be safely used in patients with advanced diabetic nephropathy, and in combination with dihydropyridine calcium channel blockers it decreases blood pressure and effectively retards the aggravation of renal insufficiency for 3 months in those patients. Received: April 3, 2002 / Accepted: August 29, 2002 Correspondence to:G. Yasuda     

Laser Florence 2008

Patients sustaining acute myocardial infarction (AMI) often require urgent percutaneous revascularization within the first 24 h from onset of the infarction due to continuous ischemia and hemodynamic instability. Upon arrival to the cardiac catheterization, the electrocardiogram of AMI patients may exhibit acute ST-elevation (STEMI) with or without accompanying Q-wave or depression of the ST segment (non-STEMI or non-Q-wave infarction). Data comparing acute outcome of device application in patients presenting for urgent revascularization with established Q-wave myocardial infarction (QWMI) versus those with non-STEMI (NQMI) are sparse. Excimer laser is a revascularization modality applied for debulking of atherosclerotic plaque and vaporization of associated thrombus in the setting of AMI. One hundred fifty-one AMI patients with continuous chest pain and ischemia who enrolled into a multicenter study and underwent urgent revascularization were divided for the purpose of a retrospective analysis into two groups. One group presented with established electrocardiographic Q-wave, whereas the other had ST-depression (NQMI). In comparison with the NQMI group, the QWMI patients had a higher incidence of failed thrombolytic therapy (17% vs 3, p = 0.006), cardiogenic shock (20 vs 6%, p = 0.01), left anterior descending as a culprit infarct-related vessel (46 vs 14%, p < 0.0001), a higher incidence of TIMI 0 flow (48 vs 24%, p = 0.04), a heavier thrombus burden (grade 4 TIMI thrombus, 58 vs 23%; p = 0.0001), and higher CPK (1272 ± 2180 vs 404 ± 577, p = 0.001) and troponin levels (62 ± 95 vs 14 ± 48, p = 0.0003). Both groups underwent laser angioplasty and stenting for relief of continuous chest pain and ischemia within 24 h of infarction onset. Quantitative coronary arteriography in an independent core laboratory measured similar improvement in baseline minimal luminal diameter and percent diameter stenosis by application of laser energy in both groups. Among the QWMI patients, a significantly higher acute gain was recorded with the laser treatment in lesions containing a large/extensive thrombus burden as compared with lesions containing only a small clot burden (1.2 ± 0.7 vs 0.8 ± 0.5, p = 0.01). Such a phenomenon was not detected among the NQMI patients (1.0 ± 0.5 vs 0.8 ± 0.6, p=ns). Baseline TIMI flow grade (0.9 ± 1.0 for QWMI vs 1.5 ± 1.2 for NQMI, p = 0.0001) increased with laser emission to 2.8 ± 0.5 and subsequently reached a final level of TIMI 3 in both groups. In comparison with the QWMI patients, there was a trend toward a reduced rate of major adverse coronary events among the NQMI patients (12% QWMI vs 4% NQMI, p = 0.09). Significant differences in baseline clinical characteristics, extent of myocardial damage, location of infarct related vessel, thrombus burden, and TIMI flow exist between QWMI and NQMI patients who require urgent intervention. However, application of excimer laser results in similar high procedural success and low complication rates in both groups. Maximal acute laser gain is achieved among QWMI patients whose lesions are laden with a heavy thrombus burden.     

Circulating Cytokeratin 18 Fragment M65—A Potential Marker of Malignancy in Colorectal Cancer Patients

Soluble cytokeratin 18 fragments (M30, M65) are released from human cancer cells during cell death and hold potential as biomarkers in colorectal cancer characterized by frequent metastatic spread. A total of 62 colorectal cancer and 27 control patients were included in the study. M65 (necrosis and apoptosis) and M30 (apoptosis) were quantified preoperatively (n = 62) and postoperatively (n = 31) using specific enzyme-linked immunosorbent assays. Presence of disseminated tumor cells (DTC) in the bone marrow was assessed by staining of A45-B/B3-positive cells in aspirates. M65 was significantly elevated in patients with International Union against Cancer stage I and IIA tumors compared to controls. A subgroup (19/31) exhibited a significant (p < 0.05) decrease of M65 after tumor surgery (503.9 ± 230.7 to 342.6 + 94.8 U/l; −32.0 ± 16.5%), in contrast to 12 patients who revealed higher M65 levels postoperatively (386.5 ± 128.5 to 519.1 ± 151 U/l; +37.4 ± 32.3%). DTC in bone marrow were found in 10% (2/19) of patients with decreasing and 50% (6/12) of the patients with increasing M65 serum concentrations after surgery (p = 0.028). In conclusion, M65 as marker is likely to be valuable to identify patients with a high incidence of systemic disease.     

Lipopolysaccharide-Binding Protein Plasma Levels and Liver TNF-Alpha Gene Expression in Obese Patients: Evidence for the Potential Role of Endotoxin in the Pathogenesis of Non-Alcoholic Steatohepatitis

Background Some lines of evidence suggest that endotoxin may induce non-alcoholic steatohepatitis (NASH) in a background of fatty liver. However, a clear association between increased endotoxemia and development of steatohepatitis in obese patients has not been confirmed. We aim to assess the endotoxemic state of patients with non-alcoholic fatty liver disease (NAFLD) and its relationship with the liver expression of TNF-α and the presence of NASH. Methods Prospective study comprising 40 patients with morbid obesity who were diagnosed with NAFLD. Blood samples and liver biopsies were collected. Endotoxemia was assessed by the evaluation of circulating level of LPS-binding protein (LBP). Plasma levels of LBP and TNF-α were assessed by ELISA. The expression of TNF-α in liver tissue was evaluated by real-time PCR. Histological examination was performed to evaluate the presence of steatosis or NASH. Results Levels of LBP were increased in obese patients with NAFLD. In addition, plasma level of LBP was increased in patients with steatohepatitis (14.2 ± 3.9 μg/mL) when compared with patients with simple steatosis (11.5 ± 3.2 μg/mL), P = 0.041.The TNF-α mRNA expression in liver tissue was significantly higher in patients with NASH.This increment correlated with the rise in plasma levels of LBP (r = 0.412, P = 0.036). Conclusion NAFLD patients have elevated plasma levels of LBP and they are further increased in patients with NASH. This increase is related to a rise in TNF-α gene expression in the hepatic tissue which supports a role for endotoxemia in the development of steatohepatitis in obese patients.     

Routine Preoperative Ultrasonography and Selective Cholecystectomy in Laparoscopic Roux-en-Y Gastric Bypass. Why Not?

Background Preoperative evaluation and treatment of biliary lithiasis in morbid obese patients who are candidates to bariatric surgery raise a series of questions which to date has no clear consensus. The aim of this study was to evaluate the results of routine preoperative abdominal ultrasonography and selective cholecystectomy comparing patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) with and without simultaneous cholecystectomy. Methods The prospective database of all the patients who underwent laparoscopic RYGBP in our institution was reviewed. The demographic characteristics, comorbidities, operative time, hospital stay, and postoperative complications were analyzed. Results From August 2001 to December 2006, 1,311 patients underwent laparoscopic RYGBP, 137 (10.4%) of them were excluded due to previous cholecystectomy. In 128 (10.9%) of the remaining 1,174 patients, a cholecystectomy associated to laparoscopic RYGBP was performed. The mean age was 38.5 ± 10.1 years, and 106 (82.8%) were women. The mean operative time in patients with and without simultaneous cholecystectomy was 129.8 ± 45 and 108.5 ± 43 min, respectively (p < 0.001). The hospital stay was 3.6 ± 0.8 days in patients with simultaneous cholecystectomy and 4 ± 3 days in patients without simultaneous cholecystectomy (p = 0.003). There were no deaths. Postoperative complications were observed in 9 (7%) and 73 (6.9%) patients with and without simultaneous cholecystectomy respectively (p = NS). Postoperative complications were not related to the cholecystectomy. Conclusion Cholecystectomy associated to laparoscopic RYGBP should be considered in all patients with preoperative ultrasound diagnosis of cholelithiasis.     

Increase of Osteopontin Plasma Concentrations After Bariatric Surgery Independent from Inflammation and Insulin Resistance

Background  Osteopontin (OPN) is a multifunctional matrix glycoprotein associated with bone metabolism and has been linked to chronic inflammation, insulin resistance, and atherosclerosis. Diet-induced weight loss decreases elevated OPN concentrations in obese patients. The aim of the current study was to investigate the role of OPN after bariatric surgery, where not only improvements of chronic inflammation, insulin resistance and comorbidities, but also malabsorption and altered bone metabolism have been reported. Methods  OPN plasma concentrations were determined in 31 morbidly obese patients (5 men, 26 women, BMI 46.2 ± 7.1 kg/m², age 41 ± 11 years; mean ± SD) before and 18 months after bariatric surgery, together with parameters of bone metabolism and inflammation. Results  OPN concentrations increased by +20.3 ± 26.6 ng/ml (mean ± SD, p < 0.01), concomitant to a weight loss of −38 ± 22 kg, and a decrease in BMI by −13.1 ± 7.7 kg/m² (both p < 0.01). HOMA-index improved from 5.2 ± 3.4 to 1.5 ± 1.0 (p < 0.01). Calcium concentrations slightly decreased, and phosphate increased (−0.06 ± 0.13 mmol/l and +0.08 ± 0.16 mmol/l, respectively; both p < 0.05), while 25-OH-VitaminD₃ remained unchanged and PTH tended to increase (+5.1 ± 14.0 pg/ml, p = 0.054). Monocyte chemoattractant protein 1 and interleukin 18 were significantly decreased and associated with HOMA both before and after bariatric surgery. ΔOPN was correlated with ΔPTH, but not with other parameters. Conclusions  OPN plasma concentrations increased concomitant to weight loss after bariatric surgery, which was independent from an improvement of insulin sensitivity and a decrease of inflammatory markers. Further studies are needed to differentiate whether these changes in bone metabolism after bariatric surgery are secondary to calcium deficiency or an adaptation to weight loss. This work has been submitted in abstract form and will be in part presented at the American Diabetes Association 68th Scientific Sessions 2008, June 6th–10th, San Francisco, CA, USA.     

Inadequate Weight Loss vs Secondary Weight Regain: Laparoscopic Conversion from Gastric Banding to Roux-en-Y Gastric Bypass

Background  Beside complications like band migration, pouch-enlargement, esophageal dilation, or port-site infections, laparoscopic adjustable gastric banding (LAGB) has shown poor long-term outcome in a growing number of patients, due to primary inadequate weight loss or secondary weight regain. The aim of this study was to assess the safety and efficacy of laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP) in these two indications. Methods  A total of 25 patients, who underwent laparoscopic conversion to RYGBP due to inadequate weight loss (n = 10) or uncontrollable weight regain (n = 15) following LAGB, were included to this prospective study analyzing weight loss and postoperative complications. Results  All procedures were completed laparoscopically within a mean duration of 219 ± 52 (135–375) min. Mean body weight was reduced from 131 ± 22 kg (range 95–194) at time of the RYGBP to 113 ± 25, 107 ± 22, and 100 ± 21 kg at 3, 6, and 12 months, respectively, which results in excess weight losses (EWL) of 28.3 ± 9.9%, 40.5 ± 12.3%, and 50.8 ± 15.2%. No statistically significant differences were found comparing weight loss within these two groups. Conclusion  RYGBP was able to achieve EWLs of 37.6 ± 16.1%, 48.5 ± 15.1%, and 56.9 ± 15.0% at 3, 6, and 12 months following conversion, respectively, based on the body weight at LAGB.     

Compensatory Exercise Hyperventilation is Restored in the Morbidly Obese After Bariatric Surgery

Background Morbidly obese individuals may have poor compensatory hyperventilation during exercise. The objective was to examine pulmonary gas exchange and the compensatory hyperventilatory response during exercise pre- and post-weight reduction surgery in obese subjects. Methods Fifteen patients (age = 39 ± 8 years, body mass index = 47 ± 6 kg/m²), with an excess weight of 69 ± 17 kg, were recruited. Pulmonary function at rest was assessed and arterial-blood gases were sampled at rest and all levels of exercise pre- and 10 ± 3 weeks postsurgery. Results There was a loss of excess weight 21 ± 6 kg (p < 0.01). Waist and hip circumference decreased by 13 ± 9 and 8 ± 7 cm, respectively (p < 0.01). Prior to surgery, there was no compensatory hyperventilation between rest and peak exercise as arterial PCO₂ (PaCO₂) remained unchanged (37± 3 mm Hg). However, postsurgery, there was compensatory hyperventilation as PaCO₂ decreased to 33 ± 2 mm Hg at peak exercise (p < 0.01), with no change in peak oxygen consumption (VO_2peak in L/min). Multiple linear regression revealed that the restored ventilatory response to exercise was most strongly associated with the reduction in overall fat mass (adjusted r ² = 0.25; p = 0.03). Total weight loss of 21 kg induces adequate compensatory hyperventilation that begins to show at about 50% of VO_2peak, resulting in improved gas exchange at moderate to peak exercise intensities. Conclusion Improvement in compensatory hyperventilation is most closely related to loss in overall fat mass. G.S. Zavorsky is the recipient of the 2005 Baxter Corporation Award in Anesthesia from the Canadian Anesthesiologist’s Society. G.S. Zavorsky is also Research Scholar–Junior 1 from the Quebec Health Research Foundation (Fonds de la Recherche en Santé du Québec). N.V. Christou is a consultant for Ethicon Endo-Surgery and has stock ownership in Weight Loss Surgery.     

Effects of Surgery on Peripheral N-Terminal Propeptide of Type III Procollagen in Patients with Crohn’s Disease

Aim This study investigates the effects of surgery on collagen turnover in patients affected by Crohn’s disease (CD). Methods Fifteen patients affected by active CD, assessed according to the Crohn’s disease activity index, and confirmed by histology, with different pharmacological treatments, were enrolled in the study. N-Terminal propeptide of type III collagen was assessed on peripheral blood before and 6 months after surgery, as an index of collagen turnover. A control group of 15 healthy age- and sex-matched subjects was also studied. Results In CD patients peripheral N-terminal propeptide of type III collagen serum levels were significantly higher than in controls before surgery (5.0 ± 1.8 vs 2.7 ± 0.7 μg/l, respectively; p = 0.0001). Six months after these values were significantly reduced (from 5.0 ± 1.8 to 3.1 ± 0.8 μg/l; p = 0.003). Independently on the pretreatment regimen and the duration of the disease, an improvement in the patients’ symptoms was observed. Conclusions The surgical resection of the affected intestinal segment in CD patients seems to be able to break down the collagen synthesis processes. Peripheral N-terminal propeptide of type III collagen could be seen as an additive marker to clinical and endoscopic observations after surgery.