Remission of Metabolic Syndrome: A Study of 140 Patients Six Months after Roux-en-Y Gastric Bypass

Background Metabolic Syndrome (MS) is a complex disorder characterized by a number of cardiovascular risk factors usually associated with central fat deposition and insulin resistance. Nowadays, there are many different medical treatments to MS, including bariatric surgery, which improves all risk factors. The present study aims to evaluate the influence of gastric bypass in the improvement of risk factors associated with MS, during the postoperative (6 months). Methods This was a retrospective study of 140 patients submitted to gastric bypass. The sample was comprised of a female majority (79.3 %). The mean body mass index (BMI) was 44.17 kg/m². We evaluated the weight of the subjects, the presence of diabetes mellitus and hypertension as comorbidities, as well as plasma levels of triglycerides (TG), total cholesterol and its fractions, and glycemia, in both preoperative and postoperative. Results The percentage of excess weight loss (%EWL) was similar in men and women, with an average of 67.82 ± 13.21%. Concerning impaired fasting glucose (≥100 mg/dl), 41 patients (95.3%) presented normal postoperative glycemia. There has been an improvement of every appraised parameter. The mean decrease in TG level was 66.33 mg/dl (p < 0.0001). Before the surgery, 47.1% were hypertensive; after it, only 15% continued in antihypertensive drug therapy (p < 0.0001). Otherwise, the only dissimilar variable between sexes was the high-density lipoprotein (HDL) level. Conclusion Gastric bypass is an effective method to improve the risk factors of metabolic syndrome in the morbidly obese.     

胃转流术对代谢综合征改善作用的研究进展

目的探讨胃转流术(GBP)对代谢综合征(MS)的影响及其作用机理。方法通过复习文献,回顾分析GBP对糖脂代谢和血压变化的影响。结果 GBP术后数天内,70%以上MS患者血糖、血脂达正常水平,血压控制有明显改善,而体重减轻迟于血糖、血脂变化。饮食、胃肠激素、脂肪细胞因子、脂肪分布等因素的改变参与GBP对MS的改善作用。结论 GBP似乎对控制MS有原发的、独立的影响,而非继发于对肥胖症的治疗。     

Impact of Laparoscopic Roux-en-Y Gastric Bypass on Metabolic Syndrome, Inflammation, and Insulin Resistance in Super Versus Morbidly Obese Women

Background  Although Roux-en-Y gastric bypass (RYGBP) is one of the preferred bariatric procedures in obese individuals, the efficacy of this procedure in the setting of super-obesity [body mass index (BMI) ≥50] is unclear. The aim of this study was to compare the efficacy of laparoscopic (L) RYGBP to reverse metabolic syndrome, inflammation, and insulin resistance in super-obese women compared to morbidly obese women. Methods  Seventy-three consecutive women were enrolled in this prospective study. Anthropometric, metabolic, and inflammatory biological parameters were assessed in 18 super-obese and 55 morbidly obese women before LRYGBP and 1 year after surgery. Metabolic syndrome was diagnosed according to the International Diabetes Federation definition. Results  Before surgery, super-obese women had a higher BMI, fat mass, blood insulin, and HOMA1-IR than morbidly obese women. Both groups had similar serum levels of C-reactive protein and orosomucoid. The incidence of metabolic syndrome, type 2 diabetes, and increased liver enzymes was comparable in the two groups. One year after LRYGBP, metabolic syndrome, type 2 diabetes, metabolic and inflammatory biological parameters were improved in the whole study population. A similar degree of improvement was observed in super-obese and morbidly obese women, although BMI and fat mass were persistently higher in super-obese patients. Conclusions  One year after surgery, LRYGBP was equally effective at reversing metabolic syndrome, inflammation, and insulin resistance in morbidly obese and super-obese women.     

Resolution of Obstructive Sleep Apnea after Laparoscopic Gastric Bypass

BACKGROUND: Obstructive sleep apnea is a common condition in patients undergoing bariatric surgery. The aim of this study was to determine the clinical outcome of a cohort of morbidly obese patients with documented sleep apnea who underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). METHODS: 56 morbidly obese patients with documented sleep apnea by polysomnography underwent LRYGBP. There were 36 females with mean age 46 years and mean BMI 49 kg/m2. The Epworth sleepiness scale (ESS) scores and the number of patients requiring the use of continuous positive airway pressure (CPAP) therapy were recorded preoperatively and at 3-month intervals. RESULTS: The mean length of sleep apnea condition was 44 +/- 55 months. Preoperative polysomnography scores were classified as severe in 50% of patients, moderate in 30%, and mild in 20%. 29 of 56 (52%) patients required CPAP therapy preoperatively. The mean excess body weight loss was 73 +/- 3% at 12 months. The mean ESS score decreased from 13.7 preoperatively to 5.3 at 1 month postoperatively (P<0.05) and maintained below the threshold level (<7) for the entire 12 months of follow-up. Of the 29 patients requiring preoperative CPAP, only 4 (14%) patients required CPAP at 3 months postoperatively and none required CPAP at 9 months. CONCLUSIONS: Weight loss associated with LRYGBP significantly improves the symptoms of sleep apnea and is effective in discontinuation in the clinical use of CPAP therapy. Improvement of obstructive sleep apnea symptoms occur as early as 1 month postoperatively.     

Predicting Stricture in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass: A Logistic Regression Analysis

Gastrojejunostomy stricture after Roux-en-Y gastric bypass occurs in 3 to 27% of morbidly obese patients in the USA. We questioned whether preoperative patient characteristics, including demographic attributes and comorbid disease, might be significant factors in the etiology of stricture. In this study from November 2001 to February 2006 (51 months), at a high-volume bariatric center, of the 1,351 patients who underwent laparoscopic gastric bypass, 92 developed stricture (6.8%). All but two were treated successfully by endoscopic dilation. All patients stopped nonsteroidal anti-inflammatory medications 2 weeks prior to surgery and did not restart them. The operative procedure included the use of a 21-mm transoral circular stapler to create the gastrojejunostomy; the Roux limb was brought retrogastric, retrocolic. In an effort to reduce our center’s stricture rate, late in the study, U-clips used at the gastrojejunostomy were replaced by absorbable sutures, and postoperative H₂ antagonists were added to the treatment protocol. The change to absorbable polyglactin suture proved to be significant, resulting in a lower stricture rate. The addition of H₂ antagonists showed no significant effect. Following the retrospective review of the prospective database, univariate and multivariate logistic regression analyses identified factors associated with the development of stricture. Gastroesophageal reflux disease and age were each shown to be statistically significant independent predictors of stricture following laparoscopic gastric bypass. Presented at the 2006 Annual Meeting of the Society for Surgery of the Alimentary Tract, May 20–24, Los Angeles, CA (poster presentation).     

Improvement of Associated Respiratory Problems in Morbidly Obese Patients after Open Roux-en-Y Gastric Bypass

Background Obstructive sleep apnea syndrome (OSAS) is present in 44% of patients scheduled for bariatric surgery. Respiratory dysfunction associated with this syndrome is attributable to chronic obstructive pulmonary disease (COPD) and/or obesity hypoventilation syndrome (OHS).We studied the long-term effect of bariatric surgery on weight loss, on the respiratory comorbidities associated with obesity, and on the need for non-invasive positive pressure ventilation. Methods We followed a sample of patients with respiratory co-morbidity scheduled for open Capella Roux-en-Y gastric bypass (RYGBP) over 5-years. Patients who were positive for polysomnographic studies and required continous positive airway pressure (CPAP) before surgery were included. All patients were subjected to the same anesthetic and surgical protocols. At 1 year after surgery, polysomnographic studies were performed and arterial blood gases and pulmonary function were tested. Results Of the 209 patients scheduled for bariatric surgery during the study period, 105 had respiratory co-morbidity. Of these, 30 required CPAP-BiPAP treatment before surgery and were included in our study. Surgery took 128 minutes (range 70 to 210 minutes). Tracheal extubation in the operating theater was possible for 26 patients (86.7%). During the early postoperative period, 7 patients (23.3%) presented respiratory complications. Length of hospitalization was 6.87 days (range 4 to 11 days). At 1 year after RYGBP, patients presented significant weight loss and improvement of hypoxemia (from 73.3 ± 10.6 to 90.5 ± 11.5, P = 0.000), hypercarbia (from 44.5 ± 5.7 to 40.6 ± 4.9, P = 0.005), and in spirometric (P = 0.004) and polysomnographic results (P = 0.001). CPAP-BiPAP treatment after weight loss was necessary in only 14% of patients (P = 0.001). Conclusions Weight loss after RYGBP improved arterial blood gases, respiratory tests and polysomnographic studies. CPAP treatment can be withdrawn in most patients.     

Bariatric Surgery Outcomes in Morbidly Obese with the Metabolic Syndrome at US Academic Centers

Background  The metabolic syndrome is associated with significant cardiovascular morbidity and mortality. We assessed the in-hospital outcomes of bariatric surgery in morbidly obese patients with the metabolic syndrome in comparison to a control group without the metabolic syndrome. Methods  Using ICD-9-CM diagnosis and procedure codes, clinical data for 20,242 patients with and without the metabolic syndrome who underwent bariatric surgery over a 5-year period were obtained from the University HealthSystem Consortium database. Results  The prevalence of the metabolic syndrome among bariatric surgery patients was 27.4%. Patients with the metabolic syndrome presented significantly higher overall morbidity as compared to morbidly obese patients without the metabolic syndrome (8.6% vs. 5.8%; p < 0.01), and similar mortality (0.04% vs. 0.01%; p = 0.2) after bariatric surgery. Hispanics with the metabolic syndrome had the highest morbidity rates, and men had the uppermost mortality. In-hospital bariatric surgery outcomes were significantly improved among patients who underwent laparoscopic adjustable gastric banding. Conclusions  The data suggest that the presence of the metabolic syndrome affects inter-ethnic and gender-specific short-term outcomes after bariatric surgery.     

Roux-en-Y胃转流术后锌缺乏的研究进展

目的总结分析2型糖尿病（T2DM）或肥胖患者Roux-en-Y胃转流术（RYGB）后锌缺乏的研究现状。方法对近年来国内、外关于RYGB术后锌缺乏的相关文献进行综述。结果 RYGB术后存在一定程度锌缺乏,其机制还没有完全阐明,其中锌摄入量及吸收减少、蛋白营养不良、膳食因素等都与术后锌缺乏有一定关系,并且手术的具体方式及术后补锌的方案也会影响术后锌的营养状态。结论导致RYGB术后锌缺乏的原因是多方面的,其具体机制仍未阐明,还需进一步的研究。     

Stapler Division of the Omentum and Small Bowel Mesentery in Morbidly Obese Patients Undergoing Gastric Bypass Surgery

Background: Roux-en-Y gastric bypass (RYGB) procedures can be technically demanding because of anatomical factors including fat distribution, organ fixation, and wound depth. We developed a technique using the Multifire Endo GIA 60 2.5 disposable surgical stapler which allows greater mobilization, less blood loss, and decreased operating time. Methods: A disposable stapler designed for laparoscopic surgery was used to transect the gastro-colic omentum and small bowel mesentery in 67 morbidly obese patients undergoing RYGB. Generally, five to six stapler cartridges were needed for the transections. Results: Stapler division of the gastro-colic omentum and small bowel mesentery decreased operating time by an average of 25 minutes. Conclusions: Applying principles of laparoscopic surgery to RYGB resulted in more efficient mobilization of the stomach and the small bowel mesentery, as well as decreased blood loss and operating time.     

Correlation between metabolic syndrome and sleep apnea

The so-called "metabolic syndrome"(MS),constitutes a cluster of metabolic and cardiovascular abnormalities,including fasting glucose,blood pressure,triglycerides,high density lipoprotein cholesterol(HDL-C),and waist circumference that arise from insulin resistance. Obstructive sleep apnea(OSA) syndrome is characterized by recurrent episodes of partial or complete obstruction of the upper airway,involving cessation or significant decreased airflow,with intermittent hypoxemia,frequent arousals from sleep and recurrent oxyhemoglobin desaturations that interfere with normal sleep patterns generating difficulty falling asleep,unrefreshing sleep and loud snoring. The relation between these two entities is known as "Syndrome Z",and there is no question about the impact of these risk factors on health and disease. This clinical condition presents a growing epidemic Worldwide,affecting approximately 60% of the general population with both MS and OSA due to the constant increase of body mass index in humans. This article presents evidence-based data that focuses on the direct relationship between MS and OSA.     

Gastric Bypass Surgery in Rats Produces Weight Loss Modeling after Human Gastric Bypass

Background  The study of the mechanisms of weight loss after bariatric surgery requires an animal model that mimics the human procedure and subsequent weight loss. A rat model eliminates the cognitive efforts associated with human weight loss and gain. Methods  A technique for gastric bypass (Roux-en-Y gastric bypass [RYGB]) was developed in Sprague–Dawley rats. A 1- to 2-cc pouch is created from the uppermost stomach using a linear stapler. A 10-cm biliopancreatic limb and 15-cm Roux limb are anastomosed side to side with running nonabsorbable suture. The gastrojejunostomy is created with a single layer of running nonabsorbable suture. Four rats underwent RYGB. Weight loss was compared to four sham rats that had a midline incision and left 60 min with an open abdomen before closure. Results  RYGB rats lost an average of 16.5% body weight (BW) at 1 week, 22% BW at 2 weeks, 20% BW at 3 weeks, and 11% BW at 4 weeks. The RYGB rat’s weight was basically level after 4 weeks. The shams lost an average of 4% BW at 1 week, 1% BW at 2 weeks, and 0% BW at 3 weeks and gained an average of 2% at weeks. Subjectively, the RYGB rats were less interested in chow and frequently had chow left in their cage. Conclusion  A Sprague–Dawley rat model for gastric bypass has been developed and yields approximately 11% BW loss. This will allow investigators to objectively view factors associated with weight loss without the confounding cognitive factors in humans. Presented at the 24th Annual Meeting of the American Society for Bariatric Surgery; June 16, 2007; San Diego, CA.     

Laparoscopic Gastric Bypass,Roux en-Y: Technique and Results in 75 Patients With 3-30 Months Follow-up

Background: Laparoscopic Roux en-Y Gastric Bypass (RYGB) has been performed in 100 patients, in our series. Methods: The results of surgery, including 3-30-months follow-up, are described with 100% follow-up, for the first 75 patients. Weight loss, operative morbidity and relief of co-morbidities have been thoroughly studied in a prospective fashion. Results: Diabetes mellitus was normalized in 22 of 24 patients and gastroesophageal reflux was relieved in all patients. Length of stay, recovery time and cosmetic results are superior to the ‘open’ technique, and the operative times are competitive. Conclusion: Laparoscopic RYGB deserves a place in the operative repertoir of bariatric surgeons.     

Calcium Intake and Metabolic Bone Disease after Eight Years of Roux-en-Y Gastric Bypass

Background Roux-en-Y gastric bypass (RYGBP) has been found to be the most efficient way to lose weight and maintain the weight loss in morbid obesity. However, with the formation of a new stomach and the modification of intestinal anatomy, there are significant changes on physiological properties of these organs that lead to nutrient deficiency, including calcium. The objectives of this study were to evaluate calcium intake, bone metabolism, and prevalence of metabolic bone disease in women subjected to RYGBP after 8 years. Methods Food frequency questionnaire and 3-day dietary recall, laboratory tests of bone metabolism and bone mineral density were accessed. Results Calcium intake was below the recommendation in all women. Serum PTH and alkaline phosphatase were elevated, whereas vitamin D and urinary calcium were significantly lower. Also, a higher prevalence of metabolic bone disease than the one expected for the normal population at the same age was noted. Conclusion These data suggest that metabolic bone disease could be a complication of this type of surgery.     

The Impact of Race on Weight Loss After Roux-en-Y Gastric Bypass Surgery

Background Gastric bypass surgery for morbid obesity has dramatically increased in volume over the past decade. Caucasian patients have been noted previously to lose more weight after bariatric surgery than African-Americans patients. Data regarding predictors of maintaining weight loss after surgery are minimal. We sought to determine predictors of long-term weight loss after bariatric surgery. Methods Retrospective analysis using a multivariate logistic regression model of all patients undergoing Roux-en-Y gastric bypass surgery at the Medical University of South Carolina from May 1993 to December 2004 for whom 2 years of follow-up data was available. Our dependent variable was the percentage of weight lost from baseline, dichotomized at ±35%. Our primary independent variable was race, defined as Caucasian, African-American, or other. Relevant covariates were added to the model to control for their potential effects on outcome. Results One hundred eleven patients (17 male/94 female; 85% Caucasian, mean age 44 years (range 18–68 years). In our model, Caucasian subjects (adjusted odds ratio [OR] = 7.60, 95% confidence intervals [95%CI] = 1.83–31.5) and late post surgical complications (adjusted OR = 2.67, 95%CI = 1.05–6.80) significantly predicted weight loss at 2 years, after controlling for relevant confounders. Other covariates did not significantly impact the model. Conclusion Race and late post surgical complications significantly impacted the percentage of weight loss at 2 years for patients undergoing Roux-en-Y gastric bypass surgery at our institution. Future research should be directed at determining potential genetic and/or social reasons for these differences.     

Serum Magnesium Status After Gastric Bypass Surgery in Obesity

Background  Roux-en-Y gastric bypass (RYGBP) has become a common surgical procedure to treat morbid obesity. Furthermore, it strongly reduces the incidence of type 2 diabetes and mortality. However, there is scant information on how magnesium status is affected by RYGBP surgery. Previous bariatric surgery methods, like jejunoileal bypass, are associated with hypomagnesemia. Methods  Twenty-one non-diabetic morbidly obese patients who underwent RYGBP were evaluated before and 1 year after surgery and compared to a matched morbidly obese control group regarding serum magnesium. Groups were matched regarding weight, BMI, abdominal sagittal diameter and fasting glucose, blood pressure, and serum magnesium concentrations before surgery in the RYGBP group. Results  The serum magnesium concentrations increased by 6% from 0.80 to 0.85 mmol/l (p = 0.019) in the RYGBP group while a decrease by 4% (p = 0.132) was observed in the control group. The increase in magnesium concentration at the 1-year follow-up in the RYGBP group was accompanied by a decreased abdominal sagittal diameter (r ² = 0.32, p = 0.009), a lowered BMI (r ² = 0.28, p = 0.0214), a lowered glucose concentration (r ² = 0.28, p = 0.027) but not by a lowered insulin concentration (p = 0.242), a lowered systolic (p = 0.789) or a lowered diastolic (p = 0.785) blood pressure. Conclusion  RYGBP surgery in morbidly obese subjects is characterized by reduced visceral adiposity, lowered plasma glucose, and increased circulating magnesium concentrations. The inverse association between lowered central obesity, lowered plasma glucose and increased magnesium concentrations, needs further detailed studies to identify underlying mechanisms.     

等离子低温射频治疗儿童阻塞性睡眠呼吸暂停低通气综合征

目的探讨扁桃体、腺样体等离子低温射频切除术治疗儿童阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS）的临床疗效。方法分析2005年8月～2007年5月,对43例患有OSAHS儿童在全身麻醉下,采用低温等离子手术系统Evac70刀头施行扁桃体切除术联合腺样体根治性切除术。结果手术时间10～20min,平均16min;术中出血1～10ml,平均3ml。与术前比较,术后6个月行PSG监测呼吸暂停低通气指数（apnea hypopnea index,AHI）明显降低[（14.6±4.6）次/hvs（4.2±2.7）次/h,t=8.563,P=0.000];阻塞性呼吸暂停指数（obstructive apnea index,OAI）明显降低[（6.9±3.5）次/hvs（3.3±1.4）次/h,t=5.443,P=0.000];最低血氧饱和度显著提高[（85.7±4.4）%vs（99.7±0.2）%,t=-6.687,P=0.000]。结论扁桃体、腺样体等离子低温射频切除术是治疗儿童OSAHS一种有效的治疗方法,具有手术时间短,术中出血少,疗效好等优点。     

The Serial Changes of Ghrelin and Leptin Levels and Their Relations to Weight Loss After Laparoscopic Minigastric Bypass Surgery

Background The ghrelin and leptin levels have been reported to be correlated with weight loss after bariatric surgery. However, the serial changes of ghrelin and leptin levels after laparoscopic minigastric bypass surgery (LMGBP) have not been reported yet. Therefore, we aimed to evaluate their serial changes and to analyze their relations to weight reduction after LMGBP. Methods Serial fasting serum leptin and ghrelin concentrations were measured in 68 morbidly obese patients before (M0) and 1 (M1), 3 (M3), 6 (M6), and 12 (M12) months after LMGBP surgery. The correlations between ghrelin, insulin, and leptin concentrations and weight reduction were analyzed. Results Leptin levels were significantly reduced at 1, 3, 6, and 12 months after surgery, respectively (vs M0, p < 0.001), whereas the ghrelin concentrations were not significantly changed after surgery. The percent of excess BMI lost (%EBL) 12 months after surgery was negatively correlated with higher preoperative ghrelin concentrations (p = 0.004) and larger preoperative BMI (p = 0.002) in the multivariate analysis. Conclusion Higher preoperative ghrelin concentrations and larger BMI are predictive of less %EBL at 12 months after LMGBP surgery.