Fat cell weight and number before and after gastric surgery for morbid obesity in women

Fifty-one morbidly obese women were randomized and operated upon with either gastroplasty or gastric bypass. The patients were studied preoperatively and 12 months after surgery. The weight loss was significantly larger after gastric bypass. Fat cell weight was determined from subcutaneous fat biopsies of the epigastric, hypogastric, femoral and gluteal regions. Intra-abdominal biopsies were also taken during the operation. Fat cell weight decreased significantly in all subcutaneous regions. Fat cell number, derived from calculated body fat and measured mean subcutaneous fat cell weight, decreased significantly in both treatment groups.     

Severe hypoglycemia after gastric bypass surgery for morbid obesity

Recently, hypoglycemia with endogenous hyperinsulinemia has been described after undergoing bariatric surgery because of morbid obesity. It has been theorized that after a gastric bypass surgery, some trophic factors affecting pancreatic beta cells could emerge. The authors present a case of morbidly obese patient with severe hypoglycemia 3 months after bariatric surgery. An abdominal helicoidally computed tomography scan showed a 1.7 cm tumor in the tail of the pancreas. Histopathology revealed an insulinoma with well-defined contours surrounded by pancreatic tissue with atrophic signs and with hyperplasia and hypertrophic phenomena compatible with nesidioblastosis in adjacent islets of the pancreatic duct. Authors hypothesize that maintenance of the stimulus produces hyperplasia/hypertrophy of the pancreatic islets and reemphasizes the dynamic qualities of pancreatic beta cells and the possibility of producing hyperplasia from the extreme resistance to insulin present in morbidly obese patients.     

Serum lipids after gastric bypass surgery for morbid obesity

Thirty-eight of 151 consecutive patients (25 percent) undergoing bypass surgery for morbid obesity had increased serum levels of total cholesterol (TC), triglycerides (TG) or both preoperatively. Ten patients had isolated TC elevation, six had isolated TG elevation and 22 had both TC and TG elevation. High density lipoprotein-cholesterol (HDL-C) levels were subnormal in 28 of the 38 patients (74 percent). Fasting lipid profiles were determined in the 38 hyperlipidemic patients at 6-month intervals postoperatively. Mean follow-up period was 29 months. By 6 months postop, patients had a greater than or equal to 20 percent mean reduction in TC and greater than or equal to 50 percent mean reduction in TG which were significant in comparison with preop levels and correlated with weight loss (P less than or equal to 0.05). Mean HDL-C levels had increased significantly vs. preop levels by 12 months postop (P less than 0.05). Lipid profiles became normal in 32 of the 38 patients (84 percent). Improvements in lipid profile were sustained in all patients with satisfactory weight loss but regressed after 12 months in patients who did not lose greater than or equal to 50 percent of their excess weight. These results suggest that abnormal serum lipid profiles can be permanently improved with sustained weight loss after gastric restriction surgery for morbid obesity.     

Endoscopic and ultrasonographic evaluation before and after Roux-en-Y gastric bypass for morbid obesity

BACKGROUND: Esophagogastric abnormalities are recognized prior and after bariatric procedures, but frequency and severity are debated. Liver and biliary tract findings are also of clinical importance, especially gallstones and liver steatosis. AIM: To compare pre-operative findings of hepatobiliary ultrasound and upper digestive endoscopy with post-operative results in patients submitted to open Roux-en-Y gastric bypass for morbid obesity. METHODS: A total of 80 patients were enrolled 16.8 +/- 12.1 months after operation, all of them on routine follow-up program, and 8 were excluded. Retrospective analysis aimed at pre-operative clinical, endoscopic and ultrasonographic examinations and were prospectively repeated. RESULTS: Pre-operative endoscopical report was available in 42 cases, and 52 examinations were performed post-operatively. Frequency of esophagitis changed from 16.7% (7/42) to 15.4% (8/52), and of gastritis from 45.2% (19/42) to 21.2% (11/52). Gastric or gastrojejunal ulcers were initially present in 4.8% (2/42) and increased to 9.6% (5/52). Post-operatively, an unusual abnormality was silastic band erosion: 7.7% (4/52). Helicobacter pylori was present in 50.0% (21/42) before and 3.5% (2/52) after operation. Ultrasonographic study had been done before intervention in 63 subjects, and 57 were executed on follow-up. Liver steatosis occurred previously in 58.7% (37/63) and in 43.9% (25/57) later on. Only 12.7% (8/63) of the patients had undergone cholecystectomy before bariatric operation, 29.1%(16/55) suffered simultaneous resection of gallbladder because of stones during Roux-en-Y gastric bypass, and an additional 26.8% (10/36) developed gallstones post-operatively. CONCLUSIONS: Liver steatosis did not statistically improve, nor did inflammatory conditions of the upper digestive tube, despite reduction of H. pylori infections; gallbladder stones requiring intervention were common.     

Dietary intake before and after gastric bypass and gastroplasty for morbid obesity in women

Fifty-one morbidly obese women were randomized to surgical treatment with gastric bypass (GBY) or gastroplasty (GPL). Their dietary intake was assessed preoperatively and 12 months postoperatively by two methods: diet history and 4-day weighted intake. Their protein intake was also checked against urinary nitrogen losses. There was a good correspondence between the results of the two dietary methods and also between estimated protein intake and urinary loss. This makes the results reliable. After 1 year the GBY patients demonstrated a mean weight loss of 41.6 +/- 10.8 kg (P less than 0.001 versus GPL) and a mean energy intake preoperatively of about 2400 kcal/day and postoperatively of 1050 kcal/day (P less than 0.05 versus GPL). The GPL patients lost 28.9 +/- 9.6 kg as a mean and had a preoperative intake of about 2500 kcal/day and a postoperative intake of about 1300 kcal/day. There were only minor changes in the quality of the food from the preoperative to the postoperative situation. Postoperatively the daily intake of several nutrients was below minimum values of recommended or required intake.     

Absence of luminal intrinsic factor after gastric bypass surgery for morbid obesity

Abnormally low serum cobalamin levels (<180 pg/ml) have been observed in 154 of 429 patients (36%) at an average of 22 months (range 3–64 months) after gastric bypass surgery for morbid obesity. Twenty-four patients underwent a Schilling test and retrograde endoscopy of the bypassed gastric segment to determine the presence of intrinsic factor (IF) in gastric aspirates and in mucosal biopsies at 22±4 months after surgery. Five patients had a normal cobalamin level (405±44 pg/ml), and gastric juice intrinsic factor was present in three of them (11±7 ng/ml). Nineteen patients had a low cobalamin level (113±8 pg/ml), and gastric juice IF was found in only two subjects of this group (10 ng/ml each). Basal gastric juice IF concentration of healthy control subjects was 24±5 ng/ml. Schilling test results were normal in all five patients of the first group and in only nine patients of the group with cobalamin deficiency after surgery. To assess whether IF was present within the parietal cells of subjects with absent luminal IF, we studied gastric biopsy material of 14 patients using a well-characterized indirect immunoperoxidase method. IF was identified in fundic mucosal biopsy specimens of all 14 patients with absent gastric juice IF. We conclude that cobalamin deficiency occurs in a significant number of patients after gastric bypass and is associated with absence of gastric juice IF. We propose that this abnormality might be caused by inadequate secretion of IF from the bypassed stomach.This work was presented in part at the annual meeting of the American Gastroenterological Association, San Francisco, California, May 1986, and has appeared in abstract form (Gastroenterology 90:1533, 1986).     

Food intake before and after gastroplasty for morbid obesity

Preoperatively, the energy intake was high, the protein intake was sufficient, whereas the relative contribution of fat was greater than and of carbohydrate less than the recommended values. After gastroplasty a dramatic fall occurred in the intake of energy and all nutrients, and a relative reduction in the contribution of fat at 3 months and of carbohydrate at 12 months was observed. Preoperatively, the intake of vitamins D, B6, folacin, biotin, magnesium, iron, zinc, manganese, copper, and fluoride was deficient. Twelve months after operation the intake of these components and of vitamin E and iodine was less than half of the values recommended.     

Vitamin D status and supplementation in morbid obesity before and after bariatric surgery

Inflammatory bowel disease, which includes Crohn’s disease and ulcerative colitis, is a chronic, relapsing and remitting set of conditions characterized by an excessive inflammatory response leading to the destruction of the gastrointestinal tract. While the exact etiology of inflammatory bowel disease remains unclear, increasing evidence suggests that the human gastrointestinal microbiome plays a critical role in disease pathogenesis. Manipulation of the gut microbiome has therefore emerged as an attractive alternative for both prophylactic and therapeutic intervention against inflammation. Despite its growing popularity among patients, review of the current literature suggests that the adult microbiome is a highly stable structure resilient to short-term interventions. In fact, most evidence to date demonstrates that therapeutic agents targeting the microflora trigger rapid changes in the microbiome, which then reverts to its pre-treatment state once the therapy is completed. Based on these findings, our ability to treat inflammatory bowel disease through short-term manipulations of the human microbiome may only have a transient effect. Thus, this review is intended to highlight the use of various therapeutic options, including diet, pre- and probiotics, antibiotics and fecal microbiota transplant, to manipulate the microbiome, with specific attention to the alterations made to the microflora along with the duration of impact.     

Quality of life after gastric bypass for morbid obesity

One year after gastric restriction surgery, 70 per cent of 118 women completed a questionnaire about lifestyle and eating behaviour changes. Mean weight loss was 35.4 kg. Patients reported a moderate reduction in appetite, and most avoided specific foods which they previously enjoyed, usually because of epigastric discomfort and/or nausea and vomiting. Patients had initiated or resumed a mean of 1.8 activities, most of which involved physical exercise. Sexual interest, enjoyment and frequency were all increased. Raised sexual satisfaction correlated strongly with overall outcome satisfaction. Seventy-two per cent of respondents rated themselves as very pleased, and 18 per cent as fairly pleased, with the overall results of the operation, and responses to the open-ended questions were often strikingly enthusiastic. However, most patients emphasized the difficulty of adjusting to radically new eating habits in the first 2-3 months after surgery, during which they experienced their greatest need for social support and encouragement.     

Gastric emptying of liquid before and after gastroplasty for morbid obesity

Gastric emptying of a liquid meal was investigated with a radionuclide method before and 1 week and 3 and 12 months after gastroplasty operation for morbid obesity. Gastroplasty results in a small proximal pouch with a narrow stoma to the remaining stomach. The total gastric emptying was delayed 3 months after gastroplasty (p less than 0.01). Twelve months after gastroplasty, emptying of the proximal pouch was faster than at 3 months (p less than 0.01). This may indicate dilatation of the stoma between the two gastric pouches during this period. Surprisingly, the total gastric emptying 12 months after gastroplasty was not only faster than at 3 months but also faster than before surgery. The explanation, therefore, cannot only be attributed to a dilated stoma, and hormonal mechanisms may be involved. A lack of correlation between preoperative weight and emptying was observed, but because the material consists of only obese subjects, no conclusion can be drawn about the postulated role of gastric emptying in developing obesity. Emptying of the total stomach and of the proximal pouch failed to correlate with postoperative weight losses. The weight loss after gastroplasty evidently bears little, if any, relation to the postoperative changes in gastric emptying of liquids.     

Transoral surgery for morbid obesity

Obesity is a serious health problem in the United States.Although laparoscopic surgical procedures are effective in achieving weight loss and improving obesity-related co-morbidities,they are not without their limitations and consequently there is a growing demand for less invasive approaches.Transoral techniques,as both primary and revisional procedures,are promising in this regard as they may provide a safer and more cost-effective means of achieving meaningful weight loss.The aim of this paper is to review the currently available transoral approaches to weight loss,with a particular focus on those applied in human trials.     

The use of endoscopy after gastric partitioning for morbid obesity

Fiberoptic endoscopy is an important diagnostic modality for evaluating the patient with upper gastrointestinal tract symptoms following gastric restrictive operations. The specific indications for endoscopy after obesity surgery include stoma evaluation in patients who fail to lose adequate weight; stomal stenosis; esophagitis; surveillance of the excluded pouch; and suspicion of a marginal ulcer after gastric bypass.     

Erythrocyte deformability in morbid obesity before bariatric surgery. Influence of abdominal obesity

Although there are several studies dealing with erythrocyte deformability (ED) in obese patients, research on this topic in morbidly obese subjects is scarce. In these studies ED seems to be decreased, although the cause remains unknown. A case-control study in 76 morbid obese subjects (23 women and 53 men, aged 44 ± 13 years) and in 79 normal-weight controls (30 women and 49 men, aged 43 ± 13 years) was undertaken. ED has been determined by ektacytometric techniques in a Rheodyn SSD, by means of the elongation index (EI) at 12, 30 and 60 Pascals, along with anthropometric, lipidic, metabolic and inflammatory parameters. EI was statistically lower in morbidly obese subjects than in controls at all the shear stresses tested (EI12: 47.3 ± 2.14 vs. 47.9 ± 2.07; p = 0.047, EI30: 52.16 ± 2.1 vs. 53.12 ± 1.4; p = 0.007, EI60: 53.9 ± 2.4 vs. 55.2 ± 2.50; p = 0.001) as were anthropometric lipidic and inflammatory parameters (p < 0.001). In the bivariate correlation EI60 correlated negatively with most anthropometric, lipidic and inflammatory parameters. However, in the multivariate analysis, the case-control status was not significantly associated with EI60 and only triglycerides, glucose, hs-CRP and waist circumference were independently associated with EI60, constituting independent predictors of altered ED although, waist circumference, showed the highest statistical significance (p = 0.007). ED is decreased in morbidly obese subjects associated with insulin resistance and inflammation parameters although abdominal obesity seems to be of paramount importance in altering this rheological parameter.     

Interventional radiologic treatment of complications following gastric bypass surgery for morbid obesity

Complications of gastric bypass surgery include leakage from the gastrojejunal anastomosis with abscess formation and anastomotic stenosis. Using interventional radiologic techniques, we have treated 18 patients with such complications following surgery for morbid obesity, with clinical success in 11. Procedures included 9 abdominal abscess drainages and 7 balloon dilatations of stenotic or occluded gastrojejunal anastomoses. Eight of 9 abscesses resolved completely; 3 of 7 balloon dilatations resulted in long-term clinical improvement. We describe the techniques used as well as problems encountered in these patients.