Mineral Metabolism in Obese Patients Following Vertical Banded Gastroplasty

Background Bone disease has been described in patients after surgical treatment for obesity, but few studies have dealt with the impact of vertical banded gastroplasty on mineral metabolism. We have examined bone mineral metabolism in morbidly obese patients before and after 3 months after vertical banded gastroplasty without vitamin D supplementation. Methods Sixteen morbidly obese patients (14 women, 2 men) with a mean (±SD) age of 38 ± 9 years and a body mass index (BMI) of 47.1 ± 8.1 kg/m² were studied. No vitamin D supplementation was given. Body weight, fat mass, calcium, 25OHD, iPTH, bone remodeling markers, and leptin levels were measured at baseline and after weight loss. Results Mean weight loss was 28 ± 11 kg; BMI and body fat mass decreased by 20 and 35%, respectively. Bone resorption markers and albumin-corrected serum calcium increased after operation, whereas iPTH fell. Serum 25OHD levels rose. Leptin levels decreased. Serum iPTH was positively correlated with weight, BMI, and fat mass before operation (p < 0.05), and its decline after weight reduction was negatively associated with the increase in bone resorption markers (p < 0.01). Leptin concentration was correlated with BMI and body fat mass (p < 0.05) both before and after surgery. Conclusions Weight reduction obtained in morbidly obese subjects 3 months after vertical banded gastroplasty increases bone turnover markers and decreases PTH secretion. Serum 25OHD levels rose. Therefore, no reasons for a metabolic bone disease related to hypovitaminosis D were readily apparent. However, an increase in bone turnover, which is generally regarded as a potential risk factor for osteoporosis, was observed. Further work is needed to clarify the importance of this turnover increase in the long run.     

Low-Back Pain in Morbidly Obese Patients and the Effect of Weight Loss Following Surgery

Background: Although low-back pain (LBP) is a common health problem and a source of significant discomfort, disability and work absences, its incidence, severity and outcome have not been extensively investigated in morbidly obese patients undergoing bariatric surgery. Methods: 50 morbidly obese candidates for vertical banded gastroplasty (VBG) were asked to fill in a questionnaire, to assess the incidence and severity of any existing LBP symptoms. 50 non-obese patients, admitted to our surgical unit for management of several benign conditions, were also asked to fill in the same questionnaire and served as controls. 24 months after VBG, the morbidly obese patients were again evaluated for their LBP symptoms. Results: LBP was identified in 29 morbidly obese patients (58%) preoperatively and in only 12 (24%) of the lean controls (P<0.01). 2 years after VBG, with a significant excess weight loss (P<0.0001), only 10 patients continued to have LBP but less frequently and requiring reduced doses of medications compared with the preoperative condition. In the remaining 19 patients with preoperative positive LBP history, the postoperative weight loss was associated with complete resolution of the symptoms. Conclusion: The frequency of LBP is significantly higher in morbidly obese patients than in lean subjects. Surgical weight reduction results in significant improvement and even disappearance of this obesity co-morbidity.     

Initial Experience with the Surgical Management of Morbid Obesity Associated with Symptomatic Gastro-esophageal Reflux: A Comparison between Gastroplasty Alone and Gastroplasty with Anterior Fundoplication

The optimal management of patients with morbid obesity and gastro-esophageal reflux disease (GERD) remains an unresolved issue. We have performed a vertical banded gastroplasty combined with an anterior fundoplication (VBG + AF) in 28 selected morbidly obese patients with moderate or severe heartburn. The patients who underwent VBG + AF are compared to patients who had similar heartburn symptoms and underwent gastroplasty alone during this period. In the VBG + AF group there were two treatment failures (7%). In the gastroplasty group there were 63 patients with 15 treatment failures (24%). These differences were independent of demographic and weight loss variables. These results suggest that VBG + AF may provide a superior option for the management of morbidly obese patients with GERD.     

Independent effect of endogenous dehydroepiandrosterone-sulphate levels and birth weight on bone turnover parameters in young adults

Data indicate that bone turnover is higher in young adults born with a low birth weight (LBW). Moreover, several data support the presence of altered adrenal hormone production in this population. The aim of our study was to investigate whether there is any connection between altered bone homeostasis and adrenal hormone levels. Bone mineral density (BMD), serum osteocalcin (OC), and urinary deoxypyridinoline (DPD) excretion were related to dehydroepiandrosterone-sulphate (DHEAS), cortisol, estradiol, testosterone, and sex-hormone binding globulin (SHBG) levels in 47 healthy young women (of those, 33 were LBW) and 65 healthy young men (of those, 49 were LBW). The age of the subjects was 19–21 years. BMD values were normal and did not correlate with any of the factors investigated. Cortisol did not have any independent effect on bone turnover parameters in either men or women. In women, birth weight, DHEAS levels, and free estradiol index were responsible for almost 50% (corrected r² = 0.45) of serum OC variability. Independent positive associations were observed between DHEAS and OC, and between DHEAS and DPD excretion. In men, birth weight and DHEAS levels together were responsible for more than one-third (corrected r² = 0.36) of the variability of serum OC. In contrast with women, DHEAS and OC were inversely correlated in men. Our results suggest that bone turnover depends on the subjects' birth weight. Moreover, DHEAS is also an independent determinant. The effect of DHEAS on bone turnover is different in women and men. DHEAS increases bone turnover in fertile women, while it decreases this in men.     

Vertical Banded Gastroplasty Modifies Plasma Ghrelin Secretion In Obese Patients

Background: Restrictive bariatric surgery causes weight loss through substantial decline of appetite with satiety after meals. Reduction of plasma ghrelin levels after Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding could contribute to these effects, although contradictory results have been reported. The only restrictive operation still not yet investigated is vertical banded gastroplasty (VBG). We studied the effects of VBG on basal plasma ghrelin levels and meal-mediated inhibition. Methods: 12 morbidly obese patients, 11 female and 1 male, were studied before and after VBG, when the BMI fell by 20%. The control group consisted of 6 lean volunteers. Active ghrelin was determined by RIA after overnight fasting and after the administration of a liquid meal. Results: Obese patients preoperatively had significantly lower basal plasma ghrelin levels than lean volunteers, and the meal did not inhibit ghrelin secretion. After VBG and 20% BMI loss, basal plasma ghrelin levels increased and the reduction caused by a meal recovered. Conclusions: Weight loss caused by VBG is associated with higher plasma ghrelin levels in obese patients. The operation restores the normal adaptation of the A- cells of the stomach to a meal.     

Prevention of Osteoporosis in Heart Transplant Recipients: A Comparison of Calcitriol with Calcitonin and Pamidronate

Bone loss and osteoporotic fractures are common in cardiac transplant recipients. To compare two prophylactic medical regimens after heart transplantation, 26 consecutive heart transplant recipients were randomized to receive either continuous oral calcitriol (0.5 μg/day) combined with nasal salmon calcitonin (200 U/day) for the first 3 months (group A) or intermittent intravenous pamidronate (0.5 mg/kg body weight) every third month (group B). Bone mineral density (BMD) and biochemical indices of bone turnover were measured at baseline and 3, 6, 12, and 18 months after transplantation. The mean pretransplant BMD, measured by dual energy X-ray absorptiometry (DXA) was significantly lower in the patients compared with age-matched healthy controls. During the first year of treatment, rates of bone loss at the lumbar spine and femoral neck were slightly but significantly slower in the patients treated with pamidronate, but there was no longer a significant difference between the two groups after 18 months of heart transplantation. Irrespective of the mode of osteoporosis prevention, osteocalcin levels increased whereas urinary deoxypyridinoline decreased after transplantation, and significant bone loss was observed in both treatment groups. We found no relationship between initial BMD, markers of bone turnover, cumulative glucocorticoid dose, or cyclosporine levels and the rate of bone loss after cardiac transplantation. In summary, we found that the rapid and severe bone loss following heart transplantation could be attenuated by two preventive measures, pamidronate or calcitriol with calcitonin. Received: 26 December 1997 / Accepted: 10 February 2000     

Exercise training in obese older adults prevents increase in bone turnover and attenuates decrease in hip bone mineral density induced by weight loss despite decline in bone‐active hormones

Weight loss therapy to improve health in obese older adults is controversial because it causes further bone loss. Therefore, it is recommended that weight loss therapy should include an intervention such as exercise training (ET) to minimize bone loss. The purpose of this study was to determine the independent and combined effects of weight loss and ET on bone metabolism in relation to bone mineral density (BMD) in obese older adults. One‐hundred‐seven older (age >65 years) obese (body mass index [BMI] ≥30 kg/m²) adults were randomly assigned to a control group, diet group, exercise group, and diet‐exercise group for 1 year. Body weight decreased in the diet (?9.6%) and diet‐exercise (?9.4%) groups, not in the exercise (?1%) and control (?0.2%) groups (between‐group p < 0.001). However, despite comparable weight loss, bone loss at the total hip was relatively less in the diet‐exercise group (?1.1%) than in the diet group (?2.6%), whereas BMD increased in the exercise group (1.5%) (between‐group p < 0.001). Serum C‐terminal telopeptide (CTX) and osteocalcin concentrations increased in the diet group (31% and 24%, respectively), whereas they decreased in the exercise group (?13% and ?15%, respectively) (between‐group p < 0.001). In contrast, similar to the control group, serum CTX and osteocalcin concentrations did not change in the diet‐exercise group. Serum procollagen propeptide concentrations decreased in the exercise group (?15%) compared with the diet group (9%) (p = 0.04). Serum leptin and estradiol concentrations decreased in the diet (?25% and ?15%, respectively) and diet‐exercise (?38% and ?13%, respectively) groups, not in the exercise and control groups (between‐group p = 0.001). Multivariate analyses revealed that changes in lean body mass (β = 0.33), serum osteocalcin (β = ?0.24), and one‐repetition maximum (1‐RM) strength (β = 0.23) were independent predictors of changes in hip BMD (all p < 0.05). In conclusion, the addition of ET to weight loss therapy among obese older adults prevents weight loss–induced increase in bone turnover and attenuates weight loss–induced reduction in hip BMD despite weight loss–induced decrease in bone‐active hormones. © 2011 American Society for Bone and Mineral Research     

Bone Loss After Bariatric Surgery: Discordant Results Between DXA and QCT Bone Density

Several studies, using dual‐energy X‐ray absorptiometry (DXA), have reported substantial bone loss after bariatric surgery. However, profound weight loss may cause artifactual changes in DXA areal bone mineral density (aBMD) results. Assessment of volumetric bone mineral density (vBMD) by quantitative computed tomography (QCT) may be less susceptible to such artifacts. We assessed changes in BMD of the lumbar spine and proximal femur prospectively for 1 year using DXA and QCT in 30 morbidly obese adults undergoing Roux‐en‐Y gastric bypass surgery and 20 obese nonsurgical controls. At 1 year, subjects who underwent gastric bypass surgery lost 37 ± 2 kg compared with 3 ± 2 kg lost in the nonsurgical controls (p < 0.0001). Spine BMD declined more in the surgical group than in the nonsurgical group whether assessed by DXA (?3.3 versus ?1.1%, p = 0.034) or by QCT (?3.4 versus 0.2%, p = 0.010). Total hip and femoral neck aBMD declined significantly in the surgical group when assessed by DXA (?8.9 versus ?1.1%, p < 0.0001 for the total hip and ?6.1 versus ?2.0%, p = 0.002 for the femoral neck), but no changes in hip vBMD were noted using QCT. Within the surgical group, serum P1NP and CTX levels increased by 82% ± 10% and by 220% ± 22%, respectively, by 6 months and remained elevated over 12 months (p < 0.0001 for all). Serum calcium, vitamin D, and PTH levels remained stable in both groups. We conclude that moderate vertebral bone loss occurs in the first year after gastric bypass surgery. However, striking declines in DXA aBMD at the proximal femur were not confirmed with QCT vBMD measurements. These discordant results suggest that artifacts induced by large changes in body weight after bariatric surgery affect DXA and/or QCT measurements of bone, particularly at the hip. © 2014 American Society for Bone and Mineral Research.     

Areal and volumetric bone mineral density and geometry at two levels of protein intake during caloric restriction: A randomized,controlled trial

Weight reduction induces bone loss by several factors, and the effect of higher protein (HP) intake during caloric restriction on bone mineral density (BMD) is not known. Previous study designs examining the longer‐term effects of HP diets have not controlled for total calcium intake between groups and have not examined the relationship between bone and endocrine changes. In this randomized, controlled study, we examined how BMD (areal and volumetric), turnover markers, and hormones [insulin‐like growth factor 1 (IGF‐1), IGF‐binding protein 3 (IGFBP‐3), 25‐hydroxyvitamin D, parathyroid hormone (PTH), and estradiol] respond to caloric restriction during a 1‐year trial using two levels of protein intake. Forty‐seven postmenopausal women (58.0 ± 4.4 years; body mass index of 32.1 ± 4.6 kg/m²) completed the 1‐year weight‐loss trial and were on a higher (HP, 24%, n = 26) or normal protein (NP, 18%, n = 21) and fat intake (28%) with controlled calcium intake of 1.2 g/d. After 1 year, subjects lost 7.0% ± 4.5% of body weight, and protein intake was 86 and 60 g/d in the HP and NP groups, respectively. HP compared with NP diet attenuated loss of BMD at the ultradistal radius, lumbar spine, and total hip and trabecular volumetric BMD and bone mineral content of the tibia. This is consistent with the higher final values of IGF‐1 and IGFBP‐3 and lower bone‐resorption marker (deoxypyridinoline) in the HP group than in the NP group (p < .05). These data show that a higher dietary protein during weight reduction increases serum IGF‐1 and attenuates total and trabecular bone loss at certain sites in postmenopausal women. © 2011 American Society for Bone and Mineral Research.     

Conversion of Failed Vertical Banded Gastroplasty to Open Adjustable Gastric Banding

Background: Occasionally, patients with failed vertical banded gastroplasty (VBG) present for secondary treatment. We performed the reoperations using adjustable gastric banding (AGB) technique. Methods: From 1991 to 1997, 80 morbidly obese patients underwent VBG. In 7 (8.7%), staple-line disruption and weight regain were detected within 2 years of follow-up. Conversion to AGB was performed between 1994 and 1998. Meanwhile, another 80 morbidly obese patients underwent primary open AGB. Results: In the 7 patients, staple-line disruption was seen on radiography as a leak of contrast material across the gastric partition. After conversion of "failed" VBGs to AGB, postoperative results have been very satisfactory and similar to those of the primary open AGB group. Conclusions: VBG is a safe technique, although conversion rates were significant. Staple-line disruption constituted the chief cause of insufficient weight loss and frequently indicated the need for further surgery. Our results of the revisional surgery confirm that the reoperations for failed VBG can be performed using AGB technique.     

The Role of Intraoperative Cholangiography in Detecting and Preventing Bile Duct Injury during Laparoscopic Cholecystectomy

Objective: To compare gastric banding (GB) and vertical banded gastroplasty (VBG) with respect to the evolution of pyrosis and patient satisfaction.

Summary Background Data: Although weight loss is the most immediate end-point in the evaluation of surgical treatment of obesity, the demonstration of changes in long-term patient satisfaction and in co-morbidity, like reflux, is an essential outcome measure.

Material and methods: Retrospective study of 243 morbidly obese patients. All patients received a questionnaire regarding the evolution of pyrosis and their satisfaction after surgery. The evolution of pyrosis was compared between 2 patient groups who had different oesophagitis stages. Group A had oesophagitis I, or no oesophagitis, and group B had oesophagitis II, III or IV.

Results: In group A of the GB group 57.8% had no complaints, 11.1% had improvement and 22.2% had aggravation of the pyrosis. In group B of the GB group 50.0% had improvement. In group A of the VBG group 51.4% had no complaints, 11.1% improvement and 23.6% aggravation of the pyrosis. In group B of the VBG group 16.7% had no complaints, 66.6% had improvement and 16.7% had aggravation of the pyrosis complaints. Statistically there is no significant difference between GB and VBG. The experience after GB is good with 67.9%, mediocre with 25.0% and bad with 7.1% of the patients; 60.7% is pleased with the weight loss. The experience after VBG is good with 47.4%, mediocre with 29.5% and bad with 23.1% of the patients. 52.6% is satisfied with the weight loss.

Conclusion: VBG and GB have a similar effect on pyrosis. From our point of view it has been evidenced that the presence or absence of pyrosis before the operation is a possible predictor of the evolution afterwards. Long-term patient satisfaction is the same after GB and VBG. Other factors influence the satisfaction.     

A Prospective Cost-Effectiveness Analysis of Vertical Banded Gastroplasty for the Treatment of Morbid Obesity

Background: Surgical treatment of morbid obesity is gaining in popularity, because conservative treatment is ineffective. However, a cost-effectiveness analysis has never been performed and is the main goal of the present study. Methods: 21 consecutive morbidly obese patients were tested before and after vertical banded gastroplasty (VBG). Quality of life was assessed with the Nottingham Health Profile and a visual analogue scale. A prevalence-based cost-of-illness analysis of morbid obesity was performed and the cost-effectiveness of VBG assessed. Results: VBG resulted in a significant weight loss and an improved quality of life. The improved quality of life combined with 3.6 life-years gained after VBG resulted in 12 quality adjusted life-years (QALY) gained in a lifelong scenario. Lifelong costs of illness of morbidly obese persons ranged from $8,304 to $9,367. Total direct costs of VBG were $5,865. The percentage of patients performing paid labor increased from 19% before VBG to 48% after VBG, resulting in an average productivity gain of $2,765 per year. In summary, the cost-effectiveness analysis revealed that surgical treatment of morbid obesity by means of VBG saves $4,004 to $3,928 per QALY (overall dominance). Conclusion: Because treatment of morbid obesity with VBG results in QALYs gained and less costs, there is no doubt that this procedure should be introduced or continued from a societal point of view.     

Patient Satisfaction and Results of Vertical Banded Gastroplasty and Gastric Bypass

Background: Morbid obesity contributes to many health risks, including physical, emotional, and social problems. Various surgical treatments for morbid obesity have developed and have so far met with good results. This study compares vertical banded gastroplasty (VBG) with gastric bypass (GBP) and the patients' satisfaction with either procedure. Methods: Between April 1993 and July 1997, 63 bariatric surgical procedures were performed at Eisenhower Army Medical Center. Of those, complete follow-up was obtained for 29 patients. The parameters evaluated included age, preoperative and postoperative weights, body mass index (BMI), type of surgery, complications, and the patient's level of satisfaction. Results: The study group consisted of 27 women and 2 men. The average preoperative weight was 135 kg, and the average preoperative BMI was 48.3 kg/m². There were 17 VBGs and 12 GBPs performed. The average total weight loss was 45.1 kg. The average postoperative BMI was 33.2 kg/m². There were no statistically significant differences in weight loss between VBG and GBP. Four of 17 patients had complications after VBG, and three of 12 patients had complications after GBP. After VBG, 94.1% of patients were satisfied, and after GBP, 100% were satisfied. Twenty-seven of 28 patients stated that they would have the surgery again. Conclusion: There were no statistically significant differences in weight loss or complications after VBG or GBP. Patient satisfaction was high after both procedures. Therefore, bariatric surgery is important in the treatment of appropriately selected, morbidly obese patients.     

Improvement of Vertical Banded Gastroplasty by Strict Dietary Management

Background: Vertical banded gastroplasty (VBG) has been found to reduce BMI significantly during the first postoperative year. However, the same trend in weight loss has not been established thereafter.The purpose of this study was to evaluate the effects of our dietary program on morbidly obese patients treated with VBG. Methods: A prospective evaluation of 40 obese patients (25 female, 15 male) undergoing VBG over a 3-year period was undertaken. Results: The age range was 24-57 (median 38) years, mean weight 133±2 SD kg, and mean BMI 45±6.4 SD kg/m2. After VBG, a special follow-up program was applied to patients. All patients (100%) were available for follow-up. Operative mortality was zero. 4 patients developed an early postoperative complication, and 1 patient was re-operated because of staple-line disruption 8 months after VBG. BMI decreased to 34±3.2 after 12 months, 27±1.3 after 24 months, and 28±1.4 after 36 months. All patients showed weight loss after VBG, and the weight loss continued with the strict follow-up program during a 3-year period, except in 1 patient who regained the weight lost despite an intact staple-line and stoma. Conclusion: Our policy for patients after VBG appears to be effective.     

Outcome of Esophageal Function and 24-hour Esophageal pH Monitoring after Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass

Background: One of the co-morbidities frequently associated with morbid obesity is gastro-esophageal reflux disease (GERD), present in >50 % of morbidly obese individuals. We compared the anti-reflux effect of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP), and their effect on esophageal function. Methods: 10 patients underwent VBG and 40 patients underwent RYGBP. Anthropometric parameters, symptomatology of GERD, esophageal manometry (EM), isotopic esophageal emptying (IEE) and 24hr esophageal pH monitoring were recorded in all patients preoperatively, and at 3 months and 1 year postoperatively. Results: Preoperatively, there was a high prevalence of GERD, symptomatic and pH-metric in both groups (57% and 80% respectively). The preoperative values of EM and IEE parameters were within the normal range in most patients. After surgery, there was an improvement at 3 months postoperatively in both groups. 1 year after surgery, the VBG group presented symptomatic GERD in 30% and pH-metric reflux in 60% of patients while the RYGBP group presented symptomatic GERD and pH-metric reflux in 12.5% and 15% of patients, respectively. There was an increase in postoperative sensation of dysphagia in both groups (70% VBG, 30% RYGBP) one year after operation. After surgery, differences in all EM parameters were minimal, and never reached statistical significance for any group (VBG and RYGBP). The IEE showed a significantly higher percentage of esophageal retention after surgery, but this retention was always within the normal range. Both groups had an improvement in anthropometric parameters, but 1 year after surgery the results were significantly better in RYGBP patients (70% excess weight loss) than in VBG patients (46% excess weight loss). Conclusion: >50% of morbidly obese individuals suffer from GERD. We did not find changes in esophageal function of morbidly obese patients to explain their gastroesophageal reflux preoperatively and postoperatively. EM and IEE studies are not indicated as standard preoperative tests, except in patients with significant symptoms of gastroesophageal reflux. RYGBP is significantly better than VBG as an anti-reflux procedure, and had better weight loss.     

Role of Vitamin D and Parathyroid Hormone in the Regulation of Bone Turnover and Bone Mass in Men: The MINOS Study

We investigated the role of vitamin D and of parathyroid hormone (PTH) in the regulation of bone mineral density (BMD), tone dimensions and seasonal variation of bone turnover in 881 men aged 19–85 years. Bone mineral content (BMC) and BMD of the lumbar spine, hip and whole body were measured with HOLOGIC 1000W and those of distal forearm with an OSTEOMETER DTX 100 device. Bone formation was evaluated using osteocalcin, bone alkaline phosphatase and N-terminal extension propeptide of type I collagen (PINP). Bone resorption was evaluated by 24-hour excretion of deoxypyridinoline and of C-terminal telopeptide of collagen type I. In young men (<55 yrs) PTH level decreased with age (r = –0.18, P < 0.005) whereas 25-hydroxyvitamin D (25OHD) concentration was stable. In older men (>55 years) 25OHD decreased whereas PTH increased with age (r = –0.27 and r = 0.21, P = 0.0001). In young men, 25OHD level varied with season but not PTH, biochemical markers of bone turnover nor BMD. In young men, 25OHD, but not PTH, was a significant determinant of BMC, cortical thickness and of biomechanical properties of the femoral neck. Biochemical bone markers and BMD were not correlated with PTH nor with 25OHD. In elderly men, winter levels of 25OHD were lowest whereas those of PTH, bone resorption markers and PINP were highest. After adjustment for age, body weight and season, biochemical markers of bone turnover were correlated with PTH. In elderly men, 25OHD and PTH were significant determinants of BMC, cortical thickness and of biomechanical parameters of the femoral neck. Men with vertebral deformities had lower concentrations of 25OHD, higher PTH levels and slightly elevated urinary excretion of biochemical markers of bone resorption compared with men without vertebral deformities. In conclusion, in young men, 25OHD discloses a seasonal variability in contrast to PTH and biochemical bone markers. In this group, 25OHD is a significant determinant of BMC and BMD but not of bone size. In elderly men, seasonal variation of 25OHD and PTH concentrations result in seasonal variation of bone resorption. In this group, both 25OHD and PTH are determinants of BMC and cortical thickness of the femoral neck and, consequently, of its mechanical parameters.     

Some Hormonal Changes Before and After Vertical Banded Gastroplasty for Severe Obesity

Background: Hormonal disturbances play a role in the development of obesity, but may be a consequence of obesity itself. In this study we assessed the influence of the surgically-induced weight loss on some important hormonal abnormalities in the morbidly obese patients. Material and Methods: Fasting serum prolactin, insulin, cortisol and thyroid hormones: free thyroxin (FT4),free triiodothyronine (FT3) and thyrotropin (TTH), have been studied by radioimmune methods before vertical banded gastroplasty (VBG) and after operation in the early (10-14 days) and late period when excess weight loss (EWL) 51.7-57.1% had been achieved. Results: On the 10-14 day after VBG, prolactin increased significantly in women (p<0.05), but decreased after weight loss (p<0.01). Fasting insulin was lowered significantly (p<0.05) soon after VBG in the hyperinsulinemic (51.7 % of the total group) and diabetic (n-9) patients. After weight loss, insulin decreased significantly (p< 0.0001) vs. preoperative. Concentration of cortisol was unchanged both in the early and in the late postoperative period. On the days 10-14, significant elevation of TTH and decrease of FT3 (p<0.05) have been noted. After essential weight loss TTH dropped significantly vs. preoperative (p< 0.05) with no changes in FT3 and FT4 concentration. Conclusions: VBG and consequent weight loss favorably influence the hormonal abnormalities in the morbidly obese. Further studies are needed to make clear a relationship between this and other parameters of metabolic syndrome. The hormonal abnormalities may influence the indications for surgery in less than morbidly obese patients with metabolic syndrome.     

Short- and Mid-term Changes in Bone Mineral Density After Laparoscopic Sleeve Gastrectomy

Background

Bariatric surgery is the most effective treatment for achieving a significant weight loss. Morbidities present a significant reduction after bariatric surgery, but it may also result in several health complications, related to nutritional deficiencies, including bone metabolism. Several studies have reported a decrease in bone mineral density (BMD), but most of them referring to malabsorptive procedures. Restrictive procedures do not imply changes in gastrointestinal anatomy, so that one may expect fewer metabolic disturbances.

Methods

We performed a retrospective observational study of all morbidly obese patients undergoing LSG between 2008 and 2011 at our institution. Bone densitometry was performed before surgery and 1 and 2 years after the intervention. Body size measurements, analytical variables and densitometric values in the lumbar spine (BMD, t score and z score) were investigated.

Results

Forty-two patients were included, 39females and 3males. Mean BMI was 51.21 kg/m². Mean excessive BMI loss was 79.9 % after 1 year and 80.6 % after 2 years. Mean BMD values for spine increased progressively, reaching statistical significance at 1 and at 2 years. Percentage of BMD increase was 5.7 % at 1 year and 7.9 % at 2 years. An inverse correlation was observed between BMD increase and parathyroid hormone (PTH) decrease and a direct correlation between BMD and vitamin D increase.

Conclusion

Bone mineral density showed a progressive increase during the first and second year after sleeve gastrectomy. BMD changes are not associated with weight loss, but showed a direct correlation with vitamin D and an inverse correlation with PTH levels.     

Results of Bariatric Surgery for Morbid Obesity in Patients Older than 50 Years

Background: Surgery is increasingly used for weight loss in morbidly obese patients. The authors evaluated the safety and efficacy of bariatric surgery in patients older than 50 years. Methods: Prospective data on 62 consecutive patients (Male = 13, Female = 49) undergoing bariatric procedures between 1985-1994 were reviewed. Mean followup was 30 ± 2 months (3-48 months). All data are mean ± sem. Results: Age was 57 ± 1 year (range 50-71 years). Patients had a mean preoperative weight of 125 ± 4 kg (275 ± 9 lb) and 119 ± 6% excess body weight. A total of 68 procedures were performed: vertical banded gastroplasty (VBG = 23), Roux-en-Y gastric bypass (RYGB = 43), and biliopancreatic diversion (BPD = 2). Six patients were converted to RYGB (5) and BPD (1) after failed VBG. Hospital mortality was nil. Complications were wound infection (5), pulmonary (4), gastric leak (2), abscess (1) and others (4). Mean weight loss at 3 years was 55 ± 7 and 33 ± 6% of percent excess body weight for RYGB and VBG, respectively. Postoperative use of medications for arthritis, diabetes mellitus and asthma was reduced by 23%, 62% and 100%, respectively. Satisfaction with the outcome of treatment and weight loss was reported by 81% of patients. Six patients that were converted from jejunoileal bypass (metabolic complications) to VBG gained weight. Conclusions: Bariatric surgery is safe and well tolerated in morbidly obese patients older than 50 years. Weight loss parallels that of younger populations and is greater in patients treated with RYGB in this subgroup. Age should not be a contraindication to bariatric surgery provided the patient has obesity-related medical morbidity. Control of obesity-related co-morbid conditions is improved by weight loss.     

Obesity-associated disorders before and after weight reduction by vertical banded gastroplasty in morbidly vs super obese individuals

Background: The amount of excess weight which must be lost in order to cure or to improve disorders associated with obesity remains unknown. This study was designed to compare super obese and morbidly obese patients in terms of weight reduction following VBG and to investigate the effects of postoperative weight changes to preexisting co-morbidities. Methods: 125 patients underwent VBG. Group A consisted of 80 morbidly obese patients (64%) and group B consisted of 45 super obese patients (36%). Preoperative examination was planned to identify and determine the severity of any disorders associated with obesity, that the patients may have had. Following VBG, all patients were followed-up at regular time periods, for at least 2 and up to 4 years. The progress of preexisting co-morbidities was evaluated and carefully recorded. Results: Among the 80 patients of Group A, there were 240 total co-morbidities (3 per patient), and in group B there were 196 co-morbidities (4.35 per patient) preoperatively. Dyspnea during fatigue and arthritis were found at statistically higher incidence in the super obese category. At the end of the second postoperative year, greater weight loss in terms of number kilograms was seen in patients in group B, but these patients did not reach a BMI lower than 35, while patients in group A had mean BMI below 30. In group A, 66% of the co-morbidities completely resolved, 19% significantly diminished and 15% remain unchanged. In group B, the respective percentages were 53% , 27.5% and 19.5%. However, after weight reduction by VBG a significant number of co-morbidities remain in the super obese patients (92 or 2.044 per/patient), and this is believed to be due to the greater remaining excess weight. Conclusion: Reduction of body weight by VBG is associated with resolution or improvement of a significant number of the obesity-associated disorders. However, super obese patients remain obese after surgery, and this results in two-fold higher remaining morbidity.