FGF 19 and Bile Acids Increase Following Roux-en-Y Gastric Bypass but Not After Medical Management in Patients with Type 2 Diabetes

Background

This study aims to quantify changes in fibroblast growth factor 19 (FGF19) and bile acids (BAs) in patients with uncontrolled type 2 diabetes randomized to Roux-en-Y gastric bypass (RYGB) vs intensive medical management (IMM) and matched for similar reduction in HbA1c after 1 year of treatment.

Methods

Blood samples were drawn from patients who underwent a test meal challenge before and 1 year after IMM (n?=?15) or RYGB (n?=?15).

Results

Mean HbA1c decreased from 9.7 to 6.4 % after RYGB and from 9.1 to 6.1 % in the IMM group. At 12 months, the number of diabetes medications used per subject in the RYGB group (2.5?±?0.5) was less than in the IMM group (4.6?±?0.3). After RYGB, FGF19 increased in the fasted (93?±?15 to 152?±?19 pg/ml; P?=?0.008) and postprandial states (area under the curve (AUC), 10.8?±?1.9 to 23.4?±?4.1 pg?×?h/ml?×?10³; P?=?0.006) but remained unchanged following IMM. BAs increased after RYGB (AUC ×10³, 6.63?±?1.3 to 15.16?±?2.56 μM?×?h; P?=?0.003) and decreased after IMM (AUC ×10³, 8.22?±?1.24 to 5.70?±?0.70; P?=?0.01). No changes were observed in the ratio of 12α-hydroxylated/non-12α-hyroxylated BAs. Following RYGB, FGF19 AUC correlated with BAs (r?=?0.54, P?=?0.04) and trended negatively with HbA1c (r?=??0.44; P?=?0.09); these associations were not observed after IMM.

Conclusions

BA and FGF19 levels increased after RYGB but not after IMM in subjects who achieved similar improvement in glycemic control. Further studies are necessary to determine whether these hormonal changes facilitate improved glucose homeostasis.

     

Gastrin Secretion After Bariatric Surgery—Response to a Protein-Rich Mixed Meal Following Roux-En-Y Gastric Bypass and Sleeve Gastrectomy: a Pilot Study in Normoglycemic Women

Background

Recent investigations have linked elevated gastrin levels to the improvement of type 2 diabetes mellitus (T2DM). Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are effective treatments for T2DM, but it is not known if this is related to postoperative alterations of gastrin secretion.

Methods

Twenty women previously operated with RYGB or SG and 13 female controls were enrolled and evaluated for body mass index, lipids, C-peptide, HbA1c, and anti-H. pylori IgG. Glucose, gastrin, insulin, and glucagon-like peptide 1 (GLP-1) concentrations were measured before and 30, 60, 90, and 120 min after ingestion of a protein-rich mixed meal.

Results

Six participants primarily selected were excluded due to usage of proton pump inhibitors, positive H.pylori IgG, or history of T2DM, yielding the following groups: RYGB (n?=?9), SG (n?=?8), and controls (n?=?10). There were no differences in age, body mass index, HbA1c, or C-peptide levels between groups. RYGB had significantly lower area under the curve (AUC) for glucose during the test compared to controls (p?=?0.013). RYGB showed lower serum gastrin levels compared to SG and controls (p?<?0.05 for all). There was a non-significant increased gastrin release in SG compared to controls (p?=?0.091). For SG and controls, there was a negative correlation between glucose and gastrin response (p?=?0.0043).

Conclusion

Gastrin secretion is diminished after RYGB. Hypergastrinemia was not present after SG, but a tendency of enhanced gastrin secretion was observed. These findings require further investigation in prospective studies.

     

Selection of Bypass vs Sleeve for the Management of Type-2 Diabetes in Severely Obese: Could Ethnicity Play a Role?

Purpose

Prospective data was evaluated to see whether bariatric procedure type made any difference to diabetes remission.

Methods

One hundred eighty-six consecutive patients of Indian ethnicity (M:F 89:97) with type 2 diabetes mellitus (T2DM) and HbA1c >?6.5 were assessed before and at 1 year following surgery. Age, BMI, C-peptide and duration of diabetes (ABCD - described by WJ Lee), insulin use, baseline HbA1c, and % weight loss were tested as modifiers. We present remission rates (HbA1c ≤?6.0%) and between group remission odds ratio (OR) and adjusted OR after controlling for key modifiers.

Results

Patients selecting RYGB (n?=?113) vs SG (n?=?73) were older (50.7 vs 44.2 years), had a lower BMI (44.1 vs 46.7), lower C-peptide (3.5 vs 4.7 ng/ml), greater duration of diabetes (8 vs 3 years), and higher HbA1c (8.90 and 7.9%) respectively p?<?0.05 for all (combined R²?=?0.38). Weight loss at 1 year was 27 and 30% for RYGB and SG respectively (p?=?0.01). Remission at 1 year was achieved by 37% of patient selecting RYGB and 74% for the SG (OR?=?0.21, 95% CI 0.11–0.41, p?<?0.001). After adjusting for ABCD, the adjusted OR (AOR) still favored the SG (AOR?=?0.32, 0.14–0.74, p?=?0.01), and adjustment for HbA1c and weight loss (AOR 0.4, 0.17–0.95, p?=?0.038) attenuated the effect.

Conclusion

The analysis suggests SG may be superior to RYGB in this Indian population. Ethnicity may play a role in predicting the response to bariatric surgery and hence the choice of procedure. A randomized controlled trial is needed to clarify the relative benefit.

     

Effects of Sleeve Gastrectomy and Gastric Bypass on Postprandial Lipid Profile in Obese Type 2 Diabetic Patients: a 2-Year Follow-up

Background

Bariatric surgery (BS) is known to favorably impact fasting lipid profile. Fasting and postprandial lipids were evaluated before and 2 years after BS in obese type 2 diabetic (T2DM) patients.

Methods

A prospective study was conducted in 19 obese T2DM patients: ten undergoing sleeve gastrectomy (SG) and nine undergoing Roux-en-Y gastric bypass (RYGB). Before and 2 years after BS, clinical parameters and the response of lipid and incretin hormones to a mixed meal (MM) were assessed.

Results

The two groups had similar characteristics at baseline. After BS, weight loss was similar in the two groups (p?≤?0.01). Fasting glucose, insulin, and triglycerides decreased while HDL cholesterol increased in a similar way (p?<?0.05); in contrast, fasting LDL cholesterol decreased only after RYGB (p?<?0.05). Post-meal glucose concentrations decreased while early insulin response significantly improved after both procedures (p?<?0.001 for both). Postprandial triglycerides decreased after both procedures (p?<?0.05) while postprandial LDL cholesterol decreased only after RYGB (p?<?0.05). Meal-GLP-1 increased postoperatively in both groups although to a greater extent after RYGB (p?<?0.001 vs. SG). GIP decreased after both procedures, especially after RYGB (p?=?0.003). At multivariate analysis, GLP-1 peak was the best predictor of LDL reduction (β?=??0.552, p?=?0.039) while the improvement of HOMA-IR (β?=?0.574, p?=?0.014) and weight loss (β?=?0.418, p?=?0.036) predicted triglycerides reduction.

Conclusions

Both surgical procedures markedly reduce fasting and postprandial triglycerides and increase HDL cholesterol levels. LDL cholesterol decreases only after RYGB through a mechanism likely mediated by the restoration of GLP-1.

     

Laparoscopic Sleeve Gastrectomy and Gastric Bypass for The Aging Population

Background

Laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most common bariatric surgeries for treating morbid obesity. The purpose of this study is to determine differences in outcomes from RYGB or SG between patients ages?≥?60 years and?<?60 years.

Methods

A retrospective review of patients who underwent RYGB and SG at our institution from 01/2008 to 05/2012 was conducted. Forty patients from each group (≥60 years and?<?60 years) were matched based on gender, body mass index (BMI), co-morbidities, and type of bariatric surgery performed, and their charts were reviewed up to 1 year post-operatively. Primary end points measured were mean length of stay, operative time, incidence of complications, and readmissions in the first post-operative year. A secondary end point measured was percent total weight loss (%TWL) and excess weight loss (%EWL).

Results

There were no significant differences between group?<?60 and group?≥?60 in operative time (210 vs. 229 min; p?=?0.177), in-hospital post-operative complication rates (2.5 vs. 5 %; p?=?1.0), long-term complication rates (2.5 vs. 10 %; p?=?0.359), and 30-day readmission rates (2.5 vs. 12.5 %; p?=?0.2). Patients in group?<?60 had shorter lengths of stay (2.2 vs. 2.7 days; p?=?0.031), but this difference is not clinically significant. Both groups achieved similar %TWL (21.4 vs. 20.5 %; p?=?0.711) and %EWL (50.6 vs. 50.7 %; p?=?0.986).

Conclusions

Advanced age (≥60 years) is not a significant predictor of a worse outcome for SG and RYGB.

     

Adiponectin is related to markers of endothelial dysfunction and neoangiogenesis in diabetic patients

Purpose

Adiponectin an adipokine, produced by mature adipocyte, has an important effect on several aspects of endothelial function, including leukocyte adhesion (mediated by adhesion molecules like intercellular adhesion molecule 1 (ICAM1) endothelial cell selective adhesion molecule ESAM). Recently, it has been linked to vascular endothelial growth factor (VEGF)-modulated angiogenesis. ESAM might also be involved in modulating VEGF-dependent actions. We studied relationship of adiponectin to ESAM, ICAM1, and VEGF in type 2 diabetic patients (T2DP) with or without microvascular complications.

Methods

Incident T2DP referred for nephrologic evaluation were included (patients with no nephropathy or stage 1–4 nephropathy). T2DP with stage 5 chronic kidney disease (CKD) were selected from a dialysis center. Clinical, standard laboratory assessment and adiponectin, ESAM, ICAM1, and VEGF (ELISA) were recorded.

Results

Eighty-seven patients were included, 15 had no CKD, 30 with stage 1 or 2 CKD, 20 with stage 3 or 4 CKD and 22 patients on dialysis. ESAM was higher in patients with CKD than in those without CKD (p?=?0.02), adiponectin, ICAM1, and VEGF were similar. Adiponectin correlated in univariate analysis to ESAM (r?=?0.32, p?=?0.002), ICAM1 (r?=?0.23, p?=?0.038), and CRP (r?=?0.31, p?=?0.012), and inversely to serum albumin (r?=???0.57, <?0.0001). In predialysis patients, adiponectin also correlated to albuminuria (r?=?0.54, p?<?0.0001) and glomerular filtration rate (r?=???0.46, p?=?0.0001). In multivariate regression ESAM (p?=?0.04), VEGF (p?=?0.03), and albumin (p?<?0.0001) are significant predictors of adiponectin. None of these cytokines were different when comparing patients with and without retinopathy.

Conclusion

Adiponectin is directly linked to adhesion molecules and VEGF in T2DP.

     

Total Weight Loss as the Outcome Measure of Choice After Roux-en-Y Gastric Bypass

Background

Currently, there is no agreement on the best method to describe weight loss (WL) after bariatric surgery. The aim of this study is to evaluate short-term outcomes using percent of total body weight loss (%TWL).

Methods

A single-institution retrospective study of 2420 patients undergoing Roux-en-Y gastric bypass (RYGB) was performed. Suboptimal WL was defined as %TWL?<?20 % at 12 months.

Results

Mean preoperative BMI was 46.8?±?7.8 kg/m². One year after surgery, patients lost an average 14.1 kg/m² units of body mass index (BMI), 30.0?±?8.5 %TWL, and 68.5?±?22.9 %EWL. At 6 and 12 months after RYGB, mean BMI and percent excess WL (%EWL) significantly improved for all baseline BMI groups (p?<?0.01, BMI; p?=?0.01, %EWL), whereas mean %TWL was not significantly different among baseline BMI groups (p?=?0.9). The regression analysis between each metric outcome and preoperative BMI demonstrated that preoperative BMI did not significantly correlate with %TWL at 1 year (r?=?0.04, p?=?0.3). On the contrary, preoperative BMI was strongly but negatively associated with the %EWL (r?=??0.52, p?<?0.01) and positively associated with the BMI units lost at 1 year (r?=?0.56, p?<?0.01). In total, 11.3 % of subjects achieved <20 %TWL at 12 months and were considered as suboptimal WL patients.

Conclusion

The results of our study confirm that %TWL should be the metric of choice when reporting WL because it is less influenced by preoperative BMI. Eleven percent of patients failed to achieve successful WL during the in the first year after RYGB based on our definition.

     

The Correlation Between Obesity-Related Diseases and Non-alcoholic Fatty Liver Disease in Women in the Pre-operative Evaluation for Bariatric Surgery Assessed by Transient Hepatic Elastography

Background

Non-alcoholic fatty liver disease (NAFLD) is a common, severe disease in obese patients. However, NAFLD is usually underestimated by ultrasonography. Liver biopsy is not routinely done in bariatric surgery or during the follow-up. This study therefore examined the correlation between metabolic syndrome and NAFLD in morbidly obese patients based on an assessment using transient hepatic elastography (THE).

Material and Methods

This study involved 50 female patients in the pre-operative phase for bariatric surgery. Before surgery, we collected clinical, laboratory, and anthropometric variables. THE measurements were obtained using a FibroScan® device (Echosens, Paris, France), and steatosis was quantified using Controlled Attenuation Parameter software (CAP). Statistical analyses were done using linear correlation and the Kruskal-Wallis test.

Results

The mean of THE and CAP values were 7.56?±?4.78 kPa and 279.94?±?45.69 dB/m, respectively, and there was a significant linear correlation between the two measurements (r?=?0.651; p?<?0.001). The numbers of metabolic syndrome parameters did not influence the THE (p?=?0.436) or CAP (p?=?0.422) values. HbA1c and HOMA-IR showed a strong linear correlation with CAP (r?=?0.643, p?=?0.013 and r?=?0.668, p?=?0.009, respectively) and a tendency to some linear correlation with THE (r?=?0.500, p?=?0.05 and r?=?0.500, p?=?0.002, respectively).

Conclusion

Morbidly obese women submitted to FibroScan® presented a high prevalence of severe steatosis and advanced fibrosis in our sample. Insulin resistance parameters were correlated with steatosis, but less with fibrosis.

     

Sleeve Gastrectomy and Roux-en-Y Gastric Bypass Lead to Comparable Changes in Body Composition after Adjustment for Initial Body Mass Index

Background

Bariatric surgery is a safe and established treatment option of morbid obesity. Mere percentage of excess weight loss (%EWL) should not be the only goal of treatment.

Methods

One hundred seventy-three obese patients were included in the study. They underwent either Roux-en-Y gastric bypass (RYGB; n?=?127, mean body mass index (BMI) 45.7?±?5.7 kg/m²) or sleeve gastrectomy (SG; n?=?46, mean BMI 55.9?±?7.8 kg/m²) for weight reduction. Body weight and body composition were assessed periodically by bioelectrical impedance analysis.

Results

After 1 year of observation, %EWL was 62.9?±?18.0 % in RYGB and 52.3?±?15.0 % in SG (p?=?0.0024). Body fat was reduced in both procedures with a slight preference for SG, and lean body mass was better preserved in the RYGB group. Due to significant differences in the initial BMI between the two groups, an analysis of covariance was performed, which demonstrated no significant differences in the %EWL as well as in the other parameters of body composition 1 year after surgery. Using percentage of total weight loss to evaluate the outcomes between the two procedures, no significant difference was found (31.7?±?8.4 % in RYGB and 30.5?±?7.6 % in SG patients, p?>?0.4).

Conclusions

Excess weight loss is highly influenced by the initial BMI. Total weight loss seems to be a better measurement tool abolishing initial weight differences. SG and RYGB do not differ in terms of body composition and weight loss 1 year after surgery.

     

Sex Effect on Obesity Indices and Metabolic Outcomes in Patients with Obese Obstructive Sleep Apnea and Type 2 Diabetes After Laparoscopic Roux-en-Y Gastric Bypass Surgery: a Preliminary Study

Background

Roux-en-Y gastric bypass (RYGB) surgery is an effective therapy for obstructive sleep apnea (OSA). However, little attention has been paid to the treatment goals systematically stratified by sex. The objective of this study was to assess how sex differences affect obesity indices and metabolic outcomes after RYGB surgery.

Methods

A sleep questionnaire was conducted and medical histories were taken. Full-night polysomnography (PSG), anthropometric variables, and blood samples were collected.

Results

Thirty-five consecutive patients with OSA who underwent laparoscopic RYGB surgery were prospectively examined for at least 6 months were included in the study. Significant improvements (p?<?0.01) in sleep parameters (except for micro-arousal), obesity indices, and metabolic outcomes [except low-density lipoprotein in men and high-density lipoprotein (HDL) in women] were obtained in men and women with OSA. Men had higher baseline triglyceride (TG) (p?<?0.01) and lower HDL levels (p?<?0.01) but a larger neck circumference (NC) (p?=?0.03) at follow-up than did women. However, only TG in men improved more than in women (p?=?0.02).

Conclusions

Sleep parameters, obesity indices, and metabolic outcomes after RYGB surgery were of similar magnitude in women and men with OSA. Alleviating sleep and obesity problems was correlated with metabolic outcomes in men and women.

     

Efficacy of Bariatric Surgery in Type 2 Diabetes Mellitus Remission: the Role of Mini Gastric Bypass/One Anastomosis Gastric Bypass and Sleeve Gastrectomy at 1 Year of Follow-up. A European survey

Background

A retrospective study was undertaken to define the efficacy of both mini gastric bypass or one anastomosis gastric bypass (MGB/OAGB) and sleeve gastrectomy (SG) in type 2 diabetes mellitus (T2DM) remission in morbidly obese patients (pts).

Methods

Eight European centers were involved in this survey. T2DM was preoperatively diagnosed in 313/3252 pts (9.62 %). In 175/313 patients, 55.9 % underwent MGB/OAGB, while in 138/313 patients, 44.1 % received SG between January 2006 and December 2014.

Results

Two hundred six out of 313 (63.7 %) pts reached 1 year of follow-up. The mean body mass index (BMI) for MGB/OAGB pts was 33.1?±?6.6, and the mean BMI for SG pts was 35.9?±?5.9 (p?<?0.001). Eighty-two out of 96 (85.4 %) MGB/OAGB pts vs. 67/110 (60.9 %) SG pts are in remission (p?<?0.001). No correlation was found in the % change vs. baseline values for hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) in relation to BMI reduction, for both MGB/OAGB or SG (ΔFPG 0.7 and ΔHbA1c 0.4 for MGB/OAGB; ΔFPG 0.7 and ΔHbA1c 0.1 for SG). At multivariate analysis, high baseline HbA1c [odds ratio (OR)?=?0.623, 95 % confidence interval (CI) 0.419–0.925, p?=?0.01], preoperative consumption of insulin or oral antidiabetic agents (OR?=?0.256, 95 % CI 0.137–0.478, p?=?<0.001), and T2DM duration >10 years (OR?=?0.752, 95 % CI 0.512–0.976, p?=?0.01) were negative predictors whereas MGB/OAGB resulted as a positive predictor (OR?=?3.888, 95 % CI 1.654–9.143, p?=?0.002) of diabetes remission.

Conclusions

A significant BMI decrease and T2DM remission unrelated from weight loss were recorded for both procedures if compared to baseline values. At univariate and multivariate analyses, MGB/OAGB seems to outperform significantly SG. Four independent variables able to influence T2DM remission at 12 months have been identified.

     

Practices Concerning Revisional Bariatric Surgery: a Survey of 460 Surgeons

Background

There is currently little evidence available on various aspects of Revisional Bariatric Surgery (RBS) and no published consensus amongst experts. The purpose of this study was to understand variation in practices concerning RBS.

Methods

Bariatric surgeons from around the world who perform RBS were invited to participate in a questionnaire-based survey on SurveyMonkey®.

Results

A total of 460 respondents from 62 countries took the survey. For revision after gastric banding, Roux-en-Y gastric bypass (RYGB) (75.5%, n?=?345) emerged as the commonest choice followed by sleeve gastrectomy (SG) (56.9%, n?=?260) and one anastomosis gastric bypass (OAGB) (37.2%, n?=?170). For revision after SG, RYGB (77.7%, n?=?355) was the commonest option followed by OAGB (42.45%, n?=?194) and re-sleeve (22.32%, n?=?102). For revision after RYGB, surgical pouch reduction (49.1%, n?=?223), prolongation of bilio-pancreatic limb (30.0%, n?=?136), and surgical stoma size reduction (26.43%, n?=?120) were the most preferred options. Approximately 90.0% of respondents (n?=?406/454) routinely perform an upper gastrointestinal endoscopy before an RBS, and 85.6% (n?=?388/453) routinely perform a contrast study. Ninety percent (n?=?403/445) reported that the demand for RBS was usually patient-driven, and there was wide variation in criteria used to define successful response, non-responders, and significant weight regain.

Conclusions

This survey is the first attempt to understand various aspects of RBS. The findings will help in identifying areas for research and allow consensus building amongst experts.

     

Ghrelin and acyl ghrelin levels are associated with inflammatory and nutritional markers and with cardiac and vascular dysfunction parameters in hemodialysis patients

Purpose

Exogenous ghrelin is associated with cardiovascular protection in experimental and human studies. Nevertheless ESRD patients have increased ghrelin levels and severe cardiovascular comorbidities. This study aims to elucidate the metabolic factors influencing endogenous ghrelin/acyl ghrelin levels and to analyze the relation between endogenous ghrelin/acyl ghrelin levels and cardiac and vascular function markers in hemodialysis patients.

Methods

The cross-sectional study was conducted in hemodialysis patients (n?=?88); 50 of them were men, mean age 61.1?±?13.5 years, 17% had diabetes. We assessed nutritional and inflammatory status and analyzed the determinants of ghrelin/acyl ghrelin and their relation with cardiac and vascular function.

Results

Ghrelin is correlated with IL-1β (r?=?0.88, p?<?0.0001), triglycerides, total cholesterol (TC), and Kt/V. IL-1β is the strongest predictor of ghrelin levels (p?<?0.0001). Acyl ghrelin is correlated with TC (r?=?0.36, p?=?0.001), LDL-cholesterol, serum bicarbonate, body mass index. TC is the strongest predictor for acyl ghrelin levels (p?=?0.038). Patients with high ghrelin levels had significantly decreased nitroglycerin-mediated dilation (p?=?0.05) and higher IL-1β levels (p?<?0.001); increased NT-proBNP is associated with lower levels of acyl ghrelin (r?=???0.33, p?=?0.02) in male patients.

Conclusion

The inflammatory marker IL-1β is in our study the strongest predictor of ghrelin levels while the nutritional marker-total cholesterol is the strongest predictor for acyl ghrelin levels in HD patients. High endogenous ghrelin level is associated with high IL-1β and with vascular smooth muscle cell dysfunction. Low acyl ghrelin level is associated with high NT-proBNP (a cardiac dysfunction marker) in male HD patients. There is a direct correlation between endogenous ghrelin level and inflammatory markers, which is not related with cardiovascular protection.

     

Finding covert fluid: methods for detecting volume overload in children on dialysis

Background

Lung ultrasound is a novel technique for detecting generalized fluid overload in children and adults with end-stage renal disease (ESRD). Echocardiography and bioimpedance spectroscopy are established methods, albeit variably adopted in clinical practice. We compared the practicality and accuracy of lung ultrasound with current objective techniques for detecting fluid overload in children with ESRD.

Methods

A prospective observational study was performed to compare lung ultrasound B-lines, echocardiographic measurement of inferior vena cava parameters and bioimpedance spectroscopy in the assessment of fluid overload in children with ESRD on dialysis. The utility of each technique in predicting fluid overload, based on short-term weight gain, was assessed. Multiple linear regression models to predict fluid overload by weight were explored.

Results

A total of 22 fluid assessments were performed in 13 children (8 on peritoneal dialysis, 5 on haemodialysis) with a median age of 4.0 (range 0.8–14.0) years. A significant linear correlation was observed between the number of B-lines detected by lung ultrasound and fluid overload by weight (r?=?0.57, p?=?0.005). A non-significant positive linear correlation was observed between fluid overload by weight and bioimpedance spectroscopy (r?=?0.43, p?=?0.2), systolic blood pressure (r?=?0.19, p?=?0.4) and physical examination measurements (r?=?0.19, p?=?0.4), while a non-significant negative linear relationship was found between the inferior vena cava collapsibility index and fluid overload by weight (r?=??0.24, p?=?0.3). In multiple linear regression models, a combination of three fluid parameters, namely lung ultrasound B-lines, clinical examination and systolic blood pressure, best predicted fluid overload (R ² ?=?0.46, p?=?0.05).

Conclusions

Lung ultrasound may be superior to echocardiographic methods and bioimpedance spectroscopy in detecting volume overload in children with ESRD. Given the practicality and sensitivity of this new technique, it can be adopted alongside clinical examination and blood pressure in the routine assessment of fluid status in children with ESRD.

     

Roux-en-Y Gastric Bypass Surgery on Obstructive Sleep Apnea-Hypopnea Syndrome: Factors Associated with Postoperative Efficacy

Background

Bariatric surgery can effectively treat obesity and improve OSAHS. However, the exact underlying mechanisms remain unclear. The objective of this follow-up study is to explore the main factors associated with the efficacy of Roux-en-Y gastric bypass surgery (RYGB) on obstructive sleep apnea-hypopnea syndrome (OSAHS).

Methods

A total of 39 OSAHS patients with obesity and type 2 diabetes mellitus (T2DM) who had received RYGB surgery were recruited. A polysomnography test was carried out in all subjects before surgery and postoperative 6 to 12 months, and the following tests were performed: fasting glucose, lipid profile, electrolyte levels, and liver and kidney function tests. The paired Student’s t test, Pearson test, Spearman correlation test, and multiple linear regression analysis were used to explore the effects of RYGB surgery on these indices and investigate the main factors associated with postoperative efficacy.

Results

RYGB surgery significantly lowered the apnea-hypopnea index (AHI), body mass index (BMI), and concentrations of total albumin, prealbumin, retinol-binding protein, total cholesterol, triglycerides, fasting blood glucose, albumin, and C-reactive protein, while postoperative blood magnesium levels were significantly increased (p?<?0.05). Changes in the AHI (delta AHI) were correlated with delta BMI (r?=?0.408, p?=?0.010) and delta prealbumin levels (r?=?0.495, p?=?0.001). However, no significant correlation was found between delta BMI and delta prealbumin. The delta AHI were assessed by multiple linear analysis as follows: delta AHI?=?0.105 × (delta prealbumin) + 1.509 × (delta BMI) + 1.006.

Conclusions

RYGB is an effective therapeutic option for OSAHS patients with obesity and T2DM; the potential factors associated with postoperative efficacy include changes in BMI and prealbumin levels.

     

Comparison of reticulocyte hemoglobin equivalent with traditional markers of iron and erythropoiesis in pediatric dialysis

Background

Anemia is a major complication for patients on chronic dialysis. Erythropoietin is effective if iron is available, however unnecessary iron supplementation results in iron overload. Reticulocyte hemoglobin equivalent (Ret-He) may be useful for assessing iron status.

Methods

A national retrospective cohort study including all children on chronic dialysis in New Zealand between 2007 and 2013, pairing Ret-He with demographic information, anemia indices, and markers of iron status.

Results

In 606 observations, we found a modest relationship between Ret-He and transferrin saturation (TSAT) (r?=?0.34, p?<?0.001) and a poor correlation between Ret-He and ferritin (r?=?0.09, p?=?0.04). There was a negative correlation between ferritin and hemoglobin (r?=??0.14, p?=?0.002), a weak positive correlation between TSAT and hemoglobin (r?=?0.12, p?=?0.007), and a modest positive correlation between Ret-He and hemoglobin (r?=?0.22, p?<?0.001). The diagnostic performance of Ret-He to detect absolute iron deficiency (cut-off value 28.9 pg, sensitivity 90 %, specificity 75 %, AUC 0.87) was good.

Conclusions

Ret-He is a more relevant marker of iron status than ferritin and TSAT. This supports prospectively testing Ret-He to distinguish between iron deficiency and suboptimal erythropoietin dosing as competing causes for anemia. Ferritin is an unhelpful biomarker of iron deficiency in this setting.

     

Influence of Drain Placement on Postoperative Pain Following Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: Randomized Controlled Trial

Background

There is currently no evidence to support the routine use of an abdominal drain following laparoscopic Roux-en-Y gastric bypass (RYGB). Our aim was to investigate drain use in laparoscopic RYGB and its effects on postoperative pain.

Methods

Sixty-six patients were randomly divided into two groups as no-drain (n?=?36) and with-drain (n?=?30). Intraoperative (time, blood loss, complications) and postoperative outcomes (morbidities, pain scores, hospital stay) were compared.

Results

Demographics of both groups were comparable. Three patients in the no-drain group required a drain (8.3%). Median visual analog scale scores for days 1–3 for with-drain and no-drain groups were 4.5 (2–9) vs. 3 (0–8) (p?=?0.02), 3 (0–7) vs. 2 (0–7) (p?=?0.10), and 2 (0–7) vs. 0 (0–4) (p?=?0.0004), respectively. There was no difference between the groups in terms of complications and length of hospital stay.

Conclusion

Drain use increased the postoperative pain following laparoscopic RYGB. Drain placement following laparoscopic RYGB should be selective instead of a routine application.

     

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Introduction

A subset of patients undergoing laparoscopic sleeve gastrectomy (SG) require eventual conversion to Roux-en-Y gastric bypass (RYGB) due to complications from SG or to enhance weight loss. The aim of this study is to characterize the indications for conversion and perioperative outcomes in a large cohort of these patients at a single institution.

Methods

Patients who underwent revisional surgery to convert SG to RYGB at our institution from January 2008 through January 2017 were retrospectively reviewed.

Results

Eighty-nine patients with previous SG underwent conversion to RYGB as part of a planned two-stage approach to gastric bypass (n?=?36), for weight recidivism (n?=?11), or for complications related to SG (n?=?42). Complications from SG that warranted conversion included refractory GERD (40.5%), sleeve stenosis (31.0%), gastrocutaneous (16.7%), or gastropleural (7.1%) fistula, and gastric torsion (4.1%). The mean (SD) age was 47.2 years (11.4 years) and median BMI at the time of revision was 43.2 kg/m². A laparoscopic approach was successfully completed in 76 patients (85.4%), with an additional of four completed robotically (4.5%). The median length of stay was 3 days. Twenty-eight patients (31.5%) had complications which included surgical site infection (20.2%), re-operation (6.7%), anastomotic stricture (3.4%), and one pulmonary embolism. There were no mortalities with a median follow-up of 15 months.

Conclusions

Conversion of SG to RYGB is safe and technically feasible when performed for complications of SG or to enhance weight loss. This operation can be successfully performed laparoscopically with a low rate of conversion and reasonable complication profile.

     

Influence of Insulin Resistance Status on the Development of Gallstones Following Roux-En-Y Gastric Bypass: a Prospective Cohort Study

Background

The occurrence of gallstones following Roux-en-Y gastric bypass (RYGB) has been extensively reported. As RYGB promotes improvement in insulin resistance (IR), which is one of the factors enrolled in the pathophysiology of gallstones, this study aims to determine the influence of IR and its post-RYGB course on the development of gallstones.

Methods

This is a prospective cohort study that enrolled 108 morbidly obese subjects free of gallstones which underwent RYGB and were followed up for 24 months, through clinical, laboratory, and ultrasound examinations. IR was assessed through the surrogate marker homeostasis model assessment (HOMA).

Results

Of the individuals evaluated, 29 (26.8 %) developed gallstones following RYGB. In the univariate analysis, postsurgical gallstones were associated with preoperative HOMA (p?<?0.0001), preoperative fasting glucose (p?=?0.0019), preoperative fasting insulin (p?=?0.0001), and preoperative triglycerides (p?=?0.0001). Multivariate analysis revealed that preoperative HOMA was the only factor independently associated with gallstones (p?<?0.0001). The incidence of gallstones among individuals with IR was 46.8 %; in the non-IR subjects, the incidence was 7.4 % (p?<?0.0001). Preoperative IR led to a relative risk of 6.02 (95 % CI?=?2.1–17.3; p?=?0.0009) of gallstones.

Conclusions

As gallstones often occur following RYGB, there is controversy regarding their management. Some authors propose systematic cholecystectomy along with RYGB, while others suggest that the aggregate risk of the concomitant approach is significantly higher. As IR was a significant risk factor in this study, an individualized approach for this population may be proposed. Further research is needed to confirm these findings.

     

Evidence That the Length of Bile Loop Determines Serum Bile Acid Concentration and Glycemic Control After Bariatric Surgery

Background

Bariatric surgery contributes to the improvement in glucose metabolism that may be related to a postoperative increase in serum bile acids (BAs). Three commonly used types of bariatric procedures, laparoscopic sleeve gastrectomy (LSG) (without creation of a bile loop), Roux-en-Y gastric bypass (RYGB), and omega-loop gastric bypass (OLGB) (with creation of shorter 100–150 cm and longer 200–280 cm bile loops, respectively), differ in their effects on glycemic control. The aim of the study was to compare the effects of various bariatric procedures on serum BA concentration and glucose homeostasis.

Methods

Serum BAs in 26 obese patients were determined by liquid chromatography-mass spectrometry prior to bariatric surgery, as well as 4 days and 3 months thereafter.

Results

Four days after the surgery, serum concentrations of BAs in LSG and OLGB groups were similar as prior to the procedure, and a slight decrease in serum BAs was observed in the RYGB group. Serum BA level in the LSG group remained unchanged also at 3 months after the surgery, whereas a significant 0.5- and 3-fold increase in this parameter was noted in the RYGB and OLGB groups, respectively. Serum concentration of BAs correlated positively with the length of the bile loop (R?=?0.47, p?<?0.05).

Conclusion

The evident improvement of glycemic control observed 3 months after OLGB might be associated with a postoperative increase in serum BAs, resulting from their better absorption from the longer bile loop. However, the changes in serum BAs probably had little or no impact on insulin sensitivity improvement at 4 days post-surgery.