Peptide YY and Glucagon-like Peptide-1 in Morbidly Obese Patients Before and After Surgically Induced Weight Loss

Background Peptide YY (PYY) and glucagon-like peptide-1 (GLP-1) are cosecreted in the same enteroendocrine L-cells of the gut and reported to inhibit food intake additively. However, findings in human studies regarding these peptides are controversial. The aim of this study was to analyze the relationships between fasting PYY, GLP-1, and weight status in morbidly obese patients before and after surgically induced weight loss. Methods Fasting GLP-1, PYY, glucose, and insulin concentrations; blood pressure; and body-mass index (BMI) were determined in 30 morbidly obese adults (mean BMI 45.8, mean age 40 years) before bariatric surgery [Roux-en-Y gastric bypass (RYGB): n = 19; gastric banding (GB): n = 11] and after weight loss (mean 50% excess weight loss) in the course of mean 2 years. Results GLP-1 concentrations decreased (mean −20 pg/ml; mean −38%; p = 0.001) and PYY concentrations increased (mean +19 pg/ml; mean +19%, p = 0.036) after bariatric surgery. The weight loss and changes of GLP-1 were significantly (p < 0.05) more pronounced after RYGB as compared to GB, whereas the changes of PYY did not differ significantly between the patients who had undergone RYGB or GB. Conclusions In morbidly obese adults reducing their weight by bariatric surgery, fasting PYY levels increased and GLP-1 concentrations decreased independently of each other. Therefore, the relationship between PYY and GLP-1 seems more complicated than might be anticipated from animal and in vitro studies. T. Reinehr and C. L. Roth contributed equally to this work.     

Gastro-Esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients before and after Bariatric Surgery

Background Obesity is a predisposing factor to gastro- esophageal reflux disease (GERD), but esophageal function remains poorly studied in morbidly obese patients and could be modified by bariatric surgery. Methods Every morbidly obese patient (BMI ≥40 kg/m² or ≥35 in association with co-morbidity) was prospectively included with an evaluation of GERD symptoms, endoscopy, 24-hour pH monitoring and esophageal manometry before and after adjustable gastric banding (AGB) or Roux-en-Y gastric bypass (RYGBP). Results Before surgery, 100 patients were included (84 F, age 38.4 ± 10.9 years, BMI 45.1 ± 6.02 kg/m2), of whom 73% reported GERD symptoms. Endoscopy evidenced hiatus hernia in 39.4% and esophagitis in 6.4%. The DeMeester score was pathological in 53.3%; 69% of patients had lower esophageal sphincter (LES) pressure <15 mmHg and 7 had esophageal dyskinesia. BMI was significantly related to the DeMeester score (P = 0.018) but not to LES tone or esophageal dyskinesia. Postoperative data were available in 27 patients (AGB n = 12/60, RYGBP n = 15/36). The DeMeester score (normal <14.72) was significantly decreased after RYGBP (24.8 ± 13.7 before vs 5.8 ± 4.9 after; P < 0.001) but tended to increase after AGB (11.5 ± 5.1 before vs 51.7 ± 70.7 after; P = 0.09), with severe dyskinesia in 2 cases. Conclusion: GERD and LES incompetence are highly prevalent in morbidly obese patients. Preliminary postoperative data show different effects of RYGBP and AGB on esophageal function, with worsening of pH-metric data with occasional severe dyskinesia after AGB.     

Short- and long-term results of laparoscopic gastric banding for morbid obesity

Background Today, gastric banding has become a common bariatric procedure. Weight loss can be excellent, but is not sufficient in a significant proportion of patients. Few long-term studies have been published. We present our results after up to 9 years of follow-up. Materials and methods One hundred twenty-seven patients (1997–2004) were analyzed retrospectively after laparoscopic gastric banding (perigastric technique: n = 60; pars flaccida technique: n = 67) in terms of preoperative characteristics, weight loss, comorbidities, short- and long-term complications, and quality of life. Results Median follow-up was 63 months (range 2–104). Incidence of postoperative complications were: gastric perforation in 3.1%, band erosion in 3.1%, band or port leak in 2.3%, port infection in 5.3%, port dislocation in 6.9%, and pouch dilatation in 16.9%. Total number of patients requiring reoperation was 34 (26.7%) [perigastric technique n = 23 (38.8%) versus pars flaccida technique n = 11 (16%), p = 0.039]. Mean excess body weight loss (%) was 50.6%. Most patients reported an increase in quality of life after surgery. Conclusions Gastric banding is effective for achieving weight loss and improving comorbidity in obese patients. Obviously, gastric banding can be performed more safely with the pars flaccida technique, although the complication rate remains relatively high. Nevertheless, based on adequate patient selection, gastric banding should still be considered a valuable therapeutic option in bariatric surgery.     

Revision of Failed Bariatric Procedures to Roux-en-Y Gastric Bypass (RYGB)

Bariatric surgery for morbid obesity has been established as an effective treatment method and has been shown to be associated with resolution of co-morbidities. Despite its success, some patients may require revision because of weight regain or mechanical complications. From September 2005 to December 2009, 42 patients underwent revisional Roux-en-Y gastric bypass (RYGB). All procedures were performed by one surgeon. Demographics, indications for revision, complications, and weight loss were reviewed. Thirty-seven patients were treated with laparoscopic (n = 36) or open (n = 1) RYGB after failed laparoscopic adjustable gastric banding. Four patient were treated with laparoscopic (n = 3) or open (n-1) RYGB after failed vertical banded gastroplasty, and one patient underwent open redo RYGB due to large gastric pouch. Conversion rate from laparoscopy to open surgery was 2.5% (one patient). Mean operative time was 145.83 ± 35.19 min, and hospital stay was 3.36 ± 1.20 days. There was no mortality. Early and late complications occurred in six patients (14.2%). The mean follow-up was 15.83 ± 13.43 months. Mean preoperative body mass index was 45.15 ± 7.95 that decreased to 35.23 ± 6.7, and mean percentage excess weight loss was 41.19 ± 20.22 after RYGB within our follow-up period. RYGB as a revisional bariatric procedure is effective to treat complications of restrictive procedures and to further reduce weight in morbidly obese patients.     

Increase in Ghrelin Levels After Weight Loss in Obese Zucker Rats is Prevented by Gastric Banding

Background Gastric banding is thought to decrease appetite in addition to the mechanical effects of food restriction, although this has been difficult to demonstrate in human studies. Our aim was to investigate the changes in orexigenic signals in the obese Zucker rat after gastric banding. Methods Obese Zucker rats (fa/fa) were submitted to gastric banding (GBP), sham gastric banding fed ad libitum (sham), or sham operation with food restriction, pair-fed to the gastric banding group (sham-PF). Lean Zucker rats (fa/+) were used as additional controls. Body weight and food intake were daily recorded for 21 days after surgery when epididymal fat was weighed and fasting ghrelin and hypothalamic NPY mRNA expression were measured. Results Gastric banding in obese Zucker rats resulted in a significant decrease of cumulative body weight gain and food intake. Furthermore, gastric banded rats were leaner than Sham-PF, as expressed by a significantly lower epididymal fat weight. Ghrelin levels of gastric banded rats were not increased when compared to sham-operated animals fed ad libitum and were significantly lower than the levels of weight matched sham-PF rats (1116.9 ± 103.3 g GBP vs 963.2 ± 54.3 g sham, 3,079.5 ± 221.6 sham-PF and 2,969.9 ± 150.9 g lean rats, p < 0.001); hypothalamic NPY mRNA expression was not increased in GBP when compared to sham-operated rats. Conclusion In obese Zucker rats, GBP prevents the increase in orexigenic signals that occur during caloric deprivation. Our data support the hypothesis that sustained weight loss observed after gastric banding does not depend solely on food restriction.     

Gastric Emptying of Semisolids and Pouch Motility Following Laparoscopic Adjustable Gastric Banding

Background  Laparoscopic adjustable gastric banding (LAGB) has been popularized as an effective, safe, minimally invasive surgical technique for the treatment of morbid obesity. We performed a pilot study to evaluate gastric emptying of semisolid meals and antral motility following LAGB. Methods  Gastric emptying half-time was compared in normal volunteers and morbidly obese patients before and 6–12 months after LAGB using sulfur colloid-labeled semisolid meals. Results  There was no difference in mean age between groups. Women were prevalent in the group of obese patients. BMI was higher in patients before surgery (p < 0.001). Patients following LAGB demonstrated prolonged gastric pouch emptying (T1/2 = 36.6 ± 9.8 min) compared to subjects without surgery (23.8 ± 4.7 min) and healthy volunteers (22.8 ± 6.8 min; p < 0.001). Similar gastric contractility was found all groups (3.3 ± 0.4; p = 0.968). No cases of band slippage or pouch dilatation were observed during mean follow-up of 11.4 months. Conclusions  A standard normal gastric pouch emptying rate of semisolids in asymptomatic patients after LAGB was established. Postoperative prolongation of gastric emptying is a matter of mechanical delay without gastric pouch denervation. This study provides a first step of future functional evaluation of complications following this type of bariatric surgery.     

Gastric Emptying of Solids and Semi-solids in Morbidly Obese and Non-obese Subjects: An Assessment Using the <Superscript>13</Superscript>C-Octanoic Acid and <Superscript>13</Superscript>C-Acetic Acid Breath Tests

Background It has been suggested that obesity is associated with an altered rate of gastric emptying. The objective of the present study was to determine whether the rates of solid and semi-solid gastric emptying differ between morbidly obese patients and lean subjects. Methods The Gastric-emptying time (GET) of solid and semi-solid meals were compared between lean healthy subjects and morbidly obese patients enrolled in two previously published studies. GET of solid and semi-solid meals was measured using the ¹³C-octanoic acid breath test and ¹³C-acetic acid breath test, respectively, in 24 lean and 14 morbidly obese individuals of both sexes. Student t-test was used to compare the mean data between the lean and morbidly obese groups. The influence of sex, gender, BMI and morbid obesity on the GET of solid meals was verified by linear regression analysis. Results Mean t(1/2) values of solid GET (± standard deviation) were 203.6 ±  76.0 min and 143.5 ± 19.1 min for lean and obese subjects, respectively (P = 0.0010). Mean t(lag) values of solid GET were 127.3 ± 42.7 min and 98.4 ± 13.0 min for lean and obese subjects, respectively (P = 0.0044). No significant difference in semi-solid GET was observed between the lean and morbidly obese groups. Conclusion The present study demonstrated a significantly enhanced gastric emptying of the solid meal test in morbidly obese patients when compared to lean subjects. This finding is compatible with the hypothesis that rapid gastric emptying in morbidly obese subjects increases caloric intake due to a more rapid loss of satiety.     

Comparison of Weight Loss and Morbidity after Gastric Bypass and Gastric Banding. A Single Center European Experience

Background Gastric bypass and gastric banding are widely used to treat morbid obesity and both procedures offer certain advantages. The indication for these two treatment options continue to be subject to debate. Methods A single-center case-controlled matched-pair cohort study was performed. Fifty-three primary gastric bypass patients (GB) operated between January 2002 and May 2005 were matched by gender, age, race, and initial bodyweight to 53 patients who underwent laparoscopic adjustable gastric banding (LAGB) in the same time period. Results Both groups were comparable regarding age, race, gender, preoperative body mass index, and excessive weight. Severe early complications occurred in six patients (11.3%) in the GB group and were not seen in the LAGB group. Severe late complications occurred in three patients (5.7%) in the GB group and one patient (1.9%) in the LAGB group. No mortality occurred in either group. Weight loss was significantly lower in the LAGB group than in the GB group at all time points during the follow-up. Significantly more patients were treated successfully (excess weight loss >50%) in the GB group than in the LAGB group. After 2 years, 76% of the patients in the GB group were treated successfully versus 40% of the patients in the LAGB group (P = 0.03). Conclusion Gastric bypass and gastric banding are safe and without mortality. Gastric bypass is more effective in terms of weight loss and the number of successfully treated patients. Gastric banding is a procedure with less severe complications.     

Serum C-Reactive Protein and White Blood Cell Count in Morbidly Obese Surgical Patients

Background  Obesity has been widely recognized as a chronic inflammatory condition and associated with elevated inflammatory indicators including C-reactive protein (CRP) and white blood cell count (WBC). Recent studies have shown elevated CRP or WBC is a significant risk factor for cardiac events and stroke but the clinical significance of CRP and WBC has not been clearly studied in morbidly obese patients. This study is aimed at the clinical significance of WBC and CRP in morbidly obese patients and the change after bariatric surgery. Methods  The study was a prospectively controlled clinical study. From December 1, 2001 to January 31, 2006, of 640 (442 females and 198 males) consecutive morbid obese patients enrolled in a surgically supervised weight loss program with at least 1 year’s follow-up were examined. Results  Of the patients, 476 (74.4%) had elevated CRP and 100 (15.6%) had elevated WBC at preoperative study. CRP and WBC were significantly related and both increased with increasing body mass index (BMI). CRP is also increased with increasing waist, glucose level, hemoglobin, albumin, Ca, insulin, C-peptide, and metabolic syndrome while WBC is increased with metabolic syndrome but decreased with increasing age. Multivariate analysis confirmed fasting glucose level and hemoglobin are independent predictors of the elevation of CRP while age is the only independent predictor for elevated WBC. Both WBC and CRP levels decreased rapidly after obesity surgery. These improvements resulted in a 69.8% reduction of CRP and 26.4% reduction of WBC 1 year after surgery. Although individuals who underwent laparoscopic gastric bypass lost significantly more weight (36.8 ± 11.7 kg vs. 17.3 ± 10.8 kg; p = 0.000) and achieved a lower BMI (27.8 ± 4.6 vs. 35.0 ± 5.5; p = 0.000) than individuals who underwent laparoscopic gastric banding, there was no difference in the resolution of elevated CRP 1 year after surgery (95.9% vs. 84.5%; p = 0.169) and WBC (99.4% vs. 98.3%; p = 0.323). Conclusions  Both baseline WBC and CRP are elevated in morbid obese patients but CRP has a better clinical significance. Significant weight reduction 1 year after surgery markedly reduced CRP and WBC with a resolution rate of 93.9% and 98.2% separately. Obesity surgery performed by laparoscopic surgery is recommended for obese patients with elevated CRP or WBC.     

Ghrelin and Obestatin Levels in Severely Obese Women Before and After Weight Loss After Roux-en-Y Gastric Bypass Surgery

Background  Ghrelin and obestatin are derived from the same gene but have different effects: Ghrelin stimulates appetite, and previous—albeit inconsistent—data show that obestatin may be involved in satiety. The present study was designed to test the hypothesis that Roux-en-Y gastric bypass (RYGB) surgery and/or the weight loss that reliably results from this procedure would alter levels of ghrelin and obestatin and ghrelin/obestatin ratios in a cohort of morbidly obese women. Methods  This is a longitudinal follow-up study in 18 morbidly obese women (mean weight 131.2 kg, mean body mass index [BMI] 47.4). Clinical parameters and fasting serum concentrations of ghrelin, obestatin, triglycerides, low-density lipoprotein cholesterol, glucose, and insulin were measured before and 2 years after RYGB surgery, which was associated with body weight reductions of 41.5 ± 11.6 kg (mean 62.5% excess weight loss). Results  Ghrelin concentrations (−12%, p = 0.022) and ghrelin/obestatin ratios (−14%, p = 0.017) were lower after surgery than before, while obestatin levels did not change. Changes in ghrelin concentrations correlated with changes in insulin levels (r = 0.45, p = 0.011). Most cardiovascular risk factors studied improved postsurgically (p < 0.01). Conclusion  In contrast to previous weight loss studies involving gastric banding, ghrelin levels decreased and obestatin levels remained stable after massive weight loss in long-term follow-up. The favorable gastrointestinal hormone profiles observed are likely to contribute to the long-term weight loss success rate attributed to RYGB. C.L. Roth and T. Reinehr contributed equally to this work.     

Clinical Characteristics and Outcome of Morbidly Obese Bariatric Patients with Concurrent Hepatitis B Viral Infection

Background Bariatric surgery is the only effective and long-lasting treatment of morbidly obese patients. However, the safety and efficacy of bariatric surgery in patients with hepatitis B viral (HBV) infection is not clear. The aim of the present study is to investigate weather HBV infection influences clinic features and outcomes of bariatric surgery. Methods The preoperative seropositivity of HBV surface antigen (HBsAg) using radioimmunoassay was determined in 592 patients (481 female, 111 male: mean age 30.5 ± 8.1 years; mean body mass index [BMI] 43.1 ± 6.0) who had undergone bariatric surgery (209 banding and 383 gastric bypass) for their morbid obesity in the past 5 years. All the clinical data were prospectively collected and stored. Results The overall seroprevalence of HbsAg was 18.8%. Morbidly obese patients positive for HBV infection were associated with older age and higher diastolic blood pressure, but not with sex, BMI, liver enzyme, blood lipid, and glucose levels. Although minigastric bypass (MGB) had a better weight reduction than gastric banding, there was no difference in weight reduction between patients who were positive and negative for HBV infection. The weight loss curves and resolution of obesity-related comorbidities were similar between the two groups except the postoperative aspartate transaminase (AST) and alanine transaminase (ALT) were significantly higher in patients who were positive for HBV infection. During follow-up, two patients developed fulminating hepatitis after MGB with one mortality. Conclusion Morbidly obese patients with the existence of HBV infection do not influence the outcome of bariatric surgery, but continuing monitor of the liver function is indicated.     

The Effect of Roux-en-Y Gastric Bypass on Gastroesophageal Reflux Disease in Morbidly Obese Chinese Patients

Background  The prevalence of gastroesophageal reflux disease (GERD) is increasing in Eastern and Western countries. Obesity is recognized as a risk factor of gastroesophageal reflux disease. However, little information is available on the prevalence of gastroesophageal reflux disease in morbidly obese Chinese patients. The aim of this study was to compare the prevalence of GERD in Chinese patients with morbid obesity and age- and sex-matched controls, and we also assessed the effect of Roux-en-Y gastric bypass on reflux symptoms and erosive esophagitis. Methods  Between November 2006 and February 2008, 150 morbidly obese Chinese patients underwent laparoscopic Roux-en-Y gastric bypass. Gastroesophageal reflux disease questionnaires and esophagogastroduodenoscopy results were assessed in all cases before surgery. The prevalence of reflux symptoms and erosive esophagitis was compared with the prevalence in a database of 300 age- and sex-matched controls. We also compared baseline and postoperative characteristics at 12 months after operation. Results  Patients with morbid obesity had higher frequencies of reflux symptoms (16% vs. 8%, P = 0.01) and erosive esophagitis (34% vs. 17%, P < 0.01) than those of controls. Twelve months after laparoscopic Roux-en-Y gastric bypass, 26 patients received follow-up evaluations. In addition to substantial weight loss, the prevalence of reflux symptoms and erosive esophagitis decreased significantly after operation (19.2% vs. 0%, P = 0.05, and 42.3% vs. 3.8%, P < 0.01, respectively). Conclusions  Gastroesophageal reflux disease is pervasive in Chinese patients with morbid obesity and Roux-en-Y gastric bypass substantially improves not only the reflux symptoms but also the erosive esophagitis.     

Impact of Laparoscopic Adjustable Gastric Banding on Obesity Co-morbidities in the Medium- and Long-Term

Background The authors evaluated the impact of laparoscopic adjustable gastric banding (LAGB) on obesity-associated diseases in a series at 3 to 8 years postoperatively, namely diabetes, pulmonary disease, hypertension and knee joint pain. Methods 145 morbidly obese patients underwent LAGB with mean age 38 years and preoperative BMI 48.5 kg/m2 (range 34–77). Changes in BMI and excess BMI loss (EBL) were evaluated. Results 138 of the 145 patients (95%) were available for full follow-up. At last follow-up, BMI had dropped to 34.0 ± 6.4 SD kg/m², and mean EBL was 61.9 ± 26.1%. Prevalence of obesity-associated disease was significantly reduced: diabetes decreased from 10% to 4%, treatment-requiring pulmonary disease from 15% to 5%, hypertension from 43% to 27%, and knee pain from 47% to 38%. Conclusion Following gastric banding, >75% of patients suffering from obesity-related disease had significant decrease or resolution of their co-morbidities.     

Laparoscopic Mini-gastric Bypass: Experience with Tailored Bypass Limb According to Body Weight

Background Gastric bypass surgery is an effective and long-lasting treatment of morbidly obese patients. However, the bypass limb may need to be tailored in morbidly obese patients with a wide range of obesity. The aim of the present study was to report clinical result of tailored bypass limb in a group of patients receiving laparoscopic mini-gastric bypass surgery. Methods From Jan 2002 to Dec 2006, laparoscopic mini-gastric bypass was performed in 644 patients [469 women, 175 men: mean age 30.5 ± 8.1 years; mean body mass index (BMI) 43.1 ± 6.0] in our department. The gastric bypass limb was tailored according to the preoperative BMI. The clinical data and outcomes were analyzed. All the clinical data were prospectively collected and stored. Results Two hundred eighty-six patients belonged to lower BMI (BMI < 40; mean 36.0), 286 patients moderate BMI (BMI 40–50; mean 43.2), and 72 patients higher BMI (BMI > 50; mean 55.4). All procedures were completed laparoscopically. Mean operative time was 130 min, and mean hospital stay was 5.0 days. Twenty-three minor early complications (4.3%) and 13 major complications (2.0%) were encountered, with one death occurred (0.016%). There was no significant difference in operation time and complication rate between the groups. The mean bypass limb was 150 cm for the lower BMI group, 250 cm for moderate BMI group, and 350 cm for the higher BMI group. The mean BMI reduction 2 years after surgery was 10.7, 15.5, and 23.3 for the lower, moderate, and higher BMI group. The weight loss curves and resolution of obesity related comorbidities were compatible with the tailored bypass limbs between the groups. However, the lower BMI patients had more severe anemia than the other two groups. Conclusion Morbidly obese patients receiving gastric bypass surgery may need to tailor the bypass limb according to BMI. The application of gastric bypass in lower BMI patients should be more carefully.     

Endoscopic Ultrasound-Guided Gastric Botulinum Toxin Injections in Obese Subjects: A Pilot Study

Background Gastric injections of botulinum toxin A (BTA) may induce changes in gastric emptying and body weight, but results vary. BTA dose and depth of injection may affect efficacy. This study assessed changes in gastric emptying, satiation, symptoms, and body weight after endoscopic ultrasound (EUS)-guided injection of 100 or 300 U BTA into gastric antral muscularis propria of obese subjects. Methods Open label study of ten healthy, obese adults (age = 29–49 years, body mass index = 31–54 kg/m²) who received 100 U (n = 4) or 300 U (n = 6) BTA and were followed for 16 weeks. Measures included gastric emptying of solids (by scintigraphy), satiation (by maximum tolerated volume [MTV] during nutrient drink test), gastrointestinal symptoms (by the Gastrointestinal Symptom Rating Scale), caloric intake (by food frequency questionnaire), and body weight. Results For the entire cohort, MTV decreased from 1,380 cc (range: 474–2,014) at baseline to 620 cc (range: 256–1,180) 2 weeks after BTA injection; decreases were statistically significant in the subjects receiving 300 U BTA (p = 0.03). Average body weight loss was 4.9 (±6.3) kg after 16 weeks. Gastric emptying T_1/2 was prolonged in the 300 U BTA group, but not significantly different from baseline (p = 0.17). BTA injections were well tolerated without significant adverse effects. Conclusion EUS-guided injection of BTA into gastric muscularis propria can be performed safely with minimal adverse effects. A dose of 300 U BTA significantly enhances satiation, is associated with weight loss, and may slow gastric emptying. Further study of higher dose BTA in obese subjects is warranted.     

Gastric Bypass Surgery is Associated with Reduced Inflammation and Less Depression: a Preliminary Investigation

Background Prior studies have documented elevated symptoms of depression among patients undergoing gastric bypass surgery, in addition to significant elevations of inflammatory markers including C-reactive protein (CRP) and interleukin-6 (IL-6). No prior study has examined the relationship of changes in depression with change in inflammation among patients undergoing gastric bypass surgery. This pilot study was designed to examine the relationship of inflammation and depression among gastric bypass patients in a 12-month longitudinal study. Methods 13 Caucasian women (mean age 46.9 ± 5.7 years) who were scheduled to undergo a Roux-en-Y gastric bypass (RYGBP) were recruited prior to surgery for measurement of body mass and blood markers of inflammation, as well as self-report measures of depression, quality of life, and disordered eating. 12 months later, subjects completed the same battery of physiological and psychological measures. Data were analyzed with paired t-tests and Pearson correlations. Results In addition to significant reductions in BMI (P < .001), participants experienced significant reductions in CRP (P < .001), IL-6 (P = .002), and depressive symptoms (P = .025). Reductions also were observed in binge eating (P = .005). Decreased depression during the 12-month follow-up was highly correlated with reduced CRP (r = .98, P < .001). Conclusions Results from this pilot study indicate that RYGBP is associated with significant reductions in inflammatory markers of cardiovascular disease risk (e.g., CRP, IL-6) and depressive symptoms, in addition to reductions in weight. Results suggested that reductions in depression were associated with the observed decreases in inflammation.     

Relationship between the Upper Airway and Obstructive Sleep Apnea-Hypopnea Syndrome in Morbidly Obese Women

Background The authors studied changes in the upper airway in morbidly obese women and the relationship to sleep apnea-hypopnea syndrome (OSAS). Methods Patients underwent a cardiorespiratory polygraphic study, respiratory function test (spirometry, plethysmography, maximum inspiratory pressures and arterial blood gas analysis), and computed tomographic studies of the upper airway. Results 40 morbidly obese women being evaluated for bariatric surgery (mean age 39.6 ± 9.6 years old, BMI 48.7 ± 5.6 kg/m²) were studied. 37 women had OSAS, and 14 had severe OSAS. Results on respiratory function tests were normal. BMI and weight had a positive correlation with apnea-hypopnea index (AHI), apnea index (AI), desaturation index (DI), lowest oxygen saturation and CT90. Uvula diameter had a negative correlation with FEV₁, FVC, VC IN and a positive correlation with TLC. Retropharynx soft tissue at the retropalatal level had a negative correlation with FEV₁, FVC and VC IN. The oropharynx area at maximal inspiration (total lung capacity) obtained a negative correlation with the AHI (r = −0.423, P = 0.044), AI (r = −0.484, P = 0.042) and DI (r = −0.484, P = 0.019). Conclusions Prevalence of OSAS in morbidly obese women is very high. Our results show the significant correlation between BMI and AHI in morbidly obese women. Uvula diameter and retropharynx soft tissue are the upper airway parameters with higher relationship with pulmonary function. A reduction in the cross-sectional area of the airway at the level of the oropharynx could be related to the severity of OSAS in morbidly obese women.     

Plasma Adhesion and Inflammation Markers: Asymmetrical Dimethyl-L-Arginine and Secretory Phospholipase A<Subscript>2</Subscript> Concentrations before and after Laparoscopic Gastric Banding in Morbidly Obese Patients

Background The aim of this study was to examine the relationship between subclinical inflammation and weight loss by laparoscopic adjustable gastric banding (LAGB). Methods Plasma concentrations of intercellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1), sensitive C-Reactive Protein (sCRP), asymmetrical dimethyl-L-arginine (ADMA), Secretory Phospholipase A2 (sPLA2), and metabolic markers, such as homeostatic model assessment – insulin resistance (HOMA-IR) and body mass index (BMI) were determined in morbidly obese patients (n = 18, BMI 48.6 ± 1.7 kg/m²) at baseline and 1 month after operations. Baseline levels in patients were also compared with age-matched controls (n = 20, BMI 21.3 ± 1.8 kg/m²). Plasma ICAM-1,VCAM, sCRP and ADMA, and sPLA₂ concentrations were determined by enzyme-linked immunoassay methods and colorimetric method, respectively. Results Plasma sCRP, ICAM-1, ADMA and sPLA₂ concentrations and HOMA-IR were significantly higher in morbidly obese patients than in controls (for each, P < 0.01). Plasma VCAM-1 concentration was not changed in obese patients. HOMA-IR was significantly correlated with ICAM-1, ADMA and sPLA₂ in the obese group at baseline (for each, P < 0.01). There was a significant correlation between plasma sCRP and plasma glucose,VCAM-1, ICAM-1, ADMA and sPLA₂ concentrations (for each, P < 0.01). 1 month after LAGB, mean body weight loss was 13.2 ± 6.3 kg, and plasma sCRP and ADMA concentrations and HOMA-IR and BMI were significantly decreased (for each, P < 0.01). However, these levels cannot be decreased to the levels of the controls. Conclusion Obesity and insulin resistance appear to be associated with low-grade inflammation and endothelial dysfunction. Insulin resistance and endothelial dysfunction were improved by weight loss after LAGB.     

Vagal Nerve Dissection During Pouch Formation in Laparoscopic Roux-Y-Gastric Bypass for Technical Simplification: Does it Matter?

Background  In Roux-Y gastric bypass surgery pouch formation is the most demanding part of the operation. The vagal nerve is usually tempted to be preserved although results reporting beneficial effects are lacking. Dividing the perigastric tissue including the anterior vagal trunk may technically alleviate gastric pouch formation. We evaluated the clinical outcome in patients with and without vagal nerve dissection in patients after Roux-Y gastric bypass (RY-BP). Methods  In this study 40 morbidly obese patients undergoing RY-BP have been included. Patients were divided into two groups according to vagal nerve preservation (Group 1, n = 25) or vagal nerve dissection (Group 2, n = 22). Clinical parameters (weight loss, complications, gastrointestinal symptoms), esophageal endoscopy, and motility data (manometry, pH-metry) and a satiety score were assessed. Serum values of ghrelin and gastrin were measured. Results  All procedures were performed by laparoscopy with a 0% mortality rate. One patient of each groups necessitated redo-laparoscopy (bleeding and a lost drainage). All patients significantly reduced body weight (p < 0.01 compared to preoperative) during a median follow-up of 36.1 months. Two patients of Group 2 showed acid reflux demonstrated by pathologic postoperative DeMeester scores. Esophageal body peristalsis and barium swallows did not reveal statistically significant differences between the two groups. Parameters of satiety assessment did not differ between the two groups as did serum values of gastrin and ghrelin. Conclusion  Pouch formation during RY-BP may be alleviated by simply dissecting the perigastric fatty tissue. In this way the anterior vagal trunk is dissected, however, no influence on clinical, functional and laboratory results occur.