Comparison of weight loss and body composition changes with four surgical procedures

BackgroundA paucity of information is available on the comparative body composition changes after bariatric procedures. The present study reports on the body mass index (BMI) and body composition changes after 4 procedures by a single group.MethodsAt the initial consultation, the weight and body composition of the patients undergoing 4 different bariatric procedures were measured by bioimpedance (Tanita 310). Follow-up examinations were performed at 1 year and at subsequent visits after surgery. Analysis of variance was used to compare the postprocedure BMI and body composition. Analysis of covariance was used to adjust for baseline differences.ResultsA total of 101 gastric bypass (GB) patients were evaluated at 19.1 ± 10.6 months, 49 biliopancreatic diversion with the duodenal switch (BPD/DS) patients at 27.5 ± 16.3 months, 41 adjustable gastric band (AGB) patients at 21.4 ± 9.2 months, and 30 sleeve gastrectomy (SG) patients at 16.7 ± 5.6 months (P <.0001). No differences were found in patient age or gender among the 4 groups. The mean preoperative BMI was significantly different among the 4 groups (P <.0001): 61.4 kg/m², 53.2, 46.7, and 44.3 kg/m² for the SG, BPD/DS, GB, and AGB group, respectively. The postoperative BMI adjusted for baseline differences was 27.8 (difference 23.6 ± 8.3), 32.5 (difference 15.6 ± 5.0), 37.2 (difference 18.2 ± 8.2), and 39.5 kg/m² (difference 7.5 ± 4.3) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The percentage of excess weight loss was 84%, 70%, 49%, and 38% for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The postoperative percentage of body fat adjusted for baseline differences was 25.7% (23.9% ± 7.0%) 32.7% (16.1% ± 10.5%) 37.7% (16.7% ± 5.6%), and 42% (6.0% ± 6.8%) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The lean body mass changes were reciprocal.ConclusionAlthough the BPD/DS procedure reduced the BMI the most effectively and promoted fat loss, all the procedures produced weight loss. The AGB procedure resulted in less body fat loss within 21.5 months than SG within 16.7 months. Longer term observation is indicated.     

Common channel length predicts outcomes of biliopancreatic diversion alone and with the duodenal switch surgery

BACKGROUND: The optimal common channel (CC) length for malabsorptive weight loss surgeries is unknown even though these surgeries were developed in the 1970s (biliopancreatic diversion [BPD]) and the 1990s (biliopancreatic diversion with a duodenal switch [BPD DS]). We hypothesized that the length of the CC correlates with a successful weight loss result. METHODS: We evaluated 3 groups of patients based on the length of the CC whose duration of follow-up evaluation was at least 1 year. We reviewed all patients who had either an open BPD (5 patients) or a BPD DS (119 patients) from August 1998 to October 2003, for which D.B.M. was the participating surgeon. RESULTS: Group I comprised 15 patients: their preoperative body mass index (BMI) was 53.9 kg/m(2); 73.3% of patients had a BMI more than 50, and the CC length was 150 cm. Group II comprised 76 patients: their preoperative BMI was 54.25 kg/m(2); 73.3% of patients had a BMI more than 50, and the CC length was 100 cm. Group III comprised 33 patients: their preoperative BMI was 60.1 kg/m(2); 84% of patients had a BMI more than 50, and the CC length was 80 to 90 cm. The mean weight loss in group I was 45 kg (44% mean excess weight loss). The mean weight loss in groups II and III was 55.8 and 61.5 kg, respectively (a 57% and 54.8% mean excess weight loss, respectively) (all P < .05 by analysis of variance). A weight loss of greater than 50% of excess body weight occurred in 40% of patients in group I versus 63% of patients in groups II and III combined (P < .01 by chi(2)). CONCLUSIONS: The length of the CC contributes significantly to successful excess weight loss in BPD and BPD DS patients. In general, the length of the CC should not exceed 100 cm.     

Metabolic and Nutritional Status Changes After 10% WeightLoss in Severely Obese Patients Treated with Laparoscopic Surgery vs Integrated Medical Treatment

BACKGROUND: Bariatric surgery is considered the most effective treatment for reducing excess body weight and maintaining weight loss (WL) in severely obese patients. There are limited data evaluating metabolic and body composition changes after different treatments in type III obese (body mass index [BMI] > 40 kg/m(2)). METHODS: Twenty patients (9 males, 11 females; 37.6 +/- 8 years; BMI = 50.1 +/- 8 kg/m(2)) treated with dietary therapy and lifestyle correction (group 1) have been compared with 20 matched patients (41.8 +/- 6 years; BMI = 50.4 +/- 6 kg/m(2)) treated with laparoscopic gastric bypass (LGBP; group 2). Patients have been evaluated before treatment and after >10% WL obtained on average 6 weeks after LGBP and 30 weeks after integrated medical treatment. Metabolic syndrome (MS) was evaluated using the Adult Treatment Panel III/America Heart Association (ATP III/AHA) criteria. Resting metabolic rate (RMR) and respiratory quotient (RQ) was assessed with indirect calorimetry; body composition with bioimpedance analysis. RESULTS: At entry, RMR/fat-free mass (FFM) was 34.2 +/- 7 kcal/24 h.kg in group 1 and 35.1 +/- 8 kcal/24 h.kg in group 2 and did not decrease in both groups after 10% WL (31.8 +/- 6 vs 34.0 +/- 6). Percent FFM and fat mass (FM) was 50.7 +/- 7% and 49.3 +/- 7% in group 1 and 52.1 +/- 6% and 47.9 +/- 6% in group 2, respectively (p = n.s.). After WL, body composition significantly changed only in group 1 (% FFM increased to 55.9 +/- 6 and % FM decreased to 44.1 +/- 6; p = 0.002). CONCLUSION: After >10% WL, MS prevalence decreases precociously in surgically treated patients; some improvements in body composition are observed in nonsurgically treated patients only. Further investigations are needed to evaluate long-term effects of bariatric surgery on body composition and RMR after stable WL.     

胆胰分流并十二指肠转位术治疗胃袖状切除术后复胖个案报告并文献复习

目的:探讨胆胰分流并十二指肠转位术作为胃袖状切除术后复胖修正手术的可行性。方法:女性患者,重度肥胖,身体质量指数(BMI)为42.3 kg/m^2,合并2型糖尿病,应用胰岛素治疗血糖控制不佳,糖化血红蛋白(HbA1c)10.5%;首次接受腹腔镜胃袖状切除术,术后1年BMI降至32.4 kg/m^2,HbA1c 8.9%;术后3年,BMI反弹至40.2 kg/m^2,HbA1c为10%。再次接受标准的胆胰分流并十二指肠转位术,即食物肠袢150 cm、共同肠袢100 cm。结果:胆胰分流并十二指肠转位术术后3个月,BMI 39.9 kg/m^2,HbA1c 8.9%,恢复正常进食,排便次数3~4次/d,质软,无特殊不适。结论:胆胰分流并十二指肠转位术作为腹腔镜胃袖状切除术的术后修正手术,对于体重反弹、血糖增高的治疗效果优异,且不影响患者进食习惯,但术后营养并发症较多见,需密切关注。     

Impact of self-reported physical activity participation on proportion of excess weight loss and BMI among gastric bypass surgery patients

Habitual physical activity is an important component of successful weight loss programs for morbidly obese individuals. This study examined self-reported physical activity (PA) participation in relation to excess weight loss and body mass index (BMI) reduction among gastric bypass surgery patients (GBS). PA participation was hypothesized to contribute to both greater excess weight loss (% EWL) and a greater reduction in BMI at 2 years postsurgery. PA participation was measured via self-report among 1585 GBS patients between 1988 and 2001. GBS patients were assigned to groups [PA (n = 1479)/no PA (n = 106)] and further stratified by presurgical BMI [35-49 kg/m2 (n = 897) and 50-70 kg/m2 (n = 688)]. Findings showed that GBS patients who reported PA participation were younger [P < 0.0001, PA (40.1 +/- 9.9) vs no PA (44.2 +/- 11.2)], had greater % EWL [P = 0.0081, PA (68.2 +/- 17.4%) vs no PA (63.9 +/- 19.5%)], and a greater decrease in BMI [P = 0.0011, PA (18.3 +/- 5.7 kg/m2) vs no PA (16.6 +/- 5.4 kg/m2)]. When stratified by presurgical BMI, only physically active patients with a BMI of 50-70 kg/m2 showed an increase in % EWL [P = 0.0444, PA (63.2 +/- 16.5) vs no PA (57.9 +/- 17.3)], whereas both BMI groups showed significant reductions in BMI at 2 years [BMI of 35-49 kg/m2 P = 0.0184, PA (16.0 +/- 4.0 kg/m2) vs no PA (14.4 +/- 4.0 kg/m2); and BMI of 50-70 kg/m2 P = 0.0221, PA (21.50 +/- 6.0 kg/m2) vs no PA (19.7 +/- 5.5 kg/m2)], respectively. PA had a favorable effect on % EWL and BMI among GBS patients at 2 years postsurgery, thus supporting the inclusion of habitual PA in a comprehensive GBS postsurgical weight maintenance program.     

Insulin resistance in morbid obesity: reversal with intramyocellular fat depletion.

Obesity is a frequent cause of insulin resistance and poses a major risk for diabetes. Abnormal fat deposition within skeletal muscle has been identified as a mechanism of obesity-associated insulin resistance. We tested the hypothesis that dietary lipid deprivation may selectively deplete intramyocellular lipids, thereby reversing insulin resistance. Whole-body insulin sensitivity (by the insulin clamp technique), intramyocellular lipids (by quantitative histochemistry on quadriceps muscle biopsies), muscle insulin action (as the expression of Glut4 glucose transporters), and postprandial lipemia were measured in 20 morbidly obese patients (BMI = 49 +/- 8 [mean +/- SD] kg x m(-2)) and 7 nonobese control subjects. Patients were restudied 6 months later after biliopancreatic diversion (BPD; n = 8), an operation that induces predominant lipid malabsorption, or hypocaloric diet (n = 9). At 6 months, BPD had caused the loss of 33 +/- 10 kg through lipid malabsorption (documented by a flat postprandial triglyceride profile). Despite an attained BMI still in the obese range (39 +/- 8 kg x m(-2)), insulin resistance (23 +/- 3 micromol/min per kg of fat-free mass; P < 0.001 vs. 53 +/- 13 of control subjects) was fully reversed (52 +/- 11 micromol/min per kg of fat-free mass; NS versus control subjects). In parallel with this change, intramyocellular-but not perivascular or interfibrillar-lipid accumulation decreased (1.63 +/- 1.06 to 0.22 +/- 0.44 score units; P < 0.01; NS vs. 0.07 +/- 0.19 of control subjects), Glut4 expression was restored, and circulating leptin concentrations were normalized. In the diet group, a weight loss of 14 +/- 12 kg was accompanied by very modest changes in insulin sensitivity and intramyocellular lipid contents. We conclude that lipid deprivation selectively depletes intramyocellular lipid stores and induces a normal metabolic state (in terms of insulin-mediated whole-body glucose disposal, intracellular insulin signaling, and circulating leptin levels) despite a persistent excess of total body fat mass.     

Restoration of euglycemia and normal acute insulin response to glucose in obese subjects with type 2 diabetes following bariatric surgery

Insulin resistance and loss of glucose-stimulated acute insulin response (AIR) are the two major and earliest defects in the course of type 2 diabetes. We investigated whether weight loss after bariatric surgery in patients with morbid obesity and type 2 diabetes could restore euglycemia and normal AIR to an intravenous glucose tolerance test (IVGTT). We studied 25 morbidly obese patients-12 with type 2 diabetes, 5 with impaired glucose tolerance, and 8 with normal glucose tolerance (NGT)-before and after a biliopancreatic diversion (BPD) with Roux-en-Y gastric bypass (RYGBP). Twelve individuals with normal BMI served as control subjects. Twelve months after surgery, in the diabetes group, BMI decreased from 53.2 +/- 2.0 to 29.2 +/- 1.7 kg/m(2), fasting glucose decreased from 9.5 +/- 0.83 to 4.5 +/- 0.13 mmol/l, and fasting insulin decreased from 168.4 +/- 25.9 to 37.7 +/- 4.4 pmol/l (mean +/- SE; P < 0.001). AIR, the mean of insulin concentration at 2, 3, and 5 min over basal in the IVGTT, increased by 770 and 935% at 3 and 12 months after surgery, respectively (from 24.0 +/- 22.7 to 209 +/- 43.4 and 248 +/- 33.1 pmol/l, respectively; P < 0,001). Conversely, in the NGT group, the AIR decreased by 40.5% (from 660 +/- 60 to 393 +/- 93 pmol/l; P = 0.027) 12 months after surgery. BPD with RYGBP performed in morbidly obese patients with type 2 diabetes leads to significant weight loss, euglycemia, and normal insulin sensitivity; but most importantly, it restores a normal beta-cell AIR to glucose and a normal relationship of AIR to insulin sensitivity. This is the first study to demonstrate that the lost glucose-induced AIR in patients with type 2 diabetes of mild or moderate severity is a reversible abnormality.     

Biliopancreatic diversion: long-term effects on gonadal function in severely obese men

BACKGROUND: This study investigated hormonal parameters of gonadal function in severely obese men before and 1 year after undergoing biliopancreatic diversion (BPD). METHODS: This observational 1-year postoperative study conducted at medical and surgical clinics at an academic medical center in Italy followed 20 severely obese men age 21 to 63 years, with a mean (+/- standard deviation) body mass index (BMI) of 47.3 +/- 13.1. The following parameters were evaluated: body composition, using body impedance analysis (BIA), and serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone, estradiol 17beta, and leptin. RESULTS: At a mean 12 +/- 1 months after surgery, the patients showed a significant decrease in weight, from 132.1 +/- 36.9 before surgery to 93.5 +/- 20 kg (P < .0001), and BMI, from 47.3 +/- 13.1 before surgery to 33.5 +/- 7 (P < .0001). LH increased from 2.42 +/- 1.59 to 4.97 +/- 2.6 mIU/ml (P < .0001), FSH increased from 2.85 +/- 1.85 to 4.9 +/- 4.2 mIU/mL (P = .021), and total testosterone increased from subnormal presurgical values to within normal range (2.81 +/- 1.08 to 9.12 +/- 1.37 ng/mL; P < .0001), whereas estradiol 17beta decreased from elevated basal levels of 44.0 +/- 29 to 16.7 +/- 6.9 pg/mL (P < .0001). The basal leptin level dropped from 33.0 +/- 9.23 to 16.6 +/- 5.12 ng/mL (P < .0001), reflecting the decrease in body fat. Subjective improvement in sexual performance was reported by 80% of patients. CONCLUSIONS: Severe obesity is coupled with some significant alterations of the gonadotropin-testicular axis and estradiol 17beta and leptin blood levels. These derangements were substantially corrected by 1 year after BPD.     

A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch

OBJECTIVE: To compare biliopancreatic diversion (BPD) without duodenal switch (DS) and with duodenal switch (BPDDS). BACKGROUND: A reduction of 70% of excess body weight can be achieved after BPD, but there is a risk of malnutrition and diarrhea. This risk may be reduced by pyloric preservation with BPDDS. METHODS: BPD was performed until 1999, when BPDDS was introduced, both with a common channel of 50 cm. At their latest clinic visit, patients filled in a questionnaire regarding weight loss, dietary history, gastrointestinal symptoms, obesity-related comorbidity, and medication including dietary supplements and underwent a serum nutritional screen. RESULTS: BPD was performed in 73 patients and BPDDS in 61 patients, with a median preoperative body mass index (BMI) of 44.8 kg/m and a median follow-up of 28 months. There were no significant differences between BPD and BPDDS with regards to age, sex, BMI, or morbidity. Median excess weight loss and BMI at 12, 24, and 36 months was 64.1, 71.0, and 72.1% and 33.1, 31.5, and 31.5 kg/m, respectively; there were no significant differences between BPD and BPDDS. There were no significant differences between BPD and BPDDS with regards to meal size, fat score, nausea, vomiting, diarrhea, or nutritional parameters. However, 18% of patients were hypoalbuminemic, 32% anemic, 25% hypocalcemic, and almost half had low vitamin A, D, and K levels, despite more than 80% taking vitamin supplementation. CONCLUSION: DS does not improve weight loss or lessen the gastrointestinal or nutritional side effects of BPD.     

Health-related quality of life does not vary among patients seeking different surgical procedures to assist with weight loss

BackgroundImprovement in quality of life (QOL) is 1 of the goals of bariatric procedures. We hypothesized that greater impairment of QOL would encourage the choice of more invasive surgical procedures. Our study was performed at a university hospital weight loss surgical center in the United States.MethodsPatients qualifying for weight loss surgery, who at their surgical consultation had chosen their surgical option and signed an informed consent form, were asked to complete 3 QOL forms—the Medical Outcomes Study Short Form 36-item Health Survey, the Beck Depression Inventory, and the Impact of Weight on Quality of Life-Lite. Analysis of variance was used to compare the surgery types with the demographics, QOL, and depression.ResultsA total of 367 patients, 114 men (31.1%) and 253 women (68.75), completed the QOL forms at their surgical consultation. Of these 367 patients, 68.9% elected gastric bypass (GB), 15% chose biliopancreatic diversion/duodenal switch (BPD/DS), and 16.1% chose adjustable gastric banding (AGB). The mean patient age was 42.5 ± 10.7 years (P = NS), with no differences in gender distribution. The body mass index was 51.9 kg/m² for the BPD/DS group, greater than that for the GB group (45.9 kg/m²) or AGB group (44.3 kg/m²; P < .0001). No significant differences were found in the Beck Depression Inventory score among the 3 groups (GB 14.6 ± 9.6, AGB 10.8 ± 8.2, and BPD/DS 13.5 ± 7.3). For the Short Form 36-item Health Survey, only the physical component score was different for the AGB group compared with the BPD/DS group (GB 49.2 ± 25.1, BPD/DS 42.8 ± 26.4, and AGB 52.3 ± 31.7; P = .05). For the Impact of Weight on Quality of Life-Lite, all differences were nonsignificant. The total score was 44.1 ± 20.7, 44.4 ± 21.1, and 52.2 ± 19.6 for the GB, BPD/DS, and AGB groups, respectively.ConclusionPatients requesting a weight loss procedure reported moderate to severe impairments in QOL and mood dysphoria compared with the community norms. However, the patients choosing from the 3 procedures studied scored similarly on the health-related QOL assessments.     

BioEnterics Intragastric Balloon: Clinical Outcomes of the First 100 Patients—A Turkish Experience

BACKGROUND: The BioEnterics Intragrastric Balloon (BIB(R)) together with restricted diet has been used for the treatment of obesity and morbid obesity. METHODS: A prospective study was conducted on 100 patients who had undergone the BIB procedure between February 2005 and February 2007. RESULTS: Mean age, mean weight, and mean BMI of the patients were 35.35 +/- 9.25 years, 113.23 +/- 24.76 kg (range 73-200 kg), and 39.28 +/- 6.98 kg/m(2) (range 30-69.2 kg/m(2)), respectively. Six months after the BIB procedure, mean weight and mean BMI were reduced to 100.46 +/- 26.05 kg (range 58-178 kg) and 34.70 +/- 11 kg/m(2) (range 21.83-61.59 kg/m(2)), respectively. There was a statistically significant reduction in weight and BMI at 6 months after the BIB procedure (p < 0.01). Excess weight loss (EWL) at 6 months ranged between 0 and 28 kg, with a mean value of 12.68 +/- 7.70 kg. The subjects had 0 to 99.2% %EWL (mean 28.63 +/- 19.29). Reduction in BMI at 6 months ranged between 0 and 12.3 kg/m(2), with a mean value of 4.51 +/- 2.85 kg/m(2), and percent excess body mass index loss (%EBMIL) was 38.20 +/- 28.78% (range 0-158%). At 6 months, there was a significant reduction in body weight and BMI (p < 0.01) in both groups. The reduction in BMI of the morbidly obese group was significantly greater than that of the obese group (p = 0.035), and both the %EWL and %EBMIL of the morbidly obese patients were significantly lower than those of the obese patients at 6 months (p = 0.001). CONCLUSIONS: BIB application is a reasonable weight loss method with few complications.     

Correlation of serum leptin concentrations with body composition and gender in Taiwanese hemodialysis patients without diabetes

OBJECTIVE: (1) To evaluate the impact of body composition and gender on serum leptin concentration in hemodialysis patients. (2) To study which marker of adiposity is most appropriate in Taiwanese hemodialysis patients without diabetes. (3) To compare the nutrition status between nonlean and lean subjects. PATIENTS AND METHODS: Serum leptin concentrations were measured by radioimmunoassay collected in 88 hemodialysis patients without diabetes. Bioimpedance analysis was performed to determine percent fat mass (%FM), lean body mass (LM), and total body water (TBW). Body mass index (BMI) was calculated as weight/height2. Albumin and transferrin were measured by standard laboratory methods. RESULTS: Serum leptin levels were more correlated with percent fat mass (r = 0.697; P < 0.001) than with body fat mass (r = 0.672; P < 0.001) or with BMI (r = 0.594; P < 0.001) in the group as a whole and in each subgroup when analyzed separately by gender. The mean (+/- SD) serum leptin levels were 32.5 +/- 34.3 ng mL(-1) in women subjects and 13.6 +/- 15.5 ng mL(-1) in men subjects (P < 0.001). Multiple regression analysis in all subjects revealed that serum leptin levels were independently affected by percent fat mass and gender. Adiposity corrected serum leptin, such as leptin/BMI, leptin/percent fat mass, and leptin/body fat mass was significantly different between sexes (P < 0.001). The significantly higher serum leptin concentrations in women than in men were observed in obese subjects with BMI > 25 kg/m2 (P < 0.001) as well as nonobese subjects with BMI < 25 kg/m2 (P < 0.05). There were no differences in lean mass and albumin between nonlean and lean subjects. CONCLUSION: Gender and adiposity had impact on serum leptin levels in hemodialysis patients without diabetes. In terms of adiposity, serum leptin levels had stronger correlation with percent fat mass than with body fat mass (FM) or BMI in Taiwanese hemodialysis patients. Steady-state serum leptin levels could serve as valuable clinical markers for the body adiposity in stable hemodialysis patients without diabetes. Protein malnutrition markers and lean mass should be checked in lean subjects for the evaluation of the protein stores of hemodialysis patients.     

Genetic variation in the peroxisome proliferator-activated receptor-gamma2 gene (Pro12Ala) affects metabolic responses to weight loss and subsequent weight regain

This study determined the effects of the peroxisome proliferator-activated receptor (PPAR)-gamma2 Pro12Ala variant on body composition and metabolism and the magnitude of weight regain in 70 postmenopausal women (BMI 25-40 kg/m(2)) who completed 6 months of a hypocaloric diet. At baseline, BMI, percent body fat, intra-abdominal and subcutaneous abdominal fat areas, resting metabolic rate, substrate oxidation, and postprandial glucose and insulin responses were not different between genotypes (Pro/Pro = 56, Pro/Ala and Ala/Ala = 14). The intervention similarly decreased body weight by 8 +/- 1% in women homozygous for the Pro allele and by 7 +/- 1% in women with the Ala allele (P < 0.0001). Fat oxidation did not change in Pro/Pro women but decreased 19 +/- 9% in women with the Ala allele (P < 0.05). Changes in glucose area were not different between groups; however, women with the Ala allele decreased their insulin area more than women homozygous for the Pro allele (P < 0.05). Weight regain during follow-up was greater in women with the Ala allele than women homozygous for the Pro allele (5.4 +/- 0.9 vs. 2.8 +/- 0.4 kg, P < 0.01). PPAR-gamma2 genotype was the best predictor of weight regain (r = 0.50, P < 0.01), followed by the change in fat oxidation (partial r = 0.35, P < 0.05; cumulative r = 0.58). Thus, the Pro12Ala variant of the PPAR-gamma2 gene may influence susceptibility for obesity.     

Single and dual anastomosis duodenal switch for obesity treatment: a single-center experience

BackgroundBiliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgery in super-obese patients, although technically complex and time consuming. As a primary surgery, single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is similar to BPD/DS in terms of short-term outcomes, but long-term and comparative data are lacking.ObjectivesThe aim of this study was to compare the outcomes of patients submitted to SADI-S and BPD/DS.SettingPublic hospital.MethodsObese patients (n = 112) submitted to SADI-S (n = 83) and BPD/DS (n = 29) for obesity treatment were prospectively compared.ResultsThe mean preoperative body mass indexes (BMIs) were 53.41 ± .93 for BPD/DS and 50.61 ± .52 kg/m² for SADI-S. Follow-up of 48 months was achieved in 18% (n = 21) of patients, with a nonsignificant difference in the percentage of excess BMI loss (%EBMIL; 81.20 ± 3.71 for BPD/DS; 74.82 ± 3.45 for SADI-S). Operative time (164.30 ± 7.78 minutes for BPD/DS; 132.70 ± 7.19 minutes for SADI-S; P = .006) and hospital stay (4.90 ± 1.10 days for BPD/DS; 4.35 ± .70 days for SADI-S; P = .006) were significantly shorter for SADI-S. There was no significant difference in the 30-day postoperative complication rate. No mortality was reported. After surgery, significant improvements were observed in glucose and lipid profiles for both groups. The type 2 diabetes remission rate was 100% for BPD/DS and ranged from 60 to 80% for SADI-S across follow-up times. Dyslipidemia remission followed a similar pattern. Protein deficiency was observed in up to 50% of patients after BPD/DS and 20% after SADI-S, without statistically significances.ConclusionSADI-S and BPD/DS as primary surgery for obesity treatment result in no significant differences in %EBMIL, improvement in obesity-related diseases, nutritional deficiencies, and postoperative morbidity. Nevertheless, there was greater total weight loss after BPD/DS. SADI-S, being less time consuming and technically simpler, can represent an advantage over BPD/DS.     

An analysis of the evolution of body compartments in anorexia nervosa--the bioelectrical impedance method

Body compartments can be assessed by means of bioelectrical impedance, a non-invasive, cost saving and simple physical method. The purpose of this study was to estimate the body compartments in anorexic patients, in the under-nutrition phase (group BMI < 17 kg/m2) and after weight restoration (BMI > 17 kg/m2). Total body water, intracellular and extracellular water have significantly decreased after weight restoration. The fat mass significantly (p < 0.001) increased in group BMI > 17 kg/m2 compared with group BMI < 17 kg/m2, and we have found a positive correlation between body mass index (BMI) and fat mass (r = 0.73, p < 0.0001). The assessment of free fat mass can provide information about the under-nutrition degree and the quality of re-feeding. The increase of free fat mass was significant (p < 0.001) in the group BMI > 17 kg/m2 as compare with the group BMI < 17 kg/m2). We have found a positive correlation between free fat mass and BMI (r = 0.73, p < 0.0001).     

Duodenal switch provides superior weight loss in the super-obese (BMI > or =50 kg/m2) compared with gastric bypass

OBJECTIVES: Although weight loss following Roux-en-Y gastric bypass is acceptable in patients with preoperative body mass index (BMI) between 35 and 50 kg/m, results from several series demonstrate that failure rates approach 40% when BMI is > or =50 kg/m. Here we report the first large single institution series directly comparing weight-loss outcomes in super-obese patients following biliopancreatic diversion with duodenal switch (DS) and Roux-en-Y Gastric Bypass (RYGB). METHODS: All super-obese patients (BMI > or =50 kg/m) undergoing standardized laparoscopic and open DS and RYGB between August 2002 and October 2005 were identified from a prospective database. Two-sample t tests were used to compare weight loss, decrease in BMI, and percentage of excess body weight loss (% EBWL) after surgery. chi analysis was used to determine the rate of successful weight loss, defined as achieving at least 50% loss of excess body weight. RESULTS: A total of 350 super-obese patients underwent DS (n = 198) or RYGB (n = 152) with equal 30-day mortality (DS,1 of 198; RYGB, 0 of 152; P = not significant). The % EBWL at follow-up was greater for DS than RY (12 months, 64.1% vs. 55.9%; 18 months, 71. 9% vs. 62.8%; 24 months, 71.6% vs. 60.1%; 36 months, 68.9% vs. 54.9%; P < 0.05). Total weight loss and decrease in BMI were also statistically greater for the DS (data not shown). Importantly, the likelihood of successful weight loss (EBWL >50%) was significantly greater in patients following DS (12 months, 83.9% vs. 70.4%; 18 months, 90.3% vs. 75.9%; 36 months, 84.2% vs. 59.3%; P < 0.05). CONCLUSIONS: Direct comparison of DS to RYGB demonstrates superior weight loss outcomes for DS.     

Effectiveness of Biliopancreatic Diversion in the Patients with Bulimia Nervosa

Background: Bulimia nervosa (BN) is an eating disorder, characterized by consumption of huge amounts of food during discrete periods. Unlike patients with binge-eating disorder (BED), patients with BN demonstrate elements of compensatory "purging" behavior to prevent weight gain and obesity: i.e. self-induced vomiting, use of laxatives and enemas. These habits may prevent patients from attaining morbid obesity (MO), but may seriously affect life-style and become an excruciating, sometimes life-threatening condition. Methods: 6 of 108 patients (5.6%) who underwent BPD in our clinic (laparoscopic Scopinaro BPD - 1, open BPD/DS - 4, Lap. BPD/DS - 1) suffered from BN preoperatively. Their preoperative weight was 68-117 kg and BMI 27.6-41.9 kg/m². 4 of 6 patients had BMI <40 kg/m² before BPD but were MO in the past. The patient with the lowest weight had repeated gastroesophageal bleeding during self-induced vomiting. 3 of the 6 patients had previously failed intragastric balloon or Lap-Band^?. Results: All 6 patients were cured or significantly improved of bulimic symptoms soon after BPD. Weight loss was very good and never reached an undesirably low level. Patient satisfaction was high. Conclusion: Severe BN may be considered as a latent and potentially malignant MO. BPD (or BPD/DS) may be an effective solution for some patients with severe BN, as a final decision after unsuccessful organized conservative attempts. All candidates for bariatric surgery should be screened for BN, because it may influence choice of procedure in favor to BPD or BPD/DS.     

Combining Laparoscopic Adjustable Gastric Banding and Biliopancreatic Diversion after Failed Bariatric Surgery

Background: A percentage of all types of bariatric surgery will fail. Our experience with failed biliopancreatic diversion (BPD) as a primary operation or revision operation for failed laparoscopic adjustable gastric banding (LAGB) convinced us that uncontrolled hunger is often the underlying cause. To control hunger after failed bariatric surgery,a novel approach combining LAGB with BPD-duodenal switch (DS) has been tried. Methods: Patients who had failed to lose weight after BPD or LAGB were considered in 2 groups. Group 1: patients who had failed LAGB underwent laparoscopic BPD-DS without sleeve gastrectomy, with the LAGB left in-situ. Group 2: patients who had failed primary (subgroup 2a) or revision (subgroup 2b) BPD had a LAGB placed with no other revision of their surgery. Results: 11 patients have undergone this form of revision surgery with little morbidity. Mean age at the original operation was 45 years, mean (range) BMI was 45.3 (38-62) kg/m². After the reoperation, at 3 months (9 patients) mean BMI was 30 kg/m² and at 6 months (4 patients) mean BMI was 27 kg/m². Conclusion: In this small study, combination surgery was safe and effective for failed BPD or LAGB. LAGB failure may be best managed with DS malabsorption without gastric resection.     

Changes in fat-free mass and muscle mass at 6 and 12 months after biliopancreatic diversion with duodenal switch surgery

BackgroundBariatric surgery is associated with concomitant loss in both fat and muscle masses. Literature on muscle composition/quality after bariatric surgery is limited.ObjectivesTo measure and compare the changes in fat-free mass with the changes in muscle composition after biliopancreatic diversion with duodenal switch surgery (BPD/DS).SettingBariatric surgery is associated with concomitant loss in both fat and muscle masses. Literature on muscle composition/quality after bariatric surgery is limited.MethodsForty patients underwent BPD/DS and 22 patients are considered as controls. Bioelectrical impedance analysis (body composition) and computed tomography scan at the midthigh and abdominal levels (muscle composition) were performed at baseline, 6, and 12 months.ResultsAt 6 and 12 months, the BPD/DS group displayed significant reduction in weight (12 months: −46.6 ± 13.5 kg) and fat-free mass (12 months: −8.2 ± 4.4 kg; both P < .001). A significant reduction in abdominal (−15 ± 8%, P < .001) and midthigh muscle areas (−18 ± 7%, P < .001) was observed during the first postoperative 6 months, followed by a plateau after 6 months (abdominal: −1 ± 5%, midthigh: −1 ± 4%, both P > .05). At 6 months, both midthigh fat-infiltrated muscle (−22 ± 10%, P < .001) and normal-density muscle (−16 ± 9%, P < .001) areas decreased. Further reduction at 12 months was only observed in the fat-infiltrated muscle (−11 ± 8%, P < .001) in comparison with an increase in the normal-density muscle area (5 ± 8%, P = .001). There was no significant change for the control group.ConclusionsReduction in muscle, assessed with computed tomography scans, occurs mostly during the first 6 months postoperatively after BPD/DS. Focus on muscle quantity as well as quality, using precise imaging methods, instead of quantifying total body lean mass, is likely to provide better assessment in body content modulation after BPD/DS.     

Insulin resistance is associated with circulating fibrinogen levels in nondiabetic patients receiving peritoneal dialysis.

BACKGROUND: Insulin resistance (IR) and inflammation are associated with increased risk of cardiovascular disease in the general population. Continuous glucose absorption in peritoneal dialysis (PD) may induce hyperglycemia and hyperinsulinemia. METHODS: We evaluated IR in nondiabetic patients receiving PD, and analyzed the association between IR and systemic inflammation biomarkers by performing a cross-sectional study on ambulatory dialysis. A total of 25 nondiabetic patients receiving PD and 25 healthy individuals, matched for gender, age, and body mass index (BMI), were included. The PD group was composed of 11 men and 14 women, with a mean age of 47 +/- 14 years and mean BMI of 25.5 +/- 4.7 kg/m(2). The control group was composed of 10 men and 15 women, with a mean age of 45 +/- 12 years and BMI of 24.0 +/- 2.8 kg/m(2). RESULTS: IR was evaluated by the homeostasis model assessment method (HOMA-IR). Inflammation was assessed through high-sensitivity C-reactive protein (CRP) and fibrinogen. Body composition and truncal fat were evaluated by dual energy x-ray absorptiometry. HOMA-IR was significantly higher (P < .0001) in subjects receiving PD (4.9, range: 2.3-9.3 mmol/L x muU/mL) compared with healthy subjects (1.2, range: 0.4-4.8 mmol/L x muU/mL). As expected, compared with controls, patients receiving PD had significantly higher levels of insulin (26.5 +/- 7.5 muU/mL vs 6.3 +/- 3.4 muU/mL; P < .0001), CRP (6.3, range: 0.3-61.1 mg/L vs 2.4, range: 0.6-5.9 mg/L; P = .001), and fibrinogen (379 +/- 101 mg/dL vs 268 +/- 66 mg/dL; P < .0001). However, there were no significant differences in body and truncal fat mass between the groups. A significant correlation between HOMA-IR and fibrinogen (Rho = 0.48; P = .01) was observed. However, no correlation was found between HOMA-IR and CRP. Also, no significant correlations were found between HOMA-IR and body fat mass (Rho = 0.11), and between HOMA-IR and truncal fat mass (Rho = 0.19). CONCLUSIONS: Patients receiving PD demonstrate a state of IR that is associated with high circulating levels of fibrinogen. This suggests that hyperfibrinogenemia may be involved in the pathogenesis of IR in this setting.