Antonio Alastrué

Increased Exercise Capacity after Surgically Induced Weight Loss in Morbid Obesity

Objective: To investigate the effects of surgically induced weight loss on exercise capacity in patients with morbid obesity (MO).

Función cardiopulmonar y capacidad de ejercicio en pacientes con obesidad mórbida

Introduction and objectives. The effect of obesity on cardiac function is still under discussion. The objective of this study was to assess cardiopulmonary capacity in morbidly obese patients. Patients and method. A symptom-limited cardiopulmonary exercise stress test was carried out in 31 morbidly obese patients (BMI 50 ± 9 kg/m 2 ) and 30 normal controls (BMI 24 ± 2 kg/m 2 ). Cardiovascular function was evaluated using the oxygen pulse (oxygen uptake/heart rate). Results. There were no differences in age, sex and height between both groups. During the effort the obese subjects presented greater oxygen uptake, heart rate, systolic arterial pressure and minute ventilation and shorter test duration than control group (14 ± 3 vs 27 ± 4 min; p < 0.001). Oxygen pulse values were higher in obese patients. However, after oxygen uptake indexation by fat free mass, these differences disappeared, suggesting a similar cardiovascular function. At the end of the exercise, the control group reached 96% of their age-predicted maximal heart rate and their respiratory exchange ratio was 1 ± 0.2. Obese patients only reached 86% and 0.87 ± 0.2, respectively. Conclusions. Due to their need of more energy output to move total body mass morbidly obese patients have a reduced exercise capacity. They finish the test having done a submaximal exercise. However, during this effort they show a normal cardiopulmonar capacity.

Intact parathyroid hormone measurement at 24 hours after thyroid surgery as predictor of parathyroid function at long term

BACKGROUND There is no consensus about the usefulness of postoperative intact parathyroid hormone (iPTH) determination to predict permanent hypoparathyroidism (pHPP). We evaluated the value of calcium (Ca2+) and iPTH concentration at 24 hours after total thyroidectomy (TT) for predicting pHPP. METHODS Ca2+ and iPTH levels from 70 consecutive patients who underwent TT were measured at 24 hours and 6 months after TT. RESULTS Five patients (7.1%) developed pHPP. An iPTH concentration ≤5.8 pg/mL at 24 hours after TT identified patients at risk for pHPP (sensitivity, 100%; specificity, 81.5%), but it was not accurate enough to predict its development (positive predictive value, 30%). Conversely, an iPTH level >5.8 pg/mL predicted normal parathyroid function at 6 months (negative predictive value, 100%). Compared with iPTH, a postoperative Ca2+ level ≤1.95 mmol/L was 60% sensitive and 78.5% specific to predict pHPP. CONCLUSIONS An iPTH concentration >5.8 pg/mL on the first postoperative day rules out pHPP with much better diagnostic accuracy than Ca2+. Postoperative iPTH could be helpful in identifying patients at risk for developing pHPP.

The Truncated Isoform of Somatostatin Receptor5 (sst5TMD4) Is Associated with Poorly Differentiated Thyroid Cancer

Somatostatin receptors (ssts) are expressed in thyroid cancer cells, but their biological significance is not well understood. The aim of this study was to assess ssts in well differentiated (WDTC) and poorly differentiated thyroid cancer (PDTC) by means of imaging and molecular tools and its relationship with the efficacy of somatostatin analog treatment. Thirty-nine cases of thyroid carcinoma were evaluated (20 PDTC and 19 WDTC). Depreotide scintigraphy and mRNA levels of sst-subtypes, including the truncated variant sst5TMD4, were carried out. Depreotide scans were positive in the recurrent tumor in the neck in 6 of 11 (54%) PDTC, and in those with lung metastases in 5/11 cases (45.4%); sst5TMD4 was present in 18/20 (90%) of PDTC, being the most densely expressed sst-subtype, with a 20-fold increase in relation to sst2. In WDTC, sst2 was the most represented, while sst5TMD4 was not found; sst2 was significantly increased in PDTC in comparison to WDTC. Five depreotide positive PDTC received octreotide for 3–6 months in a pilot study with no changes in the size of the lesions in 3 of them, and a significant increase in the pulmonary and cervical lesions in the other 2. All PDTC patients treated with octreotide showed high expression of sst5TMD4. ROC curve analysis demonstrated that only sst5TMD4 discriminates between PDTC and WDTC. We conclude that sst5TMD4 is overexpressed in PDTC and may be involved in the lack of response to somatostatin analogue treatment.

IGF1 modifications after bariatric surgery in morbidly obese patients: potential implications of nutritional status according to specific surgical technique.

OBJECTIVES IGF1 is decreased in morbidly obese (MO) patients and its changes after bariatric surgery weight loss (WL) are not well known. The aim of this study was to analyse IGF1 modifications in MO patients after WL and its relationship to ghrelin and to different types of surgeries. DESIGN Retrospective follow-up study at the University Medical Center. METHODS One hundred and nine MO patients (age 44.19.3, BMI 51.748.75KG/M(2)) were evaluated at baseline and 1 year after surgery: 28 sleeve gastrectomy (SG), 31 distal modified (m), and 50 ringed (r) Roux-en-Y gastric bypass (RYGBP) surgery. Changes in IGF1, IGFBP3, ratio IGF1:IGFBP3, and ghrelin were evaluated 1 year after surgery. RESULTS Baseline prevalence of low IGF1 (defined by s.d. IGF1<-2) was 22%, and %WL 1 year after surgery was 34.9±8.9%. There was a significant decrease in IGFBP3 in all the procedures, an increase in IGF1:IGFBP3 ratio in rRYGBP and SG, but total IGF1 only increased significantly in SG. Albumin concentrations decreased in mRYGBP, did not change in rRYGBP, but increased in SG after surgery. Total ghrelin concentrations increased after both RYGBPs and decreased after SG (P<0.05 in all cases). The prevalence of low IGF1 decreased in SG (28.6 vs 10.1%, P=0.03) and did not change in RYGPBP techniques. The %albumin change was the only dependent variable associated with the % total IGF1 change. CONCLUSIONS Recovery of low IGF1 after bariatric surgery was specifically related to the albumin modifications induced by surgery and was not related to ghrelin modifications.

Long-Term Results of Serial Transverse Enteroplasty with Neovalve Creation for Extreme Short Bowel Syndrome: Report of Two Cases

Objective: The aim of this article was to determine whether serial transverse enteroplasty (STEP) and the creation of a new ileocecal valve in extreme short bowel syndrome (SBS) cases (<45 cm) is effective in intestinal adaptation and improvement of nutritional parameters and serum citrulline levels. Patients and Methods: We present 2 cases of SBS treated with STEP. Enterectomy was performed for massive intestinal ischemia secondary to a gastrointestinal stromal tumor in the first case and to catastrophic antiphospholipid syndrome in the second. After enterectomy, the short residual bowel measured 34 cm in the first patient and 45 cm in the second. In both cases STEP, cholecystectomy, and gastrostomy were performed. In the first case a Brooke neovalve was created, and in the other the ileocecal valve was preserved. Results: Both patients could finally be weaned off total parenteral nutrition (TPN) and gastrostomy feeding, maintaining a good nutritional status 1 year after surgery. Conclusions: In extreme SBS, a minimum length of 80–90 cm of functioning small bowel and an intact ileocecal valve are necessary. We plead for the use of STEP with preservation of the ileocecal valve or creation of a neovalve using the Brooke technique in order to achieve the ultimate goal, which is to wean patients off TPN. After a critical review of different surgical techniques, a treatment algorithm is proposed.

Radiological evaluation of the vertical banded gastroplasty for morbid obesity

Vertical banded gastroplasty (VBG) was performed in 70 morbidly obese patients between September 1988 and February 1991. All patients underwent a routine abdominal ultrasonographic (US) ctudy preoperatively, an upper gastrointestinal (GI) contrast study on the fifth day after VBG, and US and upper GI studies at 6, 12, 18 and 24 months postoperatively. The main abnormalities detected included staple-line distuption (22.85%), extragastric leak (2.85%), outlet obstruction (7.14%), gallstones (37.14%) and fatty liver (75.50 %). Asymptomatic cholelithiasis following VBG was detected by US in 25.8% of cases. Hepatic US follow-up showed the echographic pattern had returned to normal in 47.61% of cases. The 100% sensitivity and 100% specificity of gallstone detection at pre-VBG study in this series further confirms the role of US in the evaluation of cholithiasis, even in the morbidly abese. The 88.67% sensitivity and 100% specificity of fatty liver detection by US is similar to results from other studies. We suggest US and upper GI studies should be carried out routinely in morbidly obese patients not only for early detection of postsurgical complications but also to evaluate cholelithiasis and hepatic parenchyma following VBG.