Arthur B. Garrido

Effects of bariatric surgery on nonalcoholic fatty liver disease: Preliminary findings after 2 years

Background and Aim:  Although nonalcoholic fatty liver disease (NAFLD) is very common among morbidly obese patients, the effect of weight loss after bariatric surgery on inflammation and fibrosis related to NAFLD is still a matter of debate. The aim of this study was to evaluate the impact of Roux‐en‐Y gastric bypass (RYGB) surgery on NAFLD with a follow up of 2 years.

Severe Protein-Calorie Malnutrition after Bariatric Procedures

Background: Serious nutritional complications after Roux-en-Y gastric bypass (RYGBP) are infrequent. In a retrospective study of patients operated during a 68-month period, malnutrition was investigated to analyze circumstances associated with nutritional failure. Methods: In 236 consecutive RYGBPs, 11 patients with severe malnutrition were identified (4.7%) with age 45.1 ± 10.6 years (10 females/1 male) and initial BMI 54.6 ± 8.4 kg/m2. Results: In these 11 patients, the derangement was diagnosed 17.9 ± 15.8 months after RYGBP, following defined events in 63.6% (gastric stenosis, associated diseases ) or mostly exaggeration of expected symptoms in 36.4% (vomiting without endoscopic abnormalities). BMI then was 31.4 ± 8.6 kg/m2 (42.5 ± 9.9% total reduction, or 2.4 ± 2.1% decrease/month), and serum albumin and hemoglobin were 24.0 ± 8.2 g/L and 97.0 ± 23.0 g/L respectively. Edema was present in 45.4% (5/11), hospitalization was required in 54.5% (6/11), and 18.2% (2/11) eventually died. Conclusions: Serious malnutrition was unusual but not exceedingly rare in this series. Exogenous precipitating factors were clearly identified in 63.6% of the patients. Careful clinical and nutritional follow-up is recommended to prevent these uncommon but potentially dangerous complications.

Early marginal ulcer following Roux-en-Y gastric bypass under proton pump inhibitor treatment: prospective multicentric study

CONTEXT Causal factors of gastrojejunal ulcers after Roux-en-Y gastric bypass include peptic acid secretion from the gastric pouch. Esomeprazole is a potent inhibitor of acid secretion. OBJECTIVE To assess the occurrence of dyspepsia and gastrojejunal ulcers within the first 2 months after Roux-en-Y gastric bypass during the use of esomeprazole. METHODS One hundred eighteen morbid obese subjects were submitted to Roux-en-Y gastric bypass. Preoperative upper gastrointestinal tract endoscopy was negative for H. pylori. All subjects received esomeprazole for 60 days after surgery. RESULTS Two weeks after surgery only 13 mild symptoms were reported. After 2 months, 17 also moderate complaints were registered. Endoscopy around the 60th day showed esophagitis in 10 (8.5%), hiatal hernia in 2 (1.7%), foreign body in the anastomotic line in 12 (10.2%) and gastrojejunal ulcers was observed in 9 (7.6%) subjects, 2 of which had a suture material or metallic staple granuloma in the gastrojejunostomy. Ten subjects took nonsteroidal anti-inflammatory drugs at least once during study, but none of them developed ulcer. None of the subjects with ulcer had dyspeptic symptoms. CONCLUSION The incidence of ulcer in the gastrojejunal anastomosis within the first 2 months following Rouxen-Y gastric bypass under proton pump inhibitors is considerable. It was not related to the use of non-steroidal anti-inflammatory drugs, highlighting the possibility of ischemia and foreign body as causal factors. The ulcers were asymptomatic, and all post-surgical dyspeptic symptoms were moderate in severity.

Cancer in the Excluded Stomach 4 Years after Gastric Bypass

Gastric bypass is the preferred operation for treatment of morbid obesity on many services. The evaluation of the excluded stomach is always difficult and a matter of concern for the attending physician. There are only four reported cases of gastric cancer in the distal stomach after gastric bypass. We report a 57-year-old man who had intestinal metaplasia at the time of the Roux-en-Y gastric bypass 4 years ago and now developed an aggressive carcinoma in the bypassed stomach.

Zinc Nutritional Status of Morbidly Obese Patients Before and After Roux-en-Y Gastric Bypass: A Preliminary Report

Background: Previous researchers have found that the nutritional zinc status in obese and diabetic subjects is altered: low zinc concentrations in plasma and erythrocytes with high urinary zinc excretion were observed. This study assessed the influence of the Roux-en-Y gastric bypass (RYGBP) on the plasma, erythrocyte and urinary zinc concentrations before the beginning of the mineral supplementation. Methods: 24 morbidly obese patients were studied before and 2 months after RYGBP (the period in which the patients were still not ingesting mineral supplements). Fast blood sample, 24-hour urine, and 3-day food records were collected in the pre- and postoperative phases. Zinc concentration in the samples was analyzed by flame atomic absorption spectrophotometry, and dietary analysis of the food records were performed using the software Virtual Nutri with the inclusion of zinc concentration in the database for regional foods. Results: Pre- and postoperative results were respectively: plasma 68.0 and 66.3 μg/dL; erythrocytes 36.6 and 43.8 μg/g Hb; urine 884.7 μg/24h and 385.9 μg/24h; and zinc intake 10.5 and 6.7 mg/day. Conclusion: These results suggest that RYGBP changed mainly the zinc erythrocyte and urinary concentrations. As expected, the zinc intake was lower in the postoperative phase, which in the medium and long term, could cause problems for the patients.

Associations between glutathione peroxidase-1 Pro198Leu polymorphism, selenium status, and DNA damage levels in obese women after consumption of Brazil nuts

OBJECTIVE Alterations in selenium (Se) status may result in suboptimal amounts of selenoproteins, which have been associated with increased oxidative stress levels. The Pro198Leu polymorphism at the glutathione peroxidase-1 (GPx1) gene is supposed to be functional. The response of Se status, GPx activity, and levels of DNA damage to a Se supplementation trial between the genotypes related to that polymorphism was investigated. METHODS A randomized trial was conducted with 37 morbidly obese women. Participants consumed one Brazil nut, which provided approximately 290 μg of Se a day, for 8 wk. Blood Se concentrations, erythrocyte GPx activity, and DNA damage levels were measured at baseline and at 8 wk. The results were compared by genotypes. RESULTS The genotype frequencies were 0.487, 0.378, and 0.135 for Pro/Pro (the wild-type genotype), Pro/Leu, and Leu/Leu, respectively. At baseline, 100% of the subjects were Se deficient, and after the supplementation, there was an improvement in plasma Se (P < 0.001 for Pro/Pro and Pro/Leu, P < 0.05 for Leu/Leu), erythrocyte Se (P = 0.00 for Pro/Pro and Pro/Leu, P < 0.05 for Leu/Leu), and GPx activity (P = 0.00 for Pro/Pro, P < 0.00001 for Pro/Leu, P < 0.001 for Leu/Leu). In addition, the Pro/Pro group showed a decrease in DNA damage after Brazil nut consumption compared with baseline (P < 0.005), and those levels were higher in Leu/Leu subjects compared with those with the wild-type genotype (P < 0.05). CONCLUSION Consumption of one unit of Brazil nuts daily effectively increases Se status and increases GPx activity in obese women, regardless of GPx1 Pro198Leu polymorphism. However, the evaluated biomarkers showed distinct results in response to the supplementation when the polymorphism was considered.

Brazilian nut consumption improves selenium status and glutathione peroxidase activity and reduces atherogenic risk in obese women

Studies have shown that there are inverse relationships between nut consumption and the reduction of cardiovascular risk. This study tested the hypothesis that daily consumption of Brazilian nuts would have a positive effect upon selenium (Se) status, erythrocyte glutathione peroxidase activity, lipid profile, and atherogenic risk in severely obese women. Thirty-seven severely obese women each consumed 1 Brazilian nut a day (290 μg of Se a day) for 8 weeks. Blood Se concentrations, total erythrocyte glutathione peroxidase activity, lipid profile, and Castelli I and II indexes were evaluated before and after the nuts consumption. All the patients were Se deficient at baseline; this deficiency was remedied by the consumption of the Brazilian nut (P < .0001). The intake of Brazilian nuts promoted a significant increase in high-density lipoprotein cholesterol concentrations (P < .00001), which then resulted in a significant improvement of the Castelli I (P < .0002) and II (P < .0004) indexes. This study shows that obese people who implement daily consumption of Brazilian nuts can improve both Se status and lipid profile, especially high-density lipoprotein cholesterol levels, thereby reducing cardiovascular risks.

Lipid Peroxidation in Bariatric Candidates with Nonalcoholic Fatty Liver Disease (NAFLD) – Preliminary Findings

Background: Pathogenesis of nonalcoholic fatty liver disease (NAFLD) remains incompletely known, and oxidative stress is one of the mechanisms incriminated. The aim of this study was to evaluate the role of liver oxidative stress in NAFLD affecting morbidly obese patients. Methods: 39 consecutive patients with BMI >40 kg/m2 submitted to Roux-en-Y gastric bypass were enrolled, and wedge liver biopsy was obtained during operation. Oxidative stress was measured by concentration of hydroperoxides (CEOOH) in liver tissue. Results: Female gender was dominant (89.7%) and median age was 43.6 ± 11.1 years. Histology showed fatty liver in 92.3%, including 43.6% with nonalcoholic steatohepatitis (NASH), 48.7% with isolated steatosis and just 7.7% with normal liver. Liver cirrhosis was present in 11.7% of those with nonalcoholic steatohepatitis. Concentration of CEOOH was increased in the liver of patients with NASH when compared to isolated steatosis and normal liver (0.26± 0.17, 0.20± 0.01 and 0.14± 0.00 nmol/mg protein, respectively) (P <0.01). Liver biochemical variables were normal in 92.3% of all cases, and no difference between NASH and isolated steatosis could be demonstrated. Conclusions: 1) Nonalcoholic steatosis, steatohepatitis and cirrhosis were identified in substantial numbers of morbidly obese patients; 2) Concentration of hydroperoxides was increased in steatohepatitis, consistent with a pathogenetic role for oxidative stress in this condition.

Effect of gastric bypass on spontaneous growth hormone and ghrelin release profiles.

Objective: The purpose of this study was to analyze growth hormone (GH) concentrations in obese women before and after Roux‐en‐Y gastric bypass (RYGBP) and how resulting changes in weight, fat mass, ghrelin levels, and insulin sensitivity affect GH secretion.

Relationship Between Persistence of Helicobacter pylori and Dysplasia, Intestinal Metaplasia, Atrophy, Inflammation, and Cell Proliferation Following Partial Gastrectomy

Helicobacter pylori and partial gastricresection are risk factors for gastric cancer. Our aimswere to investigate the presence of H. pylori inpostgastrectomy patients and to correlate that withalterations in mucosal architecture and cell proliferation.One hundred fifty-one endoscopic biopsies from 22patients, (15-47 years of age, mean 29.2 years)following partial gastrectomy with Billroth IIreconstruction for peptic ulcer disease, were examined for thepresence of H. pylori using Giemsa staining. Sectionswere scored for grade of hyperplasia, intestinalmetaplasia, dysplasia, inflammation, and atrophy.Immunohistochemistry for proliferative cell nuclear antigen (PCNA)was used to characterize cell proliferation. H. pyloriwas observed in 17/22 (77.3%) of patients or in 57/151(37.7%) of biopsies. Metaplasia was seen in 18/22, chronic atrophic gastritis in 20/22, and cysticglandular dilation in 21/22 patients. The highest typeof metaplasia in each patient was: four Type I, fiveType IIA and nine Type IIB. Dysplasia was present in 16 biopsies from nine patients. H. pyloriwas more prevalent in intestinal metaplasia type I(44.8% of biopsies), than in type IIA (32.7%) or typeIIB (25%). No H. pylori was detected in regions showing dysplasia or cystic glandular dilation. H.pylori colonization was associated with degree ofinflammation (P = 0.00001) and cell proliferation (P =0.0001). In conclusion, H. pylori is commonly seen many years after gastrectomy, it is associated withan increased epithelial cell proliferation, and it isnot present in areas of histologic markers ofpremalignancy (type IIB metaplasia anddysplasia).