Cyrus Jahansouz

Bile Acids Increase Independently From Hypocaloric Restriction After Bariatric Surgery.

Objectives: To measure changes in the composition of serum bile acids (BA) and the expression of Takeda G-protein-coupled receptor 5 (TGR5) acutely after bariatric surgery or caloric restriction. Summary Background Data: Metabolic improvement after bariatric surgery occurs before substantial weight loss. BA are important metabolic regulators acting through the farnesoid X receptor and TGR5 receptor. The acute effects of surgery on BA and the TGR5 receptor in subcutaneous white adipose tissue (WAT) are unknown. Methods: A total of 27 obese patients with type 2 diabetes mellitus were randomized to Roux-en-Y gastric bypass (RYGB) or to hypocaloric diet (HC diet) restriction (NCT 1882036). A cohort of obese patients with and without type 2 diabetes mellitus undergoing vertical sleeve gastrectomy was also recruited (n = 12) as a comparison. Results: After vertical sleeve gastrectomy, the level of BA increased [total: 1.17 ± 1.56 &mgr;mol/L to 4.42 ± 3.92 &mgr;mol/L (P = 0.005); conjugated BA levels increased from 0.99 ± 1.42 &mgr;mol/L to 3.59 ± 3.70 &mgr;mol/L (P = 0.01) and unconjugated BA levels increased from 0.18 ± 0.24 &mgr;mol/L to 0.83 ± 0.70 &mgr;mol/L (P = 0.009)]. With RYGB, there was a trend toward increased BA [total: 1.37 ± 0.97 &mgr;mol/L to 3.26 ± 3.01 &mgr;mol/L (P = 0.07); conjugated: 1.06 ± 0.81 &mgr;mol/L to 2.99 ± 3.02 &mgr;mol/L (P = 0.06)]. After HC diet, the level of unconjugated BA decreased [0.92 ± 0.55 &mgr;mol/L to 0.32 ± 0.43 &mgr;mol/L (P = 0.05)]. The level of WAT TGR5 gene expression decreased after surgery, but not in HC diet. Protein levels did not change. Conclusions: The levels of serum BA increase after bariatric surgery independently from caloric restriction, whereas the level of WAT TGR5 protein is unaffected.

National Trends in Bariatric Surgery 2012–2015: Demographics, Procedure Selection, Readmissions, and Cost

BackgroundBariatric surgery is widely accepted as the best treatment for obesity and type 2 diabetes mellitus (T2DM). The Roux-en-Y gastric bypass (RYGB) and the sleeve gastrectomy (SG) have become the predominant bariatric procedures in the USA over the last several years, although the most recent trends in selection are unknown.ObjectiveThe objective of this study is to assess selection trends, readmission rates, and cost of bariatric procedures in the USA from 2012 to 2015.MethodsWe used the Premier database from 2012 to 2015 to examine trends in incidence of RYGB, adjustable gastric banding (LAGB), and SG; readmissions; and cost. Multivariate regression was performed to identify predictors of readmission.ResultsThe proportion of SG went up from 38 to 63% while the RYGB decreased from 44 to 30% over this time period. LAGB has decreased in use from 13 to 2%. In comparison to RYGB, readmission was less likely for SG (OR 0.64), males (OR 0.91), and more likely for black race (OR 1.27). The overall proportion of patients seeking RYGB with type 2 diabetes was higher than with SG (36 versus 25%), but SG has now overtaken RYGB as the most common procedure among diabetics. The SG is less costly than RYGB (

The Influence of Bariatric Surgery on Serum Bile Acids in Humans and Potential Metabolic and Hormonal Implications: a Systematic Review.

11,183 versus

Sleeve gastrectomy drives persistent shifts in the gut microbiome

13,485).ConclusionsThere is a continued overall trend in the increased popularity of the SG and decreased utilization of the RYGB and LAGB, although growth of the SG appears to be slowing. This is also true among patients with type 2 diabetes mellitus. Regardless of surgery type, underinsured and African-American race were more likely to be readmitted.

Long-Term Body Composition Changes in Women Following Roux-en-Y Gastric Bypass Surgery.

Recent research suggests a mechanistic role for bile acids (BA) in the metabolic improvement following bariatric surgery. It is believed that the hormonal and metabolic effects associated with changes in systemic BAs may be related to the farnesoid X receptor (FXR) and a G-protein coupled receptor (TGR5). This systematic review examines changes in systemic BAs following bariatric procedures. Studies were included if they reported the measurement of systemic BAs in humans at at least one time point after bariatric surgery. Eleven papers were identified that met the inclusion criteria. Seven studies reported the effect of Roux-en-Y gastric bypass (RYGB) on fasting BAs. The majority (6/7) reported that fasting BAs increased after RYGB. Data regarding fasting BAs after vertical sleeve gastrectomy (VSG) and laparoscopic gastric banding (LAGB) are inconsistent. Data regarding post-prandial BA changes after RYGB, VSG, and LAGB are also inconsistent. More research is needed to investigate the connection between BAs and the metabolic improvement seen after bariatric surgery.

Characterizing Patient-Generated Clinical Data and Associated Implications for Electronic Health Records.

BACKGROUND Changes in the gut microbiome following bariatric surgery have been causally linked to metabolic benefits. OBJECTIVES We sought to characterize and assess the stability of gut microbiome shifts following sleeve gastrectomy (SG). SETTING University laboratories. METHODS Diet-induced obese mice were randomized to SG or sham surgery. Mice were housed individually or cohoused such that one SG mouse was housed with one weight-matched, sham-operated mouse. Fecal samples were collected before and on postoperative days 7 and 28. Bacterial composition in feces was characterized by using next-generation Illumina sequencing of 16 S rRNA. RESULTS SG mice lost more weight and were more insulin sensitive than sham mice independent of housing status (P<.05). One week following surgery, fecal samples from all mice showed shifts in the microbiome that only persisted in SG-operated mice. Cohousing did not alter the microbial composition of SG-operated mice. Cohoused sham-operated mice showed a unique shift in microbial composition on postoperative day 28 that differed from individually housed, sham-operated mice (P<.001). Cohousing did not affect metabolic outcomes of either SG or sham surgeries. CONCLUSION SG results in acute and sustained shifts in the gut microbiome. SG associated shifts are not altered by reexposure to obesity-associated gut microbiota.

Adipocyte Dysfunction, Inflammation, and Insulin Resistance in Obesity

Background: Although most individuals experience successful weight loss following Roux-en-Y gastric bypass (RYGB), weight regain is a concern, the composition of which is not well documented. Our aim was to evaluate changes in body composition and handgrip strength as a measure of functional status in participants from a previous 1-year post-RYGB longitudinal study who had undergone RYGB approximately 9 years prior. Methods: Five women from an original larger cohort were monitored pre-RYGB and 1.5 months, 6 months, 1 year, and 9 years post-RYGB. Body composition was assessed at all time points using dual energy x-ray absorptiometry and multiple dilution. Handgrip strength was measured using a digital isokinetic hand dynamometer (Takei Scientific Instruments, Ltd, Tokyo, Japan). Results: Mean time to final follow-up was 8.7 years. Lean soft tissue (LST) loss over the ~9-year period was on average 11.9 ± 5.6 kg. Compared with 1-year post-RYGB, 9-year LST was 4.4 ± 3.0 kg lower (P = .03). Fat-free mass decreased over the 9-year period by 12.6 ± 5.8 kg. Mean fat mass (FM) decreased from 75.4 ± 22.6 kg pre-RYGB to 35.5 ± 21.5 kg 1 year post-RYGB but then trended toward an increase of 8.6 ± 7.0 kg between 1 year and 9 years post-RYGB (P = .053). Loss of LST was correlated with loss of handgrip strength (r = 0.64, P = .0005). Conclusion: The continued loss of lean mass associated with decreased handgrip strength occurring with long-term trend toward FM regain post-RYGB is concerning. The loss of LST and functional strength carries particular implications for the aging bariatric population and should be investigated further.

Serum FABP4 concentrations decrease after Roux-en-Y gastric bypass but not after intensive medical management

Patient-facing technologies are increasingly utilized for direct patient data entry for potential incorporation into the electronic health record. We analyzed patient-entered data during implementation of a patient-facing data entry technology using an online patient portal and clinic-based tablet computers at a University-based tertiary medical center clinic, including entries for past medical history, past surgical history, and social history. Entries were assessed for granularity, clinical accuracy, and the addition of novel information into the record. We found that over half of patient-generated diagnoses were duplicates of lesser or equal granularity compared to previous provider-entered diagnoses. Approximately one fifth of patient-generated diagnoses were found to meet the criteria for new, meaningful additions to the medical record. Our findings demonstrate that while patient-generated data provides important additional information, it may also present challenges including generating inaccurate or less granular information.

Supplementing Resident Research Funding Through a Partnership With Local Industry

Only recently has the complexity of adipose tissue become more apparent and appreciated. The two well-known forms of adipose tissue have been recognized: brown and white. This chapter focuses on white adipose tissue, and its derangement with the onset and progression of obesity and insulin resistance. It begins with a brief overview characterizing white adipose tissue and the adipocyte, and then proceeds to a discussion regarding the multifaceted dysfunction that accompanies obesity.

Partitioning of adipose lipid metabolism by altered expression and function of PPAR isoforms after bariatric surgery

Background: Serum concentrations of fatty acid binding protein 4, an adipose tissue fatty acid chaperone, have been correlated with insulin resistance and cardiovascular risk factors. The objective of this study were to assess relationships among Roux‐en‐Y gastric bypass, intensive lifestyle modification and medical management protocol, fatty acid binding protein 4, and metabolic parameters in obese patients with severe type 2 diabetes mellitus; and to evaluate the relative contribution of abdominal subcutaneous adipose and visceral adipose to the secretion of fatty acid binding protein 4. Methods: Participants were randomly assigned to intensive lifestyle modification and medical management protocol (n = 29) or to intensive lifestyle modification and medical management protocol augmented with Roux‐en‐Y gastric bypass (n = 34). Relationships among fatty acid binding protein 4 and demographic characteristics, metabolic parameters, and 12‐month changes in these values were examined. Visceral and subcutaneous adipose tissue explants from obese nondiabetic patients (n = 5) were obtained and treated with forskolin to evaluate relative secretion of fatty acid binding protein 4 in the different adipose tissue depots. Results: The intensive lifestyle modification and medical management protocol and Roux‐en‐Y gastric bypass cohorts had similar fasting serum fatty acid binding protein 4 concentrations at baseline. At 1 year, mean serum fatty acid binding protein 4 decreased by 42% in Roux‐en‐Y gastric bypass participants (P = .002) but did not change significantly in the intensive lifestyle modification and medical management protocol cohort. Percentage of weight change was not a significant predictor of 12‐month fatty acid binding protein 4 within treatment arm or in multivariate models adjusted for treatment arm. In adipose tissue explants, fatty acid binding protein 4 was secreted similarly between visceral and subcutaneous adipose tissue. Conclusion: After Roux‐en‐Y gastric bypass, fatty acid binding protein 4 is reduced 12 months after surgery but not after intensive lifestyle modification and medical management protocol in patients with type 2 diabetes mellitus. Fatty acid binding protein 4 was secreted similarly between subcutaneous and visceral adipose tissue explants.