David Benaiges

Laparoscopic sleeve gastrectomy and laparoscopic gastric bypass are equally effective for reduction of cardiovascular risk in severely obese patients at one year of follow-up.

BACKGROUND Very few studies have compared laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) outcomes or analyzed improvement in cardiovascular risk (CVR) after bariatric surgery. None of the studies considered the Mediterranean population. Our primary objective was to compare the 10-year estimated CVR reduction achieved by LRYGB and LSG in Spanish subjects with severe obesity. The secondary objectives were to compare the techniques in terms of weight loss and co-morbidity improvement. The study was performed at a university hospital in Barcelona, Spain. METHODS A 12-month prospective cohort study of 140 consecutive patients (95 LRYGB and 45 LSG) compared the 2 surgical intervention groups to study the percentage of excess weight loss, resolution and improvement/resolution of co-morbidities, and effect on CVR using both the Framingham risk score (FRS) and the Registre Gironí del Cor (REGICOR) model. RESULTS At 12 months, the overall CVR decreased from 6.6% to 3.4% using the FRS and from 3.7% to 1.9% using the REGICOR score. Neither model found a difference between the 2 surgical intervention groups in decreased postoperative CVR risk, with a FRS of 3.4% ± 2.2% for LRYGB versus 3.3% ± 2.1% for LSG (P = .872) and a REGICOR score of 1.9% ± 1.5% versus 1.8% ± 1.6%, respectively (P = .813). No differences were observed in the percentage of excess weight loss or the resolution of type 2 diabetes mellitus and hypertension. The hypercholesterolemia improvement/resolution rate was lower in the LSG group than in the LRYGB group. CONCLUSION Bariatric surgery reduces the estimated CVR by one half at 1 year after surgery. Except for the less-improved cholesterol metabolism, LSG, a restrictive technique, proved to be equally as effective at 1 year of follow-up as LRYGB.

[Bone mass loss after sleeve gastrectomy: a prospective comparative study with gastric bypass].

Abstract Introduction Bariatric surgery is the most effective option for the treatment of patients with a high risk of complications due to their obesity. However, it brings about a series of changes in calcium and vitamin D metabolism and an increase in resorption which lead to a loss of bone mass. Aim The objective of this study is to compare sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) as regards loss of bone mass using bone densitometry and bone remodelling markers. Patients and methods Fifteen women with morbid obesity were included, 8 by SG and 7 by RYGB, with a mean age of 47.8±9 and mean body mass index 43.3±3.4. Bone mass measurements were made on the lumbar spine, femur and distal radius, and the bone remodelling markers N-telopeptide (NTx) and bone alkaline phosphatase (BALP), as well as vitamin D levels before and 12 months after surgery. Results A significant bone mass loss was observed was observed with SG and RYGB, in the lumbar spine and hip, whilst no differences were observed in the radial. The percentage bone mass loss was less in the column and femur after SG than with RYGB, although it did not reach statistical significance, 4.6%±4.4 (mean±SD) and 6.3%±5.4 (mean±SD), respectively. At 12 months the Ntx increased for both types of surgery, and the BAP was only increased for SG. Conclusion SG causes less, although not significant, bone mass loss compared to RYGB.

Type 1 diabetes, metabolic syndrome and cardiovascular risk

Patients with type 1 diabetes mellitus (T1DM) traditionally had a low body mass index and microangiopathic complications were common, while macroangiopathy and the metabolic syndrome were exceptional. The Diabetes Control and Complications Trial, published in 1993, demonstrated that therapy aimed at maintaining HbA1c levels as close to normal as feasible reduced the incidence of microangiopathy. Since then, the use of intensive insulin therapy to optimize metabolic control became generalized. Improved glycemic control resulted in a lower incidence of microangiopathy; however, its side effects included a higher rate of severe hypoglycemia and increased weight gain. Approximately 50% of patients with T1DM are currently obese or overweight, and between 8% and 40% meet the metabolic syndrome criteria. The components of the metabolic syndrome and insulin resistance have been linked to chronic T1DM complications, and cardiovascular disease is now the leading cause of death in these patients. Therefore, new therapeutic strategies are required in T1DM subjects, not only to intensively lower glycemia, but to control all associated metabolic syndrome traits.

Laparoscopic sleeve gastrectomy: More than a restrictive bariatric surgery procedure?

Sleeve gastrectomy (SG) is a restrictive bariatric surgery technique that was first used as part of restrictive horizontal gastrectomy in the original Scopinaro type biliopancreatic diversion. Its good results as a single technique have led to a rise in its use, and it is currently the second most performed technique worldwide. SG achieves clearly better results than other restrictive techniques and is comparable in some aspects to the Roux-en-Y gastric bypass, the current gold standard in bariatric surgery. These benefits have been associated with different pathophysiologic mechanisms unrelated to weight loss such as increased gastric emptying and intestinal transit, and activation of hormonal mechanisms such as increased GLP-1 hormone and decreased ghrelin. The aim of this review was to highlight the salient aspects of SG regarding its historical evolution, pathophysiologic mechanisms, main results, clinical applications and perioperative complications.

Seven-year mortality in heart failure patients with undiagnosed diabetes: an observational study

BackgroundPatients with type 2 diabetes mellitus and heart failure have adverse clinical outcomes, but the characteristics and prognosis of those with undiagnosed diabetes in this setting has not been established.MethodsIn total, 400 patients admitted consecutively with acute heart failure were grouped in three glycaemic categories: no diabetes, clinical diabetes (previously reported or with hypoglycaemic treatment) and undiagnosed diabetes. The latter was defined by the presence of at least two measurements of fasting plasma glycaemia ≥ 7 mmol/L before or after the acute episode.Group differences were tested by proportional hazards models in all-cause and cardiovascular mortality during a 7-year follow-up.ResultsThere were 188 (47%) patients without diabetes, 149 (37%) with clinical diabetes and 63 (16%) with undiagnosed diabetes. Patients with undiagnosed diabetes had a lower prevalence of hypertension, dyslipidaemia, peripheral vascular disease and previous myocardial infarction than those with clinical diabetes and similar to that of those without diabetes. The adjusted hazards ratios for 7-year total and cardiovascular mortality compared with the group of subjects without diabetes were 1.69 (95% CI: 1.17-2.46) and 2.45 (95% CI: 1.58-3.81) for those with undiagnosed diabetes, and 1.48 (95% CI: 1.10-1.99) and 2.01 (95% CI: 1.40-2.89) for those with clinical diabetes.ConclusionsUndiagnosed diabetes is common in patients requiring hospitalization for acute heart failure. Patients with undiagnosed diabetes, despite having a lower cardiovascular risk profile than those with clinical diabetes, show a similar increased mortality.

Statins for primary cardiovascular prevention in the elderly

The elderly population is increasing worldwide, with subjects > 65 years of age constituting the fastest-growing age group. Furthermore, the elderly face the greatest risk and burden of cardiovascular disease mortality and morbidity. Although elderly patients, particularly those older > 75, have not been well represented in randomized clinical trials evaluating lipid-lowering therapy, the available evidence supporting the use of statin therapy in primary prevention in older individuals is derived mainly from subgroup analyses and post-hoc data. On the other hand, elderly patients often have multiple co-morbidities that require a high number of concurrent medications; this may increase the risk for drug-drug interactions, thereby reducing the potential benefits of statin therapy. The aim of this review was to present the relevant literature regarding statin use in the elderly for their primary cardiovascular disease, with the associated risks and benefits of treatment.

Síndrome metabólico y diabetes mellitus tipo 1: prevalencia y factores relacionados

Introduccion y objetivos. Numerosas evidencias han puesto de relieve la importancia clinica y epidemiologica del sindrome metabolico como precursor de la enfermedad cardiovascular. El sindrome metabolico se asocia en general a la diabetes tipo 2, pero son escasos los datos en la diabetes tipo 1. En el presente estudio se evalua la prevalencia de sindrome metabolico en pacientes con diabetes tipo 1 y los factores relacionados. Metodos. Estudio transversal que incluyo a los pacientes mayores de 18 anos de edad con diabetes tipo 1 autoinmune de mas de 6 meses de evolucion atendidos consecutivamente en la Consulta Externa de Endocrinologia del Hospital del Mar de Barcelona durante el ano 2008. La identificacion del sindrome metabolico se establecio segun los criterios modificados del Panel III del National Cholesterol Education Program. Resultados. Tenia sindrome metabolico el 31,9% (intervalo de confianza [IC] del 95%, 22,3%-41,5%) de los pacientes con diabetes tipo 1. La edad (odds ratio [OR] = 1,09; IC del 95%, 1,029-1,154), el indice de masa corporal (OR = 1,389; IC del 95%, 1,134-1,702) y la glucohemoglobina (OR = 1,745; IC del 95%, 1,081-2,815) fueron los factores que se asociaron de forma independiente y significativa con la presencia de sindrome metabolico en los pacientes con diabetes tipo 1. Se constato una relacion directa entre el numero de componentes de sindrome metabolico y la prevalencia de microangiopatia, que llego a ser del 100% en los pacientes que cumplian todos los criterios diagnosticos. Conclusiones. El sindrome metabolico es frecuente en los pacientes con diabetes tipo 1 y se asocia con las complicaciones microvasculares

Insulin resistance and hypertension in patients with type 1 diabetes

AIM The aims of this study were to determine the prevalence of hypertension in type 1 diabetes patients and to analyze its relationship with insulin resistance and other associated factors. DESIGN AND METHODS A cross-sectional study on 291 patients with type 1 immune-mediated diabetes managed at two outpatient endocrinology clinics was performed. All participants were Caucasian, 18 years or older with type 1 diabetes duration of more than 6 months, who had completed the study protocol. Hypertension was defined as blood pressure ≥130/80 mmHg or use of antihypertensive medication, excluding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers when used as treatment for micro- or macroalbuminuria. RESULTS Hypertension was found in 87 [29.9% (95% confidence interval, or CI): 24.6%-35.2%] patients with type 1 diabetes. Hypertensive patients presented older age, male predominance, higher body mass index and overweight/obesity prevalence, and longer diabetes duration compared with normotensive patients. Insulin sensitivity quantified by estimated glucose disposal rate (eGDR) was lower in patients with hypertension compared with normotensives (5.2±1.4 vs. 9.1±1.2 mg kg(-1) min(-1), P<.001) and showed a negative correlation with systolic blood pressure level (r=-0.612, P<.01). In multivariate logistic regression analysis, eGDR, besides nephropathy, emerged significantly and independently associated with hypertension. An increment of 1 unit in insulin sensitivity assessed by eGDR was associated with a 5.7% decrease in hypertension prevalence (95% CI: 0.018-0.175) and the absence of nephropathy with an 88.2% decrease (95% CI: 0.15-0.92). CONCLUSIONS Hypertension was present in approximately one third of patients with type 1 diabetes, especially in men, those with microangiopathy, overweight or obesity, older age and longer diabetes duration. Hypertension prevalence increased in parallel to the degree of renal impairment and was inversely related to insulin sensitivity.

Preoperative Predictors of Weight Loss at 4 Years Following Bariatric Surgery

BACKGROUND This study evaluated the influence of patient characteristics, preoperative weight loss, and type of surgical procedure on long-term weight loss after bariatric surgery (BS). METHODS Subjects were a prospective cohort of 95 patients who underwent BS with 4 years of follow-up. Seventy-seven patients (81.1%) underwent laparoscopic Roux-en-Y gastric bypass, and 18 (18.9%) had laparoscopic sleeve gastrectomy. Age, gender, initial body mass index (BMI), preoperative percentage of excess weight loss, presence of type 2 diabetes mellitus, current smoking status, and surgical technique were analyzed via multivariate linear regression analysis to identify predictors of weight loss during the 4 years after the surgery. RESULTS Maximum percentage of excess weight loss was obtained at 18 months. Age and preoperative BMI were negatively associated with percentage of excess weight loss at 1, 2, 3, and 4 years after BS (P < .005). At 4 years, laparoscopic Roux-en-Y gastric bypass was independently associated with a higher weight loss than laparoscopic sleeve gastrectomy (P < .05). CONCLUSIONS Younger age, lower BMI, and laparoscopic Roux-en-Y gastric bypass are independent predictors of long-term weight loss after BS.

A prospective evaluation of neonatal hypoglycaemia in infants of women with gestational diabetes mellitus

OBJECTIVE To analyse first-day-of-life glucose levels in infants of women with gestational diabetes (GDM) and the influence of maternal, gestational and peripartum factors on the development of neonatal hypoglycaemia. STUDY DESIGN Prospective cohort study including newborns of GDM mothers. Capillary blood glucose (CBG) was measured serially on the first day of life. CBG values were defined as normal (≥ 2.5 mmol/l), mild hypoglycaemia (2.2-2.4 mmol/l), moderate hypoglycaemia (1.6-2.1 mmol/l) and severe hypoglycaemia (<1.6 mmol/l). RESULTS One hundred and ninety infants were included: 23 (12.1%) presented mild, 20 (10.5%) moderate and only 5 (2.6%) severe hypoglycaemia. Hypoglycaemic infants were more frequently large-for-gestational-age (29.3% vs 11.3%, p=0.003), had lower umbilical cord pH (7.28 vs 7.31, p=0.03) and their mothers had more frequently been hyperglycaemic during labour (18.8% vs 8.5%, p=0.04). In multivariate analysis Pakistani origin (OR: 2.94; 95% CI: 1.14-7.55) and umbilical cord venous pH (OR: 0.04, 95% CI: 0.261-0.99) were significantly and independently associated with hypoglycaemia. CONCLUSIONS Mild and moderate neonatal hypoglycaemias were common although severe episodes were unusual in infants of women with GDM. Hypoglycaemia is mainly influenced by ethnicity and cord blood pH, although maternal peripartum glycaemic control and large-for-gestational-age condition may also play a role.