F. Anders Karlsson

Preoperative 4-week low-calorie diet reduces liver volume and intrahepatic fat, and facilitates laparoscopic gastric bypass in morbidly obese

BackgroundThe aim of this study was to explore changes in liver volume and intrahepatic fat in morbidly obese patients during 4xa0weeks of low-calorie diet (LCD) before surgery and to investigate if these changes would facilitate the following laparoscopic gastric bypass.MethodsFifteen female patients (121.3xa0kg, BMI 42.9) were treated preoperatively in an open study with LCD (800–1,100xa0kcal/day) during 4xa0weeks. Liver volume and fat content were assessed by magnetic resonance imaging and spectroscopy before and after the LCD treatment.ResultsLiver appearance and the complexity of the surgery were scored at the operation. Eighteen control patients (114.4xa0kg, BMI 40.8), without LCD were scored similarly. Average weight loss in the LCD group was 7.5xa0kg, giving a mean weight of 113.9xa0kg at surgery. Liver volume decreased by 12% (pu2009<u20090.001) and intrahepatic fat by 40% (pu2009<u20090.001). According to the preoperative scoring, the size of the left liver lobe, sharpness of the liver edge, and exposure of the hiatal region were improved in the LCD group compared to the controls (all pu2009<u20090.05).ConclusionsThe overall complexity of the surgery was perceived lower in the LCD group (pu2009<u20090.05), due to improved exposure and reduced psychological stress (both pu2009<u20090.05). Four weeks of preoperative LCD resulted in a significant decrease in liver volume and intrahepatic fat content, and facilitated the subsequent laparoscopic gastric bypass as scored by the surgeon.

Long-term results 11 years after primary gastric bypass in 384 patients

BACKGROUNDnRoux-en-Y gastric bypass surgery (RYGB) as treatment of morbid obesity results in substantial weight loss. Most published long-term studies have included few patients at the last follow-up point. The aim of the present study was to explore long-term results in a large cohort of patients 7-17 years after gastric bypass.nnnMETHODSnAll 539 patients who had undergone primary RYGB from 1993 to 2003 at Uppsala and Örebro University Hospitals received a questionnaire regarding their postoperative status. Blood samples were obtained and the medical charts studied.nnnRESULTSnOf the 539 patients, 384 responded (71.2% response rate, mean age 37.9 yr, body mass index 44.5 kg/m(2) at surgery, 317 women, and 67 men). At a mean follow-up of 11.4 years (range 7-17), the body mass index had decreased to 32.5 kg/m(2), corresponding to an excess body mass index loss of 63.3%. Similar weight loss was observed, regardless of the length of follow-up. Orally treated diabetes resolved in 72% and sleep apnea and hyperlipidemia were improved. Revisional bariatric surgery had been performed in 2.1% and abdominoplasty in 40.2%. The gastrointestinal symptoms were considered tolerable. The overall result was satisfactory for 79% of the patients and 92% would recommend Roux-en-Y gastric bypass to a friend. Attendance to the annual checkups was 37%. Vitamin B12 supplements were taken by 72% and multivitamins by 24%.nnnCONCLUSIONnAt 11 years, substantial weight loss was maintained and revisional surgery was rare. Surprisingly few patients were compliant with the recommendation of lifelong supplements and yearly evaluations; however, patient satisfaction was high.

Effects of Dehydroepiandrosterone Supplement on Health-related Quality of Life in Glucocorticoid Treated Female Patients with Systemic Lupus Erythematosus

The objective of this study was to evaluate the efficacy of low dose dehydroepiandrosterone (DHEA) on health-related quality of life (HRQOL) in glucocorticoid treated female patients with systemic lupus erythematosus (SLE). Forty one women ( ≥ 5 mg prednisolone/day) were included in a double-blind, randomized, placebo-controlled study for 6 months where DHEA was given at 30 mg/20 mg ( ≤ 45/ ≥ 46 years) daily, or placebo, followed by 6 months open DHEA treatment to all patients. HRQOL was assessed at baseline, 6 and 12 months, using four validated questionnaires and the patients partners completed a questionnaire assessing mood and behaviour at 6 months. DHEA treatment increased serum levels of sulphated DHEA from subnormal to normal. The DHEA group improved in SF-36 “role emotional” and HSCL-56 total score (both p < 0.05). During open DHEA treatment, the former placebo group improved in SF-36 “mental health” (p < 0.05) with a tendency for improvement in HSCL-56 total score (p = 0.10). Both groups improved in McCoys Sex Scale during active treatment (p < 0.05). DHEA replacement decreased high-density lipoprotein (HDL) cholesterol and increased insulin-like growth factor I (IGF-I) and haematocrit. There were no effects on bone density or disease activity and no serious adverse events. Side effects were mild. We conclude that low dose DHEA treatment improves HRQOL with regard to mental well-being and sexuality and can be offered to women with SLE where mental distress and/or impaired sexuality constitutes a problem.

Physical-chemical properties of β2-microglobulin

Abstract The hydrodynamic and optical properties of β2-microglobulin, a low mol. wt protein with established sequence homologies to the immunoglobulin G molecule, was studied by analytical gel chromatography, circular dichroism (CD), optical rotatory dispersion (ORD) and fluorescence measurements. The protein has a Stokes radius of 16 A and a low frictional ratio, indicating an almost spherical shape. The CD and ORD analysis suggest the presence of small amounts of ordered β structure. The β2-microglobulin tryptophan fluorescence has its maximum at 350 nm with a quantum yield of about 0·09. The results of the present study are discussed with reference to immunoglobulin structure.

Vitamin D Status 10 Years After Primary Gastric Bypass: Gravely High Prevalence of Hypovitaminosis D and Raised PTH Levels

BackgroundThe primary aim of this study was to evaluate the prevalence of vitamin D deficiency and secondary hyperparathyroidism after Roux-en-Y gastric bypass. Secondly, we have tried to assess predictors for vitamin D deficiency.MethodsFive hundred thirty-seven patients who underwent primary Roux-en-Y gastric bypass surgery between 1993 and 2003 at the Örebro University Hospital and Uppsala University Hospital were eligible for the study. Patients were asked to provide a blood sample between November 2009 and June 2010 and to complete a questionnaire about their postoperative health status. Serum values of 25-OH vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium were determined.ResultsFollow-up was completed in 293 patients, of which 83xa0% were female, with an age of 49u2009±u20099.9xa0years after a median time of 11u2009±u20092.8xa0years. Vitamin D, PTH and albumin-corrected calcium values were 42u2009±u200920.4xa0nmol/L, 89.1u2009±u200952.7xa0ng/L and 2.3u2009±u20090.1xa0mmol/L, respectively. Of all patients, 65xa0% were vitamin D deficient, i.e. 25-OH vitamin D <50xa0nmol/L, and 69xa0% had PTH above the upper normal reference range, i.e. >73xa0ng/L. Vitamin D was inversely correlated with PTH levels (pu2009<u20090.001) and positively correlated with calcium (pu2009=u20090.016). Vitamin D did not correlate with ALP. The only factor found to predict vitamin D deficiency was high preoperative body mass index (BMI) (pu2009=u20090.008), whereas gender, age, time after surgery and BMI at follow-up did not.ConclusionsVitamin D deficiency and secondary hyperparathyroidism after Roux-en-Y gastric bypass (RYGB) were confirmed in our study because 65xa0% of patients had vitamin D deficiency, and 69xa0% had increased PTH levels more than 10xa0years after surgery. These data are alarming and highlight the need for improved long-term follow-up. Vitamin D deficiency does not seem to progress with time after surgery, possibly due to weight loss. Only preoperative BMI, cutoff point 43xa0kg/m2, was a predictor of vitamin D deficiency at follow-up. Improved long-term follow-up of patients that undergo RYGB is needed.

Health-Related Quality-of-Life (HRQoL) on an Average of 12 Years After Gastric Bypass Surgery

BackgroundIt is evident that morbidly obese patients have a low health-related quality-of-life (HRQoL), and this low HRQoL has become a common reason for them to seek bariatric surgery. Several HRQoL studies demonstrate a dramatic postoperative improvement, but most of these have had a short follow-up period.Material and MethodsAn observational, cross-sectional study for HRQoL was conducted to study 486 patients (average age of 50.7u2009±u200910.0xa0years, with 84xa0% of them being female) operated with gastric bypass (GBP) in the period 1993 to 2003 at the University Hospitals of Örebro and Uppsala. Mean follow-up after gastric bypass was 11.5u2009±u20092.7xa0years (range 7–17). Two HRQoL instruments were used, SF-36 and the Obesity-related Problems scale (OP). The study group was compared with two control groups, both matched for age and gender, one from the general population and one containing morbidly obese patients evaluated and awaiting bariatric surgery.ResultsThe study group scored better in the SF-36 domains (all four physical domains and the vitality subscore) and OP scale compared to obese controls, but their HRQoL scores were lower than those of the general population. HRQoL was better among younger patients and in the following subgroups: men, patients with satisfactory weight loss, satisfied with the procedure, free from co-morbidities and gastrointestinal symptoms, employment, good oral status and those not hospitalised or regularly followed up for non-bariatric reasons.ConclusionLong-term follow-up after GBP for morbid obesity showed better scores in most aspects of HRQoL compared to obese controls but did not achieve the levels of the general population. Patients with better medical outcome after gastric bypass operation had better HRQoL.

Prevalence of Anemia and Related Deficiencies 10 Years After Gastric Bypass—a Retrospective Study

BackgroundBariatric surgery has gained wide acceptance as treatment for severe obesity and is associated with decreased overall mortality. The aims of this study were to evaluate the prevalence of anemia long term after Roux-en-Y gastric bypass (RYGB) and to search for factors predicting anemia.MethodsAll 745 patients who underwent RYGB between 1993 and 2003 at either Örebro or Uppsala University Hospital and who were living in Sweden were invited to participate by providing a fasting blood sample and completing a questionnaire about their health status. Full blood count, serum iron, transferrin, vitamin B12, and folic acid were determined.ResultsFollow-up was completed in 431 patients (58xa0%) with mean age 51.3u2009±u200910xa0years. Of all patients, 27xa0% had anemia postoperatively and related deficiencies; iron, folic acid, and vitamin B12 were seen in 20, 12, and 2xa0%, respectively. There was no correlation between anemia and sex, follow-up time, 25-OH vitamin D level, and preoperative or postoperative BMI. An inverse correlation was found between anemia and regular medical checkups concerning gastric bypass surgery.ConclusionTwenty-seven percent of patients had anemia more than 10xa0years after RYGB. Anemia does not seem to progress with time and was less common in patients with regular medical checkups. Thus, improved long-term follow-up is needed.

Gastric Emptying and Postprandial PYY Response After Biliopancreatic Diversion with Duodenal Switch

BackgroundSuper-obesity (BMIu2009>u200950) is increasing rapidly. We use the biliopancreatic diversion with duodenal switch (BPD-DS) as one option in this patient category. The aim of the present study was to investigate the emptying of the gastric tube, PYY levels and dumping symptoms after BPD-DS.MethodsEmptying of the gastric tube was investigated with scintigraphy after an overnight fast. Twenty patients (median age 43xa0years, BMI 31.1xa0kg/m2) having undergone BPD-DS in median 3.5xa0years previously were included in the scintigraphic study. A technetium-labelled omelette was ingested and scintigraphic evaluation of gastric emptying was undertaken. Ten of the patients also underwent PYY measurements after a standardised meal and were compared to nine non-operated age-matched normal weight controls, both in the fasting state and after the test meal. Frequency of dumping symptoms was evaluated in all patients.ResultsThe half-emptying time was 28u2009±u200916xa0min. Lag phase was present in 30% of the patients. PYY levels were significantly higher in BPD-DS patients as compared to controls both in the fasting state (pu2009<u20090.001) and after the test meal (pu2009<u20090.001). Dumping symptoms were scarce and occurred in 17 of the 20 patients only few times yearly or less.ConclusionsAlthough the pylorus is preserved in BPD-DS, the stomach emptying is faster than in non-operated subjects. PYY levels are elevated in the fasting state after BPD-DS and a marked response to a test meal is seen, likely due to the rapid stimulation of intraluminal nutrients in the distal ileum. In spite of this, dumping symptoms are uncommon.

Changes in liver volume and body composition during 4 weeks of low calorie diet before laparoscopic gastric bypass.

BACKGROUNDnWeight loss before laparoscopic Roux-en-Y gastric bypass (LRYGB) is desirable, because it can reduce liver volume and thereby facilitate the procedure. The optimal duration of a low-calorie diet (LCD) has not been established. The objective of this study was to assess changes in liver volume and body composition during 4 weeks of LCD.nnnMETHODSnTen women (aged 43±8.9 years, 114±12.1 kg, and body mass index 42±2.6 kg/m(2)) were examined on days 0, 3, 7, 14, and 28 after commencing the LCD. At each evaluation, body composition was assessed through bioelectric impedance analysis, and liver volume and intrahepatic fat content were assessed by magnetic resonance imaging. Serum and urine samples were obtained. Questionnaires regarding quality of life and LCD-related symptoms were administered.nnnRESULTSnIn total, mean weight decreased by 7.4±1.2 kg (range 5.7-9.1 kg), and 71% of the weight loss consisted of fat mass according to bioelectric impedance analysis. From day 0 to day 3, the weight loss (2.0 kg) consisted mainly of water. Liver volume decreased by 18%±6.2%, from 2.1 to 1.7 liters (P<.01), during the first 2 weeks with no further change thereafter. A continuous 51%±16% decrease was seen in intrahepatic fat content. Systolic blood pressure, insulin, and lipids improved, while liver enzymes, glucose levels, and quality of life were unaffected.nnnCONCLUSIONnA significant decrease in liver volume (18%) occurred during the first 2 weeks of LCD treatment, and intrahepatic fat gradually decreased throughout the study period. A preoperative 2-week LCD treatment seems sufficient in similar patients.

Gastric Bypass Surgery Elevates NT-ProBNP Levels

BackgroundBrain natriuretic peptide (BNP) is produced in the heart in response to stretching of the myocardium. BNP levels are negatively correlated to obesity, and in obese subjects, a reduced BNP responsiveness has been described. Diet-induced weight loss has been found to lower or to have no effect on BNP levels, whereas gastric banding and gastric bypass have reported divergent results. We studied obese patients undergoing gastric bypass (GBP) surgery during follow-up of 1xa0year.MethodsTwenty patients, 18 women, mean 41 (SD 9.5) years old, with a mean preoperative BMI of 44.6 (SD 5.5)u2009kg/m2 were examined. N-terminal pro-brain natriuretic peptide (NT-ProBNP), glucose and insulin were measured preoperatively, at day 6 and months 1, 6 and 12. In 14 of the patients, samples were also taken at days 1, 2 and 4.ResultsThe NT-ProBNP levels showed a marked increase during the postoperative week (from 54xa0pg/mL preop to 359xa0pg/mL on day 2 and fell to 155 on day 6). At 1xa0year, NT-ProBNP was 122xa0pg/mL (125xa0% increase, pu2009=u20090.01). Glucose, insulin and HOMA indices decreased shortly after surgery without correlation to NT-ProBNP change. Mean BMI was reduced from 44.6 to 30.5xa0kg/m2 at 1xa0year and was not related to NT-ProBNP change.ConclusionsThe data indicate that GBP surgery rapidly alters the tone of BNP release, by a mechanism not related to weight loss or to changes in glucometabolic parameters. The GBP-induced conversion of obese subjects, from low to high NT-ProBNP responders, is likely to influence the evaluation of cardiac function in GBP operated individuals.