Flavia Carlini

A 15-year evaluation of biliopancreatic diversion according to the Bariatric Analysis Reporting Outcome System (BAROS).

Background: Biliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss. However, analysis of the quality of life (QoL) has never been reported. The BAROS, giving a score to each operated patient on weight loss, improvement in medical conditions, QoL, complications and reoperations, has proven to be a standard reference for evaluating bariatric surgery outcomes. Methods: In order to apply the BAROS to BPD, we sent a questionnaire to 1,800 BPD patients who had been operated between 1984 and 1998.The responserate was 51.2%. Out of 1,709 questionnaires which actually reached their destination, we had 858 fully compiled returned. There were 615 women. 596 patients had had an ad hoc stomach (AHS) BPD, and 262 had had an ad hoc stomach ad hoc alimentarylimb (AHS-AHAL) BPD. Results: According to the scoring key, 3.5% were classified as a failure, 11% were fair results, 22.8% good, 39.5% very good , and 23.2% excellent results. Considering AHS BPD and AHS-AHAL BPD separately,while the mean excess weight percent loss was 70.5±23 and 64.7±17 respectively, the failure rate was 6% in the first group and 2% in the AHAL group, while 11% and 6% of cases respectively were fair results, 24% and 20% good, 36% and 47% very good, 23% and 25% excellent results. Conclusion: The BAROS evaluation of BPD highlights the importance of its flexibility: the new policy of adapting the procedure to individual characteristics caused a drop in the failure rate and an increase in good, very good and excellent results.

Liver damage in severely obese patients: a clinical-biochemical-morphologic study on 1,000 liver biopsies.

Background: Preoperative clinical and biochemical data and intraoperative liver biopsy of 1,000 obese patients submitted to biliopancreatic diversion (BPD) were analyzed, and correlations investigated. Methods: Of 2,645 patients submitted to BPD between May 1976 and November 2002, the last 1,000 consecutive obese patients with no history of alcohol consumption or infectious hepatitis were selected. Clinical data included: age, body weight, BMI, waist-to-hip ratio (W/H), arterial blood pressure, serum glucose, triglycerides, cholesterol, albumin/γ-globulin ratio, total, conjugated and unconjugated bilirubin, γ-GT, alkaline phosphatase, AST, ALT, and prothrombin time. The degree of steatosis, inflammation and fibrosis on intraoperative wedge liver biopsy was determined and scored. Liver steatosis >70% and presence of bridging fibrosis were analyzed separately. Results: Mean BMI was 48 kg/m2. 263 patients had steatosis of >70%, and 79 had bridging fibrosis. Regression analysis showed an association between steatosis and AST, ALT, AST/ALT ratio, body weight, W/H, serum glucose, serum tryglicerides, BMI, γ-GT, age, and unconjugated bilirubin. Inflammation was significantly greater in older patients. Patients with bridging fibrosis had significantly higher values of serum glucose, AST, γ-GT, serum cholesterol and were significantly older. Bridging fibrosis was associated with diabetes, W/H >1, hypertension, albumin/γ-globulin ratio <1. Conclusion: Severe steatosis and bridging fibrosis seem to be associated with the metabolic syndrome. No reliable biochemical data could identify patients with severe chronic liver damage with sufficient sensitivity to avoid liver biopsy for diagnosis and staging of the disease.

Body weight at developmental age in siblings born to mothers before and after surgically induced weight loss.

BACKGROUND To gain insight into the role of epigenetic factors in determining body weight in adolescence, we studied the body weight of siblings born to the same mother before and after biliopancreatic diversion (BPD) for obesity. The study was performed in a university hospital during a 20-year period. METHODS The siblings born before and after BPD were retrospectively rated by their mother as normal, overweight, or obese at 1, 6, and 12 years. RESULTS At 1 and 6 years, the body weight was rated as similar in the subsets. However, at 12 years of age, a greater percentage of those born before BPD were considered overweight (42% versus 33%) and obese (22% versus 3%; P <.009) than their counterparts born after BPD. Considering only the subjects aged 21-25 years at the study period, the body weight and body mass index in subjects born before BPD were greater (P <.02 and P <.012, respectively) than in those born after BPD (79.5 ± 16.5 kg versus 66.7 ± 11.8 kg, and 27.5 ± 3.9 kg/m(2) versus 23.4 ± 3.7 kg/m(2), respectively). CONCLUSION The results of the present study, in which the influences of the genetic pattern and environmental and educational factors were minimized, show that adolescents born to post-BPD mothers weigh less than their siblings born to the same mother before BPD when she was still obese. An insulin-resistant milieu during pregnancy could account for the greater body weight later in adolescence.

Short-Term Liver Function after Biliopancreatic Diversion

Background: Liver failure after biliopancreatic diversion (BPD) has been reported. Although in our series of 2,515 BPD with a minimum follow-up of 12 months we have never observed this complication, a transitory and significant rise in serum AST and ALT has been detected in some cases, suggesting the occurrence of transient liver damage. To assess if risk factors for acute liver damage after BPD could be identified, we studied the evolution of hepatic biochemistry in a sample of our operated subjects. Methods: We studied 99 consecutive patients submitted to the same type of BPD (ad hoc stomach, ad hoc alimentary limb). Patients with a history of alcohol consumption or positive hepatic serology were excluded. Preoperative body weight (BW), body mass index (BMI), excess weight (EW), % excess weight (%EW), fasting serum glucose level (SG), hepatic histology (HI), weight loss (WL) at 2, 4 and 12 months, and excess weight % loss (IEW%L) at the same time were correlated with preoperative and 2, 4 and 12 months hepatic biochemistry. Results: Compared with preoperative values, AST levels at 2 months significantly increased (Students t-test, P=0.0003) and significantly decreased at 12 months (P=0.0001). Spearmans Rank test showed significant correlations between 2 months AST levels and WL at 2 months (P =0.005), preoperative BW (P <0.0001), SG (P =0.01), and HI (inflammation P<0.0001, fibrosis P=0.001). Conclusion: Hepatocellular necrosis in our series peaks at 2 months, and decreases afterwards.WL at 2 months, preoperative BW, SG and HI seem to be of help in identifying patients at increased risk for acute liver damage, prompting the need for an enhanced surveillance.

Effect of biliopancreatic diversion on hypertension in severely obese patients

Hypertension is a medical disorder frequently associated with severe obesity, and the effect of weight loss on the reduction of blood pressure has been well established. In this study, the relationships between the weight loss surgically obtained by biliopancreatic diversion and blood pressure were investigated in a population of severely obese patients with preoperative hypertension. At 1 year following the operation, blood pressure was normalized in more than half of patients; in a further 10% of cases the hypertensive status resolved within the 3-year follow-up period. The resolution of hypertension was independently associated with age and body weight and was unrelated to sex, the amount of weight loss, or body fat distribution. In severely obese patients with hypertension undergoing bariatric surgery, biliopancreatic diversion is advisable since it achieves and supports the maintenance of body weight close to the ideal value.

The long-term impact of biliopancreatic diversion on glycemic control in the severely obese with type 2 diabetes mellitus in relation to preoperative duration of diabetes.

BACKGROUND Bariatric surgery has been shown to be effective in severely obese patients with type 2 diabetes mellitus (T2DM). OBJECTIVE Evaluate the long-term efficacy of biliopancreatic diversion (BPD) for the treatment of T2DM depending on the preoperative duration of T2DM. SETTING University Hospital. METHODS Retrospective analysis investigating 2 subsets of severely obese patients who had undergone BPD from 1984 to 1995. The first included 52 patients with a preoperative T2DM duration of ~1 year (SD group - 49 on oral agents and 3 on insulin), and the second included 68 patients who had been diabetic for>5 years before BPD (LD group - 52 on oral agents and 16 on insulin). Postoperatively, T2DM was regarded as in remission when fasting serum glucose (FSG) was lower than 100 mg/dL on regular diet and without antidiabetic therapy. RESULTS In the SD patients, the number of individuals without T2DM remission were lower both at 5-10 (0/31, 0% of patients, versus 8/54, 15% of patients, p<.04) and at>15 years (1/28, 3% of patients, versus 10/41, 24% of patients, p<.0012). Furthermore, after BPD, the number of patients with dyslipidemia strongly reduced (p<.001) in both groups, values at 5-10 years remaining very similar to those observed at>15 years. CONCLUSION These results indicate that severely obese patients with longer T2DM duration have a worse metabolic outcome maintained at long and very long term following BPD.

Radiology of Patients with Vertical Banded Gastroplasty

Background: The authors evaluated the usefulness of routine traditional radiology in the management of patients submitted to VBG. Methods: Radiological findings in 65 subjects who had undergone VBG were evaluated. Post-surgical clinical and radiological examinations were performed 3 days, 1, 4 and 12 months after surgery. Upper GI symptoms, gastroesophageal imaging and 80% solid meal pouch emptying time were recorded. Results: The routine postoperative study, in the absence of clinical symptoms, showed no unsuspected complication in any patient, both in the early and in the late postoperative period. There was no significant correlation at 4 and 12 months between emptying time and duration of satiation, emptying time and percent excess weight loss (%EWL), and duration of satiation and %EWL. Conclusions: Traditional radiological studies can be safely omitted from both the immediate postoperative period and from the long-term follow-up in asymptomatic VBG patients. The studies were not helpful in understanding functional changes leading to weight loss after VBG.

Pouch diverticula after vertical-banded gastroplasty

Purpose.Diverticula of the proximal gastric pouch are rare after vertical-banded gastroplasty (VBG) for morbid obesity. We report the radiographic findings observed in a series of 12 patients with pouch diverticula.Materials and methods.Lesions were found along the posteromedial wall of the proximal gastric pouch and ranged in size from 10 to 25 mm. Only two patients were symptomatic at the time of diagnosis; in most cases, diverticula were discovered during studies performed as part of the standard follow-up protocol. Diverticula were followed up in 7/12 cases, and four showed slight enlargement over a period ranging from 14 to 53 months.Results.The presence of diverticula was not correlated with symptoms, postoperative weight loss, or clinical history, and no differences in long-term complications were demonstrated between VBG patients with diverticula and those without them.Conclusions.We do not believe these lesions to be clinically important; at present, our patients are no longer followed up for this problem and undergo diagnostic examinations only if and when they develop symptoms.