Grant Beban

Lower Fetuin-A, Retinol Binding Protein 4 and Several Metabolites after Gastric Bypass Compared to Sleeve Gastrectomy in Patients with Type 2 Diabetes

Background Bypass of foregut secreted factors promoting insulin resistance is hypothesized to be one of the mechanisms by which resolution of type 2 diabetes (T2D) follows roux-en-y gastric bypass (GBP) surgery. Aim To identify insulin resistance-associated proteins and metabolites which decrease more after GBP than after sleeve gastrectomy (SG) prior to diabetes remission. Methods Fasting plasma from 15 subjects with T2D undergoing GBP or SG was analyzed by proteomic and metabolomic methods 3 days before and 3 days after surgery. Subjects were matched for age, BMI, metformin therapy and glycemic control. Insulin resistance was calculated using homeostasis model assessment (HOMA-IR). For proteomics, samples were depleted of abundant plasma proteins, digested with trypsin and labeled with iTRAQ isobaric tags prior to liquid chromatography-tandem mass spectrometry analysis. Metabolomic analysis was performed using gas chromatography-mass spectrometry. The effect of the respective bariatric surgery on identified proteins and metabolites was evaluated using two-way analysis of variance and appropriate post-hoc tests. Results HOMA-IR improved, albeit not significantly, in both groups after surgery. Proteomic analysis yielded seven proteins which decreased significantly after GBP only, including Fetuin-A and Retinol binding protein 4, both previously linked to insulin resistance. Significant decrease in Fetuin-A and Retinol binding protein 4 after GBP was confirmed using ELISA and immunoassay. Metabolomic analysis identified significant decrease of citrate, proline, histidine and decanoic acid specifically after GBP. Conclusion Greater early decrease was seen for Fetuin-A, Retinol binding protein 4, and several metabolites after GBP compared to SG, preceding significant weight loss. This may contribute to enhanced T2D remission observed following foregut bypass procedures.

Progression of diabetic retinopathy after bariatric surgery

To assess the impact of bariatric surgery on the progression of diabetic retinopathy in patients with Type 2 diabetes.

Randomized clinical trial of expressive writing on wound healing following bariatric surgery.

Objective: Writing emotionally about upsetting life events (expressive writing) has been shown to speed healing of punch-biopsy wounds compared to writing objectively about daily activities. We aimed to investigate whether a presurgical expressive writing intervention could improve surgical wound healing. Method: Seventy-six patients undergoing elective laparoscopic bariatric surgery were randomized either to write emotionally about traumatic life events (expressive writing) or to write objectively about how they spent their time (daily activities writing) for 20 min a day for 3 consecutive days beginning 2 weeks prior to surgery. A wound drain was inserted into a laparoscopic port site and wound fluid analyzed for proinflammatory cytokines collected over 24 hr postoperatively. Expanded polytetrafluoroethylene tubes were inserted into separate laparoscopic port sites during surgery and removed after 14 days. Tubes were analyzed for hydroxyproline deposition (the primary outcome), a major component of collagen and marker of healing. Fifty-four patients completed the study. Results: Patients who wrote about daily activities had significantly more hydroxyproline than did expressive writing patients, t(34) = −2.43, p = .020, 95% confidence interval [−4.61, −0.41], and higher tumor necrosis factor–alpha, t(29) = −2.42, p = .022, 95% confidence interval [−0.42, −0.04]. Perceived stress significantly reduced in both groups after surgery. Conclusions: Expressive writing prior to bariatric surgery was not effective at increasing hydroxyproline at the wound site 14 days after surgery. However, writing about daily activities did predict such an increase. Future research needs to replicate these findings and investigate generalizability to other surgical groups.

Indigenous child health in New Zealand: Some surgical issues

New Zealand Maori make up nearly 15% of the population of New Zealand, and their population has increased significantly in the last 20 years. Because of this, the average age of Maori is only 22.7 years with 35% of Maori aged 15 years or less. In spite of this youthful profile, the Maori population has high health needs with trauma, ear disease, respiratory disease and infectious diseases as significant causes of hospitalisation and death. The role of surgery in the management of three potentially preventable but significant health issues affecting Maori children – trauma, cutaneous sepsis (cellulitis and superficial abscess) and obesity – is reviewed.

Attrition after Acceptance onto a Publicly Funded Bariatric Surgery Program

BackgroundFactors such as ethnicity, gender, and socioeconomic status may play a role in both access to and attrition from bariatric programs before surgery is undertaken. New Zealand (NZ) has high rates of obesity in its Pacific population and the indigenous Māori. These groups also experience poorer health outcomes and therefore have the greatest need for surgery.MethodologyA retrospective cross-sectional study of 704 people referred for and accepted onto a publicly funded bariatric surgery from 2007 to 2016. The demographic and clinical features of two groups were compared: those that completed surgery successfully (n = 326) and those that dropped out of the program before surgery (n = 378). We also attempted to identify factors associated with attrition.ResultsThe attrition rate was high (54%), with a significant difference according to gender (men 66% vs 45% women, p < 0.001) and ethnicity (39% in NZ Europeans, 50% in Māori, and 73% in Pacific patients, p < 0.001). Two out of three European women proceeded to surgery, but fewer than one in seven Pacific men. Attrition was associated with having a higher mean BMI and being a smoker. Logistic regression modeling showed that while employment seemed to be protective against attrition for NZ Europeans (p < 0.004), it was not for Pacific patients.ConclusionsWhile there was no obvious bias in rates of referral, there is clearly a need for better ways to support Māori and Pacific people, and men in particular, to complete bariatric surgery. Further research is needed to clarify the socio-economic and cultural barriers that underlie this phenomenon.

Crohn's disease presenting as gastric outlet obstruction

We present a unique presentation of Crohns disease in a 25-year-old male with a 3-month history of progressive gastric outlet obstruction symptoms including reflux, vomiting, postprandial pain and weight loss, with no other symptoms. Multiple imaging investigations as well as gastroscopic biopsies revealed a non-specific prepyloric lesion, without evidence of malignancy. A distal gastrectomy was performed. Subsequent histological evaluation revealed gastroduodenal Crohns disease. Follow-up revealed no evidence of disease elsewhere in the gastrointestinal system or systemically. While it is not uncommon for Crohns disease to involve the stomach and duodenum, it is rare for gastroduodenal disease to be the initial presentation. Isolated gastroduodenal Crohns disease typically presents with non-specific gastritis-like symptoms over a number of years. This patient had a unique course of Crohns disease with rapid onset of symptoms, predominantly relating to gastric outlet obstruction and no prior or subsequent history of gastrointestinal symptoms.