João Regis Ivar Carneiro

Adipose Tissue of Control and Ex-Obese Patients Exhibit Differences in Blood Vessel Content and Resident Mesenchymal Stem Cell Population

BackgroundThe normal function of white adipose tissue is disturbed in obesity. After weight loss that follows bariatric surgery, ex-obese patients undergo plastic surgery to remove residual tissues and it is not known whether their adipose tissue returns to its original state. The aim of this study was to compare the white adipose tissue composition of ex-obese with control patients with regard to blood vessels and resident mesenchymal stem cells (MSC).MethodsQuantification of blood vessels was performed on histological sections of adipose tissue stained with hematoxylin and eosin and for von Willebrand antigen. MSC were induced to the adipogenic and osteogenic lineages by specific inductive culture media. Expression of PPARγ2 was analyzed by reverse transcription polymerase chain reaction.ResultsEx-obese adipose tissue showed a higher number (p = 0.0286) of small (107.3 ± 22.0) and large (22.5 ± 6.4) blood vessels, when compared to control patients (42.0 ± 24.4 and 7.2 ± 2.2, respectively) and they also occupied a larger area (control versus ex-obese, p = 0.0286). Adipose tissue MSC from both groups of patients expressed PPARγ2 and were equally able to differentiate to the osteogenic lineage, but ex-obese MSC showed a higher adipogenic potential when induced in vitro (p < 0.05).ConclusionsThe higher number of adipose tissue blood vessels in ex-obese patients explains the excessive bleeding observed during their plastic surgery. The presence of more committed cells to the adipogenic lineage may favor the easy weight regain that occurs in ex-obese patients. These results show that, after extensive weight loss, adipose tissue cell composition was not totally restored.

Prevalence of goiter and thyroid nodular disease in patients with class III obesity

OBJECTIVES To evaluate the prevalence of goiter and nodular disease in patients with class III obesity, and to correlate results with serum leptin levels and insulin resistance (IR) parameters. SUBJECTS AND METHODS A cross-sectional study was performed to assess thyroid ultrasound (US) patterns, HOMA-IR, serum leptin, and TSH levels in obese patients and controls. RESULTS Thyroid volume was positively correlated with body mass index (BMI) (r = 0.240, p = 0.039) and with HOMA-IR (r = 0.329; p < 0.01). Thyroid US patterns were similar between groups. However, when data from the male group was considered, greater thyroid volume was detected in the obese group compared with controls (10.8 vs. 8.5 cm³; p = 0.04). Also, nodules were more frequently detected (67% vs. 18%), as were nodules requiring FNAB (33.3% vs. 0%, p ≥ 0.05-0.09), in this group. CONCLUSION Although IR did not correlate directly with the presence of nodules, the results support the hypothesis of a direct association between insulin resistance and thyroid volume.

Stromal-vascular fraction content and adipose stem cell behavior are altered in morbid obese and post bariatric surgery ex-obese women

IntroductionSubcutaneous adipose tissue is an interesting source of autologous stem cells with a fundamental role in the pathophysiology of obesity, metabolic syndromes and insulin resistance. We hypothesize that obesity could alter the stromal-vascular fraction (SVF) and adipose stem cell (ASCs) functions, which could compromise its regenerative behavior. Furthermore, we aimed to evaluate whether ASCs derived from post bariatric surgery ex-obese women maintain their functions in a similar fashion as do those from individuals who have never been obese.MethodsThe SVF of subcutaneous adipose tissue from control (n = 6, body mass index – BMI - 27.5 ± 0.5 kg/m2), obese (n = 12, BMI 46.2 ± 5.1 kg/m2) and post bariatric surgery ex-obese (n = 7, initial BMI 47.8 ± 1.3 kg/m2; final BMI 28.1 ± 1.1 kg/m2) women were isolated and evaluated by flow cytometry. ASCs were tested for lipid accumulation by perilipin, adipose differentiation-related protein (ADRP) and Oil Red O staining after adipogenic stimulus. The cytokines secreted by the ASCs and after lipid accumulation induction were also evaluated.ResultsThe subcutaneous adipose tissue of obese and post bariatric surgery ex-obese women was enriched in pericytes (p = 0.0345). The number of supra-adventitial cells was not altered in the obese patients, but it was highly enriched in the post bariatric surgery ex-obese women (p = 0.0099). The ASCs of the post bariatric surgery ex-obese patients secreted more MCP-1 (monocyte chemoattractant protein-1; p = 0.0078). After lipid accumulation induction, the ASCs of the patients in all groups secreted less IL-6 than the ASCs with no adipogenic stimulus (p < 0.0001). Obese ASCs with lipid accumulation secreted the highest amount of IL-6 (p < 0.001) whereas the ASCs from the controls secreted the highest amount of adiponectin (p < 0.0001). The ASCs from the post bariatric surgery ex-obese patients showed the highest levels of lipid accumulation whereas those from the obese women had the lowest levels (p < 0.0001).ConclusionsSVF content and ASC behavior are altered in the subcutaneous adipose tissue of morbid obese women; these changes are not completely restored after bariatric surgery-induced weight loss. The cellular alterations described in this study could affect the regenerative effects of adipose stem cells. Further investigations are required to avoid jeopardizing the development of autologous stem cell-based therapies.

Weight loss and nutritional anemia in patients submitted to Roux-en-Y gastric bypass on use of vitamin and mineral supplementation

Background Obesity is a chronic disease with high growth in population and bariatric surgery is currently considered the most effective treatment for weight reduction; on the other hand, nutritional deficiencies are observed after this procedure. Aim To analyze weight loss progression and nutritional anemia in patients submitted to Roux-en-Y gastric bypass on use of vitamin and mineral supplementation. Methods Retrospective analysis of 137 patients of both sexes, aged between 18-60 years, using supplemental multivitamins and minerals, were included; personal information, anthropometric and laboratory data in the preoperative, 12, 24, 36 and 48 months postoperatively were collected. Results Postoperatively, in both sexes, occurred weight loss compared to the pre-operative weight gain at 48 months and maintenance of body mass index. There was a decrease in the percentage of excess weight loss at 48 months postoperatively compared to the time of 12, 24 and 36 months in men and decreased at 48 postoperative months compared to the time of 24 months in females. There was a decreased in serum ferritin in both sexes and increased serum iron at 48 months postoperatively in males. There was a decreased in vitamin B12 and folic acid increased serum at 48 postoperative months in females. Conclusions Surgical treatment was effective for reducing weight, body mass index reduction and achievement of success in the late postoperative period along with multivitamin and mineral supplementation on prevention of serious nutritional deficiencies and anemia.

Thyrotoxicosis after gastric bypass

Obesity surgery is the optimal therapy for morbid obesity. A case is presented of a young woman who developed thyrotoxicosis, believed to be part of subacute thyroiditis, some days after undergoing laparoscopic Roux-en-Y gastric bypass. This clinical entity can present difficulties in differential diagnosis from potential postoperative complications. The correct diagnosis and adequate treatment made possible a favorable recovery.

Perda ponderal e presença de anemias carenciais em pacientes submetidos à bypass gástrico em Y-de-roux em uso de suplementação de vitaminas e mine

RACIONAL: A obesidade e doenca cronica com elevado crescimento na populacao. A cirurgia bariatrica e considerada o tratamento mais efetivo para reducao de peso; por outro lado, deficiencias nutricionais sao observadas apos esse procedimento. OBJETIVO: Avaliar a evolucao da perda ponderal e a presenca de anemias carenciais em pacientes submetidos ao bypass gastrico em Y-de-Roux em uso de suplementacao de vitaminas e minerais. METODOS: Analise retrospectiva de 137 pacientes de ambos os sexos, com idade entre 18-60 anos, em uso de suplementacao de polivitaminas e minerais incluindo informacoes pessoais, dados antropometricos e laboratoriais nos periodos pre-operatorio, 12, 24, 36 e 48 meses de pos-operatorio. RESULTADOS: No pos-operatorio, em ambos os sexos, ocorreu perda de peso em relacao ao pre-operatorio, ganho de peso aos 48 meses e manutencao do indice de massa corporal. Houve diminuicao do percentual de perda de excesso de peso aos 48 meses pos-operatorios comparado com os tempos 12, 24 e 36 meses em homens e diminuicao aos 48 meses pos-operatorios em relacao aos 24 meses no sexo feminino. Houve diminuicao da ferritina serica em ambos os sexos e aumento do ferro serico aos 48 meses pos-operatorio no sexo masculino. Houve diminuicao da vitamina B12 e aumento do acido folico sericos aos 48 meses do pos-operatorio no sexo feminino. CONCLUSOES: O tratamento cirurgico mostrou-se eficaz para reducao de peso, reducao do indice de massa corporal e alcance do sucesso no pos-operatorio tardio juntamente com a suplementacao de polivitaminico e minerais na prevencao de deficiencias nutricionais importantes e anemias.

Anesthesia for Bariatric Surgery in an Achondroplastic Dwarf with Morbid Obesity

BACKGROUND AND OBJECTIVES Achondroplasia is the most common form among the different types of osteochondrodysplasia that cause dwarfism. Dwarves develop obesity quite frequently and surgical treatment has shown greater efficacy, both for effective weight loss and long term maintenance. The objective of this report was to present the case of bariatric surgery with Y-en-Roux gastric bypass in an achondroplastic dwarf with morbid obesity. The different difficulties in the anesthetic management of this patient and the way they were dealt with were discussed in order to decrease intraoperative morbidity and mortality. CASE REPORT This is a 29 years old female dwarf with achondroplasia and morbid obesity since childhood. She was 123 cm tall and weighed 144 kg at the time of admission to the Bariatric Surgery service. With a body mass index (BMI) of 95.18 kg.m2, she had several associated diseases especially of the respiratory system and osteoarticular system. After a long follow-up with diet, exercises, and psychological support, her clinical condition improved and she was referred for surgery: Y-en-Roux gastroplasty using the technique of Capella-Fobi. Intubation of the awake patient under direct laryngoscopy was difficult and a bronchofibroscope had to be used. Surgery was uneventful and the patient was maintained under total intravenous anesthesia with continuous infusion of remifentanil and propofol. She was extubated at the end of the surgery still in the operating room. CONCLUSIONS The simultaneous comorbidities of achondroplasia and morbid obesity can hinder the anesthetic management, especially regarding the airways. A thorough pre-anesthetic evaluation is necessary to anticipate the conducts and minimize risks, therefore optimizing the evolution of anesthesia.

Characterization of stromal vascular fraction and adipose stem cells from subcutaneous, preperitoneal and visceral morbidly obese human adipose tissue depots

Background/Objectives The pathological condition of obesity is accompanied by a dysfunctional adipose tissue. We postulate that subcutaneous, preperitoneal and visceral obese abdominal white adipose tissue depots could have stromal vascular fractions (SVF) with distinct composition and adipose stem cells (ASC) that would differentially account for the pathogenesis of obesity. Methods In order to evaluate the distribution of SVF subpopulations, samples of subcutaneous, preperitoneal and visceral adipose tissues from morbidly obese women (n = 12, BMI: 46.2±5.1 kg/m2) were collected during bariatric surgery, enzymatically digested and analyzed by flow cytometry (n = 12). ASC from all depots were evaluated for morphology, surface expression, ability to accumulate lipid after induction and cytokine secretion (n = 3). Results A high content of preadipocytes was found in the SVF of subcutaneous depot (p = 0.0178). ASC from the three depots had similar fibroblastoid morphology with a homogeneous expression of CD34, CD146, CD105, CD73 and CD90. ASC from the visceral depot secreted the highest levels of IL-6, MCP-1 and G-CSF (p = 0.0278). Interestingly, preperitoneal ASC under lipid accumulation stimulus showed the lowest levels of all the secreted cytokines, except for adiponectin that was enhanced (p = 0.0278). Conclusions ASC from preperitoneal adipose tissue revealed the less pro-inflammatory properties, although it is an internal adipose depot. Conversely, ASC from visceral adipose tissue are the most pro-inflammatory. Therefore, ASC from subcutaneous, visceral and preperitoneal adipose depots could differentially contribute to the chronic inflammatory scenario of obesity.

Cardiovascular Autonomic Dysfunction in Patients with Morbid Obesity

Background Morbid obesity is directly related to deterioration in cardiorespiratory capacity, including changes in cardiovascular autonomic modulation. Objective This study aimed to assess the cardiovascular autonomic function in morbidly obese individuals. Methods Cross-sectional study, including two groups of participants: Group I, composed by 50 morbidly obese subjects, and Group II, composed by 30 nonobese subjects. The autonomic function was assessed by heart rate variability in the time domain (standard deviation of all normal RR intervals [SDNN]; standard deviation of the normal R-R intervals [SDNN]; square root of the mean squared differences of successive R-R intervals [RMSSD]; and the percentage of interval differences of successive R-R intervals greater than 50 milliseconds [pNN50] than the adjacent interval), and in the frequency domain (high frequency [HF]; low frequency [LF]: integration of power spectral density function in high frequency and low frequency ranges respectively). Between-group comparisons were performed by the Student’s t-test, with a level of significance of 5%. Results Obese subjects had lower values of SDNN (40.0 ± 18.0 ms vs. 70.0 ± 27.8 ms; p = 0.0004), RMSSD (23.7 ± 13.0 ms vs. 40.3 ± 22.4 ms; p = 0.0030), pNN50 (14.8 ± 10.4 % vs. 25.9 ± 7.2%; p = 0.0061) and HF (30.0 ± 17.5 Hz vs. 51.7 ± 25.5 Hz; p = 0.0023) than controls. Mean LF/HF ratio was higher in Group I (5.0 ± 2.8 vs. 1.0 ± 0.9; p = 0.0189), indicating changes in the sympathovagal balance. No statistical difference in LF was observed between Group I and Group II (50.1 ± 30.2 Hz vs. 40.9 ± 23.9 Hz; p = 0.9013). Conclusion morbidly obese individuals have increased sympathetic activity and reduced parasympathetic activity, featuring cardiovascular autonomic dysfunction.

Nutritional profile of patients in a multidisciplinary treatment program for severe obesity and preoperative bariatric surgery

Background Along with the augmentation in obesity rates in recent years, the demand for bariatric surgery has startlingly increased. Nutritional counseling in the preoperative period is very important because it contributes to higher success rate in the post-operative period. Aim To assess the nutritional status of patients in a multidisciplinary program for the treatment of severe obesity and pre-operatively for bariatric surgery, characterizing the consumption of healthy nutrients. Methods A retrospective analysis of 30 patients was conducted. Personal information, anthropometric data and dietary assessment by 24-hour food record were collected. The analysis of energy intake was performed in Dietpro 5.1 Professional® program. The statistical treatment of the caloric intake was performed by an ANOVA test with Bonferronis post hoc and for anthropometric data the paired t test was used. Results From the total, 73% of the patients were women and 27% male, mean age was 48.4+12.9 and 49.8+8.1, respectively. A lower weight in the 5th appointment was observed when compared with the 1st one. There was a reduction in caloric intake in the 2nd, 3rd, 4th and 5th appointments when compared with the 1st. It was observed that in the 5th appointment more than 50% of the patients underwent six meals a day. There was an increase in the consumption of fruit along the appointments and 72.2% of patients consumed 1-2 servings of fruit a day. Vegetables intake was high in all appointments in the pre-operative period and, although low, the whole grain products consumption has increased during the pre-operative period achieving 30% of the study population. Conclusion There was a decrease in body weight, a trend in the decrease of the body mass index and waist circumference and quantitative and qualitative improvement of food consumption.