Lawrence E. Tabone

Cerebral Cortical Microvascular Rarefaction in Metabolic Syndrome is Dependent on Insulin Resistance and Loss of Nitric Oxide Bioavailability.

Chronic presentation of the MS is associated with an increased likelihood for stroke and poor stroke outcomes following occlusive cerebrovascular events. However, the physiological mechanisms contributing to compromised outcomes remain unclear, and the degree of cerebral cortical MVD may represent a central determinant of stroke outcomes.

Can bariatric surgery improve cardiovascular risk factors in the metabolically healthy but morbidly obese patient

BACKGROUND Bariatric surgery has been shown to be effective in resolving co-morbid conditions even in patients with a body mass index (BMI)<35 kg/m(2). A question arises regarding the metabolic benefits of bariatric surgery in metabolically healthy but morbidly obese (MHMO) patients, characterized by a low cardiometabolic risk. The objective of this study was to assess the effects of bariatric surgery on cardiometabolic risk factors among MHMO and metabolically unhealthy morbidly obese (MUMO) adults. METHODS A nonrandomized, prospective cohort study was conducted on 222 severely obese patients (BMI>40 kg/m(2)) undergoing either laparoscopic roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy. Patients were classified as MHMO if only 1 or no cardiometabolic factors were present: high blood pressure, triglycerides, blood glucose (or use of medication for any of these conditions), decreased high-density lipoprotein-cholesterol (HDL-C) levels, and insulin resistance defined as homeostasis model assessment for insulin-resistance (HOMA-IR)> 3.29. RESULTS Forty-two (18.9%) patients fulfilled the criteria for MHMO. They were younger and more frequently female than MUMO patients. No differences between groups were observed for weight, BMI, waist and hip circumference, total and LDL-C. MHMO patients showed a significant decrease in blood pressure, plasma glucose, HOMA-IR, total cholesterol, LDL-C and triglycerides and an increase in HDL-C 1 year after bariatric surgery. Weight loss 1 year after bariatric surgery was similar in both groups. CONCLUSION Eighteen percent of patients with morbid obesity fulfilled the criteria for MHMO. Although cardiovascular risk factors in these patients were within normal range, an improvement in all these factors was observed 1 year after bariatric surgery. Thus, from a metabolic point of view, MHMO patients benefited from bariatric surgery.

Metabolic syndrome impairs reactivity and wall mechanics of cerebral resistance arteries in obese Zucker rats

The metabolic syndrome (MetS) is highly prevalent in the North American population and is associated with increased risk for development of cerebrovascular disease. This study determined the structural and functional changes in the middle cerebral arteries (MCA) during the progression of MetS and the effects of chronic pharmacological interventions on mitigating vascular alterations in obese Zucker rats (OZR), a translationally relevant model of MetS. The reactivity and wall mechanics of ex vivo pressurized MCA from lean Zucker rats (LZR) and OZR were determined at 7-8, 12-13, and 16-17 wk of age under control conditions and following chronic treatment with pharmacological agents targeting specific systemic pathologies. With increasing age, control OZR demonstrated reduced nitric oxide bioavailability, impaired dilator (acetylcholine) reactivity, elevated myogenic properties, structural narrowing, and wall stiffening compared with LZR. Antihypertensive therapy (e.g., captopril or hydralazine) starting at 7-8 wk of age blunted the progression of arterial stiffening compared with OZR controls, while treatments that reduced inflammation and oxidative stress (e.g., atorvastatin, rosiglitazone, and captopril) improved NO bioavailability and vascular reactivity compared with OZR controls and had mixed effects on structural remodeling. These data identify specific functional and structural cerebral adaptations that limit cerebrovascular blood flow in MetS patients, contributing to increased risk of cognitive decline, cerebral hypoperfusion, and ischemic stroke; however, these pathological adaptations could potentially be blunted if treated early in the progression of MetS.

Influence of a rural environment on patient access and outcomes for bariatric surgery

BACKGROUND Despite a higher rate of obesity in rural populations, there is a 23% decrease in performed bariatric procedures. The influence of a rural environment on surgical outcomes and treatment efficacy is unknown. METHODS We retrospectively reviewed all bariatric surgeries performed in a large university hospital in West Virginia from September 2012 to September 2014. Patients were categorized based on their rural-urban commuting area codes. Subject demographic characteristics, insurance provider, type of surgery, completion of program, preoperative body mass index (BMI), percent excess weight loss (%EWL), and percent total weight loss (%TWL) at 6 and 12 months postoperatively, and follow-up appointment attendance were collected. Logistic and linear regression analyses were conducted. RESULTS A total of 122 patients were evaluated with 82 receiving surgery. Of these patients, 77 had Roux-en-Y gastric bypass, and 5 had Sleeve Gastrectomy. Nine patients out of 82 were lost to follow-up at 6 months (n = 73), and 12 patients out of 62 were lost to follow-up at 12 months (n = 50). Rural patients were .283 times less likely to receive bariatric surgery, (P = .004). However, this relationship was confounded by insurance provider; after controlling for this variable, the relationship between rural status and surgery completion was nonsignificant (P = .066). Rural status did not predict change in BMI, %EWL, or %TWL at 6 months (P = .738; P = .848; P = .334) or 12 months (P = .902; P = .143; P = .195), or compliance for follow-up appointments (P = .232). CONCLUSIONS Rural bariatric patients seem to have decreased success at completing bariatric programs, which is likely confounded by insurance type. Yet, when the rural patient is able to realize the benefits of bariatric surgery, their outcomes are unchanged compared with urban patients. Although the study is limited by sample size, it highlights the need for reducing obstacles for bariatric surgery in an already underserved population, the rural community.

Comment on: Single stage conversion from adjustable gastric banding to sleeve gastrectomy or Roux-en-Y gastric bypass: an analysis of 4875 patients

Is a single-stage conversion from an adjustable gastric band (AGB) to either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) safe? Despite early reports [1], more evidence is confirming that single-stage conversion comes with an acceptable level of perioperative risk [2,3]. Early studies looking at AGB conversion to SG have shown a high incidence of leak from staple line dehiscence [4–7]. To avoid this complication, many advocate for a staged approach to AGB revisions and a preference to RYGB conversion over SG. It has been postulated that gastric pouch formation for RYGB could be done in a manner to minimize transection of scar tissue associated with previous gastric band placement and therefore reduce the risk of leak compared with conversion to SG. Additionally, RYGB has been considered a lower pressure system through bypassing the pylorus compared with SG, which may reduce the risk of leak by reducing stress on a potentially vulnerable staple line that incorporates scar tissue from the previous band placement. Newer data are challenging this approach [8]. In this issue of Surgery of Obesity and Related Diseases, Spaniolas et al. [8] use the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program data to compare the safety of single-stage AGB conversion to SG versus gastric bypass surgery [8]. The study included 3364 patients that were converted from AGB to SG and 1501 patients undergoing conversion to RYGB. The data set represents the largest number of patients included in a study comparing single-stage conversion of ABG to either SG or RYGB. The findings, while contradictory to other studies [5], may not be surprising to most surgeons given that the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program database has twice as many singlestage conversions from AGB to SG compared with RYGB. This may reflect surgeon preference that is oftentimes dictated by experience. Spaniolas et al. [8] found a statistically significant reduction in the incidence of reoperation, readmission, and reintervention in conversion to SG over RYGB [8].

Gastric Plication for Obesity

Laparoscopic adjustable gastric banding (LAGB) is an established primary bariatric procedure. However, LAGB is associated with lower expected weight loss when compared to other primary bariatric procedures, and this is cited as the primary limitation of LAGB as a weight loss procedure. Greater curvature plication has been used in both bariatric and non-bariatric procedures with limited morbidity and comparable short-term weight loss to sleeve gastrectomy and gastric bypass. We describe the combination of LAGB and greater curvature plication as a single and novel bariatric procedure. In addition, this procedure can be performed through single-incision laparoscopic surgery (SLS).