Marco Túlio Costa Diniz

Elevated Serum Parathormone after Roux-en-Y Gastric Bypass

BACKGROUND Abnormalities in calcium and vitamin D metabolism are observed early after gastric bypass, whereas clinical or biochemical evidence of metabolic bone disease might not be detected until many years after the procedure. The aim of the present study was to evaluate the impact of bariatric surgery on bone metabolism determined on the basis of postoperative laboratory changes in calcium, phosphorus, magnesium, alkaline phosphatase and parathormone (PTH) levels. METHODS 110 patients submitted to Roux-en-Y gastric bypass (RYGBP) were followed after surgery, and the following parameters were determined: intact PTH molecule (PTHi; chemiluminescence), alkaline phosphatase (colorimetric method), ionic calcium (selective electrode), phosphorus and magnesium (colorimetric method). RESULTS Elevated serum PTHi levels were observed in 29% of the patients and hypocalcemia in 0.9% from the 3rd postoperative month and afterwards (3 to 80 months after surgery). CONCLUSION There is a need for careful evaluation of bone metabolism and for routine calcium replacement after RYGBP.Background: Abnormalities in calcium and vitamin D metabolism are observed early after gastric bypass, whereas clinical or biochemical evidence of metabolic bone disease might not be detected until many years after the procedure. The aim of the present study was to evaluate the impact of bariatric surgery on bone metabolism determined on the basis of postoperative laboratory changes in calcium, phosphorus, magnesium, alkaline phosphatase and parathormone (PTH) levels. Methods: 110 patients submitted to Roux-en-Y gastric bypass (RYGBP) were followed after surgery, and the following parameters were determined: intact PTH molecule (PTHi; chemiluminescence), alkaline phosphatase (colorimetric method), ionic calcium (selective electrode), phosphorus and magnesium (colorimetric method). Results: Elevated serum PTHi levels were observed in 29% of the patients and hypocalcemia in 0.9% from the 3rd postoperative month and afterwards (3 to 80 months after surgery). Conclusion: There is a need for careful evaluation of bone metabolism and for routine calcium replacement after RYGBP.

Iatrogenic bile duct injuries.

Background: The real incidence of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is not known. Methods: Using questionnaires, we analyzed 91,232 LC performed by 170 surgical units in Brazil between 1990 and 1997. Results: A total of 167 BDI occurred (0.18%); the most frequent were Bismuth type 1 injuries (67.7%). Most injuries (56.8%) occurred at the hands of surgeons who had surpassed the learning curve (50 operations). However, the incidence dropped with increasing experience; it was 0.77% at surgical departments with <50 operations vs 0.16% at departments with >500 operations. The diagnosis was made intraoperatively in 67.7%, but it was based on intraoperative cholangiography in only 19.5%. The procedure was converted to open surgery in 85.8% when the diagnosis of injury occurred intraoperatively, and laparotomy was performed in 90.7% when the injury was diagnosed postoperatively. The mean hospitalization time was 7.6 ± 5.9 days, the major complications were stenosis and fistulas, and the mortality rate was 4.2%. Conclusion: The incidence of BDI after LC is similar to that reported for the open procedure. BDI increases mortality and morbidity and prolongs hospitalization; therefore, all efforts should be made to reduce its incidence.

Botulinum A Toxin Injected into the Gastric Wall for the Treatment of Class III Obesity: A Pilot Study

Background: Obesity represents a major public health problem in western countries. Initial studies suggest that injection of botulinum A toxin (Btx-A) into the antropyloric region inhibits propulsive contractions of the antral pump, with delay in gastric emptying, early satiety and weight loss. Methods: After approval by the University Ethics Committee, we prospectively evaluated 12 patients with class III obesity divided into 4 groups of 3 patients each. In groups I and II, 200 U Btx-A were injected into the antropyloric region at 8 and 16 sites, respectively. Groups III and IV received 300 U Btx-A into the antropyloric region at 16 and 24 sites, respectively. Body weight and gastric emptying time (GET) of solids and semi-solids using 13C-octanoic acid breath test and 13C-acetic acid breath test, respectively, were determined before and after injection over a period of 12 weeks. Results: Pre- and post-treatment body weight or solid and semi-solid GET did not differ significantly between groups (P>0.05). All patients reported a feeling of early satiety. No adverse effects related to BtxA or complications resulting from the endoscopic procedure were observed. Conclusion: The injection of different doses of BtxA at different sites in the antropyloric region of patients with class III obesity did not interfere significantly with the solid and semi-solid GET or body weight of these individuals. However, early satiety was reported by all patients, the procedure was safe and no side-effects of the treatment were observed. Further controlled studies involving different methodologies regarding dosage of Btx-A and sites of injection are necessary.

Hepatic Histopathology of Patients with Morbid Obesity Submitted to Gastric Bypass

BACKGROUND The authors analyze and describe the hepatic histopathology of patients with morbid obesity submitted to gastric bypass. METHODS A liver biopsy was performed in 112 patients at the beginning of gastric bypass, and clinical data (gender, age, BMI and associated diseases) were obtained from the patient records. RESULTS Among the patients, 74.1% (n=83) were females and 25.9% (n=29) were males, age 39.59+/-10.12 years, with BMI 48.79+/-7.54. Regarding the diseases associated with morbid obesity, arterial hypertension was observed in 67.9% (n=76) of the patients, joint diseases in 55.4% (n=62), dyslipidemia in 40.2% (n=45), and diabetes type 2 in 27.7% (n=31). 111 patients (99.1%) showed different types of non-alcoholic fatty liver disease (NAFLD) (types 1, 2, 3 and 4), with types 3 and 4 accounting for 57.7% (n=64). A significant association was observed between NAFLD type 4 and diabetes type 2 (P=0.018). The presence of glycogen nuclei was significantly correlated with steatosis (P=0.000), lobular inflammation (P=0.019) and perisinusoidal fibrosis (P=0.000). CONCLUSION 1) Liver biopsy taken at gastric bypass reveals different types of NAFLD; 2) Diabetes type 2 is associated with NAFLD type 4; 3) Glycogen nuclei are correlated with steatosis, lobular inflammation and perisinusoidal fibrosis; 4) Steatosis represents the basic injury in NAFLD and is associated with hepato-cellular ballooning. 5) In view of the frequency of hepatic alterations, a biopsy should be part of the surgical protocol of morbid obesity, this method being the only one able to determine the presence of lesions and to stage fibrosis.Background: The authors analyze and describe the hepatic histopathology of patients with morbid obesity submitted to gastric bypass. Methods: A liver biopsy was performed in 112 patients at the beginning of gastric bypass, and clinical data (gender, age, BMI and associated diseases) were obtained from the patient records. Results: Among the patients, 74.1% (n=83) were females and 25.9% (n=29) were males, age 39.59±10.12 years, with BMI 48.79±7.54. Regarding the diseases associated with morbid obesity, arterial hypertension was observed in 67.9% (n=76) of the patients, joint diseases in 55.4% (n=62), dyslipidemia in 40.2% (n=45), and diabetes type 2 in 27.7% (n=31). 111 patients (99.1%) showed different types of non-alcoholic fatty liver disease (NAFLD) (types 1, 2, 3 and 4), with types 3 and 4 accounting for 57.7% (n=64). A significant association was observed between NAFLD type 4 and diabetes type 2 (P=0.018). The presence of glycogen nuclei was significantly correlated with steatosis (P=0.000), lobular inflammation (P=0.019) and perisinusoidal fibrosis (P=0.000). Conclusion: 1) Liver biopsy taken at gastric bypass reveals different types of NAFLD; 2) Diabetes type 2 is associated with NAFLD type 4; 3) Glycogen nuclei are correlated with steatosis, lobular inflammation and perisinusoidal fibrosis; 4) Steatosis represents the basic injury in NAFLD and is associated with hepato-cellular ballooning. 5) In view of the frequency of hepatic alterations, a biopsy should be part of the surgical protocol of morbid obesity, this method being the only one able to determine the presence of lesions and to stage fibrosis.

Modulation of adipose tissue inflammation by FOXP3+ Treg cells, IL-10, and TGF-β in metabolically healthy class III obese individuals

OBJECTIVE The objective of this study was to compare the profiles of proinflammatory (interleukin [IL]-6 and tumor necrosis factor [TNF]) and anti-inflammatory (IL-10 and transforming growth factor [TGF]-β) adipokines in the blood, subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT) of metabolically healthy class III obese individuals and normal-weight controls. METHODS The serum concentrations (enzyme-linked immunosorbent assay [ELISA]), mRNA expression levels (reverse transcriptase polymerase chain reaction), and adipose tissue secretion (ELISA) of IL-6, TNF, IL-10, and TGF-β were analyzed, as were the mRNA expression of FOXP3 (present in regulatory T cells) and the secretion (Western blotting) of matrix metalloproteinases in the adipose tissue. RESULTS There were no differences in the circulating levels, expression, or secretion of IL-6 and TNF between the groups or tissues. The expression and circulating levels of IL-10 were higher in obese individuals, especially in the SAT. Although the blood concentration of TGF-β was similar between the groups, its expression and secretion levels were higher in the adipose tissues of obese individuals compared with controls. FOXP3 and MMP expression levels were higher in the SAT and VAT of obese individuals, respectively, compared with the controls. CONCLUSION Metabolically healthy, extremely obese individuals have effective immunoregulation to counter chronic obesity-related inflammation through the increased production of the anti-inflammatory cytokines IL-10 and TGF-β in adipose tissue, especially SAT; the increased presence of FOXP3-positive regulatory T cells; and increases in angiogenesis and adipogenesis induced by TGF-β and MMPs. These regulatory mechanisms could be important in the delayed onset of metabolic complications, even in extremely obese individuals.

Glycemic Control in Diabetic Patients after Bariatric Surgery

Background: Morbid obesity is associated with a high prevalence of diabetes mellitus, and weight loss is fundamental to improve glycemic control. The aim of the present study was to evaluate the impact of weight reduction during the late postoperative period (≥ 12 months) after gastric bypass on the glycemic control of diabetic patients. Methods: Fasting glycemia (glucose oxidase) and glycohemoglobin A1c (enzymatic fluorescence, reference value: 4-6%) were determined before and after surgery. Results were compared by the Student t-test for paired samples (P <0.05). Results: 23 women and 8 men with diabetes, with a mean follow-up of 27.2 months and a mean age of 42.5 years (30-68), were studied. Before surgery, mean ± SD weight, BMI, excess weight, glycemia and glycohemoglobin were 135.9±11.6 kg, 51.8±6.4 kg/m2, 68.3±14.5kg, 173±71.2 mg/dl, and 7.4±1.9%, respectively. After surgery, mean weight, BMI, excess weight, percent weight loss, percent excess weight loss, glycemia and glycohemoglobin were 89.7±8.8 kg, 35±4.5 kg/m2, 24.6±11.6 kg, 32.6%±1.8 (12.6-46.5%), 64.7±18.3%, 98±17.3 mg/dl (P <0.01), and 5.4±1.0% (P <0.05), respectively. Oral anti-diabetic drug and/or insulin treatment was discontinued in 89.2% of the patients. After surgery, 90.3% of the patients maintained glycohemoglobin A1c levels <7.0%. Conclusion: Weight loss led to a significant and sustained improvement of glycemic control in these patients submitted to bariatric surgery.

Effects of breathing exercises on breathing pattern and thoracoabdominal motion after gastroplasty

OBJECTIVE To evaluate breathing pattern and thoracoabdominal motion during breathing exercises. METHODS Twenty-four patients with class II or III obesity (18 women; 6 men) were studied on the second postoperative day after gastroplasty. The mean age was 37 +/- 11 years, and the mean BMI was 44 +/- 3 kg/m(2). Diaphragmatic breathing, incentive spirometry with a flow-oriented device and incentive spirometry with a volume-oriented device were performed in random order. Respiratory inductive plethysmography was used in order to measure respiratory variables and thoracoabdominal motion. RESULTS Comparisons among the three exercises showed significant differences: tidal volume was higher during incentive spirometry (with the flow-oriented device or with the volume-oriented device) than during diaphragmatic breathing; the respiratory rate was lower during incentive spirometry with the volume-oriented device than during incentive spirometry with the flow-oriented device; and minute ventilation was higher during incentive spirometry (with the flow-oriented device or with the volume-oriented device) than during diaphragmatic breathing. Rib cage motion did not vary during breathing exercises, although there was an increase in thoracoabdominal asynchrony, especially during incentive spirometry with the flow-oriented device. CONCLUSIONS Among the breathing exercises evaluated, incentive spirometry with the volume-oriented device provided the best results, because it allowed slower, deeper inhalation.

Bariatric surgery and the gut-brain communication—The state of the art three years later

OBJECTIVE This review analyzes the literature concerning gut peptides and bariatric surgery, from 2005 to July 2009. In particular, we are interested in whether, and how, gastrointestinal peptide alterations following surgery interfere with appetite/satiety, and what role they might play in the resolution of comorbidities. RESEARCH METHODS AND PROCEDURE PubMed/MEDLINE and ISI Web of Knowledge were used to search for human studies concerning gut peptides profiles after any bariatric operation technique. RESULTS Most of the studies reviewed had longitudinal design, short follow-up, and low statistical power. The diversity of study results may be partially explained by methodological aspects. Glucagon-like peptide-1, gastric inhibitory peptide, and peptide YY alterations may contribute to the excellent results in glycemic control of diabetics. Results do vary depending on bariatric operation technique; this is particularly evident in the case of ghrelin, which has been much studied in recent years. Ghrelin suppression has been linked to increased satiety, alterations in energy homeostasis, and better glucose metabolism. CONCLUSIONS There is a lack of long-term data on gastrointestinal hormone profiles after bariatric surgery and the studies have many methodological pitfalls. We still need prospective, long-term, good methodological studies in this area.

Long-term mortality of patients submitted to Roux-en-Y gastric bypass in Public Health System: high prevalence of alcoholic cirrhosis and suicides.

BACKGROUND Bariatric surgery is a valuable therapeutic option to severe obesity. Many researches have assessed the procedure efficiency on weight reduction, improvement in comorbidities and reduction of mortality. However, studies of late mortality and its causes are still necessary, mainly in the Brazilian population. AIM To assess late mortality, discriminating causes of death and its association with pre-operative characteristics in a series of patients submitted to bariatric surgery. METHODS Data analyses of 248 patients submitted to Roux-en-Y gastric bypass through Public Health System, from one up to 12 years of follow-up. The analyzed variables were: gender, age by the time of the surgery, pre-operative body mass index, comorbidities and smoking. The information about mortality was obtained through the Mortality Information System. The deaths were categorized according to International Classification of Diseases 10 and statistics analysis was done through the software STATA TM 9.2. RESULTS There were nine deaths, five of them were female. The mean age of the patients who died was 48.3 ± 8.4 years and the pre-operative body mass index was 56.0 ± 7.4 kg/m². The causes of death were: alcoholic cirrhosis (n=2), suicide (n=2), infectious causes (n=2), respiratory insufficiency (n=1), agranulocytosis (n=1) and unknown causes (n=1). None of the deaths was directly related to the surgery and there was no association of the pre-operative characteristics in mortality. CONCLUSION There was not any association between late mortality and pre-operative characteristics. The high frequency of suicide and alcoholic cirrhosis mortality indicates the strict follow-up concerns, with appropriate psychological support to the patients.

Type 2 diabetes mellitus 5 to 10 years after Roux-en-Y gastric bypass: remission and relapses—a longitudinal prospective study

We read with great interest the article by Blackstone et al. [1], recently published in Surgery for Obesity and Related Diseases, that reported on short-term remission rates of type 2 diabetes (T2DM) and the preoperative factors associated with remission in a cohort of patients submitted to bariatric surgery. The assessment of the long-term effect of bariatric surgery on the remission of T2DM is of paramount importance as well. We performed a prospective 5-year through up to 10-year study with 58 severely obese patients with T2DM from the Brazilian Public Health System (SUS) who underwent Roux-en-Y gastric bypass (RYGB). Preoperative and postoperative visits were performed by a multidisciplinary team, and the study was approved by the local ethical board. Baseline T2DM was defined according to the Expert Committee on Diagnosis and Classification of Diabetes Mellitus [2]. Total diabetes remission was defined at each annual follow-up as fasting blood glucose (FBG) r100 mg/dL (5.6 mmol/L) and HbA1c o5.7% without any anti-diabetic medication [3]. Partial remission was defined as FBG Z100 to 125 mg/dL (6.9 mmol/L) and HbA1c Z5.7% to 6.4% without anti-diabetic medications. Prolonged remission at the fifth year was defined as remission at all of the 5 past years [3]. Relapse was defined as FBG Z126 mg/dL and/or HbA1c Z6.5% in those who had previously achieved remission. Among patients who were eligible for the long-term followup, data were available for 41 (69.5%). Mean age was 43.1 10.3 years, and 77.6% were female. Mean preoperative body mass index (BMI), excess weight, glycemia, and HbA1c were, respectively, 53.4 9.5 kg/m , 72.5 24.4 kg, 130.5 53.2 mg/dL, and 7.3% 1.6%. Patients were treated preoperatively with oral antidiabetic drugs (n 1⁄4 37; 64%), insulin plus oral antidiabetic drugs (n 1⁄4 5; 8.6%), insulin (n 1⁄4 2; 3.4%), and diet alone (n 1⁄4 14; 24%). Median follow-up time was 8 years. Remission (total plus partial) rates of 75% to 92.3% were observed between the first and tenth years of follow-up. At the fifth year of followup, 11 patients (26.8%) had prolonged remission of T2DM.