Mitchell S. Wachtel

Adipose tissue: the new endocrine organ? A review article.

Fat is either white or brown, the latter being found principally in neonates. White fat, which comprises adipocytes, pre-adipocytes, macrophages, endothelial cells, fibroblasts, and leukocytes, actively participates in hormonal and inflammatory systems. Adipokines include hormones such as leptin, adiponectin, visfatin, apelin, vaspin, hepcidine, chemerin, omentin, and inflammatory cytokines, including tumor necrosis factor alpha (TNF), monocyte chemoattractant protein-1 (MCP-1), and plasminogen activator protein (PAI). Multiple roles in metabolic and inflammatory responses have been assigned to adipokines; this review describes the molecular actions and clinical significance of the more important adipokines. The array of adipokines evidences diverse roles for adipose tissue, which looms large in the mediators of inflammation and metabolism. For this reason, treating obesity is more than a reduction of excess fat; it is also the treatment of obesity’s comorbidities, many of which will some day be treated by drugs that counteract derangements induced by adipokine excesses.

Reinforcement Does Not Necessarily Reduce the Rate of Staple Line Leaks After Sleeve Gastrectomy. A Review of the Literature and Clinical Experiences

BackgroundLaparoscopic sleeve gastrectomy (SG) is an accepted bariatric procedure, with an advantaged by a low complication rate. A feared complication is stapler line leak. Buttressing materials have been suggested as a means of reducing staple line leak rates. We analyzed the leak rates from published series to help in demonstrating a potential cause.MethodsThe study was institutional review board (IRB) approved retrospectively. A Medline search using the key words sleeve gastrectomy and bariatric surgery obtained 54 articles. Attention was restricted to 11 articles written in English that listed numbers of gastrectomy procedures and leaks. Poisson regression assessed the possibility that patients who received buttressing materials had a reduced rate of leaks.ResultsThirty-five patients were evaluated from Greece (15) and the United States (20); two patients developed staple line leaks that appeared to be related to problems associated with buttressing materials. Eleven prior studies and the present series yielded 1,589 procedures, 15 (0.94%) of which were complicated by leaks. The leak rate for patients who were known to have received reinforcement of some sort was 1.45 (95% confidence interval 0.41–3.43) times that for other patients. To detect a difference between 1% and 0.5% as statistically significant in 80% of cases, with a two tailed test and alpha set at 0.05, would require 9,346 procedures.ConclusionsThere is no reason to believe, at this point, that reduction in leak rates occur because reinforcement is used. Because the leak rate is small, the routine reinforcement of the staple line after sleeve gastrectomy is questionable at best, although a decrease in hemorrhage has been reported.

Analysis of the results of sleeve gastrectomy for morbid obesity and the role of ghrelin

To evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG), a relatively new bariatric surgical procedure associated with duodenal switch (DS), we analyzed the findings of ten published studies on LSG. No relationship was found between the excess weight loss and the size of the bougie or the follow-up period. The amount of gastric fundus removed may be an important consideration because most ghrelin-producing cells are in the fundus; however, there is insufficient evidence that lowered ghrelin is the sole reason for the resulting weight loss after this procedure. Laparoscopic sleeve gastrectomy is still considered experimental by many, but the initial results are promising, with one study even suggesting long-term results comparable with those of other bariatric procedures. Ghrelin may play a role in the weight loss associated with LSG, but is unlikely to be the sole reason for its success.

A Simple Venous Thromboembolism Prophylaxis Protocol for Patients Undergoing Bariatric Surgery

Objective: Pulmonary embolism is a leading cause of death for bariatric patients. Numerous regimens have been proposed, but a comprehensive, simple approach is lacking. This study provides a simple, easily implemented prophylaxis regimen.

Oral delivery of low-molecular-weight heparin using sodium caprate as absorption enhancer reaches therapeutic levels

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Laparoscopic Sleeve Gastrectomy After Gastric Banding Removal: A Feasibility Study:

Background and objectives. Laparoscopic adjustable gastric banding (LAGB) is a commonly performed bariatric procedure. When LAGB fails, restrictive procedures such as gastric bypass have been performed. Laparoscopic sleeve gastrectomy (LSG) has been suggested as an alternative, but it has not yet been fully studied. Evaluated in this report are the experiences of patients who underwent LSG, a restrictive procedure, as a rescue procedure for failed LAGB. Methods. From June 2002 to June 2007, charts of patients who underwent LAGB were reviewed to find those who had undergone LSG as a rescue procedure. Results. Of 294 patients who underwent LAGB, 10 later underwent LSG. Median excess weight loss (EWL) prior to LSG had been 34%; after LSG, median EWL was 55%. Before LSG was performed, patients had a median 11.5 comorbidities, all of which improved after LSG. No major complications or deaths resulted. Conclusion. The results suggest LSG might be a reasonable choice for patients who fail LAGB. A formal study comparing LSG with other rescue procedures should be performed.

The Multiple Faces of Glucagon-Like Peptide-1—Obesity, Appetite, and Stress: What Is Next? A Review

By itself, glucagon-like peptide-1(GLP-1) appears to be an excellent drug for appetite control and the treatment of obesity. Unfortunately, few enzymes, such as IV dipeptidyl peptidase and renal excretin, degrade and render GLP-1 inactive within minutes. A receptor agonist, exendin-4, with a longer biological half-life than GLP-1, has been tried. Subcutaneous injection of exendin-4 or continuous IV injection of GLP-1 warrants further research and investigation.

Laparoscopic sleeve gastrectomy with endoscopic guidance in morbid obesity

BACKGROUND Sleeve gastrectomy (SG) has been shown to be an effective first-stage procedure for morbidly obese patients. The SG is presently performed over a bougie of varying sizes, which is useful, but known to produce injuries on insertion. In a retrospective study, we evaluated the effect of the laparoscopic SG (LSG) on excess weight loss during 1 year of follow-up using a 29F endoscope instead of a bougie. METHODS During a 1-year period, LSG was performed on 20 (18 women and 2 men) consecutive patients. Gamma regression analysis was used to determine whether the variation in gender, age, initial body mass index, Hispanic ethnicity, and interval after surgery were related to excess weight loss. RESULTS No deaths and 1 minor complication of oozing from the staple line occurred. The excess weight loss increased steadily over time, with a median 20% at 3 months, 32% at 6 months, 42% at 9 months, and 53% at 12 months. The median initial body mass index was 44.5 kg/m2, and the median age was 50 years. Of the 20 patients, 2 were men (10%) and 18 women (90%); 5 (25%) were Hispanic and 15 (75%) were non-Hispanic. The patients had a median 11.5 co-morbidities. Nausea was common for about 7 days postoperatively. An increase in the initial body mass index and increased co-morbidities were the only 2 variables directly and statistically connected with the percentage of excess weight loss (P <.05). CONCLUSION The results of our study have shown that LSG with endoscopic guidance appears safe and effective and could be tried using a larger set of patients as a single-stage operation.

The economic impact of morbid obesity

The percentage of Americans who are obese doubled from 15% in 1968 to 30% currently. An obesity epidemic is obvious and expected to worsen [1–5]. Lower productivity and higher health care costs resulting from obesity and its comorbidities have led to proposals for governmental intervention [6–10]. Methods for quantifying the costs of obesity costs and the benefits of treatment remain controversial [11–13]. Nonetheless, it is well established that about 10% of health care dollars are devoted to obesity treatment, which is economically justified by the increased absenteeism and decreased productivity associated with this disorder [14–19]. Bariatric surgery gives to the patient increased qualityadjusted life years [20]. A recent review of 18 trials involving 1,891 subjects concluded that surgical management of obesity yielded an average of 30 to 28 kg more weight loss than medical management after 2 years, with marked amelioration of obesity-related diseases such as diabetes, hypertension, and hypertriglyceridemia [21]. Metabolic syndrome, in particular, is cured by surgery in 95.6% of cases [22]. Ultimately, surgical management yields, at 5 years, a mortality rate 42% that of medical management and an 89% reduction in the relative risk of death [23]. That bariatric surgery benefits the health of patients is unquestioned. This review, however, focuses on the benefits of this surgery with respect to the general economy as well as workers and insurers, exemplifying matters by analyzing the costs of diabetes, one of obesity’s comorbidities.

Zonula occludens toxin synthetic peptide derivative AT1002 enhances in vitro and in vivo intestinal absorption of low molecular weight heparin.

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