Sean Woodcock

Weight Loss Decreases Excess Pancreatic Triacylglycerol Specifically in Type 2 Diabetes

OBJECTIVE This study determined whether the decrease in pancreatic triacylglycerol during weight loss in type 2 diabetes mellitus (T2DM) is simply reflective of whole-body fat or specific to diabetes and associated with the simultaneous recovery of insulin secretory function. RESEARCH DESIGN AND METHODS Individuals listed for gastric bypass surgery who had T2DM or normal glucose tolerance (NGT) matched for age, weight, and sex were studied before and 8 weeks after surgery. Pancreas and liver triacylglycerol were quantified using in-phase, out-of-phase MRI. Also measured were the first-phase insulin response to a stepped intravenous glucose infusion, hepatic insulin sensitivity, and glycemic and incretin responses to a semisolid test meal. RESULTS Weight loss after surgery was similar (NGT: 12.8 ± 0.8% and T2DM: 13.6 ± 0.7%) as was the change in fat mass (56.7 ± 3.3 to 45.4 ± 2.3 vs. 56.6 ± 2.4 to 43.0 ± 2.4 kg). Pancreatic triacylglycerol did not change in NGT (5.1 ± 0.2 to 5.5 ± 0.4%) but decreased in the group with T2DM (6.6 ± 0.5 to 5.4 ± 0.4%; P = 0.007). First-phase insulin response to a stepped intravenous glucose infusion did not change in NGT (0.24 [0.13–0.46] to 0.23 [0.19–0.37] nmol ⋅ min−1 ⋅ m−2) but normalized in T2DM (0.08 [−0.01 to –0.10] to 0.22 [0.07–0.30]) nmol ⋅ min−1 ⋅ m−2 at week 8 (P = 0.005). No differential effect of incretin secretion was observed after gastric bypass, with more rapid glucose absorption bringing about equivalently enhanced glucagon-like peptide 1 secretion in the two groups. CONCLUSIONS The fall in intrapancreatic triacylglycerol in T2DM, which occurs during weight loss, is associated with the condition itself rather than decreased total body fat.

Risk factors in laparoscopic cholecystectomy: A multivariate analysis

BACKGROUND Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality. METHODS All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis. RESULTS 2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025). CONCLUSION Adverse outcome from LC is particularly associated with male gender, but also the patients co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.

The surgical management of obesity in young women: consideration of the mother’s and baby’s health before, during, and after pregnancy

BackgroundMaternal obesity has a substantial associated morbidity and mortality affecting both mother and child. This has a major impact on provision of care due to increased requirements for both medical and surgical management of the consequences that follow obesity in pregnancy.MethodsA review examined the English language literature on Medline databases describing the effect of obesity on pregnancy and outcomes of pregnancy after bariatric surgery. Guidelines from the National Institute for Clinical Excellence yielded information on selection criteria for fertility treatment and bariatric surgery. The World Health Organization definitions of overweight and obesity were adhered to throughout this review.ResultsThe level of clinical and morbid obesity has shown a dramatic increase in women of childbearing age, with far-reaching consequences for both their own health and that of their offspring. Obese women require a substantial amount of additional clinical care beyond that offered to women of normal weight due to the wide range of medical and obstetric complications they experience. Recent evidence suggests that obesity may be implicated in approximately one-third of maternal deaths. The consensus of the literature is that the best way to reduce obesity-associated morbidity is by weight reduction before pregnancy. Where behavioral and medical interventions fail, the most successful method is bariatric surgery. The effect of surgery on the outcome of subsequent pregnancies indicate improved chances of normal pregnancy, delivery, and healthy babies.ConclusionsBariatric surgery is a safe and effective method of weight loss for morbidly obese women of childbearing age, with favorable outcomes for pregnancies after surgery.

Outcome of patients in laparoscopic training courses compared to standard patients

BACKGROUND & AIM Current Laparoscopic simulators have limited usefulness and patients have been used for training since the dawn of surgery. NUGITS (Northumbrian Upper Gastro Intestinal Team of Surgeons) Laparoscopic Skills courses utilise hands-on experience with simulators moving to live operating on volunteer patients. It is vital to know that the volunteer patient is not disadvantaged by greater surgical risk. METHODS This was a case-controlled prospective comparison of patients undergoing both Laparoscopic Cholecystectomy (LC) [n=51] and Laparoscopic Inguinal Hernia (LIH) [n=62] during NUGITS training courses. They are compared with a matched (age, sex and ASA grade) control group LC (n=51) and LIH (n=62) operated on by consultants. The outcome measures were surgical peri-and post-operative complications, post-operative hospital stay, readmission and early recurrence of inguinal hernia (<6 months). RESULTS In the LC cohort, there was no significant difference in the length of hospital stay (p=0.07) or readmission (p=0.16) in both the groups. The mean operating time was higher in the trainee compared to the control group (p=0.001). There was no difference in the post-operative morbidity or mortality in either group. In LIH cohort, the mean operating time was higher in the trainee compared with the control group. There was no significant difference in post-operative complications (p>0.05) and early post-operative recurrence of hernia (p>0.05). CONCLUSION The post-operative outcomes of patients undergoing laparoscopic surgery during laparoscopic training courses are similar to consultant-operated patients. Thus, it is acceptable and safe to encourage patients to volunteer for laparoscopic training courses.

Calorie restriction and not glucagon‐like peptide‐1 explains the acute improvement in glucose control after gastric bypass in Type 2 diabetes

To compare directly the impact of glucagon‐like peptide‐1 secretion on glucose metabolism in individuals with Type 2 diabetes listed for Roux‐en‐Y gastric bypass surgery, randomized to be studied before and 7 days after undergoing Roux‐en‐Y gastric bypass or after following a very‐low‐calorie diet.

Changes in physical activity after bariatric surgery: using objective and self-reported measures

BACKGROUND Many studies using self-reported physical activity (PA) assessment tools have suggested there is an increase in PA after bariatric surgery. OBJECTIVES Our aim was to assess PA and sedentary behavior before bariatric surgery and at 6 months after, using subjective and objective tools. SETTING Bariatric surgery candidates were recruited from a single center. METHODS Demographic data, medical history, current medications, and anthropometric measurements were recorded. Participants were asked to complete a PA and lifestyle questionnaire and to wear an accelerometer on their nondominant wrist. Data were collected before and at 6 months after surgery. RESULTS Twenty-two participants were included (17 gastric bypass; 4 sleeve gastrectomy; 1 intragastric balloon). Mean age was 46 years and the majority were female (72%). At a median of 6.3 months follow-up, there were significant reductions in measures of body fatness with a mean reduction of 27 kg in weight. The majority of daytime (12.5±1.1 out of 16 h) was spent in sedentary behavior presurgery with little change postsurgery (12.2±1.2; P = .186). Objectively measured mean moderate-vigorous PA did not change significantly from pre- to postsurgery (mean 11.5±13.9 and 11.6±13.1 min/d, respectively; P = .971). Self-reported total nonoccupational PA did not change significantly (P = .390). CONCLUSIONS The majority of bariatric surgery candidates were physically inactive presurgery, and there was no significant change in either subjectively or objectively measured PA at follow-up. This patient group may benefit from objective PA assessment and interventions aimed at increasing PA.

Type 2 diabetes, bariatric surgery and the risk of subsequent gestational diabetes

Women with pre-existing abnormal glucose regulation are certain to develop gestational diabetes in pregnancy and pre-gestational type 2 diabetes will become more difficult to control. However, an increasing number of women with type 2 diabetes have had bariatric surgery. In this group, the effect of pregnancy on glucose metabolism is unknown. We report two women with type 2 diabetes who underwent laparoscopic gastric bypass surgery with normalization of plasma glucose levels. During subsequent pregnancy, maternal blood glucose levels remained completely normal throughout. This is remarkable given the predisposition to abnormal glucose tolerance and the ongoing obesity, in the face of the insulin resistance of pregnancy. Women with prior type 2 diabetes reversed by gastric bypass surgery are not at high risk for gestational diabetes.