Plasma lipids and lipoprotein changes after biliopancreatic diversion for morbid obesity.

BACKGROUND: The reduction in plasma cholesterol with increase in large and lower dense LDL (pattern A) obtained by statins is usually associated with a prompt reduction in cardiovascular risk, but after bariatric surgery for morbid obesity a delay of some years is observed. No data regarding LDL pattern are available in obese subjects after biliopancreatic surgery. OBJECTIVE: To evaluate the modifications in LDL composition and LDL density after biliopancreatic surgery. SUBJECTS: 29 patients (17 type 2 diabetics (type 2) and 12 non-diabetics (ND)) with BMI <35, who failed previous attempts to decrease weight by diet, were studied before and 6 months after biliopancreatic diversion for morbid obesity. MEASUREMENTS: In all subjects, besides fasting circulating lipids, glucose and insulin, LDL and VLDL composition were determined and LDL density was evaluated as well. RESULTS: After surgery we observed a significant reduction of all circulating lipids, including apolipoprotein (Apo) B. The decrease was more marked for total cholesterol (-41%) than for triglycerides (-28%), without a significant difference between type 2 and ND. After surgery, LDL presented a marked decrease in the percentage of cholesterol (from 36 to 32%) with a marked increase in the percentage of triglycerides (from 13 to 18%), without appreciable modification of ApoB. After surgery, 1 patient changed from pattern B to A, while 2 patients previously pattern A became pattern B. Also a decrease in HDL and ApoAI was evident in all the subjects with an increase in the VLDL-1. CONCLUSIONS: Our data indicate that after biliopancreatic diversion, the plasma lipid profile improves along with improvement of plasma glucose and insulin sensitivity, but the LDLs become richer in triglycerides. It is possible that the greater atherogenicity of these LDLs is compensated by an improvement in the general metabolic condition.

Additive effects of Simvastatin beyond its effects on LDL cholesterol in hypertensive type 2 diabetic patients.

BACKGROUND: Experimental evidence indicates that statins might have direct vascular effects independently from low-density lipoprotein (LDL) cholesterol reduction and we reported that the reduction in urinary albumin excretion rate during Simvastatin treatment in type 2 diabetic patients was not correlated with LDL-cholesterol decrease. However in humans there are no data regarding possible additional effects of Simvastatin on blood pressure and urinary albumin excretion beyond its capacity to lower serum cholesterol. PATIENTS AND METHODS: Twenty-six microalbuminuric hypertensive type 2 diabetic patients (diastolic blood pressure - after four months wash-out from the previous antihypertensive therapy - consistently > 90 and < 100 mmHg; plasma LDL-cholesterol > 3.9 and < 6.5 mmol L-1) were enrolled in the study. In random order, these patients received Simvastatin (20 mg day-1) or Cholestyramine (6 g three times a day) for a period of 10 months and after three months of wash-out (cross-over) the sequence was reversed for an additional 10 months. Blood pressure, lipid parameters, glycated haemoglobin and urinary albumin excretion were measured during the study. Additionally, in eight patients, urinary glycosaminoglycan excretion (GAG) was also measured during the study. RESULTS: Simvastatin and Cholestyramine were equally effective in reducing total and LDL cholesterol. Only during Simvastatin treatment a significant reduction in diastolic blood pressure and both 24 h urinary albumin and GAG excretion rates were observed, while no significant changes were seen with Cholestyramine treatment. CONCLUSIONS: Our results clearly show for the first time that the reduction of blood pressure, together with 24 h urinary albumin excretion rate - two established cardiovascular risk factors, obtained during Simvastatin therapy in hypertensive type 2 diabetic patients - is in large part independent from the reduction of LDL Cholesterol.

Association of Trp64Arg beta 3-adrenergic-receptor gene polymorphism with essential hypertension in the Sardinian population.

OBJECTIVE: To evaluate the possible association of three candidate gene polymorphisms with essential hypertension in the genetically homogeneous Sardinian population. SUBJECTS AND METHODS: We studied 494 unrelated, nondiabetic subjects, 213 (43.2%) with essential hypertension. All subjects underwent a 75 g oral glucose tolerance test with determination of glycemia and insulinemia and serum lipids. The polymorphisms evaluated comprised Trp64Arg of the beta 3-adrenergic receptor, Gly40Ser of the glucagon receptor gene and the insertion/deletion polymorphism of the angiotensin converting enzyme (ACE) gene. RESULTS: Among the overall population studied, 48 (9.7%) were heterozygous carriers of the Trp64Arg polymorphism. The frequency of the Trp64Arg variant was significantly higher in hypertensives (13.6%) than normotensives (6.8%; chi 2 5.73, P = 0.017). The 48 subjects with the Trp64Arg variant had significantly higher (P < 0.049) serum triglyceride levels than the 446 with the Trp64Trp variant, while no significant differences were observed, either fasting or during the 75 g oral glucose tolerance test, in glycemia and insulinemia. No differences were found between hypertensive and normotensive subjects for ACE gene insertion/deletion polymorphism nor in the frequency of the Gly40Ser coding change in exon 2 of the glucagon receptor gene. CONCLUSIONS: Our results are consistent with the thesis that the Trp64Arg polymorphism of the beta 3-adrenergic receptor gene is associated more often with the condition of high blood pressure than with normal blood pressure.

Biliopancreatic diversion for treatment of morbid obesity: experience in 50 cases.

BACKGROUND: Biliopancreatic diversion (BPD) by Scopinaro's method is an operation advocated by some surgeons as an effective treatment for morbid obesity. METHODS: Between February 1995 and April 1997 we performed BPD by Scopinaro's method on 50 patients with morbid obesity (23 males), average age 41.4 years (range 20-63 years), average body weight 135.08 kg (range 89-256 kg), mean body mass index (BMI) 50.65 kg/m2 (range 37.01-81.56 kg/m2). RESULTS: In all cases a gradual decrease in weight was obtained [mean BMI at 1 month: 44.8 kg/m2, at 6 months (31 patients): 35.09 kg/m2, at 1 year (23 patients): 31.36 kg/m2, at 18 months (14 patients): 29.89 kg/m2 and at 2 years (5 patients): 29.27 kg/m2]. At the same time a significant improvement in the pathological conditions associated with morbid obesity was observed. The patients were able to suspend oral antihypertensive and antidiabetic therapy as these parameters spontaneously returned to normal values by the sixth postoperative month; all cases showed a marked reduction in hypercholesterolemia and hypertriglyceridemia. Postoperative complications were: one death (2%) on the third day due to heart failure; two late intestinal occlusions (4%); one acute dilatation of the stomach (2%); one peritonitis caused by early dehiscence of the anastomosis (2%); five anastomotic ulcers (10%); two cases of protein malnutrition (4%). CONCLUSIONS: BPD by Scopinaro's method is a bariatric procedure which is technically complex. However is it safe and reproducible and it induces a substantial weight loss.

Biliopancreatic diversion preserving the stomach and pylorus in the treatment of hypercholesterolemia and diabetes type II: results in the first 10 cases.

BACKGROUND: Besides weight loss Scopinaro's operation produces correction of hypercholesterolemia and noninsulin dependent diabetes mellitus in all patients who suffer from these conditions. These results encouraged us to perform biliopancreatic diversion (BPD) without gastric resection, thus preserving the functions of the stomach and pylorus in moderately overweight patients with hypercholesterolemia associated with diabetes type II and hypertriglyceridemia. METHODS: Between March 1996 and July 1997 we performed BPD without gastric resection on 10 moderately overweight patients [mean body mass index (BMI) = 33.2 kg/m2]. All patients had suffered from hypercholesterolemia and hypertriglyceridemia for more than 5 years. Ten patients suffered from diabetes type 11; four of them had had insulin treatment or oral anti-diabetic agents; the other patients all had hyperglycaemia in the fasted state and diabetes confirmed by preoperative oral glucose tolerance test (OGTT). Five patients suffered from hypertension. RESULTS: In all patients, cholesterol and triglyceride levels returned to normal within the first postoperative month. Glycemia also stabilized at normal values in nine patients within the early weeks after surgery. One patient who took 70 U of insulin reduced his daily intake to 35 U 2 months postoperatively. In all patients blood pressure returned to normal. Weight loss was predictably slight (10-15 kg). CONCLUSIONS: Our experience with the procedure found that this new method seems to be as effective in controlling lipidic metabolism and diabetes II as the original version of BPD. As expected, weight loss is only moderate, so that the modified BPD is not suitable for very obese patients.