Aminotransferase and gamma-glutamyltranspeptidase levels in obesity are associated with insulin resistance and the metabolic syndrome.

Fatty liver at ultrasounds, with/ without raised plasma levels of hepatic enzymes, is common in obesity. In most cases, it is the hallmark of non-alcoholic fatty liver disease (NAFLD), a potentially progressive disease associated with insulin resistance and the metabolic syndrome (MS). We tested the hypothesis that insulin resistance per se might be associated with hepatocellular necrosis. Alanine and aspartate aminotransferases (ALT and AST; no.=799) and gamma-glutamyltranspeptidase (GGT; no.=459) were analyzed in a group of treatment-seeking obese patients recruited in 12 Italian medical centers. Insulin resistance was calculated by the homeostasis model assessment method (HOMA-IR; no.=522). Median ALT and AST increased with increasing obesity class (p=0.001 and p=0.005) and exceeded normal limits in 21.0% of cases. Also HOMA-IR increased with the obesity class (p<0.0001), and was higher in subjects with elevated ALT (median, 4.93 vs 2.89; p<0.0001). A significant correlation was observed between HOMA-IR and ALT (R2=0.208; p<0.0001), as well as between HOMA-IR and AST or GGT (R2=0.112 and R2=0.080; p<0.0001). The correlation was maintained when cases with elevated enzyme levels were omitted from analysis. Diabetes and hypertriglyceridemia were the features of the MS most commonly associated with raised liver enzymes. In logistic regression, after correction for age, gender, BMI and features of the MS, HOMA-IR maintained a highly predictive value for raised ALT, AST and GGT. We conclude that in obesity insulin resistance is a risk factor for raised liver enzyme levels, possibly related to NAFLD.

Arginine but not pyridostigmine, a cholinesterase inhibitor, enhances the GHRH-induced GH rise in patients with anorexia nervosa.

Pirenzepine, a muscarinic antagonist probably acting via stimulation of hypothalamic somatostatin release, abolishes the growth hormone releasing hormone (GHRH)-stimulated growth hormone (GH) rise in normal subjects but only blunts it in patients with anorexia nervosa (AN). This finding suggested the existence in AN of an alteration of cholinergic system and/or somatostatinergic tone. To further investigate these mechanisms, in 11 AN women patients (age 18.8 +/- 0.9 years; BMI 13.4 +/- 0.4) we studied the GH response alone (1 microgram/Kg IV as a bolus at 0 min) and combined with pyridostigmine (PD, 120 mg orally, 60 min before GHRH administration), a cholinesterase inhibitor, or arginine (ARG 30 g infused over 30 min starting at 0 min), two compounds probably acting via inhibition of hypothalamic somatostatin (SS) release. The GH response to GHRH preceded by a previous (120 min before) neurohormone administration also was studied. All these tests also were performed in 20 normal age-matched women (age 22.0 +/- 1.8 yrs; BMI20.1 +/- 2.4). Basal serum GH levels were higher in AN patients than in normal volunteers (NV) (10.3 +/- 3.4 versus 2.8 +/- 0.3 microgram/L; p < 0.001), whereas plasma IGF-I levels were lower in AN patients than in NV (43.3 +/- 10.6 versus 172.4 +/- 13.9 micrograms/L; p < 0.00001). In AN patients, GHRH administration induced a GH rise higher, though not significantly, than that in NV [delta area under the curve (AUC) 1173.6 +/- 167.6 versus 834.6 +/- 188.1 micrograms/L/h]. The GH response to the second of two consecutive GHRH boluses was lower (p < 0.01) than that of the first one either in AN patients or in NV (67.6 +/- 27.4 and 53.1 +/- 25.7 micrograms/L/h, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Staple-line Disruptions in Vertical Banded Gastroplasty Related to Different Stapling Techniques.

We performed one or more upper G.I. barium single-contrast studies on 125 out of 166 Mason vertical banded gastroplasty (VBG) operated patients (total: 226 X-ray examinations during a 3 month-10 year postoperative period). Forty four patients had a staple-line performed by double application of a 2-row stapler with manual reinforcement (group 1); 12 had a single application of a 4-row stapler with reinforcement (group 2); the last 69 patients had a partition with a 4-row stapler without reinforcement (group 3). A staple-line disruption was observed in 34 cases (27.2%); 17/44 (38.6%) cases belong to group 1, 6/12 cases (50%) to group 2 and 11/69 cases (15.9%) to group 3. The range of breakdowns diameter was 2-30 mm (nine cases double, one case quadruple). In 16 out of 34 cases we observed a preferential contrast pathway through the perforations. In 23 cases we noted a weight regain and in one case an initial failure on weight loss; in 12 cases the excess weight loss (EWL) was less than 30%. In group 3, we found two tiny perforations at the top of the partition, but another nine along with the staple-lines. In our experience, staple line disruptions are only reduced using the 4-row stapler without reinforcement; even with this stapling technique late breakdowns along the staple-line, not only at the apex of the partition, can occur.

Weight Loss and Complications After Vertical Banded Gastroplasty.

We have performed 124 vertical banded gastroplasties (VBG) according to Mason, except that we used a collar 5.5 cm in circumference. We carried out a midline incision In 68 cases and a left subcostal incision in 56, with double application of a 2-row stapler with reinforcement In the first 69 cases and a single application of a 4-row stapler in 55 (15 with reinforcement, 40 without). We have followed 107 (86.2%) patients for a mean of 30 months (range 3-84). The mortality rate was nil. The intraoperative complications were three spleen lacerations (splenectomy), and the early complications were two gastric leaks (re-intervention) and one gastric bleeding. The late complications were one gastric perforation (re-intervention), four outlet stenoses (one re-intervention), one bleeding by collar erosion and nine ventral hernias (occurring only with the midline incision). The percentage excess weight loss was 46.3 +/- 16.4 at 6 months, 53.4 +/- 17.9 at 1 year, 47.8 +/- 19.6 at 3 years, and 45 +/- 23.3 at 5 years. In 12 cases the weight loss was unsatisfactory (less than 30% of the initial excess weight). Often such failures were due to staple-line disruption. We have had no staple-line disruptions since we stopped performing the reinforcement. VBG has a low incidence of complications, but sometimes these may be serious. In our opinion, the technical procedures which offer a stronger vertical partition give better results for weight loss.

Radiological Investigations in Vertical Banded Gastroplasty Patients.

In our institute we have performed 124 vertical banded gastroplasties. Patients with a follow-up beyond 3 months were studied with a barium meal, in order to evaluate the efficiency of surgery and the eventual complications. Seventy-nine patients have had one or more X-ray investigations at various times after surgery (for a total of 136 studies). The first 20 patients were routinely studied at 1, 2 and 3 years after the operation; the next 32 patients were studied for features such as vomiting, poor weight loss or low food intake; the last 27 patients were studied with an early overlook beginning 3 months after surgery. We noted gastroesophageal reflux in eight (10.1%) cases, outlet dilatation in four (5%) cases, outlet substenosis (diameter 6-8 mm) in 13 (16.4%) cases, outlet stenosis (diameter

[The role of the intestine in the pathogenesis and treatment of multiple organ failure]. / Il ruolo dell'intestino nella patogenesi e nel trattamento della "multiple organ failure".

Infection and sepsis remain major causes of death in medical and surgical services, despite the availability of potent antibiotics, aggressive surgery and close monitoring of patients in intensive-care units. Actually the terminology to define this type of events in multiple organ failure: we considered the role of intestine in its pathogenesis and its management.

Lymphocyte (Na,K) ATPase-dependent 86Rb+ uptake in human obesity.

Sodium and potassium ion-activated adenosinetriphosphatase (EC number 3.6.1.3) activity, measured as the uptake of 86 rubidium (an analogue of potassium) was determined on peripheral lymphocytes isolated from 20 normotensive obese subjects and 20 normal weight subjects. No difference in the total uptake of 86Rb or in the Na, K-ATPase-dependent uptake was observed in either group. Furthermore, no correlation between the body mass index (BMI) and the Na,K-ATPase-dependent 86Rb uptake was observed. However the Na,K-ATPase mediated 86Rb uptake was always positively correlated with basal blood insulin levels and the insulin sensitivity index. It may be concluded that no lymphocyte dysfunction of Na,K-ATPase was present in our obese patients and that its activity is controlled by insulin in both normal-weight and obese subjects.

[Evaluation of the nutritional state of patients with maxillo-facial pathology]. / Valutazione dell'andamento nutrizionale in pazienti con patologia maxillo-facciale.

We have studied 19 patients with maxillo-facial trauma from the nutritional point at view. We observed that subjects with serious multiple fractures need a high caloric intake (a positive nitrogen balance is achieved by 100% of patients only when their intake is greater than or equal to 46 cal./kg/day) while patients with less serious fractures need lower caloric intake. The A. underline the importance of nutritional therapy in the patients with "intramaxillar fixation" both for the practical and psychological problems connected with their feeding and for the relationship between nutritional conditions and "metabolic response".