Bariatry - surgical therapy of the severe obesity.

When conservative therapy of the morbid obesity repeatedly fails bariatric surgery begins. Adults patients from 18 to 60 age with obesity 3rd grade (BMI > 40 kg/m2 ), respectively 2nd grade (BMI > 35 kg/m2 ), with symptomatic diseases caused by obesity as type 2 diabetes, hypertension, dyslipidaemia or heavy failure of the joints, in which conservative therapy failed, are indicate for bariatric surgery. Nearly all of the bariatric procedures are providing by laparoscopy at present. Contemporary bariatric surgery is using restrictive or malabsorptive or combination of both operating methods. Adjustable gastric banding and vertical gastric plication are pure restrictive bariatric method. The most popular restrictive method with partial hormonal effect is sleeve gastrectomy at present. Biliopancreatic diversion is considered to be a pure malabsorptive bariatric method. Majority of the bariatric surgeons consider gastric bypasses as malabsorptive restrictive method.

Laparoscopic sleeve gastrectomy without over-sewing of the staple line is effective and safe.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is a bariatric procedure with very good long-term weight-reducing and metabolic effects. AIM: Here we report 6 years' experience with LSG performed in morbidly obese patients by one surgical team focusing on the impact of the degree of sleeve restriction and safety of the procedure without over-sewing the staple line. MATERIAL AND METHODS: From 2006 to 2012, 207 morbid obese patients with average age of 43.4 years and average body mass index 44.9 kg/m(2) underwent LSG without over-sewing the staple line. The complete 5- and 3-year follow-up is recorded in 59 and 117 patients with prospective data collection at 3, 6, 9, 12, 18, 24, 36, 42 and 60 months after LSG. Group 1 patients operated in 2006-2008 had smaller sleeve restriction. Group 2 patients operated in 2009-2012 had major sleeve restriction. All procedures were performed without over-sewing of the staple line. RESULTS: The average %EBMIL (excess body mass index loss) in group 1 patients with minor sleeve restriction reached 54.1% and average %EWL (excess weight loss) was 50.8% while in group 2 with major sleeve restriction the average %EBMIL reached 69.7% and average %EWL was 66.8%. Final weight reduction was significantly higher in group 2 patients compared to group 1 patients with smaller sleeve restriction. Out of 49 patients with preoperatively diagnosed T2DM (type 2 diabetes mellitus) was completely resolved in 70.8%. Pre-operatively diagnosed hypertension normalized in 64.2%, improved in 23.2%, and remained unchanged in 12.6% of patients. CONCLUSIONS: Carefully performed LSG without over-sewing the staple line is feasible and safe. A better weight-reducing effect was present in patients with major sleeve restriction.

Radical resection of the pyloric antrum and its effect on gastric emptying after sleeve gastrectomy.

BACKGROUND: The surgical technique of laparoscopic sleeve gastrectomy (LSG) has not been fully standardized yet and there is the unresolved question of what is the optimum size of retained pyloric antrum. The aim of our research was to prove that even after a radical resection of the pyloric antrum the physiological stomach evacuation function can still be preserved. METHODS: Our study was based on 12 patients, who were randomly divided into two groups. Patients undergoing radical antrum resection (RA group) underwent gastric emptying scintigraphy to determine the evacuation half-time (T1/2) and food retention in the 90th minute of the test (%GE) both before the operation and 3 months afterward. Patients in whom the antrum was preserved (PA group) served as a control group for comparison of postoperative weight loss (in kilogram), decrease in body mass index (BMI), and decline in excess weight (%EWL). The resulting changes were statistically processed. RESULTS: In the RA group, the average time T1/2 declined from 57.5 to 32.25 min (p = 0.016) and average retention %GE dropped from 20.5 to 9.5% (p = 0.073). Differences in the average values of weight, BMI, or %EWL between both groups were of no statistical significance (p > 0.8). CONCLUSIONS: In the RA group, an increase in gastric emptying postoperatively was noted. Complications such as failure of stomach evacuation were not observed in the RA group. Our results suggest that even more radical resection of the pyloric antrum performed by LSG is possible without concerns of postoperative disorder of the stomach evacuation function.

Discrepant results of adrenal venous sampling in seven patients with primary aldosteronism.

BACKGROUND: Adrenal venous sampling serves as a discrimination between uni- and bilateral forms of primary aldosteronism (PA). Even correctly performed adrenal venous sampling may lead to non-diagnostic results in some cases. RESULTS: We describe 7 subjects with PA in whom correct cannulation of adrenal veins (high selectivity index defined as cortisol((adrenal))/cortisol((periphery)) ratio) was associated with aldosterone (ALDO) suppression (ALDO/cortisol((adrenal))/ALDO/cortisol((periphery)) ratio <1) in the left adrenal gland and in whom all subjects underwent a successful adrenalectomy on the right side. In 3 subjects, samples from the right side with lower selectivity indexes (1.11-1.7) compared to those samples with a higher index of selectivity (10.4-44.9) pointed to lateralization. Next, 2 subjects were operated because of relatively large adrenal masses in the right adrenal gland on CT despite ALDO suppression on this side. One subject presented with high selectivity indexes from the right side (19.5 and 37.6), but only one sample showed ALDO secretion. Patient 7 was treated with right-sided adrenalectomy despite a low lateralization index (ALDO/cortisol((right))/ALDO/cortisol((left)) 1.78). CONCLUSIONS: Our results document some uncertainties in interpreting results of adrenal venous sampling in subjects with PA which may result from deep catheter insertion, anomalous venous drainage, or fluctuations in ALDO secretion.

Factors influencing arterial stiffness in pheochromocytoma and effect of adrenalectomy.

The aim of the study was to evaluate arterial stiffness and its modulating factors measured by carotid-femoral pulse wave velocity (PWV) and central augmentation index (AI) in patients with pheochromocytoma (PHEO) before and after surgery. Forty-five patients with PHEO and 45 healthy controls were investigated using an applanation tonometer (SphygmoCor, AtCor Medical). The gender, age, BMI and lipid profiles were comparable among both groups. The main difference in basic characteristic was as expected for fasting plasma glucose (P<0.001) and all blood pressure modalities. PWV in PHEO was significantly higher than in controls (7.2+/-1.4 vs. 5.8+/-0.5 ms(-1); P<0.001). Between-group difference in PWV remained significant even after the adjustment for age, heart rate, fasting plasma glucose and each of brachial (P<0.001) and 24 h blood pressure parameters (P<0.01). The difference in AI between groups did not reach the statistical significance (19+/-14 vs. 16+/-13%; NS). In multiple regression analysis, age (P<0.001), mean blood pressure (P=0.002), high-sensitive C-reactive protein (hs-CRP) (P=0.007) and 24 h urine norepinephrine (P=0.007) were independently associated with PWV in PHEO. In addition, 27 patients with PHEO were studied 1 year after tumor removal. Successful tumor removal led to a significant decrease in PWV (7.0+/-1.2 vs. 6.0+/-1.1 ms(-1); P<0.001). In conclusion, patients with PHEO have an increase in PWV, which is reversed by the successful tumor removal. Age, mean blood pressure, hs-CRP and norepinephrine levels are independent predictors of PWV.

Life-threatening arrhythmia caused by primary aldosteronism.

BACKGROUND: Arrhythmias are one of the typical complications of primary aldosteronism (PA), is commonly characterized by hypertension and hypokalemia. CASE REPORT: In this report, we present 3 cases of subjects in whom primary aldosteronism manifested with life-threatening arrhythmias. In 2 subjects, after excluding organic heart disease, an implantable cardioverter defibrillator was inserted and, only after the second episode of polymorphic ventricular tachycardia accompanied with low plasma potassium levels, the diagnosis of primary aldosteronism was made. CONCLUSIONS: It is important to include diagnosis of primary aldosteronism in the diagnostic work-up of hypertensive subjects without any structural cardiovascular impairment who present with malignant arrhythmia and hypokalemia. Appropriate treatment of primary aldosteronism may avoid insertion of an implantable cardioverter defibrillator.

Increased serum concentrations of macrophage inhibitory cytokine-1 in patients with obesity and type 2 diabetes mellitus: the influence of very low calorie diet.

OBJECTIVE: Macrophage inhibitory cytokine-1 (MIC-1) is a novel regulator of energy homeostasis. We explored whether alterations in MIC-1 levels contribute to metabolic disturbances in patients with obesity and/or obesity and type 2 diabetes mellitus (T2DM). DESIGN: We measured serum MIC-1 levels and its mRNA expression in subcutaneous and visceral adipose tissue of 17 obese nondiabetic women, 14 obese women with T2DM and 23 healthy lean women. We also explored the relationship of MIC-1 with anthropometric and biochemical parameters and studied the influence of 2-week very low calorie diet (VLCD) on serum MIC-1 levels. METHODS: Serum MIC-1 levels were measured by ELISA and its mRNA expression was determined by RT-PCR. RESULTS: Both obese and T2DM group had significantly elevated serum MIC-1 levels relative to controls. T2DM group had significantly higher serum MIC-1 levels relative to obese group. Serum MIC-1 positively correlated with body weight, body fat, and serum levels of triglycerides, glucose, HbAlc, and C-reactive protein and it was inversely related to serum high-density lipoprotein cholesterol. Fat mRNA MIC-1 expression did not significantly differ between lean and obese women but it was significantly higher in subcutaneous than in visceral fat in both groups. VLCD significantly increased serum MIC-1 levels in obese but not T2DM group. CONCLUSION: Elevated MIC-1 levels in patients with obesity are further increased by the presence of T2DM. We suggest that in contrast to patients with cancer cachexia, increased MIC-1 levels in obese patients and diabetic patients do not induce weight loss.

Adrenalectomy improves arterial stiffness in primary aldosteronism.

BackgroundAldosterone has been shown to substantially contribute to the accumulation of different types of collagen fibers and growth factors in the arterial wall, which increase wall stiffness. We previously showed that arterial wall stiffness is increased in primary aldosteronism (PA) independently of concomitant hypertension. This study was aimed at assessing the effects of specific treatment of PA on the arterial stiffness.MethodsTwenty-nine patients with confirmed PA (15 with aldosterone-producing adenoma treated by unilateral laparoscopic adrenalectomy, 14 treated with spironolactone (mainly idiopathic aldosteronism) were investigated by Sphygmocor applanation tonometer (using measurement of carotid-femoral pulse wave velocity (PWV) and augmentation index (AI)) at the time of the diagnosis and then approximately 1 year after the specific treatment.ResultsThe office blood pressure (BP) decreased from 167 +/- 18/96 +/- 9 to 136 +/- 12/80 +/- 7 mm Hg after adrenalectomy (P = 0.001), and from 165 +/- 21/91 +/- 13 to 151 +/- 22/88 +/- 8 mm Hg (not significant (n.s.)) on spironolactone. The mean 24-h BP decreased from 150 +/- 18/93 +/- 11 mm Hg to 126 +/- 17/80 +/- 10 mm Hg after adrenalectomy (P < 0.01), and from 155 +/- 16/94 +/- 12 to 139 +/- 18/88 +/- 8 mm Hg (n.s.) on spironolactone. The PWV significantly decreased after surgery from 9.5 +/- 2.7 m/s to 7.6 +/- 2 m/s (P = 0.001), and the AI (recalculated for heart rate 75/min) decreased significantly from 27 +/- 10 to 19 +/- 9% (P < 0.01). On the other hand, we did not find significant change of arterial stiffness indices in patients treated with spironolactone (PWV: 9.3 +/- 1.6 m/s vs. 8.8 +/- 1.3 m/s (n.s.); AI: 25 +/- 9% vs. 25 +/- 8% (n.s.)).ConclusionsSurgical but not conservative treatment of PA led to a significant decrease of BP and arterial stiffness parameters.American Journal of Hypertension (2008). doi:10.1038/ajh.2008.243American Journal of Hypertension (2008); 21, 10, 1086-1092. doi 10.1038/ajh.2008.243.

Laparoscopic sleeve gastrectomy without an over-sewing of the staple line.

BACKGROUND: In the past few years, laparoscopic sleeve gastrectomy (LSG) became a widely used bariatric method. Based on results of recent LSG studies, LSG is being increasingly used even as a single bariatric method. On contrary with some other reports, we do not reinforce the LSG staple line with over-sewing. Our pilot study presents treatment outcomes and results 18 months after LSG. METHODS: Sixty-one consecutive morbidly obese (MO) patients (19 male and 42 female) who underwent LSG from January 2006 to May 2008 were included into the study. The mean age, height, and weight were 37.3 years (29-57), 168 cm (151-187), and 118 kg (97-181), respectively, while mean body mass index (BMI) was 41.8 (36.1-60.4). LSG started at 6 cm from pylorus and ended at the angle of Hiss. For gastric sleeve calibration 38F, intragastric tube was used. All 61 LSG were performed without over-sewing of the staple line. In the last 24 cases, the staple line was covered with Surgiceltrade mark strips, which were however placed without any fixation to the underlying gastric tissue. RESULTS: Mean operating time was 105 min (80-170) and no conversion to open surgery. An 18-month follow-up was recorded in 39 MO patients. The mean weight loss was 31.3 (range, 21-67 kg) and mean % excess BMI loss reached 72% (range, 64-97%). Neither leak nor disruptions of the staple line and/or sleeve dilatation were recorded. CONCLUSION: LSG is an effective and safe bariatric procedure with low incidence of complications and mortality in our experience.

Comparison of SAGB QC "classic" titanium port and Velocity port: pilot phase prospective randomized study on perioperative and short-term postoperative implantation outcomes.

BACKGROUND: Port implantation in adjustable gastric banding (AGB) is usually considered as the least compelling, however, it is one of the very important parts of the operation. Port placement can take up to 10% of the overall AGB operating time, and inadequate technique can result in complications in the short- and long-term postoperative period (port torsion, infection, protrusion, port-site persistent pain, etc). METHODS: From Dec 2005-Feb 2006, 40 consecutive patients were recruited into a Pilot phase prospective randomized study and operated in a single institution by bariatric teams with >300 SAGB experience. In 2 patient groups, intraoperative and immediate postoperative outcomes of the SAGB QuickClose (SAGB QC) "classic" titanium port and Velocity port were compared. Recorded parameters were: preoperative BMI and sex; duration of port implantation (min); length of incision (mm); complications (signs of infection/skin reaction, port-torsion, protrusion, etc); port-site pain scoring (day 1, end of week 1 and 6 postoperatively). RESULTS AND CONCLUSIONS: 1) Velocity port implantation time was significantly shorter than that in "classic" titanium port (mean 2.5 min vs 6 min, P<0.01). 2) Port-site skin incision was longer in the Velocity group (45 mm) compared to the "classic" titanium port group (35 mm). 3) Reduction in patient subjective pain complaints in favor of Velocity port recipients was noted in the immediate postoperative period but no difference at 6 weeks after the operation. 4) Port-site infection occurred in 1 patient from the "classic" titanium port group and in none in the Velocity group.

Current status of non-adjustable gastric banding.

BACKGROUND: The purpose of this study is to review the current status of non-adjustable gastric banding (NGB) and to determine whether this operation is still acceptable in the management of morbid obesity, especially when compared with the adjustable GB (AGB) in long-term results. MATERIALS AND METHODS: A literature search was conducted of data published on NGB and AGB in Obesity Surgery in the past 12 months or available from other sources, with records of early and late band-related complications, reoperation rate and weight loss in groups reporting > or = 100 patients with minimum 3-year postoperative follow-up. RESULTS: 1,812 NGB and 1,968 AGB patients were included. Mean BMI was 42.4 in NGB vs 44.0 in AGB. No statistical difference occurred in the early complication rate (1.4% in NGB vs 1.6% in AGB). A statistical difference was noted in long-term complication rate, (1.9% in NGB vs 6.7% in AGB), and in reoperation rate (3.4% vs 7.2%). There was no difference in excess weight loss at 48 months following both operations (54.2% vs 53.0%). CONCLUSION: A significant difference in favor of NGB occurred in the long-term reoperation rate. No other differences were identified, other than in band material. NGB is a softer material and therefore, according to computerized images, has greater flexibility in copying gastric peristaltic waves, which may result in less irritation and more physiological behavior by this band.