Association between polymorphisms in candidate genes and morbid obesity.

Polymorphisms in a number of candidate genes have been reported to be associated with obesity. We have determined the incidence of the following polymorphisms in the following candidate genes in a group of 388 morbid obese patients (mean body mass index (BMI) 52+/-8.01) who underwent gastric banding surgery: lipoprotein lipase (LpL) t-93 g and N291S; peroxisome proliferator receptor gamma (PPARgamma), P12A, P115Q and c1431t; peroxisome proliferator receptor alpha (PPARalpha) L162V; beta-adrenergic receptor 2 (beta-AR 2), Q27E; beta-adrenergic receptor 3 (beta-AR 3) W64R; uncoupling protein 1 (ucp-1), a-3826g, ucp-2, 45 bp insertion. Only for the ucp2 polymorphism did we find a statistically significant association with obesity. The beta-AR 3 W64R and ucp-1 a-3826g polymorphisms influenced the rate of the development of obesity and may act synergistically.

Results of bariatric surgery.

OBJECTIVE: To present the results of bariatric surgery performed in our hospital over the last ten years. DESIGN: Longitudinal, clinical intervention with obesity surgery. SUBJECTS: To date in our hospital we have performed bariatric surgery on 496 patients. Ninety-seven percent of them received a restrictive method and 3% a combined procedure. The mean age of our patients was 39+/-9 y. The mean weight was 144+/-28 kg which corresponds to a mean BMI of 51+/-8 kg/m(2). The gender distribution is 18% male and 82% female patients. MEASUREMENTS: Success of surgery with early and late complications, no laboratory measurements. RESULTS: The early postoperative complications were the following: wound infection 3%, lethality 1.2%, pleural infusion 0.7% and evisceration 0.5%. The important late complications were pouch dilatation and stomastenosis in 18% and staple line disruption in 11%. Slippage of the adjustable silicone gastric banding (ASGB) amounted to 5% and hernias emerged in 7% of patients. A migration and band infection occurred in 0.7%. Reoperations were necessary in 10% of the silastic ring vertical gastroplasty (SRVG) and in 39% of the ASGB patients. Patients were followed up every two months in the first year and later, annually. Blood samples were taken after 25%, 50%, 75% and 100% loss of excess weight. To date, 91% of our patients have reached an excess weight loss of 25%. 71% lost half of their overweight and one third (32%) were able to reduce it by 75%. 8% of our patients attained normal weight. CONCLUSIONS: For long term compliance and to avoid regain of weight, a close follow-up is necessary. We therefore offer special care which, in addition to the postoperative surgical care, includes visits by dieticians, internists, psychologists as well as exercise therapy. Knowledge of morbid obesity and skill in bariatric surgery are prior conditions to avoid complications and for success in bariatric surgery.

BAROS: an effective system to evaluate the results of patients after bariatric surgery.

BACKGROUND: Success in bariatric surgery is most often evaluated by a sufficient loss of excess weight and an improvement in the medical conditions. The expected increase in quality of life (QoL) after weight loss, however, has not often been systematically analyzed. BAROS (Bariatric Analysis and Reporting Outcome System) is a scoring system which, along with easy handling, allows comparisons to be made internationally. METHODS: 386 morbidly obese patients who had undergone bariatric surgery in our hospital were evaluated with BAROS. Five categories- failure, fair, good, very good, excellent- were taken from the scoring system that BAROS offers. This system has three major points: excess weight loss, medical co-morbidities and QoL. Points are subtracted for reoperations and defined complications. The operations performed were silastic ring vertical gastroplasty (72%), adjustable gastric banding (23%), biliopancreatic diversion (3%), vertical banded gastroplasty (1%) and gastric banding of Molina (1%). RESULTS: In 1991 and 1993, we had a fair result in 3% and 10% of the patients. A good score with a mean of 3.6 to 4.1 was reached in 1992, 1994 and 1995. In the last 3 years, 1996 to 1998, the mean score was 5.0 to 5.7, which is a very good result when compared with the scoring key. CONCLUSION: BAROS is a valuable tool to access the QoL of patients who have undergone bariatric surgery.

Variation in the gene for human peroxisome proliferator activated receptor gamma (PPARgamma) does not play a major role in the development of morbid obesity.

OBJECTIVE: To determine the extent of variation in the gene for peroxisome proliferator activated receptor gamma (PPARgamma) in patients with morbid obesity. SUBJECTS: Two hundred morbidly obese patients who underwent gastric banding surgery and 192 healthy blood donors. Diabetics were excluded. EXPERIMENTAL: The frequency of the P115Q and P12A variants in the PPARgamma gene was determined. Single strand conformational polymorphism (SSCP) analysis was performed on all exons, exon/intron boundaries and part of the promoter of the PPARgamma gene on a sub-group of 67 morbid obese patients. RESULTS: None of the morbid patients or the blood donors were carriers of the P115Q mutation. The frequency of the P12A polymorphism did not differ significantly between morbid obese patients and controls and there was no statistically significant association between P12A and BMI. Male blood donors who were A12A homozygotes had statistically significant higher serum leptin concentrations (P = 0.001). Mutation screening revealed that one patient had a T -->G transversion at -208 in the promoter of PPARgamma-2, two had silent mutations, one a T-->C transition in the third base of codon 144 and the other a C-->T transition in codon 297. The fourth patient had a CGC-->TGC transition in codon 316 resulting in the replacement of an arginine with a cysteine. This mutation was not found in any other morbidly obese patient. CONCLUSION: Variation in the PPARgamma gene is unlikely to play a major role in the development of morbid obesity.

Lack of association between a human beta-2 adrenoceptor gene polymorphism (gln27glu) and morbid obesity.

OBJECTIVE: To determine the frequency of the gln27glu polymorphism in the beta-2 adrenoceptor gene in patients with morbid obesity. SUBJECTS: 243 patients with morbid obesity (mean body mass index 51. 6) and 199 healthy blood donors. RESULTS: The same frequency, 0.42, of the glu allele was observed in both groups. Neither the incidence in obese women (0.41, n=197) compared to control women (0.43, n=61), nor that in obese men (0.44, n=46) compared to control men (0.41, n=138) was significantly different. The difference in frequency between obese men and women, 0.44 vs 0.41 was not significant (P=0. 68). Genotype information from the families of 18 of the obese patients showed no association between the glu27 allele and BMI. CONCLUSIONS: We find no evidence for a role of the glu27 variant in the beta-2 adrenoceptor gene in the development of morbid obesity.

Does gastric restriction surgery reduce the risks of metabolic diseases?

BACKGROUND: Certain risk factors for arteriosclerosis are associated with obesity, e.g. hypertension, insulin resistance, the high triglyceride - low HDL pattern. One aim in treating morbid obesity is to reduce these risk factors. This study was designed to follow metabolic risk factors after weight loss in 165 morbidly obese patients who underwent a gastric restriction operation. METHODS AND PATIENTS: Lipid and hormone levels were analyzed before surgery and after 25, 50, 75 and 100% loss of excess weight. Mean cholesterol and triglyceride levels were normal or slightly elevated. HDL cholesterol was also normal (41 mg/dl). Thirty eight percent of the patients had elevated cholesterol and triglyceride levels. Insulin levels were measured as an indicator of potential insulin resistance, and with a mean of 21 microU/ml it was at the upper normal level. RESULTS: After reaching 75% reduction of overweight in a mean time of 10 months, serum cholesterol levels were unchanged. Serum triglycerides, however, decreased by 35% (P<0.0001) and HDL cholesterol increased by 24% (P<0.0001). Insulin levels decreased to 8 microU/ml (P<0.0001). CONCLUSION: We found an amelioration in the metabolic parameters in 75% of the patients. Nevertheless morbidly obese patients were found to have fewer abnormalities in lipid and glucose metabolism than expected from data of overweight patients with metabolic syndrome. Further long-term studies with careful evaluation of the metabolic parameters as risk factors in patients with morbid obesity need to be performed.

[Surgery for obesity: a current trend or a specialty to be taken seriously?]. / Adipositaschirurgie: Modeerscheinung oder ernst zu nehmendes Spezialgebiet?

We performed gastric restriction operations in our hospital on 320 patients. 55% of them lost 50% of their excess weight within 7 months. The success of this kind of operation depends on a comprehensive therapeutic concept in addition to the surgical treatment.

Silastic Ring Vertical Gastroplasty Using a Modified TA 90 BNtrade mark.

Silastic Ring Vertical Gastroplasty (SRVG) is a well-established method in obesity surgery. In the last 5 years we performed SRVG on 76 patients who suffered from morbid obesity. Not included are those patients who received an SRVG as second or third gastric segmentation operation. In performing the first 27 silastic ring vertical gastroplasties using the TA 90BNtrade mark we repeatedly experienced difficulties in guiding the nasal tube along the lesser curvature through the notch. This problem stimulated us to develop a more simplified procedure of setting the staple-line. In co-operation with AutoSuture Deutschland GmBH, the notched part of the TA 90 BNtrade mark was bent in a 90 degree angle to the left side of the instrument. This way it is much easier to place the nasal tube exactly at the lesser curvature and through the bent notch of the newly developed TA 90 BNK. Thus, we were able to create a sufficient pouch along the lesser curvature. Of 76 patients 27 underwent the SRVG with a TA 90 BNtrade mark and 49 with the TA 90 BNK. The average age of the patients was 39 years, 83% women, 17% men. The overweight ranged from 40 kg to 177 kg, the BMI from 39 to 94. In 12 cases a staple-line rupture occurred, 26% with the TA 90 BNtrade mark and 10% with the TA 90 BNK. In nine patients a reoperative because of stoma stenosis was necessary, 11% with the TA 90 BNtrade mark and 12% with the TA 90 BNK.