Alexithymia and eating behaviour in severely obese patients.

BACKGROUND: Alexithymia is the inability to express feelings with words and comprises a psychological construct frequently found in obese individuals. In eating disordered patients who show a tendency to lose control over food intake, personality traits with alexithymic characteristics have been demonstrated. The present cross-sectional study investigated the relationships between alexithymia and eating behaviour in severely obese patients. METHODS: This study analysed 150 obese patients undergoing bariatric surgery and 132 subjects at more than 1 year after biliopancreatic diversion (BPD), when body weight has steadily normalised and any preoccupation with weight, food and diet has been completely abandoned. Obese and operated subjects completed the Toronto Alexithymia Scale (TAS), and eating behaviour was assessed via a semi-structured interview exploring binge eating disorder (BED), night eating and emotional eating, as well as by utilisation of the Three Factor Eating Questionnaire (TFEQ). RESULTS: Although alexithymic patients showed deranged eating behaviour, as evaluated by the TFEQ scores, the frequency of BED, night eating and emotional eating was similar in alexithymic (TAS > 60) and non-alexithymic patients. However, the prevalence of alexithymia was similar in obese and BPD subjects, whereas, in the operated subjects, TFEQ scores were lower (P < 0.005) than those in obese patients. CONCLUSIONS: These data suggest that, in severely obese patients, alexithymia does not influence eating behaviour; in severely obese patients, the tendency to lose control over food intake apparently represents a psychological construct that is substantially independent from alexithymia.

Long-term normalization of insulin sensitivity following biliopancreatic diversion for obesity.

OBJECTIVE: Assess insulin sensitivity and metabolic status of obese patients with stable weight loss at long term following biliopancreatic diversion (BPD). MATERIAL AND METHODS: The study was carried out in 36 nondiabetic severely obese patients undergoing BPD. Serum concentration of glucose, insulin and leptin were determined prior to and at 2 y following the operation. Insulin sensitivity was calculated according to the homeostatic model assessment (HOMA IR). RESULTS: At 2 y following BPD, weight loss in all subjects corresponded to a marked drop in serum leptin concentration and improvement of insulin sensitivity within physiological range. Following the operation, HOMA IR values were positively correlated with serum leptin concentration independently of body mass index values. DISCUSSION: The stable weight loss following BPD at long term is accompanied by a complete reversal of the preoperative insulin resistance. Serum leptin concentration and HOMA IR data were positively related only postoperatively, suggesting that the action of factors that could influence the relation between leptin and insulin action in the obese status can be reverted.

Satiety after vertical banded gastroplasty.

Early satiety following gastroplasty is due to the new anatomic conditions created by the operation and refers to a distressing or painful epigastric sensation after food consumption. Early satiation may act as an aversive stimulus, shaping eating habits and behaviour in such a way as to promote satisfactory weight loss and maintenance. This hypothesis was tested in patients who had undergone vertical banded gastroplasty (VBG). The duration of the sensation of early satiety was associated with the scores of questionnaires assessing eating behaviour, but seemed to be completely unrelated to the radiologically measured proximal pouch volume, energy intake and weight loss data. These findings suggest that cognitive factors play a substantial role in determining food intake and therefore in achieving weight goals following gastric restriction.

Metabolic syndrome in severely obese patients.

BACKGROUND: The authors assessed the prevalence of diabetes, hypertension, dyslipidemia and metabolic syndrome in patients with a high degree of obesity. METHODS: A retrospective investigation was planned in a cohort of obese patients with a wide range of body mass index (BMI) referred to a large University Hospital for weight loss. RESULTS: An increase in prevalence of diabetes and hypertension with increase in the degree of obesity was observed, while the prevalence of dyslipidemia and metabolic syndrome appeared to be independent of the BMI values. CONCLUSION: In severely obese patients a still unknown factor which affects differently glucose and lipid metabolism cannot be excluded.

Failure of preoperative resting energy expenditure in predicting weight loss after gastroplasty.

OBJECTIVE: To evaluate the predictive efficacy of preoperative resting energy expenditure (REE) on weight loss after vertical banded gastroplasty (VBG). When subjected to a gastric restriction procedure of similar extent, the patients with higher energy expenditure should experience a greater negative energy balance than those with lower-energy expenditure, and thus, lose more weight, thereby making REE a reliable predictor of weight loss after VBG. RESEARCH METHODS AND PROCEDURES: This was a prospective investigation after VBG, taking into account the relationship between preoperative REE values and the results at 1-year follow-up in terms of weight loss and success of the procedure. The correlations were evaluated by multiple and logistic regression analysis. RESULTS: The weight loss and the outcome at 1 year after VBG seemed to be completely independent of preoperative energy expenditure. DISCUSSION: These findings suggest that, despite gastric restriction, patients may voluntarily adjust their energy intake, and that the weight outcome after VBG is influenced more by behavioral and cognitive variables than by biological or surgical factors.

Outcome of biliopancreatic diversion in subjects with Prader-Willi Syndrome.

BACKGROUND: In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is mandatory to lengthen the survival; therefore, the lack of compliance in voluntary food restriction requires a surgical malabsorptive approach. METHODS: 15 PWS subjects were submitted to biliopancreatic diversion (BPD) and followed (100%) for a mean period of 8.5 (4-13) years. BPD consists of a distal gastrectomy with a long Roux-en-Y reconstruction which, by delaying the meeting between food and biliopancreatic juices, causes an intestinal malabsorption. Indication for BPD was BMI > 40 or > 35 with metabolic complications. Preoperative mean age was 21 +/- 5 years, mean weight 127 +/- 26 kg, and mean Body Mass Index (BMI, kg/m2) 53 +/- 10. According to Holm's criteria, all of the subjects had a total score > or = 8. IQ assessment was performed in each subject, with a mean score of 72 +/- 10. An arbitrary lifestyle score was given to each subject. RESULTS: No perioperative complications were observed. Percent excess weight loss (%EWL) was 59 +/- 15 at 2 years and 56 +/- 16 at 3 years, and then progressive regain occurred; at 5 years %EWL was 46 +/- 22 and at 10 years 40 +/- 27. Spearman rank test failed to demonstrate any correlation between weight loss at 5 years and patient data, except with lifestyle score (Spearman r = 0.8548, p < .0001). Current mean age is 31 +/- 7 years. CONCLUSION: BPD has to be considered for its value in prolonging and qualitatively improving the PWS patient's life.

Leptin and HDL-cholesterol in non-diabetic normotensive subjects.

BACKGROUND: We investigated the relationships between body mass index (BMI), serum leptin and serum HDL-cholesterol. MATERIAL AND METHODS: A retrospective study was carried out in 80 patients who did not have type 2 diabetes mellitus and/or high blood pressure. RESULTS: Both serum leptin and HDL-cholesterol serum levels correlated with BMI (r = 0.616 and r = -0.269, respectively), but when the BMI values were kept constant no correlation was found between serum leptin and HDL-cholesterol both in simple and in multiple regression. CONCLUSION: The findings suggest that serum leptin concentration is completely independent of lipid metabolism.

Intraluminal penetration of the band in patients with adjustable silicone gastric banding: radiological findings.

The aim of this study was to analyse radiological findings in patients surgically treated for adjustable silicone gastric banding (ASGB) for morbid obesity complicated by band penetration into the gastric lumen. We reviewed the records of four patients with surgically confirmed penetration of gastric band into the gastric lumen; three had preoperative opaque meal, one only a plain abdominal film. Vomiting was the presenting symptom in two cases, whereas others had new weight gain and loss of early satiety. Two patients had normally closed bands: radiography showed that their position had changed from previous controls and the barium meal had passed out of their lumen. Two patients had an open band. One patient had the band at the duodeno-jejunal junction, and the tube connecting the band to the subcutaneous port presented a winding course suggesting the duodenum. In the other case, both plain film and barium studies failed to demonstrate with certainty the intragastric position of the band. As ASGB is becoming widely used, radiologists need to be familiar with its appearances and its complications. Band penetration into the stomach is a serious complication which needs band removal. Patients with this problem, often with non-specific symptoms and even those who are asymptomatic, are encountered during radiographic examinations requested either for gastric problems or follow-up purposes, and have to be properly diagnosed.

Energy and nitrogen absorption after biliopancreatic diversion.

BACKGROUND: The strict long-term weight maintenance in good nutritional conditions observed after biliopancreatic diversion (BPD) needs to be explained. MATERIALS AND METHODS: 15 operated subjects were maintained at an isoenergetic and isonitrogenic diet as similar as possible to their usual diet. Apparent absorption (AA) of energy, fat, nitrogen and calcium was calculated subtracting the fecal content, measured directly, from the oral intake, derived from tables. The alimentary protein absorption was directly determined by I125 albumin oral administration. RESULTS: Mean AA for energy and fat was 57% and 32%, respectively; AAs were unrelated as absolute value and negatively associated as percent of the intake with the energy and fat intake. I125 intestinal absorption was 73%, while nitrogen percent AA was 57%, indicating higher than normal loss of endogenous nitrogen. Calcium AA was 551 mEq/day, 26% of the intake. A positive correlation between nitrogen and calcium AA as absolute values and alimentary intake was observed, while there was no correlation when AA were considered as per cent of the intake. CONCLUSIONS: For energy and fat, an increase in intake corresponds to an increase in percent malabsorption, so that the absolute amount absorbed tends to remain constant, accounting for the excellent weight maintenance observed following BPD. This was confirmed by a long-term hypernutrition study after BPD. On the contrary, for nitrogen and calcium, the percent absorption tends to remain constant when intake varies, so that an increase in alimentary intake results in an increased absolute amount absorbed.

Short-term changes in serum leptin concentration following biliopancreatic diversion.

BACKGROUND: The influence of the new anatomico-functional structure created by biliopancreatic diversion (BPD) in the postoperative fall of serum leptin concentration was evaluated. METHODS: Serum leptin concentration was determined in obese women before and immediately after BPD, before the usual postoperative intestinal rest. The measurements were repeated at the second postoperative month, when oral intake had nearly totally resumed and the patients had lost the first amount of weight. RESULTS: 5 days following BPD, a sharp reduction of serum leptin concentration was observed. At the second postoperative month the values remained nearly unchanged and were indistinguishable from those observed in a group of obese non-operated patients with a closely similar body weight. CONCLUSIONS: Changes in the upper gastrointestinal tract due to BPD appear to have no influence in the postoperative reduction of serum leptin concentration, which appears to be substantially related only to the patientís adiposity.

Body image in binge eating disorder.

BACKGROUND: The purpose of this study was to evaluate the impairment of body image in patients with binge eating disorder (BED). MATERIALS AND METHODS: A 3-year longitudinal study was undertaken in 25 BED obese patients and 26 non-BED obese patients who had undergone biliopancreatic diversion (BPD) for obesity. The body image was evaluated by the Eating Disorder Inventory body dissatisfaction scale. RESULTS: Within the third postoperative year, 95% of patients had stopped binge eating. After the first postoperative year, the BED patients showed body dissatisfaction scores higher than those of the non-BED group, whereas the longer-term results were closely similar. CONCLUSIONS: Over the long term following BPD, binge eating disappears, which suggests that the loss of control over food intake is mainly dependent on dieting and on the preoccupation with food and body shape. The derangement of body image in obese patients with BED is only partly dependent on inner feelings. In fact, the stable weight normalization after BPD is accompanied by a sharp improvement in body image in all cases. It appears that the complete normalization requires more time in BED patients than in their non-BED counterparts.

Radiology of adjustable silicone gastric banding for morbid obesity.

We reviewed the radiological findings in 45 morbidly obese patients (weight range 80-129 kg; mean 95.7 kg) after gastric restriction surgery with adjustable silicone gastric banding (ASBG) according to the Kuzmak technique. Radiographic studies of the stomach were performed before, and at 4 and 12 months after surgery; symptomatic patients underwent additional studies when needed. Patients were evaluated using both liquid barium and a solid opaque meal to assess post-operative gastric morphology as well as emptying time of the proximal gastric pouch. 27 patients had a normal clinical course. Variation of the calibre of the silicone band under radiographic guidance was required in 12 of these patients, based on dilatation of the proximal pouch, variation of the stomal calibre from operative values, or an emptying time longer than 30 min. All these problems disappeared after the adjustment manoeuvres. 18 patients had complications, of which five had stomal stenosis which could not be managed through simple deflation of the band; two had posterior bending and dilatation of the proximal pouch; four had gastritis and oesophagitis; six had infection of the inflatable reservoir; one had cranial displacement of the band, and two had migration of the band into the stomach. Removal of the gastric band was necessary in 11 cases, and removal of the reservoir alone had to be performed in three additional patients. Radiology plays an important role in evaluating complications after gastric restriction surgery. Knowing the variety of findings enables accurate treatment planning and follow-up of these patients.

Biliopancreatic diversion.

Biliopancreatic diversion (BPD) has made reacceptable the malabsorptive approach to the surgical treatment of obesity. The procedure, in a series of 2241 patients operated on during a 21-year period, caused a mean permanent reduction of about 75% of the initial excess weight. The indefinite weight maintenance appears to be due to the existence of a threshold absorption capacity for fat and starch, and thus energy, and the weight loss is partly due to increased resting energy expenditure. Beneficial effects other than those consequent to weight loss or reduced nutrient absorption included permanent normalization of serum glucose and cholesterol without any medication and on totally free diet in 100% of cases, both phenomena being due to a specific action of the operation. Operative mortality was less than 0.5%. Specific late complications included anemia, less than 5% with adequate iron or folate supplementation (or both); stomal ulcer, reduced to 3.2% by oral H2-blocker prophylaxis; bone demineralization, increasing up to the fourth year and tending to decrease thereafter, with need of calcium and vitamin D supplementation; neurologic complications, totally avoidable by prompt vitamin B administration to patients at risk; protein malnutrition, which was reduced to a minimum of 3% with 1.3% recurrence, in exchange with a smaller weight loss, by adapting the volume of the gastric remnant and the length of the alimentary limb to the patient's individual characteristics. It is concluded that the correct use of BPD, based on the knowledge of its mechanisms of action, can make the procedure an effective, safe one in all hands.

Role of impression cytology during hypovitaminosis A.

AIMS: Evaluation of the morphological damage to the ocular surface of patients operated for biliopancreatic diversion for pathological obesity and the correlation of impression cytology with vitamin A plasma levels, adaptometry, and other general variables. METHODS: 48 patients (15 males, 33 females, age range 21-73) and 34 normal subjects were examined with fluorescein and rose bengal, a plasma dose of vitamin A, and adaptometry. The results of the various tests were subdivided into three levels (0 = normal, 1 = moderately altered, 2 = seriously altered). The impression cytology and adaptometry results were correlated with vitamin A levels and other patient data (age, nutritional condition, time since operation, percentage weight loss). All the examinations were repeated after intramuscular therapy with vitamin A. RESULTS: Corneoconjunctival alterations visible with fluorescein and rose bengal staining were present in 67.7% of cases, impression cytology alterations in 93.7%, adaptometric alterations in 82.2%; vitamin A plasma levels were below normal in 95.8% of cases. After the therapy with vitamin A a significant reduction was found for every examination. The correlation between impression cytology and adaptometry and vitamin A plasma levels and between corneoconjunctival alterations and vitamin A plasma levels was significant. There was no significant correlation between impression cytology and nutritional condition, age time since operation, and percentage weight loss. CONCLUSION: These results show impression cytology is a specific indicator for hypovitaminosis A because it is not influenced by other factors related to the general condition of the patient. Many patients with hypovitaminosis A not demonstrating ocular symptoms of changes visible with fluorescein and rose bengal showed alterations with impression cytology.

Hernia repair in elderly patients.

BACKGROUND: This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population. METHODS: From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66-93) years). Concomitant diseases were present in 157 patients. A mesh repair was performed with 'tension-free' or 'plug' techniques in all but 23 inguinal and two femoral hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia. RESULTS: There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotal haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair. CONCLUSION: Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.

Achievement of near-normal body weight as the prerequisite to normalize sex hormone-binding globulin concentrations in massively obese men.

OBJECTIVE: To investigate the effects of weight loss on sex hormone-binding globulin (SHBG) in massively obese males and whether normal SHBG concentrations could be obtained regardless or not of the achievement of normal body weight values. DESIGN AND SUBJECTS: Sera were collected for SHBG determination from 63 massively obese men, partly before they underwent biliopancreatic diversion (pre-op group = 11) and partly during the post-surgical follow up (post-op group = 52), and twenty normal weight healthy control men. MEASUREMENTS: Serum SHBG was measured using a noncompetitive liquid-phase immunoradiometric assay. RESULTS: Baseline general characteristics were similar in both obese groups. Obese patients in the post-op group had lost 46.4 +/- 2.9 kg since they had undergone operation, namely during a mean period of 14.9 +/- 13.8 (range 1-58) months follow up. Obese groups had significantly lower SHBG than normal weight controls (66.2 +/- 18.6 nmol/l). However, pre-op obese (19.9 +/- 5.5 nmol/l) had significantly lower values than post-op obese subjects (45.5 +/- 24.8 nmol/l; P < 0.001). There were a highly significant correlation between SHBG and individual BMI values (r = -0.629; P < 0.001). Moreover, the post-op obese with BMI values lower or equal to 28 had significantly higher SHBG concentrations than those with BMI greater than 28 (62.8 +/- 22.2 nmol/l vs 32.1 +/- 19.6 nmol/l; P < 0.001), but not significantly different with respect to normal weight controls. CONCLUSIONS: Massively obese men weight loss can completely reverse SHBG abnormalities, which can be restored to the normal range when near-normal body weight is achieved. Since reduced SHBG concentrations can be an independent risk factor for the development of diabetes and cardiovascular disease, this represents an additional benefit of weight loss program in massively obese individuals.

[Morpho-functional adaptation and motility of the small intestine and colon after extensive intestinal exclusions]. / Adattamento morfo-funzionale e motorio del tenue e del colon dopo estese esclusioni intestinali.

Recent advances in anesthetic and surgical techniques have increased the survival of patients after extensive bowel exclusions. This, in addition to the increased use of intestinal bypass for the treatment of obesity, has substantially increased the number of persons living with a short bowel. Proper management of these individuals is based on a thorough understanding of the pathophysiology of the shortened gastrointestinal tract.

[Pregnancy after surgical therapy of obesity. Bibliographic review and our experience with biliopancreatic diversion]. / Gravidanza dopo terapia chirurgica dell'obesità. Revisione bibliografica e nostra esperienza con la diversione biliopancreatica.

BACKGROUND: An increasing number of women in childbearing age are submitted to surgical treatment of obesity; for this reason pregnancy represents a frequent event in operated patients. METHODS: In this study pregnancy in patients with morbid obesity submitted to jejunoileal bypass (JIB) and gastric bypass (GB) are reviewed from the literature and the analysis of our experience with biliopancreatic diversion (BPD) is reported. RESULTS: In 113 pregnancies after JIB reviewed from the literature, the results seem to be debated either about the course of pregnancy or about maternal and neonatal status. The data of literature concerning the pregnancies following GB are less debated but rather slight. One hundred and fifty-two pregnancies after BPD have a complete documentation concerning maternal conditions, modality of outcome and neonatal situation. CONCLUSIONS: Pregnancy occurred in the obese women represents an increased maternal-fetal risk. The excess weight loss, the weight maintenance and the reduced weight changes during pregnancy are an advantage in the operate women who, in any case, need accurate controls of the nutritional status during the whole gestational period. Keeping these cautions pregnancy following surgical treatment of obesity represents an event not only possible but even with less problems than in pregnancy in obese women.

Body composition and energy expenditure in obese patients prior to and following biliopancreatic diversion for obesity.

Body composition and resting energy expenditure (REE) were assessed in 69 obese patients prior to and 1 year following biliopancreatic diversion (BPD). Fat-free mass (FFM) and body fat sizes were very similar to those of nonoperated subjects closely matched for body weight and FFM size. In the BPD subjects, the REE data were high, thus excluding a dilatation of non-energy-consuming extracellular spaces and suggesting an increase in the ratio between the organs and the less metabolically active muscle mass within the FFM.