Tissue-specific inflammation and insulin sensitivity in subjects with obesity.

Obesity is associated with low-grade inflammation and insulin resistance (IR). The contribution of adipose tissue (AT) and hepatic inflammation to IR remains unclear. We conducted a study across three cohorts to investigate this relationship. The first cohort consists of six women with normal weight and twenty with obesity. In women with obesity, we found an upregulation of inflammatory markers in subcutaneous and visceral adipose tissue, isolated AT macrophages, and the liver, but no linear correlation with tissue-specific insulin sensitivity. In the second cohort, we studied 24 women with obesity in the upper vs lower insulin sensitivity quartile. We demonstrated that several omental and mesenteric AT inflammatory genes and T cell-related pathways are upregulated in IR, independent of BMI. The third cohort consists of 23 women and 18 men with obesity, studied before and one year after bariatric surgery. Weight loss following surgery was associated with downregulation of multiple immune pathways in subcutaneous AT and skeletal muscle, alongside notable metabolic improvements. Our results show that obesity is characterised by systemic and tissue-specific inflammation. Subjects with obesity and IR show a more pronounced inflammation phenotype, independent of BMI. Bariatric surgery-induced weight loss is associated with reduced inflammation and improved metabolic health.

Increased plasma ANGPTL7 levels with increased obstructive sleep apnea severity.

Background: Weight-loss surgery is one of the recommended methods for treating obstructive sleep apnea (OSA) in obese patients. While weight reduction is critical to relieve symptoms of OSA, the biochemical factors involved in post-surgery improvement are still unknown. We aimed to explore the link between ANGPTL7 and OSA in patients with different OSA severity. Furthermore, we examined the effect of treating OSA with bariatric surgery on ANGPTL7 level. Methods: We quantified levels of circulating ANGPTL7 in fasting plasma and adipose tissue samples of 88 participants before and after bariatric surgery. Confocal microscopy analyses were also performed to assess the ANGPTL7 expression in subcutaneous white adipose tissue biopsies obtained from people with moderate-to-severe OSA compared to those with none or mild OSA. The study involved 57 individuals with none or mild OSA and 31 patients with moderate-to-severe OSA. Results: Levels of circulating ANGPTL7 were significantly higher in people with moderate-to-severe OSA (1440 ± 1310 pg/ml) compared to the none or mild OSA group (734 ± 904 pg/ml, p = 0.01). The increase in ANGPTL7 correlated significantly and positively with the apnea-hypopnea index (AHI, r = .226, p = .037), and AHI-supine (r = .266, p = .019) in participants with moderate-to-severe OSA. Multivariate logistic regression analysis demonstrated an association between ANGPTL7 and OSA severity (log2 ANGPTL7; OR =1.24, p = 0.024). ANGPTL7 levels exhibited significant positive correlations with the levels of TG and oxLDL (p-value = 0.002 and 0.01 respectively). Bariatric surgery reduced the levels of both ANGPTL7 and AHI significantly. Conclusion: Here we report significantly increased levels of ANGPTL7 both in the circulation and in adipose tissue of patients with OSA, which concurred with increased inflammation and OSA severity. Levels of ANGPTL7 decreased significantly as OSA showed a significant improvement post-surgery supporting a potential role for ANGPTL7 in either OSA progression or a role in an OSA-related mechanism.

Recommendations on the most suitable quality-of-life measurement instruments for bariatric and body contouring surgery: a systematic review.

OBJECTIVE: The objective of this study is to systematically assess the quality of existing patient-reported outcome measures developed and/or validated for Quality of Life measurement in bariatric surgery (BS) and body contouring surgery (BCS). METHODS: We conducted a systematic literature search in PubMed, EMBASE, PsycINFO, CINAHL, Cochrane Database Systematic Reviews and CENTRAL identifying studies on measurement properties of BS and BCS Quality of Life instruments. For all eligible studies, we evaluated the methodological quality of the studies by using the COnsensus-based Standards for the selection of health Measurement INstruments checklist and the quality of the measurement instruments by applying quality criteria. Four degrees of recommendation were assigned to validated instruments (A-D). RESULTS: Out of 4,354 articles, a total of 26 articles describing 24 instruments were included. No instrument met all requirements (category A). Seven instruments have the potential to be recommended depending on further validation studies (category B). Of these seven, the BODY-Q has the strongest evidence for content validity in BS and BCS. Two instruments had poor quality in at least one required quality criterion (category C). Fifteen instruments were minimally validated (category D). CONCLUSION: The BODY-Q, developed for BS and BCS, possessed the strongest evidence for quality of measurement properties and has the potential to be recommended in future clinical trials.

Validity of a simple sleep monitor for diagnosing OSA in bariatric surgery patients.

BACKGROUND: One third of bariatric surgery patients have an apnea-hypopnea index (AHI)>15/hr, representing moderate and severe forms of obstructive sleep apnea (OSA). Treating these forms of OSA is recommended to reduce the risk of perioperative complications. The AHI derived from poly(somno)graphy [P(S)G] is the gold standard for OSA diagnosis. However, performing P(S)G in all patients scheduled for bariatric surgery is time consuming and expensive. An accurate and simple screening tool able to rule out moderate to severe OSA would reduce the number of patients needing mandatory P(S)Gs. OBJECTIVES: To assess the validity of a simple sleep monitor (Checkme Health Monitor) as a screening tool for OSA in bariatric surgery patients. SETTING: Obesity Center Amsterdam, OLVG-West, Amsterdam, the Netherlands METHODS: Patients scheduled for bariatric surgery were prospectively enrolled in this study. All patients underwent preoperative P(S)G and simultaneously used the Checkme to assess the oxygen desaturation index. The diagnostic performance of the Checkme for AHI ≥15/hr was assessed using receiver operating characteristic curve analysis. RESULTS: A total of 50 patients were analyzed. Sensitivity and negative predictive value were 100% and 100%, respectively, specificity and positive predictive value were 69% and 64%, respectively, for the optimal cutoff value of Checkme-3% oxygen desaturation index ≥9/hr for P(S)G-AHI ≥15. The area under the curve value expressed by the receiver operating characteristic curve was .95. CONCLUSION: The Checkme is valid for exclusion of moderate and severe OSA in bariatric surgery patients. The Checkme enables bariatric clinics not to perform P(S)G in all patients scheduled for bariatric surgery.

Impact of obstructive sleep apnea on quality of life after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: To examine the influence of obstructive sleep apnea (OSA) on the quality of life (QoL) in bariatric surgery. METHODS: All patients who underwent a laparoscopic Roux-and-Y gastric bypass (LRYGB), preoperative poly(somno)graphy and completed an Impact of Weight on QoL-Lite questionnaire before and after surgery were included. RESULTS: A total of 276 patients were included. OSA was diagnosed in 150 (53.3%) patients. All subscale scores improved 15 months post-surgery (p < 0.01). Total score improved from 51.2 (SD 19.1) to 89.7 (SD 13.9). Lower postoperative scores were seen in OSA patients on subscales Public Distress (90.4 SD 18.8 versus 95.7 SD 10.2; p = 0.003) and Work (92.9 SD 15 versus 96.1 SD 9.7; p = 0.031). All postoperative subscale scores were negatively correlated with OSA severity (p < 0.01). CONCLUSIONS: After LRYGB, QoL improved in both OSA and non-OSA patients. OSA patients, especially patients with severe OSA, have lower postoperative scores on subscales Public Distress and Work after LRYGB.

[Splenic abscess]. / Het miltabces.

Splenic abscess is a rare and potentially lethal clinical condition. The most common symptoms of a splenic abscess - abdominal pain, nausea and fever - are non-specific. As a result, a splenic abscess is often not considered in the initial work-up. This might lead to a delay in diagnosis and treatment. In this case series we successively describe a 41-year-old female with a splenic abscess after Streptococcus milleri bacteraemia, a 78-year-old male with a splenic abscess caused by a colon carcinoma and a 52-year-old male with a splenic abscess resulting from a colosplenic fistula after bariatric surgery. By emphasizing the different aetiologies, the different clinical presentations and the different therapeutic options of a splenic abscess, we aim to create greater awareness of this rare clinical phenomenon.

Do Complications Alter Postoperative Weight Loss 1 Year After Primary and Revisional Roux-en-Y Gastric Bypass?

BACKGROUND: Around 10 % of the bariatric surgery patients experience postoperative complications (<30 days). It could be hypothesized that complications influence postoperative weight loss, which is one of the most important endpoints of bariatric surgery. Therefore, this study inventoried the effect of complications on postoperative weight loss. METHODS: A consecutive database including patients who were operated from November 2007 onwards was retrospectively reviewed. All short-term complications were classified according to the Clavien-Dindo classification. Weight loss was assessed at 6 and 12 months postoperatively. RESULTS: A total of 1130 patients underwent either primary (n = 907, 80.3 %) or revisional (n = 233, 19.7 %) surgery till October 2013. Short-term complications occurred in 115 (10.2 %) patients, of whom 48 (41.7 %) had a severe (Clavien-Dindo ≥ 3) complication. One year post surgery, 184 patients (16.3 %) were lost to follow-up. Patients with a short-term complication had a higher percentage of excess weight loss (%EWL) at 6 months (58.6 (SD 16.6) versus 52.9 (SD 17.6), p = 0.003) and 1 year (71.9 (SD 22.3) versus 65.9 (SD 21.3), p = 0.017) of follow-up. Although a trend was seen toward higher BMI loss and total weight loss (TWL) after 6 months, no effect was seen 1 year postoperatively. In multivariable linear regression analysis, complications were not a significant predictor for 1-year %EWL. CONCLUSIONS: Although short-term complications alter 1-year %EWL, no effect was seen on BMI loss and TWL. In addition, complications were not a predictor in a multivariable linear regression model for 1-year %EWL. It can be concluded that short-term complications do not impair weight loss after Roux-en-Y gastric bypass.

Multicentre randomized controlled trial comparing ferric(III)carboxymaltose infusion with oral iron supplementation in the treatment of preoperative anaemia in colorectal cancer patients.

BACKGROUND: At least a third of patients with a colorectal carcinoma who are candidate for surgery, are anaemic preoperatively. Preoperative anaemia is associated with increased morbidity and mortality. In general practice, little attention is paid to these anaemic patients. Some will have oral iron prescribed others not. The waiting period prior to elective colorectal surgery could be used to optimize a patients' physiological status. The aim of this study is to determine the efficacy of preoperative intravenous iron supplementation in comparison with the standard preoperative oral supplementation in anaemic patients with colorectal cancer. METHODS/DESIGN: In this multicentre randomized controlled trial, patients with an M0-staged colorectal carcinoma who are scheduled for curative resection and with a proven iron deficiency anaemia are eligible for inclusion. Main exclusion criteria are palliative surgery, metastatic disease, neoadjuvant chemoradiotherapy (5 × 5 Gy = no exclusion) and the use of Recombinant Human Erythropoietin within three months before inclusion or a blood transfusion within a month before inclusion. Primary endpoint is the percentage of patients that achieve normalisation of the haemoglobin level between the start of the treatment and the day of admission for surgery. This study is a superiority trial, hypothesizing a greater proportion of patients achieving the primary endpoint in favour of iron infusion compared to oral supplementation. A total of 198 patients will be randomized to either ferric(III)carboxymaltose infusion in the intervention arm or ferrofumarate in the control arm. This study will be performed in ten centres nationwide and one centre in Ireland. DISCUSSION: This is the first randomized controlled trial to determine the efficacy of preoperative iron supplementation in exclusively anaemic patients with a colorectal carcinoma. Our trial hypotheses a more profound haemoglobin increase with intravenous iron which may contribute to a superior optimisation of the patient's condition and possibly a decrease in postoperative morbidity. TRIAL REGISTRATION: ClincalTrials.gov: NCT02243735 .

Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients: a systematic review.

Obesity is a major risk factor for the development of knee osteoarthritis, and over the past 30 years the prevalence of obesity has more than doubled. In an advanced-stage knee osteoarthritis is treated with total knee arthroplasty, and the demand for primary total knee arthroplasties is expected to grow exponentially. However, total knee arthroplasty in obese patients is associated with more complications, longer hospital stay and higher costs. We aimed to determine the effects of bariatric surgery on knee complaints in (morbidly) obese (body mass index >30 kg m(-2) ) adult patients. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, TRIP, BIOSIS-Previews and reference lists of retrieved publications were systematically searched from earliest available up to 20 April 2014 for any English, German, French and Dutch studies. There was no restriction on study design. We included studies on the effect of surgically induced weight reduction on knee complaints in (morbidly) obese adult patients, with a minimal follow-up of 3 months. Studies on the effects of lipectomy or liposuction and studies in which patients had already received a total knee arthroplasty were excluded. Thirteen studies were included in this systematic review with a total of 3,837 patients. Although different assessment tools were used, an overall significant improvement in knee pain was seen in 73% out of the used assessments. All studies measuring intensity of knee pain, knee physical function and knee stiffness showed a significant improvement after bariatric surgery. The quality of evidence was very low or too low for most of the included studies and moderate for one study. Bariatric surgery with subsequent marked weight loss is likely to improve knee pain, physical function and stiffness in (morbidly) obese adult patients. However, with the current available evidence, there is need for high-quality studies.

Small bowel obstruction, incisional hernia and survival after laparoscopic and open colonic resection (LAFA study).

BACKGROUND: Short-term advantages to laparoscopic surgery are well described. This study compared medium- to long-term outcomes of a randomized clinical trial comparing laparoscopic and open colonic resection for cancer. METHODS: The case notes of patients included in the LAFA study (perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care) were reviewed 2-5 years after randomization for incisional hernia, adhesional small bowel obstruction (SBO), overall survival, cancer recurrence and quality of life (QoL). The laparoscopic and open groups were compared irrespective of fast-track or standard perioperative care. RESULTS: Data on incisional hernias, SBO, survival and recurrence were available for 399 of 400 patients: 208 laparoscopic and 191 open resections. These outcomes were corrected for duration of follow-up. Median follow-up was 3·4 (i.q.r. 2·6-4·4) years. Multivariable regression analysis showed that open resection was a risk factor for incisional hernia (odds ratio (OR) 2·44, 95 per cent confidence interval (c.i.) 1·12 to 5·26; P = 0·022) and SBO (OR 3·70, 1·07 to 12·50; P = 0·039). There were no differences in overall survival (hazard ratio 1·10, 95 per cent c.i. 0·67 to 1·80; P = 0·730) or in cumulative incidence of recurrence (P = 0·514) between the laparoscopic and open groups. There were no measured differences in QoL in 281 respondents (P > 0·350 for all scales). CONCLUSION: Laparoscopic colonic surgery led to fewer incisional hernia and adhesional SBO events. REGISTRATION NUMBER: NTR222 (http://www.trialregister.nl).

The impact of surgical complications as a main risk factor for venous thromboembolism: a multicenter study.

BACKGROUND: Studies suggest that postoperative complications are a risk factor for venous thromboembolism (VTE) after bariatric surgery. Knowledge of factors associated with a higher risk of VTE after bariatric surgery may be essential to select patients who may benefit from either prolonged or intensified thrombosis prophylaxis. The aim of this study is to determine the relationship between postoperative complications and VTE after bariatric surgery and other classical risk factors. METHODS: A retrospective multicenter case-control study was performed in patients who had bariatric surgery between January 2008 and September 2011. VTE until 6 months after surgery was registered, and patients were contacted to ascertain the results. For every case of VTE after surgery, 6 control patients were selected who were matched for gender, age, participating center and type of surgery. Risk factors for VTE before and after surgery and postoperative complications were registered. RESULTS: A total of 2,064 surgeries were included. In 12 patients, VTE occurred within 6 months after bariatric surgery (incidence 0.58 %, 95 % confidence interval (CI) = 0.25-0.93). There was a strong association of complications after surgery (cases 91.7 %, controls 15.3 %, odds ratio (OR) 61.0; 95 % CI = 7.1-521.3) or intensive care admission (cases 50.0 %, controls 11.1 %, OR = 8.0; 95 % CI = 2.1-30.8) with VTE. The majority of postoperative complications were anastomotic leak, abdominal abscess, and infection. We could not detect an association between classical thrombosis risk factors and postoperative VTE. CONCLUSIONS: The incidence of VTE is low after bariatric surgery using thrombosis prophylaxis. However, there is a strong association between postoperative complications and VTE. These patients may benefit from more intensive thrombosis prophylaxis.

Assessment of the effect of bariatric surgery on obstructive sleep apnea at two postoperative intervals.

BACKGROUND: Studies have reported significant improvement of obstructive sleep apnea (OSA) in obese patients after bariatric surgery (BS). Weight loss following BS is rapid in the first few months, but it can take at least 1 year to reach the final result. The aim of this study is to measure the effect of BS on various clinical, respiratory, and sleep parameters of OSA at two postoperative intervals. METHODS: Prospectively, all patients being evaluated for BS underwent a polysomnography (PSG). Patients diagnosed with OSA preoperatively were invited to undergo a PSG at least 6 months postoperatively and if OSA persisted, again at least 12 months postoperatively. RESULTS: One hundred ten patients underwent a first postoperative PSG 7.7 months after surgery. The mean apnea-hypopnea index (AHI) significantly decreased from 39.5 to 15.6/h. In 58.2 %, the AHI was reduced to below 10 and in 25.5 % to below 5. Fifty patients underwent a first PSG 7.1 months and a second PSG 16.9 months after surgery. The mean AHI decreased from 49.1 to 22.7 to 17.4/h following BS. CONCLUSIONS: BS initiates dramatic improvement and even remission of clinical and sleep parameters during the first 7 months, which continues at a slower rate over the next 10 months. We recommend a follow-up PSG after surgery to check for residual disease and if necessary retritration of continuous positive airway pressure, which may lead to higher treatment compliance.

Ethnicity influences weight loss 1 year after bariatric surgery: a study in Turkish, Moroccan, South Asian, African and ethnic Dutch patients.

Several studies conducted in the USA have demonstrated that the effectiveness of bariatric surgery differs between patients from African and European origin. However, little is known on differences in outcomes after bariatric surgery between individuals from other ethnic backgrounds. In this retrospective study, we found that, in terms of weight loss, gastric bypass surgery is less effective in African, South Asian, Turkish and Moroccan patients than in their ethnic Dutch counterparts. Our results underscore that ethnic differences in the effectiveness of bariatric surgery are not limited to those between patients of African and European origin, but extend to other minority groups as well. Therefore, it is important that prospective studies both determine ethnic differences in weight loss-related improvement of co-morbidities and elucidate the exact reasons for these ethnic disparities.

Bariatric surgery is an effective treatment for morbid obesity.

The global obesity epidemic is also affecting the Netherlands, paralleled by a proportional increase in the number of morbidly obese persons. Bariatric surgery has been included as a treatment for morbid obesity in the Dutch Guideline for Obesity (2008). Nonetheless, bariatric surgery is applied in only a limited number of morbidly obese subjects in the Netherlands. Based on the most recent literature and Dutch statistics, this review provides a summary of current knowledge on the impact of obesity on health and health care and highlights the effective role of bariatric surgery in reducing this threat to public health.

Evaluation of the appendicitis inflammatory response score for patients with acute appendicitis.

BACKGROUND: Acute appendicitis is still a difficult diagnosis. Scoring systems are designed to aid in the clinical assessment of patients with acute appendicitis. The Alvarado score is the most well known and best performing in validation studies. The purpose of the present study was to externally validate a recently developed appendicitis inflammatory response (AIR) score and compare it to the Alvarado score. METHODS: The present study selected consecutive patients who presented with suspicion of acute appendicitis between 2006 and 2009. Variables necessary to evaluate the scoring systems were registered. The diagnostic performance of the two scores was compared. RESULTS: The present study included 941 consecutive patients with suspicion of acute appendicitis. There were 410 male patients (44%) and 531 female patients (56%). The area under the receiver operating characteristic curve of the AIR score was 0.96 and significantly better than the area under the curve of 0.82 of the Alvarado score (p < 0.05). The AIR score also outperformed the Alvarado score when analyzing the more difficult patients, including women, children, and the elderly. CONCLUSIONS: This study externally validates the AIR Score for patients with acute appendicitis. The scoring system has a high discriminating power and outperforms the Alvarado score.

Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery.

The aim of this study was to evaluate prevalence of obstructive sleep apnea among patients undergoing bariatric surgery and the predictive value of various clinical parameters: body mass index (BMI), neck circumference (NC) and the Epworth Sleepiness Scale (ESS). We performed a prospective, multidisciplinary, single-center observational study including all patients on the waiting list for bariatric surgery between June 2009 and June 2010, irrespective of history or clinical findings. Patients visited our ENT outpatient clinic for patient history, ENT and general examination and underwent a full night polysomnography, unless performed previously. As much as 69.9% of the patients fulfilled the criteria for OSA (mean BMI 44.2 ± SD 6.4 kg/m(2)); 40.4% of the patients met the criteria for severe OSA. The regression models found BMI to be the best clinical predictor, while the ROC curve found the NC to be the most accurate predictor of the presence of OSA. The discrepancy of the results and the poor statistical power suggest that all three clinical parameters are inadequate predictors of OSA. In conclusion, in this large patient series, 69.9% of patients undergoing BS meet the criteria for OSA. More than 40% of these patients have severe OSA. A mere 13.3% of the patients were diagnosed with OSA before being placed on the waiting list for BS. On statistical analysis, increased neck circumference, BMI and the ESS were found to be insufficient predictors of the presence of OSA. Polysomnography is an essential component of the preoperative workup of patients undergoing BS. When OSA is found, specific perioperative measures are indicated.

Evaluating routine diagnostic imaging in acute appendicitis.

AIM: To evaluate the impact of selective imaging on clinical management of patients who present with symptoms suggesting acute appendicitis. MATERIALS AND METHODS: During a two-and-half year period, 941 consecutive patients with right lower quadrant pain were analyzed. Patients who underwent selective imaging were compared to those treated without further imaging. RESULTS: In 650 (69%) patients with right lower quadrant pain, diagnosis was based on medical history, physical and laboratory examination only. The diagnostic accuracy was 84%. Another 291 patients (31%) underwent selective imaging reaching a diagnostic accuracy of 71%. Ultrasound was conducted in 277 patients (sensitivity: 59%; specificity: 91%). CT scan was conducted in 43 patients (sensitivity: 100%; specificity: 95%). CONCLUSION: The present study shows that, in the majority of patients, appendicitis acuta can be diagnosed without the aid of imaging studies. In all these cases, high diagnostic accuracy rates and low morbidity rates were achieved. In all the other cases when clinical diagnosis is uncertain, further evaluation should include imaging. In our series ultrasound is of limited value; CT scan or diagnostic laparoscopy seems superior.