Serum levels of osteopontin predict diabetes remission after bariatric surgery.

AIM: Bariatric surgery has been shown to effectively improve glycaemic control in morbidly obese subjects. However, the molecular bases of this association are still elusive and may act independently of weight loss. Here, our retrospective study has investigated the inflammatory molecule osteopontin (OPN) as a potential predictor of type 2 diabetes mellitus (T2DM) remission. METHODS: Baseline serum levels of OPN were analyzed in 41 T2DM patients who underwent bariatric surgery. Anthropometric measures and biochemical variables, including insulin sensitivity indices (HOMA2), were assessed at baseline and at 1 and 3 years after surgery. RESULTS: At baseline, patients who experienced T2DM remission had increased waist circumference, body weight and BMI, and higher serum OPN, compared with non-remitters. Patients with and without T2DM remission improved their lipid and glucose profiles, although insulin resistance indices were only improved in the T2DM remission group. In the overall cohort of both T2DM remission and non-remission patients, baseline circulating levels of OPN significantly correlated with reductions of body weight and BMI over time, and insulin sensitivity improved as well. However, only the HOMA2-%S remained independently associated with serum OPN on multivariate linear regression analysis (B: 0.227, 95% CI: 0.067-0.387, ß = 0.831; P = 0.010). Baseline values of OPN predicted 3-year T2DM remission independently of body weight loss, lower BMI and duration of diabetes (OR: 1.046, 95% CI: 1.004-1.090; P = 0.033). CONCLUSION: Although larger studies are still needed to confirm our preliminary results, pre-operative OPN serum levels might be useful for predicting 3-year T2DM remission independently of weight loss in patients undergoing bariatric surgery.

High baseline C-reactive protein levels predict partial type 2 diabetes mellitus remission after biliopancreatic diversion.

BACKGROUND AND AIMS: Several studies demonstrated that surgery can improve inflammation parameters, such as C-reactive protein (CRP). Few biomarkers have been investigated to potentially predict type 2 diabetes mellitus (T2DM) remission. We aimed at determining whether pre-surgery serum CRP levels could predict T2DM remission after 3 years in patients undergoing bariatric surgery, especially biliopancreatic diversion (BPD). METHODS AND RESULTS: This study was conducted from 2007 to 2009 at the Surgical Department of the University of Genoa, Italy. Forty-four patients with T2DM undergoing BPD (n = 38) or Roux-en-Y gastric bypass (n = 6) were enrolled. The primary endpoint was to evaluate whether pre-surgery CRP levels could predict T2DM partial remission at 3-year follow-up. Secondary endpoints were to assess whether glycaemic, lipid, and inflammatory parameters modified during the follow-up. At baseline, patients with T2DM ranged from overweight to morbid obesity, had mild dyslipidaemia, and a low-grade inflammation. Bariatric surgery improved body weight, lipid and glycaemic profile both at 1- and 3-year follow-up. Pre-surgery CRP levels progressively decreased at 1- and 3-year follow-up. Among inflammatory pre-surgery parameters, only high CRP levels were shown to predict T2DM partial remission after 3 years. Multivariate analysis confirmed the predictive value of pre-surgery CRP levels independently of age, gender, type of surgery, and body mass index. CONCLUSION: Bariatric surgery, in particular BPD, improved both metabolic and inflammatory biomarkers at 1- and 3-year follow-up. Pre-surgery high CRP levels predicted 3-year T2DM partial remission, indicating a promising target population to be especially treated with BPD.

Do clinical and behavioural correlates of obese patients seeking bariatric surgery differ from those of individuals involved in conservative weight loss programme?

BACKGROUND: Clinical practice has suggested that, in severely obese patients seeking bariatric surgery, clinical conditions, behavioural characteristics and psychological status might all differ from those of their counterparts starting conventional conservative therapy. METHODS: Two groups of obese patients with closely similar body mass values were considered. The first group included individuals voluntarily and spontaneously seeking biliopancreatic diversion and the second group comprised patients at the beginning of a weight loss programme. After anthropometric and metabolic evaluation, the patients underwent an alimentary interview; eating behaviour and psychological status were assessed by Three Factor Eating Questionnaire and by Toronto Alexithymia Scale (TAS). RESULTS: Among bariatric candidates, a greater number of individuals with type 2 diabetes and dyslipidaemia and high tendency to disinhibition and susceptibility to hunger scores was observed, whereas the other aspects of eating pattern were essentially similar. In the two groups, no difference in TAS score and or number of patients with alexithymic traits was observed. Finally, a logistic regression model showed that only age and metabolic derangement predicted the bariatric option, whereas eating behaviour or psychological status did not influence individual therapeutic choice. CONCLUSIONS: Independently of the degree of obesity, bariatric surgery was requested by the more metabolically deranged patients, whereas, in the surgical candidates, the eating pattern and psychological conditions were very similar to those of obese persons at the beginning of a conservative weight loss programme. These results suggest a highly realistic and practical attitude in severely obese patients towards obesity and bariatric surgery.

Preoperative assessment of respiratory function in severely obese patients undergoing biliopancreatic diversion.

Since severe obesity is often associated with a pulmonary function defect and abdominal surgery increases the risks of respiratory postoperative complications (RPC), an increased incidence of RPC might occur after bariatric operations. A cohort of 146 severely obese patients undergoing biliopancreatic diversion (BPD) was retrospectively evaluated for the occurrence of RPC. Respiratory function was evaluated prior to BPD from the quotient between measured and predicted values of forced vital capacity (FVC), forced expiratory volume in 1 s (FEV(1)) and the Tiffeneau index (TI: FEV(1)/FVC). In this cohort of obese individuals the BMI degree prior to the operation was totally unrelated to the standardized values of TI and to the presence of restrictive or obstructive pulmonary disease. Globally, a very low rate of RPC (7.5%) was found; in patients with suspected restrictive pulmonary impairment, a high occurrence of RPC was observed (p < 0.05). When data are controlled for preoperative BMI values, smoking status and presence of sleep apnoea, a logistic regression model indicates that respiratory function data cannot predict the occurrence of RPC after bariatric surgery.

Norethisterone acetate in the treatment of colorectal endometriosis: a pilot study.

BACKGROUND: This pilot study evaluates the efficacy of norethisterone acetate in treating pain and gastrointestinal symptoms of women with colorectal endometriosis. METHODS: This prospective study included 40 women with colorectal endometriosis, who had pain and gastrointestinal symptoms. Patients received norethisterone acetate (2.5 mg/day) for 12 months; in case of breakthrough bleeding, the dose of norethisterone acetate was increased by 2.5 mg/day. The degree of patient satisfaction with treatment (primary end-point) and the changes in symptoms (secondary end-point) were evaluated. Side effects of treatment were recorded. RESULTS: Norethisterone acetate determined a significant improvement in the intensity of chronic pelvic pain, deep dyspareunia, dyschezia. Treatment determined the disappearance of symptoms related to the menstrual cycle (dysmenorrhea, constipation during the menstrual cycle, diarrhoea during the menstrual cycle and cyclical rectal bleeding). The severity of diarrhoea, intestinal cramping and passage of mucus significantly improved during treatment. On the contrary, the administration of norethisterone acetate did not determine a significant effect on constipation, abdominal bloating and feeling of incomplete evacuation after bowel movements. At the completion of treatment, 57% of the patients with diarrhoea or diarrhoea during the menstrual cycle continued the treatment with norethisterone acetate compared with 17% of the patients with constipation or constipation during the menstrual cycle. CONCLUSIONS: In some patients with bowel endometriosis, the administration of norethisterone acetate may determine a relief of pain and gastrointestinal symptoms. This therapy has greater benefits in patients with gastrointestinal symptoms related to the menstrual cycle, diarrhoea and intestinal cramping.

Influence of 5-HT4 receptor activation on acetylcholine release in human large intestine with endometriosis.

BACKGROUND: The 5-HT(4) receptor agonist prucalopride enhances large intestinal contractility by facilitating acetylcholine release through activation of 5-HT(4) receptors on cholinergic nerves and is effective in patients with constipation. Patients with intestinal endometriosis can present with constipation. We investigated in vitro whether large intestinal endometriotic infiltration influences contractility and facilitation of acetylcholine release by prucalopride. METHODS: Sigmoid colon or rectum circular muscle strips were obtained at the level of an endometriotic nodule with infiltration of the Auerbach plexus, and at a macroscopically healthy site at least 5 cm cranially from the nodule, in patients undergoing laparoscopic colorectal resection because of symptomatic bowel endometriosis. Responses to muscarinic receptor stimulation and to electrical field stimulation (EFS), and the facilitating effect of prucalopride on acetylcholine release were evaluated. KEY RESULTS: The EC50 and E(max) of the contractile responses to the muscarinic receptor agonist carbachol did not differ between healthy and lesioned strips. EFS-induced on-contractions were not different between the healthy and lesioned strips, while the non-nitrergic relaxant responses induced by EFS were decreased in the lesioned strips. The facilitating effect of prucalopride on acetylcholine release in healthy strips was similar to that reported before in macroscopically healthy colon tissue of patients with colon cancer; in lesioned strips, the effect of prucalopride was fully maintained in 6/8 patients and absent in two. CONCLUSIONS & INFERENCES: Large intestinal endometriosis does not lead to a systematic interference with the cholinergic facilitating effect of prucalopride.

Letrozole combined with norethisterone acetate compared with norethisterone acetate alone in the treatment of pain symptoms caused by endometriosis.

BACKGROUND: The available data on effectiveness of aromatase inhibitors in treating pain symptoms related to endometriosis is limited. We compared the efficacy and tolerability of the aromatase inhibitor letrozole combined with norethisterone acetate versus norethisterone acetate alone in treating pain symptoms. METHODS: This prospective, open-label, non-randomized trial included 82 women with pain symptoms caused by rectovaginal endometriosis. Patients received either a combination of letrozole and norethisterone acetate (group L) or norethisterone acetate alone (group N) for 6 months. Changes in pain symptoms during treatment and in the 12 months of follow-up were evaluated. Side effects of each treatment protocol were recorded. RESULTS: Intensity of chronic pelvic pain and deep dyspareunia significantly decreased during treatment (P < 0.001 versus baseline by 3 months) in both study groups. At both 3- and 6-month assessment, the intensity of chronic pelvic pain (P < 0.001, P = 0.002, respectively) and deep dyspareunia (P < 0.001, P = 0.005, respectively) was significantly lower in group L than group N. At completion of treatment, 63.4% of women in group N were satisfied with treatment compared with 56.1% in group L (P = 0.49). Pain symptoms recurred after the completion of treatment; at 6-month follow-up no difference was observed in the intensity of pain symptoms between the groups. Adverse effects were more frequent in group L than in group N (P = 0.02). CONCLUSIONS: The combination drug regimen was more effective in reducing pain and deep dyspareunia than norethisterone acetate; however, letrozole caused a higher incidence of adverse effects, cost more and did not improve patients' satisfaction or influence recurrence of pain.

Functional heartburn has more in common with functional dyspepsia than with non-erosive reflux disease.

INTRODUCTION: Functional dyspepsia and non-erosive reflux disease (NERD) are prevalent gastrointestinal conditions with accumulating evidence regarding an overlap between the two. Still, patients with NERD represent a very heterogeneous group and limited data on dyspeptic symptoms in various subgroups of NERD are available. AIM: To evaluate the prevalence of dyspeptic symptoms in patients with NERD subclassified by using 24 h impedance-pH monitoring (MII-pH). METHODS: Patients with typical reflux symptoms and normal endoscopy underwent impedance-pH monitoring off proton pump inhibitor treatment. Oesophageal acid exposure time (AET), type of acid and non-acid reflux episodes, and symptom association probability (SAP) were calculated. A validated dyspepsia questionnaire was used to quantify dyspeptic symptoms prior to reflux monitoring. RESULTS: Of 200 patients with NERD (105 female; median age, 48 years), 81 (41%) had an abnormal oesophageal AET (NERD pH-POS), 65 (32%) had normal oesophageal AET and positive SAP for acid and/or non-acid reflux (hypersensitive oesophagus), and 54 (27%) had normal oesophageal AET and negative SAP (functional heartburn). Patients with functional heartburn had more frequent (p<0.01) postprandial fullness, bloating, early satiety and nausea compared to patients with NERD pH-POS and hypersensitive oesophagus. CONCLUSION: The increased prevalence of dyspeptic symptoms in patients with functional heartburn reinforces the concept that functional gastrointestinal disorders extend beyond the boundaries suggested by the anatomical location of symptoms. This should be regarded as a further argument to test patients with symptoms of gastro-oesophageal reflux disease in order to separate patients with functional heartburn from patients with NERD in whom symptoms are associated with gastro-oesophageal reflux.

Pouch diverticula after vertical-banded gastroplasty.

PURPOSE: Diverticula of the proximal gastric pouch are rare after vertical-banded gastroplasty (VBG) for morbid obesity. We report the radiographic findings observed in a series of 12 patients with pouch diverticula. MATERIALS AND METHODS: Lesions were found along the posteromedial wall of the proximal gastric pouch and ranged in size from 10 to 25 mm. Only two patients were symptomatic at the time of diagnosis; in most cases, diverticula were discovered during studies performed as part of the standard follow-up protocol. Diverticula were followed up in 7/12 cases, and four showed slight enlargement over a period ranging from 14 to 53 months. RESULTS: The presence of diverticula was not correlated with symptoms, postoperative weight loss, or clinical history, and no differences in long-term complications were demonstrated between VBG patients with diverticula and those without them. CONCLUSIONS: We do not believe these lesions to be clinically important; at present, our patients are no longer followed up for this problem and undergo diagnostic examinations only if and when they develop symptoms.

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.

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.

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.

Anterior tension-free repair of recurrent inguinal hernia under local anesthesia: a 7-year experience in a teaching hospital.

OBJECTIVE: To describe a 7-year experience with recurrent inguinal hernia repair performed mainly with tension-free mesh or plug technique under local anesthesia through the anterior approach, and to evaluate the safety and effectiveness of this method of treatment. METHODS: One hundred forty-five elective and 1 emergency herniorrhaphies for recurrent groin hernia were performed in 141 subjects (134 men and 7 women) with a mean age of 65 years (range 30-89). Concomitant medical and surgical problems were present in 73% and 8% of subjects, respectively. In 28 instances, the relapsed hernia had already been operated on once or twice for recurrence. A traditional hernioplasty had been previously performed in the vast majority of cases (136). Tension-free mesh or plug techniques through an anterior approach under local anesthesia were performed in 144 reoperations. Preperitoneal mesh repair and general or spinal anesthesia were used in all but one case when herniorrhaphy was performed during simultaneous operations. RESULTS: Mean hospital stay after surgery was 1.5 days (range 3 hours-14 days). No perioperative deaths occurred in this series. General complications were one case of acute intestinal bleeding and two cases of urinary retention. Local complications consisted of eight (5.5%) minor complications and one case of orchitis (0.7%) followed by testicular atrophy. In no instance was postoperative neuralgia or chronic pain reported. Two re-recurrences occurred. CONCLUSIONS: Given the low complication rate in this and other reported series and the absence of surgical or general complications described after preperitoneal open or laparoscopic repair and after general and spinal anesthesia, anterior mesh repair under local anesthesia seems to be a low-cost surgical technique that can be safely and effectively used even in a teaching hospital for the treatment of the majority of patients with recurrent groin hernias.