Increased mitochondrial respiration of adipocytes from metabolically unhealthy obese compared to healthy obese individuals.

Among obese subjects, metabolically healthy (MHO) and unhealthy obese (MUHO) subjects exist, the latter being characterized by whole-body insulin resistance, hepatic steatosis, and subclinical inflammation. Insulin resistance and obesity are known to associate with alterations in mitochondrial density, morphology, and function. Therefore, we assessed mitochondrial function in human subcutaneous preadipocytes as well as in differentiated adipocytes derived from well-matched donors. Primary subcutaneous preadipocytes from 4 insulin-resistant (MUHO) versus 4 insulin-sensitive (MHO), non-diabetic, morbidly obese Caucasians (BMI > 40 kg/m2), matched for sex, age, BMI, and percentage of body fat, were differentiated in vitro to adipocytes. Real-time cellular respiration was measured using an XF24 Extracellular Flux Analyzer (Seahorse). Lipolysis was stimulated by forskolin (FSK) treatment. Mitochondrial respiration was fourfold higher in adipocytes versus preadipocytes (p = 1.6*10-9). In adipocytes, a negative correlation of mitochondrial respiration with donors' insulin sensitivity was shown (p = 0.0008). Correspondingly, in adipocytes of MUHO subjects, an increased basal respiration (p = 0.002), higher proton leak (p = 0.04), elevated ATP production (p = 0.01), increased maximal respiration (p = 0.02), and higher spare respiratory capacity (p = 0.03) were found, compared to MHO. After stimulation with FSK, the differences in ATP production, maximal respiration and spare respiratory capacity were blunted. The differences in mitochondrial respiration between MUHO/MHO were not due to altered mitochondrial content, fuel switch, or lipid metabolism. Thus, despite the insulin resistance of MUHO, we could clearly show an elevated mitochondrial respiration of MUHO adipocytes. We suggest that the higher mitochondrial respiration reflects a compensatory mechanism to cope with insulin resistance and its consequences. Preserving this state of compensation might be an attractive goal for preventing or delaying the transition from insulin resistance to overt diabetes.

Patients with Schizophrenia Do Not Demonstrate Worse Outcome After Sleeve Gastrectomy: a Short-Term Cohort Study.

PURPOSE: The aim of this study was to compare surgical and psychiatric outcome and weight loss in schizophrenia patients with mentally healthy patients after sleeve gastrectomy. MATERIALS AND METHODS: A cohort study design was selected, comprising patients with schizophrenia with mentally healthy patients who underwent sleeve gastrectomy and were adherent to a follow-up at least 12 months after surgery. RESULTS: Seven schizophrenia (5 male, 2 female) and 59 (12 male, 47 female) mentally healthy patients were included in this study. A laparoscopic sleeve gastrectomy was performed safely in all 66 patients. The calculated excess weight loss (%EWL) showed no significant differences in both groups and reached 51.68 ± 15.84% for schizophrenia group and 60.68 ± 19.95% for mentally healthy group at 24-month follow-up (p = 0.33). The decrease in the HbA1c levels within 2 years after sleeve gastrectomy was similar in both groups (p = 0.79, 0.88, 0.82, 0.73 for surgery time, time of 6-, 12-, and 24-month follow-up respectively). The psychiatric status of the patients of the schizophrenia group was stable in all cases and no exacerbation of psychiatric symptoms was observed during time of follow-up. Furthermore, an overall significant improvement of the self-estimated mood and satisfaction was observed in both groups (Manova: f = 1.26, p < 0.0001). CONCLUSIONS: The results 2 years after sleeve gastrectomy in stable patients with schizophrenia and after an adequate psychological evaluation were encouraging and comparable to the outcome in mentally healthy patients.

Impact of protein supplementation after bariatric surgery: A randomized controlled double-blind pilot study.

OBJECTIVES: Bariatric patients are at risk of protein deficiency. The aim of this study was to determine possible benefits of postoperative protein supplementation weight reduction, body composition, and protein status. METHODS: Twenty obese patients who underwent bariatric surgery were randomized either to the protein (PRO) group, which received a daily protein supplement over 6 months postoperatively, or to the control (CON) group, which received an isocaloric placebo in a double-blind fashion. Data on protein and energy intake, body weight, body composition, blood proteins, and grip force was collected preinterventionally and at 1, 3, and 6 months postoperatively. RESULTS: In both groups body weight was significantly reduced to a similar extent (after 6 months: PRO group 25.4 ± 7.2%, CON group 20.9 ± 3.9%; intergroup comparison P > 0.05). Protein intake was steadily increased in the PRO group, but not in the CON group, and reached maximum at month 6 (25.4 ± 3.7% of energy intake versus 15.8 ± 4.4%; P < 0.001). In the PRO group, body fat mass loss was higher than that in the CON group (79% of absolute weight loss versus 73%; P = 0.02) while lean body mass loss was less pronounced (21% versus 27%, P = 0.05). Blood proteins and grip force did not differ at any time point between the two groups. CONCLUSIONS: The present study suggests that protein supplementation after bariatric surgery improves body composition by enhancing loss of body fat mass and reducing loss of lean body mass within the 6 months follow up.

A 1-year videoconferencing-based psychoeducational group intervention following bariatric surgery: results of a randomized controlled study.

BACKGROUND: For severely obese patients, bariatric surgery has been recommended as an effective therapy. OBJECTIVES: The Bariataric Surgery and Education (BaSE) study aimed to assess the efficacy of a videoconferencing-based psychoeducational group intervention in patients after bariatric surgery. SETTING: The BaSE study is a randomized, controlled multicenter clinical trial involving 117 patients undergoing bariatric surgery (mean preoperative body mass index [BMI] 49.9 kg/m(2), SD 6.4). Patients were enrolled between May 2009 and November 2012 and were randomly assigned to receive either conventional postsurgical visits or, in addition, a videoconferencing-based 1-year group program. METHODS: Primary outcome measures were weight in kilograms, health-related quality of life (HRQOL), and general self-efficacy (GSE). Secondary outcome measures were depression symptoms and eating behavior. RESULTS: 94% of the patients completed the study. Mean weight loss for all patients was 45.9 kg (SD 16.4) 1 year after surgery (mean excess weight loss [EWL] 63%). Intention-to-treat analyses revealed no differences in weight loss, EWL, HRQOL, or self-efficacy between study groups at 1 year after surgery. However, patients with clinically significant depression symptoms (CSD) at baseline assigned to the intervention group (n = 29) had a significantly better HRQOL (P = .03), lower depression scores (P = .02), and a trend for a better EWL (.06) 1 year after surgery compared with the control group (n = 20). CONCLUSION: We could not prove the efficacy of the group program for the whole study sample. However, results indicate that the intervention is effective for the important subgroup of patients with CSD.

Fibroblast growth factor 21 is elevated in metabolically unhealthy obesity and affects lipid deposition, adipogenesis, and adipokine secretion of human abdominal subcutaneous adipocytes.

OBJECTIVE: Serum concentrations of the hepatokine fibroblast growth factor (FGF) 21 are elevated in obesity, type-2 diabetes, and the metabolic syndrome. We asked whether FGF21 levels differ between subjects with metabolically healthy vs. unhealthy obesity (MHO vs. MUHO), opening the possibility that FGF21 is a cross-talker between liver and adipose tissue in MUHO. Furthermore, we studied the effects of chronic FGF21 treatment on adipocyte differentiation, lipid storage, and adipokine secretion. METHODS: In 20 morbidly obese donors of abdominal subcutaneous fat biopsies discordant for their whole-body insulin sensitivity (hereby classified as MHO or MUHO subjects), serum FGF21 was quantified. The impact of chronic FGF21 treatment on differentiation, lipid accumulation, and adipokine release was assessed in isolated preadipocytes differentiated in vitro. RESULTS: Serum FGF21 concentrations were more than two-fold higher in MUHO as compared to MHO subjects (457 ± 378 vs. 211 ± 123 pg/mL; p < 0.05). FGF21 treatment of human preadipocytes for the entire differentiation period was modestly lipogenic (+15%; p < 0.05), reduced the expression of key adipogenic transcription factors (PPARG and CEBPA, -15% and -40%, respectively; p < 0.01 both), reduced adiponectin expression (-20%; p < 0.05), markedly reduced adiponectin release (-60%; p < 0.01), and substantially increased leptin (+60%; p < 0.01) and interleukin-6 (+50%; p < 0.001) release. CONCLUSIONS: The hepatokine FGF21 exerts weak lipogenic and anti-adipogenic actions and marked adiponectin-suppressive and leptin and interleukin-6 release-promoting effects in human differentiating preadipocytes. Together with the higher serum concentrations in MUHO subjects, our findings reveal FGF21 as a circulating factor promoting the development of metabolically unhealthy adipocytes.

New telemetry device for the measurement of gastrointestinal motility in rats and comparison with standard equipment.

To perform stress-free recording of gastrointestinal motility in rats with strain gauge transducers, telemetry equipment had to be developed. We developed, programmed, and tested a new telemetry device that records gastrointestinal motility in freely moving rats using strain gauge transducers. The device can collect and transmit data in freely moving rats. Data are received and stored for later analysis with a regular PC. Linear calibration curves were obtained for the strain gauge transducers used. We compared data obtained with the new telemetry device with data gathered with standard equipment and could not find any statistically significant difference. Wired gastric and colonic contraction frequencies were 4.6 ± 0.3 per minute and 1.5 ± 0.3 per minute, whereas telemetric contraction frequencies were 4.4 ± 0.1 per minute and 1.25 ± 0.1 per minute. The new telemetry device is a very useful tool for the measurement of gastrointestinal motility in rats.

Effects of surgical and dietary weight loss therapy for obesity on gut microbiota composition and nutrient absorption.

Evidence suggests a correlation between the gut microbiota composition and weight loss caused by caloric restriction. Laparoscopic sleeve gastrectomy (LSG), a surgical intervention for obesity, is classified as predominantly restrictive procedure. In this study we investigated functional weight loss mechanisms with regard to gut microbial changes and energy harvest induced by LSG and a very low calorie diet in ten obese subjects (n = 5 per group) demonstrating identical weight loss during a follow-up period of six months. For gut microbiome analysis next generation sequencing was performed and faeces were analyzed for targeted metabolomics. The energy-reabsorbing potential of the gut microbiota decreased following LSG, indicated by the Bacteroidetes/Firmicutes ratio, but increased during diet. Changes in butyrate-producing bacterial species were responsible for the Firmicutes changes in both groups. No alteration of faecal butyrate was observed, but the microbial capacity for butyrate fermentation decreased following LSG and increased following dietetic intervention. LSG resulted in enhanced faecal excretion of nonesterified fatty acids and bile acids. LSG, but not dietetic restriction, improved the obesity-associated gut microbiota composition towards a lean microbiome phenotype. Moreover, LSG increased malabsorption due to loss in energy-rich faecal substrates and impairment of bile acid circulation. This trial is registered with ClinicalTrials.gov NCT01344525.

Single-port live donor nephrectomy using a novel Curved Radius r2 Surgical System in an in vivo model.

OBJECTIVE: Single-port laparoscopic donor nephrectomy provides low morbidity and satisfactory cosmetic results for patients. The aim of this animal study was to establish a surgical technique of single-site (LESS) living donor nephrectomy using novel curved r2 CURVE manipulators specially designed for single-port access. MATERIAL AND METHODS: A total of six LESS nephrectomies were performed in three female pigs. r2 CURVE-instruments (Tuebingen Scientific Medical GmbH) were used providing a curved rotatable shaft, endless tip rotation, as well as 90° tip deflection. A 10 mm 30° extra long laparoscope, r2-curved Grasper, Maryland dissector and bipolar scissors were used for mobilization and dissection. RESULTS: All LESS nephrectomies were performed successfully. Average operative time was 80 min (range, 42-149 min). No technical problems were observed. Insertion and extraction of the instruments through the single-port were easy to conduct. The diameter of the used single-port was sufficient for safe manual organ harvesting. Potential conflict between the laparoscope and the instrument handles was avoided by using an extra long laparoscope. CONCLUSIONS: The new curved and deflectable instruments showed that single-port nephrectomy using the R2 manipulators is feasible. Single-port laparoscopic nephrectomy might be more patient-friendly and improve the willingness of potential donors to donate live organs.

Markers of Bone Metabolism in Obese Individuals Undergoing Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Besides its advantages, bariatric surgery implicates a risk of nutritional deficiencies, which might result in impaired bone metabolism. We assessed the effect of laparoscopic sleeve gastrectomy (LSG) on blood markers of bone metabolism in obese patients during a 3-year observation period. METHODS: In 39 obese patients (29 women, 10 men, mean BMI 51.8 ± 6.8 kg/m(2)) undergoing LSG, we measured blood concentrations of 25-hydroxyvitamin D (25(OH)D), calcium, parathyroid hormone (PTH), bone alkaline phosphatase (BAP), and N-telopeptides crosslinks (NTx) before LSG and up to 3 years postoperatively. Vitamin D and calcium supplementations were recorded. RESULTS: LSG caused an excess weight loss (EWL) of 54 ± 20 % after 3 years. Before surgery, we found decreased levels of 25(OH)D and calcium in 80 and 5 % of the subjects, respectively, while increased levels of PTH, BAP, and NTx were found in 39, 28, and 21 %, respectively. Mean levels of NTx and the prevalence of elevated levels of NTx increased within 2 years (p < 0.001 and p < 0.01). Neither mean blood concentrations of 25(OH)D, calcium, PTH, and BAP nor relative prevalence of deficiencies regarding these markers changed during the study period. The supplementation rates of calcium and vitamin D increased postoperatively. CONCLUSIONS: Morbid obesity is associated with pronounced changes of markers of bone metabolism; LSG did neither aggravate nor ameliorate vitamin D metabolism within a 3-year time period, but led to increased bone resorption 2 years postoperatively. Routine supplementation of calcium and vitamin D is not likely sufficient to compensate the obesity-associated deficiencies in bone metabolism.

Metabolic signatures of cultured human adipocytes from metabolically healthy versus unhealthy obese individuals.

BACKGROUND AND AIMS: Among obese subjects, metabolically healthy and unhealthy obesity (MHO/MUHO) can be differentiated: the latter is characterized by whole-body insulin resistance, hepatic steatosis, and subclinical inflammation. Aim of this study was, to identify adipocyte-specific metabolic signatures and functional biomarkers for MHO versus MUHO. METHODS: 10 insulin-resistant (IR) vs. 10 insulin-sensitive (IS) non-diabetic morbidly obese (BMI >40 kg/m2) Caucasians were matched for gender, age, BMI, and percentage of body fat. From subcutaneous fat biopsies, primary preadipocytes were isolated and differentiated to adipocytes in vitro. About 280 metabolites were investigated by a targeted metabolomic approach intracellularly, extracellularly, and in plasma. RESULTS/INTERPRETATION: Among others, aspartate was reduced intracellularly to one third (p = 0.0039) in IR adipocytes, pointing to a relative depletion of citric acid cycle metabolites or reduced aspartate uptake in MUHO. Other amino acids, already known to correlate with diabetes and/or obesity, were identified to differ between MUHO's and MHO's adipocytes, namely glutamine, histidine, and spermidine. Most species of phosphatidylcholines (PCs) were lower in MUHO's extracellular milieu, though simultaneously elevated intracellularly, e.g., PC aa C32∶3, pointing to increased PC synthesis and/or reduced PC release. Furthermore, altered arachidonic acid (AA) metabolism was found: 15(S)-HETE (15-hydroxy-eicosatetraenoic acid; 0 vs. 120pM; p = 0.0014), AA (1.5-fold; p = 0.0055) and docosahexaenoic acid (DHA, C22∶6; 2-fold; p = 0.0033) were higher in MUHO. This emphasizes a direct contribution of adipocytes to local adipose tissue inflammation. Elevated DHA, as an inhibitor of prostaglandin synthesis, might be a hint for counter-regulatory mechanisms in MUHO. CONCLUSION/INTERPRETATION: We identified adipocyte-inherent metabolic alterations discriminating between MHO and MUHO.

Effects of laparoscopic sleeve gastrectomy on attentional processing of food-related information: evidence from eye-tracking.

BACKGROUND: Weight loss after laparoscopic sleeve gastrectomy (LSG) might be associated partially with changes in reward system functioning and altered appetitive responses to food cues. Food cue processing refers to motivational, affective, and cognitive responses to stimuli that are associated with food. We investigated if food cue processing is altered 6 months after weight loss that is induced by LSG. We expected patients after LSG to show reduced appetitive responses to food cues. METHODS: In an experimental longitudinal exploratory study, 17 severely obese patients (body mass index [BMI]: 48.3 ± 6.5 kg/m²) were investigated presurgery and 6 months postsurgery. We used eye-tracking to assess attentional biases during free viewing of food versus nonfood cues, assessed pleasantness ratings of food cues, and self-reported food craving. RESULTS: After LSG, the mean BMI of patients was 36.4 ± 6.0 kg/m², and the percentage of excess weight loss (%EWL) was 46.6% ± 14.0%. Six months after LSG, patients showed an attentional bias toward nonfood cues compared with presurgery, reported lower food craving, and rated presented food stimuli as less pleasant. CONCLUSION: Evidence of altered food cue processing was found in patients after LSG, which may be interpreted as reduced food reward associated with increased cognitive control. Surgery-induced physiologic, cognitive-motivational, and behavioral changes may lead to a desensitization of the reward system and enhanced cognitive control.

Acute and elective laparoscopic resection for complicated sigmoid diverticulitis: clinical and histological outcome.

BACKGROUND: Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis. METHODS: A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results. RESULTS: Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified. CONCLUSIONS: Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.

Laparoscopic sleeve gastrectomy compared to a multidisciplinary weight loss program for obesity--effects on body composition and protein status.

BACKGROUND: Optimal obesity therapy is a matter of debate. Besides weight reduction, other criteria such as safety and nutritional status are of relevance. Therefore, we compared a favored surgical intervention with the most effective conservative treatment regarding anthropometry and nutritional status. METHODS: Fifty-four obese patients were included who underwent laparoscopic sleeve gastrectomy (LSG, n = 27) or a 52-week multidisciplinary intervention program (MIP, n = 27) for weight loss. Body weight, body composition assessed by bioelectrical impedance analysis, and serum protein levels were measured before and within 12 months after intervention. RESULTS: After 1 year of observation, excess weight loss was more pronounced following LSG (65 %) compared to MIP (38 %, p < 0.001). In both groups, body fat was clearly reduced, but a higher reduction occurred in the LSG group. However, protein status deteriorated particularly in the LSG group. Within 1 year, body cell mass declined from 37.1 to 26.9 kg in the LSG group, but only from 35.7 to 32.2 kg in the MIP group. This resulted in an increased mean extracellular mass/body cell mass ratio (1.42 versus 1.00, p < 0.001), in a decreased mean phase angle (4.4° versus 6.6°, p < 0.001), and in a lower prealbumin level in serum (p < 0.02) in the LSG group compared to the MIP group. CONCLUSIONS: LSG, compared to MIP, was more effective regarding excess weight loss and body fat loss within 1 year, however, induced more pronounced muscle mass and protein loss, possibly requiring particular interventions such as exercise or protein supplements.

Surgical technique of a vertical sleeve gastrectomy in mice.

BACKGROUND/AIMS: The prevalence of morbid obesity is increasing. In failing of conservative methods to weight reduction, one effective surgical option is the sleeve gastrectomy. Aim of this study was to show the feasibility of simplified surgical techniques of sleeve gastrectomy in normal weight mice as base model for surgery in super-obese mice. METHODS: In an animal study, 15 male C57/Bl6 mice were randomized into two groups of 5 (1) and 10 animals (2) to undergo sleeve gastrectomy with antidromic suture course. The sutures of the tubular stomach were performed from aborally to orally in group 1 and from orally to aborally in group 2. Mean body weight was 20.8 ± 0.6 g. Body weight was recorded daily for 14 days after surgery and weekly for further 10 weeks. RESULTS: In our study, 12 of 15 animals survived the procedure and follow-up period. Out of group 1, two mice died because of leakage of the gastric sleeve with diffuse peritonitis. Out of group 2, one animal died seven weeks after surgery due to an abscess in the abdominal wall. Regarding the weight charts, there was a decrease until the third postoperative day with continuous increase thereafter. CONCLUSION: The presented model of sleeve gastrectomy is feasible in mice with low mortality and tolerable morbidity. The simplified model enables short operation times, which is decisive especially in obese mice.

Histological characterization of appendectomy specimens with intraoperative appearance of vascular injection.

BACKGROUND: Acute appendicitis frequently needs acute surgical intervention. Laparoscopic appendectomy (LA) and conventional open appendectomy (OA) are well established procedures, but appendectomy for intraoperative inconspicuous or vascular injected appendixes remains under debate because of potential postoperative morbidity. The aim of this study was to correlate intraoperative nonacute appendixes with histological and clinical outcome. METHODS: Between 2005 and 2009, a total of 1,017 patients underwent OA or LA. A total of 1,005 patients were enrolled with inclusion criteria of suspicious acute appendicitis preoperatively. One hundred twenty-nine of 1,005 patients had intraoperative normal, vascular injected or chronic appendixes that were defined as nonacute appendicitis. Intraoperative findings were correlated with histological results and clinical outcome of patients. RESULTS: Of 129 (12.8 %) of 1,005 patients with macroscopically nonacute appendicitis intraoperatively, 16.3 % had normal findings, 81.4 % vascular injection, and 2.3 % chronic alterations; and 94.6 % of nonacute appendixes had histopathological alterations: 38.9 % chronic, 14.0 % neurogenic, 26.4 % acute, 13.2 % phlegmonous, and 2.3 % malignant. Coproliths were found in 21.7 % of patients, most in vascular injected appendixes. Four of seven patients with histopathological normal appendixes had coproliths. Morbidity rate was 2.3 %, with no mortality. CONCLUSIONS: Appendiceal resection for intraoperative nonacute appendixes should be recommended because of high incidence of histopathological findings with low morbidity. In particular, chronic and neurogenous alterations cannot be predicted clinically or verified by radiological examination, but may cause recurrent symptoms.

Psychological dimensions after laparoscopic sleeve gastrectomy: reduced mental burden, improved eating behavior, and ongoing need for cognitive eating control.

BACKGROUND: Obesity as a chronic disease has spread worldwide. Conservative treatment, especially with severe obesity, often fails. Obesity surgery has been shown to be an effective treatment. Laparoscopic sleeve gastrectomy (LSG), as a restrictive procedure, has low risks and results in good weight loss outcomes. However, to date, no studies have investigated the changes in psychological dimensions-especially concerning eating behavior and cognitive restraint-after LSG. The present study investigated, for the first time, eating behavior (cognitive restraint, disinhibition, hunger), depression, and perceived stress before and 1 year after LSG. The setting was a university hospital, comprehensive obesity center. METHODS: Of 59 patients who had undergone LSG from 2008 to 2010, 40 patients were evaluated using questionnaires on eating behavior, depression, and stress, with measurements made before and 1 year after surgery. RESULTS: The body mass index had decreased, on average, by 15.5 kg/m(2) 1 year after LSG (62.7% excess weight loss). The eating behaviors had changed, with patients experiencing less hunger, fewer food cravings, and decreased disinhibition. Depressive symptoms and perceived stress improved. However, the results showed high levels in the dimension of cognitive restraint of eating 1 year after LSG. CONCLUSIONS: Most psychological dimensions improved as expected. The patients were less distracted by food, experienced less hunger, and were less disturbed by emotional distress. However, we found persistent cognitive restraint, reflecting an ongoing need for central eating control. Additional investigations are needed to describe the communication between the gut and brain after surgery.

Impact of risk factors for prolonged operative time in laparoscopic cholecystectomy.

OBJECTIVE: Laparoscopic cholecystectomy (LC) remains one of the most frequent surgical therapies for symptomatic gallstone disorders. Prolonged operative time is frequently associated with increased complication rates. The aim of this study was to identify the risk factors for prolonged operative times to minimize perioperative morbidity and optimize clinical management. METHODS: A total of 677 consecutive patients underwent LC. The exclusion criteria were conversion to an open procedure, intraoperative cholangiography, and liver cirrhosis (n=81). Data were analyzed retrospectively with respect to age, sex, BMI, ASA score, previous abdominal surgery, preoperative endoscopic retrograde cholangiopancreatography, acute cholecystitis, and surgeon's experience. Univariate and multivariate analyses were performed. RESULTS: A total of 596 patients, mean (± SD) age of 52.2 ± 16.7 years, were analyzed. In all, 29% of the patients were obese (BMI ≥ 30 kg/m); 11% had ASA III. Five percent of patients had undergone previous upper abdominal surgery. Overall, 105/596 patients had an acute cholecystitis. Residents of general surgery performed 58% of all operations. The median operative time was 80 min (range, 15-281 min). No statistical significance was found between intraoperative and postoperative complications by surgeon's experience. Statistically, independent preoperative predictors for prolonged operative time as identified through multivariate analysis were acute cholecystitis, obesity, previous upper abdominal surgery, male sex, and low degree of surgical expertise. CONCLUSION: The risk for prolonged operative times in LC can be assessed on the basis of patients' characteristics. Assessment of these factors not only helps to optimize the individual outcome for each patient but also improves the decision process toward operative training for junior surgeons.

Body image after sleeve gastrectomy: reduced dissatisfaction and increased dynamics.

BACKGROUND: Individuals with severe obesity commonly report poor body image. Improvement in body image has been found after conservative weight reduction programs as well as after bariatric surgery (gastric bypass, biliopancreatic diversion, or gastric banding). However, no studies investigating body image after laparoscopic sleeve gastrectomy (LSG) are available. METHODS: Of 70 consecutive patients who planned to undergo LSG at a comprehensive obesity center, 62 patients were included in the study and evaluated before surgery. Their mean body mass index (BMI) was 51.3 kg/m(2) and the patients' mean age before surgery was 43.8 years. One-year follow-up data were obtained for 51 patients (82.3 %). Body image was assessed using the body image questionnaire (BIQ-20), and depression was assessed using the Patient Health Questionnaire (PHQ-9). RESULTS: Patients reported poor body image before surgery. One year after LSG, negative evaluations of the body and perceptions of body dynamics and vitality had markedly improved, without reaching healthy levels. No correlations between body image and weight-related parameters (BMI, percentage of excess weight loss) or mood after 1 year were found. CONCLUSIONS: Body image improves after LSG. This improvement might reflect changes to patients' attitudes, beliefs, and thoughts rather than real weight lost. Further studies should investigate the factors that mediate improvement of body image after bariatric surgery.

Pre- and postoperative nutritional deficiencies in obese patients undergoing laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been identified as an innovative surgical approach for the treatment of obesity and is increasingly applied worldwide. However, data on outcome of LSG regarding nutrient deficiencies, protein status, and body composition are scarce. METHODS: Obese subjects (54; f:m = 4:1) scheduled for LSG were included in this study. Micronutrient analysis, protein status assessment, and bioimpedance measures were performed before and 1, 3, 6, and 12 months after LSG. RESULTS: In 51% of the subjects, at least one micronutrient deficiency was found prior to surgery. Baseline concentrations were below normal for 25-OH vitamin D (27%), iron (29%), vitamin B6 (11%), vitamin B12 (9%), folate (6%), and potassium (7%). Frequencies of deficiencies for vitamin B12, folate, iron, and vitamin B6 tended to increase following LSG within the first year after intervention. Also, parameters of protein status (albumin, transferrin, cholinesterase, and total protein) decreased. After surgery, bioimpedance measures indicated a reduction of total body fat, but also of body cell mass. CONCLUSIONS: Preoperative micronutrient deficiencies were common in morbid obese individuals scheduled for LSG. LSG had a modest effect on micronutrient status by further reducing iron, vitamin B12, vitamin B6, and folate within the first year after intervention. Our data suggest that especially obese patients with preoperative deficits require control and supplementation of micronutrients and protein in the postoperative period.

Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity.

BACKGROUND: Obesity is characterized by excess body fat measured in body mass index (BMI), which is the weight in kilograms (kg) divided by the height in square meters [m(2)]. In the Northern Hemisphere, the prevalence of overweight has increased by up to 34%. This situation is associated with high incidence of comorbidities such as gastroesophageal reflux disease. Bariatric surgery is the only effective treatment for severe obesity, resulting in amelioration of obesity comorbidities. Data on LES competence following sleeve gastrectomy (SG), one of the several bariatric procedures, are conflicting. METHODS: In a prospective study, we enrolled 37 patients and divided them into two subgroups in order to evaluate lower esophageal sphincter pressure (LESP) and esophageal motility before and after laparoscopic sleeve gastrectomy (LSG) by means of stationary esophageal manometry. A study collective also underwent a gastroscopy. Participants (20) were healthy controls who volunteered. RESULTS: Preoperative median BMI in group I (control) differed statistically significantly (p < 0.0001) as compared to groups II and III (22 vs. 50.5 or 47.5 kg/m², respectively). After LSG, the BMI of groups II and III decreased to 39.5 and 45 kg/m², respectively. Postoperatively, LESP increased significantly, namely, from preoperative 8.4 to 21.2 mmHg in group II and from 11 to 24 mmHg (p < 0.0001) in group III. Tubular esophageal motility profits from LSG. As expected, the gastroscopy findings ranged from cardiac insufficiency, esophagitis and hiatal hernia to gastric ulcer. CONCLUSION: LSG significantly increased lower esophageal pressure independent of weight loss after LSG and may protect obese patients from gastroesophageal reflux.