[Changes in metabolic parameters and glomerular filtration rate in patients with morbid obesity after bariatric surgery].

AIM: To study the effect of weight loss in the short term after bariatric surgery (BO) on metabolic parameters and glomerular filtration rate (GFR) in patients with morbid obesity. MATERIALS AND METHODS: We studied 40 adult (over 18 years) patients with morbid obesity who underwent bariatric surgery. Metabolic indices and calculated GFR according to the CKD-EPI formula in patients before and after bariatric surgery were compared. RESULTS: In the whole group of operated patients, the average body mass index (BMI) after surgery decreased from 45.8 to 30.5 kg/m2. In 11 (92%) patients with impaired carbohydrate metabolism, remission of diabetes mellitus was achieved and sugar-lowering drugs were canceled. In patients with baseline GFR90 ml/min/1.73 m2 after surgery, there is a tendency towards a decrease in GFR, probably due to a decrease in hyperfiltration. In patients with baseline GFR90 ml/min/1.73 m2 after surgery, a statistically significant increase in the level of GFR was noted. The greater metabolic efficacy of combined operations (mini-gastric bypass, biliopancreatic diversion) in relation to the correction of carbohydrate and fat metabolism was revealed. CONCLUSION: Obesity is a modifiable risk factor for decreased kidney function and the progression of chronic kidney disease. Bariatric surgery is an effective treatment for morbid obesity. The study proved the positive effect of weight loss after BO on renal function, including by improving the course of diseases associated with obesity.

[Glycemia normalization in patients with obesity and type 2 diabetes mellitus: bariatric surgery vs pharmacological therapy].

AIMS: To compare glucose - lowering and weight reduction capacity of bypass operations (gastric bypass (GB), biliopancreatic diversion (BPD) vs GLP-1 agonist liraglutide 3.0 mg (models of maximum incretin effect) for 6 months. MATERIALS AND METHODS: 46 patients with type 2 diabetes and long history (≥10 years) of obesity were divided into 2 groups: surgery - group (n=23) and liraglutide - group (n=23), where liraglutide 3.0 mg in dose - escalation manner was added to baseline glucose - lowering therapy. Anthropometric parameters, HbA1c and insulin resistance (IR) by hyperinsulinemic euglycemic clamp (M-value) were measured before and 16 weeks after the intervention. With the stabilization of glycemia (≤6.5 mmol/l at fasting state, ≤8 mmol/l postprandial) the initial glucose - lowering therapy was canceled. RESULTS AND DISCUSSION: Both surgery and liraglutide 3.0 mg provided target HbA1c in 16 weeks. Bypass operations led to elimination of glucose - lowering therapy in 82.6% patients due to a more significant weight reduction and decrease in IR. In liraglutide - group previous glucose - lowering therapy was cancelled in 78.3% patients, mainly receiving baseline mono - and two - component therapy. The most significant difference between interventions was achieved in BMI (-8.9 kg in surgery group vs -3.8 kg in liraglutide group, p.

Low proliferative potential of adipose-derived stromal cells associates with hypertrophy and inflammation in subcutaneous and omental adipose tissue of patients with type 2 diabetes mellitus.

BACKGROUND: Obesity and type 2 diabetes mellitus (T2DM) are among the most important morbidity factors. In this study we tested the hypothesis that low proliferative potential of adipose derived stromal cells (ADSC) associates with reduced formation of new fat depots, excess accumulation of fat in the functional adipocytes and their hypertrophy, resulting in fat inflammation and insulin resistance. METHODS: We screened two groups of obese patients with or without T2DM, matched for BMI, age, and duration of obesity to test the hypothesis that hypertrophy and decreased renewal of adipocytes may underlie transition from obesity to T2DM. All patients were matched for carbohydrate metabolism (fasting blood glucose level, glycated hemoglobin, HOMA-IR index and M-index). The subcutaneous and omental fat tissue biopsies were obtained during bariatric surgery from obese individuals with or without T2DM. The morphology and immunophenotype of subcutaneous and omental fat was assessed in frozen tissue sections. ADSC were isolated from both types of fat tissue biopsies and screened for morphology, proliferative potential and inflammatory status. RESULTS: The non-diabetic patients had normal carbohydrate metabolism and moderate insulin resistance measured by HOMA-IR and hyperinsulinemic clamp (M-index), while T2DM patients were extremely insulin resistant by both indexes. The average size of diabetic adipocytes was higher than that of non-diabetic in both subcutaneous and omental fat tissues, indicating adipocyte hypertrophy in T2DM. Both these tissues contained higher level of macrophage infiltration and increased M1-like to M2-like ratio of macrophage subpopulations, suggesting increased fat inflammation in T2DM. This was confirmed by increased activatory phosphorylation of stress-induced JNK1/2 in diabetic ADSC. CONCLUSION: These results suggest that blunted proliferation and increased hypertrophy of diabetic ADSC may lead to reduced insulin sensitivity via increased inflammation mediated by M1 macrophages and JNK1/2 pathway.

[Interdisciplinary European guidelines on metabolic and bariatric surgery]. / Interdisciplinární Evropská doporucení metabolické a bariatrické chirurgie.

In 2012, an outstanding expert panel derived from IFSO-EC (International Federation for the Surgery of Obesity - European Chapter) and EASO (European Association for the Study of Obesity), composed by key representatives of both Societies including past and present presidents together with EASOs OMTF (Obesity Management Task Force) chair, agreed to devote the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery as a pre-satellite of the 2013 European Congress on Obesity (ECO) to be held in Liverpool given the extraordinarily advancement made specifically in this field during the past years. It was further agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced in cooperation of both Societies by focusing in particular on the evidence gathered in relation to the effects on diabetes during this lustrum and the subsequent changes that have taken place in patient eligibility criteria. The expert panel composition allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.

Interdisciplinary European guidelines on metabolic and bariatric surgery.

In 2012, an expert panel composed of presidents of each of the societies, the European Chapter of the International Federation for the Surgery of Obesity (IFSO-EC), and of the European Association for the Study of Obesity (EASO), as well as of the chair of EASO Obesity Management Task Force (EASO OMTF) and other key representatives from IFSO-EC and EASO, devoted the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery in advance of the 2013 European Congress on Obesity held in Liverpool. This meeting was prompted by the extraordinary advancement made in the field of metabolic and bariatric surgery during the past decade. It was agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced by focusing in particular on the evidence gathered in relation to the effects on diabetes and the changes in the recommendations of patient eligibility criteria. The expert panel allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.

Improvement of weight loss and metabolic effects of vertical banded gastroplasty by an added duodenal switch procedure.

BACKGROUND: Some patients who underwent vertical banded gastroplasty (VBG) need revisional operations because of poor weight loss and remaining comorbidities. The duodenal switch (DS) procedure with partial gastrectomy is known as an effective method for treatment of severe obesity and related dyslipoproteinemias and diabetes mellitus type 2 (DM2). Other investigations have shown that DS without gastric resection similarly corrects hypercholesterolemia and DM2 in the "less than" morbidly obese patients. METHODS: Based on this knowledge, we performed a DS simultaneously with hernioplasty and panniculectomy in a 63-year-old woman with a fair EWL (36.4%), with remaining hypercholesterolemia and DM2 4 years after VBG. The pouch stoma diameter was 13 mm, and there was no pouch dilation nor staple-line disruption. The previously partitioned stomach was left in place. H2-blockers and polyvitamins were prescribed after operation. RESULTS: 1 year after DS there were no postoperative complications and undesirable effects except slight anemia. DS allowed improvement in weight loss, improved carbohydrate handling without need for insulin or other hypoglycemic agents, and corrected severe hypercholesterolemia. CONCLUSION: DS per se in the case presented had a decisive effect on DM2 and hypercholesterolemia. DS should be kept in mind as a second-step malabsorptive procedure after a failed purely restrictive operation.

Some hormonal changes before and after vertical banded gastroplasty for severe obesity.

BACKGROUND: Hormonal disturbances play a role in the development of obesity, but may be a consequence of obesity itself. In this study we assessed the influence of the surgically-induced weight loss on some important hormonal abnormalities in the morbidly obese patients. MATERIAL AND METHODS: Fasting serum prolactin, insulin, cortisol and thyroid hormones: free thyroxin (FT4), free triiodothyronine (FT3) and thyrotropin (TTH), have been studied by radioimmune methods before vertical banded gastroplasty (VBG) and after operation in the early (10-14 days) and late period when excess weight loss (EWL) 51.7-57.1% had been achieved. RESULTS: On the 10-14 day after VBG, prolactin increased significantly in women (p<0.05), but decreased after weight loss (p<0.01). Fasting insulin was lowered significantly (p<0.05) soon after VBG in the hyperinsulinemic (51.7% of the total group) and diabetic (n-9) patients. After weight loss, insulin decreased significantly (p<0.0001) vs. preoperative. Concentration of cortisol was unchanged both in the early and in the late postoperative period. On the days 10-14, significant elevation of TTH and decrease of FT3 (p<0.05) have been noted. After essential weight loss TTH dropped significantly vs. preoperative (p<0.05) with no changes in FT3 and FT4 concentration. CONCLUSIONS: VBG and consequent weight loss favorably influence the hormonal abnormalities in the morbidly obese. Further studies are needed to make clear a relationship between this and other parameters of metabolic syndrome. The hormonal abnormalities may influence the indications for surgery in less than morbidly obese patients with metabolic syndrome.

Successful bariatric surgery in a patient who underwent more than 100 various operations.

A 44-year-old woman who weighed 130 kg (height 158 cm, BMI 52) with a complicated psychiatric history was referred for obesity surgery because of severe sleep apnea, obesity hypoventilation syndrome with frequent pneumonias, arterial hypertension, diabetes mellitus, polyarthralgia and back pain, venous insufficiency, dysmenorrhea, severe heartburn, and incisional hernia. From childhood until 1983, she had undergone 106 operations, mainly for septic/pyemic and intra-abdominal abscesses, 86 of them under general anesthesia. In the 4 years before undergoing bariatric surgery, she had gained 40 kg, nonoperative attempts at weight reduction had failed. Some months before obesity surgery she could fall asleep while standing, and she noticed an entire loss of capacity for work. Respiratory disturbance index measured during sleep by Mesam-4 device was 68 events per hour. Preoperative controlled positive airway pressure (C-PAP) therapy was used. Vital indications for weight reduction were established. Bariatric surgical steps included six operations: (1) vertical banded gastroplasty (VBG); (2) relaparotomy with suspicion of peritonitis, no complications found; (3) hernioplasty simultaneously with panniculectomy; (4) revision and removal of additional flap because of marginal skin necrosis; (5) bilateral thigh dermatolipectomy simultaneously with right-side saphenectomy; and (6) removal of intramammary abscess. Twenty-four months after VBG, she had lost 39 kg (56.5 % EWL) and was doing rather well. Obesity-related diseases except back pain were relieved.

Obesity surgery in Russia.

BACKGROUND: In Russia, 40% of the population are overweight, and 26% are obese. As was mentioned at the IFSO Symposium in Cancun, very little is known about obesity surgery in Russia. METHODS: The authors undertook a literature search and interviewed surgeons who are known to perform bariatric procedures. RESULTS: Jejunoileal bypass (JIB) was used in the 1970s but has been abandoned by most surgeons. Since 1977, 334 JIBs, of a total of 360 bariatric operations, have been performed at I Saint Petersburg Medical University. The remaining 26 operations included 14 gastric bandings, 6 horizontal and 4 vertical gastroplasties, and 2 gastric bypasses. Since 1984, 545 gastric banding procedures have been done at the Moscow Medical Academy, where the current approach is the lap-band type of gastric banding. The laparoscopic technique of adjustable gastric banding is beginning to be used. Vertical banded gastroplasty (VBG) was begun in the early 1990s. At the Russian Research Center of Surgery in Moscow, 48 Mason VBGs have been done. The other group in Moscow reported 28 VBGs without the creation of a window and including covering the stoma by polypropylene mesh. There are only a few known cases of gastric bypass procedures. No data on biliopancreatic diversion were found. CONCLUSIONS: Obesity surgery is not being performed enough to satisfy the requirements of the Russian population. Simple operations are more common than complex ones. The use of the laparoscopic approach has begun and probably will increase.

Vertical banded gastroplasty: first experience in Russia.

BACKGROUND: The first experience of vertical banded gastroplasty (VBG) in the Russian National Research Center of Surgery is presented. METHODS: From November 1992 to October 1996, 24 morbidly obese patients (mean body weight 147.7 kg, BMI 52.1 kg/m2) underwent VBG according to Mason. RESULTS: The early complication rate was 20.8%. The mean excess weight loss (EWL) after weight stabilization (first 12 patients) was 48.0% in the whole group and 53.9% (range 36.0-73.0%) in 10 patients without staple-line disruptions. Significant positive changes in obesity related diseases were noted. Nine of 23 patients presented with incisional hernias some months after operation. CONCLUSION: The impression of VBG is favorable; however, gaining further experience with the standard techniques and increasing the long-term results are necessary.