It has been previously demonstrated that T lymphocytes may be involved in the development of hypertension and microvascular remodeling, and that circulating T effector lymphocytes may be increased in ...hypertension. In particular, Th1 and Th 17 lymphocytes may contribute to the progression of hypertension and microvascular damage while T-regulatory (Treg) lymphocytes seem to be protective in this regard. However, no data is available about patients with severe obesity, in which pronounced microvascular alterations were observed.
We have investigated 32 severely obese patients undergoing bariatric surgery, as well as 24 normotensive lean subjects and 12 hypertensive lean subjects undergoing an elective surgical intervention. A peripheral blood sample was obtained before surgery for assessment of CD4+ T lymphocyte subpopulations. Lymphocyte phenotype was evaluated by flow cytometry in order to assess T-effector and Treg lymphocytes.
A marked reduction of several Treg subpopulations was observed in obese patients compared with controls, together with an increased in CD4+ effector memory T-effector cells.
In severely obese patients, Treg lymphocytes are clearly reduced and CD4+ effector memory cells are increased. It may be hypothesized that they might contribute to the development of marked microvascular alterations previously observed in these patients.
Objective. Aim of this study is to evaluate determinants of secondary normocalcemic hyperparathyroidism (SNHPT) persistence in patients who have undergone Roux-en-Y gastric bypass on vertical-banded ...gastroplasty. Methods. 226 consecutive patients submitted to bariatric surgery were prospectively enrolled and divided in two groups on the basis of preoperative presence of SNHPT. For each patient, we evaluated anthropometric and laboratory parameters. Calcium metabolism (calcemia, PTH, and 25-hydroxy vitamin D serum levels) was studied before surgery and at 6-month intervals (6, 12, and 18 months) as surgical follow-up. Results. Based on presurgical SNHPT presence or absence, we defined group 1—201 patients and group 2—25 patients, respectively. Among the group 1, 153 (76%) recovered from this endocrinopathy within 6 months after surgery (group 3), while the remaining 48 patients (24%) had persistent SNHPT (group 4). Comparing the anthropometric and laboratory data of group 3 with group 2, the only statistically significant factor was the elapsed time since a prior effective medically controlled diet that led to a steady and substantial weight loss. We found also a statistically significant difference (p<0.05) between group 3 and group 4 in term of % of weight loss and PTH levels. Conclusions. Patients suitable for bariatric surgery must have history of at least one efficient medically controlled diet, not dating back more than 5 years before surgery. This elapsed time represent the cut-off time within which it is possible to recover from SNHPT in the first semester after Roux-en-Y gastric bypass on vertical-banded gastroplasty. The treatment of vitamin D insufficiency and the evaluation of SNHPT before bariatric surgery should be recommended. The clinical significance of preoperative SNHPT and in particular SNHPT after bariatric surgery remains undefined and further studies are required.
Background Over the years, several modifications of the Scopinaro biliopancreatic diversion (BPD) have been proposed. This retrospective study reported the results of 15 years of follow-up after open ...BPD coupled with a type of transient gastroplasty (TG) and duodenal switch (DS), termed BPD-TG with DS. Methods Data were analyzed for 874 patients operated on between January 1993 and May 2010 in 3 different surgical departments. Results The median preoperative body mass index (BMI) was 52 kg/m² (range, 35–63). Comorbidities present were hypertension (57%), hypercholesterolemia (87%), hypertriglyceridemia (53%), type 2 diabetes (35%), and obstructive sleep apnea syndrome (OSAS; 9%). The mean follow-up was 11.9 ± 3.1 years. The median BMI decreased to 33.9 after 1 year from bariatric surgery, 31.1 after 2–5 years, 30.9 after 5–10 years, and 31.2 kg/m² after 10–15 years. Overall, 67% of diabetic patients were able to stop insulin and 97% were able to stop oral hypoglycemic drugs within 1 year. Blood pressure, triglyceride levels, and cholesterol levels became normal in >96% of patients within 1 year. OSAS was resolved within 8 months in all cases. One year postoperatively, but absent thereafter, we observed severe hypoalbuminemia (serum albumin <3 g/dL) in 1.7% of patients and severe iron-deficiency anemia in 1.9%. Incisional hernias were recorded in 30% and anastomotic ulcers in 2.4% of cases. Mortality was null. Conclusion Our results suggest considering BPD-TG with DS as a viable bariatric operation, with its excellent long-term outcome in terms of weight loss, improvement of obesity-related diseases, and quality of life.
Background
This prospective study assessed the prevalence of the extralaryngeal branching of the recurrent laryngeal nerve (RLN) and its impact on the incidence of postoperative transient or ...permanent RLN palsy.
Methods
Total or hemithyroidectomy was performed in 115 patients, with a total of 195 RLNs displayed. The RLN extralaryngeal branches were routinely identified and preserved. The postoperative course of each patient was evaluated. Outcomes of patients with and without branching RLN were compared.
Results
In all, 36 of 195 (18.5%) nerves showed extralaryngeal branching: 27 cases (25.5%) on the right and 9 on the left side (10.1%;
p
= 0.0088).Trifurcation of the RLN was identified in two dissections (1%). Bilateral bifurcations were observed in 3 of 80 (3.7%) patients. We reported four (2.1%) unilateral permanent RLN palsies, eight cases of unilateral transient nerve palsy (4.1%), and one bilateral transient RLN injury (0.6%). The comparative analysis of postoperative outcomes between branched and nonbranched RLNs revealed that the anatomical variation was more frequently associated both with unilateral permanent RLN palsy (relative risk, 13.25; 95% confidence interval, 1.42–123.73;
p
= 0.0204) and unilateral transient RLN palsy (relative risk, 7.36; 95% confidence interval, 1.84–29.4;
p
= 0.0061). The only case of bilateral transient RLN injury was associated with a nonrecurrent inferior laryngeal nerve.
Conclusions
Branched RLNs represent a risk factor both for transient and permanent nerve palsy after surgery. Awareness of this anatomical variation and its routine investigation are essential during thyroid surgery to limit its relevant impact on postoperative RLN injury rate.
Drug malabsorption is a potential concern after bariatric surgery. We present four case reports of hypothyroid patients who were well replaced with thyroxine tablets to euthyroid thyrotropin (TSH) ...levels prior to Roux-en-Y gastric bypass surgery. These patients developed elevated TSH levels after the surgery, the TSH responded reversibly to switching from treatment with oral tablets to a liquid formulation.
Objective
This study aimed to assess the impact of intragastric balloon (IGB)-induced body weight loss on metabolic syndrome in obese patients and evaluate what happens during 1-year follow-up.
...Methods
To this end, data were collected on 143 obese patients (body mass index (BMI) 36.2 ± 5.7 kg/m²) who underwent IGB insertion between January 2000 and December 2005. Outcomes were recorded at BioEnterics Intragastric Balloon removal time (
t
0
) and at 6-month (
t
6
) and 12-month (
t
12
) follow-up.
Results
Significant BMI, excess body weight loss percentage, and body weight loss percentage (BWL%) were observed at
t
0
(29.6 ± 4.6 kg/m²; 29.3 ± 4.8%; 14.1 ± 5.7%), followed by partial weight regain at
t
12
(32.4 ± 4.3 kg/m²; 26.1 ± 4.9%; 11.2 ± 4.6%). Incidence of metabolic syndrome dropped from 34.8% (pre-IGB value) to 14.5% (
t
0
) and 11.6% (
t
12
). Likewise, type 2 diabetes mellitus (DM), hypertriglyceridemia, hypercholesterolemia, and blood hypertension (BH) incidence decreased from 32.6%, 37.7%, 33.4%, and 44.9% (pre-IGB values) to 20.9%, 14.5%, 16.7%, and 30.4% at
t
0
and 21.3%, 17.4%, 18.9%, and 34.8% at
t
12
. HbA1c blood concentration shifted from an initial value of 7.5 ± 2.1% to 5.7 ± 1.9% (
t
0
), 5.6 ± 0.7% (
t
6
), and 5.5 ± 0.9% (
t
12
). Patients suffering from DM or BH stopped or diminished relative drug consumption at
t
12.
Negligible modifications were reported as regards HDL cholesterol and hyperuricemia.
Conclusion
Weight regain is commonly observed during long-term follow-up after IGB removal. Nevertheless, the maintenance of at least 10% of the BWL%, as reported at 1-year follow-up, is associated with an improvement in metabolic syndrome.
We aimed at comparing our long-term results after biliopancreatic diversion (BPD) with or without gastric preservation for morbid obesity. Between 1999 and 2009, we performed 540 BPD: 287 patients ...(group A) underwent BPD with distal gastric resection (BPD-AHS) and 253 (group B) underwent BPD associated with transitory vertical gastroplasty (TGR) with duodenal switch (DS). The results have been analyzed in terms of weight loss, improvement of comorbidities, and quality of life (Bariatric Analysis and Reporting Outcome System). The mean follow-up was 7.4 ± 2.9 years. One year after surgery, mean initial excess weight loss percentage was 69% for patients in group A (
n
= 287) and 65% for group B (
n
= 253); after 2–5 years, it was 74% for patients who underwent BPD-AHS (
n
= 130) and 75% for patients who underwent BPD-TGR-DS (
n
= 116); it was 71% and 74% for patients in group A (
n
= 157) and B (
n
= 137), respectively, followed up for >5 years (
P
= 0.27). Among the diabetic patients in both groups (191 patients), 64% discontinued the medication with insulin (
P
= 0.25), and 98% had stopped oral drugs within 1 year from surgery (
P
= 0.29). We did not observe deficiencies of vitamins and proteins. The overall incidence of incisional hernias was 38% (
P
= 0.35). We recorded 13 anastomotic ulcers (2.4%;
P
= 0.28). BPD represents, in spite of the side effects, an effective technique for treatment of morbid obesity and its associated diseases. Moreover, our results showed that patients who underwent BPD-TGR-DS had slightly better results in terms of postoperative metabolic complications and improvement in quality of life.
We aimed to evaluate the impact of loupe magnification (LM) on incidental parathyroid gland removal (from pathology reports), hypocalcemia, and recurrent laryngeal nerve (RLN) injury after total ...thyroidectomy and answer the question of whether this tool should be always recommended for patient's safety. Between January 2005 and December 2008, 126 patients underwent total thyroidectomy with routine use of 2.5 x galilean loupes; their charts were compared with data on 118 patients operated on between January 1997 and December 2000 without LM (two different equally skilled surgical teams operating in the two periods). LM decreased the rate of inadvertent parathyroid glands removal (3.8 vs 7.8% of total parathyroid glands; P = 0.01), as well as of biochemical (20.6 vs 33.9%; P = 0.028) and clinical (12.7 vs 33%; P = 0.0003) hypocalcemia after thyroidectomy. All cases (16 of 16) of symptomatic hypocalcaemia in the LM group proved to be associated with parathyroidectomy vs 76.9 per cent (30 of 39) without LM (P = 0.046). A trend toward decreased RLN injury rate, although statistically insignificant, was reported, being unilateral transient, unilateral permanent, and bilateral transient palsy rates 6.8, 2.5, and 1.7 per cent, respectively, without LM vs 4.8, 2.4, and 0.8 per cent, respectively, with LM (P = 0.69; P = 1, and P = 0.61, respectively). Our results do support the routine use of LM during total thyroidectomy.
Background
Several factors alter the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis in obese patients, but GH/IGF-1 correlation with anthropometric parameters and lipid metabolism is ...still unclear. We evaluated this relationship and the postoperative axis modifications in candidates for bariatric surgery.
Methods
Eighty-eight patients (males/females (M/F), 34/54) scheduled for bariatric surgery (biliopancreatic diversion or laparoscopic-adjustable gastric banding) between 2008 and 2010 were included in this observational, open, prospective study.
Results
Preoperative serum GH concentrations were found near the lowest limit of normal range in both sexes, with males showing the lowest values (130 vs. 1,405 pg/ml;
p
< 0.01). Serum concentrations of IGF-1 were within the normal range (M/F, 179/168.5 ng/ml), whereas IGF-binding protein (BP)1 and 3 values were at the lowest limits of normal range in both sexes (M/F 1.8/3.1 μg/ml and M/F 4.1/4.2 μg/ml, respectively). A statistically significant inverse correlation was found between GH, IGF-1, and IGF-BP1-3 values and total cholesterol, LDL-cholesterol, and triglycerides values in both sexes. GH and IGF-BP1-3 values were also inversely related to waist circumference and waist/hip ratio (WHR). GH, IGF-1, and IGF-BP1 and 3 values (35 cases) increased 1 year postoperatively in both sexes, mainly after malabsorptive procedures.
Conclusions
Our results support the hypothesis that GH deficiency associated with low levels of binding proteins in obese patients may be an endocrine response to visceral fat and high levels of non-esterified fatty acids, assessable in daily clinical practice by WHR, total and LDL-cholesterol, and triglycerides. In these patients, malabsorptive procedures might be the treatment of choice due to the metabolic adaptations induced.
Structural alterations of subcutaneous small resistance arteries, as indicated by an increased media:lumen ratio, are frequently present in hypertensive and/or diabetic patients and may represent the ...earliest alteration observed. In addition, media:lumen ratios of small arteries have a strong prognostic significance. However, no data are available about the structure of small resistance arteries of obese patients, particularly after weight loss. We have investigated 27 patients with severe obesity. Twelve of them were normotensive, and 15 were hypertensive. All of the obese patients underwent bariatric surgery. We compared results obtained with those observed in 13 normotensive lean controls and in 13 hypertensive lean patients. All of the subjects and patients underwent a biopsy of subcutaneous fat during surgical intervention. In 8 obese patients, a second biopsy was obtained after consistent weight loss, during a surgical intervention for abdominoplasty. Subcutaneous small resistance arteries were dissected and mounted on a wire myograph, and structural parameters were measured. A concentration-response curve to acetylcholine was performed to evaluate endothelial function. Obese patients, independent from the presence of hypertension, show the presence of an increased media:lumen ratio and media cross-sectional area, together with an impaired endothelial-dependent vasodilatation. After surgical correction of obesity and consistent weight loss, a significant improvement of microvascular structure and of some oxidative stress/inflammation markers were observed. In conclusion, our data suggest that the presence of obesity is associated with structural alterations of subcutaneous small resistance arteries, mainly characterized by hypertrophic remodeling. Weight loss may improve microvascular structure.
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