CONGRESSO NAZIONALE SICOB 2012
CONGRESSO NAZIONALE SICOB 2012
CONGRESSO NAZIONALE SICOB 2012
Patients undergoing laparoscopic adjustable gastric band (LAGB) have significant weight loss and reductions in estimated ten to 30-year cardiovascular risk within one year post-LAGB, according to a study published in the journal Advances in Therapy, a Springer link publication.
Data from a US healthcare database revealed that ten- and 30-year estimated cardiovascular risk decreased from 10.8 to 7.6% (p\0.0001) and 44.34 to 32.30% (p\0.0001), respectively, 12–15 months post-LAGB. Improvements were significantly greater than in non-LAGB patients (n= 4,295) (p\0.0001).
The researchers set out to examine whether weight loss in obese patients treated with LAGB is associated with meaningful reductions in estimated 10- and 30- year Framingham CVD risk 12–15 months post-LAGB.
Obese adult patients (BMI30) treated with LAGB were identified in a large US healthcare database. Patients without CVD at baseline and with measures of BMI, systolic blood pressure, diabetes, and smoking status at baseline and follow-up were eligible. Non- LAGB patients were propensity score matched to LAGB patients on baseline BMI, age, and gender.
The estimated 10- and 30-year Framingham CVD risks were 10.8 and 44.34% for LAGB patients and 10.56 and 41.79% for comparison patients at baseline, respectively.
The outcomes showed that the mean BMI in LAGB patients (n= 647, average age 45.66 years, 81.1% female) decreased from 42.7 to 33.4 (p\0.0001), with 35.4% no longer obese.
In the subset with lipid data (n=74), improvements in total (-20.6mg/dL; p\0.05) and high-density lipoprotein ( 10.6 mg/dL, p\0.0001) cholesterol 1 year post-LAGB were also observed.
At 12–15 months’ follow-up, mean BMI decreased significantly in LAGB patients (-9.3kg/m2, p\0.0001) and in comparison patients (-0.6kg/m2, p\0.0001. In addition, the researchers also report that there were significant reductions in SBP for both LAGB (p\0.0001) and comparison patients (p\0.05). At follow-up, the proportion of patients using anti-diabetic medications decreased in LAGB patients (p\0.0001) and increased in comparison group (p\0.01).
Estimated 10- and 30-year CVD risk scores decreased significantly in LAGB patients (-3.2%, p\0.0001 and -12.04%, p\0.0001, respectively), but did not change significantly in comparison patients ( 0.01%, p= 0.91 and 0.13%, p= 0.42, respectively). Changes in CVD risk factors and scores were evaluated for subgroups stratified by gender and
baseline BMI (Figure 1).
Figure 1: Change in estimated 10- and 30-year CVD risk at 12–15 months by gender and baseline BMI. BMI body mass index, CVD cardiovascular disease, LAGB laparoscopic adjustable gastric banding. *P\0.05 for changes from baseline between LAGB and non-LAGB groups; BMI was presented as kg/m2.
Although the authors acknowledge that Framingham CVD risk scores have not been validated for measuring changes in CVD risk over time or specifically in obese populations, “in the present analysis scores based on BMI versus lipid data indicate similar and consistent magnitude of risk reduction,” they note.
The researchers concluded that the data showed patients receiving LAGB to have significant weight loss, and reduced CVD risk factors and estimated CVD risk, supporting the effectiveness of the LAGB procedure as a potential approach for management of obesity.
“These results add to the evidence of the cardiovascular benefits of significant weight loss among obese individuals and the potential long-term clinical impact of the LAGB procedure as a therapeutic intervention for obesity,” the researchers write. “Larger and long-term studies are needed to further document whether effects of LAGB on weight loss and CVD risk factors translate into reduced CVD incidence.”
The analysis and publication charges were sponsored by Allergan.
Owen Haskins – Editor in chief, Bariatric News
The weight loss seen in patients after gastric bypass surgery for obesity may be helped by changes in the way the brain itself responds to food, reducing not only hunger but also the drive to eat for pleasure, according to a new study from the Medical Research Council (MRC).
The research, published in the journal Gut, helps to explain why gastric bypass patients lose more weight over the long term than those who undergo a gastric band operation.
“It is well established that patients after gastric bypass lose more weight than after gastric band and we think this is because of the different physical changes made to the gut during surgery, which somehow have an effect on the drive to eat for pleasure,” said Dr Tony Goldstone from the MRC Clinical Sciences Centre at Imperial College London and consultant endocrinologist at Imperial College Healthcare NHS Trust. “Both procedures reduce appetite and have health benefits including long-term weight loss and improvement or even complete resolution of type 2 diabetes. However, gastric bypass surgery appears to be more effective for weight loss and has a more profound effect on the way in which the brain responds to food.”
Previous studies in animals and humans have shown that those who undergo a gastric bypass tend to shift away from eating high-fat and sweet foods. However, the effect of different types of weight loss surgery on the brain that may be responsible for changes in food preference has not been explored until now.
Using magnetic resonance imaging (fMRI), which measures brain activity by detecting changes in blood oxygen levels, scientists from Imperial College London, UK, studied 61 men and women who had lost weight from either a gastric bypass (21 people) or gastric band surgery (20 people).
The scans were carried out on average eight to nine months previously, as well as a control group of un-operated participants (20 people). These three groups were of similar body weight.
They found marked differences in the brain’s response to food in patients after gastric bypass, compared to gastric band surgery. Patients who had gastric bypass had less activity in the brain’s reward regions when shown pictures of food compared with those who had gastric banding.
Patients after gastric bypass also rated high-calorie foods as less appealing to look at and less pleasant to eat (on a scale), had healthier eating habits and ate less fat in their diet than patients after gastric banding or the un-operated control group.
Both the gastric bypass and banding patients had similarly reduced hunger compared with the un-operated group, and the findings were not explained by differences in psychological traits between the surgical groups, such as binge eating, mood, impulsivity, or their sensitivity to seek rewards in general.
The researchers did not find conclusive evidence of what caused these changes, but they did observe several differences in the patients’ metabolism that could play a role. Levels of the gut hormones (GLP-1 and PYY) that make us feel full after a meal were higher in the gastric bypass group, as were levels of bile salts, which play a role in digestion.
Patients after gastric bypass also reported more intestinal discomfort and nausea after eating foods high in fat and sugar in the early months after the surgery than patients after banding, which may also be influencing what foods they want to eat.
The researchers concluded that “the identification of these differences in food hedonic responses as a result of altered gut anatomy/physiology provides a novel explanation for the more favourable long-term weight loss seen after RYGB than after BAND surgery, highlighting the importance of the gut–brain axis in the control of reward-based eating behaviour.”
Further work by the researchers will focus on which of these factors may be influencing the brain’s response to food following bypass surgery.
“These findings emphasise that different bariatric procedures work in different ways to influence eating behaviour,” added Goldstone. “This may have important implications for the way we treat patients with obesity and could help pave the way for a more personalised approach when deciding on the choice of bariatric procedure by taking the impact on food preferences and cravings into account.”
“Humans don’t just eat when they’re hungry – the pleasure and rewarding feelings we get from eating play a huge role in determining what kind of foods we eat, as well as how much,” said Professor David Lomas, Chair of the MRC’s Population and Systems Medicine Board. “This work adds to a growing body of evidence supporting the role of the gut-brain interplay in controlling our eating behaviour. Being able to influence this relationship may in future play an important role in the development of non-surgical treatments for obesity.”
This research was supported by the Medical Research Council, Wellcome Trust, National Institute for Health Research (NIHR), and Imperial College Healthcare Charity and the Imperial Weight Centre, from which patients were recruited.
Owen Haskins – Editor in chief, Bariatric News
A powerful association exists between hypovitaminosis D and metabolic syndrome in obese patients that is independent from body fat mass and its clinical correlates, according to a study titled ‘Hypovitaminosis D is Independently Associated with Metabolic Syndrome in Obese Patients’, published in Plos One.
According to the study authors, the outcomes from the researcher indicates that the association between low 25(OH) D3 levels and metabolic syndrome is not merely induced by vitamin D deposition in fat tissue but reinforces the hypothesis that hypovitaminosis D represent a crucial independent determinant of MS.
They explain that vitamin D is a lipophilic hormone synthesised in the skin by ultraviolet-mediated isomerisation of 7-dehydrocholesterol and subsequently converted to active 1,25(OH)2D3 by two consecutive renal and hepatic hydroxylations.
However, as well as playing a role in calcium-phosphate regulation and bone metabolism, it has a potential role in the development of insulin resistance-related conditions, such as obesity, type 2 diabetes mellitus, systemic hypertension and metabolic syndrome. Previous studies have reported that vitamin D insufficiency is now considered to involve more than 75% of those with MS.
They also note that obese patients show a reduced response of serum 25(OH) vitamin D3 levels to ultraviolet-B irradiation and to oral vitamin D administration, compared with non-obese individuals.
Therefore, the investigators wanted to examine whether there an independent association between low 25(OH) vitamin D3 and metabolic syndrome in obese patients with and without metabolic syndrome.
“Two groups of subjects with the same degree of obesity, selected based on the presence or absence of MS, were compared to determine the contribution of body fat mass in the association between vitamin D insufficiency and the development of metabolic abnormalities,” they write. “This is to our knowledge the first study designed to establish the role of body fat mass in the link between hypovitaminosis D and MS.”
The investigators recruited 107 consecutive obese patients, 61 patients with a diagnosis of metabolic syndrome (30 patients with 3, 21 patients with 4 and 10 patients with 5 metabolic syndrome components) and 46 without MS, among subjects referring to the Endocrinology day-hospital of Sapienza University of Rome who underwent metabolic evaluation.
The two groups were comparable for sex, age, BMI, waist circumference and body fat percentage.
They report that serum 25(OH) vitamin D3 levels were significantly reduced in obese patients with metabolic syndrome, compared to obese subjects without metabolic syndrome, all comparable for sex, age, BMI, waist circumference and body fat mass percentage (13.5(3.3–32) ng/ml vs. 17.4(5.1–37.4) ng/ml, p<0.007, respectively). This difference persisted also excluding patients affected by type 2 diabetes (n = 26) from study population (14.4(5.7–32) ng/ml vs. 17.4(5.1–37.4) ng/ml, p = 0.01, respectively).
As expected, patients with metabolic syndrome had PAS, PAD, FBG, HbA1c and blood insulin significantly higher and HDL lower than subjects without metabolic syndrome. Reduction of insulin sensitivity as expressed by increased HOMA-IR and lower ISI was detected in metabolic syndrome patients, compared with non-MS.
Serum 25(OH) vitamin D3 concentrations inversely correlated with FBG (Pearson’s coefficient: -0.26, p<0.007) serum phosphate (Pearson’s coefficient: −0.21, p<0.03) and PTH levels (Pearson’s coefficient: −0.28, p<0.003) but were not associated with anthropometrical parameters, fat mass percentage, the diagnosis of type 2 diabetes and insulin resistance indexes in the univariate analysis.
Linear multivariate regression analysis demonstrated that low serum 25(OH) vitamin D3 levels are associated with the presence of metabolic syndrome independently from gender, age, BMI and serum PTH concentrations (Table 1).
Table 1: Multivariate linear regression analysis
“In this study, we demonstrated that serum 25(OH) vitamin D3 levels are significantly lower in obese patients affected by metabolic syndrome than in obese subjects without metabolic syndrome and comparable for sex, age, BMI, waist circumference and body fat mass,” the authors write. “The association between low serum 25(OH) vitamin D3 concentration and the diagnosis of MS was independent from PTH levels and the presence of type 2 diabetes.”
They also note that although the existence of an independent association between hypovitaminosis D and dysmetabolic conditions such as metabolic syndrome, type 2 diabetes, hypertension and liver steatosis has been demonstrated in several studies, the potential cause-effect relationship between the presence of low 25(OH) vitamin D3 levels and obesity/obesity-related conditions is still debatable.
“Reduced serum 25(OH) vitamin D3 concentrations represent a determinant of metabolic syndrome in obese patients,” they conclude. “The insulin-sensitising action of vitamin D rather than the distribution volume of this hormone is likely to be responsible for the thigh association between hypovitaminosis D and dismetabolic conditions.”
The small intestine changes the way the body processes glucose helping to regulate levels in the rest of the body and helping to resolve type 2 diabetes following gastric bypass surgery, according to a study from researchers at Boston Children’s Hospital.
Published in the journal Science, The researchers report that f type 2 diabetes was resolved in 100% of the rats that underwent gastric bypass. Sixty-four percent of type 2 diabetes was resolved by the intestine, and they researchers hypothesise that the other 36% may be due to weight loss or other factors.
“We have seen type 2 diabetes resolve in humans after gastric bypass, but have never known why,” said the study’s lead author, Dr Nicholas Stylopoulos. “”Previously, we had not considered the intestine as a major glucose-utilising organ. We have found this process is exactly what happens after surgery. People have been focusing on hormones, fat and muscle, but we have shown in this study that the answer lies somewhere in the small intestine most of the time.”
The researchers said that their findings add further evidence to the notion that gastric bypass surgery’s effects stem simply from limiting caloric intake. Their findings could pave the way for future investigations of how to create a medical pathway to mimic the intestine’s reprogramming without the surgery.
“With further research, we may find ways to bypass the bypass,” said Stylopoulos. “The results of our study are promising because, unlike the brain and other organs, intestines are easily accessible. Furthermore, since cells in the intestine have such a short lifespan, we can easily study and pharmacologically manipulate them to use glucose, without long-term problems.”
Stylopoulos and team injected a radioactive form of glucose into the bloodstream of rats that had undergone bypass surgery. Compared with rats that underwent a sham surgery, rats with gastric bypasses processed nearly twice as much sugar to the intestine, especially to the Roux limb.
When the researchers dissected the animals, they noticed that the Roux limb looked large. In fact, the Roux limb grows to a thickness at least 40% bigger than the intestine of normal rats, said Stylopoulos.
The researchers are trying to figure out why surgery makes the Roux limb get so big. The researchers suspect that undigested food dumped into the intestines from the stomach pouch might somehow trigger the growth.
Moreover, the animals that had undergone a bypass switched their food preferences from eating fatty meals to foods with fewer calories. This is contrary to what was expected, because if the drastically smaller stomach were the main driver of the weight loss, animals should chow down on fatty foods to pack in calories before their pouches get too full.
The ‘new gut section’ increases metabolism and starts producing specific glucose transporter-1 protein, which removes glucose from circulation and utilising it within the organ, stabilising blood glucose levels in the rest of the body.
“Enhancing intestinal glucose uptake and use could offer an opportunity to regulate whole-body glucose disposal and improve glycaemic control in type 2 diabetes,” the authors write.
“Exploitation of the changes that occur in intestinal metabolism after [Roux-en-Y gastric bypass] could represent an approach to bypass the bypass, that is, to replace the gastric bypass by equally effective, but less invasive, treatments for obesity-related diabetes,” they conclude.
Owen Haskins – Editor in chief, Bariatric News
New Jersey Gov. Chris Christie revealed earlier this week that he had secretly undergone Lap-Band surgery in February to bring his weight under control, a top Christie aide told ABC News.
Lap-Band surgery is among the less-invasive forms of gastric band surgery.According to the company’s website,the procedure is performed laparoscopically,meaning the surgeon makes a few small incisions in the abdomen,then uses long,thin surgical instruments to encircle the stomach with a silicone and titanium band.
Although as with any weight-loss surgery, the goal is massive weight loss, Dr. Jaime Ponce, a bariatric surgeon and president of the American Society for Metabolic and Bariatric Surgery, explained that Lap-Band surgery differed from other types of weight-loss operations.
According to Ponce, the most popular type of bariatric surgery is gastric bypass. This involves cutting the stomach into smaller pouches, then rerouting the digestive tract to reduce the amount of food eaten and the amount of nutrients the body absorbs. Gastric bypass accounts for more than 50 percent of the 200,000 or so bariatric surgeries performed in the United States each year.
Another surgery, gastric sleeve, involves removing about 80 percent of the stomach, Ponce explained. He said this type of surgery also diminished the hunger-regulating hormones, so one of its benefits is that hunger is greatly reduced compared to other types of surgeries.
Dr. Richard Besser, ABC News’ chief health and medical correspondent, said he believed the governor may have chosen Lap-Band because it restricts food intake without making any surgical alterations to the digestive tract.
Da oltre venti anni si occupa di Chirurgia Mini-Invasiva e Laparoscopica con particolare interesse nella Chirurgia della grande Obesità e Metabolica. Attualmente è responsabile della Unità Operativa di Chirurgia Bariatrica dell’Università di Roma – Tor Vergata, presso il Policlinico di Tor Vergata. È inoltre docente di Chirurgia dell’Obesità Patologica, presso la Scuola di Specializzazione in Chirurgia Generale della stessa Università.
Nel 1996, ha eseguito il primo intervento laparoscopico bariatrico e da allora si è dedicato in maniera particolare a questo tipo di chirurgia, raggiungendo una casistica ed una esperienza professionale notevole in chirurgia laparoscopica bariatrica e metabolica.
È Consigliere della S.I.C.O.B. (Società Italiana di Chirurgia dell’Obesità e della Malattie Metaboliche) ed inoltre è in contatto e in collaborazione continua con le maggiori Istituzioni americane di Chirurgia bariatrica e metabolica.
E’ direttore del Master di II livello in Chirurgia dell’Obesità Patologica, presso l’Università di Roma Tor Vergata di cui è anche membro del Senato Accademico.
Il Prof. Paolo Gentileschi è membro della I.F.S.O. (International Federation for Surgery of Obesity) ed è Socio Fondatore del LAP GROUP ROMA – GRUPPO LAPAROSCOPICO ROMANO, un’Associazione scientifica costituita dai rappresentanti di tutti gli Ospedali romani esperti in chirurgia mini-invasiva e fa parte del Consiglio Direttivo dell’associazione “Lazio Chirurgia”, fondata nel 2003, con fini di studio e comparazione dei risultati clinici ottenuti nei principali Ospedali romani, su diverse patologie.
È membro del Consiglio Direttivo della S.I.C.A.D.S. (Società Italiana di Chirurgia Ambulatoriale e Day-Surgery).
È Docente presso il Dottorato di Ricerca in Robotica ed Innovazioni Informatiche Applicate alle Scienze Chirurgiche dell’Università di Roma, Tor Vergata, diretto dal Prof. A.L. Gaspari.
RICONOSCIMENTI ACCADEMICI E PREMI RECENTI
Medical Education Development Award, concesso dalla S.L.S (Society of Laparoendoscopic Surgeons, USA) in “riconoscimento della sua esemplare e continua leadership nella didattica in campo laparoendoscopico”, Orlando, Florida.
Premio per il miglior contributo scientifico per la relazione dal titolo “Approccio laparoscopico nei re-interventi bariatrici: esperienza personale” al XXVI Congresso Nazionale della S.I.E.C. (Società Italiana di Endocrinochirurgia), Napoli.
Roma, 29 apr. – Continua a crescere, anche se di poco, la percentuale di italiani in perenne conflitto con la bilancia: nel 2011, oltre un terzo della popolazione adulta (35,8%, mentre era il 35,6% nel 2010) e’ in sovrappeso mentre una persona su dieci (10%) e’ obesa)….continua a leggere….
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