Live_Surgery_FrankfurterMeeting_Gagner 3

Come il cervello reagisce al cibo, dopo un intervento di bypass gastrico

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.

(Whole brain comparison of activation to high-calorie foods between obese patients after gastric bypass and gastric banding).

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

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L`Ipovitaminosi D è associata con la Sindrome Metabolica negli obesi


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.”


Study design

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.”


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BY PASS GASTRICO – Piccole modifiche dell`intestino tenue sono decisive per la risoluzione del diabete di tipo 2


stomach generalThe 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.


Dr Nicholas Stylopoulos

“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.


Tuesday, July 30, 2013 – 09:37

Owen Haskins – Editor in chief, Bariatric News

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Sleeve more effective than banding, more studies needed

Thursday, July 4, 2013 – 12:52

Owen Haskins – Editor in chief, Bariatric News

A meta-analysis has showed that laparoscopic sleeve gastrectomy (LSG) is a more effective procedure for morbid obesity than laparoscopic adjustable gastric banding (LAGB), with a greater effect on excess weight loss EWL and improvement of type 2 diabetes. The study authors from Nanjing Medical University, Nanjing, and Subei People’s Hospital of Jiangsu Province, Yangzhou, China, write that the meta-analysis confirms the need for larger, randomised, and long-term follow-up studies to compare the efficacy of LSG, LAGB, and laparoscopic Roux-en-Y gastric bypass.

The study, published in Obesity Surgery and available online, included 1,004 patients from 11 studies published between 2000 to 2012. The authors used the following inclusion criteria:

  • Studies including randomized controlled trials and non-randomized studies that compared LAGB with LSG;
  • Studies that provided information on at least one of the outcome measures; and
  • Studies published in English

The authors decided not to include case reports, articles that were not full text or non-comparative studies, and open operations (ie. those not performed by laparoscopic surgery).


The results (Table 1) showed that LSG had a greater effect than LAGB on EWL at six and 12 months. For LAGB, the mean percentage EWL was 33.9 % after six months from six studies and 37.8 % after 12 months from four studies. In comparison, EWL was 50.6 % after six months and 51.8 % after 12 months from the same studies for LSG.


Improve or resolve T2DM

EWL% (6ms)

EWL% (12ms)







Simon   KH Wong et al




63      ±      33

31      ±      24

65      ±      32

B   Breznikar et al.





52.4 (−2.0–145.3)

57.9 (7.6–92.3)

Juan   J. Omana et al.







Joshua   B. Alley et al.







Kazunori   Kasama et al.







Paul   Brunault et al.







Susan   S. H. Gan







W.   K. Fenske et al.







S.   K. H. Wong







F.   B. Langer et al.







M.   A. Kueper et al.







H.   R. Hady et al.







Table 1: Main outcomes of the 12 studies included in the meta-analysis

After six and 12 months, the mean percentage EWL was higher for LSG than for LAGB by 33.0 and 27.0 %, respectively, indicating that (at these time points) LSG had a greater effect on weight loss than LAGB.

LSG was also superior to LAGB in treating type 2 diabetes. In five studies, 42 of 68 (61.8 %) type 2 diabetes patients experienced improvement of their diabetes after LAGB, whereas 66 of 80 (82.5 %) type 2 diabetes patients improved after LSG, an increase of 20.7 %.

They concluded that LSG was a more effective procedure than LAGB, with a pooled OR of 0.34 (95 % CI 0.16–0.73; Fig. 1) and pooled mean differences of −12.55 (95 % CI −15.66 to −9.43; Figure. 2) and −4.97 (95 % CI −7.58 to −8.36; Figure. 1), respectively.

Table 1: Forest plot of comparison: (1) LAGB vs LSG in terms of short-term results, outcome: (1.1) resolution of diabetes. Odds ratios are shown with 95 % CI

Table 2: Forest plot of comparison: (1) LAGB vs LSG in terms of short-term results, outcome: (1.1) resolution of diabetes. Odds ratios are shown with 95 % CI

The investigators created funnel plots to access the publication bias of the literature, they report that the shapes of the plots did not reveal “any evidence of obvious asymmetry.”

“Because LSG is a comparatively new procedure that has become popular in recent years, there is also concern about the long-term results; the follow-up periods in most reports are 6 or 12 months, and the studies analysed here provided relatively short-term findings,” the authors note. “Some studies that reported three-year results were not included in this meta-analysis because of insufficient data, but their numbers are low. There are few reports with a follow-up period of 5 years or more.”








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Governatore del New Jersey si sottopone al bendaggio gastrico


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.

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Iniezioni di plasmidi capaci di ridurre CD8

Iniezioni di plasmidi capaci di ridurre CD8 e aumentare la produzione di insulina nel diabete tipo 1

Mercoledì 26 Giugno 2013 19:08

Un gruppo di immunologi ha pubblicato i dati di un primo trial su diabetici di tipo 1 con la somministrazione di un plasmide, capace di produrre un modulatore dell’autoimmunita e proinsulina, che ha determinato un significativo aumento (20%) della produzione di C-peptide.

Il trial, di fase II, non ha tuttavia dimostrato la eliminazione dell’insulino-dipendenza. L’aumento si è dimostrato significativo a 15 settimane dalla somministrazione del plasmide (sulla stampa definito vaccino). Nele settimane successive, inoltre, il declino della secrezione di C-peptide era sovrapponibile al gruppo trattato con placebo.

Sebbene il dato non appaia esaltante, si è comunque dimostrata una modulazione dell’autoimmunità ed un (parziale e temporaneo) ripristino della secrezione di insulina.


Plasmid-Encoded Proinsulin Preserves C-Peptide While Specifically Reducing Proinsulin-Specific CD8+ T Cells in Type 1 Diabetes
Roep BO, Solvason N, Gottlieb PA, Abreu JRF, Harrison LC, Eisenbarth GS, Yu L, Leviten M, Hagopian WA, JBuse JB, von Herrath M, Quan J, King RS, Robinson WH, Utz PJ, Garren H, The BHT-3021 Investigators, and Steinman L
Sci Transl Med 26 June 2013 5:191ra82.
doi: 10.1126/scitranslmed.3006103

PMID: pending




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Prof. Paolo Gentileschi

Prof. Dott. Paolo Gentileschi

Specialista in Chirurgia dell`Apparato Digerente – Responsabile dell`Unità Operativa di Chirurgia Bariatrica del Policlinico di Tor Vergata (Roma)

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.


Anno 2001

 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.

Anno 2006

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. 


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“Le operazioni di chirurgia dell’obesità non solo permettono di evitare malattie cardiovascolari e risolvono nel 90% il diabete, ma hanno anche una valida funzione protettiva contro le patologie osteo-articolari. Eliminare i chili di troppo, infatti, riduce i danni all’apparato scheletrico e migliora la mobilità dei pazienti”.
E’ questo il commento a un recente studio australiano di Marcello Lucchese, Direttore della chirurgia bariatrica e metabolica del Policlinico “Careggi” di Firenze e Presidente della Società Italiana di Chirurgia dell’Obesità e delle malattie metaboliche (SICOB). La ricerca, pubblicata sulla rivista Obesity Reviews, sostiene che la chirurgia dell’obesità può causare, in alcuni casi, la perdita della massa ossea. Secondo i ricercatori del Garvan Institute of Medical Research di Sydney, interventi come il bendaggio o il by pass gastrico, provocando alterazioni ormonali, possono incidere negativamente sulla salute delle ossa, indebolendole. “E’ vero, in alcuni casi questo può avvenire – continua Lucchese – ma si tratta di una condizione facilmente risolvibile. Il pericolo della carenza di calcio dopo un intervento può verificarsi solo quando ci si rivolge a centri non specializzati, che non seguono adeguatamente i loro pazienti una volta operati. Chi è stato sottoposto a un’operazione di chirurgia bariatrica, infatti, deve pretendere controlli periodici dalle strutture in cui è stato curato e dove sarà seguito per tutta la vita. Il metabolismo del calcio è un parametro che dovrebbe essere sempre e costantemente monitorato”.
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