Morphological Changes in the Carotid Artery Intima after Gastric Bypass for Morbid Obesity

Impact of bariatric surgery on carotid intima-media thickness and arterial stiffness in metabolically healthy obesity: a prospective study

PURPOSE

Cardiovascular disease is one of the leading causes of mortality in patients with obesity. Metabolically healthy obesity (MHO), in which people do not have metabolic disorders, is a transient state of obesity. However, over the long term, a proportion of individuals with MHO develop metabolic syndrome (MetS). We aimed to investigate the effect of substantial weight loss following bariatric surgery in MHO on carotid intima-media thickness (CIMT) and pulse-wave velocity (PWV), which are independent predictors of subclinical atherosclerosis.

METHODS

This prospective study included 38 patients (34 women, four men) undergoing bariatric surgery who had severe obesity but without comorbidities (hypertension, diabetes, and hyperlipidemia), and 28 control individuals who were matched for age and sex. CIMT and PWV of the left common carotid artery were measured. At 12-month follow-up after bariatric surgery, measurements were repeated in the 38 patients with obesity.

RESULTS

Mean baseline body mass index (BMI) in the MHO group was 40.55 ± 3.59 kg/m2, which decreased by 33.1% after bariatric surgery. Compared with controls, CIMT and PWV were increased in MHO (543.53 ± 55.29 vs. 407.82 ± 53.09 μm, 6.70 ± 1.22 vs. 5.45 ± 0.74 m/s, respectively; all P < 0.001). At 12 months post-bariatric surgery, CIMT in MHO was lower than baseline (466.79 ± 53.74 vs. 543.53 ± 55.29 μm, P = 0.009), but PWV was not significantly different from baseline (6.27 ± 0.86 vs. 6.70 ± 1.22 m/s, P = 0.132). Multivariate regression showed that BMI was an independent predictor of CIMT (β = 0.531, P < 0.001).

CONCLUSION

Carotid artery structure and function were impaired in MHO, and improved carotid artery structure was associated with weight loss in MHO after bariatric surgery.

Impact on carotid intima-media thickness after laparoscopic sleeve gastrectomy in patients with morbid obesity

BACKGROUND

We aimed to investigate the impact of laparoscopic sleeve gastrectomy (LSG) on carotid intima-media thickness (CIMT) & left ventricular dysfunction (LVD) which are the independent predictors of subclinical atherosclerosis.

METHODS

To assess the change in CIMT & echocardiographic parameters of left ventricular function & correlate with %EWL 6 months and 12 months after LSG, the mean CIMT of bilateral common carotid arteries were measured at 3 different places & 7 parameters were assessed for left ventricular dysfunction after 6 and 12 months of LSG & correlated with the %EWL.

RESULTS

A total of 30 patients (27(90%) women & 3(10%) men) with the mean age of 38 ± 7.84 were prospectively enrolled. BMI was significantly reduced from 42.66 ± 3.79 to 37.93 ± 3.60 kg/m2 at six months to 36 ± 3.34 at 12 months after LSG. CIMT values were significantly decreased at 6 months after surgery from 0.50 ± 0.11 mm to 0.46 ± 0.09 mm (p < 0.01) to 0.39 ± 0.07 (p < 0.05) at 12 months. However, no significant change was observed in the right mean CCA values at 6 months after surgery 0.50 ± 0.11 mm vs 0.47 ± 0.09 mm (p = 0.07) as compared to decrease at 12 months after surgery to 0.40 ± 0.08 (p < 0.05). Left mean CCA values at 6 months changed from 0.50 ± 0.11 to 0.45 ± 0.09 (p < 0.01) and at 12 months after surgery to 0.39 ± 007(p < 0.05). On 2D ECHO, ejection fraction increased at 6 months from 60.80 ± 5.89 to 61.93 ± 4.47 (p < 0.5) to after 12 months at 64.30 ± 4.20 (p < 0.05). Wave deceleration time changed at 6 months from 170 ± 36.80 to 150 ± 28.82 (p < 0.05) to 12 months 139.07 ± 17.98 (p < 0.05). Peak early diastolic mitral annular velocity (e) changed at 6 months from 8.12 ± 1.66 to 7.02 ± 1.76 (p < 0.05) to 12 months 6.33 ± 0.76 (p < 0.05). Inter-ventricular septum thickness (IVSD) changed at 6 months from 0.99 ± 0.14 to 0.91 ± 0.14 (p < 0.05) to 12 months 0.82 ± 0.09 (p < 0.05). Intraventricular relaxation time (IVRT) at 6 months changed from 94.33 ± 21.71 to 84.36 ± 14.85 (p < 0.03) to 12 months after surgery 77.40 ± 10.19 (p < 0.05). Left atrial volume index (LAVI) at 6 months decreased from 38.08 ± 11.23 to 30.93 ± 7.16 (p < 0.01) to 12 months after surgery 25.43 ± 3.65 (p < 0.05). Left ventricular diastolic dysfunction [LVIDD] at 6 months changed from 4.32 ± 0.52 to 4.11 ± 0.52 (p < 0.02) to 3.94 ± 0.26 (p < 0.05) to 3.94 ± 0.26 (p < 0.05) at 12 months after surgery. PwD at 6 and 12 months changed from 1.00 ± 0.19 to 0.87 ± 0.10 (p < 0.01) to 0.82 ± 0.08 (p < 0.05) respectively. LV mass changed in 6 months from 148.37 ± 33.09 to 117 ± 29.90 (p < 0.001) to 12 months at 110.64 ± 20.79 (p < 0.05) and left ventricular mass index [LVMI] changed in 6 months from 70 ± 16.89 to 59.626 ± 15.35 (p < 0.001) reaching a value of 57.53 ± 11.18 (p < 0.05) at 12 months. The mean 10-year risk of death due to CVD calculated was significantly reduced from 5.45 ± 6.6 to 2.8 ± 1.7% at 6 months (p < 0.05). This significant decrease in CVD risk has a positive correlation with the decrease in CIMT over 6 months showing a correlation coefficient of 0.018 with statistically significant analysis (p value < 0.05).

CONCLUSION

We observed a significant reduction in CIMT & improvement in 2D ECHO parameters at 6 after LSG although no statistically significant change was observed in mean right CIMT & EF at 6 months.

Impact of bariatric surgery on carotid intima-media thickness, flow-mediated dilation, and nitrite-mediated dilation: a systematic review and meta-analysis

Obesity is considered one of the independent risk factors for atherosclerosis and is strongly correlated with cardiovascular morbidity and mortality. Previous studies showed carotid intima-media thickness (CIMT), flow-mediated dilation (FMD), and nitrite-mediated dilatation (NMD) are reliable non-invasive markers of arterial damage and dysfunction. The aim of this study was to evaluate the effect of bariatric surgery on CIMT, FMD, and NMD markers in patients with obesity. A systematic search was performed in the PubMed, Embase, Scopus, and Web of Science databases until May 2022. All the English-published studies on the effect of bariatric surgery on CIMT, FMD, and NMD were included. A quantitative meta-analysis was performed, as well as subgroup analyses for the type of procedure and duration of follow-up. Meta-analysis of 41 studies with 1639 patients showed CIMT was significantly reduced by .11 mm after bariatric surgery (95% CI, -.14 to -.08; P < .001; mean follow-up = 10.8 mo). The pooled analysis of 23 studies with 1106 patients showed an increase of FMD by 4.57% after bariatric surgery (95% CI, 2.69-6.44; P < .001; mean follow-up = 11.5 mo). The results of a pooled analysis of 12 studies with 346 patients showed a significant increase of NMD by 2.46% after bariatric surgery (95% CI, .99-3.94; P < .001; mean follow-up = 11.4 mo). The random effect meta-regression demonstrated that baseline CIMT and FMD significantly affect the changes in CIMT and FMD. This meta-analysis showed bariatric surgery can improve CIMT, FMD, and NMD markers in patients with obesity. These improvements show the known effect of metabolic surgery in decreasing cardiovascular risk.

Effect of Bariatric Surgery on Intima Media Thickness: A Systematic Review and Meta-Analysis

BACKGROUND

Obesity, and in particular extreme obesity, as a global health problem is an important risk factor for many diseases, including atherosclerotic cardiovascular disease (ACVD). Bariatric surgery might stop or slow atherogenesis by decreasing excessive weight in the early stages of atherogenesis, by suppressing low-grade systemic inflammation as well as by inhibiting oxidative stress and endothelial dysfunction. The aim of this meta-analysis was to provide an answer to whether bariatric surgery has a significant effect on intima-media thickness (IMT) which is a surrogate marker of early atherosclerosis and has a good correlation with atherosclerotic coronary heart disease.

METHODS

A systematic literature search in PubMed, Scopus, Embase, and Web of Science as well as grey literature was performed from inception to 1 July 2022. The meta-analysis was performed using Comprehensive Meta-Analysis (CMA) V3 software. Overall, the estimate of effect size was measured by a random effects meta-analysis. To account for the heterogeneity of studies regarding study design, characteristics of the populations, and treatment duration, a random-effects model (using the DerSimonian-Laird method) and the generic inverse variance weighting approach were used. To assess the existence of publication bias in the meta-analysis, the funnel plot, Begg's rank correlation, and Egger's weighted regression tests were used.

RESULTS

The meta-analysis of 30 trials, including 1488 subjects, demonstrated a significant decrease in IMT after bariatric surgery. The reduction in IMT was also robust in the leave-one-out sensitivity analysis. It must be stressed that the results of the random-effects meta-regression did not suggest any relationship between the changes in IMT and delta body mass index (BMI) or duration of follow-up after the bariatric surgery. However, the subgroup analyses showed a better IMT reduction after laparoscopic sleeve gastrectomy (LSG) when compared to Roux-en-Y gastric bypass (RYGB). Within a year, the IMT follow-up values showed a further improvement.

CONCLUSIONS

Bariatric surgery significantly reduced IMT. Significant associations were found between the surgery type and IMT changes, as well as a significant effect of follow-up duration on the changes of IMT after bariatric surgery.

Impact of Bariatric Surgery on Carotid Intima-Media Thickness in Patients with Morbid Obesity: a Prospective Study and Review of the Literature

BACKGROUND AND AIM

One of the main causes of mortality among obese patients is cardiovascular disease (CVD). Carotid intima-media thickness (CIMT) is an independent predictor for atherosclerosis and risk of CVD, and has been demonstrated to be related with obesity. This study aimed to evaluate the effect of substantial weight loss after bariatric surgery on CIMT.

METHODS

This prospective study was performed on patients with morbid obesity and standard indications for bariatric surgery in a tertiary referral center in Iran. The mean CIMT values were assessed using B-mode ultrasonography before and 6 months after bariatric surgery.

RESULTS

A total of 32 patients (25 females, 7 males) with a mean age of 38.18 ± 1.18 years were enrolled. Body mass index (BMI) was significantly reduced from 43.66 ± 6.44 to 29.01 ± 2.56 kg/m² during 6 months following surgery (p: 0.001). The mean CIMT values at 6 months after surgery were significantly lower than the baseline (0.53 ± 0.06 vs. 0.50 ± 0.08; p: 0.001). Along with a significant hypertension and metabolic syndrome remission, we observed considerable reduction in FBS (p: 0.019), cholesterol (p: 0.061), triglycerides (p: 0.001), and insulin levels (p: 0.001). Besides, liver stiffness was significantly decreased after surgery (6.15 ± 0.82 vs. 5.26 ± 0.83; p: 0.001). There was no statistically significant correlation between changes in quantitative variables and changes in CIMT.

CONCLUSION

Bariatric surgery results in significant reduction in CIMT, metabolic syndrome factors, and liver stiffness in patients with morbid obesity.

Ockham's razor and the metabolic syndrome

The broad effects of bariatric/metabolic surgery on virtually every tissue and organ system remain unexplained. Weight loss, although a major factor, does not fully account for the rapid, full, and durable remission of type 2 diabetes, return of islet function, reduction of the prevalence of cancers, increase in gray matter of the brain, and decrease in all-cause mortality. This review supports the thesis that the metabolic syndrome is not a group of separate diseases but rather multiple expressions of a shared defect in the utilization of carbohydrates and lipids. That error is probably caused by a dysmetabolic signal from the foregut, stimulated by food, that limits entry of 2-carbon fragments into the tricarboxylic acid cycle, the accumulation of lactate and, in turn, increases in glucose and insulin. Surgery limits that signal by reducing contact between food and foregut mucosa. Speciation of that signal(s) may offer a new pathway for drug development.

Impact of bariatric surgery on carotid intima-medial thickness and cardiovascular risk: results of a prospective study

BACKGROUND

The impact of bariatric surgery on atherosclerosis is a relatively less studied subject. Obesity has been identified as an independent risk factor for cardiovascular disease (CVD). Carotid intima-media thickness (CIMT), a surrogate marker for atherosclerosis and risk of CVD, has been found to be associated with obesity. Recent literature has shown that there is significant reduction in CIMT following bariatric surgery. The aim of this study was to evaluate the impact of bariatric surgery on CIMT and risk of CVD in an Indian population.

METHODS

This is a prospective study conducted in a tertiary referral centre in India. Patients undergoing bariatric surgery from December 2017 to September 2019 were included. CIMT measurements and American College of Cardiology/American Heart Association (ACC/AHA)-pooled cohort CVD risk scores were done before and at 6 months and 12 months after surgery.

RESULTS

Fifty-four patients were enrolled, of which 70% were females. Mean age was 40.8 ± 10.7 years. Mean pre-operative weight and mean BMI were 115.2 ± 21.9 kg and 45.9 ± 6.5 kg/m², respectively. Patients who completed 12-month follow-up were considered for analysis of outcomes. There was significant reduction in BMI to 33.1 ± 5.7 kg/m² at 12 months after surgery (p < 0.0001). Mean CIMT reduced significantly from 0.58 ± 0.08 mm at baseline to 0.52 ± 0.10 mm at 12 months. Lipid profile, fasting blood sugar and HbA_1C also improved, which resulted in reduction of lifetime and 10-year CVD risk from 42.3 to 26% and 4 to 1.5%, respectively, at 12 months after surgery.

CONCLUSIONS

Bariatric surgery results in significant reduction in CIMT and CVD risk in patients with morbid obesity.

Bariatric Surgery-Induced Changes in Intima-Media Thickness and Cardiovascular Risk Factors in Class 3 Obesity: A 3-Year Follow-Up Study

OBJECTIVE

The impact of weight loss induced by bariatric surgery (BS) and nonsurgical approaches on cardiovascular risk factors (CVRFs) has not been fully elucidated. We assessed the effects of BS and a nonsurgical approach on carotid intima-media thickness (CIMT) and CVRFs in participants with class 3 obesity.

METHODS

A total of 87 participants with obesity (59 women; 46 [37-52] years old; BMI, 43 [40-47]) and 75 controls were recruited; 21 (25%) participants with obesity underwent BS. BMI, blood pressure, cholesterol, triglycerides, fasting plasma glucose, C-reactive protein, CIMT, and Framingham Risk Score were measured at baseline and at 3-year follow-up. Independent factors for reduction in CIMT were analyzed. The literature on the effects of BS and CIMT was reviewed.

RESULTS

After BS, BMI decreased from 45.45 to 27.28 (P < 0.001), and mean CIMT decreased from 0.64 mm (0.56-0.75 mm) to 0.54 mm (0.46-0.65) mm (P < 0.012), equivalent to 0.005 mm/kg of weight lost. At 3-year follow-up, participants who had undergone BS had similar CIMT and CVRFs to the control group. No changes in CVRFs were seen related to the nonsurgical approach. BMI reduction after BS had the strongest independent association with decreased CIMT.

CONCLUSIONS

Weight loss after BS decreases CIMT and CVRFs in middle-aged participants with class 3 obesity, resulting in CIMT similar to that observed in lean participants.

Assessment of Carotid Artery Distensibility and Elasticity After Laparoscopic Sleeve Gastrectomy: a Prospective Study

PURPOSE

Although it is well known that obesity increases the risk of atherosclerosis in carotid arteries, it is not clear whether this risk changes after obesity surgery. The aim of this study was to investigate whether weight reduction with a laparoscopic sleeve gastrectomy (LSG) has any effect on distensibility and elasticity which show subclinical atherosclerosis in the carotid arteries of obese individuals.

MATERIALS AND METHODS

This prospective study included 130 patients (body mass index (BMI) 48.21 ± 6.97 kg/m²) who underwent LSG. The patients were followed up for 1 year. Comparisons were made of the distensibiliy and elasticity values calculated preoperatively and at 1, 3, 6, and 12 months, postoperatively.

RESULTS

There was a statistically significant increase in distensibility and elasticity values from baseline to 1, 3, 6, and 12 months postoperatively (p < 0.001 for both comparisons). The multiple linear regression analysis was used to find the variables affecting both distensibility and elasticity. According to the results, the presence of BMI decreases distensibility percentage change level by 0.38 units (β= - 0.38, 95% CI - 0.51;- 0.25, p < 0.001). The presence of fasting plasma glucose decreases elasticity percentage change level by 0.20 units. (β= - 0.20, 95% CI - 0.39; - 0.01, p = 0.037).

CONCLUSION

Carotid artery distensibility and elasticity values increase after LSG, and this change could be caused by the change in metabolic parameters and heart geometry. These results may indirectly suggest that subclinical atherosclerosis in carotid arteries has decreased after obesity surgery.

Influence of Morbid Obesity and Bariatric Surgery Impact on the Carotid Adventitial Vasa Vasorum Signal

INTRODUCTION/PURPOSE

Adventitial vasa vasorum (VV) expansion to the avascular intima precedes an increase in carotid intima-media thickness. However, factors involved in the development of the atherosclerotic process and its reversibility remain unclear. We aimed to evaluate the VV signal in both morbid obesity and after bariatric surgery (BS).

MATERIALS/METHODS

We conducted a case-control study to examine the VV signal in the carotid of 40 morbidly obese patients and 40 non-obese controls. The effect of BS was evaluated in 33 patients. Contrast-enhanced carotid ultrasound was used to assess the VV signal.

RESULTS

The mean VV density was higher in obese than in non-obese subjects (0.739 ± 0.117 vs. 0.570 ± 0.111, p < 0.001). The VV signal positively correlated with BMI (p < 0.001) and waist circumference (p = 0.001) but was not related to cIMT. The stepwise multivariate regression analysis revealed that waist circumference (beta = 0.507, p < 0.001) together with fasting plasma glucose (beta = 0.229, p = 0.024) were independently associated with the VV signal (R² = 0.382). Before BS, the median VV signal correlated with soluble intercellular adhesion molecule 1 (p = 0.022). After a 12-month follow-up, a 12.0% decrease in VV (0.731 ± 0.126 vs. 0.643 ± 0.115, p = 0.003) was observed. In the univariate analysis, the decrease in VV was associated with the baseline VV density (p < 0.001), baseline systolic blood pressure (p = 0.019) and a decrease in sICAM (p = 0.005). However, only baseline systolic pressure (beta = 0.417, p = 0.024) independently predicted the absolute change in VV signal (R² = 0.174).

CONCLUSIONS

Morbidly obesity is associated with increased VV density. In addition, BS appears to reduce the earlier expansion of the adventitial vasa vasorum.

Peripheral neuropathies after bariatric surgery. Preliminary results from a single-centre prospective study in Northern Italy

INTRODUCTION

Bariatric surgery (BS) has gained popularity in order to treat morbid obesity. However, post-operative (PO) neurologic complications have become increasingly recognized. Our aim was to examine incidence, clinical presentation, and outcomes of neurologic disorders secondary to BS.

METHODS

Patients who underwent BS between the years 2012 and 2015 at Parma University were included in this survey, and assessed before (T0) and 1 year after surgery (T1). Baseline characteristics and medical comorbidities, type of surgery, and PO complications were retrieved. Patients with a previous history of peripheral neuropathic disease were excluded from the analysis. If a patient presented with a new onset neurologic symptom including extremity numbness, paresthesia, muscle weakness, the status was considered "positive" for PO-neuropathy.

RESULTS

Overall, we retrieved data from 61 patients (n=30 Roux-en-Y Gastric bypasses, n=31 Gastric banding; 81.0% females). Of them, 7 (11.4%) developed some signs of PO-neuropathy, that eventually disappeared at T+24 months. The most common manifestations were paresthesia (n=6) and muscle weakness (n=4), similarly distributed in Gastric Bypass (n=4) and Gastric Banding (n=3) groups. Although patients affected by PO-neuropathy exhibited higher SF-36 score at T0 (p=0.018), no significant differences were found regarding BMI (T0, T1), percentual weight loss, serological data (i.e. vitamin B1, B2, B6, B12: in all cases p>0.05).

CONCLUSION

PO-BS neuropathy is usually associated with lower levels of vitamin B1, B2, B12. However, no differences in PO-BMI, excess weight loss, and metabolic data levels were found. Larger data and more extended follow-up are required to validate our results.

Abdominal pain and internal hernias after Roux-en-Y Gastric Bypass: are we dealing with the tip of an iceberg?

Background:

Abdominal pain is the most frequent cause of hospital admission after Roux-en-y gastric bypass (RYGB). Among numerous possible underlying causes, internal hernias represent one of the most peculiar and insidious conditions, setting challenging diagnostic and therapeutic problems for the surgeon. The aim of this study is to analyze aspecific abdominal pain incidence and characteristics after RYGB, discriminating peculiar aspects suggestive of internal hernias.

Methods:

13 patients submitted to internal hernia repair after laparoscopic antecolic RYGB and a group of 49 controls (non-complicated RYGB) have been assessed using a specific questionnaire. Overall aspecific abdominal pain incidence and characteristics have been analysed. Typical pain traits and predisposing conditions for internal hernias have been investigated.

Results:

33% of controls reported aspecific abdominal pain after RYGB, mainly early postprandial, deep, remittent, colicky, located in the upper left abdomen. 77% of the case patients reported prodromal episodes of pain similar to the controls. The only significant differences between prodromal and acute episodes were pain intensity and quality (continuous). Excess weight lost at 3 months significantly correlated with internal hernia occurrence (p: 0.002). Conclusions: Based on abdominal pain characteristics, we can reasonably postulate the presence of remittent bowel torsions (remittent internal hernia) in many patients after antecolic RYGB, only occasionally complicating. Therapeutic management of these cases remains controversial, being laparoscopic exploration a reasonable option when symptomatology is suggestive.(www.actabiomedica.it)

Surgical management of obesity

Weight loss surgery is the most effective intervention for addressing obesity and related metabolic disorders such as diabetes. We describe common surgical procedures as well as emerging and investigational procedures in terms of their capacity to induce weight reduction and their risk profiles. We then discuss the impact of weight loss surgery on important obesity related disorders including diabetes, cardiovascular disease, and non-alcoholic fatty liver disease. The question of operative choice is discussed with respect to benefits and risks of common procedures. Reoperative weight loss surgery, an increasingly common element of weight loss surgical practice, is reviewed. We briefly discuss the metabolic mechanism of action of weight loss surgery. Lack of access to and under-utilization of weight loss surgery represent important challenges to adequate obesity treatment, and we review these topics as well.

Age-Related Effects of Bariatric Surgery on Early Atherosclerosis and Cardiovascular Risk Reduction

BACKGROUND

Carotid intima-media thickness (CIMT) is increasingly used as a prognostic indicator for early atherosclerosis and the development of cardiovascular disease. The objective of this study is to assess the exact effects of bariatric surgery on CIMT reduction in different age groups.

METHODS

CIMT was measured just proximal to the bifurcation of the carotid artery in 166 patients with mean body mass index of 43.4 kg/m² before and at 6 and 12 months after bariatric surgery. Preoperative CIMT and Framingham Risk Score (FRS) were compared to measurements at 6 and 12 months, postoperatively. Impact of age on CIMT change and cardiovascular risk reduction was analyzed.

RESULTS

Median follow-up was 12 months; 12% were lost to follow-up. Mean CIMT values at 12 months after bariatric surgery were significantly lower compared to baseline (0.619 vs. 0.587 mm, p = 0.005 in women and 0.675 vs. 0.622 mm, p = 0.037 in men, respectively), and these effects were statistically significant in all age groups. The mean reduction of CIMT for patients < 50 years at 12 months was 0.043 mm (- 7.0%), while CIMT was reduced with 0.013 mm for patients ≥ 50 years (- 1.9%, p = 0.022). At 12 months after bariatric surgery, FRS had decreased with 52% in patients < 50 years as compared with 35% in patients ≥ 50 years (p = 0.025).

CONCLUSIONS

Bariatric surgery resulted in a significant CIMT decrease in patients with morbid obesity in all evaluated age categories. These beneficial effects of bariatric surgery were more pronounced in younger patients, while cardiovascular risk reduction by bariatric surgery appeared inferior in patients of 50 years and older.

Early Regression of Carotid Intima-Media Thickness after Bariatric Surgery and Its Relation to Serum Leptin Reduction

PURPOSE

Bariatric surgery (BS) promotes carotid intima-media thickness (C-IMT) regression as early as 6 months post-surgery. To verify whether C-IMT regression occurs even earlier, we aimed at the effect of Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD) on C-IMT 1-2 months and 12 months post-surgery.

SUBJECTS/METHODS

Prospective trial. BS was performed on 109 patients either with (RYGBP = 42; BDP = 40) or without type 2 diabetes (RYGBP = 27). Healthy volunteers served as control group.

FOLLOW-UP

baseline, 1-2 months, 12 months post-surgery.

ENDPOINTS

changes (∆) in C-IMT, weight, body mass index, fat mass, waist and neck circumferences, blood pressure, HbA1c, glucose, insulin, insulin sensitivity [HOMA-IR; OGIS, from meal tolerance test], lipids, C-reactive protein, leptin, adiponectin, MCP-1.

RESULTS

All surgery subgroups had similar levels of ∆-C-IMT. C-IMT in the pooled surgery group reduced from [mean (95% confidence interval)] 0.81 (0.77-0.84) mm to 0.66 (0.63-0.69) mm, p < 0.001 [-17.1 (-20.4 to -13.8)%] at 1-2 months, and to 0.63 (0.59-0.66) mm, p < 0.001 [-21.8 (-25.3 to -18.4)%] at 12 months post-surgery. ∆-C-IMT 1-2 months and 12 months post-surgery correlated to baseline C-IMT, and with ∆-leptin at 1-2 months, but not at 12 months post-surgery. In linear regression analysis, ∆-leptin and baseline C-IMT were predictors of ∆-C-IMT 1-2 months post-surgery.

CONCLUSIONS

A remarkable C-IMT regression occurred as early as 1-2 months after BS in obese patients either with or without type 2 diabetes, which was associated to the early reduction in leptin, (at least partially) independent of weight loss. Whether this is a causative or correlative association needs further investigation.

Impact of weight loss on epicardial fat and carotid intima media thickness after laparoscopic sleeve gastrectomy: A prospective study

BACKGROUND AND AIMS

Cardiovascular disease (CVD) is one of the leading causes of mortality in obese patients. We aimed to investigate the influence of significant weight loss following laparoscopic sleeve gastrectomy (LSG) on carotid intima media thickness (CIMT) and epicardial fat thickness (EFT) which are the independent predictors of subclinical atherosclerosis.

METHODS AND RESULTS

Patients were recruited for standard indications. A total of 105 patients (79 women and 26 men) with the mean age of 43.61 ± 12.42 were prospectively enrolled. On B-mode duplex ultrasound; the mean CIMT at the far wall of both left and right common carotid arteries were measured. EFT was measured on the free wall of the right ventricle at end-diastole from the parasternal long-axis view by standard transthorasic 2D echocardiography. Delta (Δ) values were obtained by subtracting sixth month values from the baseline values. Body mass index (BMI) was significantly reduced from 46.95 ± 7.54 to 33.54 ± 6.41 kg/m2 (p < 0.001) in sixth months after LSG. Both EFT and CIMT were significantly decreased after surgery (8.68 ± 1.95 mm vs. 7.41 ± 1.87 mm; p < 0.001 and 0.74 ± 0.13 mm vs. 0.67 ± 0.11 mm; p < 0.001 respectively). A significant correlation between ΔEFT and ΔBMI (r = 0.431, p < 0.001) was shown. ΔCIMT is significantly correlated with ΔEFT, ΔBMI and Δ systolic blood pressure (r = 0.310, r = 0.285 and r = 0.231 respectively, p < 0.05 for all). In multivariate stepwise linear regression analysis; among variables only ΔBMI was the independent predictor of ΔEFT (β = 153, p = 0.001).

CONCLUSION

Early atherosclerotic structural changes may be reversed or improved by sustained weight loss after LSG in asymptomatic obese patients.

Laparoscopic gastric bypass with remnant gastrectomy in a super-super obese patient with gastric metaplasia: a surgical hazard?

The endoscopic inaccessibility of the gastric remnant after Roux-en-Y gastric bypass (RYGBP) for morbid obesity represents an important issue for patients with familiar history of gastric cancer (GC) or affected by premalignant lesions, such as intestinal metaplasia. If a different bariatric procedure is contraindicated, RYGBP with remnant gastrectomy represents a reasonable alternative, significantly reducing the risk of GC but potentially increasing postoperative morbidity. For this reason, only few cases have been reported in the recent Literature and none regarding a super-super obese patient. We present the case of a 55-year-old super-super obese man with a family history of GC and antral gastritis with extensive intestinal metaplasia at preoperative upper endoscopy, who underwent laparoscopic RYGBP with remnant gastrectomy. (www.actabiomedica.it)

Lipid changes 8 years post gastric bypass in adolescents with severe obesity (FABS-5+ study)

OBJECTIVE

Severe obesity in adolescents is increasing and few effective treatments exist. Bariatric surgery is one option, but the extent to which surgery influences cardiovascular risk factors over time in youth is not clear. We hypothesized that Roux-en Y gastric bypass (RYGB) would be associated with sustained improvements in lipids over time (>5 years).

PARTICIPANTS/METHODS

Youth who underwent RYGB from 2001 to 2007 were recruited for the Follow-up of Adolescent Bariatric Surgery-5+ (FABS-5+) in 2011-2014. Baseline body mass index (BMI) and lipids were abstracted from medical records. Follow-up data were obtained at a research visit. Analyses included paired t-tests to assess changes in BMI and lipids over time. General linear models were used to evaluate predictors of high-density lipoprotein (HDL) and non-HDL-cholesterol at follow-up. A non-operative group was recruited for comparison.

RESULTS

Surgical participants (n=58) were a mean±s.d. age of 17±2 years at baseline and 25±2 years at long-term follow-up. Eighty-six percent were Caucasian and 64% were female. At long-term follow-up BMI decreased by 29% and all lipids (except total cholesterol) significantly improved (P<0.01). Female sex was a significant predictor of non-HDL-cholesterol level at 1 year, while change in BMI from 1 year to long-term follow-up was a significant predictor of non-HDL-cholesterol and HDL-cholesterol during the same interval (P<0.05). In the non-operative group, BMI increased by 8% and lipid parameters were unchanged.

CONCLUSIONS

This is the longest and most complete follow-up of youth following RYGB. Weight loss maintenance over time was significantly associated with improvements in lipid profile over 5 years.

Vascular Endothelial Growth Factor Augments Arginine Transport and Nitric Oxide Generation via a KDR Receptor Signaling Pathway

BACKGROUND/AIMS

Vascular endothelial growth factor (VEGF) is an endothelium-specific peptide that stimulates angiogenesis via two receptor tyrosine kinases, Flt-1 and KDR. Endothelial nitric oxide synthase (eNOS) plays a major role in VEGF signaling. Delivery of arginine to membrane bound eNOS by the cationic amino acid transporter-1 (CAT-1) has been shown to modulate eNOS activity. The current studies were designed to test the hypothesis that VEGF enhances eNOS activity via modulation of arginine transport by CAT-1.

METHODS

Using radio-labeled arginine, {[3H] L-arginine} uptake was determined in human umbilical vein endothelial cells (HUVEC) following incubation with VEGF with and without silencing the VEGF receptors Flt-1 or KDR. Subsequently, western blotting for CAT-1, PKCα, ERK 1/2, JNK, and their phosphorylated forms were performed. NO generation was measured by the Griess reaction.

RESULTS

VEGF (50 and 100 ng/ml) significantly augmented endothelial arginine transport in a time dependent manner, an effect which was prevented by Sunitinib (2 µM), a multi targeted receptor tyrosine kinase inhibitor. The increase in arginine transport velocities by VEGF was not affected by silencing Flt-1 while silencing KDR abrogated VEGF effect. Furthermore, incubating cells with 50 and 100 ng of VEGF for 30 minutes significantly augmented CAT-1 abundance. The expression of PKC-α, JNK, and ERK1/2 and their phosphorylated forms were unchanged following incubation of HUVEC with VEGF. The concentration of NO2/NO3 following incubation with VEGF was significantly higher than from untreated cells. This increase was significantly attenuated by silencing KDR.

CONCLUSIONS

VEGF increases arginine transport via modulation of CAT-1 in endothelial cells. This effect is exclusively dependent on KDR rather than Flt-1.