Weight Loss and Glycemic Control After Bariatric Surgery in Adolescents With Severe Obesity: A Randomized Controlled Trial

PURPOSE

Bariatric surgery is regarded as a valuable treatment option for adolescents with severe obesity. However, high-quality evidence of its superiority over prolonged conservative treatment with multidisciplinary lifestyle intervention (MLI) is limited. This study investigated the efficacy and safety of bariatric surgery in adolescents without sufficient weight loss after MLI for severe obesity.

METHODS

A two-group randomized controlled trial was designed to assess one-year health effects of bariatric surgery in adolescents with severe obesity. The participants were referred by pediatricians after completing MLI without sufficient effects. Eligible for participation were adolescents aged 14-16 years with severe obesity (age- and sex-adjusted body mass index (BMI) using the International Obesity Task Force cutoffs: BMI ≥40 kg/m2, or ≥35 kg/m2 in combination with comorbidity). Participants were assigned to MLI combined with laparoscopic adjustable gastric banding (n = 29) versus only MLI (n = 30). Participants were included from 2011 to 2019. Main outcomes were weight change and sex- and age-specific BMI loss. Additionaly, glucose metabolism, blood pressure and lipid profile were analysed.

RESULTS

53 patients completed the 12-months follow-up (89.8%). Mean (±standard deviation [SD]) weight loss in the surgery group was 11.2 ± 7.8% after 12 months, compared to a weight gain of 1.7 ± 8.1% in the control group. The fasting insulin, insulin resistance score and lipid profile improved significantly in the surgery group.

DISCUSSION

Bariatric surgery was associated with substantial weight loss and improvements in glucose and lipid metabolism after 12 months compared to conservative treatment in adolescents with severe obesity.

Hiatal hernia recurrences after laparoscopic surgery: exploring the optimal technique

INTRODUCTION

The recurrence rate of hiatal hernia (HH) after laparoscopic surgery with crural repair and Nissen or Toupet fundoplication is high (< 25-42%). HH repair can be reinforced with additional anterior sutures, vertical mesh strips (VMS) or mesh placement but the effect in the long-term (> 1 year) is still unclear. We determined the recurrence rate of HH after surgery and established whether the use of reinforcement techniques could reduce long-term recurrence rates.

METHODS

In this retrospective cohort study patients were included if they underwent a laparoscopic fundoplication in this hospital between 2012 and 2019. HH was measured with computed tomography and baseline patient characteristics and surgical details were collected. Primary outcomes were recurrence of symptoms and re-intervention, secondary outcome was effect of surgical reinforcement techniques. Statistical analyses comprised chi-square tests, Mann-Whitney U tests and uni- and multivariable logistic regression analyses.

RESULTS

In total, 307 patients were included, 206 women and 101 men. During primary surgery, 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of anterior sutures in 132 patients, VMS in 89 patients and mesh in 17 patients. After primary surgery, recurrence of HH was diagnostically confirmed in 64 patients (20.8%). Use of VMS during primary surgery was significantly associated with fewer recurrences (OR = 0.34, p = 0.048), corrected for confounding factors. Secondary surgery was performed in 54 patients (17.6%) and tertiary surgery in five patients (1.6%). Mesh and VMS were used more during secondary and tertiary surgery.

CONCLUSION

The recurrence rate among HH patients in this cohort study was 20.8% with a mean follow-up time of 6 years. Secondary surgery was performed in 17.6% of the patients. In future, the use of VMS might lead to fewer recurrences after primary laparoscopic repair of HH.

OC-067 HIATAL HERNIA RECURRENCES AFTER LAPAROSCOPIC SURGERY: EXPLORING CONTRIBUTING SURGICAL FACTORS

Aim

The recurrence rate of hiatus hernia (HH) is high after laparascopic surgery (25–42%). HH repair can be reinforced by means of additional ventral sutures, pledgets or mesh placement. We determined the recurrence rate of HH after surgery and established whether lower long-term recurrence rates can be achieved with reinforcement techniques.

Methods

Patients were included in this retrospective cohort study if they underwent a laparoscopic fundoplication in our hospital between 2012–2019. HH was measured on CT scans and patient files were reviewed.

Results

In total, 307 patients were included, 206 women and 101 men. Pre-operatively, 102 patients were diagnosed with type III HH and 68 patients with type IV HH. The median transverse diameter of the HH was 3.2 cm. 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of ventral sutures in 132 patients, pledgets in 89 patients and mesh in 17 patients. After primary surgery, recurrence of HH was diagnostically confirmed in 64 patients (20.8%). Secondary surgery was performed in 54 patients (17.6%) and tertiary surgery in 5 patients (1.6%). Use of pledgets during primary surgery (OR=0.34, p=0.048) was significantly associated with fewer recurrences, corrected for confounding factors. Use of ventral sutures and mesh were not significantly associated with reduced recurrence rates.

Conclusions

The recurrence rate among HH patients in our hospital was 20.8% with a mean follow-up time of 6 years. In future, the use of pledgets might lead to fewer recurrences after primary laparoscopic repair of HH.

Protocol of a multicentre, prospective cohort study that evaluates cost-effectiveness of two perioperative care strategies for potential obstructive sleep apnoea in morbidly obese patients undergoing bariatric surgery

INTRODUCTION

Despite the high prevalence of obstructive sleep apnoea (OSA) in obese patients undergoing bariatric surgery, OSA is undiagnosed in the majority of patients and thus untreated. While untreated OSA is associated with an increased risk of preoperative and postoperative complications, no evidence-based guidelines on perioperative care for these patients are available. The aim of the POPCORN study (Post-Operative Pulse oximetry without OSA sCreening vs perioperative continuous positive airway pressure (CPAP) treatment following OSA scReeNing by polygraphy (PG)) is to evaluate which perioperative strategy is the most cost-effective for obese patients undergoing bariatric surgery without a history of OSA.

METHODS AND ANALYSIS

In this multicentre observational cohort study, data from 1380 patients who will undergo bariatric surgery will be collected. Patients will receive either postoperative care with pulse oximetry monitoring and supplemental oxygen during the first postoperative night, or care that includes preoperative PG and CPAP treatment in case of moderate or severe OSA. Local protocols for perioperative care in each participating hospital will determine into which cohort a patient is placed. The primary outcome is cost-effectiveness, which will be calculated by comparing all healthcare costs with the quality-adjusted life-years (QALYs, calculated using EQ-5D questionnaires). Secondary outcomes are mortality, complications within 30 days after surgery, readmissions, reoperations, length of stay, weight loss, generic quality of life (QOL), OSA-specific QOL, OSA symptoms and CPAP adherence. Patients will receive questionnaires before surgery and 1, 3, 6 and 12 months after surgery to report QALYs and other patient-reported outcomes.

ETHICS AND DISSEMINATION

Approval from the Medical Research Ethics Committees United was granted in accordance with the Dutch law for Medical Research Involving Human Subjects Act (WMO) (reference number W17.050). Results will be submitted for publication in peer-reviewed journals and presented at (inter)national conferences.

TRIAL REGISTRATION NUMBER

NTR6991.

Bariatric surgery in adolescents: a prospective randomized controlled trial comparing laparoscopic gastric banding to combined lifestyle interventions in adolescents with severe obesity (BASIC trial)

Background

Obesity in children and adolescents is an increasing problem associated with multiple co-morbidities including metabolic and endocrine changes, cardiovascular abnormalities, and impaired quality of life. Combined lifestyle interventions are the current standard treatment for severe obesity in children. However, the medium- and long-term results of these interventions are relatively poor. Bariatric surgery shows substantial weight loss and health improvement in adults and retrospective studies in adolescents show similar outcomes. However, well-designed prospective studies in this young age group are rare. Our objectives are to determine whether combining surgery with lifestyle interventions in severely obese adolescents leads to a significant additional weight reduction compared to lifestyle interventions solely, and to assess its effect on obesity-associated co-morbidities in a prospective randomized controlled setting.

Methods

Patients aged 14–16 years with sex- and age-adjusted BMI > 40 kg/m² (or > 35 kg/m² with comorbidity) and failure to achieve weight reduction > 5% during at least one year of combined lifestyle interventions are included in this trial. Randomization determines whether laparoscopic adjustable gastric banding will be added to combined lifestyle intervention throughout the trial period. Sixty children will be included in this trial. Follow-up visits are planned at 6 months, 1,2 and 3 years. Primary endpoints are percentage of total weight loss, and change of BMI. Secondary endpoints include body composition, pubertal development, metabolic and endocrine changes, inflammatory status, cardiovascular abnormalities, non-alcoholic steatohepatitis, quality of life and changes in behaviour.

Discussion

This randomized controlled trial is designed to provide important information about the safety and efficacy of laparoscopic adjustable gastric banding treatment in severely obese adolescents with unsuccessful combined lifestyle interventions. The reversibility of this surgical procedure forms a strong argument to decide for gastric banding over other surgical procedures, since bariatric surgery in adolescents is still in its infancy.

Trial registration

The BASIC trial is registered in the register of ClinicalTrials.gov since July 2010, Identifier: NCT01172899

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1395-9) contains supplementary material, which is available to authorized users.

Lipid-rich enteral nutrition regulates mucosal mast cell activation via the vagal anti-inflammatory reflex

Nutritional stimulation of the cholecystokinin-1 receptor (CCK-1R) and nicotinic acetylcholine receptor (nAChR)-mediated vagal reflex was shown to reduce inflammation and preserve intestinal integrity. Mast cells are important early effectors of the innate immune response; therefore modulation of mucosal mast cells is a potential therapeutic target to control the acute inflammatory response in the intestine. The present study investigates intestinal mast cell responsiveness upon nutritional activation of the vagal anti-inflammatory reflex during acute inflammation. Mucosal mast cell degranulation was induced in C57/Bl6 mice by administration of Salmonella enterica LPS. Lipid-rich enteral feeding prior to LPS significantly decreased circulatory levels of mouse mast cell protease at 30 min post-LPS compared with isocaloric low-lipid nutrition or fasting. CCK-1R blockage reversed the inhibitory effects of lipid-rich feeding, whereas stimulation of the peripheral CCK-1R mimicked nutritional mast cell inhibition. The effects of lipid-rich nutrition were negated by nAChR blockers chlorisondamine and α-bungarotoxin and vagal intestinal denervation. Accordingly, release of β-hexosaminidase by MC/9 mast cells following LPS or IgE-ovalbumin complexes was dose dependently inhibited by acetylcholine and nicotine. Application of GSK1345038A, a specific agonist of the nAChR α7, in bone marrow-derived mast cells from nAChR β2-/- and wild types indicated that cholinergic inhibition of mast cells is mediated by the nAChR α7 and is independent of the nAChR β2. Together, the present study reveals mucosal mast cells as a previously unknown target of the nutritional anti-inflammatory vagal reflex.

Coated meshes for hernia repair provide comparable intraperitoneal adhesion prevention

BACKGROUND

Laparoscopic incisional hernia repair with intraperitoneal mesh is associated with a certain degree of adhesion formation to the mesh. This experimental study examined the efficacy of several coated meshes for adhesion reduction.

METHODS

Five commercially available meshes with a layered coating were placed intraperitoneally in rats and followed up for 90 days: polypropylene and polyester meshes, both coated with absorbable collagen (Parietene Composite and Parietex Composite, respectively), and three polypropylene meshes respectively coated with absorbable omega-3 fatty acids (C-Qur Edge), absorbable cellulose (Sepramesh IP), and nonabsorbable expanded polytetrafluoroethylene (Intramesh T1). Uncoated polypropylene and collagen meshs (Parietene and Permacol, respectively) served as the control condition. Adhesions, incorporation, and tissue reaction were evaluated macro- and microscopically. Additionally, the development of the neoperitoneum was examined.

RESULTS

All the coated meshes performed equally well in terms of adhesion reduction. The collagen mesh performed comparably, but the uncoated polypropylene mesh performed significantly worse. The different coatings led to very differing degrees of inflammation. Ingrowth was observed only at the place of suture but was comparable for all the meshes except C-Qur Edge, which showed the weakest incorporation. Development of a neoperitoneum on the mesh surface occurred independently of whether an absorbable or nonabsorbable coating or no coating at all was present.

CONCLUSIONS

Commercially available meshes with a layered coating deliver comparable adhesion reduction. The physical presence of a layered coating between the intraperitoneal content and the abdominal wall seems to be more important than the chemical properties of the coating in adhesion formation.

[A gastric pacemaker in obese type 2 diabetic patients]

The combination of obesity and type 2 diabetes mellitus forms a growing global epidemic. The primary treatment for patients with this combination of conditions is to advise them to adopt a healthier lifestyle, but only a few patients succeed in doing this. Patients with type 2 diabetes who have to switch to insulin treatment can experience negative consequences, such as weight gain and an increased risk of hypoglycaemia. An alternative treatment that does not have these adverse effects is a gastric pacemaker, which can be implanted via laparoscopy: the patients lose weight and show an improvement in glucose regulation. The gastric pacemaker uses non-excitatory stimulation to influence the amplitude of gastric contraction. It simultaneously stimulates afferent fibres of the vagal nerve to influence the cerebral satiation centre, which is involved in registration of satiety and in insulin secretion and resistance. A randomized trial on the effects of the gastric pacemaker in patients with obesity and type 2 diabetes mellitus is currently being conducted in the Atrium Medical Centre in Heerlen.

Bariatric surgery for metabolic disorders

Help for diabetics

[Gastric reduction in morbidly obese adults in the Netherlands]

Obesity results in several health problems, the most important of these being diabetes mellitus type 2. In patients with morbid obesity (BMI > or = 35 kg/m(2) and comorbidity or BMI > or = 40 kg/m(2)) in particular, prevention or treatment of health problems resulting from the obesity is only possible with considerable and lasting weight loss. Gastric reduction surgery with the adjustable gastric band has been shown to be safe and effective. This is also true for the more invasive techniques such as the gastric bypass and the biliopancreatic diversion. Surgical treatment is the only treatment that can induce substantial and lasting weight loss (> 50% of the excess weight, on average) in this patient group in the long run. Although the availability of surgical treatment is as yet inadequate in the Netherlands, it has recently improved considerably. Reimbursement of the treatment is however still an obscure issue and the reimbursement of the follow-up is uncertain. Possibly, the current experiments with independent treatment centers will be able to put an end to this uncertainty.

Inter-disciplinary European guidelines on surgery of severe obesity

In 2005, for the first time in European history, an extraordinary Expert panel named 'The BSCG' (Bariatric Scientific Collaborative Group), was appointed through joint effort of the major European Scientific Societies which are active in the field of obesity management. Societies that constituted this panel were: IFSO - International Federation for the Surgery of Obesity, IFSO-EC - International Federation for the Surgery of Obesity - European Chapter, EASO - European Association for Study of Obesity, ECOG - European Childhood Obesity Group, together with the IOTF (International Obesity Task Force) which was represented during the completion process by its representative. The BSCG was composed not only of the top officers representing the respective Scientific Societies (four acting presidents, two past presidents, one honorary president, two executive directors), but was balanced with the presence of many other key opinion leaders in the field of obesity. The BSCG composition allowed the coverage of key disciplines in comprehensive obesity management, as well as reflecting European geographical and ethnic diversity. This joint BSCG expert panel convened several meetings which were entirely focused on guidelines creation, during the past two years. There was a specific effort to develop clinical guidelines, which will reflect current knowledge, expertise and evidence based data on morbid obesity treatment.

Re-operation after laparoscopic adjustable gastric banding leads to a further decrease in BMI and obesity-related co-morbidities: results in 33 patients

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is a safe technique with few direct postoperative complications. However, long-term complications such as slippage and pouch dilatation are a well-known problem and re-operations are necessary in a substantial number of patients. In this study, the results of laparoscopic re-operations after LAGB are evaluated.

METHODS

33 patients had a re-operation because of failed LAGB. 29 patients had major re-operation and 4 patients minor re-operation under local anesthesia. The charts of these patients were retrospectively studied.

RESULTS

Mean time between the first band placement and re-operation was 28.1 +/- 17.6 months. The cause of band dysfunction was anterior slippage (n=17), band erosion (n=5), band intolerance (n=3), posterior slippage (n=2) and band leakage (n=2). Symptoms of band dysfunction were vomiting (n=16), pyrosis (n=13), nausea (n=8), retrosternal pain (n=11) and regurgitation (n=5). Laparoscopic refixation of the band was performed in 19 patients: the band was replaced in 4 patients while in 1 patient the band was removed; in 3 patients, the laparoscopic procedure was converted to open surgery; 5 patients underwent conversion to a bypass procedure (biliopancreatic diversion in 3 and gastric bypass in 2). There were no direct postoperative complications except for wound infections (n=2). Postoperative follow-up was 100% with a mean period of 34 +/- 19 months. BMI decreased further from 37.5 +/- 6.4 kg/m(2) before re-operation to 33 +/- 7 kg/m(2). Obesity-related co-morbidity also decreased further or completely dissolved. 3 patients (9%) again developed anterior slippage and a second laparoscopic re-operation was necessary.

CONCLUSIONS

A laparoscopic re-operation for band-related complications after LAGB is safe and feasible. With band slippage, a laparoscopic refixation was possible in 89%. Re-operation leads to further decrease in BMI and obesity-related co-morbidities.

Low number of omental preadipocytes with high leptin and low adiponectin secretion is associated with high fasting plasma glucose levels in obese subjects

OBJECTIVE

This study investigates whether fasting plasma glucose (FPG) levels in obese subjects are associated with the number of preadipocytes and their adipokine-secretion capabilities.

DESIGN

Abdominal subcutaneous and omental adipose tissues were obtained from 10 female and four male obese subjects (age 37 +/- 8 years; BMI 48 +/- 13 kgm(2)) with a wide range of FPG (range: 4.3-10.6 mm). Stromal vascular cells (SVC) were isolated and cultured and the number of attached SVC (aSVC) per gram adipose tissue determined. The aSVCs were differentiated in vitro to become adipocytes, and the secretion of the adipokine leptin and adiponectin in the culture media was determined. Spearman rank correlation coefficients were calculated between FPG and preadipocyte number and adipokine secretion.

PATIENTS

Subject-inclusion criteria: BMI >40 kg/m(2) and for severe comorbid conditions BMI >35 kg/m(2). Subject-exclusion criteria: severe cardiopulmonary pathology (ASA class 3), history of bariatric surgery, manifest psychopathology, 18 years < age > 60 years and for upper-abdominal surgery, age >50 years. All females in the study had regular menstrual periods. None of participants received glucose-lowering medication.

RESULTS

No association was observed between BMI and fasting glucose levels. More than 90 +/- 20% of the cultured aSVC fraction was able to store fat droplets, indicating the presence of preadipocytes. A strong negative association was observed between omental preadipocyte number and FPG. A strong association was observed between adipokine secretion by the omental preadipocytes and FPG. No association was observed between subcutaneous preadipocyte number and adipokine secretion and FPG.

CONCLUSIONS

In morbid obese subjects, low number of omental preadipocytes with high-leptin- and low-adiponectin-secretion profiles is associated with high FPG.

Advantages of advanced laparoscopic systems

BACKGROUND

Conventional laparoscopy offers great benefits to our patients, but suffers from major technical drawbacks. Advanced laparoscopic systems are being developed addressing some of these drawbacks.

METHODS

We performed a training-box based study, performing laparoscopic tasks using conventional laparoscopy and advanced laparoscopic systems in order to assess the influence of these technical drawbacks in order to predict where the biggest advantages of newly developed surgical systems can be expected.

RESULTS

The most significant technical drawbacks were two-dimensional vision, disturbed eye-hand target axis and (possibly to a lesser extent) the rigid instruments with a limited five degrees of freedom.

CONCLUSION

Major advances in advanced laparoscopy might only be expected using console-based robot-arm manipulated systems like the daVinci surgical system, or a combination of a high-quality 3-dimensional vision system, restoration of the eye-hand-target axis and the use of an advanced handheld instrument offering seven degrees of freedom such as the Radius surgical system.

Laparoscopic adjustable gastric banding versus open vertical banded gastroplasty: a prospective randomized trial

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) and open vertical banded gastroplasty (VBG) are treatment modalities for morbid obesity. However, few prospective randomized clinical trials (RCT) have been performed to compare both operations.

METHODS

100 patients (50 per group) were included in the study. Postoperative outcomes included hospital length of stay (LOS), complications, percent excess weight loss (%EWL), BMI and reduction in total comorbidities. Follow-up in all patients was 2 years.

RESULTS

LOS was significantly shorter in the LAGB group. 3 LAGB were converted to open (1 to gastric bypass). Directly after VBG, 3 patients needed relaparotomies due to leakage, of which one (2%) died. After 2 years, 100% follow-up was achieved. BMI and %EWL were significantly decreased in both groups but significantly more in the VBG group compared to the LAGB group (31.0 kg/m2 and 70.1% vs 34.6 and 54.9% respectively). Co-morbidities significantly decreased in both groups in time. 2 years after LAGB, 20 patients needed reoperation for pouch dilation/slippage (n=12), band leakage (n=2), band erosion (n=2) and access-port problems (n=4). In the VBG group, 18 patients needed revisional surgery due to staple-line disruption (n=15), narrow outlet (n=2) or insufficient weight loss (n=1). Furthermore, 8 VBG patients developed an incisional hernia.

CONCLUSION

This RCT demonstrates that, despite the initial better weight loss in the VBG group, based on complication rates and clinical outcome, LAGB is preferred. It had a shorter LOS and less postoperative morbidity.

Combination of laparoscopic adjustable gastric banding and gastric bypass: current situation and future prospects -- routine use not advised

Although bariatric surgery has proven to be the most effective treatment for morbid obesity, most surgical techniques do have failures. In an effort to improve the reliability, several surgeons started to use a combination of a laparoscopic gastric bypass with an adjustable gastric band. Because of concerns regarding a possible negative outcome, an expert meeting was organized to evaluate the current situation and future application. In total, 104 operations were reported,with several technical variations. The overall complication rate was acceptable, but the percentage of the band erosions was 6.7%, which is too high. The potential advantages (adjustability, maintained access to the stomach and biliary tree, and reversibility) do not compensate for this complication rate. Based on the results and the opinion of the surgeons experienced in this technique, it is concluded that the combination of gastric bypass with an adjustable gastric band to form the pouch is not recommended.

Gastric myoelectrical activity in morbidly obese patients before and 3 months after gastric restrictive surgery

BACKGROUND

Morbid obesity is often associated with gastrointestinal motor disorders. The aim of this study was to investigate gastric motility in morbid obesity, using electrogastrography (EGG) before and 3 months after gastric restrictive surgery.

METHODS

40 morbidly obese subjects (age 40.6+/-10.3 years, BMI 46.4+/-5.7 kg/m2) were studied. VBG and Lap-Band operations were performed in 19 and 21 patients respectively. The following EGG-parameters were determined, both during fasting (f) and postprandially (pp): dominant frequency (DF(f/pp)), dominant power (DP(f/pp)), dominant frequency and power instability coefficient (DFIC and DPIC respectively) and power ratio.

RESULTS

In the Lap-Band group, DF(pp), DP(pp) and DFIC(pp) were significantly higher compared with the preprandial state, both preoperatively and 3 months postoperatively. After VBG, DF(f) and DFIC(pp) were significantly lower and DPIC(f) significantly higher compared with the preoperative state. Furthermore, DF(pp) and DP(pp) were significantly higher than the preprandial values. However, in both types of operations, power ratio did not differ significantly between the preoperative and postoperative situation. Furthermore, no clear difference in EGG-parameters between both operations could be observed.

CONCLUSION

After gastric restrictive surgery, no major changes in gastric myoelectrical activity occurred, suggesting that if clinical motility problems occur after bariatric surgery, they are not due to gastric myoelectrical dysfunction.

Increased hepatosplanchnic inflammation precedes the development of organ dysfunction after elective high-risk surgery

This study investigated the relationship of the hepatosplanchnic production and uptake of inflammatory mediators, hepatosplanchnic perfusion, and outcome during major abdominal surgery to evaluate the hypothesis that regional production of inflammatory mediators precedes the development of hepatic dysfunction. This retrospective analysis of data and blood samples collected during a randomized controlled clinical trial included high-risk surgical patients undergoing major abdominal surgery in a 24-bed university-afilliated intensive care unit. Patients were divided into a subgroup that developed hepatic dysfunction (HD+) postoperatively and a subgroup without hepatic dysfunction (HD-). Hepatic vein and arterial plasma levels of IL-6, IL-8, s-E-selectin, s-ICAM-1, and the TNF-receptors 55 and 75 were measured, and the flux was calculated by multiplying the difference in hepatic vein minus arterial levels of the mediators by the hepatosplanchnic flow. Systemic (thermodilution) and total hepatosplanchnic blood flow (using indocyanine green [ICG]-dilution method) and gastric intramucosal pH (pHi) were assessed preoperatively, 4, 24, and 36 h postoperatively. Of a total of 26 patients, 6 patients developed hepatic dysfunction after their abdominal surgery (mean 6 days postoperatively). The number of sepsis-related deaths and postoperative days on the ventilator were significantly higher in this group. A higher production of IL-8, TNF-receptor-75 and 55 in the hepatosplanchnic area in the HD+ subgroups was found, which preceded the development of organ dysfunction (P = 0.04, P = 0.02, and P = 0.02, respectively). Moreover, the uptake of s-ICAM-1 was significantly increased in this subgroup. Furthermore, total hepatosplanchnic blood flow was significantly higher and pHi was significantly lower in the HD+ group, whereas global hemodynamic data were similar in the two subgroups. In conclusion, the development of postoperative organ dysfunction is preceded by an increased regional inflammatory response, indicated by an increased soluble TNF-receptor shedding and IL-8 production from the hepatosplanchnic area together with an increased uptake of s-ICAM-1. Moreover, an increased total hepatosplanchnic blood flow with intramucosal acidosis was associated with this regional inflammatory response.

Decreased plasma orexin-A levels in obese individuals

Orexin-A and -B stimulate appetite and food intake in rats. Orexins and orexin receptors are present in the hypothalamus as well as the enteric nervous system, the pancreas and the gut. The presence of orexins in peripheral blood, however, has not yet been reported. To determine whether orexin-A is present in human plasma and is related to body weight, we measured plasma orexin-A and leptin levels in a population with a body mass index (BMI) range from 19.8 to 59 kg/m(2). Plasma orexin-A levels correlated negatively and plasma leptin levels correlated positively with BMI. In obese and morbidly obese individuals, orexin-A levels were significantly lower and leptin levels were significantly higher when compared to normal. Our results support previous data suggesting that orexin-A acts also in a peripheral manner. The fact that lower levels of plasma orexin-A are present in obese individuals suggests that it is involved in the regulation of human energy metabolism.

Lipopolysaccharide Binding Protein and Serum Amyloid A Secretion by Human Intestinal Epithelial Cells During the Acute Phase Response

The acute phase proteins LPS binding protein (LBP) and serum amyloid A (SAA) are produced by the liver and are present in the circulation. Both proteins have been shown to participate in the immune response to endotoxins. The intestinal mucosa forms a large surface that is continuously exposed to these microbial products. By secretion of antimicrobial and immunomodulating agents, the intestinal epithelium contributes to the defense against bacteria and their products. The aim of this study was to explore the influence of the inflammatory mediators TNF-α, IL-6, and IL-1β on the release of LBP and SAA by intestinal epithelial cells (IEC). In addition, the induction of LBP and SAA release by cell lines of intestinal epithelial cells and hepatic cells was compared. The data obtained show that in addition to liver cells, IEC also expressed LBP mRNA and released bioactive LBP and SAA upon stimulation. Regulation of LBP and SAA release by IEC and hepatocytes was typical for class 1 acute phase proteins, although differences in regulation between the cell types were observed. Endotoxin did not induce LBP and SAA release. Glucocorticoids were demonstrated to strongly enhance the cytokine-induced release of LBP and SAA by IEC, corresponding to hepatocytes. The data from this study, which imply that human IEC can produce LBP and SAA, suggest a role for these proteins in the local defense mechanism of the gut to endotoxin. Furthermore, the results demonstrate that tissues other than the liver are involved in the acute phase response.