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BACKGROUND Continuous ambulatory peritoneal dialysis (CAPD) is a treatment for patients with end-stage renal disease (ESRD). Peritoneal dialysis catheters are usually placed using a small laparotomy. This traditional technique is usually safe if well executed, but it cannot be safely performed if the patient has had a previous abdominal operation. A minimally invasive procedure may progress safely by laparoscopic intervention. However, dysfunction of the catheter during a laparoscopic intervention is a common complication related to CAPD. This usually involves intra-abdominal migration of the catheter, even with one intra-abdominal fixation. In an effort to increase catheter survival, we tested a modified laparoscopic technique with two intra-abdominal fixations of a Tenckhoff catheter. MATERIALS AND METHODS Forty-one consecutive ESRD patients (mean age, 53.4 y; range, 31 to 84 y) underwent modified laparoscopic Tenckhoff catheter implantation with 2 intra-abdominal fixations between September 2009 and January 2013. The same perioperative protocol and surgical technique were used in all patients. Another 49 ESRD patients who had received laparoscopic Tenckhoff catheter implantation with 1 intra-abdominal fixation performed by the same surgeon were retrospectively recruited for comparison. RESULTS The modified laparoscopic procedure with two intra-abdominal fixations of a Tenckhoff catheter was successfully performed in all patients. The mean operating time was 24.3 minutes (range, 15 to 37 min). The mean blood loss was 5.6 mL (range, 5 to 20 mL). Catheter survival was 100% until February 2013. No major perioperative complications were found. A Kaplan-Meier Survival Analysis found no significant difference between the 2 groups in sex, age, operative time, or blood loss. The catheter survival rate was significantly higher in the patients with two intra-abdominal fixations. Most patients were satisfied with the functional results of the Tenckhoff catheter. CONCLUSIONS The laparoscopic 2-site fixation technique is an effective and safe procedure but long-term follow-up and more cases are necessary.

Single-anastomosis (mini-) gastric bypass (SAGB) was proposed by Dr. Robert Rutledge. Criticism and prejudice against this procedure was raised by surgeons who preferred a more difficult procedure, laparoscopic Roux-en-Y gastric bypass (RYGB). Increasing data indicates the procedure is an effective and durable bariatric procedure. SAGB has lower operation risks compared to RYGB. The weight loss is better after SAGB because of a greater malabsorptive component than RYGB, but SAGB had a higher incidence of micronutrient deficiencies. Randomized controlled trial and long-term data demonstrate that SAGB can be regarded as a simpler and safer alternative to RYGB. We propose this procedure to be renamed "single-anastomosis gastric bypass (SAGB)" because the key feature of SAGB is the "single anastomosis" compared with the two anastomoses of RYGB.

Large-scale randomized clinical trials are needed to assess the role of Roux-en-Y gastric bypass (RYGB) in treating patients with type 2 diabetes mellitus (T2DM). Recruitment challenges must be understood.One hundred twenty participants were needed for a prospective randomized controlled trial investigating treatments for hyperglycemia and cardiovascular disease risk factors in patients with T2DM. The trial had two arms-intensive medical management plus a rigorous lifestyle intervention (LS/IMM) versus LS/IMM with RYGB. Medical inclusion criteria included glycosylated hemoglobin (HbA1c) ≥ 8.0 % while under the care of a physician and body mass index (BMI) 30.0-39.9 kg/m(2). Another inclusion criterion was expressed willingness to accept randomization and participate fully. Varied recruitment strategies were employed at four academic hospitals in the USA and Taiwan, including referrals, mass media, direct mail to patients drawn from a practice-based database, and direct mail to commercial mailing lists.Between February 2008 and December 2011, 2,648 candidates were phone-screened and 240 were screened on site; 120 participants were eventually randomized. Impediments included stringent medical inclusion criteria and a lack of equipoise (i.e., strong beliefs or preferences) among patients and their personal community-based physicians. To meet timeline requirements, the upper limit for BMI was increased from 34.9 to 39.9 kg/m(2) and an additional site was added.We successfully recruited 120 participants with poorly controlled T2DM and mild to moderate obesity. Participants had to be willing to accept randomization to either surgical or nonsurgical treatments. Recruitment took 4 years.

Summary Background Single-incision laparoscopic surgery (SILS) has emerged recently, and this procedure minimizes surgical trauma. Laparoscopic Roux-en-Y gastric bypass is one of the most effective bariatric surgeries. From five to seven small skin incisions are usually required to perform this procedure. In regard to the single-incision laparoscopic surgery procedure, we developed a modified single-laparoscopic technique (2-site incision technique) to perform a Roux-en-Y gastric bypass. Our method and the associated learning curve will be presented here. Methods Three hundred consecutive patients with a mean age of 31.7 years (range, 19–52 years) underwent a two-site incision laparoscopic Roux-en-Y gastric bypass (TILRYGB) between February 2009 and December 2010. The mean body mass index of the patients was 40.5 kg/m2 (range, 30.1–59.9 kg/m2) preoperatively. The same perioperative protocol and surgical technique were used in all patients. These 300 patients were equally divided into three groups in sequence. The pre- and postoperative data were collected and compared. Results The TILRYGB procedure was performed successfully in all patients. The mean operative time of the groups in sequence was 170.9 minutes, 157.3 minutes, and 149.0 minutes. No perioperative major complications occurred. Minor complications occurred in these three groups in five, three, and zero cases. These minor complications included gastrointestinal bleeding and ileus, all of which resolved with conservative treatment. The mean hospital stay in sequence was 4.1 days, 3.8 days, and 3.5 days. Conclusion TILRYGB is a safe, feasible, and reproducible bariatric procedure; once the learning curve is overcome, it can provide better postoperative results than other surgical procedures.

Gastric cancer in the stomach after Roux-en-Y gastric bypass or mini-gastric bypass is rare, but a few cases have been reported since 1991, when the first case emerged. According to the literature, the interval between bypass surgery and the diagnosis of cancer ranged from 1 to 22 years. Given the difficulty of monitoring a bypassed stomach, the potential for gastric cancer must be considered, especially in countries with high incidence of this cancer. The literature reported the first case in the Asia-Pacific region - a woman developed advanced gastric cancer in her stomach 9 years after laparoscopic mini-gastric bypass for morbid obesity.

Objective: The mechanisms by which bariatric surgeries, including gastric bypass (GB) and sleeve gastrectomy (SG), achieve remission of type 2 diabetes mellitus (T2DM) and sustained weight reduction are unknown. We hypothesized that the novel anorexic hormone nesfatin-1 and another new hormone obestatin might contribute to the marked improvement in glycemic homeostasis and weight loss in diabetics after GB and SG. Methods: A hospital-based, prospective study was conducted. Overnight fasting plasma concentrations of nesfatin-1 and obestatin were analyzed in T2DM patients before surgery, and at 3 and 12 months after laparoscopic GB (n =12) and SG (n = 6). Results: At 12 months, reductions of body mass index (BMI), fasting blood glucose, and glycated hemoglobin were similar between GB and SG groups (P all > 0.05). Plasma nesfatin-1 levels in patients undergoing GB or SG significantly decreased after surgeries (P both < 0.05). In contrast, plasma obestatin concentrations significantly increased in patients after SG (P < 0.05) but without any alteration after GB. The alterations of plasma nesfatin-1 were significantly and negatively associated with the reduction of fasting blood glucose (P < 0.05) at 12 months after GB and SG. In the SG group, the reduction of nesfatin-1 significantly and positively correlated with the decrease of BMI (P < 0.05). Conclusions: GB and SG produce differential influences with regards to circulating nesfatin-1 and obestatin levels in non-morbidly obese, T2DM patients. Circulating nesfatin-1 may modulate glucose homeostasis in two surgical procedures, and participate in regulating body weight in SG.

Elevated oxidative stress is closely associated with obesity. Emerging evidence shows that instead of being a consequence of obesity, oxidative stress may also contribute to fat formation. Nonselenocysteine-containing phospholipid hydroperoxide glutathione peroxidase (NPGPx) is a conserved oxidative stress sensor/transducer and deficiency of NPGPx causes accumulation of reactive oxygen species (ROS). In this communication, we show that NPGPx was highly expressed in preadipocytes of adipose tissue. Deficiency of NPGPx promoted preadipocytes to differentiate to adipocytes via ROS-dependent dimerization of protein kinase A regulatory subunits and activation of CCAAT/enhancer-binding protein beta (C/EBPβ). This enhanced adipogenesis was alleviated by antioxidant N-acetylcysteine (NAC). Consistently, NPGPx-deficient mice exhibited markedly increased fat mass and adipocyte hypertrophy, while treatment with NAC ablated these phenotypes. Furthermore, single nucleotide polymorphisms (SNPs) in human NPGPx gene, which correlated with lower NPGPx expression level in adipose tissue, were associated with higher body mass index (BMI) in several independent human populations. These results indicate that NPGPx protects against fat accumulation in mice and human via modulating ROS, and highlight the importance of targeting redox homeostasis in obesity management. Deficiency of the glutathione peroxidase NPGPx increases ROS levels in preadipocytes and promotes adipocyte differentiation via increasing oxidative stress and consequent increased fat mass and adipocyte hypertrophy.

Surgery is the most effective treatment of morbid obesity and leads to dramatic improvements in type 2 diabetes mellitus (T2DM). Gastrointestinal metabolic surgery has been proposed as a treatment option for T2DM. However, a grading system to categorize and predict the outcome of metabolic surgery is lacking. The study setting was a tertiary referral hospital (Taoyuan City, Taoyuan County, Taiwan).We first evaluated 63 patients and identified 4 factors that predicted the success of T2DM remission after bariatric surgery in this cohort: body mass index, C-peptide level, T2DM duration, and patient age. We used these variables to construct the Diabetes Surgery Score, a multidimensional 10-point scale along which greater scores indicate a better chance of T2DM remission. We then validated the index in a prospective collected cohort of 176 patients, using remission of T2DM at 1 year after surgery as the outcome variable.A total of 48 T2DM remissions occurred among the 63 patients and 115 remissions (65.3%) in the validation cohort. Patients with T2DM remission after surgery had a greater Diabetes Surgery Score than those without (8 ± 4 versus 4 ± 4, P.05). Patients with a greater Diabetes Surgery Score also had a greater rate of success with T2DM remission (from 33% at score 0 to 100% at score 10); A 1-point increase in the Diabetes Surgery Score translated to an absolute 6.7% in the success rate.The Diabetes Surgery Score is a simple multidimensional grading system that can predict the success of T2DM treatment using bariatric surgery among patients with inadequately controlled T2DM.

To compare endocrine, metabolic, and inflammatory changes induced by gastric bypass (GB) and sleeve gastrectomy (SG) in patients with type 2 diabetes mellitus (T2DM), and to investigate the mechanisms of success after metabolic surgery. Sixteen GB and 16 SG patients were followed up before and at 1 year after surgery. The 75-g oral glucose tolerance test (OGTT) was performed before and after surgery. Glucose homeostasis, serum interleukin-1β, plasma gut hormones and adipokines, and the United Kingdom Prospective Diabetes Study (UKPDS) ten-year cardiovascular risks were evaluated. The diabetes remission rate was significantly higher in GB than SG. Changes in the area under the curve (AUC) for glucose were greater in those with complete and partial remission after GB and remitters after SG than non-remitters after SG, whereas changes in AUC for C-peptide were higher in complete and partial remitters after GB than non-remitters after SG. Insulinogenic index was enhanced and serum interleukin-1β was reduced in complete remitters after GB and remitters after SG. Logistic regression analysis confirmed that insulinogenic index and interleukin-1β, not insulin resistance, were the factors determining the success of diabetes remission after metabolic surgeries. GB and SG significantly reduced the ten-year risk of coronary heart disease and fatal coronary heart disease in T2DM patients after surgery, while GB had the additional benefit of reduced stroke risk. Human diabetes remission after metabolic surgery is through insulin secretion and interleukin-1β dependent mechanisms. GB is superior to SG in cardiocerebral risk reduction in Asian non-morbidly obese, not well-controlled T2DM patients.

Background The purpose of this study is to compare effects of different nations on Roux-en-Y gastric bypass (RYGB) vs. intensive medical management (IMM) in achieving remission of type 2 diabetes mellitus (T2DM). Materials and Methods Between April 2008 and December 2011, this randomized, controlled clinical trial was conducted at four teaching hospitals in the United States and Taiwan involving 71 participants with mild obesity (BMI 30–35 kg/m2). Thirty-six of 71 participants were randomly assigned to the RYGB group, and the others were in IMM group. Partial or complete remission of T2DM was defined as blood HbA1c

Gastric bypass surgery has been well accepted as a novel treatment modality for type 2 diabetes mellitus (T2DM) in obese patients. Some scoring systems have been proposed for the selection of T2DM patients who are eligible for gastric bypass surgery. This study compares two scoring systems with regard to remission of T2DM after gastric bypass surgery. This retrospective cohort study included 245 patients (150 females and 95 males) who had undergone gastric bypass surgery for the treatment of T2DM with 1 year follow-up. We examined the predictive power of complete remission of two scoring systems, the DiaRem score, and the ABCD score. The DiaRem score includes the factors of age, HbA1c, medication, and insulin usage. The ABCD score includes the factors of age, BMI, C-peptide level, and duration of T2DM. The rate of remission of T2DM after gastric bypass surgery was evaluated using both scoring systems. At 1 year after surgery, the percent weight loss was 26.5 % and the mean BMI decreased from 35.7 to 26.2 kg/m2. The mean HbA1c decreased from 8.8 to 6.2 %. A significant number of patients showed improvement in glycemic control, including 130 (53.1 %) patients with complete remission (HbA1c

The incidence of obesity is increasing in Asia, with implications on gastrointestinal (GI) and liver diseases. The Gut and Obesity in Asia Workgroup comprises regional experts with the aim of studying relationship between obesity and the GI and liver diseases in Asia. Through literature review and the modified Delphi process, consensus statements examining the impact of obesity on esophageal, gastric, pancreatic, colorectal, and liver diseases, exploring relationship between gut microbiome and obesity, and assessing obesity therapies have been produced by the Gut and Obesity in Asia Workgroup. Sixteen experts participated with 9/15 statements having strong consensus (80% agreement). The prevalence of obesity in Asia is increasing (100% percentage agreement in brackets), and this increased prevalence of obesity will result in a greater burden of obesity-related GI and liver diseases (93.8%). There was consensus that obesity increases the risk of gastric cancer (75%) and colorectal neoplasia (87.5%). Obesity was also associated with Barrett's esophagus and esophageal adenocarcinoma (66.7%) and pancreatic cancer (66.7%) in Asia. The prevalence of non-alcoholic fatty liver disease (NAFLD) in Asia is on the rise (100%), and the risk of NAFLD in Asia (100%) is increased by obesity. Obesity is a risk factor for the development of hepatocellular carcinoma (93.8%). Regarding therapy, it was agreed that bariatric surgery was an effective treatment modality for obesity (93.8%) but there was less agreement on its benefit for NAFLD (62.5%). These experts' consensus on obesity and GI diseases in Asia forms the basis for further research, and its translation into addressing this emerging issue.

Laparoscopic surgery has been widely adopted and new technical innovation, procedures and evidence based knowledge are persistently emerging. This review documents recent major advancements in laparoscopic surgery. A PubMed search was made in order to identify recent advances in this field. We reviewed the recent data on randomized trials in this field as well as papers of systematic review. Laparoscopic cholecystectomy is the most frequently performed procedure, followed by laparoscopic bariatric surgery. Although bile duct injuries are relatively uncommon (0.15%-0.6%), intraoperative cholangiography still plays a role in reducing the cost of litigation. Laparoscopic bariatric surgery is the most commonly performed laparoscopic gastrointestinal surgery in the USA, and laparoscopic Nissen fundoplication is the treatment of choice for intractable gastroesophageal reflux disease. Recent randomized trials have demonstrated that laparoscopic gastric and colorectal cancer resection are safe and oncologically correct procedures. Laparoscopic surgery has also been widely developed in hepatic, pancreatic, gynecological and urological surgery. Recently, SILS and robotic surgery have penetrated all specialties of abdominal surgery. However, evidence-based medicine has failed to show major advantages in SILS, and the disadvantage of robotic surgery is the high costs related to purchase and maintenance of technology. Laparoscopic surgery has become well developed in recent decades and is the choice of treatment in abdominal surgery. Recently developed SILS techniques and robotic surgery are promising but their benefits remain to be determined.

To fill a void in the literature, we performed a literature search and subsequently reviewed randomized controlled trials (RCTs) in the field of obesity surgery that were published over the past 40 years. All RCTs published in the English between January 1972 and December 2011 were identified through a literature search using the PubMed database. The following search terms were used: "bariatric surgery", "obesity surgery", and "weight reducing surgery". Studies of basic science and anesthesia-related pain management were excluded. The extracted trials were divided into four groups: comparisons of different interventions, intraoperative surgical techniques, preoperative evaluation, and postoperative care. The literature search produced 753 manuscripts, of which 168 met the eligibility criteria. Among 168 papers, 32 % compared different interventions, 48 % assessed intraoperative surgical techniques, 18 % assessed postoperative care, and the remaining 2 % assessed preoperative evaluation. The RCTs were published in 47 different journals, most commonly in Obesity Surgery (28.6 %) and the Annals of Surgery (11.9 %). Trials were conducted in 25 different countries, with the greatest contribution from the USA (35.1 %). There was a progressive increase in published trials from 1972 to 2011, with 119 RCTs (70.8 %) being published over the last decade. A trend for an increasing number of published RCTs in the field of bariatric surgery was observed over the recent years. Although data from large, adequately powered, long-term RCTs are still lacking, any surgical intervention appears to be more effective than medical care for the treatment of morbid obesity.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the gold standard for the treatment of morbid obesity but is technically challenging and results in significant perioperative complications. While laparoscopic mini-gastric bypass (LMGB) has been reported to be a simple and effective treatment for morbid obesity, controversy exists. Long-term follow-up data from a large number of patients comparing LMGB to LRYGB are lacking. Between October 2001 and September 2010, 1,657 patients who received gastric bypass surgery (1,163 for LMGB and 494 for LRYGB) for their morbid obesity were recruited from our comprehensive obesity surgery center. Patients who received revision surgeries were excluded. Minimum follow-up was 1 year (mean 5.6 years, from 1 to 10 years). The operative time, estimated blood loss, length of hospital stay, and operative complications were assessed. Late complication, changes in body weight loss, BMI, quality of life, and comorbidities were determined at follow-up. Changes in quality of life were assessed using the Gastrointestinal Quality of Life Index. There was no difference in preoperative clinical parameters between the two groups. Surgical time was significantly longer for LRYGB (159.2 vs. 115.3 min for LMGB, p

The purpose of this study was to investigate the impact of intracerebroventricular (ICV) injection of the two endogenous forms of acyl ghrelin, O-n-octanoylated ghrelin and des-Gln¹⁴-ghrelin, on feeding behavior, as well as their interactions with insulin, obestatin, and corticotropin-releasing factor receptor (CRF-R) antagonist in the forebrain to influence food intake.We examined the food intake in conscious, freely fed rats, which were chronically implanted with ICV catheters.O-n-octanoylated ghrelin and des-Gln¹⁴-ghrelin (0.1 nmol/rat) were equally potent in stimulating food intake in freely fed rats, up to 8 h after ICV injection (P0.05). In contrast, ICV administration of insulin (8 mU/rat), obestatin (2 nmol/rat), and astressin (2 nmol/rat), a specific CRF-R antagonist, did not modify feeding in freely fed rats. Furthermore, pretreatment with ICV insulin (P0.01), but not obestatin or astressin, at the abovementioned dose, blocked central acyl-ghrelin-induced hyperphagic effects.ICV O-n-octanoylated ghrelin and its splice variant, des-Gln¹⁴-ghrelin, are equally potent to elicit food intake in freely fed rats, while these feeding-stimulating effects are opposed by insulin, but independent of obestatin and endogenous CRF-R in the forebrain.

Background: Obesity and type II diabetes mellitus (T2DM) are closely related and difficult to control by current medical treatment. Bariatric surgery has been proposed for inadequately controlled T2DM in association with obesity. However, prediction of successful T2DM remission after surgery has not been clearly studied in Asian patients. This information might be helpful for applying gastrointestinal surgery as metabolic surgery for T2DM. Methods: This was a retrospective clinical study. From January 2002 to December 2008, 88 consecutive patients with morbid obesity, who were enrolled into a surgically supervised weight loss program, and who had T2DM before surgery with at least 1 year complete follow-up data were included. Sixty-eight (77.2%) patients received gastric bypass procedures, and the remaining 20 (22.8%) received restrictive procedures. We analyzed the available information during the initial evaluation of patients who were referred for bariatric surgery, by logistic regression analysis and data mining methods for predictors of successful diabetes remission after surgery. Results: Overall, 68 (77.2%) of the 88 patients had remission of their T2DM 1 year after surgery. Patients in the bypass group had a higher remission rate than those in the restrictive group [59/68 (86.7%) vs. 9/20 (45.0%), p=0.000]. In univariate analysis, patients who had T2DM remission after surgery were younger, heavier, had a wider waist, less severe disease, shorter duration, and higher C-peptide levels than those without remission. Type of operation and T2DM duration remained independent predictors of success after multivariate logistical regression analysis (p

Summary Background A recent genome-wide association study for type 2 diabetes in Han Chinese identified several novel genetic variants. We investigated their associations with quantitative measures to explore the mechanism by which these variants influence glucose homoeostasis. We also examined whether these variants predict progression to diabetes in a large prospective family based Chinese cohort. Methods Five single nucleotide polymorphisms (SNPs) near the protein tyrosine phosphatase, receptor type, D (PTPRD), SRR, MAF/WWOX, and KCNQ1 genes were genotyped in 1138 subjects of Chinese origin from the Stanford Asia-Pacific Program for Hypertension and Insulin Resistance study. Results At baseline, the risk-conferring rs7192960 C allele near the MAF/WWOX genes was associated with lower homoeostasis model assessment of β-cell (HOMA-β) (P = 0·01) and second-phase insulin response in oral glucose tolerance test (OGTT) (P = 0·04). The risk-conferring rs2237897 C alleles in the KCNQ1 gene were associated with higher fasting glucose (P = 0·009), lower HOMA-β (P = 0·03), and lower first-phase insulin response in OGTT (P = 0·03). Over an average follow-up period of 5·43 years, participants with the risk-conferring rs17584499 TT genotype in the PTPRD gene were more likely to progress from nondiabetes to diabetes than were noncarriers (hazard ratio: 8·82, P = 4 × 10−5). The risk-conferring T allele in the PTPRD gene was associated with greater increase in homoeostasis model assessment of insulin resistance (HOMA-IR) (P = 0·04) over time. PTPRD gene expression in human adipose tissues was negatively associated with fasting insulin levels and HOMA-IR. Conclusion Genetic variants near the KCNQ1 and MAF/WWOX genes are associated with reduced insulin secretion. The PTPRD genetic variant appears to be associated with progression to diabetes in Han Chinese, most likely through increased insulin resistance.

Nonalcoholic fatty liver disease (NAFLD) is associated with obesity. We retrospectively studied the clinicopathology and different hepatic adipocytokine expressions between nonalcoholic steatohepatitis (NASH) and non-NASH in morbid obesity.We enrolled 40 patients undergoing liver biopsy during bariatric surgery. We analyzed hepatic mRNA and immunohistochemistry of TNF-α, leptin, adiponectin and adiponectin receptor.Thirty patients (75%) presented with NASH, including 11 with mild fibrosis and 19 with advanced fibrosis. The HbA1c (P = 0.000), AST (P = 0.000), ALT (P = 0.000), GGT (P = 0.016) and liver fibrosis (P = 0.028) have statistically difference between NASH and non-NASH groups. Steatosis was the only significant factor (r = 0.348, P0.05) associated with TNF-α mRNA level. Adiponectin mRNA was inversely associated with C-peptide (r = -0.416, P0.05) and uric acid level (r = -0.426, P0.05). The best predictors for TNF-α immunostain were hemoglobin (r = 0.432, P0.01), AST (r = 0.371, P0.05), lobular inflammation (r = 0.315, P0.05), portal inflammation (r = 0.331, P0.05), and NAS (r = 0.365, P0.05). Leptin immunostain was correlated with C-peptide (r = 0.356, P0.05) and portal inflammation (r = 0.334, P0.05). The AdipoRII immunoexpression was negatively correlated with systolic blood pressure (r = -0.481, P0.01). Multivariate linear regressions of adipocytokine profile related mostly to age, gender, systolic blood pressure, serum uric acid, steatosis, NAS and portal inflammation.Although different adipocytokines may be associated with NAFLD progression in morbid obesity, their major correlations in the pathogenesis of obesity-related NASH are not clear. Additional confirmatory studies are deserved.

Laparoscopic gastric bypass (GB) is reportedly more effective than laparoscopic sleeve gastrectomy (SG) in the treatment of patients with a low body mass index and type 2 diabetes mellitus. However, the mechanism remains speculative. We compared the postprandial gut hormone patterns between patients undergoing laparoscopic GB and laparoscopic SG at 2 years after surgery in a hospital-based, prospective study.A total of 16 laparoscopic GB and 16 laparoscopic SG patients were followed up and appraised for glucose homeostasis. Two years after surgery, the mixed meal test and gut hormones were evaluated in 13 laparoscopic GB and 13 laparoscopic SG patients who had been included in the previous randomized trial.The preoperative characteristics, such as body mass index, body weight, waist circumference, and duration of T2DM were comparable between the 2 groups. T2DM remission was achieved in 13 (81%) laparoscopic GB and 3 (19%) laparoscopic SG patients (P.05) 2 years after surgery. The laparoscopic GB patients had lost more weight and had a smaller waist circumference and lower levels of glucose and hemoglobin A1c, and lower insulin resistance than the SG patients. Significant differences were found in acyl ghrelin, des-acyl ghrelin, cholecystokinin, and resistin between the 2 groups, but none in obestatin, gastric inhibitory peptide, glucagon-like peptide-1, and leptin.Both laparoscopic GB and laparoscopic SG have strong hindgut effects after surgery, but GB has a significant duodenal exclusion effect on cholecystokinin. The laparoscopic SG group had lower acyl ghrelin and des-acyl ghrelin levels but greater concentrations of resistin than the laparoscopic GB group.

BACKGROUND/AIMS: The effectiveness of laparoscopic sleeve gastrectomy (LSG) in measuring the quality of life (QOL) and personality in obese patients has not been previously investigated. This study aims to investigate different clinical outcome variables, the relationships between quality of life and different personality one-year after LSG in obese patients. METHODOLOGY: Sixty-one consecutive obese patients (49 females) who underwent LSG were evaluated for clinical characteristics after weight reduction. Chinese Personality Assessment Inventory and Gastrointestinal Quality-of-Life Index (GIQLI) were analyzed. RESULTS: One year after LSG, mean body weight (BW), mean body mass index (BMI) and excess weight loss (EWL) were 66.5±13.6kg, 24.4±4.4kg/m2 and 88.1±32.5%, respectively. Metabolic syndrome decreased from 45.1% to 9.8%. The significant variables were systolic blood pressure, fasting glucose, triglyceride, uric acid, aspartate aminotransferase, alanine aminotransferase, insulin, high sensitivity C-reactive protein, HbA1c, C-peptide and HOMA. All patients demonstrated improvement in two domains of the questionnaire (physical status and emotion status), but not in gastrointestinal symptoms. Although the 'Agreeableness' dimension of Chinese personality had a lower presenting BMI (23.9kg/m2) and better excess weight loss (88.0%), this group showed less improvement in gastrointestinal symptoms and had poorer physical status. CONCLUSIONS: LSG provided meaningful weight loss and improvement in quality of life. Chinese personality was the predictor of weight loss and GIQLI.

Significant variability in weight loss and glycemic control has been observed in obese patients receiving bariatric surgery. Genetic factors may play a role in the different outcomes. Five hundred and twenty severely obese patients with body mass index (BMI) ≥35 were recruited. Among them, 149 and 371 subjects received laparoscopic adjustable gastric banding (LAGB) and laparoscopic mini-gastric bypass (LMGB), respectively. All individuals were genotyped for five obesity-related single nucleotide polymorphisms on ESR1, FTO, PPARγ, and UCP2 genes to explore how these genes affect weight loss and glycemic control after bariatric surgery at the 6th month. Obese patients with risk genotypes on rs660339-UCP2 had greater decrease in BMI after LAGB compared to patients with non-risk genotypes (−7.5 vs. −6 U, p = 0.02). In contrast, after LMGB, obese patients with risk genotypes on either rs712221-ESR1 or rs9939609-FTO had significant decreases in BMI (risk vs. non-risk genotype, −12.5 vs. −10.0 U on rs712221, p = 0.02 and −12.1 vs. −10.6 U on rs9939609, p = 0.04) and a significant amelioration in HbA1c levels (p = 0.038 for rs712221 and p

Most morbidly obese patients who undergo gastric bypass experience rapid remission of type 2 diabetes mellitus (T2DM) but the response in non-morbidly obese patients is not clear. This trial prospectively assessed the effect of diabetes remission, glucose metabolism, and the serial changes of insulin secretion after gastric bypass in inadequately controlled T2DM patients with a BMI of 23-35 kg/m(2).A total of 62 consecutive patients with T2DM and a BMI of 23-35 kg/m(2) underwent gastric bypass. Data were prospectively collected before surgery and 1, 4, 12, 26, and 52 weeks and 2 years after surgery. Insulin secretion was measured by insulinogenic index and area under the curve (AUC) during a standard oral glucose tolerance test (OGTT). Remission of type 2 diabetes was defined as fasting glucose level110 mg/dl and HbA1c6.0% without any glycemic therapy.Of the 62 patients, 24 were men and 38 were women (age 43.1 ± 10.8 years). Their preoperative characteristics were as follows: BMI 30.1 ± 3.3 kg/m(2), waist circumference 99.6 ± 9.6 cm, C-peptide 3.1 ± 1.4 ng/ml, and duration of T2DM 5.4 ± 5.1 years. The mean BMI decreased postoperatively to 22.6 ± 2.3 kg/m(2) in 1 year and 23.0 ± 2.7 kg/m(2) in 2 years. The mean HbA1c decreased from 9.7 ± 1.9% to 5.8 ± 0.5% in 1 year and 5.9 ± 0.5% in 2 years. Complete remission of T2DM was achieved in 57% in 1 year and 55% in 2 years after surgery. Before surgery, the OGTT test showed a blunted insulin secretion pattern with an insulinogenic index of 0.1 ± 0.2 and AUC of 2,324 ± 1,015 μIU min/ml. In 1 week after surgery, the insulinogenic index increased to 0.16 and AUC decreased to 1,366 μIU min/ml along with a rapid drop of insulin resistance. The insulinogenic index and AUC gradually increased to 0.27 and 3,220, respectively, 1 year after surgery and remained stable up to 2 years with a very low insulin resistance.Laparoscopic gastric bypass facilitates immediate improvement in the glucose metabolism of inadequately controlled non-severe obese T2DM patients, and the benefit is sustained up to 2 years after surgery. The benefit is regulated by the decrease in insulin resistance, increase in early insulin response, and total insulin secretion to glucose load.

Several thousands of laparoscopic mini-gastric bypass have been performed globally by a number of surgeons. There is growing evidence that mini-gastric bypass is a safe and effective procedure. We report a rare case of massive gastric remnant dilation in a 45-year-old man after laparoscopic mini-gastric bypass. Acute gastric dilatation is a surgical emergency. In our case, a triad of clinical suspicion, laboratory profile, and emergency radiologic investigation were essential for early diagnosis and management. Image-guided gastrostomy tube placement provides an effective decompression of the gastric remnant. A literature review revealed no previous reports of similar complications in mini-gastric bypass.

Apolipoprotein A-V (apo A-V) exerts a potent triglyceride (TG)-lowering effect through enhanced intravascular TG-hydrolysis with increased uptake of TG-derived free fatty acids into muscle and adipose tissue. Genetic variants in the APOA5 gene were strongly associated with plasma TG concentrations. The aim of this study was to examine whether APOA5 genetic variation was associated with obesity. We genotyped the missense c.553 G>T polymorphism (p.G185C) in the APOA5 gene in 1,085 Chinese (333 obese subjects and 752 nonobese controls). We analyzed the association between the c.553 G>T polymorphism and obesity and related metabolic phenotypes. The T allele at the c.553 G>T polymorphism was associated with higher plasma TG concentrations. Each additional T allele was associated with an increased TG concentration of 53.5 mg/dl (95% confidence interval (CI) 29.6–76.0, P < 0.0001). However, the T allele was associated lower risk of obesity (odds ratio (OR), 0.48; 95% CI 0.32–0.73, P = 0.0004). Each additional copy of the T allele was associated with a BMI decrease of 0.73 kg/m2 (95% CI 0.26–1.16, P = 0.002), equivalent to 2.11 kg in a person 1.7 m tall. We may then conclude that the TG-raising APOA5 genetic variant was associated with a decrease in BMI and reduced risk of obesity in the Chinese population.

Background Fetuin-A and leukocyte cell-derived chemotaxin-2 (LECT-2) are liver-derived proteins. Fetuin-A is an independent risk factor for type 2 diabetes (T2D) and obese patients with T2D have higher plasma fetuin-A levels than those without T2D. LECT-2 has positive correlation with the severity of both obesity and insulin resistance. The changes in plasma fetuin-A are not consistent after bariatric surgery and no studies have investigated the changes in LECT-2 on the obese patients with T2D after bariatric surgery. Methods Overall, 18 patients undergoing gastric bypass (GB) and 16 patients undergoing sleeve gastrectomy (SG) were enrolled. The fasting plasma fetuin-A and LECT-2 levels were measured at baseline, one week, three months, and one year after surgery. Results Both the GB and SG groups significantly decreased the body mass index (BMI), waist-to-hip ratio, a body shape index; the triglyceride, fasting blood sugar (FBS), hemoglobin A1c, C-peptide levels; and homeostatic model assessment (HOMA-IR) one year after surgery. The SG group showed a decreasing trend in plasma fetuin-A levels one year after SG surgery. There are no significant changes in LECT-2 one year after either GB or SG. Fetuin-A had a near significant negative relationship with insulin (P = 0.056) and HOMA-IR (P = 0.050) in the SG group. Changes in fetuin-A had a significant positive relationship with changes in BMI (P = 0.031) and waist-to-hip ratio (P = 0.031) in the GB group and had a near significant positive correlation with FBS (P = 0.051) in the SG group. Discussion Neither GB nor SG modifies plasma levels of plasma fetuin-A or LECT-2 in T2D patients after surgery. The changes in plasma fetuin-A have a positive correlation with those of the BMI and waist-to-hip ratio 12 months after GB.

Importance The Roux-en-Y gastric bypass is effective in achieving established diabetes treatment targets, but durability is unknown. Objective To compare durability of Roux-en-Y gastric bypass added to intensive lifestyle and medical management in achieving diabetes control targets. Design, Setting, and Participants Observational follow-up of a randomized clinical trial at 4 sites in the United States and Taiwan, involving 120 participants who had a hemoglobin A1c(HbA1c) level of 8.0% or higher and a body mass index between 30.0 and 39.9 (enrolled between April 2008 and December 2011) were followed up for 5 years, ending in November 2016. Interventions Lifestyle-intensive medical management intervention based on the Diabetes Prevention Program and LookAHEAD trials for 2 years, with and without (60 participants each) Roux-en-Y gastric bypass surgery followed by observation to year 5. Main Outcomes and Measures The American Diabetes Association composite triple end point of hemoglobin A1cless than 7.0%, low-density lipoprotein cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg at 5 years. Results Of 120 participants who were initially randomized (mean age, 49 years [SD, 8 years], 72 women [60%]), 98 (82%) completed 5 years of follow-up. Baseline characteristics were similar between groups: mean (SD) body mass index 34.4 (3.2) for the lifestyle–medical management group and 34.9 (3.0) for the gastric bypass group and had hemoglobin A1clevels of 9.6% (1.2) and 9.6% (1.0), respectively. At 5 years, 13 participants (23%) in the gastric bypass group and 2 (4%) in the lifestyle-intensive medical management group had achieved the composite triple end point (difference, 19%; 95% CI, 4%-34%;P = .01). In the fifth year, 31 patients (55%) in the gastric bypass group vs 8 (14%) in the lifestyle–medical management group achieved an HbA1clevel of less than 7.0% (difference, 41%; 95% CI, 19%-63%;P = .002). Gastric bypass had more serious adverse events than did the lifestyle–medical management intervention, 66 events vs 38 events, most frequently gastrointestinal events and surgical complications such as strictures, small bowel obstructions, and leaks. Gastric bypass had more parathyroid hormone elevation but no difference in B12deficiency. Conclusions and Relevance In extended follow-up of obese adults with type 2 diabetes randomized to adding gastric bypass compared with lifestyle and intensive medical management alone, there remained a significantly better composite triple end point in the surgical group at 5 years. However, because the effect size diminished over 5 years, further follow-up is needed to understand the durability of the improvement. Trial Registration clinicaltrials.gov Identifier:NCT00641251

The LPIN1 gene, encoding lipin-1 protein, plays critical roles in adipocyte differentiation and lipid metabolism. This study aimed to analyze the association of LPIN1 mRNA levels in human adipose tissue with metabolic phenotypes. We also examined the association of LPIN1 genetic variation with type 2 diabetes and related metabolic phenotypes in the Chinese population. The relative LPIN1 mRNA levels were measured in abdominal visceral (VAT) and subcutaneous adipose tissue (SAT) obtained from 102 nondiabetic Chinese females. Seven single-nucleotide polymorphisms (SNPs) spanning from the 5'-upstream region to the 3'-end of the LPIN1 gene were genotyped in 1,520 Chinese (760 type 2 diabetic cases and 760 controls). LPIN1 mRNA levels in VAT were negatively correlated with BMI (r = -0.21, P = 0.03), body fat percentage (r = -0.22, P = 0.02), plasma triglycerides levels (r = -0.21, P = 0.03), and plasma leptin levels (r = -0.63, P = 0.0002). LPIN1 mRNA levels were positively correlated with PPARG and ADIPOQ mRNA levels in both VAT and SAT. No single SNP of the LPIN1 gene was associated with type 2 diabetes in our population. One rare haplotype showed a significant association with type 2 diabetes (odds ratio (OR), 4.35; 95% confidence interval, 1.86-11.75; P = 4 x 10(-4)). No SNP or haplotype of the LPIN1 gene was associated with quantitative metabolic traits in the nondiabetic subjects. The results confirmed the association of LPIN1 gene expression in adipose tissue with lower adiposity and favorable metabolic profiles in the Chinese population. However, the LPIN1 gene seemed not to be a major susceptibility gene for type 2 diabetes or related metabolic phenotypes in the Chinese population.

Objective: Obesity surgery is the most effective treatment for morbid obesity and leads to dramatic improvement in related co-morbidities. The aim of this study was to present the long-term results of a prospective trial studying the efficacy of laparoscopic obesity surgery in a group of oriental patients. Method: From April 1998 to March 2009, 2385 patients who underwent obesity surgery in a single bariatric center in Asia were recruited. Various procedures have been adopted so far, including laparoscopic vertical banded gastric partition in 652 patients (27.3%), laparoscopic gastric bypass (LGB) in 1228 patients (51.5%), laparoscopic adjustable gastric banding in 226 patients (9.5%), laparoscopic sleeve gastrectomy in 128 patients (5.4%), gastric balloon in 68 patients (2.8%) and laparoscopic revision surgery in 83 patients (3.5%). We evaluated the clinical data and effect of obesity surgery on different procedures. Results: Overall, the major complication rate and mortality were 1.5% and 0.12%. There was an increase of surgical risk in laparoscopic sleeve gastrectomy and laparoscopic revision surgery patients. The mean total weight loss for the population was 28.1%, 33.9%, 21.3% 18.7% and 17.4% at 1, 3, 5, 7 and 9 years after surgery, respectively. LGB had a better weight loss (30.1%) than that of the restrictive-type procedures (20.9%) at 5 years after surgery. After surgery, most of the obesity-associated co-morbidities were resolved or improved in these patients. Conclusion: Laparoscopic obesity surgery resulted in significant and sustained weight loss in morbidly obese Asian patients with resolution of associated co-morbidities. LGB had a better result in weight reduction than other restrictive procedures.

Obesity is a major risk factor for the development of type 2 diabetes mellitus (T2DM). Surgery is the most effective treatment for morbid obesity, and it has been shown to lead to dramatic improvement in type T2DM. However, data concerning obese Asian patients have not been reported, and the mechanism of improving T2DM after bariatric surgery in this population remains speculative. From April 1997 to March 2006, 1,375 patients undergoing obesity surgery were recruited for our study of the effects of weight loss surgery on type 2 diabetes mellitus (T2DM). Laparoscopic vertical banded gastric partition (LVBG) was performed in 552 patients (40.1%), laparoscopic gastric bypass in 660 patients (48.0%), and laparoscopic adjustable gastric banding (LAGB) in 140 patients (10.2%). Another 23 patients (1.7%) received open or revision surgery. We evaluated the clinical data and effect of obesity surgery on T2DM, impaired fasting glucose (IFG) and compared the changes with those with normal fasting glucose. Among all the patients, 166 (12.1%) had impaired fasting glucose (IFG) and 247 (18.0%) had T2DM. Patients with IFG or DM were significantly older, more central obese, and they had higher insulin resistance and a higher HbA1C level than those with normal fasting glucose. The mean total weight loss for the population was 28.6%, 29.1%, 28.5%, 23.8%, and 24.4% (at 1, 2, 3, 5, and 7 years after surgery). There was no increase of surgical risk in T2DM or IFG patients. One year after operation, fasting plasma glucose returned to normal in 78.5% of T2DM patients and 94.7% of IFG patients. The HbA1C level returned to under 7.0 in 81.5% of T2DM and in 100% of IFG patients. Laparoscopic gastric bypass patients had a greater weight loss and a higher rate of glucose normalization (93.1%) than the LVBG patients (85.3%) and LAGB patients (73.9%), but no difference in HbA1C normalization. Obesity surgery resulted in significant and sustained weight loss with a cure rate of T2DM up to 80% in morbidly obese Asian patients. Gastric bypass surgery had a better result in T2DM cure rate than LVBG and LAGB because of better weight reduction.

Purpose Laparoscopic cholecystectomy (LC) is a safe and effective treatment for gallbladder disease in elderly patients. However, there is little convincing prospective data regarding the outcome of LC in patients above 75 years of age. Methods Fifty-six cholecystitis patients were enrolled. Group 1 consisted of 17 patients above 76-years-old, group 2 of 39 patients aged between 65 and 75 years. Intraoperative and postoperative parameters were measured. Results Hypertension, diabetes mellitus, and coronary artery disease were the most common medical comorbidities. Operation time, length of hospital stay, and incidence of complications did not differ significantly between the 2 groups. Blood loss did increase significantly in group 1. Similar results were noted in patients with acute cholecystitis. No mortality occurred. Conclusions LC is a safe and effective treatment for older patients suffering from cholelithiasis, but these patients are at greater risk of blood loss. Preoperative coagulation profiles should be arranged.

BACKGROUND Laparoscopically assisted distal gastrectomy has been used for distal part early gastric cancer resection. However, use of totally laparoscopic gastric cancer resection remains limited because of technical problems, especially when standard D2 nodal dissection was applied. We had reported the first totally laparoscopic Billroth II (BII) subtotal gastrectomy with lymphadenectomy for early gastric cancer in the year 1998. The aim of this study is to determine whether this procedure is superior to conventional open technique. METHODS The clinical course of 34 consecutive patients who underwent totally laparoscopic BII gastrectomy using an upper to lower, right to left, and clockwise quadrant-to-quadrant technique was compared with 34 sex-matched and age-matched patients who underwent open gastrectomy. Main outcome measures included operative time, blood loss, length of stay, morbidity and mortality, adequacy of lymphadenectomy, and long-term outcome. RESULTS In the laparoscopic group, all the operations were completed by laparoscopic technique, but 1 patient required secondary laparotomy for total gastrectomy owing to inadequate resection margin. There was no operation mortality in this study. The postoperative complication rates were similar in these 2 groups. The mean operative time for laparoscopic group was 283+/-122 minutes (range: 186 to 480 min), significantly longer than the 195+/-26 minutes in the conventional group (P

Obesity has been widely recognized as a chronic inflammatory condition and associated with elevated inflammatory indicators including C-reactive protein (CRP) and white blood cell count (WBC). Recent studies have shown elevated CRP or WBC is a significant risk factor for cardiac events and stroke but the clinical significance of CRP and WBC has not been clearly studied in morbidly obese patients. This study is aimed at the clinical significance of WBC and CRP in morbidly obese patients and the change after bariatric surgery.The study was a prospectively controlled clinical study. From December 1, 2001 to January 31, 2006, of 640 (442 females and 198 males) consecutive morbid obese patients enrolled in a surgically supervised weight loss program with at least 1 year's follow-up were examined.Of the patients, 476 (74.4%) had elevated CRP and 100 (15.6%) had elevated WBC at preoperative study. CRP and WBC were significantly related and both increased with increasing body mass index (BMI). CRP is also increased with increasing waist, glucose level, hemoglobin, albumin, Ca, insulin, C-peptide, and metabolic syndrome while WBC is increased with metabolic syndrome but decreased with increasing age. Multivariate analysis confirmed fasting glucose level and hemoglobin are independent predictors of the elevation of CRP while age is the only independent predictor for elevated WBC. Both WBC and CRP levels decreased rapidly after obesity surgery. These improvements resulted in a 69.8% reduction of CRP and 26.4% reduction of WBC 1 year after surgery. Although individuals who underwent laparoscopic gastric bypass lost significantly more weight (36.8 +/- 11.7 kg vs. 17.3 +/- 10.8 kg; p = 0.000) and achieved a lower BMI (27.8 +/- 4.6 vs. 35.0 +/- 5.5; p = 0.000) than individuals who underwent laparoscopic gastric banding, there was no difference in the resolution of elevated CRP 1 year after surgery (95.9% vs. 84.5%; p = 0.169) and WBC (99.4% vs. 98.3%; p = 0.323).Both baseline WBC and CRP are elevated in morbid obese patients but CRP has a better clinical significance. Significant weight reduction 1 year after surgery markedly reduced CRP and WBC with a resolution rate of 93.9% and 98.2% separately. Obesity surgery performed by laparoscopic surgery is recommended for obese patients with elevated CRP or WBC.

Nonalcoholic steatohepatitis (NASH) and gallbladder disease (GD) are members of metabolic syndrome in morbidly obesity. Insulin resistance is a risk factor for NASH and GD. The aim of the present study was to investigate the relationship between insulin resistance (HOMA-IR), liver fibrosis, NASH and GD in morbidly obese patients who presented with fatty liver during preoperative abdominal ultrasonography examination.We studied 152 morbid obese patients with fatty liver disease including 54 with NASH, 11 with GD and two with concurrent NASH and GD that were undergoing laparoscopic bariatric surgery. Clinical data (gender, age, body mass index [BMI], and associated diseases), laboratory evaluation, and histopathology were obtained from the patient databases. We analyzed the relationship between clinical characteristics, histological parameters, HOMA-IR, and fibrosis stage associated with NASH and GD in morbid obese patients.Among the 152 patients with fatty liver disease, 93 were females and 59 were males. The mean age was 30.3 +/- 8.9 years and the mean BMI was 44.9 +/- 5.4 kg/m(2). Fifty-four patients (54/152, 35.5%) were diagnosed as NASH and 11 patients (11/152, 7.2%) received concomitant laparoscopic cholecystectomy because of gallbladder disease (GD). Morbidly obese patients with fatty liver disease and GD were significantly older (P = 0.020), had higher serum levels of cholesterol (P = 0.020) and low-density lipoprotein (LDL)-cholesterol (P = 0.044), and had lower serum levels of total bilirubin (P = 0.044), C-peptide (P = 0.023), and insulin (P = 0.039) than the NASH group. Histopathology factors of hepatic steatosis (P = 0.012), ballooning degeneration (P = 0.001), lobular inflammation (P = 0.019), fibrosis (P = 0.026), and glycogenated nuclei (P = 0.028) were significantly different between NASH and GD groups. However, further multivariate analysis failed to demonstrate any independent clinicopathological factor. The prevalence of chronic hepatitis B and NASH was the same (18%) in all 11 GD patients. Besides, when we compared NASH patients (n = 54) with concurrent NASH-GD patients (n = 2), we found that waist (P = 0.016), waist/hip (P = 0.039), and HOMA-IR (P = 0.040) were independent associated factors. We further assessed the HOMA-IR distribution and the relationship between fibrosis stage in patients with NASH and GD. In the NASH group, HOMA-IR distribution progressively decreased when the severity of fibrosis was plotted as a function of insulin resistance.The prevalence of NASH in gallbladder disease was 18% in morbid obese population. We concluded that age, serum cholesterol, and low-density lipoprotein cholesterol levels were risk factors associated with gallbladder disease and fatty liver disease. Insulin resistance was more common in concurrent NASH and gallbladder disease. The mechanism between insulin resistance, fibrosis stage, NASH, and gallbladder disease is unknown.

Laparoscopic antireflux surgery (LARS) has long been introduced as an alternative method for the treatment of gastroesophageal reflux disease (GERD) in young adults. However, the safety of this procedure and the associated improvement in the quality of life for the elderly are rarely discussed. This study compared the results between young and elderly patients who underwent laparoscopic fundoplication for the treatment of GERD.From January 1999 to January 2006, there were 231 adult patients who underwent LARS for GERD at a single institute. Among all patients, 33 patients were older than 70 years old (14.3%, 73.0 +/- 1.9, range 70-76), 198 patients were younger than 70 years old (85.7%, 46.6 +/- 11.5, range 20-69). The clinical characteristics, operation time, postoperative hospital stay, surgical complications, and quality of life were retrospectively analyzed.The mean operation time had no significant difference between the younger group and the elderly group. The mean postoperative hospital stay in the elderly group was slightly longer than the younger group (4.1 +/- 2.5 days vs 3.4 +/- 1.3 days, P = 0.19). There were no mortalities and no major complications found in each group. No patients required conversion to an open procedure. Four patients had minor complications (three in the elderly group, rate: 9.0%; one in the younger group, rate: 0.5%, P0.05). There were two patients in the nonelderly group who had recurrence. A comparison of the preoperative and postoperative Gastro-Intestinal Quality of Life Index (GIQLI) scores showed significant improvements (99.3 +/- 19.2 points, and 110.2 +/- 20.6 points, respectively, P0.05) with no significant difference between the two groups.Laparoscopic antireflux surgery thus appears to provide an equivalent degree of safety and symptomatic relief for elderly patients with GERD as that observed in young patients.

Obesity is a major risk factor for the development of type 2 diabetes mellitus (T2DM). Insulin resistance (IR) is considered the pathologic link between T2DM and obesity. The mechanism in improving T2DM after bariatric surgery remains speculative. This trial assessed the effect of duodenal jejunal exclusion on the resolution of IR in gastric banding and gastric bypass procedures.660 patients with complete biochemical and clinical data at baseline and at 3 years were selected for analysis. There were 197 males and 463 females. The mean age was 31.5 years (18-64) and mean BMI was 41.4 (32-77). There were 544 patients who received laparoscopic gastric bypass, and 116 patients received laparoscopic gastric banding. IR was measured by homeostatic model assessment (HOMA) index (HI), that can be calculated as HI = plasma glucose (mmol/l) x insulin (UI/ml)/22.5. HI was measured before surgery and 1, 3, 6, 12, 24, and 36 months after surgery.Of the 660 individuals, 517 (78.4%) had IR. The mean HI was 7.62 +/- 13.13. The HI was correlated with BMI, waist circumference, insulin resistance, hyperlipidemia, inflammatory indicators, and abnormal liver enzymes. Before surgery, the HI was 7.92 +/- 14.18 for the bypass group and 6.27 +/- 6.47 for the banding group. After surgery, the HI began to lower in both groups, and this reduction was maintained during follow-up. At 36 months after surgery, mean percentage of excess weight loss (%EWL) was 70.5% for the bypass group and 41.9% for the banding group. The HI was 1.00 +/- 0.79 for bypass and 1.51 +/- 1.25 for banding. The bypass patients had a better and faster weight reduction, but the HI was similar between the two groups at the same weight reduction percentage.IR is common in morbidly obese patients. Both gastric banding and gastric bypass are effective for the reverse of IR in these patients. It seems that the effect is related to the absolute weight loss rather than different surgical procedures. There is no duodenal jejunal exclusion effect on IR resolution was observed in this study.

Non-alcoholic fatty liver disease is prevalent in obese patients. Liver biopsy remains the best diagnostic tool for confirmation. We evaluated the effectiveness of macroscopic parameters of laparoscopy in diagnosis of liver diseases. Moreover, correlations of laparoscopy with histology and laboratory data were also studied.From December 2004 to April 2006, 126 morbidly obese patients submitted to laparoscopic bariatric surgery at the En-Chu-Kong Hospital were prospectively studied.There were correlations of histologic steatosis with liver surface fat spot density, liver margin shape, and liver size. Histologic inflammation was related to liver color, vascularity beneath hepatic capsule, liver margin shape, liver size, and liver surface nodularity. Histologic fibrosis had relations to liver color, liver surface nodularity, liver size, varices of ligamentum teres. Spleen size was related to liver surface nodularity and spleen congestion. Relationships of laboratory data with laparoscopic findings included: aspartate transaminase (AST) level with liver size, alanine transaminase (ALT) level with liver color and liver size, albumin level with liver margin shape and liver surface fibrosis and liver size, total protein level with liver size, alkaline phosphatase (ALP) level with liver surface fibrosis, blood glucose level with liver surface nodularity and spleen size, C-peptide with liver size. Besides, there were relations of gamma-GT level with liver color, liver margin shape, liver and spleen size.Besides histology and laboratory studies, laparoscopic inspection of the abdominal cavity provides important and additional information, which contributed to the final diagnosis of chronic liver diseases and detection of possible pathology in patients.

The ghrelin and leptin levels have been reported to be correlated with weight loss after bariatric surgery. However, the serial changes of ghrelin and leptin levels after laparoscopic minigastric bypass surgery (LMGBP) have not been reported yet. Therefore, we aimed to evaluate their serial changes and to analyze their relations to weight reduction after LMGBP. Serial fasting serum leptin and ghrelin concentrations were measured in 68 morbidly obese patients before (M0) and 1 (M1), 3 (M3), 6 (M6), and 12 (M12) months after LMGBP surgery. The correlations between ghrelin, insulin, and leptin concentrations and weight reduction were analyzed. Leptin levels were significantly reduced at 1, 3, 6, and 12 months after surgery, respectively (vs M0, p

Today, bariatric surgery, as the only effective therapy for morbid obesity, is expanding exponentially to meet the global epidemic of obesity. There is increasing evidence that effective long-term weight loss is achieved after bariatric surgery. A substantial majority of patients with diabetes, hyperlipidemia, hypertension and obstructive sleep apnea have experienced complete resolution or improvement with significant survival benefits. Patients with a body mass index (BMI) > 35.0 kg/m2 and comorbidities, or Asian people with a BMI of 32.0 kg/m2 and diabetes mellitus can be candidates for weight-reducing surgery. Currently, laparoscopic adjustable gastric banding (LAGB) and laparoscopic gastric bypass (LGB) are two commonly used procedures in weight-reducing surgery. LAGB, a purely restrictive method, is the safest procedure. LGB, a mixed type procedure, is more effective but technically more demanding and carries a higher risk. Laparoscopic sleeve gastrectomy is a new procedure for high-risk or lower BMI patients. Biliopancreatic diversion or duodenal switch, a malabsorption procedure, is used as a second-line operation. The survival benefits of bariatric surgeries rely heavily on their safety. Unlike other gastrointestinal operations performed by general surgeons, bariatric surgery requires a team approach in a center of excellence. The surgeon requires training in advanced laparoscopic techniques and also in the care of the bariatric patient. How safe laparoscopic bariatric surgery can be provided to meet the soaring demand from morbidly obese Asian patients will be an important issue in the near future.

Metabolic syndrome (MetS) and nonalcoholic fatty liver disease (NAFLD), ranging from simple steatosis to steatohepatitis (NASH), have become important health issues in obese subjects. In this study, we investigated the relationship between MetS and NASH in severely obese subjects.A total of 111 non-alcoholic obese patients who underwent laparoscopic bariatric surgery (BMI 45.4 +/- 5.7 kg/m2) were enrolled from February to September 2004 in a referral center in North Taiwan. MetS and its individual components were defined using the American Heart Association/National Heart, Lung, and Blood Institute criteria. Based on liver biopsy during surgery, subjects were classified into either having NASH or not. The relationship among NASH, adiponectin, insulin resistance, MetS and its individual components was examined using a multivariate logistic regression analysis.The prevalence of NASH and MetS in these subjects was 79.3% and 68.5%, respectively. Using a multivariate logistic regression analysis with NASH as the outcome variable, odds ratio (OR) of NASH for subjects with MetS versus without MetS was 2.96 (95% CI = 1.14-7.68) adjusted for age, gender, and BMI. Also, high blood pressure (OR = 2.97, 1.31-6.73) and high fasting glucose (OR = 2.94, 1.13-7.67) were independently associated with NASH after adjustment for age, gender, and BMI. Insulin resistance measured as HOMA-IR and serum adiponectin level were not significantly different between the NASH and non-NASH group.MetS and NASH were common in severely obese Taiwanese adults. Presence of MetS, high blood pressure, and high fasting glucose was independently related to increased risk of NASH. The underlying mechanism deserves to be explored in the future.

Background Obesity is a risk factor for gallbladder disease. The authors retrospectively analyse the prevalence and risk factors of gallbladder disease using logistic regression and artificial neural networks among obese patients in Taiwan. Methods Artificial neural networks is a popular technique, which can detect complex patterns within data. They have not been applied to risk of gallbladder disease in obese population. We studied the risk factors associated with gallstones in 117 obese patients who were undergoing bariatric surgery between February 1999 and October 2005. Artificial neural networks, constructed with three-layered back-propagation algorithm, were trained to predict the risk of gallbladder disease. Thirty input variables including clinical data (gender, age, body mass index and associated diseases), laboratory evaluation and histopathologic findings of gallbladder were obtained from the patient records. The result was compared with a logistic regression model developed from the same database. Results Artificial neural networks demonstrated better average classification rate and lower Type II errors than those of logistic regression. The risk factors from both data mining techniques were diastolic blood pressure, inflammatory condition, abnormal glucose metabolism and cholesterolosis. The biological significance of inflammatory condition in obese population requires further investigation. Conclusion Artificial neural networks might be a useful tool to predict the risk factors and prevalence of gallbladder disease and gallstone development in obese patients on the basis of multiple variables related to laboratory and pathological features. The performance of artificial neural networks was better than traditional modeling techniques.

Background: Obesity is a risk factor for gallbladder disease. The authors analyze the prevalence and clinicopathology of gallbladder disease among obese patients in Taiwan. Methods: Prevalence and various clinical factors associated with cholelithiasis were studied in 199 patients who were undergoing bariatric surgery for obesity. Clinical data (gender, age, BMI and associated diseases), laboratory evaluation and immunoglobulin G antibodies against Helicobacter pylori were obtained from the patient records. The histopathologic findings of the gallbladder were also examined retrospectively. The degree of acute inflammation, chronic inflammation, cholesterolosis, cholesterol polyp and gastric metaplasia was determined and scored. Results: Of the patients, 91% (n=181) were females and 9% (n=18) were males, age 34.26 ± 8.41 years, with mean BMI 35.28 ± 6.11 kg/m 2 . The prevalence of cholelithiasis was 10.1%. Increased diastolic blood pressure and HBsAg carrier were the only significant factors associated with cholelithiasis. All obese patients in our study presented with variable degrees of chronic mononuclear cell infiltration in the gallbladder mucosa. Cholesterolosis was present in 100 patients (50.3%), followed by gastric metaplasia (27.1%), cholesterol polyp (16.1%) and acute inflammation (9.5%). Multivariate analysis showed an association between cholelithiasis and acute and chronic inflammation. The predictors of cholesterolosis were BMI, waist circumference and high-sensitivity C-reactive protein. The seroprevalence of H. pylori was 42.2%. Older age, abnormal liver function tests, calcium and HBsAg carrier were significantly different between H. pylori-seropositive and H. pylori-seronegative obese patients. However, we could rarely find H. pylori within the gallbladder mucosa. Conclusion: Cholelithiasis in Asian obese patients is significantly associated with increased diastolic blood pressure and hepatitis B surface antigen carriers. Because chronic liver disease seems to be a risk factor for cholelithiasis in both non-obese and obese populations, prophylactic cholecystectomy can be considered in obese patients with HBsAg positivity. We did not find evidence that H. pylori has a role in the pathogenesis of gallbladder disease and gallstone by histologic and serologic examinations. Furthermore, mucosal abnormalities of acute and chronic inflammatory cell infiltration are common in obese patients, which related to cholelithiasis.

Obesity is associated with vascular endothelial cell dysfunction (ECD). Studies on nitric oxide (NO) production of vascular system in these subjects may help delineate the pathogenesis of obesity-associated ECD. In this study, we recruited 69 severely obese patients who were treated with gastric partition surgery for weight reduction and 69 matched healthy controls for comparison. The following parameters were obtained in the healthy control subjects and in the obese subjects both before and after gastric partition surgery: body mass index, blood pressure, serum lipids, high sensitivity C-reactive protein (hs-CRP), adiponectin, total nitrite and nitrate (NO(x)), and 8-iso-prostaglandin F2alpha (8-iso-PGF2alpha), and insulin resistance index (as measured by homeostasis model assessment (HOMA-IR). At baseline, serum lipids, glucose, insulin, hs-CRP and 8-iso-PGF2alpha and HOMA-IR were all higher while adiponectin lower in the obese group than in the control group. The serum NO(x) levels were not different between the two groups. In the obese subjects, the adiponectin levels were significantly elevated but NO(x) markedly decreased after surgery. All other measurements, except for systolic blood pressure, were decreased after surgery. For healthy controls, the serum NO(x) levels were negatively associated with HOMA-IR and positively associated with serum adiponectin levels as analyzed by multiple linear regression analysis. In obese patients, the baseline serum NO(x) was positively associated with the serum TG levels. The changes of serum NO(x) levels after weight reduction surgery were positively associated with the changes of body mass index and serum TG levels. These observations suggested that, in the extremely obese patients, there might be excessive production and/or inactivation of NO and, after weight reduction surgery, the NO production was down-regulated. In conclusion, in the severely obese patients, the apparently normal NO production might be due to over-expression of iNOS. After gastric partition surgery, the NO production was significantly decreased which might be reflecting the usual status of NO production in obese subjects. The positive correlation between NO(x) and serum TG level might suggest that the metabolism of TG plays a role in the regulation of NO production.