Applied nutritional investigation
Changes in ghrelin concentrations one year after resective and
non-resective gastric bypass: Associations with weight loss and
energy and macronutrient intakes
Fernando Carrasco M.D.a,*, Pamela Rojas M.D.a, Attila Csendes M.D.b,
Juana Codoceo M.T.a, Jorge Inostroza M.T.a, Karen Basfi-fer M.Sc.a, Karin Papapietro M.D.b,
Guillermo Watkins M.D.b, Jorge Rojas M.D.b, Manuel Ruz Ph.D.a
aDepartment of Nutrition, Faculty of Medicine, University of Chile, Santiago, Chile
bDepartment of Surgery, Clinical Hospital, University of Chile, Santiago, Chile
a r t i c l e i n f o
Received 31 May 2011
Accepted 1 November 2011
a b s t r a c t
Objective: Ghrelin is a potent stimulator of appetite and synthesized in the stomach. Its role in
weight loss after gastric bypass (GBP) is still controversial. The aim of this study was to evaluate the
relation between weight loss and food intake and between weight loss and changes in serum
ghrelin concentrations 1 y after GBP with resection of the bypassed stomach (R-GBP) and without
Methods: Of 50 women (37.6 ? 10.2 y old, body mass index 43.8 ? 4.8 kg/m2) with GBP, 26 had
R-GBP and 24 had NR-GBP. Body weight, body composition (dual energy x-ray absorptiometry),
food intake, and serum ghrelin at baseline and 12 mo after GBP were measured.
Results: The percentage of excess weight loss was 68.9 ? 12.8% at 12 mo after GBP. At 12 mo, the
decrease of serum ghrelin was greater in the R-GBP group (?25.3 ? 22.5%) compared with the
NR-GBP group (þ11.2 ? 50.9%, P < 0.005). After adjustment by the baseline excess of body weight,
there was a greater percentage of excess weight loss in the R-GBP group only at 6 mo (61.8% versus
54.9%, P ¼ 0.011). After controlling for the baseline intake, a significant lower carbohydrate intake
was observed in the R-GBP group 6 mo after surgery (P < 0.05).
Conclusion: A greater decrease in ghrelin levels was observed only in patients who underwent
R-GBP at 12 mo after surgery. This difference was not associated with differences in dietary intakes
or weight loss at the same time point. Therefore, the small gastric pouch is probably more
important than decreased ghrelin levels in producing long-term weight loss after R-GBP.
? 2012 Elsevier Inc. All rights reserved.
In severely and morbidly obese patients (body mass index
[BMI] 35–39.9 and ?40 kg/m2, respectively), bariatric surgery is
considered the most effective method to induce significant
weight loss (w70% of excess weight) that is maintained in the
long term [1–3]. Roux-en-Y gastric bypass (RYGBP) is the most
recommended currently used technique and has become the
“gold standard” technique [1,4,5]. In Chile, the same surgical
approach has been employed [6–8]. However, the use of vertical
sleeve gastrectomy (SG) has been growing worldwide in the
previous 5 y. Initially, SG was proposed as a first-step surgery in
patients at high surgical risk before a GBP or other more
sophisticated techniques [9,10], and more recently it has been
used as a definitive treatment replacing other classically
restrictive procedures such asadjustable gastric banding [11–13].
The preliminary encouraging results with SG in weight loss have
been attributed in part not only to the restriction of the gastric
capacity but also to the drastic decrease in postoperative plasma
ghrelin levels resulting from a gastric resection greater than 80%,
leading to large decreases in appetite and food intake [14–18].
Ghrelin is a 28-amino acid peptide that acts as a powerful
appetite stimulant. It is mainly produced in the stomach but also
in the upper intestine . Its secretion increases immediately
before a meal and is rapidly suppressed by a food intake in
This study was funded in part by grant 1080576 from the National Research
Fund for Science and Technology, FONDECYT.
* Corresponding author. Tel.: þ562-978-6136; fax: þ562-737-8778.
E-mail address: email@example.com (F. Carrasco).
0899-9007/$ - see front matter ? 2012 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
journal homepage: www.nutritionjrnl.com
Nutrition 28 (2012) 757–761
proportion to an energy intake [19,20]. Ghrelin increases in
response to the food restriction and weight loss induced
by a low-calorie diet . Fasting plasma ghrelin decreases in
obese subjects in direct proportion to the degree of insulin
The role of ghrelin in weight loss after GBP is controversial
[23–26]. The changes in plasma ghrelin after RYGBP are not
consistent. These discrepancies have been explained by the
differences in the length of postoperative follow-up, whether the
patient is underweight, losing weight, or has a stable weight, or
whether surgery includes or does not include truncal vagotomy
. In a recent analysis of patients who lost weight after GBP
and were in a stable condition, it was found that fasting
concentrations of plasma ghrelin were inversely related to the
final BMI .
At our university hospital, resection of the distal gastric
segment has become a routine procedure . Although the
reported cases of gastric cancer in the excluded gastric segment
are scarce in the literature [7,27], the high incidence of gastric
cancer in the population (27 of 100 000 inhabitants) should lead
bariatric surgeons to behave more cautiously toward this
potential serious long-term complication [28,29]. Another
potential benefit of GBP with resection of the excluded segment
may be a decrease in ghrelin secretion, which in turn could
induce a greater weight loss compared with GBP without distal
The aim of this study was to evaluate the changes in ghrelin
plasma levels 1 y after RYGBP by comparing patients with
resection with patients without resection of the excluded
stomach and its relation to changes in body weight and food
Material and methods
Fifty adult women (37.6 ? 10.2 y old, age range 23–53 y), with a BMI ?40 or
?35 kg/m2and comorbidities such as type 2 diabetes, hypertension, dyslipide-
mia, sleep apnea, osteoarthritis, among other conditions, who underwent RYGBP
in the Department of Surgery, University of Chile Clinical Hospital from
November 2004 through February 2010 were prospectively studied. The initial
mean BMI was 43.8 ? 4.8 kg/m2. All patients who agreed to enter the study
signed an authorized consent form. The study was approved by the ethics
committee for human investigation of the university hospital. In 26 patients, the
surgical technique consisted of a 95% distal gastrectomy with resection of the
bypassed stomach (resective GBP [R-GBP]), and 24 patients underwent RYGBP
without resection of the distal stomach (non-resective GBP [NR-GBP]). This was
not a randomized study, and the selection of the patients to undergo R-GBP or
NR-GBP was based on the preoperative endoscopic and histologic studies. If the
gastric mucosa was normal, the excluded stomach was maintained in situ.
Conversely, if chronic atrophic gastritis or intestinal metaplasia was present, the
distal excluded stomach was resected.
In the two groups, a small gastric pouch of 15 to 20 mL was left [7,29]. Then,
an end-to-side gastrojejunostomy with a circular no. 25 stapler was performed.
The length of the Roux-en-Y was 125 to 150 cm. All patients underwent complete
preoperative work, including nutritional and psychological evaluations, upper
endoscopic and biopsy samples, the eradication of Helicobacter pylori, if present,
and a complete biochemical evaluation.
Before and 6 and 12 mo after surgery, the parameters anthropometry and
food intake were analyzed in all patients. Fasting serum ghrelin concentration
and body composition were measured at baseline and 12 mo after surgery.
Anthropometrics, body composition, and food intake
Weight was measured to the nearest 0.1 kg on a digital scale (Seca, Vogel &
Halke GmbH & Co., Hamburg, Germany), and height (meters) was measured to
the nearest 0.1 cm with a scale-mounted stadiometer. The BMI was calculated as
weight (kilograms) divided by height (meters) squared. The percentage of body
fat was measured by dual energy x-ray absorptiometry using a Lunar DPX-L
densitometer (Lunar, Madison, WI, USA; software 1.30).
At baseline and 6 and 12 mo of the postoperative period, patients were
interviewed by a dietitian and a 3-d record that corresponded to 2 weekdays and
1 weekend day was filled out. The data registered were analyzed using
a computer program (Food Processor II, ESHA Research, Salem, OR, USA) to
calculate energy and nutrient intakes by using a database that contained locally
generated nutrient composition data and information from the literature.
In serum obtained from morning fasted blood samples, total ghrelin was
analyzed by radioimmunoassay using a kit from Linco Research Inc. (St. Charles,
MO, USA). We used total ghrelin in this study, because it has been observed to
have a good correlation with the active form  and it changes in parallel to the
active levels of this peptide . In addition, the two forms of ghrelin have
several biological effects at the peripheral and central levels [32–34].
Plasma glucose was determined by the glucose oxidase method and plasma
insulin by radioimmunoassay (Linco Research Inc.). Fasting plasma glucose and
insulin concentrations were used to calculate insulin resistance by the homeo-
stasis model assessment index using the formula: fasting serum glucose (milli-
grams per deciliter) ? fasting serum insulin (microunits per milliliter)/405.
Data are expressed as mean ? standard deviation. Differences between
means were evaluated using a two-tailed Wilcoxon signed ranks test (pre- versus
postoperative) and a two-samples Mann–Whitney Test. Two-factor repeated-
measures analysis of variance with treatment groups as a between-subjects
factor and time as a within-subjects factor followed by a Bonferroni test for
multiple comparisons were performed. To evaluate the association among
variables, Spearman correlation coefficient analyses were performed. SPSS 10.0
(SPSS Inc, Chicago IL, USA) was used for all analyses. Statistical significance was
considered at P < 0.05.
The main baseline characteristics of the two groups are pre-
sented in Table 1. Significant differences in body weight, BMI,
percentage of body fat, and excess body weight were found
between the two groups of patients. Type 2 diabetes was present
in five patients in the R-GBP group (19.2%) and in two patients in
the NR-GBP group (8.3%, P ¼ NS, chi-square test). The percentage
of patients with insulin resistance was similar in the two groups.
No significant differences in fasting glucose concentration
(80.3 ? 9.7 versus 85.1 ?8.3 mg/dL, P ¼ 0.620) and fasting insulin
levels (6.9 ? 3.6 versus 8.5 ? 4.9 mU/mL, P ¼ 0.126) were
observed between the NR-GBP and R-GBP groups, respectively.
The mean length of hospital stay was 6.3 ? 2.0 d, with no
significant differences between the groups (R-GBP 6.4 ? 1.7 d
versus NR-GBP 6.3 ? 2.8 d, P ¼ NS). Postoperative complications
related to the surgical site occurred in 5.9% of patients (5.6% in
the R-GBP group versus 6.3% in the NR-GBP group, P ¼ NS). No
mortality was registered in any group. None of the studied
percentage of excess weight loss (%EWL) was 58.5 ? 10.9% and
68.9 ? 12.8% at 6 and 12 mo after GBP. The %EWL was signifi-
cantly greater in the R-GBP group compared with the NR-GBP
group at 6 mo (63.4 ? 9.8% versus 53.1 ? 9.6%, P < 0.001) and
12 mo (72.8 ? 12.0% versus 64.6 ? 12.5%, P < 0.05) after surgery
(Fig. 1). Nevertheless, after adjusting for baseline excess body
weight, the %EWL differences remained significant at 6 mo
only (61.8%, 95% confidence interval 58.3–66.3, versus 54.9%,
51.2–58.6, P ¼ 0.011; Fig. 1).
of fasting total serum ghrelin concentrations after GBP. A signifi-
cant decrease was observed in the R-GBP group (?25.3 ? 22.5%,
range ?70.5% to þ36.7%, P < 0.001) but not in the NR-GBP group
(þ11.2 ? 50.9%, range ?54.5% to þ192.4%, P ¼ NS).
After controlling for the baseline excess body weight, there
was no correlation between the percentage of decrease in serum
F. Carrasco et al. / Nutrition 28 (2012) 757–761
ghrelin concentrations and %EWL at 12 mo after GBP (r ¼ ?0.273,
P ¼ 0.057).
Table 2 lists the calculated energy and nutrient intakes
observed before and 6 and 12 mo after R-GBP and NR-GBP. There
was a significant effect of time for all macronutrients and energy.
The interaction between time and group was not significant. At
6 mo after surgery, the carbohydrate intakedadjusted by base-
line valuesdwas significantly decreased in the R-GBP group
compared with the NR-GBP group (P ¼ 0.047). This difference
was not maintained at 12 mo after the operation.
In this article we reported the changes in body weight and
food intake in subjects undergoing GBP with resection of a 95%
gastrectomy distal to the gastric pouch, a technique with the
greatest potential forlowering plasma ghrelin,possiblysimilar to
the effects of SG compared with the traditional NR-GBP. Fasting
plasma ghrelin was significantly decreased 1 y after R-GBP but
remained unchanged in patients undergoing the standard tech-
It has been suggested that the positive results in weight loss
seen after SG could be explained in part by the decreased levels
of ghrelin [14,18,35], an effect that has been shown to persist
even 5 y after surgery .
It was not the purpose of the present study to discuss the
reasons for performing R-GBP versus NR-GBP, which is per-
formed by most North American surgeons. This point has been
discussed extensively in previous publications [7,29]. However, it
is worth noting that previous studies in patients with morbid
obesity have shown that an important proportion presents
pathologic gastric mucosa before surgery  and after GBP .
Thus, our approach in morbidly obese patients is to perform
laparoscopic NR-GBP if the gastric mucosa is normal or has slight
histologic findings and resection of the distal excluded stomach
if chronic atrophic gastritis or intestinal metaplasia is found,
because it is impossible to perform endoscopic surveillance of
the excluded stomach at a later date.
The changes in ghrelin concentrations after GBP are not
consistent across several studies, and it has been considered that
these variations are not determining factors of the outcomes of
this surgical technique in the short and long term. Our results
support the latter conclusion. Although not significant, the
differences of the %EWL adjusted by the initial excess weight
tended to be greater by about 5.5% at month 12 of the post-
operative period in the R-GBP group compared with the standard
NR-GBP procedure. We did not observe any significant associa-
tion between the magnitude of the weight loss and the change in
We observed a significant decrease in the calculated energy
and macronutrient intake of a greater magnitude in the first 6
mo after surgery in the two groups of patients. For instance, the
mean decreases in energy and carbohydrate intakes were w63%
and 64%, respectively. Although energy and carbohydrate were
significantly lower in the R-GBP group 6 mo after surgery, the
percentage of variation from the preoperative intake showed no
significant difference between the groups. These results lead us
to suggest that the greatest weight-decreasing effect of GBP is
related mainly to the dramatic decrease in the intake capacity
achieved by a small gastric pouch. It may be concluded that at
12 mo, despite the significant greater decreases in ghrelin
Fig. 1. The %EWL (mean ? SE, adjusted by baseline excess weight) up to month 12
of the postoperative period in the R-GBP group (open bars; n ¼ 26) and NR-GBP
group (solid bars; n ¼ 24). %EWL, percentage of excess weight loss; NR-GBP, non-
resective gastric bypass; R-GBP, resective gastric bypass.
Fig. 2. Percent of change in serum ghrelin concentration (mean ? SD) 12 mo after
surgery in the R-GBP group (open bars; n ¼ 26) and NR-GBP group (solid bars; n ¼
24). NR-GBP, non-resective gastric bypass; R-GBP, resective gastric bypass.
Baseline anthropometrics, body composition, and metabolic characteristics of patients before R-GBP and NR-GBP
R-GBP (n ¼ 26)
39.7 ? 9.5 (19–55)
106.2 ? 12.5 (81.2–135.4)
48.8 ? 10.5 (27.7–68.9)
42.3 ? 3.6 (35.6–50.9)
46.0 ? 4.0 (36.7–53.6)
108.3 ? 30.3 (72–204)
23.7 ? 12.0 (5.1–58.0)
6.0 ? 3.5 (1.1–14.8)
818.0 ? 370.7 (418–2190)
NR-GBP (n ¼ 24)
36.0 ? 10.9 (18–55)
116.0 ? 15.7 (89.7–156.4)
57.8 ? 14.0 (38.4–91.6)
45.5 ? 5.4 (38.0–58.8)
48.9 ? 4.5 (42.2–56.9)
100.5 ? 11.9 (79.9–130.0)
30.6 ? 17.4 (7.0–71.0)
7.8 ? 5.0 (1.5–22.0)
745.9 ? 368.8 (290–2264)
Weight excess (kg)
Body fat (%)
Blood glucose (mg/dL)
Serum insulin (mU/mL)
Plasma ghrelin (pg/mL)
BMI, body mass index; HOMA, homeostasis model assessment index; NR-GBP, non-resective gastric bypass; R-GBP, resective gastric bypass
Values are expressed as mean ? SD (range).
F. Carrasco et al. / Nutrition 28 (2012) 757–761
concentrations in patients with R-GBP, these are not associated
to the magnitude of weight loss. Our results are consistent with
those obtained by Karamanakos et al.  who found a signifi-
cant decrease in ghrelin concentration after SG and no change
after GBP; this decrease was associated with a weight loss
significantly greater with SG only at 6 mo after surgery. For
variations of ghrelin concentration over time, there is informa-
tion in the literature suggesting a relative stability of postsurgical
values. Thus, in standard GBP, Sundbom et al.  and
Karamanakos et al.  observed that ghrelin levels remain high
and stable from the first month after the surgery to 1 y. No data
are available on the observed decreases in ghrelin during the first
year after R-GBP, but the observations in patients undergoing SG
showed a decrease in ghrelin levels from the first month that
remained stable throughout the first postoperative year. This
observation and the data of Bohdjalian et al.  up to 5 y after
SG rule out a possible adaptive mechanism to restore the levels
of ghrelin in the medium and long term after a surgical gastric
In conclusion, R-GBP surgery is associated with a greater
decrease in plasma ghrelin concentrations than traditional NR-
GBP; this difference was not associated with differences in die-
tary intakes or weight loss at the same time point.
It is very likely that, in surgical procedures such as GBP, the
maximal restriction of the stomach capacity and other mecha-
nisms (e.g., increased glucagon-like peptide-1 [GLP-1] and
peptide-YY) are quantitatively more relevant than the decrease
of ghrelin concentration on food intake and weight loss.
The authors are indebted to Dr. Juan C D? ıaz, Dr. Fernando
Maluenda, Dr. Luis Guti? errez, and Dr, Enrique Lanzarini from the
Department of Surgery, University Clinical Hospital, who per-
formed a significant number of the surgical procedures; to Dr.
Daniela Adjemian for her crucial participation in the enrollment
and control of patients; and to the nutritionists Ms. Emma D? ıaz
and Ms. Andrea Riffo from the University Clinical Hospital and
Ms. Alejandra Valencia from the Department of Nutrition,
University Clinical Hospital, for their invaluable collaboration in
the dietary control of the subjects.
 Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al.
 Maggard MA, Shugarman LR, Suttorp M, Maglione M, Sugerman HJ,
Livingston EH, et al. Meta-analysis: surgical treatment of obesity. Ann
Intern Med 2005;142:547–59.
 Demaria EJ. Bariatric surgery for morbid obesity. N Engl J Med
 Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B,
et al, Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes,
and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med
 Guzm? an S, Boza C. Reflexiones sobre la cirug? ıa de la obesidad m? orbida. Rev
Chilena Cirugia 2001;53:129–34.
 Csendes A, Burdiles P, Papapietro K, Diaz JC, Maluenda F, Burgos A, et al.
Results of gastric bypass plus resection of the distal excluded gastric
segmentinpatients withmorbidobesity.JGastrointest Surg2005;9:121–31.
 Awad W, Garay A, Mart? ınez C, O~ nate V, Turu I, Yarmuch J. Experiencia de 10
a~ nos con el bypass g? astrico. Rev Chilena Cirugia 2007;59:443–7.
 Almogy G, Crookes PF, Anthone GJ. Longitudinal gastrectomy as a treat-
ment for the high-risk super-obese patient. Obes Surg 2004;14:492–7.
 Regan JP, Inabnet WB, Gagner M, Pomp A. Early experience with two-stage
laparoscopic Roux-en-Y gastric bypass as an alternative in the super obese
patient. Obes Surg 2003;13:861–4.
 Baltasar A, Serra C, P? erez N, Bou R, Bengochea M, Ferri L. Laparoscopic
sleeve gastrectomy: a multi-purpose bariatric operation. Obes Surg
 Deitel M, Crosby RD, Gagner M. The first international consensus summit
for sleeve gastrectomy (SG); New York City; October 25–27, 2007. Obes
 Tucker ON, Szomstein S, Rosenthal RJ. Indications for sleeve gastrectomy as
a primary procedure for weight loss in the morbidly obese. J Gastrointest
 Langer FB, Reza Hoda MA, Bohdjalian A, Felberbauer FX, Zacherl J, Wenzl E,
et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin
levels. Obes Surg 2005;15:1024–9.
 Han SM, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG)
at 1 year in morbidly obese Korean patients. Obes Surg 2005;15:1469–75.
 Braghetto I, Korn O, Valladares H, Guti? errez L, Csendes A, Debandi A, et al.
Laparoscopic sleeve gastrectomy: surgical technique, indications and
clinical results. Obes Surg 2007;17:1442–50.
 Melissas J, Koukouraki S, Askoxylakis J, Stathaki M, Daskalakis M,
Perisinakis K, et al. Sleeve gastrectomyda restrictive procedure? Obes Surg
 Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. Weight loss,
appetite suppression, and changes in fasting and postprandial ghrelin and
peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy:
a prospective, double blind study. Ann Surg 2008;247:401–7.
 Vincent RP, le Roux CW. Changes in gut hormones after bariatric surgery.
Clin Endocrinol 2008;69:173–9.
 Ashrafian H, le Roux CW. Metabolic surgery and gut hormonesda review
of bariatric entero-humoral modulation. Physiol Behav 2009;97:620–31.
 Cummings DE, Weigle DS, Frayo RS, Breen PA, Ma MK, Dellinger EP, et al.
Plasma ghrelin levels after diet-induced weight loss or gastric bypass
surgery. N Engl J Med 2002;346:1623–30.
 McLaughlin T, Abbasi F, Lamendola C, Frayo RS, Cummings DE. Plasma
ghrelin concentrations are decreased in insulin-resistant obese adults
relative to equally obese insulin-sensitive controls. J Clin Endocr Metab
 Christou NV, Look D, McLean AP. Pre- and post-prandial plasma ghrelin
levels do not correlate with satiety or failure to achieve a successful
outcome after Roux-en-Y gastric bypass. Obes Surg 2005;15:1017–23.
 Sundbom M, Holdstock C, Engström BE, Karlsson FA. Early changes in
ghrelin following Roux-en-Y gastric bypass: influence of vagal nerve
functionality? Obes Surg 2007;17:304–10.
 Ybarra J, Bobbioni-Harsch E, Chassot G, Huber O, Morel P, Assimacopoulos-
Jeannet F, et al. Persistent correlation of ghrelin plasma levels with body
mass index both in stable weight conditions and during gastric-bypass–
induced weight loss. Obes Surg 2009;19:327–31.
 Tymitz K, Engel A, McDonough S, Hendy MP, Kerlakian G. Changes in
ghrelin levels following bariatric surgery: review of the literature. Obes
Calculated energy and macronutrient intakes before and after R-GBP and NR-GBP
Baseline Month 6Month 12
R-GBP NR-GBP R-GBPNR-GBP R-GBPNR-GBP
1426 ? 410
60.8 ? 15.0
189.9 ? 66.7
47.9 ? 20.2
1935 ? 881
76.9 ? 28.6
270.2 ? 132.6
61.8 ? 31.9
781 ? 188
45.7 ? 16.3
94.8 ? 26.4*
24.6 ? 9.0
987 ? 333
43.7 ? 16.4
124.1 ? 43.2*
36.4 ? 23.3
982 ? 251
50.6 ? 20.8
129.0 ? 39.5
35.2 ? 10.3
1096 ? 261
53.2 ? 13.4
135.6 ? 36.7
38.4 ? 13.8
CHO, total dietary carbohydrates; NR-GBP, non-resective gastric bypass; R-GBP, resective gastric bypass
Values are presented as mean ? SD. Repeated-measures analysis of variancedenergy intake: group effect, NS; time effect, P < 0.01; time-by-group interaction, NS;
carbohydrate intake: group effect, NS; time effect, P < 0.01; time-by-group interaction, NS; fat intake: group effect, NS; time effect, P < 0.01; time-by-group interaction,
NS; protein intake: group effect, NS; time effect, P < 0.05; time-by-group interaction, NS.
* Significant difference between groups at month 6 adjusted by baseline intake (univariate analysis of variance, P ¼ 0.047).
F. Carrasco et al. / Nutrition 28 (2012) 757–761
 Harper JL, Beech D, Tichansky DS, Madan AK. Case report: cancer in the Download full-text
bypassed stomach presenting early after gastric bypass. Obes Surg
 Voellinger D, Inabnet W. Laparoscopic Roux-en-Y gastric bypass with
remnant gastrectomy for focal intestinal metaplasia of the gastric antrum.
Obes Surg 2002;12:695–8.
 Braghetto I, Csendes A, Korn O, Gutierrez L, Brunet L, Lanzarini E,
et al. Laparoscopic resectional gastric bypass in patients with morbid
obesity: experience on 112 consecutive patients. J Gastrointest Surg
 Marzullo P, Verti B, Savia G, Walker GE, Guzzaloni G, Tagliaferri M, et al. The
relationship between active ghrelin levels and human obesity involves
alterations in resting energy expenditure. J Clin Endocrinol Metab
 Veldhuis JD, Bowers CY. Integrating GHS into the ghrelin system. Int J Pept
2010;2010. pii: 879503.
 Fujimiya M, Asakawa A, Ataka K, Kato I, Inui A. Different effects of ghrelin,
des-acyl ghrelin and obestatin on gastroduodenal motility in conscious
rats. World J Gastroenterol 2008;14:6318–26.
 Bulgarelli I, Tamiazzo L, Bresciani E, Rapetti D, Caporali S, Lattuada D, et al.
Desacyl-ghrelin and synthetic GH-secretagogues modulate the production
of inflammatory cytokines in mouse microglia cells stimulated by beta-
amyloid fibrils. J Neurosci Res 2009;87:2718–27.
 Filigheddu N, Gnocchi VF, Coscia M, Cappelli M, Porporato PE, Taulli R, et al.
Ghrelin and des-acyl ghrelin promote differentiation and fusion of C2C12
skeletal muscle cells. Mol Biol Cell 2007;18:986–94.
 Freezza EE, Chiriva-Internati M, Wachtel MS. Analysis of the results of
sleeve gastrectomy for morbid obesity and the role of ghrelin. Surg Today
 Bohdjalian A, Langer FB, Shakeri-Leidenmühler S, Gfrerer L, Ludvik B,
Zacherl J, et al. Gastrectomy as sole and definitive bariatric procedure:
5-year results for weight loss and ghrelin. Obes Surg 2010;20:535–40.
 Csendes A, Smok G, Burgos AM. Endoscopic and histologic findings in the
gastric pouch and the Roux limb after gastric bypass. Obes Surg
 Kuga R, Safatle-Ribeiro AV, Faintuch J, Ishida RK, Furuya CK Jr, Garrido AB Jr,
et al. Endoscopic findings in the excluded stomach after Roux-en-Y gastric
bypass surgery. Arch Surg 2007;142:942–6.
F. Carrasco et al. / Nutrition 28 (2012) 757–761