Publications (5)17.76 Total impact
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Article: Metabolic and hormonal changes after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: a randomized, prospective trial.
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ABSTRACT: The mechanisms of amelioration of glycemic control early after laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) are not fully understood. In this prospective, randomized 1-year trial, outcomes of LRYGB and LSG patients were compared, focusing on possibly responsible mechanisms. Twelve patients were randomized to LRYGB and 11 to LSG. These non-diabetic patients were investigated before and 1 week, 3 months, and 12 months after surgery. A standard test meal was given after an overnight fast, and blood samples were collected before, during, and after food intake for hormone profiles (cholecystokinin (CCK), ghrelin, glucagon-like peptide 1 (GLP-1), peptide YY (PYY)). In both groups, body weight and BMI decreased markedly and comparably leading to an identical improvement of abnormal glycemic control (HOMA index). Post-surgery, patients had markedly increased postprandial plasma GLP-1 and PYY levels (p < 0.05) with ensuing improvement in glucose homeostasis. At 12 months, LRYGB ghrelin levels approached preoperative values. The postprandial, physiologic fluctuation returned, however, while LSG ghrelin levels were still markedly attenuated. One year postoperatively, CCK concentrations after test meals increased less in the LRYGB group than they did in the LSG group, with the latter showing significantly higher maximal CCK concentrations (p < 0.012 vs. LRYGB). Bypassing the foregut is not the only mechanism responsible for improved glucose homeostasis. The balance between foregut (ghrelin, CCK) and hindgut (GLP-1, PYY) hormones is a key to understanding the underlying mechanisms.Obesity Surgery 02/2012; 22(5):740-8. · 3.29 Impact Factor -
Article: Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study.
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ABSTRACT: Deficiencies in micronutrients after bariatric operations are frequent, despite routine supplementation. Main outcome measures were pre- and postoperative frequency of nutrient deficiencies and success rate of their treatment. Between 5/2004 and 12/2006, 136 patients (m:f = 0:4) with an average body mass index of 45 (35-58) kg/m(2) and age of 53 (21-66) years were prospectively analysed. Laparoscopic Roux-Y-gastric bypass (LRYGB) was performed in 86 patients and laparoscopic sleeve gastrectomy (LSG) was performed in 50 patients. The patients were examined before surgery as well as 3, 6, 12, 24, 30, and 36 months postoperatively using a standard protocol including laboratory tests. The mean follow-up time was 24.4 (12-40) months; the follow-up rate was 100%. Prior to surgery, 57% of the patients had at least one deficiency, 23% of whom had vitamin D(3) deficiency. Frequent postoperative deficiencies after LSG were zinc, vitamin D(3), folic acid, iron, and vitamin B(12); after LRYGB, vitamin B(12), vitamin D(3), zinc, and secondary hyperparathyroidism. No vitamin B(1) or B(6) deficiencies were found. Calcium levels were normal in all patients. Treatment of the deficiencies was mostly successful. Preoperatively, 57% of morbidly obese patients already had a deficiency. Postoperatively, significantly more vitamin B(12) and vitamin D deficiencies and hyperparathyroidism were found in patients who had undergone LRYGB. After LSG, folate deficiency was more frequent (but not significantly so). Calcium levels were normal in all patients; therefore, parathyroid hormone and vitamin D(3) levels are more sensitive markers for early detection of disorders of calcium metabolism. Iron deficiency anaemia is most efficiently treated by IV therapy.Obesity Surgery 04/2010; 20(4):447-53. · 3.29 Impact Factor -
Article: Improvement in glucose metabolism after bariatric surgery: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy: a prospective randomized trial.
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ABSTRACT: The exclusion of the proximal small intestine is thought to play a major role in the rapid improvement in the metabolic control of diabetes after gastric bypass. In this randomized, prospective, parallel group study, we sought to evaluate and compare the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) with those of laparoscopic sleeve gastrectomy (LSG) on fasting, and meal-stimulated insulin, glucose, and glucagon-like peptide-1 (GLP-1) levels. Thirteen patients were randomized to LRYGB and 14 patients to LSG. The mostly nondiabetic patients were evaluated before, and 1 week and 3 months after surgery. A standard test meal was given after an overnight fast, and blood samples were collected before and after food intake in both groups for insulin, GLP-1, glucose, PYY, and ghrelin concentrations. This trial was registered in www.clinicaltrials.gov (NCT00356213) before the first patient was randomized. Body weight and body mass index decreased markedly (P < 0.002) and comparably after either procedure. Excess BMI loss was similar at 3 months (43.3 +/- 12.1% vs. 39.4 +/- 9.4%, P > 0.36). After surgery, patients had markedly increased postprandial plasma insulin and GLP-1 levels, respectively (P < 0.01) after both of these surgical procedures, which favor improved glucose homeostasis. Compared with LSG, LRYGB patients had early and augmented insulin responses as early as 1-week postoperative; potentially mediating improved early glycemic control. After 3 months, no significant difference was observed with respect to insulin and GLP-1 secretion between the 2 procedures. Both procedures markedly improved glucose homeostasis: insulin, GLP-1, and PYY levels increased similarly after either procedure. Our results do not support the idea that the proximal small intestine mediates the improvement in glucose homeostasis.Annals of surgery 08/2009; 250(2):234-41. · 7.90 Impact Factor -
Article: Midterm results of primary vs. secondary laparoscopic sleeve gastrectomy (LSG) as an isolated operation.
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ABSTRACT: We investigated early and midterm results of laparoscopic sleeve gastrectomy (LSG) as an isolated primary and secondary operation after failed gastric banding. Between May 2004 and October 2007, a total of 70 patients (female 77%, mean age 43 (21-65) years, mean initial body mass index (BMI) 46 (35-61) kg/m(2)) were prospectively evaluated and operated by LSG. In 41 patients, LSG was performed as a primary operation (group 1) and in 29 patients as a secondary procedure after failed gastric banding (group 2). The overall average follow-up time after LSG was 24 (12-53) months; follow-up rate 1 year after operation was 100%, after 2 years 98%, and after 3 years 95%. There were no intraoperative complications, no conversion with shorter operation time in group 1 (91 vs. 132 min, p = 0.001). Early morbidity of LSG was 5% (major) and 7% (minor); mortality was zero. Average excessive BMI loss after 1 year was 65% (9-127%), after 2 years 63% (13-123%), and after 3 years 60% (9-111%). Midterm morbidity was 13%. There was no significant difference between the two groups regarding early and midterm morbidity, reoperation rate for complications (11.4%), or insufficient weight loss (7%). LSG is a safe bariatric procedure with good weight loss in the first 3 years postop. It can be used as an isolated initial treatment and as a secondary treatment after failed gastric banding. However, in the absence of long-term results, we suggest LSG to be performed only in controlled trials.Obesity Surgery 02/2009; 19(4):401-6. · 3.29 Impact Factor -
Article: Improvement in glucose metabolism after bariatric surgery: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy: a prospective …
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ABSTRACT: Background: The exclusion of the proximal small intestine is thought to play a major role in the rapid improvement in the metabolic control of diabetes after gastric bypass. Objective: In this randomized, prospective, parallel group study, we sought to evaluate and compare the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) with those of laparoscopic sleeve gastrectomy (LSG) on fasting, and meal-stimulated insulin, glucose, and glucagon-like peptide-1 (GLP-1) levels. Methods: Thirteen patients were randomized to LRYGB and 14 patients to LSG. The mostly nondiabetic patients were evaluated before, and 1 week and 3 months after surgery. A standard test meal was given after an overnight fast, and blood samples were collected before and after food intake in both groups for insulin, GLP-1, glucose, PYY, and ghrelin concentrations. This trial was registered in www.clinicaltrials.gov (NCT00356213) before the first patient was randomized. Results: Body weight and body mass index decreased markedly (P 0.002) and comparably after either procedure. Excess BMI loss was similar at 3 months (43.3 12.1% vs. 39.4 9.4%, P 0.36). After surgery, patients had markedly increased postprandial plasma insulin and GLP-1 levels, respectively (P 0.01) after both of these surgical procedures, which favor improved glucose homeostasis. Compared with LSG, LRYGB patients had early and augmented insulin responses as early as 1-week postoperative; potentially mediating improved early glycemic control. After 3 months, no significant difference was observed with respect to insulin and GLP-1 secretion between the 2 procedures. Conclusion: Both procedures markedly improved glucose homeostasis: insulin, GLP-1, and PYY levels increased similarly after either procedure. Our results do not support the idea that the proximal small intestine mediates the improvement in glucose homeostasis. T he World Health Organization has described obesity as the greatest current threat to human health. 1 The rising prevalence of obesity is causing a major health burden in terms of morbidity and mortality. 2 The complications of obesity, especially type 2 diabetes mellitus (T2D), are placing growing demand on health care re-sources. Existing medical therapeutic strategies (diet, behavioral changes, drugs) to achieve and maintain clinically significant weight loss remain limited. 3 Bariatric surgery is currently the only effective treatment for morbid obesity. 3– 6 Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the most commonly performed bari-atric operation in many parts of the world and has superseded other restrictive and malabsorptive procedures. 4,7 LRYGB results in greater weight loss than do restrictive procedures (such as gastric banding) in the absence of clinically significant malabsorption for macronutrients. 3,4,8 Furthermore, dramatic improvements in glyce-mic control have been observed in subjects with T2D after the RYGB procedure. 3,4,9 In the early postoperative period, many pa-tients achieve normal fasting glucose concentrations before any substantial weight loss has occurred. 10 It has been proposed that the improvement in glycemic control may be due to changes in circulating hormones (mainly glucagon-like peptide-1 or GLP-1) from the distal gut. This "hind-gut hypothesis" holds that diabetes control results from the expedited delivery of nutrients to the distal small intestine, enhancing hormone release, such as GLP-1, as a physiologic signal that improves glucose metabo-lism. This incretin hormone is secreted by L cells of the distal bowel in response to intestinal nutrients. It stimulates insulin secretion and suppresses glucagon secretion thereby improving glucose metabolism. 10 –13 An alternative hypothesis is that the positive effects of RYGB surgery on diabetes depends on the exclusion of the duodenum and proximal jejunum from the transit of nutrients, possibly preventing secretion of a putative signal that promotes insulin resistance and T2D ("fore-gut hypothesis"). 14,15 Laparoscopic sleeve gastrectomy (LSG) is the restrictive part of biliopancreatic diversion duodenal switch and was initially applied as an isolated operation on superobese patients with severe comorbidities in a staged concept. 16 It is a purely restric-tive operation with no malabsorptive effect. Long-term results of LSG do not exist, but weight loss in the first postoperative years is promising. 17–20 LSG may have the potential to be a dependable isolated bariatric procedure. In a staged-therapy concept, LSG seems to be superior to laparoscopic gastric banding as the first-stage procedure. 21,22 LSG preserves the integrity of the pylorus and does not include intestinal bypass as part of the technique. There-fore, no significant changes in distal gut hormone release would be expected. The purpose of this prospective, randomized study was to investigate and compare the effects of LRYGB to the effects of LSG on glycemic control (primarily insulin and GLP-1 release) in morbidly obese, mostly nondiabetic patients undergoing bari-atric surgery.Ann Surg. 01/2009; 250:234-241.
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Institutions
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2009–2012
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Claraspital Basel
Basel, BS, Switzerland
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