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Gastrografin studies after bariatric surgery—to swallow or not to swallow?
Abstracts / Surgery for Obesity and Related Diseases 6 (2010) 224 –234
Background: Obesity is closely associated with the precursors of cardiovascular disease, such as insulin resistance and endothelial dysfunction. Novel signals from adipose tissue, such as asymmetric dimethyl arginine (ADMA), an endogenous nitric oxide inhibitor, may explain this association. This study aimed to investigate the depot-specific differences in ADMA release and the expression of dimethylarginine dimethyaminohydrolase (DDAH) and protein arginine methyl transferase (PRMT-3), the enzymes responsible for ADMA hydrolysis and synthesis, respectively, in human omental and subcutaneous adipose tissue. Methods: A cross-sectional cohort study was performed of 17 white morbidly obese, nondiabetic female patients undergoing gastric banding or cholecystectomy (mean age 44 ⫾ 7 years, body mass index 43 ⫾ 10 kg/m2). The circulating adipose tissue content and generation of ADMA and tissue expression of DDAH-1 and ⫺2 and PRMT-3 were determined from the omental and subcutaneous depots. In a subgroup of patients (n ⫽ 9), the stromavascular fraction was separated from the whole adipose tissue, and ADMA and DDAH were analyzed. Insulin resistance was assessed using the Homeostasis Model Assessment-Insulin Resistance and body fat content by electrical bioimpedance. Results: Serum insulin and systolic blood pressure correlated directly with the subcutaneous ADMA content. ADMA release was significantly greater from the omental depot (P ⫽ .025) and correlated with the body mass index. Although DDAH2 expression was greater than DDAH1 expression in both the whole adipose tissue and the stromavascular fraction of both depots, no depotspecific difference in the expression of either isoform was detected. However, PRMT-3 protein expression was greater in the omental than in the subcutaneous adipose tissue. Conclusions: The direct associations of omental ADMA release and body mass index and greater omental ADMA content points to a link between visceral obesity and endothelial dysfunction. Modulation of adipose ADMA generation might reduce the obesityassociated co-morbidities. GASTROGRAFIN STUDIES AFTER BARIATRIC SURGERY—TO SWALLOW OR NOT TO SWALLOW? Vasha Kaur, Mohammad Mobasheri, Suleman Aktaa, Naresh Pore, Rajesh Jain, Cathy Edge, Marcus Reddy, Andrew Wan, David Hou, St. George’s Hospital, London, United Kingdom Background: Before April 2009, all bariatric patients at our unit routinely received a Gastrografin study (GGS) 48 hours postoperatively to exclude an anastomotic leak. After a negative GGS, the patients began oral fluids. This meant a minimum 3-day inpatient stay. The aim of this study was to assess the utility of GGS on patient outcomes after bariatric surgery. Methods: All patients undergoing bariatric surgery from April to November 2009 were included. The patients treated from April to June 2009 (group A) routinely underwent GGS postoperatively; those treated from June to September 2009 (group B) underwent GGS selectively (revision surgery or clinical suspicion of a leak); and those treated from September to November 2009 (group C) underwent no GGS. The patients in groups B and C received oral fluids on the first postoperative day if a GGS had not been performed. The outcomes of these groups were compared in terms of leak rates and length of postoperative stay.
231
Results: The gender, body mass index, and American Society of Anesthesiologists grades were comparable in all 3 groups. Variable
Group A (n ⫽ 22)
Group B (n ⫽ 25)
Group C (n ⫽ 15)
Primary Roux-en-Y bypass Primary sleeve gastrectomy Revision surgeryⴱ GGSs Leaks (n) Mean postoperative hospital stay (d)
15 (68%) 5 (23%) 2 (9%) 22 (100%) 1 4.1
19 (76%) 2 (8%) 4 (16%) 13 (52%) 1 3.9
12 (80%) 1 (7%) 2 (13%) 0 (0%) 1 3.1
ⴱThe revision procedures consisted of 5 gastric band removals and conversion to sleeve gastrectomy, 2 conversions of sleeve gastrectomy to Roux-en-Y bypass, and 1 conversion of vertical band gastroplasty to sleeve gastrectomy. In group B, 9 (69%) of 13 patients underwent GGSs for suspicion of leak and 4 patients (31%) underwent GGSs after revision surgery. The GGS failed to identify the leak in the patient from group A; however, owing to high clinical suspicion, surgery was performed and a leak was clearly identified. In the group B patient, selective GGS was performed on clinical suspicion and demonstrated the leak. In the group C patient, a leak was diagnosed clinically without GGS and confirmed intraoperatively.
Conclusions: This study has demonstrated no benefit in performing GGS in bariatric patients postoperatively. All 3 leaks were identifiable clinically, without the need for a GGS. Furthermore, the patients who did not receive a GGS had a shorter hospital stay, with a possible reduction in associated costs. COMPARISON OF VITAMIN CONCENTRATIONS AFTER GASTRIC BYPASS AND LIFESTYLE INTERVENTION Erlend T. Aasheima, Line Johnsonb, Dag Hofsøc, Thomas Bøhmerd, Jøran Hjelmesæthc, aOslo University Hospital Aker, Oslo, Norway, and Imperial Weight Centre, London, United Kingdom, bOslo University Hospital Rikshospitalet, Oslo, Norway, cVestfold Hospital Trust, Tønsberg, Norway, dUniversity of Oslo, Oslo, Norway Background: We aimed to study the vitamin concentration changes after gastric bypass in patients taking a set of dietary supplements. Methods: Of 53 patients, 29 underwent gastric bypass and 24 controls underwent lifestyle intervention in a prospective, nonrandomized trial. Patients in the surgical group received multivitamin, iron, calcium, vitamin D, and vitamin B12 supplements. No supplements were prescribed to the lifestyle group. The median body mass index decreased from 46 to 32 kg/m2 after surgery and from 40 to 39 kg/m2 after the lifestyle intervention. Results: Of the 59 patients, 94% completed the 1-year follow-up. Compared with the lifestyle patients, the surgical patients had increased vitamin B6, folic acid, vitamin B12, and lipid-adjusted vitamin E concentrations (P ⬍.020 for each) but decreased vitamin A concentrations (P ⬍.01) during follow-up. No significant difference between the 2 groups was found for vitamin B1, vitamin C, or 25-hydroxyvitamin D. Most surgical patients reported taking their supplements. Conclusions: Gastric bypass patients adhering to a set of dietary supplements had mostly stable or increased vitamin concentrations compared with both their baseline values and the changes in a nonsurgical control group. (Trial registration: ClinicalTrials.gov identifier: NCT00273104.)
Background: Obesity is closely associated with the precursors of cardiovascular disease, such as insulin resistance and endothelial dysfunction. Novel signals from adipose tissue, such as asymmetric dimethyl arginine (ADMA), an endogenous nitric oxide inhibitor, may explain this association. This study aimed to investigate the depot-specific differences in ADMA release and the expression of dimethylarginine dimethyaminohydrolase (DDAH) and protein arginine methyl transferase (PRMT-3), the enzymes responsible for ADMA hydrolysis and synthesis, respectively, in human omental and subcutaneous adipose tissue. Methods: A cross-sectional cohort study was performed of 17 white morbidly obese, nondiabetic female patients undergoing gastric banding or cholecystectomy (mean age 44 ⫾ 7 years, body mass index 43 ⫾ 10 kg/m2). The circulating adipose tissue content and generation of ADMA and tissue expression of DDAH-1 and ⫺2 and PRMT-3 were determined from the omental and subcutaneous depots. In a subgroup of patients (n ⫽ 9), the stromavascular fraction was separated from the whole adipose tissue, and ADMA and DDAH were analyzed. Insulin resistance was assessed using the Homeostasis Model Assessment-Insulin Resistance and body fat content by electrical bioimpedance. Results: Serum insulin and systolic blood pressure correlated directly with the subcutaneous ADMA content. ADMA release was significantly greater from the omental depot (P ⫽ .025) and correlated with the body mass index. Although DDAH2 expression was greater than DDAH1 expression in both the whole adipose tissue and the stromavascular fraction of both depots, no depotspecific difference in the expression of either isoform was detected. However, PRMT-3 protein expression was greater in the omental than in the subcutaneous adipose tissue. Conclusions: The direct associations of omental ADMA release and body mass index and greater omental ADMA content points to a link between visceral obesity and endothelial dysfunction. Modulation of adipose ADMA generation might reduce the obesityassociated co-morbidities. GASTROGRAFIN STUDIES AFTER BARIATRIC SURGERY—TO SWALLOW OR NOT TO SWALLOW? Vasha Kaur, Mohammad Mobasheri, Suleman Aktaa, Naresh Pore, Rajesh Jain, Cathy Edge, Marcus Reddy, Andrew Wan, David Hou, St. George’s Hospital, London, United Kingdom Background: Before April 2009, all bariatric patients at our unit routinely received a Gastrografin study (GGS) 48 hours postoperatively to exclude an anastomotic leak. After a negative GGS, the patients began oral fluids. This meant a minimum 3-day inpatient stay. The aim of this study was to assess the utility of GGS on patient outcomes after bariatric surgery. Methods: All patients undergoing bariatric surgery from April to November 2009 were included. The patients treated from April to June 2009 (group A) routinely underwent GGS postoperatively; those treated from June to September 2009 (group B) underwent GGS selectively (revision surgery or clinical suspicion of a leak); and those treated from September to November 2009 (group C) underwent no GGS. The patients in groups B and C received oral fluids on the first postoperative day if a GGS had not been performed. The outcomes of these groups were compared in terms of leak rates and length of postoperative stay.
231
Results: The gender, body mass index, and American Society of Anesthesiologists grades were comparable in all 3 groups. Variable
Group A (n ⫽ 22)
Group B (n ⫽ 25)
Group C (n ⫽ 15)
Primary Roux-en-Y bypass Primary sleeve gastrectomy Revision surgeryⴱ GGSs Leaks (n) Mean postoperative hospital stay (d)
15 (68%) 5 (23%) 2 (9%) 22 (100%) 1 4.1
19 (76%) 2 (8%) 4 (16%) 13 (52%) 1 3.9
12 (80%) 1 (7%) 2 (13%) 0 (0%) 1 3.1
ⴱThe revision procedures consisted of 5 gastric band removals and conversion to sleeve gastrectomy, 2 conversions of sleeve gastrectomy to Roux-en-Y bypass, and 1 conversion of vertical band gastroplasty to sleeve gastrectomy. In group B, 9 (69%) of 13 patients underwent GGSs for suspicion of leak and 4 patients (31%) underwent GGSs after revision surgery. The GGS failed to identify the leak in the patient from group A; however, owing to high clinical suspicion, surgery was performed and a leak was clearly identified. In the group B patient, selective GGS was performed on clinical suspicion and demonstrated the leak. In the group C patient, a leak was diagnosed clinically without GGS and confirmed intraoperatively.
Conclusions: This study has demonstrated no benefit in performing GGS in bariatric patients postoperatively. All 3 leaks were identifiable clinically, without the need for a GGS. Furthermore, the patients who did not receive a GGS had a shorter hospital stay, with a possible reduction in associated costs. COMPARISON OF VITAMIN CONCENTRATIONS AFTER GASTRIC BYPASS AND LIFESTYLE INTERVENTION Erlend T. Aasheima, Line Johnsonb, Dag Hofsøc, Thomas Bøhmerd, Jøran Hjelmesæthc, aOslo University Hospital Aker, Oslo, Norway, and Imperial Weight Centre, London, United Kingdom, bOslo University Hospital Rikshospitalet, Oslo, Norway, cVestfold Hospital Trust, Tønsberg, Norway, dUniversity of Oslo, Oslo, Norway Background: We aimed to study the vitamin concentration changes after gastric bypass in patients taking a set of dietary supplements. Methods: Of 53 patients, 29 underwent gastric bypass and 24 controls underwent lifestyle intervention in a prospective, nonrandomized trial. Patients in the surgical group received multivitamin, iron, calcium, vitamin D, and vitamin B12 supplements. No supplements were prescribed to the lifestyle group. The median body mass index decreased from 46 to 32 kg/m2 after surgery and from 40 to 39 kg/m2 after the lifestyle intervention. Results: Of the 59 patients, 94% completed the 1-year follow-up. Compared with the lifestyle patients, the surgical patients had increased vitamin B6, folic acid, vitamin B12, and lipid-adjusted vitamin E concentrations (P ⬍.020 for each) but decreased vitamin A concentrations (P ⬍.01) during follow-up. No significant difference between the 2 groups was found for vitamin B1, vitamin C, or 25-hydroxyvitamin D. Most surgical patients reported taking their supplements. Conclusions: Gastric bypass patients adhering to a set of dietary supplements had mostly stable or increased vitamin concentrations compared with both their baseline values and the changes in a nonsurgical control group. (Trial registration: ClinicalTrials.gov identifier: NCT00273104.)