Sa1342 Demographic and Socioeconomic Predictors of Weight Re-Gain Following Bariatric Surgery: A 3-Year Retrospective Review

AGA Abstracts

severity of gastrointestinal symptoms in FD and GvHD to identify potential differences in symptom severity and manifestation. Methods: Sixty-seven patients with aGvHD (I°-III°) and 45 patients with FD according to ROME III criteria were recruited. The following key symptoms were assessed utilizing the standardized Gastrointestinal Symptom Score: epigastric pain, cramps, fullness, early satiety, nausea and vomiting. AX and DEP were measured with the Hospital Anxiety and Depression Scale. Patients scoring 0-7 on each subscale were considered not having a psychological co-morbidity. Patients with 8-10 were categorized as probable (p) AX/DEP while patients scoring ≥11 were considered having a relevant (r) AX/ DEP. Analysis was performed by Spearman rank correlations and T test. Results: In GvHD pAX was found in 12/67, rAX in 6/67, pDEP in 4/67 and rDEP in 8/67. In FD pAX was observed in 12/45, rAX in 8/45, pDEP in 11/45 and rDEP in 6/45. Overall AX (p=0.54) and DEP (p=0.75) scores did not differ between FD and GvHD. AX in GvHD was correlated with severity of pain (r=.25, p=0.04), fullness (r=.43, p ,0.001), satiety (r=.40, p=0.001), nausea (r=.36, p=0.003) and vomiting (r= .40, p=0.001). In FD AX correlated with pain (r=.44, p,0.028), fullness (r=.38, p,0.001), satiety (r=.23, p=0.03), vomiting (r=.32, p= 0.002). FD patients without AX showed significantly more severe cramps and nausea but less vomiting compared to GvHD without Ax. In FD patients with pAX and rAX pain was more prominent while vomiting was less evident compared to GvHD with pAX and rAX. DEP was associated with pain (r=.58, p ,=0.001), cramps (r= .53, p ,0.001), fullness (r= .64, p,0.001), satiety (r=.50, p,0.001), nausea (r=.43, p,0.001) and vomiting (r= .48, p,0.001) in GvHD but only with pain (r=.23, p ,0.001) in FD. FD patients with and without DEP were characterized by increased pain but decreased early satiety and less vomiting compared to respective GvHD groups. Conclusion: Psychological co-morbidity is closely linked to symptom severity in FD and organic GI disease. While patients with FD experience more pain, vomiting is more severe in GvHD. These differences may indicate different underlying pathophysiological mechanisms rather than psychologically driven factors.

Sa1340 Whey Protein Pre-Load Attenuates Post-Prandial Hyperglycemia and Slows Carbohydrate Absorption in Patients With Roux-en-Y Gastric Bypass Nam Q. Nguyen, Tamara L. Debreceni, Carly M. Burgstad, Max Bellon, Judith M. Wishart, Chris Rayner, Michael Horowitz Consumption of whey protein before a carbohydrate meal has been shown to reduce postprandial glycaemia in type 2 diabetic (T2DM) patients by stimulating incretin secretion as well as slowing gastric emptying. Due to the altered GI anatomy and dumping of food into the small intestine, patients who undergo Roux-en-Y gastric bypass (RYGB) for morbid obesity also experience marked post-prandial hyperglycaemia. The effects of a fat or protein preload on blood glucose (BG), carbohydrate absorption and related gut hormones in postsurgical RYGB patients have not been evaluated. Aim: To determine the effects of a fat or protein preload on BG response and absorption, pouch emptying (PE) and gut hormones in patients with RYGB. Method: Ten subjects who underwent RYGB (5M:5F; age: 52.2±2.5yrs, BMI: 31.1±1.3kg/m2) were studied on 3 occasions in randomized order with a different type of preload: (i) water (200ml), (ii) fat (30ml olive oil + 170ml water) and (iii) whey protein (55g + 100ml of both skim milk & water). Both fat and whey protein preloads had a total energy content of 1080kj. Thirty minutes after administration of the "preload", patients ingested a mixed meal (50g beef patty labelled with 15MBq 99mTc-sulfur colloid and 150ml of water + 16.5g glucose, 3g 3-O-methyl-D-glucopyranose (3-OMG) labelled with 3MBq 67Ga-EDTA). Simultaneous measurements of (i) scintigraphic PE, (ii) BG levels (iii) gut hormones (gastrointestinal inhibitory peptide (GIP), glucagon-like peptide-1 (GLP-1) and insulin) and (iv) 3-OMG (glucose analogue) were performed over 240min. Results: There were no differences in fasting plasma concentrations of BG, 3-OMG, GIP, GLP-1 or insulin between preloads. In contrast to water, both fat (P ,0.001) and protein (P,0.01) preloads induced a small but significant increase in BG and plasma GLP-1 concentrations prior to the meal. Meal consumption after whey protein preload was associated with a greater postprandial rise of plasma insulin concentrations, but lesser increases in BG, 3-OMG, GIP and GLP-1 concentrations as compared to those after fat (P ,0.001) and water (P,0.01) preloads. Post-prandial plasma concentrations of insulin, 3-OMG and BG were similar between fat and water preloads. There were no differences in PE between the three groups (T50: water: 1.6±0.7; fat: 1.1±0.5; whey 1.3±0.5 min). Conclusion: In patients with RYGB, consumption of whey protein, but not fat, prior to a carbohydrate meal attenuated post-prandial hyperglycaemia and reduced 3-OMG absorption. Unlike T2DM, the improved glycaemic effects of whey protein in RYGB patients were mediated solely through the increased incretin response but were not related to PE. In addition to maintaining weight loss through reduced carbohydrate absorption, the use of whey protein prior to a meal in RYGB patients may reduce the long-term adverse effect(s) of post-prandial hyperglycaemia.

Sa1339 A Comparison of Psychological Associations With IBS and Ulcerative Colitis Eric D. Shah, Amit Sachdev, Mark S. Riddle, Mark Pimentel A psychological hypothesis for irritable bowel syndrome (IBS) suggests that psychiatric illness/ stressful life events promote IBS onset, although this is controversial. Similar hypotheses were prominent in the description of other gastrointestinal illnesses with long-disputed etiology, including ulcerative colitis (UC). In study design it is often erroneous to compare a disease state to healthy controls since the disease itself can contribute to anxiety and psychological pressures. In this study we compare the prevalence and severity of psychological disorders in IBS compared to UC (a well-recognized organic gastrointestinal disease), relative to healthy controls based on systematic review. Methods: A systematic review was conducted of Englishlanguage literature to identify case-control studies reporting the prevalence of depression or anxiety in IBS populations relative to healthy controls. A parallel search for case-control studies of ulcerative colitis patients and healthy (non-UC) controls was also performed. Studies reporting average scores of depression and anxiety using methods such as the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory, or State-Trait Anxiety Index (STAI) in IBS/UC patients and healthy controls were sought. IBS, UC, anxiety, depression, as well as the measures of anxiety and depression, must have been defined a priori, and use Rome criteria to define IBS. Our primary endpoint was the pooled prevalence or average score of depression or anxiety in an IBS/UC population relative to healthy control. Results: Seven case-control studies evaluating IBS (representing 668 patients with IBS and 294 controls) and three evaluating ulcerative colitis (261 with UC and 282 controls) were identified. For both depression and anxiety, six out of seven total IBS studies reported excess prevalence or higher score in IBS patients relative to controls. All 3 UC studies found a higher prevalence or higher average score for depression (two studies) or anxiety (three studies) among ulcerative colitis patients relative to controls. Average HADS anxiety scores were above a validated cutoff for anxiety ( .7) for both IBS and UC. The degree of psychological abnormality was either not different or greater for UC than IBS (Table). Conclusion: In this unique review, we show that anxiety and depression are equally common and greater than controls in both IBS and UC suggesting psychological factors could be due to GI disease and not causing the disorder. The use of healthy controls against any chronic medical illness is insufficient to support a hypothesis of psychological factors being unique to a disease such as IBS. Most chronic disease would produce these sequelae. Prospective studies or welldesigned case control studies are needed to explore the antecedent influence of depression and anxiety on triggering these diseases. Pooled results of case-control studies evaluating psychological illness in IBS or ulcerative colitis

Sa1341 Association Between Dumping Syndrome With Weight Loss and Quality of Life After Roux-en-Y Gastric Bypass for Morbid Obesity Nam Q. Nguyen, Tamara L. Debreceni, Melissa Neo, Trehan K. Dinesh, Philip A. Game, Gary A. Wittert, Michael Horowitz Dumping syndrome (DS) is a well recognized sequelae of Roux-en-Y gastric bypass (RYGB) for morbid obesity. There are, however, limited data in relation to its risk factors and potential impact on both weight loss and quality of life (QOL). Aim: To evaluate (i) the prevalence of DS, (ii) predisposing risk factors and (iii) the association of dumping syndrome with post-operative weight loss and QOL following RYGB for morbid obesity. Method: Data relating to demographics, co-morbidities and surgical outcomes of 447 patients who underwent RYGB between 2000 and 2011 at the Royal Adelaide Hospital were reviewed from a prospectively collected database. Questionnaires were sent to these patients to evaluate the presence and severity of DS, as well as QOL. Sigstad's diagnostic index was used to identify the presence of DS (score .7); and a score .10 with reported symptoms of dizziness, fainting and need to lie down after eating were deemed to be "severe". QOL was assessed using the Moorehead-Ardelt QOL Questionnaire II. Results: Complete data were collected in 142 patients (40M:102F; 52.4±0.8yrs; pre-op BMI=48.1±0.7kg/m2), who had a mean weight loss of -15.3±0.6kg/m2 at 15 (12-24) months after RYGB. Neither the characteristics (vs. 61M:244F; 49.9±0.8yrs; pre-op BMI=47.1±0.5kg/m2, respectively) nor the magnitude of post-operative weight loss (vs. -15.1±0.8kg/m2) of these patients were different to those who did not complete the questionnaire (n=305). Pre-operative type 2 diabetes (T2DM) was present in 39 (27%) patients and open surgery was performed in 100 (70%) patients. Overall, DS occurred in 31 (22%) RYGB patients and was severe in 11 (7.7%) cases. The presence of DS was not related to either the open or laparoscopic approach, presence or absence of T2DM, QOL or the magnitude of weight loss. However, in patients with severe DS, weight loss was greater (16.6±0.5 vs. 12.7±0.6 kg/m2; P=0.04) and the QOL tended to be lower (1.0±0.1 vs. 1.5±0.1, P=0.07) than those with less severe DS (score between 7 and 10). Despite similar weight loss (15.0±1.1 vs. 15.3±0.8kg/m2; P=0.8) and Sigstad's score (3.3±0.7 vs. 3.6±0.5, P=0.71), patients with T2DM had lower QOL (1.1±0.2 vs. 1.7±0.1, P,0.01) than those without T2DM. Conclusion: Dumping syndrome is relatively common after RYGB but the majority is mild in severity and does not adversely affect the patient's QOL. Despite the similar surgical outcomes, the lower QOL in RYGB patients with preexisting T2DM suggests RYGB should be performed as early as possible to prevent the onset of irreversible diabetic related complications that are associated with lower QOL. Sa1342 Demographic and Socioeconomic Predictors of Weight Re-Gain Following Bariatric Surgery: A 3-Year Retrospective Review Christine M. Granato, Uma K. Murthy, Dongliang Wang, Renee Williams Background: The National Health and Nutrition Examination Survey estimate that more than 35% of the U.S. population is obese. With the growing prevalence of obesity, bariatric surgery has become increasingly popular. Although bariatric surgery is an established treatment for obesity, we have previously shown that a significant number of patients re-gain

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included patients undergoing gastric bypass who received a prophylactic course of PPI postoperatively were eligible. Two reviewers independently selected trials and extracted data. The primary outcome was the incidence of marginal ulcers diagnosed on the basis of endoscopic findings. Inverse variance random effect model was used to estimate odds ratio (OR) of ulcers. OR and weighted pooled proportion with corresponding 95% confidence intervals (CI) are reported. Results The strategic search identified 167 citations. A total of 6 studies involving 2878 participants were eligible for inclusion. The weighted pooled proportion of ulcer formation in PPI single group cohort studies was 4.1% (0.2% - 12.6%) (N=891). The odds ratio of marginal ulcer formation comparing PPI to no PPI for 3 cohort studies was 0.50 (0.28 - 0.90, p= 0.02) with low heterogeneity (I2 = 12 %) showing that the PPI group significantly experienced twice less ulceration with PPI treatment compared to no PPI treatment (N=1022). The Newcastle-Ottawa scale was used for study quality assessment. Conclusion Despite the limitations of the current systematic review (only 3 cohort studies included; inherent biases of observational design), this suggests a significant incremental benefit of prophylactic PPI in reducing marginal ulcer after gastric bypass surgery. Prospective randomized trials are needed to further define the role of PPI following gastric bypass surgery and to support their routine use. Sa1344 National Trends and in-Hospital Outcomes of Inflammatory Bowel Disease Patients Undergoing Bariatric Surgery Douglas L. Nguyen, Nimisha K. Parekh, M. Mazen Jamal Background: Recent reports have shown an increasing frequency of obesity among patients with inflammatory bowel disease (IBD), mirroring the increasing prevalence of obesity in the general population. In this study, we seek to determine the frequency of bariatric surgery in the IBD population and the in-hospital outcomes of IBD patients undergoing these surgeries over the last two decades. Methods: We analyzed the Nationwide Inpatient Sample from 1988-2006 to determine the prevalence of bariatric surgery among IBD patients and to determine in-patient outcomes. Results: The age-adjusted rate of bariatric surgery among IBD patients has increased from 0.036 per 100,000 adults in 1988-1991 to 0.073 per 100,000 adults in 2004- 2006. The mean age of IBD patients undergoing bariatric surgery was 48.07 years ± 17.82. The frequencies of commonly performed surgeries are—biopancreatic diversion (51.7%), Roux-en-Y gastric bypass (35.1%), gastric sleeve (10.3%), and gastric banding (2.9%). Compared to the general population, there was an increased length of hospitalizations post-operatively among patients with IBD undergoing gastric banding (4.82 v 1.29 days, p,0.01), Roux-en-Y gastric bypass (14.68 v 8.99 days, p ,0.01), and biliopancreatic diversion (13.00 v 12.33 days, p ,0.01). Though the age-adjusted post-operative mortality rate for IBD patients was lower in the IBD group compared to the general population (0.089% vs 0.16%, p,0.01), there was a higher post-operative risk for Clostridium difficile colitis in the IBD group compared to the general population (OR 3.70 95% CI 1.87-7.68). However, the rate of other major post-operative complications such as pulmonary embolism, respiratory failure, pneumonia, prolonged mechanical ventilation, and need for re-operations were similar between the two groups. Conclusions: Though there is a two fold increase in rate in bariatric surgery among IBD patients nationally in the last two decades, the estimated rate remains significant lower than the general population. The mortality rate and other major post-operative complications among patients are similar to the general population, indicating that the short-term outcome of carefully selected IBD patients undergoing bariatric surgery is acceptable. Additionally, given significantly higher post-operative risk for Clostridium difficile colitis among IBD patients, early recognition and treatment may reduce length of hospitalization and post-operative morbidity.

Table 2. Demographic and socioeconomic data in groups A and B at 36 months

Sa1345 Prevalence of Mc4r, Lep, Lepr Gene Mutations in Obese Patients Submitted to Bariatric Surgery Barbara Paolini, Irene Del Ciondolo, Cristina Ciuoli, Massimo Vincenzi, Elisa Lapini, Elisa Pasquini, Francesca Cinci, Lucia Ceccarelli, Monia Menci, Matteo Bertelli, Katia Gennai Obesity is the result of genetic, environmental, physiological, social factors. According to the thrifty genotype hypothesis, genetic polymorphisms which promote excessive fat deposition have been preserved in the evolution for millions of years. In particular obesity has been associated with single mutated alleles inherity of 3 genes: LEP which encodes for leptin, LEPR for leptin receptor, MC4R for melanocortin4 receptor. The aim of our study was to evaluate the prevalence of MC4R, LEP, LEPR gene mutations in a group of obese patients submitted to bariatric surgery. The inclusion criteria were: presence of severe obesity (BMI>35), obesity beginning during childhood and familiarity for overweight. METHODS We considered a group of 78 bariatric surgery patients, 62 women (mean preoperative BMI 44,8±7,47) and 16 men (mean preoperative BMI 45,2±8,37). 22 patients were submitted to malabsorbitive procedures, 56 to restrictive procedures. All the patients underwent a preoperative nutritional status examination which included anthropometric measurements, bioimpedance and blood tests. All the patients were genotyped for LEP (NM_000230; 2 exons), LEPR (NM_002303; 18 exons), MC4R (NM_005912; 1 exon); we sequenced exons and introns with Polymerase Chain Reaction (PCR) with direct sequencing. We evaluated nucleotide sequences that caused an aminoacid replacement with Mutation Taster algorithm to discover their eventual pathogenicity and we searched for them in Human Genome Mutation Database (HGMD). We searched even in single nucleotide polymorphisms database (SNP) to exclude polymorphisms. RESULTS A preliminary analysis of the results didn't show any alteration in LEP and LEPR genes but we discovered 4 different mutations in MC4R gene in 6 women. These mutations caused an aminoacid substitution in the melanocortin receptor and they were considered pathogenic by Mutation Taster. 2 of them, according to HGMD (p.V103I identified in 3 patients; p. T112M identified in 1 patient) had already been associated to autosomal dominant obesity phenotype, 1 of them (p.I251L identified in 1 patient) has a dubious clinical implication and 1 of them (p.Y302D identified in 1 patient) had never been discovered before. Searching these mutations in dbSNP, we found out that the missense mutations (p.V1031 e p.I251L) had been recorded respectively, with frequencies close to 1% (rs2229616) and ranging from 0,6% up to 0,9% (rs52820871). CONCLUSIONS In our sample, representative of the Italian population affected by non

Sa1343 Can Prophylactic PPI Help Reduce Marginal Ulcers After Gastric Bypass Surgery? A Systematic Review and Meta Analysis Valerie Wu Chao Ying, Song Hon Harry Kim, Khurram J. Khan, Forough Farrokhyar, Joanne D'Souza, Scott Gmora, Mehran Anvari, Dennis Hong Objectives Gastric bypass is the most common procedure performed in North America for control of morbid obesity. Marginal ulceration after gastric bypass surgery is a recognised complication and has been reported in 1-16% of patients after gastric bypass surgery (Mac Lean, 1997, Sapala, 1998, DeMaria 2002). There is evidence that acidity may play a role in the disease pathophysiology and it is common practice for bariatric surgeons to begin a prophylactic course of proton pump inhibitors (PPI) postoperatively. We conducted a systematic review and meta analysis of the current literature to estimate the efficacy of prophylactic PPI in reducing the incidence of marginal ulcers after gastric bypass surgery. Methods MEDLINE, EMBASE, CINAHL and the Cochrane Controlled Trials Register were searched using the most comprehensive timeline for each database up to January 2012. Studies that

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weight at 24 and 36 months post-surgery, with no significant pre-operative predictors of weight loss maintenance. Despite this, very little is known regarding the interplay of demographic and socioeconomic factors and the effect on post-operative weight re-gain. Our objective was to identify demographic and socioeconomic predictors of weight re-gain 3 years post-bariatric surgery. Methods: A retrospective, cohort study was performed at the Central New York Bariatric Center, an accredited Level 1A institution, on patients undergoing bariatric surgery over a 5-year period (1/1/2003-12/31/2008). Charts of 656 subjects were reviewed for pre-operative demographic, socioeconomic, and medical data. Demographic and socioeconomic variables included gender, race, marital status, level of education, employment status, insurance type, and urban versus rural residence. Post-operative weight gain, complications, and resolution of co-morbid conditions up to 36 months were also assessed. Urban area boundaries were defined by the 2000 Census Bureau of New York State. Patients with at least 18 months of follow-up were included in the study. Statistical analysis was performed by the Center for Research and Evaluation at SUNY Upstate Medical University. Descriptive statistics compared subjects with post-operative weight gain versus those with weight loss maintenance at 24 and 36 months (Group A=gained weight, Group B=maintained weight loss). A prediction model was built using multivariate logistic regression analysis. Results: Of the 622 subjects meeting inclusion criteria, 61% (218/359) and 66% (174/263) gained weight at 24 and 36 months, respectively. At 24 months, there was a statistically significant difference in weight re-gain between Caucasian (63%) and non-Caucasian (37%) subjects (p=0.003). However, this significance was not seen at 36 months. At 24 and 36 months, the remaining variables did not confer a significant difference in weight re-gain post-bariatric surgery. See Tables 1 and 2. Conclusions: Caucasian subjects had significant weight re-gain at 24 months post-bariatric surgery. No additional statistically significant demographic or socioeconomic predictive factors of weight re-gain were identified in this 3-year review. To our knowledge, this is the first study evaluating demographic and socioeconomic predictive factors of weight re-gain up to 36 months post-bariatric surgery. Table 1. Demographic and socioeconomic data in groups A and B at 24 months