Sa1345 Prevalence of Mc4r, Lep, Lepr Gene Mutations in Obese Patients Submitted to Bariatric Surgery

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

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syndromic pathologic obesity, 7% of the patients has a mutation on MC4R, probably responsible of their phenotype. This kind of genetic test will be useful in the future in particular for those obese patients who don't respond to a dietetic therapy, to address them to the bariatric surgeon and to choose the most suitable type of surgical procedure

to a tertiary care center for abdominal pain with finding of remnant gastritis on deviceassisted enteroscopy were retrospectively included. Therapy had been randomly initiated with ursodiol 500mg BID upon endoscopic finding of gastritis. Clinical follow-up and biopsy pathology results were collected. Means were compared with Student's t-test and proportional comparison between groups was performed with Fisher's Exact test. All statistics are reported as mean ± SEM. Results: 22 patients with chronic abdominal pain and normal upper endoscopy underwent device-assisted enteroscopy and had pooled bile in the gastric remnant. Biopsy revealed H. pylori-negative gastritis in all patients. Ursodiol was initiated in 10/22 patients. All patients were maintained on PPI. Of the ursodiol group, 8/10 (80%) patients reported clinical improvement in abdominal pain at follow-up. Of the patients on PPI alone, 1/12 (8.3%) reported clinical improvement in abdominal pain at follow-up at 7.3 ±1.9 months (p=0.002). Conclusions: Patients with gastritis of the remnant stomach demonstrated a significantly higher rate of abdominal pain resolution after ursodiol treatment than patients on PPI alone. Given the high prevalence of pooled bile in the remnant stomach in symptomatic patients, and the relative difficulty of evaluation the remnant stomach, ursodiol may be considered for empiric treatment in Roux-en-Y patients with chronic abdominal pain not explained by standard evaluation.

Sa1346 Eligibility for Bariatric Surgery Among Adults in England: Analysis of National Cross Sectional Survey Ahmir Ahmad, Anthony A. Laverty, Erlend T. Aasheim, Azeem Majeed, Christopher Millett, Sonia Saxena The number of people in England who are potentially eligible for bariatric surgery according to criteria set out in UK national guidance is not known. We used data from Health Survey for England (HSE) 2006, representative of the non-institutionalised English population, to determine the number of people eligible for bariatric surgery and their socio-demographic characteristics. The National Institute for Health and Clinical Excellence (NICE) criteria for eligibility are those with body mass index (BMI) 35-40 kg/m2 with at least one comorbidity that could be improved by losing weight, or a BMI .40 kg/m2. The comorbidities examined were hypertension, type 2 diabetes, stroke, coronary heart disease, and osteoarthritis. Of 13,742 adult respondents in HSE 2006, we excluded participants with invalid data for BMI (N=2103), comorbidities (N=2187) or sociodemographic variables (N=27), for a final study sample of 9,425 participants. 374 (4.0%) had BMI 35-40 kg/m2 with at least one comorbid condition and 179 (1.9%) had BMI .40 kg/m2. 5.9% of the general adult population therefore fulfilled criteria for bariatric surgery in England. Those eligible were more likely than the general population to be women (60.1% vs 39.9% P ,0.01), retired (22.4% vs 12.8% P,0.01), and have no educational qualifications (35.7% vs 21.3% P ,0.01). The number of adults potentially eligible for bariatric surgery in England (2,346,542 people based on census data) far exceeds provision. Greater investment may be required to ensure the National Health Service (NHS) and other health services internationally have the capacity to meet the needs of all those eligible for bariatric surgery under national guidance. In doing so, monitoring of implementation is essential to ensure access based on need.

Sa1349 Incidence of Cholelithiasis Post-Sleeve Gastrectomy in a Community Hospital Wuttiporn Manatsathit, Hussein Al-Hamid, Aiman Mahmood, Anacleto Diaz, Abdelkader Hawasli Background: Cholelithiasis is a well-defined complication after bariatric surgery, especially with Roux-en-Y gastric bypass (RYGB). It has been reported that 40% of patients developed gallstone in the first year after the operation and approximately 10% of gallstone formers developed symptoms requiring medical attention or surgical intervention. Rapid weight loss within the first twelve months was also found to be associated with gallstone formation. Sleeve gastrectomy (SG) is becoming a more popular type of bariatric surgery with increasing experience with laparoscopic techniques aimed at decreasing post-operative complications and hospital length of stay. It has been postulated that SG might result in fewer post-surgical complications including decreased development of cholelithiasis when compared to RYGB procedure due to less anatomical disruption. Method: We recruited patients who had SG performed at St John Hospital and Medical Center in Detroit, Michigan from January 2011 to December 2011 and followed for development of cholelithiasis by abdominal ultrasonography after one year post-operatively or 100-pound weight loss whichever comes first. Patients included in this study were mostly . 18 years of age and had body mass index (BMI) . 35 kg/m2 with obesity-related co-morbidities such as, diabetes , sleep apnea, or obesity-associated cardiomyopathy. Patients with BMI . 40 kg/m2 with or without obesity-related co-morbidities were also included in the study. Patients excluded from the study were those who had pre-existing cholelithiasis or already had cholecystectomy prior to SG. Patients without history of cholelithiasis or cholecystectomy prior to SG had preoperative abdominal ultrasonography and if found to have gallstone disease were also excluded. No patient included in the study received urosodeoxycholic acid for cholelithiasis prophylaxis. Results: One hundred and sixty seven SG procedures were performed from January 2011 to December 2012 from. Eighty four patients were excluded from the study due to history of cholecystectomy in 25 patients and no pre-operative abdominal ultrasonography in 44 patients, and preoperative ultrasonography found to have gallstone in 15 cases. A total of 83 patients were followed by abdominal ultrasonography approximately within one-year post-operatively. Ten patients developed post-operative cholelithiasis (12.05%) with only one patient who required surgical intervention (1.2%). Conclusion: The incidence of cholelithiasis post-sleeve gastrectomy in our study at St John Hospital and Medical Center was low (12.05%) when compared RYBG (40%). This study might also suggest that gallstone prophylaxis with ursodeoxycholic acid in bypass surgery using SG may not be necessary considering the rate of symptomatic gallstone is very low (1.2%) yet longer term follow-up is still needed.

Sa1347 Acid Suppression Medications Delay PEAK Weight Loss After Bariatric Surgery Emily K. Ward, Elsbeth Jensen-Otsu, Breana Mitchell, Jonathan A. Schoen, Gregory L. Austin Background and Aims: Bariatric surgery, including Roux-en-Y gastric bypass (RYGB), achieves the greatest long-term weight loss in severely obese patients (BMI>40kg/m2). Approximately 50-60% of severely obese patients have chronic GERD, and a substantial proportion take proton pump inhibitor (PPI) or H2 Blocker (H2B) therapy. It is unknown if PPI/H2B use interferes with weight loss following RYGB. The aim of this study is to understand the association of PPI/H2B use and percent weight loss (PWL) in patients at 6 and 12 months following RYGB. Methods: This is a retrospective database review of 477 eligible patients who underwent RYGB for severe obesity at a single academic medical center from 20052011. Age, gender, co-morbidities, and roux length were collected. Weight (kg), BMI (kg/ m2), PPI (or H2B) use, and exercise frequency (dichotomized into those exercising at least 3 times per week and those not) were obtained pre-operatively and at 9 weeks, 6 months, and 12 months post-operatively. Complete data were available for 335 patients at 6 months and for 239 patients at 12 months. Linear regression was used to assess the relationship between PPI/H2B use and PWL at 6 and 12 months and to assess the effect of potential confounders. Results: There was no difference in pre-operative BMI based on pre-operative PPI/H2B use. The average PWL for all subjects was 31% at 6 months and 38% at 12 months. Being on a PPI/H2B pre-operatively was associated with a significant decrease in PWL of 1.72 percentage points at 6 months compared to those who were not on a PPI pre-operatively (p=0.013). This equates to an absolute weight loss difference of 4.4 kg between PPI/H2B users and non-users at 6 months (p=0.002). PWL at 6 months was decreased by 2.33 percentage points in patients who were on a PPI/H2B pre-operatively and at 9 weeks postoperatively compared to those who were not on these medications at either time point (p= 0.024). PPI/H2B use pre-operatively, at 9 weeks, and at 6 months was not associated with significant differences in PWL at 12 months. Increasing age was associated with increasing PPI/H2B use (p=0.01) and with a significant decrease in PWL at 6 months (p=0.002) and 12 months (p=0.004). Exercise following RYGB at 9 weeks or 6 months was not associated with PWL at 6 or 12 months (all p .0.34). Conclusion: These results suggest PPI/H2B use was associated with delays in peak PWL at 6 months. This finding could be due to changes in intestinal microbiota, motility, metabolic signaling, or nutrient absorption. The lack of a difference in PWL at 12 months could indicate that PPI/H2B use does not interfere with long-term weight loss or reflects a lack of study power due to patients being lost to followup. The next step is to assess potential mechanisms by which PPI/H2B use may modify weight loss following bariatric surgery.

Sa1350 Lipotoxicity Drives Inflammation and Necrosis in Human Acute Pancreatitis Pawan Noel, Chandra Durgampudi, Sarah Navina, Kenneth Lee, Faris Murad, Randall Brand, Jennifer S. Chennat, Dhiraj Yadav, Adam Slivka, Georgios I. Papachristou, Asif Khalid, David C. Whitcomb, James P. DeLany, Rachel Cline, Krutika Patel, Vivek Mishra, Ram N. Trivedi, Chathur Acharya, Deepthi Jaligama, Vijay Singh BACKGROUND: Our recent work (Sci Transl Med. 2011 Nov 2;3(107):107ra110) suggests that non-esterified fatty acids (NEFA) and specifically unsaturated fatty acids (UFA) generated from visceral fat lipolysis may play a major role in local necrosis and systemic inflammation during severe acute pancreatitis (SAP). However the driver of necrosis and systemic inflammation remains to be confirmed. Potential factors include cytokines, proteases and UFAs. Our aim was to characterize factors present in various human pancreatic fluid collections; comparing those of inflammatory origin with non inflammatory collections. We further tested causality in determining severe outcomes using an animal model of acute pancreatitis. MATERIALS AND METHODS: Pancreatic fluids from patients with post-necrotic fluid collection (n=16), pseudocysts (n=11) and non inflammatory collections (NIC; n=10) were analyzed for trypsin, amylase, DNA, NEFA, and cytokines. The triglyceride glyceryl trilinoleate (GTL) was infused into the pancreatic ducts of rats with or without the lipase inhibitor orlistat and their effects on cytokines, NEFA levels, severity of pancreatitis and mortality were studied. A p value , 0.05 was considered significant (*) when comparing 2 groups. RESULTS: Results (mean +/- SEM) for the human (Table 1) and rat (Table 2) studies are presented below. Trypsin and amylase were significantly higher in pseudocysts compared to necrosis and NIC fluids consistent with leakage of these exocrine proteins into the pseudocyst. Postnecrotic fluid collections had significantly more DNA consistent with increased cell death, and significantly higher NEFA, UFA and IL-1beta compared to pseudocyst and NIC fluid. IL-8 was increased in inflammatory fluids compared to NIC fluids. Rats (table 2) with the GTL infusion had 100% mortality within 1 day, with 70-80% parenchymal necrosis, renal failure, lung injury, and elevated serum NEFA, UFAs, linoleic acid (LA), IL-1beta and KC/ GRO (the rat homolog of IL-8). Rats receiving GTL+ orlistat had 0% mortality over 5 days,

Sa1348 Ursodiol Is Effective for Treatment of Abdominal Pain Associated With Gastritis of the Remnant Stomach in Roux-en-Y Gastric Bypass Patients Nitin Kumar, Christopher C. Thompson Background: Patients with Roux-en-Y anatomy referred for diagnosis of abdominal pain frequently have unremarkable upper endoscopy, but examination of the remnant stomach with device-assisted enteroscopy often confirms the presence of pooled bile and gastritis. Therefore, therapy to address gastritis may be of value in these patients. Ursodiol, a secondary bile acid, may change the composition of bile, resulting in less gastritis. Aim: To determine the effectiveness of ursodiol therapy for treatment of abdominal pain associated with gastritis found in the remnant stomach in patients with Roux-en-Y anatomy and unremarkable evaluation, including normal upper endoscopy. Methods: All consecutive patients referred

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