Gastroesophageal reflux disease and morbid obesity: To sleeve or not to sleeve?

Laparoscopic sleeve gastrectomy(LSG) has reached wide popularity during the last 15 years, due to the limited morbidity and mortality rates, and the very good weight loss results and effects on comorbid conditions. However, there are concerns regarding the effects of LSG on gastroesophageal reflux disease(GERD). The interpretation of the current evidence is challenged by the fact that the LSG technique is not standardized, and most studies investigate the presence of GERD by assessing symptoms and the use of acid reducing medications only. A few studies objectively investigated gastroesophageal function and the reflux profile by esophageal manometry and 24-h p H monitoring, reporting postoperative normalization of esophageal acid exposure in up to 85% of patients with preoperative GERD, and occurrence of de novo GERD in about 5% of cases. There is increasing evidence showing the key role of the surgical technique on the incidence of postoperative GERD. Main technical issues are a relative narrowing of the mid portion of the gastric sleeve, a redundant upper part of the sleeve(both depending on the angle under which the sleeve is stapled), and the presence of a hiatal hernia. Concomitant hiatal hernia repair is recommended. To date, either medical therapy with proton pump inhibitors or conversion of LSG to laparoscopic Rouxen-Y gastric bypass are the available options for the management of GERD after LSG. Recently, new minimally invasive approaches have been proposed in patients with GERD and hypotensive LES: the LINX? Reflux Management System procedure and the Stretta? procedure. Large studies are needed to assess the safety and long-term efficacy of these new approaches. In conclusion, the recent publication of p H monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5^(th) International Consensus Conference on sleeve gastrectomy.

Five-year outcomes of laparoscopic sleeve gastrectomy as a primary procedure for morbid obesity:A prospective study

AIM To prospectively evaluate the postoperative morbimortality and weight loss evolution of patients who underwent a laparoscopic sleeve gastrectomy(LSG) as a primary bariatric procedure during 5 years of follow-up. METHODS Since 2006,data from patients undergoing a highly restrictive primary LSG have been prospectively registered in a database and analysed. Preoperative co-morbid conditions,operating time,hospital stay,early and late complications rate and evolution of weight loss after 5 years of follow-up were analysed.RESULTS A total of 156 patients were included,74.3% of whom were women. The mean age was 43.2 ± 13.1 years and the mean body mass index(BMI) was 41.5 ± 7.9 kg/m^2. Seventy patients(44.8%) presented a BMI under 40 kg/m^2. The mortality rate was 0%. The leakage rate was 1.2%,and the total 30-d morbidity rate was 5.1%(8/156). With a mean follow-up of 32.7 ± 28.5(range 6-112) mo,the mean percent of excess of weight loss(%EWL) was 82.0 ± 18.8 at 1 year,76.7 ± 21.3 at 3 years and 60.3 ± 28.9 at 5 years. The mean percent of excess of BMI loss(%EBMIL) was 94.9 ± 22.4 at 1 year,89.4 ± 27.4 at 3 years and 74.8 ± 29.4 at 5 years. Patients with preoperative BMI less than 40 kg/m^2 achieved greaterweight loss than did the overall study population. Diabetes remitted in 75% of the patients and HTA improved in 71.7%. CPAP masks were withdrawn in all patients with obstructive sleep apnoea.CONCLUSION LSG built with a narrow 34 F bougie and starting 3 cm from the pylorus proved to be safe and highly effective in terms of weight loss as a stand-alone procedure,particularly in patients with a preoperative BMI lower than 40 kg/m^2.

Endoscopic management of intragastric penetrated adjustable gastric band for morbid obesity

This report describes a case of successful endoscopic management of intragastric penetrated adjustable gastric band in a patient with morbid obesity. The favorable course of the case described here demonstrates that adjustable gastric bands in the process of migration need not be removed surgically in patients who are asymptomatic.

Distribution of transient receptor potential vanilloid-1 channels in gastrointestinal tract of patients with morbid obesity

BACKGROUND Transient receptor potential vanilloid-1(TRPV1),a nonselective cation channel,is activated by capsaicin,a pungent ingredient of hot pepper.Previous studies have suggested a link between obesity and capsaicin-associated pathways,and activation of TRPV1 may provide an alternative approach for obesity treatment.However,data on the TRPV1 distribution in human gastric mucosa are limited,and the degree of TRPV1 distribution in the gastric and duodenal mucosal cells of obese people in comparison with normal-weight individuals is unknown.AIM To clarify gastric and duodenal mucosal expression of TRPV1 in humans and compare TRPV1 expression in obese and healthy individuals.METHODS Forty-six patients with a body mass index(BMI)of>40 kg/m^(2) and 20 patients with a BMI between 18-25 kg/m^(2) were included.Simultaneous biopsies from the fundus,antrum,and duodenum tissues were obtained from subjects between the ages of 18 and 65 who underwent esophagogastroduodenoscopy.Age,sex,history of alcohol and cigarette consumption,and past medical history regarding chronic diseases and medications were accessed from patient charts and were analyzed accordingly.Evaluation with anti-TRPV1 antibody was performed separately according to cell types in the fundus,antrum,and duodenum tissues using an immunoreactivity score.Data were analyzed using SPSS 17.0.RESULTS TRPV1 expression was higher in the stomach than in the duodenum and was predominantly found in parietal and chief cells of the fundus and mucous and foveolar cells of the antrum.Unlike foveolar cells in the antrum,TRPV1 was relatively low in foveolar cells in the fundus(4.92±0.49 vs 0.48±0.16,P<0.01,Mann-Whitney U test).Additionally,the mucous cells in the duodenum also had low levels of TRPV1 compared to mucous cells in the antrum(1.33±0.31 vs 2.95±0.46,P<0.01,Mann-Whitney U test).TRPV1 expression levels of different cell types in the fundus,antrum,and duodenum tissues of the morbidly obese group were similar to those of the control group.Staining with TRPV1 in fundus chief cells and antrum and duodenum mucous cells was higher in patients aged≥45 years than in patients<45 years(3.03±0.42,4.37±0.76,2.28±0.55 vs 1.9±0.46,1.58±0.44,0.37±0.18,P=0.03,P<0.01,P<0.01,respectively,Mann-Whitney U test).The mean staining levels of TRPV1 in duodenal mucous cells in patients with diabetes and hypertension were higher than those in patients without diabetes and hypertension(diabetes:2.11±0.67 vs 1.02±0.34,P=0.04;hypertension:2.42±0.75 vs 1.02±0.33,P<0.01 Mann-Whitney U test).CONCLUSION The expression of TRPV1 is unchanged in the gastroduodenal mucosa of morbidly obese patients demonstrating that drugs targeting TRPV1 may be effective in these patients.

CRP, but not TNF-α or IL-6, decreases after weight loss in patients with morbid obesity exposed to intensive weight reduction and balneological treatment

Objective：The aim of this study was to evaluate the concentrations of C-reactive protein （CRP）, tumor necrosis factor-α （TNF-α）, interleukin-6 （IL-6）, and the degree of homeostasis model assessment-insulin resistance （HOMA-IR） in patients with morbid obesity exposed to a three-week low-calorie diet and balneotherapy. Methods：The study included 33 patients （25 females and 8 males; mean age 46 years） with body mass index （BMI） values of〉40 kg/m2. Evaluations of CRP, IL-6, TNF-α, lipid profile, HOMA-IR, and fasting glucose were carried out before （baseline data） and three weeks after the treatment. The control group consisted of 20 healthy volunteers （15 females and 5 males） with a mean age of 39 years and BMI values of≤24.9 kg/m2. Results：In the blood of patients with morbid obesity we found significantly elevated levels of CRP, TNF-α, triglycerides, HOMA-IR and fasting glucose, but a de-creased level of high density lipoprotein （HDL）-cholesterol, compared with the healthy individuals. The treatment resulted in about a 9.4%reduction in body weight from 122.5 to 111.0 kg and a significant decrease in the concen-tration of CRP, but no change in TNF-αor IL-6. HOMA-IR was significantly reduced. Conclusions：The decrease in CRP level without changes in TNF-α or IL-6 concentrations after the low-calorie diet and balneological treatment, suggests that an essential amount of adipose tissue must be removed before proper adipocyte function is restored. The decrease in HOMA-IR indicates an improvement in insulin sensitivity, which is beneficial in obese patients.

Perforated appendicitis masquerading as acute pancreatitis in a morbidly obese patient

Diagnosis and treatment of common conditions in morbidly obese patients still pose a challenge to physicians and surgeons.Sometimes too much reliance is put on investigations that can lead to a misdiagnosis.This case demonstrates an obese woman admitted under the medical team with a presumed diagnosis of pneumonia, who was later found to have an acute abdomen and raised amylase,which led to an assumed diagnosis of pancreatitis.She died within 24 h of admission and post mortem confirmed the cause of death as systemic sepsis due to perforated appendicitis,with no evidence of pancreatitis.Significantly elevated serum amylase level may occur in non-pancreatitic acute abdomen.

Predictors for advanced fibrosis in morbidly obese nonalcoholic fatty liver patients

AIMTo investigate predictors for fibrosis specifically in a high risk population of morbidly obese patients, including detailed evaluation of lifestyle. METHODSWe conducted a cross-sectional study among morbidly obese patients attending the bariatric clinic at the Tel-Aviv Medical Center between the years 2013-2014 with body mass index (BMI) above 40 or above 35 with co-morbidity. Patients with serum hepatitis B surface antigen or anti-hepatitis C virus antibodies, genetic liver diseases, autoimmune disease or high alcohol intake (≥ 30 g/d in men or ≥ 20 g/d in women) were excluded from the study. Liver fibrosis was estimated by transient elastography (FibroScan®), using the ‘‘XL’’ probe. We collected data on age and gender, education, smoking status and amount, medical history, nutrition and lifestyle habits. All these data were collected using structured and validated questionnaires. Fasting blood test were available for a subsample. RESULTSFibroscan was performed on a total of 91 patients, of which 77 had a valid examination according to the accepted criteria. Of those, 21% had significant fibrosis (F2) and 39% had advanced or severe fibrosis (F3 or F4). In multivariate analysis, male gender and BMI had a positive association with advanced fibrosis; the OR for fibrosis F ≥ 2 was 7.93 (95%CI: 2.36-26.64, P = 0.001) for male gender and 1.33 (1.11-1.60 kg/m2, P = 0.002) for BMI. The OR for fibrosis F ≥ 3 was 2.92 (1.08-7.91, P = 0.035) for male gender and 1.17 (1.03-1.33, P = 0.018) for BMI. Subjects were categorized to subgroups based on the combination of male gender and BMI of 40 and above. A significant dose response association with stiffness level was noted across these categories, with the highest stiffness among men with a higher BMI (P = 0.001). In addition, a significant positive correlation between pack-years cigarette smoking and liver stiffness was demonstrated among men (r = 0.54, P = 0.012). CONCLUSIONIn the morbidly obese population, a higher BMI, male gender and degree of smoking in men bears a greater risk for advanced nonalcoholic fatty liver disease.

Apolipoprotein E in diet-induced obesity:a paradigm shift from conventional perception

Apolipoprotein E（APOE） is a major protein component of peripheral and brain lipoprotein transport systems.APOE in peripheral circulation does not cross the blood brain barrier or blood cerebrospinal fluid barrier. As a result,peripheral APOE expression does not affect brain APOE levels and vice versa. Numerous epidemiological studies suggest a key role of peripherally expressed APOE in the development and progression of coronary heart disease while brain APOE has been associated with dementia and Alzheimer＇s disease. More recent studies, mainly in experimental mice, suggested a link between Apoe and morbid obesity. According to the latest findings, expression of human apolipoprotein E3（APOE3） isoform in the brain of mice is associated with a potent inhibition of visceral white adipose tissue（WAT） mitochondrial oxidative phosphorylation leading to significantly reduced substrate oxidation,increased fat accumulation and obesity. In contrast, hepatically expressed APOE3 is associated with a notable shift of substrate oxidation towards non-shivering thermogenesis in visceral WAT mitochondria, leading to resistance to obesity. These novel findings constitute a major paradigm shift from the widely accepted perception that APOE promotes obesity via receptor-mediated postprandial lipid delivery to WAT. Here, we provide a critical review of the latest facts on the role of APOE in morbid obesity.

Sugammadex is associated with better respiratory recovery than neostigmine following reversal of anaesthesia-associated neuromuscular blockade in the morbidly obese patients following elective laparoscopic surgery

Complete and reliable neuromuscular reversal is important to successful anaesthetic recovery in the morbidly obese patient undergoing laparoscopic surgery.Our goal was to determine whether sugammadex,a selective reversal agent is associated with better respiratory recovery than neostigmine following the reversal of anaesthesia-associated neuromuscular blockade by rocuronium in the morbidly obese.Peak Expiratory Flow Rate a surrogate marker for respiratory function,was the primary outcome measured and secondary outcome measures included post-operative nausea and vomiting,pain and head lifting.We found that patients reversed with sugammadex had a significantly higher post-operative PEFR as compared to those reversed with neostigmine and glycopyrrolate group.

Laparoscopic Sleeve Gastrectomy following Pylorus-Preserving Pancreaticoduodenectomy

Background: A 35-year-old married female (68 kg, 150 cm, BMI: 30.2) with pancreatic divisum complicated chronic pancreatitis and underwent pylorus-preserving pancreaticoduodenectomy in 2010. After that, her condition was well. However, body weight gained progressively to 76 kg (BMI: 33.7) and hypertension developed. During these two years, tried exercise and medication control for hypertension, but in vain. She received a laparoscopic sleeve gastrectomy in October 2013. The post-operative course was uneventful. Methods: We applied three ports for laparoscopic operation, including two 12 mm and one 5 mm trocars. The liver was not needed to be elevated due to adhesion. The operative time was 75 minutes. Results: The patient’s body weight was 10 kg reduced in the first two months and reduced to 59 kg 6 months later. Conclusions: We report a case that received laparoscopic sleeve gastrectomy following pylorus-preserving pancreaticoduodenectomy due to pancreatic divisum. This case encourages us to extend the indication of laparoscopic sleeve gastrectomy.

Two case reports of acute upper gastrointestinal bleeding from duodenal ulcers after Roux-en-Y gastric bypass surgery: Endoscopic diagnosis and therapy by single balloon or push enteroscopy after missed diagnosis by standard esophagogastroduodenoscopy

The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy(EGD) because of technical difficulty in intubating at EGD the postoperatively excluded stomach and proximal duodenum in patients status post Roux-en-Y gastric bypass(RYGB). Two cases are reported of acute upper gastrointestinal bleeding 10 or 11 years status postRYGB, performed for morbid obesity, in which the EGD was non-diagnostic due to failure to intubate the excluded stomach and proximal duodenum, whereas subsequent push enteroscopy or single balloon enteroscopy were diagnostic and revealed 4-cm-wide or 5-mm-wide bulbar ulcers and even permitted application of endoscopic therapy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the endoscopic evaluation of acute UGI bleeding in patients status post RYGB surgery when the EGD was non-diagnostic because of failure to intubate these excluded segments.

Management of gallstones and gallbladder disease in patients undergoing gastric bypass

The appropriate management of gallstones and gallbladder disease in patients undergoing gastric bypass remains unknown.Several therapeutic modalities are used and include performing cholecystectomy on all patients at the time of gastric bypass,performing concomitant cholecystectomy only when patients have gallstones and performing cholecystectomy only in the presence of both symptoms and gallstones.Some groups administer ursodeoxycholic acid for gallstone prevention in the postoperative period.All treatment modalities are analyzed and their results and rationality are discussed.

Jejunoileal bypass:A surgery of the past and a review of its complications

Jejunoileal bypass(JIB),popular in the 1960s and 1970s,had remarkable success in achieving weight loss by creating a surgical short bowel syndrome.Our patient had an unusual case of liver disease and provided no history of prior bariatric surgery.Later,it was recognized that he had a JIB in the 1970s,which was also responsible for the gamut of his illnesses.Patients with JIB are often not recognized,as they died of complications,or underwent reversal of their surgery or a liver-kidney transplant.Early identification with prompt reversal,and the recognition and treatment of the life-threatening consequences play a critical role in the management of such patients.

Role of endoscopy in the bariatric surgery of patients

Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett&#x02019;s esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett&#x02019;s esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.

Surgical outcome of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass for resolution of type 2 diabetes mellitus:A systematic review and meta-analysis

BACKGROUND Bariatric procedures are considered superior to medical therapies in managing type 2 diabetes mellitus(T2DM).Laparoscopic Roux-en-Y gastric bypass(LRYGB)and laparoscopic sleeve gastrectomy(LSG)are the most commonly used procedures for weight loss and comorbidity resolution worldwide.However,it is not yet known whether the degree of T2DM is influenced by the choice of bariatric procedure.AIM To quantitatively compare T2DM resolution over 1-5 years follow-up by LRYGB and LSG in morbidly obese patients.METHODS We searched the selected databases for full-text English language clinical studies that compared the effectiveness of LRYGB and LSG for T2DM resolution.Review manager 5.3 was used for data analysis,and the overall effect summary was represented in a forest plot.RESULTS From 1,650 titles retrieved by an initial search,we selected nine studies for this research.We found insignificant differences for T2DM resolution by LRYGB and LSG,with an odds ratio of 0.93(95%CI:0.64-1.35,Z statistics=0.38,P=0.71).Additionally,subset analyses for T2DM resolution showed insignificant differences after 24 mo(χ^2=1.24,df=4,P=0.87,overall Z effect=0.23),36 mo(χ^2=0.41,df=2,P=0.81,overall Z effect=0.51),and 60 mo(χ^2=4.75,df=3,P=0.19,overall Z effect=1.20)by LRYGB and LSG.This study reports a T2DM remission rate of 82.3%by LRYGB and 80.7%by LSG.CONCLUSION This study reports similar T2DM resolution rates by both LRYGB and LSG during 1-5 years of follow-up.However,long-term follow-up of 10 years is needed to further substantiate these findings.

Sleeve gastrectomy prevents lipoprotein receptor-1 expression in aortas of obese rats

AIM: To investigate the effects of sleeve gastrectomy on adipose tissue infiltration and lectin-like oxidized low density lipoprotein receptor-1 (LOX-1) expression in rat aortas. METHODS: Twenty-four rats were randomized into three groups: normal chow (control), high fat diet (HD) and high fat diet with sleeve gastrectomy (SG). After surgery, the HD and SG groups were fed a high fat diet. Animals were sacrificed and plasma high density lipoprotein (HDL) and low density lipoprotein (LDL) levels were determined. LOX-1 protein and LOX-1 mRNA expression was also measured. Aortas were stained with Nile red to visualize adipose tissue. RESULT: Body weights were higher in the HD group compared to the other groups. HDL levels in control,HD, and SG groups were 32.9 ± 6.2 mg/dL, 43.4 ± 4.0 mg/dL and 37.5 ± 4.3 mg/dL, respectively. LDL levels in control, HD, and SG groups were 31.8 ± 4.5 mg/dL, 53.3 ± 5.1 mg/dL and 40.5 ± 3.7 mg/dL, respectively. LOX-1 protein and LOX-1 mRNA expression was greater in the HD group versus the other groups. Staining for adipose tissue in aortas was greater in the HD group in comparison to the other groups. Thus, a high fat diet elevates LOX-1 protein and mRNA expression in aorta. CONCLUSION: Sleeve gastrectomy decreases plasma LDL levels, and downregulates LOX-1 protein and mRNA expression.

Endoscopic therapy of weight regain after bariatric surgery

Weight regain following primary bariatric surgery occurs in a significant proportion of patients and is attributed to epidemiological,anatomical and metabolic factors.Surgical revision of these patients has significant risks and limited benefits.Endoscopic revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective,safe,less invasive and even reproducible treatment.We herein discuss the indication,selection and feasibility of different endoscopic techniques that could be used in the management of weight regain following primary bariatric surgery.Future research could optimize a personalized approach not only in the endoscopic management but also in combination with other therapeutic modalities for weight regain after bariatric surgery.

Laparoscopic Sleeve Gastrectomy Outcomes

Introduction: Sleeve gastrectomy was first defined in 1990 as a part of the duodenal switch procedure with the formation of a narrow stomach tube along the small curvature of the stomach. Later, researchers proposed that Laparoscopic leave gastrectomy (LSG) reduced the risk profile of the duodenal switch procedure in high risk patients. Additionally, LSG was accepted as a rapid single bariatric surgical procedure due to its simplicity and efficacy. The aim of this study was to describe the outcomes of LSG at a single bariatric unit in King Salman North West Armed Forced Hospital (KSAFH), Tabuk, Saudi Arabia. Objective: To compare outcomes of primary LSG regarding pre and post operative sleep apnea, diabetes mellitus (DM), arterial hypertension (HTN), bronchial asthma, female urinary incontinence, infertility, and gastroesophageal reflux (GERD). We will assess our complications according to the Clavein-Dindo classification. We reviewed the medical records of patients who underwent LSG in King Salman Armed Forces Hospital from 1/1/2015 till 31/6/2017. Methods: This retrospective comparative study is performed in the Department of Surgery, KSAFH. All patients are instructed for follow-up at 1 week and 1, 3, 6, 12, 18, 24 months postoperatively. Laboratory tests are requested every 6 months post op. Improvement of Comorbidities assessed post-operatively. Surgical Complications reported according to the Clavein-Dindo classification. Our results were compared with international studies. Inclusion criteria (more than 14 years, morbid obese with BMI > 40 and obese class 11 with comorbidities). Exclusion criteria (less than 14 years, BMI < 35 and BMI < 40 with no medical illness, revisional cases). Results: A total of 127 patients underwent LSG at King Salman Armed Forces Hospital from 1/1/2015 till 31/5/2017. Of these, 40 were male (31.5%) and 87 were female (68.5%). The mean age was 35 years. Comorbidities included diabetes 31 (24.4%),

Anhedonia and functional dyspepsia in obese patients:Relationship with binge eating behaviour

BACKGROUND Obese patients(Ob)with a binge eating disorders(BED)behavior pattern have a higher prevalence of postprandial distress syndrome(PDS)compared to Ob without a BED behavior pattern,while an increase of PDS has been described in Ob after sleeve gastrectomy(SG).Hedonic response to a meal is dissociable from satiation in healthy subjects.Anhedonia is the lowered ability to experience pleasure.There are no studies investigating the presence of anhedonia in Ob with and without SG and its relationship to PDS symptoms.AIM To assess the relationship among anhedonia,BED and upper gastrointestinal symptoms in two group of morbidly Ob with and without SG.METHODS Eighty-one Ob without SG,45 Ob with SG and 55 healthy controls(HC)were studied.All subjects fulfilled the binge eating scale(BES)to investigate BED,the validated 14 items Snaith-Hamilton pleasure scale(SHAPS)to assess Anhedonia as well as the Beck Depression Inventory-II(BDI II)and State Trait Anxiety Inventory(STAI)questionnaires to screen for depression and anxiety.All patients underwent a standardized questionnaire investigating the intensity-frequency scores(0-6)of upper gastrointestinal symptoms and were diagnosed for the presence of functional dyspepsia(FD)and its subtypes according to ROME IV criteria.RESULTS Ob without SG who were positive for BED had a 4.7 higher risk of FD compared to Ob without SG who were negative for BED(OR:4.7;95.0%CI 1.23-18.24;P=0.02).STAI-Y2 scores were significantly higher in Ob without SG positive for BED(42.2±1.5 vs Ob negative for BED:39.6±1.0,P=0.04),while SHAPS scores and BDI II did not differ in the two groups(1.16±1.30 vs 0.89±1.02,P=0.49).A lower prevalence of BED(BES>17:11.4%vs 40.7%,P=0.001)and BDI-II(6.8±1.2 vs 13.8±1.9,P=0.005)was reported in Ob with SG than Ob without SG,on the contrary total mean scores of STAI-Y1 and STAI-Y2 were significantly higher in Ob with SG than Ob without SG.Thirty-five percent of Ob with SG fulfilled the diagnosis of FD.SHAPS mean scores and the prevalence of anhedonia did not differ among the two groups(18.2 vs 8.1%,P=0.2).Fifty-four percent of Ob with SG achieved surgical success excess weight loss>50%.Excess weight loss was negatively related to SHAPS total mean scores[adjusted B:-7.099(95%CI:-13.91 to-0.29),P=0.04].CONCLUSION Ob without SG showed a higher prevalence of PDS,mood disorders and anxiety when positive for BE behavior compared to those negative for BE behavior,whereas no differences were found in SHAPS score.Ob with SG showed a higher prevalence of PDS compared to Ob without SG.Concerning psychological aspect,BED and depression are less frequent in the Ob with SG,while both state and trait anxiety are significantly higher.Moreover,the more an Ob with SG is anhedonic,less surgical success was achieved.

Range of adiposity and cardiorenal syndrome

Obesity and obesity-related co-morbidities,diabetes mellitus,and hypertension are among the fastest-growing risk factors of heart failure and kidney disease worldwide.Obesity,which is not a unitary concept,or a static process,ranges from alterations in distribution to the amount of adiposity.Visceral adiposity,which includes intraabdominal visceral fat mass and ectopic fat deposition such as hepatic,cardiac,or renal,was robustly associated with a greater risk for cardiorenal morbidity than subcutaneous adiposity.In addition,morbid obesity has also demonstrated a negative effect on cardiac and renal functioning.The mechanisms by which adipose tissue is linked with the cardiorenal syndrome(CRS)are hemodynamic and mechanical changes,as well neurohumoral pathways such as insulin resistance,endothelial dysfunction,nitric oxide bioavailability,renin-angiotensin-aldosterone,oxidative stress,sympathetic nervous systems,natriuretic peptides,adipokines and inflammation.Adiposity and other associated co-morbidities induce adverse cardiac remodeling and interstitial fibrosis.Heart failure with preserved ejection fraction has been associated with obesity-related functional and structural abnormalities.Obesity might also impair kidney function through hyperfiltration,increased glomerular capillary wall tension,and podocyte dysfunction,which leads to tubulointerstitial fibrosis and loss of nephrons and,finally,chronic kidney disease.The development of new treatments with renal and cardiac effects in the context of type 2 diabetes,which improves mortality outcome,has highlighted the importance of CRS and its prevalence.Increased body fat triggers cellular,neurohumoral and metabolic pathways,which create a phenotype of the CRS with specific cellular and biochemical biomarkers.Obesity has become a single cardiorenal umbrella or type of cardiorenal metabolic syndrome.This review article provides a clinical overview of the available data on the relationship between a range of adiposity and CRS,the support for obesity as a single cardiorenal umbrella,and the most relevant studies on the recent therapeutic approaches.