Influence of insulin resistance on the development of cholecystolithiasis in individuals who underwent Roux-en-Y gastric bypass

Orientador: Elinton Adami ChaimTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: A ocorrência de colecistolitíase após o bypass gástrico em Y de Roux foi extensivamente descrita na literatura. Uma vez que este procedimento cirúrgico promove significativa melhora na resistência de insulina, que é um dos fatores envolvidos na fisiopatologia da colecistolitíase, este estudo tem por objetivo determinar a influência da resistência insulínica e de sua evolução pós-cirúrgica no desenvolvimento de cálculos biliares. Foi realizado um estudo prospectivo tipo coorte, que envolveu 108 indivíduos obesos mórbidos sem cálculos biliares que foram submetidos ao bypass gástrico em Y de Roux. Os indivíduos foram acompanhados por 24 meses através de exames clínicos, laboratoriais e ultrassonográficos. A resistência insulínica foi mensurada através do marcador indireto "modelo de avaliação homeostática" (HOMA). Dos indivíduos avaliados, 29 (26,8%) desenvolveram cálculos biliares após a cirurgia. Na análise univariada, a ocorrência de colecistolitíase foi associada com o índice HOMA pré-operatório (p<0,0001), glicemia de jejum pré-operatória (p=0,0019), insulinemia de jejum pré-operatória (p=0,0001) e trigliceridemia pré-operatória (p=0,0001). A análise multivariada revelou que o índice HOMA pré-operatório foi o único fator associado de forma independente com os cálculos biliares (p<0,0001). A incidência de colecistolitíase entre indivíduos com resistência insulínica foi de 46,8%; nos indivíduos sem resistência insulínica, a incidência foi de 7,4% (p <0,0001). A resistência insulínica pré-operatória levou a um risco relativo de 6,02 (Intervalo de confiança de 95%: 2,1 ¿ 17,3; p=0,0009) de colecistolitíase. Uma vez que a colecistolitíase comumente ocorre após o bypass gástrico em Y de Roux, há controvérsias quanto a seu manejo. Alguns autores propõem a realização de colecistectomia sistemática juntamente com o bypass gástrico, enquanto outros sugerem que o risco agregado da abordagem concomitante é significativamente maior. Como a resistência insulínica pré-operatória foi um fator de risco significativo neste estudo, pode ser proposta uma abordagem individualizada para esta população. A realização de mais estudos é necessária para confirmar estes resultados e possibilitar uma análise mais profundaAbstract: The occurrence of gallstones following Roux-en-Y gastric bypass has been extensively reported. As Roux-en-Y gastric bypass promotes improvement in insulin resistance, which is one of the factors enrolled in the pathophysiology of gallstones, this study aims to determine the influence of insulin resistance and its postoperative course on the development of gallstones. This is a prospective cohort study that enrolled 108 morbidly obese subjects free of gallstones which underwent Roux-en-Y gastric bypass and were followed up for 24 months, through clinical, laboratory, and ultrasound examinations. Insulin resistance was assessed through the surrogate marker homeostasis model assessment (HOMA). Of the individuals evaluated, 29 (26.8%) developed gallstones following Roux-en-Y gastric bypass. In the univariate analysis, postsurgical gallstones were associated with preoperative HOMA (p<0.0001), preoperative fasting glucose (p=0.0019), preoperative fasting insulin (p=0.0001), and preoperative triglycerides (p=0.0001). Multivariate analysis revealed that preoperative HOMA was the only factor independently associated with gallstones (p<0.0001). The incidence of gallstones among individuals with insulin resistance was 46.8%; in the group without insulin resistance, the incidence was 7.4% (p<0.0001). Preoperative IR led to a relative risk of 6.02 (95% Confidence interval: 2.1 ¿ 17.3; p= 0.0009) of gallstones. As gallstones often occur following Roux-en-Y gastric bypass, there is controversy regarding their management. Some authors propose systematic cholecystectomy along with Roux-en-Y gastric bypass, while others suggest that the aggregate risk of the concomitant approach is significantly higher. As insulin resistance was a significant risk factor in this study, an individualized approach for this population may be proposed. Further research is needed to confirm these findingsDoutoradoFisiopatologia CirúrgicaDoutor em Ciência

Influência do diabetes mellitus tipo 2 sobre a histologia hepática entre indivíduos com obesidade mórbida. Um estudo transversal

CONTEXT AND OBJECTIVE: Nonalcoholic fatty liver disease (NAFLD) has become a public health concern. It encompasses a wide spectrum of histological abnormalities and has close relationships with insulin resistance and type 2 diabetes mellitus (T2DM). This study sought to compare the histological alterations observed in morbidly obese individuals with and without T2DM who underwent Roux-en-Y gastric bypass. DESIGN AND SETTING: Cross-sectional study in a tertiary-level public hospital. METHODS: This was a cross-sectional study on 197 individuals who underwent gastric bypass surgery between 2011 and 2013. NAFLD was assessed through liver biopsies. T2DM was diagnosed through the International Diabetes Federation criteria. RESULTS: Non-diabetics presented significantly more biopsies without any histological abnormalities, regarding steatosis (42.6% versus 25.5%; P = 0.0400), fibrosis (60.6% versus 36.2%; P = 0.0042) and steatohepatitis (27.3% versus 12.8%; P = 0.0495), while diabetics presented significantly higher frequency of moderate forms of steatosis (36.2% versus 20%; P = 0.0307) and fibrosis (23.4% versus 4%; P = 0.0002). DISCUSSION: T2DM was associated with more advanced forms of NAFLD within the population studied. NAFLD has previously been correlated with severe forms of heart disease. CONCLUSION: Screening for and early detecting of NAFLD in high-risk populations are important for avoiding further development of severe forms and the need for liver transplantation.CONTEXTO E OBJETIVO: A doença gordurosa não alcoólica do fígado se tornou um problema de saúde pública. Ela compreende um amplo espectro de alterações histológicas e se relaciona intimamente com a resistência insulínica e o diabetes mellitus tipo 2. Este estudo tem por objetivo comparar as alterações histológicas observadas em obesos mórbidos com e sem diabetes submetidos ao bypass gástrico em Y de Roux. TIPO DE ESTUDO E LOCAL: Estudo transversal em um hospital terciário público. MÉTODOS: Este é um estudo transversal que envolveu 197 indivíduos submetidos ao bypass gástrico entre 2011 e 2013. A doença gordurosa do fígado foi avaliada através de biópsia hepática. O diabetes mellitus tipo 2 foi diagnosticado através dos critérios da Federação Internacional de Diabetes. RESULTADOS: Indivíduos não diabéticos apresentaram significativamente mais biópsias sem anormalidades histológicas, em relação a esteatose (42,6% versus 25,5%; P = 0.04), fibrose (60,6% versus 36,2%; P = 0.0042) e esteato-hepatite (27,3% versus 12,8%; P = 0.0495); os diabéticos apresentaram uma frequência significativamente mais alta de formas moderadas de esteatose (36,2% versus 20%; P = 0.0307) e fibrose (23,4% versus 4%; P = 0.0002). DISCUSSÃO: O DM-2 associou-se a formas mais avançadas de doença gordurosa do fígado dentro da população estudada. A doença gordurosa não alcoólica do fígado foi associada previamente com formas graves de doença cardíaca. CONCLUSÃO: A busca e detecção precoce da doença gordurosa em populações de alto risco são importantes para evitar o futuro desenvolvimento de formas graves e a necessidade de transplante hepático.1341798

NON-ALCOHOLIC FATTY LIVER DISEASE AND EXTRA-HEPATIC CANCER: A NARRATIVE REVIEW

ABSTRACT Background: Recently, significant associations between non-alcoholic fatty liver disease (NAFLD) and extra-hepatic cancer have been reported. Objective: To carry out a comprehensive review of the current evidence in the literature on the association between NAFLD and extra-hepatic cancer. Methods: A narrative literature review was performed through an online search for the MeSH terms “fatty liver” and “cancer” in MEDLINE (via PubMed) and LILACS (via BVS). Original studies that described the impact of NAFLD on different types of extra-hepatic malignancies were included. Results: After careful analysis, nine prospective cohort studies, one retrospective cohort study, three case-control studies, and three cross-sectional studies were selected. Conclusion: There is consistent evidence on the association between NAFLD and extra-hepatic carcinogenesis, especially in relation to colorectal, gastric, pancreatic, breast, prostate, and bladder cancers

Analysis of quality of life among asthmatic individuals with obesity and its relationship with pulmonary function: cross-sectional study

FAPESP - FUNDAÇÃO DE AMPARO À PESQUISA DO ESTADO DE SÃO PAULOThe combined effect of obesity and asthma may lead to significant impairment of quality of life (QOL). The aim here was to evaluate the prevalence of asthma among obese individuals, characterize the severity of impairment of quality of life and measure it1354332338FAPESP - FUNDAÇÃO DE AMPARO À PESQUISA DO ESTADO DE SÃO PAULOFAPESP - FUNDAÇÃO DE AMPARO À PESQUISA DO ESTADO DE SÃO PAULOsem informaçã

Cirurgia Bariátrica Em Indivíduos Com Déficits Cognitivos Graves: Relato De Dois Casos

Bariatric surgery has become the gold-standard treatment for refractory morbid obesity. Obesity is frequently associated with certain syndromes that include coexisting cognitive deficits. However, the outcomes from bariatric surgery in this group of individuals remain incompletely determined. CASE REPORT: A 25-year-old male with Prader-Willi syndrome, whose intelligence quotient (IQ) was 54, was admitted with a body mass index (BMI) of 55 kg/m2, associated with glucose intolerance. He underwent the Scopinaro procedure for biliopancreatic diversion, with uneventful postoperative evolution, and presented a 55% loss of excess weight one year after the surgery, with resolution of glucose intolerance, and without any manifestation of protein-calorie malnutrition. A 28-year-old male with Down syndrome, whose IQ was 68, was admitted with BMI of 41.5 kg/m2, associated with hypertension. He underwent Roux-en-Y gastric bypass, with uneventful postoperative evolution. He presented a 90% loss of excess weight one year after the surgery, with resolution of the hypertension. CONCLUSION: Bariatric surgery among individuals with intellectual impairment is a controversial topic. There is a tendency among these individuals to present significant weight loss and comorbidity control, but less than what is observed in the general obese population. The severity of the intellectual impairment may be taken into consideration in the decision-making process regarding the most appropriate surgical technique. Bariatric surgery is feasible and safe among these individuals, but further research is necessary to deepen these observations

DIAGNOSTIC ACCURACY OF THE NON-INVASIVE MARKERS NFLS, NI-NASH-DS, AND FIB-4 FOR ASSESSMENT OF DIFFERENT ASPECTS OF NON-ALCOHOLIC FATTY LIVER DISEASE IN INDIVIDUALS WITH OBESITY: CROSS-SECTIONAL STUDY

ABSTRACT Background: Non-invasive markers have been developed to assess the presence and severity of liver abnormalities related to non-alcoholic fatty liver disease (NAFLD). Objective: To analyze the diagnostic accuracy of non-invasive NAFLD markers (NAFLD liver fat score [NLFS], non-invasive non-alcoholic steatohepatitis detection score [NI-NASH-DS] and fibrosis score based on four variables [FIB-4]) in individuals with obesity undergoing bariatric surgery. Methods: A descriptive retrospective cross-sectional study was carried out enrolling 91 individuals who underwent bariatric surgery at a tertiary-level public university hospital. Non-invasive NAFLD markers were calculated using laboratory tests, clinical and anthropometric variables and diagnostic accuracy tests were calculated comparing them in relation to the gold-standard test for this analysis (histopathological evaluation). Results: A total of 85.7% of the participants were female and mean age was 39.1±9.8 years. The average body mass index was 38.4±3.6 kg/m2. At histopathological examination, 84 (92.3%) patients presented with steatosis, 82 (90.1%) with some type of fibrosis; 21 (23.1%) patients were diagnosed with NASH according to the NAFLD activity score criteria. The overall accuracy of NLFS score was 58.2% for general hepatic steatosis and 61.5% for moderate to severe steatosis. The overall accuracy of FIB-4 was 95.4% for advanced fibrosis. NI-NASH-DS had a 74.7% overall accuracy for NASH. Conclusion: In a population of individuals with obesity, the FIB-4 score had high overall accuracy in assessing the presence of advanced liver fibrosis, whereas the NFLS and NI-NASH-DS had moderate accuracies for the assessment of steatosis and NASH, respectively

GASTRIC PLICATION ASSOCIATED WITH FUNDOPLICATION IN INDIVIDUALS WITH CLASS I OBESITY AND GASTROESOPHAGEAL REFLUX DISEASE: WEIGHT LOSS OUTCOMES, REFLUX-RELATED SYMPTOMS, ENDOSCOPIC AND pH MONITORING FINDINGS

ABSTRACT BACKGROUND: The association of gastric plication with fundoplication is a reliable option for the treatment of individuals with obesity associated with gastroesophageal reflux disease. AIMS: To describe weight loss, endoscopic, and gastroesophageal reflux disease-related outcomes of gastric plication with fundoplication in individuals with mild obesity. METHODS: A retrospective cohort study was carried out, enrolling individuals who underwent gastric plication with fundoplication at a tertiary private hospital from 2015–2019. Data regarding perioperative and weight loss outcomes, endoscopic and 24-hour pH monitoring findings, and gastroesophageal reflux disease-related symptoms were analyzed. RESULTS: Of 98 individuals, 90.2% were female. The median age was 40.4 years (IQR 32.1–47.8). The median body mass index decreased from 32 kg/m2 (IQR 30,5–34) to 29.5 kg/m2 (IQR 26.7–33.9) at 1–2 years (p<0.05); and to 27.4 kg/m2 (IQR 24.1–30.6) at 2–4 years (p=0.059). The median percentage of total weight loss at 1–2 years was 7.8% (IQR −4.1–14.7) and at 2–4 years, it was 16.4% (IQR 4.3–24.1). Both esophageal and extra-esophageal symptoms showed a significant reduction (p<0.05). A significant decrease in the occurrence of esophagitis was observed (p<0.01). The median DeMeester score decreased from 30 (IQR 15.1–48.4) to 1.9 (IQR 0.93–5.4) (p<0.0001). CONCLUSIONS: The gastric plication with fundoplication proved to be an effective and safe technique, leading to a significant and sustained weight loss in addition to endoscopic and clinical improvement of gastroesophageal reflux disease