Prognostic factors of various bariatric procedures

Debljina je kronična endokrino-metabolička bolest karakterizirana prekomjernim nakupljanjem masti u organizmu i povećanjem tjelesne težine. To je bolest koja se treba liječiti jer ako se ne liječi napreduje i sa sobom nosi rizik nastanka različitih kliničkih komplikacija. U slučajevima ekstremne debljine u obzir dolazi liječenje intragastričnim balonom ili barijatrijskim kirurškim zahvatom. Liječenje intragastričnim balonom (BIB) provodi se u periodu od šest mjeseci. Barijatrijsko kirurško liječenje debljine je metoda za dugotrajnu kontrolu tjelesne mase kod ekstremno debelih ljudi. Cilj ovog istraživanja bilo je analizirati promjene u koncentracijama grelina, leptina, inzulina i hormona rasta, HOMA-IR i HOMA β nakon pojedinog barijatrijskog zahvata, te utvrditi povezanost koncentracije grelina, leptina i hormona rasta nakon pojedinog barijatrijskog zahvata s gubitkom tjelesne mase 12 mjeseci nakon zahvata, te pokušati pronaći prognostičke čimbenike uspjeha pojedine barijatrijske metode. U istraživanje je uključeno 102 ispitanika, od kojih je sedam odustalo iz osobnih razloga. Dob ispitanika kretala se od 18-60 godina, ITM > 35 kg/m2. Ispitivanje je trajalo 12 mjeseci i bilo je prospektivnog tipa. Kod 21 ispitanika laparoskopski je postavljen LAGB, kod 15 bolesnika učinjena je LSG, a kod 15 RYGB. Kod 44 ispitanika gastroskopski je postavljen BIB. Istraživanjem smo zaključili da su ispitanici u LSG skupini imali značajno veći ITM u odnosu na preostale skupine, a ITM se značajno smanjio u svim skupinama. Inzulin i HOMA-IR su se značajno smanjili, a HOMAβ značajno porastao LSG skupini. Iz navedenog se indirektno može zaključiti da je LSG metoda liječenja, kojom se postiže najpovoljniji učinak na funkciju beta-stanice i metabolizam glukoze. Značajan porast HR zabilježen je u svim skupinama, najveći u RYGB skupini. U ispitanika u BIB skupini, HOMAβ u prvom mjesecu negativno korelirala s EWL u šestom mjesecu, a HOMAβ u trećem negativno korelirala s uspjehom nakon 12 mjeseci. HOMAβ jest prognostički čimbenik uspjeha liječenja BIB-om uz osjetljivost 75,8% i specifičnost 100,0%. HR je pozitivno korelirao s EWL, a leptin negativno u BIB skupini. Porast HR ovisi o padu inzulinske rezistencije, a pad leptina o gubitku na tjelesnoj masi. NaĎena je snažna pozitivna korelacija grelina prije početka liječenja i EWL nakon 6 mjeseci i 12 mjeseci liječenja. Istraživanjem smo dokazali da su bazalne vrijednosti grelina neovisni prognostički čimbenik ishoda u ispitanika liječenih LSG metodom uz osjetljivost 81,8% i specifičnost 100,0%. Pacijenti s koncentracijom grelina većom od 664 pg/ml trebali bi se liječiti LSG metodom, pošto će većina tih pacijenata postići uspjeh. Nismo našli značajne povezanosti metaboličkih hormona i uspjeha liječenja u RYGB skupini.Introduction: Obesity is a chronic metabolic disease that is characterized by an excessive accumulation of body fat and increased body weight. In the last decade, the worldwide prevalence of obesity has increased significantly; with 400 million obese adults worldwide. Obesity is a serious metabolic disease that has many clinical complications. It is associated with decreased life expectancy as well as a decreased quality of life. Multiple factors contribute to the development of obesity. In order to maintain optimal body weight, it is important to establish and maintain a balance between food intake and energy expenditure. Obesity is the result of complex interactions between genetic, hormonal and environmental factors. Obesity-related morbidity places a burden on healthcare systems. If left untreated, obesity is associated with the development of serious clinical complications such as type 2 diabetes, myocardial infarction, stroke, degenerative changes of the locomotor system, and hormone-dependent malignant tumors. If morbidly obese patients are unable to reduce their body weight by various measures (increasing physical activity, diet, and pharmacotherapeutic measures) then intragastric balloon procedures or bariatric surgery is taken into consideration. Treatment with the intragastric balloon is carried out over a period of six months, and if caloric reductions and life style changes are maintained, weight loss varies from 5 to 30%. Numerous studies have shown that in obese subjects, long-term weight control can be achieved with surgical methods. Bariatric surgery is a branch of abdominal surgery that is specialized in the treatment of obesity, and patients undergoing bariatric surgery experience a weight loss of approximately 35-40%. Improvements in obesity-related comorbidities are also seen. Bariatric procedures are divided into malabsorptive, restrictive and predominantly restrictive procedures. Malabsorptive procedures ("jejunoileal bypass", "biliopancreatic diversion with duodenal switch") shorten or bypass part of the small intestine, which reduces the amount of calories and nutrients the body absorbs. These procedures are used for the most severe forms of obesity (BMI ≥50 kg/m2). Restrictive operations ("sleeve resection", "horizontal gastroplasty", "silastic ring gastroplasty", "vertical banded gastroplasty," "gastric banding adjustable / non-adjustable") do not affect food digestion or absorption, but physically limit the amount of food the stomach can hold. In Roux-en Y gastric bypass, weight loss is attributed to limited food intake, as well as decreased absorption. Bariatric surgery has proved to be the most effective method for long-term weight loss in obese patients; however, not all patients experience the same degree of weight loss. For example, 15-20% of patients have insignificant weight loss and require repeated procedures. Weight loss after intragastric balloon procedures is even more variable. Satisfactory weight loss after 6 months is seen in only 50% of patients, and after balloon removal, only 25% continue to lose weight. Given the above, it would be useful to identify patients that will have unsuccessful weight loss following bariatric procedures, in order to provide these patients with additional weight loss methods such as diet, medical therapy, and psychotherapy. Furthermore, prognostic factors that could be used to determine which bariatric procedure the patient would most likely benefit from could be of great clinical significance. Studies examining prognostic factors for successful long-term weight loss have found that age, preoperative weight loss, initial body mass index, dietary habits, presence of depression, the desire for a change of diet and intensified physical activity are all correlated with treatment outcome. The primary aim of this research was to determine the correlation of HOMAβ (activity of beta cells) and HOMA IRv (sensitivity to insulin) values, before and after bariatric surgery, with successful weight loss on the 12th postoperative month. Secondary aims included determining changes in the concentrations of ghrelin, leptin, insulin and growth hormone (GH) after bariatric surgical procedures and to examine their correlation with successful weight loss after 12 months. In addition, to determine the association of ghrelin, leptin and GH before and after the first postoperative month with HOMAβ and HOMA IR values. Another aim was to determine if HOMAβ and HOMA IR measured on the 1st postoperative month, as well as concentrations of ghrelin, leptin, insulin and GH, could be used as prognostic factors for successful weight loss following bariatric procedures. The hypothesis: HOMA IR and leptin concentrations before and after the first postoperative month will be negatively correlated with weight loss 12 months after bariatric surgery, while HOMAβ, ghrelin and growth hormone will be positively correlated with weight loss. Patients and Methods: This prospective study was conducted at the University hospital centre ‘Sestre Milosrdnice’ and lasted 12 months. The study included 102 patients, seven of which left the study, due to personal reasons. The study was approved by the hospital ethics committee. All patients signed informed consent. Patient age ranged from 18 to 60 years, and all patients had a BMI> 35 kg/m2. In the group of patients treated with surgery, 21 patients were treated with laparoscopic adjustable gastric band (LAGB), 15 patients underwent gastric "sleeve resection" (LSG), and 15 patients underwent Roux-en bypass (RYGB) procedures. All patients underwent routine hematological and biochemical laboratory evaluation. The following was measured in all patients: serum glucose (GUP) insulin, c-peptide, growth hormone (GH) and regulatory peptide ghrelin and leptin. All the patients had venous blood samples taken between 7:00 and 09:00 am, after a 12 h fast. All patients underwent abdominal ultrasound with emphasis on the sequelae of obesity. In addition, all patients underwent esophagogastroduodenoscopy to identify possible endoscopic contraindications for the various bariatric procedures. All patients were examined by and anesthesiologist and were approved for surgery. Psychological testing was done in all patients. Blood samples were taken for analysis and anthropometric measurements were recorded. BMI before treatment, and one, three, six and 12 months after treatment were recorded. Percent of expected weight loss (% EWL) was determined. Intragastric balloon procedures were performed by an experienced gastroenterologist. All bariatric surgical procedures were performed by the same experienced abdominal surgeon. Results: The treatment of obesity is extremely complex and requires an interdisciplinary approach. We assessed the role of insulin, leptin, ghrelin and growth hormone on weight loss following bariatric procedures. Based on these parameters, optimal bariatric procedures could be planned for obese patients. These parameters could also help predict which patients are at an increased risk of treatment failure, so that additional interventions could be performed. This is the first research that has examined the role of hormones, regulatory peptides and metabolic parameters for prediction of successful weight loss following bariatric treatment. We found the following results: Patients with successful weight loss in the LSG group had a significantly higher BMI compared to other groups, and BMI was significantly decreased in all groups. Overall, insulin and HOMA-IR were significantly reduced, and HOMAβ significantly increased in patients. HOMA-IR was significantly decreased only in the BIB group and LSG group and HOMAβ increased significantly only in the LSG group. Based on the above findings, we can conclude that the LSG provides the most favorable effect on beta cell function and glucose metabolism. Therefore, LSG is the method of choice in obese patients that require treatment of metabolic complications. A significant increase in HR was observed in all groups, but the largest increase was seen in the RYGB group with successful weight loss. In the BIB group HOMAβ in the 1st month was negatively correlated with the EWL in 6th month, and HOMAβ in the 3rd month was negatively correlated with success after 12 months. HOMAβ was a prognostic factor for successful weight loss in the BIB group with sensitivity of 75,8% and specificity of 100,0%. GH was positively correlated with the EWL, and leptin was negatively correlated with EWL in BIB group. No correlation with GH was seen after adjustment for HOMAβ, and the correlation with leptin was lost after correcting for EWL in the first and 3rd month. From the following we can conclude that the increase in GH depends on a decrease in insulin resistance, and a decrease in leptin depends on weight loss. In LAGB group, ghrelin in the first month was positively correlated with the EWL at 12 months, but this association disappeared after adjustment of EWL in the 1st month. This means that ghrelin is not an independent prognostic factor, but depends on weight loss in the 1st month. We also found a strong positive correlation between ghrelin before treatment and EWL after 6 and 12 months. The above correlation remained statistically significant even after adjusting for initial BMI. Baseline ghrelin was an independent prognostic factor for outcome in patients treated with LSG, with a sensitivity 81,8% and specificity of 100,0%. Conclusion: We can conclude that patients with ghrelin concentration greater than 664 pg / ml should be treated LSG, since the majority of these patients achieve success. However we did not find significant association between metabolic hormones and the success of treatment in the RYGB group

LIJEČENJE TEŠKE DIJABETIČKE KETOACIDOZE U MLADE OSOBE

We present a case of severe diabetic ketoacidosis in a 19-year-old male with a history of poor compliance to insulin therapy. At arrival to our Emergency Department, the patient was comatose with extreme hyperglycemia, severe diabetic ketoacidosis, lactic acidosis and dehydration. The treatment consisted of intensive fl uid replacement and correction of all metabolic disturbances until complete recovery. In the vast majority of severe diabetic ketoacidosis cases, relatively fast and successful treatment result can be expected if intensive therapy is applied and if ketoacidosis is not triggered by a serious illness. Some essential contemporary guidelines and the importance of individual treatment approach are pointed out in the article. The role of high serum procalcitonin value in diabetic ketoacidosis is discussed.Prikazan je slučaj 19-godišnjeg bolesnika od dijabetesa koji nije redovito primjenjivao inzulin. Bolesnik je doveden na naš objedinjeni hitni prijam u komatoznom stanju, s ekstremnom hiperglikemijom, teškom dijabetičkom ketoacidozom, laktacidozom i dehidracijom. Liječen je intenzivnom nadoknadom volumena i korekcijom svih metaboličkih poremećaja do potpunog oporavka. U velikoj većini slučajeva teških dijabetičkih ketoacidoza može se očekivati relativno brza i uspješna korekcija ako se primijeni intenzivno liječenje i ako ketoacidoza nije potaknuta ozbiljnom bolesti. U članku su navedene neke bitne suvremene smjernice u liječenju i naglašena je važnost individualnog pristupa. Raspravljena je i uloga visoke serumske vrijednosti prokalcitonina u dijabetičkoj ketoacidozi

Recidivirajući hiperparatiroidizam: prikaz slučaja

A 57-year-old man with a history of primary hyperparathyroidism, consequential chronic renal failure and associated chronic Hashimoto.s thyroiditis presented with recurrent hypercalcemia. Hypercalcemia persisted despite three resections of enlarged parathyroid glands and multiple sclerosations of the remaining parathyroid tissue. The possible causes of persisting hypercalcemia include unrecognized asymmetric parathyroid hyperplasia, multiple parathyroid adenomas, however, parathyromatosis as a complication of parathyroid resection could not be ruled out. Dispersion of parathyroid tissue and growth of multiple parathyroid nodules could lead to primary hyperparathyroidism. With intermittent parenteral pamidronate normocalcemia was temporarily achieved, although fourth resection of parathyroid tissue and subtotal thyroidectomy eventually led to normocalcemia and normal parathyroid hormone levels in this patient.Prikazuje se 57-godišnji bolesnik s recidivirajućim primarnim hiperparatiroidizmom i posljedičnom kroničnom bubrežnom insuficijencijom.U tri navrata učinjena je ekstirpacija povećanih paratiroidnih žlijezda i višekratna sklerozacija preostalog paratiroidnog tkiva, uz i dalje prisutnu hiperkalcemiju. Moguća objašnjenja su da se kod bolesnika radilo o višestrukim adenomima paratiroidnih žlijezda koji su se razvili metakrono ili se od samog početka radilo o neprepoznatoj asimetričnoj hiperplaziji svih paratiroidnih žlijezda. Ne može se, međutim, isključiti niti paratiromatoza kao posljedica poslijeoperacijske rupture kapsule adenoma, što je dovelo do rasapa i ponovnog rasta višestrukih paratiroidnih čvorova i recidiva primarnog hiperparatiroidizma. Bolesnik je uz intermitentnu parenteralnu terapiju pamidronatom bio u prolaznoj normokalcemiji, a nakon ponovne pojave hiperparatiroidizma učinjena je radikalna disekcija paratiroidnog tkiva i subtotalnalna resekcija štitne žlijezde, čime je uspostavljena normokalcemija i postignuta uredna razina paratiroidnog hormona

Validation of diabetes knowledge questionnaire in Croatian with assessment of diabetes knowledge and quality of life in patients with type 2 diabetes mellitus

Background. Diabetes mellitus (DM) is one of the biggest challenges in global healthcare and society in general. Assessment of the patient’s level of knowledge regarding diabetes is an important step in adapting group education programs to achieve better treatment outcomes. The aim of this study was to validate Diabetes Knowledge Questionnaire (DKQ) in Croatian language, to evaluate knowledge about diabetes and examine the relationship between knowledge and quality of life among type 2 DM patient’s in Croatia.Methods. The study was conducted as a cross-sectional study on 500 subjects. Validation of DKQ questionnaire in Croatian language was done using forward-backward method and internal consistency was examined using Cronbach’s Alpha. Quality of life was assessed using WHOQOL-BREF Questionnaire.Results. Good reliability and internal consistency of DKQ was confirmed (a = 0,740). Overall knowledge about diabetes was satisfactory (average DKQ score was 12,13). Longer duration of disease and previous education about diabetes were observed as predictive factors of better knowledge. No association was found between diabetes knowledge and quality of life.Conclusions. Our study confirms that DKQ is a good tool for assessing diabetes knowledge in Croatian language. Patients with DM demonstrated good diabetes knowledge but education in areas of self-care and nutrition needs to be improved which may increase quality of life

Bolesnik s adrenalnom insuficijencijom i pernicioznom anemijom: je li nova podjela autoimunog poliglandularnog sindroma primjerena?

A case of autoimmune polyglandular syndrome (APS) is presented. A 45-year-old man was admitted due to fatigue, malaise and inappetence. He had a history of primary hypothyroidism and was on levothyroxine substitution therapy. One year before, he was diagnosed with normocytic anemia and vitamin B12 deficiency, which was treated with vitamin B12 substitution therapy. Physical examination revealed hypotension and marked hyperpigmentation. Laboratory testing showed hyponatremia, hyperkaliemia and severe normocytic anemia. Endocrinological evaluation disclosed low morning cortisol and increased adrenocorticotropic hormone levels. Hence, the diagnosis of Addison’s disease was established. Additional laboratory workup showed positive parietal cell antibodies. However, his vitamin B12 levels were increased due to vitamin B12 supplementation therapy, which was initiated earlier. Gastroscopy and histopathology of gastric mucosa confirmed atrophic gastritis. Based on prior low serum vitamin B12 levels, positive parietal cell antibodies and atrophic gastritis, the patient was diagnosed with pernicious anemia. Hydrocortisone supplementation therapy was administered and titrated according to urinary-free cortisol levels. Electrolyte disbalance and red blood cell count were normalized. This case report demonstrates rather unique features of pernicious anemia in a patient with Addison’s disease. It also highlights the link between type II and type III APS. Not only do they share the same etiological factors, but also overlap in pathophysiological and clinical characteristics. This case report favors older classification of APS, which consolidates all endocrine and other organ-specific autoimmune diseases into one category. This is important since it might help avoid pitfalls in the diagnosis and treatment of patients with APS.Prikazujemo slučaj bolesnika s autoimunim poliglandularnim sindromom (APS). Muškarac u dobi od 45 godina hospitaliziran je zbog opće slabosti i malaksalosti. Od ranije je bolovao od primarne hipotireoze i uzimao je nadomjesnu terapiju levotiroksinom. Jednu godinu ranije otkrivena je normocitna anemija i deficit vitamina B12, zbog čega je liječen nadomjesnom terapijom vitaminom B12. Pri fizikalnom pregledu nađena je hipotenzija i naglašena hiperpigmentacija kože. Ulaboratorijskim nalazima nađena je hiponatremija, hiperkalemija i teška normocitna anemija. Endokrinološkom obradom nađen je snižen jutarnji kortizol te povišen ACTH, nakon čega je postavljena dijagnoza Addisonove bolesti. Dodatnom laboratorijskom obradom nađena su i pozitivna protutijela na parijetalne stanice uz povišenu koncentraciju vitamina B12 posljedično nadomjesnoj terapiji. Nalaz gastroskopije i patohistološke analize sluznice upućivao je na atrofični gastritis te je stoga postavljena dijagnoza perniciozne anemije. Započeta je nadomjesna terapija hidrokortizonom i titrirana prema ciljnim vrijednostima slobodnog kortizola u 24-satnoj mokraći. Elektrolitski disbalans i anemija su se normalizirali. Ovaj prikaz slučaja je opisao karakteristike perniciozne anemije u bolesnika s Addisonovom bolešću te naglašava vezu između APS tip II. i III. Ova dva sindroma dijele istu etiologiju te se njihove komponente često preklapaju. Slučaj našega bolesnika daje prednost starijoj klasifikaciji APS koja dopušta kombinacije svih primarnih endokrinih insufucijencija i drugih za organ specifičnih bolesti. Poštivajući staru podjelu APS mogu se izbjeći potencijalne zamke u dijagnostici i liječenju

Initial weight loss after restrictive bariatric procedures may predict mid-term weight maintenance: results from a 12-month pilot trial

Background: Bariatric procedures are effective options for weight loss (WL) in the morbidly obese. However, some patients fail to lose any weight after bariatric surgery, and mid-term weight maintenance is variable. The aim of this study was to investigate whether initial WL could predict mid-term weight maintenance. ----- Methods: Eighty patients were enrolled, of whom 44 were treated with the BioEnterics Intragastric Balloon (BIB), 21 with laparoscopic adjustable gastric lap-banding (LAGB), and 15 with laparoscopic sleeve gastrectomy (LSG). Percentage of body WL and percentage of excess weight loss (EWL) were calculated at baseline and after 1, 3, 6, and 12 months. Successful WL was defined as EWL >20% for patients treated with BIB and >50% for patients treated with LAGB and SG. ----- Results: Success in the 6th and 12th month was achieved in 80% and 58% of patients in the BIB group, 33% and 40% in the LAGB group, and 60% and 73% in the LSG group. In the BIB group, WL in the 1st month correlated positively with WL at the 6th and 12th month, and an initial WL >6.5% best predicted success (sensitivity 50%, specificity 80%). A similar association was observed in the LAGB group at the 6th and 12th month and an initial WL >9.4% best predicted success (sensitivity 90.0%, specificity 81.2%). In patients treated with LSG, WL in the 3rd month correlated positively with EWL at the 6th and 12th month, with a cutoff value of 17% (sensitivity 66.7%, specificity 100%). ----- Conclusions: WL in the 1st month in patients treated with BIB and LAGB and WL in the 3rd month in patients treated with LSG could be used as a prognostic factor to predict mid-term weight maintenance

Position of Intragastric Balloons in Global Initiative for Obesity Treatment

Obesity is chronic disease with multiple health consequences and among the most severe health problems worldwide. According to public health records around 65% of population in Croatia are overweight and 20% obese. National physicians chamber with support of Health and Social Welfare Ministry gave recommendations on diagnosing and treating of obesity in form of national consensus. Treatment of obesity is complex and enrolls multiple clinical specialties. Change of life style, strenuous physical activity and pharmacotherapy are part of conservative treatments. Patients are treated more efficiently by minimally invasive endoscopic procedures or bariatric surgery depending on starting body mass index score. Implantation of intragastric balloons is conceptually simple method of obesity treatment. Modern devices as Bio- Enterics intragastric balloons (BIB®), (Inamed Health, USA) are gaining wide popularity among both patients and physicians. BIB intragastric offers the best gains with individuals ranging BMI from 35 to 40. Efficiency has relative timeline dependance from 85% at 6 months to 24% at 36 months. BIB offers substantial ameliorative influence on obesity comorbidities, particularly cardiovascular risk. Treatment with BIB is also efficient but transient treatment modality in morbidly and superobese individuals to reduce preoperative risks of general and bariatric surgery. Obesity treatment with BIB is well tolerated and safe, offering better quality of life. Nevertheless, due to relative poor results of conservative obesity treatments on long term follow up further investigations defining new clinical parameters for solving treatment resistance. In order to provide resourcefully individualized approach modern perspectives are focused on endocrine constitutes of obesity. Hormonal effects of BIB treatment in compare to bariatric surgery are potentially interesting for the prospect studies

Scoring systems for peptic ulcer bleeding: which one to use?

AIM: To compare the Glasgow-Blatchford score (GBS), Rockall score (RS) and Baylor bleeding score (BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers. METHODS: Between January 2008 and December 2013, 1012 consecutive patients admitted with peptic ulcer bleeding (PUB) were prospectively followed. The pre-endoscopic RS, BBS and GBS, as well as the post-endoscopic diagnostic scores (RS and BBS) were calculated for all patients according to their urgent upper endoscopy findings. Area under the receiver-operating characteristics (AUROC) curves were calculated for the prediction of lethal outcome, rebleeding, needs for blood transfusion and/or surgical intervention, and the optimal cutoff values were evaluated. RESULTS: PUB accounted for 41.9% of all upper gastrointestinal tract bleeding, 5.2% patients died and 5.4% patients underwent surgery. By comparing the AUROC curves of the aforementioned pre-endoscopic scores, the RS best predicted lethal outcome (AUROC 0.82 vs 0.67 vs 0.63, respectively), but the GBS best predicted need for hospital-based intervention or 30-d mortality (AUROC 0.84 vs 0.57 vs 0.64), rebleeding (AUROC 0.75 vs 0.61 vs 0.53), need for blood transfusion (AUROC 0.83 vs 0.63 vs 0.58) and surgical intervention (0.82 vs 0.63 vs 0.52) The post-endoscopic RS was also better than the post-endoscopic BBS in predicting lethal outcome (AUROC 0.82 vs 0.69, respectively). CONCLUSION: The RS is the best predictor of mortality and the GBS is the best predictor of rebleeding, need for blood transfusion and/or surgical intervention in patients with PUB. There is no one 'perfect score' and we suggest that these two tests be used concomitantly

A First Case of Endoscopical Removal of an Eroded Adjustable Gastric Band in Croatia

Laparoscopic gastric banding (LAGB) is one of the most common surgical procedures in the treatment of morbid obesity since it provides good long-term outcomes in weight loss and decrease of comorbidities associated with obesity. Although the procedure has low morbidity and almost none-existing mortality, certain complications can occur. Erosion of the band into the gastric wall is one of the rare complications in LAGB. The reported incidence varies from 1% to 11%, however the largest study reported an incidence of 1,6%. This is in accordance with the incidence in our Centre for obesity, where only one case of erosion occurred among 112 operative procedures. The aim of this paper is to present a patient with gastric band erosion and it’s removal by using the endoscopic techniques as a minimally invasive management method

CROATIAN GUIDELINES FOR THE TREATMENT OF ADULTS WITH OBESITY

Debljina ili pretilost je kronična metabolička bolest karakterizirana prekomjernim nakupljanjem masnog tkiva u organizmu. Iako većinu ljudi zabrinjava uglavnom zbog estetskih razloga, debljina je ponajprije zdravstveni problem jer je povezana s nizom bolesti i kraćim životnim vijekom. Recentno je debljina stavljena u fokus i zbog pandemije bolesti COVID-19gdje se utvrdilo kako osobe s debljinom, oboljele od bolesti COVID-19, imaju povećan rizik od hospitalizacije i smrti. U kliničkoj praksi debljina se procjenjuje indeksom tjelesne mase (ITM), a za dodatnu procjenu nakupljanja visceralnog masnog tkiva, koje predstavlja veći rizik od metaboličkih i kardiovaskularnih bolesti koristi se mjera opsega struka (OS). U regulaciju energetske ravnoteže i zaliha masti uključene su složene interakcije između bioloških, bihevioralnih, socijalnih i okolišnih čimbenika. Ciljevi kontrole tjelesne mase naglašavaju važnost realističnog pristupa mršavljenju kako bi se postiglo smanjenje zdravstvenih rizika, a uključuju promicanje gubitka tjelesne mase, održavanje postignute niže tjelesne mase i prevenciju ponovnog debljanja. Kontrola komorbiditeta povezanih s debljinom i poboljšanje kvalitete života osoba koje žive s preuhranjenošću ili debljinom bitan su aspekt liječenja. Liječenje debljine u prvom redu podrazumijeva promjenu načina života i trajno prihvaćanje zdravih navika. Smanjenje prekomjerne tjelesne mase, kao i njeno kasnije održavanje, temelji se na kombinaciji prehrane s energetskom vrijednošću za 500 kcal manjom od dnevnih energetskih potreba i redovitoj tjelesnoj aktivnosti. Bihevioralno-kognitivni pristup usmjeren je na prevladavanje psiholoških prepreka za usvajanje i primjenu učinkovitih ponašanja u kontroli tjelesne mase. Farmakoterapija za smanjenje tjelesne mase indicirana je kao dodatak dijeti sa smanjenim unosom kalorija i povećanoj tjelesnoj aktivnosti u odraslih osoba s ITM ≥30 kg/m², ali i u osoba s preuhranjenošću s ITM-om ≥27 do 35 kg/m² s komorbiditetima ili ITM >40 kg/m2 s komorbiditetima ili bez njih. Barijatrijska kirurgija najučinkovitija je metoda liječenja osoba s morbidnom debljinom i njom se može postići dugoročni gubitak tjelesne mase. Ove smjernice mogu se jednostavno primijeniti u svakodnevnom radu, a cilj je prepoznavanje i adekvatno liječenje osoba s preuhranjenošću i debljinom od svakog liječnika s naglaskom na primjerenu komunikaciju, motivacijski razgovor i edukaciju.Obesity is a chronic metabolic disease characterized by abnormal and excessive adipose tissue accumulation in the body. Although most people are concerned mainly for aesthetic reasons, obesity is primarily a health problem because it is associated with a wide range of diseases and shorter life expectancy. Obesity has recently been put in focus due to the COVID-19 pandemic since it has been revealed that patients with obesity are at an increased risk of both hospitalization and death related to COVID-19. In clinical practice, obesity is assessed by body mass index (BMI), whilst for additional assessment of visceral adipose tissue accumulation and distribution, which poses a greater risk of metabolic and cardiovascular disease development, waist circumference is used. A complex interaction among biological, behavioral, social and environmental factors is included in the regulation of energy balance and fat storage. Body weight control goals emphasize the importance of a realistic approach to weight loss in order to reduce health risks. They include promoting weight loss, maintenance of achieved lower/optimal body weight, and prevention of weight regain. Control of obesityrelated comorbidities and improvement of the quality of life of people living with overweight or obesity is an important aspect of treatment. Obesity treatment is primarily based on lifestyle changes and permanent acceptance of healthy habits. A combination of diet with an overall energy value of 500 kcal less than daily energy needs and regular physical activity are of utmost importance for reduction of excess weight, as well as its subsequent maintenance. The cognitive-behavioral approach is aimed at overcoming psychological barriers to the adoption and application of effective behaviors in weight control. Pharmacotherapy for weight loss is indicated as an adjunct to a low-calorie diet and increased physical activity in adults with a BMI ≥30 kg/m2, but also in overweight adults with a BMI ≥27 to 35 kg/m2 with obesity-related comorbidities and in adults with BMI >40 kg/m2 with or without comorbidities. Bariatric surgery is the most effective therapeutic method for treating people with morbid obesity, and thus can ensure long-term weight loss. These guidelines can be easily applied in everyday clinical practice, and their goal is recognition and treatment of persons with overweight and obesity by each physician, with special emphasis on appropriate communication, motivational interviewing/conversation, and education