A gordura epicárdica é biologicamente ativa e sua espessura nos obesos é aumentada. A repercussão da gordura epicárdica sobre o remodelamento cardíaco ainda não está completamente elucidada. No presente estudo, foi avaliada a gordura epicárdica e sua influência no remodelamento cardíaco de obesos mórbidos, antes e após a cirurgia bariátrica. Métodos: No Hospital das Clínicas da Universidade de São Paulo, foram recrutados de forma prospectiva 20 obesos mórbidos sem outras comorbidades e 20 controles. Os participantes realizaram avaliação clínica e laboratorial, medida da duração da onda P no ECG e ecocardiograma transtorácico. O grupo de obesos repetiu essa avaliação 12 meses após a cirurgia bariátrica. A medida da gordura epicárdica foi feita pelo ecocardiograma. Para comparar as variáveis contínuas, foram utilizados os testes t de Student (não pareado e pareado), de Mann-Whitney ou de Wilcoxson. Para definir correlação entre as variáveis lineares, foi utilizado o coeficiente de correlação de Pearson. Para definir a associação entre variáveis categóricas, foi usado o teste exato de Fisher. Para avaliar a associação entre variáveis dependentes e independentes, foi realizada uma análise de regressão múltipla. Os dados foram examinados no software R. Um valor de p abaixo de 0,05 foi considerado significativo. Resultados: No préoperatório, foram observados níveis elevados de proteína C reativa, uma maior duração da onda P, da massa ventricular e do diâmetro do átrio esquerdo nos obesos em relação aos controles (p < 0,05). Uma menor fração de ejeção do ventrículo esquerdo foi observada no grupo de obesos (p < 0,05). A gordura epicárdica foi maior nos obesos (p < 0,01). Uma correlação positiva foi encontrada entre a gordura epicárdica, a duração da onda P (r=0,70; p < 0,01), o diâmetro do átrio esquerdo (r=0,67; p < 0,01) e a massa ventricular (r=0,58; p < 0,01). Uma correlação inversa foi observada entre a gordura epicárdica e a fração de ejeção do ventrículo esquerdo (r=- 0,52; p < 0,01). Na análise de regressão múltipla, a gordura epicárdica permaneceu correlacionada com a duração da onda P, o diâmetro do átrio esquerdo e a fração de ejeção do ventrículo esquerdo (p < 0,05). Em 60% dos obesos, foi identificada alguma alteração na geometria ventricular. Uma associação entre a espessura da gordura epicárdica maior ou igual a 3,7 mm e a presença de remodelamento ventricular geométrico foi demonstrada (p=0,03). No pós-operatório, observou-se uma redução do índice de massa corporal, da proteína C reativa e da gordura epicárdica (p < 0,01). Uma redução da duração da onda P e um aumento da fração de ejeção do ventrículo esquerdo também foram observados (p < 0,01). Na análise de regressão múltipla esses achados permaneceram correlacionados à redução da gordura epicárdica (p < 0,05), independente da variação do índice de massa corporal e da proteína C reativa. Conclusões: Em obesos mórbidos sem outras comorbidades, a gordura epicárdica foi associada a um aumento da duração da onda P, do diâmetro do átrio esquerdo e da massa ventricular, além de uma menor fração de ejeção do ventrículo esquerdo. A espessura da gordura epicárdica igual ou acima de 3,7 mm foi associada a alterações do remodelamento ventricular. A redução da gordura epicárdica após a cirurgia bariátrica foi associada com a redução da duração da onda P e o aumento da fração de ejeção do ventrículo esquerdo, independente da variação do índice de massa corporal e da proteína C reativa / Epicardial fat is biologically active and its thickness is increased in obese subjects. The effects of epicardial fat on cardiac remodeling are still not fully understood. In the present study we evaluated epicardial fat and its influence on cardiac remodeling of morbidly obese, before and after bariatric surgery. Methods: We prospectively recruited 20 morbid obese subjects without other comorbidities and 20 control subjects at Hospital das Clínicas, Universidade de São Paulo. Participants underwent clinical and laboratory assessment, measure of P-wave duration on ECG and transthoracic echocardiogram. The obese group repeated this evaluation 12 months after the bariatric surgery. To compare continuous variables, we used t Student test (paired and nonpaired), Mann-Whitney and Wilcoxson tests. To define the correlation between linear variables we used Pearson correlation coefficient. To define the association between categorical variables we used Fisher exact test. A multiple regression analysis was performed to assess the association between dependent and independent variables. Data were analyzed by software R. A p value below 0.05 was considered statistically significant. Results: Preoperatively, we observed high levels of C-reactive protein, longer P-wave duration, larger ventricular mass and left atrial diameter in obese subjects compared to the controls (p < 0.05). Lower left ventricle ejection fraction was observed in the obese group (p < 0.05). Epicardial fat was higher among obese subjects (p < 0.01). A positive correlation was found between epicardial fat and P-wave duration (r=0.70; p < 0.01), left atrial diameter (r=0.67; p < 0.01), and ventricular mass (r=0.58; p < 0.01). An inverse correlation was observed between epicardial fat and left ventricle ejection fraction (r=-0.52; p < 0.01). In the multiple regression analysis, epicardial fat remained correlated with P-wave duration, left atrial diameter and left ventricle ejection fraction (p < 0.05). In 60% of the obese subjects, there was some abnormality in ventricular geometry. We showed association between thickness of epicardial fat equal to or higher than 3.7 mm and presence of geometric ventricular remodeling (p=0.03). Postoperatively, we observed reduction in body mass index, C-reactive protein and epicardial fat (p < 0.01). Reduction in P-wave duration and an increase in left ventricle ejection fraction were also observed (p < 0.01). In the multiple regression analysis, these findings were correlated with reduction in epicardial fat (p < 0.05), regardless of the variation in body mass index and C-reactive protein. Conclusion: In morbid obese subjects without other comorbidities, epicardial fat was associated with increase in P-wave duration, left atrial diameter and ventricular mass, in addition to smaller left ventricle ejection fraction. Epicardial fat thickness equal to or greater than 3.7 mm was associated with abnormalities in ventricular remodeling. Reduction of epicardial fat after bariatric surgery was associated with reduction of P-wave duration and increase in left ventricle ejection fraction, regardless of the variation in body mass index and C-reactive protein

Made available in DSpace on 2016-08-19T18:16:09Z (GMT). No. of bitstreams: 1 Dissertacao THALITA DE ALBUQUERQUE VERAS.pdf: 1228117 bytes, checksum: ef9a2fea64bd1f59d9de3091281a24f4 (MD5) Previous issue date: 2014-11-26 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Introduction: The association between hyperuricemia and cardiovascular risk factors, especially the metabolic syndrome and his components, has been widely documented. Despite of don t be a treatment directed to hyperuricemia, has been verified that, the bariatric surgery allowed to reach improvements on the acid uric metabolism. Methodology: It was accomplished an retrospective, observational, coorte and analytic study, through secondary data , women s with diagnosed metabolic syndrome according to the criterions of the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III), 2001, underwent to Roux-en-Y gastric bypass mixed technique, in the period of january of 2012 to january of 2014. Of 391 medical records only 84 attempted to the selected sample criterions. It was collected the plasmatic acid uric values, the syndrome metabolic components and otters cardiovascular risk factors. Results: It was noticed a high prevalence of young adult woman s (27 to 34 years), 38,1% (32) , mean age to 33,5±10,1 years, with the mean Body Mass Index (BMI) levels to 39,3±4,3 Kg/m², degree II of obesity occurred with more often in 47,6% (40). The mean of triglycerides (TG) (202,1±92,8 mg/dL), diabetes glucose plasma (135,3±42,6 mg/dL), diastolic e systolic blood pressure, low density lipoprotein (LDL-c) (126,3± 30,5 mg/dL), very low density lipoprotein (VLDL-c) (41,2±19,2 mg/dL) all this data demonstrated an increase when the uric acid levels was &#8805; 6 mg/dL, however there was a significant difference only to the variables triglycerides (p=0,0435) , of the hypertensives patients diastolic blood pressure (p=0,0413), and VLDL-c (p=0,0357). The only variable that was positively and significantly correlated (p =0,0026) with the uric acid was the systolic blood pressure, however demonstrated a weak correlation (r=0,3249). And those who presented uric acid level < 6mg/dL and 3, 4 e 5 aggregation of the metabolic syndrome components, the frequency was 100% (43), 77, 8% (21) and 35, 7% (5), respectively, demonstrating reduction of the frequency according with the inclusion of one more syndrome metabolic criteria. And on the cutoff &#8805; 6mg/dL, that define hyperuricemia, occurred the opposite, and on the aggregation 4 and 5 the frequency was 22, 2% (6) and 66, 3% (9), and none of the participant with hyperuricemia on the aggregation 3. Conclusion: Surgery for Gastric Bypass Roux-Y was able to reduce the levels of uric acid and cardiometabolic control, including the metabolic syndrome. / Introdução: A associação entre os níveis de ácido úrico e fatores de risco cardiovascular, especialmente, na síndrome metabólica e com seus componentes tem sido amplamente documentada. Apesar de não ser um tratamento dirigido à hiperuricemia, tem sido verificado que a cirurgia bariátrica permite alcançar uma melhoria no metabolismo do ácido úrico. Objetivo: Verificar o impacto da cirurgia bariátrica na uricemia e nos indicadores de risco cardiovascular, e associação, em mulheres com síndrome metabólica. Metodologia: Foi realizado um estudo retrospectivo, observacional do tipo coorte e analítico com coleta de dados secundários de mulheres com Síndrome Metabólica, diagnosticadas de acordo com os critérios do Programa Nacional de Educação sobre Colesterol, ligado ao III Painel de Tratamento do Adulto (NCEP-ATP III), 2001, submetidas à cirurgia bariátrica pela técnica mista do bypass gástrico em Y de Roux, no período de janeiro de 2012 a janeiro de 2014. De 391 prontuários, apenas 84 atenderam aos critérios de seleção da amostra. Foram coletados valores de ácido úrico plasmático, componentes da síndrome metabólica e outros fatores de risco cardiovascular. Resultados: Notou-se elevada prevalência de mulheres adultas jovens (faixa de 27 a 34 anos), 38,1% (32), média de idade de 33,5±10,1 anos, Índice de Massa Corporal (IMC) com média de 39,3±4,3kg/m² e grau II de obesidade foi o mais frequente, 47,6% (40). Demonstrou-se que as médias de triglicerídeos (202,1±92,8 mg/dL), glicemia das diabéticas (135,3±42,6 mg/dL), pressão arterial sistólica e diastólica, lipoproteína de baixa densidade (LDL-c) (126,3±30,5 mg/dL), e lipoproteínas de muito baixa densidade (VLDL-c) (41,2±19,2 mg/dL) foram mais elevadas quando os níveis de ácido úrico estavam &#8805; 6mg/dL, no entanto, houve diferença significativa apenas para as variáveis triglicerídeos (p=0,0435), pressão arterial diastólica das hipertensas (p=0,0413) e VLDL-c (p=0,0357). E, aquelas que apresentaram níveis de ácido úrico < 6mg/dL e aglomerado 3, 4 e 5 de componentes da SM, a frequência foi de 100% (43), 77,8% (21) e 35,7% (5), respectivamente, mostrando redução da frequência de acordo com a inclusão de mais um critério da síndrome metabólica. No ponto de corte &#8805; 6 mg/dl, que determina a hiperuricemia, ocorreu o inverso, no aglomerado 4 e 5 a frequência foi de 22,2% (6) e 64,3% (9), e nenhuma participante com hiperuricemia no aglomerado 3. Conclusão: A cirurgia do bypass gástrico em Y de Roux foi capaz de reduzir os níveis de ácido úrico e controle cardiometabolico, incluindo a Síndrome Metabólica.

Submitted by Rosivalda Pereira (mrs.pereira@ufma.br) on 2017-05-17T18:34:39Z No. of bitstreams: 1 ThalitaCamara.pdf: 1228117 bytes, checksum: ef9a2fea64bd1f59d9de3091281a24f4 (MD5) / Made available in DSpace on 2017-05-17T18:34:39Z (GMT). No. of bitstreams: 1 ThalitaCamara.pdf: 1228117 bytes, checksum: ef9a2fea64bd1f59d9de3091281a24f4 (MD5) Previous issue date: 2014-11-26 / Introduction: The association between hyperuricemia and cardiovascular risk factors, especially the metabolic syndrome and his components, has been widely documented. Despite of don’t be a treatment directed to hyperuricemia, has been verified that, the bariatric surgery allowed to reach improvements on the acid uric metabolism. Methodology: It was accomplished an retrospective, observational, coorte and analytic study, through secondary data , women’s with diagnosed metabolic syndrome according to the criterions of the National Cholesterol Education Program Adult Treatment Panel – III (NCEP-ATP III), 2001, underwent to Roux-en-Y gastric bypass mixed technique, in the period of january of 2012 to january of 2014. Of 391 medical records only 84 attempted to the selected sample criterions. It was collected the plasmatic acid uric values, the syndrome metabolic components and otters cardiovascular risk factors. Results: It was noticed a high prevalence of young adult woman’s (27 to 34 years), 38,1% (32) , mean age to 33,5±10,1 years, with the mean Body Mass Index (BMI) levels to 39,3±4,3 Kg/m², degree II of obesity occurred with more often in 47,6% (40). The mean of triglycerides (TG) (202,1±92,8 mg/dL), diabetes glucose plasma (135,3±42,6 mg/dL), diastolic e systolic blood pressure, low density lipoprotein (LDL-c) (126,3± 30,5 mg/dL), very low density lipoprotein (VLDL-c) (41,2±19,2 mg/dL) all this data demonstrated an increase when the uric acid levels was ≥ 6 mg/dL, however there was a significant difference only to the variables triglycerides (p=0,0435) , of the hypertensives patients diastolic blood pressure (p=0,0413), and VLDL-c (p=0,0357). The only variable that was positively and significantly correlated (p =0,0026) with the uric acid was the systolic blood pressure, however demonstrated a weak correlation (r=0,3249). And those who presented uric acid level < 6mg/dL and 3, 4 e 5 aggregation of the metabolic syndrome components, the frequency was 100% (43), 77, 8% (21) and 35, 7% (5), respectively, demonstrating reduction of the frequency according with the inclusion of one more syndrome metabolic criteria. And on the cutoff ≥ 6mg/dL, that define hyperuricemia, occurred the opposite, and on the aggregation 4 and 5 the frequency was 22, 2% (6) and 66, 3% (9), and none of the participant with hyperuricemia on the aggregation 3. Conclusion: Surgery for Gastric Bypass Roux-Y was able to reduce the levels of uric acid and cardiometabolic control, including the metabolic syndrome. / ntrodução: A associação entre os níveis de ácido úrico e fatores de risco cardiovascular, especialmente, na síndrome metabólica e com seus componentes tem sido amplamente documentada. Apesar de não ser um tratamento dirigido à hiperuricemia, tem sido verificado que a cirurgia bariátrica permite alcançar uma melhoria no metabolismo do ácido úrico. Objetivo: Verificar o impacto da cirurgia bariátrica na uricemia e nos indicadores de risco cardiovascular, e associação, em mulheres com síndrome metabólica. Metodologia: Foi realizado um estudo retrospectivo, observacional do tipo coorte e analítico com coleta de dados secundários de mulheres com Síndrome Metabólica, diagnosticadas de acordo com os critérios do Programa Nacional de Educação sobre Colesterol, ligado ao III Painel de Tratamento do Adulto (NCEP-ATP III), 2001, submetidas à cirurgia bariátrica pela técnica mista do bypass gástrico em Y de Roux, no período de janeiro de 2012 a janeiro de 2014. De 391 prontuários, apenas 84 atenderam aos critérios de seleção da amostra. Foram coletados valores de ácido úrico plasmático, componentes da síndrome metabólica e outros fatores de risco cardiovascular. Resultados: Notou-se elevada prevalência de mulheres adultas jovens (faixa de 27 a 34 anos), 38,1% (32), média de idade de 33,5±10,1 anos, Índice de Massa Corporal (IMC) com média de 39,3±4,3kg/m² e grau II de obesidade foi o mais frequente, 47,6% (40). Demonstrou-se que as médias de triglicerídeos (202,1±92,8 mg/dL), glicemia das diabéticas (135,3±42,6 mg/dL), pressão arterial sistólica e diastólica, lipoproteína de baixa densidade (LDL-c) (126,3±30,5 mg/dL), e lipoproteínas de muito baixa densidade (VLDL-c) (41,2±19,2 mg/dL) foram mais elevadas quando os níveis de ácido úrico estavam ≥ 6mg/dL, no entanto, houve diferença significativa apenas para as variáveis triglicerídeos (p=0,0435), pressão arterial diastólica das hipertensas (p=0,0413) e VLDL-c (p=0,0357). E, aquelas que apresentaram níveis de ácido úrico < 6mg/dL e aglomerado 3, 4 e 5 de componentes da SM, a frequência foi de 100% (43), 77,8% (21) e 35,7% (5), respectivamente, mostrando redução da frequência de acordo com a inclusão de mais um critério da síndrome metabólica. No ponto de corte ≥ 6 mg/dl, que determina a hiperuricemia, ocorreu o inverso, no aglomerado 4 e 5 a frequência foi de 22,2% (6) e 64,3% (9), e nenhuma participante com hiperuricemia no aglomerado 3. Conclusão: A cirurgia do bypass gástrico em Y de Roux foi capaz de reduzir os níveis de ácido úrico e controle cardiometabolico, incluindo a Síndrome Metabólica.

A obesidade está associada com um perfil hormonal reprodutivo alterado que afeta ambos os sexos. A perda de peso decorrente de intervenções cirúrgicas normaliza os níveis androgênicos nos indivíduos masculinos no curto prazo, porém nenhum estudo avaliou se estas alterações são duradouras, e se estão relacionadas a uma melhora da qualidade de vida sexual destes indivíduos. Objetivos: Avaliar o comportamento dos hormônios sexuais masculinos e a qualidade de vida sexual nos indivíduos obesos graves que perderam peso após a cirurgia bariátrica, em um seguimento pós-operatório cinco anos. Materiais e Métodos: Realizou-se um estudo prospectivo e observacional com 52 pacientes, que foram divididos em três grupos. O grupo operado compreendeu 23 indivíduos obesos graves que foram submetidos à cirurgia bariátrica há mais de cinco anos na Disciplina de Cirurgia do Aparelho Digestivo do Departamento de Gastroenterologia da Faculdade de Medicina da Universidade de São Paulo (FMUSP). O grupo obeso controle era formado de 14 indivíduos obesos (IMC 30 kg/m2) atendidos no ambulatório da mesma instituição. O grupo controle não-obeso foi composto de 15 indivíduos com IMC < 30 kg/m2 selecionados de um ambulatório de urologia geral. Foram avaliados parâmetros antropométricos (índice de massa corporal (IMC), circunferência abdominal, volume testicular, ginecomastia e pressão arterial), exames bioquímicos, análise hormonal (incluindo testosterona total (TT), testosterona livre (TL), globulina ligadora dos hormônios sexuais (SHBG), sulfato de dehidroepiandrosterona (SDHEA), dehidroepiandrosterona (DHEA), hormônio folículo-estimulante (FSH), hormônio luteinizante (LH), estradiol (E2), prolactina, hormônio tireoestimulante (TSH), tiroxina (T4) e leptina), e questionários validados IIEF e AMS. O protocolo foi aplicado entre agosto de 2010 e janeiro de 2011. Resultados: A idade média (dp) dos participantes foi 47.6 ± 12.6, 53.1 ± 8.7 e 51.4 ± 9.8, respectivamente, o IMC nos pacientes operados reduziu de 59.8 ± 12.1 kg/m2 para 35.1 ± 7.7 kg/m2 (P<0.001), e o percentual de perda do excesso de peso médio foi de 71%. Nos três grupos, respectivamente, foram encontrados os seguintes valores hormonais relevantes, sendo que os demais hormônios não se mostraram diferentes (média ± dp): TT- 534.2 ± 231.4, 297.0 ± 110.3 e 494.7 ± 143.3 (P=0.001); TL - 349.4 ± 169.2, 243.3 ± 75 e 378.8 ± 147.6 (P=0.03); SHBG - 48.8 ± 23.8, 23.5 ± 8.3 e 32.8 ± 15.7 (P=0.001); insulina - 7.9 ± 6.5, 17.1 ± 6.9 e 5.7 ± 2.6 (P<.001). No grupo operado, TT se correlacionou negativamente com IMC (P<0.02), circunferência abdominal (P=0.009), níveis de insulina (P=0.004), leptina (P=0.001) e glicemia (P=0.002). SHBG correlacionou-se negativamente com IMC (P=0.002), circunferência abdominal (P=0.003), triglicérides (P=0.02), e leptina (P=0.01). TL correlacionou-se negativamente com idade (P=0.003), glicemia (P=0.01) e insulina (P=0.03). Os exames de função hepática TGO/ALT, TGP/AST e GGT mostraram diferenças estatísticas significantes entre os grupos, assim como HDL e LDL - colesterol, PCR, leucócitos e fibrinogênio (P<0.05). No questionário IIEF, os índices médios globais do grupo obeso operado foram melhores do que os do grupo obeso controle (56.7 ± 14.5, 49.1 ± 11.9 e 61.7 ± 7.5), embora sem significância estatística para qualquer das três populações. Na análise por domínios deste questionário, houve diferença estatística significante relativa à função erétil (P=0.01) e satisfação sexual de modo geral (p=0.04), mas somente entre os grupos controles obesos e não- obesos. O questionário AMS mostrou que, embora sem significância estatística, os indivíduos do grupo operado apresentavam o mesmo padrão de respostas dos não-obesos controles (31.0 ± 9.4, 37.4 ± 15.1 e 31.0 ± 8.8). Conclusão: Após cinco anos ou mais, os níveis de alguns hormônios sexuais e certos aspectos da qualidade de vida sexual mostraram-se melhores nos operados que em obesos controles, e compatíveis com os da população não obesa. Tal sucedeu a despeito da manutenção na categoria de obesos de quase ¾ dos indivíduos. Pode-se afirmar, portanto, que a cirurgia bariátrica, ainda sem reverter a totalidade das anormalidades androgênicas, revelou-se um método útil e vantajoso a longo prazo sob este prisma / Obesity is associated with an altered reproductive hormonal profile that can affect both sexes. The weight loss caused by bariatric surgery normalizes male hormone levels in the short term. However, the outcome of the levels of these hormones in the long term, and whether they are related to an improved sexual quality of life has not been evaluated. Objective: Evaluate the outcome of sex hormones and sexual quality of life of male subjects who underwent bariatric surgery for morbid obesity over a long follow-up period (> 5 years). Material and Methods: This was a prospective, observational study. Male patients (N=52) were consecutively recruited and three groups were considered: I) Bariatric subjects who underwent Roux-en-Y gastric bypass (RYGB) >5 years earlier (n=23) at the Division of Digestive Surgery, Department of Gastroenterology at the Faculty of Medicine, São Paulo University; II) Overweight and obese non-operated controls (n= 14) (IMC 30 kg/m2) recruited from the outpatient clinic of the same institution; III) Non-obese controls (n= 15) (IMC < 30 kg/m2) recruited from a urological outpatient clinic. Clinical, hormonal and biochemical parameters were evaluated, including retrospective information collected from hospital files. Variables analyzed were anthropometric parameters (body mass index (BMI), waist circumference, testicular volume, gynecomastia and blood pressure), inflammatory markers (C- reactive protein, fibrinogen), total testosterone (TT), free testosterone (FT), sex hormone binding globulin (SHBG), follicle-stimulating hormone (FSH), luteinizing hormone (LH), dehydroepiandrosterone (DHEA), DHEA sulfate (DHEA-S), estradiol (E2), prolactin, thyroid-stimulating hormone (TSH), thyroxine (T4) and leptin, along with two validated questionnaires (International Index of Erectile Function (IIEF) and the Aging Males` Symptoms (AMS). The protocol was applied between August 2010 and January 2011. Results: Mean age (sd) of the subjects was 47.6 ± 12.6, 53.1 ± 8.7 and 51.4 ± 9.8, respectively, BMI of the operated patients decreased from 59.8 ± 12.1 kg/m2 to 35.1 ± 7.7 kg/m2 (P<0.001), and mean percentage weight loss was 71%. In the three groups, respectively, the following hormones showed significant differences in mean levels (mean ± sd): TT- 534.2 ± 231.4, 297.0 ± 110.3 and 494.7 ± 143.3 (P=0.001); FT- 349.4 ± 169.2, 243.3 ± 75 and 378.8 ± 147.6 (P=0.03); SHBG - 48.8 ± 23.8, 23.5 ± 8.3 and 32.8 ± 15.7 (P=0.001); insulin - 7.9 ± 6.5, 17.1 ± 6.9 and 5.7 ± 2.6 (P<.001). In the operated group, TT correlated negatively with BMI (P<0.02), waist circumference (P=0.009), insulin levels (P=0.004), leptin (P=0.001) and glucose (P=0.002). SHBG correlated negatively with IMC (P=0.002), waist circumference (P=0.003), triglycerides (P=0.02), and leptine (P=0.01). TL correlated negatively with age (P=0.003), glucose (P=0.01) and insulin (P=0.03). Liver function tests (LFT) TGO/ALT, TGP/AST and gamma-glutamyltransferase (GGT) showed statistically significant differences among the groups, as well as HDL and LDL cholesterol, CRP, leucocytes and fibrinogen (P<0.05). The operated group scored higher in the IIEF questionnaire than the obese controls (56.7 ± 14.5, 49.1 ± 11.9 e 61.7 ± 7.5), but no significant differences among the three groups were found. Significant improvements in the IIEF domains erectile function (P=0.01) and overall sexual satisfaction (p=0.04) were found, but only between the obese controls and non-obese individuals. In the AMS questionnaire, operated patients and non-obese individuals showed the same pattern of responses, but no significant differences between these groups could be found (31.0 ± 9.4, 37.4 ± 15.1 e 31.0 ± 8.8). Conclusion: Despite almost ¾ of patients that were submitted to bariatric surgery 6- 16 years earlier were still categorized in the obese category, these individuals have shown a healthier sex hormone profile than obese control individuals and, in some aspects, they behaved like non-obese individuals. Bariatric surgery proved to be a reliable method to improve both male androgens and sexual quality of life in the longterm, even when a complete resolution of the hormonal imbalance has not been achieved

Syfte: Syftet med denna litteraturstudie var att utifrån vetenskaplig litteratur beskriva patienters upplevelser av livskvalitet i samband med genomförd bariatrisk kirurgi utifrån aspekterna mental och fysisk hälsa, samt att granska och redovisa valda vetenskapliga artiklar. Metod: Författarna utförde en beskrivande litteraturstudie vilken baserades på 12 vetenskapliga artiklar. Eftersökningar utfördes på databaserna Cinahl, PubMed via Medline och Mosby´s index. Huvudresultat: Flertalet studier påvisade att övervikt och fetma påverkade deltagarnas upplevelser av livskvalitet på ett negativt sätt. Livskvalitetssänkande faktorer utgjordes av bl.a. brist på självförtroende, skamkänslor samt rädslor för följdproblematik. Bariatrisk kirurgi sågs för flertalet deltagare som en chans till förbättrad mental och fysisk hälsa, där exempelvis självförtroende, ett mer socialt aktivt liv och förbättrad rörelseförmåga var motiverande faktorer, vilka även förbättrade deltagarnas upplevelser av livskvalitet postoperativt. Trots flertalet positiva resultat, framkom även negativa upplevelser bland deltagarna. Negativa effekter, såsom smärta och kosmetiska defekter bidrog för dessa deltagare till försämrad upplevelse av livskvalitet. Slutsats: Bariatrisk kirurgi bidrog i de flesta fall till förbättrad mental och fysisk hälsa samt förbättrad upplevelse av livskvalitet i jämförelse med innan utförd kirurgi. För att uppnå fler resultat som skildrar patienters subjektiva upplevelser beskrivna med ord finns ett behov av vidare forskning av kvalitativ ansats. / Aim: The aim of this literature review was to by scientific articles describe patient’s experiences in conjunction with undergone bariatric surgery and to examine and report on selected scientific articles. Method: The authors performed a descriptive literature review that was based on 12 scientific articles research by databases Cinahl, PubMed through Medline and Mosby´s index. Main result: Several studies showed that overweight and morbid obesity had negative influence on the participant’s experience of quality of life. Factors that caused this experience were for example lack of self-esteem, feelings of shame and fears of consequential problems. Bariatric surgery were seen as a chance to improve mental and physical health, where self-esteem, a active social life and improved mobility were motivating factors that also improved the participant’s quality of life postoperative. Despite several positive outcomes, negative experiences were also revealed among the participants. Negative effects, such as pain and cosmetic defects, contributed for these participants to increased experiences of quality of life. Conclusion: Bariatric surgery in most cases contributes to improved mental and physical health and improved experiences of quality of life, then before undergone surgery. To achieve more results that in words, describes patient’s subjective experiences there is a need of further research with a qualitative approach.

Όπως φαίνεται από τα ερευνητικά δεδομένα, η παχυσαρκία αποτελεί ένα από τα πιο σημαντικά προβλήματα των συγχρόνων κοινωνιών, καθώς αυτή αποτελεί μια προδιαθεσική κατάσταση και έναν παράγοντα κινδύνου για την εμφάνιση διαφόρων παθήσεων. Η παχυσαρκία αποτελεί ένα σημαντικό παράγοντα κινδύνου για ανάπτυξη καρδιοαγγειακής νόσου, σακχαρώδη διαβήτη, διαφόρων μορφών καρκίνου και άλλων χρόνιων παθήσεων όπως οστεοαρθρίτιδας, νόσων του ήπατος και των νεφρών, υπνικής άπνοιας, ουρικής αρθρίτιδας, γαστροοισοφαγικής παλινδρόμησης και κατάθλιψης. Τα μακροπρόθεσμα αποτελέσματα της δίαιτας, της άσκησης και της φαρμακευτικής αγωγής στην μείωση του σωματικού βάρους παραμένουν σχετικά πτωχά, έως αναποτελεσματικά. Η βαριατρική χειρουργική είναι η πιο αποτελεσματική θεραπεία για την παχυσαρκία και συνιστάται για όλους τους ασθενείς με ΒΜΙ ≥40 kg/m2 (νοσογόνος παχυσαρκία) και για όσους έχουν ΒΜΙ ≥35 kg/m2 οι οποίοι παρουσιάζουν και συμπαρομαρτούσες διαταραχές, οι οποίες αποτελούν συννοσηρότητα της παχυσαρκίας, έπειτα από αποτυχία άλλων θεραπευτικών προσπαθειών, όπως η αλλαγή του τρόπου ζωής με δίαιτα, άσκηση και φαρμακευτική αγωγή, οι οποίες είναι τις περισσότερες φορές αναποτελεσματικές. Η παρούσα μελέτη διενεργήθηκε στην Χειρουργική Κλινική του Ιατρικού Τμήματος του Πανεπιστημίου Πατρών, μεταξύ του Οκτωβρίου του 2008 και του Απριλίου του 2010. Το δείγμα των ασθενών της μελέτης αποτελούσαν 80 διαδοχικοί ασθενείς (50 γυναίκες και 30 άνδρες), οι οποίοι εισήχθησαν στην χειρουργική κλινική για να υποβληθούν σε βαριατρική χειρουργική επέμβαση. Οι ασθενείς ενημερώθηκαν για την μελέτη προτού υποβληθούν στην χειρουργική επέμβαση, και συμφώνησαν να λάβουν μέρος σε αυτή. Ο σκοπός της μελέτης ήταν να εκτιμήσει την ποιότητα ζωής (HRQOL) και την σεξουαλική λειτουργικότητα (SF), πριν και μετά από βαριατρική χειρουργική επέμβαση σε ασθενείς με νοσογόνο παχυσαρκία. Η ποιότητα ζωής είναι μια πολυδιάστατη έννοια η οποία περιλαμβάνει τομείς που σχετίζονται με την φυσική (σωματική), ψυχική, συναισθηματική και κοινωνική λειτουργικότητα του ατόμου. Η ποιότητα ζωής (HRQOL), εκφράζει τον αντίκτυπο που έχει μια νοσηρή κατάσταση ή μια θεραπευτική αγωγή, στην αίσθηση σωματικής και ψυχικής ευεξίας του ατόμου και στην καθημερινή προσωπική και κοινωνική του ζωή. Η σεξουαλικότητα είναι μια εξίσου σημαντική παράμετρος της ανθρώπινης ευεξίας και ευημερίας. Παρουσιάζει αμφιδρομη αλληλεπίδραση με την ψυχική υγεία και με την ποιότητα ζωής. Τα αποτελέσματα των ερευνών δείχνουν ότι η παχυσαρκία επιδρά αρνητικά στην σεξουαλική ζωή του ατόμου. Σχετίζεται με σεξουαλική δυσλειτουργία στις παχύσαρκες γυναίκες και με στυτική δυσλειτουργία και γενικότερη σεξουαλική δυσλειτουργία στους παχύσαρκους άνδρες. Αυτό καθιστά πλέον αναγκαία την εκτίμηση της σεξουαλικής λειτουργικότητας, όταν αξιολογούμε την αποτελεσματικότητα των διαφόρων θεραπειών για την παχυσαρκία. Όλοι οι ασθενείς που αποδέχθηκαν την συμμετοχή τους στην μελέτη συμπλήρωσαν το SF-36 ερωτηματολόγιο για την εκτίμηση της HRQOL. Η σεξουαλική λειτουργικότητα εκτιμήθηκε με το δείκτη γυναικείας σεξουαλικής λειτουργίας (FSFI-Female Sexual Function Index), για τις γυναίκες και με το Διεθνή Δείκτη της στυτικής λειτουργίας ( IIEF -International Index of Erectile Function), για τους άνδρες. Οι ασθενείς συμπλήρωσαν τα ερωτηματολόγια με την συνδρομή ενός ατόμου από την ερευνητική ομάδα, το οποίο καθοδηγούσε τους ασθενείς για να καταλάβουν τις ιδιαιτερότητες των ερωτηματολογίων και να διευκρινίσει τυχόν ασάφειες στις ερωτήσεις που δεν μπορούσαν να διαχειριστούν οι ίδιοι οι ασθενείς, πρόσφερε βοήθεια όπου χρειαζόταν και έλεγχε για τυχόν παραλείψεις στην απάντηση των ερωτήσεων . Οι ασθενείς συμπλήρωσαν τα ερωτηματολόγια πριν το χειρουργείο(Τ1), καθώς και 1 μήνα(Τ2), 6 μήνες(Τ3) και 1 χρόνο(Τ4) μετά το χειρουργείο. Κοινωνικο-δημογραφικά δεδομένα συλλέχτηκαν που συμπεριλάμβαναν την ηλικία, το φύλο, την χρήση καπνού, το μορφωτικό επίπεδο καθώς και την οικογενειακή κατάσταση. Η παρουσία συμπαρομαρτούντων παθολογικών καταστάσεων διαπιστώθηκε από τα ιστορικά των ασθενών. Οι γυναίκες ερωτήθηκαν και για την γυναικολογική τους κατάσταση (για τον αν είχαν κανονικό ή ακανόνιστο κύκλο ή αν ήταν μετεμμηνοπαυσιακές). Η μελέτη εγκρίθηκε από την αρμόδια Επιτροπή Ηθικής και Δεοντολογίας του Νοσοκομείου και όλοι οι ασθενείς έδωσαν την έγγραφη ενημερωμένη συγκατάθεσή τους πριν την είσοδό τους στην μελέτη. Όλοι οι ασθενείς ήταν κατάλληλοι για βαριατρική χειρουργική επέμβαση σύμφωνα με τις υφιστάμενες ενδείξεις. Η σοβαρότητα της παχυσαρκίας μετρήθηκε με τον Δείκτη Μάζας Σώματος (ΒΜΙ) σε Kg βάρους σώματος διηρημένα με το ύψος του ατόμου σε μέτρα εις το τετράγωνο (kg/m2). Ενήλικες με ΒΜΙ ≥25kg/m2 θεωρούνται υπέρβαροι, με ΒΜΙ ≥30 kg/m2 θεωρούνται παχύσαρκοι και με ΒΜΙ ≥40 kg/m2 ως πάσχοντες από νοσογόνο παχυσαρκία (νοσηρά παχύσαρκοι). Το είδος της χειρουργικής επέμβασης που εφαρμόσθηκε σε κάθε ασθενή βασίστηκε σε ειδικά χειρουργικά κριτήρια σύμφωνα με χειρουργικό πλάνο το οποίο εφαρμόζεται στην χειρουργική κλινική. Σύμφωνα με αυτό, ασθενείς με ΒΜΙ ≥50 kg/m2 υπεβλήθησαν σε χολοπαγκρεατική εκτροπή με Roux-en-Y διαμόρφωση,όπως τροποποιήθηκε στο κέντρο μας (BPD), ενώ ασθενείς με ΒΜΙ<50kg/m2 υποβλήθηκαν σε γαστρικό bypass με μακρές έλικες (RYGBP-LL), ή επιμήκη γαστρεκτομή (SG), ανάλογα με τις συνυπάρχουσες νοσηρότητες και τις διαιτητικές συνήθειες. Αποτελέσματα Η στατιστική ανάλυση έδειξε μια σημαντικού βαθμού μείωση του ΒΜΙ με πάροδο του χρόνου(p<0,001). Όλοι οι τομείς της σεξουαλικής λειτουργίας βελτιώθηκαν μεταξύ του Τ1 και Τ4, με μόνη εξαίρεση την ανδρική οργασμική λειτουργία. Όλοι οι τομείς της HRQOL βελτιώθηκαν και αυτή η βελτίωση έφθασε στο μέγιστο επίπεδο ανάμεσα από το Τ2 και Τ3 χρονικό διάστημα. Το βασικό επίπεδο της HRQOL (Τ1), βρέθηκε να συσχετίζεται σημαντικά με την βελτίωση όλων των τομέων της HRQOL μετεγχειρητικά και η μείωση του ΒΜΙ βρέθηκε να συσχετίζεται μόνον με την βελτίωση στις βαθμολογίες στους τομείς του σωματικού ρόλου, του σωματικού πόνου και της ψυχικής υγείας. Τα βασικά επίπεδα της συνολικής σεξουαλικής ικανοποίησης, αποτελούσαν ανεξάρτητο στατιστικά σημαντικό προγνωστικό παράγοντα για την βελτίωση μετεγχειρητικά της συνολικής σεξουαλικής ικανοποίησης και στα δύο φύλα. Τα αποτελέσματα έδειξαν ότι η σωματική λειτουργία, η ζωτικότητα, ο σωματικός πόνος, και η γενική υγεία, βελτιώθηκαν όλα με την πρόοδο του χρόνου. Ο σωματικός ρόλος βελτιώθηκε με την πρόοδο του χρόνου και τελικά οι πορείες του συναισθηματικού ρόλου, και της ψυχικής υγείας, ακολούθησαν τις ίδιες τάσεις. Τα αποτελέσματα για κάθε ηλικία και φύλο ήταν στατιστικά παρόμοια. Η σεξουαλική ποιότητα ζωής βελτιώθηκε 1 χρόνο μετά την βαριατρική χειρουργική επέμβαση και στους άνδρες και στις γυναίκες. Όλοι οι δείκτες συνηγορούν για το ότι η HRQOL και η σεξουαλική ποιότητα ζωής βελτιώθηκαν μετά το χειρουργείο σε σύγκριση με τα επίπεδα στα οποία βρισκόταν προ του χειρουργείου . Συμπεράσματα Η Βαριατρική χειρουργική συνοδεύεται από σημαντικού βαθμού μείωση του σωματικού βάρους (ΒΜΙ) και βελτίωση στην ποιότητα ζωής (HRQOL) και στην σεξουαλική λειτουργικότητα σε ασθενείς με νοσογόνο παχυσαρκία. Ο μεγαλύτερος βαθμός βελτίωσης παρατηρήθηκε ανάμεσα από τον 1 και 6 μήνες μετεγχειρητικά. Η βελτίωση στην HRQOL και στην σεξουαλική λειτουργικότητα συσχετιζόταν σημαντικά με τα βασικά προεγχειρητικά επίπεδα αυτών, ενώ η μείωση του ΒΜΙ συσχετιζόταν σημαντικά με βελτίωση μόνο σε 3 τομείς της HRQOL. Η τιμή του ΒΜΙ προεγχειρητικά συσχετιζόταν αντίστροφα με την επακόλουθη βελτίωση στην σωματική λειτουργικότητα και στο επίπεδο του σωματικού πόνου 1 χρόνο μετεγχειρητικά. / Obesity is considered one of the most relevant problems of modern societies, as it constitutes a predominant risk factor in the development of various diseases. Obesity is a significant risk factor for cardiovascular disease (CVD) and diabetes, for cancer and chronic diseases, including osteoarthritis, liver and kidney disease, sleep apnea and depression. The long term effects of diet, exercise and medical therapy on weight are relatively poor. Bariatric surgery is the most effective treatment for obesity and is considered for all patients with BMI more than 40 kg/m2 and for those with a BMI of more than 35 kg/m2 with concomitant obesity related conditions, after failure of other options as dietary, lifestyle and drug administration, which are often ineffective. The current study was conducted in the Department of Surgery of the University of Patras Medical School, between October 2008 and April 2010. Our sample are 80 (30 men and 50 women) patients who admitted in the Surgery Clinic to undergo a Bariatric Operation.The patients were approached before the operation and invited to take part in the study. The purpose of the study was to measure the Health related quality of life and Sexual functioning, before and after a Bariatric surgery in patients with morbid obesity. Health-related quality of life (HRQOL) is a multi-dimensional concept that includes domains related to physical, mental, emotional and social functioning. HRQOL focuses on the impact of a disease or a medical treatment, on one’s physical and mental wellbeing and on his every day private and social life. Sexuality is an equally important aspect of human well-being and prosperity. Sexual functioning interacts and influences the mental health and the quality of life. The research results show that obesity negatively affects the sexual quality life of the individual, associated with sexual dysfunction in obese women and with erectile dysfunction and general sexual dysfunction in obese men. This makes it necessary to assess sexual functioning when evaluating the effectiveness of several treatments for obesity. All the patients who accepted, were administered the questionnaires accessing Health related quality of life as the sort form 36 questionnaire (SF36). Sexual Functioning was estimated by the Female Sexual function Index (FSFI) for the women, and the International Index of Erectile Function (IIEF) for the men. Patients were administered the questionnaires by a member of our research team who offered assistance when needed and checked the answers for omissions. The patients completed the questionnaires before the operation and 1 month, 6 months and 1 year after the weight loss operation. Sociodemographic data were elicited including age, gender, smoking, educational level and marital status. Comorbidities information was obtained from the hospital charts. The women asked for their gynecological status. If the cycle was regular, irregular or if they were after menopausal. The study protocol was approved by the Institutional Review Board of The University Hospital of Patras, and all participants gave written inform consent before study entry. All the patients were eligible for bariatric operation according the indications for bariatric surgery. The severity of obesity was measured by the B.M.I. (kg/m2). Adults with BMI >25 kg/m2 are overweight, >30 kg/m2 are obese and >40 kg/m2 are considered morbidly obese. The type of procedure performed, was based on specific selection criteria according to an algorithm developed in our center, whereby patients with body mass index (BMI) over 50 kg/m2 undergo biliopancreatic diversion with RYGB (BPD-RYGB) as modified in our center, while patients with BMI under 50 kg/m2 undergo RYGB with long limb (RYGB-LL) or Sleeve Gastrectomy (S.G.), depending on comorbidities and eating habits. RESULTS: Body mass index (BMI) significantly decreased over time (p<0.001). Apart from male orgasm, all sexual functioning components as well as all SF-36 sub-scales improved between T1 and T4. The maximum improvement was observed between T2 and T3. Baseline HRQOL scores correlated with postoperative improvement in all HRQOL components. BMI improvement was correlated with improvement in role physical, bodily pain and mental health scores. Baseline total sexual satisfaction score independently predicted total satisfaction improvement in both genders. The basic levels of total sexual satisfaction (T1-Total Satisfaction score) were independent significant predictor for postoperative improvement in overall sexual satisfaction in both sexes. The results showed that Physical Function,Vitality, the Bodily Pain, and General Health, all improved with the progress of time. The Role Physical improved over time, and finally the improvement in Role Emotional, and Mental Health, followed the same trends. The results for each age and sex were statistically similar. Sexual quality of life improved 1 year after bariatric surgery, in both men and women. All indicators suggest that HRQOL and sexual quality of life improved postoperatively compared to the levels before surgery. CONCLUTIONS The Bariatric surgery accompanied by a significant degree of reduction in body weight (BMI) and improvement in quality of life (HRQOL) and sexual function in patients with morbid obesity. The greatest degree of improvement was observed between the 1 and 6 months postoperatively. The improvement in HRQOL and sexual function correlated significantly with basic preoperative levels of these, while the reduction in BMI was associated with significant improvement in only three aspects of HRQOL. The baseline levels of BMI was reversely significant associated with postoperatively improvement in physical functioning and bodily pain aspects of HRQOL, 1 year postoperatively.

Η βαριατρική χειρουργική είναι η μόνη διαδικασία που μπορεί να εφαρμοσθεί προκειμένου να επιτευχθεί μόνιμη απώλεια βάρους στην πλειονότητα των ασθενών με υπερ-νοσογόνο παχυσαρκία (130). Οι βαριατρικές χειρουργικές επεμβάσεις ορίζονται ως περιοριστικές, δυσαπορροφητικές ή περιοριστικές και δυσαπορροφητικές ταυτόχρονα. Οι περιοριστικού τύπου χειρουργικές επεμβάσεις έχουν συνδεθεί με αυξημένα ποσοστά αποτυχίας όσον αφορά στην απώλεια βάρους στους υπερ-παχύσαρκους ασθενείς, με αποτέλεσμα να παρατηρείται προοδευτική αύξηση της εφαρμογής βαριατρικών εγχειρήσεων δυσαπορροφητικού τύπου σε όλο τον κόσμο για αυτήν την υπο-ομάδα παχυσαρκίας (100, 108, 130, 131). Παρά την απώλεια βάρους που μπορεί να επιτευχθεί με αυτές τις χειρουργικές επεμβάσεις, οι μετεγχειρητικές ανεπάρκειες σε πρωτεΐνη, σίδηρο, βιταμίνες, άλατα και λιποδιαλυτές βιταμίνες αποτελούν σύνηθες φαινόμενο και απαιτούν χορήγηση συμπληρωμάτων προκειμένου να διατηρηθούν σε φυσιολογικά επίπεδα. Οι ανεπάρκειες αυτές οφείλονται στη δυσαπορρόφηση που προκύπτει από τη χειρουργική παράκαμψη τμημάτων του γαστρεντερικού σωλήνα, όπου τα διάφορα διατροφικά συστατικά απορροφούνται (118). Αν και αναμενόμενες, οι μεταβολικές ανωμαλίες πολύ συχνά δε διαγιγνώσκονται ή υποεκτιμούνται. Τα βιβλιογραφικά δεδομένα που αναφέρονται στις διατροφικές ανεπάρκειες που παρατηρούνται μετά τις βαριατρικές εγχειρήσεις είναι περιορισμένα, και απαρτίζονται από αναφορές σε μεμονωμένα περιστατικά ασθενών (124-126), από επισκοπήσεις αποτελεσμάτων παλαιότερων ερευνών (118, 132) και από περιστασιακές προοπτικές μελέτες (118, 131). Αν και υπάρχουν αρκετές πληροφορίες για διατροφικά συστατικά, όπως είναι η πρωτεϊνη, ο σίδηρος, η βιταμίνη Β12, το φυλλικό οξύ και το ασβέστιο (118, 131), τα στοιχεία που παρατίθενται για τις λιποδιαλυτές βιταμίνες είναι ελάχιστα και ελλιπή. Αυτό οφείλεται σε σημαντικό βαθμό στη δυσκολία απομόνωσης και προσδιορισμού των λιποδιαλυτών βιταμινών από τον ορό του αίματος, διαδικασία αρκετά επίπονη, δαπανηρή και χρονοβόρα. Οι περισσότεροι χειρούργοι προσπαθούν να ελέγξουν με έμμεσο τρόπο τα επίπεδα των λιποδιαλυτών βιταμινών, όπως για παράδειγμα με παρακολούθηση των τιμών της PTH, άνοδος της οποίας συνηγορεί σε πιθανή ελάττωση των επιπέδων της βιταμίνης D3 (133), ή με παρακολούθηση του χρόνου προθρομβίνης των ασθενών ανά τακτά χρονικά διαστήματα, αύξηση του οποίου μπορεί να υποδεικνύει την ελάττωση των επιπέδων της βιταμίνης Κ (134). Στις περισσότερες περιπτώσεις, η ανεπάρκεια των λιποδιαλυτών βιταμινών γίνεται αντιληπτή μόνο από τις κλινικές της εκδηλώσεις ( 124, 125, 135). Σκοπός αυτής της εργασίας ήταν η προεγχειρητική εκτίμηση των επιπέδων λιποδιαλυτών βιταμινών στο αίμα υπερ-παχύσαρκων ασθενών που υποβλήθηκαν σε δυσαπορροφητική επέμβαση κατά Roux-en-Y γαστρικής παράκαμψης με χολοπαγκρεατική εκτροπή, καθώς και η μετεγχειρητική παρακολούθησή τους για ένα έτος, ώστε να καταστεί δυνατή η άμεση εκτίμηση της κατάστασης των ασθενών ως προς τα αποθέματα βιταμίνης A, D E και Κ και να διερευνηθεί κατά πόσο η χειρουργικά προκαλούμενη δυσαπορρόφηση λίπους επηρεάζει την απορρόφησή και τα επίπεδα των λιποδιαλυτών βιταμινών στο αίμα. / Background: Bariatric surgery seems to be the only effective approach for the long-term management of morbid obesity. Weight loss after Roux-en-Y Gastric Bypass with Biliopancreatic Diversion (RYGBP/BPD) is mainly due to decreased calorie absorption secondary to fat malabsorption. Fat malabsorption may also cause essential fat-soluble vitamin deficiencies which may become clinically significant if not recognized and properly treated. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. In this work, an investigation was undertaken to examine preoperative and short-term (1 year) postoperative levels of fat-soluble vitamins in patients undergoing RYGBP/BPD. Methods: Study population consisted of 15 super-obese (BMI>50kg/m2) patients who had undergone RYGBP/BPD. Routine postoperative daily supplementation consisted of 4000 IU (1200 μg) vitamin A, 2000 IU (50 μg) vitamin D3, 10 mg vitamin E and 2000 mg calcium. Preoperative and postoperative serum levels of fat-soluble vitamins A, D3, 25(OH)D3, E, K2, were measured in these patients by HPLC. Results: All vitamin levels tended to decrease with time after RYGBP/BPD operation despite that all patients were taking daily multivitamin supplements p.o. postoperatively. One year after the bariatric operation, a significant decrease (P<0.05) in D3, 25(OH)D3, E and K2 levels was observed compared to the preoperative levels. This decrease led to vitamin deficiency one year after the operation, the incidence of which was 7,7% for vitamin A, 41.7% for vitamin 25(OH) D3 and 27.3% for K2. Concerning vitamin E, all patients had lower than normal levels even before operation and the deficiency insisted even after operation, despite the administration of vitamin supplements to the patients. The low preoperative serum vitamin E levels in the patients confirmed that obese individuals are at high risk of vitamin E deficiency. Conclusions: The serum levels of fat-soluble vitamins A, D, E and K decreased with time following RYGBP/BPD operation in morbidly obese patients, despite that the patients received vitamin supplements postoperatively. The results of our study indicate that patients undergoing the RYGBP/BPD operation need long-term postoperative monitoring of serum fat-soluble vitamin levels. This will facilitate the administration of appropriate doses of multivitamin supplements to these patients, preventing vitamin deficiency to become of clinical significance.

Background: In morbidly obese individuals (MO) cardiorespiratory comorbidities and body habitus challenge the perioperative management of anesthesia. To implement safe and reproducible routines for anesthesia and fluid therapy is the cornerstone in order to minimize anesthesia-related complications and to meet individual variability in rehydration needs. Methods: Paper I: Impact of rapid-weight-loss preparation prior to bariatric surgery was investigated. Prevalence of preoperative dehydration and cardiac function were assessed with transthoracic echocardiography (TTE). Paper II: The anesthetic technique for rapid sequence induction (RSI) in MO based on a combination of volatile and i.v. anesthetics was developed. Pre- and post-induction oxygenation, blood pressure levels and feasibility of the method was evaluated. Paper III: The preoperative ideal body weight based rehydration regime was evaluated by TTE. Paper IV: Need of rehydration during bariatric surgery was evaluated by comparing conventional monitoring to a more advanced approach (i.e. preoperative TTE and arterial pulse wave analysis). Results: Rapid-weight-loss preparation prior to bariatric surgery may expose MO to dehydration. TTE was shown to be a robust modality for preoperative screening of the level of venous return, assessment of filling pressures and biventricular function of the heart in MO. The combination of sevoflurane, propofol, alfentanil and suxamethonium was demonstrated to be a safe method for RSI regardless of BMI. The preoperative rehydration regime implemented by colloids 6 ml/kg IBW was an adequate treatment to obtain euvolemia. In addition, preoperative rehydration seems to increase hemodynamic stability during intravenous induction of anesthesia and even intraoperatively. Conclusion: This thesis describes a safe and comprehensive perioperative management of morbidly obese individuals scheduled for bariatric surgery. Hemodynamic and respiratory stability can be achieved by implementation of strict and proven methods of anesthesia and fluid therapy. Much focus should be placed on feasible monitoring and preoperative optimization in morbidly obese individuals for increased perioperative safety.

Šiuo metu Pasaulyje skrandžio apjuosimo reguliuojama juosta operacijos sudaro apie 43 % visų chirurginių operacijų, atliekamų nutukimui gydyti. Iki šiol nėra pilnai ištirta operacijoje naudojamų skrandį apjuosiančių reguliuojamų juostų konstrukcijos skirtumų įtaka gydymo rezultatams, taip pat nėra priimtų pacientų atrankos šiai operacijai kriterijų. Disertacijoje palyginome vienerių metų nutukimo chirurginio gydymo rezultatus naudojant skirtingas skrandį apjuosiančias reguliuojamas juostas – SAGB ir MiniMizer Extra. Nustatėme, kad skrandžio apjuosimo reguliuojama juosta operacija yra efektyvus ir saugus nutukimo gydymo būdas: vidutinis procentinis perteklinio kūno masės indekso sumažėjimas buvo 33,1 ± 21,9%; vertinant pagal BAROS, 34.1% pacientų pasiekė patenkinamą, 30,6% - gerą, 9,4% – labai gerą ir 2,4% – puikų gydymo rezultatą; pasitaikė 5 (4,9%) „didžiosios” komplikacijos. Esminių skirtumų tarp lygintų juostų efektyvumo ir komplikacijų skaičiaus po vienerių metų po operacijos nenustatyta: vidutinis procentinis perteklinio kūno masės indekso sumažėjimas SAGB ir MiniMizer Extra grupėse buvo atitinkamai 28,9 ± 21,3% ir 36,8 ± 22.1%, p=0.075, o „didžiųjų” komplikacijų skaičius atitinkamai 0 (0%) ir 5 (9.3%), p=0.069. 40 metų ir vyresni pacientai geresnių rezultatų pasiekė naudojant MiniMizer Extra juostą - vidutinis procentinis perteklinio kūno masės indekso sumažėjimas buvo 37,5 ± 20,8% prieš 23,6 ± 13,8 % SAGB grupėje, p=0.002. Pacientai, kurių pradinis KMI ≤ 47, geresnių... [toliau žr. visą tekstą] / It has been estimated that LAGB represents about 42% of bariatric operations performed worldwide. There are a number of different adjustable gastric bands available. Few attempts have been made to compare the influence of band design differences for efficiency and complication rate. There are no accepted criteria for choosing this particular operation. In the dissertation we compared one year results after adjustable gastric banding using different adjustable gastric bands – SAGB and MiniMizer Extra. We have determined that laparoscopic adjustable gastric banding is effective and safe bariatric procedure: the average percentage of initial excess body mass index loss was 33,1 ± 21,9%; 34.1% of patients achieved fair, 30,6% - good, 9,4% - very good and 2,4% - excellent results according to BAROS; only 5 (4,9%) major complications were diagnosed. No radical differences were stated between the efficiency and complication rate of the compared adjustable gastric bands: the average percentage of initial excess body mass index loss in SAGB and MiniMizer Extra groups was 28,9 ± 21,3% and 36,8 ± 22.1% respectively, p=0.075; major complication rate was 0 (0%) and 5 (9.3%) respectively, p=0.069. Patients at the age of 40 and older achieved better results using MiniMizer Extra band - the average percentage of initial excess body mass index loss was 37,5 ± 20,8% versus 23,6 ± 13,8% in SAGB group, p=0.002. Patients with initial BMI ≤ 47 achieved better results using MiniMizer Extra band... [to full text]

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