Obesity is often associated with oxidative stress and lipid peroxidation, which are known risk factors for insulin resistance and type 2 diabetes. Cell differentiating-36 (CD36) is a cell membrane receptor that is also implicated in early stages of insulin resistance and diabetes due to its ability to bind and internalize oxidatively modified low-density lipoprotein (oxLDL). Bariatric surgery is an effective procedure that induces substantial weight loss and improves obesity-associated comorbidities. This study investigated the effect of Roux-en-Y Gastric Bypass Surgery (RYGB) on plasma oxLDL and CD36 expression and assessed possible link with insulin activity.Th study was conducted prospectively in thirty-six obese subjects who underwent RYGB. Weight loss was recorded before and at 6 and 12 months postoperatively. The expression of CD36 in monocytes was analyzed by flow cytometry and polymerase chain reaction (PCR). The concentrations of blood lipids, glucose, insulin and oxLDL were assayed in plasma, and the homeostatic model assessment insulin resistance index (HOMA-IR) was determined.There was a significant reduction of monocyte CD36 levels at 6 months (-48%) and 12 months (-63%) post-surgery. The concentrations of plasma insulin, oxLDL and triglycerides were reduced after 6 months (-38%, -41% and -29%, respectively) and after 12 months (-51%, -61% and -36%, respectively) post-surgery. The level of monocyte CD36 was positively correlated with body mass index (BMI), blood insulin and HOMA-IR.The reduction of monocyte CD36 expression and plasma oxLDL level following RYGB-induced weight loss may contribute to the improvement of insulin resistance cardiovascular disease risk factors.

BACKGROUND:Bariatric surgery is considered the most effective treatment for severe obesity. Despite this wide success, bariatric surgery is associated with increased risks of nutritional deficiencies.OBJECTIVES:To examine whether Roux-en-Y-gastric bypass (RYGB) alters essential fatty acid (FA) status and inflammation markers.METHODS:Subjects with obesity (n = 28; BMI > 40 kg/m2; mean age 48 years) were studied before and 1 year after RYGB. We collected blood samples before and 12 months after RYGB, and analyzed FA in RBCs and peripheral blood mononuclear cells (PBMC), and measured inflammation parameters in plasma. The proportion of total n-3 FAs was the primary outcome, while parameters related to other FAs and inflammation factors were the secondary parameters. In addition, PBMCs from 15 of the participants were cultured alone or with 100 and 200 μM DHA, and the production of IL-6, IL-1β, PGE2, and prostaglandin F2-alpha (PGF2α) was assayed after endotoxin (LPS) stimulation.RESULTS:RYGB induced a significant reduction of BMI (-30%) and improvement of insulin resistance (-49%). While the proportion of arachidonic acid was 15% higher after RYGB, the proportions of total and individual n-3 FAs were 50%-75% lower (P < 0.01). Consequently, the RBC omega-3 index and n-3:n-6 fatty acid ratio were 45% and 50% lower after surgery, respectively. In isolated PBMCs, LPS induced the production of IL-6, IL-1β, PGE2, and PGF2α in both pre- and post-RYGB cells, but the effects were 34%-65% higher (P < 0.05) after RYGB. This effect was abrogated by DHA supplementation.CONCLUSIONS:This study presents evidence that RBC and PBMC n-3 FAs are severely reduced in patients with obesity after RYGB. DHA supplementation in PBMC moderates the production of inflammation markers, suggesting that n-3 FA supplementation would merit a trial in bariatric patients.

Background/Introduction Qualification for bariatric surgery is based upon strict medical guidelines, but individual insurance companies may introduce additional requirements for approval and coverage as they deem necessary. A mandatory preoperative medical weight loss management (MWM) program is commonly such a requirement. Objective The primary objective of this study is to assess the effect of MWM programs on weight loss outcomes. Methods A retrospective review of all sleeve gastrectomies performed between 2012 and 2016 at our institution was conducted. Patients were divided into two groups: those who required a preoperative MWM program, and those who did not. A 1:1 greedy nearest-neighbor method matching algorithm was used to match patients based on age, BMI, smoking, gender, race, sleep apnea, and diabetes. Total weight loss and percent excess weight loss at 1 year for each group were compared. Results A total of 3059 sleeve gastrectomy patients were reviewed. Of these, 941 patients had adequate data points to be evaluated. The matching algorithm resulted in 530 patients for the final analysis, 265 patients in each group. There were no significant differences between the groups in terms of age, BMI, smoking, gender, race, sleep apnea, or diabetes. A paired t test found no significant differences between the MWM group and the control group at 1 year in both total weight loss (36.7 kg vs 36.2 kg) and in percent excess weight loss (56.5% vs 55.8%, p = 0.24). Conclusion There was no significant difference in weight loss outcomes after 1 year in patients required by insurance to participate in MWM programs compared to those who were not. The necessity of these programs should be questioned.

Hackensack University Medical Center.

BACKGROUNDVery‐low density lipoprotein receptor (VLDLR) is a member of the low‐density lipoprotein receptor family highly expressed in adipose tissue. It binds a variety of ligands including apolipoprotein E‐containing triglyceride‐rich lipoproteins, and plays a significant role in the catabolism of triglyceride‐rich lipoproteins. The role of VLDLR had been demonstrated in cell culture and animal models, but little is known about its regulation in human. The objective of this study was to assess the impact of obesity on VLDLR expression in adipose tissue, and to evaluate the role of VLDLR in human adipocyte differentiation and lipid deposition.SUBJECTS AND SAMPLESPaired subcutaneous and visceral adipose tissue aliquots, as well as blood samples, were obtained from a total of 76 subjects, 16 lean (body mass index: BMI ≤ 24.9 kg/m2), 18 overweight (25 ≤ BMI ≤ 29.9 kg/m2) and 42 obese and morbid obese (BMI ≥ 30 kg/m2) subjects. Concentration of plasma lipids (triglycerides, free fatty acids and cholesterol) and glucose was measured enzymatically. Blood insulin level was assayed by enzyme‐linked immunosorbent assay, and homeostasis model assessment of insulin resistance (HOMA‐IR) was determined. Adipocyte size was examined in hematoxylin and eosin‐stained sections, and VLDLR expression was analyzed in adipose tissue using Western blotting and RT‐PCR. In addition, VLDLR expression was examined in isolated pre‐adipocytes before differentiation and during differentiation to mature adipocytes.RESULTSCompared to lean subjects, VLDLR protein level and mRNA abundance in subcutaneous adipose tissue, was up‐regulated in overweight (+46%) and obese subjects (+119%). Similarly, VLDLR expression was up‐regulated in visceral fat but to lesser extent than subcutaneous fat. The abundance of VLDLR mRNA in subcutaneous adipose tissue was positively (p < 0.05) associated with BMI and HOMA‐IR, but not with blood lipids. In addition, VLDLR expression in subcutaneous fat was significantly (p<0.05) associated with increased adipocyte size and triglyceride content. In pre‐adipocytes, VLDLR protein level was virtually inexistent, but increased gradually during differentiation to reach a maximum level in mature adipocytes. Moreover, induction of VLDLR expression in differentiated adipocytes was associated with increased deposition of triglycerides derived mainly from VLDL.CONCLUSIONThe study indicates that obesity up‐regulates VLDLR expression in adipose tissue, and that induction of VLDLR expression during pre‐adipocyte differentiation is associated with increased lipid deposition suggesting a possible role of VLDLR in adipose tissue expansion in human.Support or Funding InformationHackensack University Medical Center

Objective: Very low density lipoprotein receptor (VLDLR) is a member of the low-density lipoprotein receptor family that binds multiple ligands including TG-rich lipoproteins. The role of VLDLR in lipid uptake had been demonstrated in cell culture and animal models, but little is known about the effects of obesity on VLDLR expression in human. Accordingly, we examined the impact of obesity on VLDLR expression in peripheral blood monocytes and explored possible links with monocyte inflammatory markers and circulating lipids. Subjects and measurements: Blood was collected from a total of 69 subjects including 23 normal-weight (body mass index: BMI < 25 kg/m 2 ) controls and 46 obese (BMI > 30 kg/m 2 ) subjects. Blood lipids, glucose and hormones were measured. Monocytes were isolated from buffy coats using Ficoll density centrifugation followed by magnetic separation of CD14-positive cells with magnetic beads. Expression of VLDLR, and pro- and ant-inflammatory markers of monocytes was examined by western blotting and quantitative qPCR. The uptake of labeled VLDL (DiI-VLDL) was also assessed in monocyte cultures. Results: Insulin, and total and VLDL triglycerides were increased in plasma of obese subjects. In addition, VLDLR protein and mRNA levels were significantly (p< 0.05) higher (~ 40%) in obese compared to lean subjects. Monocytes of obese subjects exhibited higher expression of IL-6 and TNF-α (+29 to 43%), but lower expression of IL-10 and CD163 (-30 to 47%). The levels of monocyte VLDLR was positively correlated with blood triglycerides and insulin, and negatively with adiponectin. The uptake of labeled VLDL, assessed by fluorescence microscope, was higher in monocytes of obese subjects. Conclusions: Our findings indicate that obesity upregulates the expression of VLDLR and pro-inflammatory markers in peripheral blood monocytes. The uptake VLDL was also increased in monocyte of obese subjects suggesting that obesity-induced VLDLR expression may explain the changes of VLDL uptake and monocyte phenotype.

Enhanced recovery protocols and fast-track pathways have been gaining popularity in bariatric surgery. However, little information is available regarding the optimal time to initiate post-operative feeds. The objective of this study was to compare the length of stay (LOS) and 30-day re-admission rates for laparoscopic sleeve gastrectomy (LSG) patients starting liquid diet immediately post-operatively and for those starting on the first post-operative day.

Bariatric surgery has not traditionally been offered to patients at extremes of age, given the belief that surgical risk increases with age. Studies have been limited in regard to the safety and efficacy of bariatric surgery in the elderly. In this study we evaluated our experience with the laparoscopic sleeve gastrectomy in patients more than 70 years of age.

Roux-en-Y gastric bypass (RYGB) has been considered the gold standard operation for the treatment of morbid obesity for over 30 years. However, obesity is a chronic condition and some patients may fail to lose adequate weight while others regain some or all of the weight that they have lost. Treatments for failure of gastric bypass include revision of the pouch/anastomosis, increasing the length of the Roux limb, and endoscopic interventions. However, surgeons have struggled in finding reliable revisional operations that yield acceptable weight loss while minimizing post-operative complications. Laparoscopic adjustable gastric band (LAGB) placement has been shown to be a feasible salvage procedure when placed around the previous RYGB but there is little data in the literature regarding the long-term success and safety of this operation.

BACKGROUND:We previously reported that telerobotic-assisted laparoscopic colectomy was feasible and could be accomplished safely. Nonetheless, we found that the current iteration of da Vinci was not well suited to a lateral to medial (LtM) dissection of the colonic mesentery. The motion scaling made the large excursion arcs required for adequate exposure in a LtM dissection cumbersome to achieve. AIM:As a result, the aim of this study was to compare the ability of the da Vinci telerobotic surgical system to perform telerobotic-assisted laparoscopic right hemicolectomy using a LtM dissection with a medial to lateral (MtL) dissection technique. METHODS:We compared 8 consecutive da Vinci-assisted laparoscopic right hemicolectomies performed using a LtM dissection to 8 consecutive operations using a MtL dissection technique. Results were compared using analysis of variance. RESULTS:Age for the 2 groups were not significantly different: LtM 64 (43 to 71) years and MtL 56 (39 to 68) years. Body mass index was similar: LtM 27 (22 to 34) and MtL 25 (20 to 32) kg/m. Total surgical time (including cystoscopy and intraoperative colonoscopy) were similar: LtM 212 (188 to 610) minutes and MtL 203 (135 to 220) minutes. There was no significant difference in lymph node harvest: LtM 12 (3 to 20) lymph nodes and MtL 18 (3 to 35) lymph nodes. There were no deaths or anastomotic leaks in either groups. Median length of stay was similar for both groups: LtM 5 (3 to 10) days and MtL 4 (2 to 9) days. CONCLUSIONS:da Vinci-assisted laparoscopic right hemicolectomy using a MtL dissection technique achieves similar outcomes as a LtM dissection approach.

Background: Surgeons must overcome a substantial learning curve before mastering laparoscopic Rouxen-Y gastric bypass (LRYGBP). This learning curve can be defined in terms of mortality, morbidity or length of surgery. The aim of this study was to compare the learning curves in terms of surgical time for the first 3 surgeons performing LRYGBP in our hospital with the length of surgery for open gastric bypass (CONTROLS). Methods: We compared 494 primary LRYGBPs performed by 3 surgeons (393 by 1st SURGEON, 57 by 2nd SURGEON and 44 by 3rd SURGEON) to 159 open vertical banded gastroplasty-Roux-en-Y gastric bypasses (CONTROLS). Data for LRYGBP patients were prospectively recorded while those for CONTROLS were retrospectively obtained. Factors that significantly affected the length of surgery were identified by univariate and multivariate linear regression analysis. Results: LRYGBP and CONTROL patients were similar in age, height, weight and BMI, although more CONTROLS were male. Median time for the 1st SURGEON performing LRYGBP dropped for each subsequent 100 operations: 1st 100 – 190 min, 2nd 100 – 135 min, 3rd 100 – 110 min and 4th 100 – 100 min. Median time for the 2nd SURGEON performing LRYGBP was 120 min, 3rd SURGEON 173 min and CONTROLS 64 min. Length of surgery significantly correlated with surgical experience in terms of number of operations and BMI of patient. Times for 2nd SURGEON, a fellowship trained laparoscopic surgeon, started significantly faster than 1st SURGEON's, but did not significantly improve with experience. 3rd SURGEON's initial times were similar to 1st SURGEON's, but his times improved more rapidly with experience. Times for CONTROLS were significantly faster than all laparoscopic groups and did not correlate with operation number or patient BMI. Conclusions: The length of surgery for LRYGBPs continued to shorten beyond 400 operations for the first surgeon performing LRYGBP in our hospital. Previous fellowship training in LRYGBP shortened surgical times during initial clinical experience as an attending for the second surgeon. The learning curve for a subsequent experienced laparoscopic surgeon was truncated because of the already established LRYGBP program.