Menstrual irregularity: a possible clinical marker of metabolic dysfunction in women with class III obesity

Purpose. To evaluate whether menstrual irregularity in morbidly obese women is indicative of metabolic dysfunction.Patients and Methods. Fifty-seven women with morbid obesity were evaluated. They were divided into two groups: one comprising women without menstrual dysfunctions or hirsutism (Group 1), and another obese women showing menstrual dysfunction with or without hirsutism (Group 2). The following were evaluated: age, colour, childbirth, marital status, profession, socio-economic level, education, age at menarche, body weight, height, body mass index, presence of hirsutism (Ferriman Gallwey Index), abdominal circumference, hip circumference, waist-to-hip ratio, menstrual cycle, blood pressure, presence of acanthosis nigricans, insulin resistance (IR), fasting glycaemia, total cholesterol, HDL-C, LDL-C, triglycerides, thyroid-stimulating hormone, free T4, luteinising hormone (LH), follicle-stimulating hormone, prolactin, total testosterone, dehydroepiandrosterone sulfate, insulin and the Homeostasis Model Assessment (HOMA test).Results. Clinical and epidemiological aspects did not present statistical differences. Clinical and laboratory parameters did not show statistically significant alterations; however, HOMA test values for Group 2 were significantly higher than those for Group 1.Conclusions. The presence of IR in class III obese women can cause menstrual dysfunctions such as amenorrhoea or oligomenorrhoea even in the absence of hyperandrogenism, suggesting that IR plays an important role in the ovarian mechanisms involved in the menstrual cycle control.

Nouvelles directives assécurologiques pour la prise en charge de la chirurgie bariatrique: conséquences pratiques [New guidelines for bariatric surgery care: practical implications].

From the 1st of January 2011, new conditions have been validated in which surgery for weight loss is borne by the basic insurance. These are very significant changes compared to the old criteria. Indeed, on one hand, patients with BMI > or = 35 kg/m2 may, without age limit and in the absence of comorbidities benefit from surgery without prior request to the medical council health insurance company concerned. On the other hand, the notion of a minimum casuistry is for the first time introduced in centers performing this type of intervention. In addition, certified centers are required to follow standard procedures for the patients' teaching and follow up.

Videolaryngoscopy improves intubation condition in morbidly obese patients

Résumé : Contexte clinique et objectifs: l'intubation oro-trachéale peut être plus difficile chez les patients obèses morbides (index de masse corporelle BMI > 35 kg/m2) que chez les patients non-obèses. Récemment, de nouveaux instruments permettant une intubation assistée au moyen d'une caméra ont été développés. Notre expérience pratique avec la vidéolaryngoscopie nous a conduit à l'hypothèse que celle-ci pourrait améliorer la vision laryngoscopique chez cette population spécifique et de ce fait faciliter l'intubation. Le but de cette étude était donc d'évaluer le bénéfice du vidéolaryngoscope sur le grade de laryngoscopie chez le patient obèse morbide. Résultats : le grade laryngoscopique fut abaissé de manière significative avec le vidéolaryngoscope comparé à la vision directe avec un laryngoscope standard. Lorsque le grade laryngoscopique était plus grand que 1 à la laryngoscopie directe, il fut dans la grande majorité des cas (93% des patients) abaissé avec le vidéolaryngoscope. Chez les 7 % restant, le grade laryngoscopique resta identique. Conclusions : chez le patient obèse morbide, l'utilisation du vidéolaryngoscope améliore de manière significative la visualisation du larynx et de ce fait facilite l'intubation. Une application systématique de ce procédé pourrait donc permettre de réduire l'incidence d'une intubation difficile ainsi que ses conséquences chez cette population de patients. Summary : Background and objective: Tracheal intubation may be more difficult in morbidly obese patients (body mass index >35 kgM-2) than in the non-obese. Recently, new video-assisted intubation devices have been developed. After some experience with videolaryngoscopy, we hypothesized that it could improve the laryngoscopic view in this specific population and therefore facilitate intubation. The aim of this study was to assess the benefit of a videolaryngoscope on the grade of laryngoscopy in morbid obesity. Methods: We studied 80 morbidly obese patients undergoing bariatric surgery. They were randomly assigned to one of two groups. One group was intubated with the help of the videolaryngoscope and in the control group the screen of the videolaryngoscope was hidden to the intubating anaesthesiologist. The primary end-point of the study was to assess in both groups the Cormack and Lehane direct and indirect grades of laryngoscopy. The duration of intubation, the number of attempts needed as well as the minimal SPO2 reached during the intubation process were measured. Results: Grade of laryngoscopy was significantly lower with the videolaryngoscope compared with the direct vision (P < 0.001). When the grade of laryngoscopy was higher than one with the direct laryngoscopy (n = 30), it was lower in 28 cases with the videolaryngoscope and remained the same only in two cases (P < 0.001). The minimal SPO2 reached during the intubation was higher with the videolaryngoscope but it did not reach statistical significance. Conclusions: In morbidly obese patients, the use of the videolaryngoscope significantly improves the visualization of the larynx and thereby facilitates intubation.

Gestação após gastroplastia para tratamento de obesidade mórbida: série de casos e revisão da literatura

Objetivo: relatar a evolução de uma série de casos de gestação em mulheres previamente submetidas à cirurgia de bypass gástrico para tratamento de obesidade grave. Métodos: cinco casos consecutivos de gravidez após gastroplastia ocorridos entre 2001 e 2004 foram avaliados. As pacientes tinham idade entre 30 e 34 anos e todas haviam sido submetidas à cirurgia de Capella. Aspectos clínicos, laboratoriais e do acompanhamento materno e fetal foram considerados, durante o período gestacional e após o parto. Foi realizada revisão da literatura internacional, por meio das bases de dados MEDLINE e Web of Science, utilizando os seguintes unitermos: gastroplasty, gastric bypass surgery, bariatric surgery e pregnancy. Resultados: todas as gestações observadas foram únicas e não ocorreram complicações obstétricas, durante o seguimento pré-natal e parto. Também não houve registro de recém-nascidos prematuros ou de baixo peso ao nascimento. Conclusão: nossos dados sugerem que a gravidez após gastroplastia é segura para a mãe e feto. Entretanto, em virtude do limitado volume de informação disponível sobre o tema, investigações adicionais são necessárias para estabelecer recomendações apropriadas com relação ao seguimento dessas gestações _________________________________________________ABSTRACT Purpose: we report a small series of pregnant women who underwent gastric bypass surgery for severe obesity, with a review of the literature on this topic. Methods: five consecutive cases of pregnancy after gastroplasty between 2001 and 2004 were evaluated, and clinical, laboratory and therapeutic features were considered. Patients were 30 to 34 years old and all had been submitted to gastroplasty by the Capella technique. The outcomes for both the pregnant woman and the fetus were evaluated. A search of the English language literature was done through MEDLINE and Web of Science databases with the following terms: gastroplasty, gastric bypass surgery, bariatric surgery, and pregnancy. Results: all 5 pregnancies were singleton. No major obstetric complications were observed and there were no premature or lowbirth weight infants. Conclusion: our data suggest that pregnancy following gastroplasty is safe for mother and fetus. However, since information about this topic is limited, further investigations are required to establish appropriate recommendations concerning the follow-up of these pregnancies

Evaluation of obstructive sleep apnea in obese patients scheduled for bariactric surgery

PURPOSE: To evaluate the frequency of obstructive sleep apnea (OSA) in obese patients scheduled for bariatric surgery and their identification for risk of OSA by Berlin Questionnaire (BQ) and excessive daytime sleepiness by Epworth Sleepiness Scale (ESS). METHODS: Fifty nine patients were evaluated by BQ and ESS. Out of these individuals, 35 performed a full-night sleep study using a type 3 portable monitoring (PM). The questionnaire results were compared for gender and BMI. The presence and severity of OSA was correlated with gender and both questionnaires. RESULTS: 94.75% of the respondents presented high risk for OSA by BQ and 59.65% presented positivity by ESS. Taking into account the AHI> 5 per hour for OSA diagnosis, all of them presented OSA, average AHI of 45.31±26.3 per hour and 68.6% have severe OSA (AHI>30). The male patients had a higher AHI (p<0.05). There was a positive correlation between the positivity in both questionnaires as well as the severity of OSA measured by AHI (p<0.05). CONCLUSION: The frequency and severe obstructive sleep apnea in the studied group is high. The Berlin Questionnaire and Epworth Sleepiness Scale had a positive correlation with the diagnosis of OSA in the group studied.

Cirurgias plásticas para readequação de contorno corporal de pacientes submetidos a cirurgia bariátrica durante a adolescência

INTRODUÇÃO: A partir da década de 1990 foram iniciados os primeiros tratamentos cirúrgicos da obesidade em adolescentes, seguindo a sequência cirurgia bariátrica, perda ponderal e dismorfismo corporal, criando demanda por cirurgias plásticas para readequação do contorno corporal. O objetivo deste estudo foi identificar fatores associados a cirurgias plásticas de readequação de contorno corporal (morbidade e mortalidade), realizadas em pacientes submetidos a cirurgia bariátrica durante a adolescência. MÉTODO: Entre janeiro de 2008 e janeiro de 2011, 5 pacientes submetidos a gastroplastia redutora durante a adolescência, com consequente perda e estabilização de peso, foram submetidos a cirurgias plásticas do contorno corporal. A média de idade no início das cirurgias plásticas foi de 19,7 anos, sendo 3 (60%) pacientes do sexo feminino. Foram realizadas dermolipectomias abdominais em todos (100%) os pacientes, dermolipectomias crurais em 4 (80%), dermolipectomias braquiais em 2 (40%), mamoplastia com inclusão de implantes de silicone em 2 (40%) pacientes do sexo feminino, mastopexia na terceira paciente do sexo feminino (20%) e correção de ginecomastia em 1 (20%), toracoplastia em 2 (40%), torsoplastia em 2 (40%) e torsoplastia reversa em 1 (20%). Foram realizadas, em média, 3 intervenções cirúrgicas por paciente, sendo operados 20 sítios cirúrgicos. RESULTADOS: Ocorreram deiscências em 3 (15% dos sítios cirúrgicos) casos e foi necessário revisar a ressecção dermogordurosa por flacidez residual em 3 (15% dos sítios cirúrgicos) casos. CONCLUSÕES: Foram identificados alguns fatores associados às cirurgias plásticas de readequação de contorno corporal na amostra de 5 pacientes submetidos a cirurgia bariátrica durante a adolescência, comparáveis aos da literatura específica.

Progressive regression of left ventricular hypertrophy two years after bariatric surgery.

BACKGROUND: Obesity is a systemic disorder associated with an increase in left ventricular mass and premature death and disability from cardiovascular disease. Although bariatric surgery reverses many of the hormonal and hemodynamic derangements, the long-term collective effects on body composition and left ventricular mass have not been considered before. We hypothesized that the decrease in fat mass and lean mass after weight loss surgery is associated with a decrease in left ventricular mass. METHODS: Fifteen severely obese women (mean body mass index [BMI]: 46.7+/-1.7 kg/m(2)) with medically controlled hypertension underwent bariatric surgery. Left ventricular mass and plasma markers of systemic metabolism, together with body mass index (BMI), waist and hip circumferences, body composition (fat mass and lean mass), and resting energy expenditure were measured at 0, 3, 9, 12, and 24 months. RESULTS: Left ventricular mass continued to decrease linearly over the entire period of observation, while rates of weight loss, loss of lean mass, loss of fat mass, and resting energy expenditure all plateaued at 9 [corrected] months (P <.001 for all). Parameters of systemic metabolism normalized by 9 months, and showed no further change at 24 months after surgery. CONCLUSIONS: Even though parameters of obesity, including BMI and body composition, plateau, the benefits of bariatric surgery on systemic metabolism and left ventricular mass are sustained. We propose that the progressive decrease of left ventricular mass after weight loss surgery is regulated by neurohumoral factors, and may contribute to improved long-term survival.

Explanations for unsuccessful weight loss among bariatric surgery candidates.

BACKGROUND: Our objective was to analyze subjective explanations for unsuccessful weight loss among bariatric surgery candidates. METHODS: This was a retrospective analysis of 909 bariatric surgery candidates (78.2% female, average body mass index [BMI] 47.3) at a university center from 2001 to April 2007 who answered an open-ended question about why they were unable to lose weight. We generated a coding scheme for answers to the question and established inter-rater reliability of the coding process. Associations with demographic parameters and initial BMI were tested. RESULTS: The most common categories of answers were nonspecific explanations related to diet (25.3%), physical activity (21.0%), or motivation (19.7%), followed by diet-related motivation (12.7%) and medical conditions or medications affecting physical activity (12.7%). Categories related to time, financial cost, social support, physical environment, and knowledge occurred in less than 4% each. Men were more likely than women to cite a medical condition or medication affecting physical activity (19.2% vs 10.8%, P = 0.002, odds ratio [OR] = 1.96, 95% confidence interval [CI] = 1.28-2.99) but less likely to cite diet-related motivation (7.1% vs 14.2%, P = 0.008, OR = 0.46, 95% CI = 0.26-0.82). CONCLUSIONS: Our findings suggest that addressing diet, physical activity, and motivation in a comprehensive approach would meet the stated needs of obese patients. Raising patient awareness of under-recognized barriers to weight loss, such as the physical environment and lack of social support, should also be considered. Lastly, anticipating gender-specific attributions may facilitate tailoring of interventions.

Body weight, insulin resistance, and serum adipokine levels 2 years after 2 types of bariatric surgery.

OBJECTIVE: Bariatric surgery reverses obesity-related comorbidities, including type 2 diabetes mellitus. Several studies have already described differences in anthropometrics and body composition in patients undergoing Roux-en-Y gastric bypass compared with laparoscopic adjustable gastric banding, but the role of adipokines in the outcomes after the different types of surgery is not known. Differences in weight loss and reversal of insulin resistance exist between the 2 groups and correlate with changes in adipokines. METHODS: Fifteen severely obese women (mean body mass index [BMI]: 46.7 kg/m(2)) underwent 2 types of laparoscopic weight loss surgery (Roux-en-Y gastric bypass=10, adjustable gastric banding=5). Weight, waist and hip circumference, body composition, plasma metabolic markers, and lipids were measured at set intervals during a 24-month period after surgery. RESULTS: At 24 months, patients who underwent Roux-en-Y were overweight (BMI 29.7 kg/m(2)), whereas patients who underwent gastric banding remained obese (BMI 36.3 kg/m(2)). Patients who underwent Roux-en-Y lost significantly more fat mass than patients who underwent gastric banding (mean difference 16.8 kg, P<.05). Likewise, leptin levels were lower in the patients who underwent Roux-en-Y (P=.003), and levels correlated with weight loss, loss of fat mass, insulin levels, and Homeostasis Model of Assessment 2. Adiponectin correlated with insulin levels and Homeostasis Model of Assessment 2 (r=-0.653, P=.04 and r=-0.674, P=.032, respectively) in the patients who underwent Roux-en-Y at 24 months. CONCLUSION: After 2 years, weight loss and normalization of metabolic parameters were less pronounced in patients who underwent gastric banding compared with patients who underwent Roux-en-Y gastric bypass. Our findings require confirmation in a prospective randomized trial.

The effect of body mass index on therapeutic response to bacterial vaginosis in pregnancy.

Our objective was to determine the effect of body mass index (BMI) on response to bacterial vaginosis (BV) treatment. A secondary analysis was conducted of two multicenter trials of therapy for BV and TRICHOMONAS VAGINALIS. Gravida were screened for BV between 8 and 22 weeks and randomized between 16 and 23 weeks to metronidazole or placebo. Of 1497 gravida with asymptomatic BV and preconceptional BMI, 738 were randomized to metronidazole; BMI was divided into categories: < 25, 25 to 29.9, and > or = 30. Rates of BV persistence at follow-up were compared using the Mantel-Haenszel chi square. Multiple logistic regression was used to evaluate the effect of BMI on BV persistence at follow-up, adjusting for potential confounders. No association was identified between BMI and BV rate at follow-up ( P = 0.21). BMI was associated with maternal age, smoking, marital status, and black race. Compared with women with BMI of < 25, adjusted odds ratio (OR) of BV at follow-up were BMI 25 to 29.9: OR, 0.66, 95% CI 0.43 to 1.02; BMI > or = 30: OR, 0.83, 95% CI 0.54 to 1.26. We concluded that the persistence of BV after treatment was not related to BMI.

The effect of body mass index on therapeutic response to bacterial vaginosis in pregnancy.

Our objective was to determine the effect of body mass index (BMI) on response to bacterial vaginosis (BV) treatment. A secondary analysis was conducted of two multicenter trials of therapy for BV and TRICHOMONAS VAGINALIS. Gravida were screened for BV between 8 and 22 weeks and randomized between 16 and 23 weeks to metronidazole or placebo. Of 1497 gravida with asymptomatic BV and preconceptional BMI, 738 were randomized to metronidazole; BMI was divided into categories: < 25, 25 to 29.9, and > or = 30. Rates of BV persistence at follow-up were compared using the Mantel-Haenszel chi square. Multiple logistic regression was used to evaluate the effect of BMI on BV persistence at follow-up, adjusting for potential confounders. No association was identified between BMI and BV rate at follow-up ( P = 0.21). BMI was associated with maternal age, smoking, marital status, and black race. Compared with women with BMI of < 25, adjusted odds ratio (OR) of BV at follow-up were BMI 25 to 29.9: OR, 0.66, 95% CI 0.43 to 1.02; BMI > or = 30: OR, 0.83, 95% CI 0.54 to 1.26. We concluded that the persistence of BV after treatment was not related to BMI.

Análise crítica das técnicas de tratamento cirúrgico da obesidade mórbida

Introdução: A obesidade é uma afecção com alta prevalência no Brasil e no mundo. É fator de risco para comorbidades como Diabetes tipo 2 (DM2), Hipertensão Arterial Sistêmica (HAS), Dislipidemia, Apneia Obstrutiva do Sono (AOS), entre outras. Seu tratamento é complexo e a cirurgia bariátrica, executada por diferentes técnicas, tem sido uma das opções. Objetivo: Analisar os resultados publicados na literatura em relação às técnicas cirúrgicas de Banda Gástrica Ajustável (BGA), Gastrectomia Vertical (GV), Gastroplastia com derivação em Y de Roux (GDYR) e Derivação Biliopancreática (DBP) - técnica de \"Scopinaro\" e de \"Duodenal Switch\" quanto às complicações operatórias, à mortalidade, à perda do excesso de peso (PEP) e ao reganho, e a resolução das comorbidades após a operação. Método: Foram analisados 116 estudos selecionados na base de dados MEDLINE por meio da PubMed publicados na Língua Inglesa entre 2003 e 2014. Para comparar as diferentes técnicas cirúrgicas (BGA, GV, GDYR e DBP), realizou-se estudo estatístico por meio da análise de variância (ANOVA) aplicando os testes de Duncan e de Kruskal Wallis avaliando: complicações pós-operatórias (fístula, sangramento e óbito); perda e reganho do excesso de peso, e resolução das comorbidades. Resultados: A ocorrência de sangramento foi de 0,6% na média entre todos os estudos, sendo 0,44% na BGA; 1,29% na GV; 0,81% na GDYR e 2,09% na DBP. Já a ocorrência de fístulas foi de 1,3% na média entre todos os estudos, 0,68% para BGA; 1,93% para GV; 2,18% para GDYR e 5,23% para DBP. A mortalidade nos primeiros 30 dias pós-operatórios foi de 0,9% na média entre todos os estudos, 0,05% na BGA; 0,16% na GV; 0,60% na GDYR e 2,52% na DBP. A PEP após cinco anos na média entre todos os estudos foi de 63,86%, especificamente na BGA, foi de 48,35%; 52,7% na GV; 71,04% na GDYR e 77,90% na DBP. A taxa de DM2 resolvida foi de 76,9% na média entre todos os estudos, sendo 46,80% na BGA; 79,38% na GV; 79,86% na GDYR e 90,78% na DBP. A taxa de Dislipidemia resolvida após a operação foi de 74,0% na média de todo o estudo, sendo 51,28% na BGA; 58,00% na GV; 73,28% na GDYR e 90,75% na DBP. A taxa de HAS resolvida após a operação foi de 61,80% na média de todo o estudo, sendo 54,50% na BGA; 52,27% na GV; 68,11% na GDYR e 82,12% na DBP. A taxa de AOS resolvida após a operação foi de 75,0% na média de todo o estudo, sendo 56,85% na BGA; 51,43% na GV; 80,31% na GDYR e 92,50% na DBP. Conclusão: quando analisadas e comparada as quatro técnicas observa-se que nos primeiros 30 dias pós-operatório a taxa de sangramento é superior nos pacientes submetidos à DBP e taxa de fístula inferior nos pacientes da BGA. Quanto à mortalidade observou-se taxa mais pronunciada nos pacientes submetidos à DBP e menos nos submetidos à BGA. Quanto à PEP observou-se uma uniformidade entre os pacientes submetidos à GV, GDYR E DBP até o terceiro ano. Após esse período observa-se reganho de peso nos submetidos à GV até o quinto ano de seguimento. Já nos pacientes submetidos à BGA observou-se taxas de PEP menos pronunciadas em relação às demais desde o início do seguimento. Quanto à resolução das comorbidades observou-se taxas de resolução de DM2 inferiores nos pacientes submetidos à BGA, e não houve diferença entre nenhuma técnica quanto à resolução das demais comorbidades: HAS, AOS e dislipidemia

Gestação após gastroplastia para tratamento de obesidade mórbida: série de casos e revisão da literatura

Objetivo: relatar a evolução de uma série de casos de gestação em mulheres previamente submetidas à cirurgia de bypass gástrico para tratamento de obesidade grave. Métodos: cinco casos consecutivos de gravidez após gastroplastia ocorridos entre 2001 e 2004 foram avaliados. As pacientes tinham idade entre 30 e 34 anos e todas haviam sido submetidas à cirurgia de Capella. Aspectos clínicos, laboratoriais e do acompanhamento materno e fetal foram considerados, durante o período gestacional e após o parto. Foi realizada revisão da literatura internacional, por meio das bases de dados MEDLINE e Web of Science, utilizando os seguintes unitermos: gastroplasty, gastric bypass surgery, bariatric surgery e pregnancy. Resultados: todas as gestações observadas foram únicas e não ocorreram complicações obstétricas, durante o seguimento pré-natal e parto. Também não houve registro de recém-nascidos prematuros ou de baixo peso ao nascimento. Conclusão: nossos dados sugerem que a gravidez após gastroplastia é segura para a mãe e feto. Entretanto, em virtude do limitado volume de informação disponível sobre o tema, investigações adicionais são necessárias para estabelecer recomendações apropriadas com relação ao seguimento dessas gestações _________________________________________________ABSTRACT Purpose: we report a small series of pregnant women who underwent gastric bypass surgery for severe obesity, with a review of the literature on this topic. Methods: five consecutive cases of pregnancy after gastroplasty between 2001 and 2004 were evaluated, and clinical, laboratory and therapeutic features were considered. Patients were 30 to 34 years old and all had been submitted to gastroplasty by the Capella technique. The outcomes for both the pregnant woman and the fetus were evaluated. A search of the English language literature was done through MEDLINE and Web of Science databases with the following terms: gastroplasty, gastric bypass surgery, bariatric surgery, and pregnancy. Results: all 5 pregnancies were singleton. No major obstetric complications were observed and there were no premature or lowbirth weight infants. Conclusion: our data suggest that pregnancy following gastroplasty is safe for mother and fetus. However, since information about this topic is limited, further investigations are required to establish appropriate recommendations concerning the follow-up of these pregnancies

Sellar Spine Associated with Endocrine and Neuro-Ophthalmological Manifestations

A case of sellar spine, associated with neuro-ophthalmological and endocrine abnormalities, is reported. The case described is a rare malformation, of which the authors found only six cases in the literature.