Fundus Functionality and Ghrelin Concentrations after Bariatric Surgery
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《新英格兰医药杂志》
To the Editor: Circulating ghrelin concentrations have been reported to be suppressed in morbidly obese patients after Roux-en-Y gastric bypass surgery,1 whereas no significant changes have been observed after adjustable gastric banding.2 The placement of an adjustable gastric band is a purely restrictive technique, producing an approximately 30-ml stomach pouch with functional conservation of the fundus. In contrast, gastric bypass surgery leaves a 15-ml pouch near the esophagogastric junction and excludes the major curvature, thus isolating the fundus — the richest source of ghrelin production3 — from direct contact with food. We hypothesized that circulating ghrelin concentrations in patients undergoing bariatric surgery depend on the degree to which the procedure excludes the fundus and the subsequent isolation of ghrelin-producing cells from direct stimuli. To avoid the potential confounding effect of long-term weight loss, we focused on the changes occurring 24 hours after the intervention.
Thirty-eight matched obese white patients undergoing adjustable gastric banding, gastric bypass surgery, or Nissen fundoplication by the laparoscopic approach were studied. To avoid potential confounding influences due to diurnal variation, blood was withdrawn at 8 a.m. before surgery and at 8 a.m. the day after surgery. Patients in the three groups had similar clinical, biochemical, and hormonal characteristics (Table 1). As would be expected from the long fasting period, glucose and insulin concentrations fell in all the patients 24 hours after surgery, without significant changes in body weight. The decrease in glucose and insulin concentrations from the preoperative measurement to the postoperative measurement was statistically significant within each surgical group (P<0.01), whereas no significant differences were observed among the groups (Figure 1). Twenty-four hours after the surgical intervention, ghrelin concentrations had significantly increased in the groups that underwent Nissen fundoplication (P=0.01) or adjustable gastric banding (P=0.02) but had decreased in the group that underwent gastric bypass surgery (P<0.001). Our data provide evidence that fundus functionality after surgery determines ghrelin concentrations. This finding is in agreement with the significantly low ghrelin concentrations previously observed in patients 30 minutes after gastrectomy and over the long term.4
Table 1. Characteristics of the Patients before Surgery.
Figure 1. Hormonal Changes Associated with the Three Surgical Procedures.
Panel A shows changes in fasting plasma concentrations of glucose, insulin, and ghrelin 24 hours after Nissen fundoplication, adjustable gastric banding, or Roux-en-Y gastric bypass. Panel B shows changes from preoperative to postoperative ghrelin plasma concentrations in patients who underwent Nissen fundoplication, adjustable gastric banding, or Roux-en-Y gastric bypass. The arrowheads indicate the average values before and 24 hours after surgery. The asterisks indicate P<0.001 for the comparison with Nissen fundoplication and adjustable gastric banding, by one-factor analysis of variance followed by Scheffé's pairwise comparisons; the dagger P<0.01 for the comparison with preoperative values, by two-tailed paired t-tests; the double dagger P<0.05 for the comparison with preoperative values, by two-tailed paired t-tests; and the section mark P<0.001 for the comparison with preoperative values, by two-tailed paired t-tests.
Gema Frühbeck, M.D., Ph.D.
Alberto Diez Caballero, M.D., Ph.D.
Maria J. Gil, Ph.D.
University of Navarra
31008 Pamplona, Spain
gfruhbeck@unav.es
References
Cummings DE, Weigle DS, Frayo RS, et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med 2002;346:1623-1630.
Hanusch-Enserer U, Brabant G, Roden M. Ghrelin concentrations in morbidly obese patients after adjustable gastric banding. N Engl J Med 2003;348:2159-2160.
Gnanapavan S, Kola B, Bustin SA, et al. The tissue distribution of the mRNA of ghrelin and subtypes of its receptor, GHS-R, in humans. J Clin Endocrinol Metab 2002;87:2988-2988.
Ariyasu H, Takaya K, Tagami T, et al. Stomach is a major source of circulating ghrelin, and feeding state determines plasma ghrelin-like immunoreactivity levels in humans. J Clin Endocrinol Metab 2001;86:4753-4758.
This article has been cited by other articles:
Mancini, M. C., Costa, A. P.A.C., de Melo, M. E., Cercato, C., Giannella-Neto, D., Garrido, A. B. Jr., Rosberg, S., Albertsson-Wikland, K., Villares, S. M.F., Halpern, A. (2006). Effect of Gastric Bypass on Spontaneous Growth Hormone and Ghrelin Release Profiles. Obesity 14: 383-387
Williams, D. L., Cummings, D. E. (2005). Regulation of Ghrelin in Physiologic and Pathophysiologic States. J. Nutr. 135: 1320-1325
Sjostrom, L., Lindroos, A.-K., Peltonen, M., Torgerson, J., Bouchard, C., Carlsson, B., Dahlgren, S., Larsson, B., Narbro, K., Sjostrom, C. D., Sullivan, M., Wedel, H., the Swedish Obese Subjects Study Scientific Group, (2004). Lifestyle, Diabetes, and Cardiovascular Risk Factors 10 Years after Bariatric Surgery. NEJM 351: 2683-2693
Cummings, D. E., Overduin, J., Foster-Schubert, K. E. (2004). Gastric Bypass for Obesity: Mechanisms of Weight Loss and Diabetes Resolution. J Clin Endocrinol Metab 89: 2608-2615
Thirty-eight matched obese white patients undergoing adjustable gastric banding, gastric bypass surgery, or Nissen fundoplication by the laparoscopic approach were studied. To avoid potential confounding influences due to diurnal variation, blood was withdrawn at 8 a.m. before surgery and at 8 a.m. the day after surgery. Patients in the three groups had similar clinical, biochemical, and hormonal characteristics (Table 1). As would be expected from the long fasting period, glucose and insulin concentrations fell in all the patients 24 hours after surgery, without significant changes in body weight. The decrease in glucose and insulin concentrations from the preoperative measurement to the postoperative measurement was statistically significant within each surgical group (P<0.01), whereas no significant differences were observed among the groups (Figure 1). Twenty-four hours after the surgical intervention, ghrelin concentrations had significantly increased in the groups that underwent Nissen fundoplication (P=0.01) or adjustable gastric banding (P=0.02) but had decreased in the group that underwent gastric bypass surgery (P<0.001). Our data provide evidence that fundus functionality after surgery determines ghrelin concentrations. This finding is in agreement with the significantly low ghrelin concentrations previously observed in patients 30 minutes after gastrectomy and over the long term.4
Table 1. Characteristics of the Patients before Surgery.
Figure 1. Hormonal Changes Associated with the Three Surgical Procedures.
Panel A shows changes in fasting plasma concentrations of glucose, insulin, and ghrelin 24 hours after Nissen fundoplication, adjustable gastric banding, or Roux-en-Y gastric bypass. Panel B shows changes from preoperative to postoperative ghrelin plasma concentrations in patients who underwent Nissen fundoplication, adjustable gastric banding, or Roux-en-Y gastric bypass. The arrowheads indicate the average values before and 24 hours after surgery. The asterisks indicate P<0.001 for the comparison with Nissen fundoplication and adjustable gastric banding, by one-factor analysis of variance followed by Scheffé's pairwise comparisons; the dagger P<0.01 for the comparison with preoperative values, by two-tailed paired t-tests; the double dagger P<0.05 for the comparison with preoperative values, by two-tailed paired t-tests; and the section mark P<0.001 for the comparison with preoperative values, by two-tailed paired t-tests.
Gema Frühbeck, M.D., Ph.D.
Alberto Diez Caballero, M.D., Ph.D.
Maria J. Gil, Ph.D.
University of Navarra
31008 Pamplona, Spain
gfruhbeck@unav.es
References
Cummings DE, Weigle DS, Frayo RS, et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med 2002;346:1623-1630.
Hanusch-Enserer U, Brabant G, Roden M. Ghrelin concentrations in morbidly obese patients after adjustable gastric banding. N Engl J Med 2003;348:2159-2160.
Gnanapavan S, Kola B, Bustin SA, et al. The tissue distribution of the mRNA of ghrelin and subtypes of its receptor, GHS-R, in humans. J Clin Endocrinol Metab 2002;87:2988-2988.
Ariyasu H, Takaya K, Tagami T, et al. Stomach is a major source of circulating ghrelin, and feeding state determines plasma ghrelin-like immunoreactivity levels in humans. J Clin Endocrinol Metab 2001;86:4753-4758.
This article has been cited by other articles:
Mancini, M. C., Costa, A. P.A.C., de Melo, M. E., Cercato, C., Giannella-Neto, D., Garrido, A. B. Jr., Rosberg, S., Albertsson-Wikland, K., Villares, S. M.F., Halpern, A. (2006). Effect of Gastric Bypass on Spontaneous Growth Hormone and Ghrelin Release Profiles. Obesity 14: 383-387
Williams, D. L., Cummings, D. E. (2005). Regulation of Ghrelin in Physiologic and Pathophysiologic States. J. Nutr. 135: 1320-1325
Sjostrom, L., Lindroos, A.-K., Peltonen, M., Torgerson, J., Bouchard, C., Carlsson, B., Dahlgren, S., Larsson, B., Narbro, K., Sjostrom, C. D., Sullivan, M., Wedel, H., the Swedish Obese Subjects Study Scientific Group, (2004). Lifestyle, Diabetes, and Cardiovascular Risk Factors 10 Years after Bariatric Surgery. NEJM 351: 2683-2693
Cummings, D. E., Overduin, J., Foster-Schubert, K. E. (2004). Gastric Bypass for Obesity: Mechanisms of Weight Loss and Diabetes Resolution. J Clin Endocrinol Metab 89: 2608-2615