The accurate diagnosis of submucosal gastric lesions is difficult. In an attempt to study this problem, the endoscopic records for 8 consecutive years (July 1976-June 1984) were scanned with the help of a computer-based registration of the endoscopic findings. The examinations were identified in which the endoscopic diagnosis indicated the presence of a submucosal tumor. Fifty-four such patients were found in 15,104 routine examinations, giving an incidence of 0.36%. Six patients were lost to follow-up, so the study is based on 48 patients. The most common reason these patients underwent endoscopy was abdominal pain. Five patient groups were identified: (a) nine patients were correctly diagnosed as having gastric wall neoplasia at the initial endoscopy + biopsy; (b) in an additional 13 patients, the suspected gastric wall neoplasia was verified by further nonoperative diagnostic procedures; (c) five patients were found to have benign non-neoplastic gastric disease; (d) five patients had extra-gastric disease that pressed against the gastric wall; (e) in 14 patients a further work-up indicated that the initial endoscopy was false-positive. These five groups were confirmed by additional diagnostic procedures (including laparotomy) and a follow-up time of more than 5 years or autopsy. Two patients refused further examinations and died shortly afterward. No autopsies were performed. Based on our data, it would seem that in the vast majority of patients the suspicion of a submucosal gastric lesion at endoscopy indicates the presence of a serious condition.

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BackgroundThe objective of the present study was to evaluate the cost-utility of bariatric surgery in a lifetime horizon from a Swedish health care payer perspective.MethodsA decision analytic model using the Markov process was developed covering cardiovascular diseases, type 2 diabetes, and surgical complications. Clinical effectiveness and safety were based on the literature and data from the Scandinavian Obesity Surgery Registry. Gastric bypass, sleeve gastrectomy, and gastric banding were included in the analysis. Cost data were obtained from Swedish sources.ResultsBariatric surgery was cost saving in comparison with conservative management. It also led to a substantial reduction in lifetime risk of events: from a 16 % reduction in the risk of transient ischaemic attacks to a 62 % reduction in the incidence of type 2 diabetes. Over a lifetime, surgery led to savings of €8408 and generated an additional 0.8 years of life and 4.1 quality-adjusted life years (QALYs) per patient, which translates into gains of 32,390 quality-adjusted person-years and savings of €66 million for the cohort, operated in 2012. Analysis of the consequences of a 3-year delay in surgery provision showed that the overall lifetime cost of treatment may be increased in patients with diabetes or a body mass index >40 kg/m2. Delays in surgery may also lead to a loss of clinical benefits: up to 0.6 life years and 1.2 QALYs per patient over a lifetime.ConclusionBariatric surgery, over a lifetime horizon, may lead to significant cost savings to health care systems in addition to the known clinical benefits.Electronic supplementary materialThe online version of this article (doi:10.1007/s11695-014-1567-5) contains supplementary material, which is available to authorized users.

Helicobacter pylori causes gastritis, peptic ulcer disease and gastric cancer. The microbe is found in the gastric mucus layer where a pH gradient ranging from acidic in the lumen to neutral at the cell surface is maintained. The aim of the present study was to investigate the effects of pH on H. pylori binding to gastric mucins from healthy individuals. At pH 3, all strains bound to the most charged MUC5AC glycoform and to a putative mucin of higher charge and larger size than subunits of MUC5AC and MUC6, irrespective of host blood-group. In contrast, at pH 7.4 only Le(b)-binding BabA-positive strains bound to Le(b)-positive MUC5AC and to smaller mucin-like molecules, including MUC1. H. pylori binding to the latter component(s) seems to occur via the H-type-1 structure. All strains bound to a proteoglycan containing chondroitin sulphate/dermatan sulphate side chains at acidic pH, whereas binding to secreted MUC5AC and putative membrane-bound strains occurred both at neutral and acidic pH. The binding properties at acidic pH are thus common to all H. pylori strains, whereas mucin binding at neutral pH occurs via the bacterial BabA adhesin and the Le(b) antigen/related structures on the glycoprotein. Our work shows that microbe binding to membrane-bound mucins must be considered in H. pylori colonization, and the potential of these glycoproteins to participate in signalling events implies that microbe binding to such structures may initiate signal transduction over the epithelial layer. Competition between microbe binding to membrane-bound and secreted mucins is therefore an important aspect of host-microbe interaction.

Using this systematic approach, it has been possible to cover >99% of all bariatric surgery, cross-matching our data with nation-wide registries for in-hospital care, cause of death, and permitting regular nation-wide audit. Several scientific studies have used, or are using, what seems to be the most comprehensive database in obesity surgery.

Adiponutrin is one of three recently identified adipocyte lipases. Surprisingly, these proteins also retain transacylase activity, a hitherto unknown pathway of triacylglycerol synthesis in the adipocytes. This may enable them to participate in both anabolic and catabolic processes. The adiponutrin gene (ADPN) is downregulated by fasting and upregulated by refeeding, suggesting a role in lipogenesis. Experiments in human adipocytes confirmed that the gene is upregulated in response to insulin in a glucose-dependent fashion. Obese subjects had increased levels of subcutaneous and visceral abdominal adipose tissue ADPN mRNA. Visceral ADPN mRNA expression was correlated to measures of insulin sensitivity (fasting insulin and homeostasis model assessment). We also studied genetic variation in ADPN and its relation to obesity, lipolysis, and mRNA expression. Two ADPN polymorphisms showed association with obesity. Carriers of the obesity-associated variants showed a lesser increase in the levels of adipose tissue ADPN mRNA and an increased basal lipolysis. Our results suggest that obese subjects that are insulin resistant and/or carriers of the obesity-associated ADPN alleles fail to upregulate the gene and that upregulation of adiponutrin may be an appropriate response to orchestrate energy excess. Diabetes 55: 826 -833, 2006 O besity is a growing health problem associated with development of type 2 diabetes and coronary heart disease. Obesity results from interaction between genetic, environmental, and psychosocial factors. Collectively, these factors alter the balance between energy intake and expenditure (1-3). Energy is stored as triacylglycerol in adipose tissue found at subcutaneous or visceral abdominal sites. The release of energy is governed by several circulating factors, including insulin, cortisol, growth hormone, and cathecholamines, ultimately by regulating the rate of lipolysis (4). Hormone-sensitive lipase (HSL), an adipocyte triacyland diacylglycerol lipase, is believed to be the rate-limiting enzyme in the lipolytic process. However, recent findings have identified three different proteins that seem to complement HSL, particularly concerning triacylglycerol hydrolysis under nonstimulated conditions (4 -8). Surprisingly, these proteins also exhibit transacylase activity (6). This may enable them to participate in both lipolysis and lipogenesis, in the latter case defining a previously unknown pathway of triglyceride synthesis in adipocytes.The expression of one of these proteins, a membraneassociated protein called adiponutrin, is increased during adipogenesis and strongly influenced by nutritional status (5). In both rodents and humans in vivo and in mice preadipocyte cell lines in vitro, fasting results in very low or undetectable adiponutrin mRNA levels, whereas refeeding, particularly with a carbohydrate-rich diet, increases expression (5,9 -13). This indicates that adiponutrin may promote adipocyte energy storage or recycling and plays an anabolic lipogenic rather than catabolic lipolytic rol...

BackgroundSeveral studies indicate that increasing the alimentary limb length in gastric bypass surgery produces only a minor improvement of excess BMI loss. Few studies have addressed the efficacy of increasing the length of the pancreatico-biliary limb.MethodsHere, we present a prospective randomized study of 187 consecutive laparoscopic Roux-Y gastric bypass operations operated over 2 years (2004–2005) in Iceland. The patients were operated with a gastric bypass with either a 2-m biliopancreatic (BP)-limb and a 60-cm alimentary (A)-limb (n = 93) or with a 150-cm A-limb and a 60-cm BP-limb (n = 94).ResultsPreoperative median BMI was 44.1 (38–70), median age 35.5 (17–74) years, and 85 % of the patients were female. Follow-up rate after 5 years was 85 %. Eighteen months following surgery, the weight loss was significantly higher in the BP-limb group (p < 0.001), and this difference remained 7 years after surgery. Weight regain occurred in both groups, and 7 years after surgery, excess BMI loss (EBMIL) was 78.4 % in the BP-limb group compared to 67.1 % in the A-limb group (p < 0.001). Most patients (78 %) needed supplementation adjustment (iron, vitamin D and calcium) during the study period, significantly more often in the BP-limb group compared to the A-limb group (p < 0.001). Patients in the BP-limb group had more frequent stools than patients in the A-limb group; otherwise, gastro-intestinal symptoms rating scoring were comparable. Complication rate was similar.ConclusionsGastric bypass with a 2-m BP-limb gives better weight loss than gastric bypass with a 60-cm BP-limb and a 150-cm A-limb. Metabolic follow-up is of utmost importance, as most patients needed repeated adjustments of their supplementation.

BackgroundBowel obstruction due to internal hernia is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRGB). Increasing evidence supports primary closing of the mesenteric defects, but controversy continues about surgical technique of systematic closure. This paper reviews our experience with internal hernia after LRGB and describes a new method of preemptive closure of the mesenteric defects.Material and MethodsTwo thousand four hundred seventy-two consecutive patients undergoing LRGB from September 2005 to June 2010 were entered into our prospective longitudinal database. The mesenteric defects were not closed. Patients entered a 5-year follow-up program, and all who subsequently presented with internal hernia were analyzed. A further 1,630 patients operated on in the last 12 months were subjected to our new technique of closing the defects; data were entered in our own database as well as in the Scandinavian quality registry. Follow-up time for these patients is limited.ResultsIn the first group, 117 patients developed an internal hernia (4.7%) at a mean interval after LRGB of 13 (range, 4–43 months). Four patients needed bowel resections because of severe ischemia. There was one death associated with complication of the internal hernia. In the primary closure group, four patients early in the series had reoperations for kinking of the enteroanastomosis. There have been no mesenteric haematomas encountered.ConclusionsInternal hernia should be ruled out in patients with previous LRGB and abdominal pain. Our technique for primary closing of the mesenteric defects seems to be safe and is so far promising.