Metabolic Improvements After Gastric Sleeve Surgery in a Patient With Familial Partial Lipodystrophy

Familial Partial Lipodystrophy (FPLD) is a rare genetic disorder characterized by loss of subcutaneous adipose tissue mainly from peripheral areas but preservation, or increase, of fat in the face, neck, and trunk. This abnormal fat redistribution leads to a characteristic phenotype and severe metabolic derangements that are difficult to manage. FPLD often present with severe insulin resistance causing type 2 diabetes mellitus (DM2), acanthosis nigricans, hypertriglyceridemia (HTG), and non-alcoholic steatohepatitis (NASH). We present a case of FPLD with severe HTG and HTG induced pancreatitis requiring plasmapheresis, with dramatic metabolic improvements after gastric sleeve surgery. Case presentation: Our patient is a 40-year-old Caucasian male who was diagnosed with DM2 and HTG at age 18 when he presented with pancreatitis. He reported eruptive xanthomas with triglyceride (TG) >3000 mg/dl on the initial presentation. He has central obesity with disproportionately thin extremities and NASH. He has a strong family history of HTG and premature coronary artery disease. He was in a leptin trial; however, he was not included in an extended arm due to deterioration of his metabolic profile, specifically NASH. Despite aggressive therapy with dietary changes, fenofibrate, statin, omega-3, and niacin, he had multiple episodes of pancreatitis with TG levels >5000 mg/dl on many occasions. As a result, he was started on biweekly plasmapheresis that was later changed to weekly. His insulin requirement increased to 450 units daily on U-500. A decision was made for him to proceed with bariatric surgery with his history of insulin-resistant DM2 and morbid obesity. He lost 54 lbs in one year with sleeve gastrectomy and his insulin requirement decreased to 120 units daily. Above all, he had only a single incomplete session of plasmapheresis since his bariatric surgery. He has not required plasmapheresis for over a year so far and his TG levels are consistently <500 mg/dl while only on rosuvastatin 40 mg, with the most recent TG level of 182 mg/dl. Discussion: Bariatric surgery has shown tremendous results in terms of reversal of diabetes and other metabolic derangements. These metabolic benefits are attributed mainly to weight loss in restrictive surgeries and proposed increased GLP-1 levels with Roux-en-Y Gastric Bypass Surgery (RYGB). There are a few case reports of FPLD patients with positive outcomes in terms of metabolic profile with RYGB. In our patient, bariatric surgery was decided due to his DM2 and morbid obesity. He had an unexpected dramatic improvement in the metabolic control of his lipodystrophy. To our knowledge, this is the first case of a FPLD patient with severe HTG requiring plasmapheresis with striking metabolic improvements after sleeve gastrectomy. Gastric sleeve surgery may be an important adjunct or alternative treatment option to the current standard of therapy in patients with FPLD.

Extraoral Halitosis due to Exhaled Acetone in Patients Undergoing Sleeve Gastrectomy

Introduction: Bariatric surgery is widely used and considered as one of the most effective treatments for morbid obesity, but it can be associated with medical and dental adverse side-effects. It is frequently associated with major metabolic changes that may lead to extraoral halitosis. Aim: To assess the role of exhaled acetone produced as a result of weight loss in the production of extra-oral halitosis in patients undergoing bariatric surgery. Materials and Methods: A prospective longitudinal cohort study was designed from October 2018 to November 2019 and monitored for six months postsurgery. The subjects were patients undergoing sleeve gastrectomy surgery with a Body Mass Index (BMI) of 35-50 kg/m2. Subjects were divided into two groups of low BMI loss (<5 Kg/m2) and high BMI loss (≥5 Kg/m2) postsurgery, Breath samples were collected with a portable breath ketone analyser for measurement of acetone concentrations, and blood samples were taken for measurement of 3-hydroxybutyrate levels. Breath and blood samples were taken at baseline then at one month, three months, and six months postsurgery. All statistical analysis were performed using the SPSS version 22.0 with a significance value of p-value set at p<0.05. Results: Out of 43 patients enrolled initially, eventually 39 patients completed the study. The mean level of breath acetone was 4.1, 3.4, and 3.8 ppm at one month, three months, and six months, respectively (p=0.018). There was a statistically significant increase in breath acetone at one month in patients with a high rate of BMI loss. At one month, the mean blood level of 3-hydroxybutyrate was higher in patients with a high rate of BMI loss than in those with a low rate of BMI loss (1.9 vs. 1.2 mmol/L; p=0.049). The levels of breath acetone and blood 3-hydroxybutyrate were significantly correlated at one month (r=0.6, p<0.05). Conclusion: Rapid weight loss one month after gastric sleeve surgery resulted in high acetone levels suggestive of increased extraoral halitosis in such patients. Increased Acetone levels in breath and 3-hydroxybutyrate in blood are suggestive of increased extraoral halitosis in patients undergoing gastric sleeve surgery particularly within a month after surgery.

Impact of Gastric Sleeve Surgery on Plasma Retinol Binding Protein 4 and Adipsin Levels in Healthy Male Population

Objectives: Bariatric surgery provides most substantial and sustainable weight loss measures in individuals with obesity. Caloric restriction is not only intervention, changes in hormonal secretions are also leading contributory mechanisms to reduce body weight and improve the glycaemic control. The aim of this study was to evaluate the impact of gastric sleeve surgery on plasma retinol binding protein 4 (RBP4) and adipsin levels among Saudi male obese population. Methods: This prospective study was conducted in the Departments of Physiology and Surgery, College of Medicine, King Saud University. Thirty-three obese (BMI>38.3) male patients age ranged from 25 to 50 years were recruited. RBP4 and adipsin levels were analyzed before and 6-12 months after gastric sleeve surgery by ELISA along with plasma glucose, insulin, HOMA-IR and lipid profile. Results: Circulating RBP4 levels were not significantly changed by bariatric surgery (4382.85±40.35 ng before, and 4393.28±33.13 ng after surgery, p=0.842), neither did adipsin (2949.68±46.86 pg before, and 2917.90±41.90 pg after surgery, p=0.535). Segregation of study participants into two age groups, 25-35 and 35-50 years of age, revealed that before surgery older age group (35-50) had higher RBP4 levels compared to younger group (25-35) (p=0.016). However, after surgery RBP4 levels were decreased in older group but not to a significant level (p=0.174). In younger age group after surgery, there was a near significant increase in RBP4 levels (p=0.052). There were no significant changes in RBP4 levels in both age groups after surgery (p=0.461). For adipsin, there were no significant differences before and after surgery in both age groups. Insulin, BMI and HOMA-IR index were decreased after surgery, however there was no correlation with RBP4 and adipsin levels. Conclusions: The present study findings do not suggest a role for RBP4 and adipsin in the improvement of insulin sensitivity in Saudi male obese population after gastric sleeve surgery. However, a decrease in RBP4 levels in older individuals after surgery needs further investigations to understand its effect on weight and glycemic control. doi: https://doi.org/10.12669/pjms.36.7.2329 How to cite this:Alshubrami S, Al-Regaiey K, Alfadda AA, Iqbal M. Impact of Gastric Sleeve Surgery on Plasma Retinol Binding Protein 4 and Adipsin Levels in Healthy Male Population. Pak J Med Sci. 2020;36(7):---------. doi: https://doi.org/10.12669/pjms.36.7.2329 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.