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3JOURNAL OF CARDIORESPIRATORY RESEARCH
ЖУРНАЛ КАРДИОРЕСПИРАТОРНЫХ ИССЛЕДООАНИЙ
ОРИГИНАЛЬНЫЕ СТАТЬИ UDK: 616-056.52-06:616.33-072.1-089
Nazirov Feruz Gafurovich
Doctor of Medical Sciences, Professor, Academician of the Academy of Sciences of Uzbekistan, director of State Institution "Republican Specialized Sciense-Practical Medical Center of Surgery, named after academician V.Vakhidov", Tashkent, Uzbekistan.
https://orcid.org/0000-0002-2772-3984 Khaybullina Zarina Ruslanovna DSc, the chief of biochemistry department of State Institution "Republican Specialized Sciense-Practical Medical Center of Surgery, named after academician V.Vakhidov", Tashkent, Uzbekistan.
Khashimov Shukhrat Khurshidovich DSc, the chief of endovisual surgery department of State Institution "Republican Specialized Sciense-Practical Medical Center of Surgery, named after academician V.Vakhidov", Tashkent, Uzbekistan.
Sharapov Nodir Utkurovich DSc, the chief of functional diagnostics department of State Institution "Republican Specialized Sciense-Practical Medical Center of Surgery, named after academician V.Vakhidov", Tashkent, Uzbekistan.
Makhmudov Ulugbek Marufjanovich PhD, endovisual surgery department of State Institution "Republican Specialized Sciense-Practical Medical Center of Surgery, named after academician V.Vakhidov", Tashkent, Uzbekistan.
Abdullaeva Saodat Daniyarovna a doctor of biochemistry department of State Institution "Republican Specialized Sciense-Practical Medical Center of Surgery, named after academician V.Vakhidov", Tashkent, Uzbekistan.
CARDIOMETABOLIC RISK REDUCTION AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY
For citation: Nazirov F. G. Khaybullina Z. R., Khashimov Sh.t Kh., Sharapov N. U., Makhmudov U. M. Abdullaeva S.D. Cardiometabolic risk reduction after laparoscopic sleeve gasterectomy. Journal of cardiorespiratory research. 2020, vol. 1, issue 1, pp.54-58
d http://dx.doi.org/10.26739/2181-0974-2020-l-7
ABSTRACT
According to statistical data, published in New England Journal of Medicine, Republic of Uzbekistan is leading among the countries of the Central Asia by number of people with excessive weight - they are 44,5 %, and 20,4 % of them are with superobesity. Surgical bariatric treatment of obesity is the unique method which has proved stable efficiency in reduction of excessive weight at patients with morbid obesity for a long time. The purpose of this study was evaluation of cardiometabolic risk regression after laparoscopic sleeve gasterectomy (LSG). There were observed 35 women with morbid obesity. It was established that cardiometabolic risk reduced after LSG because number of women with average risk by CMDS is reduced in 2 times, with low risk is increased in 1,6 times 12 month after surgery. Level of proinflammatory cytokine IL-6 and CRP start declining at earlier period after LSG. Volumetric - linear parameters of heart change synchronously with reduction of excessive weight and is proportional to changes of a surface of a body. Key words: morbid obesity, cardiometabolic risk, laparoscopic sleeve gastrectomy
Назиров Феруз Гафурович
доктор медицинских наук, профессор, академик АН РУз, директор ГУ «Республиканского специализированного научно-практического медицинского центра хирургии им. академика В.Вахидова», г.Ташкент, Узбекистан.
https://orcid.org/0000-0002-2772-3984 Хайбуллина Зарина Руслановна
доктор медицинских наук, руководитель отдела биохимии ГУ «Республиканского специализированного научно-практического медицинского центра хирургии им. академика В.Вахидова», г.Ташкент, Узбекистан.
Хашимов Шухрат Хуршидович
доктор медицинских наук, руководитель отдела эндовизуальной хирургии ГУ «Республиканского специализированного
научно-практического
медицинского центра хирургии им. академика В.Вахидова», г.Ташкент, Узбекистан.
Шарапов Нодир Уткурович доктор медицинских наук, руководитель отдела функциональной диагностики ГУ «Республиканского специализированного научно-практического медицинского центра хирургии им.
академика В.Вахидова», г.Ташкент, Узбекистан.
Махмудов Улугбек Маъруфжанович кандидат медицинских наук, заведующий отделением ГУ «Республиканского специализированного научно-практического медицинского центра хирургии им. академика В.Вахидова», г.Ташкент, Узбекистан.
Абдуллаева Саодат Данияровна врач-биохимик отдела биохимии ГУ «Республиканского специализированного научно-практического медицинского центра хирургии им.
академика В.Вахидова», г.Ташкент, Узбекистан.
СНИЖЕНИЕ КАРДИОМЕТАБОЛИЧЕСКОГО РИСКА ПОСЛЕ ЛАПАРОСКОПИЧЕСКОЙ РУКАВНОЙ
РЕЗЕКЦИИ ЖЕЛУДКА
РЕЗЮМЕ
Республика Узбекистан лидирует среди стран Центральной Азии по количеству людей с излишним весом - их 44,5%, причем у 20,4% - сверхожирение. Хирургическое лечение является наиболее эффективным методом лечения морбидного ожирения (МО) в аспекте долгосрочного эффекта снижения избыточной массы тела. Целью исследования было изучение регресса кардиометаболического риска после лапароскопической рукавной резекции желудка (ЛРРЖ). Обследовано 35 женщин с МО. Установлено, что после ЛРРЖ кардиометаболический риск статистически значимо снижается: число женщин со средним риском по СМББ снижается в 2 раза, с низким риском - увеличивается в 1,6 раза. После ЛРРЖ снижается уровень провоспалительных факторов - С-реактивного белка и интерлейкина-6. Объемно-линейные параметры сердца через 12 месяцев после ЛРРЖ изменяются синхронно со снижением избыточной массы тела и пропорционально изменениям поверхности тела.
Ключевые слова: морбидное ожирение, кардиометаболический риск, лапароскопическая рукавная резекция желудка.
Nazirov Feruz Gafurovich
tibbiyot fanlari doktori, akademik, DK "akad. V.Voxidov nomli Respublika ixtisoslashtirilgan ilmiy-amaliy tibbiet xirurgiya markazi" direktori, Toshkent sh., O'zbekiston.
https://orcid.org/0000-0002-2772-3984 Xaybullina Zarina Ruslanovna tibbiyot fanlari doktori, professor, O'zbekiston Respublikasi Fanlar akademiyasi akademigi, DK "akad. V.Voxidov nomli Respublika ixtisoslashtirilgan ilmiy-amaliy tibbiyot xirurgiya markazi" biokimyo bo'limi boshlig'i, Toshkent, O'zbekiston.
Xashimov Shuxrat Xurshidovich tibbiyot fanlari doktori, DK "akad. V.Voxidov nomli Respublika ixtisoslashtirilgan ilmiy-amaliy tibbiet xirurgiya markazi" endovizual jarroxlik bulimi boshligi, Toshkent, O'zbekiston.
Sharapov Nodir Utkurovich tibbiyot fanlari doktori, DK "akad. V.Voxidov nomli Respublika ixtisoslashtirilgan ilmiy-amaliy tibbiyot xirurgiya markazi" funktsional diagnostika bo'limi boshlig'I, Toshkent, O'zbekiston.
Maxmudov Ulug'bek Ma'rufjanovich tibbiyot fanlari nomzodi, DK "akad. V.Voxidov nomli Respublika ixtisoslashtirilgan ilmiy-amaliy tibbiyot xirurgiya markazi" endovizual jarroxlik bo'limi jarrox, Toshkent, O'zbekiston.
Abdullaeva Saodat Daniyarovna DK "akad. V.Voxidov nomli Respublika ixtisoslashtirilgan ilmiy-amaliy tibbiyot xirurgiya markazi" biokimyo bo'limi shifokor-bioximik, Toshkent, O'zbekiston.
OSHQOZONNING LAPAROSKOPIK QISMA REZEKTSIYASIDAN KEYINGI KARDIOMETABOLIK XAVFNING
KAMAYISHI
ANNOTATSIYA
O'rta Osiyo bo'yicha O'zbekiston Respublikasi og'ir vaznli, ya'ni semizlikning ko'rsatkichlari yuqoriligi bilan - 44.5% ni, shuningdek o 'ta semizlikning - 20,4% ko 'rsatkichlari bilan yetakchi o 'rinni egallaydi. Uzoq muddat davomida tananing ortiqcha vaznini yetarlicha
kamaytirishdan ko'ra xirurgik jarrohlik morbid semirishni (MS) davolashda eng samarali usul hisoblanadi. Tadqiqot maqsadi oshqozonni laporoskopik qismi rezektsiyadan (OLQR) keyingi kardiometabolik xavfning pasayishini o'rganish. Morbid semirgan 35 nafar ayol ko'rib chiqilgan. OLQR dan so'ng kardiometabolik xavf statistik jihatdan sezilarli darajada pasaygani aniqlandi: CMDS bo'yicha aniklanganida o'rtacha xavfga moyil ayollar soni 2 barobarga kamaydi, past xavfga moyilliklari esa 1,6 marotaba oshdi. OLQR so'ng yallig'lanishga moyil faktorlar - S reaktiv oqsili va interleykin - 6 miqdorlari pasaydi. Yurakning hajmli-chiziqli parametrlari OLQR dan 12 oydan keyin ortiqcha vaznning kamayishi bilan birgalikda sinxron ravishda tana yuzasi proportsional o'zgarib borishi kuzatildi.
Kalit so'zlari: morbid semirishi, kardiometabolik xavf, oshqozonning laparoskopik qismi rezektsiyasi.
Introduction. According to statistical data, published in New England Journal of Medicine, Republic of Uzbekistan is leading among the countries of the Central Asia by number of people with excessive weight - they are 44,5 %, and 20,4 % of them are with superobesity [10]. Surgical bariatric treatment of obesity is the unique method which has proved stable efficiency in reduction of excessive weight at patients with morbid obesity for a long time [4,12]. Weight loss is associated with reduction of comorbidity, because reduction of cardiovascular diseases (CVD) observed in 80% of patients [15], number of patients with arterial hypertension (AG) decreased on 52-92%, with dyslipidemia - on 63%; reduction degree of hepatosis observed in 82% of patients after bariatric surgery. Liver fibroses at nonalcoholic fatty liver disease patients decreased in 20% of cases; 83% of patients achieved remission of diabetes mellitus 2 type (DM2), in 95% of patients the quality of life became improved after bariatric surgery [2,4,6]. Taking into account importance of the problem of obesity, in 1997 the International federation of surgery of obesity (IFSO) was formed. Its annually publishes the report about bariatric operations worldwide in the Global Register of IFSO. According to this data, women are 73,7% (50-93 %) of bariatric surgeon patients [7], most of operations - 99,3% performed by laparoscopy technique [11]. In view of close link of obesity with arterial hypertension and disturbances in carbohydrate and lipid metabolism, WHO (2014) offered to expand diagnostic criteria of obesity with accentuation of its metabolically healthy (MHP) and metabolically unhealthy (MUHP) phenotypes. MUHP characterizes with increase visceral adipose tissue depots (abdominal, epicardial, perivascular) and laboratory markers such as hyperglycemia, hypertriglyceridemia, insulin resistance, dyslipidemia, C-reactive protein (CRP) increasing in combination with arterial hypertension [14].
Besides, it is recommended to estimate "global cardiometabolic risk", which represents absolute risk of development of cardiovascular diseases and DM-2 for patients with morbid obesity (MO) [8,13]. For this purpose it is offered to use as classical risk factors of CVD - smoking, high cholesterol, AG, hyperglicemia and the factors directly associated with obesity (insulin resistance, a low level of high density lipoproteins (HDL-C), hypertriglyceridemia (TG) and proinflammatory markers [1,3]. The TG/HDL-C index is an independent predictor for coronary heart disease and can identify cardiometabolic risk [9]. Data of echocardiography (Echo-KG) at patients with obesity can approve cardiac function disturbances.
The purpose of this study was evaluation of cardiometabolic risk regression after laparoscopic sleeve gasterectomy (LSG).
Material and Methods. There were observed 35 women with morbid obesity, treated in State Institution "Republican Specialized Science-Practical Medical Center of Surgery, named after academician V.Vakhidov" in 2015-2020 years. Inclusion criteria were sex (only women), age (only 18-44 years), morbid obesity (BMI>40,0 kg/m2), non smoking. An average age was 33,2±0,9 years ; BMI = 44,4 ±1,0 kg/m2. 10 controls were women - volunteer at age 38,4±1,9 years old without obesity, BMI=23,4±0,3kg/m2, WC = 76,1±1,0sm. Phenotype of obesity determined according S.V. Nedogoda (2016) [3], criteria of MUHP were waist circumference (WC) more 88 sm, fast glucose level more 5,6 mmol/l, TG level more 1,7 mmol/l, dyslipidemia - HDL-C less 1,3 mmol/l, systolic blood pressure more 130/80 mm Hg [3]. Laboratory tests
included CRP and routine biochemical tests (lipidomic panel, total protein, albumin, glucose, which were made in automatic biochemical analyzer "VITR0S-350" (Ortho Clinical Diagnostics, USA). IL-6 were measured in the blood serum using commercially available ELISA kits (VECTOR-BEST, Russia) in immunoassay analyzer ST-360, (China). Cardiometabolic Disease Staging (CMDS) evaluated according Guo F. et al. (2015) recommendations [8]. Laparoscopic sleeve gasterectomy (LSG) was performed on laparoscopic track (Karl Storz, GMBH & CoKG, Germany) with energy platform Force Triad and technology Liger Sure (USA). Duration of observation was 12 months after LSG. For each patient up to 10 controls were matched by pre-surgery BMI, WC, age, laboratory tests. The results are presented as the M ± m. Echo-KG was performed on "Sonos 2500".
Results and Discussion. Laboratory tests data shows that mean level of total cholesterol (TC), TG, HDL-C levels were increased in obese women versus to the control in 1,17 (p>0,05); 2,9 (p<0,05) and 1,67 (p<0,05) times respectively; TG/HDL-C ratio was increased in 3,7 times (p<0,05). Before LSG distribution of MUHP components of obesity at women has shown, that the increase the systolic blood pressure (SBP) had 24 (68,6%) patients, increase of glucose more than 5,6 mmol/l - had 20 (57,1%), hypertriglyceridemia more than 1,7 mmol/l - had 6 (17,1%) women, decrease HDL-C less than 1,3 mmol/l - had 29 (82,8%) patients. Proinflammatory cytokine IL-6 and CRP level were increased exactly versus to the control (p<0,05) in 2,7 and 3,5 times respectively.
The estimation of cardiometabolic risk by CMDS has shown, that before bariatric surgery increase of WC, without pathological changes in markers of carbohydrate and lipid metabolism was at 5 patients (14,3%). A combination of increase of SBP with dyslipidemia (1 stage on CMDS) is revealed at 7 (20 %); a combination of increase of SBP with hyperglycemia and disturbances of one of the lipidomic profile markers (2 stage on CMDS) - at 11 (31,4 %); increase WC, hyperglycemia and pathological changes of two and more parameters of lipidomic profile (3 stage on CMDS) - at 3 (8,6 %), and 4 stage on CMDS was at 9 (25,7 %) patients at whom was DM-2 (n=8) and ischemic heart disease (IHD) (n=1).
Early postoperative period after LSG (7-th day) characterized by significant decreasing TG (from 2,4±0,3 before surgery to 1,8±0,2 mmol/l after LSG), TC (from 5,3±0,2 to 4,4±0,2 mmol/l and TG/HDL-C ratio (from 2,8±0,1 to 1,9±0,2) (p<0,05) versus pre-surgery level. This changes took place long before weight loss and may be caused by positive changes in adipose tissue (AT) metabolism after LSG due to decreasing of inflammation and TG accumulation in AT. This hypotheses is confirmed by IL-6 and CRP concentrations decreasing exactly on the 7-th day after LSG. IL-6 level decreased from 24,7±2,2 to 17,9 ±3,0 pg/ml; CRP decreased from 16,1± 0,3 to 10.2 ±0,3 mg/l at 7-th day after LSG.
12 months after LSG BMI was 33,2 ±0,7 kg/m2, that demonstrates high restrictive effect of this method of bariatric surgery. The estimation of metabolic efficiency of LSG in 12 months after surgery has shown, that number of patients with hyperglycemia decreased in 2,9 times, with AG- in 3,5 times. Mechanism of hypoglycemic efficacy of LSG may include not only restriction of food intake, but incretines secretion change. LSG does not cause malabsorbtion and digestive tract reconstruction, but it can causes elevation of incretines secretion and may have positive effect on insulin resistance. Incretines
provides insulinocytes activation and early secretion of the insulin as a response to hit of the food in gastrointestinal tract. Some of incretines, such as glucagon-like peptide -1 (GPP-1) can inhibited gluconeogenesis and glycogen degradation in liver, raises the consumption and salvaging the glucose in skeletal musculature. Hypothalamus and pituitary gland have receptor to GPP-1 too, stimulation of these receptors decreased appetite [5].
The estimation of CMDS has shown, that 1 year after LSG the number of patients with III and IV stages authentically
high risk
9\W
Г14Т8 P
^2 Г 19 О
has not decreased, because IHD and DM-2 have only regression but not total recovery. However, there was a clinical improvement of IHD and DM-2 that was showed in transition of disease in easier stage. The amount of patients with II stage on CMDS has decreased in 2,8 times, and with I a stage - has increased, due to change of ratio of patients with low and high cardiometabolic risk. In comparative aspect the diagram of distribution of patients with low and high cardiometabolic risk according CMDS 12 months after LSG is shown on fig. 1,2.
□ before LSG
□ 12 month after LSG
□ low risk □ middle risk ■ high risk
12 month after LSG
54
23
23
I
34
40
26
P
middle risk
Fig.1. Distribution of women with МО depending on a degree of CMDS (number of patients).
Fig.2. Distribution of women with МО on a degree of CMDS (%).
The estimation of factors of an inflammation after LSG has shown, that IL-6 decreased in 1,6 time versus level before surgery (p<0,05), CRP was 4,9±0,3 mg/l, that not differ from the control (p > 0,05).
Studying of volumetric - straight-line characteristics of heart according to Echo - KG data has shown, that at women with МО end diastolic volume (EDV), end systolic volume (ESV)
l parameters are necessary for estimating extremely in recalculation on the area of a surface of a body. The threshold of values for an establishment high cardiometabolic risk at women with BMI more 40 kg/m2 according ROC analysis were more than 55,0 ml for EDV (AUC= 0,719, Sensitivity- 60,5%) and less than 22 ml for ESV (AUC= 0,724, Sensitivity- 62,5%) (fig.3).
---- EDV/m2 -----ECV/m2
ICOSpecifidty
Fig.3. AUC for EDV and ESV in obese women.
Measurement of output fraction of left ventricular (OF) have not different from reference value both before and after LSG. Echo-KG in women with MO before and after LSG shown in the table 1.
Data of Echo-KG in women with MO before and after LSG
Data of
Table 1.
0
0
Period of estimation ESV/m2 (ml) EDV/m2 (ml) OF, (%)
Before LSG, р1 24,9±0,8 62,0±1,6 60,3±0,4
12 months after LSG, р2 23,5±1,1 57,4±1,0 58,8±0,4
P1:P2 >0,05 >0,05 >0,05
This data suggests that changes of geometry of heart and its constrictive function in dynamics of weight reduction occur synchronously to decrease of excessive weight and is proportional to changes of a surface of a body. Conclusions.
1. Cardiometabolic risk reduced after LSG because number of women with average risk is reduced in 2
times, with low risk is increased in 1,6 times 12 month after surgery.
2. Level of proinflammatory cytokine IL-6 and CRP start declining at earlier period after LSG.
3. Volumetric - linear parameters of heart change synchronously with reduction of excessive weight and is proportional to changes of a surface of a body.
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