Anthropometric measurements were assessed using a bioimpedance balance (Tanita TBF 350^®)

BP: blood pressure EF: ejection fraction ¹From 42

Discussion

Obesity is associated with an increased risk of coronary artery disease (CAD) and mortality 678. Morbidity and mortality rates rise proportionally to the degree of obesity in men and women and the impact of excess body fat is more significant in younger subjects than older ones 9101112. In a 10-year follow-up, men and women with a BMI ≥ 35.0 kg/m² had a relative increased risk of developing diabetes of ~23 and ~17 fold respectively compared to a control group with a BMI between 18.5 and 24.9 kg/m² 13. Independently of the BMI, the relative risk of developing diabetes mellitus increases with weight gain as shown in the Nurse's Health Study 14. Moreover, in that study, women who voluntary lost more than 5.0 kg reduced their risk of diabetes by 50%. Weight loss also lowers blood pressure. In a 3-year follow-up of non-morbidly obese patients with a mean BMI of 31 kg/m², patients who maintained a 4.5 kg weight loss had a relative risk of hypertension of 0.35 or, a reduction of 0.45 mmHg in systolic blood pressure and 0.35 mmHg in diastolic pressure per kg of weight lost 15.

Heart function is directly influenced by excess body fat 16. In addition to higher cardiac output in obese patients, left ventricular volume and filling pressures are higher than normal. This usually results in the development of left ventricular strain, which leads to hypertrophy, often of the eccentric type 1718. Left ventricular diastolic function is thus frequently impaired 1719.

Weight loss has a beneficial impact on the functional and the structural cardiac status. In a study of obese patients with a mean BMI of 32.7 kg/m², weight loss of 8 kg over a period of 25 weeks was associated with a significant decrease in left ventricular mass 20. Weight loss lowers oxygen consumption at any given work rate, decreases cardiac output and blood pressure while left ventricular filling pressures decreased as left ventricular stroke volume diminishes 2122. In a study of obese patients with a BMI > 40 kg/m² in whom surgical weight loss with vertical gastric banding (VGB) induced a decrease in body weight of 20% at six months, left ventricular wall thickness, particularly the septal and posterior walls, decreased 23.

The National Institutes of Health (NIH) suggested that surgical therapy be proposed to those patients with a BMI level > 40 kg/m² or > 35 kg/m² with serious medical conditions including hypertension and obstructive sleep apnea 24. Surgical intervention, when indicated, brings significant improvement such as a decrease in excess weight and comorbidities; these include hypertension, diabetes, dyslipidemia 31425262728 and sleep-related disorders 1829. One can expect a mean reduction of 60 to 75% of excess body weight with biliopancreatic diversion which can persist for 4 to 8 years after surgery 3453031. The duodenal switch operation, introduced by Hess in 1988 5, variant of the biliopancreatic diversion of Scopinaro 12, helps in preserving normal eating habits, and the majority of patients undergoing the procedure will have normalization of glucose levels, triglyceride levels and blood pressure early weeks after the surgery 345. Indeed, in a review of 440 obese patients (mean weight of 183 kg) who underwent biliopancreatic diversion with duodenal switch, all of the 36 type 2 diabetic patients discontinued their medication over a 7-year follow-up period 5. Operative mortality is between 0.5% and 2% 353032 and early complications include pulmonary embolus (0.5%) and anastomotic leaks (1–2.5%) 343233. Late complications presents in the form of anemia, anastomotic ulcerations, bone demineralization, neurological complications and protein malabsorption; all of which can be addressed with appropriate supplements. Moreover, significant nutritional and metabolic complications may be less frequent than previously thought 30. Surgical revisions are needed in 0.1% to 4% of cases 35.

Eleven months after the surgery, our patient had lost 40% of his body weight, and body fat mass was reduced by 41 % (Figure 1). The medication was greatly lightened while the patient maintained fasting glucose values ranging from 5 to 7 mmol/L and a blood pressure less than 130/80 mmHg (Table 2). Indeed, rosiglitazone was discontinued, the insulin that averaged > 200 U daily was no more necessary, diltiazem was discontinued and the dose of irbesartan was halved. The 25% decreased in waist circumference is probably clinically significant 3435 albeit waist circumference may be less reliable in patients with a BMI > 35 kg/m² 36. Finally, sleep apnea syndrome improved as the patient was no longer on C-PAP.

Left ventricle hypertrophy is recognized as a strong independent risk factor for cardiovascular morbidity and death and changes in cardiac structure following surgical weight loss have been observed 3738. In the present case, the left ventricle mass index decreased by 15% and the thickness of the septal and posterior walls of the left ventricle were reduced (Table 3). Moreover, using Doppler mitral flow velocity with the E/A ratio, we demonstrated that left ventricular diastolic dysfunction actually improved. Before the operation, the E/A ratio was higher than 1 with a significant decrease during the Valsalva maneuver which corresponds to a pseudonormal ventricular filling or grade 2 filling pattern 3940. After the operation, the E/A ratio was smaller than 1 indicating a delayed relaxation of grade 1 filling pattern, representing an improvement in the diastolic function 3941 (Table 4).