Correspondence
Ghrelin Concentrations in Morbidly Obese Patients after Adjustable Gastric Banding
N Engl J Med 2003; 348:2159-2160May 22, 2003
- Article
To the Editor:
It has been suggested that the reduction in plasma ghrelin concentrations in five morbidly obese patients after treatment with a proximal Roux-en-Y gastric bypass contributed to the weight-reducing effect of the surgery.1 This hypothesis has been questioned,2 because decreased plasma ghrelin concentrations are present in obese people before any intervention and were documented approximately 1.4 years after gastric bypass surgery, when weight loss of approximately 36 percent had occurred.
Bariatric surgery is becoming more common — particularly, laparoscopic adjustable gastric banding. This procedure, which was recently approved by the Food and Drug Administration, causes less dramatic weight loss than gastric bypass.3 Although both techniques alter the capacity of the stomach and lead to satiety, the mechanism responsible for the greater efficacy of gastric bypass surgery is unclear.
We tested the hypothesis that laparoscopic adjustable gastric banding also decreases the plasma ghrelin concentration and that this effect precedes changes in body weight. To this end, plasma ghrelin was measured in 12 morbidly obese patients (9 women and 3 men; mean [±SD] age, 41.8±11.0 years; mean body-mass index [the weight in kilograms divided by the square of the height in meters], 44.1±3.5) 6 and 12 months after laparoscopic adjustable gastric banding. The mean weight loss was 18.8 kg (15 percent of initial body weight) after 6 months and 31.3 kg (25 percent of initial body weight) after 12 months. The weight loss after six months was similar to that achieved with dieting and less than that achieved with gastric bypass.1 The mean fasting plasma ghrelin concentrations before and after surgery did not differ significantly (235±64 pmol per liter before surgery, 236±65 pmol per liter at 6 months, and 255±82 pmol per liter at 12 months), although there was a trend toward a higher plasma ghrelin concentration at 12 months. In addition, there were decreases in the plasma leptin concentration (P<0.001), plasma glucose concentration (P=0.05), and plasma C-peptide concentration (P<0.001) at this time, whereas insulin sensitivity, as assessed by an oral glucose-tolerance test, improved (P=0.03).
These results extend the previous findings1 in that the success of gastric bypass cannot be explained simply by the reduction of the gastric volume, but also involves other mechanisms resulting in the maintenance of the reduced weight despite unchanged gastric ghrelin secretion. We speculate that the reduction in insulin secretion, which occurs as a result of improved insulin sensitivity and weight loss, could stimulate ghrelin secretion, as has recently been demonstrated in animals.4 The interaction of insulin and ghrelin could be involved in a central control system that counteracts a negative energy balance after interventions designed to induce major weight loss.5
5 ReferencesUrsula Hanusch-Enserer, M.D.
Wilhelminenspital, 1170 Vienna, AustriaGeorg Brabant, M.D.
Hannover Medical School, D-30623 Hannover, GermanyMichael Roden, M.D.
University of Vienna, 1080 Vienna, Austria
michael.roden@akh-wien. ac. at 1
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Frühbeck, Gema, Caballero, Alberto Diez, Gil, Maria J., . (2004) Fundus Functionality and Ghrelin Concentrations after Bariatric Surgery. New England Journal of Medicine 350:3, 308-309
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