Correspondence

Fundus Functionality and Ghrelin Concentrations after Bariatric Surgery

N Engl J Med 2004; 350:308-309January 15, 2004

Article

To the Editor:

Circulating ghrelin concentrations have been reported to be suppressed in morbidly obese patients after Roux-en-Y gastric bypass surgery,1 whereas no significant changes have been observed after adjustable gastric banding.2 The placement of an adjustable gastric band is a purely restrictive technique, producing an approximately 30-ml stomach pouch with functional conservation of the fundus. In contrast, gastric bypass surgery leaves a 15-ml pouch near the esophagogastric junction and excludes the major curvature, thus isolating the fundus — the richest source of ghrelin production3 — from direct contact with food. We hypothesized that circulating ghrelin concentrations in patients undergoing bariatric surgery depend on the degree to which the procedure excludes the fundus and the subsequent isolation of ghrelin-producing cells from direct stimuli. To avoid the potential confounding effect of long-term weight loss, we focused on the changes occurring 24 hours after the intervention.

Thirty-eight matched obese white patients undergoing adjustable gastric banding, gastric bypass surgery, or Nissen fundoplication by the laparoscopic approach were studied. To avoid potential confounding influences due to diurnal variation, blood was withdrawn at 8 a.m. before surgery and at 8 a.m. the day after surgery. Patients in the three groups had similar clinical, biochemical, and hormonal characteristics (Table 1Table 1Characteristics of the Patients before Surgery.). As would be expected from the long fasting period, glucose and insulin concentrations fell in all the patients 24 hours after surgery, without significant changes in body weight. The decrease in glucose and insulin concentrations from the preoperative measurement to the postoperative measurement was statistically significant within each surgical group (P<0.01), whereas no significant differences were observed among the groups (Figure 1Figure 1Hormonal Changes Associated with the Three Surgical Procedures.). Twenty-four hours after the surgical intervention, ghrelin concentrations had significantly increased in the groups that underwent Nissen fundoplication (P=0.01) or adjustable gastric banding (P=0.02) but had decreased in the group that underwent gastric bypass surgery (P<0.001). Our data provide evidence that fundus functionality after surgery determines ghrelin concentrations. This finding is in agreement with the significantly low ghrelin concentrations previously observed in patients 30 minutes after gastrectomy and over the long term.4

Gema Frühbeck, M.D., Ph.D.
Alberto Diez Caballero, M.D., Ph.D.
Maria J. Gil, Ph.D.
University of Navarra, 31008 Pamplona, Spain
gfruhbeck@unav.es

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