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Cholesterol metabolism

BIBP reduces cholesterol more than restrictive procedures

Procedure found to have an effect on cholesterol levels, independent of weight loss

Biliopancreatic diversion and biliointestinal bypass (BIBP) achieves greater cholesterol lowering than gastric banding, according to a study published in the journal Diabetes Care.

Dr Alberto Benetti, from Universita degli Studi di Milano, and colleagues evaluated the changes of cholesterol metabolism induced by malabsorptive and restrictive surgery independent of weight loss, and reported malabsorptive surgery specifically affects cholesterol levels, independent of weight loss and independent of glucose metabolism and insulin resistance.

They noted that decreased sterol absorption lead to decreased cholesterol and LDL cholesterol levels, accompanied by enhanced cholesterol synthesis and enhanced cholesterol catabolism, and concluded that “compared with banding, biliopancreatic diversion and biliointestinal bypass provides greater cholesterol lowering”.

The researchers measured glucose metabolism (blood glucose and serum insulin levels and homeostasis model assessment of insulin resistance [HOMA-IR] index) and cholesterol metabolism (absorption: serum campesterol and sitosterol levels; synthesis: serum lathosterol levels; catabolism: rate of appearance and serum concentrations of serum 7-α- and serum 27-OH-cholesterol after infusions of deuterated 7-α- and 27-OH-cholesterol in sequence) were assessed in grade 3 obesity subjects undergoing BIBP (n=10) and gastric banding (n=10), before and six months after surgery.

They report that patients had similar values at baseline with weight loss after six months similar in the two groups, and that and blood glucose, insulin levels, HOMA-IR, and triglycerides reduction were also similar.

However, serum cholesterol, LDL cholesterol, non-HDL cholesterol, serum sitosterol, and campesterol levels decreased and lathosterol levels increased only in BIBP subjects, not in banding patients. A significant increase in 7-α-OH-cholesterol occurred only with BIBP, although serum 27-OH-cholesterol decreased in both groups.

The results “leads us to speculate that with malabsorptive surgery, cholesterol absorption decreases, which is associated with a clear decrease of LDL cholesterol (and of non-HDL cholesterol),” the authors write. “As a compensation, cholesterol synthesis increases, and this is associated with enhanced hepatic catabolism. The increase in lathosterol, a marker of cholesterol synthesis, would also point to enhanced LDL receptor activity in the liver, which would lead to reduced circulating LDL levels.”

They claim that the only effect of purely restrictive surgery is a decrease in extrahepatic cholesterol catabolism, parallel with an increase in LDL cholesterol. A finding, they state, “that at present is unexplained”.

Although the authors caution that the six month data cannot be assumed as “representative of the full picture of cholesterol metabolism afterward”, they do indicate that different technical surgical techniques have a different effect on cholesterol levels, independent of weight loss.

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