Hypothesis: Circulating ghrelin, produced primarily in the stomach, is a powerful orexigen. Ghrelin levels are elevated in states of hunger, but rapidly decline postprandially. Early alterations in ghrelin levels in morbidly obese patients undergoing weight reduction surgery may be attributed to gastric partitioning. Design and Patients: Thirty-four patients underwent Roux-en-Y gastric bypass with a completely divided gastroplasty to create a 15-mL vertically oriented gastric pouch. Eight other patients underwent other gastric procedures that did not involve complete division of the stomach, including 4 vertical banded gastroplasties and 4 antireflux surgical procedures. Six additional patients undergoing antireflux surgery served as lean control subjects. Plasma samples were obtained before surgery and immediately after surgery. In a substudy, plasma was collected after Rouxen-Y limb formation and after dividing the stomach to identify any changes in plasma ghrelin levels. Setting: Tertiary university medical center. Main Outcome Measures: Ghrelin levels at different stages of surgical intervention.

Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure since its introduction in 1991. There are few studies with greater than 5-year outcomes. Herein we report a series of 312 consecutive patients who underwent primary LNF before 1996. Follow-up of more than 6 years was available in 166 patients, and the mean follow-up was 11 years (median 11.1 years, range 6.1-13.3 years). Prospective data collection included preoperative and current symptom scores (scale 0 = none to 3 = severe), as well as the level of patient satisfaction and use of antireflux medications. Total symptom score for each patient was summed from seven symptoms for a maximum value of 21. Heartburn and regurgitation were the most improved symptoms; however, all symptoms were significantly improved (P < 0.01). The total symptom score at follow-up was 2.6 down from 7.5 at baseline, with a mean difference of -4.9 (range -12 to 3). The percentage of patients stating they would have the procedure again was 93.3%, and 70% were off daily antireflux medications. Outcomes at a mean of 11 years after LNF are excellent, and the majority of patients had their symptoms resolved or significantly improved and are satisfied with their results.

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The renin-angiotensin system is widely known for its importance in control of blood pressure, electrolyte homeostasis and volume regulation. Recently, renin-angiotensin system function was studied using homologous recombination in embryonic stem cells to manipulate the mouse genome. Angiotensinogen, angiotensin-converting enzyme and angiotensin II receptors were each eliminated in separate lines of mice. These null animals share similar phenotypes, such as a lowering of blood pressure, abnormal renal development, malfunction of the kidney and, unexpectedly, a decrease in hematocrit. In addition, angiotensin-converting enzyme null male mice sire far smaller litters than male wild-type mice. This suggests an unexplored role for angiotensin-converting enzyme in conception. Future studies with these and other genetically engineered mice lines will reveal novel physiological effects of angiotensin II.

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