Is Dermolipectomy Effective in Improving Insulin Action and Lowering Inflammatory Markers in Obese Women?

M. R. Rizzo; G. Paolisso; R. Grella; M. Barbieri; E. Grella; E. Ragno; R. Grella; G. Nicoletti F. D'Andrea

Disclosures

Clin Endocrinol. 2005;63(3):252-258. 

In This Article

Discussion

Our study shows that dermolipectomy is a surgical procedure associated with a significant improvement in insulin-mediated glucose uptake and substrate oxidation and a decline in inflammatory markers. Such metabolic improvements are mainly associated with a significant decline in FM and WHR.

Several previous studies have shown that obesity is a major risk factor for a number of age-related disorders. The molecular mechanisms underlying many of these associations are not yet completely characterized. Recent research has shown that adipose tissue is not simply an inert storage deposit for lipids, but is an important endocrine organ regulating whole-body metabolism and other vital functions related to inflammation and immune responses.[33,34,35] These actions are mediated by a number of molecules that are secreted by adipocytes and act in an autocrine, paracrine or endocrine fashion. Among those identified to date are leptin, adipsin, resistin and adiponectin TNF-α, IL-6 and IL-10, which are thought to adapt metabolic fluxes to the amount of stored energy.[33] Deregulation of this network has been implicated in the aetiology of insulin resistance and other components of the insulin resistance syndrome, such as glucose intolerance, obesity, dyslipidaemia and high arterial blood pressure.[36]

As insulin resistance and raised inflammatory markers are risk factors for coronary heart disease, there is a major debate on how to solve the metabolic problems related to obesity. Drug administration in association with compliance towards diet therapy is largely used,[19–21] but this can take a long time and have a large number of failures. Alternatively, surgical approaches seem to provide Results more rapidly, but they are not devoid of complications. Liposuction and dermolipectomy are the most frequently used Methods to address obesity by plastic surgery techniques. As far as liposuction is concerned, contrasting data regarding the role of liposuction on insulin resistance and pro-inflammatory markers have been reported.[37,38] The reasons for such discrepancy might be found in the diverse approach to the determination of degree of insulin resistance (homeostatic model assessment (HOMA) vs. euglycaemic glucose clamp combined with tracers) as well as in the number (30 vs. 8) and quality (healthy vs. diabetics) of patients studied. By contrast, in the present study we investigated the possible beneficial effect of dermolipectomy, an alternative and safe method by which a reduction in abdominal fat is achieved without an intensive surgical approach.[22,23]

Our data seem to indicate that dermolipectomy is more useful than liposuction in improving insulin action and lowering pro-inflammatory markers. The differences between liposuction and dermolipectomy might be found in: (a) the characteristics of the surgical approach, because liposuction can be applied only when the overlying skin can retract and adapt to the new situation. When a considerable excess of skin and fat is present, dermolipectomy is a useful method for removing the excess fat by surgical resection with larger incisions along with shorter operation times compared with liposuction;[28,29] (b) the possibility that dermolipectomy may remove a larger amount of abdominal fat than liposuction[28,29] and thus have a greater lowering effect on tissue release from abdominal fat. The latter hypothesis is strengthened by our data showing that a reduction in a small amount of abdominal fat is able to improve insulin action in both oxidative and nonoxidative components and to lower the degree of inflammation with a significant rise in anti-inflammatory markers such as IL-10. A decline in plasma FFA might have a key role in explaining the dramatic improvement in glucose handling. Indeed, it is well known that FFA, which are mainly driven to liver and skeletal muscles by the abdominal fat,[39] are able to impair insulin action[40] and to inhibit oxidative and nonoxidative glucose metabolism[41] with a secondary rise in pro-inflammatory markers.[42] Nevertheless, the possibility cannot be ruled out that elevated plasma FFA might also have an inflammatory role per se,[43] with a secondary negative impact on insulin action.[44] Such a hypothesis is supported by the evidence that our patients had a strong decline in plasma FFA following dermolipectomy and such changes were correlated with the improvement in insulin action and substrate oxidation. Additional evidence of a major role for plasma FFA is also provided by the rise in Rq, thus demonstrating a qualitative improvement in substrate oxidation. Whether the anti-inflammatory effect of dermolipectomy is due to the decline in plasma FFA per se or to an improvement in insulin action, or both, is difficult to assess with the a limited number of patients we enrolled; nevertheless, it is most likely that both mechanisms were operating on inflammatory cytokines.

In addition, a time-dependent effect of dermolipectomy on FFA cannot be ruled out. Klein et al.[36] did not observe any effect of liposuction on insulin action after almost 10–12 weeks whereas in our study a significant 'acute' improvement in insulin action and pro-inflammatory markers was found after 5–6 weeks. Such a difference might also be explained by the occurrence in our study of a negative energy balance, as was also suggested by Kelley et al.[45] Thus, it is possible that after several weeks a return of the energy balance towards a positive trend might contribute to negating the effect of liposuction and dermolipectomy on insulin action, such as was demonstrated for the changes in blood pressure in severe obese patients treated by bariatric surgery.[45,46]

In Conclusion, our study demonstrates that, in obese patients, dermolipectomy is associated with weight loss, improved glucose handling and a lower degree of inflammation. Because of the particular goal of the dermolipectomy, our study was carried out only in women and we acknowledge that this could be a potential limitation of our study. Thus, further long-term studies will be needed to confirm our finding in a larger population (also including men) and to determine if the metabolic effect of dermolipectomy will translate into a reduced incidence of type 2 diabetes and cardiovascular disease.


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