Is screening for Cushing's syndrome before bariatric surgery necessary?

Abstract

Purpose: Recent studies have shown a higher prevalence of Cushing's syndrome in obese patients with type 2 diabetes, but its prevalence in overweight and obese populations is not clear. The aim of this study was to evaluate the need for screening tests for Cushing's syndrome in morbidly obese individuals before bariatric surgery.

Materials and methods: Between January 2015 and December 2019, 300 patients with Body Mass Index (BMI) ≥35 kg/m² that admitted to our endocrine outpatient clinic for evaluation before bariatric surgery were included in this study. Overnight low dose 1 mg dexamethasone suppression test was applied to all patients. Next day 8 am serum cortisol concentration less than 1.8 μg/dL was defined as normal suppression.

Results: Three hundred patients undergoing bariatric surgery were screened for Cushing's syndrome. The mean±standard deviation age of the patients was 39.4±11.7 years and 236 (77.3%) were women. The mean BMI of the patients was 45.9±5.5 kg/m² before bariatric surgery. Forty-seven (15.7%) patients in type 2 diabetes mellitus, 28 (9.3%) patients with hypertension and 3 (1%) patients who had achived euthyroidism after levothyroxine treatment. The mean one year BMI after bariatric surgery was 28±4.6 kg/m². Serum cortisol concentration was <1.8 μg/dL after 1 mg overnight dexamethasone suppression test in all patients.

Conclusion: The results of the evaluated data  revealed that the routine screening of morbidly obese individuals for Cushing's syndrome before bariatric surgery is not necessary.

Keywords

• Obesity
• Bariatric Surgery
• Cushing's syndrome
• dexamethasone suppression test

Bariatrik cerrahi öncesi Cushing sendromu için tarama testi gerekli midir?

Öz

Amaç: Son çalışmalar diyabeti bulunan obez hastalarda Cushing sendromu prevalansının daha yüksek olduğunu göstermiştir, ancak aşırı kilolu ve obez popülasyonlardaki prevalansı net değildir. Bu çalışmanın amacı, bariatrik cerrahi öncesi morbid obez bireylerde Cushing sendromu için tarama testlerine duyulan ihtiyacı değerlendirmektir.

Gereç ve yöntem: Ocak 2015-Aralık 2019 tarihleri ​​arasında bariatrik cerrahi öncesi değerlendirme için endokrin polikliniğimize başvuran Vücut Kitle İndeksi (VKİ) ≥ 35 kg/m² olan 300 hasta çalışmaya dahil edildi. Tüm hastalara gece 23:00’de  düşük doz 1 mg deksametazon supresyon testi uygulandı. Ertesi gün sabah serum kortizol konsantrasyonu 1,8 μg/dL'den az olması normal supresyon olarak tanımlandı.

Bulgular: Bariatrik cerrahi geçiren 300 hasta Cushing sendromu açısından tarandı. Hastaların yaşı 39,4±11,7 yıl ve %77,3'ü kadındı. Bariatrik cerrahi öncesi hastaların ortalama VKİ'si 45,9±5,5 kg/m² idi. Tip 2 diyabetli 47 (%15,7) hasta, hipertansif olan 28 (%9,3) hasta ve hipotiroidi tedavisi sonrası ötiroidi ile takip edilen 3 (%1) hasta olduğu saptandı. Bariatrik cerrahi sonrası ortalama 1 yıllık VKİ 28±4,6 kg/m² idi. Tüm hastalarda 1 gecelik 1 mg deksametazon supresyon testinden sonra serum kortizol konsantrasyonu <1,8 μg/dL idi.

Sonuç: Çalışmamızda değerlendirilen verilerin sonuçları, morbid obez bireylerin bariatrik cerrahi öncesi Cushing sendromu için rutin olarak taranmasının gerekli olmadığını göstermiştir.

Anahtar Kelimeler

• Obezite
• Bariatrik Cerrahi
• Cushing sendromu
• deksametazon supresyon testi

References

1. 1- Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health. Obes Res 1998;6:51S-209S.
2. 2- Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:i-xii, 1-253.
3. 3- Arterburn DE, Olsen MK, Smith VA, et al. Association between bariatric surgery and long-term survival. JAMA 2015;313:62-70. https://doi.org/10.1001/jama.2014.16968
4. 4- Pories WJ, Albrecht RJ. Etiology of type II diabetes mellitus: role of the foregut. World J Surg 2001;25:527–531. https://doi.org/10.1007/s002680020348
5. 5- Christakis NA1, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357:370-379. https://doi.org/10.1056/NEJMsa066082
6. 6- Satman I, Omer B, Tutuncu Y, et al. Twelve-year trends in the prevalence and risk factors of diabetes and prediabetes in Turkish adults. Eur J Epidemiol 2013;28:169-180. https://doi.org/10.1007/s10654-013-9771-5
7. 7- DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med 2007;356:2176-2183. https://doi.org/10.1056/NEJMct067019
8. 8- Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess 2009;13:1–190. https://doi.org/10.3310/hta13410

9. 9- Lipid Metabolizması, Hipertansiyon Çalışma Grubu. Bariyatrik Cerrahi Kilavuzu. Türkiye Endokrinoloji ve Metabolizma Derneği 2019; 11-13.
10. 10- Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic & Bariatric Surgery. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring) 2009;17:1-70. https://doi.org/10.1038/oby.2009.28
11. 11- Baid SK, Rubino D, Sinaii N, Ramsey S, Frank A, Nieman LK. Specificity of screening tests for Cushing’s syndrome in an overweight and obese population. J Clin Endocrinol Metab 2009;94:3857-3864. https://doi.org/10.1210/jc.2008-2766
12. 12- Varadhan L, Laing R, Cheruvu CV, Varughese GI, Clayton RN. Should every patient being assessed for bariatric surgery be screened for Cushing syndrome? Endocr Pract 2011;17(2):309.
13. 13- Sahin SB, Sezgin H, Ayaz T, Uslu Gur E, Ilkkilic K. Routine Screening for Cushing's Syndrome Is Not Required in Patients Presenting with Obesity. ISRN Endocrinol 2013;2013:321063. https://doi.org/10.1155/2013/321063
14. 14- Tiryakioglu O, Ugurlu S, Yalin S, Yirmibescik S, Caglar E, Yetkin DO, Kadioglu P. Screening for Cushing's syndrome in obese patients. Clinics (Sao Paulo) 2010;65:9-13. https://doi.org/10.1590/S1807-59322010000100003