GAstric Bypass to Treat obEse Patients With steAdy hYpertension (GATEWAY)

• Efficacy of Roux-en-Y Gastroplasty to decrease the number of antihypertensive drugs. [ Time Frame: 24, 36, 48 and 60 months ]
  Evaluate the efficacy of Roux-en-Y Gastric Bypass on the reduction of the number of antihypertensive drugs, maintaining a controlled blood pressure (<140x90 mmHg).
• Absolute change from baseline in blood pressure levels [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Change on systemic blood pressure assessed by ambulatory blood pressure monitoring (ABPM).
• Effect on central blood pressure augmentation index and pulse wave velocity [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Change on central blood pressureaugmentation index and pulse wave velocity as measured by SphygmoCor device
• Absolute change from baseline on systolic blood pressure [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline in systolic blood pressure
• Absolute change from baseline on diastolic blood pressure [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline in diastolic blood pressure
• Absolute change from baseline on weight loss and BMI [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline on weight loss and BMI
• Absolute change from baseline on waist circumference [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline on waist circumference
• Absolute change from baseline on fasting plasm glucose level, HbA1c and insulin resistance [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Change from baseline on fasting plasm glucose level, HbA1c and insulin resistance
• Absolute change from baseline on LDL-cholesterol level [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline on LDL-cholesterol level
• Absolute change from baseline on HDL-cholesterol level [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline on HDL-cholesterol level
• Absolute change from baseline on triglycerides levels [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline on triglycerides levels
• Absolute change from baseline on uric acid levels [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline on uric acid levels
• Absolute change from baseline on ultra-sensitive CRP levels [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline on ultra-sensitive CRP levels
• Absolute change from baseline of cardiovascular risk [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Absolute change from baseline of cardiovascular risk calculated by Framingham Score
• Change on heart anatomy [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Change on heart anatomy as evaluated by echocardiogram
• Change on sleep quality [ Time Frame: 12, 24, 36, 48 and 60 months ]
  Change on sleep quality as evaluated by polissonography
• Adverse events [ Time Frame: At any time during the study period ]
  Describe the main adverse events

• change from baseline values in blood pressure level [ Time Frame: 12 and 24 months ]
  mean difference of change from baseline blood pressure values using ambulatory blood pressure monitoring (ABPM)and using Sphygmomanometer blood pressure monitor
• change from baseline in corporeal weight and body mass index. [ Time Frame: 12 and 24 months ]
• change from baseline fasting plasm glucose level [ Time Frame: 12 and 24 months ]
• change from baseline in HbA1c percentual [ Time Frame: 12 and 24 months ]
• change from baseline in insulin level [ Time Frame: 12 and 24 months ]
• change from baseline in LDL-cholesterol level [ Time Frame: 12 and 24 months ]
• change from baseline in HDL-cholesterol level [ Time Frame: 12 and 24 months ]
• change from baseline in triglyceride level [ Time Frame: 12 and 24 months ]
• change from baseline in antropometric measurements [ Time Frame: 12 and 24 months ]
• adverse events [ Time Frame: 15 days, 1, 6, 12 and 24 months ]
  all adverse reaction reported at least at all follow-up visits.

Randomization:

The randomization list is electronically generated through specific software. A block randomization is conducted with varying block sizes at the rate of 1:1. Confidentiality of the randomization list is ensured by the central automated randomization system, through the Internet, available 24 hours a day (Sistema de Estudos Clínicos do IEP HCor).

Blinding Scheme:

Because the study involves a surgical procedure, investigators and patients cannot be blind for treatment allocated to patients.

Roux-en-Y Gastroplasty Patients allocated to surgical treatment will be admitted to the hospital to be subjected to a Roux-en-Y gastric bypass with a biliopancreatic loop of 100cm and a alimentary limb of 150cm.

Antihypertensive Treatment:

The treatment of hypertension will be standardized for all study patients. Prescribed drugs will include preferably a renin-angiotensin blocking system drug and a calcium channels blocker, except if these are contraindicated or the patient has achieved good blood pressure control using other drugs prior to study recruitment. Other drugs can be added at discretion of the attending investigator to achieve a target blood pressure of 130 x 80 mmHg. Patients are treated individually for the other associated comorbidities. Obesity treatment in the control group includes dietary advice, motivation for the practice of physical activities, and drug treatments for diabetes and dyslipidemias if applicable.

Laboratory tests and other exams:

All patients will be subjected to the following measurements throughout the study:

• Outpatient Blood Pressure Monitoring (ABPM)
• Blood pressure measurements taken in doctors' offices:
• Central pressure and associated measurements (SphygmoCor®)
• Polissonography
• Anthropometry
• Nutritional survey
• Laboratory tests
• Echocardiogram
• Electrocardiogram
• Abdominal ultrasound
• Upper gastrointestinal endoscopy with H.pilory testing

• Systemic Hypertension
• Obesity

• Procedure: Laparoscopic Roux-en-Y gastric bypass (LRYGB)
  Laparoscopic Roux-en-Y gastric bypass (LRYGB)is the one of the techniques of bariatric surgery
• Other: Clinical treatment
  Medical treatment aiming the control of risk factors for cardiovascular diseases (including adequate control of blood pressure), psychological assistance and dietetic advice for body weight reduction.

• Experimental: Laparoscopic Roux-en-Y gastric bypass
  Laparoscopic Roux-en-Y gastric bypass performed as a treatment for obesity.
  Interventions:

  • Procedure: Laparoscopic Roux-en-Y gastric bypass (LRYGB)
  • Other: Clinical treatment
• Active Comparator: Clinical treatment
  Optimized clinical treatment including medical management of hypertension.
  Intervention: Other: Clinical treatment

Inclusion Criteria:

• Adults aged between 18 and 65 years old.
• hypertension diagnosis defined as in use of at least 2 high blood pressure medication at full doses.
• body mass index between 30,0 and 39,9 kg/m2.

Exclusion Criteria:

• hypertension ≥ 180/120 mmHg;
• cerebrovascular diseases in the last 6 months.
• Cardiovascular diseases (myocardial infarction, angina, cardiac failure) in the last 6 months.
• Baseline psychiatric disorders: schizophrenia, bipolar disorder, severe depression, psychosis.
• Renal diseases: diabetic nephropathy, creatinine clearance < 30 ml/min.
• Patients with secondary hypertension except due to the sleep apnea.
• Advanced peripheral arterial disease
• atrophic gastritis
• Diabetes mellitus type 1 and type 2 with HbA1 c >7,0%
• alcoholism or use of illicit drugs
• smokers
• previous laparotomy
• severe hepatic disorders
• Pregnancy or women not using effective contraceptive methods.
• Recent neoplasm (< 5 years)
• Immunosuppressant drugs
• Unable to understanding and follow the study protocol orientations.