Nutritional and metabolic complications of bariatric surgery

The use of serum uric acid concentration as an indicator of laparoscopic sleeve gastrectomy success

Laparoscopic sleeve gastrectomy (LSG) effectively reduces weight by restricting gastric capacity and altering gut hormones levels. We designed a prospective study to investigate the correlation of serum uric acid (SUA) concentration and weight loss. SUA and body mass index (BMI) were measured preoperatively and on first postoperative month and year in patients who underwent LSG in our department of bariatric surgery. Data on 55 patients were analyzed. Preoperative SUA concentration had a significant positive correlation with percentage of total weight loss (TWL) on first postoperative month (P = 0.001) and year (P = 0.002). SUA concentration on first postoperative month had a positive correlation with percentage of TWL on first postoperative year (P = 0.004). SUA concentration could be used as a predictor of LSG's success and could help in early detection of patients with rapid loss of weight, in order to prevent complications.

Presence of Serum Ferritin before and after Bariatric Surgery: Analysis in Dentate and Edentulous Patients

Society has changed its own lifestyle, specially its eating habits and physical activities, leading to excessive weight and a sedentary behavior, which has contributed to obesity increase. Bariatric surgery is the most effective treatment to obesity, allowing weight loss and its maintenance. However, it has been related high levels of iron deficiency after surgery. A person's nutritional status might be affected by total or partial tooth loss. The aim of this longitudinal prospective cohort study was to evaluate the levels of serum ferritin before and after bariatric surgery and to identify if there is a relation with tooth loss. The sample was composed of 50 patients selected and assisted at Amaral Carvalho Hospital, located in Jaú city, Brazil. The use and necessity of prosthesis, dental absence or presence, and serum ferritin dosage were evaluated. Student's t test, Univariate analysis, Chi-square and Odds Ratio were adopted (p<0.05). There was no significant difference regarding the serum ferritin levels between dentate and edentulous patients prior to surgery (p = 0.436). After surgery, the serum ferritin levels were higher in edentulous patients (prosthesis users) when compared to the pre-surgical levels, and the post-surgical levels presented significant difference regarding the dentate patients (p = 0.024). It can be concluded that rehabilitated patients in postoperative period showed better levels of serum ferritin after surgical intervention.

Improvement of anthropometric and biochemical, but not of vitamin A, status in adolescents who undergo Roux-en-Y gastric bypass: a 1-year follow up study

BACKGROUND

The aim of this study was to describe anthropometric, biochemical, co-morbidity, and vitamin A nutritional status in severely obese adolescents before and 30, 180, and 365 days after Roux-en-Y gastric bypass (RYGB).

SETTING

Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.

METHODS

Sixty-four adolescents (15-19 years old) with a body mass index≥40 kg/m² were enrolled in a prospective follow-up study. Vitamin A status was evaluated before surgery (T0), and 30 (T30), 180 (T180), and 365 (T365) days after surgery, applying biochemical and functional indicators. Anthropometric measures, lipid profile, glycemia, and basal insulin also were assessed. No patients were lost during follow-up.

RESULTS

Before surgery, 26.6% of the sample group experienced vitamin A deficiency (VAD). Serum retinol levels dropped significantly 30 days after surgery and then returned to basal levels. There was a significant increase in the prevalence of β-carotene deficiency and night blindness throughout the postsurgery period. A significant reduction in blood glucose, insulin resistance, lipid profile, and anthropometric parameters was observed.

CONCLUSION

The finding that oral daily supplementation with 5000 IU retinol acetate failed to reverse VAD and night blindness after RYGB is highly significant. We recommend assessment of VAD and night blindness in extremely obese adolescents before and after RYGB. We further recommend monitoring for an additional 180 days (for VAD) and 365 days (for night blindness) after surgery, with particular attention to daily supplementation needs.

Phrynoderma and acquired acrodermatitis enteropathica in breastfeeding women after bariatric surgery

BACKGROUND AND OBJECTIVES

Women who have undergone bariatric surgery are susceptible to nutritional deficiencies in subsequent pregnancies. We highlight the importance of dermatologists in the early recognition of cutaneous signs of malnutrition occurring in this specific clinical setting.

PATIENTS AND METHODS

We compare clinical characteristics of two young women with dermatological signs of combined post-gestational nutritional deficiencies following Roux-en-Y gastric bypass surgery.

RESULTS

Patient 1 exhibited follicular papules on the extremities, perianal eczema, perlèche, alopecia, and depigmentation of hair. Patient 2 showed erythematous plaques in genitoanal and acral areas, perlèche, diffuse alopecia, and depigmentation of hair. Based on clinical and histopathological findings, decreased vitamin A (patient 1) and zinc levels (patient 2), we diagnosed phrynoderma and acquired acrodermatitis enteropathica, respectively. Comparison of the two patients revealed that both (i) were lacking follow-up after gastric bypass surgery, (ii) developed skin lesions as primary symptoms with (iii) mixed clinical manifestations due to combined deficiencies, and (iv) experienced initial symptoms during lactation suggesting a causal relationship.

CONCLUSIONS

Our observations highlight the potentially increased risk of women to develop post-gestational dermatological manifestations of malnutrition following bariatric surgery. The awareness of dermatologists with respect to this emerging, susceptible patient group may help avert damage to mother and child.

Burden of Iron Deficiency Anemia in a Bariatric Surgery Population in the United States

BACKGROUND

Obesity is a serious condition affecting more than 35% of adults in the United States. In obese individuals for whom other weight control methods have been ineffective, bariatric surgery is a safe and effective method of weight control. An estimated 150,000 to 160,000 bariatric surgeries are performed in the United States yearly. Iron deficiency anemia is common in patients after bariatric surgery, with incidence rates up to 49%, and may be due to malabsorption of nutrients. 

OBJECTIVES

To (a) compare the medical resource utilization (MRU)- both medical care and treatment resources-and associated costs in a sample of commercially insured adult bariatric surgery patients with and without iron deficiency anemia (IDA), and (b) describe anti-anemia treatment patterns in those bariatric surgery patients diagnosed with IDA.

METHODS

Using Truven Health MarketScan claims data, bariatric surgery patients were identified by the ICD-9-CM and CPT procedure codes for bariatric surgery and classified by surgery and IDA diagnosis within 2 years of initial surgery. Intravenous (IV) iron treatment was determined by HCPCS codes, prescription oral iron by NDC numbers, and blood transfusions by CPT and ICD-9-CM codes. Clinical, MRU, and economic outcomes for all-cause health services were compared between IDA and non-IDA patients. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression, controlling for demographic and clinical characteristics on outcomes of complications and hospitalization.

RESULTS

Of the 24,344 bariatric surgery patients analyzed, 11.6% received an IDA diagnosis 2 years after surgery (average days to diagnosis = 279). Most IDA patients (78.5%) received a test for iron in the post-index period; only 9.1% received IV iron treatment, with iron dextran (3.8%) and iron sucrose (3.4%) being the most common (average days to IV iron treatment = 403 days). Prescription oral iron was found in 4.9% of all IDA patients (average days to oral iron treatment = 476.7). Approximately 9% of IDA patients received a blood transfusion (average days to transfusion = 304.8). For the total sample, the average age was 46 years with a higher percentage of females (83.9% IDA; 78.7% non-IDA). Most clinical characteristics were similar among patients with and without IDA, except heart disease (1.3% IDA vs. 0.8% non-IDA; P = 0.005) and gallbladder disease (0.0% IDA vs. 0.2% non-IDA; P = 0.037). More IDA patients had complications after surgery (40.4% vs. 27.7%; P  less than  0.001), such as nonabsorption (22.4% vs. 16.5%; P  less than  0.001); digestive (15.6% vs. 10.2%; P  less than  0.001); and gastrojejunal ulcer (7.6% vs. 2.0%; P  less than  0.001). Multivariate results showed that IDA patients were more likely to have a bariatric surgery complication over non-IDA patients (OR = 1.367, 95% CI = 1.257-1.487; P  less than  0.05). Adjusted results showed IDA patients more than twice as likely to be hospitalized (OR = 2.567, 95% CI = 2.363-2.790; P  less than  0.05). Total costs were twice as much in the IDA group compared with the non-IDA group ($37,882 vs. $19,253; P  less than  0.001). 

CONCLUSIONS

Bariatric surgery patients who develop IDA may be subject to higher complication rates, MRU, and direct medical costs. Although most bariatric surgery patients who develop IDA are tested for iron, most are not treated with IV iron or oral iron and do not receive blood transfusions. Further research is needed to determine if IDA is a result of bariatric surgery complications or a predictor of increased MRU and costs.

Duodenum inclusion in alimentary transit for preventing or correcting nutritional deficiencies resulting from Roux-en-y gastric bypass in obesity treatment

Nutritional and metabolic complications can develop after Roux-en-Y gastric bypass (RYGB) when there is an exaggerated response to the anatomical and functional changes or when there is inadequate nutritional supplementation. Severe malnutrition is rare, but deficiencies of vitamin B12, iron, calcium and thiamin, metabolic bone disease and gallstones are common after RYGB. Shortage of vitamin B12, iron, calcium and also cholelithiasis are caused at least partially by excluding the duodenum and proximal jejunum from food transit. We designed a new procedure, with the maintenance of the duodenum and proximal jejunum in the gastrointestinal transit through interposition of jejunal loop, as a primary operation to prevent such deficiencies or as corrective surgery for severe malnutrition after RYGB with failure in responding to conservative treatment. Complicações nutricionais e metabólicas podem se desenvolver após a derivação gástrica em Y de Roux (DGYR) quando há uma resposta exagerada às mudanças anatômicas e funcionais ou quando há suplementação nutricional inadequada. A desnutrição grave é rara, mas deficiências de vitamina B12, ferro, cálcio e tiamina, doença óssea metabólica e cálculos biliares são comuns após a DGYR. Dessas deficiências mencionadas, a de vitamina B12, de ferro, de cálcio e também a colelitíase, são causadas, ao menos parcialmente, pela exclusão do duodeno e jejuno proximal. Um novo procedimento com a manutenção do duodeno e do jejuno proximal no trânsito gastrointestinal, mediante interposição de alça jejunal, foi idealizado como operação primária para prevenir essas deficiências ou como cirurgia corretiva de desnutrição grave após DGYR com falha na resposta a exaustivas tentativas de tratamento conservador.

Malabsorption as a Therapeutic Approach in Bariatric Surgery

Background

The increasing prevalence of obese patients will lead to a more frequent use of bariatric procedures in the future. Compared to conservative medical therapy, bariatric procedures achieve greater weight loss and superior control of comorbidities, resulting in improved overall mortality.

Methods

A search for current literature regarding mechanisms, indications, and outcomes of bariatric surgery was performed.

Results

In order to care for patients after bariatric surgery properly, it is important to understand its mechanisms of action and effects on gastrointestinal physiology. Recent investigations indicate that the beneficial effects of bariatric procedures are much more complex than simply limiting food intake or an associated malabsorption. Changes in gastrointestinal hormone secretion, energy expenditure, intestinal bacterial colonization, bile acid metabolism, and epigenetic modifications resulting in altered gene expression are likely responsible for the majority of the beneficial effects of bariatric surgery. Malabsorptive bariatric procedures divert the flow of bile and pancreatic enzymes from food and therefore limit the digestion and absorption of nutrients, resulting in reduced calorie intake and subsequent weight loss. Essential micronutrients such as vitamins and trace elements are also absorbed to a lesser extent, potentially leading to severe side effects.

Conclusion

To prevent malnutrition, dietary supplementation and regular control of micronutrient levels are mandatory for patients undergoing malabsorptive bariatric procedures, in whom the fat-soluble vitamins A and D are commonly deficient.

Post-Bariatric Body Contouring

BACKGROUND

The "epidemic" of obesity has recently been accompanied by a new "epidemic" of massive weight loss. The demand for post-bariatric contouring is rising and, as such, it is extremely important for plastic surgeons to be well versed in the treatment of these patients. Unfortunately, the problem is not solely surgical.

OBJECTIVES

The aim of this article is to understand the nutritional and psychological complications that can occur in patients following massive weight loss, to understand the anatomic deformities in massive weight loss as a means to correct those deformities surgically, and to understand the complications from post-bariatric contouring procedures in an effort to avoid them.

METHODS

This article discusses the nutritional and psychological considerations in the massive weight loss patient, anatomical considerations in this patient group, and the surgical techniques designed to address these anatomic concerns. Important pertinent studies are reviewed and discussed.

RESULTS

Anatomical changes are encountered in each region of the body: there are surgical options available to correct them, although potential complications are associated with these surgical procedures. These surgical options are reviewed as well as the risk and benefits associated with them.

CONCLUSIONS

There are many problems that need to be addressed in the massive weight loss patient prior to embarking on surgical treatment. Additionally, surgery on massive weight loss patients has unique considerations that distinguish these operations from those performed on the non-bariatric population.

Nutrient deficiencies before and after sleeve gastrectomy

BACKGROUND

Obesity is associated with nutritional deficiencies. Bariatric surgery could worsen these deficiencies. Fewer nutritional deficiencies would be seen after sleeve gastrectomy compared to the Roux-en-Y gastric bypass, but sleeve gastrectomy would also cause further deterioration of the deficiencies. The aim of this study was to determine the amount of pre-operative nutrient deficiencies in sleeve gastrectomy patients and assess the evolution of the nutritional status during the first post-operative year.

METHODS

Four hundred seven sleeve gastrectomy patients were assigned to a standardized follow-up program. Data of interest were weight loss, pre-operative nutrient status and evolution of nutrient deficiencies during the first post-operative year. Deficiencies were supplemented when found.

RESULTS

Two hundred patients completed blood withdrawal pre-operatively and in the first post-operative year. pre-operatively, 5 % of the patients were anemic, 7 % had low serum ferritin and 24 % had low folic acid. Hypovitaminosis D was present in 81 %. Vitamin A had excessive levels in 72 %. One year post-operatively, mean excess weight loss was 70 %. Anemia was found in 6 %. Low-ferritin levels were found in 8 % of the patients. Folate deficiency decreased significantly and hypovitaminosis D was still found in 36 %.

CONCLUSIONS

In this study, a considerable amount of patients suffered from a deficient micronutrient status pre-operatively. One year after surgery, micronutrient deficiencies persisted or were found de novo in a considerable amount of patients, despite significant weight loss and supplementation. Significant reductions were seen only for folate and vitamin D.

Anaemia and related nutrient deficiencies after Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis

OBJECTIVE

To obtain a pooled risk estimate on the long-term impact of anaemia and related nutritional deficiencies in patients receiving Roux-en-Y gastric bypass (RYGB) surgery.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE and Cochrane databases were searched to identify English reports published before 16 May 2014.

ELIGIBILITY CRITERIA

Articles with case numbers >100, follow-up period >12 months, and complete data from both before and after surgery were selected. Outcomes of interest were changes in baseline measurements of proportion of patients with anaemia, by haemoglobin, haematocrit, ferritin, iron, vitamin B12 and folate levels.

DATA COLLECTION AND ANALYSIS

Two reviewers independently reviewed data and selected six prospective and nine retrospective studies with a total of 5909 patients. A random effect model with inverse variance weighting was used to calculate summary estimates of outcomes at 6, 12, 24 and 36 months postoperatively.

RESULTS

Proportion of patients with anaemia was 12.2% at baseline, which, respectively, increased to 20.9% and 25.9% at 12 and 24 months follow-up, consistent with decreases in haemoglobin and haematocrit levels. Although the serum iron level did not change substantially after surgery, the frequency of patients with ferritin deficiency increased from 7.9% at baseline to 13.4% and 23.0% at 12 and 24 months, respectively, postoperation. Vitamin B12 deficiency increased from 2.3% at baseline to 6.5% at 12 months after surgery in those subjects receiving RYGB. There was no obvious increase in folate deficiency.

CONCLUSIONS

RYGB surgery is associated with an increased risk of anaemia and deficiencies of iron and vitamin B12, but not folate. Ferritin is more sensitive when serum iron level is within normal range.

Weight loss and nutritional anemia in patients submitted to Roux-en-Y gastric bypass on use of vitamin and mineral supplementation

BACKGROUND

Obesity is a chronic disease with high growth in population and bariatric surgery is currently considered the most effective treatment for weight reduction; on the other hand, nutritional deficiencies are observed after this procedure.

AIM

To analyze weight loss progression and nutritional anemia in patients submitted to Roux-en-Y gastric bypass on use of vitamin and mineral supplementation.

METHODS

Retrospective analysis of 137 patients of both sexes, aged between 18-60 years, using supplemental multivitamins and minerals, were included; personal information, anthropometric and laboratory data in the preoperative, 12, 24, 36 and 48 months postoperatively were collected.

RESULTS

Postoperatively, in both sexes, occurred weight loss compared to the pre-operative weight gain at 48 months and maintenance of body mass index. There was a decrease in the percentage of excess weight loss at 48 months postoperatively compared to the time of 12, 24 and 36 months in men and decreased at 48 postoperative months compared to the time of 24 months in females. There was a decreased in serum ferritin in both sexes and increased serum iron at 48 months postoperatively in males. There was a decreased in vitamin B12 and folic acid increased serum at 48 postoperative months in females.

CONCLUSIONS

Surgical treatment was effective for reducing weight, body mass index reduction and achievement of success in the late postoperative period along with multivitamin and mineral supplementation on prevention of serious nutritional deficiencies and anemia.

Optimization of vitamin suppletion after Roux-en-Y gastric bypass surgery can lower postoperative deficiencies: a randomized controlled trial

Iron, vitamin B12, and folic acid deficiencies are among the most common deficiencies occurring after laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study evaluates the effectiveness of a specially designed multivitamin supplement (WLS Forte, FitForMe, Rotterdam, the Netherlands) specifically developed for LRYGB patients.A triple-blind, randomized, 12-month study was conducted comparing WLS forte with a standard multivitamin supplement (sMVS) containing approximately 100% of the recommended daily allowance (RDA) for iron, vitamin B12, and folic acid. WLS Forte contains vitamin B12 14000% RDA, iron 500% RDA, and folic acid 300% RDA.In total, 148 patients (74 in each group) underwent a LRYGB procedure. Baseline characteristics were similar for both groups. Per protocol analysis demonstrated that sMVS treatment was associated with a decline in ferritin (-24.4 ± 70.1 μg/L) and vitamin B12 (-45.9 ± 150.3 pmol/L) over 12 months, whereas in WLS Forte patients, ferritin remained stable (+3.2 ± 93.2 μg/L) and vitamin B12 increased significantly (+55.1 ± 144.2 pmol/L). The number of patients developing ferritin or vitamin B12 deficiency was significantly lower with WLS Forte compared with sMVS (P < 0.05). Iron deficiency (ID) was reduced by 88% after WLS Forte compared with sMVS. Adverse events related to supplement use did not occur.An optimized multivitamin supplement is safe and reduces the development of iron and vitamin B12 deficiencies after LRYGB.

Laparoscopic sleeve gastrectomy compared to a multidisciplinary weight loss program for obesity--effects on body composition and protein status

BACKGROUND

Optimal obesity therapy is a matter of debate. Besides weight reduction, other criteria such as safety and nutritional status are of relevance. Therefore, we compared a favored surgical intervention with the most effective conservative treatment regarding anthropometry and nutritional status.

METHODS

Fifty-four obese patients were included who underwent laparoscopic sleeve gastrectomy (LSG, n = 27) or a 52-week multidisciplinary intervention program (MIP, n = 27) for weight loss. Body weight, body composition assessed by bioelectrical impedance analysis, and serum protein levels were measured before and within 12 months after intervention.

RESULTS

After 1 year of observation, excess weight loss was more pronounced following LSG (65 %) compared to MIP (38 %, p < 0.001). In both groups, body fat was clearly reduced, but a higher reduction occurred in the LSG group. However, protein status deteriorated particularly in the LSG group. Within 1 year, body cell mass declined from 37.1 to 26.9 kg in the LSG group, but only from 35.7 to 32.2 kg in the MIP group. This resulted in an increased mean extracellular mass/body cell mass ratio (1.42 versus 1.00, p < 0.001), in a decreased mean phase angle (4.4° versus 6.6°, p < 0.001), and in a lower prealbumin level in serum (p < 0.02) in the LSG group compared to the MIP group.

CONCLUSIONS

LSG, compared to MIP, was more effective regarding excess weight loss and body fat loss within 1 year, however, induced more pronounced muscle mass and protein loss, possibly requiring particular interventions such as exercise or protein supplements.

Impact of bariatric surgery on oral health conditions: 6-months cohort study

OBJECTIVES

We evaluate oral health conditions before and after bariatric surgery.

METHODS

The sample was composed of 59 patients who had undergone Roux-en-Y gastric bypass (RYGB). Salivary flow, periodontal pocket depth and dental wear were evaluated before and after 6 months of surgery. Body mass index (BMI), C-reactive protein (CRP) and glucose levels were obtained from the patient's medical files. A t-test was used for dependent samples.

RESULTS

The mean BMI decreased from 49.31 ± 8.76 to 35.52 ± 8.12 kg/m(2) in 6 months after surgery (P < 0.000). Before surgery, 67% of patients had high levels of CRP and 38% higher blood glucose levels and after surgery there were significant reductions in these levels (P < 0.001). Salivary flow ranged from 0.84 to 0.95 ml/min. There was increased prevalence of periodontal pockets (P = 0.022) and mean pocket depth increased to about 0.5 mm (P < 0.001). The percentage of surfaces with dental wear in dentine was significantly higher after bariatric surgery (P = 0.002), while dental wear in enamel decreased (P = 0.019).

CONCLUSIONS

Bariatric surgery may improve systemic conditions. However, it had a negative impact on oral health conditions because of an increase in periodontal disease and dental wear.

Neurologic complications of bariatric surgery

PURPOSE OF REVIEW

The increasing utilization of bariatric surgery has been accompanied by an increased incidence and awareness of related neurologic complications. The purpose of this review is to provide up-to-date information on the neurologic complications related to bariatric surgery.

RECENT FINDINGS

Neurologic complications related to bariatric surgery are predominantly due to nutrient deficiencies. Common early complications include Wernicke encephalopathy due to thiamine deficiency, and late complications include myelopathy or myeloneuropathy due to vitamin B12 or copper deficiency.

SUMMARY

Early recognition and prompt institution of treatment is essential to prevent long-term disability. Often, life-long supplementation may be required.

Micronutrient and physiologic parameters before and 6 months after RYGB

BACKGROUND

Bariatric surgery is considered an effective method for sustained weight loss, but may cause various nutritional complications. The aim of this study was to evaluate the nutritional status of minerals and vitamins, food consumption, and to monitor physiologic parameters in patients with obesity before and 6 months after Roux-en-Y gastric bypass surgery (RYGB).

METHODS

Thirty-six patients who had undergone RYGB were prospectively evaluated before and 6 months after surgery. At each phase their weight, height, body mass index (BMI), Electro Sensor Complex (ES Complex) data, food consumption, and total protein serum levels, albumin, prealbumin, parathyroid hormone (PTH), zinc (Zn), B12 vitamin (VitB12), iron (Fe), ferritin, copper (Cu), ionic calcium (CaI), magnesium (Mg), and folic acid were assessed.

RESULTS

The mean weight loss from baseline to 6 months after surgery was 35.34±4.82%. Markers of autonomic nervous system balance (P<.01), stiffness index (P<.01), standard deviation of normal-to-normal R-R intervals (SDNN) (P<.01), and insulin resistance (P<.001) were also improved. With regard to the micronutrients measured, 34 patients demonstrated some kind of deficiency. There was a high percentage of Zn deficiency in both pre- (55.55%) and postoperative (61.11%) patients, and 33.33% of the patients were deficient in prealbumin postoperatively. The protein intake after 6 months of surgery was below the recommended intake (<70 g/d) for 88.88% of the patients. Laboratory analyses demonstrated an average decrease in total protein (P<.05), prealbumin (P = .002), and PTH (P = .008) between pre- and postsurgery, and a decrease in the percentage of deficiencies for Mg (P<.05), CaI (P<.05), and Fe (P = .021).

CONCLUSION

Despite improvements in the autonomic nervous system balance, stiffness index markers and insulin resistance, we found a high prevalence of hypozincemia at 6 months post-RYGB. Furthermore, protein supplements were needed to maintain an adequate protein intake up to 6 months postsurgery.

Long-term medical complications after malabsorptive procedures: effects of a late clinical nutritional intervention

OBJECTIVE

The growing prevalence of severe obesity, combined with the failure of conservative treatments, has led to a significant spread of bariatric surgical procedures. The aim of this study was to emphasize the need of adequate presurgery patient selection and close follow-up after malabsorptive procedures for bariatric surgery.

METHODS

The study retrospectively evaluated 25 (20 F, 5 M; mean age 43 ± 13 y) obese patients (mean weight before intervention 134 ± 30.7 kg, body mass index 50.7 ± 10.1 kg/m(2)) attending our outpatient clinical nutrition unit for severe malabsorption and secondary malnutrition after surgical intervention that had been performed outside the regional area.

RESULTS

All patients received personalized dietetic indications; in 12 of 25 (48%) cases integrated by oral protein supplements and in 5 of 25 (20%) by medium chain triglycerides. According to screening exams, patients were prescribed oral/parenteral iron, vitamins A, B group, D, and folate supplementation. In 14 of 25 (56%) patients, parenteral hydration and in 4 of 25 (16%), long-term parenteral nutrition was required. Five patients required hospitalization for severely complicated protein-energy malnutrition.

CONCLUSION

Nutritional deficiencies are common after malabsorptive procedures for bariatric surgery; these can be present or latent before surgery, frequently going unrecognized and/or inadequately treated particularly when patients are not strictly followed up by the operating center. Despite the adequate-even intensive-intervention, clinical nutritional status moderately improved in all patients.

Obesity and surgical wound healing: a current review

Objective. The correlation between obesity and deficient wound healing has long been established. This review examines the current literature on the mechanisms involved in obesity-related perioperative morbidity. Methods. A literature search was performed using Medline, PubMed, Cochrane Library, and Internet searches. Keywords used include obesity, wound healing, adipose healing, and bariatric and surgical complications. Results. Substantial evidence exists demonstrating that obesity is associated with a number of postoperative complications. Specifically in relation to wound healing, explanations include inherent anatomic features of adipose tissue, vascular insufficiencies, cellular and composition modifications, oxidative stress, alterations in immune mediators, and nutritional deficiencies. Most recently, advances made in the field of gene array have allowed researchers to determine a few plausible alterations and deficiencies in obese individuals that contribute to their increased risk of morbidity and mortality, especially wound complications. Conclusion. While the literature discusses how obesity may negatively affect health on various of medical fronts, there is yet to be a comprehensive study detailing all the mechanisms involved in obesity-related morbidities in their entirety. Improved knowledge and understanding of obesity-induced physiological, cellular, molecular, and chemical changes will facilitate better assessments of surgical risks and outcomes and create efficient treatment protocols for improved patient care of the obese patient population.

Short- and mid-term changes in bone mineral density after laparoscopic sleeve gastrectomy

BACKGROUND

Bariatric surgery is the most effective treatment for achieving a significant weight loss. Morbidities present a significant reduction after bariatric surgery, but it may also result in several health complications, related to nutritional deficiencies, including bone metabolism. Several studies have reported a decrease in bone mineral density (BMD), but most of them referring to malabsorptive procedures. Restrictive procedures do not imply changes in gastrointestinal anatomy, so that one may expect fewer metabolic disturbances.

METHODS

We performed a retrospective observational study of all morbidly obese patients undergoing LSG between 2008 and 2011 at our institution. Bone densitometry was performed before surgery and 1 and 2 years after the intervention. Body size measurements, analytical variables and densitometric values in the lumbar spine (BMD, t score and z score) were investigated.

RESULTS

Forty-two patients were included, 39 females and 3 males. Mean BMI was 51.21 kg/m(2). Mean excessive BMI loss was 79.9 % after 1 year and 80.6 % after 2 years. Mean BMD values for spine increased progressively, reaching statistical significance at 1 and at 2 years. Percentage of BMD increase was 5.7 % at 1 year and 7.9 % at 2 years. An inverse correlation was observed between BMD increase and parathyroid hormone (PTH) decrease and a direct correlation between BMD and vitamin D increase.

CONCLUSION

Bone mineral density showed a progressive increase during the first and second year after sleeve gastrectomy. BMD changes are not associated with weight loss, but showed a direct correlation with vitamin D and an inverse correlation with PTH levels.

Profile of the obese patients submitted to Roux-en-Y gastric bypass whithout diabetes melittus type 2 remission and/or insufficient weight loss

BACKGROUND

The literature reports that gastrojejunal derivation with Roux-en-Y gastric bypass is highly efficient in controlling weight and resolving; but studies have shown worsened glycemic control in a considerable number of patients and associated factors that have not been fully elucidated.

AIM

To analyze the profile of patients submitted to gastric bypass that did not achieve satisfactory weight loss or complete diabetes remission.

METHODS

Case-control study of 32 patients submitted to gastric bypass with at least two years postoperative time, unsatisfactory results in terms of weight loss or absence of complete diabetes remission. The control group was composed of another 32 patients submitted to the same operation at the same facility, matched for age and postoperative time. A structured questionnaire was applied and clinical and laboratory data were analyzed.

RESULTS

Among the cases and controls, BMI was 38.9 kg/m² and 29.5 kg/m2, excess weight loss was 56.1% and 77.2%, % excess weight regain of initial excess weight loss, was 20.2% and 7.7%, respectively. Family history of type 2 diabetes mellitus, hypertension and food intolerance showed a significant relationship between cases and controls.

CONCLUSION

Food intolerance and family history of hypertension and diabetes were associated to lower loss and weight regain or less likelihood of complete diabetes remission after gastric bypass.

Validation of ultrasound examination for assessment of the abdominal visceral fat in clinically serious obese patient

BACKGROUND

Computerized tomography is the gold-standard for measurement of abdominal visceral fat. However, it is costly and involves submitting patients to ionizing radiation.

AIM

To validate the use of ultrasonography in assessing abdominal visceral fat among clinically serious obese patients of both genders.

METHODS

The sample included adult patients with clinically serious obesity with body mass index of 40 kg/m2 or from 35 kg/m(2) to 40 kg/m2 with co-morbidities. Abdominal visceral fat thickness was measured using ultrasound and tomography. Two ultrasonographic exams were conducted to assess the interobserver reproducibility among a patient subsample. Validation was done by comparing these results with the tomographic findings.

RESULTS

The study included 13 patients (61.54% female) with an average BMI of 38.82 kg/m2. In terms of validation, the result obtained from applying the Pearson correlation coefficient was equal to 0.94 (p = 0.0005), showing a strong positive correlation between the two measurements. As for the results for reproducibility, the interobserver was equal to 0.822, with a confidence interval of 95% (-0.076 to 0.980), revealing good interobserver agreement. The average difference between the two ultrasound interobserver examination was equal to 0.10 ± 1.51 (p=0.8898) and so not significant. Interobserver bias was also not significant.

CONCLUSION

The validation of ultrasonographic examination to replace tomographic method in assessing abdominal visceral fat among clinically serious obese patients was effective. The ultrasound measurement is independent of the examiner.

Cross-sectional long-term micronutrient deficiencies after sleeve gastrectomy versus Roux-en-Y gastric bypass: a pilot study

BACKGROUND

Nutritional deficiencies are highly prevalent in obese patients. Bariatric surgery has been associated with adverse effects on homeostasis of significant vitamins and micronutrients, mainly after gastric bypass. The aim of the present study was to compare the extent of long-term postsurgical nutritional deficiencies between Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

METHODS

This cross-sectional, pilot study included 95 patients who underwent RYGB or SG surgery with a mean follow-up of 4 years. Demographic, anthropometric, and biochemical parameters were compared according to the type of surgery.

RESULTS

Both types of surgery were associated with significant nutritional deficiencies. Vitamin B12 deficiency was significantly higher in patients with RYGB compared with SG (42.1% versus 5%, P = .003). The type of surgery was associated neither with anemia nor with iron or folate deficiency (SG versus RYGB: anemia, 54.2% versus 64.3%, P = .418; folate deficiency, 20% versus 18.4%, P = .884; iron deficiency, 30% versus 36.4%, P = .635).

CONCLUSION

During a mean follow up period of 4 years postRYGB or SG, patients were identified with several micronutrient deficiencies, including vitamin D, folate, and vitamin B12. SG may have a more favorable effect on the metabolism of vitamin B12 compared with RYGB, being associated with less malabsorption. Adherence to supplemental iron and vitamin intake is of primary significance in all cases of bariatric surgery.

Common misconceptions about vitamin D--implications for clinicians

Misconceptions about vitamin D continue to grow despite publications in the past few years that have attempted to clarify risk. We present our perspective, and offer several conclusions. Calcium and vitamin D supplementation can reduce fracture risk by ∼10%. On the other hand, little evidence exists to support a threshold measure for vitamin D status (serum levels of 25-hydroxyvitamin D) above which fractures are reduced. The association of serum concentrations of 25-hydroxyvitamin D with other chronic diseases is confounded by multiple factors and conflicting outcomes that cannot be used to support a causal association. High doses of vitamin D supplements might not be completely harmless and should be avoided until additional data becomes available. Similarly, scant rationale exists for aggressive vitamin D supplementation for pregnant or lactating women. Dispelling misconceptions about vitamin D will ultimately benefit health-care providers and patients alike.

Disease-specific nutrition therapy: one size does not fit all

INTRODUCTION

The delivery of adequate nutrition is an integral part of the care of the critically ill surgical patient, and the provision of nutrition may have a greater impact on outcome than many other therapies commonly employed in the treatment of certain disease states.

METHODS

A review of the existing literature was performed to summarize the evidence for utilizing disease-specific nutrition in critically ill surgical patients.

RESULTS

Enteral nutrition, unless specifically contraindicated, is always preferable to parenteral nutrition. Methodological heterogeneity and conflicting results plague research in immunonutrition, and routine use is not currently recommended in critically ill patients.

CONCLUSION

There is currently insufficient evidence to recommend the routine initial use of most disease-specific formulas, as most patients with the disease in question will tolerate standard enteral formulas. However, the clinician should closely monitor for signs of intolerance and utilize disease-specific formulas when appropriate.

Iron deficiency and bariatric surgery

It is estimated that the prevalence of anaemia in patients scheduled for bariatric surgery is higher than in the general population and the prevalence of iron deficiencies (with or without anaemia) may be higher as well. After surgery, iron deficiencies and anaemia may occur in a higher percentage of patients, mainly as a consequence of nutrient deficiencies. In addition, perioperative anaemia has been related with increased postoperative morbidity and mortality and poorer quality of life after bariatric surgery. The treatment of perioperative anaemia and nutrient deficiencies has been shown to improve patients’ outcomes and quality of life. All patients should undergo an appropriate nutritional evaluation, including selective micronutrient measurements (e.g., iron), before any bariatric surgical procedure. In comparison with purely restrictive procedures, more extensive perioperative nutritional evaluations are required for malabsorptive procedures due to their nutritional consequences. The aim of this study was to review the current knowledge of nutritional deficits in obese patients and those that commonly appear after bariatric surgery, specifically iron deficiencies and their consequences. As a result, some recommendations for screening and supplementation are presented.

Oxidative stress markers in adults 2 years after Roux-en-Y gastric bypass

INTRODUCTION

Obesity is a chronic disease associated with oxidative stress. Bariatric surgery for the treatment of obesity may affect biomarkers of oxidative stress.

OBJECTIVES

The aim of the present study was to evaluate the effect of Roux-en-Y gastric bypass (RYGB) on blood markers of oxidative stress, such as vitamins C and E, β-carotene, reduced glutathione (GSH), catalase (CAT), ferric reducing antioxidant potential (FRAP), and thiobarbituric acid-reactive substances (TBARS).

METHODS

A prospective controlled clinical trial was carried out. The participants were distributed into two groups: a control group (n=35), which was evaluated once, and a bariatric group (n=35), which was evaluated at baseline as well as 6, 12, and 24 months after surgery.

RESULTS

After surgery, the BMI decreased from 47.05±1.46 to 30.53±1.14 kg/m (P<0.001), but 25.7% of the participants regained weight after 24 months. In relation to the baseline, postsurgery reductions were found in vitamin C (31.9±4.6%, P<0.001), β-carotene (360.7±368.3%, P<0.001), vitamin E (22.8±4.1%, P<0.001), GSH (6.6±5.2%, P=0.090), CAT (12.7±5.6%, P=0.029), and FRAP (1.2±3.8%, P=0.085) 2 years after RYGB. TBARS levels decreased after 12 months (71.6±2.9%, P<0.001) in relation to the baseline but increased by 195.0±28.2% between the 12th and the 24th month (P<0.001).

CONCLUSION

The present findings show that oxidative stress returned 2 years after RYGB. Concentrations of vitamin C, β-carotene, GSH, CAT, and FRAP were decreased, whereas the concentration of TBARS decreased in the first year but increased in the following year, which may be partly explained by the imbalance between antioxidants and pro-oxidants.

100 kg more or less, still the same person (and disorder): from overweight to underweight--exacerbation of an eating disorder after bariatric surgery

OBJECTIVE

To report the case of a morbidly obese 49-year-old woman with nonspecific interstitial pneumonia who underwent bariatric surgery. Because of inadequate weight loss after sleeve gastrectomy, duodenal switch as component of a stepwise treatment was performed and led to unexplained progressive weight loss and malnutrition.

METHOD

Case report.

RESULTS

After duodenal switch surgery, the patient presented with late postsurgical symptoms of malabsorption. Postsurgical psychological evaluation revealed a persistent binge eating disorder. Along with exocrine pancreatic insufficiency, binge eating had led to progressive weight loss of ≈100 kg from a body mass index of 50.3 kg/m(2) presurgery to 17.3 kg/m(2) postsurgery.

DISCUSSION

Recent research has focused on eating patterns after bariatric surgery and the risks of exacerbating eating disorders after surgery. This case study illustrates the need for auxiliary prepsychotherapeutic and postpsychotherapeutic evaluation and subsequent support for patients with eating disorders preparing for bariatric surgery.

[Bariatric surgery - significance, risks, long term consequences]

In recent years the number of bariatric surgery has markedly increased in industrial nations. Surgery provides a more rapid decrease of body weight than conservative approach. However a long term conservative follow up therapy is mandatory to stabilize reduced weight. Due to increasing knowledge from long term follow up of surgically treated obese patients there is a growing body of evidence that frequently there is necessity of reoperations and of substitution both of trace elementsand of minerals or vitamins due to their hampered enteral resorption. Additionally therapy of surgery induced endocrine alterations not seldom is necessary.These insights are of outstanding importance because meanwhile an enlargement of the indications for bariatric surgery as a therapeutic option for metabolic disorders is being discussed. This review refers to the recent internationally published papers concerning consequences of bariatric surgery.

[Bariatric surgery: how and why to supplement]

Patients who have undergone bariatric surgery are at increased risk of developing nutritional deficiencies from limited food intake and absorption of different nutrients. A systematic review of several database websites (PubMed and ISI Web of Science) was conducted from September 1983 to April 2010 to identify literature related to micronutrient deficiencies occurring after bariatric surgery. Keywords used individually or in various combinations in the search were bariatric surgery, obesity, vitamin/mineral deficiencies, protein deficiency, nutrient absorption and nutrient supplementation. Literature suggests that to prevent or treat nutritional deficiencies resulting from anatomical changes due to surgical techniques nutritional supplementation is usually necessary. The success of oral nutritional supplementation to correct or prevent nutritional deficiencies depends on several factors. Thus, to understand how nutrients can be administered is very important for clinical practice. This review aims to provide help for the best selection of nutrients to ensure an adequate replacement of nutrients in patients who have undergone bariatric surgery.

Systemic consequences of bariatric surgery and its repercussions on oral health

INTRODUCTION

Morbid obesity control can be done by bariatric surgery that restricts or reduces the amount of food absorption. The objective of this review was to identify the consequences of bariatric surgery and its repercussions on oral health.

METHOD

It was used the Virtual Library of Health, which included articles that had any direct or indirect connection between bariatric surgery and oral health, and published in the last ten years.

RESULTS

Some complications of the surgery are chronicle reflux and nutritional deficiency, which may bring repercussions on the oral cavity, such as tooth erosion, bone loss and dental caries. On the other hand, there are also positive impacts, such as the decrease of diabetes, apnea and improvement on self-esteem, that makes the patients less vulnerable to complications regarding oral health, for example xerostomy and periodontal disease.

CONCLUSION

Maintaining proper oral health in patients undergoing bariatric surgery contributes to success after surgery protecting benefits and minimizing side effects.

Accelerated gastric emptying but no carbohydrate malabsorption 1 year after gastric bypass surgery (GBP)

BACKGROUND

Following gastric bypass surgery (GBP), there is a post-prandial rise of incretin and satiety gut peptides. The mechanisms of enhanced incretin release in response to nutrients after GBP is not elucidated and may be in relation to altered nutrient transit time and/or malabsorption.

METHODS

Seven morbidly obese subjects (BMI = 44.5 ± 2.8 kg/m(2)) were studied before and 1 year after GBP with a D: -xylose test. After ingestion of 25 g of D: -xylose in 200 mL of non-carbonated water, blood samples were collected at frequent time intervals to determine gastric emptying (time to appearance of D: -xylose) and carbohydrate absorption using standard criteria.

RESULTS

One year after GBP, subjects lost 45.0 ± 9.7 kg and had a BMI of 27.1 ± 4.7 kg/m(2). Gastric emptying was more rapid after GBP. The mean time to appearance of D: -xylose in serum decreased from 18.6 ± 6.9 min prior to GBP to 7.9 ± 2.7 min after GBP (p = 0.006). There was no significant difference in absorption before (serum D: -xylose concentrations = 35.6 ± 12.6 mg/dL at 60 min and 33.9 ± 9.1 mg/dL at 180 min) or 1 year after GBP (serum D: -xylose = 31.5 ± 18.1 mg/dL at 60 min and 27.2 ± 11.9 mg/dL at 180 min).

CONCLUSIONS

These data confirm the acceleration of gastric emptying for liquid and the absence of carbohydrate malabsorption 1 year after GBP. Rapid gastric emptying may play a role in incretin response after GBP and the resulting improved glucose homeostasis.

[Impact of bariatric surgery on obstetric prognosis]

OBJECTIVES

Assessment of pregnancy outcomes after bariatric surgery and analysis of follow-up particularities of such pregnancies.

PATIENTS AND METHODS

A retrospective study of 63 post-bariatric surgery pregnancies compared to 259 pregnancies of obese un-operated patients. Pregnancy outcomes, neonatal datas, delay influence between surgery and pregnancy beginning, bariatric surgery type and gastric banding (GB) loosening consequences were analysed.

RESULTS

In the surgical brand were developed less gestational diabetes (DG) (P=0,05), deliveries were more often normal (P=0,004) and births shown less macrosomias and small for gestational age newborns (P=0,04). Neonatal state was improved among operated patients: less Apgar scores less than 7 at 1 minute (P=0,05) and less cord blood pH less than 7,2 (P=0,03). They gained more weight during the pregnancy (P=0,0003) and only 53% had a nutritional management and assessment. Patients with GB loosening gained more weight (P=0,0003). Lastly, there were no difference due to the different bariatric surgery techniques or nutritional follow-up in the pregnancy course and neonatal state.

DISCUSSION AND CONCLUSION

Bariatric surgery improves obstetric and neonatal prognosis. Improvements have to be developed in the multidisciplinary follow-up in order to avoid nutritional deficiencies or important weight gain pregnancy in case of GB.

Mid-term effects of sleeve gastrectomy on calcium metabolism parameters, vitamin D and parathormone (PTH) in morbid obese women

BACKGROUND

Despite routine supplementation of vitamins and minerals after bariatric surgery, an important number of patients suffer from deficiencies. Little is still known about the novel restrictive procedure, sleeve gastrectomy.

METHODS

A retrospective study of 30 morbidly obese patients undergoing a laparoscopic sleeve gastrectomy, between May 2008 and September 2010, was performed. Baseline albumin, ferritin, iron, zinc, calcium, vitamin D, parathormone (PTH), vitamin B12, and folic acid were obtained before operation and postoperative determinations 1, 3, 6, 9, 12, 18, and 24 months after surgery.

RESULTS

Before surgery, 96.7% of the patients presented vitamin D deficiency, 20% had elevated PTH, 3.3% hypoalbuminemia, and 3.3% folic acid deficiency. One year after surgery, only one patient (3.3%) presented vitamin D deficiency and had elevated PTH. The rest of parameters were within normal range. The second year after surgery, the results remain similar. A significant difference was obtained when comparing preoperative vitamin D values and postoperative determinations 12 months after surgery (increase of 51.9 ng/dl, 95% confidence interval (CI) (41.8-61.3); p < 0.001). A significant difference was determined when comparing preoperative PTH values and postoperative determinations 3 months after surgery (decrease of 16.6 pg/ml, 95% CI (2.6-30.6); p = 0.03). A significant inverse correlation was observed between weight loss and vitamin D increase at the third month after surgery (Pearson correlation coefficient -0.948; p = 0.033).

CONCLUSIONS

Postoperative values of vitamin D show a progressive increase, while PTH ones present a significant reduction, without any impact on serum calcium levels. We have demonstrated an inverse correlation between weight loss and vitamin D increase at the third month after surgery.

Food intake in women two years or more after bariatric surgery meets adequate intake requirements

Restricted food intake after bariatric surgery can be an important factor both in the long-term control of body weight and in the onset of nutritional deficiencies. The objective of this study was to assess the adequacy of food intake in women two or more years after bariatric surgery according to the excess weight lost. A group of 141 women who underwent banded Roux-en-Y gastric bypass (RYGB) was divided according to the percentage of excess weight they lost (%EWL)<50; 50┤75; = 75. The habitual energy and nutrient intakes were determined by a 24-hour recall over two days and the probability of adequate intake was based on the Dietary Reference Intake. The mean total estimated energy requirement (EER) as well as energy, macronutrient and cholesterol intakes did not differ among the groups. Only the %EWL<50 group had an intake equal to their EER, but they presented a higher number of inadequacies, such as low levels of magnesium, folic acid and vitamins C and E. Calcium and dietary fiber intakes were extremely low in all three groups. In conclusion, weight loss after surgery is associated with food habits that favor energy intake over micronutrient intake.

Late micronutrient deficiency and neurological dysfunction after laparoscopic sleeve gastrectomy: a case report

Although the micronutrient deficiencies and the related neurological manifestations are widely reported after malabsorbitive weight loss surgery, little is known about cerebral dysfunction secondary to micronutrient impairment in subjects undergoing restrictive interventions (that is, sleeve gastrectomy). We describe a case of a 27-year-old woman with a late development of a Wernicke's encephalopathy (WE) and of severe polyneuropathy following a sleeve gastrectomy without any sleeve stenosis. The impact of WE after bariatric surgery is significantly underestimated. Such a risk should be taken into consideration also after restrictive weight loss surgery. Thus, surgeon/clinicians involved in bariatric patients management must be aware of neurological sequelae related to this intervention.

Role of bariatric-metabolic surgery in the treatment of obese type 2 diabetes with body mass index <35 kg/m2: a literature review

Bariatric surgery has been used to treat type 2 diabetes mellitus (T2DM); however, its efficacy is still debatable. This literature review analyzed articles that evaluated the effects of bariatric surgery in treatment of T2DM in obese patients with a body mass index (BMI) of <35 kg/m(2). A paired t test was applied for the analysis of pre- and postintervention mean BMI, fasting plasma glucose (FPG), and glycosylated hemoglobin (A1c) values. A significant (P<0.001) reduction in BMI (from 29.95±0.51 kg/m(2) to 24.83±0.44 kg/m(2)), FPG (from 207.86±8.51 mg/dL to 113.54±4.93 mg/dL), and A1c (from 8.89±0.15% to 6.35±0.18%) was observed in 29 articles (n=675). T2DM resolution (A1c <7% without antidiabetes medication) was achieved in 84.0% (n=567) of the subjects. T2DM remission, control, and improvement were observed in 55.41%, 28.59%, and 14.37%, respectively. Only 1.63% (n=11) of the subjects presented similar or worse glycemic control after the surgery. T2DM remission (A1c <6% without antidiabetes medication) was higher after mini-gastric bypass (72.22%) and laparoscopic/Roux-en-Y gastric bypass (70.43%). According to the Foregut and Hindgut Hypotheses, T2DM results from the imbalance between the incretins and diabetogenic signals. The procedures that remove the proximal intestine and do ileal transposition contribute to the increase of glucagon-like peptide-1 levels and improvement of insulin sensitivity. These findings provide preliminary evidence of the benefits of bariatric-metabolic surgery on glycemic control of T2DM obese subjects with a BMI of <35 kg/m(2). However, more clinical trials are needed to investigate the metabolic effects of bariatric surgery in T2DM remission on pre-obese and obese class I patients.