Hematological variables and iron status in abdominoplasty after bariatric surgery

Preventing and Managing Pre- and Postoperative Micronutrient Deficiencies: A Vital Component of Long-Term Success in Bariatric Surgery

Bariatric surgery (BS) is an effective treatment for severe obesity and its related comorbidities, such as type 2 diabetes and hypertension. However, the anatomical and physiological changes associated with these procedures significantly increase the risk of preoperative and postoperative micronutrient deficiencies, which can lead to severe complications such as anemia, osteoporosis, and neurological disorders. This narrative review examines the prevalence and clinical implications of micronutrient deficiencies in BS patients, as well as evidence-based strategies for their prevention and management. The most common deficiencies include iron, vitamin B12, folate, calcium, vitamin D, and fat-soluble vitamins (A, E, and K). Procedures with a hypoabsorptive component, such as Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS), pose higher risks of deficiencies compared to restrictive procedures like sleeve gastrectomy (SG). Effective strategies involve the preoperative correction of deficiencies, continuous monitoring, and tailored supplementation. However, long-term adherence to supplementation tends to decrease over time, influenced by behavioral and socioeconomic factors. Hence, preventing and managing micronutrient deficiencies are crucial for the long-term success of BS. While current guidelines provide valuable recommendations, many are based on low-certainty evidence, underscoring the need for more robust studies. A multidisciplinary approach, combined with innovative strategies, such as telemedicine, can enhance adherence and achieve sustainable clinical outcomes.

[Increased risk of bleeding during abdominal dermolipectomies in men: Myth or reality?]

INTRODUCTION

Abdominoplasty is the most frequently performed procedure for the treatment of weight loss sequelaes. It carries risks of complications, especially in patients with multiple metabolic comorbidities. It is commonly accepted that the male population develops more postoperative complications, particularly haemorrhage, but there are very few studies showing this excessive morbidity. The aim of this study was to determine the increased risk of bleeding after anterior and circular abdominoplasty in men by comparing two series of 105 male and female patients.

MATERIALS AND METHODS

This is a retrospective, single-center study including 105 male subjects undergoing simple or circular abdominoplasty between 2013 and 2022. The control group was composed of 105 women screened on the same terms. The data collection focused on different pre-, intra-, and postoperative variables, with the occurrence of a hematoma or the need for a transfusion during follow-up as the primary outcome. The analysis was performed according to a univariate and multivariate models.

RESULTS

The rate of hematoma or transfusion, seroma, infection, amount of blood loss, and length of hospital stay were significantly greater in the male group. Multivariate analysis confirmed the independence of gender on the risk of developing a hematoma or requiring a transfusion.

CONCLUSION

This study shows the excess morbidity in men, particularly haemorrhage, after abdominoplasty. This underlines the importance of a rigorous haemostasis and follow-up in this at risk population.

Iron Deficiency in Obesity and after Bariatric Surgery

Iron deficiency (ID) is particularly frequent in obese patients due to increased circulating levels of acute-phase reactant hepcidin and adiposity-associated inflammation. Inflammation in obese subjects is closely related to ID. It induces reduced iron absorption correlated to the inhibition of duodenal ferroportin expression, parallel to the increased concentrations of hepcidin. Obese subjects often get decreased inflammatory response after bariatric surgery, accompanied by decreased serum hepcidin and therefore improved iron absorption. Bariatric surgery can induce the mitigation or resolution of obesity-associated complications, such as hypertension, insulin resistance, diabetes mellitus, and hyperlipidemia, adjusting many parameters in the metabolism. However, gastric bypass surgery and sleeve gastrectomy can induce malabsorption and may accentuate ID. The present review explores the burden and characteristics of ID and anemia in obese patients after bariatric surgery, accounting for gastric bypass technique (Roux-en-Y gastric bypass-RYGB) and sleeve gastrectomy (SG). After bariatric surgery, obese subjects' iron status should be monitored, and they should be motivated to use adequate and recommended iron supplementation.

Complications after lower body contouring surgery due to massive weight loss unaffected by weight loss method

Body contouring surgery following massive weight loss positively affects a patient's quality of life. However, the procedure is prone to complications. Herein, we stratified complications timewise. Furthermore, we examined whether the weight loss method - bariatric surgery or lifestyle changes - affected the frequency or severity of complications. In this single-centre retrospective analysis, we included 158 patients with massive weight loss undergoing body contouring surgery between 2009 and 2015. We recorded 96 complications in 80 patients, with an overall rate of 51%. Most complications (80.2%) were minor (Clavien-Dindo grades 1 and 2) and superficial wound infections. Immediate complications (0-24 hours post-operation) affected 8.3% of patients, with early complications (1-7 post-operative days) affecting 16.7% of them and late complications (8-30 post-operative days) affecting 58.3% of them. We found no statistical difference in complication rates when comparing bariatric and non-bariatric patients. Older age (p = 0.042) at operation is associated with an increased risk for immediate haematoma or bleeding requiring surgery. Among early complications, a high maximum weight (p = 0.035) and a high preoperative weight (p = 0.0053) significantly correlated with a haematoma or bleeding requiring surgery. For late complications, seroma correlated with older age (p = 0.0061). Complications are primarily minor and non-life threatening after body contouring surgery because of frequent massive weight loss. Here, no particular subgroup of massive weight loss patients appeared more prone to complications. Thus, for each patient, the risks associated with body contouring surgery following massive weight loss should be considered individually.

Intravenous iron sucrose versus oral iron administration for the postoperative treatment of post-bariatric abdominoplasty anaemia: an open-label, randomised, superiority trial in Brazil

BACKGROUND

Anaemia and iron deficiency are common after post-bariatric abdominoplasty, which can involve removal of large areas of skin with associated blood loss. Because the oral absorbability of iron is reduced after bariatric surgery (through reduced intake, reduction of gastric acid secretion for conjugation of iron, and separation of the iron-absorptive areas of the duodenum and jejunum), it has been hypothesised that postoperative intravenous iron supplementation might be used to treat anaemia and iron deficiency in patients submitted to post-bariatric plastic surgeries. We aimed to assess whether intravenous iron administered postoperatively in post-bariatric abdominoplasty could result in increased blood haemoglobin concentrations compared with oral iron supplementation.

METHODS

In this open-label, randomised, superiority trial, we recruited women aged 18-55 years undergoing post-bariatric abdominoplasty at two public tertiary referral hospitals in São Paulo, Brazil. Eligible women had been treated for previous obesity with bariatric surgery using the vertical banded gastroplasty technique with Roux-en-Y gastric bypass by laparotomy; had grade III contour deformity via the Pittsburgh rating scale; and had a post-bariatric body-mass index (BMI) lower than 32 kg/m2, with stabilised weight loss for at least 6 months. Women were randomly assigned (1:1) to receive postoperative iron supplementation with two intravenous infusions of 200 mg of iron sucrose (intravenous group) or 100 mg of iron polymaltose complex orally twice a day for 8 weeks (oral group). The primary outcome in both groups was blood haemoglobin concentration at postoperative day 56 after abdominoplasty, with a minimum clinically relevant difference of 1·5 g/dL. Analyses were performed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT01857011, and the Brazilian Clinical Trials Registry, number RBR-2JGRKQ. The trial is completed.

FINDINGS

From April 7, 2014, to June 27, 2016, 102 post-bariatric patients were assessed for eligibility. 56 patients were eligible and were randomly assigned, with 28 allocated to each group. Mean baseline haemoglobin concentration was slightly higher in the oral group than in the intravenous group (12·71 g/dL [SD 1·06] vs 12·24 g/L [1·09]), and by post-operative day 56 was 12·54 g/dL (SD 1·18) and 12·80 g/dL (0·81), respectively (mean difference of 0·26 g/dL, 95% CI -0·28 to 0·80; p=0·009 in favour of the intravenous group). The minimum clinically relevant difference in concentrations was not reached. No adverse events were recorded in the intravenous group, whereas in the oral group, constipation was recorded in five (18%) patients, diarrhoea in three (11%), and nausea in one (4%) patient.

INTERPRETATION

Postoperative intravenous administration of iron increased haemoglobin concentrations at 56 days post-operatively and reduced iron deficiency, without adverse events. Although superiority of intravenous iron was not shown, intravenous administration might be useful in post-bariatric patients, especially in those who have body-contouring treatment involving a second surgery within a short period of time. Larger trials, and trials using higher intravenous doses of iron, are needed to further assess the potential efficacy and safety of intravenous iron administration after post-bariatric plastic surgery.

FUNDING

The São Paulo Research Foundation (FAPESP).

Postoperative intravenously administered iron sucrose versus postoperative orally administered iron to treat post-bariatric abdominoplasty anaemia (ISAPA): the study protocol for a randomised controlled trial

Background

Anaemia and iron deficiency are common complications following post-bariatric abdominoplasty. Given the low oral absorbability of iron resulting from bariatric surgery, it has been hypothesised that postoperative intravenously administered iron supplementation could be used to treat anaemia and to prevent the development of iron deficiency in these patients.

Methods/Design

In this multicentre open-label randomised clinical trial, 56 adult women undergoing post-bariatric anchor-line abdominoplasty will be allocated at a ratio of 1:1 for postoperative supplementation with two intravenously administered applications of 200 mg of iron saccharate or postoperative supplementation with 100 mg of iron polymaltose complex administered orally, twice a day for 8 weeks. The primary outcome is the difference in mean haemoglobin levels between the two groups at eight postoperative weeks. Secondary outcomes evaluated at one, four and eight postoperative weeks include iron profile, reticulocyte count, overall quality of life measured using the Short-Form 36 Health Survey (SF-36) questionnaire, fatigue measured using the Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F), adverse effects and postoperative complications.

Discussion

This randomised clinical trial aims to evaluate the haematopoietic effectiveness of intravenously administered iron supplementation in patients undergoing post-bariatric abdominoplasty. A more effective recovery of haemoglobin levels could help improve the patients’ quality of life and could provide an improved haematological status in preparation for the subsequent and frequent plastic surgeries these patients undergo.

Trial registration

Clinicaltrials.gov Identifier: NCT01857011 (8 May 2013), Universal Trial Number U111-1169-6223, Brazilian Clinical Trials Registry (REBEC): RBR-2JGRKQ.

Evaluation of Medical Students' Attitudes and Performance of Basic Surgery Skills in a Training Program Using Fresh Human skin, Excised During Body Contouring Surgeries

BACKGROUND

Learning surgical skills in the operating room may be a challenge for medical students. Therefore, more approaches using simulation to enable students to develop their practical skills are required.

OBJECTIVES

We hypothesized that (1) there would be a need for additional surgical training for medical students in the pre-final year, and (2) our basic surgery skills training program using fresh human skin would improve medical students' surgical skills.

DESIGN

We conducted a preliminary survey of medical students to clarify the need for further training in basic surgery procedures. A new approach using simulation to teach surgical skills on human skin was set up. The procedural skills of 15 randomly selected students were assessed in the operating room before and after participation in the simulation, using Objective Structured Assessment of Technical Skills. Furthermore, subjective assessment was performed based on students' self-evaluation. The data were analyzed using SPSS, version 21 (SPSS, Inc., Chicago, IL).

SETTING

The study took place at the Inselspital, Bern University Hospital.

PARTICIPANTS

A total of 186 pre-final-year medical students were enrolled into the preliminary survey; 15 randomly selected medical students participated in the basic surgical skills training course on the fresh human skin operating room.

RESULTS

The preliminary survey revealed the need for a surgical skills curriculum. The simulation approach we developed showed significant (p < 0.001) improvement for all 12 surgical skills, with mean cumulative precourse and postcourse values of 31.25 ± 5.013 and 45.38 ± 3.557, respectively. The self-evaluation contained positive feedback as well.

CONCLUSION

Simulation of surgery using human tissue samples could help medical students become more proficient in handling surgical instruments before stepping into a real surgical situation. We suggest further studies evaluating our proposed teaching method and the possibility of integrating this simulation approach into the medical school curriculum.

Desire for body contouring surgery after bariatric surgery: do body mass index and weight loss matter?

BACKGROUND

There is disparity between the number of postbariatric surgery subjects who desire body contouring and those who receive it due to lack of resources or insurance criteria.

OBJECTIVES

The authors evaluate the desire for body contouring after bariatric surgery and its relationship with demographic patient characteristics.

METHODS

Three hundred sixty patients who had undergone bariatric surgery procedures >1 year previously completed a questionnaire designed by the surgical team to analyze each patient's desire for body contouring by area (face, upper arm, upper back, chin/neck, chest/breast, waist/abdomen, lower back, rear/buttock), scored from 0 to 3 (do not want, want somewhat, want, want a great deal). Data were compared with patient characteristics, postoperative body mass index (BMI), amount of weight loss, and BMI difference (ΔBMI).

RESULTS

Most patients desired body contouring surgery, with high or very high desire for waist/abdomen (62.2%), upper arm (37.6%), chest/breast (28.3%), and rear/buttock (35.6%) contouring. Many patients (36.4%) cited "very high" expectations for how body contouring might change their appearance. Patients >50 years old and >3 years postsurgery had a significantly lower desire. Patients with a ΔBMI >10 and with a weight loss >20 kg showed a significantly stronger overall desire for body contouring compared with other groups.

CONCLUSIONS

Most patients desire body contouring surgery after bariatric surgery, and our multivariate analysis showed a significant positive association between female sex, younger age, amount of weight loss, and ΔBMI with desire for body contouring.