Preventing Wernicke Encephalopathy After Bariatric Surgery

Wernicke Encephalopathy After Roux-en-Y Gastric Bypass Presenting with Altered Mental Status-A Video Case Report

Wernicke encephalopathy (WE) is a seldom encountered yet significant neuropsychiatric ailment resulting from a deficiency in thiamine (vitamin B1). While commonly linked with chronic alcoholism or insufficient dietary intake, instances of WE following bariatric and metabolic surgeries, notably laparoscopic Roux-en-Y gastric bypass (RYGB), have been sporadically documented. This case study elucidates the condition of a male patient who, 3 months after undergoing RYGB to address severe obesity, displayed abrupt alterations in mental status, swiftly ameliorated by immediate administration of intravenous high-dose thiamine.

The Efficacy and Safety of Endoscopic Balloon Dilatation in the Treatment of Functional Post-Sleeve-Gastrectomy Stenosis

Background and Objectives: Functional gastric stenosis, a consequence of sleeve gastrectomy, is defined as a rotation of the gastric tube along its longitudinal axis. It is brought on by gastric twisting without the anatomical constriction of the gastric lumen. During endoscopic examination, the staple line is deviated with a clockwise rotation, and the stenosis requires additional endoscopic manipulations for its transposition. Upper gastrointestinal series show the gastric twist with an upstream dilatation of the gastric tube in some patients. Data on its management have remained scarce. The objective was to assess the efficacy and safety of endoscopic balloon dilatation in the management of functional post-sleeve gastrectomy stenosis. Patients and Methods: Twenty-two patients with functional post-primary-sleeve-gastrectomy stenosis who had an endoscopic balloon dilatation between 2017 and 2023 were included in this retrospective study. Patients with alternative treatment plans and those undergoing endoscopic dilatation for other forms of gastric stenosis were excluded. The clinical outcomes were used to evaluate the efficacy and safety of balloon dilatation in the management of functional gastric stenosis. Results: A total of 45 dilatations were performed with a 30 mm balloon in 22 patients (100%), a 35 mm balloon in 18 patients (81.82%), and a 40 mm balloon in 5 patients (22.73%). The patients' clinical responses after the first balloon dilatation were a complete clinical response (4 patients, 18.18%), a partial clinical response (12 patients, 54.55%), and a non-response (6 patients, 27.27%). Nineteen patients (86.36%) had achieved clinical success at six months. Three patients (13.64%) who remained symptomatic even after achieving the maximal balloon dilation of 40 mm were considered failure of endoscopic dilatation, and they were referred for surgical intervention. No significant adverse events were found during or following the balloon dilatation. Conclusions: Endoscopic balloon dilatation is an effective and safe minimally invasive procedure in the management of functional post-sleeve-gastrectomy stenosis.

Neurologic complications of thiamine (B1) deficiency following bariatric surgery in adolescents

BACKGROUND

The prevalence of obesity among children and adolescents is rising and poses a major health concern. Bariatric surgery is well established in adults and has become an option for adolescents. Thiamine (B1) deficiency is common following bariatric surgery in adults. It may present as Beri-Beri, Wernicke encephalopathy, or Korsakoff psychosis.

OBJECTIVE

Our aim was to describe the clinical features, diagnosis, and treatment of adolescents who presented with B1 deficiency after bariatric surgery at one center, and to summarize the data from the literature.

PATIENTS

Three adolescents with morbid obesity (two boys and one girl, aged 15.5 to- 17-years-old), presented at Schneider Children's Medical Center of Israel with progressive lower limb pain and weakness 2-3 month following a bariatric procedure (sleeve gastrectomy or narrowing of a bariatric band). The girl also had upper limb involvement and cerebellar signs. All three were non-compliant with micronutrient supplementation. After admission, they received intravenous B1 and oral multivitamin supplementation, and their symptoms improved considerably.

CONCLUSIONS

Micronutrient supplementation following bariatric surgery is crucial to prevent deficiencies. In adolescents, compliance with micronutrient supplementation should be assessed before and after such surgery. Thiamine deficiency may cause polyneuropathy, among other symptoms. Treatment reduces the severity of neurological complications.

Vitamin C and Thiamin Deficiencies in Patients Undergoing Laparoscopic and Robotic Gastric Band Removal

Outcomes after adjustable gastric banding (AGB) were unsatisfactory and many devices need to be removed for dysphagia. Vitamin C and thiamin deficiency are rare conditions in industrialized countries. Patients undergoing AGB removal (90% for dysphagia) from 2021 to 2023 (laparoscopic 15 and robotic 5) were tested for vitamin C and thiamin levels. Twenty patients (8 m/12 f median aged 56 (range 33.6-79.4) were included. BMI at AGB removal was 39.7 (range 24.4-50.1) kg/m2. Only 20% of patients had normal thiamin levels, 30% had low levels, 20% were deficient, and 30% were critically low. Only 25% of patients had normal vitamin C levels, 40% had low levels, 25% were deficient, and 10% were critically low. One third of patients had HbA1c levels between 5.8 and 6.4 and 22% had levels >6.5; 60% of patients had hyperlipidemia. Adjustable gastric banding patients develop concerning rates of vitamin C and thiamin deficiency, and routine testing for levels is recommended.

Thiamine Deficiency Neuropathy in a Patient with Malnutrition due to Melancholic Depression

Introduction

Melancholic depression is a daily clinical reality in psychiatry. It is a therapeutic emergency that can jeopardize life if not promptly and adequately treated. Apart from its high suicidal risk, complications related to the under-nourishment state are to be feared. Case Presentation. A 36-year-old woman was admitted with depressive symptoms, significant weight loss, and total functional impotence. Laboratory investigations revealed severe thiamine (vitamin B1) deficiency. An electromyography confirmed a sensory axonal neuropathy involving all four extremities suggesting a deficiency origin. Discussion. Vitamin and mineral deficiencies have been described in patients with malnutrition resulting from psychiatric illness (anorexia nervosa, eating disorders, severe depression, etc.). Thiamine is an essential cofactor in several biochemical pathways. Its deficiency can lead to neuropsychiatric morbidity.

Conclusion

In our case, the rapid weight loss facilitated a cascade of complications related to nutritional deficiencies. Based on our clinical observations and the literature, thiamine deficiency should be considered in the presence of malnutrition and vulnerability, both on an organic and psychiatric level.

ESPEN practical short micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. The importance of MNs in common pathologies is recognized by recent research, with deficiencies significantly impacting the outcome.

OBJECTIVE

This short version of the guideline aims to provide practical recommendations for clinical practice.

METHODS

An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL for the initial guideline. The search focused on physiological data, historical evidence (for papers published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

The limited number of interventional trials prevented meta-analysis and led to a low level of evidence for most recommendations. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90 % of votes. Altogether the guideline proposes 3 general recommendations and specific recommendations for the 26 MNs. Monitoring and management strategies are proposed.

CONCLUSION

This short version of the MN guideline should facilitate handling of the MNs in at-risk diseases, whilst offering practical advice on MN provision and monitoring during nutritional support.

Wernicke's Encephalopathy in Acute and Chronic Kidney Disease: A Systematic Review

Thiamine (vitamin B1) deficiency is relatively common in patients with kidney disease. Wernicke's encephalopathy (WE) is caused by vitamin B1 deficiency. Our aim was to systematically review the signs and symptoms of WE in patients with kidney disease. We conducted a systematic literature review on WE in kidney disease and recorded clinical and radiographic characteristics, treatment and outcome. In total 323 manuscripts were reviewed, which yielded 46 cases diagnosed with acute and chronic kidney disease and WE published in 37 reports. Prodromal characteristics of WE were loss of appetite, vomiting, weight loss, abdominal pain, and diarrhea. Parenteral thiamine 500 mg 3 times per day often led to full recovery, while Korsakoff's syndrome was found in those receiving low doses. To prevent WE in kidney failure, we suggest administering high doses of parenteral thiamine in patients with kidney disease who present with severe malnutrition and (prodromal) signs of thiamine deficiency.

Feasibility of Identifying Factors Related to Alzheimer's Disease and Related Dementia in Real-World Data

A comprehensive view of factors associated with AD/ADRD will significantly aid in studies to develop new treatments for AD/ADRD and identify high-risk populations and patients for prevention efforts. In our study, we summarized the risk factors for AD/ADRD by reviewing existing meta-analyses and review articles on risk and preventive factors for AD/ADRD. In total, we extracted 477 risk factors in 10 categories from 537 studies. We constructed an interactive knowledge map to disseminate our study results. Most of the risk factors are accessible from structured Electronic Health Records (EHRs), and clinical narratives show promise as information sources. However, evaluating genomic risk factors using RWD remains a challenge, as genetic testing for AD/ADRD is still not a common practice and is poorly documented in both structured and unstructured EHRs. Considering the constantly evolving research on AD/ADRD risk factors, literature mining via NLP methods offers a solution to automatically update our knowledge map.

Infrequent but serious? Beriberi And Thiamine deficiency among adolescents and young adults after bariatric surgery

BACKGROUND

Thiamine deficiency (TD) among adolescents following metabolic and bariatric surgery (MBS) has not been assessed.

OBJECTIVE

We assessed TD among adolescents following MBS.

SETTING

University Hospital.

METHODS

A retrospective chart review was conducted for all adolescents and young adults (aged 10-25 years) who had MBS and subsequently presented with TD at our institution (n = 30). Diagnosis used clinical, laboratory, brain imaging, and neurophysiology criteria. Of 1575 patients, 7 subsequently had TD. Another 23 adolescents had MBS at private hospitals or overseas and presented at our institution with TD.

RESULTS

Based on MBS undertaken at our institution, TD prevalence was .45 cases per 100 MBS. The mean age of patients was 19.5 ± 3.23 years, 53.3% were male, 96.7% had sleeve gastrectomy, and time from MBS to admission averaged 4.97 ± 11.94 months. Mean weight loss from surgery to admission was 33.68 ± 10.90 kg. Associated factors included poor oral intake (90%), nausea and vomiting (80%), and noncompliance with multivitamins (71%). Signs and symptoms included generalized weakness, nystagmus, numbness, and paraparesis (83.3%-80%). Seven patients had Wernicke encephalopathy full triad; 16 displayed a mixed picture of Wernicke encephalopathy and dry beriberi; and there were no cases of wet beriberi. Half the patients achieved complete resolution of symptoms, whereas 47% and 40% had residual weakness or persistent sensory symptoms, respectively. There was no mortality. Most common concurrent nutritional deficiencies were of vitamins K, D, and A.

CONCLUSIONS

This is the first in-depth study of TD among adolescents after MBS. Although TD is uncommon among adolescents after MBS, it is serious, requiring diligent suspicion and prompt treatment. Bariatric teams should emphasize compliance with multivitamin regimens and follow it up.

Atypical Wernicke's encephalopathy without mental status changes following bariatric surgery in an adolescent patient

Morbid obesity is a systemic disease which can result in chronic complications, including hypertension, diabetes mellitus, depression, osteoarthritis and low self-esteem in the adolescent population.Bariatric surgery can be indicated to treat more severe forms of obesity, but these procedures are not without long-term risks. Therefore, adequate preoperative and postoperative care, which includes preoperative psychosocial evaluation for compliance, ongoing nutrition counselling and vitamin and micronutrient supplementation, is required for all patients, especially adolescent patients, who generally may not comply with medical therapies and/or be able to developmentally fully appreciate or comprehend the health consequences of their behaviours, prior to as well as after bariatric surgery to prevent complications.Thiamine pyrophosphate, an active form of thiamine (also known as vitamin B1, a water-soluble vitamin), which functions as a coenzyme in glucose and energy metabolism, is one such vitamin that requires supplementation postoperatively. It is mandatory for glucose to be administered concomitantly with thiamine, as glucose alone can precipitate Wernicke's encephalopathy (WE) in thiamine-deficient individuals. WE is a medical emergency, with a mortality rate of up to 20%. WE is best understood as a classic triad of mental confusion, gait ataxia and eye movement abnormalities, and atypical WE or Wernicke's syndrome (WS) is seen when the classic triad is not present. Cases that meet some, but do not necessarily meet all three criteria, are referred to as atypical WE or WS which can lead to delayed diagnosis. Atypical WE has an incidence of 19% which can lead to misdiagnosis of a preventable medical emergency with fatal complications.The following case reviews the consequences of post-bariatric thiamine supplementation therapy non-adherence and resulting in a deficiency in an adolescent patient.

Case report: Wernicke-Korsakoff syndrome after bariatric surgery

Vitamin and mineral deficiencies are prevalent nutritional disorders following bariatric surgery. Although they are more prevalent after malabsorptive procedures such as bypass, they also occur in restrictive procedures such as gastric sleeve. The mechanisms that lead to the occurrence of these deficits are related to the presence of poor nutritional intake or poor adherence to multivitamins and multimineral supplementation. Wernicke-Korsakoff syndrome (WKS) is an acute neurological disorder resulting from thiamine deficiency. This syndrome is composed of two distinct phases: first, Wernicke Encephalopathy (WE), the acute phase of this syndrome, which is characterized by a triad of mental confusion, ocular signs, and ataxia, followed by the chronic phase of WKS, called Korsakoff's syndrome (KS), which is known for the presence of anterograde amnesia and confabulation. We aimed to report a case of a patient with WKS after bariatric surgery. The patient's retrospective chart review was performed in order to retrieve the relevant clinical data. The patient was a 24-year-old female student with a BMI of 48 kg/m2 who underwent sleeve gastrectomy surgery for morbid obesity. Over the following 2 months, recovery from surgery was complicated by non-specific symptoms such as nausea, recurrent vomiting, and a significant reduction in food intake, which led the patient to visit the emergency department six times with hospitalization on the last occasion for a definitive diagnosis. During the 15 days of hospitalization, the patient developed ocular diplopia, nystagmus, complaints of rotatory vertigo, and gait abnormalities. A magnetic resonance imaging of the head was performed but revealed no significant changes. After a formal neurological assessment, treatment with parenteral thiamine (100 mg, three times a day) was started without prior dosing. The observed clinical improvement confirmed the diagnosis of WKS. Bariatric surgery may contribute to thiamine deficiency and, consequently, to WKS. Education about the adverse consequences of malnourishment is mandatory before and after the surgery. Investigation of nutritional deficiencies both pre- and post-operatively is crucial in order to prevent complications such as WKS.

Development and complications of nutritional deficiencies after bariatric surgery

The clinical effectiveness of bariatric surgery has encouraged the use of bariatric procedures for the treatment of morbid obesity and its comorbidities, with sleeve gastrectomy and Roux-en-Y gastric bypass being the most common procedures. Notwithstanding its success, bariatric procedures are recognised to predispose the development of nutritional deficiencies. A framework is proposed that provides clarity regarding the immediate role of diet, the gastrointestinal tract and the medical state of the patient in the development of nutritional deficiencies after bariatric surgery, while highlighting different enabling resources that may contribute. Untreated, these nutritional deficiencies can progress in the short term into haematological, muscular and neurological complications and in the long term into skeletal complications. In this review, we explore the development of nutritional deficiencies after bariatric surgery through a newly developed conceptual framework. An in-depth understanding will enable the optimisation of the post-operative follow-up, including detecting clinical signs of complications, screening for laboratory abnormalities and treating nutritional deficiencies.

Wernicke Encephalopathy After Bariatric Surgery: a Literature Review

Wernicke encephalopathy (WE) is an acute neurological disorder classically characterized by ataxia, ophthalmoplegia, and altered mental status. This is caused by thiamine deficiency and is usually seen in malnourished populations. However, with the advent and rise of bariatric surgery in the last 50 years, WE has become an increasingly recognized and potentially deadly complication. Here, we review the populations at risk, clinical presentation, and the incidence of WE in the bariatric surgery population from 1985 to 2023. While the predominant procedure shifts throughout the years, the overall incidence of WE per 100,000 cases for the following procedures are sleeve gastrectomy (1.06), gastric band (1.16), RYGB (4.29), and biliopancreatic diversion with duodenal switch (8.92). Thus, early intervention and post-operative supplementation is recommended to prevent WE.

Eating disorders among bariatric surgery patients: The chicken or the egg?

ABSTRACT

Postoperative eating behaviors and unhealthy weight control measures are leading causes of bariatric surgery complications. Candidates for bariatric surgery and individuals with eating disorders may share common risk factors, such as a history of dieting, and/or being bullied or teased for their weight. Binge-eating disorder, night eating syndrome, and bulimia nervosa are the most common eating disorders among candidates for bariatric surgery before the operation. Malnutrition, stress, and intense fear of weight gain can lead to the development of an eating disorder after surgery as well. Plugging, grazing, loss of control eating, dumping, and food avoidance are specific disordered behaviors that may present after bariatric surgery. To improve physical and psychological outcomes for individuals under their care, clinicians can screen for these disordered behaviors and distinguish them from a healthy diet and the expected postsurgical course.

Abdominal Pain After Roux-en-Y Gastric Bypass: A Review

Importance

Roux-en-Y gastric bypass (RYGB) remains one of the most commonly performed operations for morbid obesity and is associated with significant long-term weight loss and comorbidity remission. However, health care utilization rates following RYGB are high and abdominal pain is reported as the most common presenting symptom for those seeking care.

Observations

Given the limitations of physical examination in patients with obesity, correct diagnosis of abdominal pain following RYGB depends on a careful history and appropriate use of radiologic, laboratory and endoscopic studies, as well as a clear understanding of post-RYGB anatomy. The most common etiologies of abdominal pain after RYGB are internal hernia, marginal ulcer, biliary disease (eg, cholelithiasis and choledocholithiasis), and jejunojejunal anastomotic issues. Early identification of the etiology of the pain is essential, as some causes, such as internal hernia or perforated gastrojejunal ulcer, may require urgent or emergent intervention to avoid significant morbidity. While laboratory findings and imaging may prove useful, they remain imperfect, and clinical judgment should always be used to determine if surgical exploration is warranted.

Conclusions and Relevance

The etiologies of abdominal pain after RYGB range from the relatively benign to potentially life-threatening. This Review highlights the importance of understanding key anatomical and technical aspects of RYGB to guide appropriate workup, diagnosis, and treatment.

Wernicke's Encephalopathy in a Patient With Type III Intestinal Failure: A Case Report

This case is about a 38-year-old male patient with a history of type III intestinal failure due to chronic intestinal pseudo-obstruction caused by gastrointestinal dysmotility, cardiac and intestinal arrhythmia syndrome, dependence on parenteral nutrition, sinus dysfunction, and carrying a pacemaker. The patient presented with symptoms suggestive of a new episode of intestinal obstruction. A contrast-enhanced abdominal computed tomography scan was performed, revealing intestinal obstruction with a transition zone in the jejunum. Non-operative medical management of the obstructive condition was initiated. However, after 10 days of medical management, the patient began experiencing nausea and dizziness. Initially, symptomatic management was provided, but the patient reported persistent vertigo-like sensations. Following evaluation by multiple specialties, magnetic resonance imaging (MRI) was requested, which showed bilateral and symmetrical hyperintensity on T2-weighted images of the dorsomedial aspect of the thalami around the third ventricle, in the periaqueductal gray matter, the mesencephalic tectum, and, to a lesser extent, the bulbar tectum, findings suggestive of Wernicke's encephalopathy. Urgent intravenous thiamine replacement was initiated. After 10 days of effective treatment, the patient exhibited a nearly complete improvement in symptoms. A follow-up MRI was ordered, indicating considerable improvement when compared to the previous study.

The complexity of obesity-related health problems after bariatric surgery: The patient perspective

Background

Bariatric surgery aims to improve quality of life by means of weight loss. Obesity-related physical and psychological health problems should improve, but long-term data are scarce.

Objectives

To evaluate preoperative physical and mental health problems perceived by the patient and the association with weight loss and quality of life, 5 years after bariatric surgery.

Methods

101 persons (response rate 67%) who had had bariatric surgery an average of 4.6 years before this study completed a written survey on obesity-related physical and psychological health problems and three psychological questionnaires collecting information on eating behavior and quality of life. Over half of the participants (55%) had had a laparoscopic adjustable gastric banding.

Results

Preoperatively reported health problems improved but were not necessarily associated with weight loss. Minimal improvement in tiredness, shame and weight instability were associated with significantly less weight loss. Preoperative type 2 diabetes mellitus (T2D) improved but participants had significantly less weight loss and more dissatisfaction regarding the bariatric trajectory than participants without T2D. Eating concerns, emotional eating and external eating improved but not restrained eating. Compared to the Dutch population reference, most quality of life scores of the participants were lower.

Conclusion

In this analysis, participants did report satisfaction although from a patients' perspective, improvements of weight and health did not necessarily lead to satisfaction regarding the bariatric trajectory. Participants with postoperative reported fatigue and shame as well as participants with preoperative T2D showed significant less weight loss. More long-term research is necessary to close the current knowledge gap.

Thiamine responsive high output heart failure of adults: an under-recognized entity

Thiamine deficiency, commonly presenting as dry and wet beriberi, a lesser-known entity in the present era, is increasingly being reported from Kashmir, a north Indian state. The present study aims to present the clinical profile of patients presenting with high-output heart failure (HOHF). Subjects with a primary diagnosis of denovo heart failure and features suggestive of HOHF were recruited; those who responded to intravenous administration of thiamine alone (responders) were adults with no co-morbidities and those who required other medications particularly diuretics (non-responders) were elderly with co-morbidities and underlying heart disease. Responders showed considerably lower mean thiamine pyrophosphate (TPP) levels and higher mean lactate and venous oxygen saturation than non-responders. More importantly, the mean drop in lactate and SVO2 following thiamine therapy was more in responders. In a setting of high risk for thiamine deficiency, features suggestive of HOHF along with elevated lactate and higher venous oxygen saturation, a response to thiamine challenge may serve as surrogate marker of thiamine deficiency.

Wernicke Encephalopathy: An Updated Narrative Review

Wernicke's encephalopathy (WE) and Korsakoff Syndrome (KS) are distinct neurological disorders that may have overlapping clinical features. Due to the overlap, they are collectively known as Wernicke-Korsakoff syndrome. WE is related to diencephalic and mesencephalic dysfunction due to thiamine. WE typically manifests as confusion, ophthalmoplegia, nystagmus, and gait ataxia (Wernicke's triad), although they may not consistently occur together. Although WE mostly occurs in alcoholics, other etiologies, such as post-bariatric surgery, must be considered. Early diagnosis and therapy by intravenous thiamine are essential to prevent WE complications and to reduce morbidity and mortality. Therefore, physicians' and patients' awareness of WE is essential for early diagnosis and therapy. Accordingly, this narrative review aimed to provide an update on WE by reviewing articles published between April 2015 to April 2022 about the etiology, pathophysiology, diagnosis, and WE management updates. EMBASE, PubMed, Google Scholar, Google, and Scopus search engines were used to conduct the literature search.

Oxidative stress in Wernicke's encephalopathy

Wernicke's encephalopathy (WE) is a severe life-threatening disease that occurs due to vitamin B1 (thiamine) deficiency (TD). It is characterized by acute mental disorder, ataxia, and ophthalmoplegia. TD occurs because of the following reasons: insufficient intake, increased demand, and long-term drinking due to corresponding organ damage or failure. Recent studies showed that oxidative stress (OS) can damage organs and cause TD in the brain, which further leads to neurodegenerative diseases, such as WE. In this review, we discuss the effects of TD caused by OS on multiple organ systems, including the liver, intestines, and brain in WE. We believe that strengthening the human antioxidant system and reducing TD can effectively treat WE.

Young Nonalcoholic Wernicke Encephalopathy Patient Achieves Remission Following Prolonged Thiamine Treatment and Cognitive Rehabilitation

Wernicke encephalopathy (WE), a neurological emergency commonly associated with alcohol use disorder, results from a severe deficiency of vitamin B1. If left untreated, patients either succumb to the illness or develop chronic Korsakoff's syndrome (KS). Recently, an increasing number of nonalcoholic WE case studies have been published, highlighting a lack of understanding of malnutrition-related disorders among high-functioning patients. We present the case of a 26 year old female who developed life-threatening WE after COVID-19-complicated obesity surgery. She experienced the full triad of WE symptoms, including eye-movement disorders, delirium, and ataxia, and suffered for over 70 days before receiving her initial WE diagnosis. Late treatment resulted in progression of WE symptoms. Despite the severity, the patient achieved remission of some of the symptoms in the post-acute phase due to prolonged parenteral thiamine injections and intensive specialized rehabilitation designed for young traumatic brain injury (TBI) patients. The rehabilitation resulted in gradual remission of amnesia symptomatology, mainly increasing her autonomy. The late recognition of this case highlights the importance of early diagnosis and prompt, targeted intervention in the management of nonalcoholic WE, as well as underscores the potential for positive outcomes after delayed treatment through intensive cognitive rehabilitation in specialized treatment centers.

Consultation-Liaison Case Conference: Psychiatric Care of Patients Who Undergo Bariatric Surgery

We present the case of a 42-year-old female with major depressive disorder who received a Roux-en-Y gastric bypass and subsequently decompensated in her depression symptoms and began newly engaging in problematic alcohol use. Top experts in the consultation-liaison field, specifically bariatric surgery psychiatry, provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching points include the presurgical psychosocial assessment, pertinent perioperative psychopharmacology, and problematic alcohol use after bariatric surgery.

Which nutritional prognosis is better? comparison of the three most commonly performed bariatric surgeries: A systematic review and network meta-analysis

Background

Obesity is one of the most important public health conditions in the world, and surgical intervention is the only medical treatment recognized by the medical community as a complete and permanent cure for morbid obesity and its complications. The choice of surgical modality is also based more on the experience of the physician or the requirements of people with obesity, rather than on scientific data. In this issue, a thorough comparison of the nutritional deficiencies caused by the three most commonly used surgical modalities is needed.

Objectives

We aimed to use the network meta-analysis to compare the nutritional deficiencies caused by the three most common BS procedures in many subjects who underwent BS to help physicians determine the best BS surgical approach to apply to their clinical people with obesity.

Setting

A systematic review and network meta-analysis of world literature.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, systematically reviewed the literature, and conducted a network meta-analysis using R Studio.

Results

For the four vitamins calcium, vitamin B12, iron and vitamin D, the micronutrient deficiency caused by RYGB is the most serious.

Conclusions

RYGB causes slightly higher nutritional deficiencies in Bariatric surgery, but RYGB remains the most commonly used modality for Bariatric surgery.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022351956, identifier: CRD42022351956.

Duodenal Adenocarcinoma in the Setting of Bariatric Surgery: A Perfect Storm for Wernicke's Encephalopathy

Wernicke's encephalopathy (WE) is a condition resulting from thiamine deficiency that typically presents with acute neurologic symptoms including ataxia, eye movement disorders, and altered mental status. Though classically seen in patients with alcohol use disorder, it can also occur as a complication of bariatric surgery and gastrointestinal cancers. Here, we present a patient with a history of gastric band surgery and an intact alimentary tract. She presented with acute, intractable vomiting and epigastric abdominal pain, incompletely relieved by deflating her gastric band, and was found to have duodenal adenocarcinoma causing partial duodenal obstruction. She was then found to have binocular diplopia, horizontal nystagmus, dizziness, reduced proprioception, and pins-and-needles numbness in her bilateral lower extremities, and there was concern for gait instability; thus, WE was suspected. The patient was treated with high-dose thiamine repletion, and her symptoms resolved shortly thereafter. WE is rare in patients who have undergone gastric band surgery, and to our knowledge, this is the first case of WE in a patient with concurrent duodenal adenocarcinoma. This case illustrates that patients with a history of bariatric surgery may be more susceptible to developing WE in the face of a new gastrointestinal insult, such as duodenal cancer.

Peripapillary Retinal Haemorrhages in Wernicke's Encephalopathy Following Bariatric Surgery in a Young Patient

Wernicke's encephalopathy (WE) is an acute neuropsychiatric syndrome resulting from thiamine deficiency (vitamin B₁). It is characterised classically by a triad of ophthalmoplegia, confusion, and ataxia. WE is classically associated with alcoholism but increasingly has been observed due to other causes, particularly in undernourished post-bariatric surgery patients. Herein, we describe a case of WE following laparoscopic sleeve gastrectomy in a young male patient who presented with binocular horizontal diplopia and was found to have preretinal peripapillary haemorrhages. This case raises the awareness that posterior segment findings can occur in WE but have been under-reported previously.

Wernicke Encephalopathy Presenting with Dysphagia: A Case Report and Systematic Literature Review

Wernicke encephalopathy (WE) is a well-known neurological condition caused by thiamine (vitamin B1) deficiency that occurs in both alcoholic and non-alcoholic populations. We aimed to report a case of a patient with WE who presented with dysphagia and dysphonia and later developed typical symptoms of thiamine deficiency and to conduct a systematic review of the literature on this rare presentation of WE. We searched two databases (PubMed and Scopus) and included publications up to November 2022. We found 12 cases of WE and dysphagia, aged between 12 and 81 years; swallowing problems presented at the onset in nine patients (including the current case report). Our findings suggest that thiamine deficiency should be suspected in patients with dysphagia of unknown cause, even in the absence of alcohol abuse. In contrast to most WE patients, the majority of patients included in this review presented with dysphagia at the onset of their disease, even in the absence of the classic triad of cognitive impairment, ataxia, and oculomotor abnormalities, indicating that there could be varying susceptibilities to clinical manifestations of thiamine deficiency in different brain regions.

A Clinician's View of Wernicke-Korsakoff Syndrome

The purpose of this article is to improve recognition and treatment of Wernicke-Korsakoff syndrome. It is well known that Korsakoff syndrome is a chronic amnesia resulting from unrecognized or undertreated Wernicke encephalopathy and is caused by thiamine (vitamin B1) deficiency. The clinical presentation of thiamine deficiency includes loss of appetite, dizziness, tachycardia, and urinary bladder retention. These symptoms can be attributed to anticholinergic autonomic dysfunction, as well as confusion or delirium, which is part of the classic triad of Wernicke encephalopathy. Severe concomitant infections including sepsis of unknown origin are common during the Wernicke phase. These infections can be prodromal signs of severe thiamine deficiency, as has been shown in select case descriptions which present infections and lactic acidosis. The clinical symptoms of Wernicke delirium commonly arise within a few days before or during hospitalization and may occur as part of a refeeding syndrome. Wernicke encephalopathy is mostly related to alcohol addiction, but can also occur in other conditions, such as bariatric surgery, hyperemesis gravidarum, and anorexia nervosa. Alcohol related Wernicke encephalopathy may be identified by the presence of a delirium in malnourished alcoholic patients who have trouble walking. The onset of non-alcohol-related Wernicke encephalopathy is often characterized by vomiting, weight loss, and symptoms such as visual complaints due to optic neuropathy in thiamine deficiency. Regarding thiamine therapy, patients with hypomagnesemia may fail to respond to thiamine. This may especially be the case in the context of alcohol withdrawal or in adverse side effects of proton pump inhibitors combined with diuretics. Clinician awareness of the clinical significance of Wernicke delirium, urinary bladder retention, comorbid infections, refeeding syndrome, and hypomagnesemia may contribute to the recognition and treatment of the Wernicke-Korsakoff syndrome.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Acute Cholecystitis in a Gastric Bypass Patient Complicated by Takotsubo Cardiomyopathy

Background. Gallbladder disease is a common condition after gastric bypass surgery. Even after weight loss, many bariatric patients continue to suffer from comorbid conditions. Takotsubo cardiomyopathy is a rare condition that mimics acute cardiac ischemia but seems to be caused by a catecholamine storm triggered by intense stress. Case Report. A 62-year-old female presented with acute right upper quadrant (RUQ) pain to the ER. She had a history of laparoscopic gastric bypass 5 years ago and had been noncompliant for 2 years. This noncompliance included missing follow-up appointments, gaining weight which caused poorly controlled DM, and not taking her vitamin supplements. Upon presentation, her WBC was elevated, her LFTs were normal, and imaging showed acute calculous cholecystitis. She was admitted and started on antibiotics with plans for laparoscopic cholecystectomy. The next day, she developed acute chest pain, and troponins were elevated with ST changes on EKG. Echocardiography showed a ballooned left ventricle indicative for Takotsubo cardiomyopathy. Symptomatic treatment including antibiotics, betablocker, and thiamine infusion was initiated. At three-month follow-up, ejection fraction had improved from <20% to >50%. The patient underwent interval laparoscopic cholecystectomy, which was technically very challenging due to severe ongoing acute and chronic cholecystitis. There were no cardiac issues, but the patient developed an abscess in the gallbladder fossa, which was successfully treated with oral antibiotics. Conclusions. Takotsubo cardiomyopathy complicating acute cholecystitis has thus far not been reported. Our patient had a history of gastric bypass and was noncompliant with vitamin supplementation. Thiamine deficiency may have contributed to the cardiac condition (wet beriberi).

ESPEN micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome.

OBJECTIVE

This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement".

METHODS

The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed.

CONCLUSION

This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.

Bariatric surgery-what the ophthalmologist needs to know

The incidence of bariatric surgery is increasing due to obesity being one of our top public health challenges. As such, bariatric-related ophthalmic changes are a potentially new clinical area of knowledge, with increasing published evidence on post-bariatric complications experienced by patients and identified by clinicians. We reviewed the available literature and summarised the different complications and potential recommendations. A search strategy was conducted with PubMed, Cochrane, Medline, Embase, Allied and Complementary Medicine and DH-DATA databases to look for papers answering our research question: "What are the ophthalmological complications for patients after bariatric surgery?". Our search gave a total of 59 relevant papers. Bariatric surgery, particularly subtypes that cause direct bypass of nutrients from the stomach, lead to nutritional deficiencies. Vitamin A, crucial for proper functioning of body systems and specialised cells, manifests ophthalmologically as corneal ulceration, nyctalopia, conjunctival xerosis and more. Thiamine levels are also depleted, leading to Wernicke's Encephalopathy. Pre-existing diabetic retinopathy is also noted to worsen sub acutely, although evidence is conflicting. Patients undergoing surgery to treat idiopathic intracranial hypertension would have reduced IOP and resolving papilloedema. Other comorbidities of obesity like HBA1C levels, obstructive sleep apnoea, and metabolic syndrome also resolve post-surgery. History taking remains the cornerstone of medical practice. From the evidence, we suggest consideration of pre-surgery screening for ophthalmic pathology and post-operative monitoring of disease progression. Real-world data needs to continuously be analysed to create definitive management pathways that can help clinicians recognise ophthalmic complications early, improving patient outcomes.

Confabulations in post-acute and chronic alcoholic Korsakoff's syndrome: a cross-sectional study conducted in two centres

INTRODUCTION

Confabulations refer to the emergence of memories of experiences and events that are incorrect in place and time, or never took place. In alcoholic Korsakoff's syndrome, confabulations have been frequently reported, but seldomly been investigated. Traditional reports on confabulations state that confabulations in KS mainly occur in the post-acute phase of the illness. The aim of the study was to investigate whether confabulations extinguish in KS.

METHODS

An observational rating of confabulation behaviour (the NVCL-R) was completed for 172 KS patients with alcoholic KS. Post-acute and chronic KS patients were compared cross-sectionally in two centres.

RESULTS

Provoked and spontaneous confabulations were present in post-acute and chronic patients. Patients residing in a long-term care facility more often presented themselves with spontaneous confabulations than patients in a diagnostic centre.

CONCLUSIONS

In contrast to the traditional view, confabulations may be present throughout the course of KS, and are possibly more frequently present in patients receiving care in specialised long-term care facilities than in patients who receive less intensive support.Key pointsConfabulations are a central characteristic of Korsakoff's syndromeIn contrast to popular belief, confabulations may be present in acute and chronic Korsakoff's syndromeThe severity of confabulations is related to an unfavourable disease outcome in KSA longitudinal approach would help the confirmation of finding no decline in confabulations over time.

Bariatric surgery for the management of type 2 diabetes mellitus-current trends and challenges: a review article

Obesity has become an epidemic and has emerged as a serious ailment of global concern. Longstanding obesity may lead to several complications, including type 2 diabetes mellitus (T2DM). Considering the role of the gastrointestinal tract (GIT) in glycemic control, altering it would be relevant to the T2DM management algorithm. Bariatric surgery is a well-known surgical procedure that alters the GIT for managing T2DM among moderate to severely obese patients. T2DM remissions (adequate glycemic control without any other antidiabetic drugs) among the post-bariatric patients are due to weight loss related and weight loss unrelated pathophysiological mechanisms, including caloric intake restriction, increased insulin secretion, sensitivity, and malabsorption. Evidence suggests that bariatric surgeries among T2DM patients improved micro and macrovascular complications. Bariatric surgical procedures have more advantages of post-operative weight loss and glycemic control in biliopancreatic diversions than other available bariatric surgical procedures. Several concerns raised on the short and long-term risks associated with the bariatric surgery were nutritional deficiencies, psychological issues, GIT ulcers, and survival rates. Data related to follow-up of complications related to the above-stated risk are still elusive. According to some of the recently published studies, relapse of T2DM after remission is a worrying phenomenon among post-bariatric surgery patients, requiring more clinical trials and long-term follow-up on the relapsed patients. The effectiveness of reoperation among the relapsed patients also needs to be evaluated. Other unresolved issues related to bariatric surgery are patient compliance, cost-effectiveness, quality of life among post-bariatric patients, and the effectiveness of the post-operative holistic approach to avoid relapse. Future studies, especially randomized controlled trials, are recommended to resolve the existing controversies associated with bariatric surgery.

Wernicke Encephalopathy From Olfactory Dysfunction After COVID-19 Infection

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has affected millions of people worldwide and is caused by infection from the severe acute respiratory syndrome coronavirus-2 pathogen. While COVID-19 most commonly affects the respiratory system, multiple neurological complications have been associated with this pathogen. We report a case of Wernicke encephalopathy in a young girl with poor oral intake secondary to anosmia and dysgeusia after a COVID-19 infection.

CASE REPORT

After a recent infection of COVID-19, a 15-year-old girl developed an overwhelming noxious metallic tase resulting in a 30 lb weight loss from being unable to tolerate oral foods. She presented to the hospital 3 months later with bilateral horizontal conjugate gaze palsies, up beating vertical nystagmus, difficulty with limb coordination and gait ataxia. She was found to have a thiamine level of 51 nmol/L (reference range: 70 to 180 nmol/L) and her brain magnetic resonance imaging showed fluid-attenuated inversion recovery and diffusion-weighted imaging changes in the periaqueductal gray and dorsomedial thalami suggestive of Wernicke encephalopathy. She was started on parenteral thiamine replacement and had significant neurological improvement.

CONCLUSIONS

As this pandemic continues to progress, more long-term neurological sequelae from COVID-19 such as Wernicke encephalopathy can be expected. Strong clinical suspicion for these complications is needed to allow for earlier diagnosis and faster treatment initiation.

Hiding in Plain Sight: Modern Thiamine Deficiency

Thiamine or vitamin B1 is an essential, water-soluble vitamin required for mitochondrial energetics—the production of adenosine triphosphate (ATP). It is a critical and rate-limiting cofactor to multiple enzymes involved in this process, including those at the entry points and at critical junctures for the glucose, fatty acid, and amino acid pathways. It has a very short half-life, limited storage capacity, and is susceptible to degradation and depletion by a number of products that epitomize modern life, including environmental and pharmaceutical chemicals. The RDA for thiamine is 1.1–1.2 mg for adult females and males, respectively. With an average diet, even a poor one, it is not difficult to meet that daily requirement, and yet, measurable thiamine deficiency has been observed across multiple patient populations with incidence rates ranging from 20% to over 90% depending upon the study. This suggests that the RDA requirement may be insufficient to meet the demands of modern living. Inasmuch as thiamine deficiency syndromes pose great risk of chronic morbidity, and if left untreated, mortality, a more comprehensive understanding thiamine chemistry, relative to energy production, modern living, and disease, may prove useful.

Management of Postoperative Complications Following Bariatric and Metabolic Procedures

Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.

Complications Requiring Intensive Nutritional Care After Bariatric Surgery Result in More Long-Term Weight Loss but Has No Impact on Nutritional Deficiencies and Depression-Anxiety Scores

PURPOSE

Bariatric surgery is associated with significant weight loss and improvement in comorbid conditions but in rare cases can expose to complications requiring intensive nutritional care (INC). INC in this context is poorly described and no data are available concerning long-term impact.

MATERIALS AND METHODS

We retrospectively reviewed charts of bariatric patients who were hospitalized in our institution between 2013 and 2018. We identified patients with a postoperative complication requiring INC and we described their nutritional management (INC group). These patients were compared with controls matched to age, gender, preoperative BMI, and type of surgery selected from our database (control group). The primary endpoint was the percentage of total weight loss (%TWL) at 2.5 years. Secondary endpoints were improvement of co-morbidities, vitamin deficiencies, and depression/anxiety scores.

RESULTS

The INC group consisted of 18 patients among which 77.8% had sleeve gastrectomy (SG). Half of these patients underwent revisional surgery. The most common complication was fistula formation (66.7%). Patients in the INC group, compared to the control group, showed a significantly higher %TWL at 2.5 years (33.6% vs 26.1%, P = 0.03). There was no significant difference in either reduction of preoperative comorbidities or depression/anxiety scores between the two groups. The number of patients with more than three nutritional deficiencies was similar in both groups. Thiamine deficiency was only observed in the INC group.

CONCLUSION

Complications requiring INC after bariatric surgery occur mainly after revisional surgery and may increase long-term %TWL but have no impact on nutritional deficiencies or symptoms of anxiety/depression.

Korsakoff syndrome: An overlook (Review)

This review aimed to analyze the latest neurobiological findings regarding Korsakoff syndrome, since alcoholism is the most prevalent addiction worldwide. In addition, we analyzed the optimal treatment that can be administered in order to minimize the symptoms and improve the outcome of these patients. The disruption of memory circuits within the brain of alcoholic patients results in the amnestic syndrome known as Korsakoff syndrome. It is generally characterized by a chronic neuropsychiatric syndrome caused by vitamin B1 (thiamine) deficiency. Other categories of patients can develop Korsakoff syndrome without consuming alcohol such as AIDS patients, terminally ill cancer patients, or patients with chronic infections and malnutrition. Vitamin B1 is required in the Krebs cycle for production of adenosine triphosphate (ATP). It is also a cofactor in the production of acetylcholine and certain neurotransmitters. Alcohol consumption can decrease the intake, gastrointestinal absorption and cellular utilization of vitamin B1. Treatment of alcohol withdrawal along with high doses of vitamin B1 can improve the general outcome of patients. A small percentage of patients can recover from Wernicke's encephalopathy with no permanent brain damage. The onset of Korsakoff syndrome darkens the prognosis. Alcohol abstinence is an absolute recommendation and prevents the extension of neural damage.

The Bariatric-Metabolic Physician's Role in Managing Clinically Severe Obesity

PURPOSE OF REVIEW

The aim of this review is to outline the obesity physician's role in managing patients with severe obesity with a particular emphasis on bariatric surgery candidates.

RECENT FINDINGS

Obesity is a chronic, relapsing and progressive disease. Scoring systems that evaluate the severity of obesity based on the clinical assessment, rather than the Body Mass Index, are a valuable tool. The clinical assessment should explore the underlying contributors for weight gain and screen for obesity-related complications. Bariatric surgery remains the most effective management approach for severe and complex obesity. Nevertheless, pharmacotherapy and other non-surgical approaches play an important role. The bariatric-metabolic physician's role is paramount in delivering effective care to patients with obesity. The multiple complications of patients with clinically severe obesity highlight the complexity of their management and reinforce the need for adequate assessment and long-term follow-up to ensure optimal clinical outcomes.

Delirium in Critical Illness Patients and the Potential Role of Thiamine Therapy in Prevention and Treatment: Findings from a Scoping Review with Implications for Evidence-Based Practice

INTRODUCTION

Thiamine is a water-soluble vitamin and is necessary for energy metabolism. Critically ill patients are at particular risk of developing thiamine deficiency and related complications. One of the complications that can occur is delirium. Delirium is a disorder that affects the body's response to treatment, length of stay in the ward, mortality, long-term cognitive impairment, and significantly increases treatment costs. In addition, studies show that delirium medication is more effective in preventing than in treating delirium. Given its low cost, availability, and minimal risk of side effects, thiamine supplementation could prove to be a relevant strategy in the prevention and treatment of delirium.

METHODS

PubMed, Cochrane Library, Ovid, and ClinicalTrials.gov databases were searched using relevant keywords that focus on the use of thiamine to prevent or treat delirium in critically ill patients.

RESULTS

Seven articles were included in the analysis.

CONCLUSION

The small number of studies and considerable heterogeneity prevent conclusions supporting the use of thiamine as an adjuvant in the prevention and treatment of delirium among critically ill patients. There is a need for high-quality, large-scale randomized clinical trials to confirm the beneficial effects of thiamine in the prevention and treatment of delirium.

AGA Clinical Practice Update on Evaluation and Management of Early Complications After Bariatric/Metabolic Surgery: Expert Review

DESCRIPTION

Endoscopic techniques are paramount in the identification and management of complications after surgery, though collaboration with other specialties is obligatory. Unfortunately, the evaluation and treatment algorithms are not standardized and there is a paucity of high-quality prospective studies to provide clarity regarding the best approach. The purpose of this clinical practice update is to apprise the clinician with respect to the endoscopic evaluation and management of patients with early (<90 days) complications after undergoing bariatric/metabolic surgery.

METHODS

The best practice advice outlined in this expert review are based on available published evidence, including observational studies and systematic reviews, and incorporates expert opinion where applicable. BEST PRACTICE ADVICE 1: Clinicians performing endoscopic approaches to treat early major postoperative complications should do so in a multidisciplinary manner with interventional radiology and bariatric/metabolic surgery co-managing the patient. Daily communication is advised. BEST PRACTICE ADVICE 2: Clinicians embarking on incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a comprehensive knowledge of the indications, contraindications, risks, benefits, and outcomes of each of the endoscopic treatment techniques. They should also have knowledge of the risks and benefits of alternative methods such as surgical and interventional radiological based approaches. BEST PRACTICE ADVICE 3: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have expertise in interventional endoscopy techniques, including but not limited to: using concomitant fluoroscopy, stent deployment and retrieval, managing stenosis, and managing percutaneous drains. BEST PRACTICE ADVICE 4: Clinicians should screen all patients undergoing endoscopic management of bariatric/metabolic surgical complications and dietary intolerance for comorbid medical (nutrient deficiencies, infection, pulmonary embolism) and psychological (depression, anxiety) conditions. BEST PRACTICE ADVICE 5: Endoscopic approaches to managing complications of bariatric/metabolic surgery may be considered for patients in the immediate, early and late postoperative periods depending on hemodynamic stability. BEST PRACTICE ADVICE 6: Clinicians incorporating endoscopic management of bariatric/metabolic surgical complications into their clinical practice should have a detailed understanding of the pathophysiologic mechanisms initiating and perpetuating conditions such as staple-line leaks. This will allow for a prompt diagnosis and appropriate therapy to be targeted not only at the area of interest, but also any concomitant downstream stenosis. BEST PRACTICE ADVICE 7: Clinicians should recognize that the goal for endoscopic management of staple-line leaks are often not necessarily initial closure of the leak site, but rather techniques to promote drainage of material from the perigastric collection into the gastric lumen such that the leak site closes by secondary intention.

Preoperative Dexamethasone for Airway-Related "Calibration Tube" Complications After Sleeve Gastrectomy: a Randomised Clinical Trial

BACKGROUND

Bariatric surgeries utilise Bougie device to guide stomach resection. The device implementation is associated with many underreported complications. This study aims to compare nebulised vs. intravenous preoperative dexamethasone in mitigating airway-related Bougie complications after sleeve gastrectomy.

METHODOLOGY

This is a prospective double-blinded interventional study conducted by a tertiary hospital. The study involved 105 patients allocated to 3 groups: Group (I) received 8 mg dexamethasone intravenously (IV) preoperatively, group (N) received 8 mg dexamethasone from a nebulizer mask preoperatively, and Group (S) received nebulised normal saline. Outcomes evaluated were postoperative sore throat, odynophagia, change of voice, and nausea and vomiting.

RESULTS

Nebulized dexamethasone was found to be significantly superior to IV dexamethasone in terms of postoperative sore throat at zero-hour (p = 0.001) and 1-h intervals (p = 0.011). No significant difference was found at 6- and 24-h intervals. For odynophagia, post hoc analysis showed there was no significant difference between (I), (N), and (S) groups. Incidence of change of voice was significantly lower in (N) and (I) groups compared to (S) group, with p values of 0.0067 and 0.00014, respectively. The incidence of post-operative sore-throat (PONV) in (I) group was significantly lower than incidences in (S) group (p = 0.00002) and (N) group (p = 0.0004).

CONCLUSION

Preoperative nebulized and IV dexamethasone are effective strategies in mitigating complications related to mechanical effects of Bougie insertion. IV dexamethasone was as effective as nebulized dexamethasone in terms of late postoperative sore throat, and was superior in postoperative nausea and vomiting.

Micronutrients deficiences in patients after bariatric surgery

Bariatric surgery is an effective option for managing obesity and has gained general acceptance among patients in recent years. Generally, despite the high caloric intake, a bad nutritional habit of obese people results in the deficiency of several vitamins, minerals, and trace elements essential for body metabolism and normal physiological processes. Additionally, the current bariatric surgical approaches such as sleeve gastrectomy (SG), Roux-en-Y-gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), and jejunoileal bypass (JIB) can cause or exacerbate these deficiencies. Based on several reports, it appears that the various bariatric surgical procedures affect nutrient absorption differently. Being purely restrictive, LAGB and SG affect the absorption of iron, selenium, and vitamin B₁₂, while RYGB, JIB, and biliopancreatic diversion have a more profound impact on the absorption of essential vitamins, minerals, and trace elements. Nutritional deficiencies in vitamins, minerals, and trace elements may follow bariatric surgery and are associated with clinical manifestations and diseases, including anemia, ataxia, hair loss, and Wernicke encephalopathy. The present review summarizes some of the major vitamin and micronutrient deficiencies associated with bariatric surgery, particularly those presented post-surgically. To avoid any adverse consequences of vitamin and trace element deficiency, proper monitoring and tests are recommended at any stage, from pre- to post-surgery (periodical check-up), followed by specific and individual nutritional supplementation treatments and a proper healthy diet.