Fracture risk after surgery for peptic ulcer disease: a population-based cohort study

Risk of fracture following gastric surgery for benign and malignant conditions: A study level pooled analysis of population-based cohort studies

BACKGROUND

Metabolic changes may occur following gastric surgery, which has been reported to contribute to bone loss, osteoporosis and even bone fracture. However, the evidence regarding the relationship between gastric surgery for benign and malignant conditions and risk of fracture is controversial. This study was conducted with the aim to evaluate whether gastric surgery is associated with a high risk of fracture.

METHODS

Major electronic databases were searched from inception through October 2021 for population-based cohort studies investigating the associations between gastric surgery (including bariatric gastric surgeries and surgeries for gastric benign and malignant gastric tumors) and risk of fracture compared with controls. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were derived using the random-effects Mantel-Haenszel model. Multiple subgroup analyses and sensitivity analyses were carried out to test sources of heterogeneity stratified by various study characteristics and the robustness of the results.

RESULTS

A total of 14 studies comprising 693134 individuals were identified for analysis. The RR for the risk of fracture in people undergoing gastric surgery was 1.45 [95% confidence interval (CI) 1.23 - 1.72; I2 = 95.8%; P < 0.001] compared with that in control populations, among which the fracture sites of upper limb, spine, lower limb, pelvis and hip showed consistent significant results (all P < 0.05), whereas nonsignificant associations was noted for other fracture sites. Significant associations were also observed for patients having total or subtotal gastrectomy (RR 2.22, 95% CI 1.66 to 3.00), gastric bypass (RR 1.48, 95% CI 1.26 to 1.74), and a similar trend was observed for preserved passage procedures (including sleeve gastrectomy, gastric banding, vertical banded gastroplasty and other procedures that preserved the passage through the duodenum and proximal small bowel, in contrast to gastric bypass), though the difference did not reach statistically significant (RR 1.10, 95% CI 0.95 to 1.26). An evident increased risk in the age range from 40-59 years was observed (40-49 years: RR 1.36, 95% CI 1.19-1.55; 50-59 years: RR 2.48, 95% CI 1.58-3.90).

CONCLUSION

From this large pooled analysis of population-based cohort studies, evidence supports that fracture risk is increased in gastric surgery survivors compared with the control population. Early prevention and effective intervention strategies of bone fracture should be taken from clinicians and health policy makers.

CLINICAL TRIAL REGISTRATION

PROSPERO (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=291394), identifier CRD42021291394.

Bone Fragility in Gastrointestinal Disorders

Osteoporosis is a common systemic disease of the skeleton, characterized by compromised bone mass and strength, consequently leading to an increased risk of fragility fractures. In women, the disease mainly occurs due to the menopausal fall in estrogen levels, leading to an imbalance between bone resorption and bone formation and, consequently, to bone loss and bone fragility. Moreover, osteoporosis may affect men and may occur as a sequela to different diseases or even to their treatments. Despite their wide prevalence in the general population, the skeletal implications of many gastrointestinal diseases have been poorly investigated and their potential contribution to bone fragility is often underestimated in clinical practice. However, proper functioning of the gastrointestinal system appears essential for the skeleton, allowing correct absorption of calcium, vitamins, or other nutrients relevant to bone, preserving the gastrointestinal barrier function, and maintaining an optimal endocrine-metabolic balance, so that it is very likely that most chronic diseases of the gastrointestinal tract, and even gastrointestinal dysbiosis, may have profound implications for bone health. In this manuscript, we provide an updated and critical revision of the role of major gastrointestinal disorders in the pathogenesis of osteoporosis and fragility fractures.

Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review)

Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.

Association between proton pump inhibitors use and risk of hip fracture: A general population-based cohort study

Previous studies comparing risk of fracture among Proton Pump Inhibitors (PPIs) users with that among non-users were susceptible to confounding by indication. Epidemiologic studies of this association using an active medication as a comparator would appropriately address this bias. We conducted a propensity-score matched cohort study to compare the risk of incident fracture over five years among initiators of PPIs with initiators of histamine 2 receptor antagonist (H2RA) using data collected from The Health Improvement Network (THIN) database in the United Kingdom (2000-2016). The prevalence of PPIs prescription increased 3.8-fold from 2000 (7.9%) to 2012 (30.3%) and remained stable since then. Of the 50,265 propensity-score matched participants in each cohort (mean age was 65 years, and 57% were women), 370 (1.9/1000 person-years) incident hip fracture occurred in the PPIs initiators and 294 (1.5/1000 person-years) in the H2RA initiators during the follow-up period. The rate difference of incident hip fracture for PPIs initiation was 0.4 (95% confidence interval [CI]: 0.2-0.7)/1000 person-years compared with H2RA initiation and the corresponding hazard ratio (HR) was 1.27 (95%CI: 1.09-1.48). Compared with non-PPI use, multivariable-adjusted odds ratios (ORs) of hip fracture were 1.17 (95%CI: 0.94-1.46), 1.55 (95%CI: 1.23-1.96), and 1.67 (95%CI: 1.33-2.10) for 1-2, 3-9 and ≥ 10 prescriptions of PPIs, respectively (P for trend = 0.001). We found that PPIs prescription has been increasing rapidly over the past decade in the United Kingdom, and the initiation of PPIs was associated with a higher risk of hip fracture than initiation of H2RA.

Increased risk of osteoporosis in patients with peptic ulcer: a follow-up study using a national sample cohort

We performed a nationwide, population-based cohort study to investigate the risk of osteoporosis in patients with peptic ulcer disease in South Korea and concluded that peptic ulcer disease is associated with an increased risk of osteoporosis.

PURPOSE

This study aimed to evaluate the association between peptic ulcer disease (PUD) and the occurrence of osteoporosis using a national sample cohort from South Korea.

METHODS

Using the national cohort study from the Korean National Health Insurance Service, we extracted data for patients with PUD (n = 50,002) and for 1:1 matched control participants (n = 50,002); we then analyzed the occurrence of osteoporosis from 2002 to 2013. The patients were matched according to age, sex, income, region of residence, and past medical history. A stratified Cox proportional hazards model was used to analyze the hazard ratios (HRs) and the 95% confidence intervals (CIs). Subgroup analyses were performed based on age and sex.

RESULTS

The adjusted HR for osteoporosis was 1.36 (95% CI = 1.33-1.40, P < 0.001) in the PUD group. In the subgroup analysis based on age and sex, the respective adjusted HRs of PUD for osteoporosis were 1.33 (95% CI = 1.21-1.47) in the < 65-year-old group of men and 1.42 (95% CI = 1.30-1.56) in the ≥ 65-year-old group of men (each P < 0.001). The respective adjusted HRs of PUD for osteoporosis were 1.34 (95% CI = 1.29-1.39) in the < 65-year-old group of women and 1.38 (95% CI = 1.33-1.47) in the ≥ 65-year-old group of women (each P < 0.001).

CONCLUSION

In the current nationwide cohort study, we found that PUD is associated with an increased risk of osteoporosis regardless of sex.

Increased risk of osteoporotic fracture in community-dwelling elderly men 20 or more years after gastrectomy: The Fujiwara-kyo Osteoporosis Risk in Men (FORMEN) Cohort Study

PURPOSE

Many studies have reported that patients with a history of gastrectomy (gastrectomized patients) have lower areal bone mineral density (aBMD) and higher fracture risk than those without. However, population-based studies on this topic are scarce, and little is known regarding the bone metabolic status of gastrectomized patients in the long-term. This study aimed to clarify the association of gastrectomy with aBMD, bone metabolism markers, and fracture risk in community-dwelling elderly Japanese men.

METHODS

A total of 1992 men aged ≥65 years completed baseline measurements including aBMD at the spine and hip, serum levels of intact parathyroid hormone (PTH), intact osteocalcin (OC), tartrate-resistant acid phosphatase isoenzyme 5b (TRACP5b), and undercarboxylated OC (ucOC), and an interview regarding past medical history including gastrectomy. Osteoporotic fractures (OPFs) that occurred during the 5-year follow-up period were determined through structured interviews.

RESULTS

After excluding participants with type 1 diabetes mellitus and those with missing values, 1985 men, including 132 gastrectomized men, were analyzed. Gastrectomized men had significantly higher PTH, TRACP5b, and ucOC levels, and lower aBMD, than non-gastrectomized men. Gastrectomy was associated with a significantly higher risk of OPF after adjusting for confounding variables (hazard ratio (HR): 2.55, 95% confidence interval (CI): 1.17, 5.55), and the risk was no longer significant when further adjusted for PTH and aBMD. Even in this model, however, increase in OPF risk was significant in gastrectomized men who survived 20 years or more after the surgery (HR: 3.56, 95% CI: 1.33, 9.52).

CONCLUSIONS

History of gastrectomy was associated with elevated bone resorption, decreased aBMD, and increased fracture risk in community-dwelling elderly Japanese men. This increase in fracture risk was more prominent long after gastrectomy.

Osteoporosis and Osteoporotic Fractures in Gastrointestinal Disease

Patients with gastrointestinal disease (GI) are at risk for osteopenia or osteoporosis, which can lead to fractures. Although these patients may be at risk from a young age, gastroenterologists often overlook this fact in practice. There are well-known GI diseases associated with osteopenia and osteoporosis, such as the post-gastrectomy state, inflammatory bowel disease (IBD), and celiac disease. As there is an increase in the prevalence of IBD patients, newly diagnosed celiac disease in adulthood, and gastric cancer survivors following gastrectomy, bone disease in these patients becomes an important issue. Here, we have discussed osteoporosis and fractures in GI disease, especially in the post-gastrectomy state, IBD, and celiac disease. Although the pathogenesis of bone loss in each disease has not been fully identified, we have confirmed that the prevalence of osteoporosis and fractures in each of these diseases is high. There are scarce studies comparing the prevalence of osteoporosis or osteoporotic fractures in GI disease patients with studies in postmenopausal women, and specific guidelines for their management in each disease have not been established. Intensive surveillance and management are needed to ensure that these patients attain peak bone mass for age and sex to prevent fractures.

Osteoporosis and fracture after gastrectomy for stomach cancer: A nationwide claims study

This study was planned to evaluate the incidence and risk factors of osteoporosis and fracture after gastrectomy for stomach cancer using a nationwide claims database in South Korea.Data from 41,512 patients (50-79 years) who underwent gastrectomy for stomach cancer from 2008 to 2010 with at least 5 years of follow-up were obtained from the Health Insurance Review and Assessment Service database. Patients diagnosed with osteoporosis and prescribed bisphosphonate or raloxifene or who experienced osteoporotic fractures after gastrectomy were operationally defined as osteoporosis. Osteoporotic fracture was defined as a fracture at common osteoporotic fracture sites (spine, pelvis, hip, forearm, or rib).In total, 37,076 patients were included in the final analysis. The incidences of postgastrectomy osteoporosis and osteoporotic fractures were 41.9 and 27.6 cases per 1000 person-years, respectively. Multivariate analysis showed that older age (hazard ratio [HR] 1.88; 95% confidence interval [CI] 1.79-1.96), female gender (HR 2.46; 2.35-2.58), total gastrectomy (HR 1.10; 1.04-1.16), and diabetes (HR 1.16; 1.11-1.22) were significantly associated with osteoporosis and that older age (HR 1.90; 95% CI 1.80-2.01), female gender (HR 1.50; 1.41-1.58), total gastrectomy (HR 1.17; 1.10-1.25), chemotherapy (HR 1.06; 1.00-1.12), and diabetes (HR 1.26; 1.19-1.33) were significantly associated with fractures. Osteoporotic fractures occurred a median 3.1 years after gastrectomy. Among the 5175 fracture patients, 780 (15.1%) experienced multisite fractures, mostly in the elderly and chemotherapy groups.The osteoporosis and osteoporotic fracture incidences are high in patients within a relatively short timeframe after gastrectomy for stomach cancer. Systematic management of osteoporosis is necessary after this surgery.

Fracture Risk After Bariatric Surgery: Roux-en-Y Gastric Bypass Versus Adjustable Gastric Banding

The long-term consequences of bariatric surgery on fracture risk are unclear but are likely to vary by procedure type. In physiologic studies, Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) have differential effects on rates of bone loss. Therefore, our objective was to compare fracture risk in obese adults after RYGB and AGB procedures. Using claims data from a US commercial health plan, we analyzed rates of nonvertebral fractures within a propensity score-matched cohort (n = 15,032) of morbidly obese adults who received either RYGB or AGB surgery between 2005 and 2013. A total of 281 nonvertebral fractures occurred during a mean follow-up time of 2.3 ± 1.9 years. RYGB patients had an increased risk of nonvertebral fracture (hazard ratio [HR] = 1.43, 95% confidence interval [CI] 1.13-1.81) compared with AGB patients. In fracture site-specific analyses, RYGB patients had increased risk of fracture at the hip (HR = 1.54, 95% CI 1.03-2.30) and wrist (HR = 1.45, 95% CI 1.01-2.07). Nonvertebral fracture risk associated with RYGB manifested >2 years after surgery and increased in subsequent years, with the highest risk in the fifth year after surgery (HR = 3.91, 95% CI 1.58-9.64). In summary, RYGB is associated with a 43% increased risk of nonvertebral fracture compared with AGB, with risk increasing >2 years after surgery. Fracture risk should be considered in risk/benefit discussions of bariatric surgery, particularly among patients with high baseline risk of osteoporosis who are deciding between RYGB and AGB procedures. © 2017 American Society for Bone and Mineral Research.

Fundectomy-Evoked Osteopenia in Pigs Is Mediated by the Gastric-Hypothalamic-Pituitary Axis

The aim of the study was to determine the effects of gastric impairment in pigs on the axial and peripheral skeletal system properties and to test the hypothesis that fundectomy-evoked osteopenia is related to disturbed gastric-hypothalamic-pituitary axis function. Forty-day-old male piglets were subjected to experimental fundectomy (FX group, n = 6) to induce osteopenia, while sham operation was performed in the controls (SHO group, n = 6). At the age of 8 months, serum samples were collected, and the animals were sacrificed to obtain lumbar vertebrae (L1–L6) and right humerus for analysis. Using quantitative computed tomography (QCT) and dual-energy x-ray absorptiometry (DEXA) methods, bone mineral density and bone mineral content of the vertebrae and humerus were measured. The compression and three-point bending tests were applied to determine mechanical properties of lumbar vertebrae and humerus, respectively. Furthermore, geometric properties of humerus were assessed. Serum concentrations of ghrelin, growth hormone (GH), insulin-like growth factor-1 (IGF-1), and selected macro- and microelements were also determined. Performed fundectomy decreased body weight in pigs by 66% compared with pair-fed sham operated pigs ( P < 0.0001). Bone weight, bone mineral density, and bone mineral content of the lumbar vertebrae and humerus were significantly decreased in the fundectomized pigs ( P < 0.01). Mechanical parameters of the lumbar spine and humerus were decreased after the fundectomy, as well. Serum concentrations of ghrelin, GH, and IGF-1 were lowered by 74.4%, 90.6%, and 54.6% in the fundectomized pigs, respectively (all P < 0.001). Moreover, the serum concentrations of calcium, magnesium, iron and copper in the fundectomized animals were significantly decreased by 15.5%, 45.3%, 26.7%, and 26.2%, respectively ( P ≤ 0.05). In conclusion, the results obtained showed that both the disturbed gastric-hypothalamic-pituitary axis function and impaired mineral metabolism are associated with development of postfundectomy osteopenia of axial and peripheral skeleton in pigs.

Loose and frequent stools and PTH levels are positively correlated post-gastric bypass surgery due to less efficient intestinal calcium absorption

BACKGROUND

After Roux-en-Y gastric bypass, calcium and vitamin D deficiencies are frequently reported. In the presence of adequate vitamin D levels, calcium deficiency is caused by a lower efficacy of the intestinal calcium transport.

OBJECTIVE

To investigate whether the use of a simple clinical score quantifying bowel habits (fecal score [FS]) correlates with the degree of secondary hyperparathyroidism that arises to compensate for calcium deficiency postsurgery.

SETTING

Large peripheral hospital.

METHODS

Seventy-five patients supplemented with calcium and vitamin D were prospectively studied before and 6 and 12 months after Roux-en-Y gastric bypass. FS, calcium (mmol/L), phosphate (mmol/L), magnesium (mmol/L), vitamin D (nmol/L), and parathyroid hormone (PTH; pmol/L) were measured in each patient.

RESULTS

Mean body mass index was 44.7±5.4 kg/m² preoperatively and decreased to 34.3±5.0 kg/m² at 6 months and 30.8±4.8 kg/m² at 12 months, corresponding to a total weight loss of 23.2±5.9% and 30.9±8.3% respectively. There were no significant changes in serum calcium levels. Mean PTH levels rose from 3.5 pmol/L at baseline to 4.1 pmol/L at 6 months (P = .01) and to 4.9 pmol/L at 12 months (P<.001). Nine patients (12%) had increased PTH levels at 6 months, and 14 patients (19%) had increased PTH levels at 12 months. A significant positive correlation between FS and PTH at 12 months was found, which persisted after adjusting for vitamin D levels.

CONCLUSION

FS is positively correlated with secondary hyperparathyroidism using vitamin D-adjusted PTH levels as a biochemical marker. The present study in humans confirms the relation reported in animal studies. These results emphasize that managing stool habits are important after bariatric surgery.

Negative Effects of Total Gastrectomy on Bone Tissue Metabolism and Volumetric Bone Mineral Density (vBMD) of Lumbar Spine in 1-Year Study in Men

Gastrectomy induces severe osteoporosis in humans but its quantitative scale within trabecular and cortical compartments was not estimated. The aim of the study was to determine changes of volumetric bone mineral density (vBMD) in lumbar vertebrae (L1-L4) and biochemical bone metabolism markers in serum of patients 1 year after total gastrectomy. The control group consisted of patients (N = 8) subjected to abdominal surgery due to cardiospasmus. Total gastrectomy was performed in the experimental group (N = 6). Volumetric bone mineral density of trabecular and cortical bone of lumbar spine was measured before (baseline) and 1 year after the gastric surgery using the quantitative computed tomography method. Serum concentrations of insulin, insulin-like growth factor-1, tyroxine, interleukin-6, C-terminal telopeptides of type II collagen and bone formation, and resorption markers were determined at baseline and 1 year later, using ELISA, EIA, and IEMA methods. Total gastrectomy induced significant decrease of vBMD values, up to 16.8% and 10.0%, within the trabecular and cortical bone compartments of lumbar spine (P < 0.05). These negative changes of vBMD were associated with significantly increased serum concentration of bone resorption markers such as deoxypyridinoline, pyridinoline, and C-terminal telopeptides of type I collagen, by 13.5%, 32.2%, and 121.5%, respectively (P < 0.05). Neither vBMD nor biochemical bone turnover markers and hormone concentrations were influenced in the control patients. Dramatic bone loss during the first year in gastrectomized patients has proven dynamic osteoporosis progress indicating an importance of treatment interventions in these patients with emphasis on inhibition of intensive bone resorption processes.

The effect of supplementation of a glutamine precursor on the growth plate, articular cartilage and cancellous bone in fundectomy-induced osteopenic bone

The aim of the study was to investigate the effect of 2-oxoglutaric acid (2-Ox) supplementation (a precursor of glutamine and hydroxyproline, the most abundant amino acid of collagen) on cartilage and bone in pigs after fundectomy. Pigs at the age of forty days were subjected to fundectomy and divided into two groups depending on 2-Ox supplementation (at the daily dosage of 0.4 g/kg of body weight). Other pigs were sham operated. Pigs were euthanized at the age of eight months. An analysis of the morphometry of trabeculae, growth plate and articular cartilage in fundectomy-induced osteopenic bone was performed. Moreover, the levels of expression of osteocalcin, osteopontin and osteoprotegerin in trabecular bone and osteocalcin in articular cartilage were evaluated. Articular cartilage was thinnest in fundectomized pigs and thickest in 2-Ox-supplemented animals after fundectomy. Moreover, 2-Ox supplementation after fundectomy enhanced the total thickness of the growth plate and trabeculae in fundectomized pigs. The most evident signal for osteocalcin and osteoprotegerin in trabecular bone was in sham-operated and 2-Ox-supplemented pigs; a low reaction was observed in the fundectomized group. Additionally, as a long-term postoperative consequence, a change was observed in the expression of osteocalcin in articular cartilage. It seems that 2-Ox is suitable for use in preventing the negative effects of fundectomy on cancellous bone and cartilage.

Vitamin K2 improves femoral bone strength without altering bone mineral density in gastrectomized rats

Gastrectomy (GX) induces osteopenia in rats. The present study examined the skeletal effects of vitamin K2 in GX rats. Thirty male Sprague-Dawley rats (12 wk old) were randomized by the stratified weight method into the following three groups of 10 animals each: sham operation (control) group; GX group; and GX+oral vitamin K2 (menatetrenone, 30 mg/kg, 5 d/wk) group. Treatment was initiated at 1 wk after surgery. After 6 wk of treatment, the bone mineral content (BMC), bone mineral density (BMD), and mechanical strength of the femoral diaphysis and distal metaphysis were determined by peripheral quantitative computed tomography and mechanical strength tests, respectively. GX induced decreases in the BMC, BMD, and ultimate force of the femoral diaphysis and distal metaphysis. Vitamin K2 did not significantly influence the BMC or BMD of the femoral diaphysis or distal metaphysis in GX rats, but attenuated the decrease in the ultimate force and increased the stiffness of the femoral diaphysis. The present study showed that administration of vitamin K2 to GX rats improved the bone strength of the femoral diaphysis without altering the BMC or BMD, suggesting effects of vitamin K2 on the cortical bone quality.

Bone metabolism after bariatric surgery

Bariatric surgery is a popular and effective treatment for severe obesity but may have negative effects on the skeleton. This review summarizes changes in bone density and bone metabolism from animal and clinical studies of bariatric surgery, with specific attention to Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and sleeve gastrectomy (SG). Skeletal imaging artifacts from obesity and weight loss are also considered. Despite challenges in bone density imaging, the preponderance of evidence suggests that bariatric surgery procedures have negative skeletal effects that persist beyond the first year of surgery, and that these effects vary by surgical type. The long-term clinical implications and current clinical recommendations are presented. Further study is required to determine mechanisms of bone loss after bariatric surgery. Although early studies focused on calcium/vitamin D metabolism and mechanical unloading of the skeleton, it seems likely that surgically induced changes in the hormonal and metabolic profile may be responsible for the skeletal phenotypes observed after bariatric surgery.

Bone loss after bariatric surgery: discordant results between DXA and QCT bone density

Several studies, using dual-energy X-ray absorptiometry (DXA), have reported substantial bone loss after bariatric surgery. However, profound weight loss may cause artifactual changes in DXA areal bone mineral density (aBMD) results. Assessment of volumetric bone mineral density (vBMD) by quantitative computed tomography (QCT) may be less susceptible to such artifacts. We assessed changes in BMD of the lumbar spine and proximal femur prospectively for 1 year using DXA and QCT in 30 morbidly obese adults undergoing Roux-en-Y gastric bypass surgery and 20 obese nonsurgical controls. At 1 year, subjects who underwent gastric bypass surgery lost 37 ± 2 kg compared with 3 ± 2 kg lost in the nonsurgical controls (p < 0.0001). Spine BMD declined more in the surgical group than in the nonsurgical group whether assessed by DXA (-3.3 versus -1.1%, p = 0.034) or by QCT (-3.4 versus 0.2%, p = 0.010). Total hip and femoral neck aBMD declined significantly in the surgical group when assessed by DXA (-8.9 versus -1.1%, p < 0.0001 for the total hip and -6.1 versus -2.0%, p = 0.002 for the femoral neck), but no changes in hip vBMD were noted using QCT. Within the surgical group, serum P1NP and CTX levels increased by 82% ± 10% and by 220% ± 22%, respectively, by 6 months and remained elevated over 12 months (p < 0.0001 for all). Serum calcium, vitamin D, and PTH levels remained stable in both groups. We conclude that moderate vertebral bone loss occurs in the first year after gastric bypass surgery. However, striking declines in DXA aBMD at the proximal femur were not confirmed with QCT vBMD measurements. These discordant results suggest that artifacts induced by large changes in body weight after bariatric surgery affect DXA and/or QCT measurements of bone, particularly at the hip.

Influence of gastrectomy on cortical and cancellous bones in rats

The aim of the present study was to examine the influence of gastrectomy (GX) on cortical and cancellous bones in rats. Twenty male Sprague-Dawley rats were randomized into the two groups of 10 animals each: a sham operation (control) group and a GX group. Seven weeks after surgery, the bone mineral content and density (BMC and BMD, resp.) and the mechanical strength of the femur were determined, and bone histomorphometric analyses were performed on the tibia. GX induced decreases in the BMC, BMD, ultimate force, work to failure, and stiffness of the femoral distal metaphysis and the BMC, BMD, and ultimate force of the femoral diaphysis. GX induced a decrease in cancellous bone mass, characterized by an increased osteoid thickness, osteoid surface, osteoid volume, and bone formation. GX also induced a decrease in cortical bone mass, characterized by increased endocortical bone resorption. The GX induced reductions in the bone mass and strength parameters were greater in cancellous bone than in cortical bone. The present study showed that the response of bone formation, resorption, and osteoid parameters to GX and the degree of GX-induced osteopenia and the deterioration of bone strength appeared to differ between cortical and cancellous bones in rats.

Effect of bisphosphonates on bone mineral density and fracture prevention in gastric cancer patients after gastrectomy

GOAL

To evaluate the effectiveness of bisphosphonates in preventing fractures in gastric cancer patients by increasing bone mineral density (BMD).

BACKGROUND

The effectiveness of bisphosphonates is questionable in gastric cancer patients who have undergone gastrectomy, although they display a high prevalence of osteoporosis.

STUDY

Forty-seven gastric cancer patients with osteoporosis were retrospectively analyzed. All patients were supplemented with calcium and vitamin D. Twenty-four patients were treated with bisphosphonate (bisphosphonate group) and 23 patients were untreated (control group). Fractures, severe bone pain, and adverse effects of bisphosphonates were monitored. BMD of the lumbar spine and femoral neck were measured before and 1-year treatment with bisphosphonates by dual-energy X-ray absorptiometry.

RESULTS

During a 1-year follow-up, 7 of the 47 (15%) patients developed new fractures. The bisphosphonate-treated group had a significantly lower fracture rate than the control group (n=1 vs. 6, P<0.05). Lumbar spine BMD increased in both groups (0.047 ± 0.03 vs. 0.021 ± 0.03 g/cm², respectively), whereas femoral neck BMD increased only in the bisphosphonate group (0.032 ± 0.03 vs. -0.004 ± 0.02 g/cm², respectively). Furthermore, the bisphosphonate group showed greater increases in lumbar spine and femoral neck BMDs than the controls (P<0.05). No difference was found between alendronate and risedronate in terms of BMD at follow-up.

CONCLUSIONS

Therapy using bisphosphonates might be effective at increasing BMD and reducing fracture risk in gastric cancer patients after gastrectomy. Further well-designed randomized controlled trials are needed for confirmation.

Postgastrectomy syndromes

The first postgastrectomy syndrome was noted not long after the first gastrectomy was performed. The indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient's long-term follow-up and care. The article does not deal with the sequelae of bariatric surgery.

Prevalence, pathophysiology, screening and management of osteoporosis in gastric cancer patients

Osteoporosis in gastric cancer patients is often overlooked or even neglected despite its high prevalence in these patients. Considering that old age, malnutrition, chronic disease, chemotherapy, decreased body mass index and gastrectomy are independent risk factors for osteoporosis, it is reasonable that the prevalence of osteoporosis in gastric cancer patients would be high. Many surviving patients suffer from back pain and pathological fractures, which are related to osteoporosis. Fractures have obvious associated morbidities, negative impact on quality of life, and impose both direct and indirect costs. In the era of a >55.6% 5-year survival rate of gastric cancer and increased longevity in gastric cancer patients, it is very important to eliminate common sequelae such as osteoporosis. Fortunately, the diagnosis of osteoporosis is well established and many therapeutic agents have been shown to be effective and safe not only in postmenopausal females but also in elderly males. Recently, effective treatments of gastric cancer patients with osteoporosis using bisphosphonates, which are commonly used in postmenopausal woman, were reported.

Semiquantitative assessment of bowel habits and its relation with calcium metabolism after gastric bypass surgery: a retrospective study

Background. Calcium malabsorption after bariatric surgery may be harmful to skeletal health and demands for optimal skeletal management. Methods. 103 Patients were evaluated retrospectively at 12 months after surgery. The evaluation included a questionnaire about stool frequency and consistency and laboratory assessments. Results. 103 Patients, 27 males and 76 females, were included in the study. 83 Patients had an alimentary limb of 100 cm and 20 patients one of 150 cm. At 12 months after surgery, 77.7% reported changes of bowel habits, albumin adjusted calcium levels were normal in all but 2 patients, and PTH levels were increased in 35%. Correlations between semiquantified bowel scores (fecal scores) and data from the laboratory demonstrated increasing PTH values along with more frequent and softer/watery stools (RR 30.5, CI 6.2-149.2, P < .001). There was a trend for higher PTH levels in patients with an alimentary limb of 150 cm. Normal PTH levels were more frequently found in case of calcium and vitamin D3 use (RR 14.3, CI 3.6-56.5, P < .001). Conclusion. This study demonstrates interrelationships between semi-quantified fecal scores, PTH levels, and the compliance of taking calcium/vitamin D3 suppletion. However, prospective randomized studies are necessary to show causal relationships.

The gutsy side of bone

Though surgical removal of the stomach has long been linked to low bone mass, the molecular mechanism has been elusive. Amling and coworkers now demonstrate that gastric cell acid production is necessary for calcium absorption. Mice lacking this acidification develop hypocalcemia, with increased parathyroid hormone and osteoclast differentiation, and decreased bone mass.

Dietary alpha-ketoglutarate reduces gastrectomy-evoked loss of calvaria and trabecular bone in female rats

OBJECTIVE

Surgical removal of the stomach (gastrectomy, Gx) leads to osteopenia in animals and in humans. In the rat, Gx adversely affects calvaria and trabecular bone. alpha-Ketoglutarate (AKG) is a precursor of hydroxyproline--the most abundant amino acid in bone collagen. The purpose of this study was to investigate the effects of dietary AKG on Gx-induced osteopenia.

MATERIAL AND METHODS

Twenty female Sprague-Dawley rats were subjected to Gx and divided between two groups: Gx+AKG in the drinking water and Gx+Vehicle (i.e. drinking water without AKG). Another 20 rats were sham-operated and divided between two groups: Sham+AKG and Sham+Vehicle. The daily dose of AKG was 0.43 g per 100 g rat. All the rats were killed 8 weeks later and the calvariae, femora and tibiae were collected. The integrity of the calvariae was analysed planimetrically, following transillumination and photography. The bone mineral content (BMC) and bone mineral density (BMD) were measured in the right femorae and tibiae (bone densitometry), leaving the left femorae and tibiae to be analysed histomorphometrically (measurement of trabecular bone volume and trabecular fractal dimension).

RESULTS

Gx caused calvarial bone degradation, reduced trabecular bone (femur and tibia) and impaired trabecular architecture. In addition, Gx lowered the femoral/tibial BMC and BMD (mainly cortical bone). Dietary AKG counteracted the Gx-evoked impairment of calvaria and trabecular bone but failed to affect the BMC and the BMD in either sham- operated or Gx rats.

CONCLUSIONS

Gx resulted in loss of calvarial, trabecular and cortical bone in the rat. AKG counteracted the effect of Gx on calvaria and trabecular bone but not on cortical bone.

Peptic ulcer disease and calcium intake as risk factors of osteoporosis in women

INTRODUCTION

Low dietary intake and decreased absorption of calcium are known as important risk factors of osteoporosis. Peptic ulcer disease may be accompanied by dietary restrictions influencing negatively calcium intake. Inflammation of gastric and duodenal mucosa as well as alkali used may significantly decrease calcium absorption. Additionally, bone metabolism may be changed by inflammatory mediators released as a result of mucosal inflammation.

AIMS

Comparison of bone mineral density and calcium dietary intake in women with and without (control group) peptic ulcer disease.

METHODS

Two hundred and sixty-three women were studied: 143 (mean age 60.3 years) with peptic ulcer disease diagnosed by endoscopy and/or upper gastrointestinal X-ray, and 120 (mean age 58.4 years) as controls. History of alimentary tract diseases and presence of risk factors of osteoporosis, as well as history of hormone replacement therapy, were collected based on specially designed questionnaires. Women with present risk factors of secondary osteoporosis and with previously diagnosed osteoporosis were excluded. The calcium dietary intake was determined using a standard questionnaire assessing milk and milk products intake as well as calcium supplementation when used. Bone mineral density of the lumbar spine and femoral bone was determined by DXA.

RESULTS

Women with peptic ulcer disease not using hormone replacement therapy had lower bone mineral density in all studied regions as compared to control group without peptic ulcer disease. In the subgroup not using hormone replacement therapy all studied values differed significantly. In the smaller subgroup of women using hormone replacement therapy not all values were statistically significant. There was no statistical significance between studied groups in dietary calcium intake as milk, milk products, and calcium supplements.

CONCLUSIONS

Calcium intake in women with ulcer disease is similar to healthy subjects. Peptic ulcer disease is an independent risk factor for osteoporosis in women.