Nutritional and metabolic complications of bariatric surgery

The physiological role of copper: Dietary sources, metabolic regulation, and safety concerns

Copper plays an important physiological role in the body, with both deficiency and excess potentially impacting overall health. The body maintains a stringent copper metabolism mechanism to oversee absorption, utilization, storage, and elimination. Dietary consumption serves as the principal source of copper. The dietary factors may interfere with the absorption and metabolism of copper, leading to fluctuation of copper levels in the body. However, these dietary factors can also be strategically employed to facilitate the precise regulation of copper. This paper delved into the advancements in research concerning copper in food processing, including dietary sources of copper, the regulatory processes of copper metabolism and health implications of copper. The safety and its underlying mechanisms of excess copper were also highlighted. In particular, the paper examines the influence of dietary factors on the absorption and metabolism of copper, aiming to provide direction for accurate copper regulation and the creation of functional foods and pharmaceuticals.

Beyond weight loss: exploring the neurological ramifications of altered gut microbiota post-bariatric surgery

This review discusses findings related to neurological disorders, gut microbiota, and bariatric surgery, focusing on neurotransmitters, neuroendocrine, the pathophysiology of bacteria contributing to disorders, and possible therapeutic interventions. Research on neurotransmitters suggests that their levels are heavily influenced by gut microbiota, which may link them to neurological disorders such as Alzheimer's disease, Parkinson's disease, Multiple sclerosis, Depression, and Autism spectrum disorder. The pathophysiology of bacteria that reach and influence the central nervous system has been documented. Trends in microbiota are often observed in specific neurological disorders, with a prominence of pro-inflammatory bacteria and a reduction in anti-inflammatory types. Furthermore, bariatric surgery has been shown to alter microbiota profiles similar to those observed in neurological disorders. Therapeutic interventions, including fecal microbiota transplants and probiotics, have shown potential to alleviate neurological symptoms. We suggest a framework for future studies that integrates knowledge from diverse research areas, employs rigorous methodologies, and includes long-trial clinical control groups.

Assessing Nutritional Deficiencies in Bariatric Surgery Patients: A Comparative Study of Roux-en-Y Gastric Bypass versus Sleeve Gastrectomy

Obesity is a worldwide epidemic, and bariatric surgery is considered the primary treatment for long-term weight loss and managing obesity-related health issues. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most performed procedures. Nutritional deficiencies are a significant concern following bariatric surgery and can have serious consequences. This study aims to compare the incidence of nutritional deficiencies in patients undergoing RYGB and SG. A retrospective analysis was conducted on the nutritional status of 505 consecutive patients who underwent either RYGB or SG between January and December 2019. Data were collected regarding vitamin B12, folic acid, vitamin D, calcium, PTH, magnesium, hemoglobin, iron, ferritin, and transferrin at preoperative, 6-month, and 12-month intervals post-surgery. The RYGB group showed significantly higher excess weight loss. Vitamin B12, hemoglobin, and ferritin levels were consistently higher in the SG group throughout the study. Vitamin D deficiency was prevalent, with no significant difference between the groups. Vitamin B12 deficiency was significantly more common in the RYGB group (6 months: 17.46% vs. 4.69%, p < 0.001; 12 months: 16.74% vs. 0.93%, p < 0.001). Despite differences in their mechanisms, bariatric surgeries were associated with nutritional deficiencies. It is crucial to efficiently assess, prevent, and manage these deficiencies tailored to each surgical procedure.

The role of dietitian follow-ups on nutritional outcomes post-bariatric surgery

BACKGROUND

Current evidence recommends dietary counselling with a registered dietitian (RD) for successful weight loss after metabolic bariatric surgery; however, there are limited data on the effect of RD follow-ups on micronutrient deficiencies. This study evaluated the effects of the number of postoperative RD visits on nutritional outcomes, including weight loss and micronutrient deficiencies.

OBJECTIVES

The aim of this study was to evaluate the effects of the number of postoperative registered dietitian visits on nutritional outcomes, including weight loss and micronutrient deficiencies after metabolic and bariatric surgery.

SETTING

Cleveland Clinic Abu Dhabi, United Arab Emirates METHODS: This retrospective study included patients who underwent bariatric surgery between September 2015 and June 2020. Demographics, weight loss, micronutrients, and the number of postoperative RD visits were evaluated. Baseline and 12-month postsurgery outcomes were compared based on the number of RD follow-ups.

RESULTS

A total of 174 primary and 46 revisions were included. Patients were 73.6% female, with a mean age of 40 years. The initial mean body mass index was 42.8 kg/m2. Number of RD visits were as follows: 0-1 (39 patients), 2 (59 patients), 3 (55 patients), and 4 or more (67 patients). Baseline (pre-operative) micronutrient values were within normal range. In comparison with the reference group (REF = 0-1 post-op RD visits), patients with 3 RD visits had 7% higher total body weight loss (P < .001) and maintained micronutrients within the normal range at 12 months postoperative. Mean differences in postoperative values were statistically significant (P < .05) for weight, vitamin B12, and vitamin D but not for hemoglobin, ferritin, calcium, folate, vitamin B1, copper, and zinc.

CONCLUSION

Our study suggests that three or more RD visits during the first 12 months after bariatric surgery are associated with improved outcomes, including significant percent total body weight loss and lower rates of micronutrient deficiencies.

Revisional Bariatric Surgery due to Complications: Indications and Outcomes

BACKGROUND

The increasing prevalence of bariatric procedures has led to a surge in revisional surgeries. Failure of bariatric surgery can be attributed to inadequate weight loss or complications necessitating revisional surgery. In this study, we investigated the indications and outcomes of revisional surgery due to complications following primary bariatric surgery.

MATERIALS AND METHODS

A retrospective study was conducted using data from the Tehran Obesity Treatment Study, which included patients who underwent revisional bariatric surgery between March 2013 and September 2021 due to complications following primary bariatric surgery.

RESULTS

Of the 5382 patients who underwent primary bariatric surgery (sleeve gastrectomy, one-anastomosis gastric bypass, and Roux-en-Y gastric bypass), 203 (3.70%) required revisional surgery, with 37 cases performed due to surgical complications. The indications of revisional operations were gastroesophageal reflux disease (GERD) (n=17, 45.9%), protein-calorie malnutrition (PCM) (n=14, 37.8%), unexplained abdominal pain (n=5, 13.5%), and phytobezoar (n=1, 0.03%). In the postoperative follow-up, most patients exhibited improvement in signs and symptoms related to underlying causes. However, eight patients experienced early or late complications of grade III or higher according to the Clavien-Dindo classification, with one death resulting from liver failure.

CONCLUSION

Revisional bariatric surgery may effectively address complications from primary bariatric surgery, with the majority of patients experiencing improvements in symptoms. While the overall incidence of revisional surgery due to complications is relatively low, our findings suggest that GERD and PCM are the most common indications for revisional surgery.

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.

[Complications and quality of life after bodylift: About 143 patients]

INTRODUCTION

The rise of bariatric surgery has led to a considerable increase in the demand for weight loss surgery. The lower body lift consists of removing the residual abdominal fat and skin excess and re-tensioning the surfaces. The objective of our study was to evaluate the associated complications, as well as the consequences of this surgery on the quality of life of the patients.

MATERIALS AND METHODS

A retrospective monocentric study was conducted in patients operated on for lower body lift between 2010 and 2019 at the University Hospital of Besançon. We collected postoperative complications and studied the satisfaction and quality of life of the operated patients using the Body-QoL and SF-36 questionnaires.

RESULTS

One hundred forty-three patients were included with a mean age of 41.2 years. The mean body mass index was 26.6kg/m² with a mean weight of 73.8kg and a mean weight loss of 54.4kg. Forty-one patients (29.7%) had at least one complication. Most complications were minor, with 16.8% of scar disunions, and 7% of complications were major, requiring revision surgery. Ninety-three patients (65%) responded to the satisfaction questionnaires with improvement mostly in physical symptoms and social life.

CONCLUSION

The lower body lift is an effective, safe procedure with mostly minor complications that do not influence quality of life. Patient satisfaction is high, and it is therefore justified to continue offering this procedure to correct the sequelae of massive weight loss.

Effect of Body Mass Index on Femur Fracture Location: A Retrospective Database Study

OBJECTIVES

Use a large database design and multivariable analyses to assess the associations between body mass index (BMI) and femur fracture patterns after controlling for other risk factors.

DESIGN

Retrospective cohort study.

SETTING

National insurance claims database of patient records from 2010 to 2018.

PATIENTS/PARTICIPANTS

Patients with femur fracture diagnoses were identified. Patients with multiple fractures within 1 week (polytrauma patients), patients without a BMI diagnosis code within 6 months of fracture, and patients with multiple BMI diagnosis codes (implying a substantial change in weight) were excluded.

INTERVENTION

N/A.

MAIN OUTCOME MEASUREMENTS

Patients were divided into groups based on fracture location: proximal (OTA/AO 31), shaft (OTA/AO 32), or distal (OTA/AO 33). The distribution of femur fractures was compared across BMI categories.

RESULTS

A total of 57,042 patients with femur fracture were identified: 45,586 proximal fractures, 4216 shaft fractures, and 7240 distal fractures. Patients with BMI &lt;29.9 have increased odds ( P &lt; 0.0001) of proximal fracture and decreased odds ( P &lt; 0.0001) of shaft or distal fractures. Patients with BMI &gt;30.0 have decreased odds ( P &lt; 0.0001) of proximal fracture and increased odds ( P &lt; 0.0001) of distal fractures.

CONCLUSIONS

Increasing BMI is associated with a decreased proportion of proximal femur fractures and a corresponding increase in the proportion of shaft and distal fractures. Regression analyses determined that age, sex, osteoporosis, diabetes, and tobacco use are not the cause of this trend.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Changes in the Bone Mineral Density after Sleeve Gastrectomy vs. Roux-En-Y Gastric Bypass 2 Years after Surgery

The aim of this study was to compare the analytical and densitometric changes 2 years after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). A retrospective study of a prospectively collected database was performed. Morbidly obese patients undergoing RYGB or SG, as primary bariatric procedures, were included. Weight loss; analytical levels of parathormone (PTH), vitamin D, and calcium; and densitometric parameters were investigated. In total, 650 patients were included in the study, and 523 patients (80.5%) underwent RYGB and 127 (19.5%) SG. There were no significant differences in excess weight loss at 24 months between both groups. When comparing preoperative and postoperative values, a significantly greater increase in PTH values was observed in the RYGB group, whereas there were no significant differences in calcium and vitamin D levels. The mean t-score values decreased after surgery at all the locations and in both groups. The reduction in the t-score was significantly greater in the RYGB group at the femoral trochanter and lumbar spine. A decrease in bone mineral density (BMD) was observed after both techniques. The mean BMD decrease was significantly greater in the femoral trochanter and lumbar spine after RYGB.

Impact of Bariatric Surgery-Induced Weight Loss on Anterior Eye Health in Patients with Obesity

The aim of the present research was to assess the effect of bariatric surgery-induced weight loss on the tear film and ocular surface of patients with obesity. A total of 29 participants with obesity (aged 47.2 ± 10.1 years, 8 male) were measured at baseline and followed up one year after Roux-en-Y gastric bypass (RYGB) surgery. General anthropometric data, as well as serum lipid markers of cholesterol, were assessed in all individuals. Bilateral anterior eye measurements of tear meniscus height (TMH), non-invasive tear breakup time, bulbar and limbal redness and infrared meibography were captured using the Keratograph K5M (Oculus) and ocular surface damage was evaluated using fluorescein sodium and lissamine green staining. Bariatric surgery resulted in significant loss of weight (body mass index p < 0.001) and an improvement in the blood lipid profile (p < 0.01) in all participants. However, there were no statistically significant differences between the baseline and one-year follow-up for any of the measured clinical ocular surface and tear film variables (all p > 0.05). Although there were trends for a reduced TMH and a decrease in meibomian gland dropout after bariatric surgery, these differences were also insignificant (p > 0.05). In conclusion, weight reduction through bariatric surgery did not have an effect on the tear film or ocular surface in unselected patients with obesity.

The evaluation of the relationship between Helicobacter pylori infection and frequency of postoperative complications of laparoscopic sleeve gastrectomy in Shahid Bahonar Hospital in Kerman between 2018 and 2020; a cross-sectional study

Introduction

Among the bariatric surgery procedures, laparoscopic sleeve gastrectomy (LSG) is one of the most common methods for effective and permanent weight loss among patients with severe obesity. Nonetheless, the LSG can be associated with long-term and short-term complications for the patient. The present study is aimed to investigate the effect of Helicobacter pylori on the complications of LSG, to answer the question of whether eradication of Helicobacter pylori in patients undergoing surgery can be effective in reducing postoperative complications.

Methods

In the present analytical-cross sectional study, which has been conducted in Shahid Bahonar Hospital in Kerman during 2018–2020, a total of 100 patients (including 38 males and 62 females) with an average age of 34.8 ± 2.4 years and an average BMI of 41.1 ± 3.1 underwent LSG surgery. After the operation, the gastric mucus specimens were taken from all patients for pathological examination of Helicobacter pylori infection.

Results

According to the results, 28 patients (28%) tested positive for Helicobacter pylori infection (HP positive), and 72 patients (72%) tested negative in this regard (HP negative). The results indicated no significant1 difference between the HP positive and HP negative patients in terms of demographic characteristics (age, gender, BMI). Overall, 11 patients (11%) exhibited postoperative complications of the LSG including 7 cases (7%) of the SSI, 2 cases (2%) of intraoperative2 bleeding, and 2 cases (2%) of leakage [No mortality was reported]. Out of the 11 patients with postoperative complications, 6 patients were HP positive including 4 cases of SSI, 1 case of bleeding, and 1 case of leakage.

Conclusions

As indicated by the obtained results, the HP infection has seemingly no impact on the LSG postoperative complications. Nevertheless, it is necessary to conduct further studies on a larger number of patients with a longer follow-up time focusing on the effect of other parameters, such as BMI and underlying diseases.

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Laparoscopic sleeve gastrectomy (LSG) is one of the most common surgical methods for effective and permanent weight loss among patients with morbid obesity.

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The LSG surgery can be associated with long-term and short-term complications for the patient.

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Approximately 30%–50% of patients are infected by Helicobacter pylori and this can be related to LSG postoperative complications.

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This study reveals no significant difference between the two HP+ and HP- groups in terms of the frequency of short-term postoperative complications of the LSG surgery.

Copper Deficiency-Induced Neuropathy After Bariatric Surgery Disguised as Demyelinating Disease: A Case Report

Neuropathy may arise from many different etiologies - from diabetes and nerve compression to viral infections and chemotherapy side effects; many patients suffer from neuropathic symptoms. While some etiologies produce irreversible neuropathy, others, such as vitamin and mineral deficiencies, lead to a possibly reversible disease process once treated. General clinicians should strive for early and prompt diagnosis of copper deficiency neuropathy whenever possible, especially in patients with normal vitamin B12 levels who present with a subacute gait disorder or prominent sensory ataxia. We present a case of a 73-year-old female with a surgical history of Roux-en-Y gastric bypass (RYGB) 20 years prior, who presented with difficulty with ambulation due to sensory ataxia and bilateral, ascending, sensory neuropathy, who was diagnosed with acquired copper deficiency-induced myeloneuropathy.

Behavior of Iron and Ferritin After Bariatric Surgery in Patients With and Without Hepatic Steatosis

BACKGROUND

Iron deficiency and hepatic steatosis are common in bariatric surgery patients. Steatosis can falsely elevate ferritin values even in presence of iron deficiency. This study aims to assess the influence of hepatic steatosis on iron deficiency and replacement therapy after bariatric surgery.

METHODS

Seventy-nine individuals undergoing gastric bypass have been studied at 4 time points (preoperative and 1, 3, and 6 months after surgery). Weight, body mass index (BMI), iron, ferritin, vitamin B12, folate, hemoglobin, gamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and use of iron replacement were recorded.

RESULTS

Forty-two individuals (53%) had moderate/severe steatosis assessed by ultrasound. No differences were seen in iron profile and replacement therapy features compared to individuals with no/mild steatosis both in the preoperative and postoperative periods. Mixed model analysis showed ferritin levels to be higher in the moderate/severe steatosis group than in no/mild steatosis at the 6th month (139 ± 131 vs. 60.9 ± 49.8, p < 0.05). Values in both groups were lower than baseline, with p < 0.0001. The same was observed with serum iron (92.1 ± 39.6 moderate/severe steatosis vs. 68.6 ± 33.4 no/mild steatosis, p < 0.001; p from baseline < 0.01 for both). GGT was higher in moderate/severe steatosis in the 3rd month (38.8 ± 40.5 vs. 28.8 ± 20.8, p < 0.05; p from baseline < 0.0001 for both).

CONCLUSIONS

Ferritin levels were consistently higher in individuals with steatosis in the follow-up of bariatric surgery, but no apparent implication on the diagnosis of iron deficiency and in the prescription of replacement therapy was demonstrated at 6 months of follow-up. Longer studies are probably necessary to investigate this matter.

Micronutrient status in bariatric surgery patients receiving postoperative supplementation per guidelines: Insights from a systematic review and meta-analysis of longitudinal studies

The micronutrient status and optimal monitoring schedule after bariatric surgery have not been sufficiently assessed. This systematic review and meta-analysis investigated the longitudinal changes in micronutrient status after bariatric surgery. PubMed, EMBASE, and Cochrane Library were searched for articles that measured preoperative and postoperative serum micronutrient levels in patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Among guideline-adherent studies, the longitudinal changes in micronutrient status were investigated using weighted mean difference (WMD) using a random-effects model. Among the 82 included studies, the guideline adherence rates for micronutrient supplementation after bariatric surgery did not exceed 20%. In patients supplemented per guidelines, vitamin A significantly decreased after RYGB by -7.54 (95% confidence interval [CI], -10.16 to -4.92) μg/dl at 12-23 months, vitamin E decreased after RYGB by -2.35 (95% CI, -3.65 to -1.05) μg/dl at ≥24 months, and ferritin by -54.93 (95% CI, -77.19 to -32.67] μg/L at ≥24 months after SG, compared with baseline, with moderate level of evidence. Significant decreases in micronutrient levels at certain follow-up intervals in studies with supplementation per guidelines need to be considered to establish a post-bariatric micronutrient monitoring schedule for timely detection and management of micronutrient deficiencies.

An intraoral device for weight loss: initial clinical findings

Introduction Obesity is a global epidemic, increasing the risk of many associated health issues.Aim The aim of this clinical study was to investigate the acceptability and tolerability of an intraoral device, designed to facilitate weight loss.Method Seven healthy obese participants were recruited. The device, which incorporated closed-field magnets with keepers to restrict mouth opening, was cemented to the participants' first molars. The participants were given a commercially available liquid diet for two weeks. The comfort and tolerability of the device were assessed using a quality of life questionnaire during review appointments at 1, 7 and 14 days and two weeks after device removal.Results The participants reached a mean weight loss of 6.36 (SD = 3.79) kilograms, which represents approximately 5.1% of their body weight. The participants had trouble pronouncing some words and felt tense and embarrassed 'only occasionally'. The participants 'hardly ever' reported a change in taste sensation or felt uncomfortable drinking. However, participants indicated that they occasionally had discomfort and felt that life in general was less satisfying. Qualitative analysis showed that the participants were happy with the outcome and were motivated to lose more weight.Conclusion The participants tolerated the device for a two-week period with satisfactory weight loss and were further motivated to continue their weight loss journey.

Evaluation of the choroidal thickness and retinal nerve fiber layer and visual fields in morbid obesity: Does bariatric surgery affect retinal structure and function?

Purpose

The study aimed to investigate the changes in choroidal thickness (CT), retinal nerve fiber layer thickness (RNFL), and visual field parameters in morbidly obese patients following bariatric surgery.

Methods

The study included 40 morbidly obese patients with body mass indexes (BMI) ≥40 who had undergone bariatric surgery (Group 1) and 40 age-and sex-matched healthy subjects with normal BMI values (Group 2). RNFL and CT measurements by optical coherence tomography (OCT) and visual field test were performed preoperatively and the 1^st, 6^th, and 12th months postoperatively. CT measurements were obtained from the subfoveal, nasal (N), and temporal (T) regions at distances of 500 μm and 1,000 μm from the fovea.

Results

No significant pathology was detected during ophthalmological examinations following bariatric surgery. The BMIs were found to be significantly lower in all of the periods after bariatric surgery (P < 0.0001). The CT measurements decreased significantly in all periods after bariatric surgery (P < 0.0001). No differences were found in terms of the mean RNFL thicknesses in all postoperative periods (P = 0.125). Visual field tests showed no significant changes during scheduled visits. (P = 0.877). No visual field defect was detected in any patient during the follow-up periods after bariatric surgery.

Conclusion

These results have suggested that CT is positively correlated with BMI and decreased with a reduction in BMI progressively. Nutritional disorders resulting from malabsorption have not caused any nutritional optic neuropathy and visual field defect for at least the first postoperative year after bariatric surgery.

Vitamin D in the Preoperative and Postoperative Periods of Bariatric Surgery

OBJECTIVE

To evaluate the evolution of vitamin D levels (25OHD) in patients submitted to bariatric surgery.

METHODS

Retrospective study, conducted with patients submitted to bariatric surgery between 2013 and 2018, in a city in the Northeast of Brazil. The variations of 25OHD, weight, body mass index (BMI), and total lymphocyte count were analyzed and compared for preoperative and postoperative periods of 6 and 12 months. Vitamin D levels below 30ng/mL were considered insufficient. Analysis of variance (ANOVA) was used for repeated measures, followed by Bonferroni post hoc test. To identify variables related to vitamin D, Pearson's correlation test and linear regression analysis were used. A significance level of 5% (p <0.05) was adopted.

RESULTS

A total of 646 patients were evaluated, with a mean age of 41.3 ± 10.8 years. Most of the patients were female (75%) and had 25OHD insufficiency in the preoperative period (79.1%). It was found that in the postoperative period there was an increase in vitamin D levels. Linear regression showed that the variation in vitamin D is negatively influenced by BMI in the preoperative period (β = -0.20; p = 0.02) and by BMI (β = -0.38; p <0.001) and by age (β = -0.08; p = 0.02) in the 6-month postoperative period.

CONCLUSION

There was an increase in vitamin D levels in the postoperative period. BMI proved to be a negative factor for obtaining adequate levels of vitamin D in the preoperative period and in the 6-month postoperative period.

Dietary assessment and patient-perspective reasons for poor adherence to diet and exercise post bariatric surgery

OBJECTIVE

Obesity prevalence is increasing, and as an outcome, bariatric procedures are on the rise. Previous articles about bariatric surgery disclosed tremendous results. This study aims to assess eating patterns and identify the reasons behind poor adherence to diet and exercise in postbariatric patients.

RESULTS

According to the questionnaire used, the majority (85.5%) of our patients scored "good", 12% scored "fair", and only 2% scored "excellent". None scored "needs improvement". Fruits had a mean consumption of 1.51 ± 0.79 and vegetables 1.78 ± 0.76. The main reasons for patient nonadherence to healthy eating were low self-discipline (48%), lack of motivation (28%), and availability of healthy food and being too busy to prepare healthy meals, both at 25%. Additionally, 55.9% of the study subjects engaged in physical activity. Lack of time (47%), low self-discipline (38%), and weather (32%) were the primary reasons for not exercising regularly.

Unrecognized anemia after whipple - should we learn from gastric bypass?

INTRODUCTION

Several pathophysiologic changes after the Whipple procedure have been well described, but anemia has not. Post-surgical changes can impede micronutrient absorption. We hypothesize that patients post-pancreatoduodenectomy suffer from iron deficiency anemia.

METHODS

Patients who underwent a pancreatoduodenectomy from 2016 to 2018 were retrospectively evaluated. Preoperative, intraoperative, and postoperative data, including hemoglobin (Hb) levels and mean corpuscular volume (MCV) as well as therapies with chemoradiation, iron, and/or B12 were collected at 1-, 3-, 6-, and 12-months after surgery.

RESULTS

The dataset included 74 patients (median age: 64 years). Mean preoperative Hb and MCV were 11.7 ± 1.9 g/dl and 90.1 ± 7.3 fl, respectively. Significant changes in Hb were noted at 1 and 6 months (11.7 vs 10.9, p = 0.01 and 11.7 vs 11.3, p = 0.003, respectively), and in MCV were noted at 6 and 12 months (90.1 vs 94.6, p = 0.008 and 90.1 vs. 93.7, p = 0.02, respectively).

CONCLUSIONS

All patients remained anemic after pancreatoduodenectomy. This was not linked to chemotherapy. Iron and vitamin B12 supplementation, given in a minority, did not ameliorate the anemia. Future studies should investigate this lack of aid, as nutrient supplementation may be an important change in the standard of care of these patients.

Risk of anemia in morbidly obese patients after bariatric surgery in Taiwan

BACKGROUND

Bariatric surgery is one of most effective long-term treatments for morbid obesity. However, post-bariatric surgery anemia is identified as a common adverse effect and remains a challenge nowadays.

AIM

To estimate the risk of post-bariatric surgery anemia and to stratify the association between age, gender, and types of surgery.

METHODS

This study is a population-based cohort study. We conducted this nationwide study using claims data from National Health Insurance Research Database in Taiwan. There were 4373 morbidly obese patients in this study cohort.

RESULTS

Among patients who were diagnosed with morbid obesity, 2864 received bariatric surgery. All obesity-associated comorbidities decreased in the surgical group. Increasing risk of post-bariatric surgery anemia among obese patients was found by Cox proportional hazards regression [adjusted hazard ratio (HR): 2.36]. Also, we found significantly increasing cumulative incidence rate of anemia among patients receiving bariatric surgery by log-rank test. After adjusting for age and gender, the increasing incidence of post-bariatric surgery anemia was found among women (adjusted HR: 2.48), patients in the 20–29-year-old group (adjusted HR: 3.83), and patients in the 30-64-year-old group (adjusted HR: 2.37). Moreover, malabsorptive and restrictive procedures had significantly higher adjusted HRs, 3.18 and 1.55, respectively.

CONCLUSION

Bariatric surgery give rise to anemia risk among obese patients, specifically in women, young- and middle-aged patients, and patients undergoing malabsorptive procedures in our population-based cohort study in Taiwan.

Brown Bowel Syndrome: A Multi-institutional Case Series

Brown bowel syndrome (BBS) is a rare condition associated with vitamin E deficiency and defined by prominent lipofuscin deposition in the muscularis propria. Eight unique cases of BBS were identified: 5 men and 3 women (mean age=58.6 y). Pertinent comorbidities included bariatric surgery=2, malnourishment=2, Crohn=2, cystic fibrosis=1, alcohol and cocaine abuse=1, and prior small bowel resections=1. Presenting symptoms included abdominal pain=3, bleeding=1, nausea and vomiting=1, and nonresponsiveness=1. Imaging studies were often abnormal: thickened bowel wall=3 (1 with a mass), small bowel obstruction=2, and edematous and dilated bowel wall=2. Most specimens were surgical resections (n=7, autopsy=1): extended right colectomy=2, small bowel only=5 (terminal ileum=3, jejunum=2). Two specimens were grossly described as mahogany, and 1 case contained a perforation. Histologic sections of all cases showed finely granular, brown cytoplasmic pigment in smooth muscle cells on hematoxylin and eosin. This pigment was most conspicuous in the muscularis propria (small bowel>colon), and it was not identified in the mucosa. The pigment was reactive with Fontana-Masson, carbol lipofuscin, Periodic acid-Schiff, and Periodic acid-Schiff with diastase, and electron microscopy was compatible with lipofuscin. The mean clinical follow-up was 208 weeks: 1 patient died of complications of encephalitis, the others were alive and well. BBS is important to recognize because it is linked with malnutrition, specifically vitamin E deficiency, and it can (rarely) clinically simulate malignancy. The diagnosis is based on the identification of the lipofuscin pigment in the cytoplasm of smooth muscle cells, which is most easily seen in the muscularis propria of the small bowel.

Determining the prevalence and causes of anaemia in patients after bariatric surgery in a Saudi hospital

OBJECTIVES

Obesity is a chronic disease with high prevalence in Saudi population. Bariatric surgery is an effective method for significant weight reduction. However, various types of nutritional deficiencies occur after weight loss surgery which increase the risk of anaemia. In this study, we aimed to determine the incidence of anaemia after bariatric surgery.

METHOD

A retrospective descriptive study was conducted with 70 patients of both genders aged over 16 years. These patients underwent bariatric surgery between February 2016 and March 2018 and had completed 6 months or more of post-surgery follow-up. Anthropometric and laboratory data were obtained before and after surgery at standard time intervals. All patients were on postoperative vitamin supplements.

RESULTS

Of the total study patients, 41 were women (58.57%) and 29 were men (41.42%) with a median age of 38.5 years (range, 16-65). The median follow-up time was 8 months (6-24 months). Postoperatively, 16 patients (22.9%) developed anaemia, and interestingly, all of them were women (39%). Fifteen of these sixteen patients (93.8%) had microcytic anaemia. Two of those sixteen patients (12.5%) had Roux-en-Y gastric bypass, while fourteen (87.5%) had sleeve gastrectomy.

CONCLUSION

Anaemia and its related nutritional deficiencies are a common complication after bariatric surgery which exerts a major impact on health, particularly in women. Hence, a strict post-operative follow-up and appropriate supplementation are recommended to combat anaemia and its related nutritional deficiencies.

The advantages and disadvantages of sleeve gastrectomy; clinical laboratory to bedside review

Sleeve gastrectomy is a surgical technique and a leading method in metabolic surgery. Sleeve gastrectomy gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery and has proved to be a successful method in achieving considerable weight loss in a short time. There are some disparate effects that patients may experience after sleeve gastrectomy including a reduction in BMI, weight, blood pressure, stroke, and cancer and also a significant remission in obesity-related diseases including type 2 diabetes (T2D), Non-alcoholic fatty liver (NAFLD), cardiovascular disease, obstructive sleep apnea, and craniopharyngioma-related hypothalamic obesity as well as non-obesity-related diseases such as gout, musculoskeletal problems, ovarian disorders and urinary incontinence. The most common complications of sleeve gastrectomy are bleeding, nutrient deficiencies, and leakage. There are several studies on the impact of gender and ethnic disparities on post-operative complications. This study collects state of the art of reports on sleeve gastrectomy. The aim of this study was to analyze recent studies and review the advantages and disadvantages of sleeve gastrectomy.

Bariatric Surgery in Obesity: Effects on Gut Microbiota and Micronutrient Status

Obesity is associated with reduced gut microbial diversity and a high rate of micronutrient deficiency. Bariatric surgery, the therapy of choice for severe obesity, produces sustained weight loss and improvements in obesity-related comorbidities. Also, it significantly alters the gut microbiota (GM) composition and function, which might have an important impact on the micronutrient status as GM is able to synthesize certain vitamins, such as riboflavin, folate, B12, or vitamin K2. However, recent data have reported that GM is not fully restored after bariatric surgery; therefore, manipulation of GM through probiotics represents a promising therapeutic approach in bariatric patients. In this review, we discuss the latest evidence concerning the relationship between obesity, GM and micronutrients, the impact of bariatric surgery on GM in relation with micronutrients equilibrium, and the importance of the probiotics' supplementation in obese patients submitted to surgical treatment.

Vitamin A Deficiency in Patients Undergoing Sleeve Gastrectomy and Gastric Bypass: A 2-Year, Single-Center Review

Introduction: Vitamin A deficiency (VAD) is an underreported micronutrient deficiency after bariatric surgery (BS). Objectives: The goal of this study was to characterize VAD prevalence in patients undergoing malabsorptive and restrictive procedures up to 2 years postoperatively. Methods: Primary sleeve gastrectomy (SG; n = 322) and gastric bypass (GB; n = 249) patients were reviewed. Levels for overall VAD (oVAD; retinol <39 mcg/dL) and moderate VAD (mVAD; retinol <30 mcg/dL) were reported preoperatively and 6, 12, and 24 months postoperatively. Differences in demographic, surgical, and postoperative data were tested between these groups. Settings: Single-center academic institution. Results: Serum retinol levels were documented for 56%, 74%, 61%, and 37% of patients for listed time points. Baseline retinol inversely correlated to preop body mass index (BMI) (R = -0.15, P = .007). Both oVAD and mVAD peaked 6 months postoperatively (33% vs. 15%, P < .005; 12% vs. 4%, P = .0004, respectively). oVAD remained elevated at 24 months (22% vs. 15%, P = .03). Compared to SG, oVAD was higher following GB at 6 months (39% vs. 28%, P = .001) and 12 months (26% vs. 17%, P = .04), and mVAD was greater with GB at 6 months (18% vs. 6%, P < .0005). African American patients had higher oVAD/mVAD preoperatively (26% vs. 13%, P = .02; 13% vs. 3%, P = .001, respectively) and at 6 months (19% vs. 10%, P = .04). Prior mild VAD (retinol 1.05-1.35 μM) was significantly associated with mVAD up to 12 months postoperatively. Conclusions: Although higher following LRYGB, VAD is prevalent following both malabsorptive and restrictive procedures. Preoperative serum retinol is inversely correlated to increasing BMI, and African American race and mild VAD are associated with moderate VAD.

Anemia and Bariatric Surgery: Results of a National French Survey on Administrative Data of 306,298 Consecutive Patients Between 2008 and 2016

BACKGROUND

Bariatric surgery (BS) has grown exponentially in France, and long-term anemia due to micronutrient deficiencies has become common.

OBJECTIVES

The objective of this study was to assess the long-term risk of anemia after BS and to investigate the factors associated with the occurrence of this complication.

MATERIALS AND METHODS

Data from the French National Health Service database on patients who had undergone gastric bypass (GB), sleeve gastrectomy (SG), or adjustable gastric banding (AGB), between 2008 and 2016 were extracted. Only patients with a primary intervention were considered.

RESULTS

Data from 306,298 patients (143.733 SG, 79.188 GB, and 36.413 AGB) were analyzed. Overall, 12.930 of them (5.0%) had a diagnosis of anemia due to micronutrient deficiencies as main diagnosis or related diagnosis at time of a hospital stay between 2008 and 2016. In multivariate analysis, GB surgery, female gender, age younger than 52 years, and 25-OH vitamin D deficiency were positively associated with the occurrence of anemia whereas hospital procedural volume was negatively associated. The risk to be diagnosed with anemia after BS was 13.0% after a GB, 5.6% after a SG and 4.0% after an AGB (Log-rank p < 0.0001). The hazard ratio for anemia after GB compared to SG was 2.0 (95% CI 1.9-2.1), adjusted for age and gender.

CONCLUSION

In France, between 2008 and 2016, 5% of patients had anemia after BS. The risk to develop anemia was 2-fold higher after a GB than after a SG. Young women should be particularly aware of this long-term risk.

The incidence of iron deficiency anemia post-Roux-en-Y gastric bypass and sleeve gastrectomy: a systematic review

SETTING

The physiological and anatomical changes that occur as a consequence of bariatric surgery result in macro- and micro-nutritional deficiencies, especially iron deficiency. The reported incidence of iron deficiency and associated anemia after bariatric surgery varies widely across studies.

OBJECTIVES

The aim of this systematic review is to quantify the impact of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on the incidence of iron deficiency.

METHODS

Databases including Ovid Medline, Ovid Embase, Helthstar, Scopus, Cochrane (CDSR), LILACS, and ClinicalKey were searched for original articles with additional snowballing search. Search terms included Obesity, nutrient deficiency, iron deficiency, iron deficiency anemia, bariatric surgery, Roux-en-Y gastric bypass, and sleeve gastrectomy. Original articles reporting the incidence of iron deficiency and anemia pre- and post-RYGB and SG from January 2000 to January 2015 with minimum 1-year follow-up were selected. Data extraction from selected studies was based on protocol-defined criteria.

RESULTS

There were 1133 articles screened and 20 studies were included in the final analysis. The overall incidence of iron deficiency was 15.2% pre-operatively and 16.6% post-operatively. When analyzed by procedure, the incidence of iron deficiency was 12.9% pre-RYGB versus 24.5% post-RYGB and 36.6% pre-SG versus 12.4% post-SG. The incidence of iron deficiency-related anemia was 16.7% post-RYGB and 1.6% post-SG. Risk factors for iron deficiency were premenopausal females, duration of follow-up, and pre-operative iron deficiency. Prophylactic iron supplementation was reported in 16 studies and 2 studies provided therapeutic iron supplementation only for iron-deficient patients. Iron dosage varied from 7 to 80 mg daily across studies.

CONCLUSION

Iron deficiency is frequent in people with obesity and may be exacerbated by bariatric surgery, especially RYGB. Further investigation is warranted to determine appropriate iron supplementation dosages following bariatric surgery. Careful nutritional surveillance is important, especially for premenopausal females and those with pre-existing iron deficiency.

Copper Deficiency: Causes, Manifestations, and Treatment

BACKGROUND

The metabolism of the essential trace element copper remains incompletely understood and, until recently, nearly ignored in acute medicine. Menkes disease was for long the only known copper deficiency condition, but several case reports and investigations conducted over the last 2 decades have shown that deficiency is more frequent than previously suspected, with devastating individual consequences and potential public health consequences. The copper needs in healthy individuals are 0.9 mg/d, which translates to 0.3 mg/d intravenously in parenteral nutrition; the present review aims at gathering actual knowledge.

METHOD AND RESULTS

A review of literature was conducted in PubMed and Cochrane systematic reviews to identify the most recent information about copper deficiency and generate a narrative review. Copper deficiency has hereditary and acquired origins, the latter being the most frequent. Clinical manifestations are nonspecific but affect all organs and systems, particularly the hematologic (anemia) and the neurologic (myeloneuropathy) systems. Deficiency also affects the cardiovascular, cutaneous, and immune systems. Severe copper deficiency due to reduced absorption after bariatric bypass surgery has become frequent.

CONCLUSION

Deficiency is more frequent than previously recognized, probably because of changing nutrition patterns but also because of some treatments that have become very common such as bypass bariatric surgery and, in acute medicine, prolonged continuous renal replacement therapy. The patients may present with severe hematologic and neurologic complications that go untreated because copper deficiency was not considered in the differential diagnosis: These complications often need active intravenous repletion with doses 4-8 times the usual nutrition recommendations.

Micronutrient deficiencies following bariatric surgery: a comparative analysis between sleeve gastrectomy and Roux-en-Y gastric bypass

OBJECTIVE

to compare the prevalence of micronutrient deficiencies in patients submitted to sleeve gastrectomy (SG) and Roux- en-Y gastric bypass (RYGB).

METHODS

this is a comparative study of 576 patients submitted to bariatric surgery, 338 to SG and 238 to RYGB, and evaluated for hemoglobin, iron, ferritin, zinc and vitamin B12 serum levels. We performed these dosages in the preoperative period and at three, six, 12 and 24 months after surgery, for analysis and comparison of micronutrient deficiencies among the techniques.

RESULTS

the SG group consisted of 48 men and 290 women, with a mean BMI of 39.4±2.6kg/m2, and a mean of age of 37.2±11 years; the group RYGB consisted of 77 men and 161 women, with mean BMI 42.7±5.9kg/m2, and a mean age of 41.9±11.1 years. After 24 months, hemoglobin deficiency was present in 24.4% of the patients submitted to SG and in 40% of the RYGB individuals (p=0.054); iron deficiency was present in 6,6% of SG patients and in 15% of RYGB ones (p=0.127); ferritin deficiency occurred in 17.8% of the SG group and in 23.7% of RYGB one (p=0.399); the Zinc deficiency incidence was 6.6% in SG and 30% in RYGB (p=0.002); and B12 deficiency took place in 6.6% the SG patients and in 8.7% of RYGB ones (p=0.844).

CONCLUSION

patients undergoing SG had serum levels of iron and zinc superior to the ones undergoing RYGB, the prevalence of the latter micronutrient deficit being significantly higher in the RYGB group.

MANAGEMENT OF ENDOCRINE DISEASE: Which metabolic procedure? Comparing outcomes in sleeve gastrectomy and Roux-en Y gastric bypass

Obesity and its associated comorbidities have become one of the largest challenges for health care in the near future. Conservative therapy for obesity and related comorbidities has a very high failure rate and poor long-term results. Similarly, the conservative and medical management of the majority of metabolic diseases such as type 2 diabetes mellitus are only able to slow down disease progression but have no causal effect on the disease process. Obesity surgery has evolved as a highly effective therapy for severe obesity achieving long-lasting weight loss. Furthermore, several studies have demonstrated the beneficial effects of obesity surgery on reduction of overall mortality, reduction of cardiovascular events and superior control of obesity-related diseases such as type 2 diabetes mellitus, dyslipidemia and also the non-alcoholic steatohepatitis compared to medical therapy. Based on these findings, the term 'metabolic surgery' with the focus on treating metabolic diseases independent of body weight has been coined. Of great interest are recent studies that show that even existing complications of metabolic diseases such as diabetic nephropathy or the non-alcoholic steatohepatitis can be reversed by metabolic surgery. Although metabolic surgery has proven to be a safe and effective treatment for obesity, resolution of comorbidities and enhancing quality of life, it is still uncertain and unclear, which surgical procedure is the most effective to achieve these metabolic effects. The aim of this review is to compare the effects of the two currently most widely used metabolic operations, the Roux-en-Y gastric bypass and the sleeve gastrectomy in the treatment of obesity and its related comorbidities.

Efficacy of oral compared with intramuscular vitamin B-12 supplementation after Roux-en-Y gastric bypass: a randomized controlled trial

Background

After Roux-en-Y gastric bypass (RYGB), patients often develop a vitamin B-12 deficiency.

Objective

Our objective was to investigate whether oral supplementation increases and normalizes low vitamin B-12 concentrations (vitamin B-12 > 200 pmol/L) in RYGB patients as compared to intramuscular injections.

Design

A randomized controlled trial in RYGB patients with subnormal serum B-12 concentrations was performed. One group (IM B-12) received bimonthly intramuscular hydroxocobalamin injections (2000 µg as loading dose and 1000 µg at follow-up) for 6 mo. The second group (oral B-12) received daily doses of oral methylcobalamin (1000 µg). Serum vitamin B-12 was determined at baseline (T0) and at 2 (T1), 4 (T2), and 6 mo (T3) after start of treatment. Concentrations of the secondary markers methylmalonic acid (MMA) and homocysteine (Hcy) were measured at T0 and T3.

Results

Fifty patients were included and randomized, 27 in IM B-12 and 23 in oral B-12. The median vitamin B-12 concentration at T0 was 175 pmol/L (range: 114-196 pmol/L) for IM B-12 and 167 pmol/L (range: 129-199 pmol/L) for oral B-12. Vitamin B-12 normalized in all individuals, and there was no significant difference in vitamin B-12 between the two groups. MMA and Hcy concentrations decreased significantly after 6 mo within each group (P < 0.001 and P < 0.001 for MMA and P = 0.03 and P = 0.045 for Hcy, respectively). There was no significant difference between the groups at 6 mo for both MMA and Hcy (P = 0.53 and P = 0.79).

Conclusion

The efficacy of oral vitamin B-12 supplementation was similar to that of hydroxocobalamin injections in the present study. Oral supplementation can be used as an alternative to hydroxocobalamin injections to treat RYGB patients with low values of serum vitamin B-12. This trial was registered at clinicaltrials.gov as NCT02270749.

Long term maintenance of glucose and lipid concentrations after Roux-en-Y gastric bypass

OBJECTIVE

Roux-en-Y gastric bypass (RYGB) reduces body weight and the comorbidities associated with obesity. The aim of this study was to evaluate whether glucose and lipid profiles were maintained during a 5-year follow-up period after RYGB.

SUBJECTS AND METHODS

Anthropometric and laboratory data from 323 patients who had undergone this operation were analyzed. Differences in laboratory variables between the baseline and 12, 24, 36, 48 and 60 months postoperatively (PO) were assessed using a one-way ANOVA test to compare the three groups. Delta significance using one-way ANOVA was performed to assess anthropometric variable in the postoperative period (p < 0.05).

RESULTS

77 patients (24%) were included in Group 1 (G1), 101 (32%) in Group 2 (G2), and 141 (44%) in Group 3 (G3). The majority of patients, 71.7% in G1, 82.8% in G2, and 70% in G3, showed high triglycerides (TG) before surgery. A decrease in weight loss was observed in all groups followed by an increase in body weight in G2 and G3 at 36, 48 and 60 months. Laboratory results for G1, G2 and G3 showed no significant differences between groups at baseline and during the post-operative period.

CONCLUSION

Our results suggest that weight regain after RYGB has no significant impact on the long-term evolution of the lipid profile and glycemia.

Evaluation of Vitamin and Trace Element Requirements after Sleeve Gastrectomy at Long Term

BACKGROUND

Nutritional deficiencies are common after bariatric surgery, but data are scarce after sleeve gastrectomy (SG) at long term.

METHODS

We performed a prospective nutritional status evaluation before and at 2 and 5 years after SG in morbid obese patients receiving mulvitamin and mineral supplementation at a Spanish university hospital. One hundred seventy-six patients (49.3 ± 9.1 years and 46.7 ± 7.4 kg/m²) were evaluated; 51 of them were followed during 5 years. Anthropometric, compliance supplementation intake, and micronutrient evaluation were performed.

RESULTS

Baseline concentrations were below normal values for 25(OH) vitamin D (73%), folic acid (16.5%), cobalamin (6.9%), pyridoxine (12%), thiamine (3.4%), and copper (0.5%). Anemia was found in 23%. In 49% of the subjects, at least one micronutrient deficiency was found at 2 years after SG. Vitamin D deficiency persisted at 2 and 5 years higher than 30% of patients. Frequencies of deficiencies for folic acid, B12, B6, and B1 vitamins decreased significantly after 2 years with normalization at 5 years. Copper deficiency increased between 1 and 2 years and it persisted at 5 years after SG. Vitamin supplementation compliance decreased progressively from the first year after surgery (94.8 to 81% at 2 years and to 53% 5 years after surgery).

CONCLUSIONS

Vitamin D deficiency is the most prevalent long-term nutritional deficiency after SG. About half of patients show some micronutrient deficiency at medium long term, despite supplementation. A proactive follow-up is required to ensure a personalized and adequate supplementation in all surgically treated obese patients including those in which SG has been performed.

Bariatric surgery as a risk factor in the development of dental caries: a systematic review

OBJECTIVES

Obesity is one of the most prevalent chronic pathologies in the world and has become a public health problem. At the present time, bariatric surgery (BS) is considered the best option and the only effective method of treatment, but it can occasionally result in a series of alterations at the oral level. This study aims to review the current literature to establish the possible association of patients who have undergone BS and a greater risk of dental caries.

STUDY DESIGN

This study is a systematic review of the literature.

METHODS

A search was made in the database of Medline (via PubMed), over the last 10 years, using the keywords 'bariatric surgery' OR 'gastrectomy' OR 'obesity surgery,' combined independently with the terms 'saliva' and 'dental caries' by means of the connector 'AND.' The criteria used were those described in the PRISMA® Declaration for performing systematic reviews. Inclusion criteria and study selection: (a) studies done with humans; (b) articles published in English and Spanish; (c) series of cases; and (d) clinical trials. The risk of bias was assessed independently by two authors. In both data extraction and risk of bias assessment, disagreements were resolved through discussion with a third author.

RESULTS

Two independent reviewers read the titles and summaries of the 79 articles found. Finally, nine of them were included in the study. In the various articles, the parameters that had clinical relevance to the risk of dental caries were evaluated.

CONCLUSIONS

Within the limitations of this study, it is plausible to think that patients who have undergone BS have a greater risk of dental caries. The oral complications associated with BS could be prevented or minimized by including in the multidisciplinary treatment of these patients a team of odontologists who would be responsible for prevention and oral assessment.

Bariatric Surgery Reduces Serum Anti-mullerian Hormone Levels in Obese Women With and Without Polycystic Ovarian Syndrome

PURPOSE

Obesity in fertile women has negative effect on fertility. Anti-mullerian hormone (AMH) represents a good index of fertility, and it is considered a marker of ovarian reserve and of polycystic ovarian syndrome (PCOS) gravity. Previous studies evaluated the relationship between obesity and AMH with contradictory results. The aim of the study was to investigate the relationship between obesity and AMH and the changes of AMH in obese women in reproductive age submitted to bariatric surgery.

MATERIALS AND METHODS

Fifty-five obese patients between 18 and 39 years with (29 patients) and without PCOS (26 patients) were compared with a control group of normal weight women with (24 patients) and without PCOS (19 patients). Fourteen obese women with PCOS and 18 without PCOS underwent to bariatric surgery. Serum AMH, testosterone, androstenedione, and DHEAS were performed in all patients before and 1 year after surgical intervention.

RESULTS

AMH was significantly higher in the PCOS groups (p < 0.001), both in obese (5.84 ± 3.94 ng/ml) and non-obese women (7.35 ± 4.39 ng/ml). AMH was positively related to testosterone (p < 0.0001), androstenedione (p = 0.0005), and DHEAS (p = 0.003). After bariatric surgery, AMH levels were reduced in the both PCOS (p = 0.02) and non-PCOS group (p = 0.04).

CONCLUSIONS

AMH levels are elevated in PCOS patients regardless of the body weight. Bariatric surgery is effective in the normalization of AMH levels (a possible indirect marker of better fertility) only in obese patients with PCOS.

Laparoscopic Sleeve Gastrectomy and Nutrient Deficiencies: A Prospective Study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is being increasingly established as a definitive procedure for weight loss. The mechanism for weight loss in LSG is gastric restriction and neurohormonal changes, but there is deficient information on its nutritional effect. The aim of this prospective study was to assess vitamin and micronutrient deficiencies following LSG (whats and when) in organized follow-up visits.

PATIENTS AND METHODS

LSG was performed in 112 consecutive patients between June 2010 and December 2013. In all patients, the vitamin and micronutrient deficiencies were corrected before the LSG procedure. Patients were investigated for vitamin and micronutrient concentrations 2, 4, 6, 9, and 12 months after surgery.

RESULTS

During the study time, 112 patients (65% female) underwent LSG. The mean age was 26 years (range: 20 to 37 y), and the mean preoperative body mass index was 41 (range: 35 to 52). Complications and nutrient deficiencies were observed and analyzed throughout the follow-up period.

CONCLUSIONS

The appearance of vitamin and nutritional deficiencies after LSG is a common phenomenon. Correction of the deficiencies before surgery, sufficient supplementation immediately after the procedure, and routine long follow-up are important to avoid the serious consequences of the deficiencies.

Persisting Hypocalcemia After Surgical Parathyroidectomy: The Differential Effectiveness of Calcium Citrate Versus Calcium Carbonate With Acid Suppression

The effectiveness of oral calcium (Ca) may be contingent on a patient׳s factors beyond compliance, such as proton-pump inhibitor use and the choice of calcium supplements. A 32-year-old Hispanic male with end-stage renal disease on peritoneal dialysis underwent successful surgical parathyroidectomy (intact parathyroid hormone level: 2,328pg/mL; postsurgical: 287-69pg/mL [normal: 8.5-72.5]). His postoperative course was complicated by severe and recurrent hypocalcemia as outpatient and he needed repeated admissions for intravenous Ca gluconate. Initially, severe hypocalcemia (corrected Ca: 4.8-5.6mg/dL; nadir ionized Ca: 0.57-0.69mmol/L) was attributed solely to medical noncompliance with oral Ca carbonate (3750mg, 3×/day between meals) and calcitriol (2-4mcg/day). Recognizing coexisting treatment with proton-pump inhibitor, oral Ca supplement was changed to calcium citrate (2,850mg, 3×/day) with prompt resolution of hypocalcemia (corrected Ca: 8.1-8.3mg/dL). This current case and the included literature review emphasize the disproportionate effectiveness of Ca citrate in subjects with achlorhydria.