Follow-up of nutritional and metabolic problems after bariatric surgery

The bariatric surgery patient: a growing role for registered dietitians

Between 1998 and 2004, the total number of bariatric procedures increased almost 10-fold, from 13,386 procedures in 1998 to 121,055 in 2004. Current estimates suggest the number of bariatric operations will exceed 220,000 in 2010. Bariatric surgery encompasses several surgical techniques classified as restrictive or malabsorptive, based on the main mechanism of weight loss. Clinical studies and meta-analyses show that bariatric surgery decreases morbidity and mortality when compared with nonsurgical treatments. A successful long-term outcome of bariatric surgery is dependent on the patient's commitment to a lifetime of dietary and lifestyle changes. The registered dietitian (RD) is an important member of the bariatric team and provides critical instructions to help patients adhere to the dietary changes consistent with surgery. Referencing current literature, this article outlines the indications, contraindications, and types of bariatric surgery. The role of the RD for preoperative and postoperative nutrition assessment and medical nutrition therapy is highlighted. Management of long-term nutrition issues is also reviewed. The current recommendations include a multivitamin/mineral supplement plus vitamin B-12, calcium, vitamin D-3, iron, and folic acid. Given the increasing prevalence of obesity and bariatric surgery procedures, caring for patients who have undergone surgery will be an expanding role for the RD. Close postoperative follow-up and careful monitoring will improve the odds for successful surgical outcomes, and RDs play a very important part in this process.

Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study

BACKGROUND

Deficiencies in micronutrients after bariatric operations are frequent, despite routine supplementation. Main outcome measures were pre- and postoperative frequency of nutrient deficiencies and success rate of their treatment.

METHODS

Between 5/2004 and 12/2006, 136 patients (m:f = 0:4) with an average body mass index of 45 (35-58) kg/m(2) and age of 53 (21-66) years were prospectively analysed. Laparoscopic Roux-Y-gastric bypass (LRYGB) was performed in 86 patients and laparoscopic sleeve gastrectomy (LSG) was performed in 50 patients. The patients were examined before surgery as well as 3, 6, 12, 24, 30, and 36 months postoperatively using a standard protocol including laboratory tests. The mean follow-up time was 24.4 (12-40) months; the follow-up rate was 100%.

RESULTS

Prior to surgery, 57% of the patients had at least one deficiency, 23% of whom had vitamin D(3) deficiency. Frequent postoperative deficiencies after LSG were zinc, vitamin D(3), folic acid, iron, and vitamin B(12); after LRYGB, vitamin B(12), vitamin D(3), zinc, and secondary hyperparathyroidism. No vitamin B(1) or B(6) deficiencies were found. Calcium levels were normal in all patients. Treatment of the deficiencies was mostly successful.

CONCLUSION

Preoperatively, 57% of morbidly obese patients already had a deficiency. Postoperatively, significantly more vitamin B(12) and vitamin D deficiencies and hyperparathyroidism were found in patients who had undergone LRYGB. After LSG, folate deficiency was more frequent (but not significantly so). Calcium levels were normal in all patients; therefore, parathyroid hormone and vitamin D(3) levels are more sensitive markers for early detection of disorders of calcium metabolism. Iron deficiency anaemia is most efficiently treated by IV therapy.

A systematic review of drug absorption following bariatric surgery and its theoretical implications

Demand for bariatric surgery has risen exponentially and bariatric patients often have multiple indications for post-operative pharmacotherapy. The purpose of this study was to systematically review the published literature examining the effect of bariatric surgery on drug absorption. Studies were sought through searches of MEDLINE, EMBASE, the Cochrane Controlled Trials Registry and hand searches of reference lists. Two reviewers independently assessed studies for inclusion. Twenty-six studies (15 case reports/case series evaluating 12 different agents and 11 non-randomized controlled studies examining 15 different agents) were found. Evidence for diminished drug absorption was found in 15/22 studies involving jejunoileal bypass, 1/3 studies of gastric bypass/gastroplasty and 0/1 studies examining biliopancreatic diversion. The effect of bariatric surgery on drug absorption appears drug-specific. Drugs that are intrinsically poorly absorbed, highly lipophilic and/or undergo enterohepatic recirculation exhibited the greatest potential for malabsorption. The most consistent evidence for diminished absorption was found for cyclosporine, thyroxine, phenytoin and rifampin. Reduced drug absorption may occur post-bariatric surgery and this effect appears drug-specific. Individual dose-adjustment and therapeutic monitoring may be required. Rigorously conducted controlled studies are needed to evaluate the effect of modern bariatric procedures on drug absorption.

Nutritional deficiencies in bariatric surgery candidates

BACKGROUND

To assess the prevalence of nutritional deficiencies amongst people who suffer from morbid obesity and are candidates for bariatric surgery and to evaluate the relations between pre-operative nutritional deficiencies and demographic data and co-morbidities.

METHODS

Preoperative blood tests of 114 patients (83 women and 31 men) were collected. The blood tests included plasma chemistry (including albumin, total protein, iron, ferritin, vitamin B12, folic acid, parathyroid hormone (PTH), calcium, and phosphorous) and a blood count (for hemoglobin and mean corpuscular volume (MCV)). Demographic and socio-economic details were collected from all patients.

RESULTS

Mean age, weight, and BMI of the patients were 38 years (15-77), 122.9 kg (87-250), and 44.3 kg/m(2) (35.3-74.9), respectively. The prevalence of pre-operative nutritional deficiencies were: 35% for iron, 24% for folic acid, 24% for ferritin, 3.6% for vitamin B12, 2% for phosphorous, and 0.9% for calcium, Hb and MCV level was low in 19%. High levels of PTH were found among 39% of the patients. No hypoalbuminemia was encountered. Low iron was more common in females relative to men (40.8 vs.14.3%, p = 0.04) as well as ferritin levels (31.8 vs. 0%, p = 0.001). Men showed a greater prevalence of anemia (35.5% and 12% respectively, p = 0.01) relative to women. Patients with BMI > 50 kg/m(2) were at greater risk for low folic acid (OR = 14.57, 95% CI:1.4-151.34). Patients with high income were less likely to have iron deficiency (OR = 0.19, 95% CI:0.038-0.971).

CONCLUSIONS

A high prevalence of nutritional deficiencies was found amongst bariatric surgery candidates suffering from morbid obesity.

Análise do impacto da cirurgia bariátrica em uma população do centro do estado do Rio Grande do Sul utilizando o método BAROS

CONTEXTO: Devido às alterações metabólicas causadas pelo excesso de peso, a cirurgia bariátrica tem sido muito utilizada, a fim de proporcionar perda e manutenção de peso a longo prazo na população com obesidade mórbida. OBJETIVO: Analisar o impacto da cirurgia bariátrica em uma população do centro do estado do Rio Grande do Sul utilizando o método BAROS. MÉTODOS: Foi realizado estudo retrospectivo, com 32 pacientes, de ambos os sexos, entre 19 e 44 anos de uma clínica particular de Santa Maria, RS. Analisaram-se as variações de peso e índice de massa corpórea, hábito intestinal, uso de tabaco e prática de atividade física para comparar resultados nos períodos de pré e pós-operatório. Os pacientes foram divididos em: grupo A (pré-operatório), grupo B (até 6 meses de pós-operatório), grupo C (7 a 18 meses de pós-operatório) e grupo D (19 a 30 meses de pós-operatório). Para avaliação da eficácia da cirurgia bariátrica foi utilizado o método BAROS. Para análise estatística foi utilizado o teste ANOVA uma via e post-hoc seguido de Duncan's. Foram considerados estatisticamente significantes os dados com P<0,05. Os resultados foram expressos em média ± EP. RESULTADOS: Os pacientes apresentaram redução significativa no peso, no pré-operatório. A média foi de 118,8 kg (± 2,89), e no pós-operatório, o grupo B apresentou 89 kg (± 5,69), o grupo C 76,8 kg (± 4,85) e o grupo D 76 kg (± 4,46), demonstrando perda de peso gradativa. Do mesmo modo, o índice de massa corpórea apresentou redução significativa nos grupo B, C e D, em relação ao grupo A. Os pacientes apresentaram melhora do hábito intestinal de 15,6% no pós-operatório em relação ao pré-operatório. Quanto ao uso de tabaco, houve redução de 33,3% no pós-operatório. A prática de atividade física aumentou em 34,4% entre os pacientes após a cirurgia. De acordo com a aplicação do método BAROS, os pacientes apresentaram classificações excelente, muito bom e bom, não apresentando classificação insuficiente. CONCLUSÃO: De acordo com os resultados do método BAROS e das características avaliadas dos pacientes, pode-se observar que a cirurgia bariátrica apresentou efeitos satisfatórios nessa população.

Pre- and postsurgery behavioral compliance, patient health, and postbariatric surgical weight loss

This study investigated the relationship between weight loss from gastric bypass surgery, patient characteristics, and compliance with physician instructions before and after surgery. A chart review of psychiatric and medical files was conducted for an initial cohort of 172 patients in a postsurgical management program. A total of 112 patients (primarily women (85%), white (79%), and well educated) from this cohort had presurgical data. Of these 112 subjects, 67 (60%) had postsurgical compliance information and BMI at 24 months postsurgery. The relationships between weight loss and a number of demographic, psychiatric, comorbid, and behavioral compliance factors were examined for these 67 patients. Missed appointments and noncompliance with exercise and weight loss plan instructions were high before and after surgery (65% vs. 72% for missed appointments, 39% vs. 51% for exercise, 42% vs. 57% for weight loss instructions). Although poor food choices were not frequently a problem before surgery (11%), they increased significantly after surgery: 37%, chi(2)(1) = 25.00, P < 0.001. Participants who lost the least weight at 2 years postsurgery were more likely to be nonwhite (r = 0.27, P = 0.039), have a lower socioeconomic status (SES) (r = 0.285, P = 0.02), and have a diagnosis of binge eating before surgery (r = 0.25, P = 0.039). Having more contact with patients and requiring adherence to behavioral changes, especially with respect to exercise and dietary restrictions, may improve the long-term outcomes for bariatric procedures. In addition, those patients who are depressed and suffer from binge eating may need special attention from physicians during long-term postoperative follow-up.

Best practice updates for multidisciplinary care in weight loss surgery

The objective of this study is to update evidence-based best practice guidelines for multidisciplinary care of weight loss surgery (WLS) patients. We performed systematic search of English-language literature on WLS, patient selection, and medical, multidisciplinary, and nutritional care published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. Key words were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. A total of 150 papers were retrieved from the literature search and 112 were reviewed in detail. We made evidence-based best practice recommendations from the most recent literature on multidisciplinary care of WLS patients. New recommendations were developed in the areas of patient selection, medical evaluation, and treatment. Regular updates of evidence-based recommendations for best practices in multidisciplinary care are required to address changes in patient demographics and levels of obesity. Key factors in patient safety include comprehensive preoperative medical evaluation, patient education, appropriate perioperative care, and long-term follow-up.

Peroral endoscopic anastomotic reduction improves intractable dumping syndrome in Roux-en-Y gastric bypass patients

BACKGROUND

Dumping syndrome is a well-described consequence of Roux-en-Y gastric bypass. Although the condition can benefit some patients with morbid obesity, a subset will develop intractable dumping syndrome characterized by symptomatic episodes with most meals. We describe the first series of patients successfully treated endoscopically for intractable dumping syndrome.

METHODS

Endoscopic gastrojejunal anastomotic reduction was performed in patients with intractable dumping syndrome after Roux-en-Y gastric bypass using a combination of argon plasma coagulation, endoscopic suturing, and fibrin glue. The technical feasibility of endoscopic anastomotic reduction and the clinical improvement in dumping symptoms were assessed by clinical follow-up.

RESULTS

Endoscopic anastomotic reduction was technically successful in 6 consecutive patients with a dilated gastrojejunal anastomosis and intractable dumping syndrome. One patient reported hematemesis 2 days after the procedure that was treated endoscopically. No other significant complications occurred. Complete and persistent resolution of the dumping symptoms was achieved in all patients, with a median follow-up of 636 days.

CONCLUSION

Endoscopic anastomotic reduction appears technically feasible and safe and might be a minimally invasive treatment option for patients who experience intractable dumping symptoms after Roux-en-Y gastric bypass. Additional studies are needed to determine the long-term efficacy of this procedure.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Acquired copper deficiency: a potentially serious and preventable complication following gastric bypass surgery

Copper is an essential cofactor in many enzymatic reactions vital to the normal function of the hematologic, vascular, skeletal, antioxidant, and neurologic systems. Copper deficiency in the United States is believed to be relatively rare but has been described in the setting of zinc supplementation, myelodysplastic syndrome, use of parenteral nutrition and chronic tube feeding, and in various malabsorptive syndromes, including following gastrectomy and gastric bypass surgery. Features of copper deficiency include hematologic abnormalities (anemia, neutropenia, and leukopenia) and myeloneuropathy; the latter is a rarer and often unrecognized complication of copper deficiency. We here describe two patients who presented with severe gait abnormalities and anemia combined with neutropenia several years after roux-en-Y gastric bypass (RYGB) surgery for obesity who were found to be severely copper deficient. Intravenous copper repletion resulted in the rapid correction of hematologic indices; combined intravenous and oral copper supplementation and eventual oral copper supplements alone normalized serum copper levels in each patient, but resulted in only partial resolution of the neurologic deficits. This report serves to alert physicians of the association between RYGB procedures and subsequent copper deficiency in order to avoid diagnostic delays and to improve treatment outcomes.

Differential changes in dietary habits after gastric bypass versus gastric banding operations

BACKGROUND

Reduction of food intake is an important mechanism by which bariatric procedures reduce body weight. However, only few studies have systematically assessed what patients actually eat after different types of bariatric operations.

METHODS

Dietary habits were assessed by a food frequency questionnaire in 121 bariatric patients (48 gastric bypass patients, 73 gastric banding patients) during follow-up visits in our interdisciplinary obesity center as well as in 45 severely obese (body mass index (BMI)>35 kg/m2) and 45 nonobese (BMI<27 kg/m2) control subjects.

RESULTS

As compared with nonobese control subjects, obese control subjects consumed more meat, white bread, and diet soft drinks. Gastric bypass patients showed an enhanced consumption of foods rich in protein such as poultry, fish, and eggs as well as of cooked vegetables, while the consumption of fatty sweets like chocolate, cake, biscuits, and cookies was found to be distinctly reduced in this patient group. In contrast, gastric banding patients reported on a reduced intake of pasta, white bread, and fresh fruits and, just like gastric bypass patients, also on an enhanced intake of poultry and fish. Direct comparison of dietary habits between the two bariatric patient groups revealed that gastric bypass patients consumed more frequently fresh fruits, eggs, and diet soft drinks but strikingly less chocolate than gastric banding patients.

CONCLUSION

Collectively, data clearly point to distinct changes in dietary habits after bariatric operations which markedly differ between gastric bypass and gastric banding patients. Overall, it is tempting to conclude that gastric bypass operations lead to a healthier and a more balanced diet than gastric band implantations.

GH and IGF-I deficiency are associated with reduced loss of fat mass after laparoscopic-adjustable silicone gastric banding

CONTEXT

GH secretion is reduced in obese subjects and increases after body weight loss. It is still unclear if changes in the GH/IGF-I axis after laparoscopic-adjustable silicone gastric banding (LASGB) are associated with changes of body composition.

OBJECTIVE

To analyse the relationships between changes in the GH/IGF-I axis and those of body weight and composition before and after LASGB.

DESIGN

Observational, prospective.

SETTING

University 'Federico II' of Naples (Italy).

PATIENTS

Seventy-two severely obese females (BMI: 44.9 +/- 4.68; mean age: 33.1 +/- 11.34 years) were studied.

MAIN OUTCOME MEASURES

GH peak after GHRH plus arginine test, IGF-I, IGFBP-3 and ALS levels, fat mass (FM) and free fat mass (FFM) (by Bioelectrical Impedance Analysis) at baseline and 6 months after LASGB. The change in percentage of individual variables was calculated as well as that of excess of body weight loss (EBWL%). The FM%, FFM% and EBWL% were correlated with peak GH and IGF-I levels changes.

RESULTS

At baseline, GH deficiency (GHD) (GH peak = 4.1 microg/l) was found in 22 patients (31%), 16 of them also had IGF-I deficiency (< -2SDS). IGF-I levels were inversely correlated with waist circumference (r = -0.72, P < 0.001) and FM% (r = -0.75, P < 0.001). Post-LASGB the patients were classified as follows: group (1) GH and IGF-I sufficient (n = 44; 61.1%); group (2) GH and IGF-I deficient (n = 14; 19.4%) and group (3) GH sufficient and IGF-I deficient (n = 14; 19.4%). The percentage changes of EWBL (P < 0.05, P = 0.051, respectively) and FM (P < 0.001, P < 0.01, respectively) were lower in groups (2) and (3) than in group (1). At the stepwise linear regression analysis, postoperative IGF-I levels were the strongest determinant of percent changes of FM (P < 0.0001), of FFM (P = 0.009) and of EBWL (P < 0.0001).

CONCLUSIONS

IGF-I levels is the most sensitive to unfavourable changes in body composition 6 months after LASGB making investigation of the somatotropic axis useful in the evaluation of bariatric surgery outcomes.

Effect of Roux-en Y gastric bypass on bone metabolism in patients with morbid obesity: Mansoura experiences

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) has been found to be the most efficient way to lose weight and maintain the weight loss in morbid obesity. However, with the formation of a new stomach and the modification of intestinal anatomy, there are significant changes on bone metabolism. The objectives of this study were to evaluate effects of weight loss on bone metabolism after Roux-en Y gastric bypass in patients with morbid obesity.

METHODS

Our study included 70 patients with morbid obesity; RYGB was done for all patients. Daily postoperative oral supplementation with 1,000 mg of calcium and 800 IU of vitamin D was done for each patient. Body weight (BW), body mass index (BMI), total body fat, total lean tissue mass, bone mineral content (BMC), bone mineral density (BMD), total bone area (TBA; using dual energy X-ray absorptiometry), serum calcium, parathyroid hormone (PTH), 25-OH vitamin D, 24-h urinary calcium, and bone-specific alkaline phosphatase (BSAP) were assessed preoperatively and 1 year after surgery.

RESULTS

In our study, females comprised 70% of cases. The mean age was 35+/-8.8 years. One year after RYGB, BW decreased significantly from 132.8+/-26.5 to 90.3+/-17.3 kg (p=0.001). BMI decreased significantly from 48+/-7.3 to 32.6+/-4.1 kg/m(2) (p=0.001). BMC decreased significantly from 2,968.6+/-71.4 to 2,700.8+/-45.4 g (p=0.001). BMD decreased significantly from 1.026+/-0.03 to 1.22+/-0.015 g/cm(2) (p=0.001). TBA decreased significantly from 2,356.2+/-35.4 to 2,216.3+/-43.5 cm(2) (p=0.001). Serum calcium, 24-h urinary calcium, and BSAP were not significantly decreased while 25-OH vitamin D and PTH were not significantly increased after surgery.

CONCLUSIONS

From this study, it is shown that RYGBP operation gives very good results as regards reduction of body weight in morbidly obese patients. Postoperative supplementation with calcium and vitamin D partially corrects osteoporosis. Thus, these patients need periodic follow-up for BMD, PTH, calcium, serum vitamin D, and markers of bone resorption and formation specially postmenopausal female.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Clinical experience of transoral suturing for an endoluminal vertical gastroplasty: 1-year follow-up in 64 patients

BACKGROUND

Bariatric surgery for severe obesity has demonstrated significant health benefits, but it is not without complications. Transoral approaches to weight loss offer a minimally invasive option.

OBJECTIVE

To evaluate the safety and feasibility of a transoral suturing procedure for weight loss.

DESIGN

Single-center, uncontrolled study with a 1-year follow-up.

SETTING

Hospital de Clinicas, Caracas, Venezuela.

PATIENTS

Sixty-four patients (mean age [SD] 31.5 +/- 10.1 years, range 16-62 years; mean (SD) preoperative body mass index [BMI] 39.9 +/- 5.1 kg/m(2), range 28.0-60.2 kg/m(2)) were enrolled between 2003 and 2005.

INTERVENTION

Endoluminal vertical gastroplasty by using a continuous suture pattern to treat obesity.

MAIN OUTCOME MEASUREMENTS

Short-term complication monitoring and patient weight before the procedure and at 1, 3, and 12 months after the procedure.

RESULTS

The outpatient procedures were performed in approximately 45 minutes. Patients had a significant reduction in BMI at 12 months (mean [SD] BMI 39.9 +/- 5.1 kg/m(2) vs 30.6 +/- 4.7 kg/m(2); P < .001) and a percentage of excess weight loss (%EWL) (SD) of 21.1 +/- 6.2, 39.6 +/- 11.3, and 58.1 +/- 19.9 at 1, 3, and 12 months, respectively. By comparing the study's subpopulations, group I (baseline BMI >or=40 kg/m(2), n = 33), group II (baseline BMI 35-40 kg/m(2), n = 19), and group III (baseline BMI <35 kg/m(2), n = 12) demonstrated a %EWL (SD) of 48.9 +/- 10.7, 56.5 +/- 13.9, and 85.1 +/- 24.0, respectively, at 12 months after the procedure (P = .037 when comparing group I vs II; P < .001 when comparing group II vs III and group I vs III). No patients experienced any serious adverse events.

LIMITATIONS

This study represents a single center's clinical experience, with no sham control.

CONCLUSIONS

Endoluminal vertical gastroplasty by using a continuous suture pattern is associated with significant weight loss. Additional studies are needed to demonstrate the procedure's long-term safety and efficacy.

Need for parenteral iron therapy after bariatric surgery

BACKGROUND

Malabsorptive bariatric procedures such as Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch expose the patient to malnutrition and commonly cause iron deficiency. The optimal replacement and monitoring method remain undetermined. To identify high-risk patients who might need intravenous iron supplementation after bariatric surgery, we evaluated bariatric surgery patients who received parenteral iron at a university hospital-affiliated hematology center.

METHODS

We performed a retrospective analysis and reviewed the records of 165 patients who had received parenteral iron from May 2004 to June 2007. Of the 165 patients, 42 bariatric surgery patients were identified. The type of bariatric procedure and menstrual status of the patients were compared.

RESULTS

The average patient age was 40 years. Of the 42 patients, 2 were men and 40 were women. Of the 40 women, 32 were premenopausal and 8 were postmenopausal. The patients in the biliopancreatic diversion/duodenal switch group had a significantly lower hemoglobin at presentation (P = .02), relatively lower ferritin levels, and required more additional parenteral iron treatment after the initial resolution of anemia (P = .001). The premenopausal women required earlier parenteral replacement (P = .008) and were at a greater risk of anemia-related hospitalization (P = .00033).

CONCLUSION

The available published studies lack any data regarding parenteral iron replacement needs after bariatric surgery. Our results have identified the need for long-term parenteral iron replacement therapy after malabsorptive bariatric procedures, especially in premenopausal women. Patients who do not respond to oral iron therapy should be referred early for parenteral iron replacement therapy to prevent anemia-related complications and to maintain patients' quality of life. Iron monitoring should continue indefinitely even after the initial repletion of iron stores and the resolution of anemia.

Bariatric surgery for extreme adolescent obesity: indications, outcomes, and physiologic effects on the gut-brain axis

OBJECTIVE

This review will summarize current indications, limitations and outcomes of bariatric surgery in adolescents, as well as provide an overview of the physiologic effects of bariatric surgery on enteric hormones involved in regulating appetite, satiation and maintenance of weight.

RESULTS

Extreme obesity (BMI≥99 percentile) now affects 4% of children and adolescents in the United States. Traditional dietary and behavioral weight management methods have no demonstrated efficacy for extremely obese children and adolescents, in contrast with bariatric surgery which has produced significant and sustainable weight loss and associated improvements in comorbid diseases for the extremely obese. Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed bariatric surgical procedures in adolescents, but vertical sleeve gastrectomy may be a promising new option for selected extremely obese adolescents. A mean weight loss of 37-40% is achieved in adolescents after RYGB, with LAGB showing similar results, albeit attained at a slower rate.

CONCLUSION

Alterations in the enteric hormones involved in the gut-brain axis that regulates appetite and energy expenditure may play a role in both the anorexigenic and weight-reducing effects of certain bariatric surgical procedures. In particular, RYGB induces a rise in both fasting and post-prandial peptide tyrosine-tyrosine which could contribute to the more rapid and greater degree of weight loss than is seen with LAGB. Limitations of bariatric surgery however include the potential for post-operative morbidity and mortality, as well as possible weight regain in a small proportion of patients.

Nutritional consequences of adjustable gastric banding and gastric bypass: a 1-year prospective study

BACKGROUND

Gastric bypass (GBP) is more efficient than adjustable gastric banding (AGB) on weight loss and comorbidities, but potentially induces more nutritional deficits. However, no study has compared the prevalence of nutritional deficiencies after these two bariatric procedures. WE PROSPECTIVELY COMPARED: To prospectively compare the prevalence of nutritional deficiencies after AGB and GBP.

METHODS

We have performed a 1-year prospective study of nutritional parameters in 70 consecutive severe obese patients, who had undergone bariatric surgery, 21 AGB and 49 GBP. After GBP, multivitamin supplements were systematically prescribed and vitamin B12 supplementation was introduced if a deficiency was observed.

RESULTS

Patients lost more weight after GBP than after AGB (40 +/- 13 vs 16 +/- 8 kg, p < 0.001). Vitamins B1 and C and iron deficiencies were frequent before surgery but were not worsened by GBP. AGB only induced a slight decrease of vitamin B1 at 1 year, whereas GBP induced significant decreases of vitamins B12 and E, serum prealbumin, and creatinine concentrations, with only minor clinical consequences. Anemia was observed in 10% of the patients after bariatric surgery. Hemoglobin concentration was not correlated to vitamin B12 or folate concentrations but was related to iron status. Risk of iron deficiency anemia was better assessed by transferrin saturation than by serum ferritin concentration in this obese population.

CONCLUSION

Severe nutritional deficits can be avoided after bariatric surgery if patients are systematically supplemented with multivitamin and carefully monitored. However, specific care is required to avoid iron and vitamin B12 deficiencies, anemia, and protein malnutrition.

Micronutrient deficiencies after laparoscopic gastric bypass: recommendations

BACKGROUND

The aim of this study was to evaluate the changes of micronutrients in patients with morbid obesity after laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP).

METHODS

We retrospectively reviewed 121 patients diagnosed with morbid obesity who undertook LRYGBP and evaluated the serum iron (Fe), calcium (Ca), zinc (Zn), selenium (Se), vitamin A (VitA), 25-hydroxy vitamin D3 (VitD), vitamin B(12) (VitB(12)), and parathormone (PTH) measured at 6, 12, and 24 months after LRYGBP.

RESULTS

During a follow-up period of 69 months (June 1999 to February 2005), a cohort of 121 patients, 40 men and 81 women, underwent LRYGBP, a mean age of 46 years (range 22-67). The mean body mass index (BMI) before LRYGBP was 47.00 +/- 7.15 kg/m(2) (range 30.65-76.60 kg/m(2)). After 6 months of the surgery, the mean BMI was 33.79 +/- 6.06 kg/m(2) (range 21.70-52.76 kg/m(2)). The mean BMI decreased (P < 0.001) 6 months after the surgery. Within the following 2 years, the serum Fe, Ca, Zn, Se, VitA, VitD, and VitB(12) had normalized. The serum Zn, Se, and VitA of some patients decreased but were nearly normal. In contrast, serum PTH remained continuously at a higher level than normal.

CONCLUSIONS

This study confirms that LRYGBP is a reliable and safe weight loss method for the patients suffering from morbid obesity. After surgery, serum Ca, Zn, and Se metabolisms and PTH levels are altered in these patients. Therefore, multi-vitamin and mineral supplementation are strongly recommended in all patients after LRYGBP.

Evidence for the necessity to systematically assess micronutrient status prior to bariatric surgery

BACKGROUND

Bariatric surgery has been proven the most effective treatment of morbid obesity, but micronutrient deficiency following bariatric surgery is a major concern. Increasing evidence points to a generally poor micronutrient status in obese subjects.

METHODS

We assessed micronutrient status in 232 morbidly obese subjects (BMI > or = 35 kg/m(2)) prior to bariatric surgery. Serum albumin, calcium, phosphate, magnesium, ferritin, hemoglobin, zinc, folate, vitamin B(12), 25-OH vitamin D(3), and intact parathormone (iPTH) were determined. In a sub-sample of 89 subjects, we additionally assessed copper, selenium, vitamin B(1), B(3), B(6), A, and E levels.

RESULTS

Deficiencies were found in 12.5% of the subjects for albumin, 8.0% for phosphate, 4.7% for magnesium, 6.9% for ferritin, 6.9% for hemoglobin, 24.6% for zinc, 3.4% for folate, and 18.1% for vitamin B(12). In addition, 25.4% showed a severe 25-OH vitamin D(3) deficiency, which was accompanied by a secondary hyperparathyroidism in 36.6% cases. Prevalence of albumin deficiency (p < 0.007) and of anemia (p < 0.003; in women only) significantly increased with BMI. Of note, 48.7% of the subjects showed at least one of the most prevalent deficiencies, i.e., vitamin B(12), zinc and severe 25-OH vitamin D(3) deficiency. In the sub-sample, 32.6% showed a selenium, 5.6% a vitamin B(3), 2.2% a vitamin B(6), and 2.2% a vitamin E deficiency. Copper, vitamin B(1), and vitamin A deficiency was found in none of the subjects.

CONCLUSION

Data indicate a high prevalence of micronutrient deficiencies in morbidly obese subjects. Based on these results, we strongly recommend a systematic assessment of the micronutrient status in all candidates for bariatric surgery.

Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation

BACKGROUND

Despite the increasing use of Roux-en-Y gastric bypass (RYGBP) in the treatment of morbid obesity, data about postoperative nutritional deficiencies and their treatment remain scarce.

OBJECTIVE

The aim of this study was to evaluate the efficacy of a standard multivitamin preparation in the prevention and treatment of nutritional deficiencies in obese patients after RYGBP.

DESIGN

This was a retrospective study of 2 y of follow-up of obese patients after RYGBP surgery. Between the first and the sixth postoperative months, a standardized multivitamin preparation was prescribed for all patients. Specific requirements for additional substitutive treatments were systematically assessed by a biologic workup at 3, 6, 9, 12, 18, and 24 mo.

RESULTS

A total of 137 morbidly obese patients (110 women and 27 men) were included. The mean (+/-SD) age at the time of surgery was 39.9 +/- 10.0 y, and the body mass index (in kg/m(2)) was 46.7 +/- 6.5. Three months after RYGBP, 34% of these patients required at least one specific supplement in addition to the multivitamin preparation. At 6 and 24 mo, this proportion increased to 59% and 98%, respectively. Two years after RYGBP, a mean amount of 2.9 +/- 1.4 specific supplements had been prescribed for each patient, including vitamin B-12, iron, calcium + vitamin D, and folic acid. At that time, the mean monthly cost of the substitutive treatment was $34.83.

CONCLUSION

Nutritional deficiencies are very common after RYGBP and occur despite supplementation with the standard multivitamin preparation. Therefore, careful postoperative follow-up is indicated to detect and treat those deficiencies.

Severe protein-calorie malnutrition after gastric bypass

Bariatric surgery achieves lasting weight loss and improves the comorbidities associated with morbid obesity. After surgery, patients can develop complications, mainly mild nutritional alterations. However, in some patients, complications can be serious and lifethreatening. We present the case of a 50-year-old woman who developed severe protein-calorie malnutrition after bariatric surgery, which required surgical reversion. The factors leading to malnutrition in this patient and the treatment options are discussed.

Obesity, bariatric surgery, and iron deficiency: true, true, true and related

Morbid obesity is a health problem that has been shown to be refractory to diet, exercise, and medical treatment. Surgeries designed to promote weight loss, termed bariatric surgery and typically involving a gastric bypass procedure, have recently been implemented to treat obesity with high success rates. However, long-term sequelae can result in micronutrient deficiencies. This review will focus on iron deficiency and its association with obesity and bariatric surgery. Iron deficiency develops after gastric bypass for several reasons including intolerance for red meat, diminished gastric acid secretion, and exclusion of the duodenum from the alimentary tract. Menstruating women, pregnant women, and adolescents may be particularly predisposed toward developing iron deficiency and microcytic anemias after bypass surgery. Preoperative assessment of patients should include a complete hematological work-up, including measurement of iron stores. Postoperatively, oral iron prophylaxis and vitamin C in addition to a multivitamin should be prescribed for bypass patients, especially for vulnerable populations. Once iron deficiency has developed, it may prove refractory to oral treatment, and require parenteral iron, blood transfusions, or surgical interventions. Bariatric surgery patients require lifelong follow-up of hematological and iron parameters since iron deficiency and anemia may develop years after surgery.

Vitamin status in morbidly obese patients: a cross-sectional study

BACKGROUND

Morbid obesity is associated with low circulating concentrations of 25-hydroxyvitamin D. Few data on the concentrations of other vitamins in morbidly obese patients are available.

OBJECTIVE

The objective was to compare serum and blood vitamin concentrations in morbidly obese patients with those in healthy subjects.

DESIGN

In 2 public hospital departments (southeast Norway), we prospectively examined 110 consecutive patients (76 women) and 58 healthy controls (30 women) not taking multivitamin supplements. Patients and controls did not differ significantly in age or ethnicity. The mean (+/-SD) body mass index (in kg/m(2)) was 45 +/- 7 in the patients and was 24 +/- 3 in the controls. Patients with vitamin concentrations lower than 2 SD below the sex-specific mean in controls were considered to have inadequate vitamin status.

RESULTS

The morbidly obese women and men had significantly lower concentrations of vitamin B-6, vitamin C, 25-hydroxyvitamin D, and lipid-standardized vitamin E than did the healthy controls (P < 0.01 for each). The status of these vitamins was inadequate in a substantial proportion of the patients (11-38%). The status of vitamins A, B-1, B-2, and B-12 and of folic acid was adequate in most of the patients (95-100%). A moderately elevated C-reactive protein concentration was associated with lower vitamin A, B-6, and C concentrations. In a multiple regression analysis, concentrations of alkaline phosphatase (inverse relation) and vitamin C were the strongest determinants of serum vitamin B-6 concentrations.

CONCLUSIONS

Low concentrations of vitamin B-6, vitamin C, 25-hydroxyvitamin D, and vitamin E adjusted for lipids are prevalent in morbidly obese Norwegian patients seeking weight-loss treatment.

Nutritional deficiencies after bariatric surgery

A current review of nutritional complications following bariatric procedures is presented, focusing on the most common and clinically important deficiencies. A brief outline of nutritional supplementation protocol is presented, highlighting the need for a standardized, national or international set of guidelines for pre- and postoperative nutritional screening and appropriate supplementation.

Prevalence of iron, folate, and vitamin B12 deficiency anemia after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

One of the most common bariatric operations is the laparoscopic Roux-en-Y gastric bypass (LRYGBP) in which the gastric capacity is restricted and the absorption by the small intestine is reduced. The objective of this study was to evaluate the incidence of iron, folate, and vitamin B12 deficiency anemia in patients undergoing LRYGBP.

PATIENTS AND METHODS

Clinical records of 30 patients who underwent LRYGBP between July 2003 and January 2005 and had a minimum follow up of 24 months at our outpatient clinic were included. Multivitamin supplementation was prescribed to all patients. The complete blood cell count, plasma iron, total iron-binding capacity, transferrin saturation, serum folate, and cobalamin levels before surgery, 6 months, 1, 2, and 3 years after the surgery were analyzed.

RESULTS

There were 25 women (83.4%) and five men (16.6%) with ages from 21 to 56 years. Before surgery, two patients (6.6%) presented ferropenic anemia. Iron deficiency was seen in 40 and 54.5% 2 and 3 years after surgery, respectively. Cobalamin deficiency was observed in 33.3% at 2 years and in 27.2% at 3 years. At 2-year follow-up, 46.6% of the patients had already developed anemia and 63.6% at 3 years. Folate deficiency was not observed in any patient.

CONCLUSION

Our routine scheme of vitamin supplementation is not sufficient to prevent iron and vitamin B12 deficiencies in most patients.

Impact of bariatric surgery on type 2 diabetes

The management and prevention of diabetes through lifestyle modifications and weight loss should be the mainstay of therapy in appropriate candidates. Although the results from the Diabetes Prevention Trial and the Finnish Prevention Study support this approach, over 95% of patients not participating in a prevention research study are unable to achieve and maintain any significant weight loss over time. Bariatric surgery for weight loss is an emerging option for more sustainable weight loss in the severely obese subject, especially when obesity is complicated by diabetes or other co-morbidities. The two most common types of procedures currently used in the United States are adjustable gastric bands and Roux-en-Y gastric bypass. These procedures can be performed laparoscopically, further reducing the perioperative morbidity and mortality associated with the surgery. While the gastric bypass procedure usually results is greater sustained weight loss (40-50%) than adjustable gastric banding (20-30%), it also carries greater morbidity and nutritional/metabolic issues, such as deficiencies in iron, B12, calcium, and vitamin D. Following bariatric surgery most subjects experience improvements in diabetes control, hypertension, dyslipidemia, and other obesity-related conditions. In patients with impaired glucose tolerance most studies report 99-100% prevention of progression to diabetes, while in subjects with diabetes prior to surgery, resolution of the disease is reported in 64-93% of the cases. While improvements in insulin resistance and beta-cell function are related to surgically induced weight loss, the rapid post-operative improvement in glycemia is possibly due to a combination of decreased nutrient intake and changes in gut hormones as a result of the bypassed intestine. Post-prandial hyperinsulinemic hypoglycemia associated with nesidioblastosis has been described in a series of patients following gastric bypass surgery, and may be related to the described changes in GLP-1 and other gut hormones.

Follow-up of Roux-en-Y gastric bypass patients at 5 or more years postoperatively

BACKGROUND

Short-term results (24 to 36 months) after Roux-en-Y gastric bypass (RYGBP) have been extensively described. Little is reported on the patients operated > or = 5 years ago. We analyzed the results of weight loss, resolution of co-morbidities and nutritional complications of patients submitted to the silicone ring RYGBP, at least 5 years before.

METHODS

75 morbidly obese patients who underwent silicone ring RYGBP between Oct 1995 and Dec 1999, 18 men and 57 women, were studied. Demographic data, nutritional status and the presence of co-morbidities (type 2 diabetes, hypertension, sleep apnea, dyslipidemia) were accessed. Pre- and postoperative BMI were registered, along with excess weight loss (EWL). Nutritional deficiencies were accessed by laboratory assays.

RESULTS

Mean follow-up was 87 months. Initial BMI was 56.7 +/- 10 kg/m2. After 2 years, BMI had dropped to 29.3 +/- 6.8, and by the last interview BMI was 35.5 +/- 10. %EWL after 2 years was 80.2 +/- 17.3%, and at the end was 71.8 +/- 21.6%. After 2 years, only 1 of the 75 patients (1.33%) had not achieved an EWL of at least 50%. At the end, 23 patients (30.6%) could not maintain this EWL. Resolution of diabetes was 76.5%, arterial hypertension 37.3% and sleep apnea 93.5%. Iron, vitamin B12 and vitamin D were the most common nutritional deficiencies.

CONCLUSIONS

Long-term follow-up (5 to 9 years) after the RYGBP was associated with satisfactory mantainance of EWL, and resolution or improvement of the main co-morbidities was observed in the majority of the patients.

Parathyroid hormone and bone marker levels in patients with morbid obesity before and after biliopancreatic diversion

BACKGROUND

Scopinaro biliopancreatic diversion (BPD) is associated with malabsorption of calcium and vitamin D, which manifests as a secondary hyperparathyroidism (SHP) and may lead to osteopenia.

METHODS

96 morbidly obese patients were studied (age 19-60 years, 23 men and 73 women, with mean initial BMI 53) following intervention by Scopinaro BPD. The change in iPTH levels, urine DPD, Pyrilinks-D of DPC and serum CTx were studied at 0, 3, 6, 12, 18 and 24 months after surgery. Postoperatively, they were given supplements of calcium and vitamin D3. The control group consisted of 67 non-obese women and 10 men.

RESULTS

The iPTH levels gradually increased after BPD, with a substantial difference compared to presurgery levels at month 6. In spite of the calcium and vitamin D supplements, 77% of the patients with presurgery SHP did maintain high levels of iPTH after 2 years. The percentage of SHP among the patients with normal pre-surgery iPTH was 58%. The basal figures of DPD/cre were significantly higher than in the control group, 9.06 (4.6-13.5) nM/mMcre vs 3.9 (2.8-5.6) in men and 6.75 (5.4-7.9) vs 7.67 (3.3-11.6) in women, but not CTx, 0.24 (0.02-0.89) vs 0.22 (0.07-0.55). After the operation, there was a noticeable increase which persisted at 2 years. There was a lack of correlation between the levels of iPTH and the bone resorption markers, i.e. the first ones decreased from month 6 in men and from month 12 in women, while the levels of iPTH continued to increase.

CONCLUSION

In obese patients, we found no correlation between iPTH levels and BMI. Supplements of calcium and vitamin D did not prevent the appearance of SHP following BPD. The patients with high pre-surgery iPTH levels have a higher risk of malabsorption of calcium and vitamin D. Following malabsorptive bariatric surgery, there is an increase in bone resorption, which results in DPD and CTx increase. Those markers do not correlate with iPTH, and this may suggest that there is a phenomenon of bone reshaping parallel to the loss of weight.

Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital

The number of abdominoplasties performed in the United States has been steadily increasing over the past decade. A large proportion of these patients are bariatric patients who remain obese despite prior weight-reduction surgery. This study was done to review the experience of patients undergoing abdominoplasty at a university hospital. A retrospective chart review of 206 consecutive patients was performed. The overall complication rate was 37.4%. Major complications [hematoma requiring surgical intervention, seroma requiring aspiration or surgical drainage, cellulitis or abscess requiring hospitalization and intravenous (IV) antibiotics, deep vein thrombosis (DVT), and pulmonary embolism (PE)] occurred in 16% of patients. The rate of minor complications (hematoma or seroma requiring no intervention, epidermolysis, small-wound dehiscence, neuropathic pain, and minor cellulitis) was 26.7%. Obese patients had a significantly increased risk of developing major complications as compared with nonobese patients (53.4% versus 28.8%, P = 0.001). An in-depth analysis of all complications and risk factors was done.

Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment

In recent years, the recourse to obesity surgery to treat morbid obesities has grown. The number of "malabsorptive" interventions, such as the gastric bypass (RYGB: Roux-en-Y gastric bypass) increases each year. The RYGB, which combines two mechanisms promoting weight loss, restriction and malabsorption, has proven its effectiveness in term of weight loss and improvement of obesity-associated co-morbidities. However this intervention involves a profound change in digestive physiology and is the source of nutritional and metabolic complications. The deficits observed most frequently concern proteins, iron, calcium, vitamin B12 and vitamin D. The deficiencies in vitamin B1 are rare but potentially serious. Multidisciplinary follow-up is essential to ensure prevention, diagnosis and treatment of these complications. Based on an analysis of the literature, this article summarizes the various nutritional complications observed after RYGB and the means to diagnose it. It proposes practical recommendations for follow-up, preventive supplementation and treatment of these deficiencies, both generally and in the more specific case of a pregnancy after RYGB.

Reversible neurologic dysfunction caused by severe vitamin deficiency after malabsorptive bariatric surgery

Significant deficiencies of both fat- and water-soluble vitamins have been reported to occur after malabsorptive bariatric surgery. However, despite the potential for neurologic manifestations of such deficiencies, few cases of central neurologic dysfunction have been reported. Our group previously reported reversible neurologic dysfunction as an unusual manifestation of vitamin deficiency in a postjejunoileostomy patient. We report on a second case of reversible neurologic dysfunction associated with severe, prolonged vitamin deficiency many years after jejunoileostomy. Neurologic function returned to normal with vitamin repletion. Patients who have undergone malabsorptive surgery are at risk of late metabolic complications and should be closely monitored.

Clinical management after bariatric surgery: value of a multidisciplinary approach

Comprehensive and collaborative longitudinal care is essential for optimal outcomes after bariatric surgery. This approach is important to manage the many potential surgical and medical comorbidities in patients who undergo bariatric surgery. Medical management programs require prompt and often frequent adjustment as the nutritional program changes and as weight loss occurs. Familiarity with the recommended nutritional program, monitoring and treatment of potential vitamin and mineral deficiencies, effects of weight loss on medical comorbid conditions, and common postoperative surgical issues should allow clinicians to provide excellent care. Patients must understand the importance of regularly scheduled medical follow-up to minimize potentially serious medical and surgical complications. Because the long-term success of bariatric surgery relies on patients' ability to make sustained lifestyle changes in nutrition and physical activity, we highlight the role of these 2 modalities in their overall care. Our guidelines are based on clinical studies, when available, combined with our extensive clinical experience. We present our multidisciplinary approach to postoperative care that is provided after bariatric surgery and that builds on our presurgical evaluation.