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Velardi AM, Anoldo P, Nigro S, Navarra G. Advancements in Bariatric Surgery: A Comparative Review of Laparoscopic and Robotic Techniques. J Pers Med 2024; 14:151. [PMID: 38392584 PMCID: PMC10890254 DOI: 10.3390/jpm14020151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/26/2024] [Accepted: 01/27/2024] [Indexed: 02/24/2024] Open
Abstract
This article examines the evolution of bariatric surgery, with a focus on emerging technologies such as robotics and laparoscopy. In the case of gastric bypass, no significant differences have emerged between the two techniques in terms of hospitalization duration, weight loss, weight regain, or 30-day mortality. Robotic surgery, while requiring more time in the operating room, has been associated with lower rates of bleeding, mortality, transfusions, and infections. In revisional bariatric surgery, the robotic approach has shown fewer complications, shorter hospital stays, and a reduced need for conversion to open surgery. In the case of sleeve gastrectomy, robotic procedures have required more time and longer postoperative stays but have recorded lower rates of transfusions and bleeding compared to laparoscopy. However, robotic surgeries have proven to be more costly and potentially more complex in terms of postoperative complications. The review has also addressed the topic of the single-anastomosis duodeno-ileal switch (SADIS), finding comparable results between robotic and laparoscopic techniques, although robotic procedures have required more time in the operating room. Robotic technology has proven to be safe and effective, albeit with slightly longer operative times in some cases.
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Affiliation(s)
- Angelo Maria Velardi
- Oncologic Surgery, Department of Human Pathology of Adult and Evolutive Age, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
| | - Pietro Anoldo
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Stefania Nigro
- Oncologic Surgery, Department of Human Pathology of Adult and Evolutive Age, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
| | - Giuseppe Navarra
- Oncologic Surgery, Department of Human Pathology of Adult and Evolutive Age, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
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2
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Vitiello A, Berardi G, Peltrini R, Calabrese P, Pilone V. One-anastomosis gastric bypass (OAGB) versus Roux-en-Y gastric bypass (RYGB) as revisional procedures after failed laparoscopic sleeve gastrectomy (LSG): systematic review and meta-analysis of comparative studies. Langenbecks Arch Surg 2023; 408:440. [PMID: 37980292 PMCID: PMC10657303 DOI: 10.1007/s00423-023-03175-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/07/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION The aim of this study was to compare weight loss and gastroesophageal reflux disease (GERD) remission after one-anastomosis gastric bypass (OAGB) versus Roux-en-Y gastric bypass (RYGB) as revisional procedures after laparoscopic sleeve gastrectomy (LSG). METHODS In PubMed, Embase, and Cochrane Library, a search was performed using the terms "Roux-en-Y gastric bypass versus one anastomosis gastric bypass," "revisional surgery," and "sleeve gastrectomy." Only original articles in English language comparing OAGB and RYGB were included. No temporal interval was set. The primary outcome measure was weight loss (%TWL). The secondary endpoints were leak, bleeding, marginal ulcer, and GERD. PRISMA flowchart was used. Differences in continuous and dichotomous outcome variables were expressed as mean difference (MD) and risk difference (RD) with 95% CI, respectively. Heterogeneity was assessed by using I2 statistic. RESULTS Six retrospective comparative articles were included in the present meta-analysis. Weight loss analysis showed a MD = 5.70 (95% CI 4.84-6.57) in favor of the OAGB procedure with a statistical significance (p = 0.00001) and no significant statistical heterogeneity (I2 = 0.00%). There was no significant RD for leak, bleeding, or marginal ulcer after the two revisional procedures. After conversion to OAGB, remission from GERD was 68.6% (81/118), and it was 80.6% (150/186) after conversion to RYGB with a RD = 0.10 (95% CI -0.04, 0.24), no statistical significance (p = 0.19), and high heterogeneity (I2 = 96%). De novo GERD was 6.3% (16/255) after conversional OAGB, and it was 0.5% (1/180) after conversion to RYGB with a RD = -0.23 (95% CI -0.57, 0.11), no statistical significance (p = 0.16), and high heterogeneity (I2 = 92%).
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Affiliation(s)
- Antonio Vitiello
- Advanced Biomedical Sciences Department, University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy.
| | - Giovanna Berardi
- Advanced Biomedical Sciences Department, University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Roberto Peltrini
- Public Health Department, University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Pietro Calabrese
- Public Health Department, University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy
| | - Vincenzo Pilone
- Public Health Department, University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy
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Manigrasso M, Velotti N, De Palma GD, Musella M. Comment on Wijnia, J.W. A Clinician's View of Wernicke-Korsakoff Syndrome. J. Clin. Med. 2022, 11, 6755. J Clin Med 2023; 12:6393. [PMID: 37835037 PMCID: PMC10573923 DOI: 10.3390/jcm12196393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/01/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
We have read with great interest the article by Wijnia [...].
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Affiliation(s)
- Michele Manigrasso
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy;
| | - Nunzio Velotti
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy; (N.V.); (M.M.)
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy;
| | - Mario Musella
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, Via Sergio Pansini 5, 80131 Naples, Italy; (N.V.); (M.M.)
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Berardi G, Vitiello A, Abu-Abeid A, Schiavone V, Franzese A, Velotti N, Musella M. Micronutrients Deficiencies in Candidates of Bariatric Surgery: Results from a Single Institution over a 1-Year Period. Obes Surg 2023; 33:212-218. [PMID: 36331725 PMCID: PMC9834098 DOI: 10.1007/s11695-022-06355-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/19/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Micronutrient deficiencies represent a common condition after bariatric surgery (BS). The prevalence of these nutritional disorders before BS is still debated. The aim of our study was to retrospectively evaluate the prevalence of micronutrient deficiencies in candidates for BS. METHODS A prospectively maintained database of our institution was searched to find all patients who underwent surgery between January and December 2021. The following data were collected: age, gender, body mass index (BMI), obesity-associated diseases, and preoperative serum levels of vitamin B12, folate, and vitamin D. RESULTS A total of 174 patients were included in our study. Mean age and BMI were 39.2 ± 11.4 years and 44.3 ± 7.1 kg/m2, respectively. One hundred and thirty-nine patients (79.9%) had at least one preoperative micronutrient disorder, with vitamin D deficiency being the most common (116, 66.7%), followed by a deficit of folate (76, 43.7%) and vitamin B12 (10, 5.7%). Forty-seven (27%) individuals had insufficient levels of vitamin D. Comparison of deficiencies between sexes showed that vitamin B12 < 20 ng/ml was significantly more frequent in women (p = 0.03). DLP showed a mild significant effect on folate levels (p = 0.01), while the association of HNT and T2DM had a mild significant effect on vitamin B12 (p = 0.02). CONCLUSIONS Preoperative micronutrient deficiencies were frequently found in candidates for BS. Approximately 90% of patients had deficient or insufficient serum levels of vitamin D preoperatively. Almost half of the patients had a preoperative deficit of folate, and vitamin B12 deficiency was significantly more frequent in the female population. It is mandatory to screen all patients undergoing BS for vitamin deficiencies before surgery.
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Affiliation(s)
- Giovanna Berardi
- Advanced Biomedical Sciences Department, Naples “Federico II” University, AOU “Federico II”—via S.Pansini, 80131 Naples, Italy
| | - Antonio Vitiello
- Advanced Biomedical Sciences Department, Naples “Federico II” University, AOU “Federico II”—via S.Pansini, 80131 Naples, Italy
| | - Adam Abu-Abeid
- Division of General Surgery, Affiliated to Sackler Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, 6 Weizman Street, 64230906 Tel Aviv, Israel
| | - Vincenzo Schiavone
- Advanced Biomedical Sciences Department, Naples “Federico II” University, AOU “Federico II”—via S.Pansini, 80131 Naples, Italy
| | - Antonio Franzese
- Advanced Biomedical Sciences Department, Naples “Federico II” University, AOU “Federico II”—via S.Pansini, 80131 Naples, Italy
| | - Nunzio Velotti
- Advanced Biomedical Sciences Department, Naples “Federico II” University, AOU “Federico II”—via S.Pansini, 80131 Naples, Italy
| | - Mario Musella
- Advanced Biomedical Sciences Department, Naples “Federico II” University, AOU “Federico II”—via S.Pansini, 80131 Naples, Italy
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Alarfaj MA, Almadhi NH, Al-Amry M, Almater AI, Al-Obailan M. Peripapillary Retinal Haemorrhages in Wernicke's Encephalopathy Following Bariatric Surgery in a Young Patient. Neuroophthalmology 2022; 46:409-412. [PMID: 36544580 PMCID: PMC9762834 DOI: 10.1080/01658107.2022.2047208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Wernicke's encephalopathy (WE) is an acute neuropsychiatric syndrome resulting from thiamine deficiency (vitamin B1). It is characterised classically by a triad of ophthalmoplegia, confusion, and ataxia. WE is classically associated with alcoholism but increasingly has been observed due to other causes, particularly in undernourished post-bariatric surgery patients. Herein, we describe a case of WE following laparoscopic sleeve gastrectomy in a young male patient who presented with binocular horizontal diplopia and was found to have preretinal peripapillary haemorrhages. This case raises the awareness that posterior segment findings can occur in WE but have been under-reported previously.
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Affiliation(s)
- Motazz A. Alarfaj
- Neuro-Ophthalmology Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia,Department of Ophthalmology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia,CONTACT Motazz A. Alarfaj Department of Ophthalmology, College of Medicine, Imam Abdulrahman Bin Faisal University, P.O. Box: 12448, DammamZIP code: 31473, Saudi Arabia
| | - Nada H. Almadhi
- Neuro-Ophthalmology Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Mohammad Al-Amry
- Neuro-Ophthalmology Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Abdullah I. Almater
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Majed Al-Obailan
- Neuro-Ophthalmology Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia,Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Silverman JR. Obesity, Bariatric Surgery, and Postoperative Nutritional Management. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Eghbali F, Bhahdoust M, Sarafraz H, Naghshbandi M, Eshkevari AV, Movahedi H. Dry beriberi after sleeve gastrectomy: An undiagnosed case report. Int J Surg Case Rep 2022; 96:107357. [PMID: 35779318 PMCID: PMC9284039 DOI: 10.1016/j.ijscr.2022.107357] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Sleeve gastrectomy (SG) is a popular surgery for morbid obesity because of minimal complications, while somewhere uncommon micronutrient deficiencies occur that make problems. One of these rare complications is dry beriberi (BB). CASE PRESENTATION A 20-year-old girl with obesity that a few months after SG had non-specific symptoms like nausea, vomiting, debilitating weakness, burning, and tingling in her feet, which led to more tests and imaging and confused the physicians. During the next two months, she had a 40 kg weight loss. The critical test that helped diagnosis was Electromyography and Nerve Conduction Velocity (EMG/NCV), which showed subacute axonal sensory-motor polyneuropathy and decreased level of vitamin B1, proved the patient's diagnosis was dray BB. CLINICAL DISCUSSION SG may contribute to vitamin and trace elements deficiency development. One of the micronutrients that deficiencies can disturb the patient is vitamin B1 deficiency. Vitamin B1 deficiencies could be demonstrated with peripheral polyneuropathy, beriberi, or Wernicke-Korsakoff syndrome. Based on decreased vitamin B1 and EMG/NCV results, the diagnosis had been dry beriberi corrected with supplement therapy. CONCLUSION Thiamine deficiency should be suspected in all patients with vomiting, neurological symptoms, and rapid weight loss post-bariatric surgery (BS), even after restrictive surgery. Especially when a patient reports substantial weight loss and vomiting in short order. Hopefully, this case report will make any patient hospitalized with similar conditions evaluated for beriberi and again multivitamin supplementation therapy after SG is emphasized.
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Affiliation(s)
- Foolad Eghbali
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mansour Bhahdoust
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Corresponding author at: Minimally Invasive Surgery Research Center, Rasool-e-Akram Hospital, Niyayesh Ave, Sattarkhan St., Tehran, Iran.
| | - Hamid Sarafraz
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mobin Naghshbandi
- Student Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Hamidreza Movahedi
- Student Research Center, Iran University of Medical Sciences, Tehran, Iran
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8
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Velotti N, Vitiello A, Berardi G, Milone M, Musella M. Comment on "Wernicke-Korsakoff syndrome despite no alcohol abuse: A summary of systematic reports" - A matter of bariatric patients' management. J Neurol Sci 2021; 427:117569. [PMID: 34253350 DOI: 10.1016/j.jns.2021.117569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/02/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Nunzio Velotti
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Italy.
| | - Antonio Vitiello
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Italy
| | - Giovanna Berardi
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Italy
| | - Mario Musella
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Italy
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9
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Ha J, Kwon Y, Kwon JW, Kim D, Park SH, Hwang J, Lee CM, Park S. Micronutrient status in bariatric surgery patients receiving postoperative supplementation per guidelines: Insights from a systematic review and meta-analysis of longitudinal studies. Obes Rev 2021; 22:e13249. [PMID: 33938111 DOI: 10.1111/obr.13249] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
- Jane Ha
- Department of Medicine, Korea University College of Medicine, Seoul, South Korea.,Center for Obesity and Metabolic Diseases, Korea University Anam Hospital, Seoul, South Korea
| | - Yeongkeun Kwon
- Center for Obesity and Metabolic Diseases, Korea University Anam Hospital, Seoul, South Korea.,Division of Foregut Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Jin-Won Kwon
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, South Korea
| | - Dohyang Kim
- Department of Statistics, Daegu University, Gyeongbuk, South Korea
| | - Shin-Hoo Park
- Center for Obesity and Metabolic Diseases, Korea University Anam Hospital, Seoul, South Korea.,Division of Foregut Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Jinseub Hwang
- Department of Statistics, Daegu University, Gyeongbuk, South Korea
| | - Chang Min Lee
- Division of Foregut Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Sungsoo Park
- Center for Obesity and Metabolic Diseases, Korea University Anam Hospital, Seoul, South Korea.,Division of Foregut Surgery, Korea University College of Medicine, Seoul, South Korea
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Al Mansoori A, Shakoor H, Ali HI, Feehan J, Al Dhaheri AS, Cheikh Ismail L, Bosevski M, Apostolopoulos V, Stojanovska L. The Effects of Bariatric Surgery on Vitamin B Status and Mental Health. Nutrients 2021; 13:1383. [PMID: 33923999 PMCID: PMC8073305 DOI: 10.3390/nu13041383] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 02/06/2023] Open
Abstract
Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.
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Affiliation(s)
- Amna Al Mansoori
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 15551, United Arab Emirates; (A.A.M.); (H.S.); (H.I.A.); (A.S.A.D.)
| | - Hira Shakoor
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 15551, United Arab Emirates; (A.A.M.); (H.S.); (H.I.A.); (A.S.A.D.)
| | - Habiba I. Ali
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 15551, United Arab Emirates; (A.A.M.); (H.S.); (H.I.A.); (A.S.A.D.)
| | - Jack Feehan
- Institute for Health and Sport, Victoria University, Melbourne, VIC 8001, Australia; (J.F.); (V.A.)
- Department of Medicine-Western Health, The University of Melbourne, Melbourne, VIC 8001, Australia
| | - Ayesha S. Al Dhaheri
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 15551, United Arab Emirates; (A.A.M.); (H.S.); (H.I.A.); (A.S.A.D.)
| | - Leila Cheikh Ismail
- Clinical Nutrition and Dietetics Department, College of Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates;
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford OX1 2JD, UK
| | - Marijan Bosevski
- Faculty of Medicine Skopje, University Clinic of Cardiology, University of Ss. Cyril and Methodius, 1010 Skopje, North Macedonia;
| | - Vasso Apostolopoulos
- Institute for Health and Sport, Victoria University, Melbourne, VIC 8001, Australia; (J.F.); (V.A.)
| | - Lily Stojanovska
- Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 15551, United Arab Emirates; (A.A.M.); (H.S.); (H.I.A.); (A.S.A.D.)
- Institute for Health and Sport, Victoria University, Melbourne, VIC 8001, Australia; (J.F.); (V.A.)
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Mantero V, Rifino N, Costantino G, Farina A, Pozzetti U, Sciacco M, Ripolone M, Bianchi G, Salmaggi A, Rigamonti A. Non-alcoholic beriberi, Wernicke encephalopathy and long-term eating disorder: case report and a mini-review. Eat Weight Disord 2021; 26:729-732. [PMID: 32130681 DOI: 10.1007/s40519-020-00880-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/19/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Nowadays, reports of beriberi are rare in developed countries. Wernicke encephalopathy may be present in about 25% of patients with beriberi. CASE REPORT We report the case of a woman with history of depression and chronic eating disorder, who complained Wernicke encephalopathy and beriberi. Sural nerve and muscular biopsy were performed, showing severe axonal neuropathy. Thiamine supplementation was started with rapid improvement of the pulmonary and cardiac affections; improvement of peripheral neuropathy was incomplete. CONCLUSIONS Thiamine deficiency can be misdiagnosed. Beriberi is an important cause of acute flaccid paralysis; hence, clinicians should consider this diagnosis and prompt start thiamine treatment to avoid permanent neurological sequelae.
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Affiliation(s)
- Vittorio Mantero
- Neurology Unit, "A. Manzoni" Hospital-ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy.
| | - Nicola Rifino
- Neurology Unit, "A. Manzoni" Hospital-ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Gisella Costantino
- Neurology Unit, "A. Manzoni" Hospital-ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Andrea Farina
- Cardiology Unit, "A. Manzoni" Hospital-ASST Lecco, Lecco, Italy
| | - Ugo Pozzetti
- Department of Internal Medicine, "A. Manzoni" Hospital-ASST Lecco, Lecco, Italy
| | - Monica Sciacco
- Neuromuscular and Rare Diseases Unit, Department of Neuroscience, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michela Ripolone
- Neuromuscular and Rare Diseases Unit, Department of Neuroscience, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Graziella Bianchi
- Neurology Unit, "A. Manzoni" Hospital-ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Andrea Salmaggi
- Neurology Unit, "A. Manzoni" Hospital-ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Andrea Rigamonti
- Neurology Unit, "A. Manzoni" Hospital-ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
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12
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Khan F, Sharma N, Ud Din M, Bansal V. Isolated Pulvinar/Hockey Stick Sign in Nonalcoholic Wernicke's Encephalopathy. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e928272. [PMID: 33380716 PMCID: PMC7784713 DOI: 10.12659/ajcr.928272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Wernicke's encephalopathy (WE), a commonly misdiagnosed and underdiagnosed pathology, presents with altered mental status, ataxia, and ophthalmoplegia. WE is most commonly caused by excessive alcohol use, but also has diverse nonalcoholic etiologies. Here we describe 2 cases of nonalcoholic WE with different etiologies that were initially misdiagnosed due to lack of correlation of magnetic resonance imaging (MRI) findings with clinical information. CASE REPORT Patient A, a 50-year-old woman with recent gastric sleeve surgery, presented with horizontal gaze-evoked nystagmus, ataxia, and altered mental status. MRI fluid-attenuated inversion recovery (FLAIR) revealed isolated bilateral, symmetrical, thalamic hyperintensities, initially diagnosed as variant Creutzfeldt-Jakob disease. A review of imaging and clinical presentation provided an alternate diagnosis of nonalcoholic WE secondary to nutritional deficiency. Intravenous (IV) thiamine improved symptoms with resolution of MRI findings 6 months later. Patient B, a 64-year-old woman, presented with nausea, vomiting, dizziness, altered mental status, and weight loss. MRI FLAIR revealed isolated bilateral, symmetrical, thalamic hyperintensities, initially determined to be ischemia, prompting stroke management. A diagnosis of nonalcoholic WE was suggested, given the patient's low thiamine levels and history of malnutrition, and was confirmed by her excellent therapeutic response to IV thiamine. CONCLUSIONS Nonalcoholic WE remains a challenging diagnosis because of the variable clinical presentation, myriad of underlying etiologies, and lack of standardized diagnostic laboratory tests. A multidisciplinary approach with close collaboration between the radiologist and clinical care team is critical to narrow down the differential and initiate correct management. WE is a reversible disease with catastrophic consequences if it is not recognized and treated promptly.
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Affiliation(s)
- Faisal Khan
- Department of Neurology, Sugar Land Neurology and Sleep, Sugar Land, TX, USA.,Department of Neurology, Sam Houston University College of Osteopathic Medicine, Hunstville, TX, USA
| | - Neha Sharma
- Research Fellow, Houston Medical Clerkship, Sugar Land, TX, USA
| | - Moin Ud Din
- Research Fellow, Houston Medical Clerkship, Sugar Land, TX, USA
| | - Vivek Bansal
- Department of Neuroradiology, Radiology Partners Gulf Coast, Houston, TX, USA
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O'Kane M, Parretti HM, Pinkney J, Welbourn R, Hughes CA, Mok J, Walker N, Thomas D, Devin J, Coulman KD, Pinnock G, Batterham RL, Mahawar KK, Sharma M, Blakemore AI, McMillan I, Barth JH. British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery-2020 update. Obes Rev 2020; 21:e13087. [PMID: 32743907 PMCID: PMC7583474 DOI: 10.1111/obr.13087] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/21/2020] [Accepted: 05/31/2020] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is recognized as the most clinically and cost-effective treatment for people with severe and complex obesity. Many people presenting for surgery have pre-existing low vitamin and mineral concentrations. The incidence of these may increase after bariatric surgery as all procedures potentially cause clinically significant micronutrient deficiencies. Therefore, preparation for surgery and long-term nutritional monitoring and follow-up are essential components of bariatric surgical care. These guidelines update the 2014 British Obesity and Metabolic Surgery Society nutritional guidelines. Since the 2014 guidelines, the working group has been expanded to include healthcare professionals working in specialist and non-specialist care as well as patient representatives. In addition, in these updated guidelines, the current evidence has been systematically reviewed for adults and adolescents undergoing the following procedures: adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch. Using methods based on Scottish Intercollegiate Guidelines Network methodology, the levels of evidence and recommendations have been graded. These guidelines are comprehensive, encompassing preoperative and postoperative biochemical monitoring, vitamin and mineral supplementation and correction of nutrition deficiencies before, and following bariatric surgery, and make recommendations for safe clinical practice in the U.K. setting.
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Affiliation(s)
- Mary O'Kane
- Dietetic DepartmentLeeds Teaching Hospitals NHS TrustLeedsUK
| | | | - Jonathan Pinkney
- Faculty of Health and Human SciencesPeninsula Schools of Medicine and DentistryPlymouthUK
- Department of EndocrinologyPlymouth Hospitals NHS TrustPlymouthUK
| | - Richard Welbourn
- Department of Upper GI and Bariatric Surgery, Musgrove Park HospitalTaunton and Somerset NHS Foundation TrustTauntonUK
| | - Carly A. Hughes
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
- Fakenham Weight Management ServiceFakenham Medical PracticeFakenhamUK
| | - Jessica Mok
- Centre for Obesity Research, Rayne Institute, Department of MedicineUniversity College LondonLondonUK
| | - Nerissa Walker
- School of BiosciencesSutton Bonington Campus, University of NottinghamNottinghamUK
| | - Denise Thomas
- Department of Nutrition and DieteticsPortsmouth Hospitals NHS TrustPortsmouthUK
| | - Jennifer Devin
- Specialist Weight Management ServiceBetsi Cadwaladr University Health BoardWalesUK
| | - Karen D. Coulman
- Population Health SciencesBristol Medical School. University of BristolBristolUK
- Obesity and Bariatric Surgery ServiceSouthmead Hospital, North Bristol NHS TrustBristolUK
| | | | - Rachel L. Batterham
- Centre for Obesity Research, Rayne Institute, Department of MedicineUniversity College LondonLondonUK
- Bariatric Centre for Weight Management and Metabolic Surgery, UCLHUniversity College London Hospital (UCLH)LondonUK
- National Institute of Health ResearchUCLH Biomedical Research CentreLondonUK
| | - Kamal K. Mahawar
- Department of General SurgerySunderland Royal HospitalSunderlandUK
| | - Manisha Sharma
- Department of Clinical Biochemistry & Bariatric SurgeryHomerton University Hospital NHS TrustLondonUK
| | - Alex I. Blakemore
- Department of Life SciencesBrunel UniversityLondonUK
- Department of MedicineImperial CollegeLondonUK
| | | | - Julian H. Barth
- Department of Chemical Pathology & Metabolic MedicineLeeds Teaching Hospitals NHS TrustLeedsUK
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Velotti N, Manigrasso M, Di Lauro K, Vitiello A, Berardi G, Manzolillo D, Anoldo P, Bocchetti A, Milone F, Milone M, De Palma GD, Musella M. Comparison between LigaSure™ and Harmonic® in Laparoscopic Sleeve Gastrectomy: A Single-Center Experience on 422 Patients. J Obes 2019; 2019:3402137. [PMID: 30719344 PMCID: PMC6335858 DOI: 10.1155/2019/3402137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/26/2018] [Accepted: 12/09/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND New laparoscopic devices, such as electrothermal bipolar-activated devices (LigaSure™ (LS)) or ultrasonic systems (Harmonic® scalpel (HS)), have been applied recently to bariatric surgery allowing to reduce blood loss and surgical risks. The aim of this study was to retrospectively compare intraoperative performance of HS and LS, postoperative results, and clinical outcomes in a large cohort of patients undergoing LSG. METHODS Data from 422 morbidly obese patients undergoing LSG in our Bariatric Unit at the Advanced Biomedical Sciences Department of the "Federico II" University of Naples (Italy) between January 2009 and December 2017 were retrospectively analyzed. Subjects were divided into two groups (HS and LS), and operative time, intraoperative complications, and postoperative (within 30 days from surgery) complications were compared. Bleeding from the omentum or from the staple line, use of hemostatic clips, and absorbable hemostat were recorded as intraoperative complications; hemorrhages, abscess formation, gastric leaks, fever, and mortality were considered as postoperative complications. RESULTS Statistical analysis showed no difference in terms of baseline demographics between the two cohorts. Operative time (48 ± 9 vs 49 ± 6 min, p=0.646) and the rates of intraoperative and postoperative complications did not significantly differ between groups. CONCLUSION Harmonic® and LigaSure™ are both useful tools in bariatric surgery, and these two advanced power devices are user-friendly and can facilitate surgeon work; from this point of view, the choice of the energy device should be based on the preference of the surgeon and on the hospital costs policy and availability.
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Affiliation(s)
- N. Velotti
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - M. Manigrasso
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - K. Di Lauro
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - A. Vitiello
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - G. Berardi
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - D. Manzolillo
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - P. Anoldo
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - A. Bocchetti
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - F. Milone
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - M. Milone
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - G. D. De Palma
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
| | - M. Musella
- Department of Advanced Biomedical Sciences, “Federico II” University, Via Pansini 5, 80131 Naples, Italy
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Musella M, Di Capua F, D’Armiento M, Velotti N, Bocchetti A, Di Lauro K, Galloro G, Campione S, Petrella G, D’Armiento FP. No Difference in Ghrelin-Producing Cell Expression in Obese Versus Non-obese Stomach: a Prospective Histopathological Case-Control Study. Obes Surg 2018; 28:3604-3610. [DOI: 10.1007/s11695-018-3401-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Bianco P, Rizzuto A, Velotti N, Bocchetti A, Manzolillo D, Maietta P, Milone M, Amato M, Conzo G, Buonomo O, Petrella G, Musella M. Results following laparoscopic sleeve gastrectomy in elderly obese patients: a single center experience with follow-up at three years. MINERVA CHIR 2018; 75:77-82. [PMID: 29963791 DOI: 10.23736/s0026-4733.18.07757-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) represents the most performed bariatric surgical procedure worldwide. Morbid Overweight in elderly patients is becoming a significant health problem even in Italy. As well as in younger age groups, bariatric surgery could be indicated even in this subset of patients. However the advantages and results of LSG in patients over 60 years old have received minimal attention. METHODS The records of 375 patients underwent LSG between 2008 and 2016 were reviewed. In the entire series 18 patients were aged 60 years or older at the time of surgery. Since a 3 years follow-up was available for 12 patients out of the 18 aged over 60 we included in the study only these. General epidemiologic data, clinical findings, BMI and comorbidities surgical treatment and follow-up data were collected; postoperative measurements such as operative time, intraoperative complications, mortality rate, length of stay, incidence of early and late complications, Body mass Index (BMI), excess weight loss rate (EWL%) and comorbidities resolution were also recorded. RESULTS LSG was successfully performed for all geriatric patients. Global complications rate was 16.6% At 3 years mean BMI was 34.4±3.8 with a mean EWL% 66.1±31.9. Postoperative resolution of obesity comorbidities was observed; Hypertension (71.4%), type 2 Diabetes Mellitus (T2DM) (50.0%), obstructive sleep apnea syndrome (OSAS) (66.6%) respectively. No intraoperative complications or mortality were recorded. CONCLUSIONS LSG offered cure in geriatric patients affected by morbid obesity for weight loss and comorbidities resolution. Larger studies are necessary to analyze and minimize the incidence of postoperative complications associated to this surgical procedure in elderly patients.
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Affiliation(s)
- Paolo Bianco
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Antonia Rizzuto
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Nunzio Velotti
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Alessio Bocchetti
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Domenico Manzolillo
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Paola Maietta
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Marco Milone
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Maurizio Amato
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Giovanni Conzo
- Department of Cardiothoracic and Respiratory Sciences, Luigi Vanvitelli University, Naples, Italy
| | - Oreste Buonomo
- Department of Surgery, Tor Vergata University, Rome, Italy
| | | | - Mario Musella
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy -
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Punchai S, Hanipah ZN, Meister KM, Schauer PR, Brethauer SA, Aminian A. Neurologic Manifestations of Vitamin B Deficiency after Bariatric Surgery. Obes Surg 2018; 27:2079-2082. [PMID: 28213665 DOI: 10.1007/s11695-017-2607-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The aim of this study was to assess the incidence, clinical presentation, and outcomes of neurologic disorders secondary to vitamin B deficiencies following bariatric surgery. METHODS Patients at a single academic institution who underwent bariatric surgery and developed neurologic complications secondary to low levels of vitamins B1, B2, B6, and B12 between the years 2004 and 2015 were studied. RESULTS In total, 47 (0.7%) bariatric surgical patients (Roux-en-Y gastric bypass n = 36, sleeve gastrectomy n = 9, and duodenal switch n = 2) developed neurologic manifestations secondary to vitamin B deficiencies. Eleven (23%) patients developed postoperative anatomical complications contributed to poor oral intake. Median duration to onset of neurologic manifestation following surgery was 12 months (IQR, 5-32). Vitamin deficiencies reported in the cohort included B1 (n = 30), B2 (n = 1), B6 (n = 12), and B12 (n = 12) deficiency. The most common manifestations were paresthesia (n = 31), muscle weakness (n = 15), abnormal gait (n = 11), and polyneuropathy (n = 7). Four patients were diagnosed with Wernicke-Korsakoff syndrome (WKS) which was developed after gastric bypass (n = 3) and sleeve gastrectomy (n = 1). Seven patients required readmission for management of severe vitamin B deficiencies. Overall, resolution of neurologic symptoms with nutritional interventions and pharmacotherapy was noted in 40 patients (85%). The WKS was not reversible, and all four patients had residual mild ataxia and nystagmus at the last follow-up time. CONCLUSIONS Nutritional neurologic disorders secondary to vitamin B deficiency are relatively uncommon after bariatric surgery. While neurologic disorders are reversible in most patients (85%) with vitamin replacements, persistent residual neurologic symptoms are common in patients with WKS.
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Affiliation(s)
- Suriya Punchai
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH, 44195, USA
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Zubaidah Nor Hanipah
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH, 44195, USA
- Department of Surgery, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia
| | - Katherine M Meister
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH, 44195, USA
| | - Philip R Schauer
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH, 44195, USA
| | - Stacy A Brethauer
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH, 44195, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH, 44195, USA.
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An Autopsy Case of Misdiagnosed Wernicke's Syndrome after Intragastric Balloon Therapy. Case Rep Gastrointest Med 2018; 2018:1510850. [PMID: 29666718 PMCID: PMC5831924 DOI: 10.1155/2018/1510850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/06/2018] [Accepted: 01/21/2018] [Indexed: 01/21/2023] Open
Abstract
Intragastric balloon (IGB) therapy is a widely used technique to counter obesity, and it is known to be safe and effective. Although there can be a high rate of side effects following IGB therapy, most are self-healing and they are mainly accommodative in nature. Few cases of Wernicke's syndrome under IGB therapy have been described in the literature, and to the best of our knowledge, none have been fatal. We present here a case of a 51-year-old woman who underwent IGB therapy over 8 months. Late diagnosed Wernicke's syndrome that first appeared as lower limb neuropathy progressively immobilized the patient, until she required bed rest. Finally, a major complication of pneumonia caused her death. Wernicke's syndrome has been mainly related to bariatric surgery techniques, but it must also be linked to IGB therapy (and also to other restrictive weight-loss interventions). As the use of IGB therapy spreads, the literature must alert physicians to this complication. Wernicke's syndrome is a severe but reversible condition when diagnosed and treated early.
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Milone M, Velotti N, Musella M. Wernicke Encephalopathy Following Laparoscopic Sleeve Gastrectomy—a Call to Evaluate Thiamine Deficiencies After Restrictive Bariatric Procedures. Obes Surg 2018; 28:852-853. [PMID: 29307105 DOI: 10.1007/s11695-017-3083-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Hamilton LA, Darby SH, Hamilton AJ, Wilkerson MH, Morgan KA. Case Report of Wernicke's Encephalopathy After Sleeve Gastrectomy. Nutr Clin Pract 2017; 33:510-514. [PMID: 29730896 DOI: 10.1177/0884533617722758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We report a case of a patient who was 3 months post-sleeve gastrectomy and presented with acute stroke symptoms ultimately due to Wernicke's encephalopathy (WE) after bariatric surgery. A 20-year-old white female presented to an outside hospital 3 months after sleeve gastrectomy complaining of nausea and vomiting. She initially underwent a cholecystectomy and later became less responsive and required intubation. Magnetic resonance imaging changes, presumed to be an acute stroke, prompted her transfer to our facility. Intravenous (IV) thiamin was administered, and the patient's symptoms improved over the course of her hospital stay. RESULTS Thiamin levels were markedly low, and the patient rapidly improved with the administration of IV thiamin. The patient was discharged to inpatient rehabilitation. CONCLUSION Bariatric surgery is a less common cause of WE but can lead to acute WE due to malabsorption of thiamin. In patients undergoing bariatric surgery, clinicians should be vigilant about the potential for WE to occur. In addition, based on history, WE should be considered in the differential diagnosis for symptoms of acute ischemic stroke.
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Affiliation(s)
- Leslie A Hamilton
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Sarah H Darby
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Allan J Hamilton
- Department of Anesthesiology and Pain Management, UT Southwestern, Dallas, Texas, USA
| | - Matthew H Wilkerson
- Department of Anesthesiology, Graduate School of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Kabel A Morgan
- Department of Anesthesiology, Graduate School of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee, USA
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Lupoli R, Lembo E, Saldalamacchia G, Avola CK, Angrisani L, Capaldo B. Bariatric surgery and long-term nutritional issues. World J Diabetes 2017; 8:464-474. [PMID: 29204255 PMCID: PMC5700383 DOI: 10.4239/wjd.v8.i11.464] [Citation(s) in RCA: 193] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/11/2017] [Accepted: 09/04/2017] [Indexed: 02/05/2023] Open
Abstract
Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro- and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related co-morbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multi-vitamins and mineral supplements according to the patient's needs.
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Affiliation(s)
- Roberta Lupoli
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
| | - Erminia Lembo
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
| | - Gennaro Saldalamacchia
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
| | - Claudia Kesia Avola
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
| | - Luigi Angrisani
- Department of Public Health, Federico II University, 80131 Naples, Italy
| | - Brunella Capaldo
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
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Serlin T, Moisseiev E. Fundus Findings in Wernicke Encephalopathy. Case Rep Ophthalmol 2017; 8:406-409. [PMID: 28924437 PMCID: PMC5597920 DOI: 10.1159/000478924] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/15/2017] [Indexed: 12/14/2022] Open
Abstract
Wernicke encephalopathy (WE) is an acute neuropsychiatric syndrome resulting from thiamine (vitamin B1) deficiency, classically characterized by the triad of ophthalmoplegia, confusion, and ataxia. While commonly associated with chronic alcoholism, WE may also occur in the setting of poor nutrition or absorption. We present a 37-year-old woman who underwent laparoscopic sleeve gastrectomy and presented with visual disturbance with bilateral horizontal nystagmus, confusion, and postural imbalance. Fundus examination revealed bilateral optic disc edema with a retinal hemorrhage in the left eye. Metabolic workup demonstrated thiamine deficiency. Her symptoms resolved after thiamine treatment. This case raises the awareness of the possibility of posterior segment findings in WE, which are underreported in WE.
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Affiliation(s)
- Tal Serlin
- Department of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Elad Moisseiev
- Department of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel
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Alias T, Hoof P, Lee M, Davis D. Wernicke's encephalopathy after conversion from sleeve gastrectomy to gastric bypass. Surg Obes Relat Dis 2016; 12:e89-e91. [PMID: 27998546 DOI: 10.1016/j.soard.2016.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/27/2016] [Accepted: 10/02/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Tony Alias
- Department of Radiology, Baylor Scott & White, Dallas, TX.
| | - Pamela Hoof
- Department of Internal Medicine, Baylor Scott & White, Dallas, TX
| | - Mike Lee
- Department of Oral Surgery, Baylor Scott & White, Dallas, TX
| | - Daniel Davis
- Baylor Weight Loss Surgery, Baylor Scott & White, Dallas, TX
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Severe Infections are Common in Thiamine Deficiency and May be Related to Cognitive Outcomes: A Cohort Study of 68 Patients With Wernicke-Korsakoff Syndrome. PSYCHOSOMATICS 2016; 57:624-633. [PMID: 27498674 DOI: 10.1016/j.psym.2016.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/16/2016] [Accepted: 06/16/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Wernicke encephalopathy can have different clinical outcomes. Although infections may precipitate the encephalopathy itself, it is unknown whether infections also modify the long-term outcome in patients developing Korsakoff syndrome. OBJECTIVE To determine whether markers of infection, such as white blood cell (WBC) counts and absolute neutrophil counts in the Wernicke phase, are associated with cognitive outcomes in the end-stage Korsakoff syndrome. METHOD Retrospective, descriptive study of patients admitted to Slingedael Korsakoff Center, Rotterdam, The Netherlands. Hospital discharge letters of patients with Wernicke encephalopathy were searched for relevant data on infections present upon hospital admission. Patients were selected for further analysis if data were available on WBC counts in the Wernicke phase and at least 1 of 6 predefined neuropsychological tests on follow-up. RESULTS Infections were reported in 35 of 68 patients during the acute phase of Wernicke-Korsakoff syndrome-meningitis (1), pneumonia (14), urinary tract infections (9), acute abdominal infections (4), sepsis (5) empyema, (1) and infection "of unknown origin" (4). The neuropsychological test results showed significant lower scores on the Cambridge Cognitive Examination nonmemory section with increasing white blood cell counts (Spearman rank correlation, ρ = -0.34; 95% CI: -0.57 to -0.06; 44 patients) and on the "key search test" of the behavioral assessment of the dysexecutive syndrome with increasing absolute neutrophil counts (ρ= -0.85; 95% CI: -0.97 to -0.42; 9 patients). CONCLUSIONS Infections may be the presenting manifestation of thiamine deficiency. Patients with Wernicke-Korsakoff syndrome who suffered from an infection during the acute phase are at risk of worse neuropsychological outcomes on follow-up.
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Bohan PK, Yonge J, Connelly C, Watson JJ, Friedman E, Fielding G. Wernicke Encephalopathy after Restrictive Bariatric Surgery. Am Surg 2016. [DOI: 10.1177/000313481608200401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - John Yonge
- Oregon Health & Science University Portland, Oregon
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Abstract
Obesity has attained pandemic proportions, and bariatric surgery is increasingly being employed resulting in turn to more neurological complications which must be recognized and managed. Neurological complications may result from mechanical or inflammatory mechanisms but primarily result from micro-nutritional deficiencies. Vitamin B12, thiamine, and copper constitute the most frequent deficiencies. Neurological complications may occur at reasonably predictable times after bariatric surgery and are associated with the type of surgery used. During the early post-operative period, compressive or stretch peripheral nerve injury, rhabdomyolysis, Wernicke's encephalopathy, and inflammatory polyradiculoneuropathy may occur. Late complications ensue after months to years and include combined system degeneration (vitamin B12 deficiency) and hypocupric myelopathy. Bariatric surgery patients require careful nutritional follow-up with routine monitoring of micronutrients at 6 weeks and 3, 6, and 12 months post-operatively and then annually after surgery and multivitamin supplementation for life. Sustained vigilance for common and rare neurological complications is essential.
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Twelve key nutritional issues in bariatric surgery. Clin Nutr 2016; 35:12-17. [DOI: 10.1016/j.clnu.2015.02.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 02/14/2015] [Accepted: 02/22/2015] [Indexed: 12/14/2022]
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Beriberi: an uncommon complication of sleeve gastrectomy. Surg Obes Relat Dis 2015; 11:e53-5. [DOI: 10.1016/j.soard.2015.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 07/09/2015] [Accepted: 07/13/2015] [Indexed: 11/21/2022]
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Milone M, Lupoli R, Maietta P, Di Minno A, Bianco P, Ambrosino P, Coretti G, Milone F, Di Minno MND, Musella M. Lipid profile changes in patients undergoing bariatric surgery: a comparative study between sleeve gastrectomy and mini-gastric bypass. Int J Surg 2015; 14:28-32. [PMID: 25576760 DOI: 10.1016/j.ijsu.2014.12.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 12/24/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To prospectively evaluate the effect of different types of bariatric surgery on lipid profile. METHODS Total cholesterol (TC), High-Density-Lipoprotein cholesterol (HDLc), Low-Density-Lipoprotein cholesterol (LDLc) and triglycerides (TG) levels were evaluated before surgery and at 3 different post-operative time-points (3, 6 and 12 months) in consecutive obese subjects undergoing mini-gastric bypass (MGB) or sleeve gastrectomy (SG). RESULTS At baseline, 74 MGB and 86 SG subjects were comparable for lipid profile and prevalence of hypercholesterolemia/hypertriglyceridemia. During the post-operative follow-up, both MGB and SG subjects showed significant changes in lipid profile. However, at 3 months, MGB patients showed higher changes in TC (β = 0.179, p = 0.022) and TG (β = 0.265, p = 0.001) than those undergoing SG. At 6-month post-operative follow-up, these differences were confirmed only for TC. After a 12-month follow-up, MGB and SG were entirely comparable for changes in lipid profile with the exception of HDLc, whose changes were higher in SG group (β = 0.130, p = 0.039). Overall, the probability to normalize lipid profile during the 12-month follow-up was similar in MGB and in SG patients (OR:1.24, 95%CI:0.41-3.76, p = 0.689). CONCLUSION Despites some differences at 3-6 post-operative months, during a 12-month follow-up, SG and MGB showed a similar efficacy in the improvement of lipid profile of obese patients.
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Affiliation(s)
- Marco Milone
- Department of Advanced Biomedical Science, Federico II University, Naples, Italy.
| | - Roberta Lupoli
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Paola Maietta
- Department of Advanced Biomedical Science, Federico II University, Naples, Italy
| | - Alessandro Di Minno
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Paolo Bianco
- Department of Advanced Biomedical Science, Federico II University, Naples, Italy
| | - Pasquale Ambrosino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Guido Coretti
- Department of Advanced Biomedical Science, Federico II University, Naples, Italy
| | - Francesco Milone
- Department of Advanced Biomedical Science, Federico II University, Naples, Italy
| | | | - Mario Musella
- Department of Advanced Biomedical Science, Federico II University, Naples, Italy
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Frank LL. Thiamin in Clinical Practice. JPEN J Parenter Enteral Nutr 2015; 39:503-20. [PMID: 25564426 DOI: 10.1177/0148607114565245] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 10/20/2014] [Indexed: 01/19/2023]
Abstract
Thiamin is a water-soluble vitamin also known as vitamin B1. Its biologically active form, thiamin pyrophosphate (TPP), is a cofactor in macronutrient metabolism. In addition to its coenzyme roles, TPP plays a role in nerve structure and function as well as brain metabolism. Signs and symptoms of thiamin deficiency (TD) include lactic acidosis, peripheral neuropathy, ataxia, and ocular changes (eg, nystagmus). More advanced symptoms include confabulation and memory loss and/or psychosis, resulting in Wernicke's encephalopathy and/or Wernicke's Korsakoff syndrome, respectively. The nutrition support clinician should be aware of patients who may be at risk for TD. Risk factors include those patients with malnutrition due to 1 or more nutrition-related etiologies: decreased nutrient intake, increased nutrient losses, or impaired nutrient absorption. Clinical scenarios such as unexplained heart failure or lactic acidosis, renal failure with dialysis, alcoholism, starvation, hyperemesis gravidarum, or bariatric surgery may increase the risk for TD. Patients who are critically ill and require nutrition support may also be at risk for TD, especially those who are given intravenous dextrose void of thiamin repletion. Furthermore, understanding thiamin's role as a potential therapeutic agent for diabetes, some inborn errors of metabolism, and neurodegenerative diseases warrants further research. This tutorial describes the absorption, digestion, and metabolism of thiamin. Issues pertaining to thiamin in clinical practice will be described, and evidence-based practice suggestions for the prevention and treatment of TD will be discussed.
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Hutcheon DA. Malnutrition-induced Wernicke's encephalopathy following a water-only fasting diet. Nutr Clin Pract 2014; 30:92-9. [PMID: 25524882 DOI: 10.1177/0884533614561793] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Wernicke's encephalopathy is a critical condition of neurological dysfunction resulting from a deficiency in thiamine. Chronic alcoholism is recognized as the most common cause of Wernicke's encephalopathy, but other causes, including fasting/starvation and malnutrition, have been documented within the scientific literature. These causes may not be readily recognized by healthcare professionals and may lead to Wernicke's encephalopathy being overlooked as a diagnosis when a nonalcoholic patient presents with classic signs and symptoms of the disorder. MATERIALS AND METHODS A narrative review of thiamine and its relationship to the development, diagnosis, and treatment of Wernicke's encephalopathy is presented based on a review of evidence-based guidelines and published research. To heighten awareness of the development of Wernicke's encephalopathy in fasted/starved and malnourished patients and to contribute to the scientific body of knowledge for the identification and management of Wernicke's encephalopathy in these patients, the clinical course and treatment of an adult woman who developed Wernicke's encephalopathy following a 40-day water-only fasting diet is outlined. RESULTS Clinical suspicion was required to identify the patient's condition and initiate immediate intervention through parenteral thiamine administration. Oral thiamine supplementation of 100 to 800 mg per day for 6 months was required to aid recovery. OUTCOMES The patient's clinical course and response to treatment illustrate the necessity for clinical awareness and suspicion of Wernicke's encephalopathy among healthcare professionals, timely and adequate parenteral thiamine administration, and oral thiamine supplementation at therapeutic doses to correct the nutrient deficiency, halt the progression of Wernicke's encephalopathy, and promote recovery.
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Affiliation(s)
- Deborah A Hutcheon
- School of Health Related Professions, Department of Nutritional Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey Department of Food, Nutrition, and Packaging Sciences, Clemson, University, Clemson, South Carolina
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Haemostatic and fibrinolytic changes in obese subjects undergoing bariatric surgery: the effect of different surgical procedures. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 13:442-7. [PMID: 25545872 DOI: 10.2450/2014.0183-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 11/18/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Little is known about effects of different bariatric surgery procedures on haemostatic and fibrinolytic parameters. MATERIAL AND METHODS Consecutive obese subjects undergoing gastric bypass (GBP) or sleeve gastrectomy (SG) were enrolled. In all patients, levels of haemostatic factors (FII, FVII, FVIII, FIX, FX, vWF, fibrinogen), fibrinolytic variables (PAI-1, t-PA and D-dimer) and natural anticoagulants (AT, protein C and protein S) were evaluated before and 2 months after surgery. RESULTS A total of 77 GBP and 79 SG subjects completed the study. At baseline no difference in coagulation parameters was found between the two groups. After both GBP and SG, subjects showed significant changes in haemostatic and fibrinolytic variables and in natural anticoagulant levels. The Δ% changes in FVII, FVIII, FIX, vWF, fibrinogen, D-dimer, protein C and protein S levels were significantly higher in subjects who underwent GBP than in those who underwent SG. Multivariate analysis confirmed that GBP was a predictor of higher Δ% changes in FVII (β=0.268, p=0.010), protein C (β=0.274, p=0.003) and protein S (β=0.297, p<0.001), but not in all the other variables. Following coagulation factor reduction, 31 subjects (25.9% of GBP and 13.9% of SG; p=0.044) showed overt FVII deficiency; protein C deficiency was reported by 34 subjects (32.5% of GBP vs 11.4% of SG, p=0.033) and protein S deficiency by 39 (37.6% of GBP vs 12.6% of SG, p=0.009). Multivariate analyses showed that GBP was associated with an increased risk of deficiency of FVII (OR: 3.64; 95% CI: 1.73-7.64, p=0.001), protein C (OR: 4.319; 95% CI: 1.33-13.9, p=0.015) and protein S (OR: 5.50; 95% CI: 1.71-17.7, p=0.004). DISCUSSION GBP is associated with an increased risk of post-operative deficiency in some vitamin K-dependent coagulation factors. Whereas such deficiency is too weak to cause bleeding, it is significant enough to increase the risk of thrombosis.
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Thiamine and magnesium deficiencies: keys to disease. Med Hypotheses 2014; 84:129-34. [PMID: 25542071 DOI: 10.1016/j.mehy.2014.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 12/06/2014] [Indexed: 10/24/2022]
Abstract
Thiamine deficiency (TD) is accepted as the cause of beriberi because of its action in the metabolism of simple carbohydrates, mainly as the rate limiting cofactor for the dehydrogenases of pyruvate and alpha-ketoglutarate, both being critical to the action of the citric acid cycle. Transketolase, dependent on thiamine and magnesium, occurs twice in the oxidative pentose pathway, important in production of reducing equivalents. Thiamine is also a cofactor in the dehydrogenase complex in the degradation of the branched chain amino acids, leucine, isoleucine and valine. In spite of these well accepted facts, the overall clinical effects of TD are still poorly understood. Because of the discovery of 2-hydroxyacyl-CoA lyase (HACL1) as the first peroxisomal enzyme in mammals found to be dependent on thiamine pyrophosphate (TPP) and the ability of thiamine to bind with prion protein, these factors should improve our clinical approach to TD. HACL1 has two important roles in alpha oxidation, the degradation of phytanic acid and shortening of 2-hydroxy long-chain fatty acids so that they can be degraded further by beta oxidation. The downstream effects of a lack of efficiency in this enzyme would be expected to be critical in normal brain metabolism. Although TD has been shown experimentally to produce reversible damage to mitochondria and there are many other causes of mitochondrial dysfunction, finding TD as the potential biochemical lesion would help in differential diagnosis. Stresses imposed by infection, head injury or inoculation can initiate intermittent cerebellar ataxia in thiamine deficiency/dependency. Medication or vaccine reactions appear to be more easily initiated in the more intelligent individuals when asymptomatic marginal malnutrition exists. Erythrocyte transketolase testing has shown that thiamine deficiency is widespread. It is hypothesized that the massive consumption of empty calories, particularly those derived from carbohydrate and fat, results in a high calorie/thiamine ratio as a major cause of disease. Because mild to moderate TD results in pseudo hypoxia in the limbic system and brainstem, emotional and stress reflexes of the autonomic nervous system are stimulated and exaggerated, producing symptoms often diagnosed as psychosomatic disease. If the biochemical lesion is recognized at this stage, the symptoms are easily reversible. If not, and the malnutrition continues, neurodegeneration follows and results in a variety of chronic brain diseases. Results from acceptance of the hypothesis could be tested by performing erythrocyte transketolase tests to pick out those with TD and supplementing the affected individuals with the appropriate dietary supplements.
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