Evolution of 29 Anthropometric, Nutritional, and Cardiometabolic Parameters Among Morbidly Obese Adolescents 2 Years Post Sleeve Gastrectomy

Cumulative Incidence of Venous Thromboembolic Events In-Hospital, and at 1, 3, 6, and 12 Months After Metabolic and Bariatric Surgery: Systematic Review of 87 Studies and Meta-analysis of 2,731,797 Patients

Systematic review/meta-analysis of cumulative incidences of venous thromboembolic events (VTE) after metabolic and bariatric surgery (MBS). Electronic databases were searched for original studies. Proportional meta-analysis assessed cumulative VTE incidences. (PROSPERO ID:CRD42020184529). A total of 3066 records, and 87 studies were included (N patients = 4,991,683). Pooled in-hospital VTE of mainly laparoscopic studies = 0.15% (95% CI = 0.13-0.18%); pooled cumulative incidence increased to 0.50% (95% CI = 0.33-0.70%); 0.51% (95% CI = 0.38-0.65%); 0.72% (95% CI = 0.13-1.52%); 0.78% (95% CI = 0-3.49%) at 30 days and 3, 6, and 12 months, respectively. Studies using predominantly open approach exhibited higher incidence than laparoscopic studies. Within the first month, 60% of VTE occurred after discharge. North American and earlier studies had higher incidence than non-North American and more recent studies. This study is the first to generate detailed estimates of the incidence and patterns of VTE after MBS over time. The incidence of VTE after MBS is low. Improved estimates and time variations of VTE require longer-term designs, non-aggregated reporting of characteristics, and must consider many factors and the use of data registries. Extended surveillance of VTE after MBS is required.

The Impact of Paediatric Obesity on Drug Pharmacokinetics: A Virtual Clinical Trials Case Study with Amlodipine

The incidence of paediatric obesity continues to rise worldwide and contributes to a range of diseases including cardiovascular disease. Obesity in children has been shown to impact upon the plasma concentrations of various compounds, including amlodipine. Nonetheless, information on the influence of obesity on amlodipine pharmacokinetics and the need for dose adjustment has not been studied previously. This study applied the physiologically based pharmacokinetic modelling and established a paediatric obesity population to assess the impact of obesity on amlodipine pharmacokinetics in children and explore the possible dose adjustments required to reach the same plasma concentration as non-obese paediatrics. The difference in predicted maximum concentration (Cmax) and area under the curve (AUC) were significant between children with and without obesity across the age group 2 to 18 years old when a fixed-dose regimen was used. On the contrary, a weight-based dose regimen showed no difference in Cmax between obese and non-obese from 2 to 9 years old. Thus, when a fixed-dose regimen is to be administered, a 1.25- to 1.5-fold increase in dose is required in obese children to achieve the same Cmax concentration as non-obese children, specifically for children aged 5 years and above.

Sleeve Gastrectomy: Literature Results

Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure globally. However, data regarding short- and long-term results remain insufficient. This study aimed to evaluate the short- and longterm effects of SG. We performed a thorough PubMed search for references that mentioned sleeve gastrectomy was carried out. In terms of weight loss and resolution of comorbid disorders, the immediate results have been encouraging. Although long-term results are still being obtained, a large number of individuals have experienced persistent weight loss. Eight short-term studies were extracted for the present review. Each study clarified that SG was utilized as a management technique for a high-risk patient population or as a component of a stepwise therapeutic procedure. The laparoscopic SG method was examined in all studies. The percentage of patients who were followed up for 30 days or longer after LSG was reported. Significant weight loss has been observed in studies that evaluated short-term results. An excess weight loss of 67.3% and a significant decrease in body mass index (BMI) were observed in a systematic evaluation of 5,218 patients. In long-term studies, SG was administered to 2713 patients, of whom 1626 completed the five-year follow-up period. Among all patients, 71.3% were women and 28.7% men. The mean BMI before surgery was 46.9 kg/m². The follow-up durations ranged from 5 to 11 years. The mean five-year follow-up rate was 66% (range 57-100%). At 5, 6, 7, 8 and 11 years, the mean percentage excess weight decreases were 58.4%, 59.5%, 56.6% and 62.5%, respectively. Five years after SG, resolution of type 2 diabetes resolved in 77.8% of patients, and arterial hypertension, dyslipidemia, obstructive sleep apnea, gastroesophageal reflux disease and degenerative joint diseases improved or resolved in 68.0%, 65.9%, 75.8%, 30.6% and 55.7% of patients, respectively. Laparoscopic SG is more technically straightforward and has fewer surgical complications than other more complex surgical techniques. Laparoscopic SG is an effective treatment option for bariatric surgery. It is relatively easy to perform, well tolerated by patients and effective for longterm excessive weight loss and resolution of comorbidities.

Lipid Profile and the Frequency of Dyslipidemia in Iranian Adolescents with Severe Obesity, Who Were Candidates for Bariatric Surgery

PURPOSE

Although several studies have investigated the prevalence of dyslipidemia in adults undergoing bariatric surgery, the experience is limited in adolescents. This study aimed to evaluate the serum lipid profile and prevalence of dyslipidemia in Iranian adolescents with severe obesity undergoing bariatric surgery.

MATERIALS AND METHODS

In this cross-sectional study, a total of 92 adolescents, aged < 20 years, with severe obesity (body mass index (BMI) ≥ 99th percentile), who were candidates for bariatric surgery were enrolled during 2016-2018. The fasting serum levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were measured in this study. Dyslipidemia was defined as TC, LDL-C, and TG ≥ 95th percentile or HDL-C < 10th percentile for age and sex.

RESULTS

The mean age of the participants was 17.32 ± 1.88 years (age range, 11-19 years). Overall, 60.9% of the participants were female. Based on the results, 68.48% of the adolescents had dyslipidemia. The most frequent lipid disorder was hypertriglyceridemia (48.9%), followed by low HDL-C (39.6%), hypercholesterolemia (18.5%), and high LDL-C (16.5%). The serum concentrations of lipid components were not significantly different according to sex and age.

CONCLUSION

The prevalence of dyslipidemia was found to be high among Iranian adolescents with severe obesity. Hypertriglyceridemia and low HDL-C were the most common types of dyslipidemia in this population. Therefore, screening for dyslipidemia may be clinically useful in adolescents with severe obesity; timely diagnosis and treatment may prevent the occurrence of coronary events in the future.

Nutrient Deficiency After Bariatric Surgery in Adolescents: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis study aimed to estimate changes in blood nutrient concentrations and nutrient deficiencies in adolescents following bariatric surgery.

METHODS

We searched PubMed, Scopus, and the Web of Science to find studies published between January 2000 and August 2023. Observational studies reporting the mean blood concentration of nutrients before and after bariatric surgery or the proportion of nutrient deficiencies after the surgery in healthy adolescents were selected.

RESULTS

Fifteen studies were included. Gastric bypass and sleeve gastrostomy were the most common types of surgery. Vitamin D, iron, or ferritin, vitamin B12, calcium, and folic acid were the most studied nutrients, respectively. Other nutrients examined in the studies included zinc, phosphorus, and albumin. The serum ferritin increased by 21 mcg/L (95% CI = 10.0, 32.0 mcg/L) after the surgery, but there were no significant alterations in other nutrients. The postoperative prevalence of low albumin, ferritin, vitamin D, and vitamin B12 levels was 10%, 49%, 41%, and 20%, respectively. Also, 23% had an iron deficiency, and 10% had a calcium deficiency after bariatric surgery.

CONCLUSIONS

The serum ferritin level increased following bariatric surgery in adolescents. Vitamin D and ferritin deficiencies were estimated to be present in more than one-third of adolescents after the surgery.

Change in Mineral Status After Bariatric Surgery: a Meta-analysis

BACKGROUND

The risk of protein and vitamin deficiencies after bariatric surgery has been well studied, but the change in mineral status has not gotten enough attention. This study aimed to perform a meta-analysis regarding the change in mineral levels after bariatric surgery and the prevalence of postoperative mineral deficiency, with subgroup analyses of different surgical procedures, study regions, and follow-up time.

METHODS

CENTRAL, PubMed, and EMBASE were searched for related articles. Meta-analysis, subgroup analysis, and sensitivity analysis were performed if necessary.

RESULTS

A total of 107 articles with 47,432 patients were included. The most severe mineral deficiency after bariatric surgery was iron (20.1%), followed by zinc (18.3%), copper (14.4%), chlorine (12.2%), phosphorus (7.5%), and calcium (7.4%). Serum concentrations of potassium, sodium, selenium, manganese, and molybdenum showed no significant change before and after surgery. Subgroup analyses revealed that SG had fewer deficiencies in serum iron, calcium, zinc, magnesium, phosphorus, copper, and selenium than RYGB. OAGB showed a higher incidence of serum iron and zinc deficiencies than RYGB. Studies conducted in different regions also found various mineral statuses after surgery. Studies with follow-up ≥ 5 years had a lower prevalence of zinc, copper, and selenium deficiencies than follow-up < 5 years.

CONCLUSION

A high deficiency rate of serum iron, zinc, copper, chlorine, phosphorus, and calcium was seen after bariatric surgery. The difference in surgical procedures, study regions, and follow-up time may affect postoperative mineral status; more targeted mineral supplement programs are needed considering these influencing factors.

A Systematic Review and Meta-Analysis of Vitamin D Status of Patients with Severe Obesity in Various Regions Worldwide

INTRODUCTION

Managing nutritional deficiencies is an essential component in the treatment of severe obesity. Vitamin D deficiency is often reported in investigations in severely obese cohorts. However, no prior study has summarized findings on this topic. Consequently, the aim of this systematic review and meta-analysis was to investigate the 25-hydroxyvitamin D [25(OH)D] status in individuals with severe obesity in different regions worldwide. We also evaluated levels of calcium, parathyroid hormone (PTH), and magnesium as secondary outcome measures.

METHODS

We searched Medline, PubMed, Scopus, the Cochrane Library, and EMBASE for relevant observational studies published in English from 2009 to October 2021. The heterogeneity index among the studies was determined using the Cochran (Q) and I2 tests. Based on the heterogeneity results, the random-effect model was applied to estimate the prevalence of vitamin D deficiency.

RESULTS

We identified 109 eligible observational studies. Overall, 59.44% of patients had vitamin D deficiency [25(OH)D <20 ng/mL], whereas 26.95% had vitamin D insufficiency [25(OH)D 20-30 ng/mL]. Moreover, the mean 25(OH)D level was 18.65 ng/mL in 96 studies. The pooled mean estimate of the serum calcium, PTH, and magnesium was 9.26 mg/dL (95% confidence interval [CI]: 9.19-9.32, I2 = 99.7%, p < 0.001), 59.24 pg/mL (95% CI: 54.98, 63.51, I2 = 99.7%, p < 0.001), and 0.91 mg/dL (95% CI: 0.84, 0.98, I2 = 100.0%, p < 0.001), respectively. The results of the subgroup analysis indicated that the mean estimates of 25(OH)D were highest in North America (21.71 ng/mL [19.69, 23.74], [I2 = 97.2%, p < 0.001]) and lowest in Southeast Asia (14.93 ng/mL [14.54, 15.33], [I2 = 0.0%, p = 0.778]).

CONCLUSION

The results obtained showed a significant prevalence of vitamin D deficiency among severely obese individuals in various geographical regions, whereas the highest and lowest mean estimates were reported for North America and Southeast Asia, respectively.

Bariatric Surgery in Adolescents with Obesity: Long-Term Perspectives and Potential Alternatives

BACKGROUND

Severe obesity among adolescent shows a worrisome trend in regard to its increasing prevalence and poses a great challenge for treatment. Conservative measures have modest effects on weight loss, usually fail in achieving a sustainable weight loss and resolution of comorbidities. This has led to greater utilization of bariatric surgery (BS) that offers a fast reduction in body mass index with little perioperative complications. Despite the increasing utilization of BS, data are still insufficient, regarding their long-term outcome in adolescents. We review short- and long-term effects of BS and their implications on bone health and nutritional deficiencies in adolescents. In addition, we discuss possible pharmaceutical alternatives.

SUMMARY

BS results in a substantial weight loss of roughly 37% in the first-year post-operation and is superior to conservative measures in resolution of metabolic comorbidities. BS significantly improves health-related quality of life. Longer follow-up (F/U) shows weight regain in 50% of patients. Furthermore, reduced bone mass and nutritional deficiencies were reported in up to 90% of patients. Most recently, alternative to BS became more relevant with approval of GLP-1 analogues use in adolescents. GLP-1 analogues are potent enough to induce moderate clinically meaningful weight loss and improvement of metabolic component.

KEY MESSAGES

We conclude that obese adolescents without major obesity-related complications may benefit from pharmacological interventions with lifestyle modification. We advise considering BS as treatment approach in adolescents with severe obesity and major obesity-related complications with proper preoperative preparation and postoperative F/U in excellence centers.

Cirugía bariátrica en pediatría, ¿qué impacto tiene? Revisión de la literatura

Introducción. La obesidad en la población pediátrica ha ido aumentando de manera progresiva y el manejo médico de la obesidad mórbida en esta población se ha mostrado insuficiente. El objetivo de este artículo fue describir el estado actual de la literatura científica publicada hasta abril 15 de 2021 sobre el impacto de la cirugía bariátrica en la población pediátrica. Métodos. Se realizó una revisión de la literatura que evaluó dos bases de datos, donde se incluyeron revisiones sistemáticas, reportes de casos, series de casos y ensayos clínicos, publicados desde el 1 de enero de 2010 hasta el 15 de abril de 2021, en español, inglés y francés. Resultados. Se incluyeron 56 documentos y 18 estudios clínicos, en los que se encontró que la cirugía bariátrica (bypass gástrico por Y de Roux, gastrectomía en manga, plicatura gástrica y banda gástrica) alcanzó una pérdida de peso significativa en el primer año, con un adecuado sostenimiento de dicha pérdida al quinto año, además de una resolución completa de las comorbilidades metabólicas y cardiovasculares en la mayoría de los pacientes. Conclusión. La cirugía bariátrica se presenta como una alternativa eficaz en el manejo de la obesidad mórbida y sus complicaciones en el paciente pediátrico

Laparoscopic sleeve gastrectomy for treatment of type 2 diabetes mellitus in adolescents

Background

Metabolic diseases have been associated with childhood obesity no longer restricted to adults as previously known. Hypertension and diabetes mellitus (DM) have been reported in children with morbid obesity. Laparoscopic sleeve gastrectomy (LSG) has been used as a primary procedure for weight control among children and adolescents with acceptable records of effective weight loss together with evidence of improvement of associated co-morbidities.

Results

Thirty-two patients were diagnosed with morbid obesity and DM presented to obesity and nutrition clinic and were included in this study. Laparoscopic sleeve gastrectomy (LSG) was the chosen operation to treat their obesity and associated co-morbidities. Fasting blood sugar and HbA1c were measured before the operation and 1 year after surgery. Twenty-seven patients had significant improvement of their glycemic profile and managed to stop the hypoglycemic medication.

Conclusion

LSG may play an important role as a metabolic control procedure rather than a bariatric restrictive procedure only.

Vitamin D and Calcium Status Among Adolescents with Morbid Obesity Undergoing Bariatric Surgery

PURPOSE

Obesity is very prevalent among children and adolescents these days. Obese children are at increased risk of vitamin D and other micronutrient deficiencies. This risk is even higher in children and adolescents with morbid obesity who are candidates for bariatric surgery. Although multiple studies have studied the prevalence of vitamin D deficiency in adults undergoing bariatric surgery, studies are limited concerning adolescents in this regard. We aimed to study the prevalence of vitamin D deficiency and insufficiency and calcium status among morbidly obese children and adolescents.

MATERIALS AND METHODS

A number of 96 adolescents (20 years old and younger) with morbid obesity (BMI ≥ 99% percentile), who were candidates for bariatric surgery, were enrolled in this study (from 2016 to 2018), and their serum vitamin D and calcium levels were measured.

RESULTS

Sixty-four percent of the patients were vitamin D-deficient and 15.7% of them had insufficient levels of serum vitamin D. Only 20.2% of the children had sufficient serum vitamin D levels. Serum calcium levels were within the normal range among all of the patients. There was no significant relationship between age and sex with vitamin D levels.

CONCLUSION

Vitamin D deficiency is of very high prevalence among adolescents with morbid obesity.

Nutritional Deficiencies Among Adolescents Before and After Sleeve Gastrectomy: First Study with 9-Year Follow-up

BACKGROUND

Globally, only two studies appraised the long-term nutritional status of adolescents after laparoscopic sleeve gastrectomy (LSG).

METHODS

Retrospective chart review of all adolescents aged ≤ 18 years who underwent LSG with ≥ 5 years follow-up and had no subsequent revisional surgery (N = 146). We assessed 15 nutritional parameters preoperatively and at 1, 3, 5, 7, and 9 years post surgery.

RESULTS

Mean age was 16.51 ± 1.29 years, 51% were males. We identified three patterns: 1) Significant worsening of preoperative deficiencies: 4.7% and 0.8% of the sample exhibited zinc and vitamin B12 deficiencies, worsening to 20.8% and 12.8% at 1 year, respectively. Likewise, 0.7% of the sample had low total protein, worsening to 8.3% at year 3. A total of 32.4% of females had preoperative low hemoglobin worsening to 57.9% at year 5. 2) Significant improvement: the percentage of males with preoperative low hemoglobin (5.6%) was reduced to 4.1% and 5.1% at years 1 and 3, respectively. 3) Persistent deficiency: all (100%) of adolescents had preoperative vitamin D deficiency that persisted through years 3 and 9 at 90.5% and 100%, respectively. The most common complications were food intolerance (51%), vomiting (47.5%), gastritis/ esophagitis (35.7%), and gastroesophageal reflux disease (20.3%). We observed one case of Wernicke's encephalopathy. Across the 9 years, 15.4% of the adolescents underwent intra-abdominal surgeries where 12.6% had cholecystectomy and one patient had appendectomy.

CONCLUSION

Adolescents had several preoperative nutritional deficiencies, most of which worsened or persisted on the long term. This is the first study among adolescents to assess such deficiencies beyond 5 years.

Multiple nutritional deficiencies among adolescents undergoing bariatric surgery: who is at risk?

BACKGROUND

Nutritional deficiencies among adolescents undergoing bariatric surgery (BS) have not been evaluated a in relation to patient's sex.

OBJECTIVES

We compared the preoperative nutritional profile of adolescents characterized by sex and single versus multiple deficiencies.

SETTING

University hospital.

METHODS

Cross-sectional retrospective chart review of 415 eligible adolescents who underwent primary BS between 2011 and 2020. Data included preoperative demographic, anthropometric information as well as three sets of nutritional variables: anemia-related, calcium-related, and other nutritional variables.

RESULTS

The sample comprised 247 males (59.5%) with a mean age of 15.89 ± 1.03 years and a mean body mass index (BMI) of 47.80 ± 6.57 kg/m². Most common deficiencies were vitamin D (92.3%), albumin (51.8%), anemia (15.9%), zinc (11.1%), and vitamin B₁₂ (8%); 21.7% had hyperparathyroidism. Females exhibited a significantly higher prevalence of low hemoglobin, low hematocrit, and iron deficiency. Multiple deficiencies were present among 97.6%, 73.2%, 23.6%, 15%, and 12.6% of adolescents, who had vitamin D, albumin, hemoglobin, zinc, and vitamin B₁₂ deficiencies, respectively. Univariate analysis revealed that adolescents with a BMI of ≥50 kg/m² were 1.24 times more likely to have multiple deficiencies (P = .004). Using multivariate log-binomial regression, BMI of ≥50 kg/m² was a significant predictor of multiple nutritional deficiencies (P = .005, adjusted risk ratio = 1.23, 95% CI 1.06-1.42). Age and sex were not independent predictors of multiple nutritional deficiencies.

CONCLUSION

To our knowledge, this study is the first to appraise single and multiple nutritional deficiencies in adolescents undergoing BS by sex. Multiple deficiencies were common. Females are at higher risk of anemia-related deficiencies. A BMI of ≥50 kg/m² independently and significantly predicted multiple nutritional deficiencies. Correction before and monitoring after surgery are important.

Durability of Cardiometabolic Outcomes Among Adolescents After Sleeve Gastrectomy: First Study with 9-Year Follow-up

BACKGROUND

Long-term durability of weight loss and comorbidity resolution beyond 7 years after laparoscopic sleeve gastrectomy (LSG) among adolescents is completely lacking.

METHODS

Retrospective review of adolescents aged ≤ 18 years who underwent primary LSG at our institution between 2011 and 2015 (N = 146). We assessed anthropometric and cardiometabolic outcomes at 1, 3, 5, 7, and 9 years.

RESULTS

Follow-up rates were 57.53%, 82.87%, 85.24%, 83.92%, and 83.33% at the five time points. The preoperative mean body mass index (BMI) (45.60 ± 6.50 kg/m2) decreased at year 1 (30.04 ± 4.96 kg/m2, P=0.001) and was maintained up to 9 years (30.20 ± 3.92 kg/m2, P = 0.001). Remission rates were triglycerides, 100% (11/11) at 5 years, and 100% (1/1) at 9 years; high density lipoprotein, 89.4% (17/19) at 5 years, and 100% (3/3) at 7 years; low density lipoprotein, 71.4% (11/14) and 100% (3/3) at 5 and 7 years; total cholesterol, 70% (7/10) at 5 years, and 100% (2/2) at 9 years; uric acid, 100% (3/3) at 5 years. Remission of liver enzymes was 84.6-100% (22/26-2/2) at 5-9 years. Prediabetes remission was 87.5% (14/16 and 7/8) at 5 and 7 years and 100% (3/3) at year 9. Type 2 diabetes complete remission was 50% (3/6, 1/2) at years 5 and 7, with all cases resolved at 9 years. The only case of hypertension completely resolved.

CONCLUSIONS

LSG achieved substantial weight loss and remission of cardiometabolic risk factors that were sustained on the long term. This is the first study among adolescents to assess such outcomes beyond 7 years.

Bariatric Surgery in Adolescents: To Do or Not to Do?

Pediatric obesity is a multifaceted disease that can impact physical and mental health. It is a complex condition that interweaves biological, developmental, environmental, behavioral, and genetic factors. In most cases lifestyle and behavioral modification as well as medical treatment led to poor short-term weight reduction and long-term failure. Thus, bariatric surgery should be considered in adolescents with moderate to severe obesity who have previously participated in lifestyle interventions with unsuccessful outcomes. In particular, laparoscopic sleeve gastrectomy is considered the most commonly performed bariatric surgery worldwide. The procedure is safe and feasible. The efficacy of this weight loss surgical procedure has been demonstrated in pediatric age. Nevertheless, there are barriers at the patient, provider, and health system levels, to be removed. First and foremost, more efforts must be made to prevent decline in nutritional status that is frequent after bariatric surgery, and to avoid inadequate weight loss and weight regain, ensuring successful long-term treatment and allowing healthy growth. In this narrative review, we considered the rationale behind surgical treatment options, outcomes, and clinical indications in adolescents with severe obesity, focusing on LSG, nutritional management, and resolution of metabolic comorbidities.

Self-management Behaviors and Anthropometric Indices after Roux-en-Y Gastric Bypass

BACKGROUND

The aim of this study was to correlate the connection between self-management behaviors and anthropometric indices after Roux-en-Y gastric bypass (RYGB).

METHODS

A sample of 180 patients suffering from obesity were treated with RYGB in 2019; 6 and 18 months after surgery, anthropometric indices, including weight, waist circumference, waist- to-height ratio, body mass index (BMI), and waist-to-hip ratio, were gauged, and participants completed the post-bariatric surgery self-management behaviors questionnaire.

RESULTS

Correlation matrix results showed that all anthropometric indices had a significant positive relationship with self-management behaviors after RYGB; the results of the 18-month post-surgical follow-up exhibited no significant difference between anthropometric indices and self-management behaviors, 6 and 18 months after surgery.

CONCLUSION

Therefore, the more self-management behaviors increase, the greater decrease in anthropometric indices will happen after RYGB.

The effects of adolescent laparoscopic adjustable gastric band and sleeve gastrectomy on markers of bone health and bone turnover

25-hydroxy vitamin D (25 OHD) deficiency and secondary hyperparathyroidism have been seen after metabolic and bariatric surgery, but data are lacking on the bone health outcomes of adolescent sleeve gastrectomy (SG). The purpose of this study was to examine bone-related nutrition after SG, compared to laparoscopic adjustable gastric band (LAGB), and trend bone turnover markers following SG. This is an observational study of 197 adolescents who underwent LAGB (n = 98) or SG (n = 99). Bone health labs were collected at baseline and 6 and/or 12 months after LAGB or SG, with additional analysis of bone turnover markers in the SG group. Calcium and 25 OHD levels increased at 6 and 12 months after LAGB and SG, with no difference between the surgeries. Parathyroid hormone levels decreased only in the SG group. SG patients had increased osteocalcin and carboxy-terminal cross-linking telopeptide of type 1 collagen (CTX) at 6 and 12 months post-SG, although CTX decreased between 6 and 12 months. Excess weight loss at 6 months predicted the rise in CTX, but the changes in osteocalcin and CTX could not be attributed to 25 OHD deficiency, hypocalcemia or hyperparathyroidism. Patients had improved 25 OHD levels post-surgery, which may be secondary to stringent vitamin supplementation guidelines. However, there were marked increases in bone turnover markers following SG. More studies are needed to evaluate the effects of SG on adolescent bone health and to correlate the early changes in bone turnover with bone mineral density and fracture risk.

British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery-2020 update

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.

Laparoscopic sleeve gastrectomy in morbidly obese adolescents: Initial experience of a Pediatric Multidisciplinary Unit

INTRODUCTION

Childhood obesity is a significant health problem worldwide, associated with significant metabolic and cardiovascular morbidity. Recent evidence points to metabolic and bariatric surgery as a safe and effective treatment for morbidly obese adolescents. We aim to report the initial results after laparoscopic sleeve gastrectomy (LSG) for adolescent patients in a pediatric center.

MATERIAL AND METHODS

Retrospective data review of patients younger than 19 years who underwent LSG for treatment of morbid obesity between 2013 and 2019.

RESULTS

A total of 16 adolescents (12 female, 4 male) with a median age of 17.5 years underwent LSG. Median preoperative weight and body mass index were 129kg and 48.6kg/m^-2, respectively. All patients had at least one comorbidity. Median follow-up was 18.5 months. The overall percent total weight loss was 32.5% and percent excess weight loss was 68%. Resolution of comorbidities was noted in the majority of patients. No perioperative complications were reported.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is a safe and effective option for treatment of morbidly obese adolescents, resulting in significant weight loss and comorbidity resolution with a low risk of complications.

Recommendations Based on Evidence by the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the Pre- and Postoperative Management of Patients Undergoing Obesity Surgery

In order to develop evidence-based recommendations and expert consensus for nutrition management of patients undergoing bariatric surgery and postoperative follow-up, we conducted a systematic literature search using PRISMA methodology plus critical appraisal following the SIGN and AGREE-II procedures. The results were discussed among all members of the GARIN group, and all members answered a Likert scale questionnaire to assess the degree of support for every recommendation. Patients undergoing bariatric surgery should be screened preoperatively for some micronutrient deficiencies and treated accordingly. A VLCD (Very Low-Calorie Diet) should be used for 4-8 weeks prior to surgery. Postoperatively, a liquid diet should be maintained for a month, followed by a semi-solid diet also for one month. Protein requirements (1-1.5 g/kg) should be estimated using adjusted weight. Systematic use of specific multivitamin supplements is encouraged. Calcium citrate and vitamin D supplements should be used at higher doses than are currently recommended. The use of proton-pump inhibitors should be individualised, and vitamin B12 and iron should be supplemented in case of deficit. All patients, especially pregnant women, teenagers, and elderly patients require a multidisciplinary approach and specialised follow-up. These recommendations and suggestions regarding nutrition management when undergoing bariatric surgery and postoperative follow-up have direct clinical applicability.

Nutritional Risks in Adolescents After Bariatric Surgery

BACKGROUND & AIMS

Little is known about prevalence and risk factors for nutritional deficiencies in adolescents after metabolic bariatric surgery. We performed a 5-year prospective cohort study of these.

METHODS

Adolescents who had Roux-en-Y gastric bypass (RYGB, n = 161) or vertical sleeve gastrectomy (VSG, n = 67) were enrolled at 5 tertiary-care centers from March 2007 through February 2012. The final analysis cohort included 226 participants (161 who had RYGB and 65 who had VSG). We measured serum levels of ferritin; red blood cell folate; vitamins A, D, B₁, B₁₂; and parathyroid hormone at baseline and annually for 5 years. General linear mixed models were used to examine changes over time and identify factors associated with nutritional deficiencies.

RESULTS

The participants were 75% female and 72% white, with a mean age of 16.5 ± 1.6 years and mean body mass index of 52.7 ± 9.4 kg/m² at surgery. Mean body mass index decreased 23% at 5 years, and did not differ significantly between procedures. After RYGB, but not VSG, serum concentrations of vitamin B₁₂ significantly decreased whereas serum levels of transferrin and parathyroid hormone increased. Ferritin levels decreased significantly after both procedures. Hypo-ferritinemia was observed in 2.5% of patients before RYGB and 71% at 5 y after RYGB (P < .0001), and 11% of patients before VSG and 45% 5 y after VSG (P = .002). No significant changes in serum levels of folate or vitamins A, B₁, or D were found between baseline and 5 y after either procedure. By 5 y, 59% of RYGB and 27% of VSG recipients had 2 or more nutritional deficiencies. Risk factors associated with specific deficiencies included surgery type, female sex, black race, supplementation intake, weight regain, and for females, pregnancy.

CONCLUSIONS

In a prospective study of adolescents who underwent RYGB or VSG, we observed nutritional deficiencies by 5 y after the procedures-particularly in iron and B₁₂ after RYGB. Ongoing nutrient monitoring and supplementation are recommended for all patients, but surgery type, supplementation intake, sex, and race might affect risk. (Clinical trial registration: Adolescent Bariatrics: Assessing Health Benefits and Risk [also known as Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS)], NCT00474318.).

Single-Port Sleeve Gastrectomy Compared With Conventional Laparoscopic Sleeve Gastrectomy: 5-Year Follow-up of Weight Loss, Comorbidity Resolution, and Cost

Background. The Single-Port Instrument Delivery Extended Reach (SPIDER) surgical system is a safe revolutionary technology that defeated difficulties of single-incision surgery. We assessed the long-term outcomes of SPIDER sleeve gastrectomy (SPIDER SG) versus conventional laparoscopic sleeve gastrectomy (LSG) in morbidly obese patients. Methods. Retrospective review of patients who underwent SPIDER SG or LSG in our center matched by the date of surgery (2012-2013). We reviewed weight loss results up to 5 years, complication rates, procedure and hospitalization durations, financial cost, and effect on comorbidities. Results. Patients underwent 200 SPIDER SG and 220 LSG. At baseline, SPIDER SG versus LSG patients had a mean body mass index of 43.8 ± 5.6 and 48.6 ± 8.1 kg/m², respectively. At 1 year, both groups had comparable percentage of excess weight loss (%EWL). At 5 years, SPIDER SG had %EWL of 54.6 ± 24.8 compared with 57.8 ± 29.9 in LSG (P = .4). Nine SPIDER SG (4.5%) required conversion to LSG. Complications occurred in both groups: 4% versus 4.1% (P = .95). At 2-year follow-up, diabetes mellitus was reversed in 43% of SPIDER SG and 62% LSG. Despite a shorter hospital stay in SPIDER SG, the total cost was significantly higher ($2 041 477) compared with LSG ($1 773 834). The mean score of scar satisfaction was significantly more in SPIDER SG. Conclusions. SPIDER SG was safe with long-term effects on weight loss comparable to LSG. Despite the higher cost of SPIDER SG, a shorter hospital stay and better cosmesis were observed.

Five-year Outcomes of Laparoscopic Sleeve Gastrectomy: a Comparison Between Adults and Adolescents

BACKGROUND

Bariatric surgery in adolescents is still under debate. Literature about the long-term impact of laparoscopic sleeve gastrectomy (LSG) on adolescents' obesity and associated morbidities is scarce. It is unknown if LSG shows better long-term results in the adolescent or adult group.

AIM

To compare the long-term effectiveness of LSG on obesity and associated comorbidities between adolescents and adults.

METHODS

This retrospective study analyzed all patients with morbid obesity who underwent LSG in (2011-2012) and were followed for up to 5 years. Patients were divided into two groups: adolescents and adults. Data were compared between the two groups.

RESULTS

LSG was performed in 139 adults and 91 adolescents. The mean ages of the adults and adolescents were 37.4 ± 11.4 and 17 ± 1.5 years, respectively. The preoperative body mass index values of the adults and adolescents were 48.4 ± 8.7 and 47.6 ± 7.5 kg/m2, respectively (P = 0.95). At 5 years, percentage of total weight loss increased in adolescents (to 35.8 ± 11.5%), while it remained almost the same in adults (26.3 ± 10%). At 1 year, about 68.2% of adults and 62.5% of adolescents were cured from diabetes though, 13% of diabetic adults had relapse at 5 years and none of the adolescents relapsed. Postoperative complications occurred in both groups.

CONCLUSION

LSG showed comparable weight loss results in adults and adolescents, with better results in adolescents. LSG is more effective in preventing and treating diabetes/prediabetes in the adolescent group.

Micronutrient intake and biochemistry in adolescents adherent or nonadherent to supplements 5 years after Roux-en-Y gastric bypass surgery

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective obesity treatment in adults and has become established in adolescents. Lower adherence to supplementation in adolescents confers a risk for long-term nutritional deficiencies.

OBJECTIVES

To assess adherence to supplementation, micronutrient intake, and biochemistry in adolescents through 5 years after RYGB.

SETTING

University hospitals, multicenter study, Sweden.

METHODS

Micronutrient intake and adherence to supplementation were assessed by diet history interviews and biochemistry preoperatively, 1, 2, and 5 years after RYGB in 85 adolescents (67% females), aged 16.5 years (± 1.2) with a body mass index of 45.5 kg/m² (± 6.0). Adherence was defined as taking prescribed supplements ≥3 times a week. Micronutrient intake and biochemistry were compared with matched controls at 5 years.

RESULTS

Over 75% completed the dietary assessments across 5 years after RYGB. Adherence ranged between 44-61% through 5 years. At 5 years, ferritin and hemoglobin decreased (P < .04) and 61% had iron deficiency (P ≤ .001). Among females with iron deficiency, most did not adhere to supplementation (P = .005), and 59% of these had anemia (P < .001). Vitamin D insufficiency continued after surgery and 80% of participants who did not adhere to supplementation had insufficiency (P = .002). Adolescents not adhering had lower levels of vitamin D, B₁₂, and ferritin (females) compared with both adhering adolescents and the control group (all P < .04).

CONCLUSIONS

Half of adolescents after RYGB reported sufficient long-term adherence to supplementation. Adhering to supplements and reporting a higher micronutrient intake were associated with more favorable biochemistry. Results support the recommendations for monitoring micronutrient intake and biochemistry in all patients who have undergone RYGB surgery, and the recommendation of higher preventive supplementation of vitamin D and iron in both sexes. As hypothesized, adolescents not adhering had a higher prevalence of long-term micronutrient deficiencies.