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Alcedo González J, Estremera-Arévalo F, Cobián Malaver J, Santos Vicente J, Alcalá-González LG, Naves J, Barba Orozco E, Barber Caselles C, Serrano-Falcón B, Accarino Garaventa A, Alonso-Cotoner C, Serra Pueyo J. Common questions and rationale answers about the intestinal bacterial overgrowth syndrome (SIBO). GASTROENTEROLOGIA Y HEPATOLOGIA 2024:502216. [PMID: 38852778 DOI: 10.1016/j.gastrohep.2024.502216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/15/2024] [Accepted: 05/24/2024] [Indexed: 06/11/2024]
Affiliation(s)
- Javier Alcedo González
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Instituto de Investigación Sanitaria (IIS) Aragón, Zaragoza, España.
| | - Fermín Estremera-Arévalo
- Servicio de Aparato Digestivo, Hospital Universitario de Navarra, Navarrabiomed, Universidad Pública de Navarra - IdiSNA, Navarra, España
| | | | - Javier Santos Vicente
- Laboratorio de Neuro-Inmuno-Gastroenterología, Unidad de Investigación de Aparato Digestivo, Institut de Recerca (VHIR), Servicio de Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Instituto de Salud Carlos III, Madrid, España
| | | | - Juan Naves
- Servicio de Aparato Digestivo, Hospital del Mar, Barcelona, España
| | - Elizabeth Barba Orozco
- Unidad de Neurogastroenterología y Motilidad, Hospital Clínic de Barcelona, Barcelona, España; Departamento de Gastroenterología, Universidad de Barcelona, Barcelona, España
| | | | - Blanca Serrano-Falcón
- Servicio de Aparato Digestivo, Hospital Universitario Virgen de las Nieves, Granada, España
| | | | - Carmen Alonso-Cotoner
- Laboratorio de Neuro-Inmuno-Gastroenterología, Unidad de Investigación de Aparato Digestivo, Institut de Recerca (VHIR), Servicio de Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Instituto de Salud Carlos III, Madrid, España; Facultad de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - Jordi Serra Pueyo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Instituto de Salud Carlos III, Madrid, España; Área de Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, España
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Melali H, Abdolahi A, Sheikhbahaei E, Vakili K, Mahmoudieh M, Keleidari B, Shahabi S. Impact of Probiotics on Gastrointestinal Function and Metabolic Status After Roux-en-Y Gastric Bypass: A Double-Blind, Randomized Trial. Obes Surg 2024; 34:2033-2041. [PMID: 38653887 DOI: 10.1007/s11695-024-07225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 04/04/2024] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Postoperative changes in gut microbiota may occur in patients undergoing Roux-en-Y gastric bypass surgery. In this study, we evaluate the impact of administering probiotic tablets on the gastrointestinal function and metabolic status of these patients. MATERIALS AND METHODS This double-blinded randomized clinical trial was conducted from 2021 to 2022 on 135 Roux-en-Y surgery candidates. The intervention group underwent the surgical procedure and started receiving probiotic supplements (Familact Co.) 1 week after surgery; the control group received a placebo. The laboratory and anthropometric data were measured and analyzed before and 3 and 6 months after the intervention. GIQLI questionnaire was also used at the beginning and 6 months after the intervention to evaluate GI symptoms. RESULTS We observed significantly reduced BMI in both groups after surgeries (P < 0.001). The levels of FBS and HbA1C were significantly lower in the probiotic group compared to the placebo in 3 months (P = 0.02 and P = 0.001, respectively) and 6 months (P < 0.001 for both) after the intervention. The levels of vitamin B12 increased significantly in the probiotic group (P < 0.001), and the values were substantially higher than the placebo group in 3 and 6 months (P < 0.001), respectively. Analysis of the GIQLI questionnaire before and 6 months after interventions also revealed significant improvement in the GIQLI score in both groups (P < 0.001 for probiotics and P = 0.03 for placebo). CONCLUSION Probiotic supplement administration following RYGB improves patients' vitamin and metabolic profile, as well as GI function, although it cannot significantly affect weight loss.
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Affiliation(s)
- Hamid Melali
- Isfahan Minimally Invasive Surgery and Obesity Research Center, Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alimeh Abdolahi
- Department of General Surgery, School of Medicine, Isfahan University of Medical Science, Isfahan, Iran
| | - Erfan Sheikhbahaei
- Isfahan Minimally Invasive Surgery and Obesity Research Center, Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Iran University of Medical Sciences, Hazrat-E Rasool General Hospital, Masouri St. Niyayesh St. Satarkhan Ave., Tehran, 14665-354, Iran
| | - Kimia Vakili
- Student Research Committee, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Mahmoudieh
- Isfahan Minimally Invasive Surgery and Obesity Research Center, Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Behrouz Keleidari
- Isfahan Minimally Invasive Surgery and Obesity Research Center, Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shahab Shahabi
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Iran University of Medical Sciences, Hazrat-E Rasool General Hospital, Masouri St. Niyayesh St. Satarkhan Ave., Tehran, 14665-354, Iran.
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Mattio N, Pradat P, Machon C, Mialon A, Roman S, Cuerq C, Mion F. Glucose breath test for the detection of small intestine bacterial overgrowth: Impact of diet prior to the test. Neurogastroenterol Motil 2024; 36:e14801. [PMID: 38606691 DOI: 10.1111/nmo.14801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/20/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Glucose breath test (GBT) is used for the diagnosis of small intestine bacterial overgrowth. A restrictive diet without fibers and/or fermentable food is recommended on the day before the test. The aim of our retrospective study was to evaluate the impact of two different restrictive diets on the results of GBT. METHODS A change of the pretest restrictive diet was applied in our lab on September 1, 2020. The recommended diet was a fiber-free diet before this date, and a fiber-free diet plus restriction of all fermentable food afterward. We thus compared the results of GBT performed before (group A) and after (group B) this pretest diet modification. Demographics, reasons to perform GBT, digestive symptoms, and hydrogen and methane baseline values and variations after glucose ingestion were compared between the two groups. KEY RESULTS 269 patients underwent GBT in group A, and 316 patients in group B. The two groups were comparable in terms of demographics. Methane and hydrogen baseline values were significantly higher in group A (respectively 14 [18] vs. 8 [14] ppm, p < 0.01 and 11 [14] vs. 6 [8] ppm, p < 0.01). The percentage of positive tests was higher in group A for methane (43% vs. 28%, p < 0.05), and for hydrogen (18% vs. 12%, p = 0.03). CONCLUSION & INFERENCES This retrospective study suggests the importance of the restrictive diet prior to GBT. A strict limitation of fibers and fermentable food decreased hydrogen and methane baseline values, and the prevalence of positive GBT. Thus a strict restrictive diet should be recommended on the day before the test, in order to limit the impact of food on hydrogen and methane breath levels, and possibly improve the diagnosis quality of GBT.
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Affiliation(s)
- Nastasia Mattio
- Hospices Civils de Lyon, Digestive Functional Explorations, Lyon, France
| | - Pierre Pradat
- Hospices Civils de Lyon, Centre de recherche clinique Nord, Lyon, France
| | - Christelle Machon
- Hospices Civils de Lyon, Biochimie, Centre hospitalier Lyon Sud, Oullins, France
| | - Anne Mialon
- Hospices Civils de Lyon, Biochimie, Centre hospitalier Lyon Sud, Oullins, France
| | - Sabine Roman
- Hospices Civils de Lyon, Université Lyon 1, Digestive Functional Explorations, Lyon, France
| | - Charlotte Cuerq
- Hospices Civils de Lyon, Biochimie, Centre hospitalier Lyon Sud, Oullins, France
| | - François Mion
- Hospices Civils de Lyon, Université Lyon 1, Digestive Functional Explorations, Lyon, France
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Xie J, Wang Y. Multidisciplinary combined treatment based on bariatric surgery for metabolic syndrome: a review article. Int J Surg 2024; 110:3666-3679. [PMID: 38489549 PMCID: PMC11175773 DOI: 10.1097/js9.0000000000001320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/26/2024] [Indexed: 03/17/2024]
Abstract
As a chronic, multifactorial disease, obesity is associated with a global social and economic burden. This condition significantly affects normal daily life and healthy social interactions, and shortens the life expectancy of patients. Compared with traditional weight-loss methods, the emergence of bariatric surgery has effectively improved the management of obesity. Furthermore, bariatric surgery can also inhibit the progression of multiple metabolic diseases. Despite its potential advantages, bariatric surgery cannot completely eliminate the possibility of weight regain and inadequate weight loss following the procedure. For super-obese patients, bariatric surgery still remains a surgical risk. In addition, the psychological problems and poor eating habits of obese patients also affect the weight loss effect and daily life. Thus, various adjuvant therapies involving multiple disciplines have attracted people's attention. Recently, it has been recognized that the combination of multiple interventions based on bariatric surgery is more advantageous than a single intervention in alleviating the complex and diverse metabolic diseases associated with obesity. The combined therapy considerably enhances the long-term efficacy of bariatric surgery and plays a positive role in the mental health and social lives of patients. In this article, the authors review this multidisciplinary combination therapy to enhance the current understanding of the treatment of obesity.
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Affiliation(s)
| | - Yong Wang
- Center of Bariatric and Metabolic Surgery, Fourth Affiliated Hospital of China Medical University, Liaoning, People’s Republic of China
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Wagner NRF, Lopes MCP, Fernandes R, Taconelli CA, Nascimento GM, Pessini J, Trindade EBSDM, Campos ACL. Effects of Probiotic Use on Gastrointestinal Symptoms in the Late Postoperative Period of Bariatric Surgery: A Cross-Over, Randomized, Triple-Blind, Placebo-Controlled Study. Obes Surg 2024; 34:1306-1315. [PMID: 38418752 DOI: 10.1007/s11695-024-07117-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Despite the benefits associated with weight reduction, the anatomical and functional changes of bariatric surgery may favor the development of undesirable side effects such as the appearance of gastrointestinal symptoms (GIS). The aim of this study was to evaluate the effects of using probiotics in individuals with GIS 1 year after being submitted to Roux-en-Y Gastric Bypass (RYGB). MATERIALS AND METHODS This is an experimental, prospective, randomized, cross-over, triple-blind, placebo-controlled study, carried out with patients 1 year after being submitted to RYGB and who reported at least one moderate GIS. Subjects were randomized into two groups and completed the two research periods: in one they received placebo capsules, in the other 50 billion CFU of probiotics (Lactobacillus acidophilus, Bifidobacterium lactis, Lactobacillus rhamnosus, Bifidobacterium longum, Lactobacillus plantarum, Bifidobacterium bifidum and Lactobacillus gasseri), both for 8 weeks, with 8 weeks of wash-out period in between, and were evaluated for the presence of Small Intestine Bacterial Overgrowth (SIBO) and GIS, through the Hydrogen breath test and Gastric Symptom Rating Scale (GSRS) questionnaire. RESULTS Of a total of 56 participants, 47 individuals completed the study. No significant effects were observed in neither the gastrointestinal symptoms or in the prevalence of SIBO with the use of probiotics. CONCLUSION Supplementation of the probiotics chosen for this study does not seem to alleviate GIS or influence the improvement of SIBO in symptomatic patients after 1 year of RYGB.
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Affiliation(s)
- Nathalia Ramori Farinha Wagner
- Universidade Federal Do Paraná (UFPR), Rua General Carneiro, 181, Centro, Curitiba, PR, 80060-900, Brazil.
- , Curitiba, Brazil.
| | - Maria Clara Peixoto Lopes
- Universidade Federal Do Paraná (UFPR), Rua General Carneiro, 181, Centro, Curitiba, PR, 80060-900, Brazil
| | - Ricardo Fernandes
- Universidade Federal da Grande Dourados (UFGD), Rodovia Dourados/Itahum, Km 12, Cidade Universitária, Dourados, MS, 79804-970, Brazil
| | - Cesar Augusto Taconelli
- Universidade Federal Do Paraná (UFPR), R. Evaristo F. Ferreira da Costa, 408, Jardim Ds Americas, Curitiba, 81530-090, Brazil
| | - Giovanna Mozzaquatro Nascimento
- Universidade Federal de Santa Catarina (UFSC), Campus Universitário Reitor João David Ferreira Lima, S/nº, Trindade, Florianópolis, SC, 88040-900, Brazil
| | - Julia Pessini
- Universidade Federal de Santa Catarina (UFSC), Campus Universitário Reitor João David Ferreira Lima, S/nº, Trindade, Florianópolis, SC, 88040-900, Brazil
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Florent V, Dennetiere S, Gaudrat B, Andrieux S, Mulliez E, Norberciak L, Jacquez K. Prospective Monitoring of Small Intestinal Bacterial Overgrowth After Gastric Bypass: Clinical, Biological, and Gas Chromatographic Aspects. Obes Surg 2024; 34:947-958. [PMID: 38300481 DOI: 10.1007/s11695-024-07080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/24/2024] [Accepted: 01/24/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND AND AIMS Obesity is a predisposing factor for small intestinal bacterial overgrowth (SIBO). The aim of this study was to prospectively evaluate the prevalence of SIBO as well as its clinical, biological, and nutritional aspects before and up to 24 months after a Roux-en-Y gastric bypass (RYGB) surgery. PATIENTS AND METHODS Fifty-one patients (mean BMI 46.9 kg/m2, 66.7% women) requesting RYGB were included between 2016 and 2020. Each patient underwent a glucose breath test, a standardized interrogation on functional digestive signs, a dietary survey, a blood test, a fecalogram, and anthropometric data gathering. These investigations were carried out before surgery and at 1, 3, 6, 9, 12, 18, and 24 months after RYGB. RESULTS Before surgery, we found a prevalence of 17.6% of SIBO (95% CI = [8.9%; 31.4%]). After RYGB, at the end of 24 months of follow-up, 89.5% of patients developed SIBO. Anal incontinence appeared to be very frequent after surgery, affecting 18.8% of our population 18 months after surgery. We observed positive steatorrhea after surgery with an average of 11.1 g of lipids/24 h despite a significant limitation of dietary lipids (p = 0.0282). CONCLUSION Our study corroborates data in the literature on the prevalence of SIBO in severe obesity patients. For the first time, we observed the sudden appearance of SIBO after RYGB, with a correlation between exhaled hydrogen on a breath test and lipid malabsorption on the fecalogram. As a result, these patients develop fatty diarrhea, with frequent fecal incontinence.
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Affiliation(s)
- Vincent Florent
- Department of Nutrition, Arras General Hospital, Bd Besnier, 62000, Arras, France.
- Inserm, CHU Lille, Laboratory of Development and Plasticity of the Neuroendocrine Brain, EGID, Lille Neuroscience & Cognition, UMR-S 1172, University of Lille, 59000, Lille, France.
| | - Solen Dennetiere
- Department of Nutrition, Arras General Hospital, Bd Besnier, 62000, Arras, France
- Department of Nutrition, Douai General Hospital, 59500, Douai, France
| | - Bulle Gaudrat
- Department of Nutrition, Arras General Hospital, Bd Besnier, 62000, Arras, France
- PSITEC Lab EA4072, University of Lille, 59000, Lille, France
| | - Severine Andrieux
- Department of Nutrition, Arras General Hospital, Bd Besnier, 62000, Arras, France
| | - Emmanuel Mulliez
- Department of Nutrition, Douai General Hospital, 59500, Douai, France
| | - Laurene Norberciak
- Delegation for Clinical Research and Innovation, Biostatistics Unit, Group of Hospitals of the Catholic Institute of Lille, 59000, Lille, France
| | - Kathleen Jacquez
- Clinical Research Unit, Arras General Hospital, 62000, Arras, France
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Kitaghenda FK, Hong J, Shao Y, Yao L, Zhu X. The Prevalence of Small Intestinal Bacterial Overgrowth After Roux-en-Y Gastric Bypass (RYGB): a Systematic Review and Meta-analysis. Obes Surg 2024; 34:250-257. [PMID: 38062344 DOI: 10.1007/s11695-023-06974-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 01/11/2024]
Abstract
We reviewed the literature on the prevalence of small intestinal bacterial overgrowth (SIBO) after Roux-en-Y gastric bypass (RYGB). Eight studies examining 893 patients were included. The mean age of the patients was 48.11 ± 4.89 years. The mean BMI before surgery and at the time of SIBO diagnosis was 44.57 ± 2.89 kg/m2 and 31.53 ± 2.29 kg/m2, respectively. Moreover, the results showed a 29% and 53% prevalence of SIBO at < 3-year and > 3-year follow-up after RYGB, respectively. Symptoms included abdominal pain, diarrhea, bloating, nausea, vomiting, constipation, soft stool, frequent defecation, flatulence, rumpling, dumping syndrome, and irritable bowel syndrome. SIBO is prevalent after RYGB; digestive symptoms should prompt the consideration of SIBO as a potential etiology. Antibiotic therapy has proven to be therapeutic.
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Affiliation(s)
- Fidele Kakule Kitaghenda
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221002, People's Republic of China
| | - Jian Hong
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221002, People's Republic of China
| | - Yong Shao
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221002, People's Republic of China
| | - Libin Yao
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221002, People's Republic of China.
| | - Xiaocheng Zhu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221002, People's Republic of China.
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Carlos LDO, Ramos MRZ, Wagner NRF, Fazzino T, Ferreira M, Amorim AF, de Freitas LAC, Felicidade I, Campos ACL. The prevalence of hyperpalatable food intake among individuals with food addiction seeking bariatric surgery. Eat Behav 2024; 52:101841. [PMID: 38154321 DOI: 10.1016/j.eatbeh.2023.101841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 09/20/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION The prevalence of food addiction among patients seeking bariatric surgery is approximately 30 %. While hyper-palatable foods (HPF) have been identified as the potential 'substance' in food addiction and a contributor to severe obesity, consumption of HPF among individuals with food addiction, including those seeking bariatric surgery, is unknown. Thus, the aim of this study was to evaluate the consumption of HPF among individuals seeking bariatric surgery with food addiction, compared to those without food addiction. METHODS Participants were N = 54 individuals with severe obesity seeking bariatric surgery. The Yale Food Addiction Scale was used to identify individuals with food addiction (FA) (37 % of sample). Dietary recalls were used to quantify HPF intake. Analyses were conducted to characterize average HPF intake and to determine whether there were significant differences between HPF intake among those with FA compared to those without FA, and whether HFP intake was correlated with FA symptoms. RESULTS On average, 71 % of participants' daily calorie intake was from HPF. There were no significant differences in HPF items intake among individuals with and without FA (70.46 % vs 71.34; p = 0.85). A positive correlation between number of FA symptoms and the intake of HPF high in fat and sugar ([0.3]; p = 0.03) was observed. CONCLUSION In this pilot study, HPF consumption among individuals with and without FA seeking bariatric surgery was high overall, however there were no differences across groups. In addition, intake of HPF with fat and sugar was associated with the number of symptoms of food addiction. More studies with a larger sample are needed to confirm these preliminary findings.
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Affiliation(s)
| | | | | | - Tera Fazzino
- Department of Psychology, Cofrin Logan Center for Addiction Research and Treatment, University of Kansas, Lawrence, KS, United States of America.
| | | | | | | | - Ingrid Felicidade
- General Biology Department, State University of Londrina, Londrina, PR, Brazil
| | - Antônio Carlos Ligocki Campos
- Post-graduate Program in Clinical Surgery, Clinical Surgery Department, Federal University of Parana, Curitiba, PR, Brazil
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Wang Y, Zheng Y, Kuang L, Yang K, Xie J, Liu X, Shen S, Li X, Wu S, Yang Y, Shi J, Wu J, Wang Y. Effects of probiotics in patients with morbid obesity undergoing bariatric surgery: a systematic review and meta-analysis. Int J Obes (Lond) 2023; 47:1029-1042. [PMID: 37674033 PMCID: PMC10600003 DOI: 10.1038/s41366-023-01375-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/08/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Probiotics are commonly used after bariatric surgery. However, uncertainty remains regarding their effects. The purpose of this systematic review was to assess the effect of probiotics in patients with morbid obesity undergoing bariatric surgery. METHODS PubMed, Cochrane Library, Embase, Science Direct, and Web of Science were searched from inception to April 4, 2023. No language restrictions were applied. Relevant randomized controlled trials and controlled clinical trials were included. We used the aggregated data extracted from the trials and assessed the heterogeneity. When severe heterogeneity was detected, a random effect model was used. All stages of the review were done by independent authors. RESULTS We screened 2024 references and included 11 randomized controlled trials and controlled clinical trials. Compared with the protocol groups, probiotics showed significant effects on regulating aspartate amino transferase level (MD = -4.32 U/L; 95% CI [-7.10, -1.53], p = 0.002), triglycerides (MD = -20.16 mg/dL; 95% CI [-34.51, -5.82], p = 0.006), weight (MD = -1.99 kg; 95% CI [-3.97, -0.01], p = 0.05), vitamin B12 (MD = 2.24 pg/dL; 95% CI [-0.02, 4.51], p = 0.05), dietary energy (MD = -151.03 kcal; 95% CI [-215.68, -86.37], p < 0.00001), dietary protein (MD = -4.48 g/day, 95% CI [-8.76, -0.20], p = 0.04), dietary carbohydrate (MD = -34.25 g/day, 95% CI [-44.87, -23.62], p < 0.00001), and dietary fiber (MD = -2.17 g/day, 95% CI [-3.21, -1.14], p < 0.0001). There were no severe side effects related to probiotics. CONCLUSIONS Our meta-analysis suggested that probiotics may delay the progression of liver function injury, improve lipid metabolism, reduce weight, and reduce food intake, although the effects on other indicators were insignificant. Probiotics may be helpful for patients undergoing bariatric surgery. The review was registered on PROSPERO (International prospective register of systematic reviews): CRD42023407970. No primary source of funding.
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Affiliation(s)
- Yuting Wang
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Youwei Zheng
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Lirun Kuang
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Keyu Yang
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Jiaji Xie
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Xinde Liu
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Shan Shen
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Xinchao Li
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Shiran Wu
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Yuyi Yang
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Jiafei Shi
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Jialiang Wu
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China
| | - Yong Wang
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, 110032, China.
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Aslan I, Tarhan Celebi L, Kayhan H, Kizilay E, Gulbahar MY, Kurt H, Cakici B. Probiotic Formulations Containing Fixed and Essential Oils Ameliorates SIBO-Induced Gut Dysbiosis in Rats. Pharmaceuticals (Basel) 2023; 16:1041. [PMID: 37513952 PMCID: PMC10383999 DOI: 10.3390/ph16071041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Dysbiosis of the gut microbiota is associated with the pathogenesis of intestinal diseases such as inflammatory bowel disease, irritable bowel syndrome (IBS), small intestinal bacterial overgrowth (SIBO), and metabolic disease states such as allergies, cardiovascular diseases, obesity, and diabetes. SIBO is a condition characterized by an increased number (>1 × 103 CFU) of abnormal bacterial species in the small intestine. Interest in SIBO has gained importance due to increased awareness of the human microbiome and its potential relationships with human health and disease, which has encouraged new work in this area. In recent years, standard antibiotic regimens (rifaximin and metronidazole) have been used to treat SIBO, but solo antibiotics or their derivatives are insufficient. In this study, the therapeutic effects of the probiotic form, which contains coconut oil and traces of peppermint-lemon-patchouli essential oil, were evaluated on the Dysbiosis-Based Rat SIBO Model. There are significant differences between sick and healthy rats (p = 0.014), between sick rats and rats treated with the oil mix plus probiotic mix protocol (p = 0.026), and between rats treated with only the probiotic and only oil protocols (p = 0.030) in the evaluation of TNF-α levels. Histologically, villi distortion and loss of crypts, epithelial shedding and necrotic changes in the apical regions of the villi, and inflammatory cell infiltrations extending to the lamina propria and submucosa were observed in sick rats. Mitotic figures in villus epithelium and crypts were observed in rats treated with 9.2 × 109 CFU/1000 mg/coconut oil + trace amounts of peppermint-lemon-patchouli essential oil and a probiotic mixture (oil + probiotic mix protocol). A regression of inflammatory reactions and an increase in goblet cells were observed. A decrease was observed in inflammation markers in sick rats. On the other hand, the oil plus probiotic mix protocol recovered digestive system defects in the animals caused by dysbiosis. In the future, these treatment approaches can be effective in the treatment of SIBO.
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Affiliation(s)
- Ismail Aslan
- Department of Pharmaceutical Technology, Hamidiye Faculty of Pharmacy, University of Health Sciences, İstanbul 34668, Turkey
- SFA R&D and Analysis Services, Teknopark İstanbul, İstanbul 34906, Turkey
- ATA BIO Technologies, Teknopol İstanbul, İstanbul 34930, Turkey
| | - Leyla Tarhan Celebi
- SFA R&D and Analysis Services, Teknopark İstanbul, İstanbul 34906, Turkey
- ATA BIO Technologies, Teknopol İstanbul, İstanbul 34930, Turkey
| | - Hulya Kayhan
- Art de Huile, Teknopol İstanbul, İstanbul 34930, Turkey
| | - Emine Kizilay
- Hamidiye Vocational School of Health Services, University of Health Sciences, İstanbul 34668, Turkey
| | - Mustafa Yavuz Gulbahar
- Department of Pathology, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Samsun 55200, Turkey
| | - Halil Kurt
- Department of Medical Biology, Hamidiye International Faculty of Medicine, University of Health Sciences, İstanbul 34668, Turkey
| | - Bekir Cakici
- SFA R&D and Analysis Services, Teknopark İstanbul, İstanbul 34906, Turkey
- ATA BIO Technologies, Teknopol İstanbul, İstanbul 34930, Turkey
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11
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Fei Y, Wang R, Lu J, Peng S, Yang S, Wang Y, Zheng K, Li R, Lin L, Li M. Probiotic intervention benefits multiple neural behaviors in older adults with mild cognitive impairment. Geriatr Nurs 2023; 51:167-175. [PMID: 36990042 DOI: 10.1016/j.gerinurse.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023]
Abstract
Probiotic supplements were shown to improve cognitive function in Alzheimer's disease (AD) patients. However, it is still unclear whether this applies to older individuals with mild cognitive impairment (MCI). We aimed to explore the effects of probiotic supplementation on multiple neural behaviors in older adults with MCI. Forty-two MCI patients (age > 60 years) were randomly divided into two groups and consumed either probiotics (n=21) or placebo (n=21) for 12 weeks. Various scale scores, gut microbiota measures and serological indicators were recorded pre- and posttreatment. After 12 weeks of intervention, cognitive function and sleep quality were improved in the probiotic group compared with those in the control group, and the underlying mechanisms were associated with changes in the intestinal microbiota. In conclusion, our study demonstrated that probiotic treatment enhanced cognitive function and sleep quality in older MCI patients, thus providing important insights into the clinical prevention and treatment of MCI.
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Skrzydło-Radomańska B, Cukrowska B. How to Recognize and Treat Small Intestinal Bacterial Overgrowth? J Clin Med 2022; 11:6017. [PMID: 36294338 PMCID: PMC9604644 DOI: 10.3390/jcm11206017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/08/2022] [Accepted: 10/10/2022] [Indexed: 07/30/2023] Open
Abstract
Small Intestinal Bacterial Overgrowth (SIBO) is a form of dysbiosis that involves increased bacterial colonization of the small intestine with some of the bacteria more characteristic of the colon microbiota. The prevalence of SIBO over recent decades has been estimated to range from 2.5 to 22% (depending on the source) and to increase with age and among individuals with comorbidities. Recently, an increase in the number of diagnosed SIBO cases has been observed, which is primarily due to the availability of noninvasive breath tests that facilitate the diagnostic process. However, SIBO is still both a diagnostic and a therapeutic problem. This review presents the pathophysiology, manifestations, diagnostics, and recommended management of SIBO.
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Affiliation(s)
| | - Bożena Cukrowska
- Department of Pathomorphology, The Children Memorial Health Institute, Aleja Dzieci Polskich 20, 04-730 Warsaw, Poland
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Dysbiosis and Gastrointestinal Surgery: Current Insights and Future Research. Biomedicines 2022; 10:biomedicines10102532. [PMID: 36289792 PMCID: PMC9599064 DOI: 10.3390/biomedicines10102532] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
Surgery of the gastrointestinal tract can result in deep changes among the gut commensals in terms of abundance, function and health consequences. Elective colorectal surgery can occur for neoplastic or inflammatory bowel disease; in these settings, microbiota imbalance is described as a preoperative condition, and it is linked to post-operative complications, as well. The study of bariatric patients led to several insights into the role of gut microbiota in obesity and after major surgical injuries. Preoperative dysbiosis and post-surgical microbiota reassessment are still poorly understood, and they could become a key part of preventing post-surgical complications. In the current review, we outline the most recent literature regarding agents and molecular pathways involved in pre- and post-operative dysbiosis in patients undergoing gastrointestinal surgery. Defining the standard method for microbiota assessment in these patients could set up the future approach and clinical practice.
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Carlos LDO, Ramos MRZ, Wagner NRF, Freitas LACD, Felicidade I, Campos ACL. PROBIOTIC SUPPLEMENTATION ATTENUATES BINGE EATING AND FOOD ADDICTION 1 YEAR AFTER ROUX-EN-Y GASTRIC BYPASS: A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2022; 35:e1659. [PMID: 35766604 PMCID: PMC9254603 DOI: 10.1590/0102-672020210002e1659] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/20/2022] [Indexed: 11/22/2022]
Abstract
AIM The use of probiotics as adjuvants in the treatment of eating disorders, known as psychobiotics, has already been investigated as a means of modulating the microbiota-gut-brain axis. This study aimed to assess the effect of probiotic supplementation on binge eating and food addiction in subjects after Roux-en-Y gastric bypass surgery. METHODS This is a randomized, double-blind, placebo-controlled trial involving 101 patients who received probiotic (Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07) or placebo supplements for 90 days after bariatric surgery, starting on the seventh postoperative day. They were evaluated preoperatively (T0) and postoperatively at 90 days (T1) and 1 year (T2) after surgery. The Yale Food Addiction Scale (YFAS) and Binge Eating Scale (BES) were applied to assess food addiction and binge eating, respectively. RESULTS Before surgery, one-third of the patients presented with a food addiction and binge eating diagnosis. The number of symptoms of YFAS and the BES score decreased significantly in both groups at T1 compared to T0. However, a significant effect of treatment with probiotics was observed 1 year after surgery (T2). Both the number of symptoms of food addiction and the binge eating score were lower in the probiotic group than in the placebo group (p=0.037 and p=0.030, respectively). CONCLUSION The use of probiotic supplementation for 90 days in the immediate postoperative period may decrease food addiction symptoms and binge eating score up to 1 year after surgery compared to controls.
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Affiliation(s)
| | | | | | | | - Ingrid Felicidade
- Universidade Estadual de Londrina, Departamento de Biologia Geral - Londrina - PR - Brazil
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15
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Abstract
Weight loss surgery, also known as metabolic and bariatric surgery (MBS), is an effective weight loss treatment and is associated with reduced mortality and improvements in obesity-related health conditions and quality of life. Postsurgical anatomical and physiologic changes include decreased absorption of micronutrients and alterations in gut-brain hormonal regulation that affect many aspects of health. Patients require ongoing monitoring of their physical and mental health for lasting success. Internists, particularly primary care clinicians, are in an ideal position to monitor for nonserious complications in the short and long term, adjust management of chronic diseases accordingly, and monitor for mental health changes. This article reviews key issues that internists should be aware of for supporting patients' health in the short and long term after MBS.
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Affiliation(s)
- Carolyn Bramante
- Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Eric Wise
- Division of Advanced Gastrointestinal/Bariatric Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Zoobia Chaudhry
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Wang Y, Wu XT, Chen J. Effect of Probiotic Supplementation on Weight Loss, Inflammatory Factors, and Metabolic Effects in Patients Undergoing Bariatric Surgery. Obes Surg 2022; 32:1779-1782. [PMID: 35243603 DOI: 10.1007/s11695-022-05974-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 02/09/2022] [Accepted: 02/17/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Yong Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiao-Ting Wu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Chen
- Healthcare-Associated Infection Control Center, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chines Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China.
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Gutiérrez-Repiso C, Moreno-Indias I, Tinahones FJ. Shifts in gut microbiota and their metabolites induced by bariatric surgery. Impact of factors shaping gut microbiota on bariatric surgery outcomes. Rev Endocr Metab Disord 2021; 22:1137-1156. [PMID: 34287758 DOI: 10.1007/s11154-021-09676-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 02/06/2023]
Abstract
Evidence suggests that bariatric surgery alters gut microbiota, although its impact at compositional and functional level is not well described. In this review, the most relevant findings, mainly described in Roux-en-Y gastric bypass and sleeve gastrectomy, are outlined. Although the number of studies has increased in the last years, conclusive assertions cannot be elaborated. An issue to address is to know the influence of these alterations on host metabolism and the contribution of gut microbiota derived metabolites. New lines of research have been focusing on analysing gut microbiota functionality rather than evaluating changes at compositional level, and the functions of gut microbiota metabolites in host metabolism, what will bring more relevant information about the influence of gut microbiota in bariatric surgery outcomes. Personalized medicine, because of the predictive value of gut microbiota, is another promising field. The possibility of a specific gut microbiota pattern that could predict type 2 diabetes remission or weight loss failure after bariatric surgery is a matter of great interest. However, little is known about how gut microbiota manipulation could contribute to the beneficial effects of bariatric surgery. Peri-operative antibiotics prophylaxis or probiotic supplementation early after surgery, are strategies barely studied so far, and could constitute a novel tool in the management of weight loss and metabolic profile improvement after surgery.
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Affiliation(s)
- Carolina Gutiérrez-Repiso
- Unidad de Gestión Clínica de Endocrinología Y Nutrición del Hospital Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA) Málaga. Centro de Investigación Biomédica en Red de Fisiopatología de La Obesidad Y La Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain.
| | - Isabel Moreno-Indias
- Unidad de Gestión Clínica de Endocrinología Y Nutrición del Hospital Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA) Málaga. Centro de Investigación Biomédica en Red de Fisiopatología de La Obesidad Y La Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco J Tinahones
- Unidad de Gestión Clínica de Endocrinología Y Nutrición del Hospital Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA) Málaga. Centro de Investigación Biomédica en Red de Fisiopatología de La Obesidad Y La Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
- Departamento de Medicina Y Dermatología, Universidad de Málaga, Málaga, Spain
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DE-Oliveira GJM, Schieferdecker MEM, Campos ACL. ARE ENTEROTYPES IN OBESE MODIFIED BY BARIATRIC SURGERY, THE USE OF PROBIOTIC SUPPLEMENTS AND FOOD HABITS? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2021; 34:e1601. [PMID: 34669890 PMCID: PMC8521827 DOI: 10.1590/0102-672020210002e1601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/11/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Studies suggest that bariatric surgery, use of probiotic supplements and the dietary pattern can change enterotypes, as well as the entire microbial population. OBJECTIVE To verify the influence of bariatric surgery, the use of probiotic supplements and eating habits on enterotypes in obese patients. METHODS Articles published between the 2015 and 2020 were searched in Lilacs and PubMed with the headings: probiotics, eating behavior, food consumption, food, diet, microbiota, gastrointestinal microbiome, bariatric surgery, gastric bypass and the keyword enterotype in Portuguese, English and Spanish. RESULTS Of the 260 articles found, only studies carried out in obese adults relating changes in the enterotype after bariatric surgery or use of probiotics or dietary patterns and original articles were selected. In the end, eight papers on enterotype change and bariatric surgery were selected and categorized, four on the relationship between food consumption and microbiota and one on the effects of probiotics on enterotypes. CONCLUSION The microbial structure is widely modified after bariatric surgery, since the use of probiotic supplement does not bring lasting changes. Enterotypes appear to be shaped by long-term dietary patterns, can modulate how nutrients are metabolized and can be a useful biomarker to improve clinical management.
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Wang Z, Zeng M, Wang Z, Qin F, Chen J, He Z. Dietary Luteolin: A Narrative Review Focusing on Its Pharmacokinetic Properties and Effects on Glycolipid Metabolism. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2021; 69:1441-1454. [PMID: 33522240 DOI: 10.1021/acs.jafc.0c08085] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Luteolin, a flavone subclass of flavonoids, is commonly found in food plants and has multiple biological activities. Recently, evidence is growing with regard to the potential of luteolin intake to beneficially affect glycolipid metabolism disorders (GLMDs), particularly insulin resistance, diabetes, and obesity. The aim of this contribution is to provide an overview of recent advances in identifying and understanding the pharmacokinetic properties (absorption, metabolism, and bioavailability) of luteolin, its regulatory effects on glycolipid metabolism, and the underlying mechanisms of action of luteolin in the brain, liver, adipose tissues, and other tissues/organs. Collectively, luteolin or its principal metabolites may contribute to counteracting GLMDs, especially for human obesity and diabetes.
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Affiliation(s)
- Zhenyu Wang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
- International Joint Laboratory on Food Safety, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
| | - Maomao Zeng
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
- International Joint Laboratory on Food Safety, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
| | - Zhaojun Wang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
- International Joint Laboratory on Food Safety, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
| | - Fang Qin
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
- International Joint Laboratory on Food Safety, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
| | - Jie Chen
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
- International Joint Laboratory on Food Safety, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
| | - Zhiyong He
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
- International Joint Laboratory on Food Safety, Jiangnan University, Wuxi, Jiangsu 214122, People's Republic of China
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Effects of Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07 Supplementation on Nutritional and Metabolic Parameters in the Early Postoperative Period after Roux-en-Y Gastric Bypass: a Randomized, Double-Blind, Placebo-Controlled Trial. Obes Surg 2021; 31:2105-2114. [DOI: 10.1007/s11695-021-05222-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/11/2022]
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