Protein malnutrition after Roux-en-Y gastric bypass: a challenging case and scoping review of the literature

Optimizing Nutritional Management Before and After Bariatric Surgery: A Comprehensive Guide for Sustained Weight Loss and Metabolic Health

Obesity is associated with multiple comorbidities that contribute to increased mortality among affected individuals. There are multiple treatments for this condition, including nutritional interventions, pharmacological therapies, and surgical procedures. Within these, bariatric surgery is an effective treatment option that requires a multidisciplinary approach, both before and after surgery. Nutritional management prior to surgery aims to achieve metabolic control and reduce comorbidities associated with the procedure. Postoperative nutritional management focuses on preventing complications, ensuring adequate nourishment, and providing necessary supplementation for optimal recovery and long-term success. This narrative review examines all these critical aspects of nutritional management in bariatric surgery, including preoperative nutrition, postoperative nutrition and physical activity recommendation, different nutritional aspects according to the type of bariatric surgery, and future directions for investigation.

Efficacy of One Anastomosis Gastric Bypass Versus Sleeve Gastrectomy and Roux-en-Y Gastric Bypass for the Treatment of Type 2 Diabetes Mellitus: a Systematic Review and Meta-Analysis of Randomized Clinical Trials

The worldwide prevalence of type 2 diabetes mellitus (T2DM) is increasing in parallel with obesity. One anastomosis gastric bypass (OAGB) is considered effective to treat both T2DM and obesity. The aim of this study was to evaluate the efficacy of OAGB versus sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for treatment of T2DM, analyzing data exclusively from randomized control trials (RCTs). Α systematic review of published RCTs comparing OAGB versus RYGB or SG (control groups) in T2DM patients regarding diabetes remission and weight loss was performed. Primary endpoints were T2DM remission rate and 1-year and 5-year % weight loss postoperatively. Initial search identified 39 references, of which 8 RCTs were considered eligible for meta-analysis inclusion, comprising 636 patients (311 OAGB, 122 RYGB, 203 SG patients). Main meta-analysis findings were: i) higher 1-year %EWL for OAGB than control group (p = 0.04); ii) higher 5-year %EWL for OAGB than control group (p < 0.01); iii) no difference in 1-year remission rate of T2DM between OAGB and control group (p = 0.14); iv) 28% higher 5-year remission rate of T2DM for OAGB than control group (p < 0.01). OAGB had statistically significant better outcomes compared to RYGB and SG regarding T2DM remission and %EWL at 5 years. Further pathophysiologic studies are needed to indicate the most potent bariatric procedure in patients with T2DM and obesity.

Effect of tailoring biliopancreatic limb length based on total small bowel length versus standard limb length in one anastomosis gastric bypass: 1-year outcomes of the TAILOR randomized clinical superiority trial

BACKGROUND

Tailoring the biliopancreatic limb length in one anastomosis gastric bypass is proposed as beneficial in retrospective studies, yet randomized trials are lacking. The aim of this double-blind, single-centre RCT was to ascertain whether tailoring biliopancreatic limb length based on total small bowel length (TSBL) results in superior outcomes after one anastomosis gastric bypass compared with a fixed 150 cm biliopancreatic limb length.

METHODS

Eligible patients, meeting International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) criteria for metabolic bariatric surgery, scheduled for primary one anastomosis gastric bypass surgery, and willing to be randomized, underwent TSBL measurement during surgery. When TSBL measurement was feasible, patients were randomly assigned to a standard 150 cm biliopancreatic limb length or a tailored biliopancreatic limb based on TSBL: TSBL less than 500 cm, biliopancreatic limb 150 cm; TSBL 500-700 cm, biliopancreatic limb 180 cm; and TSBL greater than 700 cm, biliopancreatic limb 210 cm. The primary outcome was percentage total weight loss at 5 years.

RESULTS

Between September 2020 and August 2022, 212 patients were randomized into the standard biliopancreatic limb group (105 patients) or the tailored biliopancreatic limb group (107 patients). The mean(s.d.) TSBL was 657(128) cm (range 295-1020 cm). In the tailored group, 150, 180, and 210 cm biliopancreatic limb lengths were applied to 8.4%, 53.3%, and 38.3% of patients respectively. The mean(s.d.) 1-year percentage total weight loss was 32.8(6.9)% in the standard group and 33.1(6.2)% in the tailored group (P = 0.787). Nutritional deficiencies and short-term complications showed no significant differences.

CONCLUSION

Tailoring biliopancreatic limb length based on TSBL is safe and feasible. One year after surgery, it is not superior to a standard biliopancreatic limb length of 150 cm in terms of percentage total weight loss.

REGISTRATION NUMBER

Dutch Trial Register, NL7945.

Multidisciplinary combined treatment based on bariatric surgery for metabolic syndrome: a review article

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.

Nutritional management during critical illness in those with previous obesity surgery

PURPOSE OF REVIEW

The prevalence of overweight and obesity in our society is a pressing concern that has demanded immediate attention. Traditional treatments have proven ineffective for many individuals, leading to a surge in bariatric surgery as a last resort. While the rate of early and late postoperative complications may be low, when they occur, they place these patients at higher risk of requiring intensive care treatment. Therefore, it is our aim to discuss the nutritional care of these individuals.

RECENT FINDINGS

Nutritional management of critically ill postbariatric surgical patients is related to the difficulty of providing an adequate nutritional assessment, calculating the macro and micronutrient requirements, choosing the right therapy, and defining the timely moment to initiate it. The anatomic changes related to the bariatric operation pose a high risk for a nonfunctional gastrointestinal tract both in the early postoperative and late postoperative. Therefore, the route of nutrition will greatly rely on the absorptive capacity, as well as on the nutritional status, with parenteral nutrition being an early option, especially for those with high critical care severity scores. Also, these patients are known to have an altered microbiota which may influence the absorptive capacity. Immunonutrition, prebiotics, probiotics, and symbiotics may represent potential options, but there is currently little support for 'one size fits all'.

SUMMARY

The nutritional care of critically ill patients postbariatric surgery is a complex and nuanced process requiring a multifaceted precision approach. The distinct nutritional challenges of early and late postoperative patients necessitate a thorough nutritional assessment and a highly individualized nutritional care plan.

Management of Malnutrition and Hepatic Impairment After Duodenal Switch

BACKGROUND

Malnutrition and liver impairment after duodenal switch (DS) are possible and undesired complications, often conservatively treated. However, in specific cases, surgical revision may be necessary. This study aims to describe outcomes achieved by two bariatric surgery centers and address effectiveness and safety of revisional surgical procedures to resolve these complications.

METHODS

A retrospective chart review was performed in two bariatric surgery centers from 2008 to 2022. Patients who required revisional surgery to treat malnutrition and/or liver impairment refractory to nutritional and total parenteral nutrition intervention (TPN) after duodenal switch were included. No comparisons were performed due to the descriptive nature of this study.

RESULTS

Thirteen patients underwent revisional surgery, the mean age was 44.7, the 53.8% were females, and the mean preoperative BMI was 54.7 kg/m2; the mean time between DS and revisional procedure was 26.5 months, and 69.1% of patients were placed on TPN. One patient developed hepatic encephalopathy; one patient presented with ascites, pleural effusion, and renal insufficiency, undergoing reoperation after revisional procedure due to a perforated ileal loop. Mortality rate was 0%; all patients regained weight after the revisional procedure, and the mean total protein and albumin blood levels 12 months after surgery were 6.3 and 3.6 g/dl, respectively.

CONCLUSIONS

While refractory malnutrition and/or liver failure are rare among patients post-DS, if underdiagnosed and untreated, this can lead to irreversible outcomes and death. All revisional procedures included in this study resulted in improvement of the nutritional status and reversal of liver impairment, with low complication rates.