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Alencar MAVSD, Araújo IMD, Parreiras-E-Silva LT, Nogueira-Barbosa MH, Salgado W, Elias J, Salmon CEG, Paula FJAD. Hashtag bone: detrimental effects on bone contrast with metabolic benefits one and five years after Roux-en-Y gastric bypass. Braz J Med Biol Res 2021; 54:e11499. [PMID: 34878062 PMCID: PMC8647898 DOI: 10.1590/1414-431x2021e11499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 09/30/2021] [Indexed: 12/15/2022] Open
Abstract
Bone loss is a potential adverse consequence of rapid and sustained weight loss after bariatric surgery. The aim of the present study was to evaluate the bone mass, body fat distribution, and metabolic parameters in women submitted to Roux-en-Y gastric bypass (RYGB). The study included the following three groups: one group of lean women (control [C] group) and two groups of obese women, one evaluated one year (B1) and the other five years (B5) after RYGB. Dual-energy X-ray absorptiometry and magnetic resonance imaging were used to determine bone mineral density (BMD; lumbar spine, total hip, and femoral neck) and abdominal fat content (subcutaneous [SAT] and visceral [VAT] adipose tissues, and intrahepatic lipids [IHL]). The BMD/body mass index ratio was lower in the B5 compared with the C group at all sites. Serum C-terminal telopeptide of type I collagen (CTX) levels were higher in the B1 and B5 groups compared with the C group. Individuals submitted to RYGB showed greater SAT but similar VAT and IHL values compared with those in the C group. However, the B5 group had higher mean parathyroid hormone levels compared with the other two groups. Individuals submitted to RYGB presented increased levels of CTX and low BMD for body weight than those in the C group, suggesting that bone catabolism is a persistent alteration associated with RYGB. In conclusion, the long-lasting metabolic benefits obtained with RYGB in obesity are counterbalanced by a persistent catabolic effect of the procedure on bone and mineral metabolism.
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Affiliation(s)
- M A V S D Alencar
- Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - I M de Araújo
- Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - L T Parreiras-E-Silva
- Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - M H Nogueira-Barbosa
- Departamento de Imagens Médicas, Hematologia e Oncologia Clínica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - W Salgado
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - J Elias
- Departamento de Imagens Médicas, Hematologia e Oncologia Clínica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - C E G Salmon
- Departamento de Física, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - F J A de Paula
- Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Volonakis S, Koika V, Tzavelas G, Skopeliti M, Skroubis G, Kalfarentzos F, Alexandrides T. Adequate vitamin D supplementation does not ameliorate bone loss following long limb-biliopancreatic diversion in morbidly obese women. Hormones (Athens) 2021; 20:315-321. [PMID: 33155141 DOI: 10.1007/s42000-020-00254-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/16/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study is to investigate the effect of adequate vitamin D supplementation on bone mineral density (BMD) following long limb-biliopancreatic diversion (LL-BPD), a malabsorptive bariatric operation. BACKGROUND Marked weight loss following bariatric surgery is associated with significant decrease in BMD, attributed to the weight loss and to nutritional, mineral, and vitamin D deficiencies resulting in secondary hyperparathyroidism. METHODS Two groups, of 35 and 37 healthy, obese (BMI, 50.4 + 6.6 and 46.5 + 4.8 g/cm2), premenopausal, normally menstruating women underwent LL-BPD. Both groups received high-calcium diets, 600 IU of vitamin D, and 1000 mg elemental calcium daily, while group B received an extra dose of vitamin D (10,000 IU/day) during the first postoperative month, followed by dose adjustment in order to maintain 25OHD concentration higher than 30 μg/L. Areal BMD (aBMD) was measured at the lumbar spine preoperatively and 1 year postoperatively. RESULTS One year postoperatively, BMI decreased by approximately 19 kg/m2 in both groups, while 25-OH-vitamin D levels did not change in group A (18.7 + 9.1 to 20.2 + 13.0 μg/L, (p = 0.57)) and increased in group B (15.58 ± 5.73 to 52.97 ± 15.46 μg/L, (p = < 0.001). PTH levels increased in group A (from 38.5 ± 12.2 to 51.2 ± 32.8 pg/ml) (p = 0.047) and decreased in group B (from 51.61 ± 18.7 to 45.1 ± 17.8 pg/ml) (p = 0.042). Lumbar spine aBMD decreased similarly in both groups (p = 0.311, for the comparison between groups) from 1.198 + 0.14 to 1.103 + 0.15 g/cm2 in group A (p < 0.001) and from 1.157 + 0.14 to 1.076 + 0.14 g/cm2 in group B (p < 0.001) and Z-score from 0.93 + 0.97 to 0.19 + 1.02, (p < 0.001) and from 1.15 + 1.29 to 0.419 + 1.28, (p < 0.001), respectively. CONCLUSIONS LL-BPD leads to similar and significant bone mass reduction 1 year postoperatively, irrespective of adequate vitamin D replacement and in the absence of secondary hyperparathyroidism.
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Affiliation(s)
- Sotirios Volonakis
- Division of Endocrinology, Department of Internal Medicine, School of Medicine, University of Patras, 26504, Rio, Greece
| | - Vasiliki Koika
- Division of Endocrinology, Department of Internal Medicine, School of Medicine, University of Patras, 26504, Rio, Greece
| | - George Tzavelas
- Department of Radiology, School of Medicine, University of Patras, 26504, Rio, Greece
| | - Marina Skopeliti
- Division of Endocrinology, Department of Internal Medicine, School of Medicine, University of Patras, 26504, Rio, Greece
| | - George Skroubis
- Department of Surgery, School of Medicine, University of Patras, 26504, Rio, Greece
| | - Fotis Kalfarentzos
- Department of Surgery, School of Medicine, University of Patras, 26504, Rio, Greece
| | - Theodore Alexandrides
- Division of Endocrinology, Department of Internal Medicine, School of Medicine, University of Patras, 26504, Rio, Greece.
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Alejo Ramos M, Ballesteros Pomar MD, Urioste Fondo AM, González Herráez L, González de Francisco T, Sierra Vega M, Cano Rodríguez IM. Bone metabolism and fracture risk after Biliopancreatic Diversion. ENDOCRINOL DIAB NUTR 2021; 68:144-152. [PMID: 34167693 DOI: 10.1016/j.endien.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/20/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bariatric surgery (BS) is an effective treatment. However, there have been concerns regarding the negative effect on the bone. The aim of this study was to assess changes in bone metabolism and the risk of fracture after biliopancreatic diversion (BPD). MATERIAL AND METHODS A retrospective analysis of obese patients undergoing BPD between 1998 and 2017 was conducted, and patients with at least 1 year of follow-up were included. The incidence of fracture and of changes in bone metabolism was studied. RESULTS In total, 216 patients were included (78.2% female), with a mean age of 42.5(10.6) years. The median follow-up was 6.8(IQR 10.2-3.2) years. The mean body mass index (BMI) was 49.7(6.3) kg/m2. 13.2% (n=29) suffered a bone fracture after surgery; the time until the first fracture was 7.9(3.8) years (55.2% secondary to a casual fall). The rate of fracture incidence was 19.6 per 1000 person-years (95%CI: 1.3-2.7), prevalence was 13.4% (95%CI: 8.9-18.0). The risk of bone fractures seems to increase with longer postoperative evolution time. PTH (pg/ml) levels were significantly higher in patients with fractures (1 year, 98.1 vs. 77.8; 5 years, 162.5 vs. 110.3 p<0.05, adjusted HR 1.10; 95%CI 1.01-1.11). Subjects with a higher %EWL had less risk of fractures after surgery (adjusted HR 0.97; 95%CI 0.94-0.99). Moreover, 25(OH)D levels were lower, and osteocalcin and β-Crosslaps levels were slightly higher (not significant) in patients with fractures. CONCLUSION BPD is related to important changes in bone metabolism, which can lead to an increased risk of bone fractures. Assessing the risk of fractures should be part of BS patient care.
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Affiliation(s)
- Mirian Alejo Ramos
- Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, Spain.
| | | | - Ana M Urioste Fondo
- Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, Spain
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Bone metabolism and fracture risk after Biliopancreatic Diversion. ACTA ACUST UNITED AC 2021; 68:144-152. [PMID: 33495111 DOI: 10.1016/j.endinu.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 07/13/2020] [Accepted: 08/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Bariatric surgery (BS) is an effective treatment. However, there have been concerns regarding the negative effect on the bone. The aim of this study was to assess changes in bone metabolism and the risk of fracture after biliopancreatic diversion (BPD). MATERIAL AND METHODS A retrospective analysis of obese patients undergoing BPD between 1998 and 2017 was conducted, and patients with at least 1 year of follow-up were included. The incidence of fracture and of changes in bone metabolism was studied. RESULTS In total, 216 patients were included (78.2% female), with a mean age of 42.5(10.6) years. The median follow-up was 6.8(IQR 10.2-3.2) years. The mean body mass index (BMI) was 49.7(6.3) kg/m2. 13.2% (n=29) suffered a bone fracture after surgery; the time until the first fracture was 7.9(3.8) years (55.2% secondary to a casual fall). The rate of fracture incidence was 19.6 per 1000 person-years (95%CI: 1.3-2.7), prevalence was 13.4% (95%CI: 8.9-18.0). The risk of bone fractures seems to increase with longer postoperative evolution time. PTH (pg/ml) levels were significantly higher in patients with fractures (1 year, 98.1 vs. 77.8; 5 years, 162.5 vs. 110.3 p<0.05, adjusted HR 1.10; 95%CI 1.01-1.11). Subjects with a higher %EWL had less risk of fractures after surgery (adjusted HR 0.97; 95%CI 0.94-0.99). Moreover, 25(OH)D levels were lower, and osteocalcin and β-Crosslaps levels were slightly higher (not significant) in patients with fractures. CONCLUSION BPD is related to important changes in bone metabolism, which can lead to an increased risk of bone fractures. Assessing the risk of fractures should be part of BS patient care.
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Metabolic bone changes after bariatric surgery: 2020 update, American Society for Metabolic and Bariatric Surgery Clinical Issues Committee position statement. Surg Obes Relat Dis 2021; 17:1-8. [DOI: 10.1016/j.soard.2020.09.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022]
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Bühler J, Rast S, Beglinger C, Peterli R, Peters T, Gebhart M, Meyer-Gerspach AC, Wölnerhanssen BK. Long-Term Effects of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass on Body Composition and Bone Mass Density. Obes Facts 2021; 14:131-140. [PMID: 33333510 PMCID: PMC7983539 DOI: 10.1159/000512450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/12/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Currently, the two most common bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Long-term data comparing the two interventions in terms of their effect on body composition and bone mass density (BMD) are scarce. OBJECTIVE The aim of this study was to assess body composition and BMD at least 5 years after LSG and LRYGB. SETTING Department of Endocrinology and Nutrition, St. Claraspital Basel and St. Clara Research Ltd., Basel, Switzerland. METHODS Bariatric patients at least 5 years after surgery (LSG or LRYGB) were recruited, and body composition and BMD were measured by means of dual-energy X-ray absorptiometry. Data from body composition before surgery were included in the analysis. Blood samples were taken for determination of plasma calcium, parathyroid hormone, vitamin D3, alkaline phosphatase, and C-terminal telopeptide, and the individual risk for osteoporotic fracture assessed by the Fracture Risk Assessment Tool score was calculated. After surgery, all patients received multivitamins, vitamin D3, and zinc. In addition, LRYGB patients were prescribed calcium. RESULTS A total of 142 patients were included, 72 LSG and 70 LRYGB, before surgery: median body mass index 43.1, median age 45.5 years, 62.7% females. Follow-up after a median of 6.7 years. For LRYGB, the percentage total weight loss at follow-up was 26.3% and for LSG 24.1% (p = 0.243). LRYGB led to a slightly lower fat percentage in body composition. At follow-up, 45% of both groups had a T score at the femoral neck below -1, indicating osteopenia. No clinically relevant difference in BMD was found between the groups. CONCLUSIONS At 6.7 years after surgery, no difference in body composition and BMD between LRYGB and LSG was found. Deficiencies and bone loss remain an issue after both interventions and should be monitored.
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Affiliation(s)
- Julian Bühler
- St. Clara Research Ltd., St. Claraspital, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Silvan Rast
- St. Clara Research Ltd., St. Claraspital, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Ralph Peterli
- St. Clara Research Ltd., St. Claraspital, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Thomas Peters
- Endocrinology and Nutrition, St. Claraspital, Basel, Switzerland
| | - Martina Gebhart
- Endocrinology and Nutrition, St. Claraspital, Basel, Switzerland
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Minisola S, Colangelo L, Pepe J, Diacinti D, Cipriani C, Rao SD. Osteomalacia and Vitamin D Status: A Clinical Update 2020. JBMR Plus 2020; 5:e10447. [PMID: 33553992 PMCID: PMC7839817 DOI: 10.1002/jbm4.10447] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 12/23/2022] Open
Abstract
Historically, rickets and osteomalacia have been synonymous with vitamin D deficiency dating back to the 17th century. The term osteomalacia, which literally means soft bone, was traditionally applied to characteristic radiologically or histologically documented skeletal disease and not just to clinical or biochemical abnormalities. Osteomalacia results from impaired mineralization of bone that can manifest in several types, which differ from one another by the relationships of osteoid (ie, unmineralized bone matrix) thickness both with osteoid surface and mineral apposition rate. Osteomalacia related to vitamin D deficiency evolves in three stages. The initial stage is characterized by normal serum levels of calcium and phosphate and elevated alkaline phosphatase, PTH, and 1,25‐dihydroxyvitamin D [1,25(OH)2D]—the latter a consequence of increased PTH. In the second stage, serum calcium and often phosphate levels usually decline, and both serum PTH and alkaline phosphatase values increase further. However, serum 1,25(OH)2D returns to normal or low values depending on the concentration of its substrate, 25‐hydroxyvitamin D (25OHD; the best available index of vitamin D nutrition) and the degree of PTH elevation. In the final stage, hypocalcemia and hypophosphatemia are invariably low with further exacerbation of secondary hyperparathyroidism. The exact,or even an approximate, prevalence of osteomalacia caused by vitamin D deficiency is difficult to estimate, most likely it is underrecognized or misdiagnosed as osteoporosis. Signs and symptoms include diffuse bone, muscle weakness, and characteristic fracture pattern, often referred to as pseudofractures, involving ribs, scapulae, pubic rami, proximal femurs, and codfish‐type vertebrae. The goal of therapy of vitamin D‐deficiency osteomalacia is to alleviate symptoms, promote fracture healing, restore bone strength, and improve quality of life while correcting biochemical abnormalities. There is a need for better understanding of the epidemiology of osteomalacia. Simplified tools validated by concurrent bone histology should be developed to help clinicians promptly diagnose osteomalacia. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Salvatore Minisola
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome Rome Italy
| | - Luciano Colangelo
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome Rome Italy
| | - Jessica Pepe
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome Rome Italy
| | - Daniele Diacinti
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome Rome Italy
| | - Cristiana Cipriani
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome Rome Italy
| | - Sudhaker D Rao
- Bone and Mineral Research Laboratory, Division of Endocrinology Diabetes & Bore and Mineral Disorders, Henry Ford Hospital Detroit MI USA
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Abstract
PURPOSE OF REVIEW This review outlines the recent findings regarding the impact of bariatric surgery on bone. It explores potential mechanisms for skeletal changes following bariatric surgery and strategies for management. RECENT FINDINGS Bone loss following bariatric surgery is multifactorial. Probable mechanisms include skeletal unloading, abnormalities in calciotropic hormones, and changes in gut hormones. Skeletal changes that occur after bariatric surgery are specific to procedure type and persist for several years post-operatively. Studies suggest that while bone loss begins early, fracture risk may be increased later in the post-operative course, particularly after Roux-en-Y gastric bypass (RYGB). Further research is needed to assess the extent to which skeletal changes following bariatric surgery result in fragility. Current management should be geared toward prevention of bone loss, correction of nutritional deficiencies, and incorporation of weight bearing exercise. Pharmacologic treatment should be considered for high-risk patients.
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Affiliation(s)
- Alexandra N Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery New York, New York, USA
| | - Emily M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery New York, New York, USA.
- Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA.
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9
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Turcotte AF, Grenier-Larouche T, Ung RV, Simonyan D, Carreau AM, Carpentier AC, Mac-Way F, Michou L, Tchernof A, Biertho L, Lebel S, Marceau S, Gagnon C. Effects of Biliopancreatic Diversion on Bone Turnover Markers and Association with Hormonal Factors in Patients with Severe Obesity. Obes Surg 2020; 29:990-998. [PMID: 30478790 DOI: 10.1007/s11695-018-3617-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study evaluated early and medium-term changes in bone turnover markers, and their associations with weight loss, total bone mineral density (BMD), and hormonal changes after biliopancreatic diversion (BPD). METHODS Ancillary study from a one-year prospective cohort of 16 individuals assessed before, 3 days, 3 and 12 months after BPD. Bone turnover markers (C-terminal telopeptide (CTX), intact osteocalcin (OC), sclerostin, and osteoprotegerin (OPG)) and several hormones were measured at each visit. Total BMD by DXA was assessed at baseline, 3 and 12 months after BPD. Three participants were lost to follow-up. RESULTS CTX increased significantly at 3 days (+ 66%), 3 months (+ 219%), and 12 months (+ 295%). OC decreased at 3 days (- 19%) then increased at 3 months (+ 69%) and 12 months (+ 164%). Change in sclerostin was only significant between 3 days and 3 months (+ 13%), while change in OPG was significant between baseline and 3 days (+ 48%) and baseline and 12 months (+ 45%). CTX increase correlated negatively with weight loss at 3 (r = - 0.63, p = 0.009) and 12 months (r = - 0.58, p = 0.039), and total BMD decrease (r = - 0.67, p = 0.033) at 12 months. Change in insulin and adiponectin correlated with changes in bone turnover markers independently of weight loss. CONCLUSION BPD causes an earlier and greater increase in bone resorption over bone formation markers and a decrease in total BMD. Sclerostin did not increase as expected following extensive weight loss. Changes in insulin and adiponectin seem to play a role in the activation of bone remodeling after BPD.
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Affiliation(s)
- Anne-Frédérique Turcotte
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, 2705, Boulevard Laurier, Québec City, QC, G1V 4G2, Canada
| | - Thomas Grenier-Larouche
- CHU de Sherbrooke Research Centre, Sherbrooke, Canada.,Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
| | - Roth-Visal Ung
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, 2705, Boulevard Laurier, Québec City, QC, G1V 4G2, Canada
| | - David Simonyan
- Clinical and Evaluative Research Platform, CHU de Québec-Université Laval Research Centre, Québec City, QC, Canada
| | - Anne-Marie Carreau
- CHU de Sherbrooke Research Centre, Sherbrooke, Canada.,Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
| | - André C Carpentier
- CHU de Sherbrooke Research Centre, Sherbrooke, Canada.,Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
| | - Fabrice Mac-Way
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, 2705, Boulevard Laurier, Québec City, QC, G1V 4G2, Canada.,Department of Medicine, Université Laval, Québec City, Canada
| | - Laetitia Michou
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, 2705, Boulevard Laurier, Québec City, QC, G1V 4G2, Canada.,Department of Medicine, Université Laval, Québec City, Canada
| | - André Tchernof
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, 2705, Boulevard Laurier, Québec City, QC, G1V 4G2, Canada.,Department of Medicine, Université Laval, Québec City, Canada.,Québec Heart and Lung Institute Research Centre, Québec City, Canada.,Institute of Nutrition and Functional Foods, Université Laval, Quebec City, QC, Canada
| | - Laurent Biertho
- Québec Heart and Lung Institute Research Centre, Québec City, Canada.,Department of Surgery, Université Laval, Québec City, Canada
| | - Stefane Lebel
- Québec Heart and Lung Institute Research Centre, Québec City, Canada.,Department of Surgery, Université Laval, Québec City, Canada
| | - Simon Marceau
- Québec Heart and Lung Institute Research Centre, Québec City, Canada.,Department of Surgery, Université Laval, Québec City, Canada
| | - Claudia Gagnon
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, 2705, Boulevard Laurier, Québec City, QC, G1V 4G2, Canada. .,Department of Medicine, Université Laval, Québec City, Canada. .,Québec Heart and Lung Institute Research Centre, Québec City, Canada. .,Institute of Nutrition and Functional Foods, Université Laval, Quebec City, QC, Canada.
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Niu A, Carpenter TO, Grams JM, Bozorgmehri S, Tommasini SM, Schafer AL, Canales BK. High dose vitamin D supplementation does not rescue bone loss following Roux-en-Y gastric bypass in female rats. Bone 2019; 127:172-180. [PMID: 31226531 PMCID: PMC6708762 DOI: 10.1016/j.bone.2019.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/26/2019] [Accepted: 06/17/2019] [Indexed: 01/30/2023]
Abstract
Postoperative bone loss and increased fracture risk associated with Roux-en-Y gastric bypass (RYGB) have been attributed to vitamin D/calcium malabsorption and resultant secondary hyperparathyroidism (HPT). Adequate vitamin D supplementation (VDS), particularly in an older female population, reduces incidence of secondary HPT but the effect on bone loss and fracture risk remains unclear. To investigate whether VDS corrects the RYGB bone phenotype, 41 obese adult female rats were randomized to RYGB with 1000 IU (R1000) or 5000 IU (R5000) vitamin D/kg food or a sham surgical procedure with either paired (PF) or ad libitum (AL) feeding. Bone turnover markers, urinary calcium/creatinine ratio (CCR), and serum calciotropic and gut hormones were assessed throughout a 14-week postoperative period. Femurs were analyzed by micro-computed tomography (μCT), three-point bending test, and histomorphometry. 1000 IU animals had low 25‑hydroxyvitamin D (25(OH)D), high serum parathyroid hormone (PTH), and very low urine CCR levels. 5000 IU corrected the 25(OH)D and secondary HPT but did not increase urine CCR or serum levels of 1,25‑dihydroxyvitamin D (1,25(OH)D) significantly between RYGB groups. Compared to sham animals at 14 weeks, RYGB animals had significantly higher serum osteocalcin (OCN) and C-terminal telopeptide (CTX) levels. The gut hormone peptide tyrosine tyrosine hormone (PYY) was higher in the RYGB groups, and leptin was lower. μCT and biomechanical testing revealed RYGB females had decreased cortical and trabecular bone volume and weaker, stiffer bone than controls. Histomorphometry showed decreased bone volume and increased osteoid volume with increased mineral apposition rate in RYGB compared to controls. No differences in bone phenotype were identified between 1000 IU and 5000 IU groups, and osteoclast numbers were comparable across all four groups. Thus, in our model, 5000 IU VDS corrected vitamin D deficiency and secondary HPT but did not rescue RYGB mineralization rate nor the osteomalacia phenotype. Longer studies in this model are required to evaluate durability of these detrimental effects. Our findings not only underscore the importance of lifelong repletion of both calcium and vitamin D but also suggest that additional factors affect skeletal health in this population.
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Affiliation(s)
- Aidi Niu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Thomas O Carpenter
- Department of Pediatrics, Endocrine Section, Yale University School of Medicine, New Haven, CT, United States of America
| | - Jayleen M Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States of America; Department of Surgery, Birmingham VA Medical Center, Birmingham, AL, United States of America
| | - Shahab Bozorgmehri
- Department of Urology, North Florida/South Georgia Veterans Affairs Medical Center and University of Florida, Gainesville, FL, United States of America
| | - Steven M Tommasini
- Department of Orthopaedics and Rehabilitation, Yale University, New Haven, CT 06520, United States of America
| | - Anne L Schafer
- Endocrine Research Unit, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, CA, United States of America
| | - Benjamin K Canales
- Department of Urology, North Florida/South Georgia Veterans Affairs Medical Center and University of Florida, Gainesville, FL, United States of America.
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Cornejo-Pareja I, Clemente-Postigo M, Tinahones FJ. Metabolic and Endocrine Consequences of Bariatric Surgery. Front Endocrinol (Lausanne) 2019; 10:626. [PMID: 31608009 PMCID: PMC6761298 DOI: 10.3389/fendo.2019.00626] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 08/29/2019] [Indexed: 12/17/2022] Open
Abstract
Obesity is one of the most serious worldwide epidemics of the twenty-first century according to the World Health Organization. Frequently associated with a number of comorbidities, obesity threatens and compromises individual health and quality of life. Bariatric surgery (BS) has been demonstrated to be an effective treatment to achieve not only sustained weight loss but also significant metabolic improvement that goes beyond mere weight loss. The beneficial effects of BS on metabolic traits are so widely recognized that some authors have proposed BS as metabolic surgery that could be prescribed even for moderate obesity. However, most of the BS procedures imply malabsorption and/or gastric acid reduction which lead to nutrient deficiency and, consequently, further complications could be developed in the long term. In fact, BS not only affects metabolic homeostasis but also has pronounced effects on endocrine systems other than those exclusively involved in metabolic function. The somatotropic, corticotropic, and gonadal axes as well as bone health have also been shown to be affected by the various BS procedures. Accordingly, further consequences and complications of BS in the long term in systems other than metabolic system need to be addressed in large cohorts, taking into account each bariatric procedure before making generalized recommendations for BS. In this review, current data regarding these issues are summarized, paying special attention to the somatotropic, corticotropic, gonadal axes, and bone post-operative health.
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Affiliation(s)
- Isabel Cornejo-Pareja
- Unidad de Gestión Clínica Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga—IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red (CIBER) Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Málaga, Spain
| | - Mercedes Clemente-Postigo
- Unidad de Gestión Clínica Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga—IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red (CIBER) Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Málaga, Spain
- *Correspondence: Mercedes Clemente-Postigo
| | - Francisco J. Tinahones
- Unidad de Gestión Clínica Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga—IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red (CIBER) Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Málaga, Spain
- Francisco J. Tinahones
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Gagnon C, Schafer AL. Bone Health After Bariatric Surgery. JBMR Plus 2018; 2:121-133. [PMID: 30283897 PMCID: PMC6124196 DOI: 10.1002/jbm4.10048] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 03/13/2018] [Accepted: 03/26/2018] [Indexed: 02/06/2023] Open
Abstract
Bariatric surgery results in long-term weight loss and improvement or resolution in obesity-related comorbidities. However, mounting evidence indicates that it adversely affects bone health. This review summarizes clinical research findings about the impact of bariatric surgery on skeletal outcomes. The literature is the largest and strongest for the Roux-en-Y gastric bypass (RYGB) procedure, as RYGB was the most commonly performed bariatric procedure worldwide until it was very recently overtaken by the sleeve gastrectomy (SG). Because SG is a newer procedure, its skeletal effects have not yet been well defined. Epidemiologic studies have now demonstrated an increased risk of fracture after RYGB and biliopancreatic diversion with duodenal switch, both of which include a malabsorptive component. As these epidemiologic data have emerged, patient-oriented studies have elucidated the bone tissue-level changes that may account for the heightened skeletal fragility. Bariatric surgery induces early and dramatic increases in biochemical markers of bone turnover. A notable feature of recent patient-oriented clinical studies is the application of advanced skeletal imaging modalities; studies address the limitations of dual-energy X-ray absorptiometry (DXA) by using quantitative computed tomography (QCT)-based modalities to examine volumetric bone mineral density and compartment-specific density and microstructure. RYGB results in pronounced declines in bone mass at the axial skeleton demonstrated by DXA and QCT, as well as at the appendicular skeleton demonstrated by high-resolution peripheral quantitative computed tomography (HR-pQCT). RYGB has detrimental effects on trabecular and cortical microarchitecture and estimated bone strength. Skeletal changes after RYGB appear early and continue even after weight loss plateaus and weight stabilizes. The skeletal effects of bariatric surgery are presumably multifactorial, and mechanisms may involve nutritional factors, mechanical unloading, hormonal factors, and changes in body composition and bone marrow fat. Clinical guidelines address bone health and may mitigate the negative skeletal effects of surgery, although more research is needed to direct and support such guidelines. © 2018 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Claudia Gagnon
- Department of MedicineUniversité LavalQuebec CityCanada
- Endocrinology and Nephrology UnitCHU de Quebec Research CentreQuebec CityCanada
- Institute of Nutrition and Functional FoodsUniversité LavalQuebec CityCanada
- Quebec Heart and Lung Institute Research CentreQuébec CityCanada
| | - Anne L Schafer
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCAUSA
- Endocrine Research UnitSan Francisco Veterans Affairs Heath Care SystemSan FranciscoCAUSA
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Ben-Porat T, Elazary R, Sherf-Dagan S, Goldenshluger A, Brodie R, Mintz Y, Weiss R. Bone Health following Bariatric Surgery: Implications for Management Strategies to Attenuate Bone Loss. Adv Nutr 2018; 9:114-127. [PMID: 29659692 PMCID: PMC5916426 DOI: 10.1093/advances/nmx024] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/11/2017] [Accepted: 12/18/2017] [Indexed: 01/19/2023] Open
Abstract
Bariatric surgery (BS) is an effective treatment for morbid obesity and its associated comorbidities. Following such a procedure, however, patients are at risk of developing metabolic bone disease owing to the combination of rapid weight loss, severely restricted dietary intake, and reduced intestinal nutrient absorption. Patients undergoing malabsorptive procedures are at a higher risk of postoperative bone health deterioration than those undergoing restrictive procedures; however, studies have demonstrated negative skeletal consequences of restrictive procedures as well. The clinical practice guidelines of some international associations have previously addressed preoperative evaluation and postoperative clinical care in order to maintain bone health in BS patients. Nevertheless, some issues regarding bone health in BS patients remain unclear owing to the lack of relevant randomized clinical trials, including doses of nutritional supplements pre- and post-BS. This review summarizes the current data regarding the skeletal consequences of BS and its mechanisms, with an emphasis on the preventive strategies and nutritional care that may be warranted in order to attenuate bone deterioration following BS.
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Affiliation(s)
- Tair Ben-Porat
- Departments of Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Human Metabolism and Nutrition, Hebrew University, Jerusalem, Israel
| | - Ram Elazary
- Departments of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Ariela Goldenshluger
- Departments of Nutrition, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronit Brodie
- Departments of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yoav Mintz
- Departments of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ram Weiss
- Department of Human Metabolism and Nutrition, Hebrew University, Jerusalem, Israel
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Marcil G, Bourget-Murray J, Shinde S, Switzer N, Debru E, Church N, Mitchell P, Reso A, Gill RS. The incidence of fractures following bariatric surgery: A systematic review. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Shanbhogue VV, Støving RK, Frederiksen KH, Hanson S, Brixen K, Gram J, Jørgensen NR, Hansen S. Bone structural changes after gastric bypass surgery evaluated by HR-pQCT: a two-year longitudinal study. Eur J Endocrinol 2017; 176:685-693. [PMID: 28289103 PMCID: PMC5425940 DOI: 10.1530/eje-17-0014] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 03/09/2017] [Accepted: 03/13/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE, DESIGN AND METHODS Roux-en-Y gastric bypass (RYGB) has proved successful in attaining sustained weight loss but may lead to metabolic bone disease. To assess impact on bone mass and structure, we measured a real bone mineral density at the hip and spine by dual-energy X-ray absorptiometry, and volumetric BMD (vBMD) and bone microarchitecture at the distal radius and tibia by high-resolution peripheral quantitative CT in 25 morbidly obese subjects (15 females, 10 males) at 0, 12 and 24 months after RYGB. Bone turnover markers (BTMs), calciotropic and gut hormones and adipokines were measured at the same time points. RESULTS After a 24.1% mean weight loss from baseline to month 12 (P < 0.001), body weight plateaued from month 12 to 24 (-0.9%, P = 0.50). However, cortical and trabecular vBMD and microarchitecture deteriorated through the 24 months, such that there was a 5 and 7% reduction in estimated bone strength at the radius and tibia respectively (both P < 0.001). The declines observed in the first 12 months were matched or exceeded by declines in the 12- to 24-month period. While a significant increase in BTMs and decrease in leptin and insulin were seen at 24 months, these changes were maximal at month 12 and stabilized from month 12 to 24. CONCLUSIONS Despite weight stabilization and maintenance of metabolic parameters, bone loss and deterioration in bone strength continued and were substantial in the second year. The clinical importance of these changes in terms of increased risk of developing osteoporosis and fragility fractures remain an important concern.
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Affiliation(s)
- Vikram V Shanbhogue
- Department of EndocrinologyOdense University Hospital, Odense C, Denmark
- Institute of Clinical ResearchUniversity of Southern Denmark, Odense C, Denmark
- Correspondence should be addressed to V V Shanbhogue;
| | - René Klinkby Støving
- Department of EndocrinologyOdense University Hospital, Odense C, Denmark
- Institute of Clinical ResearchUniversity of Southern Denmark, Odense C, Denmark
- Center for Eating DisordersOdense University Hospital & Psychiatry of Region Southern Denmark, Odense C, Denmark
| | | | - Stine Hanson
- Department of EndocrinologyOdense University Hospital, Odense C, Denmark
| | - Kim Brixen
- Institute of Clinical ResearchUniversity of Southern Denmark, Odense C, Denmark
| | - Jeppe Gram
- Department of EndocrinologyHospital of Southwest Denmark, Esbjerg, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical BiochemistryResearch Center for Ageing and Osteoporosis, Glostrup, Denmark
- OPENOdense Patient data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Stinus Hansen
- Department of EndocrinologyOdense University Hospital, Odense C, Denmark
- Institute of Clinical ResearchUniversity of Southern Denmark, Odense C, Denmark
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Rousseau C, Jean S, Gamache P, Lebel S, Mac-Way F, Biertho L, Michou L, Gagnon C. Change in fracture risk and fracture pattern after bariatric surgery: nested case-control study. BMJ 2016; 354:i3794. [PMID: 27814663 PMCID: PMC4964103 DOI: 10.1136/bmj.i3794] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate whether bariatric surgery increases the risk of fracture. DESIGN Retrospective nested case-control study. SETTING Patients who underwent bariatric surgery in the province of Quebec, Canada, between 2001 and 2014, selected using healthcare administrative databases. PARTICIPANTS 12 676 patients who underwent bariatric surgery, age and sex matched with 38 028 obese and 126 760 non-obese controls. MAIN OUTCOME MEASURES Incidence and sites of fracture in patients who had undergone bariatric surgery compared with obese and non-obese controls. Fracture risk was also compared before and after surgery (index date) within each group and by type of surgery from 2006 to 2014. Multivariate conditional Poisson regression models were adjusted for fracture history, number of comorbidities, sociomaterial deprivation, and area of residence. RESULTS Before surgery, patients undergoing bariatric surgery (9169 (72.3%) women; mean age 42 (SD 11) years) were more likely to fracture (1326; 10.5%) than were obese (3065; 8.1%) or non-obese (8329; 6.6%) controls. A mean of 4.4 years after surgery, bariatric patients were more susceptible to fracture (514; 4.1%) than were obese (1013; 2.7%) and non-obese (3008; 2.4%) controls. Postoperative adjusted fracture risk was higher in the bariatric group than in the obese (relative risk 1.38, 95% confidence interval 1.23 to 1.55) and non-obese (1.44, 1.29 to 1.59) groups. Before surgery, the risk of distal lower limb fracture was higher, upper limb fracture risk was lower, and risk of clinical spine, hip, femur, or pelvic fractures was similar in the bariatric and obese groups compared with the non-obese group. After surgery, risk of distal lower limb fracture decreased (relative risk 0.66, 0.56 to 0.78), whereas risk of upper limb (1.64, 1.40 to 1.93), clinical spine (1.78, 1.08 to 2.93), pelvic, hip, or femur (2.52, 1.78 to 3.59) fractures increased. The increase in risk of fracture reached significance only for biliopancreatic diversion. CONCLUSIONS Patients undergoing bariatric surgery were more likely to have fractures than were obese or non-obese controls, and this risk remained higher after surgery. Fracture risk was site specific, changing from a pattern associated with obesity to a pattern typical of osteoporosis after surgery. Only biliopancreatic diversion was clearly associated with fracture risk; however, results for Roux-en-Y gastric bypass and sleeve gastrectomy remain inconclusive. Fracture risk assessment and management should be part of bariatric care.
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Affiliation(s)
- Catherine Rousseau
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, Quebec City, Canada, G1V 4G2
- Department of Medicine, Laval University, Quebec City, Canada, G1V 0A6
| | - Sonia Jean
- Department of Medicine, Laval University, Quebec City, Canada, G1V 0A6
- Institut national de santé publique du Québec, Quebec City, Canada, G1V 5B3
| | - Philippe Gamache
- Institut national de santé publique du Québec, Quebec City, Canada, G1V 5B3
| | - Stéfane Lebel
- Quebec Heart and Lung Institute - Laval University, Quebec City, Canada, G1V 4G5
| | - Fabrice Mac-Way
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, Quebec City, Canada, G1V 4G2
- Department of Medicine, Laval University, Quebec City, Canada, G1V 0A6
| | - Laurent Biertho
- Quebec Heart and Lung Institute - Laval University, Quebec City, Canada, G1V 4G5
| | - Laëtitia Michou
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, Quebec City, Canada, G1V 4G2
- Department of Medicine, Laval University, Quebec City, Canada, G1V 0A6
| | - Claudia Gagnon
- Endocrinology and Nephrology Unit, CHU de Québec Research Centre, Quebec City, Canada, G1V 4G2
- Department of Medicine, Laval University, Quebec City, Canada, G1V 0A6
- Institute of Nutrition and Functional Foods, Quebec City, Canada, G1V 0A6
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Hassan S, Hassan C. Bariatric Surgery: What the Rheumatologist Needs to Know. J Rheumatol 2016; 43:1001-7. [PMID: 27134263 DOI: 10.3899/jrheum.160075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2016] [Indexed: 12/22/2022]
Abstract
A staggering 76 million adults are obese in the United States. It is known that obesity contributes to increased incidence and worse disease outcomes in many rheumatic conditions. Bariatric surgery has emerged as the most effective treatment modality for the morbidly obese, leading to substantial and sustained weight loss. The purpose of this review article is to summarize the findings of studies investigating the effect of substantial weight loss achieved through bariatric surgery on rheumatic disease and outcomes. Second, with an increasing number of patients undergoing bariatric surgery, it is important for the rheumatologist to have a basic understanding of the commonly performed bariatric procedures and to be aware of important nutritional deficiencies and medication restrictions that apply to this patient population.
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Affiliation(s)
- Sobia Hassan
- From the Division of Rheumatology, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio; Division of Bariatric Surgery, University of Illinois, Chicago, Illinois, USA.S. Hassan, MD, MRCP, Assistant Professor, Division of Rheumatology, Case Western Reserve University/MetroHealth Medical Center; C. Hassan, MD, FRCS, Director of Bariatrics, Division of Bariatric Surgery, University of Illinois.
| | - Chandra Hassan
- From the Division of Rheumatology, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio; Division of Bariatric Surgery, University of Illinois, Chicago, Illinois, USA.S. Hassan, MD, MRCP, Assistant Professor, Division of Rheumatology, Case Western Reserve University/MetroHealth Medical Center; C. Hassan, MD, FRCS, Director of Bariatrics, Division of Bariatric Surgery, University of Illinois
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Long-term outcomes after biliopancreatic diversion with and without duodenal switch: 2-, 5-, and 10-year data. Surg Obes Relat Dis 2016; 12:1697-1705. [PMID: 27425842 DOI: 10.1016/j.soard.2016.03.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 02/21/2016] [Accepted: 03/07/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND There are minimal long-term data on biliopancreatic diversion (BPD) with or without duodenal switch (BPD/DS). OBJECTIVES To investigate the long-term weight loss, co-morbidity remission, complications, and quality of life after BPD and BPD/DS. SETTING An academic, university hospital in the United States. METHODS We conducted a retrospective review of patients who underwent BPD or BPD/DS between 1999 and 2011. Outcomes included weight loss measures at 2, 5, and 10-15 years postoperatively; co-morbidity remission; long-term complications; nutritional deficiencies; and patient satisfaction. RESULTS One hundred patients underwent BPD (34%) or BPD/DS (64%). Mean preoperative body mass index (BMI) was 50.2 kg/m2. Mean follow up was 8.2 years (range: 1-15 yr) with 72% of eligible patients in active follow up at 10-15 years postoperatively. Excess weight loss (EWL) was 65.1% at 2 years, 63.8% at 5 years, and 67.9% at 10-15 years. Approximately 10% higher %EWL was achieved for those with preoperative BMI<50 kg/m2 versus≥50 kg/m2 and patients who underwent BPD/DS versus BPD. Although co-morbidities improved, 37% of patients developed long-term complications requiring surgery. There were no 30-day mortalities; however, there was one mortality from severe malnutrition. Nutritional deficiencies in fat-soluble vitamins, anemia, and secondary hyperparathyroidism were common. Overall, 94% of patients reported satisfaction with their choice of surgery. CONCLUSION This clinical experience supports the long-term positive safety profile and efficacy of BPD and BPD/DS at a single U.S. center. Higher levels of excess weight loss are achieved by patients with a lower preoperative BMI and BPD/DS. Although nutritional deficiencies and postoperative complications are common, patient satisfaction remains high.
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Lu CW, Chang YK, Chang HH, Kuo CS, Huang CT, Hsu CC, Huang KC. Fracture Risk After Bariatric Surgery: A 12-Year Nationwide Cohort Study. Medicine (Baltimore) 2015; 94:e2087. [PMID: 26632892 PMCID: PMC4674195 DOI: 10.1097/md.0000000000002087] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Bariatric surgery has been shown to impair bone health. This study aimed to investigate the fracture risk in patients after bariatric surgery versus propensity score-matched controls. The authors used the National Health Insurance Research Database of Taiwan and identified 2064 patients who underwent bariatric surgery during 2001 to 2009. These patients were matched to 5027 obese patients who did not receive bariatric surgery, using propensity score matching accounting for age, sex, Charlson Comorbidity Index, diabetes, hypertension, hyperlipidemia and the year morbid obesity was diagnosed. The authors followed the surgical and control cohorts to death, any diagnosis of fracture, or December 31, 2012, whichever occurred first. Cox proportional hazard regression models were used to calculate relative rates of fractures in the surgical group and control group. At the end of the 12-year study period, there were 183 fractures in the surgical group (mean follow-up 4.8 years) and 374 fractures in the matched control group (mean follow-up 4.9 years). Overall, there was a 1.21-fold [95% confidence interval (CI): 1.02-1.43] significantly increased risk of fracture in the surgical group compared with the control group. Stratified by surgical procedures, malabsorptive procedures showed a significantly higher fracture risk (1.47, 95% CI: 1.01-2.15). The Kaplan-Meier estimated fracture rates were 1.60% at 1 year, 2.37% at 2 years, 1.69% at 5 years, and 2.06% after 5 years for the surgical patients, compared with 1.51%, 1.65%, 1.53%, and 1.42%, respectively, for the matched controls. Adjusted analysis showed a trend towards an increased fracture risk, 1 to 2 years after bariatric surgery. (1.42, 95% CI: 0.99-2.05). Bariatric surgery was significantly associated with an increased risk of fractures, mainly with malabsorptive procedures, with a trend of an increased fracture risk 1 to 2 years after surgery. These results provide further evidence for the adverse effects of bariatric surgery on the risk of fractures.
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Affiliation(s)
- Chia-Wen Lu
- From the Department of Family Medicine, National Taiwan University Hospital, Taipei (C-WL, H-HC, C-SK, K-CH); Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County (Y-KC, C-TH, C-CH, K-CH); Department of Family Medicine, College of Medicine, National Taiwan University, Taipei (K-CH); Department of Health Services Administration, China Medical University, Taichung City (C-CH); and Institute of Clinical Medicine, National Yang Ming University, Taipei, Taiwan (C-CH)
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Herman CK, Hoschander AS, Wong A. Post-Bariatric Body Contouring. Aesthet Surg J 2015; 35:672-87. [PMID: 25902949 DOI: 10.1093/asj/sjv008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The "epidemic" of obesity has recently been accompanied by a new "epidemic" of massive weight loss. The demand for post-bariatric contouring is rising and, as such, it is extremely important for plastic surgeons to be well versed in the treatment of these patients. Unfortunately, the problem is not solely surgical. OBJECTIVES The aim of this article is to understand the nutritional and psychological complications that can occur in patients following massive weight loss, to understand the anatomic deformities in massive weight loss as a means to correct those deformities surgically, and to understand the complications from post-bariatric contouring procedures in an effort to avoid them. METHODS This article discusses the nutritional and psychological considerations in the massive weight loss patient, anatomical considerations in this patient group, and the surgical techniques designed to address these anatomic concerns. Important pertinent studies are reviewed and discussed. RESULTS Anatomical changes are encountered in each region of the body: there are surgical options available to correct them, although potential complications are associated with these surgical procedures. These surgical options are reviewed as well as the risk and benefits associated with them. CONCLUSIONS There are many problems that need to be addressed in the massive weight loss patient prior to embarking on surgical treatment. Additionally, surgery on massive weight loss patients has unique considerations that distinguish these operations from those performed on the non-bariatric population.
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Affiliation(s)
- Charles K Herman
- Dr Herman is the Chief Medical Executive, Chairman of the Department of Surgery and Chief of the Division of Plastic and Reconstructive Surgery, Pocono Health Systems, East Stroudsburg, PA; Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA; and Assistant Clinical Professor of Surgery, Albert Einstein College of Medicine, New York, NY. Dr. Hoschander is the Chief Resident and Dr. Wong is a Resident in the Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, FL
| | - Ari S Hoschander
- Dr Herman is the Chief Medical Executive, Chairman of the Department of Surgery and Chief of the Division of Plastic and Reconstructive Surgery, Pocono Health Systems, East Stroudsburg, PA; Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA; and Assistant Clinical Professor of Surgery, Albert Einstein College of Medicine, New York, NY. Dr. Hoschander is the Chief Resident and Dr. Wong is a Resident in the Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, FL
| | - Anselm Wong
- Dr Herman is the Chief Medical Executive, Chairman of the Department of Surgery and Chief of the Division of Plastic and Reconstructive Surgery, Pocono Health Systems, East Stroudsburg, PA; Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA; and Assistant Clinical Professor of Surgery, Albert Einstein College of Medicine, New York, NY. Dr. Hoschander is the Chief Resident and Dr. Wong is a Resident in the Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, FL
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Gagner M. Bariatric surgery: To bypass or switch? That is the question in obesity surgery. Nat Rev Gastroenterol Hepatol 2015; 12:255-6. [PMID: 25869914 DOI: 10.1038/nrgastro.2015.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Michel Gagner
- Department of Surgery, Hôpital du Sacré Coeur, 315 Place D'Youville, Montréal, QC H2Y 0A4, Canada
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Marceau P, Biron S, Marceau S, Hould FS, Lebel S, Lescelleur O, Biertho L, Simard S, Kral JG. Long-Term Metabolic Outcomes 5 to 20 Years After Biliopancreatic Diversion. Obes Surg 2015; 25:1584-93. [DOI: 10.1007/s11695-015-1599-5] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Peters T, Toelle P, Gebhart M, Slawik M. Risk Factors for Secondary Hyperparathyroidism After Bariatric Surgery. Clin Rev Bone Miner Metab 2014. [DOI: 10.1007/s12018-014-9173-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Scibora LM. Skeletal effects of bariatric surgery: examining bone loss, potential mechanisms and clinical relevance. Diabetes Obes Metab 2014; 16:1204-13. [PMID: 25132010 DOI: 10.1111/dom.12363] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/27/2014] [Accepted: 07/29/2014] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is the most effective therapeutic approach to morbid obesity, resulting in substantial weight loss and improved cardiometabolic profiles; however, a growing body of evidence suggests that bariatric procedures increase both skeletal fragility and the risk of related future fracture secondary to excessive bone loss. Prospective evidence shows that areal bone mineral density (BMD) assessed by dual energy X-ray absorptiometry (DXA) declines by as much as 14% in the proximal femoral regions, including the femoral neck and total hip, 12 months postoperatively. Lumbar spine areal BMD outcomes show greater 12-month postoperative variability across surgical procedures (-8 to +6%) and contrast with no change in volumetric BMD outcomes measured by quantitative computed tomography. Diminished mechanical loading, micronutrient deficiency and malabsorption, along with neurohormonal alterations, offer plausible underlying mechanisms to explain these observed post-bariatric bone changes, but most remain largely unsubstantiated in this population. Importantly, DXA-based skeletal imaging may have limited utility in accurately detecting bone change in people undergoing bariatric surgery; partly because excessive tissue overlying bone increases the variability of areal BMD outcomes. Moreover, a paucity of fracture and osteoporosis incidence data raises questions about whether marked post-bariatric surgery bone loss is clinically relevant or a functional adaptation to skeletal unloading. Future studies that use technology which is able to accurately capture the site-specific volumetric BMD and bone architectural changes that underpin bone strength in people undergoing bariatric surgery, that consider mechanical load, and that better quantify long-term fracture and osteoporosis incidence are necessary to understand the actual skeletal effects of bariatric surgery.
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Affiliation(s)
- L M Scibora
- Health and Human Performance Department, University of St. Thomas, St. Paul, MN, USA
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Yu EW. Bone metabolism after bariatric surgery. J Bone Miner Res 2014; 29:1507-18. [PMID: 24677277 PMCID: PMC4128478 DOI: 10.1002/jbmr.2226] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/07/2014] [Accepted: 03/12/2014] [Indexed: 12/24/2022]
Abstract
Bariatric surgery is a popular and effective treatment for severe obesity but may have negative effects on the skeleton. This review summarizes changes in bone density and bone metabolism from animal and clinical studies of bariatric surgery, with specific attention to Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and sleeve gastrectomy (SG). Skeletal imaging artifacts from obesity and weight loss are also considered. Despite challenges in bone density imaging, the preponderance of evidence suggests that bariatric surgery procedures have negative skeletal effects that persist beyond the first year of surgery, and that these effects vary by surgical type. The long-term clinical implications and current clinical recommendations are presented. Further study is required to determine mechanisms of bone loss after bariatric surgery. Although early studies focused on calcium/vitamin D metabolism and mechanical unloading of the skeleton, it seems likely that surgically induced changes in the hormonal and metabolic profile may be responsible for the skeletal phenotypes observed after bariatric surgery.
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Affiliation(s)
- Elaine W Yu
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, USA
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Metabolic bone changes after bariatric surgery. Surg Obes Relat Dis 2014; 11:406-11. [PMID: 25487633 DOI: 10.1016/j.soard.2014.03.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 03/11/2014] [Indexed: 11/24/2022]
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Abstract
Bariatric surgery is an effective and increasingly common treatment for severe obesity and its many comorbidities. The side-effects of bariatric surgery can include detrimental effects on bone and mineral metabolism. Bone disease in patients who have had bariatric surgery is affected by preoperative abnormalities in bone and mineral metabolism related to severe obesity. Changes that arise after bariatric surgery are specific to procedure type: the most pronounced abnormalities in calciotropic hormones and bone loss are noted after procedures that result in the most malabsorption. The most consistent site for bone loss after all bariatric procedures is at the hip. There are limitations of dual-energy x-ray absorptiometry technology in this population, including artefact introduced by adipose tissue itself. Bone loss after bariatric surgery is probably multifactorial. Proposed mechanisms include skeletal unloading, abnormalities in calciotropic hormones, and changes in gut hormones. Few data for fracture risk in the bariatric population are available, and this is a crucial area for additional research. Treatment should be geared toward correction of nutritional deficiencies and study of bone mineral density in high-risk patients. We explore the skeletal response to bariatric surgery, potential mechanisms for changes, and strategies for management.
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Affiliation(s)
- Emily M Stein
- Columbia University College of Physicians and Surgeons, Columbia University, New York 10032, USA.
| | - Shonni J Silverberg
- Columbia University College of Physicians and Surgeons, Columbia University, New York 10032, USA
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Biliopancreatic diversion: the effectiveness of duodenal switch and its limitations. Gastroenterol Res Pract 2013; 2013:974762. [PMID: 24639868 PMCID: PMC3929999 DOI: 10.1155/2013/974762] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/06/2013] [Accepted: 10/07/2013] [Indexed: 12/18/2022] Open
Abstract
The prevalence of morbidly obese individuals is rising rapidly. Being overweight predisposes patients to multiple serious medical comorbidities including type two diabetes (T2DM), hypertension, dyslipidemia, and obstructive sleep apnea. Lifestyle modifications including diet and exercise produce modest weight reduction and bariatric surgery is the only evidence-based intervention with sustainable results. Biliopancreatic diversion (BPD) produces the most significant weight loss with amelioration of many obesity-related comorbidities compared to other bariatric surgeries; however perioperative morbidity and mortality associated with this surgery are not insignificant; additionally long-term complications including undesirable gastrointestinal side effects and metabolic derangements cannot be ignored. The overall quality of evidence in the literature is low with a lack of randomized control trials, a preponderance of uncontrolled series, and small sample sizes in the studies available. Additionally, when assessing remission of comorbidities, definitions are unclear and variable. In this review we explore the pros and cons of BPD, a less well known and perhaps underutilized bariatric procedure.
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Manco M, Calvani M, Nanni G, Greco AV, Iaconelli A, Gasbarrini G, Castagneto M, Mingrone G. Low 25-Hydroxyvitamin D Does Not Affect Insulin Sensitivity in Obesity after Bariatric Surgery. ACTA ACUST UNITED AC 2012; 13:1692-700. [PMID: 16286516 DOI: 10.1038/oby.2005.207] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE A positive correlation between levels of 25-hydroxyvitamin D [25(OH)D] and insulin sensitivity has been shown in healthy subjects. We aimed to test the hypothesis that concentration of 25(OH)D influences insulin sensitivity in obesity before and after weight loss. RESEARCH METHODS AND PROCEDURES We investigated the relation between serum 25(OH)D and insulin sensitivity (estimated by euglycemic-hyperinsulinemic clamp) in 116 obese women (BMI > or = 40 kg/m2) evaluated before and 5 and 10 years after biliopancreatic diversion (BPD). Body composition was estimated by the isotope dilution method. RESULTS Prevalence of hypovitaminosis D was 76% in the obese status and 91% and 89% at 5 and 10 years after BPD, respectively, despite ergocalciferol supplementation. 25(OH)D concentration decreased from 39.2 +/- 22.3 in obesity (p = 0.0001) to 27.4 +/- 16.4 and 25.1 +/- 13.9 nM 5 and 10 years after BPD, respectively. Whole-body glucose uptake increased from 24.27 +/- 4.44 at the baseline to 57.29 +/- 11.56 and 57.71 +/- 8.41 mumol/kg(fat free mass) per minute 5 and 10 years after BPD, respectively (p = 0.0001). Predictor of 25(OH)D was fat mass (R2 = 0.26, p = 0.0001 in obesity; R2 = 0.20, p = 0.02 after BPD). Parathormone correlated with fat mass (R2 = 0.19; p = 0.0001) and BMI (R2 = 0.053; p = 0.01) and inversely with M value (R2 = 0.16; p = 0.0001), but only in obese subjects. DISCUSSION A high prevalence of hypovitaminosis D was observed in morbid obesity both before and after BPD. Low 25(OH)D did not necessarily imply increased insulin resistance after BPD, a condition where, probably, more powerful determinants of insulin sensitivity overcome the low circulating 25(OH)D levels. However, the present data cannot exclude some kind of influence of vitamin D status on glucose and insulin metabolism.
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Affiliation(s)
- Melania Manco
- Department of Internal Medicine, Catholic University, School of Medicine, 484 Pineta Sacchetti, 00168 Rome, Italy.
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Lalmohamed A, de Vries F, Bazelier MT, Cooper A, van Staa TP, Cooper C, Harvey NC. Risk of fracture after bariatric surgery in the United Kingdom: population based, retrospective cohort study. BMJ 2012; 345:e5085. [PMID: 22867649 PMCID: PMC3413006 DOI: 10.1136/bmj.e5085] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To estimate fracture risk in patients receiving bariatric surgery versus matched controls. DESIGN Population based, retrospective cohort study. SETTING Use of records from the United Kingdom General Practice Research Database, now known as the Clinical Practice Research Datalink (from January 1987 to December 2010). PARTICIPANTS Patients with a body mass index of at least 30, with a record of bariatric surgery (n=2079), and matched controls without a record (n=10,442). Each bariatric surgery patient was matched to up to six controls by age, sex, practice, year, and body mass index. Patients were followed from the date of bariatric surgery for the occurrence of any fracture. We used time dependent Cox regression to calculate relative rates of fracture, adjusted for disease and previous drug treatment, and time-interaction terms to evaluate fracture timing patterns. MAIN OUTCOME MEASURE Relative rates of any, osteoporotic, and non-osteoporotic fractures. RESULTS Mean follow-up time was 2.2 years. Overall, there was no significantly increased risk of fracture in patients who underwent bariatric surgery, compared with controls (8.8 v 8.2 per 1000 person years; adjusted relative risk 0.89, 95% confidence interval 0.60 to 1.33). Bariatric surgery also did not affect risk of osteoporotic and non-osteoporotic fractures. However, we saw a trend towards an increased fracture risk after three to five years following surgery, as well as in patients who had a greater decrease in body mass index after surgery, but this was not significant. CONCLUSION Bariatric surgery does not have a significant effect on the risk of fracture. For the first few years after surgery, these results are reassuring for patients undergoing such operations, but do not exclude a more protracted adverse influence on skeletal health in the longer term.
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Affiliation(s)
- Arief Lalmohamed
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
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Scibora LM, Ikramuddin S, Buchwald H, Petit MA. Examining the link between bariatric surgery, bone loss, and osteoporosis: a review of bone density studies. Obes Surg 2012; 22:654-67. [PMID: 22271358 DOI: 10.1007/s11695-012-0596-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
As the popularity of bariatric surgery to treat morbid obesity has risen, so has a concern of increased skeletal fragility secondary to accelerated bone loss following bariatric procedures. We reviewed cross-sectional and prospective literature reporting bone density outcomes following bariatric surgical treatment for morbid obesity. Prospective research provides evidence of hip and lumbar spine areal bone mineral density (aBMD) reductions primarily in women despite calcium and vitamin D supplementation. Femoral neck aBMD declines of 9-11% and lumbar spine aBMD reductions up to 8% were observed at the first post-operative year following malabsorptive procedures. Mean T- and Z-scores up to 25 years following surgery remained within normal and healthy ranges. Of those studies reporting development of osteoporosis following gastric bypass, one woman became osteoporotic after 1 year. Despite observed bone loss in the hip region post-surgery, data do not conclusively support increased incidence of osteoporosis or increased fracture risk in post-bariatric patients. However, given the limitations of dual energy X-ray absorptiometry technology in this population and the relative lack of long-term prospective studies that include control populations, further research is needed to provide conclusive evidence regarding fracture outcomes in this population.
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Affiliation(s)
- Lesley M Scibora
- School of Kinesiology, University of Minnesota, 1900 University Avenue SE, Cooke Hall, Minneapolis, MN 55455, USA.
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Vázquez Prado A, Vázquez Tarragón A, Sancho Moya C, Ismail Mahmoud A, De Tursi Rispoli L, Bruna Esteban M, Cabrera IF, Cantos Pallarés M, Mulas Fernández C, Puche Plá J. [Metabolic changes after morbid obesity surgery using the duodenal switch technique. Long term follow-up]. Cir Esp 2011; 90:45-52. [PMID: 22177717 DOI: 10.1016/j.ciresp.2011.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 07/06/2011] [Accepted: 07/18/2011] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The duodenal switch (DS) technique is considered to be complex surgery with a series of metabolic complications due to its malabsorptive character. For these reasons, it has not been extensively used by bariatric surgeons. Despite this, we consider it to be a suitable technique for the grossly obese. PATIENTS AND METHODS A retrospective study was performed on 110 patients with morbid obesity operated on using the DS technique and who were followed up for a minimum period of four years after surgery. We evaluated the weight loss, the outcomes of the comorbidities, and the metabolic complications. RESULTS The loss of excess weight was greater than 50% in 75% of the patients after 12 months follow up. The comorbidities suffered by 68 patients (75.5%) were completely resolved. The most frequent metabolic complications were iron (Fe) deficiency and an increased parathyroid hormone (PTH). CONCLUSIONS DS is a safe and effective technique for the treatment of morbid obesity, with good weight loss results, a high percentage of remission of the comorbidities, a similar morbidity and mortality to other techniques, and with correctable nutritional changes, and thus acceptable.
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Abstract
BACKGROUND Severe or extreme obesity in children and adolescents is a progressive damaging disease, increasingly requiring surgical treatment. Timing and choice of operation are controversial. METHOD In the last 16 years, we performed open biliopancreatic diversion with duodenal switch (DS) in 13 adolescents aged 15-17 years, who have been followed up for 2-16 years (mean, 10.6 years); three with Prader-Willi syndrome (PWS) are presented separately. RESULTS Among the ten non-PWS children (7 girls), no deaths or perioperative complications were reported, mean body mass index (BMI) decreased from 55.9 ± 14.0 to 28.8 ± 3.7 kg/m(2) (% excess weight loss (EWL) = 82.1 ± 10.5%), and none have regained weight. All comorbidities were cured except asthma, which improved in one patient. There were two reoperations: one for intestinal obstruction and one for post-anastomotic ulcer. Glucose and lipid metabolism improved, while vitamin and mineral deficiencies were mild and rare. Five of the seven girls gave birth to 11 children, aged 2-12 years, two of whom are overweight but not severely obese. Neurodevelopment is age-appropriate in all 11 individuals. PWS children, aged 15-16 years, had postoperative respiratory and infectious complications necessitating hospitalizations of 13-22 days (versus 5.1 ± 1.2 days in non-PWS). Weight loss and comorbidity improvement lasted approximately 5 years, providing improved quality of life for patient and family. One PWS patient died from complications after reoperation for weight regain after 4 years. One was reoperated after 6 years and the third is considering reoperation 14 years after primary DS. CONCLUSION The beneficial effects of DS in adolescents exceed the risks, even in the presence of PWS.
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Bacci V, Silecchia G. Vitamin D status and supplementation in morbid obesity before and after bariatric surgery. Expert Rev Gastroenterol Hepatol 2010; 4:781-94. [PMID: 21108597 DOI: 10.1586/egh.10.69] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Interest in vitamin D has increased recently because of its role on multiple biologic mechanisms and the high prevalence of deficits, particularly in obese individuals. The epidemic of morbid obesity has led to a growing number of bariatric surgical procedures, the only therapeutic modality with a reasonable chance of success on a long-term basis. Vitamin D status following bariatric surgery depends on several interacting factors and should be monitored carefully. We review vitamin D, calcium and parathyroid hormone dynamics following the main types of bariatric surgery and the guidelines for the postoperative periodic assessment and therapy.
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Affiliation(s)
- Vincenzo Bacci
- Laparoscopic Surgical Department, Policlinico Umberto I University Hospital, 'La Sapienza' University, Viale del Policlinico 155, 00161 Rome, Italy
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Balsa JA, Botella-Carretero JI, Peromingo R, Caballero C, Muñoz-Malo T, Villafruela JJ, Arrieta F, Zamarrón I, Vázquez C. Chronic increase of bone turnover markers after biliopancreatic diversion is related to secondary hyperparathyroidism and weight loss. Relation with bone mineral density. Obes Surg 2010; 20:468-73. [PMID: 19937150 DOI: 10.1007/s11695-009-0028-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 11/04/2009] [Indexed: 01/12/2023]
Abstract
BACKGROUND Biliopancreatic diversion (BPD) is the most effective bariatric procedure. Around 70% of these patients have secondary hyperparathyroidism (SH) in the long term as a consequence of calcium and vitamin D malabsorption. This work was aimed to study the influence of SH on bone turnover and its relationship with bone mineral density (BMD). METHODS Bone turnover markers were determined in 63 BPD patients and 34 morbidly obese controls. In the BPD group, we also studied the influence of age, loss of weight, common channel length, PTH, vitamin D, and serum calcium on bone turnover as well as its relation with BMD. RESULTS BPD patients showed significantly higher PTH, osteocalcin, and beta-CTx levels than controls. In the multivariate regression analysis, only PTH (beta=0.42; P=0.0002), menopausal status (beta=0.31; P=0.007) and the percentage of lost BMI (beta=-0.24; P=0.03) significantly predicted the osteocalcin level (R2=0.33; F=9.56; P<0.0001). Similarly, only PTH (beta=0.39; P=0.0005), menopausal status (beta=0.37; P=0.001) and the percentage of lost BMI (beta=-0.23; P=0.04) significantly predicted the beta-CTx level (R2=0.33; F=9.82; P<0.0001). Osteocalcin and beta-CTx levels correlated negatively with BMD at lumbar spine (r=-0.38, P=0.002 and r=-0.30, P=0.02, respectively). CONCLUSIONS Chronic SH and the loss of weight determine a high rate of bone turnover that is associated with decreasing BMD in BPD patients.
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Affiliation(s)
- José Antonio Balsa
- Department of Endocrinology and Clinical Nutrition, Hospital Ramón y Cajal, Carretera de Colmenar Km. 9.1, Madrid, Spaine.
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Bevilacqua M, Dominguez LJ, Righini V, Vago T, Foschi D, Corsi F, Trabucchi E, Chebat E, Del Carmen Borghi M, Diana GM, Barrella M, Barbagallo M. Acute parathyroid hormone increase by oral peptones administration after roux-en-Y gastric bypass surgery in obese subjects: Role of phosphate in the rapid control of parathyroid hormone release. Surgery 2010; 147:655-61. [PMID: 20403518 DOI: 10.1016/j.surg.2009.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Accepted: 08/28/2009] [Indexed: 01/10/2023]
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Biertho L, Biron S, Hould FS, Lebel S, Marceau S, Marceau P. Is biliopancreatic diversion with duodenal switch indicated for patients with body mass index <50 kg/m2? Surg Obes Relat Dis 2010; 6:508-14. [PMID: 20627706 DOI: 10.1016/j.soard.2010.03.285] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 01/26/2010] [Accepted: 03/22/2010] [Indexed: 01/06/2023]
Abstract
BACKGROUND Biliopancreatic diversion with duodenal switch (DS) has been the standard surgical approach for the treatment of morbidly obese patients at our institution since the early 1990 s. The published data, however, have shown the use of the DS to be limited to the treatment of super-morbidly obese patients (body mass index [BMI] ≥ 50 kg/m(2)). The aim of the present study was to present our long-term results with the DS in patients with an initial BMI of <50 kg/m(2). METHODS This was a retrospective study of all patients with a BMI <50 kg/m(2) who had undergone DS from June 1992 to May 2005. The data are reported as the mean ± standard deviation. RESULTS The data from 810 consecutive patients, with a mean initial BMI of 44.2 ± 3.6 kg/m(2), were reviewed. The mean follow-up was 103 ± 49 months. Major perioperative complications occurred in 5.8% of patients, including 5 deaths (.6%). The initial excess weight loss was 76% ± 22%, and the excess weight loss was >50% in 89% of patients. Malnutrition required readmission in 4.3% and surgical revision in 1.5%. The prevalence of severe albumin deficiency (<30 g/L) was 1.1%, hemoglobin deficiency (<100 g/L), 1.6%, iron deficiency (<4 mmol/L) 2.1%, and calcium deficiency (<2 g/L) 3%. The percentage of patients "very satisfied" with the global result was 91%, and 37% would have preferred to lose more weight. CONCLUSION These results showed that in non super-obese patients, DS was very efficient in terms of weight loss and patient satisfaction. This was associated with a 1.5% risk of revision for malnutrition. However, nutritional deficiencies required frequent readjustment of supplements, particularly for calcium, vitamin A, and vitamin D.
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Affiliation(s)
- Laurent Biertho
- Department of Surgery, Division of Bariatric and General Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada.
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Effect of a single 'megadose' intramuscular vitamin D (600,000 IU) injection on vitamin D concentrations and bone mineral density following biliopancreatic diversion surgery. Obes Surg 2009; 20:732-7. [PMID: 19949888 DOI: 10.1007/s11695-009-0024-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 10/30/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Vitamin D (VitD) deficiency is common following biliopancreatic diversion (BPD). We conducted a prospective open-label study to evaluate the efficacy of a single intramuscular injection with 600,000 IU of cholecalciferol in an arachis oil depot formulation (VitD3, Arachitol Solvay Pharmacia) as an adjunct to regular oral VitD supplementation (Citrical+D) for a period of 12 months following BPD surgery. METHODS Some 29 patients who had undergone BPD during 2000-2005 were recruited and received a single injection of 600,000 IU of cholecalciferol. Venous blood VitD, parathyroid hormone (PTH), alkaline phosphatase (ALP), ionised calcium and urinary N-telopeptide (NTX) were assessed at baseline and at 1.5, 3, 6, 9 and 12 months post-injection. Bone mineral density (BMD) was determined at baseline and 12 months post-injection. RESULTS VitD concentrations (mean +/- SD) were significantly increased from baseline values (61.5 +/- 18.8 nmol/L) at 1.5 months (92.4 +/- 21.5, p < 0.001), 3 months (100.5 +/- 24.4, p < 0.001) and 6 months (79.1 +/- 20.9, p = 0.014) post-injection, with non-significant elevations at 9 months (73.3 +/- 15.1, p = 0.248) and 12 months (73.4 +/- 17.3, p = 0.278). The proportion of patients with 'normalised' VitD levels was significantly higher at all post-injection time points (range, 93-100%) compared with baseline (71.4%; p < 0.01). Ionised calcium and ALP remained within normal levels at baseline and all follow-up time points, although ionised calcium decreased by 3.4% (p = 0.015) and ALP increased by 14.6% (p = 0.021) at 12 months compared with baseline. No significant change in PTH, NTX or BMD was observed. CONCLUSIONS Intramuscular cholecalciferol injection, as an adjunct to oral supplementation, appears a safe and effective method to increase and maintain VitD levels after BPD.
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Bone Mass Decreases in Morbidly Obese Women after Long Limb-Biliopancreatic Diversion and Marked Weight Loss Without Secondary Hyperparathyroidism. A Physiological Adaptation to Weight Loss? Obes Surg 2009; 19:1497-503. [DOI: 10.1007/s11695-009-9938-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Accepted: 07/31/2009] [Indexed: 11/25/2022]
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Vilarrasa N, Gómez JM, Elio I, Gómez-Vaquero C, Masdevall C, Pujol J, Virgili N, Burgos R, Sánchez-Santos R, de Gordejuela AGR, Soler J. Evaluation of bone disease in morbidly obese women after gastric bypass and risk factors implicated in bone loss. Obes Surg 2009; 19:860-6. [PMID: 19412643 DOI: 10.1007/s11695-009-9843-5] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Accepted: 04/08/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND In patients undergoing gastric bypass, massive weight loss and impairment of calcium intake and absorption in the duodenum and proximal jejunum may increase the risk of bone mass loss and fractures. However, few data are available regarding the impact of this surgery on the skeleton. The aim of our study was to examine the skeletal changes in a cohort of morbidly obese Caucasian women during the first year after gastric bypass and to analyse the factors implicated in the development of bone loss. METHODS Sixty-two morbidly obese white women aged 45.3 +/- 8.9 years were studied. Anthropometric measurements, bone mineral density (BMD) screening using dual-energy X- ray absorptiometry and plasma determinations of calcium, phosphorus, parathyroid hormone (PTH), 25-hydroxyvitamin D [25(OH) D(3)] and insulin-like growth factor-I (IGF-I) were made prior to and 12 months after surgery. RESULTS A year after surgery, BMD significantly decreased at the femoral neck (10.2 +/- 5.7%) and at the lumbar spine (3.2 +/- 4.4%). In the follow-up, 16.1% of women had osteopenia at the femoral neck and 19.3% at the lumbar spine, and 1.6% developed osteoporosis at the lumbar spine. Patients with bone disease were significantly older; the percentage of women with menopause was greater in this group and had lower initial and final values of lean mass. However, no differences in body mass index, weight loss, fat mass, calcium, PTH, 25(OH) D(3) or IGF-I values were found between groups. In the logistic regression analysis, lean mass 12 months after surgery and menopause were found to be the main determinants of osteopenia after adjusting for age with odds ratios of 0.82 and 9.13, respectively. CONCLUSIONS There is a significant BMD loss at the femoral neck and lumbar spine a year after gastric bypass. Menopausal patients and those with greater lean mass loss are at greater risk and, consequently, should be closely followed up with periodic densitometries.
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Affiliation(s)
- Nuria Vilarrasa
- Endocrinology Service, Hospital Universitario de Bellvitge, Barcelona, Spain.
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Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J, Guven S. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring) 2009; 17 Suppl 1:S1-70, v. [PMID: 19319140 DOI: 10.1038/oby.2009.28] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.
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Berarducci A, Haines K, Murr MM. Incidence of bone loss, falls, and fractures after Roux-en-Y gastric bypass for morbid obesity. Appl Nurs Res 2009; 22:35-41. [DOI: 10.1016/j.apnr.2007.03.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2006] [Revised: 03/02/2007] [Accepted: 03/18/2007] [Indexed: 10/21/2022]
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Benhalima K, Mertens A, Van den Bruel A, Laga K, Vanderschueren D, Samson I, Van Damme B, Bouillon R. A brown tumor after biliopancreatic diversion for severe obesity. Endocr J 2009; 56:263-8. [PMID: 19122347 DOI: 10.1507/endocrj.k08e-199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A case of a brown tumor due to iatrogenic malabsorption following biliopancreatic diversion (BPD) is presented. A 52 year old women with a history of BPD 2 years before was referred to orthopedic surgery because of a painful lytic lesion of the left ankle. A bone biopsy revealed a giant cell tumor compatible with the diagnosis of a brown tumor. Subsequent metabolic evaluation showed severe 25-hydroxy vitamin D deficiency and secondary hyperparathyroidism (PTH 60 ng/L or twice the upper normal limit). Bone mineral density was decreased at the femoral neck (0.50 g/cm(2) ; T score of -3.92 or 66% of the expected value) and lumbar spine (T score of -1.75 or 93% of the expected value). A brown tumor can be the presenting symptom of iatrogenic malabsorption due to BPD. This case illustrates the severity of potential bone complications after BPD and the necessity of lifelong surveillance and vitamin supplements after BPD.
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Affiliation(s)
- Katrien Benhalima
- Department of Endocrinology, University Hospital Gasthuisberg, Leuven, Belgium
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Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract 2008; 14 Suppl 1:1-83. [PMID: 18723418 DOI: 10.4158/ep.14.s1.1] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Balsa JA, Botella-Carretero JI, Peromingo R, Zamarrón I, Arrieta F, Muñoz-Malo T, Vázquez C. Role of calcium malabsorption in the development of secondary hyperparathyroidism after biliopancreatic diversion. J Endocrinol Invest 2008; 31:845-50. [PMID: 19092286 DOI: 10.1007/bf03346429] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Secondary hyperparathyroidism (SH) is a frequent metabolic complication of bariatric surgery. Around 70%of patients who undergo biliopancreatic diversion (BPD) have this complication in the long term. The aim of this study was to evaluate the relative influence of vitamin D deficiency and calcium malabsorption in the development of SH in patients who underwent BPD. We reviewed the mean values of PTH throughout the post-operative follow-up and of related biochemical data (25-hydroxyvitamin D, calcium, magnesium) of 121 patients who underwent BPD at our institute from November 1996 to November 2004 (mean follow-up 66 months). Mean PTH correlated negatively with mean 25-hydroxyvitamin D (r=-0.27, p=0.003) and with urinary calcium(r=-0.19, p=0.047), and positively with age (r=0.22, p=0.018). However, a high mean PTH was found in 48.7% patients with mean 25-hydroxyvitamin D >or=30 ng/ml and in 80.0% patients with mean 25-hydroxyvitamin D between 20 and 30 ng/ml. The mean PTH was normal in 5 patients without calcium supplements at present, and progressively increased in parallel to the calcium dose in the rest of patients, although mean 25-hydroxyvitamin D levels were not related to the calcium dose. Our data suggest that individual differences in active and/or passive calcium absorption determine intractable SH after BPD in around half of the patients who have normal levels of 25-hydroxyvitamin D and in 80% of patients with 25-hydroxyvitamin D levels between 20 and 30 ng/ml after BPD, worsening with age.
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Affiliation(s)
- J A Balsa
- Department of Endocrinology and Clinical Nutrition, Ramón y Cajal Hospital, Madrid, Spain.
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Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis 2008; 4:S109-84. [PMID: 18848315 DOI: 10.1016/j.soard.2008.08.009] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.
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Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, Biertho L, Simard S. Duodenal Switch: Long-Term Results. Obes Surg 2008; 17:1421-30. [DOI: 10.1007/s11695-008-9435-9] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
A current review of nutritional complications following bariatric procedures is presented, focusing on the most common and clinically important deficiencies. A brief outline of nutritional supplementation protocol is presented, highlighting the need for a standardized, national or international set of guidelines for pre- and postoperative nutritional screening and appropriate supplementation.
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