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Haggag M, Salem A, Sultan AM, Elghawalby AN, Eldesoky RT, Eldegwi SA, Gad Elhak N, Shehta A. Early and intermediate term outcomes after laparoscopic one-anastomosis gastric bypass for morbidly obese patients: a single center experience. Turk J Surg 2021; 37:324-335. [PMID: 35677485 PMCID: PMC9130952 DOI: 10.47717/turkjsurg.2021.5274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 10/06/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To evaluate our outcomes of laparoscopic one-anastomosis gastric bypass (LOAGB) as a primary weight loss procedure. We evaluated the impact of biliary reflux by combination of upper endoscopy (UGIE), ambulatory pH metry, and ambulatory biliary reflux monitoring. MATERIAL AND METHODS We reviewed the data of patients who underwent LOAGB during the period between July 2015 till August 2018. RESULTS Forty consecutive patients were included in the study. Thirty-seven patients (92.5%) had obesity related comorbidities. The median follow-up duration was 18 months (6-36 months). The 1-, 2-, and 3-years excess weight loss percentages were 53.1%, 60.4%, and 62.3%. At three years follow-up, complete remission of diabetes mellitus occurred in 7/7 patients (100%) and of hypertension in 4/7 patients (57.1%). Eighteen patients (45%) accepted to undergo UGIE with routine biopsies and evaluation of acidic and biliary reflux. All examined patients had negative acid reflux results according to ambulatory PH metry with median DeMeester score of 2 (0.3-8.7). According to ambulatory biliary reflux monitoring, 17/18 patients (94.1%) had posi- tive result. Only 6/18 patients (33.3%) had symptoms of biliary reflux and had positive symptom index on bilimetric study. Regarding UGIE, all patients had just gastritis and reflux esophagitis with no evidence of gross mucosal changes. Pathological examination of all routine biopsies did not show any sign of faveolar hyperplasia, atypia or malignancy. CONCLUSION LOAGB is a safe and efficient bariatric procedure with acceptable morbidity rate. LOAGB is not associated with significant biliary reflux or pathological changes in the esophagogastric mucosa.
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Affiliation(s)
- Mahmoud Haggag
- Department of General Surgery, Gastrointestinal Surgery Center, Mansoura University Faculty of Medicine, Mansoura, Egypt
| | - Ali Salem
- Department of General Surgery, Gastrointestinal Surgery Center, Mansoura University Faculty of Medicine, Mansoura, Egypt
| | - Ahmad M. Sultan
- Department of General Surgery, Gastrointestinal Surgery Center, Mansoura University Faculty of Medicine, Mansoura, Egypt
| | - Ahmed N. Elghawalby
- Department of General Surgery, Gastrointestinal Surgery Center, Mansoura University Faculty of Medicine, Mansoura, Egypt
| | - Rehab T. Eldesoky
- Department of Clinical Pathology, Mansoura University Faculty of Medicine, Mansoura, Egypt
| | - Sara A. Eldegwi
- Department of Clinical Pathology, Mansoura University Faculty of Medicine, Mansoura, Egypt
| | - Nabil Gad Elhak
- Department of General Surgery, Gastrointestinal Surgery Center, Mansoura University Faculty of Medicine, Mansoura, Egypt
| | - Ahmed Shehta
- Department of General Surgery, Gastrointestinal Surgery Center, Mansoura University Faculty of Medicine, Mansoura, Egypt
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Karpińska IA, Kulawik J, Pisarska-Adamczyk M, Wysocki M, Pędziwiatr M, Major P. Is It Possible to Predict Weight Loss After Bariatric Surgery?-External Validation of Predictive Models. Obes Surg 2021; 31:2994-3004. [PMID: 33712937 PMCID: PMC8175311 DOI: 10.1007/s11695-021-05341-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/23/2021] [Accepted: 03/04/2021] [Indexed: 12/25/2022]
Abstract
Background Bariatric surgery is the most effective obesity treatment. Weight loss varies among patients, and not everyone achieves desired outcome. Identification of predictive factors for weight loss after bariatric surgery resulted in several prediction tools proposed. We aimed to validate the performance of available prediction models for weight reduction 1 year after surgical treatment. Materials and Methods The retrospective analysis included patients after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) who completed 1-year follow-up. Postoperative body mass index (BMI) predicted by 12 models was calculated for each patient. The correlation between predicted and observed BMI was assessed using linear regression. Accuracy was evaluated by squared Pearson’s correlation coefficient (R2). Goodness-of-fit was assessed by standard error of estimate (SE) and paired sample t test between estimated and observed BMI. Results Out of 760 patients enrolled, 509 (67.00%) were women with median age 42 years. Of patients, 65.92% underwent SG and 34.08% had RYGB. Median BMI decreased from 45.19 to 32.53kg/m2 after 1 year. EWL amounted to 62.97%. All models presented significant relationship between predicted and observed BMI in linear regression (correlation coefficient between 0.29 and 1.22). The best predictive model explained 24% variation of weight reduction (adjusted R2=0.24). Majority of models overestimated outcome with SE 5.03 to 5.13kg/m2. Conclusion Although predicted BMI had reasonable correlation with observed values, none of evaluated models presented acceptable accuracy. All models tend to overestimate the outcome. Accurate tool for weight loss prediction should be developed to enhance patient’s assessment. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05341-w.
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Affiliation(s)
- Izabela A Karpińska
- Students' Scientific Group at 2nd Department of Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland
| | - Jan Kulawik
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland
| | - Magdalena Pisarska-Adamczyk
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland
| | - Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital in Cracow, Krakow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Jakubowskiego 2 st., 30-688, Krakow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 st., 30-688, Krakow, Poland. .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Jakubowskiego 2 st., 30-688, Krakow, Poland.
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Galyean S, Sawant D, Shin AC. Immunometabolism, Micronutrients, and Bariatric Surgery: The Use of Transcriptomics and Microbiota-Targeted Therapies. Mediators Inflamm 2020; 2020:8862034. [PMID: 33281501 PMCID: PMC7685844 DOI: 10.1155/2020/8862034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Obesity is associated with the gut microbiota and decreased micronutrient status. Bariatric surgery is a recommended therapy for obesity. It can positively affect the composition of the gut bacteria but also disrupt absorption of nutrients. Low levels of micronutrients can affect metabolic processes, like glycolysis, TCA cycle, and oxidative phosphorylation, that are associated with the immune system also known as immunometabolism. METHODS MEDLINE, PUBMED, and Google Scholar were searched. Articles involving gut microbiome, micronutrient deficiency, gut-targeted therapies, transcriptome analysis, micronutrient supplementation, and bariatric surgery were included. RESULTS Studies show that micronutrients play a pivotal role in the intestinal immune system and regulating immunometabolism. Research demonstrates that gut-targeting therapies may improve the microbiome health for bariatric surgery populations. There is limited research that examines the role of micronutrients in modulating the gut microbiota among the bariatric surgery population. CONCLUSIONS Investigations are needed to understand the influence that micronutrient deficiencies have on the gut, particularly immunometabolism. Nutritional transcriptomics shows great potential in providing this type of analysis to develop gut-modulating therapies as well as more personalized nutrition recommendations for bariatric surgery patients.
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Affiliation(s)
- Shannon Galyean
- Department of Nutritional Sciences, Texas Tech University, Lubbock, Texas, USA
| | - Dhanashree Sawant
- Department of Nutritional Sciences, Texas Tech University, Lubbock, Texas, USA
| | - Andrew C. Shin
- Department of Nutritional Sciences, Texas Tech University, Lubbock, Texas, USA
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Patel K, Askari A, Mamidanna R, Jain V, Adil T. Long-term BAROS scores and independent obesity-related co-morbidity predictors of failure after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2020; 16:1954-1960. [PMID: 32958371 DOI: 10.1016/j.soard.2020.07.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/05/2020] [Accepted: 07/27/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Long-term (>5 yr) studies assessing outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) using the Bariatric Analysis and Reporting Outcome System (BAROS) are limited. Evidence of predictors of failure long-term after LRYGB is also lacking. OBJECTIVES To compare BAROS scores at 5 and 10 years post LRYGB and to establish whether individual obesity-related co-morbidities are associated with suboptimal outcomes at these time points. SETTING Single bariatric unit. METHODS BAROS scores were analyzed in patients who were 5 years (group A) and 10 years (group B) post LRYGB. Obesity-related co-morbidities as predictors of failure of surgery (defined by % excess weight loss [%EWL] <50% or BAROS total score ≤1) were examined. Intergroup comparative analysis of outcomes and logistic regression modeling to determine predictors of weight loss failure were conducted. RESULTS A total of 88 patients were 5 years post LRYGB (group A), and 91 patients were 10 years post LRYGB (group B). A total of 52.3% (46/88) in group A and 54.9% (50/91) in group B had failure of weight loss defined by %EWL <50%. There were no significant differences in percentage of total weight loss, %EWL, or BAROS scores between the 2 groups (21.8% versus 22.0%, P = .897; 48.5% versus 47.1%, P = .993; and 3.7 versus 3.3, P = .332, respectively). No individual obesity-related co-morbidity at time of surgery was associated with suboptimal outcomes (%EWL <50% or BAROS total score ≤1) at 5 years or 10 years after LRYGB. CONCLUSIONS Long-term outcomes assessed by the BAROS score appear sustainable between 5 and 10 years after LRYGB surgery, and weight loss achieved at 5 years is maintained at 10 years. Preoperative presence of specific obesity-related co-morbidities was not associated with failure of surgery long-term.
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Affiliation(s)
- Krashna Patel
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Luton, United Kingdom.
| | - Alan Askari
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Luton, United Kingdom
| | - Ravikrishna Mamidanna
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Luton, United Kingdom
| | - Vigyan Jain
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Luton, United Kingdom
| | - Tanveer Adil
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Luton, United Kingdom
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Alwasaidi TA, Alahmadi DK, Alrufayi BM, Alaofi RK, Almutairi SR. Determining the prevalence and causes of anaemia in patients after bariatric surgery in a Saudi hospital. J Taibah Univ Med Sci 2020; 15:129-135. [PMID: 32368209 PMCID: PMC7184217 DOI: 10.1016/j.jtumed.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/04/2020] [Accepted: 02/07/2020] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES Obesity is a chronic disease with high prevalence in Saudi population. Bariatric surgery is an effective method for significant weight reduction. However, various types of nutritional deficiencies occur after weight loss surgery which increase the risk of anaemia. In this study, we aimed to determine the incidence of anaemia after bariatric surgery. METHOD A retrospective descriptive study was conducted with 70 patients of both genders aged over 16 years. These patients underwent bariatric surgery between February 2016 and March 2018 and had completed 6 months or more of post-surgery follow-up. Anthropometric and laboratory data were obtained before and after surgery at standard time intervals. All patients were on postoperative vitamin supplements. RESULTS Of the total study patients, 41 were women (58.57%) and 29 were men (41.42%) with a median age of 38.5 years (range, 16-65). The median follow-up time was 8 months (6-24 months). Postoperatively, 16 patients (22.9%) developed anaemia, and interestingly, all of them were women (39%). Fifteen of these sixteen patients (93.8%) had microcytic anaemia. Two of those sixteen patients (12.5%) had Roux-en-Y gastric bypass, while fourteen (87.5%) had sleeve gastrectomy. CONCLUSION Anaemia and its related nutritional deficiencies are a common complication after bariatric surgery which exerts a major impact on health, particularly in women. Hence, a strict post-operative follow-up and appropriate supplementation are recommended to combat anaemia and its related nutritional deficiencies.
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Affiliation(s)
- Turki A. Alwasaidi
- Medicine Department, College of Medicine, Taibah University, Almadinah Almunawwarah, KSA
| | - Duha K. Alahmadi
- College of Medicine, Taibah University, Almadinah Almunawwarah, KSA
| | | | - Rawan K. Alaofi
- College of Medicine, Taibah University, Almadinah Almunawwarah, KSA
| | - Saad R. Almutairi
- Hematology Division, Medicine Department, Prince Mohammed Bin Abdulaziz Hospital, Ministry National Guard – Health Affairs, Almadinah Almunawwarah, KSA
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Conversional Weight Loss Surgery: an Australian Experience of Converting Laparoscopic Adjustable Gastric Bands to Laparoscopic Sleeve Gastrectomy. Obes Surg 2018; 28:1902-1909. [PMID: 29455406 DOI: 10.1007/s11695-018-3128-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Bariatric surgery is the most effective treatment for severe obesity, capable of producing more than 50% excess weight loss at 10-year follow-up (James Clin Dermatol 1; 22:276-80; O'Brien Br J Surg 2; 102:611-17; Buchwald et al. Metab Syndr 3; 347-56). The success of bariatric surgery extends far beyond weight loss, with up to 80-90% of patients having improvement or resolution of many of their weight-related co-morbidities including type II diabetes mellitus and hypertension (Puzziferri et al. JAMA 4; 312:934-42; Buchwald et al. Am J Med 5; 122:248-56). However, there is a paucity of data regarding conversional bariatric surgery. OBJECTIVE This study aims to explore the efficacy, safety and feasibility of conversional surgery. SETTING This study represents the largest Australasian series focusing on conversional bariatric surgery. The study was conducted in the Norwest Private Hospital and Hospital for Specialist Surgery (HSS), both private Hospitals in Sydney, Australia. METHODS Data was collected prospectively at regular intervals for more than 12 months from 1 January 2012 to 1st November 2015 for all patients requiring a laparoscopic sleeve gastrectomy (LSG) as secondary procedure after prior laparoscopic adjustable gastric band (LAGB). Excess weight loss (EWL), percentage total body weight loss (TWL) and excess BMI loss (EBMIL) as well as any complications were recorded. RESULTS There were low rates of morbidity (1.1%) and no mortality at 12-month follow-up. Satisfactory EWL of 60% (95% CI: 56.6-63.4%), EBMIL of 60.1% (95% CI: 48.8-71.4%) and 16% TWL was achieved at 12-month follow-up. CONCLUSION We therefore conclude that sleeve gastrectomy is a safe and valid option for conversional bariatric surgery following LAGB.
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Kornerup LS, Hvas CL, Abild CB, Richelsen B, Nexo E. Early changes in vitamin B12 uptake and biomarker status following Roux-en-Y gastric bypass and sleeve gastrectomy. Clin Nutr 2018; 38:906-911. [PMID: 29506877 DOI: 10.1016/j.clnu.2018.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/16/2018] [Accepted: 02/03/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Bariatric surgery increases the risk of micronutrient deficiencies, including vitamin B12 (B12) deficiency. We analysed early changes in biomarkers of B12 status following bariatric surgery. METHODS We prospectively included adult patients (n = 27) referred for either Roux-en-Y Gastric Bypass (RYGB) (n = 19) or Sleeve Gastrectomy (SG) (n = 8). Blood samples were drawn before surgery and 2 and 6 months following surgery for measurement of B12, holotranscobalamin (holoTC), and methylmalonic acid (MMA). The B12 absorption capacity was estimated from the increase in plasma holoTC two days after a standardised oral B12 challenge. RESULTS B12 status decreased following both RYBG and SG. While a decrease in plasma B12 was not evident until 6 months postoperatively, we observed a statistically significant decrease in plasma holoTC and increase in MMA already 2 months postoperatively. These changes were more pronounced at 6 months post surgery. Correspondingly, the B12 absorption capacity was decreased following surgery. CONCLUSIONS HoloTC and MMA were superior to B12 to detect early changes in B12 status following bariatric surgery. Our data challenge the current concept that liver B12 stores secure long-term maintenance of B12 status. They indicate that B12 treatment in pharmacological doses may be warranted immediately after surgery.
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Affiliation(s)
- L S Kornerup
- Department of Clinical Biochemistry, Aarhus University Hospital, Denmark; Department of Medicine, Regional Hospital Unit West Jutland, Denmark.
| | - C L Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - C B Abild
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark
| | - B Richelsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark
| | - E Nexo
- Department of Clinical Biochemistry, Aarhus University Hospital, Denmark
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Betancourt-Garcia MM, Arguelles A, Montes J, Hernandez A, Singh M, Forse RA. Pediatric Nonalcoholic Fatty Liver Disease: the Rise of a Lethal Disease Among Mexican American Hispanic Children. Obes Surg 2017; 27:236-244. [PMID: 27822768 DOI: 10.1007/s11695-016-2440-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hispanic children of Mexican origin have a high incidence of NAFLD. Susceptibility has been linked to a combination of factors including an increasing epidemic of obesity in children and adolescents, an allele substitution in the PNPLA3 gene that reduces hepatic lipid catabolism, and an altered microbiome that may increase hepatic endotoxins. The combination of NAFLD and portal vein toxins secondary to an indigenous gut microbiome appear to lead to the early occurrence of NASH, which progresses to cirrhosis and early hepatocellular carcinoma. Early detection and treatment of hepatic changes are needed. Given the success of gastric bypass in reducing body weight, modifying the gut microbiome, and improving NAFLD/NASH in adults, a trial of gastric bypass in predisposed pediatric candidates should be undertaken.
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Affiliation(s)
| | - Armando Arguelles
- Doctors Hospital at Renaissance Health Care System, 5501 S McColl Rd., Edinburg, TX, 78539, USA
| | - Jorge Montes
- Doctors Hospital at Renaissance Health Care System, 5501 S McColl Rd., Edinburg, TX, 78539, USA
| | - Ambrosio Hernandez
- Doctors Hospital at Renaissance Health Care System, 5501 S McColl Rd., Edinburg, TX, 78539, USA
| | - Manish Singh
- Doctors Hospital at Renaissance Health Care System, 5501 S McColl Rd., Edinburg, TX, 78539, USA
| | - R Armour Forse
- Doctors Hospital at Renaissance Health Care System, 5501 S McColl Rd., Edinburg, TX, 78539, USA
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Timing of food intake is associated with weight loss evolution in severe obese patients after bariatric surgery. Clin Nutr 2016; 35:1308-1314. [DOI: 10.1016/j.clnu.2016.02.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/02/2016] [Accepted: 02/09/2016] [Indexed: 01/26/2023]
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Weight-Independent Percentile Chart of 2880 Gastric Bypass Patients: a New Look at Bariatric Weight Loss Results. Obes Surg 2016; 26:2891-2898. [DOI: 10.1007/s11695-016-2200-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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van de Laar A, de Brauw L, Meesters E. Relationships between type 2 diabetes remission after gastric bypass and different weight loss metrics: arguments against excess weight loss in metabolic surgery. Surg Obes Relat Dis 2016; 12:274-82. [DOI: 10.1016/j.soard.2015.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 03/22/2015] [Accepted: 07/05/2015] [Indexed: 12/14/2022]
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Obinwanne KM, Fredrickson KA, Mathiason MA, Kallies KJ, Farnen JP, Kothari SN. Incidence, treatment, and outcomes of iron deficiency after laparoscopic Roux-en-Y gastric bypass: a 10-year analysis. J Am Coll Surg 2013; 218:246-52. [PMID: 24315892 DOI: 10.1016/j.jamcollsurg.2013.10.023] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 10/30/2013] [Accepted: 10/30/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) can lead to iron malabsorption through exclusion of the duodenum and proximal jejunum, decreased gastric acidity, and modified diet. Intravenous (IV) iron is a treatment for severe iron deficiency, but the incidence of iron deficiency and the frequency of treatment with IV iron after LRYGB are largely unknown. Our objective was to determine the incidence of iron deficiency and the frequency of IV iron administration after LRYGB. STUDY DESIGN After obtaining IRB approval, the medical records of patients who underwent LRYGB from September 2001 to December 2011 were retrospectively reviewed. Inclusion criteria consisted of determination of at least 1 ferritin value after surgery. Patients were grouped by level of iron deficiency. Patients with at least 1 ferritin <50 ng/mL were considered iron deficient. Statistical analysis included ANOVA. RESULTS There were 959 patients included; 84.9% were female. Mean age was 43.8 years, and preoperative body mass index was 47.4 kg/m(2). Four hundred ninety-two (51.3%) patients were iron deficient. Of these, 40.9% were severely iron deficient, with a ferritin <30 ng/mL. Intravenous iron was required by 6.7%. After IV iron therapy, 53% had improvement in hemoglobin and ferritin values, and 39% had improvement in ferritin values only. CONCLUSIONS Given the incidence of iron deficiency after LRYGB observed in our series, patients should have iron status monitored carefully by all providers and be appropriately referred for treatment. Female patients should be counseled that there is a 50% chance they will become iron deficient after LRYGB.
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Affiliation(s)
- Kosisochi M Obinwanne
- Minimally Invasive Bariatric Surgery and Advanced Laparoscopy Fellowship, La Crosse, WI
| | | | | | - Kara J Kallies
- Department of Research, Gundersen Medical Foundation, La Crosse, WI
| | - John P Farnen
- Department of Hematology, Gundersen Health System, La Crosse, WI
| | - Shanu N Kothari
- Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI.
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Warsch S, Byrnes J. Emerging causes of iron deficiency anemia refractory to oral iron supplementation. World J Gastrointest Pharmacol Ther 2013; 4:49-53. [PMID: 23919216 PMCID: PMC3729867 DOI: 10.4292/wjgpt.v4.i3.49] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/15/2013] [Accepted: 07/01/2013] [Indexed: 02/06/2023] Open
Abstract
While oral iron supplementation is commonly used throughout many clinical setting, treatment with intravenous (IV) iron has historically been reserved for specific settings, such as chronic kidney disease, gynecologic issues, and anemia associated with cancer and its treatments. However, the use of IV iron has begun to gain popularity in the treatment of iron deficiency anemia (IDA) associated with two conditions that are being seen more frequently than in years past: patients who are status post gastric bypass procedure and those with inflammatory bowel disease (IBD). The Roux-en-Y procedure involves connecting a gastric pouch to the jejunum, creating a blind loop consisting of distal stomach, duodenum, and proximal jejunum that connects to the Roux limb to form a common tract. IDA occurs in 6%-50% of patients who have undergone a gastric bypass, the etiology being multifactorial. The proximal gastric pouch, the primary site of gastric acid secretion, is bypassed, resulting in a decreased ability to metabolize molecular iron. Once metabolized, most iron is absorbed in the duodenum, which is entirely bypassed. After undergoing bypass procedures, most patients significantly limit their intake of red meat, another factor contributing to post-bypass IDA. Chronic anemia occurs in approximately 1/3 of patients who suffer from IBD, and almost half of all IBD patients are iron deficient. IBD leads to IDA through multiple mechanisms, including chronic intestinal blood loss, decreased absorption capabilities of the duodenum secondary to inflammation, and an inability of many IBD patients to tolerate the side effects of oral ferrous sulfate. In this study, we reviewed the charts of all patients who received IV iron at Sylvester Comprehensive Cancer Center/University of Miami Hospital Clinic from January 2007 to May 2012. The most common indications for IV iron were for issues related to cancer and its treatment (21.9%), IBD (20.1%), and gastric bypass (15.0%). Of the 262 patients who received IV iron, 230 received iron sucrose and 36 received iron dextran. While doses of 100, 200, 300, and 400 mg of iron sucrose were given, 100 and 200 mg were by far the most common dosages used, 122 and 120 times, respectively. The number of dosages of iron sucrose given ranged from 1 to 46, with a mean of 5.5 and a median of 4 doses. The average dose of iron dextran given was 870.5 mg, with 1000 mg being the most common dosage used. Most patients (22 of 36) who received iron dextran only received one dose. While patients with traditional indications for IV iron, such as gynecologic issues and kidney disease, still were represented in this study, we expect to see a continued increase in physicians using IV iron for emerging gastrointestinal indications, especially considering the increased safety of new low-molecular formulations.
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Majumder S, Soriano J, Louie Cruz A, Dasanu CA. Vitamin B12 deficiency in patients undergoing bariatric surgery: preventive strategies and key recommendations. Surg Obes Relat Dis 2013; 9:1013-9. [PMID: 24091055 DOI: 10.1016/j.soard.2013.04.017] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 04/18/2013] [Accepted: 04/22/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advances in bariatric surgery have brought about a paradigm shift in the management of obesity, with benefits extending beyond weight loss. However, nutritional deficiencies are an inherent problem in the postoperative period and often require lifelong supplementation. Vitamin B12, also referred to as cobalamin, is one of the most common micronutrient deficiencies affecting this population. This review explores the pathophysiology of cobalamin deficiency in patients undergoing bariatric surgery and provides an overview of the effectiveness of various available vitamin B12 formulations. METHODS To identify the relevant literature, a systematic review of MEDLINE was conducted from the earliest dates through September 2012 for English-language articles describing the prevention and management of vitamin B12 deficiency in patients undergoing bariatric surgery. RESULTS Intramuscular vitamin B12 continues to be the gold standard of therapy for vitamin B12 deficiency, especially in symptomatic patients. In select patients with asymptomatic vitamin B12 deficiency after Roux-en-Y gastric bypass (RYGB), high-dose oral cyanocobalamin should be given a consideration, especially when there are concerns with the adherence to intramuscular therapy or if compliance comes into question. Unlike patients post-RYGB, those undergoing restrictive procedures such as gastric banding and sleeve gastrectomy may be maintained postoperatively on a lower-dose daily vitamin B12 supplementation. Efficacy data of nasal and sublingual routes for maintenance therapy is currently awaited. CONCLUSION Patients undergoing bariatric surgery must be continuously educated on proper nutrition, the risk of developing significant vitamin B12 deficiency, and the role of supplements in avoiding catastrophic consequences.
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Affiliation(s)
- Shounak Majumder
- Department of Internal Medicine, University of Connecticut, Farmington, Connecticut.
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Sawaya RA, Jaffe J, Friedenberg L, Friedenberg FK. Vitamin, mineral, and drug absorption following bariatric surgery. Curr Drug Metab 2013; 13:1345-55. [PMID: 22746302 DOI: 10.2174/138920012803341339] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/28/2012] [Accepted: 05/02/2012] [Indexed: 02/07/2023]
Abstract
UNLABELLED The prevalence of obesity continues to rise throughout the world. Increasingly, bariatric surgery is used for those with morbid obesity as a pivotal approach to achieve weight loss. Along with substantial weight loss, malabsorption of essential vitamins, minerals, and drugs also occurs. Therefore, more than ever, a better understanding of the physiology and mechanisms by which these deficiencies occur is essential. We review the normal physiology of vitamin, mineral, and drug absorption. This is followed by a description of currently performed bariatric surgeries in the United States. A detailed review of specific nutrient and mineral deficiency states is presented, based on the most significant studies published in the last two decades. Of note, screening and supplementation recommendations have been included. Drug absorption data after these procedures is presented and discussed. Studies were identified by searching the Cochrane Registry and MEDLINE using relevant search terms, as well as through review of the reference section of included manuscripts. CONCLUSIONS Bariatric surgery can be effectively used to achieve sustainable weight-loss in morbidly obese patients. It simultaneously brings forth important functional consequences on nutrient deficiencies and drug absorption that clinician's must be aware of. Further prospective, randomized research on specific procedures and deficiencies is required.
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Castagneto-Gissey L, Mingrone G. Insulin sensitivity and secretion modifications after bariatric surgery. J Endocrinol Invest 2012; 35:692-8. [PMID: 22732257 DOI: 10.3275/8470] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Type 2 diabetes mellitus is increasing over time as result of the obesity epidemics. In fact, the prevalence of Type 2 diabetes across Europe in 2010 was estimated to be 8.2% of the population and its projection for 2030 sees figures of 10.1%. This increase in the number of diabetic individuals has also dramatically raised the health expense, with spending on diabetes in Europe in 2010 accounting for 10% of the total healthcare cost. A meta-analysis of the literature evidenced that the clinical and laboratory manifestations of Type 2 diabetes are resolved in 78.1%, and are improved in 86.6% of obese patients (body mass index >35 kg/m²) after bariatric surgery. However, a gradation of effects of different surgical techniques in improving glucose control does exist, with the largest and durable effects observed in prevalently malabsorptive procedures. The outcome of bariatric surgery on insulin sensitivity and secretion is different in relation to the type of operation performed. In fact, while Roux-en-Y Gastric Bypass enhances insulin secretion after a meal thus improving glucose metabolism, Bilio-Pancreatic Diversion acts through the amelioration of insulin sensitivity allowing a subsequent reduction of insulin hypersecretion, which is a typical feature of the insulin resistance state. Gastric banding action is mediated uniquely through the weight loss, and the effect of sleeve gastrectomy is still to be elucidated. Incretin secretion is dramatically increased under nutrient stimulation after gastric bypass leading, probably, to an overstimulation of pancreatic β-cells resulting in the increase of insulin secretion.
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Vieira C, Cosmo C, Lucena R. The importance of methylmalonic acid dosage on the assessment of patients with neurological manifestations following bariatric surgery. Obes Surg 2012; 21:1971-4. [PMID: 21688116 DOI: 10.1007/s11695-011-0449-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Vitamin B12 or cyanocobalamin is an important substance that is included in several metabolic pathways. Its deficiency is a common event after bariatric surgery, decreasing the vitamin B12 absorption after almost all of the stomach and duodenum are eliminated from the digestion process. Neurological manifestations of cyanocobalamin deficiency are not uncommon. We report a case of a young woman who developed ataxia, weakness and peripheral neuropathy after bariatric surgery, but with normal value of vitamin B12 dosage. For the diagnosis, it was necessary to dose methylmalonic acid. We discuss the importance of methylmalonic acid dosage after bariatric surgery in patients who present suspect of cyanocobalamin deficiency with normal values of this vitamin and the role of proton pump inhibitor use and vitamin supplementation in patients with early neurological presentation.
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Affiliation(s)
- Camilo Vieira
- Clinic of Neuromuscular Diseases, DINEP-Neurology and Epidemiology Division, University Complex Professor Edgar Santos, Federal University of Bahia, Salvador, Bahia, Brazil.
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Aarts EO, van Wageningen B, Janssen IMC, Berends FJ. Prevalence of Anemia and Related Deficiencies in the First Year following Laparoscopic Gastric Bypass for Morbid Obesity. J Obes 2012; 2012:193705. [PMID: 22523660 PMCID: PMC3317129 DOI: 10.1155/2012/193705] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 12/19/2011] [Indexed: 02/08/2023] Open
Abstract
Background. Anemia associated with deficiencies in iron, folic acid, and vitamin B12 are very common after Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery for morbid obesity. This study was conducted to evaluate the prevalence of anemia after LRYGB. Patients and Methods. A total of 377 morbid obese patients were included in our study. All patients underwent a LRYGB. Hematologic parameters were obtained prior to and after surgery on standardized time intervals. Results. Anemia was present in 21 (P = 0.02) patients after surgery. Iron, folic acid, and vitamin B12 deficiencies were diagnosed in 66%, 15%, and 50% of patients, respectively. In 86% of patients, anemia was accompanied by one of these deficiencies. Conclusion. These results show that anemia and deficiencies for iron, folic acid deficiency, and vitamin B12 are very common within the first year after LRYGB. We advise a minimal daily intake of 65 mg of iron in male and 100 mg in female patients, 350 μg of vitamin B12, and 400 μg of folic acid. Patients undergoing LRYGB must be closely monitored for deficiencies pre- and postoperative and supplemented when deficiencies occur.
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Affiliation(s)
- E. O. Aarts
- Department of Surgery, Rijnstate Hospital, Postal number 1190, P.O. Box 9555, 6800 TA Arnhem, The Netherlands
- Department of Bariatric Surgery, Rijnstate Hospital and Vitalys Clinic, Postal number 1190, P.O. Box 9555, 6800 TA Arnhem, The Netherlands
| | - B. van Wageningen
- Department of Surgery, Rijnstate Hospital, Postal number 1190, P.O. Box 9555, 6800 TA Arnhem, The Netherlands
| | - I. M. C. Janssen
- Department of Surgery, Rijnstate Hospital, Postal number 1190, P.O. Box 9555, 6800 TA Arnhem, The Netherlands
| | - F. J. Berends
- Department of Surgery, Rijnstate Hospital, Postal number 1190, P.O. Box 9555, 6800 TA Arnhem, The Netherlands
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Powell MS, Fernandez AZ. Surgical treatment for morbid obesity: the laparoscopic Roux-en-Y gastric bypass. Surg Clin North Am 2012; 91:1203-24, viii. [PMID: 22054149 DOI: 10.1016/j.suc.2011.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Over the past 20 years bariatric surgery proved to be a valid treatment for reduction and elimination of obesity-related diseases and long-term sustainable weight loss. Minimally invasive or laparoscopic techniques such as laparoscopic Roux-en-Y (LRNY) have replaced open procedures. Many factors play important roles in the small intricacies and variations of the procedure, chief of which is the creation and size of the gastrojejunostomy. Regardless of the variations in technique, the LRNY remains the gold standard for the surgical treatment of clinically severe or morbid obesity, with relatively low morbidity and mortality.
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Affiliation(s)
- Myron S Powell
- Department of General Surgery, Wake Forest University School Of Medicine, Winston-Salem, NC 27157, USA
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Chopra A, Chao E, Etkin Y, Merklinger L, Lieb J, Delany H. Laparoscopic sleeve gastrectomy for obesity: can it be considered a definitive procedure? Surg Endosc 2011; 26:831-7. [PMID: 22179438 DOI: 10.1007/s00464-011-1960-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 09/10/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Providing bariatric surgery services to an inner-city population is a challenge. Laparoscopic sleeve gastrectomy (LSG) is an effective operation for morbid obesity with a relatively low complication rate. LSG appears to be a suitable alternative procedure for this group of patients. METHODS This is a retrospective review and analysis of the experience with 185 consecutive LSGs that had completed at least 6 months follow-up. Eleven conversions from LSG to laparoscopic Roux-en-Y gastric bypass were excluded, leaving 174 patients for outcome analysis. Data collected were patient demographics, body mass index (BMI), comorbid conditions, operating time, length of hospital stay, and perioperative complications. Weight loss and resolution/improvement of comorbidities were analyzed. RESULTS Mean patient age was 39.58 years and mean BMI was 48.97 kg/m(2). The percentage of patients with BMI > 50 kg/m(2) was 37.94%. Mean excess weight loss (EWL) was 44.76, 55.52, 59.22, and 58.92% at 6, 12, 24, and 36 months, respectively. Six patients (3.24%) lost less than 25% EWL. Thirteen patients (7.02%) regained an average of 13 lb after reaching a plateau. Resolution/improvement of comorbidities was 84% for diabetes mellitus, 49.99% for hypertension, 90% for asthma, 90.74% for obstructive sleep apnea, and 45.92% for gastroesophageal reflux disease symptoms (GERD). The mortality rate was zero in this series. Perioperative complications occurred in 26 patients (14.05%): four staple-line leaks (2.16%), four bleeds (2.16%), four obstructions (2.16%), five vomiting/dehydration (2.70%), six new onset of GERD symptoms (3.24%), two with pneumonia (1.08%), and one with pulmonary embolism (0.54%). CONCLUSION LSG results in stable and adequate weight loss with resolution/improvement in comorbidities in a high percentage of patients. It can be considered a definitive operation for morbid obesity.
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Affiliation(s)
- Ajay Chopra
- Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Bronx, NY 10461, USA.
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Abstract
The number of bariatric surgeries performed in the United States has increased exponentially. Given that most patients are female and of reproductive age, it is important for clinicians who manage women's health issues to be aware of the surgery, its long-term goals, and the potential effect on future pregnancies. Most pregnancies after bariatric surgery have successful outcomes with decreased occurrences of gestational diabetes and hypertension and lower birth weight compared with control patients. Following nutritional guidelines and supplementation in the event of deficiencies are critical in the provision of prenatal care to this unique population. Other important issues include a multidisciplinary team management, a different approach to screening for gestational diabetes, careful evaluation of any gastrointestinal complaints, and appropriate counseling for gravidas who still remain obese during pregnancy. Further research should investigate the long-term maternal outcomes in pregnancies after bariatric surgery as well as the effect on the offspring.
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Affiliation(s)
- Michelle A. Kominiarek
- Assistant Professor of Obstetrics and Gynecology, University of Illinois at Chicago, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, 820 South Wood Street M/C 808, Chicago, Illinois 60612
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Abstract
The incidence of obesity is increasing rapidly, and it affects a greater proportion of women than men. Unfortunately, obesity has a negative impact on women's reproductive health, including increased adverse perinatal outcomes. Weight loss surgery, also known as bariatric surgery, is performed in many hospitals, and can allow for significant weight loss and improvement in medical comorbidities such as diabetes and hypertension. A woman who becomes pregnant after bariatric surgery usually has an uncomplicated pregnancy but requires special attention to some complications that can occur after these procedures. This article reviews the perinatal outcomes and provides recommendations for care regarding the unique issues that arise during a pregnancy after bariatric surgery.
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Affiliation(s)
- Michelle A Kominiarek
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, 840 South Wood Street, M/C 808, Chicago, IL 60612, USA.
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Cable CT, Colbert CY, Showalter T, Ahluwalia R, Song J, Whitfield P, Rodriguez J. Prevalence of anemia after Roux-en-Y gastric bypass surgery: what is the right number? Surg Obes Relat Dis 2010; 7:134-9. [PMID: 21195676 DOI: 10.1016/j.soard.2010.10.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 08/27/2010] [Accepted: 10/22/2010] [Indexed: 01/03/2023]
Abstract
BACKGROUND The reported prevalence of anemia after malabsorptive bariatric surgery has varied from 5% to 64% in the post-Roux-en-Y gastric bypass (RYGB) population, owing to the small study sample sizes and generally poor follow-up in surgical referral practices. The present study estimated the prevalence of anemia in the post-RYGB population and determined whether an integrated healthcare system with a shared electronic medical record could improve postoperative follow-up. METHODS The medical records from 1009 sequential patients who had undergone RYGB from 2000 to 2005 were retrospectively analyzed. All anemia data within the healthcare system's electronic medical record were accessible. RESULTS Of the 1009 medical records, 720 contained ≥1 year of follow-up data concerning anemia. Anemia had developed or worsened in 259 patients, for a prevalence of 36% in the present sample. The anemia was moderate to severe (hemoglobin <10 g/dL) in 88 patients (12.2%.), many of whom subsequently required parenteral iron. Of the 1009 patients, the follow-up data for ≥3 years concerning anemia were available for only 357 patients (35.4%). CONCLUSION The results of the present study have shown that in a large population of patients undergoing RYGB, the prevalence of anemia was great enough to justify more intensive long-term screening. We hope the findings from the present report influence the national screening standards for this patient population.
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Affiliation(s)
- Christian T Cable
- Department of Internal Medicine, Scott & White Healthcare, Texas A & M University Health Science Center College of Medicine, Temple, TX, USA.
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von Drygalski A, Andris DA. Anemia after bariatric surgery: more than just iron deficiency. Nutr Clin Pract 2009; 24:217-26. [PMID: 19321896 DOI: 10.1177/0884533609332174] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Bariatric surgery for morbid obesity is rapidly gaining popularity. Restrictive and/or malabsorptive surgical interventions result in dramatic weight loss with significantly decreased obesity-related morbidity and mortality. Anemia, which may affect as many as two-thirds of these patients, is of concern and generally thought to be caused by iron deficiency. Although iron deficiency in this population may be frequent given pouch hypoacidity, defunctionalized small bowel, and red meat intolerance, it may not account for all anemias seen. First, there is increasing evidence that obesity creates a state of chronic inflammation. Both iron deficiency anemia and anemia of chronic inflammation present with low serum iron levels. Most studies reporting anemia after bariatric surgery lack serum ferritin determinations so that the relative contribution of inflammation to anemia cannot be assessed. Second, a significant number of anemias after bariatric surgery remain unexplained and may be attributable to less frequently seen micronutrient deficiencies such as copper, fatsoluble vitamins A and E, or an imbalance in zinc intake. Third, although deficiencies of folate and vitamin B(12) are infrequent, study observation periods may be too short to detect anemia attributable to vitamin B(12) deficiency because vitamin B(12) storage depletion takes many years. This review is intended to increase awareness of the mechanisms of anemia above and beyond iron deficiency in the bariatric patient and provide healthcare providers with tools for a more thoughtful approach to anemia in this patient population.
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Affiliation(s)
- Annette von Drygalski
- VA San Diego Healthcare System, La Jolla Medical Center, 3350 La Jolla Village Dr, 111E, San Diego, CA 92161, USA.
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Oria HE, Moorehead MK. Updated Bariatric Analysis and Reporting Outcome System (BAROS). Surg Obes Relat Dis 2009; 5:60-6. [PMID: 19161935 DOI: 10.1016/j.soard.2008.10.004] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Revised: 10/01/2008] [Accepted: 10/19/2008] [Indexed: 11/18/2022]
Affiliation(s)
- Horacio E Oria
- Department of Surgery, Spring Branch Medical Center, Houston, Texas 77055, USA.
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Abstract
Morbid obesity is a significant problem in the Western world. Recently, there has been an increase in the number of patients undergoing surgical weight loss procedures. Currently, the most widely performed procedure is the Roux-en-Y gastric bypass operation which combines restriction of food intake with malabsorption of calories and various nutrients, resulting in weight loss and nutritional deficiencies, respectively. Various types of anemia may complicate Roux-en-Y and commonly include deficiencies of iron, folate, and vitamin B12. Iron deficiency is particularly common and may result from many mechanisms including poor intake, malabsorption, and mucosal bleeding from marginal ulceration. However, less appreciated etiologies of nutritional anemia include deficiencies of B-complex vitamins, ascorbic acid, and copper. Replacement of the missing or decreased constituent usually reverses the anemia. Since physicians of various medical and surgical specialties are often involved with the postoperative care of bariatric patients, a review of anemia in this patient population is warranted.
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Results of laparoscopic sleeve gastrectomy: a prospective study in 135 patients with morbid obesity. Surgery 2008; 145:106-13. [PMID: 19081482 DOI: 10.1016/j.surg.2008.07.013] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Accepted: 07/07/2008] [Indexed: 12/27/2022]
Abstract
BACKGROUND Sleeve gastrectomy is a new restrictive bariatric procedure increasingly indicated in the treatment of morbid obesity. The authors report their experience of laparoscopic sleeve gastrectomy (LSG), evaluate the efficacy of this procedure on weight loss, and analyze the short-term outcome. METHODS The data of 135 consecutive patients undergoing LSG between July 2004 and October 2007 were analyzed prospectively. LSG was indicated only for weight reduction with a body mass index (BMI) > 40 or > 35 kg/m(2) associated with severe comorbidity. Study endpoints included mean BMI, comorbidity, operative data, conversion to laparotomy, intraoperative complications, major and minor complication rates, excess weight loss, follow-up, and duration of hospital stay. Possible risk factors for postoperative gastric fistula (PGF) were investigated. RESULTS This series comprised 113 females and 22 males with a mean age of 40 years (range, 18-65). Mean weight was 132 kg (range, 94-186), and mean preoperative BMI was 48.8 kg/m(2) (range, 37-72). The mean operating time was 103 minutes (range, 30-550). No patients required conversion to laparotomy, and 96% of patients did not require drainage. The nasogastric tube was removed on postoperative day 1. The postoperative course was uneventful in 94.9% of cases, and the median duration of hospital stay was 3.8 days. The median follow-up was 12.7 months. The mean postoperative BMI decreased to 39.8 kg/m(2) at 6 months (P < .001). Average excess body weight loss was 38.6% and 49.4% at 6 months and 1 year, respectively. There was no mortality, and the major complication rate, corresponding to gastric fistula (PGF) in every case, was 5.1% (n = 7). Management of PGF required reoperation, radiologic and endoscopic procedures, and fibrin glue; the median hospital stay was 47 days. BMI > 60 kg/m(2) appears to be a risk factor for PGF. CONCLUSION LSG is a reproducible and seems to be an effective treatment to achieve significant weight loss after 12 months follow-up. LSG can be used as a standalone operation to obtain weight reduction. Management of PGF remains a major issue.
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ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis 2008; 4:S73-108. [PMID: 18490202 DOI: 10.1016/j.soard.2008.03.002] [Citation(s) in RCA: 309] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 03/12/2008] [Indexed: 12/13/2022]
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Love AL, Billett HH. Obesity, bariatric surgery, and iron deficiency: true, true, true and related. Am J Hematol 2008; 83:403-9. [PMID: 18061940 DOI: 10.1002/ajh.21106] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Morbid obesity is a health problem that has been shown to be refractory to diet, exercise, and medical treatment. Surgeries designed to promote weight loss, termed bariatric surgery and typically involving a gastric bypass procedure, have recently been implemented to treat obesity with high success rates. However, long-term sequelae can result in micronutrient deficiencies. This review will focus on iron deficiency and its association with obesity and bariatric surgery. Iron deficiency develops after gastric bypass for several reasons including intolerance for red meat, diminished gastric acid secretion, and exclusion of the duodenum from the alimentary tract. Menstruating women, pregnant women, and adolescents may be particularly predisposed toward developing iron deficiency and microcytic anemias after bypass surgery. Preoperative assessment of patients should include a complete hematological work-up, including measurement of iron stores. Postoperatively, oral iron prophylaxis and vitamin C in addition to a multivitamin should be prescribed for bypass patients, especially for vulnerable populations. Once iron deficiency has developed, it may prove refractory to oral treatment, and require parenteral iron, blood transfusions, or surgical interventions. Bariatric surgery patients require lifelong follow-up of hematological and iron parameters since iron deficiency and anemia may develop years after surgery.
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Affiliation(s)
- Aileen L Love
- Department of Medicine, Weill Cornell Medical Center, New York, New York, USA
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Ashton D, Favretti F, Segato G. Preoperative psychological testing--another form of prejudice. Obes Surg 2008; 18:1330-7. [PMID: 18335282 DOI: 10.1007/s11695-008-9469-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Accepted: 02/06/2008] [Indexed: 01/14/2023]
Abstract
Preoperative psychological screening of bariatric surgery candidates has become routine, and a significant proportion of patients have their surgery deferred as a consequence. If psychological testing is being used as a form of preoperative triage, both patients and surgeons are entitled to know whether there is sufficient evidence to justify its use in this way. We define the argument for psychological screening as consisting of four premises (p1-p4) and a conclusion (C) as follows: (p1) A significant minority of obese patients will not be successful in losing weight following bariatric surgery-the "failure" group; (p2) A significant minority of patients will exhibit abnormal psychological profiles during preoperative testing; (p3) The majority of individuals referred to in (p2) will be found in group (p1) i.e., abnormal psychological profiles identified preoperatively predict less favorable weight loss outcomes postoperatively; (p4) Identifying patients with adverse psychological profiles preoperatively would allow either exclusion of those at high risk of failure or provide a more secure rationale for targeted pre- and postoperative support; (C) Psychological screening should be part of the routine preoperative assessment for patients undergoing obesity surgery. We reviewed the literature to find evidence to support the premises and show that (p1) can be justified but that (p2) is problematic and can only be accepted in a heavily qualified version. We find no evidence for (p3) and since (p4) and (C) are predicated on (p3), the argument clearly fails. There is no evidence to suggest that preoperative psychological screening can predict postoperative outcomes and no justification for using such testing as a means of discriminating between candidates presenting themselves for bariatric surgery.
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Affiliation(s)
- David Ashton
- Imperial College School of Medicine, London, UK.
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31
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Mandel L, Da Silva K. Parotid Hypertrophy and Bariatric Surgery: Case Report. J Oral Maxillofac Surg 2008; 66:572-4. [DOI: 10.1016/j.joms.2007.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Accepted: 08/24/2007] [Indexed: 11/30/2022]
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Vargas-Ruiz AG, Hernández-Rivera G, Herrera MF. Prevalence of iron, folate, and vitamin B12 deficiency anemia after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2008; 18:288-93. [PMID: 18214631 DOI: 10.1007/s11695-007-9310-0] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Accepted: 09/11/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND One of the most common bariatric operations is the laparoscopic Roux-en-Y gastric bypass (LRYGBP) in which the gastric capacity is restricted and the absorption by the small intestine is reduced. The objective of this study was to evaluate the incidence of iron, folate, and vitamin B12 deficiency anemia in patients undergoing LRYGBP. PATIENTS AND METHODS Clinical records of 30 patients who underwent LRYGBP between July 2003 and January 2005 and had a minimum follow up of 24 months at our outpatient clinic were included. Multivitamin supplementation was prescribed to all patients. The complete blood cell count, plasma iron, total iron-binding capacity, transferrin saturation, serum folate, and cobalamin levels before surgery, 6 months, 1, 2, and 3 years after the surgery were analyzed. RESULTS There were 25 women (83.4%) and five men (16.6%) with ages from 21 to 56 years. Before surgery, two patients (6.6%) presented ferropenic anemia. Iron deficiency was seen in 40 and 54.5% 2 and 3 years after surgery, respectively. Cobalamin deficiency was observed in 33.3% at 2 years and in 27.2% at 3 years. At 2-year follow-up, 46.6% of the patients had already developed anemia and 63.6% at 3 years. Folate deficiency was not observed in any patient. CONCLUSION Our routine scheme of vitamin supplementation is not sufficient to prevent iron and vitamin B12 deficiencies in most patients.
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Affiliation(s)
- Angel G Vargas-Ruiz
- Department of Hematology/Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Tlalpan, 14000, México DF, Mexico
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Serra C, Baltasar A, Andreo L, Pérez N, Bou R, Bengochea M, Chisbert JJ. Treatment of gastric leaks with coated self-expanding stents after sleeve gastrectomy. Obes Surg 2007; 17:866-72. [PMID: 17894143 DOI: 10.1007/s11695-007-9161-8] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Duodenal switch (DS) is one of the most effective techniques for the treatment of morbid obesity and its co-morbidities, with mortality rate <1%, but with 9.4% morbidity rates (6.5% due to leaks). In our experience, leaks of the staple-line after sleeve gastrectomy (SG) are the most frequent sites of fistula formation and conservative treatment usually takes a long time. We present our experience in the treatment of gastric leaks with coated self-expandable stents (CSES). METHODS 6 patients had gastric leaks at the gastroesophageal (GE) junction after SG or DS. One patient had a symptomatic gastro-bronchial fistula. Stents were placed by the interventional radiologist under fluoroscopic control and removed endoscopically. In one case, we used an uncoated Wallstent. In two patients, percutaneous microcoil embolization of the fistula was added. RESULTS The patient treated with the Wallstent required a total gastrectomy 6 months after placement of the uncovered stent. In the other 5 patients, coated stents were successfully removed and the gastric leaks completely sealed. CONCLUSIONS CSES are proposed as an alternative therapeutic option for the management of GE junction leaks in bariatric surgery with good results in terms of morbidity and survival.
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Affiliation(s)
- Carlos Serra
- General Surgery Service, Interventional Radiology, Virgen de los Lirios Hospital, Alcoy, Alicante, Spain.
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Wadden TA, Sarwer DB, Fabricatore AN, Jones L, Stack R, Williams NS. Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin North Am 2007; 91:451-69, xi-xii. [PMID: 17509389 DOI: 10.1016/j.mcna.2007.01.003] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Extreme obesity, characterized by a body mass index (BMI) of 40 kg/m(2) or greater, is associated with significantly increased mortality, principally from cardiovascular disease, type 2 diabetes, and several cancers. It also is associated with an increased risk of psychosocial complications, including depression, eating disorders, and impaired quality of life. This article briefly examines the psychosocial status of extremely obese individuals who seek bariatric surgery and describes changes in functioning that can be expected with surgically induced weight loss. The article combines a review of the literature with clinical impressions gained from the more than 2500 candidates for bariatric surgery whom the authors have evaluated at the Hospital of the University of Pennsylvania.
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Affiliation(s)
- Thomas A Wadden
- Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market Street, 3rd Floor, Philadelphia, PA 19104, USA.
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Flancbaum L, Belsley S, Drake V, Colarusso T, Tayler E. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg 2006; 10:1033-7. [PMID: 16843874 DOI: 10.1016/j.gassur.2006.03.004] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Revised: 02/28/2006] [Accepted: 03/01/2006] [Indexed: 01/31/2023]
Abstract
Few data exist concerning preoperative nutritional status in patients undergoing bariatric surgery. We retrospectively analyzed the preoperative values of serum albumin, calcium, 25-OH vitamin D, iron, ferritin, hemoglobin, vitamin B12, and thiamine in 379 consecutive patients (320 women and 59 men; mean body mass index 51.8 +/- 10.6 kg/m2; 25.8% white, 28.4% African American, 45.8% Hispanic) undergoing bariatric surgery between 2002 and 2004. Preoperative deficiencies were noted for iron (43.9%), ferritin (8.4%), hemoglobin (22%; women 19.1%, men 40.7%), thiamine (29%), and 25-OH vitamin D (68.1%). Low ferritin levels were more prevalent in females (9.9% vs. 0%; P = 0.01); however, anemia was more prevalent in males (19.1% vs. 40.7%; P < 0.005). Patients younger than 25 years were more likely to be anemic than patients over 60 years (46% vs. 15%; P < 0.005). This correlated with iron deficiency, which was more prevalent in younger patients (79.2% vs. 41.7%; P < 0.005). Whites (78.8%) and African Americans (70.4%) had a higher prevalence of vitamin D deficiency than Hispanics (56.4%), P = 0.01. Whites were the least likely group to be thiamine deficient (6.8% vs 31.0% African Americans and 47.2% Hispanics; P < 0.005). Nutritional deficiencies are common in patients undergoing Roux-en-Y gastric bypass, and these deficiencies should be detected and corrected early to avoid postoperative complications.
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Affiliation(s)
- Louis Flancbaum
- Department of Surgery, St Luke's Roosevelt Hospital Center, New York, NY 11542, USA.
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Mathus-Vliegen EMH. Long-term health and psychosocial outcomes from surgically induced weight loss: results obtained in patients not attending protocolled follow-up visits. Int J Obes (Lond) 2006; 31:299-307. [PMID: 16755282 DOI: 10.1038/sj.ijo.0803404] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Obesity management is focused at weight loss to obtain health, psychological and social benefits. Outcomes from controlled trials, however, do not reflect the everyday routine practice. Therefore, we aimed to investigate the results from surgically induced weight loss in patients devoid of a protocol-wise follow-up, who were visited at home. PATIENTS AND METHODS Patients who underwent a vertical banded gastroplasty or a gastric bypass between 1980 and 1997 were eligible. Body weight and height were measured. Patients filled out questionnaires on health status (Nottingham Health Profile (NHP)), psychological symptoms (Symptom Check List (SCL-90-R)), personality traits (Dutch Personality Questionnaire (DPQ)) and eating behaviour (Dutch Eating Behaviour Questionnaire (DEBQ)). RESULTS Out of 451 operated patients the addresses of 313 subjects could be traced and 236 (75%) agreed to participate. They maintained a mean (s.d.) loss of 32.1 (22.6) kg and 45.2 (29.3) % of excess weight, 8.2 (4.5) years after the operation, about two-third of the largest weight loss they achieved after 17 months postoperatively. The NHP and SCL-90-R conformed to norm values in males except for energy, sleep and emotional reactions. Females differed from norm values in every aspect and even women achieving a BMI<30 kg/m(2) did not catch up to norm values. Weight loss was inversely related to physical immobility and pain. Personality traits (DPQ) showed a higher grievance and dominance and a lower rigidity and self-esteem compared to norm values. Females scored higher in inadequacy and lower in social inadequacy. Eating patterns (DEBQ) showed mainly emotional eating and restrained eating. Effect sizes of >/=0.8 s.d. were chosen to reflect the clinical relevance of statistically significant findings. Pain, disturbances in sleep, energy and mobility and emotional and restrained eating proved to be clinically relevant. In subjects operated >5 years ago, a higher sensitivity, a higher inadequacy and a lower social inadequacy were observed compared to more recently operated subjects. A more restrained eating pattern was related to an operation of recent date. CONCLUSIONS Surgically induced weight losses are satisfactory in the long-term, even in patients not attending a strict follow-up protocol. Health, psychological symptoms, personality traits and eating behaviour were related to weight loss and time lapse since the operation and did not return to reference normal-weight subject values.
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Affiliation(s)
- E M H Mathus-Vliegen
- EMH Mathus-Vliegen, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
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Klein S, Mittendorfer B, Eagon JC, Patterson B, Grant L, Feirt N, Seki E, Brenner D, Korenblat K, McCrea J. Gastric bypass surgery improves metabolic and hepatic abnormalities associated with nonalcoholic fatty liver disease. Gastroenterology 2006; 130:1564-72. [PMID: 16697719 DOI: 10.1053/j.gastro.2006.01.042] [Citation(s) in RCA: 200] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Accepted: 01/11/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Most patients with extreme obesity have nonalcoholic fatty liver disease (NAFLD). Although gastric bypass (GBP) surgery is the most common bariatric operation performed in obese patients in the United States, the effect of GBP surgery-induced weight loss on the metabolic and hepatic abnormalities associated with NAFLD are not clear. METHODS Whole-body glucose, fatty acid and lipoprotein kinetics, liver histology, and hepatic cellular factors involved in inflammation and fibrogenesis were evaluated in 7 extremely obese subjects (body mass index, 58 +/- 4 kg/m(2)) before and 1 year after GBP surgery. RESULTS At 1 year after surgery, subjects lost 29% +/- 5% of initial body weight (P < .01); palmitate rate of appearance in plasma, an index of adipose tissue lipolysis, decreased by 47% +/- 4% (P < .01); endogenous glucose production rate decreased by 27% +/- 7% (P < .01); and very-low-density lipoprotein-triglyceride secretion rate decreased by 44% +/- 9% (P < .05). In addition, GBP surgery-induced weight loss decreased hepatic steatosis but did not change standard histologic assessments of inflammation and fibrosis. However, there was a marked decrease in hepatic factors involved in regulating fibrogenesis (collagen-alpha1(I), transforming growth factor-beta1, alpha-smooth muscle actin, and tissue inhibitor of metalloproteinase 1 expression and alpha-smooth muscle actin content) and inflammation (macrophage chemoattractant protein 1 and interleukin 8 expression) (P < .05, compared with values before weight loss). CONCLUSIONS These data demonstrate that weight loss induced by GBP surgery normalizes the metabolic abnormalities involved in the pathogenesis and pathophysiology of NAFLD and decreases the hepatic expression of factors involved in the progression of liver inflammation and fibrosis.
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Affiliation(s)
- Samuel Klein
- Center for Human Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA.
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Koffman BM, Greenfield LJ, Ali II, Pirzada NA. Neurologic complications after surgery for obesity. Muscle Nerve 2006; 33:166-76. [PMID: 15973660 DOI: 10.1002/mus.20394] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Bariatric surgical procedures are increasingly common. In this review, we characterize the neurologic complications of such procedures, including their mechanisms, frequency, and prognosis. Literature review yielded 50 case reports of 96 patients with neurologic symptoms after bariatric procedures. The most common presentations were peripheral neuropathy in 60 (62%) and encephalopathy in 30 (31%). Among the 60 patients with peripheral neuropathy, 40 (67%) had a polyneuropathy and 18 (30%) had mononeuropathies, which included 17 (94%) with meralgia paresthetica and 1 with foot drop. Neurologic emergencies including Wernicke's encephalopathy, rhabdomyolysis, and Guillain-Barré syndrome were also reported. In 18 surgical series reported between 1976 and 2004, 133 of 9996 patients (1.3%) were recognized to have neurologic complications (range: 0.08-16%). The only prospective study reported a neurologic complication rate of 4.6%, and a controlled retrospective study identified 16% of patients with peripheral neuropathy. There is evidence to suggest a role for inflammation or an immunologic mechanism in neuropathy after gastric bypass. Micronutrient deficiencies following gastric bypass were evaluated in 957 patients in 8 reports. A total of 236 (25%) had vitamin B(12) deficiency and 11 (1%) had thiamine deficiency. Routine monitoring of micronutrient levels and prompt recognition of neurological complications can reduce morbidity associated with these procedures.
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Affiliation(s)
- Boyd M Koffman
- Department of Neurology, Medical University of Ohio, Toledo, 43614, USA.
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Clark JM, Alkhuraishi ARA, Solga SF, Alli P, Diehl AM, Magnuson TH. Roux-en-Y gastric bypass improves liver histology in patients with non-alcoholic fatty liver disease. ACTA ACUST UNITED AC 2006; 13:1180-6. [PMID: 16076987 DOI: 10.1038/oby.2005.140] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease in the United States and is prevalent in morbidly obese patients. While weight loss and treatment of risk factors are recommended, the reported effects of bariatric surgery on NAFLD are mixed. RESEARCH METHODS AND PROCEDURES We examined liver histology at the time of Roux-en-Y gastric bypass surgery and at elective incisional hernia repair after weight loss for 16 patients at one center. Slides were read by one pathologist, blinded to clinical data, using the Brunt criteria. Clinical and laboratory data were extracted from chart review. Alcohol use was ascertained by two interviews. RESULTS At baseline, the mean age was 44 years, 50% were women, 88% were white, and the mean BMI was 51 kg/m2. None had significant alcohol use. On initial biopsy, all patients showed steatosis, 94% had inflammation, 88% had ballooning degeneration, 88% had perisinusoidal fibrosis, and 81% had portal fibrosis. The mean time between the two biopsies was 305 +/- 131 (SD) days. The mean weight loss was 118 +/- 29 lb. Steatosis improved in 15 of 16 patients, with resolution in 13. Twelve of 15 patients with inflammation at baseline showed improvement, and 12 of 14 showed less ballooning. Six of 14 patients with perisinusoidal fibrosis and 6 of 13 with portal fibrosis showed improvement. No patient had worsening of steatosis, inflammation, ballooning, or fibrosis. DISCUSSION Our study shows improvement in all of the histological features of NAFLD after Roux-en-Y gastric bypass surgery-induced weight loss, despite significant histopathology at baseline and substantial weight loss.
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Affiliation(s)
- Jeanne M Clark
- Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, 2024 E. Monument Street, Suite 2-600, Baltimore MD 21205, USA.
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Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. ACTA ACUST UNITED AC 2005; 13:639-48. [PMID: 15897471 DOI: 10.1038/oby.2005.71] [Citation(s) in RCA: 264] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bariatric surgery has become an increasingly popular treatment option for individuals with extreme obesity (defined as a BMI > or = 40 kg/m2) or those with less severe obesity accompanied by significant comorbidities. Sustained postoperative weight loss and improvements in obesity-related health problems make bariatric surgery the most effective treatment for this population. Nevertheless, most experts agree that psychosocial and behavioral factors contribute to successful postoperative outcomes. This paper reviews the literature on the preoperative psychosocial status, eating behaviors, and quality of life of patients who seek bariatric surgery. In addition, the paper examines studies that investigated changes in these factors postoperatively. The review concludes with an agenda for future research in this area.
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Affiliation(s)
- David B Sarwer
- Weight and Eating Disorders Program, 3535 Market Street, Suite 3022, Philadelphia, PA 19104-3309, USA.
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Abstract
Roux-en-Y gastric bypass (RYGB) that is performed with at least a 150-cm Roux limb results in significantly greater weight loss than shorter (<100-cm) Roux limb procedures in superobese patients(BMI >50 kg/m2). Conversely, longer Roux limb procedures do not provide greater weight loss in less obese (BMI <50 kg/m2)patients. Modest elongation of the Roux limb-in the range of 150 cm to 200 cm-does not result in more frequent nutritional sequelae compared with shorter Roux limb procedures. This article discusses the current status of long limb Roux-en-Y gastric bypass in the context of weight loss, metabolic sequelae and CPT coding.
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Affiliation(s)
- Robert E Brolin
- University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213-2582, USA.
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Brolin RE. Postoperative complications in the context of risk:benefit. Surg Obes Relat Dis 2005; 1:343-7. [PMID: 16925245 DOI: 10.1016/j.soard.2005.03.211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Revised: 03/31/2005] [Accepted: 03/31/2005] [Indexed: 12/15/2022]
Affiliation(s)
- Robert E Brolin
- University Medical Center at Princeton, Princeton, New Jersey, USA.
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Brolin RE, LaMarca LB, Kenler HA, Cody RP. Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg 2002; 6:195-203; discussion 204-5. [PMID: 11992805 DOI: 10.1016/s1091-255x(01)00022-1] [Citation(s) in RCA: 234] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Weight loss in superobese patients has been problematic after conventional gastric restrictive operations including conventional Roux-en-Y gastric bypass (RYGB). The goal of the present study was to compare weight loss in patients with superobesity (body mass index > or =50 kg/m(2)) using a distal RYGB (D-RY) in which the Roux-en-Y anastomosis was performed 75 cm proximal to the ileocecal junction (N = 47) vs. patients who had Roux limbs of 150 cm (N = 152) and 50 to 75 cm (N = 99). All operations incorporated the same gastric restrictive parameters. Minimum follow-up was 3 years and ranged to 16 years. Weight loss and reduction in body mass index were significantly greater after D-RY vs. both RYGB-150 cm and short RYGB and in RYGB-150 cm vs. short RYGB through 5 years. Mean percentage of excess weight loss peaked at 64% after DRY, at 61% after RYGB-150 cm, and at 56% after short RYGB. Weight loss maintenance through 5 years was correlated with Roux limb length with D-RY greater than RYGB-150 cm greater than short RYGB. More than 95% of obesity-related comorbid conditions improved or resolved with weight loss. There was no difference in the early postoperative morbidity rates: 9% after D-RY; 8% after RYGB-150 cm; and 2% after short RYGB with one death (0.3%). All D-RY patients had at least one postoperative metabolic abnormality. Anemia was significantly more common after D-RY vs. the shorter RYGB with no difference in the incidence of metabolic sequelae between RYGB-150 cm and short RYGB. No operations were reversed or modified for nutritional complications. Two D-RY patients required total parenteral nutrition for protein malnutrition. These results show that Roux limb length is correlated with weight loss in superobese patients. However, the greater incidence of metabolic sequelae after D-RY vs. RYGB-150 cm calls into question its routine use in superobese patients undergoing bariatric surgery. We conclude that some degree of malabsorption should be incorporated into bariatric operations performed in superobese patients to achieve satisfactory long-term weight loss.
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Affiliation(s)
- Robert E Brolin
- Department of Surgery, St. Peter's University Hospital, New Brunswick, NJ 08903, USA.
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Abstract
Nearly all morbidly obese patients with satisfactory postoperative weight loss experience substantial improvement in the quality of their lives. Improved health status is characterized by increased exercise tolerance and improvement or resolution of obesity-related comorbidities. Improvement of obesity-related medical problems (discussed in the article by Klein elsewhere in this issue) is a primary goal of gastric bypass. The patient's ability to interact with others in social situations is also enhanced. At present, RYGB may be the only bariatric operation that has produced durable long-term weight loss at an acceptable level of risk.
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Affiliation(s)
- R E Brolin
- Bariatric Surgery Program, Saint Peter's University Hospital, New Brunswick, New Jersey 08903, USA
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Affiliation(s)
- J M Kellum
- Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, USA
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47
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Brolin RE, Gorman JH, Gorman RC, Petschenik AJ, Bradley LJ, Kenler HA, Cody RP. Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass? J Gastrointest Surg 1998; 2:436-42. [PMID: 9843603 DOI: 10.1016/s1091-255x(98)80034-6] [Citation(s) in RCA: 216] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Although iron, vitamin B12, and folate deficiency have been well documented after gastric bypass operations performed for morbid obesity, there is surprisingly little information on either the natural course or the treatment of these deficiencies in Roux-en-Y gastric bypass (RYGB) patients. During a 10-year period, a complete blood count and serum levels of iron, total iron-binding capacity, vitamin B12, and folate were obtained in 348 patients preoperatively and postoperatively at 6-month intervals for the first 2 years, then annually thereafter. The principal objectives of this study were to determine how readily patients who developed metabolic deficiencies after Roux-en-Y gastric bypass responded to postoperative supplements of the deficient micronutrient and to learn whether the risk of developing these deficiencies decreases over time. Hemoglobin and hematocrit levels were significantly decreased at all postoperative intervals in comparison to preoperative values. Moreover, at each successive interval through 5 years, hemoglobin and hematocrit were decreased significantly compared to the preceding interval. Folate levels were significantly increased compared to preoperative levels at all time intervals. Iron and vitamin B12 levels were lower than preoperative measurements and remained relatively stable postoperatively. Half of the low hemoglobin levels were not associated with iron deficiency. Taking multivitamin supplements resulted in a lower incidence of folate deficiency but did not prevent iron or vitamin B12 deficiency. Oral supplementation of iron and vitamin B12 corrected deficiencies in 43% and 81% of cases, respectively. Folate deficiency was almost always corrected with multivitamins alone. No patient had symptoms that could be attributed to either vitamin B12 or folate deficiency Conversely, many patients had symptoms of iron deficiency and anemia. Lack of symptoms of vitamin B12 and folate deficiency suggests that these deficiencies are not clinically important after RYGB. Conversely, iron deficiency and anemia are potentially serious problems after RYGB, particularly in younger women. Hence we recommend prophylactic oral iron supplements to premenopausal women who undergo RYGB.
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Affiliation(s)
- R E Brolin
- Department of Surgery, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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48
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Macgregor AMC, Thoburn EK. Gastric bypass for clinically serious (morbid) obesity. Eur Surg 1998. [DOI: 10.1007/bf02620437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
The medical risks of obesity increase exponentially as weight increases, and these risks are reduced by sustained weight loss. Behavior modification and dieting provide an approximately 6% loss of body weight at 1 year. Fenfluramine provides an approximately 8% weight loss at 1 year, which can be doubled to 16% when a drug such as phentermine, which works through a different biochemical mechanism, is added to it. This amount of weight loss is insufficient for many severely obese individuals. It was with these facts in mind that the National Institutes of Health Consensus Conference in 1992 recommended that obesity surgery is an appropriate treatment for patients with a body mass index greater than 40 kg/m2 who had failed in attempts at medical treatment and for patients with a body mass index greater than 35 kg/m2 with severe complications of obesity. Vertically banded gastroplasty and Roux-en-Y gastric bypass are the two operations presently recommended because of their relative safety and effectiveness. This article reviews previous procedures that have provided insight into the mechanisms by which these surgeries cause weight loss. The presently used surgeries and their results also are reviewed because until medical therapy improves substantially, surgery remains the most reasonable treatment option for most morbidly obese patients.
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Affiliation(s)
- F L Greenway
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, USA
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Brolin RE, Robertson LB, Kenler HA, Cody RP. Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass. Ann Surg 1994; 220:782-90. [PMID: 7986146 PMCID: PMC1234481 DOI: 10.1097/00000658-199412000-00012] [Citation(s) in RCA: 216] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The purpose of this study was to learn whether preoperative eating habits can be used to predict outcome after vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGB). BACKGROUND SUMMARY: Several independent randomized and sequential studies have reported significantly greater weight loss after RYGB in comparison with VBG. Although the mechanism responsible for weight loss after both procedures is restriction of intake rather than malabsorption, the relationships between calorie intake, food preferences, and postoperative weight loss are not well defined. METHODS During the past 5 years, 138 patients were prospectively selected for either VBG or RYGB, based on their preoperative eating habits. All patients were screened by a dietitian who determined total calorie intake and diet composition before recommending VBG or RYGB. Thirty patients were selected for VBG; the remaining 108 patients were classified as "sweets eaters" or "snackers" and had RYGB. Detailed recall diet histories also were performed at each postoperative visit. RESULTS Early morbidity rate was zero after VBG versus 3% after RYGB. There were no deaths. Mean follow-up was 39 +/- 11 months after VBG and 38 +/- 14 months after RYGB. Mean weight loss peaked at 74 +/- 23 lb at 12 months after VBG and 99 +/- 24 lb at 16 months after RYGB (p < or = 0.001). Twelve of 30 VBG patients lost > or = 50% of their excess weight versus 100 of 108 RYGB patients (p < or = 0.0001). Milk/ice cream intake was significantly greater postoperatively in patients who underwent VBG versus patients who underwent RYGB after 6 months (p < or = 0.003), whereas solid sweets intake was significantly greater after VBG during the first 18 months postoperatively (p < or = 0.004). Revision of VBG was performed in 6 of 30 patients (20%) for complications or poor weight loss, whereas only 2 of 108 patients who underwent RYGB required surgical revisions (p < or = 0.001). CONCLUSIONS These data show that VBG adversely alters postoperative eating behavior toward soft, high-calorie foods, resulting in problematic postoperative weight loss. Conversely, RYGB patients had significantly greater weight loss despite inferior preoperative eating habits. The high rate of surgical revision in conjunction with inconsistent postoperative weight loss has led us to no longer recommend VBG as treatment for morbid obesity.
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Affiliation(s)
- R E Brolin
- Department of Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick
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