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Iron Deficiency and Anemia 10 Years After Roux-en-Y Gastric Bypass for Severe Obesity.
Sandvik, J, Bjerkan, KK, Græslie, H, Hoff, DAL, Johnsen, G, Klöckner, C, Mårvik, R, Nymo, S, Hyldmo, ÅA, Kulseng, BE
Frontiers in endocrinology. 2021;:679066
Abstract
Iron deficiency with or without anemia is a well-known long-term complication after Roux-en-Y, gastric bypass (RYGB) as the procedure alters the gastrointestinal absorption of iron. Iron is essential for hemoglobin synthesis and a number of cellular processes in muscles, neurons, and other organs. Ferritin is the best marker of iron status, and in a patient without inflammation, iron deficiency occurs when ferritin levels are below 15 µg/L, while iron insufficiency occurs when ferritin levels are below 50 µg/L. Lifelong regular blood tests are recommended after RYGB, but the clinical relevance of iron deficiency and iron insufficiency might be misjudged as long as the hemoglobin levels are normal. The aim of this study was to explore the frequency of iron deficiency and iron deficiency anemia one decade or more after RYGB, the use of per oral iron supplements, and the frequency of intravenous iron treatment. Nine hundred and thirty patients who underwent RYGB for severe obesity at three public hospitals in Norway in the period 2003-2009 were invited to a follow-up visit 10-15 years later. Results from blood tests and survey data on the use of oral iron supplements and intravenous iron treatment were analyzed. Ferritin and hemoglobin levels more than 10 years after RYGB were available on 530 patients [423 (79.8%) women]. Median (IQR) ferritin was 33 (16-63) µg/L, and mean (SD) hemoglobin was 13.4 (1.3) g/dl. Iron deficiency (ferritin ≤ 15 µg/L) was seen in 125 (23.6%) patients; in addition, iron insufficiency (ferritin 16-50 µg/L) occurred in 233 (44%) patients. Mean (SD) hemoglobin levels were 12.5 (1.4) g/dl in patients with iron deficiency, 13.5 (1.2) g/dl in patients with iron insufficiency, 13.8 (1.3) g/dl in the 111 (21%) patients with ferritin 51-100 µg/L, and 13.8 (1.2) g/dl in the 55 (10%) patients with ferritin >100 µg/L. Two hundred and seventy-five (56%) patients reported taking oral iron supplements, and 138 (27.5%) had received intravenous iron treatment after the RYGB procedure. Iron deficiency or iron insufficiency occurred in two-thirds of the patients 10 years after RYGB, although more than half of them reported taking oral iron supplements.
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Computational modelling of self-reported dietary carbohydrate intake on glucose concentrations in patients undergoing Roux-en-Y gastric bypass versus one-anastomosis gastric bypass.
Ashrafi, RA, Ahola, AJ, Rosengård-Bärlund, M, Saarinen, T, Heinonen, S, Juuti, A, Marttinen, P, Pietiläinen, KH
Annals of medicine. 2021;(1):1885-1895
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Abstract
OBJECTIVES Our aim was to investigate in a real-life setting the use of machine learning for modelling the postprandial glucose concentrations in morbidly obese patients undergoing Roux-en-Y gastric bypass (RYGB) or one-anastomosis gastric bypass (OAGB). METHODS As part of the prospective randomized open-label trial (RYSA), data from obese (BMI ≥35 kg/m2) non-diabetic adult participants were included. Glucose concentrations, measured with FreeStyle Libre, were recorded over 14 preoperative and 14 postoperative days. During these periods, 3-day food intake was self-reported. A machine learning model was applied to estimate glycaemic responses to the reported carbohydrate intakes before and after the bariatric surgeries. RESULTS Altogether, 10 participants underwent RYGB and 7 participants OAGB surgeries. The glucose concentrations and carbohydrate intakes were reduced postoperatively in both groups. The relative time spent in hypoglycaemia increased regardless of the operation (RYGB, from 9.2 to 28.2%; OAGB, from 1.8 to 37.7%). Postoperatively, we observed an increase in the height of the fitted response curve and a reduction in its width, suggesting that the same amount of carbohydrates caused a larger increase in the postprandial glucose response and that the clearance of the meal-derived blood glucose was faster, with no clinically meaningful differences between the surgeries. CONCLUSIONS A detailed analysis of the glycaemic responses using food diaries has previously been difficult because of the noisy meal data. The utilized machine learning model resolved this by modelling the uncertainty in meal times. Such an approach is likely also applicable in other applications involving dietary data. A marked reduction in overall glycaemia, increase in postprandial glucose response, and rapid glucose clearance from the circulation immediately after surgery are evident after both RYGB and OAGB. Whether nondiabetic individuals would benefit from monitoring the post-surgery hypoglycaemias and the potential to prevent them by dietary means should be investigated.KEY MESSAGESThe use of a novel machine learning model was applicable for combining patient-reported data and time-series data in this clinical study.Marked increase in postprandial glucose concentrations and rapid glucose clearance were observed after both Roux-en-Y gastric bypass and one-anastomosis gastric bypass surgeries.Whether nondiabetic individuals would benefit from monitoring the post-surgery hypoglycaemias and the potential to prevent them by dietary means should be investigated.
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Postprandial Hypoglycemia in Patients after Gastric Bypass Surgery Is Mediated by Glucose-Induced IL-1β.
Hepprich, M, Wiedemann, SJ, Schelker, BL, Trinh, B, Stärkle, A, Geigges, M, Löliger, J, Böni-Schnetzler, M, Rudofsky, G, Donath, MY
Cell metabolism. 2020;(4):699-709.e5
Abstract
Postprandial hypoglycemia is a disabling complication of the treatment of obesity by gastric bypass surgery. So far, no therapy exists, and the underlying mechanisms remain unclear. Here, we hypothesized that glucose-induced IL-1β leads to an exaggerated insulin response in this condition. Therefore, we conducted a placebo-controlled, randomized, double-blind, crossover study with the SGLT2-inhibitor empagliflozin and the IL-1 receptor antagonist anakinra (clinicaltrials.govNCT03200782; n = 12). Both drugs reduced postprandial insulin release and prevented hypoglycemia (symptomatic events requiring rescue glucose: placebo = 7/12, empagliflozin = 2/12, and anakinra = 2/12, pvallikelihood ratio test (LRT) = 0.013; nadir blood glucose for placebo = 2.4 mmol/L, 95% CI 2.18-2.62, empagliflozin = 2.69 mmol/L, 95% CI 2.31-3.08, and anakinra = 2.99 mmol/L, 95% CI 2.43-3.55, pvalLRT = 0.048). Moreover, analysis of monocytes ex vivo revealed a hyper-reactive inflammatory state that has features of an exaggerated response to a meal. Our study proposes a role for glucose-induced IL-1β in postprandial hypoglycemia after gastric bypass surgery and suggests that SGLT2-inhibitors and IL-1 antagonism may improve this condition.
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Are There Ideal Small Bowel Limb Lengths for One-Anastomosis Gastric Bypass (OAGB) to Obtain Optimal Weight Loss and Remission of Comorbidities with Minimal Nutritional Deficiencies?
Ruiz-Tovar, J, Carbajo, MA, Jimenez, JM, Luque-de-Leon, E, Ortiz-de-Solorzano, J, Castro, MJ
World journal of surgery. 2020;(3):855-862
Abstract
BACKGROUND Ideal jejunal and ileal lengths in bariatric/metabolic procedures to be left in alimentary continuity still remain unclear. We aimed to evaluate different lengths of biliopancreatic limb (BPL) and common limb (CL) performed in a series of patients submitted to OAGB, and correlate them with weight loss and nutritional deficits. PATIENTS AND METHODS A prospective observational study of 350 consecutive morbidly obese patients undergoing OAGB was performed. BPL and CL lengths were determined intraoperatively; BPL/TBL and CL/TBL ratios were then calculated. Anthropometric variables, remission of comorbidities and specific supplementation needs were recorded at 1, 2 and 5 years after surgery. RESULTS Three hundred patients were included for final analysis. BPL length and BPL/TBL ratio directly correlated with Units of BMI lost (UBMIL). Conversely, CL length and CL/TBL ratio showed an inverse correlation with UBMIL. Establishing a BMI ≤ 25 kg/m2 as ideal, the most accurate AUC, to predict achieving an ideal BMI at 1, 2 and 5 years after surgery, was obtained for the CL/TBL ratio, followed by the CL length at 1, 2 and 5 years. An ideal range was established between 0.40 and 0.43 for the CL/TBL ratio, and 200 to 220 cm for the CL length. Among these ranges, there were no cases of protein or calorie malnutrition. CONCLUSION TBL measurement is essential to obtain optimal outcomes after OAGB, both in terms of excellent weight loss and remission/improvement of comorbidities, as well as with a low risk of nutritional deficiencies. The CL/TBL ratio, followed by CL length, are the most accurate parameters to predict a 5-year postoperative BMI ≤ 25 kg/m2.
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Erythrocyte deformability and aggregation in morbidly obese women undergoing laparoscopic gastric bypass surgery and effects of oral omega-3 fatty acid supplementation.
Bakker, N, Schoorl, M, Demirkiran, A, Cense, HA, Houdijk, APJ
Clinical hemorheology and microcirculation. 2020;(3):303-311
Abstract
BACKGROUND An adequate erythrocyte function is vital for tissue oxygenation and wound healing. The erythrocyte membrane phospholipid composition plays an important role in erythrocyte function and administration of omega-3 fatty acids may provide a means to improve it. OBJECTIVE To investigate peri-operative erythrocyte function and effects of oral omega-3 fatty acids in morbidly obese women undergoing gastric bypass surgeryMETHODSFifty-six morbidly obese women undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery were randomized between a low calorie diet (LCD) during 2 weeks or oral omega-3 poly-unsaturated fatty acids (n-3 PUFAs) and a normal diet during 4 weeks. Peri-operative blood samples were analyzed with the Lorrca MaxSIS Ektacytometer for erythrocyte deformability and aggregability. RESULTS There were no significant differences in erythrocyte function between the groups at any time point. Only erythrocyte aggregability parameters were affected by surgery. At six month follow-up, aggregation index (AI) and cholesterol, glucose and insulin were significantly improved. CONCLUSIONS In this study, oral Omega-3 supplementation did not affect erythrocyte function compared to a LCD. Six months after surgery a significant improvement in AI and metabolic parameters was observed in both groups, contributing to a reduction in the risk at thromboembolic and cardiovascular complications.
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Relevant Weight Reduction and Reversed Metabolic Co-morbidities Can Be Achieved by Duodenojejunal Bypass Liner in Adolescents with Morbid Obesity.
Homan, M, Kovač, J, Orel, R, Battelino, T, Kotnik, P
Obesity surgery. 2020;(3):1001-1010
Abstract
BACKGROUND Duodenojejunal bypass liner (DJBL) is an endoscopic, reversible bariatric procedure resulting in weight loss and metabolic co-morbidities improvements in the adults. OBJECTIVES To determine safety and effectiveness of 12-month treatment with DJBL in adolescents with severe obesity (BMI > 35 kg/m2) and co-morbidities. METHODS Post-pubertal subjects were treated with DJBL in an open-label, prospective clinical trial (NTC0218393). They were examined at 3 monthly intervals during the 12 months of DJBL treatment and 12 months of follow-up. RESULTS DJBL was successfully placed in 19/22 adolescents (13 females, mean age (95%CI); 17.3 (16.7-17.9) years, BMI-SDS 3.7 (3.6-3.9)). There were no serious device-related adverse effects. Clinically relevant percent total weight loss (%TWL) (mean (95%CI)) 11.4 (7.4-15.3) % and BMI decrease - 4.9 (- 2.4 to - 7.4) kg/m2 was observed at DJBL removal (n = 19). At 12 months after device removal, %TWL was 4.1 (- 2.6-10.8) % and BMI decrease - 2.6 (0.2 to - 5.4) kg/m2 when compared with values at baseline (n = 13). HOMA-IR (- 2.1 (- 3 to - 1.3), WBISI 1.15 (0.23 to 2.07), total cholesterol, LDL-c, and triglycerides levels also improved during DJBL treatment and relapsed similarly to weight at 12-month follow-up. A decrease in iron stores, Zn, and Se levels was determined during DJBL treatment and spontaneously improved at follow-up. CONCLUSIONS Twelve months of DJBL treatment was safe and effective in adolescents with morbid obesity. Weight regain following device removal and relapse of metabolic complications should be expected.
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Conversion to Roux-en-Y gastric bypass surgery through a robotic-assisted hybrid technique after failed sleeve gastrectomy: Short-term results.
Aguilar-Espinosa, F, Montoya-Ramírez, J, Gutiérrez Salinas, J, Blas-Azotla, R, Aguilar-Soto, OA, Becerra-Gutiérrez, LP
Revista de gastroenterologia de Mexico (English). 2020;(2):160-172
Abstract
INTRODUCTION AND AIMS Laparoscopic sleeve gastrectomy (LSG) is the most widely performed bariatric surgery worldwide but complications and failed procedures are on the rise. AIMS To determine the reasons for failed LSGs and report the results of conversion to gastric bypass surgery, comparing the outcomes with those of primary gastric bypass surgery. MATERIALS AND METHODS Patients with failed LSG that underwent conversion to gastric bypass surgery through a robotic-assisted and laparoscopic (hybrid) technique were evaluated. Outcomes and follow-up related to weight loss failure (WLF) were compared with those in patients that underwent primary laparoscopic gastric bypass (pLGB) surgery. RESULTS Revisional surgery was performed on 13 patients due to WLF, on 3 patients because of refractory gastroesophageal reflux disease (GERD), and on 2 patients due to gastric stricture. There were no differences between the preoperative characteristics of the patients with WLF before undergoing conversion to gastric bypass and the patients that underwent pLGB surgery. At postoperative month 36, the percentage of excess weight loss was greater in the patients that underwent pLGB surgery, than in those with WLF that underwent conversion to gastric bypass (69.17±23.73 vs. 54.17±12.48, respectively; P<0.05). Refractory GERD, symptoms due to gastric stricture, and comorbidities all improved after the revisional surgery. CONCLUSION Revisional surgery resulted in acceptable weight loss at 36 months of follow-up and favored comorbidity remission. In addition, it resolved symptoms of refractory GERD and gastric stricture.
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Metabolic Effects of Gastric Bypass Surgery: Is It All About Calories?
Herzog, K, Berggren, J, Al Majdoub, M, Balderas Arroyo, C, Lindqvist, A, Hedenbro, J, Groop, L, Wierup, N, Spégel, P
Diabetes. 2020;(9):2027-2035
Abstract
Bariatric surgery is an efficient method to induce weight loss and also, frequently, remission of type 2 diabetes (T2D). Unpaired studies have shown bariatric surgery and dietary interventions to differentially affect multiple hormonal and metabolic parameters, suggesting that bariatric surgery causes T2D remission at least partially via unique mechanisms. In the current study, plasma metabolite profiling was conducted in patients with (n = 10) and without T2D (n = 9) subjected to Roux-en-Y gastric bypass surgery (RYGB). Mixed-meal tests were conducted at baseline, after the presurgical very-low-calorie diet (VLCD) intervention, immediately after RYGB, and after a 6-week recovery period. Thereby, we could compare fasted and postprandial metabolic consequences of RYGB and VLCD in the same patients. VLCD yielded a pronounced increase in fasting acylcarnitine levels, whereas RYGB, both immediately and after a recovery period, resulted in a smaller but opposite effect. Furthermore, we observed profound changes in lipid metabolism following VLCD but not in response to RYGB. Most changes previously associated with RYGB were found to be consequences of the presurgical dietary intervention. Overall, our results question previous findings of unique metabolic effects of RYGB and suggest that the effect of RYGB on the metabolite profile is mainly attributed to caloric restriction.
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Antecolic reconstruction is associated with a lower incidence of delayed gastric emptying compared to retrocolic technique after Whipple or pylorus-preserving pancreaticoduodenectomy.
Qiu, J, Li, M, Du, C
Medicine. 2019;(34):e16663
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BACKGROUND The aim of present study is to investigate the relationship between the antecolic (AC) route of gastrojejunostomy (GJ) after pancreaticoduodenectomy (PD) or duodenojejunostomy (DJ) reconstruction after pylorus-preserving pancreaticoduodenectomy (PPPD), and the incidence of delayed gastric emptying (DGE). METHODS An electronic search of 4 databases to identify all articles comparing AC and retrocolic (RC) reconstruction after PD or PPPD was performed. RESULTS Fifteen studies involving 2270 patients were included for final pooled analysis. The overall incidence of DGE was 27.2%. Meta-analysis results showed AC group had lower incidence of DGE (odds ratio, 0.29; 95% confidence interval [CI], 0.16-0.52, P < .0001) and shorter hospital length of stay (weight mean difference, -3.29; 95% CI, -5.2 to -1.39, P = .0007). Days until to liquid and solid diet in the AC group were also significantly earlier than that in the RC group (P = .0006 and P < .0001). There was no difference in operative time, incidence of pancreatic fistula and bile leakage, and mortality, respectively. CONCLUSIONS AC route of GJ after PD or DJ after PPPD is associated with a lower incidence of DGE. However, the preferred route for GJ or DJ reconstruction remains to be investigated in well-powered, randomized, controlled trial.
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Conventional Versus Distal Laparoscopic One-Anastomosis Gastric Bypass: a Randomized Controlled Trial with 1-Year Follow-up.
Nabil, TM, Khalil, AH, Mikhail, S, Soliman, SS, Aziz, M, Antoine, H
Obesity surgery. 2019;(10):3103-3110
Abstract
BACKGROUND There is no consensus on the ideal small bowel length that should be bypassed in laparoscopic one-anastomosis gastric bypass (OAGB). This study aimed to compare the safety and efficacy of conventional versus distal techniques of laparoscopic OAGB. METHODS This randomized controlled trial involved 60 adults with morbid obesity scheduled for laparoscopic OAGB randomly assigned to one of the two techniques; conventional technique (fixed anastomosis 200 cm from the ligament of Treitz) and distal technique (anastomosis 400 cm from the ileocecal valve). Total small bowel length (TSBL) was measured in all cases. Quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI). Outcome measures were excess body weight loss percentage (EBWL%), resolution of associated comorbidities, frequency of nutritional deficiencies, and quality of life. RESULTS No patients were lost to follow-up. The two groups were comparable in TSBL, EBWL%, and complete resolution of comorbidities up to 12 months. The percentage of afferent loop length to TSBL was significantly higher in the distal group (p < 0.001) but was not correlated with EBWL%. The levels of hemoglobin, cholesterol, triglycerides, iron, and albumin were significantly lower and parathormone hormone was higher in the distal group. The GIQLI score was significantly higher in the conventional group during follow-up. CONCLUSION OAGB achieves optimum results when the afferent loop length is 200 cm; bypassing more than 200 cm does not improve weight loss or comorbidity resolution. Measuring TSBL is recommended to avoid excessive small bowel shortening that increases the risk of nutritional consequences.