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1.
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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2.
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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3.
How Effective Is the Multidisciplinary Team Approach in Bariatric Surgery?
Bullen, NL, Parmar, J, Gilbert, J, Clarke, M, Cota, A, Finlay, IG
Obesity surgery. 2019;(10):3232-3238
Abstract
BACKGROUND Multidisciplinary team (MDT) meetings are widely recommended in the management of bariatric surgery patients; however, there is limited evidence for their effectiveness. The aims of this study were to evaluate the decision-making process of a single-day bariatric MDT clinic and secondly to evaluate whether these MDT decisions were implemented. METHODS This was a retrospective observational study analysing MDT treatment decisions from February 2012 to June 2013 using an MDT proforma. The decision-making process of the MDT meeting was investigated by assessing the alterations in management plan between the surgeon and the rest of the MDT. Adherence to MDT decisions was also assessed. RESULTS Decisions regarding 200 consecutive patients were analyzed. There was MDT agreement for 55%, and patients were listed for surgery on the day of the MDT. There was MDT disagreement regarding 45%, with conflicting opinions expressed by surgeons in 33/200 (17%), anaesthetists in 60/200 (30%) and dieticians in 65/200 (33%). The MDT plan was instigated in 78% and the most common reason for failure was patients failing to attend for further assessment. By the end of the study, 85% of patients underwent bariatric surgery, 11.5% declined further input, 2.5% chose further weight loss and 1% were removed from waiting list. CONCLUSION Use of a single-day MDT clinic format resulted in a change in plan for a significant number of patients. This can be interpreted as improved quality of care for these patients, and we conclude the MDT approach is valuable.
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4.
Impact of Bariatric Surgery on Bone Mineral Density: Observational Study of 110 Patients Followed up in a Specialized Center for the Treatment of Obesity in France.
Geoffroy, M, Charlot-Lambrecht, I, Chrusciel, J, Gaubil-Kaladjian, I, Diaz-Cives, A, Eschard, JP, Salmon, JH
Obesity surgery. 2019;(6):1765-1772
Abstract
INTRODUCTION Bariatric surgery is used to treat severe obesity. We aimed to investigate the incidence of clinically significant bone mineral density (BMD) loss at 6 and 12 months after bariatric surgery. METHODS Observational study performed in a specialized center for the treatment of obesity at the University Hospital of Reims, France. Surface BMD was measured by dual x-ray absorptiometry (DEXA). A reduction of > 0.03 g/cm2 was considered clinically significant. RESULTS A total of 110 patients were included. A clinically significant reduction in BMD was observed in 62.1% of patients at 6 months, and in 71.6% at 12 months after surgery. No case of osteoporosis was observed. There were four cases of osteopenia and one fracture post-surgery. BMD loss was related by univariate analysis to the reduction in body mass index (BMI) (p < 0.01), weight loss (p < 0.01), fat mass (p < 0.01), and lean mass (p < 0.01). Multivariable analysis found a significant association between the reduction in BMD and the excess weight loss percentage (odds ratio 1.11, 95% confidence interval (1.05-1.18), p < 0.001). CONCLUSION There was a clinically significant reduction in BMD at 6 months after surgery in over 60% of patients undergoing bariatric surgery. BMD loss is persistent over time and predominantly situated at the femoral level, and strongly associated with weight loss. Systematic vitamin and calcium supplementation, as well as follow-up by DEXA scan seems appropriate. Systematic DEXA scan pre- and post-surgery, and annually thereafter until weight has stabilized seems appropriate.
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5.
One Anastomosis Gastric Bypass-Mini Gastric Bypass with Tailored Biliopancreatic Limb Length Formula Relative to Small Bowel Length: Preliminary Results.
Komaei, I, Sarra, F, Lazzara, C, Ammendola, M, Memeo, R, Sammarco, G, Navarra, G, Currò, G
Obesity surgery. 2019;(9):3062-3070
Abstract
BACKGROUND One Anastomosis Gastric Bypass-Mini Gastric Bypass (OAGB-MGB) is rapidly gaining popularity and is currently being performed by an increasing number of bariatric surgeons worldwide. However, excessive postoperative weight loss and malnutrition still remain a major concern regarding this procedure. The aim of this observational retrospective study was to investigate whether a tailored biliopancreatic limb (BPL) length relative to small bowel length (SBL) is superior to a fixed BPL length of 200 cm in terms of weight loss results and nutritional deficiencies in morbidly obese patients 1 year following OAGB-MGB. MATERIALS AND METHODS Sixty-four patients who underwent OAGB-MGB were divided into two consecutive groups depending on the BPL length used: fixed 200-cm BPL and tailored BPL groups. Anthropometric measurements (%EWL, TWL, %TWL) and nutritional parameters (vitamin A, vitamin D3, vitamin B12, serum iron, serum albumin, total protein) were compared between the two groups at 1-year follow-up. RESULTS No statistically significant differences were observed between the patients in two groups in terms of %EWL, TWL, %TWL. The number of patients with deficiencies of vitamin A (p = 0.030), vitamin D3 (p = 0.020), and albumin (p = 0.030) was significantly higher in fixed 200-cm BPL group as compared with tailored BPL group, 1 year following OAGB-MGB. No statistically significant differences were seen between the patients in two groups in terms of vitamin B12, iron, and total protein deficiencies. CONCLUSION Tailoring BPL length by bypassing about 40% of the SBL seems to be safe and effective. According to preliminary results of this study, a tailored BPL length relative to SBL is even likely to be superior to the fixed 200-cm BPL as it is associated with less nutritional deficiencies while providing similar weight loss results. Further randomized studies with larger sample sizes and longer follow-up periods are necessary to confirm the primary results of this study.
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6.
Two Years Remission of Type 2 Diabetes Mellitus after Bariatric Surgery.
Wazir, N, Arshad, MF, Finney, J, Kirk, K, Dewan, S
Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2019;(10):967-971
Abstract
OBJECTIVE To determine the influence of bariatric surgery on remission of type 2 diabetes mellitus (T2DM) in obese patients along with improvements in other obesity-associated comorbidities. STUDY DESIGN Observational study. PLACE AND DURATION OF STUDY Doncaster and Bassetlaw NHS Trust, UK, from August 2010 to August 2018. METHODOLOGY All the cases of bariatric surgery in obese patients with T2DM who had completed 2 years of follow up were included in the study. Remission of T2DM was defined as glycated hemoglobin (HbA1C) <48 mmol/mol (<6.5%) or fasting blood sugar of <7.0 mmol/L, not on hypoglycemic agents 2 years after having bariatric surgery. Student's t-test was used to see any difference in baseline HbA1C, BMI, percentage of weight loss, and duration of diabetes between remitters and non-remitters. RESULTS Two years follow-up data after bariatric surgery for remission of T2DM or otherwise was available for (n=121) patients. Majority (70.2%, n=85) were females and (29.8%, n=36) were males. Mean age was 48.21 ±9.77 years. Eightythree (68.6%) patients achieved remission of T2DM at 2 years and 31.4% (n=38) did not. Remission of other comorbidities was 33.3% (n=53 out of 159) for hypertension (HTN), 50.8% (n=60 out of 118) for dyslipidemia, 67.2% (n=43 out of 64) for obstructive sleep apnea (OSA), 52.1% (n=37 out of 71) for gastro esophageal reflux disease (GERD), 25.7% (n=18 out of 70) for asthma, and 23.3% (n=24 out of 103) for depression. CONCLUSION Bariatric surgery effectively achieves remission of T2DM and other obesity associated comorbidities.
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7.
Comparison of Repeat Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Case of Weight Loss Failure After Sleeve Gastrectomy.
Antonopulos, C, Rebibo, L, Calabrese, D, Ribeiro-Parenti, L, Arapis, K, Dhahri, A, Coupaye, M, Hansel, B, Marmuse, JP, Regimbeau, JM, et al
Obesity surgery. 2019;(12):3919-3927
Abstract
BACKGROUND Few series are available on the results of repeat sleeve gastrectomy (re-SG) and Roux-en-Y gastric bypass (RYGB) performed to manage the failure of primary sleeve gastrectomy (SG). The objective of this study was to compare the short- and medium-term outcomes of re-SG and RYGB after SG. MATERIAL & METHODS Between January 2010 and December 2017, patients undergoing re-SG (n = 61) and RYGB (n = 83) for failure of primary SG were included in this study. Revisional surgery was proposed for patients with insufficient excess weight loss (EWL ≤ 50%) or weight regain. The primary endpoint was the comparison of weight loss in the re-SG group and the RYGB group at the 1-year follow-up. The secondary endpoints were overall mortality and morbidity, specific morbidity, length of stay, weight loss, and correction of comorbidities. RESULTS The mean interval between SG and re-SG was 41.5 vs. 43.2 months between SG and RYGB (p = 0.32). The mean operative time was 103 min (re-SG group) vs. 129.4 min (RYGB group). One death (1.7%; re-SG group) and 25 complications (17.4%; 9 in the re-SG group, 16 in the RYGB group) were observed. At the 1 year, mean body mass index was 31.6 in the re-SG group and 32.5 in the RYGB group (p = 0.61) and excess weight loss was 69.5 vs. 61.2, respectively (p = 0.05). CONCLUSION Re-SG and RYGB as revisional surgery for SG are feasible with acceptable outcomes and similar results on weight loss on the first postoperative year.
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8.
The pressures of obesity: The relationship between obesity, malnutrition and pressure injuries in hospital inpatients.
Ness, SJ, Hickling, DF, Bell, JJ, Collins, PF
Clinical nutrition (Edinburgh, Scotland). 2018;(5):1569-1574
Abstract
BACKGROUND Pressure injuries (PI) are a significant clinical problem across all healthcare facilities, associated with poor patient outcomes, increased length of stay and healthcare costs. Whilst it is known that underweight (Body Mass Index (BMI) < 18.5 kg/m2) and malnourished individuals have an increased risk of developing PI, few studies have investigated the effects of obesity (BMI ≥ 30 kg/m2) and morbid obesity (BMI ≥ 40 kg/m2) on PI prevalence. This study aimed to determine whether PI prevalence was associated with levels of obesity; the complex association between morbid obesity, malnutrition and PI prevalence in hospital inpatients was also explored. METHODS Data collected from annual Queensland Patient Safety Bedside Audits conducted between 2010 and 2015 was used to examine the outcomes of interest (n = 2479). Bivariate tests were used to explore relationships between age, gender, BMI, malnutrition and PI prevalence. Regression analysis explored associations between BMI, malnutrition and PI, adjusting for potential confounders. RESULTS Overall PI prevalence was 6.9% and was significantly higher in the underweight and morbidly obese groups (underweight 12.7%, healthy weight 7.8%, overweight 5.7%, obese 4.8%, morbidly obese 12%; p = 0.001). In addition to BMI, malnutrition and age were significantly associated with PI prevalence. After adjusting for confounders, morbidly obese inpatients had over three times the odds of developing a PI compared to healthy weight inpatients (OR = 3.478, 95% CI 1.657-7.303; p = 0.001). Morbidly obese inpatients who were also malnourished had eleven-fold greater odds of developing a PI compared to the morbidly obese well-nourished in logistic regression analysis (OR = 11.143, 95% CI 2.279-54.481, p = 0.003). CONCLUSIONS Morbid obesity is a significant and independent risk factor for PI development. However, the clustering of nutritional risk factors (morbid obesity and malnutrition) substantially increases this risk. Therefore, routine and formal assessment of both BMI and malnutrition status are important to enable the identification of patients at high risk of PI.
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9.
Treatment of Vitamin and Mineral Deficiencies After Biliopancreatic Diversion With or Without Duodenal Switch: a Major Challenge.
Homan, J, Schijns, W, Aarts, EO, Janssen, IMC, Berends, FJ, de Boer, H
Obesity surgery. 2018;(1):234-241
Abstract
BACKGROUND Vitamin and mineral deficiencies are a major concern after biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS). Evidence-based guidelines how to prevent or how to treat deficiencies in these patients are currently lacking. The aim of the current study is to give an overview of postsurgical deficiencies and how to prevent and treat these deficiencies. METHODS Retrospective evaluation of a 1-year structured monitoring and treatment schedule for various deficiencies in 34 patients after BPD or BPD/DS. RESULTS Patients were introduced into the program 12-90 months after surgery. Vitamin B1, B6, B9, and B12 deficiencies could be prevented by mean daily doses of 2.75 mg, 980 μg, 600 μg, and 350 μg, respectively. However, many patients continued to develop deficiencies of vitamin A, D, iron, calcium, and zinc despite major dose adjustments. Current observations suggest that at least total daily doses of 200 mg Fe in premenopausal women and 100 mg in men, 100 mg of Zinc, 3000 mg of calcium, and weekly doses of at least 50,000 IU solubilized vitamin A and vitamin D are needed to prevent the occurrence of major deficiencies. CONCLUSION Exceptionally high supplementation doses are needed to prevent and treat vitamin and mineral deficiencies in patients after BPD or BPD/DS. Further refinement and simplification of treatment schedules is needed. Focus on improvement of compliance to treatment is recommended.
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10.
Prevalence and Risk Factors for Bariatric Surgery Readmissions: Findings From 130,007 Admissions in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.
Berger, ER, Huffman, KM, Fraker, T, Petrick, AT, Brethauer, SA, Hall, BL, Ko, CY, Morton, JM
Annals of surgery. 2018;(1):122-131
Abstract
OBJECTIVE To evaluate readmissions following laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB). BACKGROUND Few studies have evaluated national readmission rates for primary bariatric surgery with national, bariatric-specific data. METHODS Patients undergoing primary LAGB, LSG, or LRYGB from January 1, 2014 to December 31, 2014, at 698 centers were identified based upon Current Procedural Terminology codes. The primary outcome was 30-day readmission from date of initial operation. RESULTS A total of 130,007 patients who underwent primary bariatric surgery were identified: 7378 LAGB (5.7%), 80,646 LSG (62.0%), and 41,983 LRYGB (32.3%). A total of 5663 (4.4%) patients were readmitted within 30 days for all causes. Patients undergoing LAGB had the lowest related readmission rate of 1.4%, followed by LSG (2.8%), and LRYGB (4.9%). Of patients who had a complication, 17.9% (n = 785) were readmitted, whereas those without readmission had a complication 1.9% of the time (P < 0.001). The most common cause of a related readmission was nausea, vomiting, fluid, electrolyte, and nutritional depletion (35.4%), followed by abdominal pain (13.5%), anastomotic leak (6.4%), and bleeding (5.8%), accounting for more than 61% of readmissions. When compared with LAGB, LSG, and LRYGB had significantly higher rates of readmission (LSG: odds ratio 1.89; 95% confidence interval 1.52-2.33; LRYGB odds ratio 3.06; 95% confidence interval 2.46-3.81). CONCLUSIONS National bariatric readmissions after primary procedures were closely associated with complications, varied based on the type of procedure, and were most commonly due to nausea, vomiting, electrolyte, and nutritional depletion.