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Efficacy of oral compared with intramuscular vitamin B-12 supplementation after Roux-en-Y gastric bypass: a randomized controlled trial.
Schijns, W, Homan, J, van der Meer, L, Janssen, IM, van Laarhoven, CJ, Berends, FJ, Aarts, EO
The American journal of clinical nutrition. 2018;(1):6-12
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Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), patients often develop a vitamin B-12 deficiency. OBJECTIVE Our objective was to investigate whether oral supplementation increases and normalizes low vitamin B-12 concentrations (vitamin B-12 > 200 pmol/L) in RYGB patients as compared to intramuscular injections. DESIGN A randomized controlled trial in RYGB patients with subnormal serum B-12 concentrations was performed. One group (IM B-12) received bimonthly intramuscular hydroxocobalamin injections (2000 µg as loading dose and 1000 µg at follow-up) for 6 mo. The second group (oral B-12) received daily doses of oral methylcobalamin (1000 µg). Serum vitamin B-12 was determined at baseline (T0) and at 2 (T1), 4 (T2), and 6 mo (T3) after start of treatment. Concentrations of the secondary markers methylmalonic acid (MMA) and homocysteine (Hcy) were measured at T0 and T3. RESULTS Fifty patients were included and randomized, 27 in IM B-12 and 23 in oral B-12. The median vitamin B-12 concentration at T0 was 175 pmol/L (range: 114-196 pmol/L) for IM B-12 and 167 pmol/L (range: 129-199 pmol/L) for oral B-12. Vitamin B-12 normalized in all individuals, and there was no significant difference in vitamin B-12 between the two groups. MMA and Hcy concentrations decreased significantly after 6 mo within each group (P < 0.001 and P < 0.001 for MMA and P = 0.03 and P = 0.045 for Hcy, respectively). There was no significant difference between the groups at 6 mo for both MMA and Hcy (P = 0.53 and P = 0.79). CONCLUSION The efficacy of oral vitamin B-12 supplementation was similar to that of hydroxocobalamin injections in the present study. Oral supplementation can be used as an alternative to hydroxocobalamin injections to treat RYGB patients with low values of serum vitamin B-12. This trial was registered at clinicaltrials.gov as NCT02270749.
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The anorexigenic peptide neurotensin relates to insulin sensitivity in obese patients after BPD or RYGB metabolic surgery.
von Loeffelholz, C, Gissey, LC, Schumann, T, Henke, C, Kurzbach, A, Struck, J, Bergmann, A, Hanefeld, M, Schatz, U, Bornstein, SR, et al
International journal of obesity (2005). 2018;(12):2057-2061
Abstract
Neurotensin is a peptide with effects on appetite and intestinal lipid absorption. Experimental data suggest a role in glucose homeostasis, while human data is missing. Here, 20 morbidly obese subjects either underwent biliopancreatic diversion with duodenal switch (BPD), or Roux-en-Y gastric bypass (RYGB) in a randomized fashion. Before and 1 year after surgery, anthropometric data, body composition, clinical biochemistry, insulin sensitivity by means of euglycemic hyperinsulinemic clamps (HEC) and fasting plasma proneurotensin 1-117 were analyzed. Plasma proneurotensin increased significantly more 1 year after BDP than RYGB (P = 0.028), while weight loss was comparable. After metabolic surgery, proneurotensin correlated positively with insulin sensitivity (M-value) (r = 0.55, P < 0.001), while an inverse relationship with fasting glucose, HOMA-IR and HbA1c was observed (P < 0.05 for all components). After adjustment for age and gender, proneurotensin and BMI remained independently related with delta of M-value (β = 0.46 and β = 0.51, P < 0.05, resp.). From these data we conclude that proneurotensin positively correlates with insulin sensitivity uniquely after weight loss induced by metabolic surgery in humans. BDP leads to a stronger increase in the anorexigenic peptide compared to RYGB.
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Sleeve gastrectomy surgery: when 2 alcoholic drinks are converted to 4.
Acevedo, MB, Eagon, JC, Bartholow, BD, Klein, S, Bucholz, KK, Pepino, MY
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2018;(3):277-283
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Abstract
BACKGROUND While it is well established that Roux-en-Y gastric bypass (RYGB) causes a rapid and heightened peak blood alcohol concentration (BAC), results from previous studies on the effects of sleeve gastrectomy (SG) on alcohol pharmacokinetics are conflicting. Data from 2 studies found SG did not affect BAC, whereas another study found SG caused a heightened peak BAC after alcohol ingestion. Moreover, these 3 studies estimated BAC from breathalyzers, which might not reliably estimate peak BAC. OBJECTIVES The aims of this study were to evaluate (1) the effect of SG, relative to RYGB and a presurgery group, on alcohol pharmacokinetics and subjective effects, and (2) whether breathalyzers are reliable in this population. SETTING Single-center prospective nonrandomized trial. METHODS We performed alcohol challenge tests in 11 women who had SG surgery 1.9 ± .1 years ago (body mass index = 35.1 ± 6.6 kg/m2), 8 women who had RYGB surgery 2.2 ± .4 years ago (body mass index = 30.0 ± 5.2 kg/m2), and 9 women who were scheduled for bariatric surgery (body mass index = 44.1 ± 4.0 kg/m2). BACs were estimated from breath samples and measured by gas chromatography at various times after consuming approximately 2 standard drinks. RESULTS BAC increased faster, peak BAC was approximately 2-fold higher, and feelings of drunkenness were heightened in both SG and RYGB groups relative to the presurgery group (P values<.001). BAC estimated from breath samples underestimated BAC by 27% (standard deviation = 13%) and missed peak BACs postsurgery. CONCLUSIONS SG, similar to RYGB, causes marked alterations in the response to alcohol ingestion manifested by a faster and higher peak BAC. The breathalyzer is invalid to assess effects of gastric surgeries on pharmacokinetics of ingested alcohol.
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Single Anastomosis Duodeno-Ileal Switch (SADIS): A Systematic Review of Efficacy and Safety.
Shoar, S, Poliakin, L, Rubenstein, R, Saber, AA
Obesity surgery. 2018;(1):104-113
Abstract
BACKGROUND Owing to the possibility of weight regain after the long-term follow-up of gastric bypass patients and because of the high morbidity of biliopancreatic diversion with duodenal switch, single-anastomosis duodeno-ileal switch (SADIS) has emerged as a rescue procedure in bariatric surgery. OBJECTIVE The purpose of this review is to summarize the literature data on SADIS. SETTING University Hospital, NY. METHODS A comprehensive literature review was performed through October 2016 to identify English studies on SADIS performed in human subjects. Outcomes of interest were technical considerations, postoperative complications, weight loss outcome, comorbidity resolution rate, and nutritional deficiency after SADIS. RESULTS A total of 12 studies including 581 SADIS patients (217 males and 364 females) were included. SADIS was a primary procedure in 508 patients (87.4%) and a conversion procedure in 73 patients (12.6%). The length of common limb was 300 cm in 54.2%, 250 cm in 23%, and 200 cm in 13.4% of patients. Anastomosis technique was a linear stapler in 26.7% and a hand sewn suture technique in 73.3% of patients. Diarrhea was the most common complication (1.2%). The average %EWL was 30% at 3 months, 55% at 6 months, 70% at 1 year, and 85% at 2 years. Co-morbidity resolution rate was 74.1% for type 2 diabetes mellitus, 96.3% for hypertension, 68.3% for dyslipidemia, 63.3% for obstructive sleep apnea, and 87.5% for GERD. Overall, vitamin A, selenium, and iron deficiency were the most common nutritional deficiencies with the possibility of the protein malnutrition in up to 34% of the patients when measured. CONCLUSION As a modified bariatric procedure, SADIS has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients. When measured, there was a high prevalence of macro-nutrient deficiencies following SADIS. There is a high technical variability, and long-term data are required before any meaningful conclusion can be made.
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Early intake of solid food after Roux-en-Y gastric bypass and complications. A cohort study from the Scandinavian Obesity Surgery Registry.
Edholm, D
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2018;(9):1256-1260
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. There are few studies investigating how early return to solid food affects complications. OBJECTIVE The aim of this study was to explore how oral intake was resumed in RYGB patients and how the postoperative food regimen affects outcomes, such as complications and length of stay. SETTING Retrospective nationwide registry study. METHODS The Scandinavian Obesity Surgery Registry included prospective data from RYGB patients operated in 2009 to 2014. A questionnaire assessed the postoperative reintroduction of solid food applied at each bariatric center. The postoperative regimen was established in 23,589 patients. Outcomes were recorded at 30-day follow-up according to the standard Scandinavian Obesity Surgery Registry routine. RESULTS Nine percent of patients (n = 2074) returned to solid food within the first week after surgery. Most commonly solid food was resumed in week 4 (37%, n = 8659). Median length of stay was 2 days for all. Of all, 2.8% suffered from a severe complication (>Clavien-Dindo 3a). After adjusting for the annual volume of procedures at hospitals, there was no correlation that the timing of solid food affected complication rates. The odds ratio for a severe complication was significantly lower for intermediate- (odds ratio .64 95% confidence interval .48-.85) or high- (odds ratio .52 95% confidence interval .42-.66) volume centers. The rate of leaks and small bowel obstructions were evenly distributed between the different postoperative food regimens. CONCLUSION Early return to solid food after RYGB did not affect the risk of severe complications. Patients operated at centers with an annual volume of >100 procedures have a lower risk of severe complications.
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Effect of calcium citrate vs calcium carbonate on elevated parathyroid hormone after Roux-en-Y gastric bypass. A double-blinded, randomized trial.
Ring Madsen, L, Espersen, R, Rejnmark, L, Richelsen, B
Clinical endocrinology. 2018;(6):734-741
Abstract
OBJECTIVE Following Roux-en-Y gastric bypass (RYGB), elevated parathyroid hormone (PTH) levels potentially harmful to bone health are commonly observed. Owing to assumed superior absorption, calcium citrate is often recommended over calcium carbonate following RYGB for the treatment of elevated PTH. We aimed to investigate the impact of either calcium carbonate or calcium citrate (1200 mg elementary calcium) in patients with elevated PTH levels following RYGB. DESIGN Clinical, double-blinded, randomized controlled trial of a 12-week duration at a Danish University Hospital. PATIENTS AND MEASUREMENTS Thirty-nine (no drop out) RYGB operated patients with elevated PTH levels (PTH > 6.9 pmol/L) and normal plasma levels of calcium and 25-hydroxyvitamin D were randomized to either calcium carbonate or calcium citrate (1200 mg elementary calcium/daily). We assessed change in PTH as the primary outcome. RESULTS The effect of the two calcium formulations on change in PTH was comparable and neutral: -1.9% (calcium citrate) vs +0.9% (calcium carbonate), P = 0.680. Compared to the carbonate-treated group, the following bone turnover markers decreased significantly in the citrate-treated group: procollagen I N-terminal propeptide (-16.6% vs -3.2%, P = 0.021), osteocalcin (-17.2% vs -4.3%, P = 0.007) and bone-specific alkaline phosphatase (-5.9% vs 3.7%, P = 0.027) and remained significantly decreased after multivariable adjustment. CONCLUSION Increasing the dose of calcium supplementation in RYGB operated patients with slightly elevated PTH levels does not normalize PTH levels, regardless of the type of supplement. Our results do not support recommending supplementation with calcium citrate over calcium carbonate in RYGB patients.
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Copper Deficiency Myelopathy After Upper Gastrointestinal Surgery.
King, D, Siau, K, Senthil, L, Kane, KF, Cooper, SC
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2018;(4):515-519
Abstract
A well-functioning alimentary canal is required for adequate nutrient absorption. Disruption to the upper gastrointestinal tract through surgery can lead to micronutrient malnourishment. Copper deficiency has been noted in up to 10% of those undergoing Roux-en-Y gastric bypass surgery, but sequalae are not frequently reported. The resultant deficiency states can have profound and long-term consequences if not realized early and managed appropriately. Here we present a case of copper deficiency myelopathy, a condition indistinguishable from subacute combined degeneration of the spinal cord, following upper gastrointestinal bypass surgery for gastric ulceration, further complicated by inadequate nutrition.
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Abdominal Pain After Roux-En-Y Gastric Bypass for Morbid Obesity.
Mala, T, Høgestøl, I
Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society. 2018;(4):277-284
Abstract
BACKGROUND AND AIMS Roux-en-Y gastric bypass is widely used as treatment of morbid obesity. Weight loss, effects on obesity-related co-morbidities and quality of life are well documented post Roux-en-Y gastric bypass. Other outcome measures are less well studied. This review explores aspects of prevalence, diagnostic evaluations, etiology, and treatment of abdominal pain specific to Roux-en-Y gastric bypass. METHODS The review is based on PubMed searches and clinical experience with Roux-en-Y gastric bypass. Symptoms in the early postoperative phase (<30 days) were not included. RESULTS Based on limited evidence, up to about 30% of the patients may perceive recurrent abdominal pain post Roux-en-Y gastric bypass in the long term. A substantial subset of patients will need health-care evaluation for acute abdominal pain and hospital admission. The etiology of abdominal pain is heterogeneous and includes gallstone-related disease, intestinal obstruction, anastomotic ulcerations and strictures, intestinal dysmotility, dysfunctional eating, and food intolerance. Surgical treatment and guidance on diet and eating habits may allow symptom relief. The cause of pain remains undefined for a subset of patients. Impact of abdominal pain post Roux-en-Y gastric bypass on the perception of well-being, quality of life, and patient satisfaction with the procedure needs to be further evaluated and may be influenced by complex interactions between new symptoms post Roux-en-Y gastric bypass and relief of pre-existing symptoms. CONCLUSION Abdominal pain should be part of follow-up consultations post Roux-en-Y gastric bypass. Future studies should focus on combined evaluations before and after surgery to enlighten potential casual relationships between abdominal pain and Roux-en-Y gastric bypass.
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Comparison of metabolic outcomes in patients undergoing laparoscopic roux-en-Y gastric bypass versus sleeve gastrectomy - a systematic review and meta-analysis of randomised controlled trials.
Hayoz, C, Hermann, T, Raptis, DA, Brönnimann, A, Peterli, R, Zuber, M
Swiss medical weekly. 2018;:w14633
Abstract
BACKGROUND AND OBJECTIVES Bariatric surgery is the most effective treatment for morbid obesity and is known to have beneficial effects on glycaemic control in patients with type 2 diabetes mellitus (T2DM) and in diabetes prevention. The preferred type of surgery and mechanism of action is, however, unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effects of laparoscopic roux-en-Y gastric bypass (RYGB) with those of sleeve gastrectomy (SG) on metabolic outcome, with a special focus on glycaemic control. METHODS A literature search of the Medline, Pubmed, Cochrane, Embase and SCOPUS databases was performed in November 2014 for RCTs comparing RYGB with SG in overweight and obese patients with or without T2DM. The primary outcome was improvement in postoperative glycaemic control. Secondary outcomes included weight-related and lipid metabolism parameters. Synthesis of these data followed established statistical procedures for meta-analysis. RESULTS Sixteen RCTs with a total of 1132 patients with overweight or obesity were included in the analysis. When compared with patients who underwent SG, those who underwent RYGB showed no difference after 12 months in mean fasting blood glucose (mean difference [MD] -6.22 mg/dl, 95% confidence interval [CI] -17.27 to 4.83; p <0.001). However, there was a better outcome with RYGB, with lower mean fasting glucose levels at 24 months (MD -16.92 mg/dl, 95% CI -21.67 to -12.18), 36 months (MD -5.97mg/dl, 95% CI -9.32 to -2.62) and at 52 months (MD -15.20 mg/dl, 95% CI -27.35 to -3.05) mg/dl; p = 0.010) and lower mean glycated haemoglobin (HbA1 at 12 months (MD -0.47%, 95% CI -0.73 to -0.20%; p <0.001) and at 36 months postoperatively compared to SG. Fasting insulin levels and HOMA indices showed no difference at any stage of follow-up. In the subgroup including only diabetic patients HbA1c showed lower levels at 12 months (MD -0.46%, 95% CI-0.73 to -0.20%). No difference was found for the fasting insulin at baseline and after 12 months. Similarly, when compared to SG, patients that underwent RYGB had lower low-density lipoproteins at 12 months. This effect was lost at 36 months. Patients undergoing RYGB also had lower triglycerides at 12 months and at 52 months, lower cholesterol at 60 months and an improvement of BMI at 52 months postoperatively. BMI values at 12 months and low-density lipoprotein levels at 12 and 36 months were lower for diabetic patients only, as in the overall analysis. CONCLUSION Based on this meta-analysis, RYGB is more effective than SG in improving weight loss and short- and mid-term glycaemic and lipid metabolism control in patients with and without T2DM. Therefore, unless contraindicated, RYGB should be the first choice to treat patients with obesity and T2DM and/or dyslipidaemia.
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Changes in Bone Mineral Density Following Weight Loss Induced by One-Anastomosis Gastric Bypass in Patients with Vitamin D Supplementation.
Luger, M, Kruschitz, R, Winzer, E, Schindler, K, Grabovac, I, Kainberger, F, Krebs, M, Hoppichler, F, Langer, F, Prager, G, et al
Obesity surgery. 2018;(11):3454-3465
Abstract
BACKGROUND Little is known about changes in bone mineral density (BMD) following weight loss after one-anastomosis gastric bypass (OAGB) and the role of serum vitamin D and its supplementation on bone metabolism. We evaluated BMD after OAGB as a function of vitamin D supplementation with respect to a minimum threshold of 25-hydroxy-vitamin-D [25(OH)D] concentration, which could prevent or decelerate an eventual bone loss. METHODS Fifty bariatric patients who participated in the randomized controlled trial were included in this analysis. BMD and anthropometric measurements by DXA and laboratory parameters were assessed before (T0), at 6 (T6), and 12 months (T12) after surgery. RESULTS OAGB resulted in a 36% total body weight loss with a decrease in body fat and an increase in lean body mass. A significant decrease in BMD was seen in lumbar spine by 7%, left hip 13%, and total body 1%, but not in forearm. Bone turnover markers increased significantly but with normal parathyroid hormone concentrations. Weight loss was not associated with changes in BMD. A serum 25(OH)D concentration > 50 nmol/l at T6 and T12 (adequate-vitamin-D-group; AVD) showed a significant lower bone loss, compared to the inadequate-vitamin-D-group (IVD; < 50 nmol/l). Lower bone loss in the left hip showed a strong correlation with higher 25(OH)D concentrations (r = 0.635, p = 0.003). CONCLUSION These findings support a dose effect of vitamin D supplementation on bone health and suggest that 25(OH)D concentrations need to be above 50 nmol/l at least during the first postoperative year to decelerate bone loss in patients undergoing OAGB. CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE Clinicaltrials.gov (NCT02092376) at https://clinicaltrials.gov /. EudraCT (2013-003546-16) at https://eudract.ema.europa.eu /.