Cross-sectional long-term micronutrient deficiencies after sleeve gastrectomy versus Roux-en-Y gastric bypass: A pilot study

BackgroundNutritional deficiencies are highly prevalent in obese patients. Bariatric surgery has been associated with adverse effects on homeostasis of significant vitamins and micronutrients, mainly after gastric bypass. The aim of the present study was to compare the extent of long-term postsurgical nutritional deficiencies between Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).MethodsThis cross-sectional, pilot study included 95 patients who underwent RYGB or SG surgery with a mean follow-up of 4 years. Demographic, anthropometric, and biochemical parameters were compared according to the type of surgery.ResultsBoth types of surgery were associated with significant nutritional deficiencies. Vitamin B12 deficiency was significantly higher in patients with RYGB compared with SG (42.1% versus 5%, P = .003). The type of surgery was associated neither with anemia nor with iron or folate deficiency (SG versus RYGB: anemia, 54.2% versus 64.3%, P = .418; folate deficiency, 20% versus 18.4%, P = .884; iron deficiency, 30% versus 36.4%, P = .635).ConclusionDuring a mean follow up period of 4 years postRYGB or SG, patients were identified with several micronutrient deficiencies, including vitamin D, folate, and vitamin B12. SG may have a more favorable effect on the metabolism of vitamin B12 compared with RYGB, being associated with less malabsorption. Adherence to supplemental iron and vitamin intake is of primary significance in all cases of bariatric surgery.     

Comparison of early type 2 diabetes improvement after gastric bypass and sleeve gastrectomy: medication cessation at discharge predicts 1-year outcomes

BackgroundAlthough weight loss–dependent type 2 diabetes (T2D) improvement after sleeve gastrectomy (SG) is well documented, whether SG has a weight-independent impact on T2D is less studied.ObjectivesTo evaluate early, weight-independent T2D improvement after SG and Roux-en-Y gastric bypass (RYGB) and its relationship to longer-term T2D outcomes.SettingUniversity Hospital, United States.MethodsWe completed a retrospective cohort study of patients with T2D who underwent SG (n = 187) or RYGB (n = 246) from 2010 to 2015. Pre- and postoperative parameters, including demographic characteristics, T2D characteristics, and T2D medication requirements, blood glucose, glycosylated hemoglobin, weight, and body mass index, were reviewed.ResultsT2D improved within days after both SG and RYGB, with more patients off T2D medications after SG than RYGB (39% versus 25%, respectively; P < .01) at the time of discharge (2.5 ± .8 versus 2.7 ± 1 d; P = .04). Over the initial postoperative 12 months, T2D medication cessation rates remained relatively stable after SG but continued to improve after RYGB (at 12 mo: 52% versus 68%, respectively; P < .05). T2D medication cessation at discharge predicts 12-month T2D medication cessation (92% [RYGB] and 78% [SG] positive predictive value). In a mixed-effects regression model adjusting for weight loss and severity of diabetes, discharge T2D medication cessation remained a significant predictor of T2D outcomes after both RYGB (odds ratio, 51; 95% confidence interval, 16.1–161; P < .0001) and SG (6.4; 95% confidence interval, 2.8–14.7; P < .0001).ConclusionsBoth SG and RYGB lead to high rates of T2D medication cessation within days of surgery, suggesting both operations activate weight loss–independent anti-T2D pathways. T2D medication cessation at discharge is predictive of 12-month T2D outcomes, particularly in noninsulin requiring patients. By 1 year after the surgery, RYGB leads to more weight loss and higher rates of T2D medication cessation than SG.     

Micronutrient intake and biochemistry in adolescents adherent or nonadherent to supplements 5 years after Roux-en-Y gastric bypass surgery

BackgroundRoux-en-Y gastric bypass (RYGB) is an effective obesity treatment in adults and has become established in adolescents. Lower adherence to supplementation in adolescents confers a risk for long-term nutritional deficiencies.ObjectivesTo assess adherence to supplementation, micronutrient intake, and biochemistry in adolescents through 5 years after RYGB.SettingUniversity hospitals, multicenter study, Sweden.MethodsMicronutrient intake and adherence to supplementation were assessed by diet history interviews and biochemistry preoperatively, 1, 2, and 5 years after RYGB in 85 adolescents (67% females), aged 16.5 years (± 1.2) with a body mass index of 45.5 kg/m² (± 6.0). Adherence was defined as taking prescribed supplements ≥3 times a week. Micronutrient intake and biochemistry were compared with matched controls at 5 years.ResultsOver 75% completed the dietary assessments across 5 years after RYGB. Adherence ranged between 44–61% through 5 years. At 5 years, ferritin and hemoglobin decreased (P < .04) and 61% had iron deficiency (P ≤ .001). Among females with iron deficiency, most did not adhere to supplementation (P = .005), and 59% of these had anemia (P < .001). Vitamin D insufficiency continued after surgery and 80% of participants who did not adhere to supplementation had insufficiency (P = .002). Adolescents not adhering had lower levels of vitamin D, B₁₂, and ferritin (females) compared with both adhering adolescents and the control group (all P < .04).ConclusionsHalf of adolescents after RYGB reported sufficient long-term adherence to supplementation. Adhering to supplements and reporting a higher micronutrient intake were associated with more favorable biochemistry. Results support the recommendations for monitoring micronutrient intake and biochemistry in all patients who have undergone RYGB surgery, and the recommendation of higher preventive supplementation of vitamin D and iron in both sexes. As hypothesized, adolescents not adhering had a higher prevalence of long-term micronutrient deficiencies.     

Screening and Diagnosis of Micronutrient Deficiencies Before and After Bariatric Surgery

Background

Micronutrient deficiencies are key concerns after bariatric surgery. We describe the prevalence of perioperative testing and diagnosis of micronutrient deficiencies among a cohort of insured bariatric surgery patients.

Methods

We used claims data from seven health insurers to identify bariatric surgery patients from 2002–2008. Our outcomes were perioperative claims for vitamin D, B12, folate, and iron testing and diagnosed deficiencies. We analyzed results by bariatric surgery type: Roux-en-Y gastric bypass (RYGB), restrictive, and malabsorptive. We calculated the prevalence of testing and deficiency diagnosis, and performed multivariate logistic regression to determine the association with surgery type.

Results

Of 21,345 eligible patients, 84 % underwent RYGB. The pre-surgical testing prevalence for all micronutrients was <25 %. The testing prevalence during the first 12 months after surgery varied: vitamin D (12 %), vitamin B12 (60 %), folate (47 %) and iron (49 %), and declined during 13–24 and 25–36 months. The deficiency prevalence during 0–12 months post-survey varied: vitamin D (34 %), vitamin B12 (20 %), folate (13 %), and iron (10 %). The odds of vitamin B12, folate, and iron deficiency during 0–12 months were significantly lower for restrictive as compared to RYGB, but were not different during 13–24 and 25–36 months post-surgery. The odds of vitamin D deficiency were significantly greater for malabsorptive as compared to RYGB during all post-surgical periods.

Conclusion

Many patients did not receive micronutrient testing pre- or post-surgery, yet deficiencies were relatively common among those tested. These results highlight the need for surgeons and primary care providers to test all bariatric surgery patients for micronutrient deficiencies.     

Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass?

Although iron, vltamm 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 Durmg a l0-year period, a complete blood count and serum levels of iron, total iron-binding capacity, vltamin 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 developmg these deficiencies decreases over time Hemoglobin and hematocrit levels were slgnificantly decreased at all postoperative intervals in comparison to preoperative values Moreover, at each successive interval through 5 years, hemoglobin and hematocrit were decreased signifiantly compared to the preceding interval Folate levels were significantly increased compared to preoperative levels at all time intervals Iron and vltamin 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 multivltamin 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 defiaencies 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 anenua 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     

Metabolic bone disease and fracture risk after gastric bypass and sleeve gastrectomy: comparative analysis of a multi-institutional research network

BackgroundRoux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most performed bariatric procedures. Multiple studies have investigated the metabolic bone complications after bariatric surgery, but there is a paucity of data comparing bone health after RYGB and SG.ObjectivesTo compare the rates of major fractures and osteoporosis after Roux-en-Y gastric bypass and sleeve gastrectomy.SettingData from TriNetX multi-institutional research network that includes data from multiple health care organizations in the USA was analyzed at West Virginia University.MethodsWe conducted a retrospective cohort study using TriNetX, a federated multi-institutional research network. We identified patients who underwent RYGB or SG. Primary outcome was the rate of major fractures at 3 years after the procedure. Other outcomes included the rate of spine fracture, femur fracture, osteoporosis, and vitamin D deficiency at follow-up.ResultsIn unmatched analysis, patients with SG were less likely to have major fractures or an osteoporosis diagnosis than RYGB patients at 3 years after the procedure (P < .05). After propensity-score matching, similar results were noted; patients with SG were less likely to have major fractures than RYGB patients at 3 years after procedure (2.85% versus 3.66%, risk ratio [RR]: .78, 95% confidence interval [CI]: .71–.85), and a lower rate of osteoporosis diagnosis was noted in the SG group. High rates of vitamin D deficiency were noted in both cohorts. The incidence of spine fractures was significantly lower in the SG group than in the RYGB group (.76% versus 1.18%, RR: .65, 95% CI: .54–.77). Similarly, the incidence of femur fracture was significantly lower after SG (RR: .62, 95% CI: .44–.88). Female sex, higher age, smoking history, and diabetes were independently associated with osteoporosis diagnosis during follow-up (all P values <.05).ConclusionOur analyses showed that RYGB is associated with a higher risk of osteoporosis, vitamin D deficiency, and osteoporotic fractures. Thus, in patients with a higher baseline osteoporotic risk, SG may be preferred option; however, further studies are needed.     

Hospital utilization 4 years after bariatric surgery: sleeve gastrectomy versus Roux-en-Y gastric bypass

BackgroundWhile sleeve gastrectomy (SG) has lower perioperative risk compared with Roux-en-Y gastric bypass (RYGB), long-term data about their differential impact on overall health are unclear. Hospital use after bariatric surgery is an important parameter for improving peri- and postoperative care.ObjectiveThis present study was aimed to compare SG and RYGB in terms of their effect on long-term hospital-based healthcare utilization.SettingMulticenter, statewide database.MethodsA retrospective cohort study of adult patients who underwent SG and RYGB between 2009 and 2011, with follow-up until 2015 and 2-year presurgery information. Propensity score–matched SG and RYGB groups were created using preoperative demographic characteristics, co-morbidities, and presurgery hospital use, measured by cumulative length of stay (LOS) and frequency of emergency department visits. Postsurgery yearly LOS, incidence of hospital visits, and the reason for the visit were compared. Primary outcomes included postoperative hospital visits during years 1 to 4 after bariatric surgery and cumulative LOS. Secondary outcomes included specific reasons for hospital use.ResultsThere were 3540 SG and 13,587 RYGB patients, whose mean (95% confidence interval [CI]) LOS was 1.3 (1.3–1.4), .9 (.8–1), 1 (.9–1.1), and 1.2 (1–1.3) days at years 1 through 4, respectively. Postoperative yearly LOS was similar between the 2 propensity-matched groups. The risk of hospitalizations (odd ratio .73, 95% CI .64–.84, P < .0001) and emergency department visits (odds ratio .84, 95% CI .75–.95, P = .005) was significantly lower for SG, during the first postoperative year. The reverse was seen at the fourth postoperative year, with higher risk of emergency department use after SG (odds ratio 1.16, 95% CI 1.01–1.33, P = .035).ConclusionPostoperative 4-year hospital utilization remains low for both SG and RYGB. The previously established lower early perioperative risk of SG was not appreciated for longer-term hospital use compared with RYGB.     

Factors influencing long-term weight loss after bariatric surgery

BackgroundBariatric surgery provides sustained weight loss and improves comorbidities. However, long term data has shown that patients gradually regain weight after 1 year. Several factors have been associated with poor weight loss after bariatric surgery.ObjectiveOur goal is to investigate factors associated with poor weight loss following laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).SettingMilitary academic medical center.MethodsRetrospective review of 247 patients who underwent laparoscopic SG or RYGB between 2010–2012 at Eisenhower Army Medical Center and followed for 5 years postoperatively. Factors of age, type of surgery, sex, hypertension, depression, and type 2 diabetes (T2D) are analyzed in univariate and multivariate analysis with percent total weight loss (%TWL) and Body Mass Index (BMI) change as primary endpoints measured at 3 and 5 years.ResultsAverage BMI change are maximized at 1 year and decreased at 3 and 5 years post-surgery. Age, diabetes, hypertension and type of surgery significantly influenced weight loss at 3 and 5 years on univariate analysis. However, patients with diabetes, hypertension and sleeve gastrectomy were significantly older than comparable control group. Multivariable analysis showed that age and type of surgery, not diabetes or hypertension, were associated with poor %TWL and BMI change at 3 and 5 years.ConclusionWhile presence of hypertension and diabetes initially appeared to be associated with weight recidivism, their impacts were negligible on multivariable analysis. However, age and sleeve gastrectomy are independent risk factors. Our data can be used to counsel patients on expected weight loss after bariatric surgery.     

Metabolic syndrome impact on nutritional deficiencies and metabolic status 1 year after sleeve gastrectomy

BackgroundA paucity of information is available on the comparative nutritional deficiencies considering the presence of metabolic syndrome (MetS) and nutritional changes after vertical sleeve gastrectomy (SG).ObjectivesTo compare the nutritional status in patients with and without MetS before and 1 year after SG and to investigate its association with metabolic status.SettingA tertiary referral center.MethodsRetrospective study, including all patients submitted to SG between January 2011 and July 2015. Patients were evaluated before and 12 months after surgery. MetS presence was classified using the International Diabetes Federation/American Heart Association/National Heart, Lung, and Blood Institute 2009 definition. Univariate and multivariate analyses were applied to find associations between MetS, nutritional, anthropometric, and metabolic parameters.ResultsA total of 330 patients were included and MetS was present in 47%. Preoperatively, patients without MetS presented a higher percentage of folate deficiency (12% versus 2%, P < .001). Follow-up data were available for 202 patients. In the 1-year evaluation, MetS patients presented significantly lower body mass index and percent excess weight loss (70.96 ± 20.4 versus 79.55 ± 23.0, P < .001). These patients also presented lower homocysteine (11.76 ± 4.3 versus 13.66 ± 7.6, P = .027) and magnesium (19.41 ± 2.1 versus 20.22 ± 1.9, P = .004) levels but higher calcium (9.27 ± .3 versus 9.16 ± .4, P = .031) and vitamin B12 (396, P 312–504.5 versus 329, P 255–433, P = .002) levels comparing with those without MetS. Multiple linear regression evidenced that higher preoperative albumin and postoperative ferritin and homocysteine were predictors of a lower body mass index after surgery, and higher postoperative folate levels were associated with lower insulin-resistance.ConclusionsThe impact of SG on nutritional parameters is affected by MetS. If not treated, preoperative deficiencies can impair postoperative metabolic status and weight loss. MetS should be considered when evaluating bariatric surgery candidates, and preoperative supplementation and long-term nutritional follow-up are required to prevent further nutritional deficiencies.     

Early cardiac complications after bariatric surgery: does the type of procedure matter?

BackgroundMajor adverse cardiac events (MACE) can be a cause of postoperative mortality. This is specifically important in bariatric surgery due to obesity-related cardiovascular risk factors.ObjectiveTo assess postoperative cardiac adverse events after bariatric surgery and its independent predictors.SettingA retrospective analysis of 2011–2015 Healthcare Cost and Utilization Project-National Inpatient Sample.MethodsData on patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were retrieved. MACE was identified as a composite variable including myocardial infarction, acute ischemic heart disease without myocardial infarction, and acute heart failure. Dysrhythmia (excluding premature beats) was identified as a separate outcome. Multivariate regression analysis for MACE was performed using demographic factors, co-morbidities, and type of surgery.ResultsThe analysis included 108,432 patients (SG: 54.6%, RYGB: 45.4%). MACE was found in 116 patients (.1%), and dysrhythmia occurred in 3670 patients (3.4%). Median length of stay in patients with MACE was 4.5 versus 2 days in others (P < .001). There were 43 deaths overall, and 31 were in patients with MACE or dysrhythmia (P < .001). Age ≥ 50 years, male sex, congestive heart failure, chronic pulmonary disease, ischemic heart disease, history of pulmonary emboli, and fluid or electrolyte disorders were independent predictors of MACE based on multivariate analysis. Type of surgery (SG versus RYGB) was not an independent predictor for MACE (odds ratio 1.41, 95% confidence interval: .77–2.55).ConclusionsWhile cardiac complications are rare after bariatric surgery, their occurrence is associated with increased length of stay, hospital charges, and mortality. Older age, male sex, cardiopulmonary co-morbidities, and fluid or electrolyte disorders are predictive of MACE. RYGB does not increase the risk of MACE compared with SG.     

Anemia,iron and vitamin B12 deficiencies after sleeve gastrectomy compared to Roux-en-Y gastric bypass: a meta-analysis

BackgroundThe effective treatment of postoperative anemia and nutritional deficiencies is critical for the successful management of bariatric patients. However, the evidence for nutritional risk or support of bariatric patients remains scarce. The aims of this study were to assess current evidence of the association between 2 methods of bariatric surgery, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), and postoperative anemia and nutritional deficiencies.MethodsMEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for English-language studies using a list of keywords. Reference lists from relevant review articles were also searched. In the authors’ meta-analysis, they included studies with a duration of>12 months, those comparing SG with RYGB, and those with available outcome data for postoperative anemia and iron and vitamin B₁₂ deficiencies. Of 36 potentially relevant studies, 9 met the inclusion criteria. Data were combined by means of a fixed-effects model or random-effects model.ResultsCompared with the SG group, the odds ratio for postoperative vitamin B₁₂ deficiency in the RYGB group was 3.55 (95% confidence interval, 1.26–10.01; P<.001). In the subgroup analysis, studies in which prophylactic iron or vitamin B₁₂ was administered lost significance in the odds ratio for postoperative vitamin B₁₂ deficiency.ConclusionThe authors’ findings suggest that SG is more beneficial than RYGB with regard to postoperative vitamin B₁₂ deficiency risk, whereas the 2 methods are comparable with regard to the risk of postoperative anemia and iron deficiency. Postoperative prophylactic iron and B₁₂ supplementation, in addition to general multivitamin and mineral supplementation, is recommended based on the comparable deficiency risk of the 2 methods as indicated by subgroup analysis.     

Correction of preoperative vitamin D deficiency after Roux-en-Y gastric bypass surgery

BackgroundTo evaluate the adequacy of supplementation to correct preoperative vitamin D deficiency in adult patients during the year after Roux-en-Y gastric bypass (RYGB) surgery.MethodsThe medical records were reviewed and the preoperative and 12-month postoperative serum 25-hydroxyvitamin D [25(OH)D] levels were compared in patients who underwent RYGB from 2002 to 2004. The serum 25(OH)D levels were defined as being optimal (≥80 nmol/L), suboptimal (50–79 nmol/L), or deficient (<50 nmol/L). Patients with deficient 25(OH)D levels were prescribed 50,000 IU ergocalciferol weekly. The remaining patients averaged 710 IU supplemental vitamin D intake daily.ResultsThe mean patient age was 43.8 ± 10.7 years, and the mean preoperative body mass index was 51.8 ± 9.8 kg/m². Of the 95 patients with baseline and 12-month 25(OH)D levels, 89% were women. The mean preoperative 25(OH)D level was 49.7 ± 26.5 nmol/L; 34% had suboptimal 25(OH)D levels and 54% had deficient levels before surgery. Twelve months after surgery, those receiving 50,000 IU weekly (n = 40) had a mean 25(OH)D level of 69.2 ± 22.2 nmol/L; 63% had suboptimal and 8% deficient levels. Those taking 710 IU daily (n = 55) had a mean 25(OH)D level of 85.5 ± 33.0 nmol/L; 44% had suboptimal and 6% deficient levels.ConclusionVitamin D deficiency is prevalent in RYGB patients before surgery. The vitamin D status improved markedly after RYGB surgery with either 710 IU vitamin D daily or 50,000 IU weekly. Current supplementation practices do not appear to optimize the serum 25(OH)D levels and need to be more closely examined.     

Safety of bariatric surgery in patients older than 65 years

BackgroundThe increase in life expectancy along with the obesity epidemic has led to an increase in the number of older patients undergoing bariatric surgery. There is conflicting evidence regarding the safety of performing bariatric procedures on older patients.ObjectiveThe purpose of this study was to compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for older patients (>65 yr).SettingNationwide analysis of accredited centers.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2017 database was used to identify nonrevisional laparoscopic RYGB and SG procedures. Comparisons were made based on patient age. Clinical outcomes included postoperative events and mortality.ResultsThere was a total 13,422 and 5395 matched pairs for SG and RYGB in comparing patients aged 18 years to those aged 65 and >65 years, respectively, and 5395 matched RYGB and SG procedures performed in patients >65 years. The complication rate was higher in older patients undergoing RYGB compared with SG (risk difference = 2.39%, 95% confidence interval: 1.57%–3.21%, P < .0001). When comparing older to younger patients, the older group had a higher complication rate for SG but not for RYGB (SG: risk difference = 1.01%, 95% confidence interval: .59%–1.43%, P < .0001, RYGB: risk difference = .59%, 95% confidence interval: ?.29% to 1.47%, P = .2003).ConclusionsOverall complication rates of bariatric surgery are low in patients >65 years. SG appears to have a favorable safety profile in this patient population compared with RYGB. The overall complication rate for RYGB is not significantly different between the older and younger groups.     

Long-term micronutrient surveillance after gastric bypass surgery in an integrated healthcare system

BackgroundThe number of patients undergoing bariatric surgery in the United States is growing. While gastric bypass surgery is an important tool in the management of obesity, it requires lifelong metabolic monitoring and medical management. Data describing compliance with recommended laboratory follow-up are limited, particularly in long-term and primary care settings.ObjectivesTo evaluate postoperative follow-up laboratory testing for patients after laparoscopic Roux-en-Y gastric bypass (LRYGB).SettingAcademic-affiliated community hospital.MethodsA review of patients who underwent LRYGB from 2001 to 2016 was performed. The location of patients’ follow-up care and compliance with recommended laboratory testing were determined from patient records. Compliance was analyzed at 1-year intervals.ResultsOne thousand four hundred ninety patients underwent LRYGB. Five years after their surgical date, patients were more likely to follow-up with primary care than bariatric surgery clinic (369 versus 159 patients). At 5 years postoperative, 82%, 85%, and 68% of patients that followed-up with primary care did not have a vitamin D, parathyroid hormone, or vitamin B12 test, respectively. Patients that followed-up in bariatric clinic were slightly more likely to have recommended labs completed. At 5 years postprocedure, 81%, 55%, and 48% did not have a vitamin D, parathyroid hormone, or vitamin B12 test, respectively.ConclusionMost patients do not have the recommended laboratory testing completed, regardless of where their follow-up care occurred. This study identified a gap in long-term postoperative care for patients who have undergone gastric bypass surgery. Further studies will be necessary to develop interventions aimed at improving adherence to recommended monitoring after LRYGB.     

Incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting

Vitamin deficiency after gastric bypass surgery is a known complication. The purpose of this study was to measure the incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting. All patients who underwent laparoscopic Roux-en-Y gastric bypass from January 2002 to December 2004 and completed a 1- and 2-year follow-up after surgery were selected. Of the total 493 patients, 318 (65%) had vitamin results at 1-year follow-up. Of the 366 eligible for the 2-year follow-up, 141 (39%) had vitamin results. Patients were further grouped based on gender, race, and Roux limb length, and incidence of vitamin deficiencies were studied. The incidence of vitamin A (retinol) deficiency was 11 per cent, vitamin C was 34.6 per cent, vitamin D25OH was 7 per cent, vitamin B1 was 18.3 per cent, vitamin B2 was 13.6 per cent, vitamin B6 was 17.6 per cent, and vitamin B12 was 3.6 per cent 12 months after surgery. There was no statistical difference in the incidence of vitamin deficiencies between 1 and 2 years. In univariate and multivariate logistic regression of 1- and 2-year follow up, black patients (vitamins A, D, and B1 for 1 year and B1 and B6 for 2 years) and women (vitamin C at 1 year) were more likely to have vitamin deficiencies. Vitamin deficiencies after laparoscopic Roux-en-Y gastric bypass are more common and involve more vitamins, even those that are water soluble, than previously appreciated. Black patients tend to have more deficiencies than other groups. The bariatric surgeon should be committed to the long-term follow-up and care of these patients. Further prospective and randomized studies are necessary to provide appropriate guidelines for supplementation.     

Nutrient deficiencies in patients with obesity considering bariatric surgery: A cross-sectional study

BackgroundNutritional deficiencies are common after bariatric surgery, but few studies have examined them preoperatively. The objective of this study was to evaluate several vitamins, nutrients, and nutritional markers and their determinants in patients with obesity considering bariatric surgery.MethodsPreoperative values of fasting plasma glucose, insulin, lipid profile, 25-hydroxyvitamin D (25(OH)D), parathyroid hormone, thyroid-stimulating hormone, calcium, phosphate, albumin, magnesium, total proteins, liver function tests, iron, ferritin, folate, vitamin A, vitamin B12, selenium, and zinc were evaluated in 267 Caucasian outpatients (74.2% women, aged 40.5±12.6 years) who were considering bariatric surgery. The determinants of nutrient variability were analyzed by linear regression for nutrients with a prevalence of deficiency>10%, i.e., serum 25(OH)D, iron, phosphate, magnesium, and vitamin A.ResultsPrevalence of inadequate concentrations was high for 25(OH)D (67.9% with values≤20 ng/mL), magnesium (35.4%), phosphate (21.6%), iron (18.8%), and vitamin A (16.9%). Multiple deficiencies were common; 28.5%, 12.1%, and 6.3% of patients had 2, 3, and 4 deficiencies, respectively. In multivariate analyses, metabolic characteristics had an important impact on deficiencies, with lower values of 25(OH)D and vitamin A with increasing body mass index, lower values of 25(OH)D and magnesium with increasing fasting plasma glucose, and a positive correlation between vitamin A and triglycerides. Elevated TSH was associated with low iron concentrations.ConclusionAt all ages, micronutrient deficiencies were common, with high prevalence of concentration inadequacies for 25(OH)D, magnesium, phosphate, iron, and vitamin A. High body mass index and high fasting plasma glucose increased the risk of deficiencies, particularly for 25(OH)D. Preoperative screening and correction of deficiencies should be advised.     

Surgeon factors are strongly correlated with who receives a sleeve gastrectomy versus a Roux-en-Y gastric bypass

BackgroundSleeve gastrectomy (SG) has replaced Roux-en-Y gastric bypass (RYGB) as the most common bariatric operation. While SG constitutes ～70% of all bariatric volume, we hypothesize that the distribution of SG versus RYGB varies widely at the level of the surgeon and that surgeon rather than patient factors are the primary driver of the procedure performed.ObjectivesTo determine the distribution of bariatric procedures performed at the surgeon level.SettingPopulation-level analysis using the Statewide Planning and Research Cooperative System (SPARCS) for New York State (2004–2014).MethodsIdentified surgeons performing SG and RYGB using billing codes. Logistic regression performed to determine the impact of surgeon, patient, and hospital factors on receiving a RYGB.ResultsOf the 142 surgeons who perform >5 bariatric operations per year, 32 (22.5%) performed a SG in ≥95% of their bariatric cases in the year 2014. In logistic regression, diabetes (odds ratio [OR] 1.45; P < .001) and gastroesophageal reflux disease (OR 1.36; P < .001) were associated with receiving a RYGB. However, the most correlated factor was whether the surgeon had a RYGB case volume >66^th percentile in the preceding year (OR 33.8; P < .001). In pseudo-R² analysis, 83% of the power of the regression could be explained by surgeon factors alone.ConclusionsWhile the percentage of SG in this cohort closely matches the national average, there is wide variation at the surgeon level with a significant proportion predominantly performing a single procedure. Surgeon factors are more strongly correlated with procedure selection compared to patient or hospital factors.     

Resolution of diabetes,gastrointestinal symptoms,and self-reported dietary intake after gastric bypass versus sleeve gastrectomy: a randomized study

BackgroundThere is a lack of randomized studies examining diabetes remission and dietary intake between patients undergoing Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG).ObjectiveTo examine longitudinal differences in diabetes resolution, dietary intake, and gastrointestinal (GI) symptoms in patients with obesity and type 2 diabetes (T2D) randomized to either RYGB or SG and according to remission of T2D.SettingFour hospitals in Sweden, 2 of which are university hospitals.MethodsDietary intake and GI symptoms were calculated from questionnaires and morphometric differences between surgical methods and T2D remission were compared using the Student t test, effect size (ES) for parametric parameters, and Mann-Whitney U test for nonparametric parameters.ResultsFive years after RYGB or SG there was no significant difference in the rate of remission of T2D between RYGB and SG (43% versus 20%, P = .176). RYGB (n = 19) patients had greater weight loss than SG patients (n = 14) (26.4 [9.5] versus 13.1 [9.6] kg, P < .001), despite reporting higher daily caloric intake (Δ 669 kcal, P = .059, ES .67) and food weight (Δ 1029 g/d, P = .003, ES 1.11). RYGB patients, compared with SG patients, also ate 1 more fruit per day (P = .023). Pooled data showed no differences between patients with and without T2D remission regarding weight loss, but those in remission drank more nonalcoholic drinks and milk.ConclusionsFive years postoperatively, patients randomized to RYGB reported considerably higher food intake compared with SG despite lower body weight. The reason and importance of the higher food intake after RYGB compared with SG needs to be further studied.     

Folate Status Following Gastric Bypass Surgery (The Great Folate Mystery)

Several previous investigators have reported an incidence of folic acid deficiency following gastric bypass surgery of up to 38%. Failure to encounter any folic acid deficiencies in our postoperative patients led us to discontinue follow-up folate studies for several years. However, due to repeated references to this deficiency in the literature, we re-instituted folate studies as part of the routine follow-up of our patients. Preoperative serum folate levels were obtained in 1,067 patients and pre-existing deficiencies found in 63, an incidence of 6%. Of the 588 folate levels determined 1 to 10 years following gastric bypass, only six were less than 3.0 ng/dl, an incidence of 1%. All patients were instructed preoperatively and postoperatively to take multivitamin/mineral supplements after gastric restrictive surgery, and were continually educated on their importance. In a bariatric surgery practice in which patients are instructed, reminded, encouraged and even badgered into taking postoperative vitamin/mineral supplements, folate deficiency should be a rarity. In such circumstances, folate deficiency may well act as a sensitive marker of non-compliance.