Nutritional and metabolic complications of bariatric surgery

Bariatric surgery is an effective treatment for patients with clinically severe obesity. In addition to significant weight loss, it is also associated with improvements in comorbidities. Unfortunately, bariatric surgery also has the potential to cause a variety of nutritional and metabolic complications. These complications are mostly due to the extensive surgically induced anatomical changes incurred by the patient's gastrointestinal tract, particularly with roux-en-Y gastric bypass and biliopancreatic diversion. Complications associated with vertical banded gastroplasty are mostly due to decreased intake amounts of specific nutrients. Macronutrient deficiencies can include severe protein-calorie malnutrition and fat malabsorption. The most common micronutrient deficiencies are of vitamin B12, iron, calcium, and vitamin D. Other micronutrient deficiencies that can lead to serious complications include thiamine, folate, and the fat-soluble vitamins. Counseling, monitoring, and nutrient and mineral supplementation are essential for the treatment and prevention of nutritional and metabolic complications after bariatric surgery.     

Post‐operative behavioural management in bariatric surgery: a systematic review and meta‐analysis of randomized controlled trials

Recent research has provided evidence that bariatric surgery maximizes long‐term weight loss in patients with severe obesity. However, a substantial number of patients experience poor weight loss outcome and weight regain over time. Post‐operative behavioural management may facilitate long‐term weight control in bariatric surgery population. The objective of this systematic review and meta‐analysis was to determine the effects of post‐operative behavioural management on weight loss following bariatric surgery. Eligible articles were systematically searched in electronic databases. Among the 414 citations, five randomized controlled trials, two prospective and eight retrospective cohort trials analysing behavioural lifestyle interventions and support groups fulfilled the inclusion criteria. The main finding is that behavioural management had a positive effect on weight loss following surgery. In 13 studies, patients receiving behavioural management had greater weight loss than patients receiving usual care or no treatment. A meta‐analysis of five randomized controlled trials suggests greater weight loss in patients with behavioural lifestyle interventions compared with control groups. Post‐operative behavioural management has the potential to facilitate optimal weight loss following bariatric surgery, but conclusions were limited by the small and heterogeneous samples of studies. A more rigorous empirical evaluation on its clinical significance is warranted to improve effectiveness of bariatric surgery.     

Nutritional deficiencies associated with bariatric surgery

Morbidly obese patients often have nutritional deficiencies, particularly in fat-soluble vitamins, folic acid and zinc. After bariatric surgery, these deficiencies may increase and others can appear, especially because of the limitation of food intake in gastric reduction surgery and of malabsorption in by-pass procedures. The latter result in more important weight loss but also increase the risk of more severe deficiencies. The protein deficiency associated with a decrease in the fat-free mass has been described in both procedures. It can sometimes require an enteral or parenteral support. Anemia can be secondary to iron deficiency, folic acid deficiency and even to vitamin B12 deficiency. Neurological disorders such as Gayet-Wernicke encephalopathy due to thiamine deficiency, or peripheral neuropathies may also be observed. Malabsorption of fat-soluble vitamins and other nutrients, especially if diagnosed after by-pass surgery, rarely cause clinical symptoms. However, some complications have been reported such as bone demineralization due to vitamin D deficiency, hair loss secondary to zinc deficiency or hemeralopia from vitamin A deficiency. A careful nutritional follow-up should be performed during pregnancy after obesity surgery, because possible deficiencies can affect the health of both the mother and child. In conclusion, increased awareness of the risk of deficiency and the systematic dosage of micronutrients are needed in the pre- and postoperative period in obese patients undergoing bariatric surgery. The case by case correction of these deficiencies is mandatory, and their systematic prevention should be evaluated.     

减重代谢术前患者肥胖相关病耻感的质性研究

目的深入了解减重代谢手术患者术前肥胖相关的病耻感体验,以期为提高患者手术信心和术后自我管理质量提供参考。 方法选择北京市某三级甲等医院9名拟行减重代谢手术的患者为研究对象,采用半结构式访谈法,运用主题分析法对访谈资料进行分析、归纳及提炼主题。 结果减重代谢手术患者的术前病耻感体验归结为4个类属。类属一：病耻感体验,即自卑感、孤独、自责和被歧视的经历;类属二：病耻感来源,一方面来自自身,另一方面来自他人,如亲友和同事、医护人员、公众;类属三：病耻感的应对,包括盲目采取各种方法,减少社会活动、逃避、持有积极减重的态度;类属四：对手术改善肥胖的态度,包括经他人推荐相信减重效果,或对手术了解较少抱着尝试心态。 结论减重代谢手术的患者术前存在病耻感体验,医护人员应为其提供相应的心理支持,指导其采取正确的应对方式;同时应做好社会健康教育,加强公众对肥胖与代谢疾病的认识,正确认识减重代谢手术在治疗肥胖与代谢疾病中的效果。     

Bariatric Surgery and Bone Loss: Do We Need to Be Concerned?

Despite significant improvement in weight and comorbid conditions, there is growing evidence that bariatric surgery may exert a negative effect on the skeleton. This review has focused on the impact of bariatric surgery on bone health, with the concern that bariatric surgery may increase skeletal fragility and fracture risk by accelerating bone loss. We have highlighted studies evaluating changes in bone metabolism after three commonly performed bariatric procedures including laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass surgery and increasingly popular sleeve gastrectomy. This review has also discussed some of the technical issues faced in measuring bone in obese populations and during dynamic weight loss. There is limited evidence regarding potential mechanisms for the reported observations of increased bone turnover and/or bone loss after bariatric surgery. We have reviewed the evidence surrounding potential factors affecting bone health in bariatric patients such as rapid weight loss per se, nutritional deficiencies, effects of fat-derived adipokines and gut-derived appetite-regulatory hormones. Future prospective long-term cohort studies are needed to define how to quantify bone loss in individuals with obesity, particularly following massive weight loss, and for how long the bone changes continue. These studies will help clarify any negative clinical consequences of these changes, including future fracture risk in this unique group of patients.     

Review of multimodal therapies for obesity treatment: Including dietary,counseling strategies,and pharmacologic interventions

There have been several recent advances in the field of obesity medicine in the areas of structured behavioral therapies, medically supervised diet programs, pharmacotherapy, and new interactive technologies. Patients with obesity now have several options for treatment beyond the standard lifestyle modifications of reducing calories and increasing exercise. Although bariatric surgery is the gold standard of treatment for patients with severe obesity, the problem of recidivism despite surgical intervention has lead obesity medicine specialists to develop multiple treatment modalities. The addition of tailored dietary intervention, targeted behavioral therapies, and the use of Food and Drug Administration approved antiobesity pharmacotherapy can allow patients to augment weight loss or to treat weight regain after bariatric surgery and endoscopic bariatric procedures. New technologies and web-based weight loss applications can allow patients to self-monitor in between office visits.     

Performance standards in bariatric surgery

A bariatric surgeon is a fully trained general or gastrointestinal surgeon who has demonstrated specialized knowledge in the management of patients who suffer from morbid obesity and its complications. In addition to appropriate formal surgical training, preceptorships with experienced surgeons, preferably members of international bariatric societies, are highly desirable. Active participation in meetings of these societies, continuing medical education and knowledge of the current literature are necessary to maintain the required skills to treat these complex patients. Bariatric surgery should be performed at institutions that provide the necessary equipment, facilities and support systems for this particular population. When analysing outcomes of obesity surgery, long-term weight loss reports should include the number of patients followed and the time period of follow-up. Complications and re-operations should be presented, as well as modifications of techniques when various operations are compared. Weight loss should not be the only criterion used to define success or failure. Objective assessment of improvement in medical conditions related to obesity, and reliable measurements of quality of life after surgery should also be included in the final outcome analysis.     

Obesity: changing the face of geriatric care

Statistics suggest that more and more older Americans are carrying extra weight-an estimated 40% of individuals between the ages of 60 and 69 have a body mass index >30 and 30% of persons between ages of 70 and 79 years are obese. Obesity, coupled with the challenges of aging, leads to an unfortunate burden of chronic disease, functional decline, poor quality of life, and an increased risk of being homebound. Physical assessment of the elderly obese patient should include measurement of height, weight (to determine body mass index) and waist circumference (to address central obesity) and consideration of vascular, skin, and mobility issues. Weight management strategies such as diet and hydration should balance nutritional requirements with weight loss; particular attention to protein needs in chair- and bedbound patients is necessary. Additional approaches such as exercise, bariatric weight loss surgery, and weight loss medication should be considered on an individual basis related to their inherent risks in this population. Weight loss/management options framed from an interdisciplinary perspective can improve quality of life for these patients and their caregivers. Research specific to obesity in this age group is warranted.     

Nutritional deficiencies after bariatric surgery

Lifestyle intervention programmes often produce insufficient weight loss and poor weight loss maintenance. As a result, an increasing number of patients with obesity and related comorbidities undergo bariatric surgery, which includes approaches such as the adjustable gastric band or the 'divided' Roux-en-Y gastric bypass (RYGB). This Review summarizes the current knowledge on nutrient deficiencies that can develop after bariatric surgery and highlights follow-up and treatment options for bariatric surgery patients who develop a micronutrient deficiency. The major macronutrient deficiency after bariatric surgery is protein malnutrition. Deficiencies in micronutrients, which include trace elements, essential minerals, and water-soluble and fat-soluble vitamins, are common before bariatric surgery and often persist postoperatively, despite universal recommendations on multivitamin and mineral supplements. Other disorders, including small intestinal bacterial overgrowth, can promote micronutrient deficiencies, especially in patients with diabetes mellitus. Recognition of the clinical presentations of micronutrient deficiencies is important, both to enable early intervention and to minimize long-term adverse effects. A major clinical concern is the relationship between vitamin D deficiency and the development of metabolic bone diseases, such as osteoporosis or osteomalacia; metabolic bone diseases may explain the increased risk of hip fracture in patients after RYGB. Further studies are required to determine the optimal levels of nutrient supplementation and whether postoperative laboratory monitoring effectively detects nutrient deficiencies. In the absence of such data, clinicians should inquire about and treat symptoms that suggest nutrient deficiencies.     

Bariatric surgery,bone loss,obesity and possible mechanisms

Bariatric surgery remains the most effective treatment for severely obese patients. However, the potential long‐term effects of bariatric surgical procedures on health, including bone health, are only partially understood. The goal of this review was to present data on the impact of bariatric surgery on bone metabolism and to analyse possible reasons for the loss of bone mass that frequently occurs after bariatric surgery. Such factors include nutritional deficiencies, rapid weight loss per se, effects of fat‐derived adipokines and gut‐derived appetite‐regulatory hormones. However, the relative roles of these factors in skeletal regulation and the mechanisms by which they work are not yet fully defined. Our review was focussed on the complex relationship between body weight, fat mass and bone mass, as well as peripheral and central mediators potentially involved in the dual regulation of both energy and bone homeostasis. We also review the data on the inverse relationship between central obesity, bone marrow fat and osteoporosis. As the number of bariatric operations increases, it is imperative to recognize mechanisms responsible for bariatric surgery‐induced bone loss, with careful monitoring of bone health including long‐term fracture incidence in patients undergoing these procedures.     

Gastrointestinal management of the bariatric surgery patient

Beyond the acute perioperative period, the most common complications of weight loss surgery relate to GI tract structure, function, and mucosal integrity. As a result, gastroenterologists have a major role in the management of patients undergoing these procedures. Optimal care of the bariatric surgical patient requires a multi-disciplinary team to address the medical complications, nutritional management, and psychological and behavioral implications of obesity. Because of their important role in preoperative assessment and postoperative management, gastroenterologists should be integral members of these multi-disciplinary teams. A model of close collaboration among gastroenterologists, bariatric surgeons, and other members of the team will help optimize care of the bariatric patient and set the stage for effective development, testing, and use of the many new laparoscopic, endoscopic, intraluminal, and pharmacological GI-based therapies for obesity that are under development.     

Reproductive implications of bariatric surgery: Pre- and postoperative considerations for extremely obese women of childbearing age

Extreme obesity remains a frustrating and formidable disease, with most sufferers requiring surgical intervention in order to achieve long-term, sustained weight loss. Most bariatric procedures today are performed on women, many of whom are of reproductive age; yet minimal evidence exists to guide clinicians in the care of such women before, during, and after pregnancy. This review outlines the fundamental nutritional and surgical alterations of the most commonly performed bariatric procedures with the aim to elucidate a physiologically sound approach to counseling and management of extremely obese women of childbearing age who are either contemplating or have already undergone bariatric surgery. Preconception, pregnancy, and lactation guidelines are offered based on available evidence. Outstanding questions are highlighted for further investigation.     

Physiologic, psychologic, and metabolic consequences of bariatric surgery

The successful management of obesity is essential to treat effectively its associated comorbidities such as systemic hypertension, diabetes, dyslipidemias, and obstructive sleep apnea. Current weight loss recommendations include reduced caloric intake, exercise, and pharmacologic treatments that often result in a minimal weight loss that is rarely maintained. Conversely, surgical procedures such as Roux-en-Y gastric bypass, adjustable gastric banding, vertical banded gastroplasty, or biliopancreatic diversion result in a more successful and maintained long-term weight loss. Bariatric surgery-induced weight loss is associated with improvements in cardiovascular risk factors such as systemic hypertension, hypertriglyceridemia, and low levels of high-density lipoprotein cholesterol. However, hypercholesterolemia does not appear to benefit from surgically induced weight loss. Patients also note improvement in associated respiratory comorbidities such as asthma and obstructive sleep apnea as well as diabetes. Although the risks of bariatric surgery are numerous, including gastrointestinal and respiratory complications and associated nutritional deficiencies, in an appropriately selected surgical candidate, as detailed by National Institutes of Health guidelines, the surgical treatment of obesity warrants serious consideration.     

Nutritional follow‐up of patients after obesity surgery: best practice

Obesity surgery is an appropriate treatment option for patients with severe and complex obesity and helps in the improvement of comorbidities. In the first 2 years following surgery, follow‐up is provided by the obesity surgery centre. Ongoing care is then usually returned to the general practitioner. Patients need access to ongoing support and monitoring otherwise may be at risk of developing nutritional deficiencies such as anaemia or protein malnutrition. The British Obesity and Metabolic Surgery Society have developed guidelines on nutritional monitoring and nutritional supplements to support both bariatric centres and general practitioners. The Royal College of General Practitioners and BOMSS have worked collaboratively to develop Ten Top Tips for the management of obesity surgery patients to aid with the long‐term management in primary care. Women, planning to get pregnant, need access to preconception advice and additional monitoring during pregnancy. It is essential that long‐term data are collected and inputted into the National Bariatric Surgery Register. Obesity surgery improves comorbidities; however, patients must have access to long‐term nutritional monitoring.     

Lifestyle Management for Enhancing Outcomes after Bariatric Surgery

Bariatric surgery has been safe and effective for treatment of severe obesity and comorbidities like type 2 diabetes mellitus (T2D). Nonetheless, weight loss and health outcomes vary considerably across individuals. Although the factors associated with outcomes are not fully understood, postoperative weight loss following any type of bariatric surgery is largely dependent on the extent to which patients can make and sustain changes in eating and activity. Therefore, lifestyle management including diet, exercise, and behavior modification is critical to helping patients achieve long-term weight loss. Pharmacotherapy and reoperation may also play a role after bariatric surgery. In this article, we highlight recent research findings in all of these areas to provide suggestions for how to enhance outcomes following bariatric surgery. Research on the mechanisms for weight loss and improvements in T2D following the different surgical procedures is needed to support the development of more personalized approaches to the multidisciplinary management of severe obesity.     

Role of endoscopy in the bariatric surgery of patients

Obesity is an increasingly serious health problem in nearly all Western countries.It represents an important risk factor for several gastrointestinal diseases,such as gastroesophageal reflux disease,erosive esophagitis,hiatal hernia,Barrett’s esophagus,esophageal adenocarcinoma,Helicobacter pylori infection,colorectal polyps and cancer,non-alcoholic fatty liver disease,cirrhosis,and hepatocellular carcinoma.Surgery is the most effective treatment to date,resulting in sustainable and significant weight loss,along with the resolution of metabolic comorbidities in up to 80%of cases.Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery.There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings,such as large hiatal hernia or Barrett’s esophagus,are detected preoperatively.The value of a routine endoscopy before bariatric surgery in asymptomatic patients(screening esophagogastroduodenoscopy)remains controversial.The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms,the management of complications,and the evaluation of weight loss failure.It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting.The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.     

Training in bariatric endoscopy

Bariatric endoscopy has emerged as an alternative treatment modality for obesity and its related comorbidities. The field includes a wide range of procedures from endoscopic treatment for complications of bariatric surgery to performing primary endoscopic procedures for weight loss. Additionally, knowledge of adjunctive lifestyle therapy and pharmacotherapy are also critical to ensuring successful outcomes. This article reviews specific goals, resources, and specific steps for acquisition of specific cognitive and technical skills in bariatric endoscopic procedures.     

Bariatric surgery: a review of procedures and outcomes

The prevalence of obesity has increased in recent decades, and obesity is now one of the leading public health concerns on a worldwide scale. There is accumulating agreement that bariatric surgery is currently the most efficacious and enduring treatment for clinically severe obesity, and as a result, the number of bariatric surgery procedures performed has risen dramatically in recent years. This review will summarize historic and contemporary bariatric surgical techniques, including gastric bypass (open and laparoscopic), laparoscopic adjustable gastric banding, and biliopancreatic diversion (with or without duodenal switch). Data are presented on bariatric surgery outcomes, focusing on weight loss and obesity-related comorbidities. We also review possible complications from surgery. Bariatric surgery patients undergo many dramatic lifestyle changes, and comprehensive presurgical screening conducted by a multidisciplinary team is important to prepare patients for the numerous changes necessary for successful outcome. In addition, comprehensive presurgical screening can aid the treatment team in identifying patients who would benefit from additional services prior to or following surgery. Further research focused on presurgical variables that predict outcome-especially the longer term outcome-of bariatric surgery is needed. At present, approximately 1% of eligible individuals with morbid obesity receive bariatric surgery. In addition, there appears to be inequity in access to weight loss surgery. Given the accumulating evidence that bariatric surgery is efficacious in producing significant and durable weight loss, improving obesity-related comorbidities, and extending survival, the U.S. healthcare system should examine ways to improve access to this treatment for obesity.     

Nuevas tecnologías y avances en terapias para la pérdida de peso

Bariatric surgery is the most effective treatment for obesity and its comorbidities but there are barriers that prevent its general acceptance. The growing obesity epidemic has resulted in the need for the creation of new, less invasive treatments, with a wide margin of safety and effectiveness for conditioning weight loss, at least greater than that resulting from treatment based on diet and exercise. Emerging therapies include devices that are endoscopically placed and removed, classified as: space-occupying devices, restrictive or anatomic-remodeling procedures, endoluminal bypass, and duodenal mucosal resurfacing. Percutaneous techniques and less invasive surgeries are also included.In general, results have shown improvement in glucose metabolism in diabetic patients. With respect to weight loss, results do not surpass those of bariatric surgery, but are better than results with conservative treatment (diet and exercise) and have a low rate of adverse events. Clinical use of a new technique should be carried out within a multidisciplinary management program that includes nutritional, psychologic, physical activity, and medical support. It must be understood that novel therapies are not being created to substitute bariatric surgery, but rather to increase treatment options in the general population, with greater reach and impact. The aim of the present study was to provide an up-to-date literature review on emerging technologies for the treatment of obesity.     

MedioLabs随访系统在减重代谢手术患者全程管理中的应用

目的 探讨MedioLabs随访系统在减重代谢手术患者全程管理中的应用效果.方法 选取在我院接受减重代谢手术的患者资料,根据历史对照研究,将系统使用前2018年6月至2019年4月150例患者作为对照组,系统使用后2019年4月至2019年9月150例患者作为研究组.对照组采用个案管理师一对一全程管理模式,研究组采用随...