Obésité et carences préopératoires

It is a common belief that nutritional deficiencies are rare in the Western world due to a wide variety of food supply. However, obese people usually consume dense-energy food but of poor nutritional value that lacks proteins, vitamins, minerals and fiber; consequently, a high prevalence of micronutrient deficiencies in obese subjects has been reported. Moreover, bariatric surgery has been proven the most effective treatment of morbid obesity, but micronutrient deficiency following bariatric surgery is a major concern, worsening pre-operative nutritional deficiencies. In this article, we reviewed the litterature and highlighted the prevalence of nutritional deficiencies in the morbidly obese population prior to bariatric surgery, clinical consequences of these deficiencies and practical recommendations for these subjects.     

Obesity as an Emerging Risk Factor for Iron Deficiency

Iron homeostasis is affected by obesity and obesity-related insulin resistance in a many-facetted fashion. On one hand, iron deficiency and anemia are frequent findings in subjects with progressed stages of obesity. This phenomenon has been well studied in obese adolescents, women and subjects undergoing bariatric surgery. On the other hand, hyperferritinemia with normal or mildly elevated transferrin saturation is observed in approximately one-third of patients with metabolic syndrome (MetS) or nonalcoholic fatty liver disease (NAFLD). This constellation has been named the “dysmetabolic iron overload syndrome (DIOS)”. Both elevated body iron stores and iron deficiency are detrimental to health and to the course of obesity-related conditions. Iron deficiency and anemia may impair mitochondrial and cellular energy homeostasis and further increase inactivity and fatigue of obese subjects. Obesity-associated inflammation is tightly linked to iron deficiency and involves impaired duodenal iron absorption associated with low expression of duodenal ferroportin (FPN) along with elevated hepcidin concentrations. This review summarizes the current understanding of the dysregulation of iron homeostasis in obesity.     

Iron Deficiency and Bariatric Surgery

It is estimated that the prevalence of anaemia in patients scheduled for bariatric surgery is higher than in the general population and the prevalence of iron deficiencies (with or without anaemia) may be higher as well. After surgery, iron deficiencies and anaemia may occur in a higher percentage of patients, mainly as a consequence of nutrient deficiencies. In addition, perioperative anaemia has been related with increased postoperative morbidity and mortality and poorer quality of life after bariatric surgery. The treatment of perioperative anaemia and nutrient deficiencies has been shown to improve patients’ outcomes and quality of life. All patients should undergo an appropriate nutritional evaluation, including selective micronutrient measurements (e.g., iron), before any bariatric surgical procedure. In comparison with purely restrictive procedures, more extensive perioperative nutritional evaluations are required for malabsorptive procedures due to their nutritional consequences. The aim of this study was to review the current knowledge of nutritional deficits in obese patients and those that commonly appear after bariatric surgery, specifically iron deficiencies and their consequences. As a result, some recommendations for screening and supplementation are presented.     

The impact of bariatric surgery on nonalcoholic fatty liver disease

PURPOSE OF REVIEW: To analyze the effects of bariatric surgery on nonalcoholic fatty liver disease by reviewing the most important and recent studies. RECENT FINDINGS: The prevalence of obesity has increased dramatically over the last decades. Comorbidities related to obesity, such as nonalcoholic fatty liver disease are also increasing. Nonalcoholic fatty liver disease is a progressive disease with potential evolution to liver cirrhosis and hepatocellular carcinoma. Overweight patients who have nonalcoholic fatty liver disease should be considered for a weight loss program; however, long-term result with dietary interventions and drug therapy has been disappointing. Bariatric surgery is effective in promoting long-term weight loss in morbidly obese patients with control of comorbidities, especially those associated with the metabolic syndrome. On the basis of the early experience with extensive intestinal bypass, it was believed that rapid weight loss could cause liver damage. In contrast, recent prospective and retrospective observational studies and case series have demonstrated that bariatric surgery is well tolerated and is associated with nonalcoholic fatty liver disease regression in a significant number of patients. SUMMARY: There is good level of evidence that bariatric surgery is associated with nonalcoholic fatty liver disease regression in morbidly obese patients.     

Prise en charge nutritionnelle après la chirurgie bariatrique

The prevalence of obesity has been steadily increasing worldwide. In this context, we observe an increase in obesity surgery (or bariatric surgery). This type of surgery leads to complications related to the intervention in an obese patient, but also specific nutritional complications. The three major types of bariatric surgery are as follows: restrictive procedures; restrictive malabsorptive procedures and both. The metabolic changes associated with obesity can be further exacerbated by illness. Main aims of nutritionnal assistance are limiting the process of protein malnutrition and hypercatabolism. This surgery has the feature to apply to obese patients with a perioperative risk, to initiate severe metabolic changes and induce deficiencies in vitamins and trace elements. The nutritional management is a challenge for multidisciplinary teams responsible for these patients.     

Endovascular Bariatric Surgery as Novel Minimally Invasive Technique for Weight Management in the Morbidly Obese: Review of the Literature

Nowadays, obesity represents one of the most unresolved global pandemics, posing a critical health issue in developed countries. According to the World Health Organization, its prevalence has tripled since 1975, reaching a prevalence of 13% of the world population in 2016. Indeed, as obesity increases worldwide, novel strategies to fight this condition are of the utmost importance to reduce obese-related morbidity and overall mortality related to its complications. Early experimental and initial clinical data have suggested that endovascular bariatric surgery (EBS) may be a promising technique to reduce weight and hormonal imbalance in the obese population. Compared to open bariatric surgery and minimally invasive surgery (MIS), EBS is much less invasive, well tolerated, with a shorter recovery time, and is probably cost-saving. However, there are still several technical aspects to investigate before EBS can be routinely offered to all obese patients. Further prospective studies and eventually a randomized trial comparing open bariatric surgery vs. EBS are needed, powered for clinically relevant outcomes, and with adequate follow-up. Yet, EBS may already appear as an appealing alternative treatment for weight management and cardiovascular prevention in morbidly obese patients at high surgical risk.     

Prevalence of nutrient deficiencies in bariatric patients

ObjectiveThe aims of this study were to determine the prevalence of nutrient deficiencies in patients who present for bariatric surgery, assess nutritional status after surgery, and compare these with preoperative levels.MethodsA retrospective study was conducted to identify preoperative and 1-year postoperative nutrition deficiencies in patients undergoing bariatric surgery. The screening included serum ferritin, vitamin D, vitamin B₁₂, homocysteine, folate, red blood cell folate, and hemoglobin. Results were available for 232 patients preoperatively and 149 patients postoperatively. Two-tailed χ² tests and paired-sample t tests were used.ResultsPreoperatively, vitamin D deficiency was noted at 57%. The prevalence of abnormalities 1 year after roux-en-Y gastric bypass was higher compared with preoperative levels (P < .05). After surgery, anemia was detected in 17%, elevated homocysteine levels (women only) in 29%, low ferritin in 15%, low vitamin B₁₂ in 11%, and low RBC folate in 12%. Mean hemoglobin, ferritin, and RBC folate levels deteriorated significantly but remained well within normal ranges. The prevalence of vitamin D deficiencies decreased, but not significantly. In sleeve gastrectomy patients, mean ferritin levels decreased (P < .05), without any patient developing a deficiency.ConclusionVitamin D deficiency is common among morbidly obese patients seeking bariatric surgery. Because the prevalence of micronutrient deficiencies persists or worsens postoperatively, routine nutrition screening, recommendation of appropriate supplements, and monitoring adherence are imperative in this population.     

Practice guideline for the treatment of morbid obesity

The increasing prevalence of obesity and its related comorbidities represents an increasing burden for the Dutch health care and requires effective therapy. The primary treatment of obesity consists of lifestyle interventions directed at lifestyle change; in morbidly obese subjects only bariatric surgery is cost-effective in the long term, with respect to both weight loss and reduction in comorbidity. There is a new Dutch multidisciplinary practice guideline on the treatment of morbid obesity, in which the following aspects are covered: indications for surgery, pre-operative policy advice, considerations for the type of operation, and the short and long term follow-up after bariatric surgery. Patients between 18 and 65 years old are eligible for bariatric surgery if they have a BMI ≥ 40 kg/m2 or a BMI ≥ 35 kg/m2 in the presence of comorbidity. In adolescents under 18 bariatric surgery should only be performed in a research setting; in patients older than 65 years bariatric surgery can be performed exceptionally, preferably in a centre with large experience.     

Prevalence and trends in obesity among aged and disabled U.S. Medicare beneficiaries, 1997-2002

Given Medicare's recent national coverage decision on bariatric surgery, as well as potential coverage expansions for other obesity-related treatments, data on obesity in the Medicare population have great relevance. Using nationally representative data, we estimate that between 1997 and 2002, the prevalence of obesity in the Medicare population increased by 5.6 percentage points, or about 2.7 million beneficiaries. By 2002, 21.4 percent of aged beneficiaries and 39.3 percent of disabled beneficiaries were obese, compared with 16.4 percent and 32.5 percent, respectively, in 1997. Using 2002 data, we estimate that three million beneficiaries would be eligible for bariatric surgery coverage under current Medicare policy.     

Characteristics of patients undergoing bariatric surgery in Canada

OBJECTIVE: The increasing prevalence of obesity has led to an increased use of bariatric surgery in the treatment of severely obese individuals. The characteristics of patients undergoing bariatric procedures outside of clinical studies and on a national level have not previously been reported. RESEARCH METHODS AND PROCEDURES: Acute-care hospital discharge data from the Canadian Institute for Health Information were analyzed to determine the demographic and clinical features and in-hospital mortality rates of individuals undergoing bariatric surgery in Canada. Data from individuals undergoing surgery in fiscal year 2002/2003 were compared with data from 1993/1994. RESULTS: Over 1100 bariatric surgeries were performed in Canada in 2002/2003, with the vast majority being performed in middle-aged women. Ten percent of patients had hypertension or diabetes, and only 1% or fewer had dyslipidemia or cardiovascular or cerebrovascular disease. Compared with 1993/1994, patients undergoing surgery in 2002/2003 were older, more likely to have diabetes or hypertension, and had shorter hospital stays. In-hospital mortality rates were <1% in both years. DISCUSSION: In the last decade, there has been a small increase in the average age and the number of patients with concomitant cardiovascular risk factors who are undergoing bariatric procedures in Canada. However, the vast majority of surgeries are being performed in middle-aged women with little cardiovascular comorbidity, and this is likely contributing to very low in-hospital death rates. Such individuals likely represent a highly selected sample of severely obese patients within Canada.     

Risk of cholecystectomy in morbidly obese patients after bariatric surgery in Taiwan

PurposeThe anatomic rearrangement of the gastrointestinal tract after bariatric surgery may result in alterations in the bile acid pool and consequently, gallstone disease. We aimed to investigate whether patients undergoing bariatric surgery are at risk of developing gallbladder disease postoperatively.Patients and methodsWe conducted a population-based cohort study by using claims data from the Taiwan National Health Insurance Research Database. The study cohort comprised 4197 patients diagnosed with morbid obesity.ResultsAmong the morbidly obese patients, 2698 underwent bariatric surgery. Females and younger subjects were more prevalent in the surgical group than non-surgical group. Bariatric surgery reduced all obesity-related comorbidities. Cox proportional hazards regression was performed, which revealed increased risk of cholecystectomy after bariatric surgery among obese patients (adjusted hazard ratio, 3.43; p = 0.0165). After adjusting for sex and age, the incidence of cholecystectomy was increased in the females population (adjusted hazard ratio, 3.74; p < 0.05) and in 30–64 years-old-group (adjusted hazard ratio: 3.69, p < 0.05). The cumulative incidence rate of cholecystectomy showed an increased tendency in those undergoing bariatric surgery by log-rank test.ConclusionBased on the Taiwan database population-based cohort study, bariatric surgery increases the risk of cholecystectomy among morbidly obese patients, especially in the female population and patients aged 30–64 years.     

Bariatrische Chirurgie bei extremer Adipositas im Kindes- und Jugendalter

The management of childhood obesity is a clinical dilemma. Validated and evidence-based intervention programs are still missing for this age group, and pediatricians increasingly see children with morbid obesity and with obesity-related comorbidities. For those extremely obese patients who failed to respond to the classical therapeutic approaches, bariatric surgery is a therapeutic option. Although available data for bariatric surgery in childhood and adolescence is limited to date, significant postoperative reduction in BMI and an evident improvement of preoperatively existing metabolic and cardiovascular comorbidities and psychosocial well-being have been reported. The indication for bariatric surgery in adolescents follows strict criteria and should be proposed within an interdisciplinary team in specialized centers, including a clinical ethics committee. This review discusses the present guidelines for bariatric surgery in childhood and adolescence as well as available follow-up data for both adults and pediatric patients.     

Obesity in children: epidemic and opportunity

Obesity has become widespread among both adults and children in the United States, with the prevalence of overweight and obese children increasing from 15% in 1971 to more than 30% in 2000. This article discusses how to determine whether a child is overweight or obese, the causes of childhood obesity, as well as how physicians can treat this disease using family-based diet, exercise, and behavior modification programs; weight-loss medications; protein-sparing modified fasting; and bariatric surgery.     

Bariatric surgery in adolescents: an update

Bariatric surgery, although not a cure for obesity, can help selected extremely obese adolescents achieve significant weight loss and improvement of obesity-related comorbidities, in conjunction with continued dietary and behavioral interventions. This article summarizes the current guidelines for selection of adolescent candidates for bariatric surgery and discusses the types of bariatric procedures presently available for this age group. Data on the complications and outcomes of bariatric surgery in this special population are reviewed.     

Obesity research: Status quo and future outlooks

Obesity is a multifactorial disease showing a pandemic increase within the last decades in developing, and developed countries. It is associated with several severe comorbidities such as type Ⅱ diabetes, hypertension, sleep apnea, non-alcoholic steatosis hepatis and cancer. Due to the increasing number of overweight individuals worldwide, research in the field of obesity has become more vital than ever. Currently, great efforts are spend to understand this complex disease from a biological, psychological and sociological angle. Further insights of obesity research come from bariatric surgery that provides new information regarding hormonal changes during weight loss. The initiation of programs for obesity treatment, both interventional and pharmaceutical, are being pursued with the fullest intensity. Currently, bariatric surgery is the most effective therapy for weight loss and resolution of comorbidities in morbid obese patients. Reasons for weight loss and remission of comorbidities following Roux-en-Y-Gastric Bypass,Sleeve Gastrectomy, and other bariatric procedures are therefore under intense investigation. In this review, however, we will focus on obesity treatment, highlighting new insights and future trends of gut hormone research, the relation of obesity and cancer development via the obesity induced chronic state of inflammation, and new potential concepts of interventional and conservative obesity treatment.     

Bariatric surgeries in north Carolina, 1990 to 2001: a gender comparison

OBJECTIVE: The purpose of this research was to determine the number of bariatric procedures in obese men and women in a well-defined population and to examine gender differences among bariatric patients. RESEARCH METHODS AND PROCEDURES: Data on bariatric patients were taken from the North Carolina Hospital Discharge Database, which contains information on all nonfederal hospital discharges in North Carolina from 1990 to 2001. Using North Carolina Hospital Discharge Data, Census North Carolina resident estimates, and North Carolina obesity prevalence estimates, we constructed annual rates for bariatric procedures for the obese male and female population in North Carolina. RESULTS: Overall, 2197 bariatric procedures were performed between 1990 and 2001. The annual rate of bariatric procedures in obese women increased rapidly, particularly between 1998 and 2001, whereas the increase for men was considerably less than that for women. Controlling for age and year of procedure, the odds ratio for obese female North Carolina residents of having a bariatric procedure was 4.96 (95% confidence interval: 4.39, 5.59) and of having a Roux-en-Y procedure was 5.57 (95% confidence interval: 4.67, 6.64) compared with obese male North Carolina residents. Controlling for age, comorbidity burden, payment source, and year of procedure, obese male North Carolina residents had a significantly greater (22%) amount of inpatient days than obese female North Carolina residents. DISCUSSION: After controlling for population rates of obesity and year of procedure, women are more likely than men to undergo bariatric surgery, suggesting that gender-related factors may influence use. More research is needed to determine the causes for this large gender disparity.     

Costs and Outcomes of Increasing Access to Bariatric Surgery: Cohort Study and Cost-Effectiveness Analysis Using Electronic Health Records

Objectives

To estimate costs and outcomes of increasing access to bariatric surgery in obese adults and in population subgroups of age, sex, deprivation, comorbidity, and obesity category.

Hepcidin and Iron Deficiency in Women One Year after Sleeve Gastrectomy: A Prospective Cohort Study

Iron deficiency with or without anemia, needing continuous iron supplementation, is very common in obese patients, particularly those requiring bariatric surgery. The aim of this study was to address the impact of weight loss on the rescue of iron balance in patients who underwent sleeve gastrectomy (SG), a procedure that preserves the duodenum, the main site of iron absorption. The cohort included 88 obese women; sampling of blood and duodenal biopsies of 35 patients were performed before and one year after SG. An analysis of the 35 patients consisted in evaluating iron homeostasis including hepcidin, markers of erythroid iron deficiency (soluble transferrin receptor (sTfR) and erythrocyte protoporphyrin (PPIX)), expression of duodenal iron transporters (DMT1 and ferroportin) and inflammatory markers. After surgery, sTfR and PPIX were decreased. Serum hepcidin levels were increased despite the significant reduction in inflammation. DMT1 abundance was negatively correlated with higher level of serum hepcidin. Ferroportin abundance was not modified. This study shed a new light in effective iron recovery pathways after SG involving suppression of inflammation, improvement of iron absorption, iron supply and efficiency of erythropoiesis, and finally beneficial control of iron homeostasis by hepcidin. Thus, recommendations for iron supplementation of patients after SG should take into account these new parameters of iron status assessment.     

Periconceptional Folate Supplementation in Women after Bariatric Surgery—A Narrative Review

The prevalence of obesity is increasing globally, and along with it, there is a growing number of patients opting to undergo bariatric surgery to treat this condition. Whilst it has many advantages, bariatric surgery is known to induce micronutrient deficiency, with possible deleterious effects on overall health. This topic becomes even more relevant during pregnancy, where deficiencies can also affect the developing fetus, possibly being the cause of an increase in congenital anomalies. Most notably amongst these micronutrients is folate, or vitamin B9, which plays an essential role in development, gene expression and genomic stability. As insufficient levels of folate are associated with neural tube defects in the fetus, preventing and treating folate deficiencies during pregnancies after bariatric surgery is a relevant issue. Unfortunately, folate supplementation recommendations for bariatric patients who wish to become pregnant are not clear. In this narrative review, we discuss whether the recommendations for the general population are still valid for bariatric patients. Furthermore, we discuss the role of folate in the human body, folate status in both non-bariatric and bariatric patients, the various types of folate that are available for substitution and the risk associated with over-supplementation.     

Long-term complete remission of large hepatocellular adenoma after bariatric surgery

We report the case of an obese woman with a large hepatocellular adenoma (HCA) of 8.0 cm in diameter, followed for 5 years after Roux-en-Y Gastric Bypass, with a complete radiologic remission of the liver mass. Four other cases have been published with HCA regression after bariatric surgery, but none with long-term follow-up. As the association between obesity and HCA has been increasingly described, bariatric surgery should be considered a therapeutic option for stage 2 obese patients.