Vitamin D Status Before Roux-en-Y and Efficacy of Prophylactic and Therapeutic Doses of Vitamin D in Patients After Roux-en-Y Gastric Bypass Surgery

Background  Literature regarding the effect of Roux-en-Y gastric bypass (RYGBP) on vitamin D level shows contradictory findings. Our goal was to determine preoperatively vitamin D levels, to evaluate the efficacy of therapeutic and prophylactic doses of vitamin D and to assess the relationship of 25-OH vitamin D level and body mass index (BMI). Methods  We conducted a retrospective cross-sectional study of 72 patients who underwent RYGBP from April 2007 to October 2007 in Bariatric Surgery Department at Saint Vincent Charity Hospital. Results  Our study demonstrated that 80% of the obese patients undergoing RYGBP had serum 25-OH vitamin D levels of less than 32 ng/ml. Postoperative data show that 45% of these patients continue being vitamin D insufficient despite the treatment. We demonstrated that a statistically significant inverse correlation between BMI and 25-OH vitamin D levels (r = 0.464, p = 0.01) exists. Conclusion  Our finding strongly supports the need for aggressive monitoring of vitamin D levels for long-term prevention of complications of vitamin D deficiency in gastric bypass patients. Identifying the factors that predict patient’s responses to vitamin D supplementation requires larger-scale studies and further analysis of these tendencies suggested by our findings.     

Prevalence of Vitamin D Insufficiency and Deficiency in Morbidly Obese Patients: A Comparison with Non-Obese Controls

Background Vitamin D deficiency is common in patients after bariatric surgery. However, obesity itself has also been associated with decreased vitamin D. The prevalence of vitamin D deficiency in obese persons has not previously been compared to non-obese controls when controlling for factors that could affect vitamin D status. Methods We evaluated 25 hydroxy vitamin D, iPTH, calcium, albumin, and creatinine in 41 patients undergoing Roux-en-Y gastric bypass. We then compared them to healthy non-obese controls matched for age, sex, race/ethnicity, and season of vitamin D measurement. Results Ninety percent of the pre-bariatric surgery patients had 25-OH-D levels <75 nmol/l, and 61% had 25-OH-D levels <50 nmol/l versus 32 and 12% in controls, respectively. Additionally, 49% of the pre-bariatric surgery patients had secondary hyperparathyroidism versus 2% of controls. These differences persisted after controlling for sunlight exposure and dietary intake of calcium and vitamin D. Mean calcium, corrected for albumin, and creatinine were not significantly different between the groups, but mean albumin levels were significantly lower among surgery patients. Conclusion Vitamin D deficiency is common in obese patients at the time of bariatric surgery and is also accompanied by secondary hyperparathyroidism approximately half the time. These findings suggest that vitamin D deficiency after bariatric surgery is multifactorial and in part caused by preoperative vitamin D deficiency rather than postoperative malabsorption alone. In this study, increased vitamin D deficiency in obese persons cannot be explained by a difference in calcium/vitamin D intake or sunlight exposure.     

Severe obesity and vitamin D deficiency treatment options before bariatric surgery: a randomized clinical trial

BackgroundObesity, which has various complications and co-morbidities, is an epidemic issue worldwide. Vitamin D deficiency (VDD) is a well-known metabolic disorder among patients with severe obesity. While they are good candidates for bariatric surgery, this deficiency can affect the outcome of surgery negatively.ObjectivesThe aim of this study was to compare 3 different VDD treatment strategies for use before bariatric surgery and compare serum vitamin D levels after 7 weeks.SettingsUniversity hospital, Isfahan, Iran.MethodsThis was a single-blinded, randomized clinical trial on 100 patients who were referred for bariatric surgery from 2016 to 2018. Vitamin D (VitD) level was checked before surgery for the patients included in the study, if their VitD level was <30 ng/mL. We rechecked their serum VitD in the 8^th week, after 7 weeks of treatment. The participants were randomly allocated into 3 groups: 33 patients were treated with 50,000 units VitD₃ capsules every week for 7 weeks; 33 patients were treated with a single dose of 300,000 units VitD₃ ampoule; and 34 patients were treated with a combination of a half of the injection dose, followed by the oral capsule for 4 weeks.ResultsNo case was lost during the follow-up time. No significant differences were found among the 3 groups in terms of their age (P = .654), body mass index (P = .434), sex (P = .799), initial 25(OH) VitD level (P = .273), and history of supplement use (P = .45). Mean serum VitD levels were 15.21, 13.16, and 13.37 ng/mL, respectively, before the surgery and reached 32.91, 24.74, and 29.49 ng/mL after 7 weeks of treatment in oral, injection, and combined groups, respectively. Finally, the 7-week oral treatment option had significantly higher levels of VitD (P value = .034).ConclusionVDD treatment with 50,000 units VitD₃ capsule every week for 7 weeks before bariatric surgery yields a higher level of VitD. Based on our findings, injectable supplements are not recommended for VDD treatment.     

Laparoscopic vs Open Roux-en-Y Gastric Bypass: A Prospective Randomized Trial

Background: The feasibility of laparoscopic Roux-en-Y gastric bypass (Lap-RYGBP) for morbid obesity is well documented. In a prospective randomized trial, we compared laparoscopic and open surgery. Methods: 51 patients (48 females, mean (± SD) age 36 ± 9 years and BMI 42 ± 4 kg/m²) were randomly allocated to either laparoscopy (n=30) or open surgery (n=21). All patients were followed for a minimum of 1 year. Results: In the laparoscopy group, 7 patients (23%) were converted to open surgery due to various procedural difficulties. In an analysis, with the converted patients excluded, the morphine doses used postoperatively were significantly (p< 0.005) lower in the laparoscopic group compared to the open group. Likewise, postoperative hospital stay was shorter (4 vs 6 days, p<0.025). Six patients in the laparoscopy group had to be re-operated due to Roux-limb obstruction in the mesocolic tunnel within 5 weeks. The weight loss expressed in decrease in mean BMI units after year was 14 and 13 after 1 ± 3 ± 3 laparoscopy and open surgery,respectively (not significant). Conclusions: Both laparoscopic and open RYGBP are effective and well received surgical procedures in morbid obesity. Reduced postoperative pain, shorter hospital stay and shorter sick-leave are obvious benefits of laparoscopy but conversions and/or reoperations in 1/4 of the patients indicate that Lap-RYGBP at present must be considered an investigational procedure.     

Nutritional Consequences of Adjustable Gastric Banding and Gastric Bypass: A 1-year Prospective Study

Background  Gastric bypass (GBP) is more efficient than adjustable gastric banding (AGB) on weight loss and comorbidities, but potentially induces more nutritional deficits. However, no study has compared the prevalence of nutritional deficiencies after these two bariatric procedures. We prospectively compared  To prospectively compare the prevalence of nutritional deficiencies after AGB and GBP. Methods  We have performed a 1-year prospective study of nutritional parameters in 70 consecutive severe obese patients, who had undergone bariatric surgery, 21 AGB and 49 GBP. After GBP, multivitamin supplements were systematically prescribed and vitamin B12 supplementation was introduced if a deficiency was observed. Results  Patients lost more weight after GBP than after AGB (40 ± 13 vs 16 ± 8 kg, p < 0.001). Vitamins B1 and C and iron deficiencies were frequent before surgery but were not worsened by GBP. AGB only induced a slight decrease of vitamin B1 at 1 year, whereas GBP induced significant decreases of vitamins B12 and E, serum prealbumin, and creatinine concentrations, with only minor clinical consequences. Anemia was observed in 10% of the patients after bariatric surgery. Hemoglobin concentration was not correlated to vitamin B12 or folate concentrations but was related to iron status. Risk of iron deficiency anemia was better assessed by transferrin saturation than by serum ferritin concentration in this obese population. Conclusion  Severe nutritional deficits can be avoided after bariatric surgery if patients are systematically supplemented with multivitamin and carefully monitored. However, specific care is required to avoid iron and vitamin B12 deficiencies, anemia, and protein malnutrition.     

Markers of Bone and Calcium Metabolism Following Gastric Bypass and Laparoscopic Adjustable Gastric Banding

BACKGROUND: Several studies have suggested that morbid obesity is associated with vitamin D deficiency and elevated parathyroid hormone (PTH). Studies have also suggested that there is an increase in vitamin D deficiency, bone resorption, and elevated PTH after gastric bypass surgery. Few studies have evaluated markers of bone and calcium metabolism after laparoscopic adjustable gastric banding or compared these results to those after gastric bypass. METHODS: Data on all patients undergoing primary gastric bypass (GBP; n = 979) and laparoscopic adjustable gastric banding (LAGB; n = 269) procedures at a tertiary-referral center from June 1996 through March 2005 were reviewed from a prospective database. Only patients with 25OH vitamin D levels available were included in this study (n = 534; GBP = 403, LAGB = 131). All patients were advised to take at least 1,200 mg calcium and 800-1,200 IU of vitamin D daily before and subsequent to their operation. Markers for bone metabolism [25OH Vitamin D, corrected serum calcium, alkaline phosphatase (AP), and PTH] were evaluated preoperatively and 3, 6, 12, and 24 months postoperatively. An analysis of variance and chi-square were performed to determine differences between the operative groups. Linear regression analysis was performed to evaluate the relationship between preoperative body mass index (BMI) and 25OH vitamin D and PTH levels and between percent excess weight loss and 25OH vitamin D and PTH after surgery. RESULTS: Sixty-four percent of all patients presented with vitamin D deficiency (<20 ng/ml) and 14% presented with elevated PTH preoperatively. Mean 25OH vitamin D levels and AP levels increased significantly after GBP surgery (vitamin D, 17 to 25 ng/ml 12 months post-op; AP, 80 to 90 IU/L 24 months post-op). Corrected calcium levels remained within normal limits and showed no change over time after both procedures. AP levels significantly increased from 76 IU/l preoperatively to 82 IU/l 6 months after LAGB surgery and then decreased to 59 IU/l 24 months after LAGB surgery. Linear regression analysis of preoperative vitamin D, PTH, and BMI values showed a significant positive relationship between initial BMI and PTH (r = 0.29) and a significant negative relationship between vitamin D and initial BMI (r = -0.19). A significant positive linear relationship between vitamin D and percent excess weight loss was evident 12 and 24 months after GBP surgery (r = 0.39 and 0.57, respectively). A negative relationship was evident between PTH and vitamin D 6 months after GBP surgery (r = -0.35) and 12 months after LAGB surgery (r = -0.61). CONCLUSIONS: These findings suggest that morbid obesity is associated with vitamin D deficiency, and elevated PTH and with adequate supplementation, GBP, and particularly LAGB, patients can improve their bone metabolism abnormalities related to obesity. Furthermore, adequate supplementation for GBP patients may attenuate the increased risk for bone loss associated with malabsorption from the bypass.     

Probiotics Improve Outcomes After Roux-en-Y Gastric Bypass Surgery: A Prospective Randomized Trial

Introduction  Roux-en-Y gastric bypass (RNYGB) surgery offers an effective and enduring treatment for morbid obesity. Gastric bypass may alter gastrointestinal (GI) flora possibly resulting in bacterial overgrowth and dysmotility. Our hypothesis was that daily use of probiotics would improve GI outcomes after RNYGB. Methods  Forty-four patients undergoing RNYGB were randomized to either a probiotic or control group; 2.4 billion colonies of Lactobacillus were administered daily postoperatively to the probiotic group. The outcomes of H₂ levels indicative of bacterial overgrowth, GI-related quality of life (GIQoL), serologies, and weight loss were measured preoperatively and at 3 and 6 months postoperatively. Categorical variables were analyzed by χ ² test and continuous variables were analyzed by t test with a p < 0.05 for significance. Results  At 6 months, a statistically significant reduction in bacterial overgrowth was achieved in the probiotic group with a preoperative to postoperative change of sum H ₂ part per million (probiotics = −32.13, controls = 0.80). Surprisingly, the probiotic group attained significantly greater percent excess weight loss than that of control group at 6 weeks (controls = 25.5%, probiotic = 29.9%) and 3 months (38.55%, 47.68%). This trend also continued but was not significant at 6 months (60.78%, 67.15%). The probiotic group had significantly higher postoperative vitamin B12 levels than the control group. Both probiotic and control groups significantly improved their GIQoL. Conclusion  In this novel study, probiotic administration improves bacterial overgrowth, vitamin B12 availability, and weight loss after RNYGB. These data may provide further evidence that altering the GI microbiota can influence weight loss.     

Prevalence of Iron, Folate, and Vitamin B12 Deficiency Anemia After Laparoscopic Roux-en-Y Gastric Bypass

Background One of the most common bariatric operations is the laparoscopic Roux-en-Y gastric bypass (LRYGBP) in which the gastric capacity is restricted and the absorption by the small intestine is reduced. The objective of this study was to evaluate the incidence of iron, folate, and vitamin B12 deficiency anemia in patients undergoing LRYGBP. Patients and methods Clinical records of 30 patients who underwent LRYGBP between July 2003 and January 2005 and had a minimum follow up of 24 months at our outpatient clinic were included. Multivitamin supplementation was prescribed to all patients. The complete blood cell count, plasma iron, total iron-binding capacity, transferrin saturation, serum folate, and cobalamin levels before surgery, 6 months, 1, 2, and 3 years after the surgery were analyzed. Results There were 25 women (83.4%) and five men (16.6%) with ages from 21 to 56 years. Before surgery, two patients (6.6%) presented ferropenic anemia. Iron deficiency was seen in 40 and 54.5% 2 and 3 years after surgery, respectively. Cobalamin deficiency was observed in 33.3% at 2 years and in 27.2% at 3 years. At 2-year follow-up, 46.6% of the patients had already developed anemia and 63.6% at 3 years. Folate deficiency was not observed in any patient. Conclusion Our routine scheme of vitamin supplementation is not sufficient to prevent iron and vitamin B12 deficiencies in most patients.     

Predicting Stricture in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass: A Logistic Regression Analysis

Gastrojejunostomy stricture after Roux-en-Y gastric bypass occurs in 3 to 27% of morbidly obese patients in the USA. We questioned whether preoperative patient characteristics, including demographic attributes and comorbid disease, might be significant factors in the etiology of stricture. In this study from November 2001 to February 2006 (51 months), at a high-volume bariatric center, of the 1,351 patients who underwent laparoscopic gastric bypass, 92 developed stricture (6.8%). All but two were treated successfully by endoscopic dilation. All patients stopped nonsteroidal anti-inflammatory medications 2 weeks prior to surgery and did not restart them. The operative procedure included the use of a 21-mm transoral circular stapler to create the gastrojejunostomy; the Roux limb was brought retrogastric, retrocolic. In an effort to reduce our center’s stricture rate, late in the study, U-clips used at the gastrojejunostomy were replaced by absorbable sutures, and postoperative H₂ antagonists were added to the treatment protocol. The change to absorbable polyglactin suture proved to be significant, resulting in a lower stricture rate. The addition of H₂ antagonists showed no significant effect. Following the retrospective review of the prospective database, univariate and multivariate logistic regression analyses identified factors associated with the development of stricture. Gastroesophageal reflux disease and age were each shown to be statistically significant independent predictors of stricture following laparoscopic gastric bypass. Presented at the 2006 Annual Meeting of the Society for Surgery of the Alimentary Tract, May 20–24, Los Angeles, CA (poster presentation).     

Rhabdomyolysis After Bariatric Surgery by Roux-en-Y Gastric Bypass: A Prospective Study

Background  Obesity is a worldwide epidemic associated to comorbidities and increased mortality. Because it is chronic and recurrent and has little response to clinical measures, surgical treatment (bariatric surgery) is a therapeutic option frequently used. Different surgical complications have been associated with this type of procedure, but there is little knowledge about neuromuscular complications. Among the latter, rhabdomyolysis (RML), described a few years ago, has not been well characterized to date. Methods  We have studied 22 consecutive patients who underwent surgical treatment with open Roux-en-Y gastric bypass (RYGBP) for morbid obesity in a university hospital. A database was created including the following information of each patient: gender, age, body mass index (BMI), comorbidities, surgical time, pre- and postoperative creatine phosphokinase (CPK) dosages, and neuromuscular symptoms after surgery. The main outcome measure was the frequency of RML using CPK dosage after 24 h of surgery. RML was diagnosed as an increase of more than five times the superior limit of normal range of CPK. Results  Fourteen women and eight men were evaluated, with median age of 39.9 ± 11.2 years, median BMI of 52.4 ± 8.0 kg/m² and mean surgical time of 253.2 ± 51.9 min. The mean value of postoperative CPK was 7,467.7 ± 12,177.1 IU/L, being greater than 5,000 IU/L in 40.9% of the patients. RML was diagnosed in 17 (77.3%) patients. No patient had renal failure caused by RML, but there was one death (4.5%) related to abdominal infectious complications. Clinical neuromuscular symptoms occurred in 45% of patients, and muscular pain was the most common one, especially in gluteus region. Comparative analyzes between patients without and with RML diagnosis showed that longer surgical time (p = 0.005), and occurrence of neuromuscular symptoms (p = 0.04) were more common in the latter. Conclusion  The results of this study are similar to few other investigations and confirm that RML in open bariatric surgery with RYGBP (Capella) is a common complication. A longer surgical time can be involved in RML pathogenesis, and muscular pain is suggestive of RML occurrence.     

Different Effect of Laparoscopic Roux-en-Y Gastric Bypass and Open Biliopancreatic Diversion of Scopinaro on Serum PYY and Ghrelin Levels

Background  The impact of bariatric surgery on levels of peptide YY (PYY) and ghrelin is still under discussion. We undertook a simultaneous evaluation of the serum changes in PYY and ghrelin depending on the specific type of bariatric surgery. Methods  Total PYY and ghrelin were analyzed in 29 healthy persons and in morbidly obese persons undergoing open biliopancreatic diversion (BPD) of Scopinaro (n = 38) or laparoscopic Roux-en-Y gastric bypass (RYGB; n = 13). Results  RYGB resulted in a significantly greater loss of weight and body mass index than BPD. Both RYGB and BPD were associated with a significant increase in PYY, significantly greater for BDP (p = 0.001). Ghrelin rose significantly after RYGB (p = 0.022) but not after BPD. After surgery, PYY correlated positively with weight (r = 0.416, p = 0.009). Ghrelin did not correlate significantly with any of the variables studied. Analysis of variance showed that only the type of surgery contributed significantly to explain the variances in the PYY (p = 0.002) and ghrelin (p = 0.018). Conclusions  BPD results in a greater increase in PYY and a lower weight loss than RYGB. However, only RYGB was associated with a significant increase in ghrelin. The differing weight loss according to the type of bariatric surgery does not seem to be explained by changes arising in PYY and ghrelin.     

Laparoscopic Adjustable Silicone Gastric Banding vs Laparoscopic Vertical Banded Gastroplasty in Morbidly Obese Patients: Long-Term Results of a Prospective Randomized Controlled Clinical Trial

Background  Aim of the study is to present long-term results of a prospective randomized single-institution clinical trial comparing laparoscopic adjustable silicone gastric banding (LASGB) with laparoscopic vertical banded gastroplasty (LVBG) in morbid obesity. Methods  A total of 100 morbidly obese patients (body mass index 40 to 50 kg/m²) were randomized to LASGB (n = 49) or LVBG (n = 51) and followed up for a minimum of 7 years. Results  Mean operative time was 65.4 min in LASGBs and 94.2 min in LVBGs (p < 0.05); mean hospital stay was 3.7 and 6.6 days, respectively (p < 0.05). Late complication rates were 36.7% in LASGBs vs 15.7% in LVBGs at 3 years (p < 0.05), 46.9% vs 43.1% at 5 years (NS), and 55.1% vs 47.1% at 7 years (NS). Late reoperation rates were 28.6% in LASGBs and 2.0% in LVBGs at 3 years (p < 0.001), 38.8% and 2.0% at 5 years (p < 0.001), and 46.9% and 7.8% at 7 years (p < 0.001). Excess weight loss in LASGBs was 41.8% at 3 years, 33.2% at 5 years, and 29.9% at 7 years; excess weight loss in LVBGs was 60.9%, 57%, and 53.1%, respectively (p < 0.05). Conclusions  This study demonstrates that in a carefully selected group of patients, LVBG is significantly more effective than LASGB in terms of late complications, late reoperations, and long-term results on weight loss.     

Late Perforation and Abscess Formation at the Site of the Jejunojejunal Anastomosis Following Laparoscopic Roux-en-Y Gastric Bypass Surgery

Late complications involving the site of the jejunojejunal (J-J) anastomosis are uncommon after laparoscopic Roux-en-Y gastric bypass. We present a case of a perforation at the J-J anastomosis complicated by the formation of an abscess 6 months after surgery. Following clinical and radiological evaluation, the patient underwent an exploratory laparoscopy which had to be converted to an open technique because of technical difficulties. The abscess was drained, the anastomosis was resected, and a new anastomosis was undertaken. When the surgical specimen was inspected, a perforation was found at the site of the previous J-J anastomosis. The patient had an uneventful recovery. To our knowledge, this is the first report of the formation of an abscess due to a perforation at the site of the J-J anastomosis after laparoscopic Roux-en-Y gastric bypass surgery. This complication, although rare, should be taken into account in patients with abdominal pain and systemic inflammatory response syndrome after bariatric surgery. No commercial interests to disclose.     

Pregnancy Following Gastric Bypass for Morbid Obesity: Effect of Surgery-to-Conception Interval on Maternal and Neonatal Outcomes

Background  Conception is discouraged during the period of maximal weight loss following Roux-en-Y gastric bypass (RYGB) because of speculative maternal and fetal concerns. We therefore performed a retrospective cohort study of obstetrical and neonatal outcomes by surgery-to-conception interval. Methods  Women with RYGB were stratified into two groups by surgery-to-conception interval of ≤18 or >18 months. Pregnancy and newborn outcomes excluding miscarriages were compared using the chi-square or unpaired t-test for dichotomous and continuous variables, respectively. Results  Twenty subjects conceived ≤18 months (11.4 ± 5.0) and 32 conceived >18 months (47.5 ± 41) after RYGB, p < .05. Maternal age, parity, body mass index, and weight gain were similar by group. There were no statistically significant differences in adverse obstetrical outcomes (preterm premature membrane rupture, gestational diabetes, oligohydramnios, intrauterine growth restriction, preterm or post-term delivery) or adverse newborn outcomes (5-min Apgar score < 7, intensive care admission, or birth defect). Conclusion  Obstetrical and neonatal outcomes are similar in women conceiving during or after the period of maximal weight loss following RYGB.     

Revision of Staple Line Failure Following Roux-en-Y Gastric Bypass for Obesity: a follow-up of weight loss

Eighty-one patients with primary Roux-en-Y gastric bypass for obesity underwent revisional surgery for staple line failure. All patients (100%) were included in the follow-up. Two years later, patients had an excess weight loss of 77%; 91% of the patients had a final weight loss of 50% or more of their excess weight. Weight loss of revision patients was comparable to that reported for patients with primary operations. It was concluded that revision for staple line failure is clearly justified.     

Influence of Jejunoileal and Common Limb Length on Weight Loss Following Roux-en-Y Gastric Bypass

Background  Capella surgery is one of the technical variations of Roux-en-Y gastric bypass. The method includes the preparation of an alimentary (Roux) limb with a standardized length (110 cm) in order to induce deficiencies in the absorption of macronutrients and thereby contribute to weight loss. The recognized variation in jejunoileal length in humans (approximately 4 to 9 m) is not considered, although this range correlates with the wide variation in the length of the common limb. Methods  In order to assess the influence of variations in jejunoileal and common limb lengths on weight loss, intra-operative measurements were made of these segments on 100 patients undergoing Capella surgery. Patients were followed for a period of 1 year. Statistical analysis included subdivisions of the population by gender and body mass index. Results  Average jejunoileal length was 671.4 ± 115.7 cm (434–990 cm). Average common limb length was 505.3 ± 113.3 cm (268–829 cm). No correlation was detected between jejunoileal length and weight loss at 6 months or 1 year following surgery. A weak negative correlation was detected between weight loss and common limb length at 1 year following surgery in male and super-obese patients. Conclusions  Jejunoileal and common limb length vary widely in gastric bypass patients. To make modifications in the alimentary and/or biliopancreatic limb length, surgeons must consider the variability of the jejunoileal and common limb length.     

Increase of Bone Resorption and the Parathyroid Hormone in Postmenopausal Women in the Long-term after Roux-en-Y Gastric Bypass

Background  The effects of Roux-en-Y Gastric Bypass (RYGB) on bone in the long-term remains unclear. We assessed bone metabolism and bone mineral density (BMD) 1 to 5 years after RYGB. Methods  We designed a retrospective cohort study in 26 postmenopausal women (58.0 ± 3.9 years old) with RYGB 3.5 ± 1.1 years before (body mass index (BMI) 29.5 ± 3.8 kg/m², presurgery 43.6 ± 5.5 kg/m²) and 26 nonoperated women (57.5 ± 4.7 years old, BMI 29.2 ± 4.1 kg/m²) matched by age and BMI. The main measures were BMD, serum carboxy telopeptide (CTx), total alkaline phosphatases (ALP), parathyroid hormone (PTH), 25-hydroxyvitamin D (25OHD), and ghrelin. Results  RYGB group, compared to nonoperated women, had higher CTx (0.71 ± 0.21 vs. 0.43 ± 0.15 ng/ml; P < 0.01) and PTH (68.3 ± 35 vs. 49.4 ± 16 pg/ml; P = 0.02). There were no differences between RYGB and nonoperated women in: calcium and vitamin D intake (759 ± 457 vs. 705 ± 460 mg/day; 176 ± 160 vs. 111 ± 86 UI/day), ghrelin (763 ± 336 vs. 621 ± 274 pg/ml), ALP (101 ± 22 vs. 94 ± 25 UI/l), 25OHD (18.8  ± 7.6 vs. 17.4 ± 5.9 ng/ml), lumbar spine BMD (1.059 ± 0.32 vs. 1.071 ± 0.207 g/cm²), or femoral neck BMD (0.892 ± 0.109 vs. 0.934 ± 1.1 g/cm²). Conclusions  RYGB is associated to high bone resorption and hyperparathyroidism prevalence in postmenopausal women in the long-term. This occurs independently of the intake of calcium, vitamin D status, or ghrelin and does not seem to affect BMD after RYGB.     

Remission of Metabolic Syndrome: A Study of 140 Patients Six Months after Roux-en-Y Gastric Bypass

Background Metabolic Syndrome (MS) is a complex disorder characterized by a number of cardiovascular risk factors usually associated with central fat deposition and insulin resistance. Nowadays, there are many different medical treatments to MS, including bariatric surgery, which improves all risk factors. The present study aims to evaluate the influence of gastric bypass in the improvement of risk factors associated with MS, during the postoperative (6 months). Methods This was a retrospective study of 140 patients submitted to gastric bypass. The sample was comprised of a female majority (79.3 %). The mean body mass index (BMI) was 44.17 kg/m². We evaluated the weight of the subjects, the presence of diabetes mellitus and hypertension as comorbidities, as well as plasma levels of triglycerides (TG), total cholesterol and its fractions, and glycemia, in both preoperative and postoperative. Results The percentage of excess weight loss (%EWL) was similar in men and women, with an average of 67.82 ± 13.21%. Concerning impaired fasting glucose (≥100 mg/dl), 41 patients (95.3%) presented normal postoperative glycemia. There has been an improvement of every appraised parameter. The mean decrease in TG level was 66.33 mg/dl (p < 0.0001). Before the surgery, 47.1% were hypertensive; after it, only 15% continued in antihypertensive drug therapy (p < 0.0001). Otherwise, the only dissimilar variable between sexes was the high-density lipoprotein (HDL) level. Conclusion Gastric bypass is an effective method to improve the risk factors of metabolic syndrome in the morbidly obese.     

Establishing Laparoscopic Roux-en-Y Gastric Bypass: Perioperative Outcome and Characteristics of the Learning Curve

Background  Bariatric surgery was established at several Norwegian hospitals in 2004. This study evaluates the perioperative outcome and the learning curves for two surgeons while introducing laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods  Morbidly obese patients undergoing primary LRYGB were included. Lengths of surgery and postoperative hospital stay, and 30-day rates of morbidity, reoperations, and readmissions were set as indicators of the learning curve. Learning effects were evaluated by graphical analyses and comparing the first and last 40 procedures for both surgeons. Results  The 292 included patients had a mean age of 40.0 ± 9.5 years and a mean body mass index (BMI) of 46.7 ± 5.3 kg/m². The mean length of surgery was 101 ± 55 min. Complications occurred in 43 patients (14.7%), with no conversions to open surgery in the primary procedure and no mortality. Reoperations were performed in 14 patients (4.8%), of which five patients required open surgery. The median length of stay was 3 days (range 1–77), and 19 patients (6.5%) were readmitted. High patient age, but not high BMI, was associated with an increased risk of complication. For both surgeons, lengths of surgery and hospital stay were significantly reduced (p < 0.001), leveling out after 100 procedures. Reductions in the rates of morbidity, reoperations and readmissions were not found. Conclusion  LRYGB was introduced with an acceptable morbidity rate and no mortality. Only the length of surgery and postoperative hospital stay were suitable indicators of a learning curve, which comprised about 100 cases.