Rehabilitation needs after bariatric surgery.

BACKGROUND: Bariatric surgery has grown from an obscure experimental procedure to one of the most popular operations in the world. Such accelerated progress left many gaps, notably concerning subsequent rehabilitation needs of this population. AIM: In the present study, a brief description of both the patients and the interventions is provided, along with potentially disabling features especially concerning the locomotor system, which has received comparatively little attention . DESIGN: Based on reported protocols and actual experience, major issues are addressed. SETTING: Bariatric patients are initially managed in the hospital, however long-term and even lifetime needs may be recognized, requiring major lifestyle and physical activity changes. These have to be focused in all settings, inside and outside the healthcare institutions. POPULATION: Initially only adults were considered bariatric candidates, however currently also adolescents and the elderly are admitted in many centers. RESULTS: Bariatric weight loss is certainly successful for remission or prevention of metabolic, cardiovascular and cancer comorbidities. Yet benefits for bones, joints and muscles, along with general physical performance are still incompletely established. This should be no reason for denying continued care to such individuals, within the context of well-designed protocols, as available evidence points toward favorable rehabilitation in the realms of physical, social and workplace activities. CONCLUSION: The importance of a physiatric curriculum in medical schools has been emphasized. Even more crucial is the presence of such a specialists in obesity and bariatric teams, a requirement recognized in a few countries but not in others. CLINICAL REHABILITATION IMPACT: The relevance of obesity as a disabling condition is reviewed, along with the positive changes induced by surgical weight loss. Although obesity alleviation is a legitimate end-point it is not a sufficient one. The shortcomings of such result from the point of view of physical normalization are outlined, and recommendations are suggested.

Off label pharmacological therapy in patients with short bowel syndrome.

BACKGROUND: Short bowel syndrome is a disabling disease requiring long-term nutritional support and ancillary drugs. Aiming to analyze the most commonly prescribed drugs, a retrospective analysis was conducted is an outpatient cohort. PATIENTS AND METHODS: Stable patients (N= 37, 59.5% males, age 51.1 ± 20.1 years, body mass index 20.1 ± 7.9 kg/m2) with three or more appointments in the Outpatient Service during the last 18 months were retrospectively analyzed. regarding oral pharmacologic prescriptions. Medications were classified as on label or off label. RESULTS: A total of 257 oral prescriptions were retrieved from computer files, encompassing 17 different preparations. The majority was employed on label however 28.8% (74/257) were classified as off label and scrutinized with regard to indications. The main categories were pharmacologic modulators of gastrointestinal secretions and motility, along with antibiotics. Virtually all patients required one or more of such drugs, without differences regarding demographic or clinical variables. Adverse effects or premature drug discontinuation were not observed. CONCLUSIONS: This is the first study to our knowledge highlighting the importance of adjuvant drugs, particularly with unconventional indications, in the management of short bowel syndrome. Antidiarrheic agents, pancrelipase micropellets, antacids and antibiotics represented the most relevant off label prescriptions for this population.

Should ascitis volume and anthropometric measurements be estimated in hospitalized alcoholic cirrotics?

INTRODUCTION: Ascitis and undernutrition are frequent complications of cirrhosis, however ascitis volume and anthropometric assessment are not routinely documented or considered in prognostic evaluation. In a homogeneous cohort followed during two years these variables were scrutinized, aiming to ascertain relevance for longterm outcome. METHODS: Population (N = 25, all males with alcoholic cirrhosis) was recruited among patients hospitalized for uncomplicated ascitis. Exclusion criteria were refractory or tense ascitis, cancer, spontaneous bacterial peritonitis, bleeding varices and critical illness. Measurements included ultrasonographically estimated ascitis volume, dry body mass index/BMI , upper arm anthropometrics, hematologic counts and liver function tests. RESULTS: Population (age 48.3 ± 11.3 years, BMI 21.1 ± 3.5 kg/m², serum albumin 2.5 ± 0.8 g/dL) was mostly in the Child-Pugh C category (77.8%) but clinically stable. During the follow-up period of 22.6 ± 3.8 months, additional hospitalizations numbered 1.7 ± 1.0 and more than one quarter succumbed. Admission ascitis volume corresponded to 7.1 ± 3.6 L and dry BMI to 18.3 ± 3.5 kg/m². Child Pugh index was relevant for both mortality and rehospitalization. Nevertheless, similar matches for mortality were documented with ascitis volume and dry BMI, and arm circumference below the 5th percentile was highly significantly associated with rehospitalization. CONCLUSIONS: A greater association than hitherto acknowledged, between ascitis volume and anthropometric measurements from one side, and long-term rehospitalization and mortality from the other, was demonstrated in male stable alcoholic cirrhotics. Further studies with alcoholic and other modalities of cirrhosis including women are recommended.

Are calcium and fiber beneficial for poorly controlled diabetic patients?

UNLABELLED: No nutritional protocol for poorly controlled diabetic patients receiving well-managed drug treatment is currently available. OBJECTIVE: Aims were to compare dietary consumption of calcium and fibers with lipid profile and glycosilated hemoglobin HbA1c. METHODOLOGY: This was a prospective observational study. Patients with poorly controlled diabetes were consecutively recruited. A food-frequency questionnaire and tests for lipid profile, HbA1c, and C reactive protein were collected, along with clinical and anthropometric assessment. RESULTS: Patients (N = 114, age 65.7 ± 6.5 years, 75.4% females, BMI 29.0 ± 5.3 kg/m²) were often insulin-dependent (32.5%) and with systemic inflammation (C-reactive protein 4.2 ± 3.9 mg/L). Diet was energy restricted (1,365 ± 565 kcal/day) and mostly adequate but with suboptimal fiber (15.4 ± 8.6 g/day) and very low calcium (592.4 ± 204.4 mg/day). Calcium and fiber in the diet correlated with serum lipids, whereas fiber alone displayed a protective association regarding diabetes (HBA1c, insulin use) and arterial hypertension. CONCLUSIONS: Calcium and fiber ingestion exhibited correlations with important markers of metabolic status and cardiovascular risk. Future studies should address enhancement of these ingredients by means of dietary changes and supplements.

Systemic inflammation and carotid diameter in obese patients: pilot comparative study with flaxseed powder and cassava powder.

BACKGROUND: Botanical omega-3 fatty acid (alphalinolenic acid/ALA) has been shown to alleviate the prothrombotic and proinflammatory profile of metabolic syndrome, however clinical protocols are still scarce. Aiming to focus an obese population, a pilot study was designed. METHODS: Morbidly obese candidates for bariatric surgery (n = 29, age 46.3 ± 5.2 years), 82.8% females (24/29), BMI 44.9 ± 5.2 kg/m², with C-reactive protein/CRP > 5 mg/L were recruited. Twenty were randomized and after exclusions, 16 were available for analysis. Flaxseed powder (60 g/day, 10 g ALA) and isocaloric roasted cassava powder (60 g/day, fat-free) were administered in a double-blind routine for 12 weeks. RESULTS: During flaxseed consumption neutrophil count decreased and fibrinogen, complement C4, prothrombin time and carotid diameter remained stable, whereas placebo (cassava powder) was associated with further elevation of those measurements. CONCLUSIONS: Inflammatory and coagulatory markers tended to exhibit a better outlook in the flaxseed group. Also large-artery diameter stabilized whereas further increase was noticed in controls. These findings raise the hypothesis of a less deleterious cardiovascular course in seriously obese subjects receiving a flaxseed supplement.

Hip fracture prognosis: could bioimpedance be an alternative to conventional nutritional assessment?

BACKGROUND: Risk-factors for mortality in hip fractures encompass nutritional status, nominally body mass index, but not body composition. Given the difficulty of anthropometric assessment in bedridden patients a prospective study with bioimpedance analysis was designed. METHODS: Elderly patients with hip fracture were consecutively recruited. Biochemical tests, primitive bioimpedance measurements (resistance, reactance and phase angle) and follow-up till one year were targeted. RESULTS: Patients (N = 69, 81.2 ± 8.1 years old, 72.5% females) stayed in the hospital for 15.5 ± 17.1 days, and 18.8% (13/69) required further hospitalization during the ensuing months. Mortality was 11.6% within 30 days, coinciding with hospital mortality, and an additional 11.6% till one year, thus reaching 23.2%. Anemia, hypoalbuminemia and low transferrin, along with elevated glucose and urea were frequent, suggesting undernutrition with metabolic derangements. Reactance, urea and creatinine were different in patients suffering both early and late demise. Resistance, white blood cell count and osteoporosis were risk factors for early mortality only , and anemia exclusively for late mortality. CONCLUSIONS: Primitive bioimpedance measurements, which had not been hitherto investigated , were prognostically related to early and late mortality. These markers of disease-related malnutrition and especially reactance should be further studied in patients unfit for anthropometric evaluation due to fracture and immobility.

Consumption of fruits and vegetables and C-reactive protein in women undergoing cosmetic surgery.

UNLABELLED: Low-grade inflammation adversely influences metabolism and cardiovascular prognosis, nevertheless increased intake of fruits and vegetables has rarely been studied in this context. OBJECTIVE: In a prospective controlled study, the effect on C-reactive protein (CRP) levels was assessed. METHODOLOGY: Sixty consecutive women undergoing cosmetic abdominal surgery were instructed to consume six servings each of fruits and vegetables during the first postoperative month. Detailed 24 h interviewer-administered dietary recall was conducted at baseline and at the end of the study, with weekly returns to monitor unscheduled dietary changes and compliance with the protocol. Variance (ANOVA) and covariance (ANCOVA) were evaluated to confirm significance and minimize confounding variables. RESULTS: No differences concerning age (42.2±5.3 vs 41.1±6.0 years) or BMI (25.5±3.1 vs 25.0±3.0 kg/m²) occurred. Ingestion of fruits increased to approximately 5.2 vs 3.9 and of vegetables 5.9 vs 3.4 servings/ day, respectively. CRP decreased more conspicuously in the treated group (P=0.028), and correlation between vitamin C input and CRP in supplemented participants was demonstrated (P=0.014). CONCLUSIONS: Higher intake of antioxidant foods was feasible, and an antiinflammatory effect occurred. Further studies with longer administration and follow-up period are recommended.

Euglycemia and normolipidemia after anti-obesity gastric bypass.

UNLABELLED: Weight loss and resolution of comorbidities is well established after modern bariatric procedures, however chronology of glyco-lipidic biochemical response is still debated. OBJECTIVE: Aiming to analyze this variable as well as its correlation with food amount and composition, a prospective study was designed. METHODOLOGY: Eighty consecutive patients undergoing Roux-en-Y gastric bypass were investigated every three months until one year after surgery. Females only were accepted and variables included general and nutritional course as well as glucose and lipid measurements. Energy intake was documented including percentage of macronutrients in the diet. RESULTS: Surgery was successful with about 71% excess body weight loss at the end of the first year. Mean energy intake on the 4 postoperative quarters was respectively 519.6 +/- 306.6, 836.0 +/- 407.9, 702.1 +/- 313.1 and 868.8 +/- 342.8 kcal/day (mean +/- SD). Fat intake was initially low but reached 34.1 +/- 7.9% of total calories at final measurement. Blood glucose and lipid fractions tended to be borderline or abnormal preoperatively, and favorably changed by 12 months. Consumption of glucose-and lipid-lowering medication significantly diminished, but each of these was still necessary in 6.3% of the group. Correlation between body mass index and also calorie intake versus glucose and lipid measurements was highly significant (P = 0.000). CONCLUSIONS: 1) Energy intake after operation was very low; 2) Weight loss proceeded rapidly and correlated with meal pattern; 3) Improvement of glucose and lipid tests was adequate but took several quarters to normalize; 4) Decreased requirements for glucose- and lipid-lowering medication was significant but not absolute; 4) Fat percentage of total calories exceeded 30% at the end of the observation period, despite recommendations to the contrary.

Is it feasible to reach the bypassed stomach after Roux-en-Y gastric bypass for morbid obesity? The use of the double-balloon enteroscope.

BACKGROUND AND STUDY AIMS: Endoscopic evaluation of the excluded stomach after Roux-en-Y gastric bypass surgery for morbid obesity is a challenge, and the pathological changes that take place in the bypassed stomach are unclear. A new double-balloon method of evaluating the bypassed stomach after Roux-en-Y gastric bypass surgery for morbid obesity is described here. PATIENTS AND METHODS: This new enteroscope uses two balloons, one attached to the tip of the endoscope and the other to the distal end of the soft overtube. The procedures were carried out in six patients using the retrograde route, through the end-to-side jejunal anastomosis via the duodenobiliopancreatic limb up to the bypassed stomach. RESULTS: The bypassed stomach was reached in five of six patients (83.3 %). An endoscopic appearance of atrophic gastritis was found in three patients, mild in two cases and severe in one case with intestinal metaplasia. Erosive and hemorrhagic gastritis was found in two patients. CONCLUSIONS: Endoscopic evaluation of the bypassed stomach via the retrograde route after Roux-en-Y gastric bypass for morbid obesity is feasible using the double-balloon enteroscope.

Cost of drugs manufactured by the university hospital--role of the Central Pharmacy.

UNLABELLED: The hospital pharmacy in large and advanced institutions has evolved from a simple storage and distribution unit into a highly specialized manipulation and dispensation center, responsible for the handling of hundreds of clinical requests, many of them unique and not obtainable from commercial companies. It was therefore quite natural that in many environments, a manufacturing service was gradually established, to cater to both conventional and extraordinary demands of the medical staff. That was the case of Hospital das Clínicas, where multiple categories of drugs are routinely produced inside the pharmacy. However, cost-containment imperatives dictate that such activities be reassessed in the light of their efficiency and essentiality. METHODS: In a prospective study, the output of the Manufacturing Service of the Central Pharmacy during a 12-month period was documented and classified into three types. Group I comprised drugs similar to commercially distributed products, Group II included exclusive formulations for routine consumption, and Group III dealt with special demands related to clinical investigations. RESULTS: Findings for the three categories indicated that these groups represented 34.4%, 45.3%, and 20.3% of total manufacture orders, respectively. Costs of production were assessed and compared with market prices for Group 1 preparations, indicating savings of 63.5%. When applied to the other groups, for which direct equivalent in market value did not exist, these results would suggest total yearly savings of over 5 100 000 US dollars. Even considering that these calculations leave out many components of cost, notably those concerning marketing and distribution, it might still be concluded that at least part of the savings achieved were real. CONCLUSIONS: The observed savings, allied with the convenience and reliability with which the Central Pharmacy performed its obligations, support the contention that internal manufacture of pharmaceutical formulations was a cost-effective alternative in the described setting.

Refeeding procedures after 43 days of total fasting.

Refeeding syndrome encompasses fluid and electrolyte imbalances and metabolic, intestinal, and cardiorespiratory derangements associated with appreciable morbidity and mortality. Although refeeding syndrome has been well documented in concentration-camp subjects, and more recently during parenteral therapy of critically ill patients, little is known about the importance of refeeding syndrome during recovery from a hunger strike. Thus, we studied the response to a four-step dietary replenishment routine in eight hunger strikers who refused food for 43 d. In this retrospective, observational study, we assessed the safety and efficacy of the refeeding procedure and analyzed the clinical and nutritional course of the cohort during both starvation and refeeding, mainly on the basis of clinical as well as a few biochemical determinations. During starvation, average weight loss was about 18% and, with the exception of occasional oral vitamins and electrolytes, the subjects consumed only water. Available body-composition and biochemical profiles showed no clinically significant changes during starvation, but one-half of the group displayed spontaneous diarrhea at some time before refeeding. Stepwise nutritional replenishment lasted for 9 d, after which all patients tolerated a full, unrestricted diet. Only one episode of diarrhea occurred during this phase, and both clinical and biochemical indexes confirmed a favorable clinical course, without any manifestation of refeeding syndrome. In conclusion, we observed the following: 1) Hypophosphatemia and other micronutrient imbalances did not occur, nor was macronutrient intolerance detected. 2) Despite some episodes of diarrhea, nutritional replenishment was not associated with significant enteral dysfunction. 3) There was some fluid retention, but this was mild. 4) Acute-phase markers were abnormally elevated during the refeeding phase, without associated sepsis or inflammation.

Changes in body fluid and energy compartments during prolonged hunger strike.

UNLABELLED: Prolonged total food deprivation in non-obese adults is rare, and few studies have documented body composition changes in this setting. In a group of eight hunger strikers who refused alimentation for 43 days, water and energy compartments were estimated, aiming to assess the impact of progressive starvation. Measurements included body mass index (BMI), triceps skinfold (TSF), arm muscle circumference (AMC), and bioimpedance (BIA) determinations of water, fat, lean body mass (LBM), and total resistance. Indirect calorimetry was also performed in one occasion. The age of the group was 43.3+/-6.2 years (seven males, one female). Only water, intermittent vitamins and electrolytes were ingested, and average weight loss reached 17.9%. On the last two days of the fast (43rd-44th day) rapid intravenous fluid, electrolyte, and vitamin replenishment were provided before proceeding with realimentation. Body fat decreased approximately 60% (BIA and TSF), whereas BMI reduced only 18%. Initial fat was estimated by BIA as 52.2+/-5.4% of body weight, and even on the 43rd day it was still measured as 19.7+/-3.8% of weight. TSF findings were much lower and commensurate with other anthropometric results. Water was comparatively low with high total resistance, and these findings rapidly reversed upon the intravenous rapid hydration. At the end of the starvation period, BMI (21.5+/-2.6 kg/m2) and most anthropometric determinations were still acceptable, suggesting efficient energy and muscle conservation. CONCLUSIONS: 1) All compartments diminished during fasting, but body fat was by far the most affected; 2) Total water was low and total body resistance comparatively elevated, but these findings rapidly reversed upon rehydration; 3) Exaggerated fat percentage estimates from BIA tests and simultaneous increase in lean body mass estimates suggested that this method was inappropriate for assessing energy compartments in the studied population; 4) Patients were not morphologically malnourished after 43 days of fasting; however, the prognostic impact of other impairments was not considered in this analysis.

[Magnetic resonance angiography (MRA) of the abdominal aorta and its branches]. / Angiographie par résonance magnétique (ARM) de l'aorte abdominale et de ses branches.

Technical aspects of 3D contrast-enhanced magnetic resonance angiography are exposed, detailing more particularly the pulse sequence used and the mode of injection of contrast agent. Then, various vascular territories are analyzed, and illustrated using various examples of main pathologies observed in routine clinical practice: abdominal aorta, renal arteries, pelvic and mesenteric vessels, and peripheral arteries.

Pilot study with a glutamine-supplemented enteral formula in critically ill infants.

Seriously ill infants often display protein-calorie malnutrition due to the metabolic demands of sepsis and respiratory failure. Glutamine has been classified as a conditionally essential amino acid, with special usefulness in critical patients. Immunomodulation, gut protection, and prevention of protein depletion are mentioned among its positive effects in such circumstances. With the intent of evaluating the tolerance and clinical impact of a glutamine supplement in seriously ill infants, a prospective randomized study was done with nine patients. Anthropometric and biochemical determinations were made, and length of stay in the intensive care unit (ICU), in the hospital, and under artificial ventilation, and septic morbidity and mortality were tabulated. Infants in the treatment group (n = 5) were enterally administered 0.3 g/kg of glutamine, whereas controls received 0.3 g/kg of casein during a standard period of five days. Septic complications occurred in 75% of the controls (3/4) versus 20% of the glutamine-treated group (1/5, p < or = 0.10), and two patients in the control group died of bacterial infections (50% vs. 0%, p < or = 0.10). Days in the ICU, in the hospital, and with ventilation numerically favored glutamine therapy, although without statistical significance. The supplements were usually well tolerated, and no patient required discontinuation of the program. The conclusion was that glutamine supplementation was safe and tended to be associated with less infectious morbidity and mortality in this high-risk population.

Low blood glucose levels and other complications during growth hormone supplementation in sepsis.

Blood glucose levels in the high normal range or even moderate hyperglycemia is the expected profile in septic postoperative patients receiving high-calorie enteral alimentation. The addition of growth hormone as an anabolic agent should additionally reinforce this tendency. In a cancer patient undergoing partial gastrectomy with lymphadenectomy and suffering from postoperative subphrenic abscess and prolonged sepsis, tube feeding (38.3 kcal/kg/day) and growth hormone (0.17 IU/kg/day) were simultaneously administered for 25 days. Blood glucose levels were in the lower limits of the normal range before growth hormone introduction, and continued with a similar tendency during most of the therapeutic period. Two additional complications, namely heart arrest and peripheral edema, were documented during the same period. It is concluded that sepsis was the most likely mechanism for low glucose values, and that high-calorie enteral diet and growth hormone supplementation did not prevent that result. It is uncertain whether heart arrest was due to the drug, but its association with peripheral edema is well documented in clinical series.

[Comparison of color Doppler ultrasonography and endoscopic ultrasonography for preoperative evaluation of the mesenteric-portal axis in pancreatic lesions]. / Comparaison de l'échodoppler couleur et de l'échoendoscopie pour l'évaluation préopératoire de l'axe mésentéricoportal dans les lésions pancréatiques.

AIM OF THE STUDY: This prospective study was undertaken to evaluate the accuracy of ultrasonography combined with colour Doppler and endoscopic ultrasonography for predicting superior mesenteric and portal vein involvement in pancreatic diseases. MATERIAL AND METHODS: The study was prospective. Forty-four patients were included. Ultrasonography with colour Doppler was performed in 30 patients, endoscopic ultrasonography in 43. Prediction of superior mesenteric vein or portal vein involvement was blindly assessed by physicians without knowledge of results of other imaging methods. Resectability or potential resectability (n = 34) and irresectability (n = 10) were assessed in all patients by surgery. Thirty patients underwent a pancreaticoduodenectomy. RESULTS: For endoscopic ultrasonography the sensitivity (0.90), the specificity (0.88), the positive predictive value (0.69) and the negative predictive value (0.97) were better than those observed with ultrasonography and Doppler (050, 0.88, 0.69, 0.97, respectively). The specificity of computed tomography (0.96) was better than that of endoscopic ultrasonography but predictive negative values were similar. CONCLUSIONS: Imaging methods to predict superior mesenteric or portal vein involvement in pancreatic diseases are becoming increasingly numerous, complex, and expensive. Endoscopic ultrasonography has a better diagnostic value for correctly predicting resectability than ultrasonography with Doppler. However, for decision making, usefulness of these methods seems to be limited.