The prevalence of zinc deficiency in morbidly obese patients before and after different types of bariatric surgery.

BACKGROUND: The prevalence of obesity is considered to be increased worldwide. Lack of mineral elements is one of the essential side effects of bariatric surgery as a trending treatment for obesity. We aimed to assess zinc deficiency among morbidly obese patients before and following different types of bariatric surgical procedures. METHODS: In the present retrospective cohort study, 413 morbidly obese patients (body mass index (BMI) ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with a complication or risk factor, e.g., diabetes mellitus) were enrolled who received bariatric surgery, aged between 18 and 65 years old, and had a negative history of active consumption of alcohol and illicit drugs. Patients were assigned into three groups of bariatric surgeries: mini-gastric bypass, Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG). We recorded baseline clinical and demographic characteristics and zinc serum levels during the preoperative and postoperative follow-up periods at three, six, and 12 months after the operation. RESULTS: All patients with a mean age of 40.57 ± 10.63 years and a mean preoperative BMI of 45.78 ± 6.02 kg/m2 underwent bariatric surgery. 10.2% of the bariatric patients experienced zinc deficiency before the surgery, and 27.1% at 1 year after the surgery. The results showed that 27.7% of mini-gastric bypass patients, 29.8% of RYGB, and 13.3% of SG experienced zinc deficiency 12 months following surgery. We observed no statistical differences in the preoperative and postoperative zinc deficiency between different types of surgeries. CONCLUSION: A high prevalence of preoperative zinc deficiency among morbidly obese patients who underwent bariatric surgery was observed, which increased during the postoperative periods. We recommend assessing zinc serum levels and prescribing zinc supplements before the bariatric operation to alleviate the prevalence of zinc deficiency after the operation.

Short-term outcomes of the conversion of one anastomosis gastric bypass to Roux-en-Y gastric bypass in symptomatic reflux patients without revising the size of the gastric pouch.

BACKGROUND: Revising the size of the gastric pouch during the conversion of one anastomosis gastric bypass (OAGB)/mini-gastric bypass to Roux-en-Y gastric bypass (RYGB) is an important point. Even in patients undergoing RYGB, marginal ulcer is regarded as a known complication. MATERIALS AND METHODS: In our Centre of Excellence in Bariatric and Metabolic Surgery, 2492 patients underwent OAGB from February 2012 to January 2019. Twelve of 2492 patients were enrolled in this clinical case series because of persistent gastroesophageal reflux-like symptoms which underwent conversional RYGB. All patients regularly received proton-pump inhibitors (PPIs) for 6 months after the surgery. After this period, the cases with symptomatic reflux were invited to be visited in the clinic by a bariatric surgeon and a gastroenterologist and received 6 months of PPI therapy until their symptoms disappeared. Twelve refractory reflux cases underwent conversional RYGB after 1 year. An enteroenterostomy was created in all the patients 75 cm distal to the gastrojejunostomy without resizing the gastric pouch, and the jejunal loop was cut just before the gastrojejunostomy. RESULTS: Before conversional surgery, mean ± standard deviation (SD) body mass index (BMI) and gastroesophageal reflux disease (GERD)-Q score were found to be 26.45 ± 2.34 kg/m2 and 10.08 ± 0.56, respectively. At 1 year after conversion, mean ± SD BMI in the patients was 28.12 ± 4.71, and GERD-Q score was 5.08 ± 1.5. CONCLUSION: It seems that resizing the gastric pouch is not necessary during the conversion of OAGB to RYGB.

Weight loss after one-anastomosis/mini-gastric bypass - The impact of biliopancreatic limb: A retrospective cohort study.

BACKGROUND: One-anastomosis/mini-gastric bypass (OAGB/MGB), as a popular bariatric surgery method, has many advantages; however, the biliopancreatic limb length (BPL) in this surgery is under debate. The aim of the study was to evaluate the effect of BPL on weight-loss outcome after OAGB/MGB. MATERIALS AND METHODS: A retrospective cohort study was performed on 653 patients who underwent OAGB/MGB with adjusted BPL based on preoperative body mass index (BMI) and patient's age, between 2010 and 2015 with 12-month follow-ups. Weight-loss outcomes and complications were analyzed in these patients, considering BPL. RESULTS: Weight, age, sex, and type 2 diabetes mellitus were the most contributory predictors as independent predictors of 12-month excess weight loss, respectively, and BPL was the least contributory predictor. CONCLUSION: Tailoring BPL in OAGB/MGB based on patient's age and preoperative BMI seems to have acceptable results.

The comparison of severity and prevalence of major depressive disorder, general anxiety disorder and eating disorders before and after bariatric surgery.

BACKGROUND: Severe obesity is highly co-morbid with psychiatric disorders and may have effect on the quality of life. This study aimed to compare severity and prevalence rate of depression, anxiety and eating disorders and quality of life in severe obese patients before and 6 months after the gastric bypass surgery. METHODS: This was a prospective observational study which conducted at Hazarat Rasool-Akram Hospital in Tehran, 2012. Questionnaires included demographic questions, eating disorder Inventory (EDI), The Short Form Health Survey (SF-36) for quality of life, Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I) and Hamilton Rating Scale for Depression (HRSD) and anxiety (HRSA). Participants were interviewed two times, before surgery and six months after, to determine changes of the disorders. Patients with the history of bariatric surgery, individuals younger than 18 year old and those who disagreed to join the study were excluded. RESULTS: In assessing the eating disorder inventory-3rd version (EDI-3), Significant reduction in drive for thinness (DT) (p= 0.010), bulimia (B) (p< 0.0001) and body dissatisfaction mean (BD) (0.038) was observed at the 6-month follow-up. At this period, the mean for physical component summary of SF36, significantly decreased (p< 0.0001), however mental component summary did not significantly differ (p= 0.368); Also differences in severity of anxiety (p= 0.852), and depression in HRSD (p= 0.311), prevalence of depression (p= 0.189) and prevalence of general anxiety disorder according to SCID (p=0.167) did not differ significantly, at this period. CONCLUSION: Although weight loss after bariatric surgery improved the physical component of quality of life, this improvement did not affect the mental aspect of life, depression and anxiety and it seems that these psychopathologies need attention and treatment in addition to weight loss treatments in patients with obesity.

Comparison of pre-operative bilirubin level in simple appendicitis and perforated appendicitis.

BACKGROUND: Delay in diagnosis and treatment of perforated appendicitis may cause life-threatening complications.The aim of this study was to determine and compare pre-operative total and direct bilirubin levels incases of simple and perforated acute appendicitis in order to improve the clinical decision making. METHODS: This prospective observational study included eighty patients who underwent open appendectomy,during a one-year period from March 2010 to March 2011 in the surgical department of Hazrat-e-Rasool AkramHospital, an academic teaching hospital in Tehran- Iran. Pre-operative total and direct levels of bilirubin werecompared in two groups of histologically proved appendicitis (simple and perforated), each including 40 patients. RESULTS: Eighty patients who underwent open appendectomy including 70% men and 30% women with a meanage of 34±11 years in Group I (perforated appendicitis) and 47.5% women and 52.5% men with a mean age of33±14 in Group II (simple appendicitis) were included in this study. The mean bilirubin levels were higher forpatients with perforated acute appendicitis compared to those with a non-perforated simple appendicitis(1.04±05 mg/dl vs 0.7±0.1 mg/dl) and this difference is highly significant (p<0.01). CONCLUSION: Assessment of preoperative total bilirubin is useful for the differential diagnosis of perforatedversus acute simple appendicitis and total bilirubin should be used as an independent parameter in the early diagnosisof appendix perforation.

Breakfast habits, nutritional status and their relationship with academic performance in elementary school students of Tehran, Iran.

BACKGROUND: The aim of this study was to examine the breakfast habits, nutritional status and their relationship with academic performance in primary school students in Tehran, Iran. METHOD: In this cross-sectional study 829 primary school children were included. Child Body Mass Index (BMI) was calculated based on the objective measures of height and weight as well as adjusted for age and gender. Data on Breakfast habits and academic performance were collected by a valid checklist. For data analysis we used Chi-squared and Fisher's exact test using SPSS software, version 11.5; statistical significance was assumed if p-value is below the 0.05. RESULTS: The average breakfast consumption per week was 5.5 times (days) with a standard deviation of 2.9. Based on the results, 30.9% of participants did not consume full breakfast (six times or less) and 69.1% had a complete one. In terms of academic grade level, 88.4% of the participants were in a high level, 10.3% in appropriate conditions and only 1.3% of the respondents required more effort (inappropriate). There was no significant correlation between breakfast consumption and academic status (p=0.73), nutritional status of the participants according to the academic performance status Individuals showed no statistically significant relationship (P=0.9). CONCLUSION: Unlike previous studies, this study revealed no correlation between the academic grade level of elementary students with nutritional status and breakfast habits. It is suggested that according to the qualitative school scoring method, future studies are needed to assessing the students' academic performance. Other parameters will be considered in addition to the average in order to provide a better perspective of students' academic performance.

Configuring a Better Estimation of Kidney Size in Obese Children and Adolescents.

BACKGROUND: Obesity ignites numerous health and psychosocial problems and is associated with various comorbidities. Body mass index (BMI) is also independently associated with improved risk for numerous kidney disorders. As renal length is considered a vital parameter in the clinical assessment of renal patients, normal renal length has to be defined in accordance to BMI. OBJECTIVES: The aim of this study was to define normal kidney length in obese children, comparing ultrasound measurements of the kidney length in obese and non-obese children and adolescents, in order to reduce unnecessary evaluations for nephromegaly. PATIENTS AND METHODS: Fifty obese children and adolescents and 50 non-obese children and adolescents, aged 1-19 years, were selected from patients of pediatric clinics in two hospitals (Rasoul-e-Akram and Shahid Fahmideh) in Tehran between June 2010 and 2012. After the nephrologist's and endocrinologist's approval, the largest longitudinal renal dimension was measured in deep inspiration position by abdomino-pelvic ultrasonography in both groups. RESULTS: It was revealed that both kidneys in obese group were significantly larger than in control group (P = 0.044 and 0.040, respectively). Obesity status, height and age were proven to be significant and independent predictors of length of both kidneys. In both groups length of left kidney was significantly larger than that of right kidney (P < 0.001). CONCLUSIONS: A specific standard cut-point limit or norm gram has to be formulated for obese children and adolescents in order to facilitate the diagnosis of kidney diseases, including organomegaly, in these patients.

The Controversy of the Most Proper Time for Pregnancy After Bariatric Surgery: a Review of Ten Cases.

BACKGROUND: Many infertile obese women conceive after bariatric surgery after many years, while guidelines prohibit them from pregnancy for at least 12-18 months after surgery, due to complications. METHODS: We hereby present 11 cases in our research center, pregnant in less than 12 months after surgery from 2011 to 2015, to evaluate their pregnancy outcome and complications. RESULTS: The mean conception time was 3.6 months after surgery and mean birth weight was 2695 g. Regarding neonatal/fetal complications, there was one case of intrauterine growth retardation and one NICU hospitalization. Among pregnancy complications, eight patients had hyperemesis gravidarum and one had pre-eclampsia. CONCLUSIONS: The results of the present study suggest revising setting a contraindication for conception for patients undergoing bariatric surgery.

Comparing the Excessive Daytime Sleepiness of Obese and Non-obese Patients.

BACKGROUND: Obesity, particularly morbid obesity, has various physical and mental complications. Excessive daytime somnolence (EDS) is a sleep disorder that reduces individuals' performance capability and the accuracy of their short-term memory and causes learning problems. This retrospective study aimed to document the presence of EDS in a sample of obese patients in comparison to patients with a normal weight. OBJECTIVES: This article compares the excessive daytime sleepiness of obese and non-obese patients in the minimally invasive surgery research center in Tehran, Iran. PATIENTS AND METHODS: In this case-control study, we compared excessive daytime sleepiness in 55 obese patients who were candidates for laparoscopic surgery, with a body mass index (BMI) of equal to or greater than 30 kg/ m2, with 55 controls with a normal BMI (19.5 - 24.9 kg/ m2). The process of selecting the control group in our case-control study is matching in group levels, so that the controls are similar to the case group with regard to certain key characteristics, such as age, sex, and race. The sleep assessment was based on the Epworth sleepiness scale (ESS) questionnaire. Analysis of variance (ANOVA) was used to compare the means of quantitative data, such as the ESS score of groups. RESULTS: Sleepiness was not affected by gender in cases or controls. The sleepiness prevalence was 29 (52.7%) in the cases group and 17 (30.9%) in the control group (OR = 2.493 (95% CI 1.144 -5.435)). The mean ESS scores in cases and controls were 7.82 ± 3.86 and 10.54 ± 6.15, respectively (P = 0.007). Moreover, the prevalence of sleepiness and the mean ESS scores in class III of obesity differed significantly from the controls (16 (57.1%) vs. 17 (30.9%)) (OR = 2.980 (95% CI 1.162 - 7.645)) and (11.04 ± 5.93 vs. 7.82 ± 3.86) (P = 0.013), respectively. CONCLUSIONS: Our findings suggest a strong relationship between EDS and obesity, particularly morbid obesity. Therefore, physicians must be familiar with EDS as a mixed clinical entity indicating careful assessment and specific treatment planning.

Omentoplasty in deep sternal wound infection.

BACKGROUND: The aim of this study was to evaluate retrospectively the results of reconstructing infected post-sternotomy incisions with pedicled omentoplasty. METHODS: Between March 2009 and December 2012, 15 females (37.5%) and 25 males (62.5%) with an average age of 63 y (range 51-72 y) who were suffering from deep sternal wound infection (DSWI) after coronary artery bypass grafting underwent reconstructive surgery. We evaluated their pre-operative characteristics and post-operative courses. RESULTS: Thirty-four of the patients (85%) were found to have DSWI within 1 mo of their cardiac surgery. The mean operative time for the omental flap (OF) procedure was 90±16.8 min (range 70-135 min). There were three intra-operative complications (7.5%), and post-operative complications occurred in 10 patients (25%). No patient developed any sign of OF necrosis. The median lengths of the post-operative intensive care unit (ICU) and hospital stays were 4 d (range 1-6 d) and 7 d (range 5-14 d), respectively. At the time of discharge, all patients had normal cardiac and mental status. CONCLUSION: We obtained satisfactory outcomes when treating the patients with DSWI by a single-stage OF transposition. On the basis of our experience, we recommend this procedure as an option for patients with DSWI, especially those who are not in a severe low cardiac output state or malnourished.

Evaluating the Effect of Drain Site on Abdominal Pain after Laparoscopic Gastric Bypass Surgery for Morbid Obesity: A Randomized Controlled Trial.

Background: Most morbidly obese patients complain of abdominal pain after laparoscopic gastric bypass (LGBP) surgery. In this study, the relationship between the prevalence and severity of pain and the drain site was assessed. Methods: Fifty morbidly obese patients undergoing LGBP surgery were selected, and a drain was randomly inserted postoperatively to the left 5 mm port in 25 cases and to the right in the other 25. All patients filled out a questionnaire, including a visual analog scale for the quality and quantity of pain, exacerbating and alleviating factors and its relation to patient's positioning, in the first 24 hours, first week, and first month after the operation. Result: In both groups, all patients had abdominal pain 24 hours after the operation. However, in the right-sided drain group, most patients (52%) experienced mild pain, whereas most patients (56%) in the left-sided drain group had severe pain (p=0.028). At weeks 1 and 4, there was no significant difference between the two groups in terms of severity of pain (p=0.068 and 0.875, respectively, for both times). After the first 24 hours and first week, the mean pain score was significantly lower in the right-sited drain group compared to the left-sited drain group (p=0.012 and 0.006). Conclusion: Early abdominal pain after LGBP surgery is significantly reduced in the right-sided drain group.

Pre-operative rectal indomethacin for reduction of postoperative nausea and vomiting after laparoscopic cholecystectomy: a double-blind randomized clinical trial.

OBJECTIVE: To evaluate the effect of pre-operative indomethacin suppository on postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. STUDY DESIGN: A double blind placebo-controlled randomized clinical trial. PLACE AND DURATION OF STUDY: Hazrat Rasoul Akram Hospital, Tehran, Iran, from February 2010 to September 2012. METHODOLOGY: One hundred and thirty patients, scheduled for laparoscopic cholecystectomy, were randomly divided into case and control groups. Sixty-five patients received indomethacin suppository and 70 patients received rectal placebo in the case and control groups respectively. All patients underwent the same protocol in laparoscopic surgery and anesthesia, then nausea and vomiting was recorded after 1, 6, 12 and 24 hours postoperatively and compared between the two groups. Independent-sample t test or Mann-Whitney tests were used for statistical analysis. Level of statistical significance was set at P ² 0.05. RESULTS: Patients' nausea was statistically lower in the case group at the 1st hour (43.1 vs. 92.9%), 6th hour (20.0 vs. 68.6%) and 12th hour (7.7 vs. 24.3%) after surgery (for all periods, P < 0.001). Fewer patients in the case group experienced vomiting at the first (13.8 vs. 51.4%) and 6th hour (0 vs. 20%) after surgery (for both P < 0.001). The use of pethidine was also statistically less in the case group in the same hours after surgery (for all of them, P < 0.001). CONCLUSION: Rectal indomethacin before laparoscopic cholecystectomy led to lower postoperative nausea and vomiting.

Functional abdominal pain syndrome in morbidly obese patients following laparoscopic gastric bypass surgery.

BACKGROUND: Roux-en-Y gastric bypass surgery (RYGBP) is one of the most common bariatric surgeries, which is being performed using various techniques like gastrojejunostomy by hand swen, linear or circular stapler. Abdominal pain is a common complaint following laparoscopic gastric bypass procedure (LGBP), which has different aetiologies, such as overeating, adhesion, internal herniation, bile reflux and many more. In this study LGBP was performed in an ante-colic ante-gastric pattern in a double loop manner and the prevalence and distribution of pain in morbidly obese patients undergoing LGBP was assessed. OBJECTIVES: The aim of this study was to analyze the distribution and frequency of post LGBP pain in morbidly obese patients. PATIENTS AND METHODS: This study was performed on 190 morbidly obese patients referred to Hazrat Rasoul Hospital in Tehran. After LGBP, pain was measured in the following intervals: 24 hours, one week and one month after the operation. Before the operation onset, 2 mg Keflin and 5000 IU subcutaneous heparin were administered as prophylaxis. LGBP was performed using five ports including: one 11 mm port was placed 15-20 cm far from the xiphoid, one 12-mm port in mid-clavicular line at the level of camera port, one 5-mm port in subcostal area in ante-axillary region in the left, another 5-mm port in the right mid-clavicular area and a 5-mm port in sub-xyphoid. All operations were done by the same team. Staple was used for all anastomoses and hand sewn technique to close the staple insertion site. The mesenteric defect was left open and no effort was made to repair it. RESULTS: The results of this study showed that 99.94 % of the patients had complains of pain in the first 24 hours of post operation, about 60% after one week and 29.5 % still had pain after one month. In addition, left upper quadrant (LUQ) was found to be the most prevalent site for the pain in 53.7% of the patients in the first 24 hours, 59.6% after one week and 16.8% after one month (except for obscure pain) with a significance of < 0.05. CONCLUSIONS: In this study, the authors analyzed the location and disturbance level of pain after LGBP, which could serve as a cornerstone for further researches. The authors suggest that long-term follow-up (for more than a year after operation) should be considered in future studies and also the relationship between the drainage site and pain should be investigated.

Assessment of C-reactive Protein and C3 as Inflammatory Markers of Insulin Resistance in Women with Polycystic Ovary Syndrome: A Case-Control Study.

BACKGROUND: Polycystic ovary syndrome (PCOS), a common endocrine disorder, is associated with infertility, menstrual dysfunction, hirsutism and frequent miscarriages. Insulin resistance, as a major cause of PCOS, represents a disorder with increase in inflammatory markers and risk of type 2 diabetes. We aimed to investigate whether inflammatory markers, including C-reactive protein and C3 (Complement), are related and altered in polycystic ovary syndrome. METHODS: A case-control study including forty-two women diagnosed with PCOS, according to Rotterdam criteria, and forty-two healthy controls, matched for body mass index (BMI) and age, was conducted in 2012. C-Reactive protein (CRP) and C3 were assessed as possible determinants of the homeostasis model assessment (HOMA) index. Independent-sample t-test was used to compare the means of the groups in age, BMI, C3, FBS and BS 2hpp (2 hr postprandial glucose) and for CRP, Fasting Insulin and 2 hr Plasma Insulin and HOMA index. Mann-Whitney test and Pearson correlation were used for analyzing the data. The p<0.05 was considered as statistically significant. RESULTS: Levels of plasma CRP (p=0.039), 2 hr pp (p=0.045), Fasting Insulin (p=0.002), 2 hr Plasma Insulin (p=0.002) and HOMA index (p=0.002) were significantly higher in PCOS patients. But C3 was not significantly higher in cases (p=0.885). There was no significant correlation between C3 and CRP with HOMA index. CONCLUSION: CRP increased significantly in patients with PCOS and was associated with insulin resistance, the most probable cause of PCOS. However, such an association was not found in C3.