Monitoring for micronutrient deficiency after bariatric surgery-what is the risk?

BACKGROUND: Bariatric surgery may increase the risk of micronutrient deficiencies; however, confounders including preoperative deficiency, supplementation and inflammation are rarely considered. OBJECTIVE: To examine the impact of bariatric surgeries, supplementation and inflammation on micronutrient deficiency. SETTING: Two public hospitals, Australia. METHODS: Participants were recruited to an observational study monitoring biochemical micronutrient outcomes, supplementation dose, inflammation and glycaemic control, pre-operatively and at 1-3, 6 and 12 months after gastric bypass (GB; Roux-en-Y Gastric Bypass and Single Anastomosis Gastric Bypass; N = 66) or sleeve gastrectomy (SG; N = 144). Participant retention at 12 months was 81%. RESULTS: Pre-operative micronutrient deficiency was common, for vitamin D (29-30%), iron (13-22%) and selenium (39% GB cohort). Supplement intake increased after surgery; however, dose was <50% of target for most nutrients. After SG, folate was vulnerable to deficiency at 6 months (OR 13 [95% CI 2, 84]; p = 0.007), with folic acid supplementation being independently associated with reduced risk. Within 1-3 months of GB, three nutrients had higher deficiency rates compared to pre-operative levels; vitamin B1 (21% vs. 6%, p < 0.01), vitamin A (21% vs. 3%, p < 0.01) and selenium (59% vs. 39%, p < 0.05). Vitamin B1 deficiency was independently associated with surgery and inflammation, selenium deficiency with improved glycaemic control after surgery and inflammation, whilst vitamin A deficiency was associated with inflammation only. CONCLUSION: In the setting of prophylactic post-surgical micronutrient prescription, few nutrients are at risk of de novo deficiency. Although micronutrient supplementation and monitoring remains important, rationalising high-frequency biochemical testing protocols in the first year after surgery may be warranted.

Dietitian-led micronutrient management in a public bariatric surgery outpatient clinic.

AIMS: This study aimed to explore the multidisciplinary team attitudes and knowledge of bariatric surgery micronutrient management (pre- and postoperative care) and to evaluate the implementation of an extended-scope of practice dietitian-led model of care for micronutrient monitoring and management. METHODS: A mixed method study design included quantitative evaluation of micronutrient testing practices and deficiency rates. Qualitative reflexive thematic analysis was used to interpret multidisciplinary experience with micronutrient monitoring in a traditional and dietitian-led model of care. In addition, deductive analysis used normalisation process theory mapping of multidisciplinary experience with the implementation of the dietitian-led model of care. RESULTS: In the traditional model, a lack of quality evidence to guide micronutrient management, and a tension in trust between surgeons and patients related to adherence to micronutrient prescriptions were described as challenges in current practice. The dietitian-led model was seen to overcome some of these challenges, increasing collaborative, and coordinated, consistent and personalised patient care that led to increased testing for and detection of micronutrient deficiencies. Barriers to sustainability of the dietitian-led model included a lack of workforce succession planning, and no clearly defined delegation for some aspects of care. CONCLUSION: An extended scope dietitian-led model of care for micronutrient management after bariatric surgery improves clinical care. Challenges such as succession planning must be considered in design of extended scope services.

Five-year Comorbidity Outcomes in Laparoscopic Vertical Sleeve Gastrectomy (LVSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB): A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Laparoscopic vertical sleeve gastrectomy (LVSG) is now the most commonly performed bariatric procedure; however, it remains to be elucidated if it delivers equivalent long-term comorbid disease resolution outcomes similar to the longer established laparoscopic Roux-en-Y gastric bypass (LRYGB). We undertook a systematic review and meta-analysis of randomized controlled trials (RCTs) to investigate the comparative 5-year outcomes of both procedures. METHODS: Electronic databases (Pubmed, EMBASE, CINAHL) were searched for RCTs conducted in adults (>18y) that compared the 5-year- outcomes of LVSG to LRYGB and described comorbidity outcomes were included. Where data allowed, effect sizes were calculated using the Hartung-Knapp-Sidik-Jonkman estimation method for random effects model. Presence of bias was assessed with Cochrane Risk of Bias 2.0 and funnel plots, and certainty of evidence evaluated by GRADE. The study prospectively registered with PROSPERO (CRD42018112054). RESULTS: Three RCTs (LVSG=254, LRYGB=255) met inclusion criteria and reported on chronic disease outcomes. Improvement and/or resolution of hypertension favoured LRYGB (odds ratio 0.49, 95% CI 0.29, 0.84; P =0.03). Trends favoring LRYGB were seen for type 2 diabetes and dysplidemia, and LVSG for sleep apnea and back/joint conditions ( P >0.05). The certainty of evidence associated with each assessed outcome ranged from low to very low, in the setting of 'some' to 'high' bias assessed as being present. CONCLUSION: Both LRYGB and LVSG are effective in providing long-term improvements in commonly experienced obesity-related comorbidities; however, the limited certainty of the evidence does not allow for strong clinical conclusions to be made at this time regarding benefit of one procedure over the other.

Patient experiences with micronutrient and overall nutrition management after bariatric surgery: identifying facilitators and barriers to implementing care.

BACKGROUND: Adherence to perioperative guideline recommendations for prophylactic supplementation and regular biochemical monitoring is suboptimal. However, little is known about the patient perspective on this postoperative challenge. OBJECTIVES: To qualitatively explore patient experiences of postoperative micronutrient management and identify patient-reported barriers and facilitators to the provision of nutrition care. SETTING: Two tertiary public hospitals in Queensland, Australia. METHODS: Semi-structured interviews were conducted with 31 participants 12 months after bariatric surgery. Inductive analysis of interview transcripts was performed using applied thematic analysis, and deductive analysis was performed by aligning interview themes against the Theoretical Domains Framework and the Capability, Motivation, and Opportunity Behavior Change Wheel Framework. RESULTS: Participants' perceptions of engagement with the bariatric surgery multidisciplinary team greatly influenced their experience with overall nutrition care, including but not exclusive to micronutrient care. At times, this engagement negatively impacted patients' experiences with their nutrition care and related to varied acceptance of healthcare advice from the team or, at times, an unmet desire for person-centered communication styles. Engaging person-centered care techniques had a positive influence on patient experience with micronutrient and overall nutrition care. Micronutrient management (taking supplements and having regular blood tests) was broadly accepted and enabled by the presence of established medication and blood test routines preoperatively. However, challenges did exist and were practical in nature. Incorporating education on habit-forming techniques was identified as a facilitator to assist with micronutrient management. CONCLUSION: Although participants mostly accept embedding micronutrient management into their life, developing interventions that focus on habit-forming skills and that enable multidisciplinary teams to provide person-centered care is recommended to enhance care after surgery.

Micronutrient deficiency risk in long-term enterally fed patients: A systematic review.

BACKGROUND AND AIMS: The micronutrient status of those receiving long-term enteral nutrition (EN) is poorly characterised. This systematic review was undertaken to determine prevalence of micronutrient deficiency in those receiving EN; the impact of the route of feeding; whether underlying disease or clinical factors were associated with micronutrient status; and the efficacy of interventions utilised to treat identified micronutrient deficiency. METHODS: Electronic databases (CINAHL, Embase, PubMed, Web of Science) were searched to June 2021 for publications of primary investigation of micronutrient status in adults or children (>5yrs) receiving EN for >2 months in their usual residence. Independent assessment of compliance with inclusion criteria (Covidence®), data extraction of predefined data points, assessment of basis (Academy of Dietetics Quality Checklist) and certainty of evidence (GRADE) was assessed by at least two authors. (PROSPERO Registration: CRD42021261113). RESULTS: Thirty-one studies (n = 744) met inclusion criteria. Deficiency was reported for copper, zinc, selenium, beta-carotene, and vitamins A, D and E: Only copper, zinc and selenium were associated with physical/haematological manifestations of deficiency. Jejunal feeding was associated with the development of copper deficiency and often required gastric or parenteral replacement to resolve the issue. Circumstances leading to deficiency included receiving feed products formulated with inadequate amounts of the implicated nutrient, low feed product volumes in the context of low macronutrient requirements, and nutritional decline prior to commencement of EN. Potential confounding factors such as inflammation were rarely accounted for. No studies investigated the contribution of underlying clinical condition on micronutrient status, and no other clinical or demographic features appeared to impact outcomes. Reported methods for treating identified deficiencies were usually successful in reversing deficiency symptoms. The certainty of evidence is very low, and the level of bias moderate to high. CONCLUSION: While the evidence is very uncertain about the effect of long-term enteral feeding on the development of micronutrient deficiencies, clinicians should be alert to the possibility of micronutrient deficiency developing in long-term EN fed patients. Those who may be at increased risk are those receiving nutrition into the jejunum, those who meet macronutrient requirements in low volumes of EN product, and those commencing EN in a nutritionally deplete state. Further research and surveillance of micronutrient status with contemporary EN products and practices is required.

Late (≥5 y) Complications of Laparoscopic Vertical Sleeve Gastrectomy (LVSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB): A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: There is a paucity of data that compares the relative complication profiles of laparoscopic vertical sleeve gastrectomy (LVSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) at 5 years. OBJECTIVES: The aim was to compare late complications of LVSG and LRYGB. METHODS: We updated our previous systematic review and meta-analysis of randomized controlled trials of primary LVSG and LRYGB procedures in adults, to review late (5 years) complication outcomes (PROSPERO 112054). Electronic databases were searched from January 2015 to July 2021 for publications meeting inclusion criteria. The Hartung-Knapp-Sidik-Jonkman random effects model was utilized to estimate weighted mean differences where meta-analysis was possible. Bias and certainty of evidence was assessed using the Cochrane risk of bias tool and Grading of Recommendations, Assessment, Development and Evaluations. RESULTS: Four randomized controlled trials met the inclusion criteria (n=531; LVSG=272, LRYGB=259). No late treatment-related mortality was reported with either procedure. A significant reduction in surgical reoperations (odds ratio: 0.47, 95% confidence interval: 0.27-0.82, P =0.01) and endoscopic interventions (odds ratio: 0.29, 95% confidence interval: 0.12-0.71, P =0.02) were reported at 5 years post-LVSG relative to LRYGB. Reoperations were more frequently performed for reflux management in LVSG and for internal hernia repairs in LRYGB. Complications requiring medical management were common following both procedures. Limitations included few eligible studies for inclusion, and varying definitions of medically managed complications. CONCLUSIONS: LRYGB is associated with a higher proportion of surgical and endoscopic interventions at 5 years compared with LVSG. More high-quality, long-term studies are required to further elucidate both surgical and nutritional long-term outcomes post these procedures.

Revisiting the Evidence for the Reuse of Enteral Feeding Equipment in Ambulatory Patients: A Systematic Review.

BACKGROUND: The reuse of enteral tube feeding (ETF) equipment is not recommended due to the risk of microbial contamination and subsequent risk of infection; however, this practice continues in many ambulatory settings. A systematic review of the literature was undertaken to review the evidence underpinning the cleaning and reuse of ETF equipment. METHODS: Studies that investigated the reuse, decontamination, and/or cleaning of ETF equipment were considered for inclusion. Electronic databases were searched (no limits were placed on date of publication, age, or duration of reuse). Extracted data were assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. RESULTS: Ten studies met inclusion criteria: 3 investigated changes to clinical outcomes with extending reuse from 24 to ≤72 hours using water rinses; 5 considered the efficacy of various cleaning methods assessed in laboratory conditions; 2 used a combination of both approaches. Sufficient data to allow GRADE assessment was found only for bottle-type containers. CONCLUSIONS: A very low level of evidence supports the cleaning and reuse of rigid and "unspecified" bottle containers; no studies were found to inform the reuse of syringes used for bolus feeding or any equipment used for water infusion or flushes. There is an absence of literature evaluating the safety and clinical outcomes of cleaning and reusing ETF equipment, and research is required to support equipment reuse.

Five-Year Weight Loss Outcomes in Laparoscopic Vertical Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Procedures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Laparoscopic vertical sleeve gastrectomy (LVSG) has overtaken the laparoscopic Roux-en-Y gastric bypass (LRYGB) as the most frequently performed bariatric surgical procedure. To date little has been reported on the long-term outcomes of the LVSG procedure comparative to the traditionally favoured LRYGB. We undertook a systematic review and meta-analysis to review the 5-year outcomes of comparing LVSG and LRYGB. We undertook a systematic review and meta-analysis to compare 5-year weight loss outcomes of randomized controlled trials comparing LVSG to LRYGB. MATERIALS AND METHODS: Searches of electronic databases (PubMed, Embase, CINAHL, Cochrane) were undertaken for randomized controlled trials describing weight loss outcomes in adults at 5 years postoperatively. Where sufficient data was available to undertake meta-analysis, the Hartung-Knapp-Sidik-Jonkman estimation method for random effects model was utilized. The review was registered with PROSPERO and reported following in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS: Five studies met the inclusion criteria totaling 1028 patients (LVSG=520, LRYGB=508). Moderate but comparable levels of bias were observed within studies. Statistically significant body mass index loss ranged from -11.37 kg/m (range: -6.3 to -15.7 kg/m) in the LVSG group and -12.6 kg/m (range: -9.5 to -15.4 kg/m) for LRYGB at 5 years (P<0.001). Systematic review suggested that LRYGB produced a greater weight loss expressed as percent excess weight and percent excess body mass index loss than LVSG: this was not corroborated in the meta-analysis. CONCLUSIONS: Five year weight loss outcomes suggest both LRYGB and LVSG are effective in achieving significant weight loss at 5 years postoperatively, however, differences in reporting parameters limit the ability to reliably compare the outcomes using statistical methods. Furthermore, results may be impacted by large dropout rates and per protocol analysis of the 2 largest included studies. Further long-term studies are required to contradict or validate the results of this meta-analysis.

A framework to support quality of care for patients with chronic intestinal failure requiring home parenteral nutrition.

BACKGROUND AND AIM: Chronic intestinal failure requiring home parenteral nutrition (HPN) is a disabling condition that is best facilitated by a multidisciplinary approach to care. Variation in care has been identified as a key barrier to achieving quality of care for patients on HPN and requires appropriate strategies to help standardize management. METHOD: The Australasian Society for Parenteral and Enteral Nutrition (AuSPEN) assembled a multidisciplinary working group of 15 clinicians to develop a quality framework to assist with the standardization of HPN care in Australia. Obstacles to quality care specific to Australia were identified by consensus. Drafts of the framework documents were based on the available literature and refined by two Delphi rounds with the clinician work group, followed by a further two involving HPN consumers. The Oxford Centre for Evidence-Based Medicine Levels of Evidence was used to assess the strength of evidence underpinning each concept within the framework documents. RESULTS: Quality indicators, standards of care, and position statements have been developed to progress the delivery of quality care to HPN patients. CONCLUSION: The quality framework proposed by AuSPEN is intended to provide a practical structure for clinical and organizational aspects of HPN service delivery to reduce variation in care and improve quality of care and represents the initial step towards development of a national model of care for HPN patients in Australia. While developed for implementation in Australia, the evidence-based framework also has relevance to the international HPN community.

Australasian society for parenteral and enteral nutrition (AuSPEN) adult vitamin guidelines for parenteral nutrition.

BACKGROUND AND OBJECTIVES: This work represents the second part of a progressive review of AuSPEN's 1999 Guidelines for Provision of Micronutrient Supplementation in adult patients receiving parenteral nutrition. METHODS AND STUDY DESIGN: A systematic literature review was undertaken and recommendations made based on the available evidence and with consideration to specific elements of the Australian and New Zealand (NZ) practice environment. The strength of evidence underpinning each recommendation was assessed. A multidisciplinary steering committee and external reviewers provided feedback on the guidelines. RESULTS: On review of the available literature it appears that the parenteral multivitamin preparations presently available in Australia and NZ are to sufficient avoid deficiency without causing toxicity in most clinical situations for adults receiving PN when provided regularly as part of the PN prescription. Vitamin D is the most vulnerable vitamin for the Australian and NZ PN population. CONCLUSIONS: Vitamins are an essential component of PN and should be provided from commencement for all patients receiving PN. With the exception of vitamin D, which is recommended to be monitored annually, routine monitoring of vitamin levels is unlikely to be necessary in patients receiving regular parenteral multivitamin preparations. Clinical judgement is an important element when assessing, prescribing and monitoring patients receiving PN. Areas requiring further research have been identified.

Commercial Very Low Energy Meal Replacements for Preoperative Weight Loss in Obese Patients: a Systematic Review.

BACKGROUND: This systematic review assessed feasibility and effectiveness of preoperative meal replacements to improve surgical outcomes for obese patients. METHODS: PRISMA guidelines were followed and electronic databases searched for articles between January 1990 and March 2015. RESULTS: Fifteen studies (942 participants including 351 controls) were included, 13 studies (n = 750) in bariatric patients. Adverse effects and dropout rates were minimal. Ten out of 14 studies achieved 5-10 % total weight loss. Six of six studies reporting liver volume achieved 10 % reduction. Endpoints for perioperative risks and outcomes were too varied to support definitive risk benefit. CONCLUSIONS: Commercial meal replacements are feasible, have minimal side effects and facilitate weight loss and liver shrinkage in free-living obese patients awaiting elective surgery. A reduction in surgical risk is unclear.

Australasian Society for Parenteral and Enteral Nutrition guidelines for supplementation of trace elements during parenteral nutrition.

BACKGROUND: This work represents the first part of a progressive review of AuSPEN's 1999 Guidelines for Provision of Micronutrient Supplementation in Adult Patients receiving Parenteral Nutrition, in recognition of the developments in the literature on this topic since that time. METHODS: A systematic literature review was undertaken and recommendations were made based on the available evidence and with consideration to specific elements of the Australian and New Zealand practice environment. The strength of evidence underpinning each recommendation was assessed. External reviewers provided feedback on the guidelines using the AGREE II tool. RESULTS: Reduced doses of manganese, copper, chromium and molybdenum, and an increased dose of selenium are recommended when compared with the 1999 guidelines. Currently the composition of available multi-trace element formulations is recognised as an obstacle to aligning these guidelines with practice. A paucity of available literature and limitations with currently available methods of monitoring trace element status are acknowledged. The currently unknown clinical impact of changes to trace element contamination of parenteral solutions with contemporary practices highlights need for research and clinical vigilance in this area of nutrition support practice. CONCLUSIONS: Trace elements are essential and should be provided daily to patients receiving parenteral nutrition. Monitoring is generally only required in longer term parenteral nutrition, however should be determined on an individual basis. Industry is encouraged to modify existing multi-trace element solutions available in Australia and New Zealand to reflect changes in the literature outlined in these guidelines. Areas requiring research are highlighted.

Early postoperative feeding in resectional gastrointestinal surgical cancer patients.

Malnutrition is present in the majority of patients presenting for surgical management of gastrointestinal malignancies, due to the effects of the tumour and preoperative anti-neoplastic treatments. The traditional practice of fasting patients until the resumption of bowel function threatens to further contribute to the malnutrition experienced by these patients. Furthermore, the rationale behind this traditional practice has been rendered obsolete through developments in anaesthetic agents and changes to postoperative analgesia practices. Conversely, there is a growing body of literature that consistently demonstrates that providing oral or tube feeding proximal to the anastomosis within 24 h postoperatively, is not only safe, but might be associated with significant benefits to the postoperative course. Early post operative feeding should therefore be adopted as a standard of care in oncology patients undergoing gastrointestinal resections.

Magnetic resonance imaging and spectroscopy for monitoring liver steatosis.

PURPOSE: To compare noninvasive MRI and magnetic resonance spectroscopy (MRS) methods with liver biopsy to quantify liver fat content. MATERIALS AND METHODS: Quantification of liver fat was compared by liver biopsy, proton MRS, and MRI using in-phase/out-of-phase (IP/OP) and plus/minus fat saturation (+/-FS) techniques. The reproducibility of each MR measure was also determined. An additional group of overweight patients with steatosis underwent hepatic MRI and MRS before and after a six-month weight-loss program. RESULTS: A close correlation was demonstrated between histological assessment of steatosis and measurement of intrahepatocellular lipid (IHCL) by MRS (r(s) = 0.928, P < 0.0001) and MRI (IP/OP r(s) = 0.942, P < 0.0001; FS r(s) = 0.935, P < 0.0001). Following weight reduction, four of five patients with >5% weight loss had a decrease in IHCL of >or=50%. CONCLUSION: These findings suggest that standard MRI protocols provide a rapid, safe, and quantitative assessment of hepatic steatosis. This is important because MRS is not available on all clinical MRI systems. This will enable noninvasive monitoring of the effects of interventions such as weight loss or pharmacotherapy in patients with fatty liver diseases.

Obesity management in liver clinics: translation of research into clinical practice.

BACKGROUND AND AIMS: Despite the benefits of modest weight reduction for overweight patients with chronic liver disease, long-term maintenance of weight loss is difficult to achieve in clinical practice. The aims of this study were to determine if a nutrition research protocol could be translated into clinical practice and meet the demand for dietetic service, to evaluate the effectiveness and resource implications of intensive lifestyle intervention for weight loss, and to assess the effectiveness of standard dietetic therapy as a treatment option for patients unable to attend the program. METHOD: Using a modified research protocol, an intensive weight reduction program was introduced into standard clinical care for overweight patients attending a tertiary hospital liver outpatient clinic. An audit of weight loss and cost outcomes was conducted. RESULTS: Ninety-three patients were referred to the dietetic service for weight management. Of these, 50 enrolled in an intensive lifestyle intervention, 18 received standard dietetic therapy and 25 refused any intervention. After 6 months, 83% of patients in the intensive intervention achieved weight loss with a significant decrease in weight (P < 0.001) and waist circumference (P < 0.001). In contrast, only 24% of patients receiving standard dietetic therapy achieved weight loss with no significant change in mean weight or waist circumference. Cost per kilogram weight loss after intensive intervention was $AU31 and continuation of lifestyle intervention was calculated to be less than $AU100 per patient per year. CONCLUSIONS: A clinically based, intensive lifestyle intervention is a feasible treatment option for outpatient weight management in overweight patients with chronic liver disease. Providing patients who are unable to participate in intensive programs with standard dietetic therapy is not cost-effective.