Anal incontinence incidence is high in patients with obesity prior to bariatric surgery: Prevalence, risks-factors.

INTRODUCTION: Anal incontinence (AI) prevalence in general population is estimate to range from 1.4 to 19.5% (Wexner ≥ 1). Obesity could be an AI risk factor. However, AI prevalence in patients with obesity is not clearly established. The main objective of this study was to assess the prevalence of AI in patients with extreme obesity prior to bariatric surgery and to identify specific AI risk factors in this subset of patients. MATERIAL: A cross-sectional study, in a tertiary referral center in obesity was performed during one year. Patients who presented criteria for bariatric surgery (BMI>40 or BMI > 35 with co-morbidities) were asked to fill in preoperative self-questionnaires. A Wexner score ≥ 3 was used to define AI to identified patients who had a clinic impact of AI, by frequency of symptoms or alteration of quality of life. RESULTS: Two hundred and fifty patients were included. Corresponded to, 196 women (78.4%) and 54 men (21.6%). Median BMI was 44.53kg/m2. AI was diagnosed in 41 patients (prevalence 16.4%, 95CI 0.59). Constipation, urinary incontinence and the history of pregnancy (P = 0.03, OR 2.79; P = 0.01, OR 3.53 and P=0.02, OR 4.71, respectively) were significantly associated with AI. CONCLUSION: AI is frequently observed in patients with extreme obesity scheduled for bariatric surgery and should be routinely evaluated. Modifiable risk factors as constipation should be manage before surgery as well as the specific management of AI, to prevent AI exacerbation after surgery. The choice of bariatric surgical procedure should be discussed and evaluated for the treatment of patients with obesity and AI. LEVEL OF EVIDENCE: Moderate.

Recommendations for nutritional care after bariatric surgery: Recommendations for best practice and SOFFCO-MM/AFERO/SFNCM/expert consensus.

Nutritional care after bariatric surgery is an issue of major importance, especially insofar as risk of deficiency has been extensively described in the literature. Subsequent to the deliberations carried out by a multidisciplinary working group, we are proposing a series of recommendations elaborated using the Delphi-HAS (official French health authority) method, which facilitates the drawing up of best practice and consensus recommendations based on the data of the literature and on expert opinion. The recommendations in this paper pertain to dietary management and physical activity, multivitamin and trace element supplementation and the prevention and treatment of specific deficiencies in vitamins B1, B9, B12, D and calcium, iron, zinc, vitamins A, E and K, dumping syndrome and reactive hypoglycemia.

Six-month outcomes of teduglutide treatment in adult patients with short bowel syndrome with chronic intestinal failure: A real-world French observational cohort study.

BACKGROUND & AIMS: Teduglutide, a GLP-2-analog, has proven effective in two placebo-controlled studies in reducing parenteral support (PS) in patients with short bowel syndrome-associated intestinal failure (SBS-IF) after 24 weeks. The aim of this study was to describe in a real-life situation the effects of teduglutide treatment and their predictive factors. METHODS: We included 54 consecutive SBS-IF patients treated with teduglutide in France for at least 6 months from 10 expert centers. Small bowel length was 62 ± 6 cm and 65% had colon in continuity. PS was 4.4 ±0 .2 infusions per week, started 9.8 ± 1.2 years before. Response (PS reduction ≥ 20%) and PS discontinuation rates were assessed at week 24. Adjusted p values of factors associated with response and weaning were calculated using a multivariate logistic regression model. RESULTS: At week 24, 85% of patients were responders and 24% had been weaned off PS, with a 51% reduction of PS needs and 1.5 ± 0.2 days off PS per week. Response to teduglutide was influenced by a higher baseline oral intake (p = 0.02). Weaning off PS was influenced by the presence of colon (p = 0.04), a lower PS volume (p = 0.03) and a higher oral intake (p = 0.01). There were no differences based on age, bowel length or SBS-IF causes. CONCLUSIONS: Our study confirms the effectiveness of teduglutide in reducing PS needs in SBS-IF patients. We associated reduced parenteral support volume with baseline parenteral volume support, bowel anatomy, and oral intake. These findings underline the role of nutritional optimization when starting the treatment.

Evaluation of risk factors for complications after bariatric surgery.

The decision to perform a bariatric surgical procedure, the conclusion of a clinical pathway in which management is individually adapted to each patient, is taken after multidisciplinary consultation. Paradoxically, the patients who would most benefit from surgery are also those who have the highest operative risk. In practice, predictive factors of mortality and severe postoperative complications (Clavien-Dindo>III) must be used to evaluate the benefit/risk ratio most objectively. The main risk factors are age, male gender, body mass index, obstructive sleep apnea syndrome, insulin resistance and diabetes, tobacco abuse, cardiovascular disease, ability to lose weight before surgery, hypoalbuminemia and functional disability. Routine preoperative evaluation of high perioperative risk patients provides the attending physician with information to: (1) correct several of these risk factors before surgery and thereby limit the operative risk; (2) orient the patient to a less risky surgical procedure and/or to a facility with a more adapted technical capacity, as necessary; (3) contra-indicate the operation if the risks exceed the expected benefits. All in all, this preoperative evaluation combined with management of comorbidities contributes to decrease the risk of postoperative complications and to improve the overall management of obese patients.

Carotenoid deficiency in chronic pancreatitis: the effect of an increase in tomato consumption.

BACKGROUND/OBJECTIVES: Carotenoids are potentially malabsorbed in patients with chronic pancreatitis (CP). The aims of this study were: (1) to determine the prevalence of low levels of each of the major carotenoids in subjects with CP; (2) to compare carotenoids in CP subjects with or without vascular disease and (3) to test the effect of an increase in dietary lycopene intake in patients with low plasma lycopene concentration. SUBJECTS/METHODS: Simultaneous determination of carotenoids was done in 80 patients with CP and 20 healthy subjects, using high-performance liquid chromatography. Of the CP patients who had low lycopene concentration, 22 (<120 µg/l) had to consume daily 40 g tomato paste (approximately 24 mg lycopene). RESULTS: Of these patients, 84.7% had at least one carotenoid deficiency and 27.5% had more than four carotenoid deficiencies. Low plasma concentrations in ß-carotene and lycopene were correlated, in CP group, with a low body mass index (BMI), a low low-density lipoprotein (LDL) cholesterol concentration, alcohol consumption and current smoking status, whereas low plasma concentration in ß-cryptoxanthine was correlated with a low BMI, a low LDL cholesterol concentration and alcohol consumption. Lycopene concentration was decreased in patients with vascular disease (171±197 vs 99±72 µg/l; P=0.02). After an intervention period of 8±2 months, lycopene concentration increased from 67.5±30 to 121.8±102 µg/l (P=0.025). CONCLUSION: Carotenoid concentrations are dramatically decreased in CP, especially lycopene in CP patients with vascular disease. Despite malabsorption, it is possible to increase lycopene plasma concentration by increasing heated tomato consumption.

Medical follow up after bariatric surgery: nutritional and drug issues. General recommendations for the prevention and treatment of nutritional deficiencies.

This review is an update of the long-term follow-up of nutritional and metabolic issues following bariatric surgery, and also discusses the most recent guidelines for the three most common procedures: adjustable gastric bands (AGB); sleeve gastrectomy (SG); and roux-en-Y gastric bypass (GBP). The risk of nutritional deficiencies depends on the percentage of weight loss and the type of surgical procedure performed. Purely restrictive procedures (AGB, SG), for example, can induce digestive symptoms, food intolerance or maladaptative eating behaviours due to pre- or postsurgical eating disorders. GBP also has a minor malabsorptive component. Iron deficiency is common with the three types of bariatric surgery, especially in menstruating women, and GBP is also associated with an increased risk of calcium, vitamin D and vitamin B12 deficiencies. Rare deficiencies can lead to serious complications such as encephalopathy or protein-energy malnutrition. Long-term problems such as changes in bone metabolism or neurological complications need to be carefully monitored. In addition, routine nutritional screening, recommendations for appropriate supplements and monitoring compliance are imperative, whatever the bariatric procedure. Key points are: (1) virtually routine mineral and multivitamin supplementation; (2) prevention of gallstone formation with the use of ursodeoxycholic acid during the first 6 months; and (3) regular, life-long, follow-up of all patients. Pre- and postoperative therapeutic patient education (TPE) programmes, involving a new multidisciplinary approach based on patient-centred education, may be useful for increasing patients'long-term compliance, which is often poor. The role of the general practitioner has also to be emphasized: clinical visits and follow-ups should be monitored and coordinated with the bariatric team, including the surgeon, the obesity specialist, the dietitian and mental health professionals.

What is the quality of information about bariatric surgery on the internet?

BACKGROUND: The purpose of this study was to evaluate the role of Internet on patients scheduled for bariatric procedures and the quality of information available on different websites. METHODS: Between July 2003 to July 2005, patients undergoing bariatric surgical procedures completed a survey. Data were collected prospectively. One hundred valid surveys were returned. Independently, two bariatric surgeons evaluated available French and English websites using major search engines. RESULTS: Forty-two of 100 patients (42%) sought information about bariatric surgery on the Internet. Seventy-four percent of these patients (n = 31/42) used search engines with 81% visiting less than ten websites. According to the patient's evaluation, 58% of the websites visited did not provide technical details of any surgical bariatric procedures, and only 61% provided information regarding postoperative weight loss. Furthermore, 58% of websites did not provide information about the laparoscopic approach, and 54% did not give any information on potential postoperative complications. Bariatric surgeon's evaluation was similar except for two differences: laparoscopic approach and postoperative weight loss information were discussed in 90% (p < 0.001) and 43% (p < 0.1) of visited websites, respectively. CONCLUSION: When the Internet was used to search for information about bariatric surgery, search engines were preferentially used but search duration was short. Available Internet websites can be considered as moderately reliable; however, 25% of visited websites contain misleading information. Comparison between patients and surgeons views showed that patients were effective in detecting misleading information.

Potential involvement of adipocyte insulin resistance in obesity-associated up-regulation of adipocyte lysophospholipase D/autotaxin expression.

AIMS/HYPOTHESIS: Autotaxin is a lysophospholipase D that is secreted by adipocytes and whose expression is substantially up-regulated in obese, diabetic db/db mice. The aim of the present study was to depict the physiopathological and cellular mechanisms involved in regulation of adipocyte autotaxin expression. METHODS: Autotaxin mRNAs were quantified in adipose tissue from db/db mice (obese and highly diabetic type 2), gold-thioglucose-treated (GTG) mice (highly obese and moderately diabetic type 2), high-fat diet-fed (HFD) mice (obese and moderately diabetic type 2), streptozotocin-treated mice (thin and diabetic type 1), and massively obese humans with glucose intolerance. RESULTS: When compared to non-obese controls, autotaxin expression in db/db mice was significantly increased, but not in GTG, HFD, or streptozotocin-treated mice. During db/db mice development, up-regulation of autotaxin occurred only 3 weeks after the emergence of hyperinsulinaemia, and simultaneously with the emergence of hyperglycaaemia. Adipocytes from db/db mice exhibited a stronger impairment of insulin-stimulated glucose uptake than non-obese and HFD-induced obese mice. Autotaxin expression was up-regulated by treatment with TNFalpha (insulin resistance-promoting cytokine), and down-regulated by rosiglitazone treatment (insulin-sensitising compound) in 3T3F442A adipocytes. Finally, adipose tissue autotaxin expression was significantly up-regulated in patients exhibiting both insulin resistance and impaired glucose tolerance. CONCLUSIONS/INTERPRETATION: The present work demonstrates the existence of a db/db-specific up-regulation of adipocyte autotaxin expression, which could be related to the severe type 2 diabetes phenotype and adipocyte insulin resistance, rather than excess adiposity in itself. It also showed that type 2 diabetes in humans is also associated with up-regulation of adipocyte autotaxin expression.

Phytosterols have an unfavourable effect on bacterial activity and no evident protective effect on colon carcinogenesis.

The effects of physiological dietary phytosterol supplements on intestinal microflora activity and faecal sterols and their capacity to protect rats fed a normal or high saturated fatty-acid diet against tumour development were studied. A group of 80 female Wistar rats were fed an 8% lipid diet for 4 weeks (adaptation period) and then randomly assigned in a factorial experimental design study to diets containing 8% or 24% hydrogenated coconut oil, with or without a 24-mg/day/rat phytosterol supplement. They were instilled intrarectally with saline or methyl-nitroso-urea (MNU). Faecal sterol output was analysed for one week each month. Pathological analysis was done at the end of the 30-week experiment. Animals treated with MNU and given phytosterol supplements had tumour frequencies (8/20) similar to those not fed phytosterols (11/20). The fat-supplemented diet had no significant influence. Colonic glands were found in area of lymphoid follicles in all the groups, but were more frequent in rats on high-fat diets (P < 0.01). The coprostanol and the cholesterol excretion of the phytosterol-supplemented rats was significantly enhanced. Therefore phytosterols have an unfavourable effect on bacterial activity. These data confirm the capacity of phytosterols to decrease cholesterol absorption, but indicate that a large excess of phytosterol must be avoided until further research on its effects on carcinogenesis has been done.

Detection of moderate hyperhomocysteinemia: comparison of the Abbott fluorescence polarization immunoassay with the Bio-Rad and SBD-F high-performance liquid chromatographic assays.

The importance of accurate methods for homocysteine measurement has been emphasized. We compared the results obtained with the most commonly used high-performance liquid chromatography (HPLC) assay, and two recently commercially available methods: another HPLC and a fluorescence polarization immunoassay, in plasmas from normo- or hyperhomocysteinemic patients. A significant agreement between the different methods in classifying the results as hyper or normal-homocysteinemia was observed. However, a significant difference between the results was found. Standardization is urgently necessary to improve the concordance of homocysteine determination.

Influence of a high-calcium carbonate diet on the incidence of experimental colon cancer in rats.

This study was done to determine whether a high dietary calcium carbonate concentration could protect against colon tumors in rats. Female Wistar rats were randomly assigned to one of four groups and maintained on an 8% lipid diet for an adaptation period of four weeks. All groups were then fed a 24% lipid diet (sunflower oil), with (Groups 2 and 4) or without (Groups 1 and 3) a 1.5% calcium carbonate supplement. They were intrarectally instilled with saline (Groups 1 and 2) or nitrosomethylurea (NMU) (Groups 3 and 4). Fecal sterol output and pH were analyzed for one week each month. Histological analysis was done at the end of the 32-week experiment. No tumors were found in the non-NMU-treated animals. The NMU-treated rats had tumors: 31% in Group 3 and 30% in Group 4. The calcium carbonate supplement had no effect on this incidence. The lipid and cholesterol excretions of the calcium carbonate-supplemented rats were significantly enhanced. The coprostanol output was not altered, although its fecal concentration of the calcium-supplemented rats was decreased. Although neither lipid overload nor NMU treatment altered the fecal pH, it was significantly increased in both calcium carbonate-supplemented groups. These findings suggest that additional calcium as carbonate has no effect on colon tumor incidence, although the fecal composition is altered. The increased pH of the feces due to the carbonate could have the opposite effect to calcium.