Bariatric surgery and type 2 diabetes.

Type 2 diabetes is primarily managed with lifestyle modifications, self-monitoring of blood glucose, and medication. The goal is to maintain A1C less than 7% in most patients and prevent damage to other organs such as the kidneys and heart. Patients who are obese and cannot achieve normal blood glucose levels despite diet, exercise, and multiple medications may be considered for bariatric surgery. The Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy have been shown to improve A1C, reduce weight, and reduce the number of medications patients need for diabetes management. Comorbidities such as hyperlipidemia and hypertension also may improve. This article describes types of bariatric surgery, proper selection of surgical candidates, patient education, and the postoperative patient management necessary for long-term success in improving blood glucose control.

Etiology and Medical Management of Pediatric Intestinal Failure.

Pediatric intestinal failure occurs when gut function is insufficient to meet the growing child's hydration and nutrition needs. After massive bowel resection, the remnant bowel adapts to lost absorptive and digestive capacity through incompletely defined mechanisms newly targeted for pharmacologic augmentation. Management seeks to achieve enteral autonomy and mitigate the development of comorbid disease. Care has improved, most notably related to reductions in blood stream infection and liver disease. The future likely holds expansion of pharmacologic adaptation augmentation, refinement of intestinal tissue engineering techniques, and the development of a learning health network for efficient multicenter study and care improvement.

Severe malnutrition after bariatric surgery and clinic manifestations of infection.

This report describes the post-bariatric-surgery evolution of an obese patient who had low adherence to the diet and micronutrient supplementation. Four years after two bariatric surgeries, the patient was admitted due to transient loss of consciousness, slow thinking, anasarca, severe hypoalbuminemia, in addition to vitamin and mineral deficiencies. She had subcutaneous foot abscess but did not present fever. Received antibiotics, vitamins A, D, B12, thiamine, calcium, and parenteral nutrition. After hospitalization (twenty-eight days), there was a significant body weight reduction probably due to the disappearance of clinical anasarca. Parenteral nutrition was suspended after twenty-five days, and the oral diet was kept fractional. After hospitalization (weekly outpatient care), there was a gradual laboratory data improvement, which was now close to the reference values. Such outcome shows the need for specialized care in preventing and treating nutritional complications after bariatric surgeries as well as clinical manifestations of infection in previously undernourished patients.

Severe malnutrition after bariatric surgery and clinic manifestations of infection

SUMMARY This report describes the post-bariatric-surgery evolution of an obese patient who had low adherence to the diet and micronutrient supplementation. Four years after two bariatric surgeries, the patient was admitted due to transient loss of consciousness, slow thinking, anasarca, severe hypoalbuminemia, in addition to vitamin and mineral deficiencies. She had subcutaneous foot abscess but did not present fever. Received antibiotics, vitamins A, D, B12, thiamine, calcium, and parenteral nutrition. After hospitalization (twenty-eight days), there was a significant body weight reduction probably due to the disappearance of clinical anasarca. Parenteral nutrition was suspended after twenty-five days, and the oral diet was kept fractional. After hospitalization (weekly outpatient care), there was a gradual laboratory data improvement, which was now close to the reference values. Such outcome shows the need for specialized care in preventing and treating nutritional complications after bariatric surgeries as well as clinical manifestations of infection in previously undernourished patients.

RESUMO Este relato descreve a evolução pós-cirurgia bariátrica de uma paciente obesa que apresentou baixa adesão à dieta e suplementação de micronutrientes. Quatro anos após duas cirurgias bariátricas, a paciente foi internada por perda transitória de consciência, raciocínio lento, anasarca, hipoalbuminemia grave, além de deficiências vitamínicas e minerais. Apresentava abscesso subcutâneo no pé, mas não apresentava febre. Recebeu antibióticos, vitaminas A, D, B12, tiamina, cálcio e nutrição parenteral. Após a internação (28 dias) houve redução significativa do peso corporal, provavelmente devido ao desaparecimento clínico da anasarca. A nutrição parenteral foi suspensa após 25 dias e a dieta oral foi mantida fracionada. Após a internação (atendimento ambulatorial semanal) houve uma melhora gradativa dos dados laboratoriais, que estavam próximos dos valores de referência. Tal desfecho mostra a necessidade de cuidados especializados na prevenção e tratamento de complicações nutricionais após cirurgias bariátricas, bem como manifestações clínicas de infecção em pacientes previamente desnutridos.

Nutritional and vitamin status in patients with neuroendocrine neoplasms.

Symptoms of gastroenteropancreatic located neuroendocrine neoplasms (GEP-NENs) are often related to food intake and manifest as abdominal pain or diarrhoea which can influence patients nutritional status. Malnutrition is common in cancer patients and influences quality of life, treatment options and survival but is also present in up to 40% of patients with GEP-NENs. As part of malnutrition there are often deficiencies in fat-soluble vitamins, mainly vitamin D. Little knowledge exists on trace elements. Several factors influence the development of malnutrition such as size and localisation of the primary tumour as well as metastases, side effects from treatment but also hormone production of the tumour itself. One of the main influencing factors leading to malnutrition is diarrhoea which leads to dehydration and electrolyte disturbances. Treatment of diarrhoea should be guided by its cause. Screening for malnutrition should be part of routine care in every GEP-NEN patient. Multidisciplinary treatment including dietician support is necessary for all malnourished patients with GEP-NENs.

Chronic Complications of Cholestasis: Evaluation and Management.

Patients with primary biliary cholangitis (PBC) are at risk for various harmful consequences of chronic cholestasis. These include fat-soluble vitamin deficiency, even in the setting of macronutrient sufficiency, as well as metabolic bone disease, including osteoporosis with fractures. Hyperlipidemia is often present and less commonly associated with risk of cardiovascular event; however, the long-term effect of new emerging therapies for PBC remains to be determined. Patients with PBC also have infrequent but notable risk of portal hypertension despite early-stage disease. This review discusses the background, evaluation, and practical management of these complications of chronic cholestasis.

Treatment of Vitamin and Mineral Deficiencies After Biliopancreatic Diversion With or Without Duodenal Switch: a Major Challenge.

BACKGROUND: Vitamin and mineral deficiencies are a major concern after biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS). Evidence-based guidelines how to prevent or how to treat deficiencies in these patients are currently lacking. The aim of the current study is to give an overview of postsurgical deficiencies and how to prevent and treat these deficiencies. METHODS: Retrospective evaluation of a 1-year structured monitoring and treatment schedule for various deficiencies in 34 patients after BPD or BPD/DS. RESULTS: Patients were introduced into the program 12-90 months after surgery. Vitamin B1, B6, B9, and B12 deficiencies could be prevented by mean daily doses of 2.75 mg, 980 µg, 600 µg, and 350 µg, respectively. However, many patients continued to develop deficiencies of vitamin A, D, iron, calcium, and zinc despite major dose adjustments. Current observations suggest that at least total daily doses of 200 mg Fe in premenopausal women and 100 mg in men, 100 mg of Zinc, 3000 mg of calcium, and weekly doses of at least 50,000 IU solubilized vitamin A and vitamin D are needed to prevent the occurrence of major deficiencies. CONCLUSION: Exceptionally high supplementation doses are needed to prevent and treat vitamin and mineral deficiencies in patients after BPD or BPD/DS. Further refinement and simplification of treatment schedules is needed. Focus on improvement of compliance to treatment is recommended.

Fat-soluble Vitamin Deficiencies and Inflammatory Bowel Disease: Systematic Review and Meta-Analysis.

BACKGROUND: Vitamin deficiency is frequently associated with inflammatory bowel disease (IBD). Supplementation of vitamins could thus serve as an adjunctive therapy. The present meta-analysis reviews the deficiencies and alterations in serum fat-soluble vitamins (A, D, E, and K) reported in IBD patients. MATERIALS AND METHODS: PubMed database search was performed to identify all primary studies up to January 2015 that evaluated the serum concentrations of fat-soluble vitamin levels in IBD patients compared with healthy individuals. We estimated pooled mean differences between groups and estimated their relations with some compounding variables (age, disease duration, C-reactive protein, albumin), using a meta-regression analysis. RESULTS: Nineteen case-control studies met selection criteria. In patients with Crohn's disease (CD), vitamin A, D, E, K status was lower than in controls [D=212 µg/L.92; 95% confidence interval (CI), 95.36-330.48 µg/L, P=0.0002; D=6.97 nmol/L, 95% CI, 1.61-12.32 nmol/L, P=0.01; D=4.72 µmol/L, 95% CI, 1.60-7.84 µmol/L, P=0.003; D=1.46 ng/mL, 95% CI, 0.48-2.43 ng/mL, P=0.003, respectively]. Patients with ulcerative colitis had lower levels of vitamin A than controls (D=223.22 µg/L, 95% CI, 44.32-402.12 µg/L, P=0.01). Patients suffering from CD for a longer time had lower levels of vitamins A (95% CI=7.1-67.58 y, P=0.02) and K (95% CI, 0.09-0.71 y, P=0.02). Meta-regression analysis demonstrated statistically significant associations between the levels of inflammatory biomarkers: C-reactive protein (P=0.03, 95% CI, -9.74 to -0.6 mgl/L) and albumin (P=0.0003, 95% CI, 402.76-1361.98 g/dL), and vitamin A status in CD patients. CONCLUSION: Our meta-analysis shows that the levels of fat-soluble vitamins are generally lower in patients with inflammatory bowel diseases and their supplementation is undoubtedly indicated.

Maintenance of Multivitamin Supplements After Sleeve Gastrectomy.

INTRODUCTION: After all bariatric procedures, multivitamin supplements are uniformly prescribed to minimize eventual deficiencies. These supplements are usually maintained long time, even during the whole life after malabsorptive techniques, while these are maintained at least during 1 year after restrictive procedures. Given that sleeve gastrectomy does not alter intestinal absorption, the supplements are possibly unnecessary, once the patient can take an adequate diet. PATIENTS AND METHODS: A prospective randomized study of patients undergoing a laparoscopic sleeve gastrectomy was performed. Patients were randomized into two groups: those patients receiving the multivitamin supplement (Multicentrum, Pfizer, 1 tablet/day) during 3 months (group 1) and those receiving the supplement during 12 months (group 2). Laboratory data were recorded: vitamins (D, B12 and folic acid) and oligoelements (calcium, iron, phosphorus, magnesium and zinc) at 3, 6 and 12 months after surgery. RESULTS: Eighty patients were included, 40 in each group. At 3 months, 7.5 % of the patients presented iron deficiency and 2.5 % ferritin one, similarly in both groups, that was corrected with specific extra iron supplements. At 6 months, one patient (2.5 %) in group 1 presented iron deficiency and one in group 2 vitamin D deficiency (NS). At 12 months, only one patient in group 2 presented vitamin D deficiency, treated with specific supplements. CONCLUSION: The maintenance of multivitamin supplements more than 3 months postoperatively seems to be of no benefit. It is preferable monitoring laboratory values and adding specific supplements when necessary. CLINICALTRIALS. GOV IDENTIFIER: NCT02620137.

Type 1 diabetes: Syndromes in resource-challenged settings.

Type 1 Diabetes is a complex disorder that is made more complex by the myriad of co-morbid conditions associated with it. Mauriac Syndrome is a well-known but nowadays uncommon condition that presents with growth retardation secondary to poor glycaemic control. Limited Joint Mobility is an often-missed association of diabetes. Its importance lies in the fact that it can cause significant impairment of fine movements in T1DM children. It also indicates poor glycaemic control over a long period of time and can be used as a surrogate marker for development of diabetic microvascular complications. Anaemia in T1DM is protean and can develop due to a combination of nutritional factors, chronic renal disease, coeliac disease and worm infestation. Management is etiological. Vitamin deficiencies are ubiquitous in T1DM and if left untreated, can lead to neurological, haematological and skeletal dysfunction. The best-known co-morbid conditions are the local site reactions clubbed together under the moniker lipodystrophies. These can be either atrophic or hypertrophic and are usually due to repeated injections at the same site, improper technique and needle re-use. Management is often difficult and they are best prevented by appropriate diabetes education and emphasis on proper injection techniques at the time of T1DM diagnosis, with periodic reinforcement. Amyloidosis is a little known condition that shares a lot of features in common with the lipodystrophies and often needs to be differentiated from lipohypertrophy. T1DM is a disease which is often associated with a poor quality of life and these co-morbid conditions also need to be treated for effective general and psychological well-being.

[Effect of pharmacologic treatment of the nutritional status of neurologic patients]. / Efecto del tratamiento farmacológico en el estado nutricional del paciente neurológico.

Clinical manifestations accompanying neurological diseases are diverse and affect multiple organs. Nutritional status of patients with certain neurological diseases such as stroke, Alzheimer's disease, Parkinson's disease, Epilepsy and Multiple Sclerosis can be altered because of symptoms associated with disease course, including certain micronutrient deficiency (folic acid, zinc, vitamin B6 and B12, vitamin D, vitamin E and vitamin C), changes in energy expenditure, intake decreased, gastrointestinal disorders and dysfunction of the bone mass. Also, we have to take in account other factors as: advanced age, multiple co morbidities, polypharmacy, the use of herbal products, social habits, diet and pharmacological treatments effect. An assessment of the factors related to neurological treatment that cause alterations in metabolic and nutritional status was performed: side effects of anti-Parkinson drugs, antiepileptic drugs, and multiple sclerosis drugs; drug-nutrient interactions; and nutrient-drug interactions.

Seguimiento y manejo de las complicaciones médicas tardías del obeso operado / Follow-up and treatment of late medical complications after bariatric surgery

Bariatric surgery is an effective treatment to reduce obesity by means of procedures aimed at restricting food intake and /or malabsorption. All procedures cause anatomic and functional changes that alter digestive physiology and reduce macro and micronutrients bioavailability. In the long run, surgical, metabolic and nutritional complications might occur. Anemia, vitamins and minerals deficiency are more frequent with malabsorption techniques, but they may also occur with restrictive techniques. Vitamin deficiency can cause neurological, hematologic and bone disorders, some of them with severe clinical manifestation. After bariatric surgery it is recommended to prescribe specific nutritional supplements and control patients periodically for prevention, early diagnosis and treatment of any complications.

La cirugía bariátrica es un efectivo tratamiento para reducir la obesidad mediante técnicas que sólo restringen la ingesta de alimentos y otras que además disminuyen la absorción intestinal. Todos los procedimientos causan cambios anatómicos y funcionales que alteran la fisiología digestiva y disminuyen la biodisponibilidad de macro y micronutrientes. En el largo plazo, pueden ocurrir complicaciones quirúrgicas, metabólicas y nutricionales, entre las que destacan anemia, deficiencia de vitaminas y minerales que son más frecuentes con las técnicas de mala absorción, pero también pueden ocurrir con técnicas restrictivas. La deficiencia de vitaminas produce alteraciones neurológicas, hematológicas y óseas que en algunos casos pueden ser severas. Después de la cirugía bariátrica se recomienda la administración de suplementos nutricionales específicos y controlar periódicamente a los pacientes para prevención, diagnóstico y tratamiento precoz de eventuales complicaciones.

[What is a vitamin?]. / Qu'est-ce qu'une vitamine?

In industrialized countries, the major vitamin deficiency syndromes have virtually disappeared. Today they are superseded by marginal deficits, characterized by insufficient vitamins reserves to maintain normal physiologic state. These states strike populations such as infants, pregnant women, alcoholics and the elderly, and may have long-term adverse effects on health. This assumption stems from the analysis of studies that show an increase in the incidence of various diseases such as cancers and cardiovascular, ocular and osteoarticular pathologies in subjects with low vitamin status. Although causal relationships are difficult to establish, a huge scope for public health appears to be open for vitamins, substituting the notion of minimal intake, indispensable to prevent signs of deficiency, to that ensuring optimal health in the medium and long-terms. However, the paradoxical character of the results obtained in several randomized trials should prompt caution in the use of vitamin supplements to prevent chronic diseases.

Supportive care considerations during concurrent chemoradiotherapy for pancreatic adenocarcinoma: lessons learned from clinical experience.

Concurrent chemotherapy and radiotherapy (chemoradiotherapy) for the management of pancreatic adenocarcinoma in either adjuvant or locally regional advanced settings produces predictable acute toxicities that are proportional in severity to the intensity and type of systemic therapy and to the parameters of radiotherapy. In addition, relevant to the adjuvant setting, surgery for pancreatic cancer often produces physiologic alterations that may impact a patient's ability to tolerate chemoradiotherapy. Failures to anticipate, monitor, and proactively manage the effects of surgery and toxicities of chemoradiotherapy can result in the need for unplanned treatment interruptions and/or inability to complete all planned therapy. In this review, complications of pancreatic cancer itself and of pancreatic resection as well as toxicities of chemoradiotherapy are delineated, and approaches to their management before, during, and after chemoradiotherapy are presented. Planning for the treatment of side effects before the anticancer therapy begins facilitates therapy administration and improves patient tolerance.

Alagille syndrome: an overview.

Alagille syndrome is an embryofoetopathy, due to mutations in the gene JAG1. It is autosomic dominant with variable expressivity, or sporadic. Neonatal cholestasis is a main feature, due to the paucity of intrahepatic bile ducts. It can rarely develop into cirrhosis, but be responsible for a disabling pruritus and xanthomas. The other features are a peculiar facies, cardiac abnormalities, butterfly vertebrae, and ocular embryotoxon. The prognosis depends on the severity of the liver and heart diseases. Hepatocarcinoma has been reported.

Obesity, bariatric surgery, and bone.

PURPOSE OF REVIEW: A greater number of morbidly obese individuals are undergoing bariatric surgery, expanding the postbariatric surgery population. Both obesity and bariatric surgery are accompanied by a variety of vitamin and mineral deficiencies, with some affecting bone health. Currently, there is no consensus regarding bone health evaluation and its management in obese and postbariatric population. RECENT FINDINGS: This review will focus on nutritional deficiencies in obese and postbariatric surgical patients, with a special focus on bone health. The latest findings on the complicated relationship between adipose tissue and bone will be discussed. And the presumed protective effect of obesity on osteoporosis will be evaluated. SUMMARY: Nutritional deficiencies in postbariatric patients already exist prior to the surgery. Therefore, a comprehensive nutritional evaluation prior to bariatric surgery is imperative, to prevent further decline of the already deficient nutrients. Nutrients such as calcium and vitamin D have an effect on bone health. Therefore, monitoring their level is important in preventing bone loss. Taking a multivitamin with minerals postbariatric surgery is a standard of practice.

[Chonic diarrhea and malabsorption due to common variable immunodeficiency, gastrectomy and giardiasis infection: a difficult nutritional management]. / Diarrea crónica refractaria y malabsorción secundaria a hipogammaglobulinemia común variable, infestación crónica por giardia lamblia y gastrectomía total por adenocarcinoma gástrico: un manejo nutricional complejo.

Gastric cancer is a frequent cause of cancer-related mortality in the world. Surgery is the only potentially curative therapy, although the adverse effects of surgery are common and considerable. Common variable immunodeficiency is in many cases cause of gastrointestinal system problems such as chronic diarrhea caused by infestation with giardia lamblia, nodular lymphoid hiperplasia ad loss of villi leading frequently to malapsortion and malnutrition. Nutritional deficiencies due to malapsorption (postgastrectomy and secondary to loss of villi, giardiasis and common variable inmunodeficiency) are common. We present the case of a patient with gastric cancer who underwent a gastrectomy with common variable hipogammaglobulinemia and chronic infestation by giardia lamblia, with serious diarrhea resistant to treatment and malabsorption.

Vitamina D e análogos para o controle do hiperparatireodismo secundário / Vitamin D and analogues in the aontrol of secondary hyperparathyroidism

A vitamina D participa (d)o metabolismo mineral e sua deficiência está associada com doenças extra-ósseas Estudos têm evidenciado hipovitaminose Dna população geral e em renais crônicos. Na progressão da doença renal crônica (DRC), a redução dos níveis de calcitriol, hipocalcemia e hiperfosfatemiasão fatores causais do hiperparatireoidismo secundário (HPTS). Utilizamos o calcitriol para o manejo do HPTS e da hipovitaminose D per se também devemser enfatizadas. Novos análogos da vitamina D, desenvolvidos para substituírem o calcitriol devido à hipercalcemia e hiperfosfatemia associadas ao seuuso, não se mostraram superiores no controle do HPTS. O estado de conhecimento atual sugere a realização de estudos randomizados, controlados ecom amostragem maior para comparar efetividade e segurança entre estes análogos e o calcitriol. Assim, estes estudos poderiam sinalizar para um melhor controle mineral e da doença óssea e resultar em um impacto favorável na morbi-mortalidade na DRC.

Vitamin D has been reported as pivotal for mineral metabolism and bone health, and its deficiency has also been associated with non-skeletal diseases.Many studies have shown high prevalence of vitamin D deficiency in general population as well as in chronic kidney disease (CKD) patients. In CKD progression, low calcitriol levels, hypocalcemia and hyperphosphatemia have all been implicated in the genesis of the secondary hyperparathyroidism (SHPT).In addition to calcitriol supplementation for SHPT management, emphasis should be given to the diagnosis and treatment of vitamin deficiency itself. Newvitamin D analogs were developed in an attempt to overcome the hypercalcemia and hyperphosphatemia that can follow calcitriol treatment but currentknowledge does not allow any conclusion about superiority of new analogs. Large randomized controlled trials studies are needed to compare efficacy and safety of these analogs and calcitriol. These studies could promote a better understanding of mineral metabolism and bone disease control, and result in a favorable impact on morbidity and mortality of CKD patients.

Gastrointestinal complications of bariatric surgery: diagnosis and therapy.

Severe or morbid obesity, with body mass indexes exceeding 35 to 40, are often refractory to all therapies other than surgery. The increasing number of patients undergoing bariatric surgery will result in increasing numbers of patients with gastrointestinal complications. The types of complications vary with type of surgery, whether restrictive, malabsorptive, or both, depending on what anatomical and physiologic changes occur postoperatively. One complication of bariatric surgery (gallstones) is due to weight loss after surgery, not the surgery itself. Based on previous meta-analyses, most of the top 10 complications from bariatric surgery are gastrointestinal: dumping, vitamin/mineral deficiencies, vomiting (and nausea), staple line failure, infection, stenosis (and bowel obstruction), ulceration, bleeding, splenic injury, and perioperative death. Two other gastrointestinal complications of bariatric surgery are indirect consequences of the surgery: bacterial overgrowth and diarrhea. Awareness of the types and frequency of gastrointestinal complications of bariatric surgery allows for timely diagnosis and appropriate therapy. As new surgical, and even endoscopic, procedures to treat obesity are developed, new gastrointestinal complications will need to be recognized.