Clinical Impact of Enteral Protein Nutritional Therapy on Patients with Obesity Scheduled for Bariatric Surgery: A Focus on Safety, Efficacy, and Pathophysiological Changes.

BACKGROUND: Ketogenic diet-induced weight loss before bariatric surgery (BS) has beneficial effects on the reduction in the liver volume, metabolic profile, and intra- and post-operative complications. However, these beneficial effects can be limited by poor dietary adherence. A potential solution in patients showing a poor adherence in following the prescribed diet could be represented by enteral nutrition strategies. To date, no studies describe the protocol to use for the efficacy and the safety of pre-operative enteral ketogenic nutrition-based dietary protocols in terms of weight reduction, metabolic efficacy, and safety in patients with obesity scheduled for BS. AIMS AND SCOPE: To assess the clinical impact, efficacy, and safety of ketogenic nutrition enteral protein (NEP) vs. nutritional enteral hypocaloric (NEI) protocols on patients with obesity candidate to BS. PATIENTS AND METHODS: 31 NEP were compared to 29 NEI patients through a 1:1 randomization. The body weight (BW), body mass index (BMI), waist circumference (WC), hip circumference (HC), and neck circumference (NC) were assessed at the baseline and at the 4-week follow-up. Furthermore, clinical parameters were assessed by blood tests, and patients were asked daily to report any side effects, using a self-administered questionnaire. RESULTS: Compared to the baseline, the BW, BMI, WC, HC, and NC were significantly reduced in both groups studied (p < 0.001). However, we did not find any significative difference between the NEP and NEI groups in terms of weight loss (p = 0.559), BMI (p= 0.383), WC (p = 0.779), and HC (p = 0.559), while a statistically significant difference was found in terms of the NC (NEP, -7.1% vs. NEI, -4%, p = 0.011). Furthermore, we found a significant amelioration of the general clinical status in both groups. However, a statistically significant difference was found in terms of glycemia (NEP, -16% vs. NEI, -8.5%, p < 0.001), insulin (NEP, -49.6% vs. NEI, -17.8%, p < 0.0028), HOMA index (NEP, -57.7% vs. NEI, -24.9%, p < 0.001), total cholesterol (NEP, -24.3% vs. NEI, -2.8%, p < 0.001), low-density lipoprotein (NEP, -30.9% vs. NEI, 1.96%, p < 0.001), apolipoprotein A1 (NEP, -24.2% vs. NEI, -7%, p < 0.001), and apolipoprotein B (NEP, -23.1% vs. NEI, -2.3%, p < 0.001), whereas we did not find any significative difference between the NEP and NEI groups in terms of aortomesenteric fat thickness (p = 0.332), triglyceride levels (p = 0.534), degree of steatosis (p = 0.616), and left hepatic lobe volume (p = 0.264). Furthermore, the NEP and NEI treatments were well tolerated, and no major side effects were registered. CONCLUSIONS: Enteral feeding is an effective and safe treatment before BS, with NEP leading to better clinical results than NEI on the glycemic and lipid profiles. Further and larger randomized clinical trials are needed to confirm these preliminary data.

Does Time Matter in Deficit of Calcium after Total Thyroidectomy in Subjects with Previous Bariatric Surgery?

Background: Hypoparathyroidism-related hypocalcemia is a common complication after total thyroidectomy (TT), particularly if there is a history of prior bariatric surgery. However, it is still unknown if it is the surgery timing or the type of bariatric intervention that increases the risk of developing this complication. Methods: We compared the risk of hypocalcemia (serum calcium levels < 8 mg/dL) and hypoparathyroidism (both transient and permanent) between patients with restrictive procedures (LSG and GB) and patients without a history of obesity surgery in the immediate post-operative period and after 12 months. Hypoparathyroidism was considered permanent if the plasma parathyroid hormone (PTH) levels at 6 months were less than 15 pg/mL and the patient still required oral calcium (calcium carbonate) and vitamin D supplementation, in addition to the supplements that were taken routinely before thyroidectomy. Results: From the 96 patients who underwent TT, 50% had a history of bariatric surgery: 36 LSG and 12 GB. The risk of hypocalcemia was similar in patients with a history of restrictive procedures (31.35%) and in controls (25%) (p = 0.49). Furthermore, hypocalcemia risk was similar between patients with a history of LSG (30.5%) and GB (33%) (p = 0.85). The prevalences of transient and permanent hypoparathyroidism were similar between patients with a history of restrictive procedures and in controls; similarly, no differences were detected between subjects undergoing LSG and GB. Conclusions: Restrictive bariatric surgery (LSG and GB) is not a risk factor for post-thyroidectomy hypocalcemia and hypoparathyroidism and thus did not require a different perioperative supplementation protocol compared to subjects without history of bariatric surgery undergoing TT.

Vitamin D: A Role Also in Long COVID-19?

Coronavirus disease 2019 (COVID-19) has quickly become a global pandemic. Reports from different parts of the world indicate that a significant proportion of people who have recovered from COVID-19 are suffering from various health problems collectively referred to as "long COVID-19". Common symptoms include fatigue, shortness of breath, cough, joint pain, chest pain, muscle aches, headaches, and so on. Vitamin D is an immunomodulatory hormone with proven efficacy against various upper respiratory tract infections. Vitamin D can inhibit hyperinflammatory reactions and accelerate the healing process in the affected areas, especially in lung tissue. Moreover, vitamin D deficiency has been associated with the severity and mortality of COVID-19 cases, with a high prevalence of hypovitaminosis D found in patients with COVID-19 and acute respiratory failure. Thus, there are promising reasons to promote research into the effects of vitamin D supplementation in COVID-19 patients. However, no studies to date have found that vitamin D affects post-COVID-19 symptoms or biomarkers. Based on this scenario, this review aims to provide an up-to-date overview of the potential role of vitamin D in long COVID-19 and of the current literature on this topic.

Current evidence on vitamin D deficiency and kidney transplant: What's new?

Kidney transplant is the treatment of choice for end-stage chronic kidney disease. Kidneys generate 1,25-dihydroxyvitamin D (calcitriol) from 25-hydroxyvitamin D (calcidiol) for circulation in the blood to regulate calcium levels. Transplant patients with low calcidiol levels have an increased risk of metabolic and endocrine problems, cardiovascular disease, type 2 diabetes mellitus, poor graft survival, bone disorders, cancer, and mortality rate. The recommended calcidiol level after transplant is at least 30 ng/mL (75 nmol/L), which could require 1000-3000 IU/d vitamin D3 to achieve. Vitamin D3 supplementation studies have found improved endothelial function and acute rejection episodes. However, since kidney function may still be impaired, raising calcidiol levels may not lead to normal calcitriol levels. Thus, supplementation with calcitriol or an analog, alfacalcidiol, is often employed. Some beneficial effects found include possible improved bone health and reduced risk of chronic allograft nephropathy and cancer.

External lymphatic fistula after intra-abdominal lymphadenectomy for cancer. Treatment with total parenteral nutrition and somatostatin.

OBJECTIVE: External lymphatic fistula or chyloperitoneum after intra-abdominal lymphadenectomy may present challenging problems. In the absence of definite guidelines the choice of treatment is often empirical, with unpredictable effectiveness, and the reporting of new cases may broaden the available experience. METHODS: We describe two cases. One patient had high-output external fistula (1300 mL/d) after para-aortic lymphadenectomy for metastatic lymph nodes. The fistula became fully evident at postoperative day 4, with resumption of an oral diet, on the basis of a 1300-mL/d output of white milky fluid from an abdominal drainage. Oral feeding was interrupted and total parenteral nutrition was started; this was transiently associated with octreotide administration, subsequently replaced by somatostatin. The second patient had a low-output fistula (350 mL/d) after liver resection and lymphadenectomy for cholangiocarcinoma and underwent treatment with total parenteral nutrition and somatostatin. RESULTS: In the first case the lymphatic fistula healed in just less than 3 wk, with the patient constantly remaining in very good condition, without secondary complications. In the second case the low-output fistula healed more rapidly. CONCLUSION: Interruption of oral feeding with total parenteral nutrition and continuous somatostatin infusion was an effective treatment in both patients with an intra-abdominal lymphatic leak.