Dose-response relationship between dietary choline and lipid accumulation in pyloric enterocytes of Atlantic salmon (Salmo salar L.) in seawater.

Foamy, whitish appearance of the pyloric caeca, reflecting elevated lipid content, histologically visible as hypervacuolation, is frequently observed in Atlantic salmon fed high-plant diets. Lipid malabsorption syndrome (LMS) is suggested as term for the phenomenon. Earlier studies have shown that insufficient supply of phospholipids may cause similar symptoms. The objective of the present study was to strengthen knowledge on the role of choline, the key component of phosphatidylcholine, in development of LMS as well as finding the dietary required choline level in Atlantic salmon. A regression design was chosen to be able to estimate the dietary requirement level of choline, if found essential for the prevention of LMS. Atlantic salmon (456 g) were fed diets supplemented with 0, 392, 785, 1177, 1569, 1962, 2354, 2746 and 3139 mg/kg choline chloride. Fish fed the lowest-choline diet had pyloric caeca with whitish foamy surface, elevated relative weight, and the enterocytes were hypervacuolated. These characteristics diminished with increasing choline level and levelled off at levels of 2850, 3593 and 2310 mg/kg, respectively. The concomitant alterations in expression of genes related to phosphatidylcholine synthesis, cholesterol biosynthesis, lipid transport and storage confirmed the importance of choline in lipid turnover in the intestine and ability to prevent LMS. Based on the observations of the present study, the lowest level of choline which prevents LMS and intestinal lipid hypervacuolation in post-smolt Atlantic salmon is 3·4 g/kg. However, the optimal level most likely depends on the feed intake and dietary lipid level.

[The Metabolic Optimized Fast Track Concept: preoperative preparation for abdominal surgery]. / Kontseptsiia 'Bystraia Metabolicheskaia Optimizatsiia' pri predoperatsionnoi podgotovke patsientov v abdominal'noi khirurgii.

In recent years the protocols of Enhanced Recovery After Surgery (E.R.A.S.) have been introduced into clinical practice and actively used. The goal of E.R.A.S. is to increase recovery, decrease complications and reduce length of stay after surgery through optimization of perioperative management. One of the key elements of E.R.A.S. is Metabolic Optimized Fast Track Concept (MOFA). It is aimed at the reduction of the period of preoperative fasting and at the activation of glucose transport inside the cell. It involves the administration of combined carbohydrate-protein-glutamine drinks which results into decreased insulin resistance in the early postoperative period. The implementation of MOFA within the structure of perioperative nutrition and metabolic support in abdominal surgery may actually be beneficial by reducing postoperative complications, length of hospital stay and mortality rate.

Metabolic surgery and nutritional deficiencies.

The increasing prevalence of morbid obesity in Germany is associated with an increasing number of metabolic surgical interventions. Short-term surgical and long-term metabolic complications such as nutrient deficiencies can be considered as the main risks of metabolic surgery with its malabsorptive but also restrictive procedures. The aim of this review was to characterize the most relevant metabolic complications specific for the various bariatric procedures, which, subsequently, require a permanent surveillance and supplementation, respectively. Furthermore, we aimed to identify if there are diagnostic and therapeutic measures that can prevent those complications. Restrictive bariatric surgery such as "gastric banding" and "sleeve gastrectomy" can be associated with deficiencies related to B-vitamins whereas iron, folate, vitamin B1, B12 and D deficiencies are associated with the malabsorptive procedure such as "biliopancreatic diversion," "duodenal switch" and "Roux-en-Y gastric bypass". Due to possible metabolic and surgical complications after bariatric surgery, patients need to undergo life-long medical and dietetic surveillance. The recently published guidelines of the "American Association of Bariatric and Metabolic Surgery" are the basis for recommendations on supplementation and treatment following weight loss surgery.

Preterm Birth Reduces Nutrient Absorption With Limited Effect on Immune Gene Expression and Gut Colonization in Pigs.

OBJECTIVES: The primary risk factors for necrotizing enterocolitis (NEC) are preterm birth, enteral feeding, and gut colonization. It is unclear whether feeding and colonization induce excessive expression of immune genes that lead to NEC. Using a pig model, we hypothesized that reduced gestational age would upregulate immune-related genes and cause bacterial imbalance after birth. METHODS: Preterm (85%-92% gestation, n = 53) and near-term (95%-99% gestation, n = 69) pigs were delivered by cesarean section and euthanized at birth or after 2 days of infant formula or bovine colostrum feeding. RESULTS: At birth, preterm delivery reduced 5 of 30 intestinal genes related to nutrient absorption and innate immunity, relative to near-term pigs, whereas 2 genes were upregulated. Preterm birth also reduced ex vivo intestinal glucose and leucine uptake (40%-50%), but failed to increase cytokine secretions from intestinal explants relative to near-term birth. After 2 days of formula feeding, NEC incidence was increased in preterm versus near-term pigs (47% vs 0%-13%). A total of 6 of the 30 genes related to immunity (TLR2, IL1B, and IL8), permeability (CLDN3, and OCLN), and absorption (SGLT) decreased in preterm pigs without affecting Gram-negative bacteria-related responses (TLR4, IKBA, NFkB1, TNFAIP3, and PAFA). Bacterial abundance tended to be higher in preterm versus near-term pigs (P = 0.09), whereas the composition was unaffected. CONCLUSIONS: Preterm birth predisposes to NEC and reduces nutrient absorption but does not induce upregulation of immune-related genes or cause bacterial dyscolonization in the neonatal period. Excessive inflammation and bacterial overgrowth may occur relatively late in NEC progression in preterm neonates.

Biliopancreatic diversion requires multiple vitamin and micronutrient adjustments within 2 years of surgery.

BACKGROUND: Malabsorptive bariatric procedures require multiple vitamin supplements, especially regarding fat-soluble vitamins. The exact amount required to maintain normal serum concentrations is still largely unknown. Based on the initial postoperative prescription, we assessed the number of adjustments and the amount of vitamins/micronutrients to normalize the biological markers 2 years after the biliopancreatic diversion with duodenal switch (BPD/DS). METHODS: A total of 112 consecutive patients had a laparoscopic BPD/DS between February 2007 and November 2010 for a body mass index of 53.1±5.9 kg/m² at a private hospital. Complete blood checks with vitamin status were obtained at each of the 3-month interval visits during the 1(st) postoperative year as well as twice during the 2(nd) year. RESULTS: Initially, all of the patients were prescribed daily 25,000 International units (IU) of vitamin A, 1000 mg of calcium, multivitamins, and 1900 IU of vitamin D3. Significant adjustments were necessary 3.6±1.1 times during this period. A total of 80% of the patients required added vitamin A, vitamin D, as well as calcium, zinc, and iron. After 2 years,≥20% of patients exhibited vitamin A and iron deficiency with low prealbumin or micropenic anemia. Seventy percent had vitamin D deficiency and 50% secondary hyperparathyroidism. CONCLUSION: The initial prescription was insufficient to cover the requirements after BPD/DS. At least 3000 mg of calcium with 7000 IU of vitamin D, 50,000 IU of vitamin A, 40 mg of zinc, and 200 mg of iron must be prescribed to start with. The trend toward a decrease in 25 OH vitamin D and hyperparathyroidism remains difficult to control although it can result from increased bone turnover during the early postoperative period.

Specialized care for women pregnant after bariatric surgery.

Growing numbers of women today will seek bariatric surgery before pregnancy. Protein-calorie malnutrition; hyperemesis; intestinal hernias; dumping syndrome; anemia; and deficiencies in calcium, folic acid, and vitamins B12, D, and K are all possible complications that can impact pregnancy. This article reviews the nutritional and pregnancy-related consequences of current surgical procedures and summarizes existing research showing positive and negative effects of weight-loss surgery on pregnancy outcomes. Practice-based clinical recommendations will help guide clinicians caring for the increasing number of women who become pregnant after having bariatric surgery.

Nutritional considerations in patients with cystic fibrosis.

Nutritional status is strongly associated with pulmonary function and survival in cystic fibrosis patients. Attainment of a normal growth pattern in childhood and maintenance of adequate nutritional status in adulthood represent major goals of multidisciplinary cystic fibrosis centers. International guidelines on energy intake requirements, pancreatic enzyme-replacement therapy and fat-soluble vitamin supplementation are of utmost importance in daily practice. The present review summarizes the most up-to-date information on early nutritional management in newly diagnosed patients and evaluates the benefits of aggressive nutritional support, assessment of nutritional status, recommendations for nutrition-related management in pancreatic-insufficient patients and the possible therapeutic impact of fat intake modulation upon inflammatory status.

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.

[Nutritional deficiencies associated with bariatric surgery]. / Carences nutritionnelles liées à la chirurgie de l'obésité.

Morbidly obese patients often have nutritional deficiencies, particularly in fat-soluble vitamins, folic acid and zinc. After bariatric surgery, these deficiencies may increase and others can appear, especially because of the limitation of food intake in gastric reduction surgery and of malabsorption in by-pass procedures. The latter result in more important weight loss but also increase the risk of more severe deficiencies. The protein deficiency associated with a decrease in the fat-free mass has been described in both procedures. It can sometimes require an enteral or parenteral support. Anemia can be secondary to iron deficiency, folic acid deficiency and even to vitamin B12 deficiency. Neurological disorders such as Gayet-Wernicke encephalopathy due to thiamine deficiency, or peripheral neuropathies may also be observed. Malabsorption of fat-soluble vitamins and other nutrients, especially if diagnosed after by-pass surgery, rarely cause clinical symptoms. However, some complications have been reported such as bone demineralization due to vitamin D deficiency, hair loss secondary to zinc deficiency or hemeralopia from vitamin A deficiency. A careful nutritional follow-up should be performed during pregnancy after obesity surgery, because possible deficiencies can affect the health of both the mother and child. In conclusion, increased awareness of the risk of deficiency and the systematic dosage of micronutrients are needed in the pre- and postoperative period in obese patients undergoing bariatric surgery. The case by case correction of these deficiencies is mandatory, and their systematic prevention should be evaluated.

The safety of mineral oil in the treatment of constipation--a lesson from prolonged overdose.

There have been concerns regarding the interference in the absorption of fat-soluble vitamins in long-term treatment with mineral oil; however, there is no clear evidence in the literature to support this claim. We present a case report illustrating the effect of prolonged (5 months) large doses of mineral oil on the fat-soluble vitamin absorption in a 17-year-old girl.

Nutritional and metabolic complications of bariatric surgery.

Bariatric surgery is an effective treatment for patients with clinically severe obesity. In addition to significant weight loss, it is also associated with improvements in comorbidities. Unfortunately, bariatric surgery also has the potential to cause a variety of nutritional and metabolic complications. These complications are mostly due to the extensive surgically induced anatomical changes incurred by the patient's gastrointestinal tract, particularly with roux-en-Y gastric bypass and biliopancreatic diversion. Complications associated with vertical banded gastroplasty are mostly due to decreased intake amounts of specific nutrients. Macronutrient deficiencies can include severe protein-calorie malnutrition and fat malabsorption. The most common micronutrient deficiencies are of vitamin B12, iron, calcium, and vitamin D. Other micronutrient deficiencies that can lead to serious complications include thiamine, folate, and the fat-soluble vitamins. Counseling, monitoring, and nutrient and mineral supplementation are essential for the treatment and prevention of nutritional and metabolic complications after bariatric surgery.

Enhanced-calorie formulas: considerations and options.

The long-term developmental impact of nutrition on the preterm newborn has recently been shown to be of even greater importance than previously recognized. Very immature or ill infants are challenged by the need for a high caloric intake, but are unable to tolerate large fluid volumes. These patients may require enhanced-calorie formulas to achieve the desired growth goals. Formula enhancement has traditionally been performed by uniquely developed recipes of base formula concentration with the addition of powdered formula or single components such as medium-chain triglycerides oil, protein, or polycose. These mixtures have been largely unstudied for bioavailability, long-term outcomes, and tolerance. Deviation from recommended protein, fat, carbohydrate, mineral, and vitamin delivery limits may impair growth or lead to undesirable side effects. The practitioner must have an understanding of when and how to use an enhanced formula and the important monitoring and assessment needs of the patient receiving enhanced-calorie formula.

Nutritional imperatives in cystic fibrosis therapy.

Patients with CF who receive optimal nutrition have better growth, maintain better nutritional reserves, and have better pulmonary function than patients with CF who have poor nutrition. These factors influence quality of life as well as survival. The metabolic and immunologic response to infection, as well as the increased work of breathing, escalates calorie requirements in this patient population. No single strategy works for every patient. Therefore, close monitoring of growth, symptoms, and changes in respiratory status that could increase calorie requirements is necessary.

[The absence of metabolic disorders 8 years after detubulized Z entero-cystoplasty]. / Absence de trouble métabolique 8 ans après entéro-cystoplastie en Z détubulée.

Intestinal resection can lead to decreased gastrointestinal absorption of various metabolic substances. The use of these intestinal segments as materials for urinary tract reconstruction can also induce metabolic disorders. The authors studied the long-term metabolic consequences of replacement enterocystoplasty after radical cystectomy for bladder cancer.

Suplementación de DL-Ó-tocoferol acetato oral en niños con colestasis crónica y déficit de vitamina E / Supplement of Oral DL-Ó-Tocopherol Acetate in children with chronic cholestasis and vitamin E deficit

Objetivo. Determinar la dosis oral suplementaria de dl-Ó-tocoferol acetato para mantener niveles séricos de Ó-tocoferol normales en niños con colestasis crónicas y déficit de vitamina E. Antecedentes. La malabsorción y deficiencia de vitamina E en niños con colestasis crónica se presenta en un 60-70 por ciento, causando un síndrome de degeneración neurológica progresiva entre 18 y 24 meses si no se corrige. La pronta suplementación con vitamina E determina la prevención e irreversibilidad de dicho déficit. Método. Realizamos un estudio prospectivo, longitudinal y comparativo de 60 niños divididos en tres grupos, con déficit de vitamina E y colestasis crónica. Luego de una evaluación inicial y por 15 días, cada grupo recibió suplementación oral con 100 UI, 200 UI y 400 UI diarias de dl-Ó-tocoferol acetato, respectivamente. Fueron monitorizados los niveles séricos de Ó-tocoferol, la función neurológica y los parámetros bioquímicos durante la suplementación. Resultados. Ninguna de las dosis suplementarias orales de dl-Ó-tocoferol acetato administradas por 15 días normalizaron los niveles séricos de Ó-tocoferol (p>0.06). La función neurológica, que no encontraba alterada al inicio del estudio en ninguno de los pacientes, permaneció estable luego de los 15 días, a dosis de 100 UI, 200 UI y 400 UI, a pesar de ser seguro, no mantuvo los niveles séricos normales de Ó-tocoferol en niños con colestasis crónica y déficit de vitamina E

The value of intestinal myotomy and myectomy in improving the reservoir capacity of the endorectal pull-through.

In laboratory models of massive small bowel resection and colectomy, intestinal myotomy has been shown to decrease stool frequency and malabsorption. Using physiologic and anatomic parameters of gastrointestinal function, we assessed the ability of three types of ileal myotomies to improve outcome after total abdominal colectomy, mucosal proctectomy, and endorectal pull-through (ERPT) without an enteric reservoir. Twenty puppies underwent ERPT. These dogs were randomly assigned to three experimental groups or a control group consisting of animals without a myotomy. The myotomies were performed by excising the serosa and muscularis propria of the ileal wall in three different patterns. There was no difference between any of the groups with respect to general health, postoperative weight gain, stool frequency, intestinal transit time, water absorption, electrolyte absorption, barium enemas, neorectal capacity and dimensions, and histology.

Correction of malnutrition and maldigestion with enzyme supplementation in patients with surgical suppression of exocrine pancreatic function.

We studied the occurrence and extent of malnutrition and maldigestion in 13 patients who underwent pancreatoduodenectomy (PD) and injection of Neoprene (polychloroprene) (NI) into the duct of Wirsung, which results in sclerosis of hte acinar pancreatic tissue, but spares the endocrine function. At discharge, patients under took an enzyme supplementation regimen with pancreatin (18, 00 United States Pharmacopoeia units of lipase per meal). Patients were rehospitalized 24.9 months after PD plus NI to undergo nutritional and metabolic evaluation (hospital control). Nutritional status was evaluated by measuring the serum albumin level, total iron binding capacity and total lymphocyte count. Digestive function was assessed by the D-xylose tolerance test and determination of fecal fat excretion. Patients were then discharged with pancrelipase, enteric-coated microspheres (ECM) supplementation (16,050 United States Pharmacopoeia units of lipase per meal). Malnutrition, defined as the occurrence of at least two abnormal nutritional parameters, was observed in six patients at hospital control. After six months on pancrelipase ECM, the nutritional status was re-evaluated in nine patients (three previously malnourished) who were all well nourished. The mean body weight was 84.7 per cent of usual body weight at discharge after PD plus NI and raised to 88.0 per cent at the hospital control (p less than 0.01) and to 93.7 per cent )p less than 0.05) after six months on pancrelipase ECM. At hospital control, results from the D-xylose test were normal in all patients, and steatorrhea dropped from 33.6 grams per day without enzyme supplementation to 15.3 grams per day with pancrelipase ECM (16,050 United States Pharmacopoeia units of lipase per meal). Steatorrhea was incompletely but satisfactorily corrected by pancrelipase ECM. On supplementation therapy with pancrelipase ECM, patients recover a good deal of the body weight and normalize the biochemical indices of malnutrition.

Treatment with high-dose oral vitamin D2 in patients with jejunoileal bypass for morbid obesity. Effects on calcium and magnesium metabolism, vitamin D metabolites, and faecal lag time.

Calcium and magnesium balance, 47Ca turnover studies, and measurements of vitamin D metabolites were performed before and after 7-10 months of vitamin D2 treatment (36,000 IU/day) in eight patients bypass-operated 3-6 years earlier for gross obesity. All patients had received a daily supplementation of calcium (27 mmol/day) since operation. Before treatment the net calcium absorption and calcium balance were normal compared with that of nine normal controls. Vitamin D metabolites were within normal limits. The endogenous faecal calcium level was increased and the faecal lag time shortened. Bone biopsies revealed osteomalacia in three of the patients. Vitamin D2 treatment induced an increase in calcium absorption and renal excretion of calcium, a reduced bone resorption rate, a more positive calcium balance, and healing of osteomalacia. Moreover, the vitamin D2 treatment induced a prolongation and normalization of faecal lag time, an increase in magnesium absorption, and a more positive magnesium balance. The effect might be mediated through 25-hydroxyvitamin D (25-OHD), which increased, whereas serum levels of 1,25-dihydroxyvitamin D (1,25-(OH)2D) and 24,25-dihydroxyvitamin D (24,25-(OH)2D) were unchanged. The results indicate that in some bypass-operated patients high-dose vitamin D2 has a beneficial effect on calcium and magnesium metabolism.