Consequences of Small Intestinal Bacterial Overgrowth in Obese Patients Before and After Bariatric Surgery.

BACKGROUND AND AIMS: Small intestinal bacterial overgrowth (SIBO) has been described in obese patients. The aim of this study was to prospectively evaluate the prevalence and consequences of SIBO in obese patients before and after bariatric surgery. PATIENTS AND METHODS: From October 2001 to July 2009, in obese patients referred for bariatric surgery (BMI >40 kg/m2 or >35 in association with comorbidities), a glucose hydrogen (H2) breath test (BT) was performed before and/or after either Roux-en-Y gastric bypass (RYGBP) or adjustable gastric banding (AGB) to assess the presence of SIBO. Weight loss and serum vitamin concentrations were measured after bariatric surgery while a multivitamin supplement was systematically given. RESULTS: Three hundred seventy-eight (mean ± SD) patients who performed a BT before and/or after surgery were included: before surgery, BT was positive in 15.4 % (55/357). After surgery, BT was positive in 10 % (2/20) of AGB and 40 % (26/65) of RYGBP (p < 0.001 compared to preoperative situation). After RYGBP, patients with positive BT had similar vitamin levels, a lower caloric intake (983 ± 337 vs. 1271 ± 404 kcal/day, p = 0.014) but a significant lower weight loss (29.7 ± 5.6 vs. 37.7 ± 12.9 kg, p = 0.002) and lower percent of total weight loss (25.6 ± 6.0 vs. 29.2 ± 6.9 %, p = 0.044). CONCLUSION: In this study, SIBO is present in 15 % of obese patients before bariatric surgery. This prevalence does not increase after AGB while it rises up to 40 % of patients after RYGBP and it is associated with lower weight loss.

Serum Bioavailable Vitamin D Concentrations and Bone Mineral Density in Women After Obesity Surgery.

INTRODUCTION: Low bone mass after obesity surgery may arise as a consequence of chronic malabsorption of calcium and vitamin D. However, we have not found any role of serum 25-hydroxyvitamin D or of polymorphisms in the vitamin D receptor gene in previous studies. PURPOSE: To investigate the circulating bioavailable 25-hydroxyvitamin D in women after bariatric procedures and its association with bone mass. PATIENTS AND METHODS: The study consisted of 91 women on follow-up for 7 ± 2 years after bariatric surgery. We measured bone mineral density (BMD), serum parathormone (PTH), 25-hydroxyvitamin D, and vitamin D binding protein (VDBP). All patients were genotyped for two variants in the coding region of VDBP (rs4588 and rs7041). Bioavailable 25-hydroxyvitamin D was calculated in double homozygotes. RESULTS: We found a negative correlation between bioavailable 25-hydroxyvitamin D and PTH (r = -0.373, P = 0.018), but not with BMD at lumbar spine (r = -0.065, P = 0.682) or hip (r = -0.029, P = 0.857). When adjusting by age, similar results were found for PTH (r = -0.441, P = 0.005), BMD at lumbar spine (r = -0.026, P = 0.874) and hip (r = -0.096, P = 0.561). After multivariate linear regression, forcing bioavailable 25-hydroxyvitamin D into the model resulted in a weak significant association with BMD at the lumbar spine (ß = - 0.247, P = 0.025). CONCLUSIONS: Serum bioavailable 25-hydroxyvitamin D concentrations are not associated with bone mass loss after bariatric surgery in women. The negative association with serum PTH levels suggests that vitamin D supplementation partly improves secondary hyperparathyroidism, yet other mechanisms may contribute to low bone mass after bariatric surgery.

Routine supplementation does not warrant the nutritional status of vitamin D adequate after gastric bypass Roux-en-Y / Rutina de suplementación no garantiza el estado nutricional de vitamina D adecuado para bypass gástrico en Y-de ROUX

Bariatric surgery can lead to nutritional deficiencies, including those related to bone loss. The aim of this study was to evaluate serum concentrations of calcium, vitamin D and PTH in obese adults before and six months after gastric bypass surgery in Roux-en-Y (RYGB) and evaluate the doses of calcium and vitamin D supplementation after surgery. Methods: Retrospective longitudinal study of adult patients of both sexes undergoing RYGB. We obtained data on weight, height, BMI and serum concentrations of 25-hydroxyvitamin D, ionized calcium and PTH. Following surgery, patients received dietary supplementation daily 500 mg calcium carbonate and 400 IU vitamin D. Results: We studied 56 women and 27 men. Preoperative serum concentrations of vitamin D were inadequate in 45% of women and 37% of men, while in the postoperative period 91% of women and 85% of men had deficiency of this vitamin. No change in serum calcium was found before and after surgery. Serum PTH preoperatively remained adequate in 89% of individuals of both sexes. After surgery serum concentrations remained adequate and 89% women and 83% men evaluated. Conclusion: Obesity appears to be a risk factor for the development of vitamin D. The results show that supplementation routine postoperative was unable to treat and prevent vitamin D deficiency in obese adults undergoing RYGB (AU)

La cirugía bariátrica puede llevar deficiencias nutricionales, incluyendo aquellas relacionadas a perdida ósea. El objetivo de este estudio fue avaluar las concentraciones séricas de cálcio, vitamina D y PTH en adultos obesos, antes y seis meses pos cirugía de bypass Gástrico en Y-de-Roux (RYGB) y avaluar las dosis de calcio y vitamina D utilizada después da la cirugía. Métodos: Estudio longitudinal retrospectivo con pacientes adultos de ambos sexos que fueron submetidos al RYGB. Fueron obtenidos datos de peso, estatura e IMC y las concentraciones de 25-hidroxivitamina D, calcio iónicos y PTH. Pos cirugía, los pacientes recibieron la suplementación dietética diaria de 500 mg de carbonato de calcio y 400 UI de vitamina D.Resultados: Fueron avaluados 56 mujeres y 27 hombres. El preoperatorio las concentraciones séricas de vitamina D presentaron inadecuadas en 45% de las mujeres y 37% de los hombres, mientras en el periodo posoperatorio 91% de las mujeres y 85% de los hombres presentaron deficiencia de esta vitamina. Ninguna alteración en las concentraciones séricas de calcio fue encontrada antes ni pos la cirugía. Las concentraciones séricas de PTH en el preoperatorio se mantuvieron adecuadas en 89% de los individuos de ambos sexos. Pos la cirugía las concentraciones séricas se mantuvieron adecuadas en 89% y mujeres y 83% de los hombres avaluados. Conclusión: la obesidad puede ser un factor de riesgo para el desarrollo de la deficiencia de vitamina D. Los resultados enseñan que la suplementación fue incapaz de sanar y prevenir la deficiencia de vitamina D en adultos obesos submetidos RYGB (AU)

Evolución de la ingesta y del estado nutricional de zinc, hierro y cobre en mujeres sometidas a cirugía bariátrica hasta el segundo año postoperatorio / Evolution of the intake and nutritional status of zinc, iron and copper in women undergoing bariatric surgery until the second year after surgery

Introducción: La cirugía bariátrica permite una reducción significativa de peso y mejoría de comorbilidades asociadas a la obesidad a largo plazo, pero también puede afectar negativamente el estado nutricional de algunos micronutrientes. Objetivos: Evaluar cambios en ingesta e indicadores del estado nutricional de zinc, hierro y cobre en mujeres sometidas a bypass gástrico en Y de Roux (BPG) o gastrectomía tubular (GT), hasta el segundo año postoperatorio. Métodos: Se estudió prospectivamente 45 mujeres sometidas a BPG o GT (edad promedio 35,2 ± 8,4 años, IMC promedio 39,8 ± 4,0 kg/m2), cada 6 meses se realizaron determinaciones de ingesta e indicadores del estado nutricional de zinc, hierro y cobre, y en forma anual se evaluó la composición corporal. El aporte de minerales a través de los suplementos representaba dos veces la ingesta recomendada para una mujer sana en las pacientes sometidas a GT y tres veces para BPG. Resultados: 20 mujeres se sometieron a GT y 25 a BPG. En ambos grupos se produjo una reducción significativa de peso y del porcentaje de masa grasa, que se mantuvo hasta el segundo año postoperatorio. Las mujeres sometidas a BPG presentaron un mayor compromiso del estado nutricional de zinc, hierro y cobre, que las pacientes sometidas a GT. Conclusiones: El bypass gástrico en Y de Roux produce un compromiso mayor del estado nutricional de zinc, hierro y cobre que la gastrectomía tubular. Se debería evaluar si la administración fraccionada de la suplementación mejoraría la absorción de estos nutrientes (AU)

Introduction: Bariatric surgery allows a significant reduction in weight and improvement of comorbidities associated with obesity in the long term, but it can also adversely affect the nutritional status of some micronutrients. Objectives: To evaluate changes in intake and parameters of nutritional status of zinc, iron and copper in patients undergoing Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG), until the second postoperative year. Methods: We prospectively studied 45 women undergoing GBP or SG (mean age 35.2 ± 8.4 years, mean BMI 39.8 ± 4.0 kg/m2), every 6 months We measured intake and status indications nutritional zinc, iron and copper, and annually evaluated body composition. The contribution of minerals through supplements represented twice the recommended intake for a healthy woman in patients undergoing GT and three times for GBP. Results: 20 women underwent GBP and 25 SG. In both groups there was a significant reduction in weight and body fat percentage, which was maintained until the second postoperative year. Women who have had a greater commitment GBP nutritional status of zinc, iron and copper, that patients undergoing SG. Conclusions: Gastric bypass Roux-Y produces a greater commitment of nutritional status of zinc, iron and copper sleeve gastrectomy. It should evaluate whether administration of supplementation fractional improve the absorption of these nutrients (AU)

Gastric bypass surgery is associated with near-normal insulin suppression of lipolysis in nondiabetic individuals.

We hypothesized that individuals who have undergone gastric bypass have greater insulin sensitivity that obese subjects but less compared with lean. We measured free fatty acid (FFA) and glucose kinetics during a two-step, hyperinsulinemic euglycemic clamp in nondiabetic subjects who were 38 ± 5 mo post-gastric bypass surgery (GB; n = 15), in lean subjects (L; n = 15), and in obese subjects (O; n = 16). Fasting FFAa were not significantly different between the three study groups but during both doses of insulin were significantly higher in O than in either GB or L. The effective insulin concentration resulting in half-maximal suppression of FFA was similar in L and GB and significantly less in both groups compared with O. Glucose infusion rates during low-dose insulin were not significantly different in GB compared with either L or O. During high-dose insulin, glucose infusion rates were significantly greater in GB than in O but less than in L. Endogenous glucose production in GB was significantly lower than O only during low dose of insulin. We conclude that gastric bypass is associated with improvements in adipose tissue insulin sensitivity to levels similar to lean, healthy persons and also with improvements in the response of glucose metabolism to insulin. These changes may be due to preferential reduction in visceral fat and decreased FFA availability. However, some differences in insulin sensitivity in GB remain compared with L. Residual insulin resistance may be related to excess total body fat or abnormal lipolysis and requires further study.

Effects of chest physiotherapy on the respiratory function of postoperative gastroplasty patients.

INTRODUCTION: Bariatric surgery has become increasingly more recommended for the treatment of morbidly obese individuals for whom it is possible to identify co-morbidities other than alterations in pulmonary function. The objective of this study was to evaluate the effects of conventional chest physiotherapy (CCP) and of conventional physiotherapy associated with transcutaneous electrical diaphragmatic stimulation (CCP+TEDS) on pulmonary function and respiratory muscle strength in patients who have undergone Roux-en-Y gastric bypass. METHODS: In total, 44 female patients with an average age of 37 +/- 7.3 years and an average body mass index (BMI) of 47.4 +/- 6.5 K/m(2) were selected as candidates for Roux-en-Y gastric bypass laparoscopy. They were evaluated for pulmonary volume and flow using spirometry and maximum respiratory pressure through manovacuometry during the preoperative period and on the fifteenth and thirtieth postoperative days. RESULTS: No differences were detected between CCP and CCP + TEDS, and both factors contributed to the maintenance of pulmonary flow and volume as well as inhalation muscle strength. Exhalation muscle strength was not maintained in the CCP group at fifteen or thirty days postoperative, but it was maintained in patients treated with conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation. DISCUSSION: These results suggest that both conventional chest physiotherapy and conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation prevent the reduction of pulmonary function during the Roux-en-Y gastric bypass postoperative period, and that transcutaneous electric diaphragmatic stimulation also contributes to expiratory muscle strength.

Effects of chest physiotherapy on the respiratory function of postoperative gastroplasty patients

INTRODUCTION: Bariatric surgery has become increasingly more recommended for the treatment of morbidly obese individuals for whom it is possible to identify co-morbidities other than alterations in pulmonary function. The objective of this study was to evaluate the effects of conventional chest physiotherapy (CCP) and of conventional physiotherapy associated with transcutaneous electrical diaphragmatic stimulation (CCP+TEDS) on pulmonary function and respiratory muscle strength in patients who have undergone Roux-en-Y gastric bypass. METHODS: In total, 44 female patients with an average age of 37 ± 7.3 years and an average body mass index (BMI) of 47.4 ± 6.5 K/m² were selected as candidates for Roux-en-Y gastric bypass laparoscopy. They were evaluated for pulmonary volume and flow using spirometry and maximum respiratory pressure through manovacuometry during the preoperative period and on the fifteenth and thirtieth postoperative days. RESULTS: No differences were detected between CCP and CCP+TEDS, and both factors contributed to the maintenance of pulmonary flow and volume as well as inhalation muscle strength. Exhalation muscle strength was not maintained in the CCP group at fifteen or thirty days postoperative, but it was maintained in patients treated with conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation. DISCUSSION: These results suggest that both conventional chest physiotherapy and conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation prevent the reduction of pulmonary function during the Roux-en-Y gastric bypass postoperative period, and that transcutaneous electric diaphragmatic stimulation also contributes to expiratory muscle strength.

Protocolo de valoración fisioterápica en cirugíabariátrica / Protocol of phisical therapy evaluation in bariatric surgery

Este trabajo recoge una guía o protocolo de valoración de pacientes obesos mórbidos que van a ser sometidos a cirugía bariátrica, así como cuales deben ser las mediciones que debemos tener en cuenta para valorar su evolución, función respiratoria, dolor, disnea, prueba 6 minutos marcha, goniometría, perímetros, pliegues, flexibilidad de la columna vertebral, de este modo permite al fisioterapeuta establecer unos objetivos concretos así como el tratamiento a seguir (AU)

Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs.

OBJECTIVE: To compare outcomes, quality of life (QOL), and costs of laparoscopic and open gastric bypass (GBP). SUMMARY BACKGROUND DATA: Laparoscopic GBP has been reported to be a safe and effective approach for the treatment of morbid obesity. The authors performed a prospective randomized trial to compare outcomes, QOL, and costs of laparoscopic GBP with those of open GBP. METHODS: From May 1999 to March 2001, 155 patients with a body mass index (BMI) of 40 to 60 kg/m2 were randomly assigned to undergo laparoscopic (n = 79) or open (n = 76) GBP. The two groups were similar in age, sex ratio, mean BMI, and comorbidities. Main outcome measures included operative time, estimated blood loss, length of hospital stay, operative complications, percentage of excess body weight loss, and time to return to activities of daily living and work. Changes in QOL were assessed using the SF-36 Health Survey and the bariatric analysis of reporting outcome system (BAROS). Operative and hospital costs of the two operations were also compared. RESULTS: There were no deaths in either group. Mean operative time was longer for laparoscopic GBP than for open GBP, but operative blood loss was less. Two (2.5%) of the 79 patients in the laparoscopic group required conversion to laparotomy. Median length of hospital stay was shorter for laparoscopic GBP patients (3 vs 4 days). The rate of postoperative anastomotic leak was similar between groups. Wound-related complications such as infection (10.5 vs 1.3%) and incisional hernia (7.9 vs 0%) were more common after open GBP; late anastomotic stricture was less frequent after open GBP (2.6 vs 11.4%). Time to return to activities of daily living and work were shorter after laparoscopic GBP than after open GBP. Weight loss at 1 year was similar between groups. Preoperative SF-36 scores were similar between groups; however, at 1 month after surgery, laparoscopic patients had better physical conditioning, social functioning, general health, and less body pain than open GBP patients. At 6 months, the BAROS outcome was classified as good or better in 97% of laparoscopic GBP patients compared with 82% of open GBP patients. Operative costs were higher for laparoscopic GBP patients, but hospital costs were lower. CONCLUSIONS: Laparoscopic GBP is a safe and cost-effective alternative to open GBP. Despite a longer operative time, patients undergoing laparoscopic GBP benefited from less blood loss, a shorter hospital stay, and faster convalescence. Laparoscopic GBP patients had comparable weight loss at 1 year but a more rapid improvement in QOL than open GBP patients. The higher initial operative costs for laparoscopic GBP were adequately offset by the lower hospital costs.