Effects of Preoperative Quadruple Therapy for Helicobacter pylori on Bariatric Surgery Metabolic Outcomes.

PURPOSE: To assess the effects of Helicobacter pylori (HP) eradication with an omeprazole, clarithromycin, amoxicillin, and metronidazole (OCAM) regimen on the metabolic profile and weight loss 12 months after bariatric surgery (BS). METHODS: Retrospective analysis of a prospective cohort of patients with morbid obesity undergoing BS. HP presence was tested preoperatively by gastric biopsy and treated with OCAM when positive. Short-term metabolic outcomes and weight loss were evaluated. RESULTS: HP infection was detected in 75 (45.7%) of the 164 patients included. OCAM effectiveness was 90.1%. HP-negative patients had a greater reduction in glucose levels at 3 (-14.6 ± 27.5 mg/dL HP-treated vs -22.0 ± 37.1 mg/dL HP-negative, p=0.045) and 6 months (-13.7 ± 29.4 mg/dL HP-treated vs -26.4 ± 42.6 mg/dL HP-negative, p= 0.021) and greater total weight loss (%TWL) at 6 (28.7 ± 6.7% HP-treated vs 30.45 ± 6.48% HP-negative, p= 0.04) and 12 months (32.21 ± 8.11% HP-treated vs 35.14 ± 8.63% HP-negative, p= 0.023). CONCLUSIONS: Preoperative treatment with OCAM has been associated to poorer glycemic and weight loss outcomes after BS. More research is needed on the influence of OCAM on gut microbiota, and in turn, the effect of the latter on metabolic and weight loss outcomes after BS.

Bariatric surgery improves metabolic and nonalcoholic fatty liver disease markers in metabolically healthy patients with morbid obesity at 5 years.

BACKGROUND: No studies have evaluated the effect of metabolic and bariatric surgery (MBS) on nonalcoholic fatty liver disease (NAFLD) and cardiometabolic markers in metabolically healthy patients with morbid obesity (MHMO) at midterm. OBJECTIVES: To assess the effect of MBS on NAFLD and cardiometabolic markers in MHMO patients and ascertain whether metabolically unhealthy patients with morbid obesity (MUMO) remain metabolically healthy at 5 years after MBS. SETTING: University hospital. METHODS: A total of 191 patients with a body mass index >40 kg/m2 and at least 5 years of follow-up were retrospectively analyzed. Lost to follow-up were 37.6% (151 of 401 patients). Patients were classified as MHMO if 1 or 0 of the cardiometabolic markers were present using the Wildman criteria. The degree of liver fibrosis was assessed using the NAFLD fibrosis score (NFS). RESULTS: Forty-one patients (21.5%) fulfilled the criteria for MHMO. They showed significant improvements in blood pressure (from 135.1 ± 22.1 and 84.2 ± 14.3 mm Hg to 117.7 ± 19.2 and 73.0 ± 10.9 mm Hg), plasma glucose (from 91.0 ± 5.6 mg/dL to 87.2 ± 5.2 mg/dL), homeostatic model assessment for insulin resistance (from 2.2 ± .9 to 1.0 ± .8), triglycerides (from 88.0 [range, 79.5-103.5] mg/dL to 61.0 [range, 2.0-76.5] mg/dL), alanine aminotransferase, gamma-glutamyl transpeptidase NFS (from -1.0 ± 1.0 to -1.9 ± 1.2), and high-density lipoprotein cholesterol (from 56.9 ± 10.5 mg/dL to 77.9 ± 17.4 mg/dL) at 5 years after surgery. A total of 108 MUMO patients (84.4%) who became metabolically healthy after 1 year stayed healthy at 5 years. CONCLUSIONS: MBS induced a midterm improvement in cardiometabolic and NAFLD markers in MHMO patients. Seventy-six percent of MUMO patients became metabolically healthy at 5 years after MBS.

Additional Metabolic Effects of Bariatric Surgery in Patients with a Poor Mid-Term Weight Loss Response: A 5-Year Follow-Up Study.

To ascertain the 5-year metabolic effects of bariatric surgery in poor weight loss (WL) responders and establish associated factors. METHODS: Retrospective analysis of a non-randomised prospective cohort of bariatric surgery patients completing a 5-year follow-up. Mid-term poor WL was considered when 5-year excess weight loss was <50%. RESULTS: Forty-three (20.3%) of the 212 included patients were mid-term poor WL responders. They showed an improvement in all metabolic markers at 2 years, except for total cholesterol. This improvement with respect to baseline was maintained at 5 years for plasma glucose, HbA1c, HOMA, HDL and diastolic blood pressure; however, LDL cholesterol, triglycerides and systolic blood pressure were similar to presurgical values. Comorbidity remission rates were comparable to those obtained in the good WL group except for hypercholesterolaemia (45.8% vs. poor WL, p = 0.005). On multivariate analysis, lower baseline HDL cholesterol levels, advanced age and lower preoperative weight loss were independently associated with poor mid-term WL. CONCLUSIONS: Although that 1 in 5 patients presented suboptimal WL 5 years after bariatric surgery, other important metabolic benefits were maintained.

Obesidad mórbida y dislipemia: impacto de la cirugía bariátrica / Morbid obesity and dyslipidaemia: The impact of bariatric surgery

La prevalencia de la obesidad ha aumentado de manera exponencial en las últimas décadas, convirtiéndose en un problema de salud pública de primer orden. La dislipemia de la obesidad, caracterizada por niveles bajos de colesterol de las lipoproteínas de alta densidad (HDL), hipertrigliceridemia y partículas pequeñas y densas de lipoproteínas de baja densidad (LDL), es responsable en parte del elevado riesgo cardiovascular residual de esta situación clínica. Por otro lado, la cirugía bariátrica (CB) es el tratamiento más eficaz para la obesidad; con ella se obtiene una mayor pérdida ponderal que con el tratamiento médico convencional y favorece la mejoría o remisión de las comorbilidades asociadas. Las técnicas de CB más utilizadas en la actualidad son el bypass gástrico laparoscópico en Y de Roux (BGYRL) y la gastrectomía tubular laparoscópica (GTL). Estas han obtenido resultados similares tanto en cuanto a la pérdida de peso como a la remisión de ciertas comorbilidades como la diabetes mellitus tipo 2 o la hipertensión arterial. Un rasgo diferencial entre ambas técnicas podría ser el diferente impacto sobre el perfil lipoproteico. Así, estudios previos con seguimiento a corto y a medio plazo han objetivado una superioridad del BGYRL frente a la GTL en la reducción del colesterol total y del colesterol LDL. Existen resultados discordantes en cuanto a la evolución del colesterol HDL y los triglicéridos. Por todo ello, hemos considerado de interés revisar los efectos de la CB a corto y a medio plazo en el perfil lipoproteico, así como las tasas de remisión de las diferentes alteraciones lipídicas y los posibles factores relacionados

Obesity prevalence has presented an exponential increase in the last decades, becoming a first order public health issue. Dyslipidemia of obesity, characterized by low levels of high density lipoprotein (HDL) cholesterol, hypertriglyceridemia and small and dense low-density lipoprotein (LDL) particles, is partly responsible for the high residual cardiovascular risk of this clinical situation. On the other hand, bariatric surgery (BS) is the most effective treatment for obesity, obtaining a greater weight loss than achieved with conventional medical therapy and favoring the improvement or remission of associated comorbidities. The most commonly used BS techniques nowadays are laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Both of these procedures have obtained similar results in terms of weight loss and comorbidity remission such as type 2 diabetes mellitus or hypertension. A differential feature between both techniques could be the different impact on the lipoprotein profile. In this respect, previous studies with short and mid-term follow-up have proved LRYGB to be superior to LSG in total and LDL cholesterol reduction. Results regarding triglycerides and HDL cholesterol are contradictory. Therefore, we consider of interest to review the effects of BS at short and mid-term follow-up on lipoprotein profile, as well as the remission rates of the different lipid abnormalities and the possible related factors

Morbid obesity and dyslipidaemia: The impact of bariatric surgery. / Obesidad mórbida y dislipemia: impacto de la cirugía bariátrica.

Obesity prevalence has presented an exponential increase in the last decades, becoming a first order public health issue. Dyslipidemia of obesity, characterized by low levels of high density lipoprotein (HDL) cholesterol, hypertriglyceridemia and small and dense low-density lipoprotein (LDL) particles, is partly responsible for the high residual cardiovascular risk of this clinical situation. On the other hand, bariatric surgery (BS) is the most effective treatment for obesity, obtaining a greater weight loss than achieved with conventional medical therapy and favoring the improvement or remission of associated comorbidities. The most commonly used BS techniques nowadays are laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Both of these procedures have obtained similar results in terms of weight loss and comorbidity remission such as type2 diabetes mellitus or hypertension. A differential feature between both techniques could be the different impact on the lipoprotein profile. In this respect, previous studies with short and mid-term follow-up have proved LRYGB to be superior to LSG in total and LDL cholesterol reduction. Results regarding triglycerides and HDL cholesterol are contradictory. Therefore, we consider of interest to review the effects of BS at short and mid-term follow-up on lipoprotein profile, as well as the remission rates of the different lipid abnormalities and the possible related factors.

Most of qualitative dietary changes observed one year post-bariatric surgery can be achieved with a preoperative dietary intervention / La mayoría de los cambios dietéticos un año después de la cirugía bariátrica pueden conseguirse con una intervención nutricional preoperatoria

Background and objectives: Bariatric surgery (BS) leads to several changes in nutritional habits that can be attributed to different mechanisms. Some of these changes could be achievable with a preoperative nutritional intervention. The objective was to evaluate dietary modifications during the preoperative and postoperative periods of BS. Methods: Prospective observational study of patients who underwent BS between 2010 and 2014 at the Hospital del Mar; 60 consecutive patients were included. Food consumption was measured by a validated food-frequency questionnaire at inclusion in the bariatric surgery program, after preoperative nutritional intervention, and one year after surgery. Generalized estimating equation models were used to assess differences in food group intake during follow up. Results: Energy intake significantly decreased from inclusion to 1 year of surgery (p = 0.003). After the preoperative intervention and prior to surgery, there was an increase in intake of nuts, vegetables, poultry and rabbit, fruit, fish and skimmed milk products and a decrease in bread, soft drinks and pastry. At one year post-surgery, a continued decrease in the consumption of bread and soft drinks and an increase in nuts was observed (linear non-quadratic trend). Consumption of fruit, pastry, fish and skimmed milk products remained stable showing a linear and quadratic trend. Vegetables and poultry and rabbit increased in the preoperative period and decreased after surgery, showing a quadratic but not linear trend. Conclusions: a preoperative nutritional intervention in morbidly obese patients can associate favorable dietary changes that are mostly maintained one year after bariatric surgery

Introducción y objetivos: La cirugía bariátrica produce diferentes cambios en los hábitos alimentarios que se han atribuido a diferentes mecanismos. Algunos de estos cambios se podrían conseguir con una intervención nutricional preoperatoria. El objetivo fue estudiar los cambios dietéticos durante el periodo preoperatorio y postoperatorio de la cirugía bariátrica. Métodos: Estudio prospectivo de pacientes intervenidos de cirugía bariátrica entre los años 2010 y 2014 en el Hospital del Mar de Barcelona. Se incluyeron 60 pacientes consecutivos. El registro de alimentos se midió mediante cuestionarios de frecuencia de consumo de alimentos a la inclusión en el programa de cirugía bariátrica, después de una intervención nutricional preoperatoria y un año después de la cirugía. Se usaron las ecuaciones de estimación generalizadas para determinar diferencias en el consumo de los grupos de alimentos durante el seguimiento. Resultados: El consumo de energía disminuyó desde la inclusión un año después de la intervención (p = 0,003). En el periodo preoperatorio y antes de la cirugía se detectó un aumento en el consumo de frutos secos, vegetales, aves y conejo, fruta, pescado y lácticos desnatados y un descenso en el consumo de pan, bebidas azucaradas y bollería. Un año después de la cirugía, se observó que el consumo de pan y bebidas azucaradas siguió descendiendo y el de frutos secos siguió aumentando (tendencia lineal pero no cuadrática). El consumo de fruta, pescado y lácticos desnatados se mantuvo estable (tendencia lineal y cuadrática). El consumo de vegetales, aves y conejo aumentó en el periodo preoperatorio y disminuyó después de la cirugía (tendencia cuadrática pero no lineal). Conclusiones: Una intervención nutricional preoperatoria en pacientes con obesidad mórbida puede asociarse a cambios dietéticos favorables, los cuales se mantienen en su mayoría un año después de la intervención

Most of qualitative dietary changes observed one year post-bariatric surgery can be achieved with a preoperative dietary intervention.

BACKGROUND AND OBJECTIVES: Bariatric surgery (BS) leads to several changes in nutritional habits that can be attributed to different mechanisms. Some of these changes could be achievable with a preoperative nutritional intervention. The objective was to evaluate dietary modifications during the preoperative and postoperative periods of BS. METHODS: Prospective observational study of patients who underwent BS between 2010 and 2014 at the Hospital del Mar; 60 consecutive patients were included. Food consumption was measured by a validated food-frequency questionnaire at inclusion in the bariatric surgery program, after preoperative nutritional intervention, and one year after surgery. Generalized estimating equation models were used to assess differences in food group intake during follow up. RESULTS: Energy intake significantly decreased from inclusion to 1 year of surgery (p=0.003). After the preoperative intervention and prior to surgery, there was an increase in intake of nuts, vegetables, poultry and rabbit, fruit, fish and skimmed milk products and a decrease in bread, soft drinks and pastry. At one year post-surgery, a continued decrease in the consumption of bread and soft drinks and an increase in nuts was observed (linear non-quadratic trend). Consumption of fruit, pastry, fish and skimmed milk products remained stable showing a linear and quadratic trend. Vegetables and poultry and rabbit increased in the preoperative period and decreased after surgery, showing a quadratic but not linear trend. CONCLUSIONS: a preoperative nutritional intervention in morbidly obese patients can associate favorable dietary changes that are mostly maintained one year after bariatric surgery.

Changes in Thyroid Replacement Therapy after Bariatric Surgery: Differences between Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy.

INTRODUCTION: Levothyroxine (LT4) requirements can presumably be modified differently after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). The present study compared changes in LT4 dose in hypothyroid subjects undergoing LRYGB or LSG 2 years after the procedure. MATERIAL AND METHODS: A 2-year follow-up observational study was conducted in a prospective cohort of obese patients who had undergone bariatric surgery and were receiving LT4. Indication for the type of surgical procedure was based on clinical criteria. Repeated measures ANOVA models were used to examine differences within and between groups. RESULTS: Thirty-five consecutive patients were included for analysis: 22 LRYGB and 13 LSG. Total daily LT4 dosage decreased in the LSG group (133.7 ± 50.3 mcg/day at baseline to 104.3 ± 43.3 mcg/day at 2 years; p = 0.047) whereas it remained stable in the LRYGB group (129.5 ± 46.1 mcg/day at baseline to 125.2 ± 55.7 mcg/day at 2 years; p = 1.000). Differences between groups became significant at 24 months. Daily weight-based LT4 dose increased in the LRYGB group (1.11 ± 0.38 mcg/kg day at baseline to 1.57 ± 0.74 mcg/kg day at 2 years; p = 0.005) with no significant changes in the LSG group (1.15 ± 0.35 mcg/kg day at baseline vs 1.11 ± 0.49 mcg/kg day at 2 years; p = 1.000). CONCLUSION: LRYGB and LSG showed different changes in LT4 requirements 2 years after surgery. There was an early decrease in daily total LT4 dose requirements after LSG, which suggests an early preventive reduction to be validated in future studies.

Characterization of the pattern of food consumption in severely obese patients prior to bariatric surgery / Caracterización del patrón de consumo de alimentos en pacientes con obesidad severa antes de la cirugía bariátrica

Introduction: severe obesity is increasing rapidly in several countries, as well as the number of bariatric surgeries performed. However, the pattern of food consumption of the population is not well defined. Objectives: the aim of the present study was to describe the food consumption pattern (comparing men and women) of severely obese patient candidates to bariatric surgery and to determine the promoting and protecting factors. Methods: food consumption and nutrient intake were measured by a validated food frequency questionnaire (FFQ), including food and beverages. Multivariate principal component analysis (PCA) was done to analyze the component that best relates to the food pattern consumption dividing the different food groups in promotors and protectors. Results: significant differences in the food consumption pattern of men and women with severe obesity addressed for bariatric surgery were found. A positive correlation was found between the food groups that are protective factors for obesity such as the fiber (r = 0.84), vegetables (r = 0.767) and fruits (r = 0.83), whereas a negative correlation was found with those factors that are promotors of obesity such as fats (r = -0.341), saturated fats (r = -0.411), soft drinks (r = -0.386), and fast food (r = -0.17).Multivariate analysis of principal components revealed that calorie consumption is the component that correlates better with the pattern. Conclusions: there are significant differences in the food consumption pattern of men and women with severe obesity addressed for bariatric surgery and these differences should be taken into account when planning nutritional intervention. Therefore, a healthy lifestyle behaviour should be highly encouraged among the severe obese population

Introducción: la obesidad mórbida así como el número de cirugías bariátricas que se practican van en aumento en varios países. Sin embargo, el patrón de consumo alimentario de estos pacientes no está bien definido. Objetivos: describir el patrón de consumo de alimentos (comparando hombres y mujeres) de pacientes con obesidad severa candidatos a cirugía bariátrica y determinar los factores promotores y protectores de la obesidad. Métodos: el consumo de alimentos y la ingesta de nutrientes se midieron mediante un cuestionario de frecuencia de consumo de alimentos validado que incluye alimentos y bebidas. Se realizó un análisis multivariado de componentes principales para determinar qué componente se relaciona mejor con el consumo de patrones alimentarios promotores y protectores de obesidad. Resultados: el estudio mostró diferencias significativas en el patrón de consumo de alimentos entre hombres y mujeres. Se encontró una correlación positiva entre los grupos de alimentos considerados factores de protección para la obesidad, como la fibra (r = 0,84), las verduras (r = 0,767) y las frutas (r = 0,83), mientras que la correlación fue negativa con los factores promotores de la obesidad como las grasas (r = -0,341), las grasas saturadas (r = -0,411), los refrescos (r = -0,386) y la comida rápida (r = -0,17). El análisis multivariado de los componentes principales reveló que el consumo de calorías es el componente que se correlaciona mejor con el patrón. Conclusiones: existen diferencias significativas en el patrón de consumo de alimentos entre hombres y mujeres con obesidad severa y estas deben tenerse en cuenta al planificar la intervención nutricional. Asimismo, un consumo alimentario saludable debe promocionarse en la población obesa

Atherogenic Dyslipidemia Remission 1 Year After Bariatric Surgery.

PURPOSE: Given the lack of evidence of the effect of bariatric surgery (BS) on atherogenic dyslipidemia (AD), which is a characteristic of obese subjects, this study aimed to describe the remission rate of AD 1 year after BS in severely obese patients. MATERIALS AND METHODS: A non-randomised, prospective cohort study was conducted in patients undergoing laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy with a 1-year follow-up. AD was defined as triglycerides ≥1.71 mmol/l or treatment with fibrates and low high-density lipoprotein (HDL) cholesterol (<1.03 mmol/l in men or <1.3 mmol/l in women). RESULTS: AD was present in 81 (22.8%) of the 356 patients; these were more frequently men and presented higher total cholesterol and non-HDL cholesterol concentrations. AD remission rate was 74.1% at 3 months, 90.1% at 6 months and 96.3% at 12 months, respectively, after BS. In this group of patients, HDL cholesterol levels rose progressively (1.0 ± 0.2 to 1.5 ± 0.3 mmol/l, p < 0.001) and triglycerides decreased (2.5 ± 0.9 to 1.2 ± 0.5 mmol/l, p < 0.001) during follow-up. Regarding previous lipid-lowering therapy, fibrates and ezetimibe were withdrawn in all patients and statins in 69.4% 1 year after surgery. CONCLUSION: BS has beneficial effects on lipid profile, achieving complete remission of AD at 1 year of follow-up in almost all patients.

Predictors of Hypertension Remission and Recurrence After Bariatric Surgery.

BACKGROUND: Few data exist on factors associated with hypertension (HTN) remission post-bariatric surgery. No information on factors that may predict HTN relapse is available. The aims were to assess the HTN remission and relapse rates at 1 and 3 years, respectively, post-bariatric surgery, and determine predictive factors. METHODS: A nonrandomized prospective cohort study on severely obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) with a follow-up of 36 months was conducted between 2005 and 2011. Criteria for HTN diagnosis were current treatment with antihypertensive agents and/or systolic blood pressure (BP) >140 mm Hg and/or diastolic BP >90 mm Hg. HTN remission was defined as normalization of BP maintained after discontinuation of medical treatment. RESULTS: A total of 197 patients were included in the study. HTN was present in 47.7%; 68.1% of hypertensive patients showed HTN remission 1 year after the surgical procedure, 21.9% of whom had relapsed at 3 years. The number of antihypertensive drugs prior to surgery was associated with a lower remission rate at the first year and a higher recurrence at 3 years. However, a smaller weight loss during the first year was associated with increased HTN recurrence at 3 years. CONCLUSION: HTN relapses in 1 of 5 hypertensives who have achieved remission at the first year of follow-up. Weight loss during the first postoperative year should be encouraged to avoid HTN relapse at 3 years.

Preoperative predictors of weight loss at 4 years following bariatric surgery.

BACKGROUND: This study evaluated the influence of patient characteristics, preoperative weight loss, and type of surgical procedure on long-term weight loss after bariatric surgery (BS). METHODS: Subjects were a prospective cohort of 95 patients who underwent BS with 4 years of follow-up. Seventy-seven patients (81.1%) underwent laparoscopic Roux-en-Y gastric bypass, and 18 (18.9%) had laparoscopic sleeve gastrectomy. Age, gender, initial body mass index (BMI), preoperative percentage of excess weight loss, presence of type 2 diabetes mellitus, current smoking status, and surgical technique were analyzed via multivariate linear regression analysis to identify predictors of weight loss during the 4 years after the surgery. RESULTS: Maximum percentage of excess weight loss was obtained at 18 months. Age and preoperative BMI were negatively associated with percentage of excess weight loss at 1, 2, 3, and 4 years after BS (P < .005). At 4 years, laparoscopic Roux-en-Y gastric bypass was independently associated with a higher weight loss than laparoscopic sleeve gastrectomy (P < .05). CONCLUSIONS: Younger age, lower BMI, and laparoscopic Roux-en-Y gastric bypass are independent predictors of long-term weight loss after BS.

High-Dose Vitamin D Supplementation is Necessary After Bariatric Surgery: A Prospective 2-Year Follow-up Study.

BACKGROUND: We assessed the need of vitamin D supplementation to achieve normal 25-hydroxyvitamin D (25[OH]D) levels after bariatric surgery and whether there were differences between laparoscopy sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: A total of 164 morbid obese patients undergoing bariatric surgery from January 2008 to June 2011 were followed for 2 years. Serum levels of 25(OH)D and intact parathyroid hormone (iPTH) were measured preoperatively and at 3, 6, 9, 12, 18, and 24 months after operation. All patients received 400 IU/day of 25(OH)D. Patients received additional supplementation with 16,000 IU of vitamin D3 (calcifediol) every 2 weeks if 25(OH)D serum levels were < 30 ng/mL (intervention group). RESULTS: Ninety-six (58.5 %) patients underwent LSG and 68 (41.5 %) LRYGB. A total of 106 (64.6 %) patients received calcifediol supplementation (62 in the LSG group and 44 in the LRYGB group). Normal 25(OH)D levels at 24 months were recorded in 69 % of patients in the intervention group and in 48.3 % in the non-intervention group. At 24 months, mean 25(OH)D levels in the non-intervention group were significantly lower among LRYGB patients than among LSG patients (P = 0.009). In the intervention group, normal 25(OH)D levels were achieved in 60 % of patients treated with LSG and in 22.2 % of those treated with LRYGB. Secondary hyperparathyroidism was presented in 49 (29.9 %) patients preoperatively but without significant differences in iPTH levels between the two surgical procedures. CONCLUSION: Patients undergoing bariatric surgery should receive high-dose vitamin D supplementation independently of the surgical technique.