Bariatric surgery: Think about osteomalacia too.

BackgroundThe development of osteoporosis and fractures is a well-documented complication of bariatric surgery (BS), especially with procedures associated with malabsorption. Due to the gradual increase of BS performed worldwide, several...

Impact of Bariatric Surgery Upon the Incidence of Distal Radius Fractures Among Patients With Severe Obesity.

Diabetes remission after malabsorptive bariatric surgery

The aim of this study was to analyse the clinical manifestations and the most frequent causes of osteomalacia (OM) in a group of 28 patients diagnosed with this disorder during a 20-year period. OM was diagnosed by bone biopsy and/or by Bingham and Fitzpatrick criteria (two of the following: low calcium, low phosphate, elevated total alkaline phosphatase [total AP] or suggestive radiographs). Of these patients, 13 had vitamin D deficiency OM (VD-OM), 14 hypophosphatemic OM (HypoP-OM) and one had OM-associated hypophosphatasia. Deficient sun exposure and celiac disease were the most frequent etiologies of VD-OM, whereas most HypoP-OM were hereditary forms. The main clinical symptoms were polyarthralgias (89%), frequently associated with fractures (75%). Fifty seven percent had densitometric criteria of osteoporosis. Patients with VD-OM showed significantly higher total AP and PTH serum values, but lower vitamin D, serum calcium, calciuria and bone mass than patients with HypoP-OM. Conversely, HypoP-OM patients had significantly lower serum phosphate and higher phosphaturia than patients with VD-OM. Briefly, high total AP, low serum calcium and low serum phosphate were observed in 85%, 65% and 15%, respectively, of patients with VD-OM, being observed in 64%, 14% and 100%, respectively, of HypoP-OM patients. Nearly 50% of these latter showed increased FGF23 levels. In conclusion, in this study, the frequencies of HypoP-OM and VD-OM were similar. The most frequent laboratory abnormalities were increased total AP and decreased serum phosphate. A urinary calcium loss of less than 50 mg/dl was highly discriminatory for VD-OM and a serum phosphate less than 2.3 mg/dl was also high discriminatory for HypoP-OM. Low densitometric values and fractures were frequent among these patients.

Bariatric surgeries such as gastric banding (LAGB), gastric bypass (RYGB), vertical banded gastroplasty (VBG), and sleeve gastrectomy (LSG) decrease body weight in morbid obesity, leading to the resolution of coexisting diabetes mellitus and arterial hypertension in the majority of cases as well as improvements of renal function and liver steatosis. BS (LAGB, RYGB, VBG, and LSG) also reduce incident cases of diabetes, of cardiovascular diseases, and of cancer; these therapeutic and preventive effects on comorbidities of obesity have not been analyzed for malabsorptive surgeries such as biliopancreatic diversion (BPD) or biliointestinal bypass (BIBP). The aim of this study was to analyze the incidence of comorbidities, i.e., diabetes, cardiovascular diseases, and cancer, in obese subjects undergoing BPD and BIBP, in comparison with standard medical treatment of obesity. Medical records of 1983 obese patients (body mass index (BMI) > 35kg/m2, aged 18-65years, undergoing surgery (n = 472, of which 111 with diabetes) or medical treatment (n = 1511, of which 422 with diabetes), during the period 1999-2008 (visit 1)) were collected; incident cases of comorbidities were ascertained through December 31, 2016. Observation period was 12.0 ± 3.48years (mean ± SD). Compared to non-surgical patients matched for age, body mass index, and blood pressure, malabsorptive surgeries were associated with reduced new incident cases of diabetes (p = 0.001), cardiovascular diseases (p = 0.001), hyperlipidemia (p = 0.001), oculopathy (p = 0.021), and cancer (p = 0.001). The preventive effect of BS was similar in both nondiabetic and diabetic patients for cardiovascular diseases and hyperlipidemia (both p = 0.001). The preventive effect was significant in nondiabetic subjects for coronary heart disease and for cancer, not significant in diabetic subjects. Patients undergoing malabsorptive bariatric surgery show less incident cases of diabetes, cardiovascular diseases, hyperlipidemia, oculopathy, and cancer than controls receiving medical treatment.

ObjectiveDue to the global increase in obesity rates and success of bariatric surgery in weight reduction, an increasing number of women now present pregnant with a previous bariatric procedure. This...

Rickets and osteomalacia are disorders of calcification characterized by defects of bone and cartilage mineralization during growth, and bone mineralization in adults, respectively. The specific x-ray findings including a cupping, flaring, and fraying of metaphysis and the elevation of the level of serum alkaline phosphatase are essential for the diagnosis of rickets. In addition, hypophosphatemia, hypocalcemia, and some symptoms including born deformity, spinal curvature, craniotabes, enlargement of the anterior fontanel, rachitic rosary, and joint swelling are also important. Clinicians need to consider the different normal ranges of the levels of serum alkaline phosphatase and phosphate depending on their patient's age when they diagnose their childhood patients. In contrast, the radiographic diagnosis of osteomalacia is difficult. The hypophosphatemia or hypocalcemia and the elevation of serum bone alkaline phosphatase are essential for the diagnosis of osteomalacia. Moreover, some clinical features including muscle weakness and bone pain, the decrease of bone density, and the finding of multiple uptake in bone scintigraphy or of the pseudofracture in bone x-ray study are also important. It is very useful for the differential diagnosis to measure the serum levels of 25-hydroxy vitamin D and fibroblast growth factor 23.

Biliopancreatic diversion (BPD) is associated with a 70% excess weight loss (EWL) at 10 years, but there are concerns regarding long-term nutritional sequelae. Metabolic bone disease has been documented following Roux-en-Y gastric bypass. Patients who underwent a BPD from 1998 to 2001 were studied. A questionnaire was designed to review BPD patients and collect information on weight loss, frequency of gastrointestinal disturbances and compliance with multivitamin recommendations. The review included a blood test for vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium. Of the 82 patients who underwent BPD during this period, the median %EWL at 36 months was 73.0%. 75.6% suffered diarrhea. At median follow-up of 32 months (18-50), 25.9% of patients were hypocalcemic, 50% had low vitamin D, 23.8% had elevated ALP, and 63.1% had elevated PTH, despite 82.9% taking multivitamins. BPD results in significant weight loss. However, 1 in 4 patients are hypocalcemic, and 1 in 2 have a low vitamin D, despite multivitamin supplementation. BPD patients require routine calcium and vitamin D supplementation for life. Long-term sequelae from these abnormal serum levels are not known.

Secondary Kwashiorkor: A Rare Complication of Gastric Bypass Surgery

Bariatric surgery developed in the late 1970 to treat severe hyperlipidemias in overweight individuals, not necessarily obese. Several techniques have been developed, and the concept has come first of a surgery for morbid obesity, then of a cure for diabetes in morbid obesity. There are other aspects of bariatric surgery that deserve attention, beyond BMI and diabetes, such as hypertension, poor life expectancy, increased prevalence of cancer, congestive heart failure, social inadequacy. The aim of this presentation is to review some recent development in clinical research, in the fields of liver steatosis, ferritin metabolism, and cholesterol metabolism. Liver steatosis, also called fatty liver encompasses a graduation of diseases with different clinical relevance and prognosis. NAFLD correlates with atherosclerosis, insulin resistance and diabetes mellitus. There is now evidence that weight loss, obtained through diet or restrictive surgery, reduces the prevalence (and the severity) of NAFLD. An other issue is represented by serum ferritin concentrations, that are strongly associated with fibrosis, portal and lobular inflammation in NAFLD patients, especially in the presence of obesity. Body iron contributes to excess oxidative stress already at non iron overload concentrations. Moreover, serum ferritin is an important and independent predictor of the development of diabetes. Weight loss is accompanied by reduction of ferritin, more after restrictive than malabsorptive surgery. Metabolic changes are greater after malabsorptive or mixed surgery than after purely restrictive surgery, and this has been ascribed to a greater weight loss. Studies comparing the two kinds of surgery indicate that, for the same amount of weight loss, decrease of cholesterol is greater with the former than with the latter techniques, and this difference is mainly due to a greater reduction of intestinal absorption of cholesterol. In the choice of surgery for the single patient, among other aspects, malabsorptive surgery seems to be more indicated in subjects with hyperlipidemia, especially with high cholesterol levels.

Bariatric surgery is one of the most effective treatments currently available for obesity and its derived comorbidities. However, complications may occur, especially when malabsorptive surgeries like a biliopancreatic diversion is performed. We present the case of a female patient whose obesity was treated with this technique, and in the 9th year of follow-up developed an extensive dermatitis secondary to zinc deficiency and malnutrition, precipitated by therapeutic non-compliance. A close surveillance of early symptoms and signs of nutritional deficiencies as well as chronic supplementation of vitamins and trace elements is required; this case illustrates the relevance of periodical, lifelong visits to a medical physician with special training and experience in the management of post bariatric surgery patients in order to prevent, diagnosis and early treat related complications.

Noninvasive testing in the diagnosis of osteomalacia

Introduction: Bariatric, restrictive and mixed (predominantly restrictive or malabsorptive) surgery is a therapy to reduce weight and control associated diseases. This literature review discusses the relevance of procedures approved by the Federal Council of Medicine (CFM) according to bibliographic references of significant scientific evidence. Objectives: To review the techniques currently used in bariatric surgery, advantages and disadvantages. Methods: Literature review of the techniques employed in bariatric surgery, by descriptors in Portuguese (techniques in bariatric surgery, gastric banding, vertical gastrectomy, Roux-en-Y gastric bypasses and biliopancreatic bypass). Results: Gastric banding is a silicone prosthesis wrapped around the stomach, which generates weight regain. Vertical gastroplasty reduces the stomach by a ring-mediated suture with good results but high recurrence. The intragastric balloon is the introduction of a silicone prosthesis with methylene blue, which must be removed after 6 months. Gastric bypass has low mortality and high efficacy, being the most used in Brazil. Vertical gastrectomy preserves the small intestine and partially the stomach, and its low postoperative mortality determines its frequent indication. The Scopinaro technique is 5% of the procedures performed in Brazil, the duodenal switch or vertical gastrectomy with intestinal detour generates nutritional deficiency. Conclusion: Comparing the surgical methods, it is up to the surgeon and the team, the particular analysis to decide which fits best for the patient. However, regardless of the technique used, scientifically it is the conduct with more positive results in the long term, compared to clinical approaches.

Background : malabsorptive surgery (MAS) can cause huge weight loss but is also known for its serious side effects. We investigated whether conversion surgery is an effective treatment for MAS-induced complications. Methods : we searched our hospital database for patients who underwent conversion surgery after MAS. Any complication was recorded till time of conversion. The conversion techniques and their effect on the course of the patients were analyzed and compared to the situation after MAS. Results : we identified 17 patients who suffered a wide range of complications after biliopancreatic diversion (BPD) (n = 11), biliopancreatic diversion with duodenal switch (BPD-DS) (n = 4), or distal gastric bypass (D-GBP) (n = 2). After a (mean ± SD) period of 6.0 ± 3.6 years the MAS was either converted to a gastric bypass (GBP) in 6 patients or an elongation of the common limb (ECL) in 9 patients. Two conversions were atypical. After a (mean ± SD) follow-up of 2.4 ± 2.5 years the majority of blood test results improved. The incidence of most complaints diminished except abdominal discomfort, critical illness polyneuropathy, need for total parenteral nutrition (TPN), wheelchair dependency, and asthenia. One patient died of irreversible liver failure after 3 liver transplantations. Two patients died of cachexia. The preferred conversion technique is still unclear. Conclusions : MAS can cause invalidating and life-threatening side effects. If there are signs of incipient deterioration in organ function and/or nutritional status, conversion surgery should not be delayed. Although we have the impression that early conversion causes better outcome, many patients experience lifelong postoperative complications.

Introduction: Effective colon cancer screening requires adequate bowel preparation. In the setting of prior bariatric surgery, low-volume preparations or extended time delivery for high-volume preparations is recommended, although this recommendation is based on weak evidence. This study aims to evaluate bariatric surgery as a predictive risk factor for inadequate bowel preparation. Methods: Data were collected retrospectively for consecutive colonoscopies between March 1, 2013 and November 15, 2017. Only the index colonoscopy for each patient within the review period, and those scored using the Boston Bowel Preparation Scale (BBPS) were included. Incomplete data sets and patients with inflammatory bowel disease (IBD) were excluded. Inadequate preparation was defined as any one or more colon segments with a BBPS score of less than two. Patients with bariatric surgery occurring before the date of the colonoscopy were identified using ICD 9/10 codes. Data were analyzed using Wilcoxon rank-sum test for continuous variables and Fischer’s exact test for dichotomous variables. Multivariate logistic regression was performed to identify independent factors predictive of inadequate bowel preparation. Results: 70,714 colonoscopies occurred within the designated review period. 58,853 were excluded from analysis as shown in Figure 1. Of the remaining 11,861 colonoscopies, 363 (3.1%) had inadequate preparation. Factors associated with inadequate preparation on univariate analysis included: age, male sex, non-white race, body mass index (BMI), hypertension (HTN), diabetes mellitus (DM), and history of bariatric surgery (Table 1). After controlling for confounding risk factors, a history of bariatric surgery (OR = 2.98; 95% CI: 1.93-4.61) was found to be predictive of inadequate preparation (Table 1). In a subanalysis of malabsorptive vs. restrictive bariatric surgery patients, malabsorptive bariatric surgery was associated with a higher rate of inadequate preparation (12.79% vs. 4.58%, P = 0.023).515_A Figure 1 No Caption available.Conclusion: A history of bariatric surgery is an independent risk factor for inadequate bowel preparation. Furthermore, malabsorptive bariatric surgeries had higher rates of inadequate preparation when compared to restrictive bariatric surgeries. Further quality improvement initiatives should be directed at identifying the appropriate bowel preparation regimen in this population.515_B Figure 2. Risk factors for Inadequate Bowel Preparation.