Long-term Nutritional Deficiencies Research Articles

Laparoscopic Gastrogastrostomy – An Alternative Procedure for Stenosis after Sleeve Gastrectomy

Abstract Introduction: Reflux symptoms associated with stenosis after laparoscopic sleeve gastrectomy can occur secondary to anatomical abnormality including mechanical stenosis and axial deviation, commonly occurring mid-sleeve. Treatment options include endoscopic intervention, including dilatation, stenting, myotomy, and surgical revision, with Roux-en-Y gastric bypass (RYGB) being preferred by many. In this case series, we report six patients who have undergone laparoscopic gastrogastrostomy (GG) for gastric stenosis and propose this as a possible surgical alternative for appropriately selected patients with symptomatic angularis stenosis. Patients and Methods: Medical records for six patients who underwent laparoscopic GG for treatment of persistent reflux symptoms due to angularis stenosis were reviewed. All patients were preoperatively investigated with endoscopy and abdominal three-dimensional computed tomography. Hiatal hernia and esophageal dilation were excluded. After further consultation, patients proceeded to laparoscopic GG. Results: Complete resolution of symptoms was reported in three of six patients, with Visick score 1, while the other three reported significantly improved symptoms. Postoperative body mass index remained similar to prerevision baseline. There were no postoperative complications. Conclusion: Revision to RYGB is effective for stenosis and reflux but can be challenging with the potential for long-term nutritional deficiencies and surgical complications. For patients with angularis stenosis, laparoscopic GG is a simpler revisional procedure that has shown adequate initial outcomes with no short or anticipated long-term complications in this case series. Patients with persisting symptoms could undergo subsequent gastric bypass if needed.

Micronutrient status 2 years after bariatric surgery: a prospective nutritional assessment.

Among commonly performed bariatric surgeries, biliopancreatic diversion with duodenal switch (BPD-DS) provides greater weight loss than Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), with sustained metabolic improvements. However, the risk of long-term nutritional deficiencies due to the hypoabsorptive component of BPD-DS hinders its widespread use. The aim of the study was to examine nutritional status over 2 years after BPD-DS, RYGB or SG. Patients were recruited in the REMISSION trial (NCT02390973), a single-center, prospective study. Out of 215 patients, 73, 48 and 94, respectively, underwent BPD-DS, RYGB or SG. Weight loss, micronutrient serum levels (including iron, calcium, parathormone, vitamins A, B12 and D), and nutritional supplementation were assessed over 2 years. Patients were supplemented according to the type of surgery and individual micronutrient level evolution. At baseline, BPD-DS patients were younger than SG patients (p = 0.0051) and RYGB patients had lower body mass index (p < 0.001). Groups had similar micronutrient levels before surgery, with vitamin D insufficiency as the most prevalent nutritional problem (SG: 38.3%, RYGB: 39.9%, BPD-DS: 54.8%, p = 0.08). BPD-DS patients showed lower levels of iron, calcium and vitamin A than SG patients at 24 months. Groups had similar levels of vitamin D at 24 months. Prevalence of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiency was similar among groups at 24 months. Rates of vitamin D insufficiency and iron deficiency were lower at 24 months than at baseline. Micronutrient intake was consistent with recommendations in groups post-surgery, but most BPD-DS patients took vitamin A and vitamin D supplement doses above initial recommendations. With appropriate medical and nutritional management, all surgeries led to similar rates of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiencies at 24 months. However, initial vitamin A and vitamin D supplementation recommendations for BPD-DS patients should be revised upwards.

Evaluation of Long-Term Nutrition Outcomes After Duodenal Switch: A Systematic Review and Meta-Analysis.

Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective and durable metabolic and bariatric surgery to achieve a target weight loss. However, many surgeons are hesitant to adopt BPD-DS due to a lack of training, technical complexity, and long-term nutrition deficiencies. This meta-analysis aimed to investigate long-term nutrition outcomes after primary BPD-DS in the management of obesity. Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to February 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023391316). From 834 studies screened, 8 studies met the eligibility criteria, with a total of 3443 patients with obesity undergoing primary BPD-DS. At long-term follow-up (≥5years), 25.4% of patients had vitamin A deficiency (95% CI: -.012, .520, I2 = 94%), and 57.3% had vitamin D deficiency (95% CI: .059, 1.086, I2 = 86%). Calcium deficiency was observed in 125 patients (22.2%, 95% CI: .061, .383, I2 = 97%), and 69.7% had an abnormal parathyroid hormone level (95% CI: .548, .847, I2 = 78%). Ferritin level was abnormal in 30 patients (29.0%, 95% CI: .099, .481, I2 = 79%). Despite displaying comparable nutrition-related outcomes to mid-term follow-up, our study demonstrated that BPD-DS could result in a high level of long-term nutrition deficiency after BPD-DS for selected patients. However, further randomized controlled studies with standardized supplementation regimens and improvement in compliance are necessary to evaluate and prevent long-term nutritional deficiencies after BPD-DS.

Medium-Term Nutritional and Metabolic Outcome of Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S).

Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S), like other hypoabsorptive procedures, could be burdened by long-term nutritional deficiencies such as malnutrition, anemia, hypocalcemia, and hyperparathyroidism. We aimed to report our experience in terms of mid-term (2 years) bariatric, nutritional, and metabolic results in patients who underwent SADI-S both as a primary or revisional procedure. One hundred twenty-one patients were scheduled for SADI-S as a primary or revisional procedure from July 2016 to February 2020 and completed at least 2 years of follow-up. Demographic features, bariatric, nutritional, and metabolic results were analyzed during a stepped follow-up at 3 months, 6 months, 1 year and 2 years. Sixty-six patients (47 female and 19 male) were included. The median preoperative BMI was 53 (48-58) kg/m2. Comorbidities were reported in 48 (72.7%) patients. At 2 years, patients had a median BMI of 27 (27-31) kg/m2 (p < 0.001) with a median %EWL of 85.3% (72.1-96.1), a TWL of 75 (49-100) kg, and a %TWL of 50.9% (40.7-56.9). The complete remission rate was 87.5% for type 2 diabetes mellitus, 83.3% for obstructive sleep apnea syndrome and 64.5% for hypertension. The main nutritional deficiencies post SADI-S were vitamin D (31.82%) and folic acid deficiencies (9.09%). SADI-S could be considered as an efficient and safe procedure with regard to nutritional status, at least in mid-term (2 years) results. It represents a promising bariatric procedure because of the excellent metabolic and bariatric outcomes with acceptable nutritional deficiency rates. Nevertheless, larger studies with longer follow-ups are necessary to draw definitive conclusions.

PENYULUHAN PENTINGNYA STATUS GIZI ANAK DAN STUNTING DI DESA UTEUNKOT KECAMATAN MUARA DUA KOTA LHOKSEUMAWE

The incidence of stunting affects chronic growth disorders in children due to long-term nutritional deficiencies. Stunting is caused by multi-dimensional factors, not only caused by malnutrition, which is experienced by pregnant women and children under five. As for other indirect factors, they range from socio-economic factors, parental education, parental occupation, exclusive breastfeeding, immunization status, range of health care facilities, to parenting patterns. The problem of stunting is influenced by infectious diseases and lack of nutritional intake. As for other problem indirect factors, namely socio-economic factors, parental education and parental occupation, exclusive breastfeeding, immunization status, range of health care facilities and inadequate parenting patterns. The method of activity carried out in this community service was by counseling using the lecture method with media presentations containing explanations about how to fulfill nutrition for community service participants. The purpose of this service activity was to increase the knowledge and attitudes of mothers, heads of families and residents of Uteunkot Village in implementing the consumption of balanced nutritious food in children from early age. The results of this counseling activity were able to increase the knowledge of mothers and residents of Uteunkot Village. Furthermore, it is hoped that residents can understand the impact of stunting and how to prevent stunting properly.

Long-Term Iron and Vitamin B12 Deficiency Are Present after Bariatric Surgery, Despite the Widespread Use of Supplements.

There are few long-term nutritional studies in subjects undergoing bariatric surgery that have assessed weight regain and nutritional deficiencies. In this study, we report data 8 years after surgery on weight loss, use of dietary supplements and deficit of micronutrients in a cohort of patients from five centres in central and northern Italy. The study group consisted of 52 subjects (age: 38.1 ± 10.6 y, 42 females): 16 patients had Roux-en-Y gastric bypass (RYGB), 25 patients had sleeve gastrectomy (SG) and 11 subjects had adjustable gastric banding (AGB). All three bariatric procedures led to sustained weight loss: the average percentage excess weight loss, defined as weight loss divided by excess weight based on ideal body weight, was 60.6% ± 32.3. Despite good adherence to prescribed supplements, 80.7% of subjects (72.7%, AGB; 76.7%, SG; 93.8 %, RYGB) reported at least one nutritional deficiency: iron (F 64.3% vs. M 30%), vitamin B12 (F 16.6% vs. M 10%), calcium (F 33.3% vs. M 0%) and vitamin D (F 38.1% vs. M 60%). Long-term nutritional deficiencies were greater than the general population among men for iron and among women for vitamin B12.

Long-term nutritional deficiencies following sleeve gastrectomy: a 6-year single-centre retrospective study.

IntroductionSleeve gastrectomy (SG) is associated with short-term nutritional deficiencies postoperatively. This study evaluates the long-term percentage of excess weight loss (% EWL), and nutritional deficiencies in a single-centre cohort undergoing SG as a primary procedure, with a 6-year follow-up.Material and methodsFrom January 2005 to December 2010 the records of 209 patients who underwent laparoscopic SG were retrieved from a computer database for analysis. Sixty out of the 209 paients completed follow-ups for 6 years.ResultsMedian % EWL at 1, 2, 3, 4, 5, and 6 years postoperatively was 80.9%, 79.1%, 73.8%, 71.8%, 71.5%, and 64.9%, respectively. Prior to surgery, 17.2% had anaemia. Deficiencies of iron, ferritin, folic acid, vitamin B12, magnesium, and phosphorus were 22%, 5.3%, 1.4%, 3.8%, 29.7%, and 5.3%, respectively. Six years post-surgery, deficiencies of haemoglobin, ferritin, and B12 worsened (36.7%, 43.3%, and 11.7%, p = 0.001, p < 0.001, p = 0.019, respectively), whereas there was no significant difference in deficiencies of iron, folic acid, magnesium, and phosphorus (25%, 1.7%, 20%, and 3%, p = 0.625, p = 0.896, p = 0.139, p = 0.539, respectively). There was elevated PTH before and 6 years after surgery (2.9% and 1.7%, p = 0.606).ConclusionsThis retrospective study shows that laparoscopic sleeve gastrectomy had a considerable effect on specific nutritional deficiencies in our patients at 6 years post-surgery. Knowledge of micronutrient deficiencies in these patients is beneficial for both prevention and management of nutritional complications associated with SG with the administration of oral nutritional supplementation according to the patient’s needs.

Micronutrient intake and biochemistry in adolescents adherent or nonadherent to supplements 5 years after Roux-en-Y gastric bypass surgery

BackgroundRoux-en-Y gastric bypass (RYGB) is an effective obesity treatment in adults and has become established in adolescents. Lower adherence to supplementation in adolescents confers a risk for long-term nutritional deficiencies. ObjectivesTo assess adherence to supplementation, micronutrient intake, and biochemistry in adolescents through 5 years after RYGB. SettingUniversity hospitals, multicenter study, Sweden. MethodsMicronutrient intake and adherence to supplementation were assessed by diet history interviews and biochemistry preoperatively, 1, 2, and 5 years after RYGB in 85 adolescents (67% females), aged 16.5 years (± 1.2) with a body mass index of 45.5 kg/m2 (± 6.0). Adherence was defined as taking prescribed supplements ≥3 times a week. Micronutrient intake and biochemistry were compared with matched controls at 5 years. ResultsOver 75% completed the dietary assessments across 5 years after RYGB. Adherence ranged between 44–61% through 5 years. At 5 years, ferritin and hemoglobin decreased (P < .04) and 61% had iron deficiency (P ≤ .001). Among females with iron deficiency, most did not adhere to supplementation (P = .005), and 59% of these had anemia (P < .001). Vitamin D insufficiency continued after surgery and 80% of participants who did not adhere to supplementation had insufficiency (P = .002). Adolescents not adhering had lower levels of vitamin D, B12, and ferritin (females) compared with both adhering adolescents and the control group (all P < .04). ConclusionsHalf of adolescents after RYGB reported sufficient long-term adherence to supplementation. Adhering to supplements and reporting a higher micronutrient intake were associated with more favorable biochemistry. Results support the recommendations for monitoring micronutrient intake and biochemistry in all patients who have undergone RYGB surgery, and the recommendation of higher preventive supplementation of vitamin D and iron in both sexes. As hypothesized, adolescents not adhering had a higher prevalence of long-term micronutrient deficiencies.

Nutritional deficiencies four years after laparoscopic sleeve gastrectomy—are supplements required for a lifetime?

BackgroundData regarding long-term nutritional deficiencies following laparoscopic sleeve gastrectomy (LSG) are scarce. ObjectivesTo assess the prevalence of nutritional deficiencies and supplement consumption 4 years post-LSG. SettingHebrew University, Israel. MethodsData were collected prospectively from preoperative and 1 and 4 years postoperative including anthropometric parameters, biochemical tests, and supplement intake. ResultsData were available for 192, 77, and 27 patients at presurgery and 1 and 4 years post-LSG, respectively. Prevalence of nutritional deficiencies at baseline and 1 and 4 years postsurgery, respectively, were specifically for iron (44%, 41.2%, 28.6%), anemia (11.5%, 20%, 18.5%), folate (46%, 14.3%, 12.5%), vitamin B12 (7.7%, 13.6%, 15.4%), vitamin D (96.2%, 89%, 86%), and elevated parathyroid hormone (PTH) (52%, 15.4%, 60%). Vitamin D levels remained low throughout the whole period. PTH levels were 37.5 pg/mL at 1 year postsurgery and increased to 77.3 pg/mL at 4 years postsurgery (P = .009). Females had higher prevalence of elevated PTH and a tendency for higher rates of anemia, compared with males 4 years postsurgery (80% versus 20%, P = .025; and 28% versus 0%, P = .08, respectively). Of the patients, 92.6% reported taking a multivitamin and 74.1% vitamin D supplements during the first postoperative year, while after 4 years only 37% and 11.1% were still taking these supplements, respectively. ConclusionA high rate of nutritional deficiencies is common at 4 years post-LSG along with low adherence to the nutritional supplementation regimen. Long-term nutritional follow-up and supplementation maintenance are crucial for LSG patients. Future studies are needed to clarify the clinical impact of such deficiencies.

Tool of nutrition education for allergic to egg and cow's milk protein in pediatric age

Food allergy affects a large part of the population and their numbers are increasing. Although the knowing of this pathology is growing, allergic patients have really difficulties to lead a normal life, especially with food. Until now,this group hadn t practical tools that would help them in the development of a balanced daily diet, as there are for the general population in the form of pyramids and dietary guidelines . This work has covered this need for two of the most prevalent allergies in early life. gather information on the allergy of cow's milk protein and egg, to design a food pyramid for these patients, based on the consensus, recommendations and scientific guidance. After confirming the absence of a similar work, food pyramids allergy to egg and cow's milk protein, adapted to each, and a joint pyramid is designed to both allergies. Besides basic recommendations for healthy eating were included in general and in particular individuals, with special interest for the collective (food hygiene, food additives, cosmetics, medicines, etc). Due to the importance of nutrition in childhood and acquires the underlying difficulties this group, to properly plan the diet is very important as it can prevent accidents and long-term nutritional deficiencies. Therefore provide graphical tools and practices to this goal, is importance for population and medical and scientific community, and is the result of this work.

Nutritional Implications of Bariatric Surgery and the Role of Registered Dietitians

A S THE NUMBER OF INDIVIDUALS WITH OBESITY continues to increase, so has the prevalence of bariatric surgery in the United States and worldwide. Bariatric surgery is currently the only knownmethod that offers both considerable and long-termweight loss. Depending on the surgical procedure, patients can expect to lose between 29% and 87% of excess bodyweight 1 to 2 years postsurgery. Despite the substantial weight loss and improvements in comorbid conditions observed after bariatric surgery, these procedures are notwithout nutritional risk, which underscores the importance of registered dietitians (RDs) to the bariatric surgical care team. Nutritional deficiencies after bariatric surgery can arise from a variety of factors, including surgical modifications of the gastrointestinal tract that reduce dietary intake and/or promote malabsorption, or because of poor patient compliance with treatment recommendations (eg, diet and multivitamin supplementation). In this issue, MoizE and colleagues prospectively evaluated long-term nutritional deficiencies and dietary patterns after both sleeve gastrectomy and Rouxen-Y gastric bypass (RYGB). They demonstrated that nutritional deficiencies anddietary intake patternswere similar up to 5 years after sleeve gastrectomy and RYGB. Insufficient or deficient 25-hydroxyvitamin D appeared to be the most common problem before and up to 5 years after both surgeries, despite implementing a vitamin D supplementation protocol and living in aMediterranean climate (insufficiency defined by MoizE and colleges as 10 to 29 ng/mL [25 to 72 nmol/L] and deficiency defined as 10 ng/mL [ 25 mmol/L]). Considering that amajority of patients in theMoizE and colleagues studywere either insufficient or deficient before surgery suggests that routine supplementation of vitamin D should occur preoperatively. Moreover, the results from MoizE and colleagues and others highlight the importance of vitamin D supplementation in the bariatric surgery patient population and suggest that the frequently recARTICLE INFORMATION

Overview of bariatric surgery for the physician

The worldwide pandemic of obesity carries alarming health and socioeconomic implications. Bariatric surgery is currently the only effective treatment for severe obesity. It is safe, with mortality comparable to that of cholecystectomy, and effective in producing substantial and sustainable weight loss, along with high rates of resolution of associated comorbidities, including type 2 diabetes. For this reason, indications for bariatric surgery are being widened. In addition to volume restriction and malabsorption, bariatric surgery brings about neurohormonal changes that affect satiety and glucose homeostasis. Increased understanding of these mechanisms will help realise therapeutic benefits by pharmacological means. Bariatric surgery improves long-term mortality but can cause long-term nutritional deficiencies. The safety of pregnancy after bariatric surgery is still being elucidated.

Spotlight

Gronwald et al., pp. 2281–2284 Mutations in BRCA1 or BRCA2 greatly increase a woman's chance of developing breast cancer. About a third of women diagnosed with cancer in one breast will develop cancer in the other breast within 10 years of first diagnosis. Treatment with tamoxifen reduces this risk, as can removal of the ovaries. In their current report, Gronwald and colleagues asked whether tamoxifen helps prevent contralateral breast cancer in patients who have previously had their ovaries removed. Though tamoxifen exerted a strong protective effect in women who had gone through natural menopause, the drug did not protect those who had had their ovaries surgically removed. In previous work, the authors compared women with bilateral breast cancer with controls whose cancer had struck only one side. They noted that tamoxifen treatment markedly reduced the risk of contralateral cancer, but they could draw that conclusion only for patients with BRCA1 mutations. Having approximately doubled their number of subjects in the 5 years since that study appeared, the authors can investigate the question with a higher level of precision. Now, they show that tamoxifen administered after initial diagnosis prevents cancer in the opposite breast for both BRCA1 and BRCA2 carriers. Also, no effect of tamoxifen was observed among women whose ovaries had been removed, although that subgroup of women was small. On the basis of their analysis, the authors recommend tamoxifen to prevent contralateral breast cancer in BRCA carriers with intact ovaries. Kreimer et al., pp. 2293–2297 The main risk factors for oral cancer, tobacco use and alcohol consumption, account for over 90% of oral and oropharyngeal squamous cell carcinomas. Poor diet has also been related to increased oral cancer, but because people who use tobacco and alcohol heavily also typically consume a diet low in fruits and vegetables, it has been difficult to rule out the confounding effects of these risk factors. In their current article, Kreimer and colleagues report finding a strong association between a poor diet, low in fruits and vegetables, and oral cancers. The authors combined data from a number of case-control studies conducted in 9 countries to isolate the role of several food groups and body mass index (BMI) on risk of oral cancer. Their analysis confirms previous reports showing an association between low BMI and oral cancer, even among subjects who had never used tobacco or alcohol. Because the questionnaire included information about height and weight covering the 2-year period prior to diagnosis, weight loss due to the disease was less likely to be the cause of the low BMI. Rather, the indicator would seem to point to long-term nutritional deficiencies among oral cancer patients. The study also confirmed that fruit and vegetable consumption protects against oral cancer, although it could not pinpoint which anticarcinogenic agents in the foods reduced the cancer risk. Consumption of fish, red meat, and cured meats also appeared to reduce risk. From this large international study, poor diet emerges as one important risk factor for oral cancer, besides tobacco and alcohol use. Ito et al., pp. 2337–2343 A diagnosis of pancreatic cancer carries little hope of recovery; resistant to most chemotherapy and radiation regimens, this disease claims the lives of 9 out 10 patients within 5 years of diagnosis. One agent, gemcitabine, seems to work against advanced pancreatic cancer, but even with the drug, the response rate remains less than 20%. Although mechanisms have been proposed, there has been no compelling evidence to explain this high level of treatment failure. In the current study, Ito and colleagues investigate the role of mTOR, a molecule that plays a central role in cell survival and proliferation, in pancreatic cancer and show that an mTOR inhibitor stifles the cancer's growth in vitro. Previous investigations have reported activation of Akt in pancreatic cancer; mTOR, which lies downstream of the PI3K/Akt signaling pathway, therefore stands out as a potential target. Recent studies also have revealed that CCI-779, a synthetic rapamycinester that inhibits mTOR, has shown antitumor activity against certain cancers, making it a good candidate for treatment of pancreatic cancer as well. The authors showed that the Akt/mTOR signaling pathway was activated in all 6 pancreatic cancer cell lines examined, suggesting that the pathway might be important for the cancer's development. When tested on the cell lines, combined therapy with CCI-779 and gemcitabine showed no synergistic effect. In mice that had been injected with pancreatic cancer cells, however, combined therapy delayed tumor growth and increased survival compared with single agent therapy. These in vivo results raise the hope that combining CCI-779 with gemcitabine could improve clinical outcomes as well.