Anand Nath

Dysphagia after vertical sleeve gastrectomy: Evaluation of risk factors and assessment of endoscopic intervention

AIM To evaluate the risks of medical conditions, evaluate gastric sleeve narrowing, and assess hydrostatic balloon dilatation to treat dysphagia after vertical sleeve gastrectomy (VSG). METHODS VSG is being performed more frequently worldwide as a treatment for medically-complicated obesity, and dysphagia is common post-operatively. We hypothesize that post-operative dysphagia is related to underlying medical conditions or narrowing of the gastric sleeve. This is a retrospective, single institution study of consecutive patients who underwent sleeve gastrectomy from 2013 to 2015. Patients with previous bariatric procedures were excluded. Narrowing of a gastric sleeve includes: inability to pass a 9.6 mm gastroscope due to stenosis or sharp angulation or spiral hindering its passage. RESULTS Of 400 consecutive patients, 352 are included; the prevalence of dysphagia is 22.7%; 33 patients (9.3%) have narrowing of the sleeve with 25 (7.1%) having sharp angulation or a spiral while 8 (2.3%) have a stenosis. All 33 patients underwent balloon dilatation of the gastric sleeve and dysphagia resolved in 13 patients (39%); 10 patients (30%) noted resolution of dysphagia after two additional dilatations. In a multivariate model, medical conditions associated with post-operative dysphagia include diabetes mellitus, symptoms of esophageal reflux, a low whole blood thiamine level, hypothyroidism, use of non-steroidal anti-inflammatory drugs, and use of opioids. CONCLUSION Narrowing of the gastric sleeve and gastric sleeve stenosis are common after VSG. Endoscopic balloon dilatations of the gastric sleeve resolves dysphagia in 69% of patients.

Review on Recent Advances in Value Addition of Jaggery based Products

Jaggery is sugarcane based natural sweetener made by the concentration of sugarcane juice without any use of chemicals. It is available in the form of solid blocks and in semi-liquid form. Besides this, the sap collected from some palm trees such as palmyra-palm (Borassus flabellifer L.), coconut-palm (Cocos nucifera L.), wild date-palm (Phoenix sylvestris Roxb.) and sagopalm (Caryota urens L.) is used for preparation of jaggery. It contains the natural sources of minerals and vitamins inherently present in sugarcane juice and it is one of the most wholesome and healthy sugars in the world. The micro nutrients present in the jaggery possess antitoxic and anti-carcinogenic properties. In India, of the 300 Mt of sugarcane produced, 53% is processed into white sugar, 36% into jaggery and khandsari, 3% for chewing as cane juice and 8% as seed cane. The methods of converting sugarcane and manufacturing sugar, gur and khandsari are different but a great value is added in the manufacturing of these consumable final products. Further it offers employment opportunity to millions of people. Of the total world production, more than 70% of the jaggery is produced in India but most of the jaggery business suffers from losses. The development of different value added products from jaggery and their commercial availability becomes needs of the hour to sustain future profitability in the jaggery trade.

Prevalence of clinical thiamine deficiency in individuals with medically complicated obesity

Thiamine is a vitamin whose deficient can result in multiorgan symptoms. We described an 18% prevalence of clinical thiamine deficiency after gastric bypass surgery. Our hypotheses are that individuals with medically complicated obesity frequently have clinical thiamine deficiency and that diabetes mellitus is a mechanism for development of clinical thiamine deficiency. This is a single institution, retrospective observational study of consecutive patients with a body mass index of at least 35 kg/m2 who were evaluated in preoperative gastrointestinal bariatric clinic from 2013 to 2015. Each patient underwent a symptom survey. Clinical thiamine deficiency is defined by both (1) consistent clinical symptom and (2) either a low whole-blood thiamine concentration or significant improvement of or resolution of consistent clinical symptoms after receiving thiamine supplementation. After excluding 101 individuals with prior bariatric surgery or heavy alcohol consumption, 400 patients were included in the study. Sixty-six patients (16.5% of 400) fulfill a diagnosis of clinical thiamine deficiency, with 9 (14% of 66) having consistent gastrointestinal manifestations, 46 (70% of 66) having cardiac manifestations, 39 (59% of 66) having peripheral neurologic manifestations, and 3 (5% of 66) having neuropsychiatric manifestations. Diabetes mellitus is not a risk factor (P=.59). Higher body mass index is a significant risk for clinical thiamine deficiency (P=.007). Clinical thiamine deficiency is common in these individuals and a higher body mass index is an identified risk factor. Mechanisms explaining development of thiamine deficiency in obese individuals remain unclear.

Thiamine (Vitamin B1) After Weight Loss Bariatric Surgery

Bariatric surgery is a major tool for treating medically complicated obesity. Commonly utilized bariatric procedures can restrict dietary intake alone or in combination with the development of an element of malabsorption. There is growing evidence that subclinical thiamine deficiency is common in obese individuals, while thiamine stores can be depleted in as little as 2–3 weeks. Thiamine deficiency has been reported both after restrictive bariatric procedures as well as after malabsorptive bariatric procedures; thus, individuals are at risk after vertical sleeve gastrectomy. The most common clinical subtypes of thiamine deficiency after Roux-en-Y gastric bypass are cardiovascular and neuropsychiatric (neuro-psych) manifestations. Small intestinal bacterial overgrowth appears to be a major mechanism for development of symptomatic thiamine deficiency after bariatric surgery. Treatment of bacterial overgrowth with an oral antibiotic can improve oral absorption of thiamine after bariatric surgery. Wernicke’s disease is a potentially devastating complication of thiamine deficiency that should be managed with immediate intravenous infusions of high doses of thiamine.