Luigi Schiavo

Clinical impact of Mediterranean-enriched-protein diet on liver size, visceral fat, fat mass, and fat-free mass in patients undergoing sleeve gastrectomy

BACKGROUND Weight loss before laparoscopic sleeve gastrectomy (LSG) is desirable because it can reduce visceral fat and liver size thereby facilitating the surgical procedure. Preoperative very-low-energy diets have been demonstrated to decrease weight, visceral fat, and liver size. However, no studies have been conducted using the Mediterranean-protein-enriched diet (MPED) or on the amount of preoperative weight loss attributed to the loss of fat-free mass (FFM). OBJECTIVES To evaluate the effect of the MPED on weight, visceral fat, liver size, fat mass (FM), and FFM in obese patients undergoing LSG. SETTING University Hospital, Italy. MATERIALS AND METHODS Obese male patients (n = 37) with a mean body mass index (BMI) of 45.2 kg/m(2) scheduled for LSG underwent an 8-week preoperative MPED. Their weight, visceral fat, body composition, liver size, and biochemical and metabolic patterns were measured before and after the diet. Patient compliance was assessed by the presence of ketonuria and weight loss. Qualitative methods (5-point Likert questionnaire) were used to measure diet acceptability and side effects. RESULTS We observed highly significant decreases in weight, liver size, visceral fat, and FM; however, there was no significant reduction in FFM. All tested patients showed a high frequency of acceptability and compliance in following the diet, and no secondary effects were observed. CONCLUSION Based on our findings, we were able to support the hypothesis that MPED might be associated with significant reductions in weight loss, FM, and liver size without a significant loss of FFM.

Micronutrient Deficiencies in Patients Candidate for Bariatric Surgery: A Prospective, Preoperative Trial of Screening, Diagnosis, and Treatment

Bariatric surgery candidates often show preoperative micronutrient deficiency. Although it is documented that a comprehensive micronutrient assessment should be conducted preoperatively to correct the deficiencies before surgery, no previous studies have been effective in correcting deficiencies in sufficient time prior to surgery. Our aim was to identify micronutrient deficiencies preoperatively and correct them before surgery.

Why Preoperative Weight Loss in Preparation for Bariatric Surgery Is Important

Bariatric surgery has been shown to be the most effective and durable solution for the treatment and control of morbid obesity [1, 2]. However, there is evidence that it is more effective when combined with appropriate nutritional care [3]. Indeed, the role of the nutritionist is of mainstay importance before as well as after surgery. Herein, we discuss the importance of preparing patients before bariatric surgery detailing the role of an appropriate preoperative diet in order to obtain a safe and consistent weight loss. Despite several studies favoring a preoperative weight loss in morbidly obese patients scheduled for bariatric surgery [4], data concerning the feasibility, the effectiveness, and the most appropriate preoperative diet are scarce and controversial [4]. Preoperative weight loss is not only intended to facilitate the surgical procedure but also to transform the quality of a patient’s diet in order to adapt their eating habits for postsurgery, select compliant patients, correct any vitamins and/or mineral deficiency, and improve insulin resistance and obesity-linked lowgrade systemic inflammation. From a nutritional point of view, it is well established that an important goal during weight loss is to maximize fat mass (FM) loss while preserving metabolically active fat-free mass (FFM) [5, 6]. Maintaining adequate FFM is important because muscles play a central role in whole-body protein metabolism [7]. Additionally, a significant decrease in FFM may negatively affect the resting metabolic rate (RMR) [8], slow the rate of weight loss, and predispose to weight regain after surgery [9]. Several preoperative low-energy diets have been demonstrated to decrease weight [4]. However, studies reporting the amount of preoperative weight loss attributed to the loss of FFM are scarce. We recently showed that an 8-week preoperative protein-enriched diet is associatedwith significant reductions in body weight and FM without significant loss of FFM in morbidly obese patients scheduled for laparoscopic sleeve gastrectomy (LSG) [10]. Balanced preoperative meals not only preserve the FFM during the process of weight loss but also educate patients on what and how to eat after surgery. In addition, bariatric surgery candidates often show preoperative micronutrient deficiencies, most commonly in 25vitamin D, vitamin B12, vitamin A, zinc, iron, copper, calcium, and selenium [11]. Indeed, Ben-Porat et al. showed that the presence of preoperative micronutrient deficiencies is the strongest predictor of their presence in the postoperative period [12], suggesting that a specific supplemental program for each individual may consistently prevent postoperative micronutrient deficiencies. However, despite all nutritional guidelines for bariatric surgery suggesting that a comprehensive preoperative macroand micronutrient assessment with correction of any deficiency is advised, ideally, in sufficient time * Luigi Schiavo luigi.schiavo@unina2.it

Sleeve gastrectomy to treat concomitant polycystyc ovary syndrome, insulin and leptin resistance in a 27-years morbidly obese woman unresponsive to insulin-sensitizing drugs: A 3-year follow-up

Highlights • Insulin resistance (IR) and leptine resistance (LR) commonly coexist with obesity.• Polycystic ovary syndrome (PCOS) is often associated with obesity.• There is currently no medical treatment for LR.• IR and PCOS are often successfully treated with the use of insulin-lowering agents.• Some women are poorly responsive or intolerant to insulin-lowering agents.

Fat mass, fat-free mass, and resting metabolic rate in weight-stable sleeve gastrectomy patients compared with weight-stable nonoperated patients

BACKGROUND There is evidence that body composition and resting metabolic rate (RMR) in weight-stable patients after Roux-en-Y gastric bypass and duodenal switch is similar to that of nonoperated individuals within the same body mass index (BMI) interval. Currently, data concerning fat mass (FM), fat-free mass (FFM), and RMR on weight-stable patients after sleeve gastrectomy (SG) are lacking. OBJECTIVES To assess FM, FFM, and RMR, in a selected and homogenous population of weight-stable SG patients (WSSG) and compare them with those obtained from healthy normal weight-stable nonoperated (WSNO) volunteers controls of similar sex, age, and BMI. SETTING University hospital, Italy. METHODS We assessed total weight, FM, and FFM by bioelectrical impedance assay, and RMR by indirect calorimetry, in 70 WSSG patients (47 females, 23 males) at a mean follow-up of 3.2 ± 2.1 years after SG and compared them with 70 healthy WSNO volunteers, as controls (47 females, 23 males). RESULTS There was no significant difference between WSSG and WSNO groups concerning total weight (males, 72 ± 2.66 versus 72.8 ± 1.99 kg, P = .0254; females 65.1 ± 2.53 versus 63.7 ± 2.87 kg, P = .0139), FM (males, 17.7 ± 1.53 versus 16.7 ± 1.57 kg, P = .0341; females 19.6 ± 0.50 versus 18.5 ± 2.85 kg, P = .0104), FFM (males, 54.3 ± 3.07 versus 56.1 ± 3.30 kg; P = .049; females 45.5 ± 2.29 versus 45.1 ± 1.13 kg, P = .287), and RMR (males, 1541 ± 121.3 versus 1463 ± 74.4 kcal/d; P = .0118; females 1214 ± 54.9 versus 1250 ± 90.1 kcal/d, P = .0215). CONCLUSION At a mean follow-up of 3.2 ± 2.1 years after SG, WSSG patients of both sexes have a FM, FFM, and RMR comparable to that of healthy WSNO individuals within the same age and BMI interval. These findings further support bariatric surgery-induced weight loss as a physiologic process and indicate that young patients, in the setting of an adequate preoperative and postoperative specific diet and moderate physical activity, do not suffer from excessive FFM depletion after SG in the mid-term.

Nonsurgical management of multiple splenic abscesses in an obese patient that underwent laparoscopic sleeve gastrectomy: case report and review of literature.

Sleeve gastrectomy (SG) is a surgical weight‐loss procedure. Splenic abscess is a rare complication of SG. Four cases of splenic abscess after SG have been reported, all managed by surgical intervention. We report the first documented case of multiple splenic abscesses following SG managed conservatively by an integrated medical treatment.

Preservation of Fat-Free Mass After Bariatric Surgery: Our Point of View

Obesity is a well-recognized global health problem, and bariatric surgery (BS)-induced weight reduction has been demonstrated to improve survival and obesity-related conditions [1]. Indeed, contrary to lifestyle modifications and dietary programs, BS is becoming an increasingly accepted treatment for severe obesity [2] because it results in massive and sustained weight loss with consequent improvements in health and disease outcomes [3, 4]. It is universally accepted that an important goal during weight loss is to maximize fat mass (FM) loss while preserving metabolically active fat-free mass (FFM) [5]. Maintaining adequate FFM is an important point when making dietary intake recommendations for weight loss because muscles play a central role in whole-body protein metabolism [6]. Additionally, a significant decrease in FFM may negatively affect the resting metabolic rate (RMR) [7], slow the rate of weight loss, and predispose to weight regain [8]. However, it is important to underline that RMR, defined as the minimal amount of energy that the body expends in order to maintain vital processes, does not depend exclusively on the amount of FFM [5] but depends also on other factors such as age, gender, physical activity, lifestyle, and hormones [9]. However, in the nutritionist’s community, concerns have been raised that BS yields a catabolic state, with significant nutritional risks, such as a greater and rapid weight loss that may be accompanied by significant loss of FFM. For this reason, one of the key nutritional issues in patients scheduled for BS should be to measure body composition before and after surgery to quantify changes in FM and FFM [10]. Furthermore, protein and general diet composition should be adjusted to manage the risk of FFM depletion after surgery. Interestingly, available data regarding the preservation of FFM after BS are controversial. In fact, there are studies suggesting that the loss of FFM is minimized with restrictive procedures, such as sleeve gastrectomy (SG), when compared with procedures including an intestinal bypass such as Roux-en-Y gastric bypass (RYGB) and duodenal switch (BPD/DS), whereas other studies show that RYGB helps preserve overall FFM in comparison with SG [11]. Moreover, we recently

Novel nanohydrogel of hyaluronic acid loaded with quercetin alone and in combination with temozolomide as new therapeutic tool, CD44 targeted based, of glioblastoma multiforme†

Glioblastoma multiforme is the most common and aggressive primary brain cancer with only ∼3% of patients surviving more than 3 years from diagnosis. Several mechanisms are involved in drug and radiation resistance to anticancer treatments and among them one of the most important factors is the tumor microenvironment status, characterized by cancer cell hypersecretion of interleukins and cytokines. The aim of our research was the synthesis of a nanocarrier of quercetin combined with temozolomide, to enhance the specificity and efficacy of this anticancer drug commonly used in glioblastoma treatment. The nanohydrogel increased the internalization and cytotoxicity of quercetin in human glioblastoma cells and, when co‐delivered with temozolomide, contribute to an improved anticancer effect. The nanohydrogel loaded with quercetin had the ability to recognize CD44 receptor, a brain cancer cell marker, through an energy and caveolae dependent mechanism of internalization. Moreover, nanohydrogel of quercetin was able to reduce significantly IL‐8, IL‐6, and VEGF production in pro‐inflammatory conditions with interesting implications on the mechanism of glioblastoma cells drug resistance. In summary, novel CD44 targeted polymeric based nanocarriers appear to be proficient in mediating site‐specific delivery of quercetin via CD44 receptor in glioblastoma cells. This targeted therapy lead to an improved therapeutic efficacy of temozolomide by modulating the brain tumor microenvironment.

Patient adherence in following a prescribed diet and micronutrient supplements after laparoscopic sleeve gastrectomy: our experience during 1 year of follow-up.

BACKGROUND One of the most effective surgeries for sustainable weight loss in morbidly obese patients is laparoscopic sleeve gastrectomy (LSG). The present study aimed to assess the adherence of LSG patients with respect to following post-operative dietary requirements and micronutrient supplementation, as well as to investigate their perceived barriers in achieving optimal adherence. METHODS Retrospective data analysis was performed (3, 6, 9 and 12 months after LSG) using the medical records of 96 morbidly obese patients who had undergone LSG at our institution during 2011-2013. Data collected from patient records were: adherence to prescribed diet; adherence to prescribed consumption of fruit, vegetables, legumes and cereals; use of prescribed micronutrient supplements; and barriers to diet and micronutrient therapy adherence. Data were analysed using spss, version 14.0 (SPSS Inc., Chicago, IL, USA). RESULTS At 3, 6, 9 and 12 months post-LSG, the rates of patient non-adherence to a prescribed diet were 39%, 45%, 51% and 74%, respectively. In particular, there was a low consumption of fruit, vegetables, legumes and cereals compared to the post-surgery prescription. In addition, the rates of patient non-adherence to prescribed micronutrient supplements at 3, 6, 9 and 12 months post-LSG were 43%, 51%, 59% and 67%, respectively. The main reasons for patient non-adherence to diet were poor self-discipline (72%) and poor family support (11%) whereas difficulty swallowing pills or capsules (61%) and cost (20%) were reported as the main barriers to post-LSG adherence. CONCLUSIONS Morbidly obese patients who have undergone LSG do not follow exactly the post-operative dietary guidelines, including micronutrient therapy.

Nutritional issues in patients with obesity and cirrhosis

Obesity and metabolic syndrome are considered as responsible for a condition known as the non-alcoholic fatty liver disease that goes from simple accumulation of triglycerides to hepatic inflammation and may progress to cirrhosis. Patients with obesity also have an increased risk of primary liver malignancies and increased body mass index is a predictor of decompensation of liver cirrhosis. Sarcopenic obesity confers a risk of physical impairment and disability that is significantly higher than the risk induced by each of the two conditions alone as it has been shown to be an independent risk factor for chronic liver disease in patients with obesity and a prognostic negative marker for the evolution of liver cirrhosis and the results of liver transplantation. Cirrhotic patients with obesity are at high risk for depletion of various fat-soluble, water-soluble vitamins and trace elements and should be supplemented appropriately. Diet, physical activity and protein intake should be carefully monitored in these fragile patients according to recent recommendations. Bariatric surgery is sporadically used in patients with morbid obesity and cirrhosis also in the setting of liver transplantation. The risk of sarcopenia, micronutrient status, and the recommended supplementation in patients with obesity and cirrhosis are discussed in this review. Furthermore, the indications and contraindications of bariatric surgery-induced weight loss in the cirrhotic patient with obesity are discussed.