Sjaak Pouwels

Technology-based interventions in the treatment of overweight and obesity: A systematic review

The prevalence of obesity increases worldwide. The use of technology-based interventions can be beneficial in weight loss interventions. This review aims to provide insight in the effectiveness of technology-based interventions on weight loss and quality of life for patients suffering overweight or obesity compared to standard care. Pubmed, PsycInfo, Web of Science, ScienceDirect, CINAHL and Embase were searched from the earliest date (of each database) up to February 2015. Interventions needed to be aimed at reducing or maintaining weight loss in persons with a body mass index (BMI) ≥ 25 kg/m(2) and have a technology aspect. Cochrane Collaborations tool for assessing risk of bias was used for rating the methodological quality. Twenty-seven trials met inclusion criteria. Thirteen studies showed significant effects on weight loss compared to controls. Most interventions used a web-based approach (42%). Interventions were screened for five technical key components: self-monitoring, counsellor feedback and communication, group support, use of a structured program and use of an individually tailored program. All interventions that used a combination of all five or four components showed significant decreases in weight compared to controls. No significant results for quality of life were found. Outcomes on program adherence were reported in six studies. No significant results were found between weight loss and program adherence. Evidence is lacking about the optimal use of technology in weight loss interventions. However, when the optimal combination of technological components is found, technology-based interventions may be a valid tool for weight loss. Furthermore, more outcomes on quality of life and information about the effect of technology-based intervention after bariatric surgery are needed.

Aspects of Exercise before or after Bariatric Surgery: A Systematic Review

Background: Bariatric surgery has a considerable effect on weight loss. A positive relation of exercise and weight loss has been described before. However, the mode of exercise and its timing pre- or postoperatively or a combination remains unclear. Methods: A multi-database search was conducted. Identified articles were reviewed on description of exercise, timing around a bariatric intervention, and outcome. Methodological quality of the included studies was rated using the Physiotherapy Evidence Database scale. A Cohens kappa score assessed the level of agreement. Outcome measurements were improvement of anthropometric and physical fitness variables, operation related complications, weight regain, and quality of life. Results: A total of 8 prospective studies were included. Four focused on training before and 4 on training after a bariatric procedure. Details of exercises varied from 45 min treadmill up to full descriptive programs. Supervision was frequently included. Significant improvement was encountered for biometric results physical fitness variables. Conclusion: In the majority of reports on exercising in a (future) bariatric population, positive effects on anthropometrics, cardiovascular risk factors and physical fitness were described. However, the results were not unanimous, with a wide range of exercise programs and perioperative timing, therefore hampering adequate practical guidance.

Treatment of upper-extremity outflow thrombosis

Approximately 10% of all cases of deep vein thrombosis (DVT) occur in the upper extremities. The most common secondary cause of upper-extremity DVT (UEDVT) is the presence of a venous catheter. Primary UEDVT is far less common and usually occurs in patients with anatomic abnormalities of the costoclavicular space causing compression of the subclavian vein, called venous thoracic outlet syndrome (VTOS). Subsequently, movement of the arm results in repetitive microtrauma to the vein and its surrounding structures causing apparent ‘spontaneous’ thrombosis, or Paget-Schrötter syndrome. Treatment of UEDVT aims at elimination of the thrombus, thereby relieving acute symptoms, and preventing recurrence. Initial management for all UEDVT patients consists of anticoagulant therapy. In patients with Paget-Schrötter syndrome the underlying VTOS necessitates a more aggressive management strategy. Several therapeutic options exist, including catheter-directed thrombolysis, surgical decompression through first rib resection, and percutaneous transluminal angioplasty of the vein. However, several controversies exist regarding their indication and timing.

Perioperative respiratory care in obese patients undergoing bariatric surgery: Implications for clinical practice

Obesity is an increasing problem worldwide. The number of people with obesity doubled since the 1980s to affect an estimated 671 million people worldwide. Obese patients in general have an altered respiratory physiology and can have an impaired lung function, which leads to an increased risk of developing pulmonary complications during anaesthesia and after bariatric surgery (approximately 8%). Therefore the respiratory management of the bariatric surgical patient provides a number of challenges. This review will focus on the perioperative respiratory care in bariatric surgical patients discussing respiratory physiology in the obese and perioperative respiratory care in bariatric surgery. Finally the value of preoperative pulmonary function testing and preoperative OSAS screening will be discussed.

Reply to: “Patients’ Expectations Are Important for Success in Bariatric Surgery”

Dear editor, With great interest, we have read the manuscript of Pontiroli et al. [1]. They are suggesting that there are technical and non-technical factors that predict a good or bad response to bariatric surgery. In terms of expectations, patients need to be educated on what to expect and what they need to contribute to the preand post-operative period in bariatric surgery. One of the important aspects is the mandatory lifestyle change that patients need to conduct. We do agree with the statement of Pontiroli and colleagues that education is pivotal in this case and that it is time consuming. Besides that, it is important to investigate the causes of incorrect expectations. Self-image, psychosocial factors, and skin surplus in particular are a great part of these expectations. The psychological consequences of these sequelae are severe and tend to blind the patient to the overall success of their initial bariatric management. This underlines the necessity of a multi-disciplinary approach to morbid obesity [2]. However, e-Health platforms can be beneficial and might reduce the time and cost-burden of education. Recently, Raaijmakers et al. [3] did a systematic review on technology-based interventions in the treatment of obesity. They included 27 studies and showed that most interventions were web-based (42%). All the interventions had one or more of the following components: self-monitoring, counselor feedback and communication, group support, use of a structured program, and use of individually tailored program. Unfortunately, no significant differences were found in terms of outcome measures like quality of life and weight loss, but we do believe that such e-Health programs can be helpful in educating patients scheduled for bariatric surgery. Further studies need to substantiate whether these kind of programs are able to adequately educate our patients.

The Clinical Dilemma of Calcium Supplementation After Bariatric Surgery: Calcium Citrate or Calcium Carbonate That Is the Question?

Dear editor, Calcium is absorbed preferentially in the duodenum and proximal jejunum, and its absorption is facilitated by vitamin D in an acid environment. As the malabsorptive effects of surgical procedures increase, so does the likelihood of fatsoluble vitamin malabsorption related to the bypassing of the stomach, absorption sites of the intestine, and poor mixing of bile salts. Decreased dietary intake of calcium and vitamin D rich food, related to intolerance, can also increase the risk of deficiency after all surgical procedures. Supplementation with calcium and vitamin D during all weight loss modalities is critical to preventing bone resorption [1]. The preferred form of calcium supplementation is an area of debate in current clinical practice. The guidelines of the Endocrine Society [2] preferred calcium citrate preparations because this salt is better absorbed in the absence of gastric acid production. This guideline also described that calcium carbonate preparations are easily available in chewable form and are better tolerated shortly after surgery. However, patients must be instructed to take calcium carbonate preparations with meals to enhance intestinal absorption [2]. The guidelines of American Society for Metabolic and Bariatric Surgery (ASMBS) [1] advise a calcium supplement containing calcium citrate. ASMBS refers to a study of Recker [3] who described that in a low acid environment, such as occurs with the negligible secretion of acid by the pouch created with gastric bypass, absorption of calcium carbonate is poor. However, this study is performed in patients with achlorhydria and is not specific directed to the bariatric target group. Thus, no distinction is made between the different anatomical structures after different bariatric procedures. Studies have found in non-gastric bypass postmenopausal female subjects that calcium citrate (not calcium carbonate) decreased markers of bone resorption and did not increase PTH or calcium excretion [4]. A meta-analysis of calcium bioavailability suggested that calcium citrate is better absorbed than calcium carbonate by approximately 22 to 27 %, either on an empty stomach or co-administered with meals [5]. ASMBS guidelines [1] describe that these findings suggest that it is appropriate to advise calcium citrate supplementation, despite the limited evidence, because of the potential benefit without additional risk. However, this meta-analysis is for calcium citrate and calcium carbonate in general and not specific for patients after bariatric surgery where anatomic changes occur due to the performed surgical procedure. In the study of Baretta et al. [6], calcium carbonate or calcium citrate supplementation was randomly done in the treatment of secondary hyperparathyroidism after bariatric surgery. No significant difference was observed between the groups in relation to bone mineral density of the lumbar spine and femoral neck. In the study of Tondapu and colleagues [7], 19 patients were enrolled in a randomized, double-blinded, crossover study comparing the absorption of calcium from calcium carbonate and calcium citrate salts after Roux-en-Y gastric bypass (RYGB). Calcium citrate has superior bioavailability than calcium * H.J.M. Smelt marieke.smelt@catharinaziekenhuis.nl

Influence of Helicobacter pylori infection on gastrointestinal symptoms and complications in bariatric surgery patients: a review and meta-analysis

BACKGROUND Numerous papers have discussed the importance of preoperative detection and eradication of Helicobacter pylori (HP) in bariatric patients. OBJECTIVES This systematic review specifically focuses on the influence of HP infection on clinical symptoms, complications, and abnormal endoscopic findings in postbariatric patients. METHODS A systematic search on the influence of HP infection on postoperative complications in bariatric surgery was conducted. The methodologic quality of the included studies was rated using the Newcastle-Ottawa rating scale. The agreement between the reviewers was assessed with Cohens kappa. The included studies were assessed into 2 groups, studies with and without eradication therapy preoperatively. RESULTS A total of 21 studies were included with a methodologic quality ranging from poor to good. The agreement between the reviewers, assessed with the Cohens kappa, was .70. Overall, tendency in the included studies was that HP infection was associated with an increased risk for developing marginal ulcers and postoperative complications. A meta-analysis on the incidence of marginal ulcers and overall postoperative complications was conducted and showed, respectively, an odds ratio of .508 (.031-8.346) and 2.863 (.262-31.268). CONCLUSIONS HP is frequently found in patients before and after bariatric and metabolic surgery. We assessed whether, according to the current literature, HP increases the risk for developing postoperative complications after surgery. This meta-analysis shows that a methodologically good study should be performed to clarify the role of HP in bariatric patients and the question of whether HP should be eradicated before surgery.

Reply to: “Letter to the Editor for the Manuscript the complex interplay of physical fitness, protein intake and vitamin D supplementation after bariatric surgery”

Dear Editor, We agree with Seyfried et al. [1] that we do need more studies that investigate the long-term effects of vitamin and mineral supplementation, but before we do that, we need to determine two aspects: (1) what do we think is a clinically relevant deficiency and (2) how are we going to screen for them in the most optimal way. In bariatric surgical practice, vitamin and mineral deficiencies occur very frequently either with or without clinical symptoms [2]. Most common are probably the vitamin B12 and vitamin D deficiencies preoperatively [2]. But simply supplementing them is not going to be enough. Even with supplementation, some patients will not reach normal levels biochemically. For the optimisation of vitamin B12 deficiencies, several treatment and diagnostic strategies have been investigated by Smelt et al [3, 4]. This included adding methylmalonic acid (MMA) to the diagnostic process, because blood levels of vitamin B12 might not be adequate enough to determine howmuch is needed to be supplemented. Regarding vitamin D deficiencies, there is no consensus about the right dose of vitamin D supplementation and there is no clear policy for calcium supplementation after bariatric surgery. Supplementation with 400–800 IU of VD might not prevent adequate protection for postoperative patients against an increase in PTH and bone resorption. There is emerging consensus that serum vitamin D levels from ≥ 75–80 nmol/L are optimal for both bone health and skeletal benefits [5, 6]. The recommended dose of elemental calcium ranges from 1200 to 2000 mg daily [5, 6]. However, there are no large randomised trials that conform the optimal calcium and vitamin D regime after bariatric surgery. To understand the physiology of the calcium metabolism and bone density, large RCTs investigate with radioactive-labelled calcium preparations and including DEXA scans is necessary. In terms of screening for vitamin and mineral deficiencies, blood tests can be very costly, especially when life-long followup is required. To overcome this problem, Bazuin and colleagues [7] developed an algorithm based on their own experience that represents more adequate screening goals. This algorithm is built from a physiological standpoint and illustrates that significant cost reduction can be conducted. We still need to be precise because this algorithm is only suited for gastric bypass and sleeve gastrectomy patients. Still, this is one of the first efforts to optimise screening for vitamin and mineral deficiencies and potentially to reduce the costs that come with it [7].

Neuropathy by folic acid supplementation in a patient with anaemia and an untreated cobalamin deficiency: a case report: Acute polyneuropathy after bariatric surgery

The rising rates of bariatric surgery (BS) are accompanied by neurological complications related to nutrient deficiencies. One of the risk factors for neurological complications in BS patients is poor vitamin and mineral supplementation. Prevention, diagnosis and treatment of these disorders are necessary parts of lifelong care after BS. Particularly important for optimal functioning of the nervous system are vitamin B1, B6, B12 (cobalamin), E, copper and possibly vitamin B11 (folic acid). In this case report, we narrate about a patient with anaemia and multiple vitamin and mineral deficiencies after Roux‐en‐Y gastric bypass (RYGB) with an alimentary limb of 150 cm and a biliopancreatic limb of 100 cm. RYGB is associated with an increased risk of vitamin deficiencies, especially a vitamin B12 deficiency. The patient in this case report developed psychiatric‐neurological symptoms due to folic acid supplementation in an untreated cobalamin deficiency. Second, we tried to elucidate the vitamin physiology to understand specific mechanisms after BS.

Cardiac structure and function before and after bariatric surgery: a clinical overview: Cardiac function after bariatric surgery

Obesity, defined as a body mass index of ≥30 kg/m2, is the most common chronic metabolic disease worldwide and its prevalence has been strongly increasing. Obesity has deleterious effects on cardiac function. The purpose of this review is to evaluate the effects of obesity and excessive weight loss due to bariatric surgery on cardiac function, structural changes and haemodynamic responses of both the left and right ventricle.