Wilson Salgado

Anemia and iron deficiency before and after bariatric surgery

BACKGROUND Iron deficiency and anemia are changes often associated with obesity. Bariatric surgery is responsible for increasing the iron loss and reducing its absorption. The objective of this study was to evaluate anemia and iron deficiency before and after bariatric surgery and to relate them to possible predisposing factors. METHODS A retrospective study was conducted on obese patients submitted to open Roux-en-Y gastric bypass, in which clinical and laboratory data were obtained up to 48 months postoperatively. Patients were divided into groups according to the presence or absence of anemia and to the presence or absence of iron deficiency (even without anemia), and all data were compared between these groups. RESULTS Preoperatively, 21.5% of patients had anemia and 20% had iron deficiency. The number of patients with anemia did not vary through the 4 years of the study, but ferritin levels significantly decreased with time (P<.01). Younger patients and patients with greater weight loss had a higher incidence of anemia. Female gender was a variable associated with a greater incidence of iron deficiency. CONCLUSIONS Anemia and iron deficiency are frequent in obese patients and must be treated before surgery. Medical and nutritional surveillance is important in the postoperative period of bariatric surgery. Management of each condition must be directed at correcting the 2 major sources of iron deficiency and anemia: food intolerance (mostly meat intolerance) and losses (frequently due to menstruation). These are the factors more related to iron deficient anemia.

New look at nutritional care for obese patient candidates for bariatric surgery

BACKGROUND The combination of preoperative deficiencies and the restrictions and malabsorption possibly induced by bariatric surgery could lead patients to experience important nutritional deficits during the late postoperative period. Our objective was to characterize the eating, anthropometric, and biochemical profiles of obese candidates for bariatric surgery at a bariatric surgery center of a university hospital. METHODS A retrospective study with the analysis of medical records of candidates for bariatric surgery from 2007 to 2008 was performed. A total of 80 adult patients, aged 45 ± 11 years, were included in the present study. RESULTS The mean patient weight was 145 ± 24 kg, and the mean body mass index was 54 ± 8 kg/m(2). Of the 80 patients, 78% had ≥1 co-morbidities related to obesity. The reported daily energy intake before surgery was 1981 ± 882 kcal, with 48% ± 11% consisting of carbohydrate, 29% ± 8% of lipids, and 23% ± 8% of protein. The mean number of daily meals was 4 ± 1. Patients with a greater body mass index ingested a smaller amount of calories per kilogram of current weight. The occurrence of hyperglycemia, hyperuricemia, and dyslipidemia and of nutritional deficiencies, among them magnesium (19%), vitamin A (15%), vitamin C (16%), iron (9%), β-carotene (3%), and vitamin B12 (3%), was high. CONCLUSION The high occurrence of micronutrient deficiency detected by biochemical analysis in morbidly obese candidates for bariatric surgery, representing a disabsorptive process, might involve a poorer prognosis during the late postoperative period. A preoperative evaluation of the nutritional parameters and the food intake pattern is recommended for these patients, together with the necessary interventions.

Bioelectrical impedance vector analysis in obese women before and after bariatric surgery: Changes in body composition

OBJECTIVE Because of the inefficacy of standard methods for the evaluation of body composition of grade III obese individuals, it is difficult to analyze the quality of weight loss after bariatric surgery in these patients. Electrical bioimpedance vector analysis and the RXc graph uses crude resistance (R) and reactance (Xc) values, like components of the Z vector, to monitor variations in body fluid and the nutritional status of obese individuals. Using bioelectrical impedance vector analysis (BIVA) and the RXc graph, the objective of the present study was to evaluate long-term changes in weight and body composition of obese women after Roux-en-Y bariatric surgery. METHODS A study was conducted on 43 grade III obese women submitted to bariatric surgery. Anthropometric and bioimpedance (800 mA-50 kHz) data were obtained during the preoperative period and 1, 2, 3, and 4 y after surgery. BIVA was performed by plotting resistance and reactance values corrected for body height (R/H and Xc/H, Ohm/m) as bivariates on the RXc graph. BIVA software was used to plot the vectors of the RXc plane. RESULTS Surgery promoted changes in body composition, with a reduction of fat mass and of fat-free mass. During the postoperative period, the vectors demonstrated migration to the right lower quadrant of the graph, corresponding to the classification of cachexia and water retention. CONCLUSION Weight loss due to surgery results in an important reduction of fat-free mass characterized by the position of most individuals in the cachexia quadrant throughout the postoperative period.

Routine abdominal drains after Roux-en-Y gastric bypass: a prospective evaluation of the inflammatory response

BACKGROUND Despite the extensive published data regarding the use of drains in surgery, it is still controversial. Most bariatric surgeons use drains as routinely. However, drains have sometimes have been shown to be unhelpful and even to increase the anastomotic leak rates. The purpose of the present study was to evaluate the peritoneal inflammatory response in the presence of a drain left in place until the seventh postoperative day after bariatric surgery. METHODS All patients who underwent open Roux-en-Y gastric bypass from February 2007 to August 2008 were prospectively evaluated. A 24F Blake drain was left in place for 7 days. The peritoneal effluent from the drain was collected for the determination of cytokine levels and for microbiologic analysis. RESULTS A total of 107 obese patients were studied. A marked increase in the levels of tumor necrosis factor-α and interleukin-1β was observed by the seventh postoperative day, even in patients without any abdominal complications. Bacterial contamination of the peritoneal effluent was also demonstrated. CONCLUSION The results of our study have shown that at 7 days after surgery, a marked peritoneal inflammatory response and bacterial contamination are present. These findings could have resulted from the use of the drain for 7 postoperative days.

Extensive Xanthomas and Severe Subclinical Atherosclerosis in Homozygous Familial Hypercholesterolemia

![Figure][1] An asymptomatic 20-year-old man presented with a history of high plasma cholesterol levels and gigantic tendinous xanthomas over the extensor tendons of his metacarpophalangeal joints and patellas (A to C) . Laboratory tests showed total cholesterol of 785 mg/dl, low-density

The expression of LEP, LEPR, IGF1 and IL10 in obesity and the relationship with microRNAs.

Obesity is a multifactorial disease, with epigenetic alterations. Have been described modifications in the expression of some microRNAs, and some proteins related to obesity. The objective was to determine and correlate, in obese patients, the gene expression of LEP, LEPR, IGF1, IL10 and of miR-27a, miR-27b, miR-143 and miR-145. RNA was extracted from biopsies of subcutaneous fat, liver and visceral fat of 15 obese subjects submitted to bariatric surgery and of 15 non-obese subjects submitted to cholecystectomy for cDNA synthesis and for RT-PCR. The microRNAs were chosen using the TargetScan software. An increased expression of LEP and IGF1 was detected in the subcutaneous fat of the obese group compared to control, while the expression of IGF1 was higher in the control group than in the obese one. MiRNA-27a had a higher expression in the omentum of the obese patients and there was also a correlation in the expression of miRNA-145 and LEPR in the omentum of this group.

Early identification of infectious complications in bariatric surgery by the determination of peritoneal and systemic cytokines.

BackgroundObesity has become a global epidemic and bariatric surgery is one of the therapeutic tools to deal with it. Postoperative complications can occur, such as staple line dehiscence and anastomotic leaks, leading to increased patient mortality. The diagnosis of these complications is frequently difficult. The objective of the present study was to determine whether peritoneal and systemic cytokines could early detect those complications.MethodsAll patients who underwent open Roux-en-Y gastric bypass from February 2007 to August 2008 were prospectively evaluated. Blood and peritoneal effluent from the drain were collected for the determination of cytokine levels. We also evaluated the clinical signs and the leukograms of the patients.ResultsA total of 107 obese patients were studied. Ninety patients had no complications; 17 had at least one infectious complication which include five cases of staple line dehiscence. Until the third postoperative day, the vital signs and the leukogram did not predict the onset of infectious complications, but the cytokines (interleukin-1β and interleukin-6) were early markers of these complications.ConclusionCytokines are good predictors of poor postoperative evolution in bariatric surgery since peritoneal cytokines diagnose better these infectious complications even before changes in blood count and before the occurrence of clinical manifestations.

Prospective and randomized comparison of two techniques of staple line reinforcement during open Roux-en-Y gastric bypass: oversewing and bioabsorbable Seamguard®.

AIMS Surgical staple line dehiscence usually leads to severe complications. Several techniques and materials have been used to reinforce this stapling and thus reduce the related complications. The objective was to compare safety of two types of anastomotic reinforcement in open gastric bypass. METHODS A prospective, randomized study comparing an extraluminal suture, fibrin glue, and a nonpermanent buttressing material, Seamguard®, for staple line reinforcement. Fibrin glue was excluded from the study and analysis after two leaks, requiring surgical reintervention, antibiotic therapy, and prolonged patient hospitalization. RESULTS Twenty patients were assigned to the suture and Seamguard reinforcement groups. The groups were similar in terms of preoperative characteristics. No staple line dehiscence occurred in the two groups, whereas two cases of dehiscence occurred in the fibrin glue group. No mortality occurred and surgical time was statistically similar for both techniques. Seamguard made the surgery more expensive. CONCLUSION In our service, staple line reinforcement in open bariatric surgery with oversewing or Seamguard was considered to be safe. Seamguard application was considered to be easier than oversewing, but more expensive.

DESENVOLVIMENTO DE MODELO DE PERITONITE BACTERIANA PARA AVALIAÇÃO DO TRATAMENTO MEDIANTE ACESSO LAPAROTÔMICO E VIDEO-LAPAROSCÓPICO

Introduction: The use of videolaparoscopy in the treatment of digestive diseases, associated with generalized peritonitis, is controverted. Objective: To develop a model of bacterial peritonitis for the evaluation of the treatments through laparotomy and through videolaparoscopy. Methods: Male Wistar rats were submitted to occlusion of the ceacum (CLP) on a rigid mold of 3mm diameter, followed by 14 punctures of the ceacum with a 15 x 10 needle. Six hours after the induction of peritonitis, the animals were treated by laparotomy or videolaparoscopy, while analysing blood cultures and the mortality rates. The treatment involved typhlectomy followed or no by peritoneal lavage with saline solution. Results: The mortality rate in one week, after CLP without treatment, was 90%. The blood cultures were positive in 80 to 100% of the animals after 3 hours, and in 60 to 80% after 24 hours, in the animals when treated with laparotomy without peritoneal lavage and in the animals treated through videolaparoscopy with or without peritoneal lavage. The mortality rate after laparotomy was 20%, whereas after videolaparoscopy it was 80%. Conclusion: The experimental model induced severe peritonitis, and the bactereamia associated with videolaparoscopy has a high mortality rate.

Low educational status, smoking, and multidisciplinary team experience predict hospital length of stay after bariatric surgery.

Objective The objective of the present study was to identify new risk factors associated with longer hospitalization following bariatric surgery. Methods Patient clinical, social, and biochemical data in addition to multidisciplinary team experience were analyzed in a cohort that included all patients undergoing bariatric surgery at our hospital. The primary outcome was length of hospital stay (LOS). Mortality was recorded to validate the obesity surgery mortality risk score (OS-MRS). Results This study included 299 sequential patients, 41 ± 10 years of age, and BMI of 50 ± 8 kg/m2 who underwent bariatric surgery. Two thirds (196) of patients were hypertensive, a third (86) were diabetic and a third (91) were current or former smokers. Overall, LOS was 8 ± 5 days. The predictors of a longer LOS were smoking (P < 0.05) and less multidisciplinary team experience (P < 0.05). Looking at only the last three years of data, LOS was 6 ± 5 days, and the predictors of a longer LOS were low educational attainment (P < 0.02) and smoking (P < 0.01) but not team experience. The global mortality was 2.6%, with the OS-MRS identifying a high-risk group. Conclusion Excluding the initial learning phase, longer LOS independent predictors were patient low educational attainment and smoking. These predictors can help guide care to reduce complications.