complicaciones endocrinas en cirugia bariatrica -...

Dra. Karin Papapietro V.

COMPLICACIONES ENDOCRINAS EN CIRUGIA BARIATRICA

Declaración de Conflictos de Interés

Declaro no tener conflicto de interés.

CAMBIOS ANATOMICOS Y FUNCIONALES

CONDUCTA DEL PACIENTE adherencia al tratamiento

COMPLICACIONES NUTRICIONALES Y

METABOLICAS

CIRUGIA BARIATRICA

conducta del equipo?

COMPLICACIONES POST CIRUGIA BARIATRICA

Banding Bypass Sleeve

Anemia + + + + +

Osteopenia + + + ++

Depresion - + ?

Neuropatias + ++ ++

Déficit micronutrientes

+ + ++ ++

Dumping/Hipoglicemia

- +++ ++

RGE - - +

Baja ingesta / Malabsorción/ Poco control

Cambio anatómico/ fisiológico

COMPLICACIONES Y EFECTOS NO DESEADOS EN ADOLESCENTES CON CIRUGIA BARIATRICA

•  DEFICIENCIA DE MICRONUTRIENTES

•  OSTEOPENIA

•  DUMPING/HIPOGLICEMIA

•  EMBARAZOS NO PLANIFICADOS

•  AUMENTO EN CONDUCTAS DE RIESGO ALCOHOLISMO

DISMINUCION DE MASA OSEA EN CIRUGIA BARIATRICA

BAJA INGESTA DE CALCIO Y VITAMINA D

POCA ADHERENCIA A INDICACIONES

MALABSORCION

DEFICIENCIA Vit D

HIPERPARATIROIDISMO SECUNDARIO

BAJA DE PESO

!

!

BAJA DE PESO LEPTINA

ACTIVIDAD OSTEOCLASTICA

RESORCION OSEA

631

Nutr Hosp. 2013;28(3):631-636ISSN 0212-1611 • CODEN NUHOEQ

S.V.R. 318

OriginalDisminución de masa ósea post-cirugía bariátrica con by-pass en Y de RouxKarin Papapietro1, Teresa Massardo2, Andrea Riffo1, Emma Díaz1, A. Verónica Araya3, Daniela Adjemian1,Gustavo Montesinos1 y Gabriel Castro2

1Departamento Cirugía, Hospital Clínico Universidad de Chile. 2Sección Medicina Nuclear. Departamento Medicina. HospitalClínico Universidad de Chile. 3Sección de Endocrinología. Departamento Medicina. Hospital Clínico Universidad de Chile.Chile.

BONE MINERAL DENSITY DISMINUTIONPOST Y DE ROUX BY-PASS SURGERY

Abstract

Introduction: Bariatric surgery has important meta-bolic complications such as bone mass loss.

Goal: To assess bone mineral density (BMD) afterRoux-en-Y gastric by-pass (RYGB) in patients understandard calcium and vitamin D supplementation.

Method: In patients with morbid obesity submitted toRYGB, 76 women and 22 men of diverse age, all withstandard nutritional instruction including vitamin D andcalcium, we measured BMD with a dual X-ray densito-meter. They had lumbar spine and hips measurement 2-3years post-surgery. Twenty females were followed upwith BMD until of a mean of 54 months. Using WorldHealth Organization (WHO) criteria’s, values werecompared with young controls and same age and sexpopulation, evaluating osteopenia and osteoporosis.

Results: Inverse correlation was observed betweenBMD and age; positive between BMD and body massindex as well as with preoperative weight excess. Inwomen younger than 45 years, we observed a diminishedBMD in 26.8% of them, with no cases of osteoporosis. Inolder females, BMD was decreased in 65.7% (p = 0.0011);corresponding to 45.7% of osteopenia and 20% osteo-porosis, more frequent in lumbar spine. In the female’ssubgroup followed longer, BMD diminished progres-sively mainly in left hip. In men, there was 36% ofosteopenia and 14% of osteoporosis.

Conclusion: Patients from both genders and diverseages after BPYR presented osteopenia and osteoporosis,despite early supplement prescription of calcium andvitamin D. We consider important to perform serial BMDmeasurements and also to individualize therapy with riskfactors control.

(Nutr Hosp. 2013;28:631-636)DOI:10.3305/nh.2013.28.3.6400

Key words: Bariatric surgery. Roux-en-Y gastric by-pass.Osteoporosis. Bone mineral density. Obesity.

Resumen

Introducción: La cirugía bariátrica tiene complicacio-nes metabólicas importantes como la pérdida de masaósea.

Objetivo: Evaluar la densidad mineral ósea (DMO)posterior a by-pass gástrico en Y de Roux (BPYR) enpacientes con indicación de suplemento estándar de calcioy vitamina D.

Método: En pacientes con BPYR por obesidad mór-bida, 76 mujeres y 22 hombres de diversa edad, con ins-trucción nutricional, suplemento de calcio y vitamina D,se midió la DMO en columna lumbar y caderas con densi-tómetro radiológico de doble haz 2 a 3 años post-cirugía.Veinte mujeres fueron seguidas con DMO hasta 54 mesesen promedio. Según criterios de Organización Mundialde la Salud (OMS), se comparó con población controljoven y de su edad según sexo, evaluando osteopenia yosteoporosis.

Resultados: Hubo correlación negativa de DMO conedad; positiva de DMO con índice de masa corporal y conexceso de peso preoperatorio. En mujeres menores de 45años, se observó disminución de DMO en 26,8%, sin casosde osteoporosis y en 65,7% en las mayores de 45 años (p =0,0011), correspondiendo a 45,7% de osteopenia y 20%de osteoporosis, predominantemente en columna lumbar.El subgrupo de mujeres con mayor seguimiento, presentódisminución progresiva de DMO, especialmente encadera izquierda. En hombres se observó 36% de osteo-penia y 14% de osteoporosis.

Conclusión: Pacientes de ambos sexos y diversa edad,despues de un BPYR, presentaron osteopenia y osteopo-rosis, a pesar de suplemento precoz de calcio y vitaminaD. Consideramos importante medir DMO seriada, indivi-dualizando terapias y controlando factores de riesgo.

(Nutr Hosp. 2013;28:631-636)DOI:10.3305/nh.2013.28.3.6400

Palabras clave: Cirugía bariátrica. By-pass gástrico en Yde Roux. Osteoporosis. Densidad mineral ósea. Obesidad.

Correspondencia: Teresa Massardo Vega.Profesora Asociada.Sección Medicina Nuclear. Departamento Medicina.Hospital Clínico Universidad de Chile.Santos Dumont 999-1E, Independencia, Santiago Chile.E-mail: [email protected]

Recibido: 15-IX-2012.Aceptado: 17-IX-2012.

08. Disminución_01. Interacción 16/04/13 13:27 Página 631

Mujeres menores de 45a 27% osteopenia Mayores 45a 20% osteoporosis Hombres 50% con DMO disminuida 14% con osteoporosis

month), except FFM which showed no change betweenmonth 6 and 12 post GBP.

After GBP, significant reductions in total BMD, spineBMD and pelvis BMD were observed (p<0.001; Fig. 1).The change in BMD at the twelfth month showed asignificant difference among total BMD (−3,0±2,1%),spine BMD (−7,4±6,8%) and pelvis BMD (−10,5±5,6%;p<0.001). Considering total and spine BMD no patient fellto a level considered as osteopenia (T-score ≤−1 and >2.5standard deviations) or osteoporosis (T-score ≤−2.5 stan-dard deviations). Osteopenia however, was present in 4patients according to pelvis BMD measured 12 monthsafter GBP (T-score range, −1 to −1.7 standard deviations).Total BMD decrease was positively correlated (p<0.05)with baseline weight (r=0.36), initial FFM (r=0.33),percentage of weight loss (r=0.33), adiponectin change(r=0.34), and absolute adiponectin at the twelfth-monthpost GBP (r=0.35). After multiple regression analysis, 37%of the reduction of BMD could be explained by thefollowing variables: baseline weight, baseline BMD, BFreduction and adiponectin at the twelfth-month post GBP(r2=0.373; p<0.001). After adjusting for covariates (base-line weight, initial BF, initial BMD, weight loss, total, andregional BF loss), adiponectin concentrations at the twelfthmonth had a positive correlation with BMD decrease(adjusted correlation coefficient: r=0.35; p<0.05).

Serum adiponectin concentrations increased by 48% atsixth month and by 97% at the twelfth-month post GBP(p<0,001). The increase in adiponectin at the twelfth monthwas negatively correlated with baseline adiponectin levels(r=−0.61; p<0.001) and positively correlated with thepercentage of initial weight loss (r=0.41; p<0.01), percent-age of initial body fat loss (r=0.48; p<0.005), percentageof initial trunk fat mass loss (r=0.42; p<0.01), andpercentage of initial ROI fat mass loss (r=0.47; p<0.005).

In relation to nutrient intakes, a significant reduction wasobserved in energy intake at 6 months after GBP (14.6±5.9vs. 10.9±3.8 kcal/kg/day; p<0.001), although energy

intake at the twelfth month showed no difference withbaseline intake (14.3±2.8 kcal/kg/day). Protein intake(g/kg/day) showed no significant difference at sixth andtwelfth-month post GBP (0.56±0.22 years 0.69±0.17 g/kg/day, respectively) compared to baseline values (0.61±0.19 g/kg/day).

Dietary calcium intake was no different between initialestimation (486±222 mg/day; 95% Confidence Interval(CI): 158–832 mg/day) and the records obtained at sixth(393±230 mg/day; 95% CI: 116–838 mg/day) and twelfth-month post GBP (468±289 mg/day; 95% CI: 102–1069 mg/day). Calcium intake from supplements was lowerin the first 6 months post surgery (393±230 mg/day; 95%CI: 319–815 mg/day) compared to the sixth to twelfth-month period (468±289 mg/day; 95% CI: 349–973 mg/day; p<0,001). Vitamin D intake from supplements wasalso lower at the first period (322±191 U/day; 95% CI:143–652 U/day) compared to the second period (412±236 U/day; 95% CI: 185–762 U/day). No correlation wasobserved between dietary calcium intake or supplementalCa plus vitamin D and the changes of total BMD, spineBMD and pelvis BMD.

Discussion

Beneficial effects of bariatric surgery in morbid obesepatients are widely recognized, especially those related tocorrection of comorbidities [7, 10]. Some potential side-effects however, such as decreased bone mineral density(BMD), are only partially understood. The most dramaticeffects of bariatric surgery on bone mineral density havebeen noted mainly, but not exclusively, in malabsorptivesurgery [28]. Roux-en-Y gastric bypass (GBP), althoughhaving a malabsorption component, is predominantly arestrictive technique. The extent and clinical implications ofpotential adverse effects of GBP on bone metabolism arematter of debate [13, 29–31].

In the present study, we observed a 3% decrease of totalBMD after 1 year of GBP, with column and pelvis (7.4%and 10.5%, respectively) being their main contributors,which is in agreement with previous reports [13, 29, 30].

The site-dependent differential changes of BMD ob-served suggest that the effect of reduced body weightaccompanied with less mechanic load is highly relevant indetermining BMD. Nevertheless, a similar effect could alsobe induced by secondary hyperparathyroidism [32–34].This condition is more frequent in individuals older thanthe subjects studied here. We did not determine parathy-roid-related parameters in our subjects; therefore, we cannotdisregard the presence of such effect.

Unlike the femur neck and pelvis having predominantlycortical bone, the column has a higher proportion of

Fig. 1 Bone mineral density after gastric bypass: changes withrespect to baseline. *Significant change from previous value with p<0.001, **significant change from previous value with p<0.05

44 OBES SURG (2009) 19:41–46

trabecular bone. The latter is metabolically more active and,in consequence, it may be more sensitive to humoral factors[21].

Although the literature mentions decreased calcium andvitamin D intake/absorption, secondary hyperparathyroid-ism and reduced mechanic load on the skeleton as the mainfactors involved in reduced BMD after GBP, recentevidence suggests that a number of hormonal factors mayalso participate in this process [28]. The knowledge aboutthe extent of involvement and the mechanisms underlyingsuch effects is limited. Leptin concentration is markedlyaffected by drastic weight modifications as those observedafter GBP. Its association with BMD is rather weakhowever [19], possibly because this hormone has a dualrole. On one hand, it shows an indirect pro-osteoclasticactivity by activating the sympathic system and stimulatingof β2 adrenergic receptors. On the other hand, it inhibitsosteoclastic differentiaton by participating in the cocaine–amphetamine-regulated transcript pathway (CART) [28].Adiponectin has a clear anti-osteogenic activity, demonstratedby in vitro studies, probably through its role as ligand ofnecrosis factor kappa β (NFKβ) receptor [35, 36]. Berner etal. [36] have demonstrated that adiponectin and its receptors(AdipoR1 and AdipoR2) are expressed in human osteo-blasts, and also that the supplementation of culture mediumwith recombinant adiponectin enhances the proliferation ofosteoblasts. Adiponectin also is negatively associated withBMD in humans, independently of their body fat mass [21].In our study, as expected, adiponectin was dramaticallyincreased after GBP. Up to our knowledge, this is the firststudy reporting a significant association between serumadiponectin and reduction of BMD in non-menopausalwomen after 1 year of GBP. Since both variables were alsoassociated to initial body fat mass, weight change and fatmass change after 1 year of GBP, correlation analyses wereconducted adjusting these variables. Such correction did notaffect the described association.

In terms of the effects of dietary changes as determinantsof the modifications of BMD in this type of patients, it hasbeen suggested that low intakes of calcium and vitamin Dassociated to low consumption of dairy products after GBPmay be responsible for the increase of PTH and stimulationof bone resorption, especially at the cortical bone. As aresult, supplementation with these nutrients seems to bewidely justified. Nevertheless, there is no agreement on theoptimal amount to be provided after GBP. In the study byGoode et al., secondary hyperparathyroidism post BPGcould not be corrected with the administration of 1,200 mgof calcium and 8 μg of vitamin D, although the period ofobservation was only up to 6 months [29]. In our study, theprescribed daily calcium and vitamin D supplements rangedbetween 640 and 1,000 mg for calcium and between 400and 800 IU for vitamin D. Those amounts of supplemen-

tation are in agreement with the recommendations ofJohnson et al. [30]. As expected, the actual amountconsumed varied according the compliance of the individ-uals. In our study, this reached 83% of the planned amounton average. Finally, the reduction of BMD was notcorrelated to dietary calcium intakes or to the consumptionof calcium plus vitamin D from supplements.

The lack of association between BMD change andcalcium and vitamin D total intakes may be explained bythe anatomical alterations produced by the GBP. Thismodification would reduce calcium absorption, which takesplace mainly at the duodenum and proximal jejunum. Itwould also favor fat and fat-soluble vitamins malabsorptionas consequence of impaired combination with bile salts.

Since all variables significantly associated to BMDchange (initial weight, weight loss, fat mass loss, finaladiponectin) only explain 37% of the variance, it is possiblethat calcium and vitamin-D-impaired absorption is actuallyplaying a major role. In our study, calcium absorptiondeterminations were not carried out. Among the clinicalimplications of the results, it could be speculated thatcalcium and vitamin D supplementation, unless they areprovided in very high amounts, will have a modest effectpreventing BMD decrease.

BMD decrease seems to be highly associated to weightloss in both surgical and non-surgical interventions [16,37]. This, along with the concomitant adiponectin increase,would condition a loss of protective effect of obesityagainst osteoporosis [30, 38]. According to Johnson et al.[30, 39], BMD decrease is made evident mainly during thefirst year, which is also the period when the major weightchanges are observed. Beyond that point, both body weightand BMD tend to remain stable.

In conclusion, in our group of non-menopausal womenstudied after 1 year of gastric bypass, BMD was signifi-cantly reduced, mainly at the pelvis. BMD decrease wasmore important in the patients with greater values of initialbody weight, initial BMD, fat mass loss and final serumadiponectin. Adiponectin involvement in the process ofbone modeling may explain, at least partially, the decreaseof BMD observed after GBP. In order to achieve a betterunderstanding of these observations and their implications,further studies including a wide range of calcium andvitamin D supplements and calcium absorption measure-ments are needed.

Acknowledgments Supported by the National Fund for Science andTechnology, Fondecyt grant 1040765. The authors are indebted toDr Guillermo Watkins, Juan C Díaz, Fernando Maluenda andDr. Ittalo Braguetto, from the Department of Surgery, UniversityClinical Hospital who performed a significant number of the surgicalprocedures and to the Nutritionists Ms Emma Díaz and Ms AndreaRiffo for their invaluable collaboration in the dietary control of thepatients.

OBES SURG (2009) 19:41–46 4545

631

Nutr Hosp. 2013;28(3):631-636ISSN 0212-1611 • CODEN NUHOEQ

S.V.R. 318

OriginalDisminución de masa ósea post-cirugía bariátrica con by-pass en Y de RouxKarin Papapietro1, Teresa Massardo2, Andrea Riffo1, Emma Díaz1, A. Verónica Araya3, Daniela Adjemian1,Gustavo Montesinos1 y Gabriel Castro2

1Departamento Cirugía, Hospital Clínico Universidad de Chile. 2Sección Medicina Nuclear. Departamento Medicina. HospitalClínico Universidad de Chile. 3Sección de Endocrinología. Departamento Medicina. Hospital Clínico Universidad de Chile.Chile.

BONE MINERAL DENSITY DISMINUTIONPOST Y DE ROUX BY-PASS SURGERY

Abstract

Introduction: Bariatric surgery has important meta-bolic complications such as bone mass loss.

Goal: To assess bone mineral density (BMD) afterRoux-en-Y gastric by-pass (RYGB) in patients understandard calcium and vitamin D supplementation.

Method: In patients with morbid obesity submitted toRYGB, 76 women and 22 men of diverse age, all withstandard nutritional instruction including vitamin D andcalcium, we measured BMD with a dual X-ray densito-meter. They had lumbar spine and hips measurement 2-3years post-surgery. Twenty females were followed upwith BMD until of a mean of 54 months. Using WorldHealth Organization (WHO) criteria’s, values werecompared with young controls and same age and sexpopulation, evaluating osteopenia and osteoporosis.

Results: Inverse correlation was observed betweenBMD and age; positive between BMD and body massindex as well as with preoperative weight excess. Inwomen younger than 45 years, we observed a diminishedBMD in 26.8% of them, with no cases of osteoporosis. Inolder females, BMD was decreased in 65.7% (p = 0.0011);corresponding to 45.7% of osteopenia and 20% osteo-porosis, more frequent in lumbar spine. In the female’ssubgroup followed longer, BMD diminished progres-sively mainly in left hip. In men, there was 36% ofosteopenia and 14% of osteoporosis.

Conclusion: Patients from both genders and diverseages after BPYR presented osteopenia and osteoporosis,despite early supplement prescription of calcium andvitamin D. We consider important to perform serial BMDmeasurements and also to individualize therapy with riskfactors control.

(Nutr Hosp. 2013;28:631-636)DOI:10.3305/nh.2013.28.3.6400

Key words: Bariatric surgery. Roux-en-Y gastric by-pass.Osteoporosis. Bone mineral density. Obesity.

Resumen

Introducción: La cirugía bariátrica tiene complicacio-nes metabólicas importantes como la pérdida de masaósea.

Objetivo: Evaluar la densidad mineral ósea (DMO)posterior a by-pass gástrico en Y de Roux (BPYR) enpacientes con indicación de suplemento estándar de calcioy vitamina D.

Método: En pacientes con BPYR por obesidad mór-bida, 76 mujeres y 22 hombres de diversa edad, con ins-trucción nutricional, suplemento de calcio y vitamina D,se midió la DMO en columna lumbar y caderas con densi-tómetro radiológico de doble haz 2 a 3 años post-cirugía.Veinte mujeres fueron seguidas con DMO hasta 54 mesesen promedio. Según criterios de Organización Mundialde la Salud (OMS), se comparó con población controljoven y de su edad según sexo, evaluando osteopenia yosteoporosis.

Resultados: Hubo correlación negativa de DMO conedad; positiva de DMO con índice de masa corporal y conexceso de peso preoperatorio. En mujeres menores de 45años, se observó disminución de DMO en 26,8%, sin casosde osteoporosis y en 65,7% en las mayores de 45 años (p =0,0011), correspondiendo a 45,7% de osteopenia y 20%de osteoporosis, predominantemente en columna lumbar.El subgrupo de mujeres con mayor seguimiento, presentódisminución progresiva de DMO, especialmente encadera izquierda. En hombres se observó 36% de osteo-penia y 14% de osteoporosis.

Conclusión: Pacientes de ambos sexos y diversa edad,despues de un BPYR, presentaron osteopenia y osteopo-rosis, a pesar de suplemento precoz de calcio y vitaminaD. Consideramos importante medir DMO seriada, indivi-dualizando terapias y controlando factores de riesgo.

(Nutr Hosp. 2013;28:631-636)DOI:10.3305/nh.2013.28.3.6400

Palabras clave: Cirugía bariátrica. By-pass gástrico en Yde Roux. Osteoporosis. Densidad mineral ósea. Obesidad.

Correspondencia: Teresa Massardo Vega.Profesora Asociada.Sección Medicina Nuclear. Departamento Medicina.Hospital Clínico Universidad de Chile.Santos Dumont 999-1E, Independencia, Santiago Chile.E-mail: [email protected]

Recibido: 15-IX-2012.Aceptado: 17-IX-2012.

08. Disminución_01. Interacción 16/04/13 13:27 Página 631

Changes in Bone Mineral Density, Body Compositionand Adiponectin Levels in Morbidly Obese Patientsafter Bariatric Surgery

Fernando Carrasco & Manuel Ruz & Pamela Rojas &

Attila Csendes & Annabella Rebolledo & Juana Codoceo &

Jorge Inostroza & Karen Basfi-fer & Karin Papapietro &

Jorge Rojas & Fernando Pizarro & Manuel Olivares

Received: 14 May 2008 /Accepted: 7 July 2008 /Published online: 6 August 2008# Springer Science + Business Media, LLC 2008

AbstractBackground Gastric bypass surgery (GBP) is increasinglyused as a treatment option in morbid obesity. Little isknown about the effects of this surgery on bone mineraldensity (BMD) and the underlying mechanisms. Toevaluate changes on BMD after GBP and its relation withchanges in body composition and serum adiponectin, alongitudinal study in morbid obese subjects was conducted.Methods Forty-two women (BMI 45.0±4.3 kg/m2; 37.7±9.6 years) were studied before surgery and 6 and 12 monthsafter GBP. Percentage of body fat (%BF), fat-free mass(FFM), and BMD were measured by dual-energy X-rayabsorptiometry and serum adiponectin levels by RIA.Results Twelve months after, GBP weight was decreasedby 34.4±6.5% and excess weight loss was 68.2±12.8%.Significant reduction (p<0.001) in total BMD (−3.0±2.1%), spine BMD (−7.4±6.8%) and hip BMD (−10.5±5.6%) were observed. Adiponectin concentration increasedfrom 11.4±0.7 mg/L before surgery to 15.7±0.7 and 19.8±

1.0 at the sixth and twelfth month after GBP, respectively(p<0.001). Thirty-seven percent of the variation in totalBMD could be explained by baseline weight, initial BMD,BF reduction, and adiponectin at the twelfth month (r2=0.373; p<0.001). Adiponectin at the twelfth month had asignificant and positive correlation with the reduction ofBMD, unrelated to baseline and variation in body compo-sition parameters (adjusted correlation coefficient: r=0.36).Conclusion GBP induces a significant BMD loss relatedwith changes in body composition, although some meta-bolic mediators, such as adiponectin increase, may have anindependent action on BMD which deserves further study.

Keywords Bone mineral density . Gastric bypass .

Adiponectin . Body composition

Introduction

Actually, overweight and obesity represents one of themajor health hazards in the worldwide affecting nearly 1.1billion subjects [1]. According to the data in the firstnational health survey in 2003, the prevalence of over-weight, obesity, and morbid obesity in Chilean adults were38%, 22%, and 1.3%, respectively [2]. Obesity is associ-ated to increased mortality [3] and to a higher risk of type 2diabetes, hyperlipidemia, sleep apnea, gallbladder disease,coronary disease, hypertension, musculoskeletal disorders,several types of cancer and psychosocial disturbances [4,5]. Besides the greater severity of comorbidities, severe andmorbid obesity (BMI between 35 and 39.9 kg/m2 and≥40 kg/m2, respectively) sharply reduce life expectancy,especially in young adults [6].

OBES SURG (2009) 19:41–46DOI 10.1007/s11695-008-9638-0

F. Carrasco (*) :M. Ruz : P. Rojas :A. Rebolledo : J. Codoceo :J. Inostroza :K. Basfi-ferDepartment of Nutrition, Faculty of Medicine,University of Chile,Independencia 1027,Postal Code 838-0453 Santiago, Chilee-mail: [email protected]

A. Csendes :K. Papapietro : J. RojasDepartment of Surgery, Clinical Hospital, University of Chile,Santiago, Chile

F. Pizarro :M. OlivaresInstitute of Nutrition and Food Technology, University of Chile,Santiago, Chile

Original

Perdida de masa osea tras gastrectomıa tubular:estudio prospectivo comparativo con el bypass gastrico

Xavier Noguesa, Albert Godayb, Maria Jesus Penaa, David Benaigesb, Marta de Ramonc,Xenia Crousd, Manuel Viald, Manuel Perad, Luis Granded, Adolfo Dıez-Pereza yJose Manuel Ramond,!

aServicio de Medicina Interna, URFOA-IMIM, RETICEF, Universitat Autonoma de Barcelona, Hospital del Mar, Barcelona, EspanabServicio de Endocrinologıa y Nutricion, Universitat Autonoma de Barcelona, Hospital del Mar, Barcelona, EspanacLaboratori de Refer!encia de Catalunya, S.A., Universitat Autonoma de Barcelona, Hospital del Mar, Barcelona, EspanadServicio de Cirugıa General, Universitat Autonoma de Barcelona, Hospital del Mar, Barcelona, Espana

informacion del art ıculo

Historia del artıculo:

Recibido el 2 de marzo de 2010

Aceptado el 4 de abril de 2010

Palabras clave:

Cirugıa bariatrica

Densitometria osea

Osteoporosis

Marcadores de remodelado oseo

r e s u m e n

Introduccion: La cirugıa bariatrica es la opcion mas eficaz para el tratamiento de los

pacientes con alto riesgo de complicaciones por su obesidad. Sin embargo provoca una

serie de alteraciones metabolicas sobre el calcio y la vitamina D y un aumento de la

resorcion que conllevan una perdida de masa osea.

Objetivo: El objetivo del estudio es la comparacion de la gastrectomıa tubular (GT) con el

bypass gastrico en Y de Roux (BGYR) respecto la perdida de masa osea medida mediante

densitometrıa y marcadores de remodelado oseo.

Pacientes y metodos: Se incluyeron 15 mujeres con obesidad morbida, 8 en la GT y 7 en el

BGYR, de edad media 47,879 con un ındice de masa corporal 43,373,4. Se realizaron

mediciones de la masa osea a nivel de columna, femur y tercio distal del radio y

marcadores de remodelado oseo N-telopeptido (NTx), y fosfatasa alcalina especıfica osea

(FAO), ası como niveles de vitamina D antes y a los 12 meses de la intervencion.

Resultados: Se observo una perdida significativa de masa osea con la GT y el BGYR, en

columna lumbar y cadera mientras que en el radio no se observaron diferencias

significativas. El porcentaje de perdida de masa osea fue menor en columna y femur tras

la GT que con el BGYR, aunque sin llegar a la significacion estadıstica, 4,6%74,4

(media7DE) y 6,3%75,4 (media7DE) respectivamente. A los 12 meses el NTx aumento

para ambos tipos de intervencion y las FAO aumentaron solo para la GT.

Conclusion: La GT provoca una perdida menor de masa osea, aunque no significativa,

respecto el BGYR.

& 2010 AEC. Publicado por Elsevier Espana, S.L. Todos los derechos reservados.

www.elsevier.es/cirugia

CIRUGIA ESPANOLA

0009-739X/$ - see front matter & 2010 AEC. Publicado por Elsevier Espana, S.L. Todos los derechos reservados.doi:10.1016/j.ciresp.2010.04.008

!Autor para correspondencia.Correo electronico: [email protected] (J.M. Ramon).

C I R E S P. 2010 ;88 (2 ) : 1 03 –109

Original

Perdida de masa osea tras gastrectomıa tubular:estudio prospectivo comparativo con el bypass gastrico

Xavier Noguesa, Albert Godayb, Maria Jesus Penaa, David Benaigesb, Marta de Ramonc,Xenia Crousd, Manuel Viald, Manuel Perad, Luis Granded, Adolfo Dıez-Pereza yJose Manuel Ramond,!

aServicio de Medicina Interna, URFOA-IMIM, RETICEF, Universitat Autonoma de Barcelona, Hospital del Mar, Barcelona, EspanabServicio de Endocrinologıa y Nutricion, Universitat Autonoma de Barcelona, Hospital del Mar, Barcelona, EspanacLaboratori de Refer!encia de Catalunya, S.A., Universitat Autonoma de Barcelona, Hospital del Mar, Barcelona, EspanadServicio de Cirugıa General, Universitat Autonoma de Barcelona, Hospital del Mar, Barcelona, Espana

informacion del art ıculo

Historia del artıculo:

Recibido el 2 de marzo de 2010

Aceptado el 4 de abril de 2010

Palabras clave:

Cirugıa bariatrica

Densitometria osea

Osteoporosis

Marcadores de remodelado oseo

r e s u m e n

Introduccion: La cirugıa bariatrica es la opcion mas eficaz para el tratamiento de los

pacientes con alto riesgo de complicaciones por su obesidad. Sin embargo provoca una

serie de alteraciones metabolicas sobre el calcio y la vitamina D y un aumento de la

resorcion que conllevan una perdida de masa osea.

Objetivo: El objetivo del estudio es la comparacion de la gastrectomıa tubular (GT) con el

bypass gastrico en Y de Roux (BGYR) respecto la perdida de masa osea medida mediante

densitometrıa y marcadores de remodelado oseo.

Pacientes y metodos: Se incluyeron 15 mujeres con obesidad morbida, 8 en la GT y 7 en el

BGYR, de edad media 47,879 con un ındice de masa corporal 43,373,4. Se realizaron

mediciones de la masa osea a nivel de columna, femur y tercio distal del radio y

marcadores de remodelado oseo N-telopeptido (NTx), y fosfatasa alcalina especıfica osea

(FAO), ası como niveles de vitamina D antes y a los 12 meses de la intervencion.

Resultados: Se observo una perdida significativa de masa osea con la GT y el BGYR, en

columna lumbar y cadera mientras que en el radio no se observaron diferencias

significativas. El porcentaje de perdida de masa osea fue menor en columna y femur tras

la GT que con el BGYR, aunque sin llegar a la significacion estadıstica, 4,6%74,4

(media7DE) y 6,3%75,4 (media7DE) respectivamente. A los 12 meses el NTx aumento

para ambos tipos de intervencion y las FAO aumentaron solo para la GT.

Conclusion: La GT provoca una perdida menor de masa osea, aunque no significativa,

respecto el BGYR.

& 2010 AEC. Publicado por Elsevier Espana, S.L. Todos los derechos reservados.

www.elsevier.es/cirugia

CIRUGIA ESPANOLA

0009-739X/$ - see front matter & 2010 AEC. Publicado por Elsevier Espana, S.L. Todos los derechos reservados.doi:10.1016/j.ciresp.2010.04.008

!Autor para correspondencia.Correo electronico: [email protected] (J.M. Ramon).

C I R E S P. 2010 ;88 (2 ) : 1 03 –109

efecto de perdida de la masa osea relacionado con la perdida

de IMC.Los resultados del presente estudio han demostrado una

perdida significativa de DMO en CL, CF y CT con ambastecnicas IQ evaluadas, el BGYR y la GT, con un porcentaje deperdida mayor en cadera que en columna, similar a loobservado por otros autores12.

Esta diferencia en el porcentaje de perdida de DMO encadera podrıa explicarse por que esta tiene un mayorcomponente de hueso cortical que trabecular , sin embargo

esta hipotesis no estarıa confirmada por los cambios de DMOa nivel del extremo distal del radio, sobre todo en 1/3 PR, quees una region particularmente cortical.Al comparar las dos tecnicas, los resultados han demos-

trado un porcentaje de perdida de masa osea menor con la GTque con el BGYR a nivel de columna lumbar y de cadera,aunque sin significacion estadıstica. Ası mismo, en el analisismultivariado se ha demostrado que el ni el tipo de IQ ni laperdida de peso alcanzada a los 12 meses influıa en la perdidade DMO. En referencia a la longitud del asa en Y de Roux,Gleysteen JJ realizo un estudio en el que comparaba varios

tipos de asa, de 41–61cm, 130–160cm y 115–250cm. No hallodiferencias en la perdida de peso producido, ni a corto ni largoplazo, entre los pacientes obesos sometidos a intervencioncon las asas mas largas y si respecto las asas por debajo de61 cm13.Las ventajas de la GT sobre el BGYR serıan unmenor tiempo

operatorio, menor riesgo quirurgico al evitar anastomosis,una preservacion del pıloro evitando ası el dumping,una motilidad gastrointestinal no alterada y al nohaber bypass intestinal se evitarıa el riesgo de carenciasvitamınicas, absorcion de calcio y se evitarıa una excesiva

perdida de DMO.Sin embargo, los resultados del presente estudio en cuanto

a DMO, demuestran que se produce tambien una perdida deDMO, aunque con un menor porcentaje de perdida de masaosea. Ademas los hallazgos de los MRO demuestran unaumento en la resorcion y disminucion de la formacion oseacon ambas IQ, aunque la FAO no llega a ser significativa en elBGYR, probablemente por un problema de tamano de lamuestra.Los resultados de estudios similares sin by pass gastrico,

demuestran con la tecnica de la gastroplastia vertical

anillada, un aumento de los MRO de resorcion y ası como

Tabla 3 – DMO antes y a los 12 meses tras IQ en su conjunto y para cada tipo de IQ!

Ambas media7DE p SG (n¼8) media7DE p BGYR (n¼7) media7DE p

DMOL2-L4Basal 1,05470,12 1,01370,13 1,10070,1012 meses 0,99570,10 0,001 0,96770,125 0,033 1,02670,07 0,022

DMO CFBasal 0,87670,07 0,88370,09 0,86970,0412 meses 0,79270,06 0,0001 0,80870,08 0,003 0,77470,04 0,0001

DMO CTBasal 1,03070,07 1,00970,07 1,05470,0712 meses 0,93370,06 0,0001 0,93670,07 0,001 0,92970,05 0,005

DMO1/3 RadioBasal 0,67770,07 0,66170,06 0,69570,0712 meses 0,67370,06 NS 0,65670,05 NS 0,69370,06 NS

DMO UltraBasal 0,42370,03 0,41570,03 0,43370,0212 meses 0,40470,04 0,03 0,40170,04 NS 0,40770,04 NS

CF: cuello femoral; CL: columna lumbar L2-L4; CT: cadera total; DMO: densidad mineral osea; tercio proximal de radio (1/3 PR);UD: ultradistal deradio.! Valores expresados en g/cm2.

Tabla 4 – Bioquımica y hormonas antes y a los 12 mesesde la IQ

Antes 12 meses

Ca (mg/dl)Sleeve 9,370,3 9,470,2By-pass 9,470,4 9,470,3

P (mg/dl)Sleeve 3,470,5 3,970,2By-pass 3,370,6 3,770,5

25-OH VitD (ng/ml)Sleeve 24,3716,0 37,4719,5!

By-pass 20,1712,5 24,4717,8

PTH (pg/ml)Sleeve 50,1725,3 43,8712,8By-pass 46,0726,1 37,0714,7

Ca: calcio; P: fosforo; 25 hidroxi-Vitamina D (25-OH Vit D); PTH:parathormona intacta.! p¼0,03.

C I R E S P. 2010 ;88 (2 ) : 1 03 –109 107

REDUCCION MASA OSEA

GTV BPGYR

CADERA 8,3% + 5,2 10,8% +3,8

COLUMNA LUMBAR 4,6% + 4,4 6,3% +5,4

ANTEBRAZO 3,2% + 6,3 5,9% + 8,2

GTV: DISMINUCION DE MASA OSEA SIMILAR AL BPGYR AUMENTO MARCADORES DE RESORCION

DISMINUCION MARCADORES DE FORMACION

Bone Loss in Adolescents After Bariatric Surgery

WHAT’S KNOWN ON THIS SUBJECT: The rate of bariatric surgeryin teenagers is increasing rapidly, but little is known about itseffects on bone health in such a young population.

WHAT THIS STUDY ADDS: Adolescents will lose some bonedensity in the first 2 years after bariatric surgery, but the z scoredoes not typically fall below average for age and gender.

abstractOBJECTIVE: To evaluate bone loss in adolescents after Roux-en-Y gas-tric bypass surgery and to determine the extent to which bone loss wasrelated to weight loss. We hypothesized that adolescents would losebone mass after surgery and that it would be associated with weightloss.

PATIENTS AND METHODS: We conducted a retrospective case reviewof 61 adolescents after bariatric surgery. Whole-body bone mineralcontent (BMC) and density (BMD) were measured by dual-energy ra-diograph absorptiometry, and age- and gender-specific BMD z scoreswere calculated. Measurements were obtained when possible beforesurgery and then every 3 tomonths after surgery for up to 2 years. Datawere analyzed by using a mixed-models approach, and regressionmodels were adjusted for age, gender, and height.

RESULTS: Whole-body BMC, BMD z score, and weight decreased signif-icantly over time after surgery (P ! .0001 for all). In the first 2 yearsafter surgery, predicted values on the basis of regressionmodeling forBMC decreased by 7.4%, and BMD z score decreased from 1.5 to 0.1.During the first 12 months after surgery, change in weight was corre-lated with change in BMC (r" 0.31; P" .02). Weight loss accounted for14% of the decrease in BMC in the first year after surgery.

CONCLUSION: Bariatric surgery is associated with significant boneloss in adolescents. Although the predicted bone density was appro-priate for age 2 years after surgery, longer follow-up is warranted todetermine whether bone mass continues to change or stabilizes.Pediatrics 2011;127:e956–e961

AUTHORS: Anne-Marie D. Kaulfers, MD,a Judy A. Bean,PhD,b Thomas H. Inge, MD, PhD,c Lawrence M. Dolan, MD,a

and Heidi J. Kalkwarf, PhDd

Divisions of aEndocrinology, bEpidemiology and Biostatistics,cSurgery, and dGeneral and Community Pediatrics, CincinnatiChildren’s Hospital Medical Center, Cincinnati, Ohio

KEY WORDSbone density, bariatric surgery, obesity, weight loss, adolescents

ABBREVIATIONSRYGB—Roux-en Y gastric bypassWB—whole bodyBMC—bone mineral contentBMD—bone mineral densityDXA—dual-energy radiograph absorptiometry

www.pediatrics.org/cgi/doi/10.1542/peds.2010-0785

doi:10.1542/peds.2010-0785

Accepted for publication Dec 17, 2010

Address correspondence to Anne-Marie D. Kaulfers, MD, Divisionof Pediatric Endocrinology, University of South Alabama, 1504Springhill Ave, Room 5204, Mobile, AL 36695. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2011 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

Funded by the National Institutes of Health (NIH).

e956 KAULFERS et al

term, P ! .0001) (Fig 1A). Weight losswas greatest in the first year and thenstabilized. Some patients had slight in-creases in weight after 15 months. Onthe basis of the regression model, thepredicted weight loss at 6, 12, 18, and24 months after surgery was 41.4 "1.3, 58.4" 1.4, 61" 1.5, and 49.2" 2.1kg, respectively. Gender was a signifi-cant covariate in the regression modelwith male patients losing more weight(6.4 kg) than female patients.

BMC showed a slight curvilinear de-cline over time (time-squared term,P ! .0001) (Fig 1B). Predicted valueson the basis of regression modeling

for WB BMC were 2692 g before sur-gery, decreasing to 2552 g at 1 yearafter surgery (#5.2%) and 2494 g at 2years after surgery (#7.4%). Heightand gender were significant covari-ates in the regression model. Heightwas positively associated with BMC(18.95 g/cm; P ! .0001), and male pa-tients had more BMC than femalepatients (323.4 g; P $ .0004). For thepatients who may still be growing, in-cluding height in the regression mod-els accounted for the differences inbone mass and density because of lin-ear growth.

BMD z score decreased linearly overtime (P ! .0001) (Fig 1C). The pre-dicted values for BMD z score on thebasis of regression modeling were 1.5before surgery, decreasing to 0.8 at 1year after surgery and 0.1 at 2 yearsafter surgery. Although the z score de-creased over time, the z score re-mained above average for agethroughout the 2-year follow-up pe-riod. Age was included in the regres-sion model because it was negativelyassociated with BMD z score (#0.056per year; P$ .03).

Results of the regression models forweight, WB BMC, and BMD z score weresimilar when restricting the analysesto the subset of individuals (N $ 34)that had at least 1 additional measure-ment%12 months after surgery.

We examined the potential effect ofweight loss for mediating or “explain-ing” the skeletal changes after sur-gery. Because of the pronounced cur-vilinear trend in weight loss over time,we restricted this set of analyses tothose measurements that occurredwithin the first 12 months after sur-gery. The correlation between changein weight and change in BMC was r$0.31 (P$ .02), and the correlation be-tween change in weight and change inBMD z score was r $ 0.05 (P $ .73).The correlations with BMC and BMD zscore were not different when ex-

pressing weight change in absoluteterms or as a relative value (eg, per-centage of total weight).

We then fitted weight in the regressionmodels to predict BMD z score andBMC. When both weight and time aftersurgery were included in the regres-sionmodel that predicted BMD z score,the regression coefficient for time af-ter surgery was attenuated by 44%(#0.052 vs#0.029) and was no longerstatistically significant (P$ .20). Inclu-sion of weight in the model for BMCresulted in a 14% reduction in the re-gression coefficient for time (#11.15vs 9.64); however, it remained statisti-cally significant (P$ .01).

DISCUSSION

In this study a decrease in WB BMC of5.2% by 1 year and of 7.4% by 2 yearsafter bariatric surgery in adolescentsis demonstrated. The loss in WB BMCwas significantly correlated with thechange in weight, accounting for 14%of the decrease in BMC in the first yearafter surgery. Although BMD values de-clined significantly (from 1.5 to 0.1),the BMD z score did not fall below theexpected value for gender and age (ie,a z score of 0) by 2 years after surgery.This finding is likely to be a conse-quence of the high bone mineral con-tent and density before surgery in thisextremely obese population. However,if bone loss continues, even at a slowrate, these patients may have an in-crease risk of fractures later in life.

Studies of adults also have reportedbone loss after bariatric surgery.13–20

Decreases in WB BMC were 3% to 12%at 9 to 24months after surgery,14,20 andadults had a fracture rate of 5% in thefirst 2.4 years after surgery.23 In addi-tion, the magnitude of bone lost inadults after RYGB procedures hasbeen shown to be associated with theamount of weight lost.15,17,18 Our studyshows that weight loss was signifi-cantly associated with bone loss after

FIGURE 1Weight (A), BMC (B), and BMD z score (C) overtime after bariatric surgery. Lines represent the61 patients. The bold line is the predicted valuefor the regression characterizing change overtime.

ARTICLES

PEDIATRICS Volume 127, Number 4, April 2011 e959









DISCUSSION





ARTICLES










DISCUSSION





ARTICLES










DISCUSSION





ARTICLES


n=61 Seguimiento DEXA hasta 2 a Consejo dietetico Suplemento Ca y Vit D

Reducción en 7,4% del CMO en 2 años

Bone Loss in Adolescents After Bariatric Surgery

WHAT’S KNOWN ON THIS SUBJECT: The rate of bariatric surgeryin teenagers is increasing rapidly, but little is known about itseffects on bone health in such a young population.

WHAT THIS STUDY ADDS: Adolescents will lose some bonedensity in the first 2 years after bariatric surgery, but the z scoredoes not typically fall below average for age and gender.

abstractOBJECTIVE: To evaluate bone loss in adolescents after Roux-en-Y gas-tric bypass surgery and to determine the extent to which bone loss wasrelated to weight loss. We hypothesized that adolescents would losebone mass after surgery and that it would be associated with weightloss.

PATIENTS AND METHODS: We conducted a retrospective case reviewof 61 adolescents after bariatric surgery. Whole-body bone mineralcontent (BMC) and density (BMD) were measured by dual-energy ra-diograph absorptiometry, and age- and gender-specific BMD z scoreswere calculated. Measurements were obtained when possible beforesurgery and then every 3 tomonths after surgery for up to 2 years. Datawere analyzed by using a mixed-models approach, and regressionmodels were adjusted for age, gender, and height.

RESULTS: Whole-body BMC, BMD z score, and weight decreased signif-icantly over time after surgery (P ! .0001 for all). In the first 2 yearsafter surgery, predicted values on the basis of regressionmodeling forBMC decreased by 7.4%, and BMD z score decreased from 1.5 to 0.1.During the first 12 months after surgery, change in weight was corre-lated with change in BMC (r" 0.31; P" .02). Weight loss accounted for14% of the decrease in BMC in the first year after surgery.

CONCLUSION: Bariatric surgery is associated with significant boneloss in adolescents. Although the predicted bone density was appro-priate for age 2 years after surgery, longer follow-up is warranted todetermine whether bone mass continues to change or stabilizes.Pediatrics 2011;127:e956–e961

AUTHORS: Anne-Marie D. Kaulfers, MD,a Judy A. Bean,PhD,b Thomas H. Inge, MD, PhD,c Lawrence M. Dolan, MD,a

and Heidi J. Kalkwarf, PhDd

Divisions of aEndocrinology, bEpidemiology and Biostatistics,cSurgery, and dGeneral and Community Pediatrics, CincinnatiChildren’s Hospital Medical Center, Cincinnati, Ohio

KEY WORDSbone density, bariatric surgery, obesity, weight loss, adolescents

ABBREVIATIONSRYGB—Roux-en Y gastric bypassWB—whole bodyBMC—bone mineral contentBMD—bone mineral densityDXA—dual-energy radiograph absorptiometry

www.pediatrics.org/cgi/doi/10.1542/peds.2010-0785

doi:10.1542/peds.2010-0785

Accepted for publication Dec 17, 2010

Address correspondence to Anne-Marie D. Kaulfers, MD, Divisionof Pediatric Endocrinology, University of South Alabama, 1504Springhill Ave, Room 5204, Mobile, AL 36695. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2011 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

Funded by the National Institutes of Health (NIH).

e956 KAULFERS et al

•  ES NECESARIO SUPLEMENTAR •  CALCIO Y VITAMINA D EN FORMA PERMANENTE •  EN DOSIS ALTAS

SINDROMES HIPOGLICEMICOS

•  HIPOGLICEMIA REACTIVA. COMPLICACIÓN POST QUIRÚRGICA TARDIA. HIPOGLICEMIA POSTPRANDIAL, HIPERINSULINEMICA

•  DUMPING. COMPLICACIÓN POST QUIRÚRGICA TEMPRANA. TRANSITO INTESTINAL RAPIDO DE ALIMENTOS PARCIALMENTE DIGERIDOS, CON DISTENSION MECANICA Y ALTERACION DE HNAS. INTESTINALES INCLUIDO GLUCAGON

•  NESIDIOBLASTOSIS : HIPOGLICEMIA HIPERINSULINEMICA EN PEDIATRÍA ALTERACION EN LA DIFERENCIACION EN ISLOTES DE LANGHERHANS

INCRETINAS

GLP-1 GIP

MECANISMO DE LA HIPOGLICEMIA HIPERINSULINEMICA

Aumento masa cel B

AUMENTO INSULINA AUMENTO SENSIBILIDAD

HIPOGLICEMIA POST CIRUGIA BARIATRICA •  Temblor

•  Palpitaciones

•  Sudoración

•  Confusión hasta Perdida de conciencia

•  HIPOGLICEMIA que ocurre 1 – 3 horas post ingesta.

•  Síntomas revierten con ingesta de glucosa

ALTA TASA DE CONSULTA EN S. URGENCIA Y HOSPITALIZACION POR SINTOMAS RELACIONADOS CON HIPOGLICEMIA EN BYPASS GASTRICO CONFUSION-SINCOPE-EPILEPSIA-CONVULSIONES

Mars Diabetologia 2010

patterns, by affecting both the proximal and distal stomachin a significant way.

Dumping syndrome is a common complication occurringafter upper GI surgery, and well described in the era of anti-ulcer gastric surgery at a range between 3% and 40% [6]. Itrepresents a rapid gastric emptying characterised by GI andvasomotor symptoms appearing after ingestion of meals.The clinical presentation of dumping syndrome is variableand symptoms are divided into early and late, depending onhow soon after ingestion they occur. Early symptoms(within 1 h postprandially) include both GI and vasomotorsymptoms. GI symptoms include abdominal pain, diarrhoea,borborygmi, nausea and bloating. Vasomotor symptoms, onthe other hand, include fatigue, a desire to lie down aftermeals, facial flushing, palpitations, perspiration tachycardia,hypotension and syncope [7]. Late dumping develops 1 to3 h after the meal and includes symptoms of reactivehypoglycaemia such as perspiration, palpitations, hunger,fatigue, confusion, aggression, tremor and syncope [7].

Currently, certain bariatric operations have become theprincipal cause of postoperative dumping syndrome, asanti-ulcer gastric surgery has essentially been omitted whilethe number of bariatric procedures increases exponentiallyworldwide. Appearance of dumping syndrome after obesitysurgery mainly applies to Roux-en-Y gastric bypass(RYGB) [8, 9]. Data regarding dumping syndrome aftersleeve gastrectomy are not available, and, although there isscintigraphic evidence of accelerated gastric emptying afterLSG [1, 2, 10], this has been opposed [11].

Given this background, we designed a prospectiveclinical study to evaluate the presence and severity ofsymptoms suggestive of dumping syndrome on provocationtest in a cohort of patients before and after LSG.

Material and Methods

Thirty-one consecutive non-diabetic morbidly obesepatients (eight male, 23 female), scheduled for LSGbetween March 2009 and June 2010, were prospectivelyevaluated and represent the material of the present study.Inclusion criteria for surgery were based on the 1991 NIHconsensus criteria for bariatric surgery [12]. Exclusioncriteria were (a) heavy sweeters and (b) patients withsuspected gastroesophageal reflux disease (GERD) assuggested by severe symptoms and endoscopic findings.The procedure was performed by the same surgical team(GT, DZ), and the surgical technique used has beenpreviously described [13]. The demographic characteristicsof the patients are listed in Table 1.

All patients were subjected to dumping provocation testpreoperatively and 6 weeks after the operation. An oralglucose challenge with 75 g of a 50% glucose solution in

water was used as the dumping provocation test instandardized conditions. The subjects arrived at the hospitalon the morning after overnight fasting and were seatedcomfortably. An intravenous cannula was placed in anantecubital vein for blood sampling. Blood was drawnbefore and after 30, 60, 90 and 120 min of the glucose load.GI and vasomotor symptoms were recorded and scoredusing two relevant scoring system: the Sigstad’s scoringsystem [14], and the Arts’ dumping score [16]. TheSigstad’s scoring system is based on the occurrence ofdifferent symptoms suggestive of dumping syndrome and isused for its diagnosis (Table 2). Mild complaints werescored by half of the value, while the entire score was givenin the case of severe symptoms [15], as assessed by thepatient. A total score of >7 after the ingestion of glucose isconsidered diagnostic for dumping syndrome whereas ascore of ≤4 is considered as non diagnostic. The Arts’

Table 1 Demographics of patients

Preoperatively Six weekspostoperatively

No (Male/female) 31 (8/23) 31 (8/23)

Age (years) (range) 38.74±9.54 (22–58) –

Height (cm) 168.1±8.00 –

Weight (kg) 129.1±18.90 114.7±18.08

BMI (kg/m2) 45.55±5.37 40.50±5.44

EWL% (Metropolitan) – 22.88±6.66

EBMIL% – 25.88±7.73

Data are presented as mean±SD

EWL excess weight loss

Table 2 Sigstad’s scoring system for diagnosis of dumping syndrome

Symptoms Grade

Shock +5

Fainting, syncope, unconsciousness +4

Desire to lie or sit down +4

Breathlessness, dyspnoea +3

Weakness, exhaustion +3

Sleepiness, drowsiness, apathy, falling asleep +3

Palpitation +3

Restlessness +2

Dizziness +2

Headaches +1

Feeling of warmth, sweating, pallor, clammy skin +1

Nausea +1

Abdominal fullness, meteorism +1

Borborygmus +1

Eructation −1Vomiting −4

24 OBES SURG (2012) 22:23–28dumping score [16] was completed by the patients tomeasure the severity of dumping symptoms after theingestion of glucose during the first hour for early dumpingsymptoms and between 1 and 2 h for late dumping. This isa dumping severity score based on symptom-patterndescriptions in the literature using a 4-point Likert scalein response to the oral glucose challenge (Table 3). Thepatients were asked to grade the intensity (scale, 0–3: 0,absent; 1, mild; 2, relevant; 3, severe) of eight early dumpingsymptoms and six late dumping symptoms. Glucose levelswere also measured at all times of the provocation test bothpreoperatively and at 6 weeks postoperatively.

Statistical Analysis

Wilcoxon matched paired t-test was used for the compar-ison of Sigstad and Arts scores preoperatively and at6 weeks after LSG. Mann–Whitney U-test was used for thecomparison of scores (Sigstad and Arts questionnaire)between dumpers and non-dumpers. Unpaired t-test wasused for the comparison between the dumpers and non-dumpers for blood glucose levels. Mean ± SD levels wereused for the analysis of demographics, as all the demo-graphic parameters have passed the D’Agostino–Pearsonomnibus normality test. Ideal weight was defined as themidpoint weight for a medium size frame for a given heightand gender, according to the 1983 Metropolitan LifeInsurance tables [17]. P<0.05 was considered significant.

Results

All patients had a preoperative Sigstad’s score (hereafter Sscore) of ≤4 (median score 0); in other words, there was nodumper in this cohort of patients, as it was expected. Incontrast, at 6 weeks after LSG, the median S score was 3.5(Table 4) indicating the appearance of dumping symptomsin some patients postoperatively. Indeed, nine out of 31patients (29%) met the dumper’s criteria (S score, >7)whereas five more patients (16%) had S scores between 5

and 7. Overall, the median S score was significantly higherpostoperatively (p<0.0001) and this difference recorded inany case invariably for both dumpers and non-dumpersafter LSG (Table 4).

Arts dumping severity score (hereafter A score) wassignificantly higher for early symptoms after the oralglucose test at 6 weeks post-LSG compared to preoperativevalues (p<0.0001, Table 4). On the other hand, the latedumping A score did not change significantly for the totalnumber of patients (p=0.44, Table 4). Regarding thedumping severity in the subgroups of dumpers and non-dumpers (divided as already mentioned according topostoperative Sigstad’s score), it was found that A scorewas statistically significant higher postoperatively in bothgroups for early symptoms (p=0.0089 for dumpers and p<0.0001 for non-dumpers, Table 4). In contrast, late dumpingscore did not change significantly for either the dumpers orthe non-dumpers (Table 4).

Looking at the difference between preoperative andpostoperative values in Sigstad and Arts scores (ΔS scoreand ΔA score) dumpers had significantly higher differencesin total dumping score and also in early dumping severityscore at 6 weeks after LSG, but no significant changes wererecorded for late dumping symptoms as compared to non-dumpers (Table 5).

Only one female patient experienced hypoglycaemia afteroral glucose intake postoperatively (glucose levels <60 mg/dl)at 120 min) and this patient belonged to the dumperssubgroup, according to postoperative Sigstad’s score. Therewas a trend for decreased levels of glucose at 120 min fordumpers compared to non-dumpers, but this was notstatistically significant (p=0.09, Fig. 1).

Discussion

Dumping syndrome is a functional sequel in manyprocedures on the upper GI tract, especially when theseinterfere with gastric anatomy. It has been estimated tooccur in up to 20% of patients who underwent vagotomywith pyloroplasty or antrectomy, operations used in the pastfor peptic ulcer disease [6, 18]. It has also been mentionedafter Nissen fundoplication [19, 20]. In bariatric surgery,dumping syndrome occurs very often in patients after RYGBand this is the main reason that this particular operation isstrongly indicated for heavy sweeters [8, 21, 22]: patientsavoid sweet consumption in order to avoid the annoyingsymptoms of dumping syndrome. Indeed, Laferrère et al.[22] reported that 44% of patients developed dumpingsymptoms after ingestion of 50 g of glucose 1 month afterRYGB.

Surprisingly, there is no data on the occurrence of thesyndrome in patients who have been subjected to LSG, a

Table 3 Arts questionnaire for dumping syndrome

Early dumping symptoms Late dumping symptoms

Sweating Sweating

Flushing Palpitations

Dizziness Hunger

Palpitations Drowsiness/unconsciousness

Abdominal pain Tremor

Diarrhoea Irritability

Bloating

Nausea

OBES SURG (2012) 22:23–28 25

CLINICAL RESEARCH

Symptoms Suggestive of Dumping Syndrome After Provocationin Patients After Laparoscopic Sleeve Gastrectomy

George Tzovaras & Dimitris Papamargaritis &

Eleni Sioka & Eleni Zachari & Ioannis Baloyiannis &

Dimitris Zacharoulis & George Koukoulis

Published online: 7 June 2011# Springer Science+Business Media, LLC 2011

AbstractBackground Dumping syndrome is a well-known compli-cation after upper gastrointestinal (GI) surgery. There arescarce data in the literature about the incidence of dumpingafter bariatric operations but, certainly no relation betweenthis syndrome and laparoscopic sleeve gastrectomy (LSG)has been attempted.Methods We conducted a prospective clinical study in orderto evaluate the potential presence, incidence and severity ofDumping syndrome after LSG. Thirty one non-diabeticmorbidly obese patients (eight male, 23 female) eligible forLSG were evaluated. Median age was 38 (22–58 years) andmean body mass index (BMI) was 45.55 (±5.37). Thediagnosis of dumping syndrome was based on clinicalprovocation of signs and symptoms using an oral glucosechallenge before and 6 weeks after the operation. TheSigstad’s dumping score was estimated in order to separatedumpers from non-dumpers, and the Arts questionnaire wascompleted to distinguish between early and late dumping.

Moreover, blood glucose levels during the oral glucosechallenge were measured.Results No patient had symptoms of dumping afterprovocation preoperatively, whereas after LSG 9 patients(29%) experienced definite dumping and other 5 patients(16%) symptoms suggestive of dumping syndrome. Arts’questionnaire demonstrated that dumping occurrence afterLSG was associated with early symptoms. Late hypogly-caemia occurred in one patient.Conclusion A significant proportion of patients after LSGexperienced dumping syndrome upon provocation. It seemsthat LSG should no longer be considered as a purerestrictive procedure, and it might be an option for heavysweeters by changing their food tolerance patterns.

Keywords Laparoscopic sleeve gastrectomy . Bariatricsurgery . Dumping syndrome . Gastric emptying

Introduction

Laparoscopic sleeve gastrectomy (LSG) is the latestalternative in the surgical treatment of morbidly obesepatients, seeking its place in the armamentarium of thesurgical management of the disease. Although it has beenclassified among the restrictive procedures, there is increas-ing evidence in the literature that LSG probably acts withmore than one mechanism [1–4]. The procedure includesresection of approximately 90% of the stomach, mainly thefundus and body, leaving behind a gastric tube along thelesser curve [5]. It is obvious that this procedure involvesmajor disruption on the upper gastrointestinal (GI) tractanatomy, and, almost certainly, physiology. In particular,LSG is anticipated to have an impact on gastric motility

G. Tzovaras (*) : E. Sioka : E. Zachari : I. Baloyiannis :D. ZacharoulisDepartment of Surgery, University Hospital of Larissa,Viopolis,Larissa 411 10, Greecee-mail: [email protected]

D. Papamargaritis :G. KoukoulisDepartment of Endocrinology, University Hospital of Larissa,Viopolis,Larissa 411 10, Greece

Present Address:G. Tzovaras19 Agorogianni A. Street,Larissa 413 35, Greece

OBES SURG (2012) 22:23–28DOI 10.1007/s11695-011-0461-7

CLINICAL RESEARCH









Introduction





OBES SURG (2012) 22:23–28DOI 10.1007/s11695-011-0461-7

CLINICAL RESEARCH









Introduction





OBES SURG (2012) 22:23–28DOI 10.1007/s11695-011-0461-7

45% DUMPING

CLINICAL RESEARCH

Dumping Symptoms and Incidence of HypoglycaemiaAfter Provocation Test at 6 and 12 MonthsAfter Laparoscopic Sleeve Gastrectomy

Dimitris Papamargaritis & George Koukoulis &

Eleni Sioka & Eleni Zachari & Alexandra Bargiota &

Dimitris Zacharoulis & George Tzovaras

Published online: 7 July 2012# Springer Science + Business Media, LLC 2012

AbstractBackground A previous study has demonstrated that symp-toms suggestive of dumping syndrome appear after a provo-cation test early after laparoscopic sleeve gastrectomy (LSG)in 45 % of patients, and these are mainly related to earlydumping. The aim of this study is to evaluate the evolutionof dumping symptoms during the first postoperative year.Methods Twenty-five non-diabetic morbidly obese patients(6 male, 19 female) were evaluated with an oral glucosetolerance test (OGTT) preoperatively, at 6 weeks and at6 months postoperatively. In addition, 12 of them repeatedthe OGTT at 12 months after LSG. Sigstad score was usedto separate dumpers from non-dumpers and Arts’ question-naire to differentiate between early and late dumping. Insu-lin and glucose levels were also measured.Results Sigstad score remained significantly elevated at 6and 12 months postoperatively compared to preoperativevalues. Symptoms suggestive of dumping syndrome wererecorded in 40 % of patients at 6 months and in 33 % at12 months postoperatively. Arts’ questionnaire demonstratedthat early dumping score remained higher compared to base-line at 6 and 12 months postoperatively. Late dumping scoresincreased gradually during the time and that difference was

statistically significant at 12 months after LSG. Hypoglycae-mia occurred at 33 % of patients both at 6 and 12 monthspostoperatively.Conclusions Symptoms suggestive of dumping syndromeafter provocation still exist at 6 and 12 months in a signif-icant proportion of patients after LSG and include both earlyand late dumping. These findings are consistent with thehigh incidence of hypoglycaemia after OGTT at 6 and12 months after LSG.

Keywords Laparoscopic sleeve gastrectomy . Bariatricsurgery . Dumping syndrome . Gastric emptying .

Hypoglycaemia . Late dumping

Introduction

Dumping syndrome is a common complication after uppergastrointestinal (GI) surgery [1]. The clinical presentation ofdumping syndrome is variable and symptoms can be divid-ed into early and late, depending on the occurrence ofsymptoms in relation to the time elapsed after a meal. Earlydumping symptoms occur during the first hour postpran-dially and include both gastrointestinal and vasomotorsymptoms. On the other hand, late dumping develops 1 to3 h after a meal and includes symptoms of reactive hypo-glycaemia [1–3].

Currently, dumping syndrome occurs mainly after Roux-en-Y gastric bypass (RYGB) operation, and it has been pro-posed as one of the mechanisms that lead to changes in foodpreferences after this procedure [4, 5]. However, it is believedthat dumping symptoms are improved over time [6, 7].

Laparoscopic sleeve gastrectomy (LSG) is the newest bari-atric operation, virtually still under evaluation. The resectionof the best part of the stomach results in major changes inanatomy and physiology of the upper GI tract, and apart from

OBES SURG (2012) 22:1600–1606DOI 10.1007/s11695-012-0711-3

D. Papamargaritis :G. Koukoulis :A. BargiotaDepartment of Endocrinology,University Hospital of Larissa,Larissa, Greece

E. Sioka : E. Zachari :D. Zacharoulis :G. TzovarasDepartment of Surgery,University Hospital of Larissa,Larissa, Greece

G. Tzovaras (*)19 Agorogianni A. Street,Larissa 413 35, Greecee-mail: [email protected]

CLINICAL RESEARCH










Introduction




OBES SURG (2012) 22:1600–1606DOI 10.1007/s11695-012-0711-3




6 MESES PO 12 MESES PO

DUMPING 40% 33%

HIPOGLICEMIA 33% 33%

A 12 MESES AUMENTO LA INCIDENCIA Y SEVERIDAD

DEL DUMPING TARDIO

CLINICAL RESEARCH










Introduction




OBES SURG (2012) 22:1600–1606DOI 10.1007/s11695-012-0711-3




PREVENCION

•  DIETETICO: EVITAR ALIMENTOS DE ALTO INDICE GLICEMICO, ESPECIALMENTE LIQUIDOS

•  NO HACER TEST DE TOLERANCIA A GLUCOSA

TRATAMIENTO

•  CORREGIR LA DIETA

•  FARMACOLOGICO: ACARBOSA, BBLOQUEADORES

OBESIDAD Y FERTILIDAD

ANDROGENOS CIRCULANTES

AROMATIZACION DE LA TESTOSTERONA

TEJIDO ADIPOSO

ESTRADIOL

INSULINA

SHBG

TESTOSTERONA

ALTERACION DE LA OVULACION

IRREGULARIDAD MENSTRUAL

POST CIRUGIA

REDUCCION DE TEJIDO ADIPOSO AUMENTO DE SENSIBILIDAD A INSULINA

REGULARIZACION DE OVULACION

edad 19 19 19 19 19 19

Meses post BPG

14 11 21 10 22 22

Peso RN(K) 3.98 2.93 3.32 2.87 3.18 2.95

BMI preop 63 46 41 53 52 59

•  13% incremento en tasa de embarazos esperada en grupo etario •  Todos los embarazos no planificados •  Todos monoparentales

Pregnancy After GBP Surgery in Adolescentes

Anticoncepción posterior a cirugía bariatrica

•  RECOMENDACIÓN DE POSTPONER 12-18 MESES UN EMBARAZO

•  BAJA ABSORCION DE ACO PROBADA EN DVP

•  ABSORCION DE ACO EN BPG Y SLEEVE GASTRECTOMY NO ESTUDIADA

•  CONTRAINDICACIONES PARA USO DE ACO riesgo de tromboembolismo, dislipidemia, HTA, pseudotumor cerebri.

Review article

Contraceptive use among women with a history of bariatric surgery:a systematic review☆

Melissa E. Paulena, Lauren B. Zapataa, Catherine Cansinob,Kathryn M. Curtisa,⁎, Denise J. Jamiesona

aDivision of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA 30341, USAbJohns Hopkins Bayview Medical Center, Baltimore, MD, USA

Received 3 February 2010; accepted 4 February 2010

Abstract

Background: Weight loss after bariatric surgery often improves fertility but can pose substantial risks to maternal and fetal outcomes.Women who have undergone a bariatric surgical procedure are currently advised to delay conception for up to 2 years.Study Design: We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluateevidence on the safety and effectiveness of contraceptive use among women with a history of bariatric surgery.Results: From 29 articles, five met review inclusion criteria. One prospective, noncomparative study reported 2 pregnancies among 9 (22%)oral contraceptive (OC) users following biliopancreatic diversion, and one descriptive study reported no pregnancies among an unidentifiednumber of women taking OCs following laparoscopic adjustable gastric banding. Of two pharmacokinetic studies, one found lower plasmalevels of norethisterone and levonorgestrel among women having had a jejunoileal bypass, as compared to nonoperated, normal-weightcontrols. The other study found no difference in plasma levels of D-norgestrel between women having a jejunoileal bypass of either 1:3 or 3:1ratio between the length of jejunum and ileum left in continuity, but women with a 1:3 ratio had significantly higher plasma levels of D-norgestrel than extremely obese controls not operated upon.Conclusions: Evidence regarding OC effectiveness following a bariatric surgical procedure is quite limited, although no substantial decreasein effectiveness was identified from available studies. Evidence on failure rates for other contraceptive methods and evidence on safety for allcontraceptive methods was not identified.Published by Elsevier Inc.

Keywords: Contraception; Bariatric surgery; Gastric bypass; Biliopancreatic diversion; Gastric banding; Systematic review

1. Introduction

In the United States, approximately 66% of adults, aged20 years or older, are overweight or obese [1]. Thepercentage of individuals who are severely or morbidlyobese [body mass index (BMI) ≥40 kg/m2 or roughly 100lb overweight] has increased by 50% from 2000 to 2005[2], and it is estimated that approximately 6% of womenenter pregnancy categorized as morbidly obese [3,4].Conventional methods of weight loss, including behavior

modification and medications, have proven largely unsuc-cessful as treatment for morbid obesity. As a result, thedemand for bariatric surgery has greatly increased, and it isbelieved to be the most effective weight loss treatment formorbid obesity [5,6]. Between 1998 and 2005, theincidence of bariatric surgery in the United States increasedby 800%, with women accounting for 83% of bariatricprocedures undertaken by individuals of reproductive age(18–45 years) [7].

Bariatric surgical techniques can be separated into twogroups: malabsorptive procedures and restrictive procedures.Malabsorptive procedures induce decreased absorption ofnutrients and calories by shortening the functional length ofthe small intestine, whereas restrictive procedures induceweight loss by decreasing storage capacity of the stomachresulting in early satiety, decreased meal size, and lower

Contraception 82 (2010) 86–94

☆ The findings and conclusions in this report are those of the authorsand do not necessarily represent the official position of the Centers forDisease Control and Prevention.

⁎ Corresponding author. Tel.: +1 770 488 6397; fax: +1 770 488 6391.E-mail address: [email protected] (K.M. Curtis).

0010-7824/$ – see front matter. Published by Elsevier Inc.doi:10.1016/j.contraception.2010.02.008

Review article

Contraceptive use among women with a history of bariatric surgery:a systematic review☆

Melissa E. Paulena, Lauren B. Zapataa, Catherine Cansinob,Kathryn M. Curtisa,⁎, Denise J. Jamiesona

aDivision of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA 30341, USAbJohns Hopkins Bayview Medical Center, Baltimore, MD, USA

Received 3 February 2010; accepted 4 February 2010

Abstract

Background: Weight loss after bariatric surgery often improves fertility but can pose substantial risks to maternal and fetal outcomes.Women who have undergone a bariatric surgical procedure are currently advised to delay conception for up to 2 years.Study Design: We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluateevidence on the safety and effectiveness of contraceptive use among women with a history of bariatric surgery.Results: From 29 articles, five met review inclusion criteria. One prospective, noncomparative study reported 2 pregnancies among 9 (22%)oral contraceptive (OC) users following biliopancreatic diversion, and one descriptive study reported no pregnancies among an unidentifiednumber of women taking OCs following laparoscopic adjustable gastric banding. Of two pharmacokinetic studies, one found lower plasmalevels of norethisterone and levonorgestrel among women having had a jejunoileal bypass, as compared to nonoperated, normal-weightcontrols. The other study found no difference in plasma levels of D-norgestrel between women having a jejunoileal bypass of either 1:3 or 3:1ratio between the length of jejunum and ileum left in continuity, but women with a 1:3 ratio had significantly higher plasma levels of D-norgestrel than extremely obese controls not operated upon.Conclusions: Evidence regarding OC effectiveness following a bariatric surgical procedure is quite limited, although no substantial decreasein effectiveness was identified from available studies. Evidence on failure rates for other contraceptive methods and evidence on safety for allcontraceptive methods was not identified.Published by Elsevier Inc.

Keywords: Contraception; Bariatric surgery; Gastric bypass; Biliopancreatic diversion; Gastric banding; Systematic review

1. Introduction

In the United States, approximately 66% of adults, aged20 years or older, are overweight or obese [1]. Thepercentage of individuals who are severely or morbidlyobese [body mass index (BMI) ≥40 kg/m2 or roughly 100lb overweight] has increased by 50% from 2000 to 2005[2], and it is estimated that approximately 6% of womenenter pregnancy categorized as morbidly obese [3,4].Conventional methods of weight loss, including behavior

modification and medications, have proven largely unsuc-cessful as treatment for morbid obesity. As a result, thedemand for bariatric surgery has greatly increased, and it isbelieved to be the most effective weight loss treatment formorbid obesity [5,6]. Between 1998 and 2005, theincidence of bariatric surgery in the United States increasedby 800%, with women accounting for 83% of bariatricprocedures undertaken by individuals of reproductive age(18–45 years) [7].

Bariatric surgical techniques can be separated into twogroups: malabsorptive procedures and restrictive procedures.Malabsorptive procedures induce decreased absorption ofnutrients and calories by shortening the functional length ofthe small intestine, whereas restrictive procedures induceweight loss by decreasing storage capacity of the stomachresulting in early satiety, decreased meal size, and lower

Contraception 82 (2010) 86–94

☆ The findings and conclusions in this report are those of the authorsand do not necessarily represent the official position of the Centers forDisease Control and Prevention.

⁎ Corresponding author. Tel.: +1 770 488 6397; fax: +1 770 488 6391.E-mail address: [email protected] (K.M. Curtis).

0010-7824/$ – see front matter. Published by Elsevier Inc.doi:10.1016/j.contraception.2010.02.008

EMBARAZO EN USUARIAS DE ACO CON DIVESRION BILIIOPANCREATICA BAJOS NIVELES DE NORETISTERONA Y LEVONORGESTRE

NO EMBARAZO EN USUARIAS DE ACO CON BANDING GASTRICO

EMBARAZO EN USUARIAS DE ACO CON DIVESRION BILIIOPANCREATICA

NO REPORTE DE EMBARAZO EN USUARIAS DE ACO BYPASS GASTRICO

NO REPORTE DE EMBARAZO EN USUARIAS DE ACO SLEEVE GASTRECTOMY

NO HAY EVIDENCIA SUFICIENTE PARA DUDAR DE LA EFECTIVIDAD DE LOS ACO POR BAJA ABSORCION

DESPUES DE CIRUGIA BARIATRICA

Menstrual Concerns and Intrauterine ContraceptionAmong Adolescent Bariatric Surgery Patients

Jennifer B. Hillman, M.D., M.S.,1 Rachel J. Miller, M.D.,2 and Thomas H. Inge, M.D., Ph.D.3

Abstract

Objective: Adolescent obesity has dramatically increased in recent decades, and along with that so have othermedical comorbidities, such as hypertension, diabetes, hyperlipidemia, nonalcoholic steatohepatitis, polycysticovary syndrome (PCOS), and pseudotumor cerebri. Obesity and related comorbidites may be contraindicationsto hormonal contraception, making contraception counseling of morbidly obese adolescents more challenging.Obese adolescent females seeking bariatric surgery need effective contraception in the postoperative period. Thisstudy is designed to determine the acceptance rate of the levonorgestrel-releasing intrauterine device (IUD) anddescribe common menstrual problems in obese adolescent bariatric surgery patients.Methods: This is a historic cohort study of adolescent females who underwent bariatric surgery over a 2-yearperiod at a tertiary referral center for pediatric obesity. Data were systematically abstracted. The percent ofpatients with menstrual problems and the acceptance rate for the levonorgestrel-releasing IUD were determined.Results: Twenty-five adolescents met inclusion criteria. The mean age was 17.4 years (standard deviation [SD]2.6), and the mean body mass index (BMI) was 51.4 (SD 6.3) kg/m2. Eighty-four percent were white. Twenty-eight percent had menorrhagia, 32% had oligomenorrhea, 40% had dysmenorrhea, and 36% had PCOS. Ninety-two percent (23 of 25) underwent IUD placement.Conclusions: There was a high prevalence of menstrual problems among this sample of severely obese ado-lescent females. The majority accepted the IUD, indicating it is a viable option among this population.

Introduction

More than 18% of children and adolescents in theUnited States aged 6–19 are considered obese, defined

as having a body mass index (BMI) for age and gender in the95th percentile or greater.1 As more children and adolescentshave become overweight or obese, it has become apparentthat obesity affects nearly every organ system, including thereproductive organs.2,3 For example, menstrual disorders,such as dysfunctional uterine bleeding, secondary amenor-rhea, and polycystic ovary syndrome (PCOS), are increasinglyrecognized among severely obese adolescent females. In ad-dition to the menstrual concerns, such medical comorbiditiesas hypertension, hypertriglyceridemia, pseudotumor cerebri,and increased risk of venous thromboembolic events canbe contraindications for hormonal contraceptives, which addsto the complexity of addressing menstrual concerns and

providing contraception counseling for severely obese ado-lescents.4,5

In the last decade, bariatric surgery has become an optionfor treatment of morbidly obese adolescents, and the numberof bariatric procedures performed on adolescents increased 5-fold from 1997 to 20036 and continues to increase. Currentguidelines for bariatric surgery recommend avoidance ofpregnancy for at least 1 year postoperatively.7 The AmericanCollege of Obstetricians and Gynecologists (ACOG) recom-mends postponing pregnancy for 12–18 months after bariatricsurgery.8 Although the risk of anovulatory infertility is highamong women with obesity,9 loss of as little as 5% of excessbody weight can restore ovulatory function in obese adultwomen with or without PCOS.10 Changes in self-esteem,body image, and increased fertility after bariatric surgery mayin part account for an increase in unplanned pregnanciesamong adult11 and adolescent females.12 Roehrig et al.12

1Division of Adolescent Medicine, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine,Cincinnati, Ohio.

2Pediatric and Adolescent Gynecology, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota.3Department of General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of

Medicine, Cincinnati, Ohio.

JOURNAL OF WOMEN’S HEALTHVolume 20, Number 4, 2011ª Mary Ann Liebert, Inc.DOI: 10.1089/jwh.2010.2462

533



Abstract


Introduction









533



Abstract


Introduction









533

lem was dysmenorrhea (40%). Half of the patients had pre-viously used hormonal contraceptives (52%), with the mostcommon being combined oral contraceptive pills (OCPs)(40%). Twenty-eight percent were sexually active before sur-gery, and the majority self-described as heterosexual (Table 2).

Ninety-two percent of the patients had a levonorgestrel-releasing IUD placed at the time of bariatric surgery. Of thosewho declined the IUD, 1 was taking progestin-only pills be-fore surgery but discontinued them by 3 months postopera-tively; 1 patient did not give a reason for declining but statedshe was ‘‘never attracted to anyone.’’ Five patients had anendometrial biopsy performed at the time of the IUD insertionbecause of clinical symptoms of abnormal uterine bleedingand, thus, concern for endometrial hyperplasia. All endome-trial biopsies were negative for endometrial hyperplasia. Ofnote, at the time of the retrospective review in which allsubjects were at least 6 months postoperative, only 1 patientexperienced unanticipated expulsion of the IUD, and anotherpatient requested the IUD be removed at an outside facilitysecondary to vaginal bleeding. There were no known seriousside effects or complications related to the IUD (e.g., uterineperforation, pelvic inflammatory disease [PID]).

Discussion

Severely obese adolescent females seeking bariatric surgeryconstitute a group with significant menstrual problems andrelevant obesity-related comorbidities, making contraceptivecounseling more complex and challenging. Only one quarterof the patients were sexually active before surgery, and morethan half had previously used hormonal contraceptives.There was an extremely high acceptance rate for insertion ofthe levonergestrel-releasing IUD at the time of bariatric sur-gery, suggesting that this was considered a viable option bythis group of adolescents. Importantly, there were no com-plications noted among the patients who received the IUD.

Menstrual problems and obesity-relatedhealth concerns

Adolescent females in this study demonstrated a highprevalence of menstrual problems. In general, considering themajority of the sample was white, they experienced an earlierage of menarche (11.8 years) compared to the mean age atmenarche for the average white female in the United States(12.7–12.9 years).22,23 Earlier age of menarche is associatedwith an increased risk of breast and ovarian cancer, and in-creased developmental concerns (e.g., depression, delinquentbehavior).24–27 Therefore, in addition to the increased psy-chosocial problems associated with obesity in children andadolescents,28–30 girls with earlier pubertal onset have anadditional risk factor for psychological distress.24–27

More than one third of the patients in the current study hada diagnosis of PCOS, which is much higher than the estimatedprevalence of 4%–8% among adult women in the UnitedStates.31,32 Although slightly higher prevalence rates (9%–10%) have been demonstrated among obese populations inthe United States,33 the prevalence in this sample is more thanthree times as high as has been found previously. A Spanishstudy reported a 28.3% prevalence rate of PCOS amongoverweight and obese adult Spanish women.34 Of note, theauthors demonstrated that increasing severity of obesity wasnot associated with increasing likelihood of having PCOS.34

Another important point that seems to be emerging is thatobesity at an earlier age may be associated with a higher riskof developing PCOS.35 Results of a large retrospective andcross-sectional study of adult women enrolled in the Long-itudinal Assessment of Bariatric Surgery-2 study demon-strated that women who recalled being obese by age 18 yearswere more likely to report a history of PCOS and infertilityand less likely to have had a prior pregnancy compared towomen who became obese after the age of 18 years.35 Thismay provide some explanation for the high prevalence ofPCOS in this severely obese population of adolescents. Ofnote, the clinicians who evaluated the adolescents in thecurrent study used similar criteria for diagnosing PCOS aswas used in the referenced studies. Both clinicians ( J.B.H. andR.J.M.) who performed the medical assessments of thesesubjects were members of a clinical division that uses a toolbased on the NIH definition of PCOS to standardize the di-agnosis across providers in the practice.21

In addition to earlier menarche and the high prevalencerate of PCOS, the adolescents in this study reported a highprevalence of oligomenorrhea, dysmenorrhea, and menor-rhagia. The high rates of menstrual cycle disturbance are notsurprising, given what is known about gonadal steroid hor-

Table 1. Percent of Patients with ReproductiveHealth or Relevant Obesity-Related Comorbidities

Among Obese Adolescent FemalesSeeking Bariatric Surgery (n = 25)

Comorbidity n (%)

Hypertension 8 (32)Dyslipidemia 14 (56)Anemia 2 (8)Pseudotumor cerebri 2 (8)Menorrhagia 7 (28)Oligomenorrhea 8 (32)Dysmenorrhea 10 (40)Polycystic ovary syndrome 9 (36)No menstrual problemsa 4 (16)

Girls with hypothalamic amenorrhea were excluded from theseanalyses.

aMenstrual problems include menorrhagia, oligomenorrhea, dys-menorrhea, and polycystic ovary syndrome.

Table 2. Use of Contraceptives, Sexual Activity,and Sexual Orientation Among Obese Adolescent

Females Seeking Bariatric Surgery (n = 25)

Characteristic n (%)

Ever sexually active (intercourse) 7 (28)Ever used contraceptives 13 (52)Ever using specific contraceptive

Combined oral contraceptive pills 10 (40)Progestin-only pills 5 (20)Transdermal patch 1 (4)Intravaginal ring 1 (4)

Sexual orientationHeterosexual 20 (80)Homosexual 0 (0)Bisexual 3 (12)Not recorded 2 (8)

IUDs AMONG OBESE TEENS 535

lem was dysmenorrhea (40%). Half of the patients had pre-viously used hormonal contraceptives (52%), with the mostcommon being combined oral contraceptive pills (OCPs)(40%). Twenty-eight percent were sexually active before sur-gery, and the majority self-described as heterosexual (Table 2).

Ninety-two percent of the patients had a levonorgestrel-releasing IUD placed at the time of bariatric surgery. Of thosewho declined the IUD, 1 was taking progestin-only pills be-fore surgery but discontinued them by 3 months postopera-tively; 1 patient did not give a reason for declining but statedshe was ‘‘never attracted to anyone.’’ Five patients had anendometrial biopsy performed at the time of the IUD insertionbecause of clinical symptoms of abnormal uterine bleedingand, thus, concern for endometrial hyperplasia. All endome-trial biopsies were negative for endometrial hyperplasia. Ofnote, at the time of the retrospective review in which allsubjects were at least 6 months postoperative, only 1 patientexperienced unanticipated expulsion of the IUD, and anotherpatient requested the IUD be removed at an outside facilitysecondary to vaginal bleeding. There were no known seriousside effects or complications related to the IUD (e.g., uterineperforation, pelvic inflammatory disease [PID]).

Discussion

Severely obese adolescent females seeking bariatric surgeryconstitute a group with significant menstrual problems andrelevant obesity-related comorbidities, making contraceptivecounseling more complex and challenging. Only one quarterof the patients were sexually active before surgery, and morethan half had previously used hormonal contraceptives.There was an extremely high acceptance rate for insertion ofthe levonergestrel-releasing IUD at the time of bariatric sur-gery, suggesting that this was considered a viable option bythis group of adolescents. Importantly, there were no com-plications noted among the patients who received the IUD.

Menstrual problems and obesity-relatedhealth concerns

Adolescent females in this study demonstrated a highprevalence of menstrual problems. In general, considering themajority of the sample was white, they experienced an earlierage of menarche (11.8 years) compared to the mean age atmenarche for the average white female in the United States(12.7–12.9 years).22,23 Earlier age of menarche is associatedwith an increased risk of breast and ovarian cancer, and in-creased developmental concerns (e.g., depression, delinquentbehavior).24–27 Therefore, in addition to the increased psy-chosocial problems associated with obesity in children andadolescents,28–30 girls with earlier pubertal onset have anadditional risk factor for psychological distress.24–27

More than one third of the patients in the current study hada diagnosis of PCOS, which is much higher than the estimatedprevalence of 4%–8% among adult women in the UnitedStates.31,32 Although slightly higher prevalence rates (9%–10%) have been demonstrated among obese populations inthe United States,33 the prevalence in this sample is more thanthree times as high as has been found previously. A Spanishstudy reported a 28.3% prevalence rate of PCOS amongoverweight and obese adult Spanish women.34 Of note, theauthors demonstrated that increasing severity of obesity wasnot associated with increasing likelihood of having PCOS.34

Another important point that seems to be emerging is thatobesity at an earlier age may be associated with a higher riskof developing PCOS.35 Results of a large retrospective andcross-sectional study of adult women enrolled in the Long-itudinal Assessment of Bariatric Surgery-2 study demon-strated that women who recalled being obese by age 18 yearswere more likely to report a history of PCOS and infertilityand less likely to have had a prior pregnancy compared towomen who became obese after the age of 18 years.35 Thismay provide some explanation for the high prevalence ofPCOS in this severely obese population of adolescents. Ofnote, the clinicians who evaluated the adolescents in thecurrent study used similar criteria for diagnosing PCOS aswas used in the referenced studies. Both clinicians ( J.B.H. andR.J.M.) who performed the medical assessments of thesesubjects were members of a clinical division that uses a toolbased on the NIH definition of PCOS to standardize the di-agnosis across providers in the practice.21

In addition to earlier menarche and the high prevalencerate of PCOS, the adolescents in this study reported a highprevalence of oligomenorrhea, dysmenorrhea, and menor-rhagia. The high rates of menstrual cycle disturbance are notsurprising, given what is known about gonadal steroid hor-

Table 1. Percent of Patients with ReproductiveHealth or Relevant Obesity-Related Comorbidities

Among Obese Adolescent FemalesSeeking Bariatric Surgery (n = 25)

Comorbidity n (%)

Hypertension 8 (32)Dyslipidemia 14 (56)Anemia 2 (8)Pseudotumor cerebri 2 (8)Menorrhagia 7 (28)Oligomenorrhea 8 (32)Dysmenorrhea 10 (40)Polycystic ovary syndrome 9 (36)No menstrual problemsa 4 (16)

Girls with hypothalamic amenorrhea were excluded from theseanalyses.

aMenstrual problems include menorrhagia, oligomenorrhea, dys-menorrhea, and polycystic ovary syndrome.

Table 2. Use of Contraceptives, Sexual Activity,and Sexual Orientation Among Obese Adolescent

Females Seeking Bariatric Surgery (n = 25)

Characteristic n (%)

Ever sexually active (intercourse) 7 (28)Ever used contraceptives 13 (52)Ever using specific contraceptive

Combined oral contraceptive pills 10 (40)Progestin-only pills 5 (20)Transdermal patch 1 (4)Intravaginal ring 1 (4)

Sexual orientationHeterosexual 20 (80)Homosexual 0 (0)Bisexual 3 (12)Not recorded 2 (8)

IUDs AMONG OBESE TEENS 535



Abstract


Introduction









533



Abstract


Introduction









533



Abstract


Introduction









533

EVALUACION DE USO DE DIU-LEVONORGESTREL •  90% BUENA TOLERANCIA A 6 MESES •  1 PACIENTE CON SANGRADO VAGINAL •  1 PACIENTE EXPULSION DEL DIU

•  SE RECOMENDO INSERSION DURANTE LA CIRUGIA BARIATRICA PARA EVITAR DOLOR

DESPUES DE LA CIRUGIA BARIATRICA

•  DISMINUCION DE MASA OSEA

•  RIESGO DE HIPOGLICEMIA

•  RIESGO DE EMBARAZO NO PLANIFICADO

EN ADOLESCENTES

•  EVALUCION PREOPERATORIA DE RED FAMILIAR Y DE LA CAPACIDAD DE ADHERIR A TRATAMIENTO PERMANENTE CON SUPLEMENTOS NUTRICIONALES

•  CAPACIDAD DE ADHERIR PERMANENTE RESTRICCIONES EN LA DIETA

•  CONSEJERIA PARA CONTROL DE NATALIDAD PROGRAMADO

complicaciones endocrinas en cirugia bariatrica -...

Documents