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Introducción: La cirugía bariátrica permite una reducción significativa de peso y mejoría de comorbilidades asociadas a la obesidad a largo plazo, pero también puede afectar negativamente el estado nutricional de algunos micronutrientes. Objetivos: Evaluar cambios en ingesta e indicadores del estado nutricional de zinc, hierro y cobre en mujeres sometidas a bypass gástrico en Y de Roux (BPG) o gastrectomía tubular (GT), hasta el segundo año postoperatorio. Métodos: Se estudió prospectivamente 45 mujeres sometidas a BPG o GT (edad promedio 35,2 ± 8,4 años, IMC promedio 39,8 ± 4,0 kg/m²), cada 6 meses se realizaron determinaciones de ingesta e indicadores del estado nutricional de zinc, hierro y cobre, y en forma anual se evaluó la composición corporal. El aporte de minerales a través de los suplementos representaba dos veces la ingesta recomendada para una mujer sana en las pacientes sometidas a GT y tres veces para BPG. Resultados: 20 mujeres se sometieron a GT y 25 a BPG. En ambos grupos se produjo una reducción significativa de peso y del porcentaje de masa grasa, que se mantuvo hasta el segundo año postoperatorio. Las mujeres sometidas a BPG presentaron un mayor compromiso del estado nutricional de zinc, hierro y cobre, que las pacientes sometidas a GT. Conclusiones: El bypass gástrico en Y de Roux produce un compromiso mayor del estado nutricional de zinc, hierro y cobre que la gastrectomía tubular. Se debería evaluar si la administración fraccionada de la suplementación mejoraría la absorción de estos nutrientes.Introduction: Bariatric surgery allows a significant reduction in weight and improvement of comorbidities associated with obesity in the long term, but it can also adversely affect the nutritional status of some micronutrients. Objectives: To evaluate changes in intake and parameters of nutritional status of zinc, iron and copper in patients undergoing Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG), until the second postoperative year. Methods: We prospectively studied 45 women undergoing GBP or SG (mean age 35.2 ± 8.4 years, mean BMI 39.8 ± 4.0 kg/m²), every 6 months We measured intake and status indications nutritional zinc, iron and copper, and annually evaluated body composition. The contribution of minerals through supplements represented twice the recommended intake for a healthy woman in patients undergoing GT and three times for GBP. Results: 20 women underwent GBP and 25 SG. In both groups there was a significant reduction in weight and body fat percentage, which was maintained until the second postoperative year. Women who have had a greater commitment GBP nutritional status of zinc, iron and copper, that patients undergoing SG. Conclusions: Gastric bypass Roux-Y produces a greater commitment of nutritional status of zinc, iron and copper sleeve gastrectomy. It should evaluate whether administration of supplementation fractional improve the absorption of these nutrients.

Introducción: La cirugía bariátrica produce una reducción de peso significativa, pero se asocia a un mayor riesgo de presentar algunas deficiencias nutricionales. Una complicación frecuente, poco estudiada, que se ha relacionado principalmente con deficiencia de zinc, es la alopecia. Objetivos: comparar el estado nutricional de zinc, hierro, cobre, selenio y proteico-visceral en mujeres con distinto grado de caída del pelo al sexto mes post bypass gástrico o gastrectomía tubular. Métodos: Según el grado de caída de pelo las pacientes fueron divididas en dos grupos: grupo 1 o caída leve (n = 42) y grupo 2 o caída importante del pelo (n = 45). Se evaluó en el preoperatorio y al sexto mes postoperatorio la ingesta de zinc, hierro, cobre y selenio, además de indicadores del estado nutricional de zinc, hierro, cobre y proteico visceral. Resultados: En ambos grupos se produjo una reducción significativa del peso al sexto mes postoperatorio (-38,9 ± 16,4%). Las pacientes del grupo1 presentaron una ingesta significativamente mayor de zinc (20,6 ± 8,1 contra 17,1 ± 7,7 mg/d) y de hierro (39,7 ± 35,9 contra 23,8 ± 21,3 mg/d.), y un menor compromiso del estado nutricional de zinc y hierro que el grupo 2, pero las pacientes del grupo 2 presentaron un menor compromiso del estado nutricional de cobre. No hubo diferencias en las concentraciones plasmáticas de albúmina. Conclusiones: Las pacientes que presentan una menor caída del pelo hasta el sexto mes postoperatorio tienen una mayor ingesta de zinc y hierro, y un menor compromiso del estado nutricional de ambos minerales.Introduction: Bariatric surgery leads to a significant body weigh reduction although it is associated to a higher risk of presenting some nutritional deficiencies. A common complication, little studied and mainly related to zinc deficiency is alopecia. Objectives: To compare the nutritional status of zinc, iron, copper, selenium and protein-visceral in women with different degrees of hair loss at 6 months after gastric bypass or tubular gastrectomy. Methods: The patients were categorized into two groups according to the degree of hair loss: group 1 or mild loss (n = 42) and group 2 or severe hair loss (n = 45). Zinc, iron, copper, and selenium, as well as the indicators of the nutritional status of zinc, iron, copper, and proteinvisceral were assessed before and after 6 months of the surgery. Results: In both groups there was a significant body weight reduction at 6 months post-surgery (-38.9% ± 16.4%). Patients in group 1 presented a significantly higher intake of zinc (20.6 ± 8.1 vs. 17.1 ± 7.7 mg/d) and iron (39.7 ± 35.9 vs. 23.8 ± 21.3 mg/d.), and lower compromise in the nutritional status of zinc and iron than group 2. However, patients in group 2 had lower compromise in the nutritional status of copper. There were no differences regarding the plasma concentrations of albumin. Conclusions: The patients having lower hair loss at six months after surgery had higher zinc and iron intake and lower compromise of the nutritional status of both minerals.

Objetivo: Comparar el gasto energético de reposo medido con el gasto energético de reposo estimado (GER) por fórmulas predictivas diseñadas a partir de población con peso normal u obesidad, en mujeres con obesidad severa y mórbida. Material y métodos: a 66 mujeres (índice de masa corporal 44,7 ± 4,9 kg/m²; edad 35,6 ± 10,3 años) se les realizó calorimetría indirecta con monitor metabólico Deltatrac (Datex Inst., Finlandia), antes de someterse a cirugía bariátrica. Se estimó el GER con las siguientes ecuaciones: Harris-Benedict con peso real y peso ajustado, Ireton-Jones, Estimación Rápida de Carrasco (16,2 kcal × kg peso real) y Mifflin. Resultados: (x ± de). El GER medido fue 1.797 ± 239 kcal/día. Todas las fórmulas, excepto Harris-Benedict con peso ajustado, sobreestimaron el gasto energético; la ecuación de Ireton-Jones fue la que sobreestimó en mayor cuantía el GER (689 ± 329 kcal/día), mientras que la ecuación de Mifflin sobreestimó el GER sólo en 6 ± 202 kcal/día. No se encontraron diferencias significativas entre el GER medido y el GER estimado por Mifflin y Estimación Rápida. La ecuación de Mifflin fue la más exacta: en 68% de los casos la diferencia entre el GER estimado y medido estuvo dentro de ± 10%, seguida por Harris-Benedict con peso real (64%) y la Estimación Rápida (61%). Según el análisis de Bland-Altman, hubo una correlación significativa entre la diferencia GER estimado-medido y el promedio de GER estimado y medido con todas las ecuaciones, excepto con la Estimación Rápida de Carrasco. Esto implica que, con la excepción de esta última, las fórmulas estudiadas subestiman o sobrestiman el GER dependiendo de la magnitud del GER medido. Conclusión: En la serie pacientes con obesidad severa y mórbida evaluadas, la ecuación de Mifflin y la Estimación Rápida otorgan el menor error de estimación del gasto energético de reposo en mujeres. Antes de recomendar una ecuación en particular es necesario realizar estudios de validación para determinar cuál es la ecuación de predicción más exacta para este grupo de pacientes.Objective: To compare measured resting energy expenditure (REE) with that predicted by formulas derived from populations with normal weight or obesity and from women with severe and morbid obesity. Material and methods: 66 women (aged 35.6 ± 10.3 y and BMI of 44.7 ± 4.9 kg/m²) were evaluated by indirect calorimetry with a metabolic monitor Deltatrac (Datex Inst., Finland), before undergoing gastric bypass. REE was calculated with the following equations: Harris-Benedict's with both actual and adjusted weight, Ireton-Jones', Mifflin's, and Carrasco's Fast Estimation, which corresponds to 16.2 kcal × kg actual weight. Results: (mean ± sd). Measured REE was 1797 ± 239 kcal/day. All formulas, except Harris-Benedict's with adjusted weight, overestimated REE. The Ireton-Jones' equation presented the greater overestimation (689 ± 329 kcal/day), whereas Mifflin's equation overestimated REE only by 6 ± 202 kcal/day. No significant differences were detected between measured and calculated REE by Mifflin's and Carrasco's Fast Estimation. Accuracy (defined as difference between calculated and measured REE within ± 10%) was greater with Mifflin's equation (68%), followed by Harris-Benedict's with actual weight (64%) and Carrasco's Fast Estimation (61%). By using the Bland-Altman analysis, significant correlations were observed between calculated-measured REE and mean REE (calculated + measured/2) with all equations except Carrasco's Fast Estimation. This means that all but one formula underestimate or overestimate REE depending on the level of measured REE. Conclusion: In severe and morbid obese women, Mifflin's and Carrasco's Fast Estimation equations provided the best performance to estimate REE. Before recommending an equation in an a subset of individuals it is necessary to make previous validation studies to determine that equation with the best predictive power for this particular group of patients.

Weight stigma, defined as pervasive misconceptions and stereotypes associated with higher body weight, is both a social determinant of health and a human rights issue. It is imperative to consider how weight stigma may be impeding health promotion efforts on a global scale. The World Obesity Federation (WOF) convened a global working group of practitioners, researchers, policymakers, youth advocates, and individuals with lived experience of obesity to consider the ways that global obesity narratives may contribute to weight stigma. Specifically, the working group focused on how overall obesity narratives, food and physical activity narratives, and scientific and public-facing language may contribute to weight stigma. The impact of weight stigma across the lifespan was also considered. Taking a global perspective, nine recommendations resulted from this work for global health research and health promotion efforts that can help to reduce harmful obesity narratives, both inside and outside health contexts., (© 2023 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

We have previously advocated that nutritional care be raised to the level of a human right, in close relationship to two well-recognized fundamental rights: the right to food and the right to health. This article aims to analyze the implication of nutritional care as a human right for healthcare practitioners. We will focus on the impact of the Human Rights Basic Approach (HRBA) on healthcare professionals (HCPs), namely how they can translate HRBA into routine clinical practice. Ethics and human rights are guiding values for clinical nutrition practitioners. Together they ensure a patient-centered approach, in which the needs and rights of the patients are of the most significant importance. Human rights are based on the powerful idea of equal dignity for all people while expressing a set of core values, including fairness, respect, equality, dignity, and autonomy (FREDA). Through the analysis of FREDA principles, we have provided the elements to understand human rights and how an HRBA can support clinicians in the decision-making process. Clinical practice guidelines in clinical nutrition should incorporate disease-specific ethical issues and the HRBA. The HRBA should contribute to building conditions for HCPs to provide optimal and timely nutritional care. Nutritional care must be exercised by HCPs with due respect for several fundamental ethical values: attentiveness, responsibility competence, responsiveness, and solidarity., (© 2022 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism and American Society for Parenteral and Enteral Nutrition [Published by Wiley]. All rights reserved.)

Background: Roux-en-Y gastric bypass (RYGBP) is known to reduce zinc absorption; the effects of vertical sleeve gastrectomy (SG) and its long-term implications on zinc absorption have not yet been studied., Objective: The aim was to evaluate the effects of SG and RYGBP on zinc absorption and zinc status in premenopausal women with severe obesity up to 24 mo after surgery., Methods: Twenty-six premenopausal women undergoing SG [BMI (in kg/m2): 37.3 ± 3.2] and 32 undergoing RYGBP (BMI: 42.0 ± 4.2) were studied. A series of anthropometric, dietary, and zinc status parameters (plasma and hair zinc), and the size of the exchangeable zinc pool (EZP), as well as percentage zinc absorption from a standardized dose using a stable isotope methodology were evaluated in the patients before the surgical procedure and at 12 and 24 mo after SG or RYGBP. SG patients received 15 mg and RYGBP received 25 mg of supplemental Zn/d., Results: In premenopausal women, zinc absorption was decreased by 71.9% and 52.0% in SG and RYGBP, respectively, 24 mo postsurgery, compared with initial values. According to 2-factor repeated-measures ANOVA, time effect was significant (P = <0.0001), but not time × group interaction (P = 0.470). Plasma zinc below the cutoff point of 70 µg/dL increased from 0 to 15.4% and 38.1% in SG and RYGBP, respectively. Mean EZP was significantly reduced 24 mo after surgery, although no time × group interactions were observed. Hair zinc did not change across time or between groups., Conclusions: Both SG and RYGBP have profound effects on zinc absorption capacity, which are not compensated for after 24 mo. Although zinc absorption reduction was similar in both types of surgeries, plasma zinc was more affected in RYGBP than SG, despite greater zinc supplementation in RYGBP.This trial was registered at http://www.isrctn.com as ISRCTN31937503., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition., Competing Interests: Conflicts of interest Diana Cardenas: none; Maria Isabel Toulson Davisson Correia: Lecturer for Abbott, Baxter, Danone, Fresenius, Nestlé, Takeda; Juan B Ochoa: Lecturer for Nestle Health Science, Fresenius Kabi and a past Chief Medical Officer until July 1, 2018 - Nestle Health Science North America; Gil Hardy: none;(;) Dolores Rodriguez-Ventimilla: none; Charles Bermúdez: Abbott, Baxter, Fresenius, Nestlé, Amarey, Bbraun, Fenavi, Eurociencia, Takeda; Karin Papapietro: Lecturer for Fresenius;(;) Régis Hankard: none(;) André Briend: none; Katerina Zakka: none; Teresa Pounds: none; Winai Ungpinitpong: none; Cristina Cuerda: Lecturer for Abbott, Baxter, Fresenius, Nestle, Nutricia, Persan, Takeda;(;) Rocco Barazzoni: none., (Copyright © 2021 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Introduction: in patients with severe and morbid obesity it has been observed that bioimpedance (BIA) assessment generates an underestimation of fat mass (FM) and weight loss as FM after bariatric surgery, overestimating the loss of fat-free mass (FFM) and muscle mass. Objective: to evaluate the reliability of bioelectrical impedance analysis (BIA) to estimate total body water (TBW), fat-free mass (FFM), fat mass (FM), and its changes after 6 months of a Roux-en-Y gastric bypass (RYGBP), in patients with severe and morbid obesity. Methods: thirty-six patients approved for RYGBP were prospectively studied. TBW was measured by deuterium (D), and FM and FFM were calculated. A dual-frequency BIA device (5 and 200 kHz) (Bodystat Dualscan®) was used to estimate FM, FFM, TBW, extracellular water (ECW), intracellular water (ICW), and ECW/ICW ratio. Results: before RYGBP, BIA overestimated TBW by 2.6 ± 4.3 L (p = 0.002) and FFM by 3.5 ± 5.7 kg (p = 0.002), and underestimated FM% by 2.98 ± 4.7% (p = 0.002). The ECW/ICW ratio showed a significant and positive correlation with the difference BIA-D for FFM (r = 0.49; p = 0.002). After surgery, the differences between BIA and D were not significant, and the estimation error of FFM did not correlate with the ECW/ICW ratio. Conclusions: BIA generates an underestimation of FM as reported in patients with severe and morbid obesity, which is attenuated after weight reduction, underestimating weight loss as FM and overestimating FFM loss. Future research may assess whether these errors are reproduced by other BIA devices.

Background: Although Roux-en-Y gastric bypass (RYGBP) is known to reduce calcium absorption (CA), the effects of vertical sleeve gastrectomy (SG) and its long-term implications on CA have not yet been studied., Objective: The aim of this study was to evaluate changes in CA and its relation with modifications of bone mineral density (BMD), intakes of calcium and vitamin D, vitamin D status, and parathyroid hormone (PTH) concentrations ≤24 mo after SG and RYGBP, respectively., Design: Twenty-six premenopausal women undergoing SG [mean ± SD body mass index (BMI; kg/m2): 37.3 ± 3.2; age: 34.2 ± 10.2 y] and 32 undergoing RYGBP (BMI: 42.0 ± 4.2; age: 37.3 ± 8.1 y) were studied at baseline (presurgery) and followed up at 12 and 24 mo after surgery. BMD, bone alkaline phosphatase activity, and serum PTH, 25-hydroxyvitamin D [25(OH)D], calcium, magnesium, and phosphorus concentrations were determined. Food and supplement intakes were recorded. CA was measured by using a dual stable isotope method., Results: In premenopausal women, CA was significantly reduced from 36.5% ± 2.0% preoperatively to 21.0% ± 2.3% and 18.8% ± 3.4% at 12 and 24 mo post-SG surgery, respectively. CA also decreased significantly from 41.5% ± 2.8% preoperatively to 27.9% ± 3.8% and 18.5% ± 2.2% 12 and 24 mo after RYGBP, respectively. No difference was found between type of surgery (time × group interaction, P = 0.60). Considering both groups combined, 56.6% of the variance in CA at the 12-mo but not at the 24-mo follow-up was explained by serum PTH and 25(OH)D concentrations, together with vitamin D and calcium intakes., Conclusions: CA was similarly reduced in both SG and RYGBP compared with baseline, and it was not associated with changes in BMD or body weight loss. This reduction in CA could be explained only partially by calcium intake increase. This trial is registered at http://www.isrctn.com as ISRCTN31937503.

The trauma involved in any surgical procedure, even if elective, causes a metabolic stress response characterized by postoperative insulin resistance (PIR). PIR is considered a surgical stress marker and is associated with increased morbidity and postoperative length of stay. PIR worsens when the patient is operated in a state of prolonged preoperative fasting or when postoperative feeding is delayed. The ERAS Protocols (Enhanced Recovery After Surgery) includes anesthetic, surgical, kinesiology, nutritional and nursing interventions aimed to modulate PIR. The nutritional perioperative interventions in the ERAS protocols, focus on avoiding prolonged preoperative fasting by oral carbohydrate loading up to two hours before surgery, accompanied by early postoperative feeding through the digestive tube. These nutritional perioperative interventions are safe and effective to reduce complications and postoperative stay, even in patients with well controlled type 2 diabetes. Nevertheless, their implementation and compliance are rather low, therefore, we must continue to make efforts in order to change perioperative nutritional management of our patients to achieve the best possible postoperative recovery.

Background: Although morbid obesity is related to excess of energy and macronutrient intake, it does not rule out the presence of micronutrient deficiencies. The aim of this study was to evaluate food intake and the prevalence of micronutrient deficiencies in a group of morbidly obese women seeking bariatric surgery., Methods: A total of 103 morbidly obese women were studied prior to bariatric surgery. Anthropometry and body composition (dual-energy X-ray absorptiometry, DEXA) were performed on all subjects. Energy and nutrient intake was determined by food frequency questionnaire. Blood tests to assess micronutrients status, including plasma iron, ferritin, transferrin, zinc, copper, calcium, phosphorus, hemoglobin, hematocrit, mean corpuscular volume (MCV), and hair zinc, were performed. Folic acid, vitamin B12, vitamin D, and parathyroid hormone (PTH) were also assessed in 66 subjects., Results: Mean energy intake was 2801 ± 970 kcal/day. Carbohydrate, protein, and lipid intake represented 55 ± 9.1, 13.9 ± 3.3, and 32.5 ± 8.2% of total energy intake, respectively. Iron, calcium, and vitamin D intake was below the recommended dietary allowance. The prevalence of nutritional deficiencies were as follows: plasma iron 12.6%, ferritin 8.7%, transferrin 14.6%, plasma zinc 2.9%, calcium 3.3%, phosphorus 2.3%, hemoglobin 7.7%, hematocrit 13.6%, MCV 6.8%, and hair zinc 15.7%. In the subsample, 10.6% had a vitamin B12 deficiency, 71.7% showed low concentrations of vitamin D, and 66% had high PTH levels. No folic acid or copper deficiencies were detected., Conclusions: Despite high daily energy intake and adequate macronutrient distribution, morbidly obese Chilean women seeking bariatric surgery present with deficient intake of some micronutrients and a high prevalence of micronutrient deficiencies.

Introduction: Bariatric surgery has important metabolic complications such as bone mass loss., Goal: To assess bone mineral density (BMD) after Roux-en-Y gastric by-pass (RYGB) in patients under standard calcium and vitamin D supplementation., Method: In patients with morbid obesity submitted to RYGB, 76 women and 22 men of diverse age, all with standard nutritional instruction including vitamin D and calcium, we measured BMD with a dual X-ray densitometer. They had lumbar spine and hips measurement 2-3 years post-surgery. Twenty females were followed up with BMD until of a mean of 54 months. Using World Health Organization (WHO) criteria's, values were compared with young controls and same age and sex population, evaluating osteopenia and osteoporosis., Results: Inverse correlation was observed between BMD and age; positive between BMD and body mass index as well as with preoperative weight excess. In women younger than 45 years, we observed a diminished BMD in 26.8% of them, with no cases of osteoporosis. In older females, BMD was decreased in 65.7% (p = 0.0011); corresponding to 45.7% of osteopenia and 20% osteoporosis, more frequent in lumbar spine. In the female's subgroup followed longer, BMD diminished progressively mainly in left hip. In men, there was 36% of osteopenia and 14% of osteoporosis., Conclusion: Patients from both genders and diverse ages after BPYR presented osteopenia and osteoporosis, despite early supplement prescription of calcium and vitamin D. We consider important to perform serial BMD measurements and also to individualize therapy with risk factors control., (Copyright © AULA MEDICA EDICIONES 2013. Published by AULA MEDICA. All rights reserved.)

In the last years, type 2 diabetes mellitus (T2DM) and obesity have become a serious public health problem, behaving as epidemic diseases. There is great interest in exploring different options for the treatment of T2DM in nonmorbidly obese patients. The purpose of this study is to report parameters of glycemic control in patients with T2DM and mild obesity who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP). This prospective clinical trial includes patients with T2DM with a body mass index (BMI) between 30 and 35 kg/m(2) who underwent laparoscopic RYGBP from July 2008 through October 2010. Thirty-one patients were included in the study, 15 men and 16 women, with an average age of 48.7 ± 8.6 years. The average time since onset of T2DM was 5.8 years. The average postoperative follow-up was 30.4 months. The average preoperative blood glucose and glycosylated hemoglobin were 152 ± 70 mg/dl and 7.7 ± 2.1 %, respectively. All of them were using oral hypoglycemic agents, and four patients were insulin dependent. Only one patient had a postoperative complication (hemoperitoneum). At 36 months follow-up, the average BMI decreased to 24.7 kg/m(2), all patients (31) showed improvement in their glycemic control, and 29 of them (93.6 %) met the criteria for remission of T2DM in the last control. Laparoscopic RYGBP is a safe and effective procedure that improves glycemic control in patients with T2DM and mild obesity at midterm follow-up.

In this paper, we analyze and discuss the possibility of Laparoscopic sleeve gastrectomy being accepted as a primary and definitive procedure for obese patients with comorbidities. This is based on our postoperative and 5 years of follow-up result and comparing them with the data reported in the international literature. For comparison of the results, a narrative revision of the literature was performed, using the Medline, Pubmed, and data base publications (Medline, Lilacs, and Cochrane Library), looking for the term "Sleeve gastrectomy," "Obesity," "Bariatric surgery," "Laparoscopic surgery" including "Review" articles and also other 42 selected papers. The current results demonstrate very low morbidity (<10%), nil mortality (<1%), mean % weight loss after 5 years of follow-up of 57%, very satisfactory results regarding comorbidities or improvement. However, gastroesophageal reflux manifestation after the operation (20% to 31%) and the possibility of regaining weight after 5 years (15% to 75%) appear as points for analysis.

Background: The effect of bariatric surgery on iron absorption is only partially known., Objective: The objective was to study the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGBP) on heme- and nonheme-iron absorption and iron status., Design: Fifty-eight menstruating women were enrolled in this prospective study [mean (±SD) age: 35.9 ± 9.1 y; weight: 101.7 ± 13.5 kg; BMI (in kg/m²): 39.9 ± 4.4]. Anthropometric, body-composition, dietary, and hematologic indexes and heme- and nonheme-iron absorption-using a standardized meal containing 3 mg Fe-were determined before and 12 mo after surgery. Forty-three subjects completed the 12-mo follow-up. Iron supplements were strictly controlled., Results: Heme-iron absorption was 23.9% before and 6.2% 12 mo after surgery (P < 0.0001). Nonheme-iron absorption decreased from 11.1% to 4.7% (P < 0.0001). No differences were observed by type of surgery. Iron intakes from all sources of supplements were 27.9 ± 6.2 mg/d in the SG group and 63.2 ± 21.1 mg/d in the RYGBP group (P < 0.001). Serum ferritin and total-body iron decreased more after RYGBP than after SG., Conclusions: Iron (heme and nonheme) absorption is markedly reduced after SG and RYGBP. The magnitude of the decrease in heme-iron absorption is greater than that of nonheme iron. The amounts suggested as iron supplements may need to be increased to effectively prevent iron-status impairment.

Introduction: Bariatric surgery allows a significant reduction in weight and improvement of comorbidities associated with obesity in the long term, but it can also adversely affect the nutritional status of some micronutrients., Objectives: To evaluate changes in intake and parameters of nutritional status of zinc, iron and copper in patients undergoing Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG), until the second postoperative year., Methods: We prospectively studied 45 women undergoing GBP or SG (mean age 35.2 ± 8.4 years, mean BMI 39.8 ± 4.0 kg/m²), every 6 months We measured intake and status indications nutritional zinc, iron and copper, and annually evaluated body composition. The contribution of minerals through supplements represented twice the recommended intake for a healthy woman in patients undergoing GT and three times for GBP., Results: 20 women underwent GBP and 25 SG. In both groups there was a significant reduction in weight and body fat percentage, which was maintained until the second postoperative year. Women who have had a greater commitment GBP nutritional status of zinc, iron and copper, that patients undergoing SG., Conclusions: Gastric bypass Roux-Y produces a greater commitment of nutritional status of zinc, iron and copper sleeve gastrectomy. It should evaluate whether administration of supplementation fractional improve the absorption of these nutrients.

Objective: Ghrelin is a potent stimulator of appetite and synthesized in the stomach. Its role in weight loss after gastric bypass (GBP) is still controversial. The aim of this study was to evaluate the relation between weight loss and food intake and between weight loss and changes in serum ghrelin concentrations 1 y after GBP with resection of the bypassed stomach (R-GBP) and without resection (NR-GBP)., Methods: Of 50 women (37.6 ± 10.2 y old, body mass index 43.8 ± 4.8 kg/m²) with GBP, 26 had R-GBP and 24 had NR-GBP. Body weight, body composition (dual energy x-ray absorptiometry), food intake, and serum ghrelin at baseline and 12 mo after GBP were measured., Results: The percentage of excess weight loss was 68.9 ± 12.8% at 12 mo after GBP. At 12 mo, the decrease of serum ghrelin was greater in the R-GBP group (-25.3 ± 22.5%) compared with the NR-GBP group (+11.2 ± 50.9%, P < 0.005). After adjustment by the baseline excess of body weight, there was a greater percentage of excess weight loss in the R-GBP group only at 6 mo (61.8% versus 54.9%, P = 0.011). After controlling for the baseline intake, a significant lower carbohydrate intake was observed in the R-GBP group 6 mo after surgery (P < 0.05)., Conclusion: A greater decrease in ghrelin levels was observed only in patients who underwent R-GBP at 12 mo after surgery. This difference was not associated with differences in dietary intakes or weight loss at the same time point. Therefore, the small gastric pouch is probably more important than decreased ghrelin levels in producing long-term weight loss after R-GBP., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: There is a paucity of information about the long term effects of gastric bypass for morbid obesity., Aim: To study the evolution of weight and complications of obesity, seven to 10 years after gastric bypass surgery., Material and Methods: One hundred eighteen subjects with morbid obesity, aged 15 to 66 years (103 women), were followed for a mean of 94 months after surgery. Body weight, fasting blood glucose, total cholesterol, triglycerides and hemoglobin were measured before surgery and during follow up., Results: At 24 months of follow up, all patients lost weight and there was a mild weight increase at 94 months, that paralleled the preoperative body mass index. Diabetes, hypercholesterolemia and hypertriglyceridemia subsided in 95, 87 and 94% of cases, respectively. Twenty percent of patients had mild anemia and 11% moderate or severe anemia. No patient recovered the preoperative weight., Conclusions: Weight reducing effects of gastric bypass are maintained after 94 months of follow up with the expected health benefits.

Background: Micronutrient deficiencies are common in patients undergoing gastric bypass. The effect of this type of surgery on zinc absorption and zinc status is not well known., Objective: The objective was to evaluate the effects of Roux-en-Y gastric bypass (RYGBP) on zinc status and zinc absorption at different stages after surgery. We hypothesized that zinc status would be significantly impaired after surgery and that this impairment would be less severe in subjects receiving increased supplemental zinc. We also hypothesized that zinc absorption would be lower after surgery., Design: Anthropometric and body-composition variables and dietary and biochemical indexes of zinc status and zinc absorption were determined in 67 severe and morbidly obese women [mean (±SD) age: 36.9 ± 9.8 y; BMI (in kg/m(2)): 45.2 ± 4.7] who underwent RYGBP. The subjects were randomly assigned to 1 of 2 vitamin-mineral supplementation groups. Measurements were made before and 6, 12, and 18 mo after surgery. Fifty-six subjects completed the 18-mo follow-up., Results: Mean plasma zinc, erythrocyte membrane alkaline phosphatase activity, and the size of the rapidly exchangeable zinc pool decreased after RYGBP. Percentage zinc absorption decreased significantly from 32.3% to 13.6% at 6 mo after RYGBP and to 21% at 18 mo after surgery. No effect of supplement type was observed., Conclusions: Zinc status is impaired after RYGBP, despite the finding that dietary plus supplemental zinc doubled recommended zinc intakes in healthy persons. Zinc absorption capacity is significantly reduced soon after RYGBP, with no major changes until 18 mo after surgery.

Introduction: Bariatric surgery leads to a significant body weigh reduction although it is associated to a higher risk of presenting some nutritional deficiencies. A common complication, little studied and mainly related to zinc deficiency is alopecia., Objectives: To compare the nutritional status of zinc, iron, copper, selenium and protein-visceral in women with different degrees of hair loss at 6 months after gastric bypass or tubular gastrectomy., Methods: The patients were categorized into two groups according to the degree of hair loss: group 1 or mild loss (n = 42) and group 2 or severe hair loss (n = 45). Zinc, iron, copper, and selenium, as well as the indicators of the nutritional status of zinc, iron, copper, and proteinvisceral were assessed before and after 6 months of the surgery., Results: In both groups there was a significant body weight reduction at 6 months post-surgery (-38.9% ± 16.4%). Patients in group 1 presented a significantly higher intake of zinc (20.6 ± 8.1 vs. 17.1 ± 7.7 mg/d) and iron (39.7 ± 35.9 vs. 23.8 ± 21.3 mg/d.), and lower compromise in the nutritional status of zinc and iron than group 2. However, patients in group 2 had lower compromise in the nutritional status of copper. There were no differences regarding the plasma concentrations of albumin., Conclusions: The patients having lower hair loss at six months after surgery had higher zinc and iron intake and lower compromise of the nutritional status of both minerals.

Background: Knowledge about the practical consequences of the nutritional status of Fe, Zn, and Cu and inflammation in obesity is limited. The objective of this study was to evaluate changes on trace element status and their potential associations with selected inflammation parameters in patients after Roux-en-Y gastric bypass (RYGBP)., Methods: Sixty-three women (mean age, 36.9 ± 9.2 years, body mass index, 43.8 ± 4.3 kg/m²) were evaluated at baseline and 6 months after RYGBP. Anthropometric (weight, waist circumference), body composition (fat mass and fat-free mass), dietary (nutrient intakes), and metabolic and inflammation (glucose, insulin, HOMA-IR, adiponectin, HDL-cholesterol, LDL-cholesterol, triglycerides, hs-CRP, leukocytes, polymorphonuclear neutrophils (PMN)) parameters were determined in addition to selected indices of Fe, Zn, and Cu status., Results: All but one (HDL-cholesterol) metabolic and inflammation parameters had significant differences when compared before and after RYGBP. Hemoglobin, serum ferritin, the size of the rapidly exchangeable zinc pool, and plasma copper decreased after RYGBP. Plasma and hair zinc, as well as zinc protoporphyrin increased. The change in Hb was significantly associated (p < 0.05) to the change in leukocytes (r = 0.33) and adiponectin (r = -0.44). Zinc protoporphyrin change was associated to the change in PMN (r = 0.32) and HDL-cholesterol (r = -0.29). No other associations between the changes of the rest of Fe, Zn, and Cu parameters with the changes of any of the metabolic and inflammation parameters were observed., Conclusion: RYGBP produced significant weight and fat mass losses, with improvement of metabolic and inflammation parameters. Iron, zinc, and copper status were impaired after the surgery.

Background: Sleeve gastrectomy (SG) has been accepted as an option for surgical treatment for obesity. This operation could be associated with motor gastric dysfunction and abnormal gastric emptying. The purpose of this prospective study is to present the results of gastric emptying to liquids and solids using scintigraphy in patients who underwent SG compared to normal subjects., Methods: Twenty obese patients were submitted to laparoscopic SG and were compared to 18 normal subjects. Gastric emptying of liquids and solids was measured by scintigraphic technique. Results were expressed as half time of gastric emptying and the percentage of retention at 20, 30, and 60 min for liquids and at 60, 90, and 120 min for solids., Results: In the group of operated patients, 70% of them (n = 14) presented accelerated emptying for liquids and 75% (n = 15) for solids compared to 22.2% and 27.7%, respectively, in the control group. The half time of gastric emptying (T (1/2)) in patients submitted to SG both for liquids and solids were significantly more accelerated compared to the control group (34.9 +/- 24.6 vs 13.6 +/- 11.9 min for liquids and 78 +/- 15.01 vs 38.3 +/- 18.77 min for solids; p < 0.01). The gastric emptying for liquids expressed as the percentage of retention at 20, 30, and 60 min was 30.0 +/- 0.25%, 15.4 +/- 0.18%, and 5.7 +/- 0.10%, respectively, in operated patients, significantly less than the control subjects (p < 0.001). For solids, the percentage of retention at 60, 90, and 120 min was 56 +/- 28%, 34 +/- 22%, and 12 +/- 8%, respectively, for controls, while it was 25.3 +/- 0.20%, 9 +/- 0.12%, and 3 +/- 0.05%, respectively, in operated patients (p < 001)., Conclusions: Gastric emptying after SG is accelerated either for liquids as well as for solids in the majority of patients. These results could be taken in consideration for the dietary indications after surgery and could play a significant role in the definitive results during the late follow-up.

Background: Iron deficiency and iron deficiency anemia are common in patients who undergo gastric bypass. The magnitude of change in iron absorption is not well known., Objective: The objective was to evaluate the effects of Roux-en-Y gastric bypass (RYGBP) on iron status and iron absorption at different stages after surgery. We hypothesized that iron absorption would be markedly impaired immediately after surgery and would not improve after such a procedure., Design: Anthropometric, body-composition, dietary, hematologic, and iron-absorption measures were determined in 67 severe and morbidly obese women [mean age: 36.9 +/- 9.8 y; weight: 115.1 +/- 15.6 kg, body mass index (BMI: in kg/m(2)); 45.2 +/- 4.7] who underwent RYGBP. The Roux-en-Y loop length was 125-150 cm. Determinations were carried out before and 6, 12, and 18 mo after surgery. Fifty-one individuals completed all 4 evaluations., Results: The hemoglobin concentration decreased significantly throughout the study (repeated-measures analysis of variance). The percentage of anemic subjects changed from 1.5% at the beginning of the study to 38.8% at 18 mo. The proportion of patients with low serum ferritin increased from 7.5% to 37.3%. The prevalence of iron deficiency anemia was 23.9% at the end of the experimental period. Iron absorption from both a standard diet and from a standard dose of ferrous ascorbate decreased significantly after 6 mo of RYGBP to 32.7% and 40.3% of their initial values, respectively. No further significant modifications were noted., Conclusion: Iron absorption is markedly reduced after RYGBP with no further modifications, at least until 18 mo after surgery.

Background: Sleeve gastrectomy is a restrictive procedure for treatment of obese patients with different body mass index (BMI) and presents good results in terms of a reduction of percentage of excess weight loss and BMI. There is no consensus which is the optimal technique regarding to the diameter of the gastric tube, but a capacity of 100-120 ml has been suggested. In this prospective study, we compare the gastric capacity evaluated with barium sulfate or computer-aided tomography (CAT) scan early and 24 months after operation compared to the changes in body weight and BMI reduction in a small group of 15 consecutive patients submitted to sleeve gastrectomy., Methods: Fifteen successive obese patients submitted to laparoscopic sleeve gastrectomy were included. They were studied in order to measure the residual gastric capacity with barium sulfate and CAT scan early (3 days) and late (2 years) after surgery., Results: The early postoperative gastric volume was 108 +/- 25 ml (80-120 ml) and 116.2 +/- 78.24 assessed with barium sulfate and CAT scan, respectively. The gastric capacity at the late control increased to 250 +/- 85 and 254 +/- 56.8 assessed with the same techniques. However, patients remained stable with a BMI close to 25 without regain of weight at least at the time of observation., Conclusions: Gastric capacity can increase late after sleeve gastrectomy even after performing a narrow gastric tubulization. It is very important to measure objectively residual gastric volume after sleeve gastrectomy and its eventual increase in order to determine the late clinical results and to indicate eventual strategy for retreatment.

This is a review of publications comparing the results of medical and surgical treatment of morbid obesity. An overall conclusions is that the frequency of cardiovascular complications or cancer is higher among patients receiving medical treatment. Surgical treatment is associated with a better weight loss, reduction in complications and quality of life. Mortality risk decreases significantly after surgical treatment, when compared with patients receiving medical therapy Therefore, management of morbid obesity should be carried out by multidisciplinary teams with experience on gastrointestinal surgery. In this way the complications and mortality of bariatric surgery would be minimized.

Background: Gastric bypass surgery (GBP) is increasingly used as a treatment option in morbid obesity. Little is known about the effects of this surgery on bone mineral density (BMD) and the underlying mechanisms. To evaluate changes on BMD after GBP and its relation with changes in body composition and serum adiponectin, a longitudinal study in morbid obese subjects was conducted., Methods: Forty-two women (BMI 45.0 +/- 4.3 kg/m(2); 37.7 +/- 9.6 years) were studied before surgery and 6 and 12 months after GBP. Percentage of body fat (%BF), fat-free mass (FFM), and BMD were measured by dual-energy X-ray absorptiometry and serum adiponectin levels by RIA., Results: Twelve months after, GBP weight was decreased by 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 increased from 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 total BMD could be explained by baseline weight, initial BMD, BF reduction, and adiponectin at the twelfth month (r (2) = 0.373; p < 0.001). Adiponectin at the twelfth month had a significant and positive correlation with the reduction of BMD, unrelated to baseline and variation in body composition parameters (adjusted correlation coefficient: r = 0.36)., Conclusion: GBP induces a significant BMD loss related with changes in body composition, although some metabolic mediators, such as adiponectin increase, may have an independent action on BMD which deserves further study.

Background: The incidence of morbid obesity is increasing and gastric bypass is the most effective surgical treatment., Aim: To assess the long term results of resection gastric bypass among morbidly obese patients aged less than 18 and over 65 years in terms of weight loss and correction comorbidities., Material and Methods: From August 1999 to December 2006, 712 patients with morbid obesity were subjected to open resection gastric bypass. A group of 12 patients, aged less than 18 years and a second group of 8 patients aged more 65 years were selected to prospectively assess weight loss, complications and correction of associated comorbidities., Results: In the first group body mass index (BMI) decreased from 45+/-6.7 kg/m2 to 27.7+/-3.2 kg/m2, in a follow-up period of 22.9+/-8.4 months. All comorbidities disappeared or improved. A single patient (8.3%) had an incisional hernia. Among the second group, BMI decreased from 40.6+/-5.4 kg/m2 to 28.4+/-4.4 kg/m2, in a follow-up period of 26.6+/-15.9 months. All obesity comorbidities disappeared. Three patients (37.5%) presented incisional hernias. No patient died or had postoperative complications., Conclusions: In both groups resection gastric bypass was safe, obtained an appropriate weight loss and corrected all associated comorbidities to obesity.

Background: The effects of gastric bypass (GBP) on resting energy expenditure (REE) are not well known., Aim: To evaluate the changes in REE and its relationship with body composition in severe and morbid obese women before and six and twelve months after GBP., Patients and Methods: Twenty three women aged 37+/-10 years, with a body mass index of 44+/-4 kg/m(2), were evaluated before, six and twelve months after GBP. REE was measured in a Deltatrac indirect calorimeter and expressed as kcal/day Fat mass (EM), and fat free mass (EEM) were determined by double beam X-ray densitometry (DEXA)., Results: Body weight reduction six and twelve months after GBP was 29.0+/-4.3 and 35.8+/-6.9%, respectively. The best predictor of weight reduction was initial weight (p <0.01). At six and twelve months, REE decreased by 291.7+/-260.0 and 353.8+/-378.4 kcal/day, respectively. In the same periods REE/kg body weight increased by 3.3 and 4.8 kcal/kg respectively, compared to baseline. REE/kg EEM was unchanged., Conclusions: GBP was associated with significant changes in body composition after six and twelve months. However, despite weight reduction, resting energy expenditure per fat free mass unit did not change significantly.

Objective: To compare measured resting energy expenditure (REE) with that predicted by formulas derived from populations with normal weight or obesity and from women with severe and morbid obesity., Material and Methods: 66 women (aged 35.6 +/- 10.3 y and BMI of 44.7 +/- 4.9 kg/m2) were evaluated by indirect calorimetry with a metabolic monitor Deltatrac (Datex Inst., Finland), before undergoing gastric bypass. REE was calculated with the following equations: Harris-Benedict's with both actual and adjusted weight, Ireton-Jones', Mifflin's, and Carrasco's Fast Estimation, which corresponds to 16.2 kcal x kg actual weight., Results: (mean +/- sd). Measured REE was 1797 +/- 239 kcal/day. All formulas, except Harris-Benedict's with adjusted weight, overestimated REE. The Ireton-Jones' equation presented the greater overestimation (689 +/- 329 kcal/day), whereas Mifflin's equation overestimated REE only by 6 +/- 202 kcal/day. No significant differences were detected between measured and calculated REE by Mifflin's and Carrasco's Fast Estimation. Accuracy (defined as difference between calculated and measured REE within +/- 10%) was greater with Mifflin's equation (68%), followed by Harris-Benedict's with actual weight (64%) and Carrasco's Fast Estimation (61%). By using the Bland-Altman analysis, significant correlations were observed between calculated-measured REE and mean REE (calculated + measured/2) with all equations except Carrasco's Fast Estimation. This means that all but one formula underestimate or overestimate REE depending on the level of measured REE., Conclusion: In severe and morbid obese women, Mifflin's and Carrasco's Fast Estimation equations provided the best performance to estimate REE. Before recommending an equation in an a subset of individuals it is necessary to make previous validation studies to determine that equation with the best predictive power for this particular group of patients.

Background: The objective of this study was to evaluate changes in resting energy expenditure (REE), body composition and metabolic parameters, and to investigate predictors of the results in seriously obese patients after Roux-en-Y gastric bypass (RYGBP)., Methods: 31 patients (BMI 44.4 +/- 4.8 kg/m2; 27 female, 4 male; 37.3 +/- 11.1 y) were evaluated at baseline and 6 months after RYGBP. Weight, REE, waist circumference (WC), fat mass (FM) and fat-free mass (FFM), physical activity, food intake, fasting glucose (GLU), insulin (INS), HOMA-IR and lipid concentrations were measured., Results: At 6 months, percentage of weight loss (%WL) was 29.0 +/- 4.4% and percentage of excess weight loss was (%EWL) 59.7 +/- 12.3%. FM loss corresponded to 77.1 +/- 12.2% of the weight loss. REE decreased from 33.4 +/- 4.1 to 30.1 +/- 2.6 kcal/kg FFM (P<0.05). Significant decreases (P<0.001) were observed in GLU, INS, HOMA-IR, LDL-cholesterol and triglycerides. %EWL was correlated with baseline INS (r=0.44; P=0.014), baseline HOMA (r=0.43; P=0.017), change in %FM (r=0.67; P<0.001) and change in WC (r=0.5; P<0.01). Decrease in REE/FFM (%) was positively correlated with baseline REE/FFM% (r=0.51; P<0.005) and change in %FM (r=0.69; P<0.001). Initial REE/FFM, baseline energy balance and FM change explain 90% of REE/FFM decrease., Conclusion: RYGBP was an effective procedure to induce significant weight loss, fat mass loss and improvement in metabolic parameters in the short term. Metabolic adaptation was not related to FFM wasting but to a higher baseline REE. Fasting hyperinsulinemia was the best single predictor of weight loss after RYGBP.

Objective: We report the case of a 42-y-old morbidly obese woman who presented persistent anemia as result of Roux-en-Y gastric bypass., Methods: The surgical procedure conducted in 1999 consisted of horizontal gastroplasty with truncular vagotomy, Roux-en-Y gastrojejunal anastomosis with an alimentary limb of 60 cm, and cholecystectomy. In 2000 a second surgery (subtotal gastrectomy, i.e., 90%, with a 50-mL gastric pouch) was performed because of failed gastroplasty. Anemia was detected approximately 1 y after the second surgery. This condition worsened significantly after an abdominal lipectomy performed in 2001. Since then, different oral iron compounds were used for treatment, but with unsatisfactory results. The subject was anemic for 4 y., Results: The condition was corrected only after intravenous iron administration. Iron absorptions from 3 mg of iron as ferrous ascorbate and from a standardized diet that also contained 3 mg of iron were 48.4% and 39.9%, respectively., Conclusion: Iron absorption tests provided evidence that the reduction of intestinal iron absorption capacity was the most probable cause of the persistent anemia.

Obesity is a chronic disease with an increasing prevalence in all groups of age, and is associated to increased general mortality and cardiovascular risk. The multidisciplinary non surgical approach must be the treatment of choice for obese subjects. However, the results of such approach among subjects with severe or morbid obesity, are unsatisfactory. In this group of patients, bariatric surgery and specifically gastric bypass achieves good long term results, maintaining a low body mass index, reducing complications and improving quality of life. Considering the widespread practice of bariatric surgery in Chile, the Nutrition Unit of the Ministry of Health formed a task force to propose update guidelines for the surgical treatment of obesity. These guidelines were proposed after a thorough literature review and discussion with groups that practice bariatric surgery using defined protocols. This document provides a summarized version of the guidelines. The first section discusses the background for bariatric surgery and the second part give specific recommendations for patient management and the formation of reference centers for surgical management of obesity.

Background: Type 2 diabetes, hypertension and serum lipid abnormalities are common among obese people and they should improve with weight reduction., Aim: To study the outcome of these abnormalities after bariatric surgery in morbid obesity patients., Material and Methods: Two hundred thirty two morbid obese patients subjected to gastric bypass, were evaluated in the preoperative period and every three months after surgery, during a minimum of 12 months. Clinical evolution, blood glucose, serum insulin, insulin resistance measured with the homeostasis model assessment (HOMA) and serum lipid levels were analyzed., Results: In the preoperative period, 17% had type 2 diabetes, 49% had abnormal serum lipid levels and 25% had high blood pressure. Sixty six percent had at least one of these abnormalities and 20% had more than one. During follow up, body mass index decreased from 44 to 29.3 kg/m2. Total and HDL cholesterol, blood glucose and insulin resistance significantly decreased from the third month after surgery. Diabetes disappeared in 97% of diabetic subjects, blood pressure normalized in 53% of subjects with hypertension and serum lipid levels returned to normal in 88% of subjects with dyslipidemia., Conclusions: Gastric bypass in morbid obese patients achieves a significant and important weight reduction that results in significant reductions in the frequency of diabetes, dyslipidemia and hypertension among operated obese subjects.

Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a long limb Roux-en-Y anastomosis is the "gold standard" technique for these patients. We sought to determine the early and late results of open gastric bypass with resection of the distal excluded stomach in patients with morbid obesity. We included in this prospective study 400 patients who were seen from September 1999 through August 2003 (311 women and 89 men; mean age, 38.5 years). The mean body mass index of the patients was 46 kg/m2. All underwent 95% distal gastrectomy, with resection of the bypassed stomach, leaving a small gastric pouch of 15 to 20 ml. An end-to-side gastrojejunostomy was performed with circular stapler No. 25. The length of the Roux-en-Y loop was 125 to 150 cm. In all patients, a biopsy was taken from the liver and routine cholecystectomy was performed. Follow-up was as long as 36 months. A barium study was performed in all patients at 5 days after surgery. Mortality and postoperative morbidity rates were 0.5% and 4.75%, respectively, mainly due to anastomotic leak in 10 patients (2.5%). Hospital length of stay was 7 days for 95% of the patients. Follow-up data for longer than 12 months were available in 184 patients. There was excess body weight loss of 70% at 24 and 36 months, and there was an inverse correlation among preoperative body mass index and the loss of weight. Anemia was present in 10%, and incisional hernia was present in 10.2%. At 1 year after surgery, the BAROS index demonstrated very good or excellent index in 96.6% of the patients. Gastric bypass with resection of the distal excluded segment has results very similar to those of gastric bypass alone but eliminates the potential risks of gastric bypass such as anastomotic ulcer, gastrogastric fistula, postoperative bleeding due to peptic ulcer and gastritis, and the eventual future development of gastric cancer. It is also possible to perform via laparoscopy, as we started to do recently.

Summary: During the last years we have employed acid-suppression duodenal diversion procedures (truncal vagotomy-partial gastrectomy plus Roux-en-Y gastrojejunostomy) in addition to antireflux surgery in order to treat all the pathophysiological factors involved in the genesis of Barrett's esophagus. We have observed very good results concerning the clinical and objective control of GERD at the long-term follow up after this procedure. However, it could be associated with other nonesophageal symptoms or side-effects. This study was conducted to evaluate the presence of gastrointestinal symptoms (diarrhea, vomiting, dumping, weight loss and anastomotic ulcers) after this operation. In this prospective study 73 patients were assessed using a careful clinical questionnaire asking regarding these complications at the early (< 6 months) and late (> 6 months) follow-up (average of 32.4 months). In the early postoperative period, diarrhea was present in 64% (19% considered severe 10-90 days after surgery), dumping in 41% and loss of weight in 71% of cases. Diarrhea occurred daily in 47.7% in the early postoperative period, but only in 16% of cases after 1 year. Shortly after surgery, steatorrea was observed in 9% of cases and responded well to medical treatment. Severe diarrhea or dumping was rare (5% of cases). These symptoms improved significantly after 1 year with medical management (45%, 20% and 30%, respectively) and 42% of patients regained their normal body weight. Only two patients presented anastomotic ulcers and were treated satisfactory with proton pump inhibitors. Revisional surgery was indicated in two patients with severe dumping syndrome. Most side-effects identified by this study were mild and diminished 1 year after operation.

Prader-Willi Syndrome (PWS) is a multisystemic genetic disease characterized by hypothalamic hypogonadism, mental retardation and compulsive hyperphagia associated with early and severe obesity. Complications of overweight, such as type-2 diabetes Mellitus, dyslipidemia and diffuse atheromatosis are common. We report a 15 years old morbid obese male with PWS, with a body mass index of 57.7 kg/m2, refractory to weight-lowering treatments. He underwent preoperative evaluation and treatment by a multidisciplinary team, and subjected to a 95% gastrectomy, leaving a 50 ml remnant pouch and a long limb (120 cm) Y-Roux gastro-jejuno anastomosis. There were no surgical complications, oral feeding was initiated at the 5th day with an hypocaloric diet. During the first postoperative year, the patient lost 70 kg, achieving a body mass index of 30 kg/m2. Surgical treatment can become a therapeutic choice for obesity in PWS patients.

Background: Total parenteral nutrition has a high cost and frequency of complications. Enteral feeding is a feasible alternative that can be started early in the postoperative period., Aim: To assess digestive tolerance to early enteral feeding in cancer patients undergoing total gastrectomy and to compare early enteral feeding (EEF) with total parenteral nutrition plus enteral feeding (TPN + EF), initiated after overcoming postoperative ileus., Patients and Methods: Subjects with a resectable gastric cancer were considered eligible for the study. During surgery a nasoenteral tube was placed and patients were prospectively randomized to EEF or TPN + EF. Digestive tolerance, effectiveness, complications and costs between both modalities of nutritional support were compared., Results: Twenty eight patients (15 male, aged 63 +/- 14 years old) were studied. Fourteen patients were randomized to EEF and 14 to TPN + EF. Diarrhea occurred in 14 and 29% of EEF and TPN + EF patients respectively, (p: NS). Patients with TPN + EF received an average of 28 Cal/kg/day and 1.1 g/kg/day proteins. Patients with EEF received an average of 29 Cal/kg/day and 0.8 g/kg/day proteins. At the eighth postoperative day, serum albumin was 3.9 +/- 0.7 and 3.2 +/- 0.5 g/dl in EEF and TPN + EF patients respectively (p < 0.05), serum prealbumin was 16.9 +/- 5 and 12.3 +/- 4.3 mg/dl in EEF and TPN + EF patients respectively (p < 0.05) and nitrogen balance was +2.4 +/- 1.5 and -1.6 +/- 0.6 g/24 h in EEF and TPN + EF patients respectively (p < 0.05). Postoperative hyperglycemia was observed with a lower frequency and nutritional support costs and length of hospital stay were significantly lower in the EEF group., Conclusions: After total gastrectomy EEF is well tolerated, safe and effective, even during the early postoperative ileus. This therapeutic modality could be the first choice for nutritional support in these patients.

Background: Digestive refeeding in acute pancreatitis represent a difficult issue. It requires the resolution of intestinal ileus and carries a risk of reactivation., Aim: To evaluate criteria that may guide in early refeeding avoiding unnecessary prolonged fasting., Patients and Methods: Thirty patients with acute pancreatitis were evaluated in a prospective trial. The severity of the pancreatitis was evaluated according to APACHE II score and Balthazar CT scan alterations. The criteria proposed to start early refeeding were absence of nausea and vomiting, decreased abdominal pain, presence of bowel sounds and lowering of serum amylase levels. Balthazar CT scan classification, was used to decide between oral or enteral refeeding., Results: Eighty percent of patients had alterations in pancreatic density, necrosis or pancreatic or peripancreatic liquid collections in the CT scan (corresponding to Balthazar stages C, D, or E). Ten patients fullfilled the criteria for enteral refeeding at 8.1 +/- 3.5 days (range 3 to 15 days), and 21 patients fulfilled criteria fo enteral refeeding at 8.7 +/- 4.5 (range 4-19). No patient had a reactivation of his pancreatitis., Conclusions: Digestive refeeding can be done safely by using the criteria proposed in this study. Pancreatic necrosis or peripancreatic fluid collections do not contraindicate refeeding. Oral feeding may be employed (as the first option) in selected patients, without increasing the risk of complication, regardless of CT scan alterations of the pancreas.