Bariatric Times

JUN 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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Editorial Message 3 Bariatric Times • June 2017 Dear Friends and Readers, Welcome to another new issue of BT. In "Nutritional Considerations in the Bariatric Patient," author Laura Andromalos, MS, RD, CD, CDE, presents a review on nutritional complications after bariatric surgery. B12 deficiency continues to be the most feared complication because of the potential irreversible changes of ascending neuropathy or Guillain- Barré syndrome, a disorder in which the body's immune system attacks part of the peripheral nervous system. However, in my experience, intractable diarrhea and hypoglycemia are the most frequent, unpredictable, and difficult complications to prevent and manage. I have seen diarrhea ensue years after gastric bypass with neither a clear etiology nor a successful treatment modality for it. I also see hypoglycemia become intractable and debilitating, despite medication and lifestyle interventions. We continue our video case report series with a wonderful contribution from Bryce M. Bludevich, MS-IV; Sean M. Wrenn, MD; and Wasef Abu-Jaish, MD, FACS, FASMBS. The authors present an interesting case of portal vein thrombosis (PVT) in a patient with diverticulitis as a short-term complication after sleeve gastrectomy. I have to acknowledge that I have seen several cases of asymptomatic and also fulminant PVT in patients undergoing all kinds of gastrointestinal surgery. The most recent case I experienced occurred last year when a man who weighed 900 pounds expired after an uneventful sleeve gastrectomy due to PVT. The question we should raise in this case is whether the PVT was related to the diverticulitis or to the initial surgery. In my opinion, the diverticulitis is a coincidence and not the cause of the PVT. Regardless of the answer, the conundrum for clinicians is what to do in these cases. If acute and asymptomatic, most vascular surgeons will recommend anticoagulation. However, if acute and symptomatic or with hemodynamic instability, the most accepted treatment modality is a trans-jugular retrograde thrombolysis. This month, we also present an interview with Ali Aminian, MD, Associate Professor of Surgery at the Cleveland Clinic, Ohio, who presented the findings of the Individualized Metabolic Surgery (IMS) Score study during the 137th meeting of the American Surgical Association, April 20 to 22, 2017, in Philadelphia, Pennsylvania. 1 Developed from the largest reported cohort (n=900) with long-term postoperative glycemic follow-up, the Individualized Metabolic Surgery (IMS) Score is a new nomogram that classifies patients into three categories of diabetes severity—mild, moderate, and severe—and suggests which surgery type will provide the best balance between diabetes remission and procedure risk. I commend the IMS study authors for developing the IMS score. We need to continue working together with all stakeholders in further development of new types of algorithms. We need to better indicate which procedure fits which patient best. The "Body mass index (BMI) greater than 35kg/m2 with two comorbidities" as the sole indicator for a patient to qualify for a bariatric and metabolic Dear Readers, Most of us need some way to get going in the morning or to stay awake as we burn the midnight oil. Today, the beverage market is saturated with energy drinks, which have become trendy choices for a quick pick-me-up when you need it any time of day or night. This is where I throw out the caution flag, and this message is applicable to us clinicians and our patients. There are safer ways to find energy, and the research bears that out; so its important to know the facts before reaching for that energy drink. Consider the following: • A recent study published in Journal of the American Heart Association 1 found that energy drinks were linked to more heart and blood pressure changes than caffeinated drinks alone. In this randomized, double-blind, controlled, crossover study in 18 young, healthy volunteers, the researchers observed that two hours after drinking 32 ounces of a commercially available energy drink, the heart's electrical activity was abnormal compared to drinking a caffeine-matched control drink. They also found that both caffeine and energy drinks raised systolic blood pressure initially but blood pressure normalized faster after caffeine. • According to a survey by the Substance Abuse and Mental Health Services Administration, 2 between 2007 and 2011, emergency department visits related to energy drink consumption doubled doubled from 10,068 visits in 2007 to 20,783 visits in 2011. In 2005, the number of energy drink related visits was below 1,500. • The United States Food and Drug Administration (FDA) is continuing to investigate reports of illness, injury or death of people who took products marketed as "energy drinks" or "energy shots." 3 Manufacturers and marketing companies are really pushing the idea that by using their product, you will be more alert; and if you're tired, rundown, or suffer from insomnia, energy drinks could provide a convenient and cost effective remedy. Unfortunately, we seem to be easily swayed by the marketing tactics and appear to be consuming energy drinks more and more each day. While other soda products have seen a decline in sales, globally, the energy drink industry has gone from a $3.8-billion business in 1999, to a $27.5-billion business in 2015. In the United States, energy drink sales have grown by more than 5,000 percent since 1999. 4 But again, I caution you to consider the more dangerous side effects of these "quick pick-me-up" products. The consumption of energy drinks (especially by young people) comes with a number of negative consequences. Pediatrics in Review published a study by Dr. Kwabena Blankson, a Portsmouth Naval Medical Center pediatrician, detailing the potential health risks that energy drinks pose to New Score Adds Important Variables to the BMI in Guiding Procedure Selection for Patients with Obesity and T2DM Healthy Energy Doesn't Come from a Can: Energy Drink Market Continues to Boom Despite Evidence of Health Consequences A Message from Dr. Christopher Still Christopher Still, DO, FACN, FACP, Co-Clinical Editor, Bariatric Times; Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity R esearch Institute, Geisinger Medical Center, Danville, Pennsylvania. Continued on following page... Continued on following page... A Message from Dr. Raul J. Rosenthal Raul J. Rosenthal, MD, FACS, FASMBS, Clinical Editor, Bariatric Times; Professor of Surgery and Chairman, Department o f General Surgery; Director of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; General Surgery Residency Program Director; and Director, Fellowship in MIS and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida

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