Turkiye Klinikleri Journal of Health Sciences

.: REVIEW
Bariyatrik Cerrahi Sonrası Oluşan Komplikasyon: Mikro Besin Ögesi Eksiklikleri: Geleneksel Derleme
Complication of Occurring After Bariatric Surgery: Micronutrient Deficiencies: Traditional Review
Ramazan Mert ATANa, Nihal Zekiye ERDEMb
aBandırma Onyedi Eylül Üniversitesi Sağlık Bilimleri Fakültesi, Beslenme ve Diyetetik Bölümü, Balıkesir, TÜRKİYE
bİstanbul Medipol Üniversitesi Sağlık Bilimleri Yüksekokulu, Beslenme ve Diyetetik Bölümü, İstanbul, TÜRKİYE
Turkiye Klinikleri J Health Sci. 2021;6(3):656-64
doi: 10.5336/healthsci.2020-79212
Article Language: TR
Full Text
ÖZET
 Obezite, modern dünyanın karşı karşıya olduğu ciddi bir sağlık sorunudur ve son yıllarda görülme sıklığı endişe verici düzeyde artmıştır. Tedavi seçenekleri arasında diyet ve egzersiz gibi yaşam tarzı değişiklikleri ile farmakolojik ve cerrahi prosedürler yer almaktadır. Bariyatrik cerrahi, ileri derecede obez ve komorbiditeleri olan hastalara uygulanan yöntemdir. Cerrahi prosedürler genellikle; besin alımını kısıtlayıcı, malabsorptif ve hem besin alımını kısıtlayıcı hem de malabsorptif prosedürlerin kombinasyonu olarak sınıflandırılmaktadır. Cerrahiden sonra hastalarda mikro besin ögesi eksiklikleri gibi bazı komplikasyonlar meydana gelebilmektedir. Bu eksikliklerin oluşma nedenleri arasında hastaya ve cerrahi yönteme bağlı değişkenler bulunmaktadır. Hastaya bağlı değişkenler arasından özellikle bireye ve yapılan cerrahi işleme özel oluşturulmuş, beslenme programına uymama ve önerilen besin desteklerini kullanmama ön plana çıkarken, ameliyata bağlı değişkenler ise besin alımını kısıtlayıcı ve malabsorptif olan prosedürlere göre değişiklik göstermektedir. Bariyatrik cerrahi sonrasında en çok görülen mikro besin ögesi eksiklikleri arasında; tiamin, B12 vitamini, folat, demir, D, A ve K vitaminleri, çinko ve bakır bulunmaktadır. Ayrıca preoperatif dönemde bu mikro besin ögelerinin eksikliklerinin olması, postoperatif dönemde daha ciddi komplikasyonları meydana getirmektedir. Bariyatrik cerrahi sonucu görülen bu eksikliklerin yönetiminde, hastaların yaşam boyu takip edilmesi en önemli basamağı oluşturmaktadır. Özellikle hastaların, cerrahi sonrası önerilen besin desteklerine bağlı kalmaları ve tıbbi beslenme tedavisine yüksek düzeyde uyum göstermeleri gerekmektedir. Ek olarak, besin desteklerinden bazılarının birbirinin emilimini etkilemesinden dolayı uygun doz ve zaman ayarlamaları doğru bir biçimde yapılmalıdır. Bu derleme yazının amacı, bariyatrik cerrahi hastalarında postoperatif dönemde görülen mikro besin ögesi eksikliklerini tanımlamak ve bu eksikliklerin oluşmasındaki nedenler ile bunların önlenmesi hakkında literatürde yer alan güncel bilgilerin sunulmasıdır.

Anahtar Kelimeler: Bariyatrik cerrahi; morbid obezite; komplikasyonlar; mikro besin ögesi; besin desteği
ABSTRACT
 Obesity is a serious health problem facing the modern world, and its incidence has increased at an alarming rate in recent years. Treatment options include lifestyle changes such as diet and exercise and pharmacological and surgical procedures. Bariatric surgery is a method applied to patients with advanced obese and comorbidities. Surgical procedures are generally classified into restrictive, malabsorptive, or a combination of restrictive and malabsorptive elements. Some complications such as micronutrient deficiencies can occur in patients after surgery. Among the reasons for the occurrence of these deficiencies are variables depending on the patient and the surgical method. While among the patient-dependent variables came to the fore noncompliance with the nutrition program created specifically for the individual and the surgical procedure and not using the recommended dietary supplements, variables related to surgery differ according to procedures that restrictive and malabsorptive. Thiamine, vitamin B12, folate, iron, vitamins D, A, and K, zinc, and copper are the most common micronutrient deficiencies after bariatric surgery. Besides, have deficiencies of these micronutrients in the preoperative period occurs more serious complications in the postoperative period. Lifelong follow-up of patients is the most important step in the management of these deficiencies as a result of bariatric surgery. In particular, patients need to adhere to the recommended dietary supplements after surgery and to comply with medical nutrition therapy at a high level. Also, because some of these nutritional supplements interfere with each other's absorption, appropriate dosage and time adjustments must be made correctly. The purpose of this review is; to describe the micronutrient deficiencies observed in the postoperative period in bariatric surgery patients and to present the current information in the literature about the reasons for the occurrence of these deficiencies and their prevention.

Keywords: Bariatric surgery; morbid obesity; complications; micronutrients; dietary supplements
REFERENCES:
  1. WHO [İnternet]. © 2020 WHO [Erişim tarihi: 29 Ocak 2020]. Obesity and overweight. 2016. Erişim linki: [Link] 
  2. Patel JJ, Mundi MS, Hurt RT, Wolfe B, Martindale RG. Micronutrient Deficiencies After Bariatric Surgery: An Emphasis on Vitamins and Trace Minerals [Formula: see text]. Nutr Clin Pract. 2017;32(4):471-80. [Crossref]  [PubMed] 
  3. Krzizek EC, Brix JM, Herz CT, Kopp HP, Schernthaner GH, Schernthaner G, et al. Prevalence of Micronutrient Deficiency in Patients with Morbid Obesity Before Bariatric Surgery. Obes Surg. 2018;28(3):643-8. [Crossref]  [PubMed] 
  4. Patel JJ, Rosenthal MD, Miller KR, Codner P, Kiraly L, Martindale RG. The Critical Care Obesity Paradox and Implications for Nutrition Support. Curr Gastroenterol Rep. 2016;18(9):45. [Crossref]  [PubMed] 
  5. Gesquiere I, Foulon V, Augustijns P, Gils A, Lannoo M, Van der Schueren B, et al. Micronutrient intake, from diet and supplements, and association with status markers in pre- and post-RYGB patients. Clin Nutr. 2017;36(4):1175-81. [Crossref]  [PubMed] 
  6. Wolfe BM, Kvach E, Eckel RH. Treatment of Obesity: Weight Loss and Bariatric Surgery. Circ Res. 2016;118(11):1844-55. [Crossref]  [PubMed]  [PMC] 
  7. Sabuncu, T, Kıyıcı S, Eren MA, Sancak S, Sönmez A, Güldiken S, et al. Türkiye endokrinoloji ve metabolizma derneği bariatrik cerrahi kılavuzu özeti [Summary of bariatric surgery guideline of the society of endocrinology and metabolism of Turkey]. Turk J Endocrinol Metab. 2017;21:140-7. [Crossref] 
  8. Taşkın M, Zengin SÜ, Taşkın HE. Bariyatrik ve metabolik cerrahinin tarihçesi [History of bariatric and metabolic surgery]. Turkiye Klinikleri J Gen Surg-Special Topics. 2015;8(3):1-5. [Link] 
  9. Erdem NZ. Metabolik ve bariyatrik cerrahide beslenme tedavisi ve besin desteği. [Nutritional therapy and nutritional support in metabolic and bariatric surgery]. Alphan ME, editör. Hastalıklarda Beslenme Tedavisi. 5. Baskı. Ankara: Hatipoğlu Yayınları; 2019. p.313-46.
  10. Brolin RE, Gorman JH, Gorman RC, Petschenik AJ, Bradley LJ, Kenler HA, et al. Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass? J Gastrointest Surg. 1998;2(5):436-42. [Crossref]  [PubMed] 
  11. Saif T, Strain GW, Dakin G, Gagner M, Costa R, Pomp A. Evaluation of nutrient status after laparoscopic sleeve gastrectomy 1, 3, and 5 years after surgery. Surg Obes Relat Dis. 2012;8(5):542-7. [Crossref]  [PubMed]  [PMC] 
  12. Spadola CE, Wagner EF, Accornero VH, Vidot DC, de la Cruz-Munoz N, Messiah SE. Alcohol use patterns and alcohol use disorders among young adult, ethnically diverse bariatric surgery patients. Subst Abus. 2017;38(1):82-7. [Crossref]  [PubMed] 
  13. Azam H, Shahrestani S, Phan K. Alcohol use disorders before and after bariatric surgery: a systematic review and meta-analysis. Ann Transl Med. 2018;6(8):148. [Crossref]  [PubMed]  [PMC] 
  14. Ferraz ÁAB, Carvalho MRC, Siqueira LT, Santa-Cruz F, Campos JM. Micronutrient deficiencies following bariatric surgery: a comparative analysis between sleeve gastrectomy and Roux-en-Y gastric bypass. Rev Col Bras Cir. 2018;45(6):e2016. Portuguese, English. [Crossref]  [PubMed] 
  15. Nett P, Borbély Y, Kröll D. Micronutrient Supplementation after Biliopancreatic Diversion with Duodenal Switch in the Long Term. Obes Surg. 2016;26(10):2469-74. [Crossref]  [PubMed] 
  16. Saltzman E, Karl JP. Nutrient deficiencies after gastric bypass surgery. Annu Rev Nutr. 2013;33(1):183-203. [Crossref]  [PubMed] 
  17. Via MA, Mechanick JI. Nutritional and Micronutrient Care of Bariatric Surgery Patients: Current Evidence Update. Curr Obes Rep. 2017;6(3):286-96. [Crossref]  [PubMed] 
  18. Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients. Surg Obes Relat Dis. 2017;13(5):727-41. [Crossref]  [PubMed] 
  19. Matrana MR, Vasireddy S, Davis WE. The skinny on a growing problem: dry beriberi after bariatric surgery. Ann Intern Med. 2008;149(11):842-4. [Crossref]  [PubMed] 
  20. Paul C, Brady DM. Comparative Bioavailability and Utilization of Particular Forms of B12 Supplements With Potential to Mitigate B12-related Genetic Polymorphisms. Integr Med (Encinitas). 2017;16(1):42-9. [PubMed]  [PMC] 
  21. Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli R. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study. Obes Surg. 2010;20(4):447-53. [Crossref]  [PubMed] 
  22. Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by american association of clinical endocrinologists/american college of endocrinology, the obesity society, american society for metabolic & bariatric surgery, obesity medicine association, and american society of anesthesiologists - executive summary. Endocr Pract. 2019;25(12):1346-59. [Crossref]  [PubMed] 
  23. Schweiger C, Weiss R, Berry E, Keidar A. Nutritional deficiencies in bariatric surgery candidates. Obes Surg. 2010;20(2):193-7. [Crossref]  [PubMed] 
  24. Shankar P, Boylan M, Sriram K. Micronutrient deficiencies after bariatric surgery. Nutrition. 2010;26(11-12):1031-7. [Crossref]  [PubMed] 
  25. Herring LY, Stevinson C, Carter P, Biddle SJH, Bowrey D, Sutton C, et al. The effects of supervised exercise training 12-24 months after bariatric surgery on physical function and body composition: a randomised controlled trial. Int J Obes (Lond). 2017;41(6):909-16. [Crossref]  [PubMed] 
  26. Camaschella C. Iron-deficiency anemia. N Engl J Med. 2015;372(19):1832-43. [Crossref]  [PubMed] 
  27. Bloomberg RD, Fleishman A, Nalle JE, Herron DM, Kini S. Nutritional deficiencies following bariatric surgery: what have we learned? Obes Surg. 2005;15(2):145-54. [Crossref]  [PubMed] 
  28. Yu H, Du R, Zhang N, Zhang M, Tu Y, Zhang L, et al. Iron-Deficiency Anemia After Laparoscopic Roux-en-Y Gastric Bypass in Chinese Obese Patients with Type 2 Diabetes: a 2-Year Follow-Up Study. Obes Surg. 2016;26(11):2705-11. [Crossref]  [PubMed] 
  29. Fidan F, Alkan BM, Tosun A. Çağın pandemisi: D vitamini eksikliği ve yetersizliği [Pandemic era: vitamin D deficiency and insufficiency]. Turkish J Osteoporosis. 2014;20(2):71-4. [Crossref] 
  30. Topart P, Becouarn G, Sallé A, Ritz P. Biliopancreatic diversion requires multiple vitamin and micronutrient adjustments within 2 years of surgery. Surg Obes Relat Dis. 2014;10(5):936-41. [Crossref]  [PubMed] 
  31. Sánchez A, Rojas P, Basfi-Fer K, Carrasco F, Inostroza J, Codoceo J, et al. Micronutrient Deficiencies in Morbidly Obese Women Prior to Bariatric Surgery. Obes Surg. 2016;26(2):361-8. [Crossref]  [PubMed] 
  32. Vimaleswaran KS, Berry DJ, Lu C, Tikkanen E, Pilz S, Hiraki LT, et al. Causal relationship between obesity and vitamin D status: bi-directional Mendelian randomization analysis of multiple cohorts. PLoS Med. 2013;10(2):e1001383. [PubMed]  [PMC] 
  33. Olson ML, Maalouf NM, Oden JD, White PC, Hutchison MR. Vitamin D deficiency in obese children and its relationship to glucose homeostasis. J Clin Endocrinol Metab. 2012;97(1):279-85. [PubMed]  [PMC] 
  34. Goldner WS, Stoner JA, Thompson J, Taylor K, Larson L, Erickson J, et al. Prevalence of vitamin D insufficiency and deficiency in morbidly obese patients: a comparison with non-obese controls. Obes Surg. 2008;18(2):145-50. [Crossref]  [PubMed] 
  35. Pereira-Santos M, Costa PR, Assis AM, Santos CA, Santos DB. Obesity and vitamin D deficiency: a systematic review and meta-analysis. Obes Rev. 2015;16(4):341-9. [Crossref]  [PubMed] 
  36. Galior K, Grebe S, Singh R. Development of Vitamin D Toxicity from Overcorrection of Vitamin D Deficiency: A Review of Case Reports. Nutrients. 2018;10(8):953. [Crossref]  [PubMed]  [PMC] 
  37. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al; Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96(7):1911-30. Erratum in: J Clin Endocrinol Metab. 2011;96(12):3908. [Crossref]  [PubMed] 
  38. Erdem NZ. Metabolik ve bariyatrik cerrahide nütrisyonel ve metabolik sorunların çözümleri [Solutions of nutritional and metabolic problems in metabolic and bariatric surgery]. Turkiye Klinikleri J Gen Surg-Special Topics. 2015;8(3):98-106. [Link] 
  39. Ramos-Leví AM, Pérez-Ferre N, Sánchez-Pernaute A, Torres García AJ, Rubio Herrera MA. Severe vitamin A deficiency after malabsortive bariatric surgery. Nutr Hosp. 2013;28(4):1337-40. [PubMed] 
  40. Slater GH, Ren CJ, Siegel N, Williams T, Barr D, Wolfe B, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8(1):48-55; discussion 54-5. [Crossref]  [PubMed] 
  41. Espe KM, Raila J, Henze A, Krane V, Schweigert FJ, Hocher B, et al; German Diabetes and Dialysis Study Investigators. Impact of vitamin A on clinical outcomes in haemodialysis patients. Nephrol Dial Transplant. 2011;26(12):4054-61. [Crossref]  [PubMed] 
  42. Shearer MJ, Okano T. Key Pathways and Regulators of Vitamin K Function and Intermediary Metabolism. Annu Rev Nutr. 2018;38:127-51. [Crossref]  [PubMed] 
  43. Homan J, Betzel B, Aarts EO, Dogan K, van Laarhoven KJ, Janssen IM, et al. Vitamin and Mineral Deficiencies After Biliopancreatic Diversion and Biliopancreatic Diversion with Duodenal Switch--the Rule Rather than the Exception. Obes Surg. 2015;25(9):1626-32. [Crossref]  [PubMed] 
  44. Kappus H, Diplock AT. Tolerance and safety of vitamin E: a toxicological position report. Free Radic Biol Med. 1992;13(1):55-74. [Crossref]  [PubMed] 
  45. Shankar AH, Prasad AS. Zinc and immune function: the biological basis of altered resistance to infection. Am J Clin Nutr. 1998;68(2 Suppl):447S-463S. [Crossref]  [PubMed] 
  46. van den Berghe PV, Klomp LW. New developments in the regulation of intestinal copper absorption. Nutr Rev. 2009;67(11):658-72. [Crossref]  [PubMed] 

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Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com