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Nutritional Alterations After Very Low-calorie Diet Before Bariatric Surgery
Alteraciones nutricionales tras dieta muy baja en calorías previa a cirugía bariátrica
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Sensitivity and positive predictive value along the axis. Bubble size depends on comorbidity frequency.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Isabel Rodrigo-Rincón, Marta P. Martin-Vizcaíno, Belén Tirapu-León, Pedro Zabalza-López, Francisco J. Abad-Vicente, Asunción Merino-Peralta, Fabiola Oteiza-Martínez" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Isabel" "apellidos" => "Rodrigo-Rincón" ] 1 => array:2 [ "nombre" => "Marta P." "apellidos" => "Martin-Vizcaíno" ] 2 => array:2 [ "nombre" => "Belén" "apellidos" => "Tirapu-León" ] 3 => array:2 [ "nombre" => "Pedro" "apellidos" => "Zabalza-López" ] 4 => array:2 [ "nombre" => "Francisco J." 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Ángeles Bennasar Remolar, David Martínez Ramos, Joaquín Ortega Serrano, José Luis Salvador Sanchís" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M. Ángeles" "apellidos" => "Bennasar Remolar" "email" => array:1 [ 0 => "marianbennasarremolar@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "David" "apellidos" => "Martínez Ramos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Joaquín" "apellidos" => "Ortega Serrano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "José Luis" "apellidos" => "Salvador Sanchís" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital General Universitario de Castellón, Castellón, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía General, Hospital General Universitario de Castellón, Castellón, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía General, Hospital Clínico Universitario de Valencia, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alteraciones nutricionales tras dieta muy baja en calorías previa a cirugía bariátrica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1600 "Ancho" => 1665 "Tamanyo" => 84389 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Lymphocyte levels.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Bariatric surgery is the most effective treatment to bring about and maintain long-term weight loss in the majority of patients with morbid obesity, as well as to resolve their comorbidities.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">As these patients have a large number of associated pathologies and high surgical risk, it is highly important to optimise their condition before surgery.</p><p id="par0015" class="elsevierStylePara elsevierViewall">With the aim of achieving an uncomplicated surgery and postoperative period, it is increasingly recommended that patients lose weight before the operation, to improve their general condition and to prevent aggravation of their underlying disease.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although this preoperative weight loss has been shown to be effective in improving certain conditions, such as fatty liver disease, reducing intra-abdominal fat and facilitating surgery,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> no study has been performed of whether this weight loss may lead to the malnutrition of these patients.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study is to analyse the influence of preoperative weight loss on the nutritional parameters of candidate patients for bariatric surgery.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">An observational prospective study was designed to analyse whether preoperative weight loss using a very low calorie diet (VLCD) during the 4 weeks prior to bariatric surgery led to a significant alteration in nutritional parameters. This study took place in the period from 1 January 2012 to 31 October 2012.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The Optifast<span class="elsevierStyleSup">®</span> range of products was used for the VLCD. Optifast<span class="elsevierStyleSup">®</span> is a complete diet, given that it supplies the organism with all essential nutrients. Each sachet supplies 17.5<span class="elsevierStyleHsp" style=""></span>g of protein, 201 calories and a third of the daily requirement for vitamins and minerals. The proteins are of high biological value, and each sachet of Optifast<span class="elsevierStyleSup">®</span> also supplies 3.6<span class="elsevierStyleHsp" style=""></span>g of prebiotic fibre (inulin) which aids intestinal transit. This is why the patients in the study exclusively consumed 3 shakes of Optifast<span class="elsevierStyleSup">®</span>/day, supplemented with low calorie liquids such as water, defatted stock or infusions.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The subjects in the study were patients with a BMI<span class="elsevierStyleHsp" style=""></span>>35<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span> and associated comorbidity or a BMI<span class="elsevierStyleHsp" style=""></span>>40<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>. They were aged from 18 to 60 years old and were candidates for bariatric surgery using a Roux-En-Y laparoscopic gastric bypass, according to the current protocol in the Multidisciplinary Bariatric Surgery Unit of the Hospital Universitario General, Castellón. Each patient was asked to express their acceptance and sign the corresponding informed consent form. The study design was approved by the Clinical Research Commission of the hospital.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The general lineal model formerly known as ANOVA for repeated measurements was used to calculate the size of the sample. This model is useful for studying several intra- and inter-subject factors.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 50 patients were operated on according to this protocol during the period of time analysed. Of these 50 patients, monitoring was not optimum in 8 cases, so that these were finally excluded. A total of 42 patients were therefore included in the study. Of these 42 patients, 13 were men and 29 were women. They were aged from 22 to 61 years old, with an average age of 43.88 years old and a median age of 48 years. The average age of the men was 44, while for the women it was 45. During diet monitoring the patients were only evaluated at the start and end of the same, to check whether they had followed it and were suitable candidates for surgery. No side effects of the diet were recorded.</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Statistical was based on variance analysis for variables repeated at 3 different moments. The average and standard deviation were the main descriptive statistical tools used, while the median, simple range (minimum and maximum values) and the interquartile range (quartile 25 and quartile 75) were also calculated. A box plot graph was added. The general lineal model for repeated measurements was used for inferential analysis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The differences obtained were considered to be statistically significant when <span class="elsevierStyleItalic">P</span><.05.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The statistical computer programme SPSS version 15.0 for Windows was used for data analysis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Nutritional parameters were considered to be altered when figures were below the values that are deemed normal in the laboratory of our hospital. In the case of haemoglobin, when this was below 12<span class="elsevierStyleHsp" style=""></span>g/dL, for albumin when the figure was below 4<span class="elsevierStyleHsp" style=""></span>g/dL, and for lymphocytes when the value was below 900<span class="elsevierStyleHsp" style=""></span>μL.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The postoperative complications which arose were one hemoperitoneum, 2 minor digestive haemorrhages, one haemorrhage of the gastrojejunal anastomosis and a postoperative seroma. All of these were resolved without incident.</p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">During the period of time studied a total of 50 patients were operated on according to this protocol. Of these 50 patients, 8 did not attend the stipulated check-ups. Given that they were not followed up in an optimum way, they were excluded from the study. A total of 42 patients were therefore included in the study, and the calculations shown below refer to a value n of 42.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Of the 42 patients studied, 13 were men and 29 were women. They were aged from 22 to 61 years old, with an average age of 43.88 years old and a median age of 48 years. The average age of the men was 44 years old, while for the women it was 45 years old.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Weight</span><p id="par0090" class="elsevierStylePara elsevierViewall">In the month before the operation, patient weights varied from a maximum of 215.8<span class="elsevierStyleHsp" style=""></span>kg and a minimum of 92<span class="elsevierStyleHsp" style=""></span>kg, with an average of 129.8<span class="elsevierStyleHsp" style=""></span>kg, a median figure of 123.8<span class="elsevierStyleHsp" style=""></span>kg and a standard deviation of 26<span class="elsevierStyleHsp" style=""></span>kg. At the time of surgery these weights had fallen to a maximum of 197.2<span class="elsevierStyleHsp" style=""></span>kg, a minimum of 84<span class="elsevierStyleHsp" style=""></span>kg, an average of 118.7<span class="elsevierStyleHsp" style=""></span>kg, and a median of 114.4<span class="elsevierStyleHsp" style=""></span>kg, with a standard deviation of 23<span class="elsevierStyleHsp" style=""></span>kg. In the month after surgery the maximum weight was 158<span class="elsevierStyleHsp" style=""></span>kg, the minimum was 75<span class="elsevierStyleHsp" style=""></span>kg, the average was 106.5<span class="elsevierStyleHsp" style=""></span>kg, the median was 103.8<span class="elsevierStyleHsp" style=""></span>kg and the standard deviation was 18.5<span class="elsevierStyleHsp" style=""></span>kg.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The average fall in weight during the month of VLCD was from 129.8<span class="elsevierStyleHsp" style=""></span>kg to 118.7<span class="elsevierStyleHsp" style=""></span>kg (−11.1<span class="elsevierStyleHsp" style=""></span>kg; 8.6%), while in the month following surgery it was from 118.7<span class="elsevierStyleHsp" style=""></span>kg to 106.5<span class="elsevierStyleHsp" style=""></span>kg (−12.2<span class="elsevierStyleHsp" style=""></span>kg; 10.3%).</p><p id="par0100" class="elsevierStylePara elsevierViewall">The evolution of the average weight in the different periods analysed shows a statistically significant fall (<span class="elsevierStyleItalic">P</span><.001) during the whole time the study lasted.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Haemoglobin</span><p id="par0105" class="elsevierStylePara elsevierViewall">At the start of the study, this averaged 13.3<span class="elsevierStyleHsp" style=""></span>g/dL, a median value of 13.3<span class="elsevierStyleHsp" style=""></span>g/dL and a standard deviation of 1.2<span class="elsevierStyleHsp" style=""></span>g/dL, with a maximum figure of 15.5<span class="elsevierStyleHsp" style=""></span>g/dL and a minimum of 10.7<span class="elsevierStyleHsp" style=""></span>g/dL. At the time of surgery and after the VLCD, the average was 13<span class="elsevierStyleHsp" style=""></span>g/dL (a variation of −0.3<span class="elsevierStyleHsp" style=""></span>mg/dL; 2.3%), the median figure was 13.1<span class="elsevierStyleHsp" style=""></span>g/dL and the standard deviation was 1.4<span class="elsevierStyleHsp" style=""></span>g/dL, with a maximum figure of 15<span class="elsevierStyleHsp" style=""></span>g/dL and a minimum figure of 8.4<span class="elsevierStyleHsp" style=""></span>g/dL. One month after surgery, the figures for haemoglobin were an average of 12.7<span class="elsevierStyleHsp" style=""></span>g/dL (variation of −0.3<span class="elsevierStyleHsp" style=""></span>mg/dL; 2.3%), a median figure of 13.1<span class="elsevierStyleHsp" style=""></span>g/dL and a standard deviation of 1.4<span class="elsevierStyleHsp" style=""></span>g/dL, with a maximum of 15.1<span class="elsevierStyleHsp" style=""></span>g/dL and a minimum of 9.8<span class="elsevierStyleHsp" style=""></span>g/dL (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">As normal figures for haemoglobin are from 12 to 18<span class="elsevierStyleHsp" style=""></span>g/dL, it can be seen that the average remained within the normal range throughout the study.</p><p id="par0115" class="elsevierStylePara elsevierViewall">With the VLCD 9.5% of the sample became anaemic (4 patients) and this occurred with surgery in 4.76% of the patients (2 patients).</p><p id="par0120" class="elsevierStylePara elsevierViewall">When all of the patients are considered, haemoglobin levels displayed a statistically significant fall over the successive measurements (<span class="elsevierStyleItalic">P</span>=.006) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Albumin</span><p id="par0125" class="elsevierStylePara elsevierViewall">At the start of the study the average level of albumin in the patients was 4.5<span class="elsevierStyleHsp" style=""></span>g/dL, the median level was 4.5<span class="elsevierStyleHsp" style=""></span>g/dL and standard deviation was 0.2<span class="elsevierStyleHsp" style=""></span>g/dL, with a maximum figure of 5<span class="elsevierStyleHsp" style=""></span>g/dL and a minimum of 4.1<span class="elsevierStyleHsp" style=""></span>g/dL. One month later, the average was 4.4<span class="elsevierStyleHsp" style=""></span>g/dL (a variation of −0.1<span class="elsevierStyleHsp" style=""></span>mg/dL; 2.2%), the median was 4.5<span class="elsevierStyleHsp" style=""></span>g/dL and the standard deviation was 0.4<span class="elsevierStyleHsp" style=""></span>g/dL with a maximum figure of 5.2<span class="elsevierStyleHsp" style=""></span>g/dL and a minimum figure of 4.1<span class="elsevierStyleHsp" style=""></span>g/dL. In the month after the operation the average albumin level was 4.3<span class="elsevierStyleHsp" style=""></span>g/dL (a variation of −0.1<span class="elsevierStyleHsp" style=""></span>mg/dL; 2.3%), the median level was 4.3<span class="elsevierStyleHsp" style=""></span>g/dL, with a standard deviation of 0.3<span class="elsevierStyleHsp" style=""></span>g/dL, a maximum of 4.9<span class="elsevierStyleHsp" style=""></span>g/dL and a minimum of 3.4<span class="elsevierStyleHsp" style=""></span>g/dL (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">With the VLCD there 9.5% of the sample had an albumin deficit (4 patients) while after surgery this occurred in 2.38% of the patients (one patient).</p><p id="par0135" class="elsevierStylePara elsevierViewall">Considering the whole sample, albumin fell in a statistically significant degree throughout the successive measurements (<span class="elsevierStyleItalic">P</span><.001) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Lymphocytes</span><p id="par0140" class="elsevierStylePara elsevierViewall">At the start of the study the average figure for lymphocytes was 2218.4<span class="elsevierStyleHsp" style=""></span>μL, the median was 2198.5<span class="elsevierStyleHsp" style=""></span>μL and the standard deviation was 765.3<span class="elsevierStyleHsp" style=""></span>μL, with a maximum figure of 4500<span class="elsevierStyleHsp" style=""></span>μL and a minimum figure of 840<span class="elsevierStyleHsp" style=""></span>μL. One month later the average was 2062.9<span class="elsevierStyleHsp" style=""></span>μL (a variation of −155.5<span class="elsevierStyleHsp" style=""></span>mg/dL; 7%), the median was 1925<span class="elsevierStyleHsp" style=""></span>μL and the standard deviation was 803.5<span class="elsevierStyleHsp" style=""></span>μL, with a maximum figure of 4170<span class="elsevierStyleHsp" style=""></span>μL and a minimum figure of 670<span class="elsevierStyleHsp" style=""></span>μL. In the month after surgery the average figure for lymphocytes was 1959.7<span class="elsevierStyleHsp" style=""></span>μL (a variation of −103.2<span class="elsevierStyleHsp" style=""></span>mg/dL; 5%), the median was 1900.5<span class="elsevierStyleHsp" style=""></span>μL and the standard deviation was 584.2<span class="elsevierStyleHsp" style=""></span>μL, with a maximum of 3920<span class="elsevierStyleHsp" style=""></span>μL and a minimum of 920<span class="elsevierStyleHsp" style=""></span>μL (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The normal values for lymphocytes range from 900<span class="elsevierStyleHsp" style=""></span>μL to 5200<span class="elsevierStyleHsp" style=""></span>μL, so that, as it can be seen, the average figure for lymphocytes remained within this range at all times in this study.</p><p id="par0150" class="elsevierStylePara elsevierViewall">With the VLCD lymphocyte levels fell to pathological levels in 4.76% of the patients (2 patients). However, they recovered from this deficit in the month after surgery, so that their values were not significant from a clinical viewpoint.</p><p id="par0155" class="elsevierStylePara elsevierViewall">When all of the patients are considered, lymphocyte levels fell in a statistically significant way throughout the successive measurements (<span class="elsevierStyleItalic">P</span>=.013) (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0160" class="elsevierStylePara elsevierViewall">Although it is unclear when the practice started of subjecting patients who were going to receive bariatric surgery to a weight loss diet beforehand, the first published information on this dates from 1995. This described the results obtained in a cohort of patients operated on by a gastric by-pass or ringed vertical gastroplasty from 1978 to 1986.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Two outstanding benefits of subjecting patients to a period of weight loss before surgery are a reduction in hepatic volume and abdominal fat. These aid and facilitate surgery, reducing the number and severity of surgical complications and improving the response to postoperative dietary changes.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">On the other hand, it is fundamental that patients be well nourished if the surgery is to produce optimum results. In fact, increasing attention is being paid to this question, given that anything which negatively affects the nutritional state of a patient increases the probability of greater morbimortality after any surgical procedure (Cabrerizol <span class="elsevierStyleItalic">et al.</span>, 1999). In this context, and given that surgical interventions may aggravate any pre-existing state of malnutrition, it is important to ensure that preoperative weight loss does not alter the nutritional condition of obese patients who will be subjected to bariatric surgery.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Different methods of achieving a suitable weight loss before surgery have been used and analysed. They include VLCD,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> hypocaloric diets,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> intragastric balloons,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> the restrictive endoscopic duodenojejunal device<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> or cognitive-behavioural therapy.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">VLCD are the treatment of choice when rapid weight loss is desired, given that they have been shown to effective methods of safe weight loss. Due to this they are becoming more widespread in the context of bariatric surgery with the aim of achieving an appropriate weight loss before surgery.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Although increasing numbers of patients who will receive bariatric surgery are first placed on a VLCD, to date no studies have examined the nutritional safety of this practice. The importance of our study should therefore be highlighted, given that its results show that weight loss using a VLCD prior to surgery is safe in nutritional terms.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Weight loss using a VLCD usually amounts to 10% of patients’ initial weight, while in some cases a loss of 15% may be achieved. Practically 100% of patients lose from 5% to 10% of absolute weight.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> In fact, in our workgroup this percentage of weight loss is an indispensable requisite to enter the bariatric surgery programme.</p><p id="par0195" class="elsevierStylePara elsevierViewall">It has been said that up to 15% of patients placed on a VLCD may present some type of comorbidity as a result of this.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> In our study 9.5% of the patients became anaemic, while the number of lymphocytes fell to pathological levels in 4.76% of the patients and 9.5% had an albumin deficit. Additionally, these deficits were recovered during the month after surgery, so that they cannot be considered significant from a clinical point of view.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The data obtained were therefore within the expected range, given that these alterations were always less than the above-mentioned 15% complications rate. It can therefore be said that preoperative weight loss using a VLCD does not lead to a clinically significant level of malnutrition, so that this cannot be considered to be a sufficient criterion for not prescribing it.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Possible malnutrition had been one of the greatest concerns of the scientific community in connection with weight loss using a VLCD before bariatric surgery. However, this VLCD-induced weight loss does not lead to significant malnutrition, and when analytic variations occur they return to normal without complications after the operation.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Regarding the limitations of this study, one of the points that could be improved is the small number of patients who were finally included. With the aim of standardising the techniques and procedures used as far as is possible, to avoid any potential distortion that could have been caused by changes in medical and surgical practice, the study was planned to last a specific period of time rather than to cover a specific number of patients. It was also restricted to the month prior to surgery and the month after the same. Moreover, only bariatric surgery using gastric by-pass is included. This study excluded habitual bariatric procedures such as the gastric band, the sleeve gastrectomy, the duodenal switch and others. Thus given that the Hospital Universitario General de Castellón performs 1 or 2 bariatric procedures a week, except in holiday periods, and that only gastric bypass operations were included, a total of 50 patients was estimated, of which 8 were excluded due to lack of data. Nevertheless, the data analysed and the results obtained with this number of patients are sufficiently significant to infer that the results would be similar for a larger sample.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Another aspect of this work that could be improved is patient follow-up time. Nevertheless, given that the main aim was to evaluate nutritional parameters during the VLCD diet and to compare them with those corresponding to a month after surgery, this limitation is less important. However, it would be interesting to have a longer term patient follow-up of 5–10 years, opening the doors for future studies in this field.</p><p id="par0220" class="elsevierStylePara elsevierViewall">On the other hand, this study did not include a control group who did not follow a VLCD to achieve weight loss prior to surgery, so that the results of both could have been compared. This is because the good results over years of experience mean this weight loss is now part of care protocol in the Hospital Universitario General de Castellón. Following a VLCD during the month before surgery is a condition <span class="elsevierStyleItalic">sine qua non</span> for the operation. Nevertheless, it may be possible within a controlled clinical trial to consider the suitability and benefits of including a control group.</p><p id="par0225" class="elsevierStylePara elsevierViewall">Lastly, this work does not compare different ways of losing weight before surgery. These may have included longer or shorter VLCD diets, other types of hypocaloric diets or behavioural therapies, among others. Although this was not the aim of our study, here too there is a broad range of possibilities for future scientific research.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interests</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres621293" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec635543" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres621294" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec635542" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Weight" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Haemoglobin" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Albumin" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Lymphocytes" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of Interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-12-27" "fechaAceptado" => "2015-06-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec635543" "palabras" => array:3 [ 0 => "Bariatric surgery" 1 => "Pre-surgery loss of weight" 2 => "Nutritional parameters" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec635542" "palabras" => array:3 [ 0 => "Cirugía bariátrica" 1 => "Pérdida de peso preoperatoria" 2 => "Parámetros nutricionales" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There has been an alarming worldwide increase of obese people in recent years. Currently, there is no consensus on whether patients that are scheduled to undergo bariatric surgery should lose weight before the intervention. The objective of this research is to analyse the influence of pre-surgery loss of weight in the nutritional parameters of patients.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Fifty patients that were scheduled to undergo bariatric surgery followed a very low caloric diet during 4 weeks prior to the surgery. The nutritional parameters were analysed at 3 specific moments: before starting the diet, at the moment of surgery (when the diet was concluded) and one month after the surgery.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Average values for haemoglobin, albumin and lymphocytes were kept within the range of normal values at all moments, even though the decrease of those parameters was statistically significant throughout the study (<span class="elsevierStyleItalic">P</span><.05). By following the very low caloric diet, less than 9.5% of the sample suffered anaemia.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Loss of weight prior to surgery does not have a significant influence in the nutritional parameters of the patient. These results would support the indication of losing weight for patients that are considered candidates for bariatric surgery.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El número de personas obesas ha aumentado de forma alarmante en todo el mundo. Actualmente no existe un consenso acerca de si los pacientes que van a ser sometidos a una cirugía bariátrica deben o no perder peso antes de la misma. El objeto de la presente investigación es analizar la influencia de la pérdida de peso preoperatoria en los parámetros nutricionales de los pacientes.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se sometió a 50 pacientes que iban a ser intervenidos de una cirugía bariátrica a una dieta de muy bajo contenido calórico durante las 4 semanas previas a la intervención. Se analizaron los parámetros nutricionales en 3 momentos específicos: antes de empezar la dieta, en el momento de la intervención (al finalizar la dieta) y un mes después.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La media de hemoglobina, albúmina y linfocitos se mantuvo dentro del rango de la normalidad en todo momento a pesar de que los descensos de dichos parámetros fueron estadísticamente significativos a lo largo del estudio (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05). Con la dieta de muy bajo contenido calórico se anemizó menos del 9,5% de la muestra.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La pérdida de peso preoperatoria no influye de manera significativa en los parámetros nutricionales analizados. Estos resultados apoyarían la indicación de una pérdida de peso preoperatoria en los pacientes candidatos a cirugía bariátrica.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bennasar Remolar MÁ, Martínez Ramos D, Ortega Serrano J, Salvador Sanchís JL. Alteraciones nutricionales tras dieta muy baja en calorías previa a cirugía bariátrica. Cir Esp. 2016;94:159–164.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1599 "Ancho" => 1598 "Tamanyo" => 83245 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Haemoglobin levels.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1618 "Ancho" => 1612 "Tamanyo" => 71424 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Albumin levels.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1600 "Ancho" => 1665 "Tamanyo" => 84389 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Lymphocyte levels.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1341 "Ancho" => 1604 "Tamanyo" => 73912 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Changes in the average level of haemoglobin.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1336 "Ancho" => 1608 "Tamanyo" => 70097 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Changes in the average level of albumin.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1340 "Ancho" => 1622 "Tamanyo" => 81331 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Changes in the average level of lymphocytes.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of a very low calorie diet in the preoperative stage of bariatric surgery: a randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 0 | 6 |
| 2024 October | 13 | 11 | 24 |
| 2024 September | 30 | 7 | 37 |
| 2024 August | 15 | 2 | 17 |
| 2024 July | 15 | 4 | 19 |
| 2024 June | 16 | 2 | 18 |
| 2024 May | 7 | 3 | 10 |
| 2024 April | 16 | 4 | 20 |
| 2024 March | 29 | 5 | 34 |
| 2024 February | 17 | 1 | 18 |
| 2024 January | 19 | 1 | 20 |
| 2023 December | 16 | 3 | 19 |
| 2023 November | 24 | 8 | 32 |
| 2023 October | 22 | 3 | 25 |
| 2023 September | 7 | 1 | 8 |
| 2023 August | 16 | 4 | 20 |
| 2023 July | 7 | 3 | 10 |
| 2023 June | 12 | 3 | 15 |
| 2023 May | 22 | 3 | 25 |
| 2023 April | 12 | 2 | 14 |
| 2023 March | 14 | 2 | 16 |
| 2023 February | 17 | 3 | 20 |
| 2023 January | 27 | 9 | 36 |
| 2022 December | 18 | 5 | 23 |
| 2022 November | 20 | 7 | 27 |
| 2022 October | 13 | 8 | 21 |
| 2022 September | 16 | 11 | 27 |
| 2022 August | 22 | 14 | 36 |
| 2022 July | 15 | 6 | 21 |
| 2022 June | 11 | 7 | 18 |
| 2022 May | 12 | 6 | 18 |
| 2022 April | 21 | 13 | 34 |
| 2022 March | 22 | 6 | 28 |
| 2022 February | 12 | 5 | 17 |
| 2022 January | 27 | 4 | 31 |
| 2021 December | 21 | 10 | 31 |
| 2021 November | 27 | 11 | 38 |
| 2021 October | 55 | 6 | 61 |
| 2021 September | 15 | 6 | 21 |
| 2021 August | 13 | 12 | 25 |
| 2021 July | 23 | 9 | 32 |
| 2021 June | 26 | 8 | 34 |
| 2021 May | 20 | 10 | 30 |
| 2021 April | 34 | 16 | 50 |
| 2021 March | 24 | 5 | 29 |
| 2021 February | 15 | 8 | 23 |
| 2021 January | 21 | 7 | 28 |
| 2020 December | 31 | 6 | 37 |
| 2020 November | 29 | 12 | 41 |
| 2020 October | 15 | 7 | 22 |
| 2020 September | 19 | 9 | 28 |
| 2020 August | 23 | 5 | 28 |
| 2020 July | 25 | 10 | 35 |
| 2020 June | 110 | 11 | 121 |
| 2020 May | 112 | 14 | 126 |
| 2020 April | 14 | 3 | 17 |
| 2020 March | 7 | 2 | 9 |
| 2020 February | 53 | 7 | 60 |
| 2020 January | 18 | 5 | 23 |
| 2019 December | 35 | 6 | 41 |
| 2019 November | 135 | 6 | 141 |
| 2019 October | 21 | 6 | 27 |
| 2019 September | 14 | 5 | 19 |
| 2019 August | 3 | 1 | 4 |
| 2019 July | 26 | 21 | 47 |
| 2019 June | 31 | 20 | 51 |
| 2019 May | 111 | 22 | 133 |
| 2019 April | 27 | 5 | 32 |
| 2019 March | 2 | 4 | 6 |
| 2019 February | 16 | 7 | 23 |
| 2019 January | 9 | 5 | 14 |
| 2018 December | 5 | 3 | 8 |
| 2018 November | 12 | 4 | 16 |
| 2018 October | 26 | 7 | 33 |
| 2018 September | 9 | 0 | 9 |
| 2018 August | 23 | 9 | 32 |
| 2018 July | 16 | 1 | 17 |
| 2018 June | 10 | 3 | 13 |
| 2018 May | 20 | 5 | 25 |
| 2018 April | 3 | 1 | 4 |
| 2018 March | 7 | 0 | 7 |
| 2018 February | 7 | 4 | 11 |
| 2018 January | 7 | 0 | 7 |
| 2017 December | 6 | 1 | 7 |
| 2017 November | 11 | 3 | 14 |
| 2017 October | 15 | 4 | 19 |
| 2017 September | 16 | 5 | 21 |
| 2017 August | 14 | 2 | 16 |
| 2017 July | 14 | 6 | 20 |
| 2017 June | 16 | 3 | 19 |
| 2017 May | 29 | 2 | 31 |
| 2017 April | 16 | 8 | 24 |
| 2017 March | 14 | 19 | 33 |
| 2017 February | 10 | 5 | 15 |
| 2017 January | 9 | 1 | 10 |
| 2016 December | 15 | 3 | 18 |
| 2016 November | 10 | 4 | 14 |
| 2016 October | 23 | 3 | 26 |
| 2016 September | 29 | 5 | 34 |
| 2016 August | 25 | 4 | 29 |
| 2016 July | 23 | 3 | 26 |
| 2016 June | 15 | 8 | 23 |
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