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Pre-operative Very Low Calorie Ketogenic Diet (VLCKD) vs. Very Low Calorie Diet (VLCD): Surgical Impact

DOI:10.1007/s11695-018-3523-2
Authors:
Alice Albanese at University of Padova
Alice Albanese
Luca Prevedello at University-Hospital of Padova
Luca Prevedello
M. Markovich
M. Markovich
M. Markovich
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L. Busetto
L. Busetto
L. Busetto
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Abstract and Figures

Background Pre-operative diet may play an important role as far as patients’ fitness for surgery, post-operative outcomes, and successful weight loss. Our aim was to compare surgical outcome and weight loss in two groups of patients who were offered two different pre-operative kinds of diet: very low calorie diet (VLCD) and very low calorie ketogenic diet (VLCKD). Methods Patients candidate for bariatric surgery (laparoscopic sleeve gastrectomy) were registered and assessed according to pre- and post-diet BMI, operative time, hospital stay, drainage output, and hemoglobin (Hb) levels. Patients’ preference influenced the type of diet. ResultsFrom January to December 2016, 178 patients (139 F and 39 M) were enrolled in this study. The mean age was 43 years. In total, 72 patients were on VLCKD while 106 patients on VLCD. Pre-diet mean BMI was 46.3 ± 6.3 kg/m2 for VLCKD group and 43.1 ± 6.9 kg/m2 for VLCD group, while immediately pre-op BMI were 43.9 ± 5.9 kg/m2 and 41.9 ± 6.8 kg/m2, respectively. Drainage output and hemoglobin levels after surgery resulted significantly correlated with diet induced BMI reduction (141.2 ± 75.8 vs. 190.7 ± 183.6 ml, p = 0.032; 13.1 ± 1.2 vs. 12.7 ± 1.5 g/l, p = 0.04). The percentage of patients requiring a hospital stay longer than anticipated (> 3 days) was 2.8% in the VLCKD group and 10.4% in the VLCD group (p = 0.048). Conclusions In our experience, VLCKD showed better results than VLCD on surgical outcome, influencing drainage output, post-operative hemoglobin levels, and hospital stay.
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ORIGINAL CONTRIBUTIONS
Pre-operative Very Low Calorie Ketogenic Diet (VLCKD) vs. Very Low
Calorie Diet (VLCD): Surgical Impact
Alice Albanese
1
&L. Prevedello
1
&M. Markovich
1
&L. Busetto
1
&R. Vettor
1
&M. Foletto
1
Published online: 24 September 2018
#Springer Science+Business Media, LLC, part of Springer Nature 2018
Abstract
Background Pre-operative diet may play an important role as far as patients’fitness for surgery, post-operative outcomes, and
successfulweight loss. Our aim was to compare surgical outcome and weight loss in two groups ofpatients who were offered two
different pre-operative kinds of diet: very low calorie diet (VLCD) and very low calorie ketogenic diet (VLCKD).
Methods Patients candidate for bariatric surgery (laparoscopic sleeve gastrectomy) were registered and assessed according to
pre- and post-diet BMI, operative time, hospital stay, drainage output, and hemoglobin (Hb) levels. Patients’preference influ-
enced the type of diet.
Results From January to December 2016, 178 patients (139 F and 39 M) were enrolled in this study. The mean age was 43 years.
In total, 72 patients were on VLCKD while 106 patients on VLCD. Pre-diet mean BMI was 46.3 ± 6.3 kg/m
2
for VLCKD group
and 43.1 ± 6.9 kg/m
2
for VLCD group, while immediately pre-op BMI were 43.9± 5.9 kg/m
2
and 41.9 ± 6.8 kg/m
2
,respectively.
Drainage output and hemoglobin levels after surgery resulted significantly correlated with diet induced BMI reduction (141.2 ±
75.8 vs. 190.7 ± 183.6 ml, p= 0.032; 13.1 ± 1.2 vs. 12.7 ± 1.5 g/l, p= 0.04). The percentage of patients requiring a hospital stay
longer than anticipated (> 3 days) was 2.8% in the VLCKD group and 10.4% in the VLCD group (p=0.048).
Conclusions In our experience, VLCKD showed better results than VLCD on surgical outcome, influencing drainage output,
post-operative hemoglobin levels, and hospital stay.
Keywords Bariatric surgery .Pre-operative diet .Laparoscopic sleeve gastrectomy
Introduction
Accurate pre-operative multidisciplinary assessment of bariat-
ric patients plays an important role in improving performance
status, surgical outcome, weight loss, and reducing the risk of
weight regain. Dietary assessment and pre-operative weight
loss has to be considered integrated in the surgical treatment.
Inadequate accessibility to the abdominal cavity due to
large fatty liver and visceral obesity is one of the major limit-
ing factors for surgery and has a negative impact on exposition
of the surgical field. Reducing hepatomegaly and visceral ad-
ipose tissue means having several technical advantages, re-
ducing potential injuries and complications during surgery,
and in the peri-operative period.
Very low calorie diet (VLCD) regimens and intragastric
balloon placement have already been investigated and have
an established role in the pre-operative weight loss [1,2]. The
role of very low calorie ketogenic diet (VLCKD ) is consoli-
dated and increasing in importance for obesity treatment and
type 2 diabetes mellitus (T2DM) [3,4], but their role before
bariatric surgery is still less considered. In addition, in the pre-
operative period, some issues have to be taken into consider-
ation as the influence of the catabolic state and the oxidative
stress induced by ketogenic diets.
Aim
Our purpose was to compare the effects on weight loss be-
tween a consolidated pre-operative diet (VLCD) and a new
dietetic approach in bariatric surgery (VLCKD). In particular,
we concentrated our analysis on the benefits provided by the
two regimens on surgical outcomes (mean operative time,
*Alice Albanese
alicealbanese@alice.it
1
Bariatric Unit, Padua University Hospital, Padua, Italy
Obesity Surgery (2019) 29:292–296
https://doi.org/10.1007/s11695-018-3523-2
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... These studies were conducted between 2011 and 2022. Three studies were conducted in Italy [28][29][30], three in USA [31][32][33], two in Sweden [16,34], two in Turkey [35,36], and others in Spain [37], UK [38], Brazil [39], Australia [40], Netherland [41], Egypt [42], Mexico [43]. All studies were done on both genders. ...
... Characteristics of included studies 3 studies VLCKD [28][29][30]was applied to individuals in the intervention group. Duration of intervention was between 1 to 6 weeks. ...
... Pooling effect sizes from 3 studies [28][29][30] with a total sample of 241 adults, there was a significant effect of VLCKD on body weight [Effect: -8.62; 95% CI: -12.59, -4.65 kg] (Fig. 2-c). A significant heterogeneity was detected among studies (I 2 = 91.4%, ...
Evaluate the Effects of Different Types of Preoperative Restricted Calorie Diets on Weight, Body Mass Index, Operation Time and Hospital Stay in Patients Undergoing Bariatric Surgery: a Systematic Review and Meta Analysis Study
Article
Full-text available
Previous studies investigated low-calorie diets (LCD), very-low-calorie diets (VLCD), and very-low-calorie ketogenic diets (VLCKD) in relation to weight loss and outcomes for bariatric surgery patients. However, the overall effects of these diets on various outcomes remain unclear. This study aimed to assess the impact of preoperative restricted calorie diets on weight, body mass index (BMI), operation time (OT), and hospital stay (HS) in bariatric surgery patients. Seventeen articles were analyzed, revealing the highest weight loss (-8.62) and BMI reduction (-5.75) with VLCKD. Due to insufficient data, the impact of these diets on OT and HS could not be determined. Further interventional studies are required to determine the ideal preoperative diet that achieves optimal weight loss, patient compliance, tolerance, acceptance, and surgical outcomes.
View
... One of the recent dietary approaches to pre-operative weight loss is the VLCKD diet (very-low-calorie ketogenic diet) which has fewer carbohydrates (<20-30 g) and a higher percentage of fat than VLCD [60, 61]. It has been shown to increase weight loss while preserving lean body mass, improving glycemic control, lipid profile, and surgical complications due to reducing blood loss and better post-operative hemoglobin level and wound healing [19,[62][63][64][65]. VLCKD is becoming more popular due to hunger suppression (because of the ketone body production) and probably more patient satisfaction and tolerance, besides the positive effect on mood [19,62]. ...
... One of the recent dietary approaches to pre-operative weight loss is the VLCKD diet (very-low-calorie ketogenic diet) which has fewer carbohydrates (<20-30 g) and a higher percentage of fat than VLCD [60, 61]. It has been shown to increase weight loss while preserving lean body mass, improving glycemic control, lipid profile, and surgical complications due to reducing blood loss and better post-operative hemoglobin level and wound healing [19,[62][63][64][65]. VLCKD is becoming more popular due to hunger suppression (because of the ketone body production) and probably more patient satisfaction and tolerance, besides the positive effect on mood [19,62]. However, there is conflicting evidence regarding the safety of VLCKD. ...
... Some studies have reported that VLCKD is a safe diet without side effects on liver and kidney function. Still, some other studies have reported that VLCKD can induce oxidative stress and a catabolic state, which may increase the risk of surgery and cause poor post-operative recovery, so more research is needed to clear the safety of VLCKD prescription [62,64]. ...
Nutrition, Physical Activity, and Prescription of Supplements in Pre- and Post-bariatric Surgery Patients: An Updated Comprehensive Practical Guideline
Article
Full-text available
Only in the USA, 315 billion dollars are spent annually on the medical cost of obesity in adult patients. Till now, bariatric surgery is the most effective method for treating obesity and can play an essential role in reducing the direct and indirect costs of obesity treatment. Nonetheless, there are few comprehensive guidelines which include nutrition, physical activity, and supplements, before and after surgery. The purpose of the present narrative review is to provide an updated and comprehensive practical guideline to help multidisciplinary teams. The core keywords include nutrition, diet, physical activity, exercise, supplements, macronutrients, micronutrients, weight reduction, bariatric surgery, Roux-en-Y Gastric Bypass, Sleeve Gastrostomy, Laparoscopic Adjustable Gastric Banding, and Biliopancreatic diversion with duodenal switch which were searched in databases including PubMed/Medline, Cochrane, and some other sources such as Google Scholar. We answered questions in five important areas: (a) nutritional strategies before bariatric surgery, (b) nutrition after bariatric surgery, (c) physical activity before and after bariatric surgery, (d) weight regain after bariatric surgery, and (e) micronutrient assessments and recommendations before and after bariatric surgery. Some new items were added in this updated guideline including “weight regain” and “pregnancy after bariatric surgery.” Other fields were updated based on new evidence and guidelines.
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... Recent research has demonstrated that the VLCKD may be a particularly attractive pre-operative dietary treatment for patients with obesity who are candidates for bariatric surgery. In fact, a recent RCT found that VLCKD resulted in better surgical outcomes than a VLCD in 178 patients undergoing laparoscopic SG [36]. ...
... According to Albanese et al., the main advantage of VLCKD is not only fast and substantial weight loss but also its positive influence on parameters strongly related to surgical outcome [36]. In fact, in a recent study of 178 patients who underwent either VLCKD or VLCD before SG, blood drainage outputs were lower and post-operative haemoglobin levels were higher in the group following VLCKD than the group following VLCD. ...
... Considering that weight loss and mean operative time were comparable between the two groups, it can be assumed that this advantage was also influenced by the greater ease of surgical manoeuvres due to hepatomegaly and visceral adipose tissue reduction. The authors surmised that patients with VLCKD achieved a better metabolic and nutritional status that influenced tissue healing and response to surgery [36]. In line with these results, a 4-week preoperative VLCKD that included micronutrient supplementation led to better blood glucose and hypertension, as well as a 19.8% decrease in the initial volume of the left hepatic lobe [50]. ...
Very Low-Calorie Ketogenic Diet (VLCKD) as Pre-Operative First-Line Dietary Therapy in Patients with Obesity Who Are Candidates for Bariatric Surgery
Article
Full-text available
  • Apr 2023
Bariatric surgery is currently the most effective method for achieving long-term weight loss and reducing the risk of comorbidities and mortality in individuals with severe obesity. The pre-operative diet is an important factor in determining patients' suitability for surgery, as well as their post-operative outcomes and success in achieving weight loss. Therefore, the nutritional management of bariatric patients requires specialized expertise. Very low-calorie diets and intragastric balloon placement have already been studied and shown to be effective in promoting pre-operative weight loss. In addition, the very low-calorie ketogenic diet has a well-established role in the treatment of obesity and type 2 diabetes mellitus, but its potential role as a pre-operative dietary treatment prior to bariatric surgery has received less attention. Thus, this article will provide a brief overview of the current evidence on the very low-calorie ketogenic diet as a pre-operative dietary treatment in patients with obesity who are candidates for bariatric surgery.
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... Evidence suggests that VLCKDs can be effective tools for positively managing weight loss, glycemic control, and lipid profile changes [15,16]. However, these beneficial effects can be limited by poor dietary adherence. ...
... However, these beneficial effects can be limited by poor dietary adherence. In particular, cultural, religious, and economic barriers pose unique challenges to achieving nutritional compliance with VLCKDs [15,17]. A potential solution is represented by the enteral nutrition strategies. ...
... Landry, M.J.; Crimarco, A.; Perelman, D.; Durand, L.R.; Petlura, C.; Aronica, L.; Robinson, J.L.; Kim, S.H.; Gardner, C.D. Adherence to Ketogenic and Mediterranean Study Diets in a Crossover Trial: The Keto-Med Randomized Trial. Nutrients 2021, 13, 967.[CrossRef]Nutrients 2023,15, 1492 ...
Clinical Impact of Enteral Protein Nutritional Therapy on Patients with Obesity Scheduled for Bariatric Surgery: A Focus on Safety, Efficacy, and Pathophysiological Changes
Article
Full-text available
  • Mar 2023
Background: Ketogenic diet-induced weight loss before bariatric surgery (BS) has beneficial effects on the reduction in the liver volume, metabolic profile, and intra- and post-operative complications. However, these beneficial effects can be limited by poor dietary adherence. A potential solution in patients showing a poor adherence in following the prescribed diet could be represented by enteral nutrition strategies. To date, no studies describe the protocol to use for the efficacy and the safety of pre-operative enteral ketogenic nutrition-based dietary protocols in terms of weight reduction, metabolic efficacy, and safety in patients with obesity scheduled for BS. Aims and scope: To assess the clinical impact, efficacy, and safety of ketogenic nutrition enteral protein (NEP) vs. nutritional enteral hypocaloric (NEI) protocols on patients with obesity candidate to BS. Patients and methods: 31 NEP were compared to 29 NEI patients through a 1:1 randomization. The body weight (BW), body mass index (BMI), waist circumference (WC), hip circumference (HC), and neck circumference (NC) were assessed at the baseline and at the 4-week follow-up. Furthermore, clinical parameters were assessed by blood tests, and patients were asked daily to report any side effects, using a self-administered questionnaire. Results: Compared to the baseline, the BW, BMI, WC, HC, and NC were significantly reduced in both groups studied (p < 0.001). However, we did not find any significative difference between the NEP and NEI groups in terms of weight loss (p = 0.559), BMI (p= 0.383), WC (p = 0.779), and HC (p = 0.559), while a statistically significant difference was found in terms of the NC (NEP, -7.1% vs. NEI, -4%, p = 0.011). Furthermore, we found a significant amelioration of the general clinical status in both groups. However, a statistically significant difference was found in terms of glycemia (NEP, -16% vs. NEI, -8.5%, p < 0.001), insulin (NEP, -49.6% vs. NEI, -17.8%, p < 0.0028), HOMA index (NEP, -57.7% vs. NEI, -24.9%, p < 0.001), total cholesterol (NEP, -24.3% vs. NEI, -2.8%, p < 0.001), low-density lipoprotein (NEP, -30.9% vs. NEI, 1.96%, p < 0.001), apolipoprotein A1 (NEP, -24.2% vs. NEI, -7%, p < 0.001), and apolipoprotein B (NEP, -23.1% vs. NEI, -2.3%, p < 0.001), whereas we did not find any significative difference between the NEP and NEI groups in terms of aortomesenteric fat thickness (p = 0.332), triglyceride levels (p = 0.534), degree of steatosis (p = 0.616), and left hepatic lobe volume (p = 0.264). Furthermore, the NEP and NEI treatments were well tolerated, and no major side effects were registered. Conclusions: Enteral feeding is an effective and safe treatment before BS, with NEP leading to better clinical results than NEI on the glycemic and lipid profiles. Further and larger randomized clinical trials are needed to confirm these preliminary data.
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... The specific VLCKD in our study, VLCKD-SDM, contained n-3 PUFA, whey protein, and probiotic and vitamin/mineral supplements, and the MD was based on normal foods with carefully prescribed content and measures. It was comprised of an amount of protein similar to that of other VLCKDs, with a greater amount of fat 3,29,33 . The program consisted of industrial foods with whey protein, with a level of carbohydrate 17-29% higher than that of other VLCKDs and 18-20% lower than in other VLCDs and LCDs. ...
... Pre Recent short-term presurgical studies, randomized trials, and a systematic review provide a basis for estimating the relative effectiveness of VLCDs, industrial liquid formulations of VLCDs, normal food-based VLCDs, industrial liquid formulations of VLCDs, a Protein-MD, and VLCKDs on weight, BMI, waist circumference, fat percentage, lean body mass, nutrient content, triglycerides, high-density lipoprotein (HDL), and liver size [2][3][4][5][6][7][8][9][10][11][12]14,[27][28][29][30][31][32][33][34][35][36][37][38][39] . As depicted in the reference Protein-MD and VLCKDs reviewed were equivalent to one another in achieving the greatest percentage fat loss and liver size reduction; VLCKDs were also most effective in increasing lean body mass. ...
Comparison of a pre-bariatric surgery very low-calorie ketogenic diet and the Mediterranean diet effects on weight loss, metabolic parameters, and liver size reduction
Article
Full-text available
  • Nov 2022
This study compared the effects on weight as well as on metabolic parameters and liver size of a very low-calorie ketogenic diet versus a Mediterranean diet in patients with morbid obesity preparing to undergo bariatric surgery. This prospective comparison study evaluated patients 18–65 years of age who enrolled for bariatric surgery. Study duration was limited to an immediate preoperative period of 15 days. The very low-calorie ketogenic diet incorporated 10–12 kcal/kg/day of energy and 1–1.2 g/kg of protein using Kalibra (Societa Dietetica Medica) (VLCKD-SDM). The Mediterranean diet (MD) included 15–20% protein, 45–50% carbohydrate, and 25–35% fat. Changes in body mass index (BMI), liver size, and anthropometric and metabolic measurements were assessed. Between January 2016 and March 2017, of 45 patients enrolled, 30 completed the study (VLCKD-SDM, n = 15; MD, n = 15). Respective median BMI loss after VLCKD-SDM was 2.7 kg/m ² versus MD 1.4 kg/m ² (p < 0.05); median fat percentage reduction was 3.2 units versus 1.7 units (p < 0.05). Median liver size decreased 5.5% in the VLCKD-SDM group versus 1.7% in the MD group (p < 0.05). Median total cholesterol, and LDL levels decreased in both groups (p < 0.05), with greater relative decreases in the VLCKD-SDM group. Short-term preoperative diet-based weight loss in patients with morbid obesity preparing for bariatric surgery was significantly greater following a very low-calorie ketogenic diet versus a Mediterranean diet. The very low-calorie diet also significantly improved anthropometric and metabolic parameters and reduced preoperative liver size above that of the MD.
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... It contains proteins 1.4 g/kg, <20-30 g carbohydrates, and 15-20 g lipid whereas VLCD contains proteins 0.8-1.5 g/kg, carbohydrates 80 g, and lipids 15 g. 9 However, this might vary from study to study. It requires medical supervision because of the increased risk for medical complications including electrolyte imbalance and dehydration. ...
Pre-bariatric surgery acute kidney injury: Can this be prevented?
Article
Full-text available
  • Oct 2023
Key Clinical Message Pre‐bariatric surgery dietary recommendations should take into account daily protein intake and other risk factors for kidney injury. This is important because a high protein intake can potentially lead to kidney injury. Abstract Bariatric surgery has been shown to be a highly effective intervention for achieving weight loss and reducing obesity related‐comorbidities. Acute kidney injury (AKI) is considered one of the common complications in perioperative and post‐bariatric surgery. However, pre‐bariatric surgery AKI has never been reported. Several studies demonstrated that pre‐bariatric surgery weight loss improved surgical outcomes and decrease postoperative complications. Some diet regimens have been introduced including low‐caloric diet (LCD), very‐low caloric diet (VLCD), and very‐low caloric ketogenic diet (VLCKD). We present a patient who develops AKI after 10 days of having a high‐protein diet from a pre‐bariatric weight loss strategy.
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... Furthermore, KD can also inhibit the production of inflammatory factors (including NLRP3 and NF-κB) and activate GRP109A to reduce inflammatory response [3]. Thus, KD has been promoted as a weight-loss diet [10,11] and as a treatment for obesity-related diseases, such as hypertension [12,13], cardiovascular disease (CVD) [14], cancer [15,16], and sleep apnea [17]. In addition to dietary interventions, exercise is another important weight-loss strategy by increasing energy expenditure and decreasing body fat accumulation. ...
Ketogenic Diet and Multiple Health Outcomes: An Umbrella Review of Meta-Analysis
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Full-text available
  • Sep 2023
Numerous studies have examined the effects of ketogenic diets (KD) on health-related outcomes through meta-analyses. However, the presence of biases may compromise the reliability of conclusions. Therefore, we conducted an umbrella review to collate and appraise the strength of evidence on the efficacy of KD interventions. We conducted a comprehensive search on PubMed, EMBASE, and the Cochrane Database until April 2023 to identify meta-analyses that investigated the treatment effects of KD for multiple health conditions, which yielded 23 meta-analyses for quantitative analyses. The evidence suggests that KD could increase the levels of low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C), the respiratory exchange rate (RER), and could decrease total testosterone and testosterone levels (all p-random effects: <0.05). The combination of KD and physical activity can significantly reduce body weight and increase the levels of LDL-C and cortisol. In addition, KD was associated with seizure reduction in children, which can be explained by the ketosis state as induced by the diet. Furthermore, KD demonstrated a better alleviation effect in refractory childhood epilepsy, in terms of median effective rates for seizure reduction of ≥50%, ≥90%, and seizure freedom. However, the strength of evidence supporting the aforementioned associations was generally weak, thereby challenging their credibility. Consequently, future studies should prioritize stringent research protocols to ascertain whether KD interventions with longer intervention periods hold promise as a viable treatment option for various diseases.
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Very low energy diets prior to bariatric surgery may reduce postoperative morbidity: a systematic review and meta-analysis of randomized controlled trials
Article
Full-text available
  • Jun 2023
Purpose To optimize patients prior to bariatric surgery, very low energy diets (VLEDs) are often employed for 2–4 weeks preoperatively. They are known to result in preoperative weight loss, decrease liver volume, and decrease surgeon-perceived operative difficulty. Their impact on postoperative morbidity has been less extensively studied. We performed a focused systematic review and meta-analysis with the aim of comparing preoperative VLEDs prior to bariatric surgery with controls in terms of overall postoperative morbidity. Methods MEDLINE, Embase, and CENTRAL were searched from database inception to February 2023. Articles were eligible for inclusion if they were randomized controlled trials (RCTs) comparing postoperative morbidity in adult patients (i.e., over the age of 18) receiving a VLED with liquid formulation to those receiving a non-VLED control prior to elective bariatric surgery. Outcomes included overall 30-day postoperative morbidity and preoperative weight loss. An inverse variance meta-analysis was performed with GRADE assessment of the quality of evidence. Results After reviewing 2,525 citations, four RCTs with 294 patients receiving preoperative VLEDs with liquid formulation and 294 patients receiving a non-VLED control met inclusion. Patients receiving VLED experienced significantly more preoperative weight loss than patients receiving control (mean difference (MD) 3.38 kg, 95% confidence interval (CI) 1.06–5.70, p = 0.004, I² = 95%). According to low certainty evidence, there was a non-significant reduction in 30-day postoperative morbidity in patients receiving VLED prior to bariatric surgery (risk ratio (RR) 0.67, 95%CI 0.39–1.17, p = 0.16, I² = 0%). Conclusion The impact of preoperative VLEDs on postoperative outcomes following bariatric surgery remains unclear. It is possible that VLEDs may contribute to decreased postoperative morbidity, but further larger prospective trials are required to investigate the signal identified in this study.
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Prehabilitation of overweight and obese patients with dysglycemia awaiting bariatric surgery: Predicting the success of obesity treatment
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  • Dec 2022
Bariatric surgery offers the best health results in overweight and obese patients but is not a risk and/or complication-free treatment. In cases with additional hyperglycemia, the burden of surgery can be even higher and alter both short-term and long-term outcomes. Although bariatric surgery offers glycemic improvements and in the case of early onset diabetes disease remission, weight loss results are lower than for obese patients without diabetes. Different multimodal programs, usually including interventions related to patients' performance, nutritional and psychological status as well as currently available pharmacotherapy before the surgery itself might considerably improve the immediate and late postoperative course. However, there are still no clear guidelines addressing the prehabilitation of obese patients with dysglycemia undergoing bariatric surgery and therefore no unique protocols to improve patients' health. In this minireview, we summarize the current knowledge on prehabilitation before bariatric surgery procedures in patients with obesity and dysglycemia.
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Ketogenic diet in endocrine disorders: Current perspectives
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Ketogenic diet (KD) is a high-fat, adequate-protein, and low-carbohydrate diet that leads to nutritional ketosis, long known for antiepileptic effects and has been used therapeutically to treat refractory epilepsy. This review attempts to summarize the evidence and clinical application of KD in diabetes, obesity, and other endocrine disorders. KD is usually animal protein based. An empiric vegetarian Indian variant of KD has been provided keeping in mind the Indian food habits. KD has beneficial effects on cardiac ischemic preconditioning, improves oxygenation in patients with respiratory failure, improves glycemic control in diabetics, is associated with significant weight loss, and has a beneficial impact on polycystic ovarian syndrome. Multivitamin supplementations are recommended with KD. Recently, ketones are being proposed as super-metabolic fuel; and KD is currently regarded as apt dietary therapy for “diabesity.”
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Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors
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Background Leak is the second most common cause of death after bariatric surgery. The leak rate after laparoscopic sleeve gastrectomy (LSG) ranges between 1.1 and 5.3 %. The aim of the paper is to provide an overview of the current pathogenic and promoting factors of leakage after LSG on the basis of recent literature review and to report the evidence based preventive measures. Methods Risk factors and pathogenesis of leakage after LSG were examined based on an extensive review of literature and evidence based analysis of the most recent published studies using Oxford centre for evidence-based medicine, 2011, levels of evidence. Results Pathogenesis of leakage after LSG can be attributed to mechanical or ischemic causes. Many factors can predispose to leakage after LSG which are either technically related or patient related. Awareness of these predisposing factors and technical tips may decrease the incidence of leakage. Conclusions This review reports factors promoting leak and gives technical recommendations to avoid leak after LSG based on the available evidence and expert consensus which encompasses: (1) use a bougie size ≥40 Fr, EL:1, (2) begin the gastric transection 5–6 cm from the pylorus, EL:2–3, (3) use appropriate cartridge colors from antrum to fundus, EL:1, (4) reinforce the staple line with buttress material, EL:1, (5) follow a proper staple line, (6) remove the crotch staples, EL:4, (7) maintain proper traction on the stomach before firing, (8) stay away from the angle of His at least 1 cm, EL:1, (9) check the bleeding from the staple line, (10) perform an intraoperative methylene blue test, EL:4.
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Weight loss prior to bariatric surgery: An updated review of the literature
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  • Nov 2014
Background and Aims Prior to bariatric surgery, a preoperative weight-reducing regimen is usually adhered to in most centers. The clinical effects of such a regimen are yet to be determined. Material and Methods We reviewed the current literature by searching in PubMed for publications reporting clinical effects resulting from a preoperative weight loss regimen prior to bariatric surgery published from January 1, 1995 to April 30, 2014. Results In total, we identified 23 original publications and 2 review articles which met all inclusion criteria. These were included and fully analyzed with regard to effects of preoperative weight loss. In general, for parameters such as operating time and intraoperative complications including blood loss and recovery, inconsistent data were reported. Most studies included low number of patients and with heterogenic designs, and the results could not form the base for recommendations. However, for outcomes such as postoperative complications and weight development over time, data from large-scale studies and randomized controlled trials suggest beneficial effects following adherence to weight loss prior to bariatric surgery. Conclusion Although a large amount of data in the current literature on the effects of weight loss prior to bariatric surgery are inconsistent for many outcome parameters, recently published results regarding effects on postoperative complications and weight development over time strongly suggest that such a regimen should be recommended. Whether a certain degree of weight loss should be mandatory before being accepted for bariatric surgery is, however, still controversial.
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Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery
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In 2012, an outstanding expert panel derived from IFSO-EC (International Federation for the Surgery of Obesity - European Chapter) and EASO (European Association for the Study of Obesity), composed by key representatives of both Societies including past and present presidents together with EASO's OMTF (Obesity Management Task Force) chair, agreed to devote the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery as a pre-satellite of the 2013 European Congress on Obesity (ECO) to be held in Liverpool given the extraordinarily advancement made specifically in this field during the past years. It was further agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced in cooperation of both Societies by focusing in particular on the evidence gathered in relation to the effects on diabetes during this lustrum and the subsequent changes that have taken place in patient eligibility criteria. The expert panel composition allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery. © 2013 S. Karger GmbH, Freiburg.
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Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery
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In 2012, an expert panel composed of presidents of each of the societies, the European Chapter of the International Federation for the Surgery of Obesity (IFSO-EC), and of the European Association for the Study of Obesity (EASO), as well as of the chair of EASO Obesity Management Task Force (EASO OMTF) and other key representatives from IFSO-EC and EASO, devoted the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery in advance of the 2013 European Congress on Obesity held in Liverpool. This meeting was prompted by the extraordinary advancement made in the field of metabolic and bariatric surgery during the past decade. It was agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced by focusing in particular on the evidence gathered in relation to the effects on diabetes and the changes in the recommendations of patient eligibility criteria. The expert panel allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.
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Therapeutic role of low-carbohydrate ketogenic diet in diabetes
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  • Nov 2009
Changes in dietary habits influence the glycemic level. Preliminary studies using the low-carbohydrate ketogenic diet (LCKD) were found to be quite promising in controlling diabetes mellitus. Therefore, the objectives of this study are to investigate the therapeutic effects of LCKD in experimental diabetic rats following the administration of streptozotocin (STZ). Adult rats were divided into three groups: normal diet, LCKD, and high-carbohydrate diet. Each group was subdivided into normal, sham, and diabetic groups. Diabetes was induced by a single intraperitoneal injection of STZ (55mg/kg). Specific diets were given to each group of animals for a period of 8 wk and then the animals were sacrificed. The rats were monitored daily for food and water intake, whereas body weight, urine output, and blood glucose levels were monitored weekly. The histology of the islets of Langerhans was studied by histochemical methods. The results showed that LCKD was effective in bringing blood glucose level close to normal (P<0.01). Food and water intake and urine output were increased in all groups except the LCKD group (P<0.01). The body weight was significantly reduced in all diabetic animals except in the LCKD group (P<0.01). Histologic studies showed significant decrease in the islet size and number of beta cells in all the diabetic groups. This study indicates that LCKD has a significant beneficial effect in ameliorating the diabetic state and helping to stabilize hyperglycemia.
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Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS((R))) Society Recommendations
Article
  • Sep 2012
Background: This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol. Methods: Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. Results: For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system). Conclusions: Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.
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Preoperative weight loss in patients with indication of bariatric surgery: Which is the best method?
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Surgery is the only effective treatment for people with a body mass index (BMI) greater than 40 Kg/m² or even greater than 35 Kg/m² when some diseases like diabetes or hypertension appear. In order to minimize surgical risk and improve postoperative results, preoperative preparation it's very important. "Acute" preoperative weight loss just before surgery plays a crucial role in that preparation and can be achieved through different ways like a low calorie diet, a very low calorie diet or with the use of an intragastric balloon. The advantages or particularities of every one of them will be summarized in this article. Literature review of the benefits, risks and complications of preoperative weight loss through a low calorie diet, a very low calorie diet or intragastric balloon placement. Seven of thirteen initially selected reports from Medline search were considered relevant, including a total 371 patients (240 patients treated with low calorie diet, 90 with very low calorie diet and 41 cases of intragastric balloon placement). We found that weight loss was greater in patients with very low calorie diets and intragastric balloon groups but with a slightly increase in morbidity and cost. Although there are no comparative studies, data from the literature results show that diets very low in calories are more effective and require less time than low-calorie diets and cheaper with fewer side effects than the intragastric balloon.
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Systematic review of randomized controlled trials of low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity and its comorbidities
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There are few studies comparing the effects of low-carbohydrate/high-protein diets with low-fat/high-carbohydrate diets for obesity and cardiovascular disease risk. This systematic review focuses on randomized controlled trials of low-carbohydrate diets compared with low-fat/low-calorie diets. Studies conducted in adult populations with mean or median body mass index of > or =28 kg m(-2) were included. Thirteen electronic databases were searched and randomized controlled trials from January 2000 to March 2007 were evaluated. Trials were included if they lasted at least 6 months and assessed the weight-loss effects of low-carbohydrate diets against low-fat/low-calorie diets. For each study, data were abstracted and checked by two researchers prior to electronic data entry. The computer program Review Manager 4.2.2 was used for the data analysis. Thirteen articles met the inclusion criteria. There were significant differences between the groups for weight, high-density lipoprotein cholesterol, triacylglycerols and systolic blood pressure, favouring the low-carbohydrate diet. There was a higher attrition rate in the low-fat compared with the low-carbohydrate groups suggesting a patient preference for a low-carbohydrate/high-protein approach as opposed to the Public Health preference of a low-fat/high-carbohydrate diet. Evidence from this systematic review demonstrates that low-carbohydrate/high-protein diets are more effective at 6 months and are as effective, if not more, as low-fat diets in reducing weight and cardiovascular disease risk up to 1 year. More evidence and longer-term studies are needed to assess the long-term cardiovascular benefits from the weight loss achieved using these diets.
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