As the COVID-19 pandemic is charting its course into 2022, as health care providers, we have had to adapt and adjust to the transient and shifting environment. Testing for COVID-19 has been in place, and is now part of the standard for preoperative work-up. In addition, covid testing will likely be part of screening any surgical procedure for the foreseeable future.
The challenge of pandemic control is the large pockets of populations in the US and worldwide that do not have protection against the virus and are not vaccinated. Vaccination provides the only proven long-term protection against COVID-19 infection and its long-term persistent health effect. In addition, the complication rate reported in scientific journals is negligible compared to the complication and death rate from the COVID-19 infection.
There are implications of covid infection and general anesthesia published in peer-reviewed journals. The increased risk of general anesthesia after covid infection is related to the severity of the initial infection and the extent of the treatment required, and the persistence of the post covid symptoms, including shortness of breath, fatigue, and laboratory finding elevated inflammatory markers. Long after resolution of the acute COVID-19 symptoms, the most common persistent complaints are fatigue, shortness of breath, Joint and chest pain; and all these increase the risk of post-operative complications (Carfì et al., 2020)
The required delay for surgery may be as short as 2-4 weeks to as long as six months or longer if the persistent symptoms are present. Surgery may not be avoidable in a critical life-threatening situation and may be necessary even with a much-increased risk of complication (Collaborative, 2020). Recovery post-COVID-19 may not be complete with the resolution of the initial symptoms (Dexter et al., 2020)
Recent publications and scientific presentations have also shown the protection that weight loss surgery and maintained weight loss provide in those who come down with the COVID-19 infection (Aminian et al., 2021). However, the rate of weight gain, lack of weight loss is worse for weight loss surgical patients post COVID-19 disorder (Bullard et al., 2021; Conceição et al., 2021). Furthermore, patients with COVID-19 infection post weight loss are at a higher risk of malnutrition (di Filippo et al., 2021; Kikutani et al., 2021). Up to 40% of patients have malnutrition if hospitalized with COVID (Anker et al., 2021).
To summarize, Weight loss and weight loss surgery reduce the severity of the initial COVID-19 infection. However, it increases malnutrition risk, requiring nutritional support and surgical interventions in non-responsive cases.
Aminian, A., Fathalizadeh, A., Tu, C., Butsch, W. S., Pantalone, K. M., Griebeler, M. L., Kashyap, S. R., Rosenthal, R. J., Burguera, B., & Nissen, S. E. (2021). Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity. Surgery for Obesity and Related Diseases, 17(1). https://doi.org/10.1016/j.soard.2020.10.026
Anker, M. S., Landmesser, U., von Haehling, S., Butler, J., Coats, A. J. S., & Anker, S. D. (2021). Weight loss, malnutrition, and cachexia in COVID-19: facts and numbers. In Journal of Cachexia, Sarcopenia and Muscle (Vol. 12, Issue 1). https://doi.org/10.1002/jcsm.12674
Bullard, T., Medcalf, A., Rethorst, C., & Foster, G. D. (2021). Impact of the COVID-19 pandemic on initial weight loss in a digital weight management program: A natural experiment. Obesity, 29(9). https://doi.org/10.1002/oby.23233
Carfì, A., Bernabei, R., Landi, F., & Group, for the G. A. C.-19 P.-A. C. S. (2020). Persistent Symptoms in Patients After Acute COVID-19. JAMA, 324(6), 603–605. https://doi.org/10.1001/jama.2020.12603
Conceição, E., de Lourdes, M., Ramalho, S., Félix, S., Pinto-Bastos, A., & Vaz, A. R. (2021). Eating behaviors and weight outcomes in bariatric surgery patients amidst COVID-19. Surgery for Obesity and Related Diseases, 17(6).
Dexter, F., Elhakim, M., Loftus, R. W., Seering, M. S., & Epstein, R. H. (2020). Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic. Journal of Clinical Anesthesia, 64. https://doi.org/10.1016/j.jclinane.2020.109854
Di Filippo, L., De Lorenzo, R., D’Amico, M., Sofia, V., Roveri, L., Mele, R., Saibene, A., Rovere-Querini, P., & Conte, C. (2021). COVID-19 is associated with clinically significant weight loss and risk of malnutrition, independent of hospitalisation: A post-hoc analysis of a prospective cohort study. Clinical Nutrition, 40(4). https://doi.org/10.1016/j.clnu.2020.10.043
Kikutani, T., Ichikawa, Y., Kitazume, E., Mizukoshi, A., Tohara, T., Takahashi, N., Tamura, F., Matsutani, M., Onishi, J., & Makino, E. (2021). COVID-19 infection-related weight loss decreases eating/swallowing function in schizophrenic patients. Nutrients, 13(4). https://doi.org/10.3390/nu13041113
There has been extensive discussion on the importance of Vitamin D published over the last few years in regards to bone health, immune health and Calcium physiology. The importance of vitmain D and bone structure has been discussed extensively. It is also important in the absorption of Calcium. It further plays role in immune modulation.
What is new is the possible correlation of Vitamin D and COVID 19. Recently it is been shown that low vitamin D may increase the risk of a poor outcome with Covid-19 exposure and infection.
There are different standard recommendation for the Vitamin D levels.
In our practice we aim to maintain a Vitamin D level of 0ver 60 in post weight loss surgical patients.
There are a number of theories as to how the Vitamin D deficiency may play a role in this. An emerging observation is that low Vitamin D may cause abnormal and excessive blood clot formation. Mohammad et. al. in 2019 published a study on the association of low vitamin D and “…Pathogenesis of Thrombosis”
This pathologic blood clot formation in COVID-19 patients may explain the extensive lung injury and multi system organ failure in some patient. It is also one of the reason that some COVID-19 patients have loss limbs or appendages.
Please follow all supplement recommendations based on your laboratory studies and all COVID-19 recommendations. We would recommend frequent hand washing, surface cleaning, social distancing, and wearing face masks as the most basic precautions and increase precautions based on your health status.
Written By: Osheen Abnous, Maria Vardapetyan, Eric Baghdasaryan
Copper is an essential element to all organisms, and it is a contributor in several enzymes vital to the function of hematopoietic, vascular, and skeletal tissues, as well as the structure and function of the nervous system.
As a crucial metal, copper plays an important role in chemical reactions throughout the human body; this includes the central nervous system. Enzymes are substances that facilitate chemical reactions. There are many copper-dependent reactions in the human body. In humans, the major site of absorption of dietary copper is still unclear. Copper in humans is absorbed in the proximal small bowel, duodenum, and ileum. This is after it has passed the acidic environment of the stomach.
Copper deficiency can be caused by malnutrition, prematurity, parenteral or enteral feeding without copper supplementation, gastrectomy, and excessive zinc therapy. The common causes of copper deficiency have been zinc supplementation, and changes to the PH (acidity) of the stomach. This can be the result of the alteration of the stomach anatomy, and by chronic acid suppression by proton pump inhibitors (antacids), and similar medications. Physicians need to be alert with patients who show signs of copper deficiency or are at a high risk of developing a copper deficiency.
It is important to raise greater awareness about copper deficiency because there is a growing number of patients undergoing surgeries for obesity, as the occurrence of copper deficiency will increase in the future.
Studies of patients who have had weight loss surgery in the past experience common symptoms such as pain involving the feet, gait abnormality (unusual walking), lower limb weakness, and recurrent falls. Common lab results include unusually low serum copper and serum ceruloplasmin levels. In some cases, elevated zinc levels are also present. Treatment includes cupric sulfate infusion until normal copper levels are reached, which then need to be maintained for the future. Vitamin B-12 deficiency has also been reported as a possible cause of myelopathy, which is a nervous system disorder that affects the spinal cord. As stated earlier, neurological damages are often irreversible and cause permanent damage to patients. Early diagnosis from physicians is crucial for patients who have undergone gastric bypass surgery, and the sooner they are diagnosed, the less permanent damage the patient will endure.
A 49-year-old woman had gastric bypass surgery for obesity 24 years age. She presetend with increasing lower limb stiffness and numbness. Additionally she reported tingling of the feet. As her pain continued to increase, she began using a walker, and her symptoms continued to worsen. After undergoing a neurological examination, results showed that the patient had increased lower limb tone and an absent perception of vibration at the toes and ankles. Laboratory results showed that the patient had copper levels barely detectable. This included serum copper and serum ceruloplasmin levels. In addition, the patient had reduced serum carotene (vitamin A) levels.
The patient received cupric sulfate intravenously daily through an 8-week period. After each daily infusion of cupric sulfate, the patient reported to have slight decreases in numbness and an increased tingling sensation. After the 8-week period, lab results showed that serum copper levels were normal and are needed to be maintained. Her night blindness was corrected by vitamin A injections.
In another case, a 53-year-old woman had symptoms of abnormal gait (abnormal walking) and anemia (lack of healthy red blood cells), and was seen for evaluation. The patient complained of pain in the lower legs, which would worsen over time and move up towards her thighs. As her ability to walk continued to worsen, the patient resorted to using a wheelchair. Her medical history consisted of an RYGB surgery for obesity. The only significant supplementation she received was 1000 μg vitamin B12 subcutaneously for several years. She had absent positional and vibratory sensation in the lower extremities to the knee. In addition, touch sensation was decreased. Laboratory examination revealed an elevated serum zinc level, and extremely low serum copper and ceruloplasmin levels.
For treatment, the patient received intravenous copper over a 6-day period, was discharged home, and then received weekly intravenous copper infusions thereafter. After a month of receiving intravenous copper, serum copper levels returned to normal. In addition, the patient’s pain in the lower leg improved, but vibratory sensation remained absent in the same area. Four months after being discharged from the hospital, the patient began walking with a cane.
Weight loss surgical procedures, in one form or another, achieve the desired effect of weight loss by altering absorption of fat, protein, and carbohydrates. This results in decreased total absorption of required calories.
An unintended consequence is the altered absorption of medications. Frequently I am asked about the specific medication. Usually the answer is vague since the information is limited on specific medications. If the desired effect is not achieved, then it is probably not being absorbed well. Specially, if the same dose of the same medication working well before surgery.
There is a summary article about the Theoretical absorption pattern of different weight loss surgical procedures.
There are a number of lectures, posting that we have done over the years on this topic. However the questions of osteoporosis medications and their benefits and risks comes up often.
The links are attached:
Here is an updated list of medication that I had previously published. I made some clarification to explain how the medications work. There are different classes of medications and the detail of the action and soda effects were described earlier at a blog post.
The table is obtained from https://www.nof.org site.
Obesity is related to as many as 400,000 deaths each year in the US and it has increasingly been recognized as a risk factor for several nutrient deficiencies. This may seem surprising given the likelihood of over consumption of calories, however these additional calories are not from nutritious sources. One of the main reason for these nutritional deficits is the greater availability of inexpensive foods that are rich in calories and are nutrient deficient. This has led some medical professional to conclude that there is a certain group of people who are overfed but undernourished. Even with the epidemic of the obesity, there is significant nutritional deficiencies noted.
Obese subjects have increased blood volume, cardiac output, adiposity, lean mass and organ size all of which can influence volume of distribution, in addition, treatment for severe obesity involving surgical procedures can worsen these nutrient deficiencies and in some cases may cause new ones to develop.
This table shows the percentage of population below the estimated average requirement (EAR) by body weight status in adults more tan 19 years old, showing that almost 90 to 100 percent of people including normal weight (NW) are below the EAR of vitamin D and Vitamin E.
Nutritional deficiencies in obese patients may promote the development of chronic diseases including increased insulin resistance, pancreatic B-cell disfunction and diabetes, this is because specific micronutrients are involved in glucose metabolic pathways; There are other chronic diseases related to obesity that are being investigated such as decrease in focal grey matter volume and cognitive impairment or inadequate sleep due to low intake of antioxidant vitamins.
We would like to thank Miguel Rosado, MD for his significant contribution provided for this Blog.
Vitamin A is one of the 4 fat soluble vitamins along with vitamin D, Vitamin E and Vitamin K. It is multifunctional and essential which means that it is not produced by the body. In this article we will touch on aspects of Vitamin A absorption and it’s effect on wound healing as well as its metabolism.
We often think of Vitamin A as the critical vitamin for vision, however it has several other roles that related to immune function, protein synthesis, and cellular communication. Vitamin A deficiency is a concern world wide because of the natural of the side effects. Vitamin A deficiency is the leading cause of preventable childhood blindness in the world according to UNICEF and sometimes it may be undetected until there is irreversible damage.
There are 2 chemical forms of vitamin A in diet:
Retinoids (Preformed vitamin A) This group include retinol, retinyl esters, and retinal they are mostly found in animal sources like liver, egg yolk or fish oils.
Carotenoids (Provitamin A) This group includes beta-carotene, alpha-carotene and lycopene, mainly found in plant sources like leafy vegetables or yellow/orange vegetables and fruits.
1.- Ingested food is digested in the stomach where retinyl palmitates (esters) are released from proteins. Retinol and beta-carotene are absorbed directly into the small intestine where retinyl esters and betacarotene are transformed into retinol . Retinol is the most easily absorbed form of vitamin A.
2.-That retinol absorbed by the enterocytes in the ileum (small intestine) along with bile is then transported to the liver with the help of chylomicrons a protein that transports fat.
3.-Fifty to 80% of the vitamin A is stored in the liver and the remaining is deposited into adipose tissue, lungs and kidneys.
4.-When stored retinol is released from the liver into the circulation to target organs, it is bound to plasma retinol-binding protein (RBP4) a transporting protein produced by the liver that requires ZINC, which is synthesized by the liver; This complex is stabilized by transthyretin (TTR), which reduces renal excretion.
Retinol is a crucial component for reproduction, embryological development, cellular differentiation, growth, protein synthesis, and immunity in the form of retinoic acid and vision in the form of retinal.
One of Vitamin A additional roles is in epithelial health of skin and mucous membranes. It increases epithelial turnover which is crucial during would healing. It also has anti-oxidative effects which prevent cell damage and can prevent or reverse the effects of other damaging agents. In addition to these benefits it has also been associated with increasing collagen, fibronectin, keratinocytes and fibroblast, all important in wound tissue structure. There have been some studies that suggest giving higher doses of Vitamin A in patients with non or slow healing wounds.
It is important to remember that we have documents delayed diagnosis of adult vitamin A deficiency leading to significant night blindness in adults. It is critical that the patients and their primary care physicians are acutely aware of this possibility. In majority of the patients with low vitamin A, post weight loss surgery, aggressive supplementations, including injections need to be considered as a part of the treatment regimen.
We would like to thank Miguel Rosado, MD for his significant contribution provided for this Blog.
The small intestine is a long tubular organ that is approximately 460-1000cm in adults. It is divided into three sections, Duodenum, Jejunum, and Ileum. The surface area is greater than one might think due to the folds, villi, and microvilli. The surface area is approximately 30 square meters. Most of human digestion and absorption takes place within these three sections of small intestine.
The diagram of normal anatomy absorption in the small intestine is pictured to the right. It is color coded based on the area of the digestive tract the absorption takes place. You may also view here: master-normal-anatomy-with-text
Length: 22 ft. (6.7 m)
Width: 1 inch
pH: neutral or slightly alkaline (5-7)
- Neutralization in stomach, where enzymes act to breakdown food
- Digestion through greater breakdown with help of bile and pancreatic juices
- Absorption through assimilation of digested food, vitamins, and salts. Nutrients are taken into the bloodstream via specialized epithelial cells to the liver through the hepatic portal vein.
Length: 1 ft. (0.30 m)
- Main site of breakdown
- C shaped turn with 4 parts: superior, descending, inferior, ascending
- Mixes food (now in form of chyme) with bile and other digestive juices
- Passes chyme through duodenojejunal flexure which contains suspensory muscle to widen the duodenal angle and increase movement.
Length: 8.2 ft. (2.5 m)
- Coiled, vascular tube that contains a thick intestinal wall
- The wall contains epithelial projections called intestinal villi
- Smaller projections in the villi, called microvilli work to:
- project specialized transport cells called enterocytes
- increase surface area
- allow more absorption
Length: 11.5 ft. (3.5 m)
- Less vascularized and thinner intestinal wall
- Absorbs nutrients that preceding sections of the gut did not
- particularly works with vitamin B12 and bile salt absorption
- Connects to the colon through the ileocecal valve for further breakdown.
Click for:RNY Absorption Anatomy (1.1 MB)
- Campbell NA, Reece JB, Mitchell LG. Biology. 5th ed. Benjamin-Cummings Pub Co. 1999-2002; 802-805.
- Ovesen L, Bendtsen F, Tage-Jensen U, Pedersen NT, Gram BR, Rube SJ. Intraluminal pH in the stomach, duodenum, and proximal jejunum in normal subjects and patients with exocrine pancreatic insufficiency. Gastroenterology. 1986; 90(4): 958-62.
- Stevens C. E., and Hume, I. D. 1995.Comparative Physiology of the Vertebrate Digestive System. 2nd ed. New York: Cambridge University Press.
- Schmidler C. Anatomy and Function of the Digestive System. Healthpages.org. 2016.
Duodenal switch (DS) operation results in the highest success rate of all weight loss surgical procedures. Patients, over time, will experience some weight gain many years after DS procedure. There are a number of suspected mechanisms that may be responsible for the weight gain:
1-Ageing may slow the metabolism and the activity down.
2-Over time patients may not be as adherent to healthy dietary and lifestyle changes as they may have been immediately after surgery.
3- Hypertrophy of the alimentary and common channels over time increases in surface area f allowing greater caloric absorption leading to increased weight gain.
It has been demonstrated in bowel resection studies, as well as rat studies, that the nutrient stimulated regions of small intestine increase villus height and total weight, crypt depth and proliferation as well as wall thickness, as an adaptation to compensate for the loss of absorptive capacity in the resected bowel. This observation may be applied to DS procedure as seen in histological slides from a patient who had to have an operation done requiring bowel resection. The segment of the bowel resected included the junction of the biliopancreatic, common and alimentary limbs.