osteoporosis cuando no hay estómago: cirugía bariátrica y...

Carlos Grant del Rio. MD, PhD Diabetólogo – Endocrinólogo

Profesor Titular Facultad Medicina y Farmacia Universidad de Concepción, ChileSub Director Servicio Salud Concepción

Osteoporosis cuando no hay estómago: cirugía bariátrica y cirugía por cáncer

[email protected]

Gastrectomía empeora metabolismo óseo, condicionando mayor riesgo

de osteoporosis ?

• Cambios en parámetros del metabolismo calcio-fosforo

• Modificaciones en marcadores de turnover óseo

• Cambios en densidad mineral ósea

• Causas del deterioro metabolismo óseo

Temario Cirugia bariátrica empeora metabolismo óseo,

condicionando mayor riesgo de osteoporosis ?

Cambios en metabolismo calcio-fosforo según tipo de cirugía bariátrica

Folli N y cols. International Journal of Obesity 1373 – 1379, 2012

Repercusión en metabolismo óseo??

Journal of Bone and Mineral Research, Vol. 30, 1377–138, 2015

Cambios en calcio y hormonas calciotrópica a los 6 meses de

bypass gástrico Y de Roux

n=33

Clinical Endocrinology. 2018;88:372–379.

Disminución de absorción de calcio a los 6

meses de bypass gástrico

Absorción intestinal de calcio disminuye de forma significativa post bypass gastrico a pesar de optimización de los niveles de Vitamina D


Prevalencia de hiperparatiroidismo secundario

post cirugía gástrica

Clinical Endocrinology. 2018;88:372–379.

Indicaciones de medición de vitamina D?

• Grupos de riesgo:• Embarazo y en lactancia

• Desnutrición

• Adultos mayores con historia de caídas o fracturas

• Osteoporosis

• Baja exposición solar

• Sujetos piel morena

• Síndrome de malabsorción: Crohn, celiaca

Grupos de riesgo: Enfermedades granulomatosas: TBC, sarcoidosis

Antiepilépticos, Glucocorticoides, antimicóticos, VIH

Insuficiencia hepática

Hiperparatiroidismo

TFG < 60%

Síndrome Nefrótico

Obesidad

Cirugía bariátrica

J Clin Endocrinol Metab, July 2011, 96(7):1911–1930

Experimental Biology and Medicine 2017; 242: 1086–1094.

• The initial vitamin D deficiency, prior to any surgical procedure of obese patients.

• Inadequate vitamin D supplementation during rapid weight loss induced by bariatric surgery.

• Bile salt deficiency associated with bariatric surgery procedures (the absorption of vitamin D requires thepresence of bile salts).

• Malabsorption of vitamin D sometimes due to intestinal bacterial overgrowth problems.

• The absorption of vitamin D which basically occurs next to the jejunum and ileum can be affected by thedelayed blend of nutrients ingested with bile acids and pancreatic enzymes.

Mecanismos

Journal of Bone and Mineral Research, Vol. 30, No. 8, August 2015, pp 1377–1385

Cambios en marcadores óseos y DMO precozmente (6 meses)

post bypass gástrico

Mecanismos responsables de la perdida ósea post cirugía bariátrica


Las flechas rojas indican inhibición, y las flechas verdes indican estimulación.

Hasta el 2012…..no se reconocía efectos de citoquinas - neuropéptidos sobre el

metabolismo óseo post cirugía gastrica


Pero rápidamente se han ido conociendo papel de hormonas

citoquinas y neuropeptidos post by pass gastrico Y de Roux

Impacto en el hueso

Osteoporos Int. 25:423–439,2014

Cambios en composición corporal y parámetros metabólicos a los 6 meses de

Bypass gástrico Y de Roux


Journal of Endocrinology, 2018

Efectos de GLP-1 en metabolismo óseo

Necesario evaluación permanente y a largo

tiempo

Shanbhogue V y cols, European Journal of Endocrinology, 176:685-693, 2017

• Objective, design and methods: Roux-en-Y gastric bypass (RYGB) has proved successful in

attaining sustained weight loss but may lead to metabolic bone disease.

• To assess impact on bone mass and structure, we measured a real bone mineral density at

the hip and spine by dual-energy X-ray absorptiometry, and volumetric BMD (vBMD) and bone

microarchitecture at the distal radius and tibia by high-resolution peripheral quantitative CT in

25 morbidly obese subjects (15 females, 10 males) at 0, 12 and 24 months after RYGB.

• Bone turnover markers (BTMs), calciotropic and gut hormones and adipokines were measured

at the same time points.

Características generales basales, y cambios bioquímicos y densitométricos al

año y 2 años del bypass gástrico

2 años


Geometria ósea, DMO, microarquitectura, basales, al año y 2 años del bypass

gástrico



• After a 24.1% mean weight loss from baseline to month 12 (P < 0.001), body weight plateaued

from month 12 to 24 (−0.9%, P = 0.50).

• However, cortical and trabecular vBMD and microarchitecture deteriorated through the 24

months, such that there was a 5 and 7% reduction in estimated bone strength at

the radius and tibia respectively (both P < 0.001).

• The declines observed in the first 12 months were matched or exceeded by declines in the 12-

to 24-month period.

• While a significant increase in BTMs and decrease in leptin and insulin were seen at 24

months, these changes were maximal at month 12 and stabilized from month 12 to 24.

Results:


Despite weight stabilization and maintenance of metabolic parameters,

bone loss and deterioration in bone strength continued and were

substantial in the second year.

The clinical importance of these changes in terms of increased risk of

developing osteoporosis and fragility fractures remain an important

concern.

Conclusion:

La prevalencia de hiperparatiroidismo secundario (HPTS) en pacientes obesos es elevada, por deficiencia de vitamina D

ORIGINAL CONTRIBUTIONS

High Incidence of Secondary Hyperparathyroidism in Bar iatr icPatients: Compar ing Different Procedures

Jih-Hua Wei 1,2,3&Wei-Jei Lee4

&Keong Chong1&Yi-Chih Lee5

&Shu-Chun Chen4&

Po-Hsun Huang2,6,7&Shing-Jong Lin2,7

# Springer Science+Business Media, LLC 2017

Abstract

Background Bariatric surgery isan effective therapy for mor-

bid obesity but may reduce calcium absorption and signifi-

cantly decreasethebonemineral density. Thisstudy examined

the prevalence of secondary hyperparathyroidism (SHPT) in

obese subjects during follow-up after different bariatric sur-

geries. We investigated predictors of SHPT.

Methods We enrolled 1470 obese subjects undergoing

bariatric/metabolic surgery with at least 1-year follow-up, in-

cluding 322 patients undergoing Roux-en-Y gastric bypass

(RYGB), 695 undergoing single anastomosis (mini-) gastric

bypass (SAGB), 93 undergoing laparoscopic adjustable gas-

tricbanding (LAGB), and 360 undergoing sleevegastrectomy

(SG). Five years of data were available for 215 patients.

Patients were instructed to supplement their diet according

to the guideline. Calcium, parathyroid hormone (PTH), and

vitamin D levels were measured before surgery and at 1 and

5 yearsafter surgery. SHPT wasdefined asPTH > 69 pg/mL.

Results The overall prevalence of SHPT was high, 21.0%

before surgery and was not different between patients with

different bariatric procedures. Pre-operative PTH correlated

with age, BMI, and vitamin D levels. Multi-variate analysis

confirmed that vitamin D level wastheonly independent pre-

dictor of SHPT before surgery. The prevalence of SHPT in-

creased to 35.4% at 1 year after surgery and 63.3% at 5 years

after surgery. SAGB had the highest prevalence of SHPT

(50.6%) followed by RYGB (33.2%), LAGB (25.8%), and

SG (17.8%) at 1 year after surgery. At 5 years after surgery,

SAGB still had the highest prevalence of SHPT (73.6%),

followed by RYGB (56.6%), LAGB (38.5%), and SG

(41.7%). Serum PTH at 1 year after surgery correlated with

decreased BMI and weight loss. Multi-variate analysis con-

firmed that age, sex, calciumlevel, andbypassprocedurewere

independent predictor of SHPT after surgery.

Conclusions The prevalence of SHPT is high in morbidly

obese patients before bariatric surgery which is related to vi-

tamin D deficiency. The prevalence of SHPT increased con-

tinually along with the time after bariatric surgery, especially

in patients receiving SAGB, followed by RYGB. Thesupple-

mentation of vitamin D and calcium have to be higher in

bypass procedure, especially in malabsorptiveprocedure.

Keywords Bariatricsurgery . Morbidobesity .

Hyperparathyroidism

Introduction

Bariatric surgery is the most effective treatments for morbid

obesity, resulting in significant weight loss and resolution of

comorbidities[1, 2]. Long-term datahaveshown that bariatric

* Wei-Jei Lee

[email protected]

1 Department of Internal Medicine, Min-Sheng General Hospital,

Taoyuan, Taiwan

2 Instituteof Clinical Medicine, National Yang Ming University,

Taipei, Taiwan

3 Department of Nutrition and Health Sciences, School of Healthcare

Management, Kai-Nan University, Taoyuan, Taiwan

4 Department of Surgery, Min-Sheng General Hospital, No. 168, Chin

Kuo Road, Tauoyan, Taiwan, Republic of China

5 Department of International Business, Chien Hsin University of

Scienceand Technology, Taoyuan, Taiwan

6 Department of Medical Research, Taipei Veterans General Hospital,

Taipei, Taiwan

7 Division of Cardiovascular Medicine, Department of Internal

medicine, Taipei VeteransGeneral Hospital, Taipei, Taiwan

OBES SURG

DOI 10.1007/s11695-017-2932-y¿Se modifica la prevalencia de HPTS según tipo de cirugía realizada ?

Wei J y cols. OBES SURG 28:798–804, 2018

Características basales y al años post cirugía

322 patients undergoing Roux-en-Y gastric bypass (RYGB), 695 undergoing single anastomosis (mini-) gastric bypass (SAGB), 93 undergoing

laparoscopic adjustable gastric banding (LAGB), and 360 undergoing sleeve gastrectomy (SG).


Hiperparatiroidismo secundario a los 5 años post cirugía bariátrica


Tipo de procedimiento se correlaciona con prevalencia de HPTS

Predicción de HPTS según estudio de regresión

multivariable al año de la cirugía


ORIGINAL CONTRIBUTIONS

Effect of Bar iatr ic Surgery on Bone Mineral Density:Compar ison of Gastr ic Bypass and Sleeve Gastrectomy

Nuria Vilarrasa &Amador G. Ruiz de Gordejuela &Carmen Gómez-Vaquero &

Jordi Pujol &Iñaki Elio &Patr icia San José&Silvia Toro &Anna Casajoana &

JoséManuel Gómez

# Springer Science+Business Media New York 2013

Abstract The aim of our study was to compare bone mineral

density (BMD) a year after Roux-en-Y gastric bypass (RYGB)

and sleeve gastrectomy (SG) in age- and body mass index-

matched women. In 33 morbidly obese women undergoing

RYGB and 33 undergoing SG, plasma determinations of calci-

um, parathyroidhormone(PTH), 25-hydroxyvitaminD (25(OH)

D3), and insulin-likegrowth factor-I (IGF-I) weremadeprior to

and at 12 months after surgery. Dual-energy X-ray absorptiom-

etry was performed in all patients 1 year after surgery. BMD at

the femoral neck and the lumbar spine 1 year after surgery was

similar in women undergoing RYGB and SG (1.01±0.116 vs.

1.01±0.122g/cm2, p=0.993; 1.05±0.116vs. 1.08±0.123g/cm2,

p=0.384). Thepercentageof patients with osteopeniaand oste-

oporosis was not different between groups. In the linear regres-

sion analysis, age (β=−0.628, p=0.034) and lean mass 12

months after surgery (β=0.424, p=0.021) were found to be the

main determinants of femoral neck BMD. Age (β=−0.765,

p=0.025), menopause (β=−0.898, p=0.033), and lean mass

(β=0.615, p=0.023) were determinants of BMD at the lumbar

spine. No influencewasfound between low bonemassand type

of surgery, plasma PTH, 25(OH) D3, or IGF-I. The effect of

RYGB and SG on BMD was comparable a year after surgery.

Menopausal women were at a higher risk of having low bone

mass, but thepresenceof osteoporosis wasuncommon.

Keywords Bonemineral density . Gastricbypass . Sleeve

gastrectomy . Leanmass . PTH . 25-Hydroxyvitamin D

Introduction

Bariatric surgery isthemost effectivemethod to achievemajor,

long-term weight loss. It improves all obesity-related

comorbidities, the quality of life, and decreases the overall

mortality [1, 2]. However, patientsundergoingbariatric surgery

are at risk of developing several metabolic sequels, including

bonedisease. Regarding this, bariatric interventionsareknown

to represent a challenge to bone physiology although many

aspects of this surgical complication still remain unclear.

Multiplemechanismsmay beimplicated in bonelossafter

bariatric surgery. One of the most relevant is the decrease in

the skeletal load, which is common to restrictive and

malabsorptive surgical techniques [3]. In malabsorptive

techniques, the impairment of calcium and vitamin D ab-

sorption, which predisposesindividuals to hypocalcemiaand

secondary hyperparathyroidism, also contributes to bone

loss [4, 5]. Roux-en-Y gastric bypass(RYGB) isatechnique

characterized by being essentially restrictivebut also causing

moderatemalabsorption [6]. Multiple studieshaveevaluated

the influence of RYGB on bone mass and indicate that there

is an increase in bone resorption and a reduction in bone

mineral density (BMD) which is at a maximum in the first

year after surgery and takes place mainly in the hips [7–12].

Few studies have described BMD after purely restrictive

techniques such as gastric banding and vertical gastroplasty.

A measurable but modest loss of BMD at the femoral neck,

but not at the lumbar spine, has been reported 1 year after

gastric banding and vertical-banded gastroplasty [13–18].

In spite of previous exposed data on the effect of restric-

tive and RYGB surgery on bone metabolism, to date, it has

been very difficult to evaluate the independent contribution

to bone disease of weight loss and malabsorption.

N. Vilarrasa (* ) : I. Elio : P. San José: S. Toro : J. M. Gómez

Endocrinology Service, CIBER de Diabetes y Enfermedades

Metabólicas Asociadas (CIBERDEM), Bellvitge University

Hospital-IDIBELL, C/ Rambla Just Oliveras, Nº 64,

3º2ªescaleraA, 08901, L’Hospitalet deLlobregat Barcelona, Spain

e-mail: [email protected]

A. G. R. de Gordejuela: J. Pujol : A. Casajoana

Department of Bariatric Surgery, Bellvitge University

Hospital-IDIBELL, L’Hospitalet de Llobregat Barcelona, Spain

C. Gómez-Vaquero

Rheumatology Service, Bellvitge University Hospital-IDIBELL,

L’Hospitalet de Llobregat Barcelona, Spain

OBES SURG

DOI 10.1007/s11695-013-1016-x

By Pass Y de Roux

Previo cirugía 12 meses post cirugía

Gastrectomia en manga

Previo cirugía 12 meses post cirugía

Cambios en parámetros bioquímicos según tipo de cirugía

Vilarasa y cols, Obes Surg, 2018


Cambios densitométricos según cirugía

Conclusion

In summary, our data showed that the effect of RYGB and SG on BMD was

comparable a year after surgery.

Menopausal women were at higher risk of having low bone mass, even though

the presence of osteoporosis was uncommon.

The type of surgery, plasma concentrations of PTH, vitamin D, or IGF-I did not

influence BMD after the intervention.

However, further studies are needed to survey the impact of new techniques

such as SG on bone metabolism.


Pediatric Obesity 12, 239–246, June 2017

¿ Existe diferencia en riesgo de fractura según cirugía bariátrica realizada ?

Yu W Elaine y cols. Journal of Bone and Mineral Research, Vol. 32, No. 6, 1229–1236, 2017

Pacientes libre de fractura según tipo cirugía

bariátrica Curva Kaplan-Meir

P < 0.001

RYGB: bypass Y de Roux

AGB; banda gástrica ajustable

Riesgo de Fractura no vertebral con bypass Y de

roux vs banda gástrica (referencia)


Banda gástrica

Bypass Y roux

Incidencia (IRs) y riesgo relativo de fracturas


Con Bypass gástrico, pero NO con banda se produce mayor riesgo de fracturas solo en grupo de edad entre 45-55 años


Realidad de los pacientes estudiados

• Menos del 4% de los pacientes sometidos acirugía bariátrica tenían densitometría óseaprevia a la cirugía

• Solo el 11% de los pacientes con RYGB y el9% de los pacientes con AGB, tuvieronestudios de densitometría en el seguimientopost cirugía

• Se demuestra grandes diferencias entre lasrecomendaciones y la vida real.


Se demuestra que con RYGB se produce un

43% de incremento de riesgo de fracturas

clínicamente relevantes vs AGB

El mayor riesgo se observa a partir de los 2

años, principalmente en cadera y muñeca

Según el riesgo basal de fractura se debe elegir

el TIPO de cirugía bariátrica a realizar

Se debe considerar el seguimiento a largo plazo

en pacientes sometidos a cirugía bariátrica,

especialmente en aquellos con RYGB

• Metaanálisis : 5 estudios observacionales y 1 estudiorandomizado controlado con placebo

• 1003 pacientes• Riesgo de fractura en obesos morbidos• The Newcastle-Ottawa Scale was used to evaluate the

quality of the observational studies, and the Jadad scoreevaluated randomized controlled trials

Zhang y cols.Obesity reviews, Enero 2018

Incremento del riesgo de fractura en pacientes con cirugía bariátrica

Incremento del riesgo de fractura en según años de cirugía


Sitio de fracturas

Tipo de cirugía


• Risk for any type of fracture was higher in the surgical group than in

the non-surgical group (risk ratio [RR] 1.29, 95% confidence interval

[CI] 1.18–1.42).

• After surgery, the fracture risk in non-vertebral sites was significantly

increased, especially in the upper limbs (RR 1.42, 95% CI 1.08–1.87;

and RR 1.68, 95% CI 1.15– 2.45).

• Compared with those with restrictive procedures, subjects who

underwent mixed restrictive and malabsorptive procedures tended to

have an increased fracture risk (RR 1.54, 95% CI 0.96–2.46).

Conclusiones


¿ Que pasa con la densidad mineral

ósea post gastrectomía por cáncer gástrico ?

¿ El impacto es diferente según tipo de cirugía ?

Noh et al. Medicine, 97:1. 2018

Gastrectomía produce mayor deterioro de la densidad mineral ósea vs

terapia endoscópico

Noh et al. Medicine, 97:1. 2018

a; P= 0.028b; P= 0.022c; P= 0.137

-7.17

-6.30

-3.49

Gastrectomía produce mayor perdida de DMO que el tratamiento endoscópico entre los sobrevivientes de

cáncer gástrico en etapa temprana.

Y que pasa con riesgo de fracturas?

Abstract Aim: Gastrectomy is a known riskfactor for decreased bone mass. We aimed toevaluate the cumulative incidence andpredictive factors of fracture in gastric cancerpatients who underwent gastrectomy.

Method: We retrospectively reviewed therecords of 1687 patients who underwentgastrectomy for gastric cancer at our hospitalbetween September 1991 and December2008. The exclusion criteria were stage IVgastric cancer, history of cancer recurrence,medical conditions that cause osteoporosisand high-energy injury. Fractures at sitesconsidered to be associated withosteoporosis were diagnosed radiologically

H.J. Oh et al. / European Journal of Cancer 72 (2017) 28e36

H.J. Oh et al. / European Journal of Cancer 72 (2017) 28e36

Incidencia acumulativas de fracturas

Recomendaciones manejo pre y post cirugía bariátrica

Experimental Biology and Medicine 2017; 242: 1086–1094

Endocrinol Metab Clin N Am 46 (2017) 947–982

Recomendaciones

• Citrato de calcio y Vitamina D (3000 UI /diaria)

• Medición periódica de 25-hydroxyvitamin D, PTH, calcio urinario

• Densitometría ósea basal y a los 2 años de la cirugía bariátrica

Gastrectomía condiciona empeoramientodel metabolismo óseo

Necesario elegir tipo de cirugía enpacientes con alto riesgo de osteoporosis

Necesario control clínico e imagenologicode forma continua en pacientes operados

Aumenta riesgo de fracturas

Necesidad de terapias de sustitución

Carlos Grant del Rio. MD, PhD Diabetólogo – Endocrinólogo

Profesor Titular Facultad Medicina y Farmacia Universidad de Concepción, ChileSub Director Servicio Salud Concepción

Osteoporosis cuando no hay estómago: cirugía bariátrica y cirugía por cáncer

NATURE REVIEWS | ENDOCRINOLOGYVOLUME 8 | SEPTEMBER 2012 | 545

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