Ketogenic Diet for Obese COVID-19 Patients: Is Respiratory Disease a Contraindication? A Narrative Review of the Literature on Ketogenic Diet and Respiratory Function

Morbid obese people are more likely to contract SARS-CoV-2 infection and its most severe complications, as need for mechanical ventilation. Ketogenic Diet (KD) is able to induce a fast weight loss preserving lean mass and is particularly interesting as a preventive measure in obese patients. Moreover, KD has anti-inflammatory and immune-modulating properties, which may help in preventing the cytokine storm in infected patients. Respiratory failure is actually considered a contraindication for VLCKD, a very-low calorie form of KD, but in the literature there are some data reporting beneficial effects on respiratory parameters from ketogenic and low-carbohydrate high-fat diets. KD may be helpful in reducing ventilatory requirements in respiratory patients, so it should be considered in specifically addressed clinical trials as an adjuvant therapy for obese patients infected with SARS-CoV-2.

P073 SYNCHRONOUS VERSUS DELAYED SURGICAL TREATMENT OF MORBID OBESITY AND VENTRAL HERNIA. PRELIMINARY RESULTS OF A RETROSPECTIVE SINGLE CENTER STUDY

Aim The worldwide increase in morbid obese patients raises controverises regarding the best timing of treatment for concomitant ventral hernias (VH). We present the preliminary experience at a referral center for bariatric surgery (BS): synchronous versus delayed ventral hernia repair (S-VHR, D-VHR) have been compared. Material and Methods From 2009, 40 consecutive morbid obese patients eligible for BS presented with concomitant VH. Symptoms and characteristics of the VH were evaluated to choose between S-VHR (28 patients), primary (n = 12) or mesh augmented (n = 16), and D-VHR (12 patients). 90-day postoperative complications and hernia recurrence were evaluated. Results 3 patients out of 16 in the mesh group experienced superficial surgical site infections. 4 patients in the D-VHR had a bowel incarceration within 20 days after BS and required emergency surgery with mesh implantation. No complications occurred in the primary repair group. The recurrence rate was around 19% in both groups of the S-VHR. Nonetheless the group that received mesh repair had a significant higher mean value of the defect. In the D-VHR cohort 1 patient was lost at follow up while 3 patients were not operated on due to inadequate weight loss. No recurrences occurred in the 4 patients requiring emergency surgery. Conclusions: D-VHR is associated with worse early postoperative outcomes; primary suture repair should be considered in preventing bowel incarceration but synchronous mesh repair is preferred in large symptomatic hernias for its acceptable postoperative morbidity and hernia recurrence at 1 year.

Contributing Factors of Excessive Daytime Sleepiness in Morbid Obese Patients with Obstructive Sleep Apnea

Background: Obesity, obstructive sleep apnea (OSA), and excessive daytime sleepiness (EDS) are common conditions and are interrelated. Obesity is a risk factor for OSA and independently associated with EDS. We aimed to evaluate frequency of EDS in morbid obese patients with OSA and to identify contribution factor for EDS.Methods: This was a retrospective cross-sectional study in single sleep center. Consecutive patients with OSA (with apnea-hypopnea index 5/h or more) with morbid obesity (body mass index over 35 kg/m2) was enrolled. EDS were defined as Epworth Sleepiness Scale of 10 points or more. Clinical and polysomnographic variables were compared between those with and without EDS.Results: Total 110 morbid obese patients with OSA were enrolled, and 34 (31%) of them had EDS. Those with EDS had higher subjective symptom of insomnia and depression. Rapid eye movement sleep latency was shorter and minimum saturation was lower for those with EDS. Multivariate logistic regression analysis identified insomnia severity (odds ratio, 1.117) and minimum saturation (odds ratio, 0.952) as independent contribution factor for EDS.Conclusions: Result of this study suggest that 31.4% of morbid obese patients with OSA have EDS, and it can be affected by insomnia severity and desaturation during sleep.

Successful Management of Abdominal Wound Dehiscence with Bogota bag, Vacuum assisted Closure combined with Tension Sutures

The burst abdomen management has advanced significantly. Here we present a management of a burst abdomen of morbid obese patient with combination of modality including Bogota bag, vacuum assisted closure and tension suturing. The patient underwent laparotomy for removal of sigmoid tumor with local infiltration and had wound dehiscence associated with infection, tissue oedema and necrosis. As patient was morbidly obese and had large wound gap, we decided to manage it with Bogota bag principal and Vacuum Assisted Closing. After successful formation of granulation tissue, we were able to apply tension sutures. Hence using combination of above-mentioned options, the patient was successfully sent back to his normal routines without any complication.

Decreased left atrial function in morbid obese patients without known cardiac disease

Background Obesity is an important risk factor for atrial fibrillation and heart failure. However, little is known about the underlying pathophysiology. Left atrial (LA) dysfunction due to diastolic dysfunction and chronic volume overload may play a significant role in morbid obesity. Purpose To compare LA function in morbid obese and non-obese individuals, and secondly, to determine whether LA function in morbid obese patients improves one year after bariatric surgery. Methods Data of morbid obese patients without known cardiac disease included in the CARdiac Dysfunction In Obesity (CARDIOBESE) study were used. Patients and age- and gender matched non-obese controls underwent transthoracic echocardiography. In the morbid obese patients echocardiography was repeated 1 year after bariatric surgery. LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were analyzed with speckle tracking using dedicated software (TomTecArena, integrated in Sectra IDS7). Results 64 morbid obese patients were compared with 46 non-obese controls. Obese patients had significantly decreased LA function compared with non-obese individuals (LASr 39.6±10.8% vs 31.3±8.3%, p<0.001; LAScd −24.9±8.3% vs −19.5±7.2%, p<0.001; LASct −14.7±5.3% vs −11.8±3.5%, p=0.002). There was no significant difference in diastolic function between the non-obese and morbid obese group (normal function 38.2% vs 52.7%, intermediate function 3.6% vs 4.5%, dysfunction 0% vs 0.9%, p=0.689). In 47 obese patients LA strain did not improve significantly 1 year after bariatric surgery, although there was a trend of improvement in all phases of LA function (LASr 31.0±8.2% vs 33.1±8.2%, p=0.089; LAScd −19.4±7.1% vs −20.4±6.6%, p=0.349; LASct −11.6±3.3% vs −12.8±5.4%, p=0.151). Conclusions Morbid obese patients without known cardiac disease have impairment in all phases of LA function. This subclinical cardiac dysfunction would have remained largely unmasked with assessment of diastolic function according to current guidelines, as shown by the comparable proportion of obese and non-obese individuals with diastolic dysfunction. LA dysfunction in obesity may therefore be an early sign of cardiac disease and a predictor for developing atrial fibrillation and heart failure. LA function did not improve one year after bariatric surgery. Longer follow-up after bariatric surgery may be needed to investigate whether improvement of LA function will occur after a longer period following weight loss surgery. FUNDunding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): BeterKeten Outcomes of the study population Left atrial strain outcomes

Low Levels of Serum Fetuin-A and Retinol-Binding Protein 4 Correlate with Lipoprotein Subfractions in Morbid Obese and Lean Non-Diabetic Subjects

Background: Fetuin-A and retinol-binding protein 4 (RBP4) are secreted as both hepatokine and adipokine. These are involved in insulin resistance, obesity-related dyslipidemia, and atherosclerosis. To date, correlations of circulating fetuin-A and RBP4 with lipoprotein subfractions as well as high-density lipoprotein (HDL)-linked proteins have not been entirely investigated in morbid obese and lean non-diabetic subjects. Methods: One-hundred obese non-diabetic patients (body mass index, BMI: 42.5 ± 8.1 kg/m2) along with 32 gender and age-matched normal weight controls (BMI: 24.5 ± 2.5 kg/m2) were enrolled in our study. Serum fetuin-A and RBP4 were measured by ELISA. Lipoprotein subfractions were distributed by Lipoprint gelelectrophoresis. Results: Serum fetuin-A and RBP4 were unexpectedly lower in obese patients (p < 0.01 and p < 0.01, respectively) compared to controls and correlated with each other (r = 0.37; p < 0.001). Fetuin-A had positive correlations with HDL-C (r = 0.22; p = 0.02), apolipoprotein AI (apoAI) (r = 0.33; p < 0.001), very-low density lipoprotein (VLDL) subfraction (r = 0.18; p = 0.05), and large HDL subfraction levels (r = 0.3; p = 0.001) but did not show correlation with carbohydrate parameters in all subjects. RBP4 correlated positively with HDL-C (r = 0.2; p = 0.025), apoAI (r = 0.23; p = 0.01), VLDL subfraction (r = 0.37; p < 0.001), intermediate HDL subfraction (r = 0.23; p = 0.01), and small HDL subfraction (r = 0.21; p = 0.02) concentrations, as well as C-peptide levels in overall participants. Backward stepwise multiple regression analysis showed that serum fetuin-A concentration is best predicted by RBP4 and large HDL subfraction. In model 2, VLDL subfraction was the independent predictor of serum RBP4 level. Conclusions: Our data may indicate a potential role of fetuin-A and RBP4 in impaired lipoprotein metabolism associated with obesity.