Invited commentary

after the operation chosen for biopsy may be important. Regardless of the pathogenetic mechanism, most bone disease associated with reduction of the mineral content appears to end up as osteoporosis with bone fragility and fracture [1 ]. The authors have not been able to solve the question as to whether the post-gastrectomy bone changes are progressive or self-limiting. This may be due to the complicated interaction between the age of the patient at the time of surgery, the loss of mineral with age, and the loss due to gastric surgery. Also, the time of observation is comparatively short with too little variation. Therefore, the authors may not be entirely justified in drawing the conclusion that "none of the gastric operations that we evaluated seems to carry an appreciable risk of bone demineralization of clinical importance." The decrease of bone mineral content in individuals with fractures related to bone fragility, as shown by several authors, is fairly moderate. An example is presented in the accompanying Figure. Therefore, as these patients grow older, the continuing loss of bone associated with aging, and an even small continuing loss due to the gastric procedure, will probably cause bone fragility and fractures without requiting any associated conditions to explain the high risk of fractures, which in the past has been demonstrated in these patients.