Neurologic complications after surgery for obesity

Bariatric surgical procedures are increasingly common. In this review, we characterize the neurologic complications of such procedures, including their mechanisms, frequency, and prognosis. Literature review yielded 50 case reports of 96 patients with neurologic symptoms after bariatric procedures. The most common presentations were peripheral neuropathy in 60 (62%) and encephalopathy in 30 (31%). Among the 60 patients with peripheral neuropathy, 40 (67%) had a polyneuropathy and 18 (30%) had mononeuropathies, which included 17 (94%) with meralgia paresthetica and 1 with foot drop. Neurologic emergencies including Wernicke's encephalopathy, rhabdomyolysis, and Guillain-Barré syndrome were also reported. In 18 surgical series reported between 1976 and 2004, 133 of 9996 patients (1.3%) were recognized to have neurologic complications (range: 0.08-16%). The only prospective study reported a neurologic complication rate of 4.6%, and a controlled retrospective study identified 16% of patients with peripheral neuropathy. There is evidence to suggest a role for inflammation or an immunologic mechanism in neuropathy after gastric bypass. Micronutrient deficiencies following gastric bypass were evaluated in 957 patients in 8 reports. A total of 236 (25%) had vitamin B(12) deficiency and 11 (1%) had thiamine deficiency. Routine monitoring of micronutrient levels and prompt recognition of neurological complications can reduce morbidity associated with these procedures.     

Personality changes after gastric banding surgery for morbid obesity. A prospective study

89 morbidly obese patients completed the Basic Character Inventory before and 1 and 3 years after horizontal gastric banding surgery. The aim of the study was to compare preoperative scores of personality traits with those of a normal population, and to examine any change in scores on the different personality traits at the follow-up tests. There was a uniform tendency to higher scores on the Oral cluster traits (Self-doubt, Insecurity, Sensitivity, Dependence, Compliance and Emotional instability) among the patients compared to normals. There was a general significant decrease in the post-operative scores on the Oral cluster traits present already at the 1 year follow-up, most pronounced for Self-doubt, Insecurity and Sensitivity. On the other hand there was a significant increase in the postoperative scores on the Obsessive traits: Parsimony and Orderliness. As a group these patients did not show any adverse changes in their personality traits, on the contrary they seemed less neurotic and possibly exerted more control of their situation after the operation and weight loss.     

Neurologic complications of gastric partitioning

Six patients who had gastric reduction for morbid obesity suffered severe complex neurologic disturbances that included confusion and inappropriate behavior. All were profoundly weak or paraplegic, and recovery was delayed and incomplete. Encephalopathy was documented by EEG and neurologic examination. The cause is uncertain. Acute catabolism of lipid may predispose to damage of the nervous system, but relative vitamin deficiency is a more obvious and treatable explanation.     

Behavioural changes following gastric surgery for morbid obesity: A prospective, controlled study

The authors present results of a prospective, controlled longterm follow-up study of patients undergoing a gastric procedure for morbid obesity. Pre-operatively the gastric surgery group (GS) was compared with a group of normal weighted (NC) and obese (OC) individuals participating in self-help weight reduction groups. The GS group was assessed at 3-months, 6-months and one year or more post- operatively. All groups were examined by a structured self-rating schedule reflecting personal characteristics and family history, current attitudes and experiences related to personal weight, and an extensive exploration of eating habits. Moreover, the groups completed the Minnesota Multiphasic Personality Inventory (MMPI), the Katz Adjustment Scale and the Zung Self-rating Depression Scale.

The results demonstrated major differences between the GS and the NC and OC groups initially, and at follow-up; the GS demonstrated major weight loss without major psychopathologic reactions. The GS did not show, however, major alterations in eating habits, but clearly showed behavioural change subsequent to weight loss.     

Neurologic complications of bariatric surgery

With the rapid rise in the number of bariatric surgeries performed for morbid obesity, several short- and long-term neurologic complications of this procedure have been identified. These complications affect various levels of the neuraxis, and most are likely secondary to deficiency of essential minerals and vitamins. We report on 3 patients who developed unusual and severe neurologic deficits after undergoing bariatric surgery, including Wernicke encephalopathy, acute and rapidly progressive polyneuropathy, myelopathy, and visual deficits. Two developed clinical features of Parkinsonism, a complication not previously reported in this patient population. None of our patients had attended a nutrition clinic postoperatively. All 3 had a rapid weight loss and intractable vomiting preceding the development of neurologic symptoms, and all were found to have significant vitamin deficiencies. Replacement of vitamins resulted in a slow and variable degree of neurologic recovery. Patients undergoing bariatric surgery should have close monitoring of their nutritional status postoperatively. Routine supplementation of vitamins and minerals may be a cost-effective strategy for preventing neurologic complications in these patients.     

Neurologic complications of cardiovascular surgery

With significant advances in surgical technology and methodology, mortality from congenital heart surgery has been significantly reduced in recent decades. Therefore, focus has naturally turned towards predicting, evaluating, and preventing the neurodevelopmental morbidity associated with congenital heart disease and its treatment. This paper reviews recent publications evaluating preoperative neurologic abnormalities and injuries, current neurodevelopmental outcomes of congenital heart repair, and various neuromonitoring modalities that can be used to monitor neurologic function/dysfunction perioperatively. The rapidly advancing field of clinical neuromonitoring holds the promise of providing modalities that can detect injurious processes acutely to allow for intervention.     

Neurologic complications of cardiovascular surgery

With significant advances in surgical technology and methodology, mortality from congenital heart surgery has been significantly reduced in recent decades. Therefore, focus has naturally turned towards predicting, evaluating, and preventing the neurodevelopmental morbidity associated with congenital heart disease and its treatment. This paper reviews recent publications evaluating preoperative neurologic abnormalities and injuries, current neurodevelopmental outcomes of congenital heart repair, and various neuromonitoring modalities that can be used to monitor neurologic function/ dysfunction perioperatively. The rapidly advancing field of clinical neuromonitoring holds the promise of providing modalities that can detect injurious processes acutely to allow for intervention.     

Wernicke's encephalopathy after gastroplasty for morbid obesity

A young woman developed Wernicke's encephalopathy after gastroplasty for morbid obesity. Her clinical presentation of nystagmus and ocular gaze palsies, ataxia, and a sensorimotor neuropathy is described. A small number of previously described patients are compared with respect to clinical features, response to treatment, and investigative procedures.     

Depressive disorders as psychiatric complications after obesity surgery

Three case reports of morbidly obese patients (two women and a man) who underwent vertical banded gastroplasty and who subsequently fell into depression, are presented here. The psychiatric diagnosis according to DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised), the eating pattern before obesity surgery, the past history of mental disorder, social adaptation before surgery, psychological gain from their obese state, and the presence of unrealistic expectations of obesity surgery were investigated. Case 1 was diagnosed postoperatively as having a major depressive episode without a personality disorder. Case 2 was diagnosed post-operatively as having a major depressive episode. Case 3 had a depressive disorder not otherwise specified. Cases 2 and 3 had a social phobia with comorbidity of personality disorders. Binge eating disorder was confirmed in all patients before obesity surgery. There were differences between case 1 and cases 2 and 3 based on the presence of personality disorder and the time of onset of depression. When some psychiatric characteristics are confirmed in obese patients, obesity surgery should be undertaken more prudently because the patients may manifest depression postoperatively. The pre-operative psychiatric assessment is essential for a decision on indication of obesity surgery.     

Wernicke encephalopathy after subtotal gastrectomy for morbid obesity

Wernicke's encephalopathy (WE) is one of the potential complications of obesity surgery. It is an acute neuropsychiatric syndrome resulting from thiamine deficiency often associated with repeated vomiting. The classic triad is frequently reported in these patients (optic neuropathy, ataxia and confusion), associated with uncommon features. Cerebral impairment affects the dorsal medial nucleus of the thalamus and the periaqueductal grey area, appearing on MRI, as hyperintense signals on T2, Flair and Diffusion weighted imaging. Early diagnosis and parenteral thiamine are required to decrease morbidity and mortality. We report a case of WE and Korsakoff's syndrome in a young obese patient after subtotal gastrectomy, who still has substantial sequelae. The contribution of MRI with diffusion-weighted imaging is illustrated. The interest of nutritional supervision in the first weeks and preventive thiamine supplementation in case of repeated vomiting are of particular importance in these risky situations.     

Rapid sensory motor neuropathy after gastric restriction surgery

INTRODUCTION: Central and peripheral neurological complications have been described in association with bariatric surgery over the last 20 years. CASE REPORT: A 40 year-old women developed a sensory motor neuropathy 3 months after a gastric restriction operation followed by a 30 kilograms weight loss. No specific vitamin or mineral deficiency was detected but she improved after multivitamin and minerals supplementation. CONCLUSION: Acute or subacute neuropathy may develop in 1 to 2p.cent of patients who undergo bariatric surgery. Its pathogenesis is not very clear but the most commonly associated factors are rapid weight loss and non-supplementation with vitamins and minerals post-operatively.     

Neurologic complications after heart transplantation

OBJECTIVE: Neurologic complications are known as important cause of morbidity and mortality in orthotopic heart transplantation. Our aim was to identify the frequency and outcome of neurologic complications after heart transplantation in a prospective observational study. METHOD: From September 93 to September 99, as part of our routine heart transplantation protocol all patients with end-stage cardiac failure were evaluated by the same neurologist before and at the time of any neurologic event (symptom or complaint) after transplantation. RESULTS: Out of 120 candidates evaluated, 62 were successfully transplanted (53 male; median age 45.5 years, median follow-up 26.8 months). Fifteen patients (24%) had ischemic, 22 (35%) idiopathic, 24 (39%) Chagas' disease and 1 (2%) had congenital cardiomyopathy. Neurologic complications occurred in 19 patients (31%): tremor, severe headache, transient encephalopathy and seizures related to drug toxicity or metabolic changes in 13; peripheral neuropathy in 4; and spinal cord compression in two (metastatic prostate cancer and epidural abscess). No symptomatic postoperative stroke was observed. CONCLUSIONS: Although frequent, neurologic complications were seldom related to persistent neurologic disability or death. Most of the complications resulted from immunosuppression, however, CNS infection was rare. The absence of symptomatic stroke in our series may be related to the lower frequency of ischemic cardiomyopathy.     

A review of psychosocial outcomes of surgery for morbid obesity

There is consistent evidence to support the notion that morbid obesity poses serious risks to physical health and has a substantial impact on psychosocial well-being. Researchers agree that bariatric surgery is currently the most viable option for successful weight loss and maintenance in the morbidly obese individual. The drastic, major weight loss and alleviation of medical risks that patients typically experience post-surgically are accompanied by psychosocial changes that appear to be equally remarkable. These psychosocial changes have yet to be studied as systematically or diligently as the physical changes and therefore remain to be fully understood. This paper (1) reviews the literature of psychosocial outcomes of obesity surgery for the past 36 years; (2) provides a critical assessment of the methodology utilized; and (3) suggests future research directions.     

Neurologic complications related to cardiac surgery.

Neurologic complications are a major cause of morbidity, complicating open heart surgery, cardiac catheterization, and interventional techniques. Global or focal brain ischemia related to embolism or hypoperfusion predominates. Breakthrough cerebral hemorrhage and infection can complicate cardiac transplantation. Identifying individuals at risk for cerebrovascular complications may lead to more effective preventative and treatment measures.     

Neurologic complications after bone marrow transplantation]

The retrospective study presented here reports clinical, electrophysiological and CT-data from 21 patients who underwent bone marrow transplantation for leukemia or aplastic anemia between 1980 and 1985. The aim of the investigation, which was performed at the end of 1986, was to elucidate whether antineoplastic drugs and radiation can result in long-term damage of the central nervous system. In 9 patients we observed neurological signs (1 leukencephalopathy, 5 cerebellar symptoms). Seven patients revealed dysrhythmia in the EEG and five had delayed latencies of visual evoked potentials. Eight patients exhibited pathological changes in CT (3 atrophy of supratentorial structures, 3 periventricular lucencies, 2 a combination of both). The results indicate that long-term damage to the CNS may be encountered after successful bone marrow transplantation.     

Neuromuscular complications of jejunoileal shunt for morbid obesity: case report and literature review

Intestinal malabsorption by jejunoileal bypass has been used to treat morbid obesity. Although the procedure is considered safe, several long‐term neurological complications have been described. A 47‐year‐old man was evaluated because of increasing gait difficulties five years after jejunoileal bypass at age 42. Neurological examination showed upper, lower extremities proximal weakness, distal sensory loss for touch, pin‐prick, vibration and position. Deep jerks were absent. Electrophysiology was consistent with axonal neuropathy. Blood tests revealed microcitic anemia (Hb 9 g/dl), normal thyroid function, tumor marker titer, and viral screenings. Vitamin A was 1.12 umol/l (n.v. 0.56–4.25) and vitamin E was 10.7 umol/l (n.v. 11.5–31). B12, folate levels were within normal range. A 42‐year‐old obese man had a similar surgery. Two years later he developed an acute episode of confusion and unsteadiness due to lactic acidosis, from which he recovered. He was first evaluated neurologically fifteen years after jejunoileostomy because of muscle cramps, paraesthesias, and progressive imbalance. On examination there were trunk, extremity ataxia, proximal and distal muscle weakness, distal atrophy, loss of reflexes, and severe loss of all sensory modalities. Electrophysiology confirmed a sensorimotor neuropathy. Blood tests showed macrocitic anemia, low free calcium (3.7 mEq/l, n.v. 4–5), increased PTH (75 pg/ml, n.v. 10–65), and low serum level of vitamins A and E. Brachial biceps biopsy showed neurogenic changes. General conditions progressively deteriorated because of repeated episodes of dehydration leading to terminal uremia within 27 years.     

Wernicke's encephalopathy following gastroplasty for morbid obesity

BACKGROUND: The syndrome of Wernicke's encephalopathy consists of two of four features of (1) dietary deficiency; (2) oculomotor abnormality; (3) cerebellar dysfunction; and (4) confusion or mild memory impairment. Predisposing risk factors include alcoholism, hyperemesis gravidarum and prolonged intravenous feeding. METHODS: A 35-year-old female developed refractory emesis, severe weight loss, and hypokalemia following banded gastroplasty for morbid obesity. Reversal of gastroplasty was performed four months following initial surgery. Following reversal, the patient developed confusion, ataxia, leg weakness and nystagmus. RESULTS: Examination of the patient demonstrated disorientation with confusion, vertical nystagmus worse on downgaze, diffuse weakness of the lower extremities, and bilateral dysmetria. Magnetic resonance imaging of the brain demonstrated symmetrical areas of increased T2 signal present bilaterally in the medial thalamic nuclei. The patient did not demonstrate any initial improvement with intravenous thiamine but improved over two months of follow-up. CONCLUSION: Wernicke's encephalopathy has been reported in the European literature as a complication of gastroplasty, with rare recognition of this clinical entity in the North American literature. This potential complication of gastroplasty may be preventable by nutritional intervention in subjects experiencing severe weight loss and emesis following surgery.