Management of iron deficiency and anemia after Roux-en-Y gastric bypass surgery: An observational study

BackgroundIron deficiency (ID) is common after Roux-en-Y gastric bypass surgery (RYGB). Optimal iron management in this population is unclear. The objective of this study was to assess our management of RYGB patients with ID and anemia.MethodsClinic visit records of RYGB patients with ID or anemia from January 1, 2008, to February 1, 2010 were evaluated. Demographic characteristics, postsurgery iron and anemia indices, and prescribed treatments were recorded. Three separate definitions for ID and anemia were used (standard textbook, ASBMS, and recent literature). An intravenous iron protocol was later implemented, and follow-up laboratory values were obtained.ResultsA total of 125 with ID or anemia (89% female, 86% Caucasian), mean (SD) age 44.7 (8.6) years, and BMI 47.3 (10.8) kg/m² at time of RYGB, were included. Proportion of values meeting criteria for ID or anemia at first follow-up: standard textbook, hemoglobin (Hb, 35%), transferrin saturation (T_sat, 48%), ferritin (28%); ASBMS, ferritin (43%); recent literature, ferritin (58%), serum iron (21%). At mean follow-up of 45.7 (43) months, oral iron (n = 49) or intravenous iron (n = 4) had been prescribed for 53 (42.4%) patients, and 32 (25.6%) patients received multiple blood transfusions. Nine patients received intravenous iron using the new protocol (400–1400 mg), resulting in increases in Hb (1.8 g/dL; P<.05) and ferritin (31.8 ng/mL; P< .002).ConclusionIron management was inadequate. Hematologic values often were deficient for sustained periods. Initially, few patients received intravenous iron after oral iron failure, many received no iron supplementation, and there was high use of blood transfusions. Subsequently, administration of intravenous iron was beneficial.     

Severe anemia after Roux-en-Y gastric bypass: a cause for concern

Background

The current popularity of metabolic surgery has led to increasing attention to long-term nutritional complications.

Intussusception after Roux-en-Y gastric bypass

Intussusception is a common pediatric surgical problem. Its occurrence in adults is rare and usually involves a specific lead point such as a small bowel tumor or other mass. We describe two adults who developed intussusception after Roux-en-Y gastric bypass. Signs and symptoms of small bowel obstruction were seen in both of these patients, but the responsible pathology was unusual. Because of the increasing frequency with which these gastric bypass procedures are being performed, a high index of suspicion must be employed when dealing with these postoperative patients who present with abdominal complaints.     

Intussusception after Roux-en-Y gastric bypass

BackgroundJejuno-jejunal (J-J) intussusception is a rare complication after Roux-en-Y gastric bypass (RYGB). Prompt diagnosis is critical as it may lead to obstruction and bowel necrosis, but clinical presentation is nonspecific. A definitive treatment plan has not been established with intussusception after RYGB. The aim of our study was to describe clinical presentation and outcomes of treatment in patients with intussusception after RYGB.MethodsOut of 3022 patients who underwent laparoscopic RYGB between January 2003 and January 2013, 12 (0.4%) patients presented with intussusception after RYGB. A retrospective review of a prospectively collected database was performed.ResultsOf the 12 patients, 11 (91.7%) presented with left or right upper quadrant abdominal pain as their chief complaint, and 1 (8.3%) presented with persistent nausea and vomiting. Diagnosis was made by computed tomographic scan (n = 1) or intraoperative findings (n = 11) at a mean period of 24.9±26.0 months (range 3–85) after laparoscopic RYGB. Seven (58.3%) patients were treated only with reduction, 2 (16.7%) with resection and revision of J-J anastomosis, the remaining 3 (25.0%) underwent imbrication/plication of the J-J anastomosis. Only 1 (8.3%) patient, who was treated by reduction, returned with subsequent finding of recurrent intussusception at 9 months. All patients did well at a mean follow-up of 12.7±16.4 months (range 1–47).ConclusionWhile reduction alone of the intussusception is safe and effective, there is a risk of recurrence, and imbrication of the J-J anastomosis may be a more effective means of treatment.     

Correction of preoperative vitamin D deficiency after Roux-en-Y gastric bypass surgery

BackgroundTo evaluate the adequacy of supplementation to correct preoperative vitamin D deficiency in adult patients during the year after Roux-en-Y gastric bypass (RYGB) surgery.MethodsThe medical records were reviewed and the preoperative and 12-month postoperative serum 25-hydroxyvitamin D [25(OH)D] levels were compared in patients who underwent RYGB from 2002 to 2004. The serum 25(OH)D levels were defined as being optimal (≥80 nmol/L), suboptimal (50–79 nmol/L), or deficient (<50 nmol/L). Patients with deficient 25(OH)D levels were prescribed 50,000 IU ergocalciferol weekly. The remaining patients averaged 710 IU supplemental vitamin D intake daily.ResultsThe mean patient age was 43.8 ± 10.7 years, and the mean preoperative body mass index was 51.8 ± 9.8 kg/m². Of the 95 patients with baseline and 12-month 25(OH)D levels, 89% were women. The mean preoperative 25(OH)D level was 49.7 ± 26.5 nmol/L; 34% had suboptimal 25(OH)D levels and 54% had deficient levels before surgery. Twelve months after surgery, those receiving 50,000 IU weekly (n = 40) had a mean 25(OH)D level of 69.2 ± 22.2 nmol/L; 63% had suboptimal and 8% deficient levels. Those taking 710 IU daily (n = 55) had a mean 25(OH)D level of 85.5 ± 33.0 nmol/L; 44% had suboptimal and 6% deficient levels.ConclusionVitamin D deficiency is prevalent in RYGB patients before surgery. The vitamin D status improved markedly after RYGB surgery with either 710 IU vitamin D daily or 50,000 IU weekly. Current supplementation practices do not appear to optimize the serum 25(OH)D levels and need to be more closely examined.     

Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass

Background: Patients undergoing either Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) with RYGBP are at risk of developing metabolic sequelae secondary to malabsorption.We compared the differences in nutritional complications between these two bariatric operations. Methods: A retrospective analysis of a prospective database was done. From June 1994 to December 2001, 243 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 79 (BMI 45.6 ± SD=4.9) who underwent RYGBP (gastric pouch 15 ± 5ml, biliopancreatic limb 60-80 cm, alimentary limb 80-100 cm and common limb the remainder of the small intestine), and 95 super obese (BMI 57.2 ± 6.1) who underwent a BPD (gastric pouch 15 ± 5ml, biliopancreatic limb 150-200 cm, common limb 100 cm and alimentary limb the remainder of the small intestine), were selected and studied for the incidence of micronutrient deficiencies and level of serum albumin at yearly intervals postoperatively. A variety of nutritional parameters including Hb, Fe, ferritin, folic acid, vitamin B₁₂ and serum albumin were measured preoperatively and compared postoperatively at 1, 3, 6, 12, 18 and 24 months, and yearly thereafter. Results: Nutritional parameters were compared preoperatively and at similar periods postoperatively. No statistically significant (P <0.05) difference in the occurrence of deficiency was observed between the groups for any of the nutritional parameters studied, except for ferritin, which showed a significant difference at the 2-year follow-up (37.7% low ferritin levels after RYGBP vs. 15.2% after BPD, P =0.0294). All of these deficiencies were mild, without clinical symptomatology and were easily corrected with additional supplementation of the deficient micronutrient, with no need for hospitalization. Regarding serum albumin, there was only one patient with a level below 3 g/dl in the RYGBP group and two in the BPD group.These three patients were hospitalized and received total parenteral nutrition for 3 weeks, without further complications. Conclusion:There was no significant difference in the incidence of deficiency of the nutritional parameters studied, except for ferritin, following RYGBP vs. BPD with RYGBP.The most common deficiencies encountered were of iron and vitamin B₁₂. The incidence of hypoalbuminemia was negligible in both groups, with mean values above 4 g/dl.     

Risk of gastric cancer after Roux-en-Y gastric bypass

OBJECTIVE: To evaluate the risk of gastric cancer after Roux-en-Y gastric bypass (RYGB). DESIGN: Rats randomly underwent 1 of the following: RYGB, duodenojejunal bypass (DJB), or a sham operation. Postoperatively, rats underwent a protocol of cancer induction by means of both continuous (200 ppm in tap water for 16 weeks) and intermittent (50-mg/kg intraesophageal injection, once a week, for 12 weeks) administration of N-methyl-N-nitrosourea. SETTING: Institut de Recherche Contre les Canceurs de l'Appareil Digestif-European Institute of Telesurgery. STUDY ANIMALS: Fifty-five Fischer 344 rats. MAIN OUTCOME MEASURES: Seventeen weeks after the operation, we performed a pathologic examination of the whole stomach in all animals to assess for the presence of cancer and/or premalignant lesions. Bilirubin concentration, gastric bacterial flora, and any other pathologic findings were also recorded. RESULTS: In rats in the sham and DJB groups, the incidence of gastric cancer was 85% and 75%, respectively (P = .63), whereas only 23% of rats in the RYGB group developed gastric cancer (4-fold reduction; P = .002). The remnant stomach of rats in the RYGB group also showed a lower bilirubin concentration (P < .01) and a lower bacterial count (P < .05) compared with both the DJB and sham groups. CONCLUSIONS: This study shows that RYGB reduces the risk of gastric cancer in an experimental model of dietary-induced carcinogenesis. Lack of direct contact with carcinogens, lower bile reflux, and a lower bacteria concentration in the gastric content may be responsible for these observations. These data suggest that RYGB may be a safe option for the treatment of morbid obesity even in areas with high gastric cancer incidence.     

Stricture dilation after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: In surgical treatment of morbid obesity, maintaining a restrictive anastomosis is key to long-range success. However, laparoscopic Roux-en-Y gastric bypass (LRYGB) may result in gastrojejunal (GJ) stricture, requiring treatment in up to 27% of patients. METHODS: This is a retrospective review of the outcome of 223 consecutive LRYGB patients. Patients developing stricture received standard endoscopic balloon dilation by the same surgeon. Stricture and nonstricture groups were compared for excess body weight loss (EBWL) at 1, 3, 6, and 12 months. RESULTS: GJ stricture requiring dilation occurred in 38 patients (17%). After dilation all patients were relieved of stricture symptoms and none required revision. By 12 months, patients with stricture had an EBWL of 86% compared with nonstrictured patients at 75%. CONCLUSION: Endoscopic balloon dilation is a safe and effective treatment option for GJ stricture. Improved weight loss occurred for patients with stricture requiring dilation.     

Internal hernias after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Laparoscopic gastric bypass (Lap-RYGB) is an increasingly common procedure performed for severe obesity. Internal hernias are a potential problem associated with Lap-RYGB, and little is known about the clinical presentation and the diagnostic accuracy of this potentially serious complication. METHODS: A retrospective review of 1,000 retrocolic Lap-RYGB was performed to identify those who developed postoperative internal hernias. Clinical symptoms, radiologic characteristics, and operative outcomes were analyzed to determine clinical and radiologic diagnostic accuracy (including computed tomography [CT] scan and upper gastrointestinal imaging). Subsequent independent review was performed to match operative intervention with radiologic imaging and interpretation. Operative outcomes, including the hernia closure technique, hospital length of stay, and mortality were obtained. RESULTS: Of 1,000 Lap-RYGB procedures, 45 internal hernias were identified (4.5%) in 43 patients. Hernia location included transverse colon mesentery (n = 43, 95%) or Petersen's defect (n = 2, 5%). The most common clinical symptoms included intermittent, postprandial abdominal pain, and/or nausea vomiting (86%), although 20% had no abdominal tenderness. Initial radiologic imaging studies were diagnostic in 64%, although subsequent review of all imaging studies showed diagnostic abnormalities in 97%. CT findings suggestive of internal hernia include small bowel loops in the left upper quadrant and evidence of small bowel mesentery traversing the transverse colon mesentery. All patients with internal hernias underwent operative repair (98% performed laparoscopic). One patient had a negative laparoscopy, although the preoperative CT suggested an internal hernia was present. The mean time to intervention for an internal hernia repair was 225 days (range 2 to 490), whereas hospital length of stay was 1.2 days (range 1 to 4). No deaths were noted. CONCLUSIONS: Internal hernias after retrocolic lap-RYGB are associated with vague abdominal complaints and limited radiologic imaging results. A high index of clinical suspicion should be used in this patient population, and surgeon review of radiology imaging studies should be performed. Prompt surgical intervention is successful and can commonly be performed laparoscopically.     

Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass

BackgroundEarly reports described adverse perinatal outcomes of pregnancies after weight loss surgery (WLS), which subsequently raised concerns regarding safety. Our objective was to investigate, in a community-based, academic, tertiary care center, the safety of pregnancies after laparoscopic Roux-en-Y gastric bypass (LRYGB) and its potential effect on obesity-related perinatal complications.MethodsThe pregnancy outcomes of patients delivering infants after LRYGB at our institution were compared with those of control subjects (stratified by body mass index) who had not undergone WLS. The charts were retrospectively reviewed for demographics, delivery route, and perinatal complications.ResultsA total of 26 patients who delivered after LRYGB and 254 controls were identified. The mean interval from LRYGB to conception was 25.4 ± 13.0 months. In general, the perinatal complications in the LRYGB patients were similar to those in the nonobese controls and lower than in the obese and severe obese controls, although statistical significance was not noted for all complications. No spontaneous abortions or stillbirths occurred in the LRYGB patients. No LRYGB patients required intravenous nutrition or hydration. The overall incidence of cesarean section in the LRYGB patients was similar to that in the obese and severely obese controls but significantly greater than that in the nonobese controls. The complication rates were similar in pregnancies occurring “early” (<12 mo) versus “late” (>18 mo) after LRYGB.ConclusionThe results of our study have shown that pregnancy after LRYGB is safe, with an incidence of perinatal complications similar to that of nonobese patients, and lower than that of obese and severely obese patients, who had not undergone WLS. Larger studies are required to demonstrate statistically significant improvements in outcome in patients treated with WLS.