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Long Term Metabolic Complications of Gastric Bypass Surgery March 2015ACOI Las Vegas

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Long Term Metabolic Complications of Gastric Bypass Surgery

Marc G. Cote, DO FACOI FACPACP AKOMA conference April 20-22, 2017

Sheraton Hotel, Anchorage, AK

Conflict Of Interest Disclosure

• The opinions presented here are those solely of the speaker

• I have no financial interests or other relationships with commercial manufacturers and suppliers of commercial services

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Outline Understand various types of bariatric surgical

procedures and their impact on nutrition

Review roles of vitamins & micronutrients

Recognize some clinical acute and long term presentations of various nutritional deficiencies

Increase understanding of follow-up care considerations in post bariatric patient


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Obesity Epidemic

Term obesity derived from Latin word obesus “to devour”;

Obesity: Defined as high amount of fat to lean body mass

~67% in US are overweight or obese

33% U.S. adults ~ 72 million defined as obese in 2005-20061

$117 billion spent in 2000 to treat medical consequences of overweight and obesity

112,000 deaths/year attributed to obesity2

1. Centers for Disease Control and Prevention, November 20072. Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L Actual cause of death in the US. JAMA 291 (10), 1238-1245, 20043. CDC. Vital signs: State-specific prevalence of obesity among adults - United States, 2009. MMWR 2010;59:1–5. http://www.cdc.gov/obesity/data/adult.html

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Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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1990

2010

2000

2002

http://www.cdc.gov/obesity/data/adult.html

Prevalence Obesity Trends* Among U.S. AdultsBRFSS, 2011, 2012, 2013, 2015

MGC6 *Prevalence estimates reflect BRFSS methodological changes started in 2011 and should not be compared to prevalence estimates before 2011.

CA

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PRGUAM

NHMARICTNJDEMDDC

2011

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

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NHMARICTNJDEMDDC

PRGUAM2012

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NHMARICTNJDEMDDC

PRGUAM2013

http://www.cdc.gov/obesity/data/prevalence‐maps.html

2015


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Obesity Incidence Disparities

Women > men

Race-ethnic female disparities in obesity prevalent

• Among women 60 and older,

61% of non-Hispanic black women obese

37% of Mexican-American women

32% of non-Hispanic white women

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Centers for Disease Control and Prevention, November 20072009: Http:www.cdc.gov/obesity/data/trends

Why Bariatric Surgery? Body Mass Index (BMI) defined

Evidenced Based Recommendation: Bariatric surgery leads to sustainable long-term weight

loss and may reduce obesity-related co-morbidities

Cochrane Database of Systematic Reviews Http://www.cochrane.org/reviews/en/ab003641.html

BMI Weight Status

< 18.5 Underweight

18.5-24.9 Normal weight

25.0-29.9 Overweight

30 and greater Obese

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Bariatric Surgery Goals

Gastric bypass surgery aims:

Reduce absorbed

calories

Weight loss

Decrease co-morbidities

BUT -- Nutritional deficiencies may result!

Co-morbidities: Hypertension

Diabetes mellitus II

Sleep apnea

Cardiovascular disease

Stroke

Dyslipidemias

Osteoarthritis

Cancers

Gall bladder disease

Female infertility

Psychological issues


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Bariatric Surgery Volumes

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~220,000 in 2008

∑ ~1.2 million in last 12 years

Bariatric Surgical Options

Two surgical weight loss mechanisms

Gastric restriction

• Vertical Banded gastroplasty

• Sleeve gastrectomy

• Adjustable gastric banding

Intestinal Malabsorption

• Roux-en-Y

• Duodenal Switch and its variations

• Variations of the Jejuno-Ileal Bypass (JIB)

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The Restrictive ProceduresLap-Band early 2000sNow Rarely Performed

Pure Restrictive MechanismNo Malabsorption RiskOutpatient Surgery Reversible

Requires Significant Dietary Changes Low RiskMajor ComplicationsBand Slippage –ReoperationBand Erosion – Removal

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The Restrictive ProceduresSleeve Gastrectomy

Permanent partial Gastrectomy

•Resection of stomach•Body•Fundus•Antrum

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Malabsorption ProceduresProximal Roux-En-Y w/ Gastric Transection

Proximal Roux-En-Y w/ Gastric Transection

Jejuno-Ileal Bypass (JIB)

Malabsorptive Procedures

Duodenal Switch

1o mechanism

Fat malabsorption

Very effective weight loss

Malnutrition an issue

Protein malnutrition

Hypoproteinemia

Frequent foul smelling stools

Up to 7/day

Fat soluble vitamins

Hepatotoxicity

Elevated liver enzymes

Potential for liver failure

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Malabsorptive Procedures Medial Gastric Bypass w/ Jejunal Interposition

Combined ProceduresGastric Bypass

• Most common US bariatric procedure

• Combined procedure•Small malabsorptive limb•Restrictive gastric pouch

• Creates a small gastric pouch

• Creates a short Roux Limb• Difficult to reverse

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Bariatric Surgery Clinical Outcomes Average BMI Pre Op= 43.5; 82% Female ; 18% Male

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VOLUME 17 SUPPLEMENT 1 S1-S70, APRIL 2009 www.obesityjournal.org


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Potential Severe Immediate Post Op Complications

Post op (first 30 days)

Possible life-threatening complications:

Respiratory failure

Pulmonary embolism

Anastomotic leaks

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1. Mitchell JE, Lancaster KL, Burgard MA, et al. Long-term follow-up of patients’ status after gastric bypass. Obes Surg 2001;11:464–8.

Bariatric Short-Term ComplicationsWeeks 1-6 Post-op

Wound infectionsLess Common in Laparoscopic proceduresOpen Group may lead to incisional hernia

Stoma stenosisNausea, Vomiting - inability to advance dietUsually requires EGD and dilation

Marginal ulcerationRarely secondary to Acid production

• Rx: proton pump inhibitor (PPI), sucralfate, suspension

ConstipationPoor PO Fluid intake!

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Bariatric Short Term Clinical Symptoms

Three to six months post op:Rapid weight lossMay experience one or more changes

• Body aches• Feeling tired (flulike)• Feeling cold when others comfortable• Dry skin• Hair thinning and hair loss• Changes in mood• Relationship issues


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Clinical Outcomes Post Bariatric Surgery

Clinical outcomes

Disease improvement

Diabetes : 64 -90%

Hypertension : 62 - 69%

Obstructive Sleep Apnea : 85%

Dyslipidemia : 60 - 100%

Nonalcoholic fatty liver disease 90%

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JAMA, September 19, 2012—Vol 308, No. 11, 1122-31

Deficiencies Post Bariatric Procedure

Macro Nutrients

Proteins, fats

• 50% protein absorption occurs in duodenum1

Micro Nutrients

Vitamins

Trace minerals

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Ahmad DS, Esmadi M, Hammad H. Malnutrition secondary to non-compliance with vitamin and mineral supplements after gastric bypass surgery: What can we do about it? Am J Case Rep. 2012;13:209-13.

Shankar P, Boylan M, Sriram K; Micronutrient deficiencies after bariatric surgery. Nutrition 2010 Nov-Dec;26(11-12):1031-7.

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Common Malabsorption Issues Post Op

Anemia

Vitamin deficiencies

Iron and B12 not absorbed sufficiently

• Reduced appetite

• Reduced absorption

• Vitamins A, D and Calcium most common

Dumping syndrome:

Diarrhea

Reactive hypoglycemia

result of sudden intake of sugar content, nausea, vomiting, dizziness

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Dumping Syndrome 1 Common complication of extensive gastric

resection in which readily soluble carbohydrates rapidly “dump” into small intestine

Symptoms include:Cramping, full feeling

Rapid pulse

Wave of weakness, cold sweating, dizziness

Nausea, vomiting, diarrhea

Occurs 30 to 60 minutes after meal

Results in patient eating less food25

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Dumping Syndrome 2

Rapid influx of undigested carbohydrate into the jejunum of a hypertonic carbohydrate load

Procholinergic symptoms

Cramping, flushing, palpitations, diaphoresis, tachycardia, or hypotension.

Side effect of malabsorptive procedures – RYBG and biliopancreatic diversion

Early dumping first hour

• May be related to the sudden distension of the jejunum by hypertonic solids or fluids.

Late dumping 1–3 hours pc

Most likely result of rapid glucose absorption

• Hyperglycemia triggers exaggerated insulin release resulting in rebound hypoglycemia.

• Nesidioblastosis ????

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Noninsulinoma Pancreatogenous Hypoglycemia Syndrome

Aka Nesidioblastosis Nesidioblastosis

Really reactive hypoglycemia

Hyperplasia of pancreatic islet cells during obese phase

Cells continue to secrete same insulin dose on food stimulus

Service GJ, et al. Hyperinsulinemic hypoglycemia with nesidioblastosis

after gastric-bypass surgery. NEJM 2005 Jul 21;353(3):249-54.


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Compliance IssuesDesire for a Pregnancy

Pregnancy is contraindicated in near term

ACOG recommends wait 24 months

Wait at least 18 months after surgery

• Rapid weight loss and adjusting nutritional requirements

Must provide appropriate contraception

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Am Fam Physician. 2010 Apr 1;81(7):905-906. ACOG Practice Bulletin No. 105: Bariatric Surgery and Pregnancy Obstetrics & Gynecology, 113(6):1405-1413, June 2009

Post Op Incidence Vitamin Deficiencies

Vitamin A (retinol) 11%

Vitamin C (ascorbic acid) 34.6 %

Vitamin D (calciferol) 7 %

Vitamin B1 (thiamine) 18.3 %

Vitamin B2 (riboflavin) 13.6 %

Vitamin B6 (pyrodoxine) 17.6 %

Vitamin B12 (cobalamins) 3.6 % (12 months after surgery)

Clements, RH, Katasami, VG et al , Am Surg. 2006 Dec;72(12):1196-202; discussion 1203-4

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Case #1 50 y.o. female, 10 years post RGB, presented to the ED incoherent , N/V, CHF and edema. No hx of ETOH per spouse, & children. Admitted to the ICU, R/O STMI was negative. Despite CHF treatment, continues to deteriorate. Echocardiogram and cardiac catheterization showed

Biventricular failure, non obstructive CADShe continued to deteriorate with multi organ failure–She was placed on a balloon pumpA Thiamine level was obtained and she was started on IV thiamine daily. LV function improved, weaned off the balloon pump, and her edema resolved.

Severe dementia persisted - discharged to home in care of spouse


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What is the Most Likely Etiology of her CHF on admission ?

A. Idiosyncratic cardiomyopathy

B. Beriberi

C. Wet Beriberi

D. Hypothyroidism

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Case #1 DxDiagnosis= Wet Beriberi

Thiamine pyrophosphate

Coenzyme in carbohydrate metabolism

Integral in the pentose monophosphate pathway for glucose formation

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Thiamine B1

Vitamin B1 (thiamine)

Required for carbohydrate, fat, amino acid, glucose, & alcohol metabolism.Requires an acid environment for absorptionAbsorbed in the proximal intestine

Enzyme systems requiring thiamineKetoacid dehydrogenasesKrebs cycle, Pyruvate dehydrogenase, Acetyl

CoA, Pentose monophosphate shunt

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Etiologies Malabsorption, repeated vomiting, gastric resection Dialysis

Peripheral neuropathy- Ataxia, burning feet, lancinating pains, Cerebellar degeneration, encephalopathy

• Acute: Wernicke's disease, agitation, confusion, memory loss;

• Chronic: Korsakoff's psychosis Systemic organs

Cardiac failure (Wet beriberi): Congestive HF: Tachycardia; Edema

Infantile beriberi: Breast-feeding infants whose mothers are thiamine deficient Infantile: Acute cardiac failure

Thiamine B1 Deficiency Symptoms

Trace Elements Classification Approach

Macro or Major minerals

Sodium, potassium, magnesium, calcium, phosphorus, sulfur, chloride

Micro or Trace minerals(body needs relatively less) Chromium, manganese,

iron, cobalt, molybdenum, copper, zinc, fluoride, iodine, selenium, silicon, tin, arsenic, nickel…

Present in concentrations of body tissues at <50 mg/kg

(50 ppm)

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Case #2

46 y.o. female, 28 months post RGB.

Taking “lots of supplements and vitamins”

100 pound weight loss post surgery.

Pale, hair dull, skin poor elasticity

“Numbness” in her feet that progressed over an approximately 12 month period

Progressive worsening, unsteady gait, paresthesias of the lower extremities & hands

CBC was consistent with a microcytic anemia.

B12 level low normal, iron level low normal,

Serum copper level < 0.2 μg/mL (normal, 0.75 μg/ mL to 1.45 μg/mL)

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Copper Deficiency Symptoms

Highlighted in 2001 in Neurology journals

Neurologic manifestations variable

Usually consist of myelopathy with or without neuropathy,

Sensory ataxia

• CNS demyelination, peripheral neuropathy, and optic neuropathy

• Some of the abnormalities seem to mimic multiple sclerosis

If Early recognition neurological symptoms may be reversible

Schleper and Stuerenburg in 2001. (Schleper B, Stuerenburg HJ. Copper deficiency-associated myelopathy in a 46-year-old woman. J Neurol. 2001 Aug; 248 (8): 705 - 6).

Copper Deficiency Recognition

Unexplained pancytopenia concurrent with neurologic manifestations

Should prompt a serum copper evaluation

Early recognition of easily reversible myeloneuropathy and myelodysplasia

• Essential to prevent progressive neurologic deterioration

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Khan AM, Komrokji RS, Haddad RY. Myelodysplastic syndromes: What a primary care physician needs to know. Dis Mon. 2010;56(8):468–478.

Copper & Anemia

Anemia from Copper Deficiency

Acquired deficiency is rare, but deficiency has metabolic impact

Etiologies of induced deficiency

Malabsorption

Omission from TPN

High intake of Zinc

Renal dialysis patients

Use of copper chelating agents (penicillamine)

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. Reyes, Cesar V. Polyneuropathy and Pancytopenia Secondary to Copper Deficiency FEB 2011 Federal Practioner 23-26


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Copper Deficiency Post Bariatric Surgery

Consider in differential dx of etiologies for neuropathy and myelodysplasia

Anyone with a remote history of bariatric surgery

Can occur at any point up to decades post surgery

Angotti LB, Post GR, Robinson NS et al. Pancytopenia with myelodysplasia due to copper deficiency. Pediatr Blood Cancer 2008;51:693–695.

Kumar N, Gross JB, Ahlskog JE. Copper deficiency myelopathy produces a clinical picture like sub acute combined degeneration. Neurology 2004;63:33–39.

Kumar N. Copper deficiency myelopathy (human swayback). Mayo Clin Proc. 2006;81(10): 1371–1384

Other Risk Factors For Copper Deficiency

Gastrectomy

Small bowel resection or bypass

Zinc overload

Zinc supplementation

Ingestion of zinc containing dental fixatives

Malabsorption syndromes

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Copper Essential cofactor

Vital to the normal hematologic function, vascular, skeletal, antioxidant, and neurologic systems.

Copper deficiency anemia neutropenia, less commonly, thrombocytopenia

Anemia almost always present

Frequently masquerades as myelodysplastic syndrome

Mechanism of anemia/pancytopenia

• Impaired iron absorption, defective iron transfer from the reticuloendothelial cells to plasma, and decreased cytochrome oxidase activity in the mitochondria


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Copper Dependent Enzymes

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Enzyme Function Localization

Lysyl oxidase* Collagen formation secretedCeruloplasmin Iron transport secretedHephaestin Iron transport cell surfaceTyrosine oxidase Pigmentation melanosomesDopamine b-hyroxylase* Neurotransmitter synthesis synaptic vesiclesTryptophan hydroxylase* Neurotransmitter synthesis synaptic vesiclespeptidylglycine a-hydroxy Peptide hormone synthesis Pituit. sec. vesicles Cytochrome c oxidase Oxidative phosphoralation MitochondriaCu/Zn superoxide dismutase- Antioxidant Cytoplasmic

monooxygenase*

* = requires vitamin C for activity

CopperDietary Sources & Bioavailability

Stored in most tissues, especially liver

Bioavailability decreases with

Iron supplements

Antacids

Organ meats, shellfish, whole-grain products, mushrooms, nuts, legumes

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Unappreciated Copper DeficiencyPost Bariatric Surgery

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Absorption

Duodenum and proximal jejunum postulated to be primary absorption sites

Inhibitory effect of iron, zinc, and calcium

Usually supplemented at rather high doses in bariatric patients

mean s.d. serum copper levels in 78 patients post RYGB (filled circles) 77 obese control patients NO surgery; surgery (open circles). Dashed horizontal line indicates the lower limit of the reference range (13 mol/l). *** P < 0.001


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Severe Copper Deficiency Treatment

Treatment of severe deficiency

Daily oral copper sulphate supplementation (2.0 mg/ day)

Intravenous copper chloride 2.0 mg of copper

The American Society for Metabolic and Bariatric Surgery Clinical Practice guidelines recommend routine oral copper supplementation (2 mg/d). Guidelines advise intravenous copper (2-4 mg/d) for six days for severe deficiency. Treatment of mild to moderate deficiency, with oral copper (3-8 mg/d) until levels are acceptable

Mechanick JI, Youdim A, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery.; Surg Obes Relat Dis, 2013;9:159-91

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Selenium Deficiency known as Keshan disease

Can cause a congestive cardiomyopathy Primarily absorbed in duodenum #

Clinical signs of deficiency

Proximal muscle pain

Proximal &, Symmetric weakness

• Rare , only in a minority of selenium deficient patients

Laboratory diagnosis

Serum selenium: Low

Serum CK: High or Normal

Vitamin E levels: Commonly low

Muscle fiber atrophy, thinned myofibrils, Vacuoles

Mitochondria: Enlargement; Reduced Number

Treatment: Selenium supplementation

Latency to improvement post replacement ~ 4 weeks# Groff, J.L. Et al. Microminerals. In Advanced Nutrition & Human Mebolism. Minneapolis. W. Pub. Co. Minn 1995, 381-384

Selenium

Selenium is a Co factor to deiodinate thyroid hormones

Part of enzyme glutathione peroxidase

metabolizes hydroperoxides formed from polyunsaturated fatty acids.

Selenium found in poultry, meats, fish, and nuts.

Selenium RDA is 70 micrograms (mcg).

Upper adult level of selenium is 400 mcg/day based on the prevention of hair and nail brittleness and early signs of chronic toxicity.

Toxic effects when blood selenium concentrations reach a level corresponding to an intake of 850 mcg/day.

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MGC 17

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Involved in carbohydrate metabolism

Essential Coenzyme in oxidation-reduction reactions

Essentially nontoxic

Usually accompanies other B-vitamin deficiencies.

Symptoms

Sore throat, lesions of the lips, mouth mucosa glossitis,

conjunctivitis, seborrheic dermatitis, and normochromic-normocytic anemia.

USRDA 1.7 mg

Riboflavin (B2)

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Niacin B3

Coenzymes in oxidation-reduction reactions

Mild deficiency shown to slow metabolism

Pellagra

Diarrhea, dermatitis, “necklace” lesions on lower neck, hyperpigmentation, thickening of the skin, inflammation of the mouth and tongue, digestive disturbances, amnesia, delirium, death

Common psychiatric symptoms

Irritability, poor concentration, anxiety, fatigue, restlessness, apathy, depression

Pantothenic Acid (B5)

Required to form coenzyme-A (CoA),

Critical for metabolism and synthesis

Carbohydrates

Proteins, and fats.

Adults require about 5 mg/day.

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B12 Deficiency Symptoms Polyneuropathy

Sensory change: 2° spinal or peripheral nerve lesions

Early: Paresthesias

Reflexes Reduced or absent at ankles

• Plantar: Up going

Autonomic: Postural hypotension

Spinal cord: Earliest locus of involvement

Major cause of sensory & motor disability

Posterior column fiber loss

Gait ataxia

Spasticity in legs

Other CNS

Cognitive impairment in adults: Leukoencephalopathy on MRI

Sensory: Reduced smell & taste

Anemia:

Megaloblastic (reduced DNA synthesis)

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More B12

Low B12

Clinically significant: < 100 pg/ml

Suspicious: < 200 pg/ml

High homocysteine & methymalonic acid

• Confirms biological significance of low B12 levels

Pathology Spinal cord

Multifocal axonal loss & demyelination

Localization

• Cervical & thoracic

• Posterior column > Anterolateral & Anterior

MRI

• Hyperintense T2 lesions in posterior columns (50%)

• Lesions can resolve after 8 to 12 months of therapy

Early B12 Identification

50% patients with subclinical disease

Low Normal serum levels

Elevated serum methylmalonic acid & homocysteine #

More sensitive early marker of vitamin B12

deficiency

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# Sumner AE et al. Elevated methylmalonic acid and total homocysteine levels show high prevalence of vitamin B12 deficiency after gastric surgery. Ann Intern Med. 1996;124:469-476.


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Folic Acid ( B9)

Red blood cells formation

Synthesis of purines and pyrimidines

Absorbed in the duodenum & upper jejunum

Deficiency of folate in old age

Significantly increases the risk of developing dementia

RDA for folate is 400 μg

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Molybdenum

Coenzymes component

Xanthine oxidase, sulfite oxidase, and aldehyde oxidase

Transformation of sulfite to sulfate which is necessary for the metabolism of sulfur-containing amino acids, such as cysteine.

Adult RDA is 45 micrograms/day.

Legumes such as lentils, beans, & peas are good sources of molybdenum.

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Iron Iron deficiency common in RYGB patients

Multi-factorial factors contribute to deficiency

Incidence

33%

49% in menstruating women

Continual potential risk of deficiency for life

Monitor ferritin levels

Administer Fe with Vit C to acidify/improve absorption

Brolin RE et al. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obesity Surg 1999: 9, 150-4


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Calcium Deficiency Post RGB

Calcium

Duodenal absorption via active transport

Some passive absorption in jejunum & ileum

Long term deficiency with bone loss

Consider Calcium citrate for better absorption!

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Kuanal, RC Nomere I: Regulation of Intestinal Calcium transport. Ann Rev Nutr 28:179-196, 2008

Zinc Deficiency Absorbed in the duodenum and proximal jejunum ~ 50% of patients post bariatric diversions (BPD or DS-BPD)

Decreased zinc levels 11% with low levels despite daily ingestion of multivitamins 2

3 basic functions: catalytic, structural and regulatory cell division, cell growth, wound healing and immunity

Deficiency manifestations Hair loss

• Common after bariatric surgery Impaired immune function (decreased development and activation

of T lymphocytes), Altered taste Impaired wound healing Acrodermatitis enteropathica

• syndrome characterized by scaly, red desquamating skin lesions on the nasolabial folds and hands.

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1. King JC. Zinc: an essential but elusive nutrient. Am J Clin Nutr, 2011;94(suppl):679s-684s. 2. Bloomberg RD, Fleishman A, Nalle JE, Herron DM, Kini S. Nutritional deficiencies following bariatric surgery: what have we learned? Obesity Surg. 2005;15:145-154.

Chromium (Cr)Dietary Sources & Bioavailability

Regulates insulin Bioavailability affected by:Vitamin CAcidic medicationsAntacids

Transported in blood to liver Food content dependent on soilsWhole grains, fruits/veg, processed meats,

beer, wine Excess excreted in urine & feces

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MGC 21

Manganese (Mn) Deficiency & Toxicity

DeficiencyRareScaly skin, poor bone formation, growth faltering

Whole grains, pineapples, nuts, legumes, dark green leafy vegetables, water

<10% absorbed

Excess incorporated into bile & excreted in feces ToxicityRare

• Mining• Liver disease• High water levels

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Treatment for

Deficiencies

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Parrish Carol R.; Severe Micronutrient Deficiencies in RYGB Patients: Rare but Potentially Devastating; Nutrition Issues in Gastroenterology, Series #100, Practical Gastroenterology 1-27, Nov2011

Deficiency Recognition & TX

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Parrish Carol R.; Severe Micronutrient Deficiencies in RYGB Patients: Rare but Potentially Devastating, Nutrition Issues in Gastroenterology, Series #100, Practical Gastroenterology 1-27, Nov. 2011


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Selected Toxicities of Supplements

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Post-Op MonitoringFollow-up Lab Tests

Every 3 months for the 1st year

CBC, glucose, creatinine

Every 6 months for the 1st year

LFTs, protein and albumin, iron, TIBC, ferritin, vitamin B12, folic acid, calcium, thiamine, parathyroid hormone (if hypercalcemic)

Every year after the 1st year

All of the above

Virji, A., Murr, M. (2006). Caring for patients after bariatric surgery. American Family Physician, 73 (8), 1403-1408. MGC65

Post-Op RGB Monitoring Recommendations

Lab tests at 3,6, 12 months, then annually1

CBC , Electrolytes, glucose, ALT, AST, alkaline phosphatase, bilirubin, albumin

Serum Iron studies, ferritin, Vitamin B12

Lipid profile

25-hydroxyvitamin D, parathyroid hormone (PTH)

Thiamine & Folate levels

Consider other lab if neurological symptoms, anemias

MGC66 1. Kushner, Robert F et al in UpToDate® 2010


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Recommendations SummaryBariatric Patients Long Term Care

Nutritional Deficiencies-Watch for them Especially with malabsorptive procedures (RYGB)

PreventionAdherence to diet high in proteinLifelong supplementation

• High potency MVI with iron• Vitamin B12, 1000mcg IM q mo or 100 mcg p.o.

qd• Calcium 1200 mg q d• Menstruating women may require parenteral

iron infusionsMonitor patient for life

Halverson, J.D., (1992).Metabolic risk of obesity surgery and lon-term follow-up. American Journal of Clinical Nutrition, 55, S602-605. MGC67

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Closing Thoughts

“Despite reductions in disease-related deaths after gastric bypass surgery, the risk of non–disease-related death, (accidents and suicides) increased by a factor of 1.58 compared to the control group”

One of best clinical reviews with clear charts:Levinson R, Silverman JB et al Pharmacotherapy Prevention and Management of Nutritional Deficiencies Post Roux-en-Y Gastric BypassOBES SURG (2013) 23:992–1000

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Questions or Comments


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References 1 Mechanick, JI, Kushner, RF, Sugerman, HJ, et al. American

Association of clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity 2009; 17 Suppl 1:S1

Behavioral Risk Factor Surveillance System, The Prevention Status Reports CDC 2014

American Dietetic Assoc Position of ADA. 2002. J Am Dietetic Assn. 102:1145-55.

Vega GL. Obesity,The Metabolic Syndrome, & Cardiovascular Disease. Am Heart J, 142:1108-16.

Wadden, TA. (ed). Handbook of Obesity Treatment. 2002. Ny: Guilford Press.

May M.; Am I Hungry? What To Do When Diets Don’t Work. Phoenix: Nourish publishing

References 2 Virji A, Murr MM. caring for patients After Bariatric Surgery. AFP

2006;73:1403-8.

USPSTF. Screening for obesity in adults. AFP April 15, 2004;

Caring for patients after bariatric surgery. CME bulletin. AAFP. June 2006.

Mayo Clinic Proceedings, Supplement to Oct. 2006, VOL 81.

Ziegler O, Sirveaux MA, et al. Medical follow up after bariatric surgery: nutritional and drug issues. General recommendations for the prevention and treatment of nutritional deficiencies. Diabetes Metab. 2009 Dec;35(6 Pt 2):544-57.


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References 3

Acquired Copper Deficiency: A Potentially Serious and Preventable Complication Following Gastric Bypass Surgery; Griffith, Daniel P. et al Obesity (Silver Spring). 2009 April ; 17(4): 827–831.

Goldberg ME, Laczek J, Napierkowski JJ. Copper deficiency: a rare of ataxia following gastric bypass surgery. Am J Gastroenterology 2008;103:1318–1319.

Williams DM, Loukopoulos D, Lee GR, Cartwright GE. Role of copper in mitochondrial iron metabolism. Blood 1976;48:77–85.

Khan AM, Komrokji RS, Haddad RY. Myelodysplastic syndromes: What a primary care physician needs to know. Dis Mon. 2010;56(8):468–478.

Poitou Bernert C, et al Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment. Diabetes Metab. 2007, Feb;33(1):13-24.


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References 4 Fujioka K. Follow-up of nutritional and metabolic problems after

bariatric surgery. Diabetes Care 2005;28:481–484.

Angotti LB, Post GR, Robinson NS et al. Pancytopenia with myelodysplasia due to copper deficiency. Pediatr Blood Cancer 2008;51:693–695.

Kumar N, Gross JB, Ahlskog JE. Copper deficiency myelopathy produces a clinical picture like sub acute combined degeneration. Neurology 2004;63:33–39.

Kumar N. Copper deficiency myelopathy (human swayback). Mayo Clin Proc. 2006;81(10): 1371–1384.

MG, Clark MM, et al. Clinical management after bariatric surgery: value of a multidisciplinary approach. Mayo Clin Proc2006;81:Suppl 10:S34-S45.

Gasteyger C., Suter M. et al, Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation Am J ClinNutr 2008;87:1128–33. MGC73

References 5

Van Campen, DR, Mitchell EA. Absorption of Cu64, Zn65, Mo99, and Fe59 from ligated segments of the rat gastrointestinal tract. J Nutr 1965;86:120–124.

Decker, G., Swain, James M., et al “Gastrointestinal and Nutritional Complications After Bariatric Surgery Am J Gastroenterology 2007;102:1–10

Clements, RH, Katasami, VG et al et al Incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting Am Surg. 2006 Dec;72(12):1196-202; discussion 1203-4.

McMahon MM, Sa Geoffrey P. Kohn, Joseph A. Galanko, D. Wayne Overby, Timothy M. Farrell Recent trends in bariatric surgery case volume in the United States Volume 146, Issue 2, Pages 375-380 (August 2009)

Schleper and Stuerenburg in 2001. (Schleper B, Stuerenburg HJ. Copper deficiency-associated myelopathy in a 46-year-old woman. J Neurol. 2001 Aug; 248 (8): 705 - 6). MGC74

References 6 Service GJ, Thompson GB, et al Hyperinsulinemic Hypoglycemia with

Nesidioblastosis after Gastric-Bypass Surgery N Engl J Med 2005;353:249-54.

McMahon MM, Sarr MG, Clark MM, et al. Clinical management after bariatric surgery: value of a multidisciplinary approach. Mayo Clin Proc 2006;81:Suppl 10: S34-S45.

Shankar AH, Prasad AS. Zinc and immune function: the biological basis of altered resistance to infection. Am J Clin Nutr. 1998;68(2, suppl):447S-463S.


Mechanick JI, Youdim A, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery.

Surg Obes Relat Dis, 2013;9:159-91MGC75


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Vitamin Deficiencies

MGC76Matrana MR, Davis WE, Vitamin deficiency after gastric bypass surgery: a review. South Med J. 2009 Oct;102(10):1025-31.

References US RDA Chart

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