Follow-Up of Nutritional and Metabolic Problems After Bariatric Surgery
Over the next several years, the number of patients who will have had
bariatric surgery for morbid obesity will reach close to a million. Several
well-described nutritional problems such as B12 and iron deficiency will be
noted in these patients. Many of these patients will be lost to the
original surgeon and will now be in the care of the "other physicians."
These and other mineral and vitamin problems will need to be screened and
treated. If these problems are left undiagnosed, severe and irreparable
problems can result. Early problems, such as vomiting and dumping syndrome,
will be easily recognized and treated, but other long-term problems, such
as changes in bone metabolism, will need to be monitored. Again, if some of
these long-term problems are not addressed in a timely fashion, then
eventual treatment becomes much more difficult. This commentary will cover
the common as well newer problems that are now developing in the patient
who has had bariatric surgery. Patients who have
undergone bariatric surgery require medical follow-up for reasons that are
often determined by the type of surgical procedure performed. The majority
of this review will deal with patients who have had the standard Roux-en-Y
gastric bypass, which is a primarily restrictive procedure with a mild
component of noncaloric malabsorption. At the end of this report, a short
section will be devoted to the problems associated with the malabsorptive
procedures.
Diabetes Care 28:481-484, 2005
Follow-up of the morbidly obese patient who has had gastric bypass can
conveniently be divided into two areas: the issues of surgical
complications and weight loss during the first year, and the nutritional
and metabolic issues that arise after the first year.
ISSUES DURING POSTOPERATIVE YEAR 1 - The vast majority of weight loss after
gastric bypass is accomplished at or around 1 year after surgery (1,2).
Twelve to 18 months after surgery, some patients continue to lose a small
amount of weight while others begin to maintain their lower weight. At
eighteen to 24 months after surgery, almost all patients have stopped
losing weight and most patients are maintaining or regaining weight.
Vomiting and dumping syndrome
Vomiting almost always occurs during the first few months after surgery and
is often described as "spitting up food that is stuck." It typically
happens one to three times a week and is usually due to overeating or not
chewing food adequately. Patients need to adjust to the much smaller
gastric pouch that now receives food from the esophagus; bariatric surgery
has diminished the stomach's ability to grind food into small particles.
Vomiting is well tolerated by most patients. If vomiting becomes more
frequent, low potassium and/or low magnesium levels often occur, requiring
oral replacement. Liquid forms of potassium are available but are not well
tolerated by patients due to palatability; fortunately, by postoperative
month 1, pills are usually able to pass through the anastomotic or
restricted portion of the stomach. To ensure that the potassium can
traverse the 1-cm anastomoses, smaller pills or capsules are often
prescribed.
Vomiting can signal other problems and is associated with strictures and
stomal stenosis. Intolerance for solid foods is a key symptom; if this
develops, then endoscopic evaluation should be strongly considered. If
intolerance to solid food develops 6 months after surgery, then the
diagnosis of stenosis is very high. In one study, abnormal findings at
endoscopy showed stomal stenosis in 39% of patients with nausea, vomiting,
or dysphagia referred for endoscopy (3). Such stenosis can usually be
treated by balloon dilation at the time of diagnosis. Many of these
patients will require repeat dilations, determined by their ability to
tolerate most solid foods.
Dumping syndrome is an extremely common, and somewhat intentional, problem
after gastric bypass. High-osmolarity foods (e.g., foods high in sugar
content), after bypassing much of the stomach undigested, cause an osmotic
overload upon entering the small intestine. This osmotic overload brings
fluid into the lumen of the small intestine, resulting in a vagal reaction.
Patients will often complain about lightheadedness and sweating after
eating a high-glucose meal or drinking fluid with a meal. This is a very
uncomfortable feeling and is accompanied by impressive fatigue. Diarrhea
may or may not occur, as there is usually sufficient distal bowel to absorb
such food, and nutritional problems are rare. Foods that are identified in
our clinic as causing dumping syndrome include ice cream and pastries.
Dehydration occurs frequently and is due to multiple factors. The very
small surgically created gastric pouch makes it extremely difficult for
patients to hold much fluid. Because dumping syndrome occurs if fluids are
mixed with food, patients also must drink fluids separately from meals.
(Fluid with a meal can solubilize food and increase osmolarity.) As a
result, patients must constantly sip fluid throughout the day to meet their
fluid requirements. Brief hospitalizations or urgent care visits for
dehydration are very common during the first 6 months after surgery.
Water consumption is the best method to prevent dehydration. If rehydration
is needed, salty broths or liquids containing salt work well. Many patients
can tolerate sports fluid replacement drinks, either diluted 50% or
occasionally full strength. Many gastric pouches after gastric bypass are
#8804;50 ml in size, and patients must learn to constantly sip fluid and
not drink large gulps.
While protein malnutrition was very common with the truly malabsorptive
surgical procedures of the past, it is rare after gastric bypass or any of
the current restrictive surgeries. If protein malnutrition develops after
gastric bypass, one needs to look at the total food intake of the patient
and determine whether the patient is meeting his/her caloric and protein
needs (4). Protein supplements are very helpful, and with the current trend
of Americans eating high-protein diets, numerous high-protein low-
carbohydrate supplements are readily available.
Hair loss, or telogen effluvium, is seen frequently 3-6 months after
surgery. Patients note diffuse shedding of normal hair. Lasting as long as
6-12 months, it can be terribly distressing to the patient. The stress of
weight loss disrupts the normal growth cycle of individual hairs, resulting
in large numbers of growing hair simultaneously entering the dying
(telogen) phase. Although there is no known treatment, it usually reverses
without intervention (5).
Gallstone formation is very common during weight loss (6), and
surgery-induced weight loss is no exception. In one study of bariatric
surgery patients, 71% developed gallstones, despite the fact that
two-thirds of the patients received preventative treatment (7). Of those
patients who formed gallstones, 41% were symptomatic. Bariatric surgery
patients presenting with right upper quadrant abdominal pain should thus be
appropriately evaluated. At our own institution, all symptomatic patients
undergo an ultrasound of the gallbladder before surgery. If patients have
gallstones, these are removed either before or at the time of surgery.
After surgery, all patients with an intact gallbladder will be placed on a
gallstone- solubilizing agent for at least 6 months after surgery.
ISSUES AFTER POSTOPERATIVE YEAR 1
B12 deficiency
As weight loss begins to slow down, the risk of other nutritional problems
increases. B12 and iron deficiency are two of the most common problems and
often do not respond to typical multivitamin supplementation (8-10). Such
nutrient issues are primarily seen with gastric bypass and any of the
malabsorption procedures.
Because food now bypasses the lower stomach, B12 deficiency is frequently
observed. If B12 is not supplemented above and beyond a multivitamin, 30%
of patients will be unable to maintain normal levels of plasma B12 at 1
year (9). After 1 year, the prevalence of B12 deficiency appears to
increase yearly and has been reported to be between 36 and 70% in the long
term (11,12).
Over the counter oral and sublingual forms of vitamin B12 are available for
use (13,14). Optimal close and efficacy have not been well studied, but
doses of 25,000 units sublingual B12 twice a week are usually sufficient to
maintain normal plasma levels of B12. Some (up to 10%) patients will not
respond to high-dose sublingual or oral B12 and will require monthly
intramuscular B12 injections.
Iron deficiency
Iron deficiency after gastric bypass is usually only seen in menstruating
women. Ferritin or iron levels and erythrocyte counts need to be monitored,
as iron deficiency can develop early after surgery or years later; one
study found that iron stores continuously declined up to 7 years after
bypass surgery (15). Due to bypass of the lower stomach, it is very
difficult for iron- deficient patients to absorb sufficient oral iron.
Intramuscular iron can be impractical over the long run. At our
institution, intravenous iron dextran or iron sucrose is used regularly;
many patients require intravenous iron several times a year. This is done
as an outpatient procedure and is well tolerated by patients.
Ulcers, NSAIDs, and abdominal pain
Patients with persistent iron loss should be e\valuated for blood loss
through the gastrointestinal tract. Ulcers at the margin of the anastomoses
between the stomach pouch and the small intestine are a common cause of
blood loss. All NSAIDs (nonsteroidal anti- inflammatory drugs), including
aspirin, and COX-2 (cyclooxygenase- 2) inhibitors, have the potential to
cause ulcers; use of these drugs is to be avoided at all costs in gastric
bypass patients. A study of gastric bypass patients referred for endoscopy
found that marginal ulcers were present in 27% of patients (3). In our
clinic, gastric bypass patients with abdominal pain are considered to have
an ulcer until proven otherwise. Not all marginal ulcers will bleed
significantly but most will have pain.
LONG-TERM METABOLIC ISSUES AFTER GASTRIC BYPASS- Several articles are
starting to surface regarding problems with bone mineralization in gastric
bypass patients (16-18). With increasing numbers of patients undergoing
bariatric surgery (an estimated 100,000 procedures annually), long-term
follow-up of this growing and aging population will need to monitor bone
health and metabolism. While it is recommended that bone density be
measured after bariatric surgery, there are no specific guidelines for
treatment and follow- up (Table 1). In our clinic, we are currently
following vitamin D, calcium, and parathyroid hormone levels, as well as
bone densitometry.
Secondary hyperparathyroidism
One form of bone demineralization, secondary hyperparathyroidism, has been
reported by several groups to occur in patients who have had gastric bypass
(19-21). While the prevalence is unclear, it appears to be more common than
previously thought. At our institution, we studied 65 consecutive patients
seen for follow-up after gastric bypass. Time since surgery varied from 1
to 9 years; parathyroid hormone, calcium, and vitamin D levels were
measured. Twenty-nine percent of patients were found to have elevated
parathyroid hormone levels. Although the study group was small, patients at
>4 years' postsurgery had a much higher rate of secondary
hyperparathyroidism. Average 25(OH)D level in patients with secondary
hyperparathyroidism was 21 ng/ml, whereas patients with normal parathyroid
hormone levels had an average 25(OH)D level of 30 ng/ ml (normal 20-57
ng/ml). The majority of the patients with secondary hyperparathyroidism has
responded to pharmacologie replacement of vitamin D, with
normalization of parathyroid hormone levels. It should be noted that
vitamin D and calcium supplementation at the usual recommended daily
requirements did not normalize parathyroid hormone levels in at least one
study (20).
Table 1-Recommended follow-up of the bariatric surgery patient by the
nonsurgeon*
Malabsorptive bariatric surgery
Currently, Roen-en-Y gastric bypass, which is a restrictive procedure with
minimal to no malabsorption, comprises the vast majority of bariatric
surgeries. Several decades ago, a bariatric procedure known as the
biliopancreatic diversion or Scopinaro procedure was popular. It is still
occasionally performed in morbidly obese patients and is intended to cause
fat malabsorption to produce massive amounts of weight loss. The procedure
involves a gastric restriction and diverts bile and pancreatic juice into
the distal ileum (22). This leaves a very short segment of small bowel to
absorb all the nutrients that require biliary and pancreatic juices.
Variations of this procedure (biliopancreatic diversion with duodenal
switch) causing malabsorption are still performed. In addition to the
above-mentioned nutritional issues, patients who have this procedure often
have other more severe problems related to protein and fat malabsorption.
Protein deficiency is easy to recognize by following albumin. Fat
malabsorption manifests its presence by loss of fat-soluble vitamins.
Patients can present with a number of problems after this procedure. In our
clinic, the most common presenting complaint is fractured bones or a bone
density study showing "severe bone loss." Due to fat malabsorption, severe
vitamin D deficiency will develop along with an already reduced ability to
absorb calcium (23).
In general, fat-soluble vitamins A, D, and K will be deficient in
two-thirds of these patients within 4 years after surgery. Up to 50% will
have hypocalcemia, and all of these patients with low vitamin D levels will
have secondary hyperparathyroidism (24,25).
Manifestations of all the different fat-soluble vitamins can be seen,
ranging from unusual rashes, to osteomalacia, to easy bruising.
Fortunately, there is a rather simple solution: pancreatic enzyme
replacement. When pancreatic enzymes are replaced, there is some weight
regain, and physicians often observe patient noncompliance as a result. The
hyperparathyroidism may be difficult to treat and may require separate
treatment or even surgery.
Other problems associated with this type of procedure include severe hair
loss, liver disease (usually transient), kidney disease, and unusual body
odors (26). The lifestyle after this procedure can be difficult due to the
frequent bowel movements (over 10 times a day) and the foul-smelling stool
that the fat malabsorption causes.
SUMMARY - Despite billions of dollars spent on weight loss treatment, the
number of morbidly obese patients continues to increase. The only treatment
option shown to have any type of success in this population is bariatric
surgery. Over 100,000 bariatric surgeries are performed annually, with
gastric bypass being the most common surgery. Compliance with long-term
follow-up is vital, as nutritional and metabolic problems can be easily
treated or avoided. With increasing numbers of patients undergoing
bariatric surgery, physicians other than the initial surgeon will need to
become involved in the follow-up of such patients (27).
References
1. Fujioka K, Toussi RH, Brunson ME, Mendes RA: Health care utilization
before and alter bariatric surgery, the managed care experience. Obes Res 9
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3. Huang CS, Forse RA, Jacobsone BC, Farraye FA: Endoscopic findings and
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4. Moize V, Geliebter A, Gluck ME, Yahav E, Lorence M, Colarusso T, Drake
V, Flancbaum L: Obese patients have inadequate protein intake related to
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5. Bolognia JL, Braverman IM: Skin manifestations of internal disease. In
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6. Liddle RA, Goldstein RB, Saxton J: Gallstone formation during
weight-reduction dieting. Arch Intern Med 149:1750-1753, 1989
7. Wudel LJ Jr, Wright JK, Debelak JP, Allos TM, Shyr Y, Chapman WC:
Prevention of gallstone formation in morbidly obese patients undergoing
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Res 102:50-56, 2002
8. Yale CE, Gohdes PN, Schilling RF: Cobalamin absorption and hematologic
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9. Provenzale D, Reinhold RB, Golner B, Irwin V, Dallal GE,
Papathanasopoulos N, Sahyoun N, Samloff IM, Russell RM: Evidence for
diminished B12 absorption after gastric bypass: oral supplementation does
not prevent low plasma B12 levels. J Am Coll Nutr 11:29-35, 1992
10. Brolin RE, Gorman RC, Milgrim LM, Kenler HA: Multivitamin prophylaxis
in prevention of post-gastric bypass vitamin and mineral deficiencies. Int
J Obes 15: 661-667, 1991
11. Amaral JF, Thompson WR, Caldwell MD, Martin HF, Randall HT: Prospective
hematologic evaluation of gastric exclusion surgery for morbid obesity. Ann
Surg 201: 186-193, 1985
12. Halverson JD: Micronutrient deficiencies after gastric bypass for
morbid obesity. Ann Surg 52:594-598, 1986
13. Sharabi A, Cohen E, Sulkes J, Garty M: Replacement therapy for vitamin
B12 deficiency: comparison between the sublingual and oral route. Br J Clin
Pharmacol 56:635-638, 2003
14. Neville J: Sublingual vitamin B12 (Letter). J Fam Pract 42:342, 1996
15. Avinoah E, Ovnat A, Charuzi I: Nutritional status seven years after
Roux-en-Y gastric bypass surgery. Surgery 111:137-142, 1992
16. Coates PS, Fernstrom JD, Fernstrom MH, Schauer PR, Greenspan SL:
Gastric bypass surgery for morbid obesity leads to an increase in bone
turnover and a decrease in bone mass. J Clin Endocrinol Metab 89:
1061-1065, 2004
17. Collazo-Clavell ML, Jimenez A, Hodgson SF, Sarr MG: Osteomalacia after
Roux-en-Y gastric bypass. Endo Pract 1:195-198, 2004
18. von Mach MA, Stoeckli R, Bilz S, Kraenzlin M, Langer I, Keller U:
Changes in bone mineral content after surgical treatment of morbid obesity.
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131:1048-1052, 1996
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KEN FUJIOKA, MD
From the Department of Endocrinology, Scripps Clinic, San Diego,
California.
Address correspondence and reprint requests to Ken Fujioka, MD, Director of
Nutrition and Metabolic Research, Scripps Clinic, Suite 317, 12395 El
Camino Real, San Diego, CA 92130. E-mail: fujioka.ken@ scrippshealth.org.
Received for publication 12 October 2004 and accepted in revised form 19
October 2004.
2005 by the American Diabetes Association.
Copyright American Diabetes Association Feb 2005
Allgergic Reactions :
From minor reactions to sudden overwhelming reactions that can cause death
Anesthetic Complication:
Used to put you to sleep. Has been associated with a variety of different complications up to and including death 
Bleeding:
Sugery invloves incisions that can result in bleeding complications from minor to massive, that could result in tranfusion or death
Blood Clots:
Also called Deep VeinThrombosis and Pulmonary Embolus that can sometimes cause death.
There is a need to get out soon after surgery to move and flex the feet to prevent the formation of blood clots in the legs.
Infection:
Inluding wound infections, bladder infections,pneumonia, skin infections and deep abdominal infections that can sometimes lead to death
Leak:
Afteroperation to bypass the stomach the new connection can leak stomach acid, bacteria and digestive enzymes causing a severe abscess and infection.
Narrowing (Stricture):
Narrowing or ulceration of the connection between the stomach and the small bowel can occur after the operation. This can require an emergency operation, intensive care or even cause death.
Indigestion (Reflux and Ulcers):
The operation can sometimes lead to severe nausea, vomiting , indigestion, abdominal pain, gastritis, or ulcers. This can be severe and can last for days, weeks or longer. This is especially true to the patient who has had previous problems with nausea, abdominal pain or ulcers.
Dumping Syndrome:
Symptoms include cardiovascular problems with weakness, sweating, nausea, diarrhea and dizziness. In some casses dumoing has been so severe that surgery needs to be reversed.
Bowel Obstruction:
Any operationin the abdomin can leave behins scar that can put patients at risk for later risk of bowel blockage or obstruction. The bowel can twist or even perforate leading to serious complications and even death.
Side Effects of Drugs:
All drugs have inherent risks and complications and in some cases can cause a variety of side effects, reactions and in some cases death.
Loss of Bodily Function
The performance of surgery and anesthesia can stress the body's systems leading to a variet of complications inclusing stroke, heart attack, limb loss and other problems.
Risks of Transfusion
Including Hepatitis and AIDS from the administration of blood or blood componets.
Hernia
Cuts and incisions in the abdominal wall can lead to hernias after surgery. Hernias can lead to bowel blockage, obstruction and even perforation which can lead to death.
Hair Loss
Many patients develope hair loss for a period after the operation due to the falling levels of Estrogen (The hormone stored in fat). This usually responds to increaded levels of vitamins. in some cases hair loss is permanent.
Vitamin & Mineral Deficiencies
After gastric bypass there is a malabsorbtion of many vitamins and minerals. Patient must take vitamin and mineral suppliments forever to protect themselves from these problens. You need to have yearly blood tests to measure the blood levels of these vitamins and minerals. In some cases the deficiencies are so severe that they can lead to nerve and brain damage and the operation ust be reversed.
Excessive Weight Loss
Some patients sustain excessive weight loss after the operation and may require reversal of the bypass to prevent severe malnutrition, nausea, vitamin deficiancies or death.
Complications of pregnancy
Vitamin and mineral deficiencies can put the newborn babies of gastric bypass mothers at risk. No pregnancy should occur for the first year after the operation. Gastric bypass had been shown to cause multiple types of vitamin and mineral deficiencies including:B-12, Folate, calcium, iron and many others. Many of these deficiencies have been shown to cause birth defects or are suspected that they could cause birth defects.It is known that many patients who lose weight feel that they are well after surgery and forget to take their vitamins. Paitents must be certain not to miss any of their vitamins if they decide to go ahead wih pregnancy later.
Unplanned Pregnancy
Warning to women using oral contraceptives (Pills); More than 80 million women worldwide take the pill to prevent pregnancy. Typical failure rates among pill users are as high as 12%-20% in some surveys. Other factors have shown t decrease pill effectiveness are smoking, diarrhea,, vomitting, drug interactions, systemic illness, stress and menstrual disturbances.CONCLUSION; BC pills may not be an effective method after the Gatric Bypass until those factors have been resolved.
Depression
Depression and anxiety are common medical illnesses and have been found to be paticularily common after the operation.
Death
This is a major and serious operation. It may lead to death from complication in some circumstances.
