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Lin Q, Li G, Wang Z, Zhang Y. Case Report: Wernicke's encephalopathy after gastric surgery presenting as lactic acidosis and refractory thrombocytopenia. Front Surg 2023; 10:1016347. [PMID: 36896260 PMCID: PMC9989168 DOI: 10.3389/fsurg.2023.1016347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/16/2023] [Indexed: 02/23/2023] Open
Abstract
Wernicke's encephalopathy (WE) is a severe neuropsychiatric disorder, mainly resulting from a nutritional deficiency of thiamine. WE is hard to detect at an early stage. Less than 20% of WE can be diagnosed during a patient's lifetime, and WE tends to occur in patients with chronic alcoholism. Therefore, a large proportion of non-alcoholic WE patients are misdiagnosed. Lactate is an important by-product of anaerobic metabolism when the aerobic metabolism is blocked without thiamine, which can potentially serve as an alerting index for WE. Here, we report a case of a patient with WE who suffered gastric outlet obstruction following postoperative fasting, accompanied by lactic acidosis and refractory thrombocytopenia. A 67-year-old non-alcoholic woman who suffered hyperemesis for 2 months was diagnosed with gastric outlet obstruction (GOO). Gastric biopsies with endoscopy revealed gastric cancer, and total gastrectomy, together with D2 nodal dissection, was performed. She developed a coma with refractory thrombocytopenia rapidly after the surgical procedures were performed. The above conditions were treated not by the administration of antibiotics but by that of thiamine. We also found before the start of the procedures that she had a high level of blood lactate for a long period of time. Early diagnosis of WE is important because permanent injury can be caused to the central nervous system. Even today, the diagnosis of WE mainly depends on clinical symptoms, but occasionally, a typical triad occurs among WE patients. Therefore, a sensitive index for early diagnosis is critical for WE. Rising levels of blood lactate as a result of thiamine deficiency can serve as a warning for WE. In addition, we noted that this patient had a non-typical thiamine-sensitive refractory thrombocytopenia.
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Affiliation(s)
- Qi Lin
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guanghua Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhixiong Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yu Zhang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
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Culpepper T, Lux T, Trivedi S, Neal D, Hazen K, Fleisher M, Samra R, Johnson-Mann C, Friedman J. Prevalence of Postoperative Micronutrient Deficiencies in Bariatric Surgery Patients Who Use Transdermal Patches for Supplementation: A Pilot Study. Cureus 2022; 14:e25989. [PMID: 35859973 PMCID: PMC9287997 DOI: 10.7759/cureus.25989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 11/05/2022] Open
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Clinical diagnosis, outcomes and treatment of thiamine deficiency in a tertiary hospital. Clin Nutr 2021; 41:33-39. [PMID: 34864453 DOI: 10.1016/j.clnu.2021.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 10/09/2021] [Accepted: 10/29/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute thiamine deficiency can occur in patients with or without history of alcohol abuse and can lead to life-threatening complications. Clinical diagnosis is challenging, often resulting in delayed recognition and treatment. Patients may present with heterogenous symptoms, more diverse than the historical neurological description. Cerebral MRI can contribute to the diagnosis in patients with neurological signs but it is not always feasible in emergency settings. Prompt parenteral supplementation is required to obtain the improvement of symptoms and avoid chronic complications. AIMS To describe the clinical presentation of reported cases of thiamine deficiency, assess prescription and results of cerebral imaging, review treatments that had been prescribed in accordance or not with available guidelines, and study the short-term outcome of these patients. METHODS This is a monocentric retrospective analysis of all reported cases of thiamine deficiency in a French tertiary hospital between January 1st 2008 and December 31st 2018. RESULTS Fifty-six cases were identified during the study period. Forty-five (80%) patients had a history of alcohol abuse. Most patients were diagnosed based on neurological symptoms but non-specific and digestive symptoms were frequent. Thirty-four percent of patients fulfilled clinical criteria for malnutrition. A brain MRI was performed in 54% of patients and was abnormal in 63% of these cases. Eighty-five percent of patients were treated by parenteral thiamine administration and the supplementation was continued orally in 55% of them. The majority of patients initially received 1000 mg daily of IV thiamine but the dose and duration of thiamine supplementation were variable. At the time of discharge, partial or complete improvement of symptoms was noted in 59% of patients. CONCLUSION This study highlights the clinical and radiological heterogeneity of thiamine deficiency. These observations should encourage starting thiamine supplementation early in patients with risk factors or suggestive symptoms even in non-alcoholic patients, and underline the importance of early nutritional support.
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Saurabh S, Gao Y, Maduka S, Smith L, Lasley R, Singh N. Is Transdermal Multivitamin Patch Effective in Gastric Bypass Patients? Obes Surg 2020; 29:3818-3823. [PMID: 31302845 DOI: 10.1007/s11695-019-04070-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) patients are recommended to take multiple oral vitamin supplements daily. Transdermal multivitamin patches are being advertised as an alternative for use in bariatric patients with no data to support their efficacy. The purpose of this study was to evaluate response to daily transdermal use of multivitamin patch after LRYGB and to compare them with a control group of similar patients who used oral supplements. METHODS A retrospective review was carried out on patients who had LRYGB at a community hospital from February 2015 to February 2019. Patients who had completed preoperative and annual postoperative bariatric laboratory tests were included. They were divided into patch and pill (control) group. RESULTS Seventeen patients were included in the patch and 27 in the pill group. Patients in each group used either patch or pills for 12 months and they were 1 year post LRYGB. Fourteen patients (82.35%) in patch group and 11 patients (40.74%) in pill group had at least 1 deficiency at annual postoperative blood work (P = .0116). Vitamin D deficiency was seen in 81% patients in patch group vs 36% in the pill group (P = .0092). Statistically significant lower postoperative serum concentrations of vitamin D, B1, and B12 were seen in the patch group. CONCLUSIONS Multivitamin patch users are more likely to have vitamin D deficiency and lower serum concentration of various vitamins and minerals. Future large studies are needed on the efficacy of multivitamin patches before they can be recommended to bariatric patient population.
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Affiliation(s)
- Shireesh Saurabh
- General / Bariatric Surgery, Mercy Hospital, 540 East-Jefferson Street, Suite 205, Iowa City, IA, 52245, USA.
| | - Yubo Gao
- University of Iowa Hospital and Clinics, Iowa City, IA, 52242, USA
| | | | - Lori Smith
- Mercy Hospital, Iowa City, IA, 52245, USA
| | | | - Namrata Singh
- University of Iowa Hospital and Clinics, Iowa City, IA, 52242, USA
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Abstract
Half a million bariatric procedures are performed annually worldwide. Our aim was to review the signs and symptoms of Wernicke's encephalopathy (WE) after bariatric surgery. We included 118 WE cases. Descriptions involved gastric bypass (52%), but also newer procedures like the gastric sleeve. Bariatric WE patients were younger (median = 33 years) than those in a recent meta-analysis of medical procedures (mean = 39.5 years), and often presented with vomiting (87.3%), ataxia (84.7%), altered mental status (76.3%), and eye movement disorder (73.7%). Younger age seemed to protect against mental alterations and higher BMI against eye movement disorders. The WE treatment was often insufficient, specifically ignoring low parenteral thiamine levels (77.2%). In case of suspicion, thiamine levels should be tested and treated adequately with parenteral thiamine supplementation.
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Affiliation(s)
- Erik Oudman
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands.
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands.
| | - Jan W Wijnia
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Mirjam van Dam
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Laser Ulas Biter
- Department of Bariatric Surgery, Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Albert Postma
- Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, The Netherlands
- Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
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Hamilton LA, Darby SH, Hamilton AJ, Wilkerson MH, Morgan KA. Case Report of Wernicke's Encephalopathy After Sleeve Gastrectomy. Nutr Clin Pract 2017; 33:510-514. [PMID: 29730896 DOI: 10.1177/0884533617722758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We report a case of a patient who was 3 months post-sleeve gastrectomy and presented with acute stroke symptoms ultimately due to Wernicke's encephalopathy (WE) after bariatric surgery. A 20-year-old white female presented to an outside hospital 3 months after sleeve gastrectomy complaining of nausea and vomiting. She initially underwent a cholecystectomy and later became less responsive and required intubation. Magnetic resonance imaging changes, presumed to be an acute stroke, prompted her transfer to our facility. Intravenous (IV) thiamin was administered, and the patient's symptoms improved over the course of her hospital stay. RESULTS Thiamin levels were markedly low, and the patient rapidly improved with the administration of IV thiamin. The patient was discharged to inpatient rehabilitation. CONCLUSION Bariatric surgery is a less common cause of WE but can lead to acute WE due to malabsorption of thiamin. In patients undergoing bariatric surgery, clinicians should be vigilant about the potential for WE to occur. In addition, based on history, WE should be considered in the differential diagnosis for symptoms of acute ischemic stroke.
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Affiliation(s)
- Leslie A Hamilton
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Sarah H Darby
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Allan J Hamilton
- Department of Anesthesiology and Pain Management, UT Southwestern, Dallas, Texas, USA
| | - Matthew H Wilkerson
- Department of Anesthesiology, Graduate School of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Kabel A Morgan
- Department of Anesthesiology, Graduate School of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee, USA
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Tsao WC, Ro LS, Chen CM, Chang HS, Kuo HC. Non-alcoholic Wernicke's encephalopathy with cortical involvement and polyneuropathy following gastrectomy. Metab Brain Dis 2017; 32:1649-1657. [PMID: 28660359 DOI: 10.1007/s11011-017-0055-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 06/16/2017] [Indexed: 11/25/2022]
Abstract
In this study, we present the clinical manifestations, brain magnetic resonance imaging (MRI) and concurrent polyneuropathies in two patients with non-alcoholic Wernicke's encephalopathy (WE) after gastrojejunostomy (Billroth II) anastomosis procedures. These patients developed sub-acute onset of disorientation and disturbance of consciousness following several weeks of poor intake. Peripheral neuropathy of varying severity was noted before and after the onset of WE. Brain MRI of the patients showed cerebellar vermis and symmetric cortical abnormalities in addition to typical WE changes. Electrophysiological studies demonstrated axonal sensorimotor polyneuropathy. Prompt thiamine supplement therapy was initiated and both patients gradually recovered, however mild amnesia was still noted 6 months later. We reviewed non- alcoholic WE with atypical cortical abnormalities in English language literatures and identified 29 more cases. Eight out of 31 (25.8%) patients died during follow-up. Nine patients with gait disturbance or motor paresis had showed hyporeflexia in neurological examinations. In addition to classic triad, seizure was recorded in seven patients. Dietary deprivation is a risk factor for non-alcoholic WE among elderly patients receiving gastrointestinal surgery. The prognosis is good after thiamine supplement therapy. Recognizing the MRI features and predisposing factors in patients who have undergone gastrectomy can aid in the diagnosis and management.
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Affiliation(s)
- Wei-Chia Tsao
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Long-Sun Ro
- Section of Neuromuscular Disorders, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuhsing Street, Kueishan, Taoyuan, Taiwan
| | - Chiung-Mei Chen
- Section of Neuromuscular Disorders, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuhsing Street, Kueishan, Taoyuan, Taiwan
| | - Hong-Shiu Chang
- Section of Neuromuscular Disorders, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuhsing Street, Kueishan, Taoyuan, Taiwan
| | - Hung-Chou Kuo
- Section of Neuromuscular Disorders, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuhsing Street, Kueishan, Taoyuan, Taiwan.
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More than a Case Report? Should Wernicke Encephalopathy After Sleeve Gastrectomy be a Concern? Obes Surg 2017; 27:2684-2687. [DOI: 10.1007/s11695-017-2823-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Patel JJ, Mundi MS, Hurt RT, Wolfe B, Martindale RG. Micronutrient Deficiencies After Bariatric Surgery: An Emphasis on Vitamins and Trace Minerals [Formula: see text]. Nutr Clin Pract 2017; 32:471-480. [PMID: 28609642 DOI: 10.1177/0884533617712226] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Obesity has become a worldwide epidemic with a disproportionate increase in grade III obesity. Bariatric surgery offers an attractive option for sustained weight loss compared with traditional methods such as exercise and diet. Micronutrient deficiencies are common and clinically significant after bariatric surgery. These deficiencies are related to a combination of patient and surgical variables. A thorough understanding of specific micronutrient deficiencies is necessary for early recognition and optimal management. The purpose of this review is to describe indications, outcomes, and types of bariatric procedures, risk factors, and mechanisms for micronutrient deficiencies, as well as outline specific vitamin and trace element deficiencies after bariatric surgery.
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Affiliation(s)
- Jayshil J Patel
- 1 Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Manpreet S Mundi
- 2 Division of Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Bruce Wolfe
- 4 Division of Bariatric Surgery, Oregon Health Sciences University, Portland, Oregon, USA
| | - Robert G Martindale
- 5 Division of General Surgery, Oregon Health Sciences University, Portland, Oregon, USA
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Kröll D, Laimer M, Borbély YM, Laederach K, Candinas D, Nett PC. Wernicke Encephalopathy: a Future Problem Even After Sleeve Gastrectomy? A Systematic Literature Review. Obes Surg 2016; 26:205-12. [PMID: 26476834 DOI: 10.1007/s11695-015-1927-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Wernicke encephalopathy (WE) is a serious complication of bariatric surgery with significant morbidity and mortality. A few cases have been reported in the literature, mainly in patients after a Roux-en-Y gastric bypass. Since sleeve gastrectomy (SG) has become a more established and popular bariatric procedure, WE is expected to appear more frequently after SG. We performed a literature review on WE after SG, and 13 cases have been found to be sufficiently documented. The risk of WE needs to be considered in patients with a prolonged vomiting episode and any type of neurological symptoms, independent of the presence of any surgical complications.
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Bohan PK, Yonge J, Connelly C, Watson JJ, Friedman E, Fielding G. Wernicke Encephalopathy after Restrictive Bariatric Surgery. Am Surg 2016. [DOI: 10.1177/000313481608200401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - John Yonge
- Oregon Health & Science University Portland, Oregon
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Schneider R, Gass JM, Kern B, Peters T, Slawik M, Gebhart M, Peterli R. Linear compared to circular stapler anastomosis in laparoscopic Roux-en-Y gastric bypass leads to comparable weight loss with fewer complications: a matched pair study. Langenbecks Arch Surg 2016; 401:307-13. [PMID: 27001683 DOI: 10.1007/s00423-016-1397-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 03/01/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE In the course of laparoscopic Roux-en-Y gastric bypass (LRYGB), a tight gastroenterostomy (GE) may lead to higher weight loss but possibly to an increase of local complications such as strictures and ulcers. Different operative techniques for Roux-en-Y reconstruction may also influence the rate of internal hernias, a typical late complication of LRYGB. The objective of this study was to compare weight loss, rates of strictures, internal hernias, and ulcerations of linear versus circular stapler anastomosis. METHODS Retrospective analysis of prospectively collected data in a 3:1-matched pair study. A total of 228 patients with a minimal follow-up of 2 years were matched according to BMI at baseline, age, and gender. The follow-up rate was 100 % at 1 and 2 years postoperatively; the mean follow-up time was 3.8 ± 1.63 years. In group C (circular), 57 patients were operated with a 25-mm circular stapler technique (average BMI 44.7 ± 5.18 kg/m(2), age 44.1 ± 10.8 years, 80.7 % female). In group L (linear), 171 patients were operated using a linear stapler (approximately 30 mm, average BMI 43.8 ± 5.24 kg/m(2), age 43.7 ± 12.5 years, 70.8 % female). A propensity score matching and a logrank test were used for statistical analysis. RESULTS The average excessive BMI loss (EBMIL) after 1 year was not statistically different (70.6 ± 20.2 % in group C vs 72.5 ± 20.4 % in group L) as well as after 2 years (71.6 ± 22.5 % in group C vs 74.6 ± 19.6 % in group L). The average operation time was 155 ± 53 min in group C and 109 ± 57 min in group L (p = 0.0001). In group L, patients had significantly lower overall stricture rates at the GE compared to group C (0 [0 %] vs. 4 [7 %], p = 0.0004), a lower rate and severity of internal hernias (10 [5.8 %] vs. 7 [12.3 %] p = 0.466), and equal local ulcerations rates (3 [1.8 %] vs. 1 [1.8 %] p = 0.912). CONCLUSION Linear stapler anastomosis in LRYGB compared to circular anastomosis leads to equal weight loss and less strictures. The lower rate of internal hernias in linear stapler anastomosis was not significantly different.
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Affiliation(s)
- Romano Schneider
- Department of Surgery, St. Claraspital AG, Kleinriehenstrasse 30, CH-4058, Basel, Switzerland
| | - Jörn-Markus Gass
- Department of Surgery, St. Claraspital AG, Kleinriehenstrasse 30, CH-4058, Basel, Switzerland
| | - Beatrice Kern
- Department of Surgery, St. Claraspital AG, Kleinriehenstrasse 30, CH-4058, Basel, Switzerland
| | - Thomas Peters
- Interdisciplinary Center of Nutritional and Metabolic Diseases, St. Claraspital AG, Kleinriehenstrasse 30, CH-4058, Basel, Switzerland
| | - Marc Slawik
- Interdisciplinary Center of Nutritional and Metabolic Diseases, St. Claraspital AG, Kleinriehenstrasse 30, CH-4058, Basel, Switzerland.,Endocrine Research Unit, Medizinische Klinik-Innenstadt, Ludwig-Maximilians University, Munich, Germany
| | - Martina Gebhart
- Interdisciplinary Center of Nutritional and Metabolic Diseases, St. Claraspital AG, Kleinriehenstrasse 30, CH-4058, Basel, Switzerland
| | - Ralph Peterli
- Department of Surgery, St. Claraspital AG, Kleinriehenstrasse 30, CH-4058, Basel, Switzerland.
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Variations in oral vitamin and mineral supplementation following bariatric gastric bypass surgery: a national survey. Obes Surg 2015; 25:648-55. [PMID: 25403775 DOI: 10.1007/s11695-014-1425-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Bariatric surgery (including gastric bypass) is associated with long-term deficiencies in vitamins and minerals, which may have deleterious effects on physiology. The American Association of Clinical Endocrinologists' (AACE) guidelines regarding post-operative vitamin supplementation have recently been endorsed by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). Supplements have cost implications. Non-branded multivitamins may have similar compositions to branded multivitamins, but at a lower cost. This study assesses multivitamin supplementation following bariatric gastric bypass in England against AACE guidelines. It also examines the composition and cost of branded and non-branded multivitamins. METHODS Micronutrient amounts in common multivitamin preparations were obtained from product literature. Costs were collected from a standard retailer. To determine vitamin prescribing patterns, the 37 NHS hospitals performing bariatric gastric bypasses in England were contacted. Practice was assessed against AACE guidelines. RESULTS All non-branded multivitamins met AACE guidelines for composition. Most had similar compositions to branded multivitamins, and all were cheaper. There was no standard practice regarding post-operative supplementation among the 35 responding hospitals. Only 7/35 (20%) hospitals followed the guidance for two-tablet doses of multivitamins. Immediately post-operatively, 25/35 (71%) hospitals administered calcium carbonate and vitamin D (none recommended calcium citrate, as recommended by AACE to improve absorption), and only 9/35 (26%) hospitals recommended iron to all patients. CONCLUSION Most non-branded multivitamins are lower cost alternatives to branded multivitamins, with similar compositions. The AACE recommendation for two-tablet doses of multivitamins is not being met by most English centres. Calcium and iron supplementation is also inadequate.
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Herman CK, Hoschander AS, Wong A. Post-Bariatric Body Contouring. Aesthet Surg J 2015; 35:672-87. [PMID: 25902949 DOI: 10.1093/asj/sjv008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The "epidemic" of obesity has recently been accompanied by a new "epidemic" of massive weight loss. The demand for post-bariatric contouring is rising and, as such, it is extremely important for plastic surgeons to be well versed in the treatment of these patients. Unfortunately, the problem is not solely surgical. OBJECTIVES The aim of this article is to understand the nutritional and psychological complications that can occur in patients following massive weight loss, to understand the anatomic deformities in massive weight loss as a means to correct those deformities surgically, and to understand the complications from post-bariatric contouring procedures in an effort to avoid them. METHODS This article discusses the nutritional and psychological considerations in the massive weight loss patient, anatomical considerations in this patient group, and the surgical techniques designed to address these anatomic concerns. Important pertinent studies are reviewed and discussed. RESULTS Anatomical changes are encountered in each region of the body: there are surgical options available to correct them, although potential complications are associated with these surgical procedures. These surgical options are reviewed as well as the risk and benefits associated with them. CONCLUSIONS There are many problems that need to be addressed in the massive weight loss patient prior to embarking on surgical treatment. Additionally, surgery on massive weight loss patients has unique considerations that distinguish these operations from those performed on the non-bariatric population.
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Affiliation(s)
- Charles K Herman
- Dr Herman is the Chief Medical Executive, Chairman of the Department of Surgery and Chief of the Division of Plastic and Reconstructive Surgery, Pocono Health Systems, East Stroudsburg, PA; Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA; and Assistant Clinical Professor of Surgery, Albert Einstein College of Medicine, New York, NY. Dr. Hoschander is the Chief Resident and Dr. Wong is a Resident in the Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, FL
| | - Ari S Hoschander
- Dr Herman is the Chief Medical Executive, Chairman of the Department of Surgery and Chief of the Division of Plastic and Reconstructive Surgery, Pocono Health Systems, East Stroudsburg, PA; Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA; and Assistant Clinical Professor of Surgery, Albert Einstein College of Medicine, New York, NY. Dr. Hoschander is the Chief Resident and Dr. Wong is a Resident in the Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, FL
| | - Anselm Wong
- Dr Herman is the Chief Medical Executive, Chairman of the Department of Surgery and Chief of the Division of Plastic and Reconstructive Surgery, Pocono Health Systems, East Stroudsburg, PA; Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA; and Assistant Clinical Professor of Surgery, Albert Einstein College of Medicine, New York, NY. Dr. Hoschander is the Chief Resident and Dr. Wong is a Resident in the Division of Plastic Surgery, University of Miami, Miller School of Medicine, Miami, FL
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de la Monte SM, Kril JJ. Human alcohol-related neuropathology. Acta Neuropathol 2014; 127:71-90. [PMID: 24370929 DOI: 10.1007/s00401-013-1233-3] [Citation(s) in RCA: 258] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 02/08/2023]
Abstract
Alcohol-related diseases of the nervous system are caused by excessive exposures to alcohol, with or without co-existing nutritional or vitamin deficiencies. Toxic and metabolic effects of alcohol (ethanol) vary with brain region, age/developmental stage, dose, and duration of exposures. In the mature brain, heavy chronic or binge alcohol exposures can cause severe debilitating diseases of the central and peripheral nervous systems, and skeletal muscle. Most commonly, long-standing heavy alcohol abuse leads to disproportionate loss of cerebral white matter and impairments in executive function. The cerebellum (especially the vermis), cortical-limbic circuits, skeletal muscle, and peripheral nerves are also important targets of chronic alcohol-related metabolic injury and degeneration. Although all cell types within the nervous system are vulnerable to the toxic, metabolic, and degenerative effects of alcohol, astrocytes, oligodendrocytes, and synaptic terminals are major targets, accounting for the white matter atrophy, neural inflammation and toxicity, and impairments in synaptogenesis. Besides chronic degenerative neuropathology, alcoholics are predisposed to develop severe potentially life-threatening acute or subacute symmetrical hemorrhagic injury in the diencephalon and brainstem due to thiamine deficiency, which exerts toxic/metabolic effects on glia, myelin, and the microvasculature. Alcohol also has devastating neurotoxic and teratogenic effects on the developing brain in association with fetal alcohol spectrum disorder/fetal alcohol syndrome. Alcohol impairs function of neurons and glia, disrupting a broad array of functions including neuronal survival, cell migration, and glial cell (astrocytes and oligodendrocytes) differentiation. Further progress is needed to better understand the pathophysiology of this exposure-related constellation of nervous system diseases and better correlate the underlying pathology with in vivo imaging and biochemical lesions.
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Stroh C, Meyer F, Manger T. Beriberi, a severe complication after metabolic surgery - review of the literature. Obes Facts 2014; 7:246-52. [PMID: 25095897 PMCID: PMC5644786 DOI: 10.1159/000366012] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/09/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The epidemic growth of morbid obesity has led to an increase in the number of bariatric interventions. During the distribution process of bariatric surgical interventions, the risk for severe nutritious complications such as bariatric beriberi can rise. METHODS By means of systematic literature review, epidemiological data, clinical characteristics and diagnostic as well as therapeutic recommendations for bariatric beriberi were elicited. Databases and registries such as PubMed, Cochrane and Ovid were searched for a defined time period with the key words 'lack of thiamine' / 'Wernicke-Korsakoff syndrome' / 'encephalopathy' after bariatric surgical interventions. RESULTS Up to December 2013, overall 255 patients had been found as published cases, indicating that the risk for the postoperative occurrence of thiamine deficiency and Wernicke-Korsakoff syndrome is increased in women. In addition, the risk correlates with patient's age. The majority of patients developed symptoms of a dry beriberi with peripheral neuritis, ataxia and paraplegia, indicating an advanced stage of disease approximately 4-12 weeks postoperatively. Laboratory analysis in case of a suspicious clinical finding is the appropriate diagnostics. As treatment, prompt initiation of parenteral thiamine substitution under clinical monitoring is required. CONCLUSION Bariatric beriberi can occur within the first 1-3 postoperative months. To minimize the risk of severe consequences, immediate substitution of thiamine in clinical suspicion or prolonged parenteral nutrition is necessary. A delayed diagnosis or missing the correct diagnosis can lead to irreversible damages of the CNS with coma and fatal outcome. Knowledge on the subject, including development of thiamine deficiency, symptomatology and emergency treatment, are considered essential for bariatric surgeons but also for further medical disciplines involved in treatment.
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Affiliation(s)
- Christine Stroh
- SRH Municipal Hospital, Department of General, Abdominal and Pediatric Surgery, Gera, Germany, Magdeburg, Germany
- *Christine Stroh MD, Department of General, Abdominal and Pediatric Surgery, Municipal Hospital Gera, Straße des Friedens 122, 07548 Gera (Germany),
| | - Frank Meyer
- University Hospital, Department of General, Abdominal and Vascular Surgery, Magdeburg, Germany
| | - Thomas Manger
- SRH Municipal Hospital, Department of General, Abdominal and Pediatric Surgery, Gera, Germany, Magdeburg, Germany
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Abstract
Alcohol-related diseases of the nervous system are caused by excessive exposures to alcohol, with or without co-existing nutritional or vitamin deficiencies. Toxic and metabolic effects of alcohol (ethanol) vary with brain region, age/developmental stage, dose, and duration of exposures. In the mature brain, heavy chronic or binge alcohol exposures can cause severe debilitating diseases of the central and peripheral nervous systems, and skeletal muscle. Most commonly, long-standing heavy alcohol abuse leads to disproportionate loss of cerebral white matter and impairments in executive function. The cerebellum (especially the vermis), cortical-limbic circuits, skeletal muscle, and peripheral nerves are also important targets of chronic alcohol-related metabolic injury and degeneration. Although all cell types within the nervous system are vulnerable to the toxic, metabolic, and degenerative effects of alcohol, astrocytes, oligodendrocytes, and synaptic terminals are major targets, accounting for the white matter atrophy, neural inflammation and toxicity, and impairments in synaptogenesis. Besides chronic degenerative neuropathology, alcoholics are predisposed to develop severe potentially life-threatening acute or subacute symmetrical hemorrhagic injury in the diencephalon and brainstem due to thiamine deficiency, which exerts toxic/metabolic effects on glia, myelin, and the microvasculature. Alcohol also has devastating neurotoxic and teratogenic effects on the developing brain in association with fetal alcohol spectrum disorder/fetal alcohol syndrome. Alcohol impairs function of neurons and glia, disrupting a broad array of functions including neuronal survival, cell migration, and glial cell (astrocytes and oligodendrocytes) differentiation. Further progress is needed to better understand the pathophysiology of this exposure-related constellation of nervous system diseases and better correlate the underlying pathology with in vivo imaging and biochemical lesions.
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Bal BS, Finelli FC, Koch TR. Origins of and recognition of micronutrient deficiencies after gastric bypass surgery. Curr Diab Rep 2011; 11:136-41. [PMID: 21181311 DOI: 10.1007/s11892-010-0169-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Roux-en-Y gastric bypass surgery remains the major surgical option for individuals with medically complicated obesity. The importance of preoperative evaluation to permit identification of micronutrient deficiencies is being re-evaluated. The risk of complications related to pregnancy after gastric bypass supports careful follow-up. Micronutrient deficiencies are common in postoperative gastric bypass patients, despite the suggested use of routine vitamin and mineral supplements after surgery. Copper deficiency must be considered as an origin for visual disorders after gastric bypass. Vitamin D deficiency with metabolic bone disease remains common after gastric bypass and the results suggest that the present postoperative supplements of calcium and vitamin D are inadequate. Major nutritional complications of bariatric surgery are occurring more than 20 years after surgery. There is no evidence for intestinal adaptation as there remains decreased intestinal absorption of iron up to 18 months after gastric bypass surgery. This article supports ongoing examination of nutritional complications after gastric bypass surgery and supports the notion that the daily doses of micronutrient supplements, such as vitamin D, may need to be revised.
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Affiliation(s)
- Bikram S Bal
- Section of Gastroenterology, Washington Hospital Center, Washington, DC 20010, USA.
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Brandt ML, Harmon CM, Helmrath MA, Inge TH, McKay SV, Michalsky MP. Morbid obesity in pediatric diabetes mellitus: surgical options and outcomes. Nat Rev Endocrinol 2010; 6:637-45. [PMID: 20842181 DOI: 10.1038/nrendo.2010.167] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The current obesity epidemic has led to a dramatic increase in insulin resistance and type 2 diabetes mellitus among adolescents, along with other obesity-related comorbidities, such as hypertension, hyperlipidemia, obstructive sleep apnea, psychosocial impairment and nonalcoholic fatty liver disease. Medical treatment of severe obesity is effective in only a small percentage of adolescent patients. In light of the potentially life-threatening complications of obesity, bariatric surgery can be considered a treatment option for adolescent patients with morbid obesity. Indications for surgery rely on both BMI and comorbidity criteria, as well as the ability of the adolescents and their family to understand and comply with perioperative protocols. The long-term effects of bariatric surgery in adolescents are not known; therefore, participation in prospective outcome studies is important. The risk associated with bariatric surgery in adolescents seems to be similar to that observed in adult patients in the short term. Data suggest that bypass procedures successfully reverse or improve abnormal glucose metabolism in the majority of patients and may be more effective in adolescents than adults. This improvement in glucose metabolism occurs before marked weight loss in patients undergoing bypass procedures, suggesting a direct effect on the hormonal control of glucose metabolism.
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Affiliation(s)
- Mary L Brandt
- Department of Surgery, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
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Iannelli A, Addeo P, Gugenheim J. Re: Wernicke’s Encephalopathy After Laparoscopic Roux-en-Y Gastric Bypass: A Misdiagnosed Complication. Obes Surg 2010. [DOI: 10.1007/s11695-010-0206-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Re: Wernicke’s Encephalopathy after Laparoscopic Roux-en-Y Gastric Bypass: A Misdiagnosed Complication. Obes Surg 2010. [DOI: 10.1007/s11695-010-0209-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zhang KJ, Zhang HL, Zhang D, Wu J. Comments on "Wernicke's encephalopathy after laparoscopic Roux-en-Y gastric bypass: a misdiagnosed complication". Obes Surg 2010; 20:1329-30; author reply 1331. [PMID: 20526864 DOI: 10.1007/s11695-010-0207-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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