Nystagmus: an uncommon neurological manifestation of thiamine deficiency as a serious complication of sleeve gastrectomy

Evaluation of the nutritional status of morbid obesity patients in the first six months after sleeve gastrectomy

OBJECTIVE

in recent years, bariatric surgery has gained popularity as a treatment for obesity worldwide. While patients do experience weight loss after surgery, it is important to be aware that serious nutritional deficiencies may also occur. This study was conducted to evaluate the nutritional status of morbidly obese patients in the first six months after sleeve gastrectomy.

METHODS

the study was planned as a retrospective study. The data of 76 patients aged 19-64 years who had undergone bariatric surgery and were followed by a dietitian for at least 6 months were included in the study. Preoperative and postoperative biochemical parameters and anthropometric measurements of the patients were taken.

RESULTS

the lowest body weight of the patients was found at postoperative month 6 (81.74 ± 14.83 kg), the body weight at the preoperative period (115.86 ± 21.28 kg) and postoperative month 1 (100.39 ± 18.28 kg), and the body weight at postoperative month 1 was statistically lower than at the preoperative period. The preoperative body weights and BMI values of the patients were higher than at postoperative months 1 and 6, and the postoperative month 1 values were higher than at postoperative month 6 (p < 0.05). The lowest fasting blood glucose (83.48 ± 8.44 mg/dL), HbA1c (4.96 ± 0.95 %), and Homa-IR (3.34 ± 0.92) were observed at the postoperative month 6. Compared with the preoperative period, the iron level of the patients increased from 69.54 ± 29.82 µg/dL to 96.52 ± 25.39 µg/dL in postoperative month 6, vitamin D levels from 14.48 ± 8.70 µg/dL to 23.96 ± 4.79 µg/dL. While preoperative blood triglyceride and LDL values were statistically higher than in postoperative months 1 and 6, the HDL value was lower (p < 0.05).

CONCLUSION

as a result, after sleeve gastrectomy, patient body weight decreased, and blood lipid profile and diabetes symptoms improved.

Atypical Wernicke's encephalopathy without mental status changes following bariatric surgery in an adolescent patient

Morbid obesity is a systemic disease which can result in chronic complications, including hypertension, diabetes mellitus, depression, osteoarthritis and low self-esteem in the adolescent population.Bariatric surgery can be indicated to treat more severe forms of obesity, but these procedures are not without long-term risks. Therefore, adequate preoperative and postoperative care, which includes preoperative psychosocial evaluation for compliance, ongoing nutrition counselling and vitamin and micronutrient supplementation, is required for all patients, especially adolescent patients, who generally may not comply with medical therapies and/or be able to developmentally fully appreciate or comprehend the health consequences of their behaviours, prior to as well as after bariatric surgery to prevent complications.Thiamine pyrophosphate, an active form of thiamine (also known as vitamin B1, a water-soluble vitamin), which functions as a coenzyme in glucose and energy metabolism, is one such vitamin that requires supplementation postoperatively. It is mandatory for glucose to be administered concomitantly with thiamine, as glucose alone can precipitate Wernicke's encephalopathy (WE) in thiamine-deficient individuals. WE is a medical emergency, with a mortality rate of up to 20%. WE is best understood as a classic triad of mental confusion, gait ataxia and eye movement abnormalities, and atypical WE or Wernicke's syndrome (WS) is seen when the classic triad is not present. Cases that meet some, but do not necessarily meet all three criteria, are referred to as atypical WE or WS which can lead to delayed diagnosis. Atypical WE has an incidence of 19% which can lead to misdiagnosis of a preventable medical emergency with fatal complications.The following case reviews the consequences of post-bariatric thiamine supplementation therapy non-adherence and resulting in a deficiency in an adolescent patient.

Wernicke Encephalopathy: An Updated Narrative Review

Wernicke's encephalopathy (WE) and Korsakoff Syndrome (KS) are distinct neurological disorders that may have overlapping clinical features. Due to the overlap, they are collectively known as Wernicke-Korsakoff syndrome. WE is related to diencephalic and mesencephalic dysfunction due to thiamine. WE typically manifests as confusion, ophthalmoplegia, nystagmus, and gait ataxia (Wernicke's triad), although they may not consistently occur together. Although WE mostly occurs in alcoholics, other etiologies, such as post-bariatric surgery, must be considered. Early diagnosis and therapy by intravenous thiamine are essential to prevent WE complications and to reduce morbidity and mortality. Therefore, physicians' and patients' awareness of WE is essential for early diagnosis and therapy. Accordingly, this narrative review aimed to provide an update on WE by reviewing articles published between April 2015 to April 2022 about the etiology, pathophysiology, diagnosis, and WE management updates. EMBASE, PubMed, Google Scholar, Google, and Scopus search engines were used to conduct the literature search.

“Bariatric Beriberi”: A Rare Case of Wernicke Encephalopathy Two Weeks After Laparoscopic Sleeve Gastrectomy

Wernicke encephalopathy (WE) is an acute neurological syndrome caused by thiamine (vitamin B1) deficiency. This disorder manifests as a triad of gait ataxia, confusion, and vision abnormalities. The absence of a full triad does not rule out WE. Because of its vague presentation, WE is commonly missed in patients with no history of alcohol abuse. Other risk factors for WE include bariatric surgery, hemodialysis, hyperemesis gravidarum, and malabsorption syndromes. WE is a clinical diagnosis that can be confirmed with an MRI of the brain as hyperintensities in the mammillary bodies, periaqueductal area, thalami, and hippocampus. If suspected in a patient, WE must be immediately treated with intravenous thiamine to prevent evolution into Korsakoff syndrome, coma, or death. Currently, there is no consensus in the medical community as to how much thiamine must be given and for how long. Therefore, there is a need for more research in the diagnosis and management of WE after bariatric surgery. Herein, we report a rare case of a 23-year-old female with a history of morbid obesity who developed WE two weeks after a laparoscopic sleeve gastrectomy.

Wernicke's encephalopathy, refeeding syndrome and wet beriberi after laparoscopic sleeve gastrectomy: the importance of thiamine evaluation

We described the case of a young man with morbid obesity who underwent bariatric surgery who experiences different complications. After the discharge the patient starts to complain about nausea, dizziness, and visual impairment. After a first access to an emergency department, with a diagnosis of labyrinthopathy, the patient gets worse. He then has been hospitalized and a wernicke's encephalopathy was diagnosed. During the hospitalization other comploication of low thiamine appeared such as wet beriberi. The clinical picture was also complicated with the refeeding syndrome. Wernicke's encephalopathy, wet beriberi, and refeeding syndrome are life-threatening conditions that can be prevented and treated. Both physicians and patients must be warned about these potential risks in order to put in act a prompt treatment.

Preventing Wernicke Encephalopathy After Bariatric Surgery

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.

Prevalence and predictors of postoperative thiamine deficiency after vertical sleeve gastrectomy

BACKGROUND

As the vertical sleeve gastrectomy (VSG) becomes increasingly popular, its effect on postoperative micronutrient levels, such as thiamine, becomes more important. We previously found a 1.8% prevalence of thiamine deficiency in bariatric patients before surgery.

OBJECTIVE

The aims of this study were to determine the prevalence of thiamine deficiency at our center after VSG and to explore possible predictors of postoperative thiamine levels.

SETTING

University hospital, United States.

METHODS

A retrospective chart review was performed on 147 bariatric patients between 18- and 65-years old who underwent VSG between April 2011 and February 2015. Demographic characteristics, preoperative body mass index (BMI), obesity-associated co-morbidities, alcohol intake, smoking habits, insurance type, calendar year of the procedure, occurrence of postoperative complications, and compliance with postoperative nutrition and follow-up appointment guidelines were extracted from clinical charts. We defined thiamine deficiency as<78 nM on any lab draw within 1 year after the VSG. The χ², Fisher exact, and Mann-Whitney U tests, and multivariate logistic regression models were created to analyze the association of the above factors with thiamine deficiency after a VSG.

RESULTS

Of 147 patients, 105 met inclusion criteria and were analyzed, of whom 27 (25.7%) had thiamine deficiency. Overall median age was 42 years (interquartile ratio: 36, 49). The majority of patients were either African Americans or Caucasian (47.6% and 44.8%, respectively), female (77.1%), and compliant with vitamins (81.0%). The overall mean preoperative BMI was 46.4 kg/m². Patients with thiamine deficiency were more likely to be African American (66.7%, P = .024), have a larger preoperative BMI (P = .026), and to report repetitive episodes of nausea (59.3%, P = .002) and vomiting (44.4%, P = .001) at any of their postoperative appointments within 1 year after surgery. Compliance with vitamins did not differ between those with or without thiamine deficiency (70.4%, 84.6%, P = .10). After controlling for all factors, African American race (odds ratio [OR] 3.9, P = .019), higher preoperative BMI (OR 1.13, P = .001), nausea (OR 3.81, P = .02), and vomiting (OR 3.49, P = .032) were independent risk factors for the development of thiamine deficiency.

CONCLUSIONS

We found an alarmingly high prevalence of thiamine deficiency in postoperative SG patients. This disorder may have serious consequences including Wernicke encephalopathy; hence, it is important to identify predictive demographic, postoperative, and behavioral factors so that appropriate measures can be taken to prevent thiamine deficiency in VSG patients.

Thiamine and selected thiamine antivitamins - biological activity and methods of synthesis

Thiamine plays a very important coenzymatic and non-coenzymatic role in the regulation of basic metabolism. Thiamine diphosphate is a coenzyme of many enzymes, most of which occur in prokaryotes. Pyruvate dehydrogenase and 2-oxoglutarate dehydrogenase complexes as well as transketolase are the examples of thiamine-dependent enzymes present in eukaryotes, including human. Therefore, thiamine is considered as drug or diet supplement which can support the treatment of many pathologies including neurodegenerative and vascular system diseases. On the other hand, thiamine antivitamins, which can interact with thiamine-dependent enzymes impeding their native functions, thiamine transport into the cells or a thiamine diphosphate synthesis, are good propose to drug design. The development of organic chemistry in the last century allowed the synthesis of various thiamine antimetabolites such as amprolium, pyrithiamine, oxythiamine, or 3-deazathiamine. Results of biochemical and theoretical chemistry research show that affinity to thiamine diphosphate-dependent enzymes of these synthetic molecules exceeds the affinity of native coenzyme. Therefore, some of them have already been used in the treatment of coccidiosis (amprolium), other are extensively studied as cytostatics in the treatment of cancer or fungal infections (oxythiamine and pyrithiamine). This review summarizes the current knowledge concerning the synthesis and mechanisms of action of selected thiamine antivitamins and indicates the potential of their practical use.

Wernicke Encephalopathy and Sleeve Gastrectomy: A Case Report and Literature Review

As the number of obese patients increases, as will the number of bariatric procedures. Malabsorptive bariatric procedures have emerged as one of common causes of Wernicke encephalopathy (WE), an acute neuropsychiatric disorder due to thiamine deficiency. However, restrictive procedures such as sleeve gastrectomy (SG) are less prone to cause nutrient deficiencies. WE occurred after SG is an uncommon complication because the main absorptive sites for thiamine are intact after SG. Here, we report a case of WE after SG. With rapid increase in the use of SG for morbid obesity, this case deserves particular attention from clinicians.

Wernicke Encephalopathy: a Future Problem Even After Sleeve Gastrectomy? A Systematic Literature Review

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.

A Fatal Case of Wernicke's Encephalopathy after Sleeve Gastrectomy for Morbid Obesity

Wernicke's encephalopathy is an acute neuropsychiatric disorder, due to thiamine (vitamin B1) deficiency. It is traditionally described in chronic alcohol abusers; however obesity surgery is an emerging cause, as the number of bariatric procedures increases. A high index of clinical suspicion is required, since initial symptoms may be nonspecific and the classic triad of ophthalmoplegia, gait and stance disorders, and mental confusion is present only in one-third of patients. Laboratory tests can be within normal range and typical MRI brain lesions are found only in 50% of cases. Aggressive supplementation with intravenous thiamine should not be delayed until confirmation of diagnosis, as it may fully reverse symptoms, but almost half the patients will still display permanent neurological deficit. We present our experience with a fatal case of Wernicke's encephalopathy, following laparoscopic sleeve gastrectomy for morbid obesity.

Wernicke's encephalopathy three weeks after sleeve gastrectomy

Following bariatric surgeries for management of morbid obesity, less nutrients are absorbed, giving rise to complications due to vitamin deficiencies with frequently dramatic consequences. Neurologic complications resulting from folate, vitamin B12, and thiamine deficiencies have been estimated to occur in up to 16% of cases and present within weeks to months following bariatric surgery. Among bariatric surgeries, Roux-en-Y gastric bypass has been the most associated with such deficiencies due to both restrictive and malabsorptive components. Complications are less seen with restrictive surgeries. We report a case of rapid Wernicke's encephalopathy due to a thiamine deficiency in a young female patient following Sleeve gastrectomy (SG).

Thiamin diphosphate-dependent enzymes: from enzymology to metabolic regulation, drug design and disease models

Bringing a knowledge of enzymology into research in vivo and in situ is of great importance in understanding systems biology and metabolic regulation. The central metabolic significance of thiamin (vitamin B1 ) and its diphosphorylated derivative (thiamin diphosphate; ThDP), and the fundamental differences in the ThDP-dependent enzymes of metabolic networks in mammals versus plants, fungi and bacteria, or in health versus disease, suggest that these enzymes are promising targets for biotechnological and medical applications. Here, the in vivo action of known regulators of ThDP-dependent enzymes, such as synthetic structural analogs of the enzyme substrates and thiamin, is analyzed in light of the enzymological data accumulated during half a century of research. Mimicking the enzyme-specific catalytic intermediates, the phosphonate analogs of 2-oxo acids selectively inhibit particular ThDP-dependent enzymes. Because of their selectivity, use of these compounds in cellular and animal models of ThDP-dependent enzyme malfunctions improves the validity of the model and its predictive power when compared with the nonselective and enzymatically less characterized oxythiamin and pyrithiamin. In vitro studies of the interaction of thiamin analogs and their biological derivatives with potential in vivo targets are necessary to identify and attenuate the analog selectivity. For both the substrate and thiamin synthetic analogs, in vitro reactivities with potential targets are highly relevant in vivo. However, effective concentrations in vivo are often higher than in vitro studies would suggest. The significance of specific inihibition of the ThDP-dependent enzymes for the development of herbicides, antibiotics, anticancer and neuroprotective strategies is discussed.