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Acute postgastric reduction syndrome
Letters to the Editor / Surgery for Obesity and Related Diseases 8 (2012) 655– 658
References [1] Sheff SR, May MC, Carlisle SE, Kallies KJ, Mathiason MA, Kothari SN. Predictors of a difficult intubation in the bariatric patient: does preoperative body mass index matter? Surg Obes Relat Dis Epub 2012 Mar 3. [2] Cook TM. A new practical classification of laryngeal view. Anaesthesia 2000;55:274 –9. [3] Yentis SM, Lee DJH. Evaluation of an improved scoring system for the grading of direct laryngoscopy. Anaesthesia 1998;53:1041– 4.
http://dx.doi.org/10.1016/j.soard.2012.05.007
Acute postgastric reduction syndrome To the editor: Acute postgastric reduction syndrome is a complication of weight loss surgery involving systemic and central nervous system symptoms characterized by intractable vomiting, weakness, and hyporeflexia [1]. Other symptoms include pain, incontinence, visual impairment associated with diplopia, and numbness. Although less common, dysphonia and delirium, as well as attention deficit, and memory and hearing loss, can occur. Physical examination typically demonstrates gaze-evoked nystagmus and severe proximal extremity weakness. Diagnostic studies will be characterized by axonal sensory motor polyneuropathy of the lower extremities involving the quadriceps. Nerve biopsies have demonstrated multifocal myelinated fiber loss and lack of inflammatory cells. Treatment requires aggressive intravenous multivitamin administration and nutritional support, especially intravenous thiamine. Intravenous administration of gammaglobulin has also been documented for the management of this syndrome in 1 report [2]; however, substantial evidence for this practice is lacking. Acute postgastric reduction syndrome should be considered a marker of multiple vitamin and mineral deficiencies, in particular, thiamine deficiency. Thiamine (vitamin B1) has a half-life of 9 –18 days and can be rapidly depleted if the patient has inadequate intake and will be profoundly exacerbated by vomiting. Preoperative deficiency of vitamin B1 is present in 15%–29% of patients and is more commonly seen in blacks and Hispanics than in whites [3,4]. Although routine screening for thiamine deficiency is not required, patients presenting with intractable vomiting should be assessed for a possible vitamin B1 deficit. Early symptoms are related to mild central nervous system manifestations, including anorexia, gait ataxia, and irritability. Muscle cramps and paresthesia can also occur. Profound thiamine deficiency leads to beriberi and, in severe cases, to Wernicke’s encephalopathy and Korsakoff’s psychoses [5]. Ramos-de la Medina et al [6] reported the case of a man with a body mass index of 70 kg/m2 who developed acute postgastrectomy syndrome 5 months after laparoscopic
657
sleeve gastrectomy. Their case illustrates several aspects of importance to those involved in the care of bariatric surgery patients. It is quite possible that this patient had profound preoperative deficiencies. Obese patients often present with deficiencies of vitamins A, E, and D and carotenoids, zinc, selenium, and thiamine [7]. The incidence of iron [4] and vitamin D [8] deficiencies in morbidly obese patients is more the rule than the exception, occurring in 50 – 80% of preoperative subjects [9]. The greater the BMI, the more profound the deficiency [10]. Vitamin B12 deficiency was present in 13% of a small cohort of patients before bariatric surgery [11]. Folic acid deficiency was observed in more than one half of preoperative bariatric surgery patients [12]. A small cohort of patients demonstrated that 23% of patients considering Roux-en-Y gastric bypass were deficient in vitamin E [12]. A similar study reported zinc deficiency in 28% of preoperative patients [11]. These studies also suggested that these deficiencies will be exacerbated after bariatric surgery. Thus, the patient in their report likely presented with such deficiencies. Was he screened for any vitamin and mineral deficiency preoperatively? Should he have been a candidate for surgical intervention if he had had any of these preoperative deficiencies? Second, the follow-up for this patient was not adequate. Issues with compliance should also be identified preoperatively. Was he a candidate for weight reduction surgery based on compliance to adhere to a postoperative diet? Male superobese patients are more likely to have complications after weight reduction surgery than are women, and patients with a body mass index ⬍50 kg/m2 [13]. Was this patient a candidate for weight loss surgery because of his co-morbidities? This patient ultimately died of complications related to pulmonary embolism. Although retrospective analysis of this case would indicate multiple factors that might have been warning signs to delay or avoid bariatric surgery, such a case can be used proactively to remind the bariatric surgery community of the preoperative, intraoperative, and postoperative care required of patients considering weight reduction surgery. Sergio Huerta, M.D., F.A.C.S. University of Texas Southwestern Medical Center at Dallas Veterans Affairs North Texas Health Care System Dallas, Texas References [1] Akhtar M, Collins MP, Kissel JT. Acute postgastric reduction surgery (APGARS) neuropathy: a polynutritional, multisystem disorder. Neurology 2002;58:A68. [2] Chang CG, Adams-Huet B, Provost DA. Acute post-gastric reduction surgery (APGARS) neuropathy. Obes Surg 2004;14:182–9. [3] Carrodeguas L, Kaidar-Person O, Szomstein S, Antozzi P, Rosenthal R. Preoperative thiamine deficiency in obese population undergoing laparoscopic bariatric surgery. Surg Obes Relat Dis 2005;1:517–22.
658
Letters to the Editor / Surgery for Obesity and Related Diseases 8 (2012) 655– 658
[4] Flancbaum L, Belsley S, Drake V, Colarusso T, Tayler E. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg 2006;10: 1033–7. [5] Nautiyal A, Singh S, Alaimo DJ. Wernicke encephalopathy—an emerging trend after bariatric surgery. Am J Med 2004;117: 804 –5. [6] Ramos-De la, Medina A, Noguera-Rojas W, Anitúa-Valdovinos Mdel M, Muñoz-Joachim C. Acute postgastric reduction surgery neuropathy and severe malnutrition after sleeve gastrectomy for morbid obesity. Surg Obes Relat Dis 2011;7:119 –21. [7] Jacques J, Dixon J. Prevention of vitamin, mineral and nutritional deficiencies, in: Deitel M, editor. Handbook of obesity surgery: current concepts and therapy of morbid obesity and related disease. Toronto, FD-Communications; 2010, p. 326 –35. [8] Carlin AM, Rao DS, Meslemani AM, et al. Prevalence of vitamin D depletion among morbidly obese patients seeking gastric bypass surgery. Surg Obes Relat Dis 2006;2:98 –103. [9] ASMBS Allied Health Sciences Section Ad Hoc Nutrition Committee, Aills L, Blankenship J, Buffington C, Furtado M, Parrott J, Parrott J. ASMBS allied health nutritional guidelines for the surgical weight loss patient. Surg Obes Relat Dis 2008;4:S73–108. [10] Buffington C, Walker B, Cowan GS Jr, Scruggs D. Vitamin D deficiency in the morbidly obese. Obes Surg 1993;3:421– 4. [11] Madan AK, Orth WS, Tichansky DS, Ternovits CA. Vitamin and trace mineral levels after laparoscopic gastric bypass. Obes Surg 2006;16:603– 6. [12] Boylan LM, Sugerman HJ, Driskell JA. Vitamin E, vitamin B-6, vitamin B-12, and folate status of gastric bypass surgery patients. J Am Diet Assoc 1988;88:579 – 85. [13] Livingston EH, Huerta S, Arthur D, Lee S, De Shields S, Heber D. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg 2002;236:576 – 82.
tient selection, including psychosocial evaluation, is key in achieving optimal outcomes after bariatric surgery [1–3]. Our current practice is to screen patients for vitamin and mineral deficiencies during the selection process to be able to address them preoperatively. To predict a patient’s adherence to postoperative care, our bariatric surgery programs require that patients follow a strict diet and achieve some weight loss before surgery. Noncompliance with the preoperative recommendations often identifies patients who might be poor surgical candidates [4]. Our report is also relevant because, secondary to these complications, the patient had Doppler-confirmed deep vein thrombosis and, subsequently, developed classic pulmonary embolism clinical symptoms with typical electrocardiographic changes, followed by irreversible cardiac arrest, despite therapeutic anticoagulation with low-molecular-weight heparin. Finally, we are pleased that our report achieved the most important of its goals, to increase awareness about the potential risks of bariatric procedures and elicit discussion about the proper selection and adequate follow-up of patients. Sleeve gastrectomy is unfoundedly offered by some as a safer and easier alternative to other bariatric procedures and is purported to require less-intensive follow-up and lifestyle changes. This report underscores that all bariatric surgical procedures are elective operations with medical and behavioral consequences that require lifelong follow-up and for which patients must be carefully selected and treated by a multidisciplinary group.
http://dx.doi.org/10.1016/j.soard.2012.06.005
Antonio Ramos-de la Medina, M.D. Department of Surgery Veracruz Regional Hospital Veracruz, Mexico
Acute postgastric reduction syndrome To the editor: We would like to thank Dr. Huerta for his insightful comments on our report on “Acute postgastric reduction surgery, neuropathy, and severe malnutrition after sleeve gastrectomy.” We want to address the main questions raised. This patient was not preoperatively evaluated nor operated on by our service. We were involved in his care only after he sought medical attention because of intractable vomiting and severe malnutrition 5 months after his surgery. We fully agree that his follow-up and compliance with standard postoperative recommendations were inadequate. Moreover, although this patient fulfilled the criteria (body mass index and co-morbidities) to be offered bariatric surgery, he was not screened for vitamin or mineral deficiencies nor was he given a trial diet preoperatively. We consider that his poor understanding regarding the procedure and postoperative care, as well as his lack of social support, should have contraindicated the operation. Appropriate pa-
Helen Forcada-Arens, M.Sc. Department of Nutrition Hospital Español de Veracruz Veracruz, Mexico References [1] Livhits M, Mercado C, Yermilov I, et al. Is social support associated with greater weight loss after bariatric surgery?: a systematic review. Obes Rev 2011;12:142– 8. [2] van Hout G, van Heck G. Bariatric psychology, psychological aspects of weight loss surgery. Obes Facts 2009;2:10 –5. [3] Ray EC, Nickels MW, Sayeed S, Sax HC. Predicting success after gastric bypass: the role of psychosocial and behavioral factors. Surgery 2003;134:555– 63. [4] Collazo-Clavell ML, Clark MM, McAlpine DE, Jensen MD. Assessment and preparation of patients for bariatric surgery. Mayo Clin Proc 2006;81(10 Suppl):S11–7.
http://dx.doi.org/10.1016/j.soard.2012.06.004
References [1] Sheff SR, May MC, Carlisle SE, Kallies KJ, Mathiason MA, Kothari SN. Predictors of a difficult intubation in the bariatric patient: does preoperative body mass index matter? Surg Obes Relat Dis Epub 2012 Mar 3. [2] Cook TM. A new practical classification of laryngeal view. Anaesthesia 2000;55:274 –9. [3] Yentis SM, Lee DJH. Evaluation of an improved scoring system for the grading of direct laryngoscopy. Anaesthesia 1998;53:1041– 4.
http://dx.doi.org/10.1016/j.soard.2012.05.007
Acute postgastric reduction syndrome To the editor: Acute postgastric reduction syndrome is a complication of weight loss surgery involving systemic and central nervous system symptoms characterized by intractable vomiting, weakness, and hyporeflexia [1]. Other symptoms include pain, incontinence, visual impairment associated with diplopia, and numbness. Although less common, dysphonia and delirium, as well as attention deficit, and memory and hearing loss, can occur. Physical examination typically demonstrates gaze-evoked nystagmus and severe proximal extremity weakness. Diagnostic studies will be characterized by axonal sensory motor polyneuropathy of the lower extremities involving the quadriceps. Nerve biopsies have demonstrated multifocal myelinated fiber loss and lack of inflammatory cells. Treatment requires aggressive intravenous multivitamin administration and nutritional support, especially intravenous thiamine. Intravenous administration of gammaglobulin has also been documented for the management of this syndrome in 1 report [2]; however, substantial evidence for this practice is lacking. Acute postgastric reduction syndrome should be considered a marker of multiple vitamin and mineral deficiencies, in particular, thiamine deficiency. Thiamine (vitamin B1) has a half-life of 9 –18 days and can be rapidly depleted if the patient has inadequate intake and will be profoundly exacerbated by vomiting. Preoperative deficiency of vitamin B1 is present in 15%–29% of patients and is more commonly seen in blacks and Hispanics than in whites [3,4]. Although routine screening for thiamine deficiency is not required, patients presenting with intractable vomiting should be assessed for a possible vitamin B1 deficit. Early symptoms are related to mild central nervous system manifestations, including anorexia, gait ataxia, and irritability. Muscle cramps and paresthesia can also occur. Profound thiamine deficiency leads to beriberi and, in severe cases, to Wernicke’s encephalopathy and Korsakoff’s psychoses [5]. Ramos-de la Medina et al [6] reported the case of a man with a body mass index of 70 kg/m2 who developed acute postgastrectomy syndrome 5 months after laparoscopic
657
sleeve gastrectomy. Their case illustrates several aspects of importance to those involved in the care of bariatric surgery patients. It is quite possible that this patient had profound preoperative deficiencies. Obese patients often present with deficiencies of vitamins A, E, and D and carotenoids, zinc, selenium, and thiamine [7]. The incidence of iron [4] and vitamin D [8] deficiencies in morbidly obese patients is more the rule than the exception, occurring in 50 – 80% of preoperative subjects [9]. The greater the BMI, the more profound the deficiency [10]. Vitamin B12 deficiency was present in 13% of a small cohort of patients before bariatric surgery [11]. Folic acid deficiency was observed in more than one half of preoperative bariatric surgery patients [12]. A small cohort of patients demonstrated that 23% of patients considering Roux-en-Y gastric bypass were deficient in vitamin E [12]. A similar study reported zinc deficiency in 28% of preoperative patients [11]. These studies also suggested that these deficiencies will be exacerbated after bariatric surgery. Thus, the patient in their report likely presented with such deficiencies. Was he screened for any vitamin and mineral deficiency preoperatively? Should he have been a candidate for surgical intervention if he had had any of these preoperative deficiencies? Second, the follow-up for this patient was not adequate. Issues with compliance should also be identified preoperatively. Was he a candidate for weight reduction surgery based on compliance to adhere to a postoperative diet? Male superobese patients are more likely to have complications after weight reduction surgery than are women, and patients with a body mass index ⬍50 kg/m2 [13]. Was this patient a candidate for weight loss surgery because of his co-morbidities? This patient ultimately died of complications related to pulmonary embolism. Although retrospective analysis of this case would indicate multiple factors that might have been warning signs to delay or avoid bariatric surgery, such a case can be used proactively to remind the bariatric surgery community of the preoperative, intraoperative, and postoperative care required of patients considering weight reduction surgery. Sergio Huerta, M.D., F.A.C.S. University of Texas Southwestern Medical Center at Dallas Veterans Affairs North Texas Health Care System Dallas, Texas References [1] Akhtar M, Collins MP, Kissel JT. Acute postgastric reduction surgery (APGARS) neuropathy: a polynutritional, multisystem disorder. Neurology 2002;58:A68. [2] Chang CG, Adams-Huet B, Provost DA. Acute post-gastric reduction surgery (APGARS) neuropathy. Obes Surg 2004;14:182–9. [3] Carrodeguas L, Kaidar-Person O, Szomstein S, Antozzi P, Rosenthal R. Preoperative thiamine deficiency in obese population undergoing laparoscopic bariatric surgery. Surg Obes Relat Dis 2005;1:517–22.
658
Letters to the Editor / Surgery for Obesity and Related Diseases 8 (2012) 655– 658
[4] Flancbaum L, Belsley S, Drake V, Colarusso T, Tayler E. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg 2006;10: 1033–7. [5] Nautiyal A, Singh S, Alaimo DJ. Wernicke encephalopathy—an emerging trend after bariatric surgery. Am J Med 2004;117: 804 –5. [6] Ramos-De la, Medina A, Noguera-Rojas W, Anitúa-Valdovinos Mdel M, Muñoz-Joachim C. Acute postgastric reduction surgery neuropathy and severe malnutrition after sleeve gastrectomy for morbid obesity. Surg Obes Relat Dis 2011;7:119 –21. [7] Jacques J, Dixon J. Prevention of vitamin, mineral and nutritional deficiencies, in: Deitel M, editor. Handbook of obesity surgery: current concepts and therapy of morbid obesity and related disease. Toronto, FD-Communications; 2010, p. 326 –35. [8] Carlin AM, Rao DS, Meslemani AM, et al. Prevalence of vitamin D depletion among morbidly obese patients seeking gastric bypass surgery. Surg Obes Relat Dis 2006;2:98 –103. [9] ASMBS Allied Health Sciences Section Ad Hoc Nutrition Committee, Aills L, Blankenship J, Buffington C, Furtado M, Parrott J, Parrott J. ASMBS allied health nutritional guidelines for the surgical weight loss patient. Surg Obes Relat Dis 2008;4:S73–108. [10] Buffington C, Walker B, Cowan GS Jr, Scruggs D. Vitamin D deficiency in the morbidly obese. Obes Surg 1993;3:421– 4. [11] Madan AK, Orth WS, Tichansky DS, Ternovits CA. Vitamin and trace mineral levels after laparoscopic gastric bypass. Obes Surg 2006;16:603– 6. [12] Boylan LM, Sugerman HJ, Driskell JA. Vitamin E, vitamin B-6, vitamin B-12, and folate status of gastric bypass surgery patients. J Am Diet Assoc 1988;88:579 – 85. [13] Livingston EH, Huerta S, Arthur D, Lee S, De Shields S, Heber D. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg 2002;236:576 – 82.
tient selection, including psychosocial evaluation, is key in achieving optimal outcomes after bariatric surgery [1–3]. Our current practice is to screen patients for vitamin and mineral deficiencies during the selection process to be able to address them preoperatively. To predict a patient’s adherence to postoperative care, our bariatric surgery programs require that patients follow a strict diet and achieve some weight loss before surgery. Noncompliance with the preoperative recommendations often identifies patients who might be poor surgical candidates [4]. Our report is also relevant because, secondary to these complications, the patient had Doppler-confirmed deep vein thrombosis and, subsequently, developed classic pulmonary embolism clinical symptoms with typical electrocardiographic changes, followed by irreversible cardiac arrest, despite therapeutic anticoagulation with low-molecular-weight heparin. Finally, we are pleased that our report achieved the most important of its goals, to increase awareness about the potential risks of bariatric procedures and elicit discussion about the proper selection and adequate follow-up of patients. Sleeve gastrectomy is unfoundedly offered by some as a safer and easier alternative to other bariatric procedures and is purported to require less-intensive follow-up and lifestyle changes. This report underscores that all bariatric surgical procedures are elective operations with medical and behavioral consequences that require lifelong follow-up and for which patients must be carefully selected and treated by a multidisciplinary group.
http://dx.doi.org/10.1016/j.soard.2012.06.005
Antonio Ramos-de la Medina, M.D. Department of Surgery Veracruz Regional Hospital Veracruz, Mexico
Acute postgastric reduction syndrome To the editor: We would like to thank Dr. Huerta for his insightful comments on our report on “Acute postgastric reduction surgery, neuropathy, and severe malnutrition after sleeve gastrectomy.” We want to address the main questions raised. This patient was not preoperatively evaluated nor operated on by our service. We were involved in his care only after he sought medical attention because of intractable vomiting and severe malnutrition 5 months after his surgery. We fully agree that his follow-up and compliance with standard postoperative recommendations were inadequate. Moreover, although this patient fulfilled the criteria (body mass index and co-morbidities) to be offered bariatric surgery, he was not screened for vitamin or mineral deficiencies nor was he given a trial diet preoperatively. We consider that his poor understanding regarding the procedure and postoperative care, as well as his lack of social support, should have contraindicated the operation. Appropriate pa-
Helen Forcada-Arens, M.Sc. Department of Nutrition Hospital Español de Veracruz Veracruz, Mexico References [1] Livhits M, Mercado C, Yermilov I, et al. Is social support associated with greater weight loss after bariatric surgery?: a systematic review. Obes Rev 2011;12:142– 8. [2] van Hout G, van Heck G. Bariatric psychology, psychological aspects of weight loss surgery. Obes Facts 2009;2:10 –5. [3] Ray EC, Nickels MW, Sayeed S, Sax HC. Predicting success after gastric bypass: the role of psychosocial and behavioral factors. Surgery 2003;134:555– 63. [4] Collazo-Clavell ML, Clark MM, McAlpine DE, Jensen MD. Assessment and preparation of patients for bariatric surgery. Mayo Clin Proc 2006;81(10 Suppl):S11–7.
http://dx.doi.org/10.1016/j.soard.2012.06.004