Metabolic complications of Bypass surgery for Morbid Obesity

Clinical Medicine: Case Reports
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Metabolic complications of Bypass surgery for Morbid Obesity
s. Richard-Devantoy1,2, J.B. Garré1 and B. Gohier1
1Département de psychiatrie et psychologie médicale, Centre Hospitalier Universitaire d’Angers, 4 rue Larrey, Angers,
France. 2UpRes eA 2646, Université d’Angers, UNAM, Angers, France.
Abstract: Postoperative complications resulting from bariatric surgery can lead to severe vitamin-deficiency states. A patient who
underwent bariatric bypass surgery and later developed Wernicke’s encephalopathy prompted us to present her interesting case history
for discussion. Although bariatric surgery is known to be a risk factor for Wernicke’s encephalopathy, this diagnosis is only rarely
evoked in the postoperative course. We recommend that the occurrence of digestive, psychiatric or neurological symptoms after
bariatric surgery should suggest a thiamine deficiency that must be promptly assessed. Without waiting for the results, thiamine
supplementation should be initiated.
Keywords: bariatric surgery, Wernicke’s encephalopathy, morbid obesity, metabolic complications, prevention
Clinical Medicine: Case Reports 2009:2 55–58
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Richard-Devantoy et al
Introduction
of weight gain, and a wish to accelerate weight loss.
Support for the current epidemic of morbid
Within 3 months, she lost 30 kg or 27% of her initial
obesity affecting industrialized countries requires
weight. Given this self-imposed dietary restriction,
a multidisciplinary approach in which surgery
2 months after bypass surgery, Mrs. K., suddenly
is a growing (Body Mass Index (B.M.I.) 40 or
presented spontaneous nausea with vomiting along
B.M.I.  35 and comorbidities).1 This type of
with a neurological episode characterized by feelings
treatment, which should be reserved for selected
of vertigo, atactic walk, an intense rotatory sensation
patients, allows for weight loss and improved
and a vertical-inferior rotary nystagmus. Laboratory
cardiovascular satellites comorbidities of obesity such
screening did not reveal any abnormalities (blood
as diabetes, hypertension and dyslipidemia.2 Patients
cell count, blood ionogram as well as hepatic, renal
suffering from morbid obesity often have nutritional
and pancreatic functions). Investigations including
deficiencies, including fat-soluble vitamins, folate
a lombar punction, an electroencephalogramme and
and zinc.3 After bariatric surgery, these gaps are
magnetic resonance imaging did not lead to any
widening. Others may appear, especially because
conclusive diagnosis. Vitamin levels (vitamins A, E,
of the restriction of dietary intake in the gastric
and B12, erythrocyte transketolase activity, serum and
reduction surgery, and malabsorption induced in type
erythrocyte folates) were normal and all serologies
interventions bypass. The latter lead to greater weight
were negative (Lyme disease, HIV, syphilis, CMV,
loss but also to exhibit more severe deficiencies.
herpes virus, EBV, hepatitis B and C, Yersinia, and
Besides a protein undernutrition with decreased lean
Campylobacter jejuni). Immunological screening
mass, an iron deficiency anemia from deficiency
was normal (native anti-DNA antibodies, soluble
in folate or vitamin B 12 can also observe the
nuclear antigens, anti-mitochondria antibodies,
neurological manifestations such as encephalopathy
rheumatoid factor, complement, cold agglutinines,
of Gayet-Wernicke. Wernicke’s encephalopathy
and ANCA). The diagnostic hypothesis proposed
results from vitamin B1 (thiamine) deficiency and
at first was that of acute polyradiculoneuritis as
has been associated with alcoholism, gastric cancer,
seen in Miller-Fisher syndrome. As the diagnosis of
pyloric obstruction, hyperemesis gravidarum, and
Wernicke’s encephalopathy was not initially evoked,
prolonged parenteral feeding. Bariatric surgery
thiamine concentrations were not measured. Mrs. K.,
appears to be another emerging condition that may
who did not take any postoperative vitamins, was not
lead to Wernicke’s encephalopathy. The average
immediately prescribed vitamin B1 supplementation.
rates of early postoperative deaths were 0.1%,
Towards the end of 2007, Mrs. K., was admitted
0.35% and 0.5% respectively for gastric adjustable,
to the Angers University Hospital for a check-up of
the bilio-pancreatic diversion and gastric bypass.
residual neurological problems. At that time, being
The pulmonary embolism was the most common
1.65 m tall, she weighted 52 kg, which corresponded
etiology found, up to 70% of the vertical gastroplasty
to a BMI of 19 Kg/m2. The clinical picture was
size poses and the order of 50% for the other two
characterized as follows: major ataxia, only slightly
techniques.1 The diagnosis of encephalopathy of
aggravated by eye closure, a cerebellar kinetic syndrome
Gayet-Wernicke is generally referred to the history
predominant on the right side along with a discret
of bariatric surgery: vertical gastroplasty size poses,4
hypoesthesia of the right hemibody involving the face
gastric ring,5 and most often gastric bypass.6
without motor deficiency, abolition of osteotendineous
reflexes as well as a cerebellar-like dysarthria. While
Observation
the patient was well-oriented in space and time and
In 2006, Mrs. K., a 34-year-old, underwent gastric
was not in any state of confusion, she presented an
bypass surgery after failed gastroplasty at the age of
anterograde and partial retrograde amnesia associated
18 and persisting morbid obesity (weight: 109 kg;
with signs of frontal lobe dysfunction, such as
height 1.65 m; body mass index: 40 kg/m2). Following
euphoria, reduced verbal fluency, and lack of words.
surgery, the patient developed restrictive anorexia
The frontal assessment battery (FAB) which assesses
nervosa characterized by a voluntary refusal to eat,
frontal lobe function was evaluated at 14/18. The
potomania (excess intake of water and coffee), a fear
clinical symptoms evocative of cerebellar dysfunction
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Metabolic complications of bypass surgery for morbid obesity
associated with an anterograd mnesic disorder and
occurs within 4 to 12 weeks after surgery. Atypical
a normal electromyogram reinforced the hypothesis
neurological pictures are common and often
of a sequella to Wernicke’s encephalopathy.
misleading.11 Optic neuropathy, papilledema, deafness,
seizures, asterixis, weakness, and sensory and motor
Discussion
neuropathy were also reported.12 Brain magnetic
This is the only case observed within the Loire region
resonance imaging identified lesions characteristic
of France. It should be noted that the patient was not
of WE 47%.10 Characteristic radiographic findings
followed by the Angers network for surgical treatment
were hyperintense signals in the periaqueductal gray
of morbid obesity.
area and dorsal medial nucleus of the thalamus;
In response to a steep increase in morbid obesity,
radiographs were normal in 15 patients.12 Although
new therapeutic options have been developed. Among
MRI has been reported to have high specificity (93%),
these, bariatric surgery is one of the most effective
its sensitivity is low (53%).13 Vitamin measurements
methods for the long-term management of obesity and
are often flawed. For the reported cases, plasma
its complications.7 Provided that contraindications
thiamine levels and erythrocyte thiamine transketolase
are respected, the method appears to be safe with only
activity were normal in one-third of cases.12 The
0.5% to 3% of short and long-term complications and a
diagnosis is often made too late, based a posteriori
mortality rate estimated at 0.5% in France.1 In contrast,
on a bundle of arguments. Incomplete recovery was
current bariatric studies report a 20% in-hospital
observed in 41 cases (49%); memory deficits and gait
complication rate in United-States.8 Enconisa et al
difficulties were frequent sequela.10
found a significantly higher complication rate over
This observation illustrates the risks of vitamin
the six months after surgery, resulting in costly
deficiency and the necessity for its prevention
readmissions and emergency room visits.8 In addition
following bariatric surgery. The few cases reported in
to the complications related to the surgery such as
the literature along with our observation al ow us to put
stenoses of gastrojejunal anastomosis, internal hernias,
forth a simple but indispensable prevention strategy
ulcers and disruption of the suture lines, several
to reduce the risk of Wernicke’s encephalopathy.
research teams have highlighted the occurrence of
A preoperative assessment of thiamine levels does
nutritional complications, such as malnutrition
not appear to be pertinent. However, the pre-operative
due to protein deficiency, hypophosphatemia, and
check-up should systematically include a screening
Wernicke’s syndrome. This latter complication is
for eating disorders, and the surgeons need to ascertain
particularly serious because of the sequellae that it
the patient’s compliance to treatment.
may induce in the case of an erroneous diagnosis.
In the postoperative period after any type of
Of note, thiamine’s primary absorption occurs in the
bariatric surgery, the occurrence of digestive
jejunum, which is partly by-passed by this type of
symptoms (anorexia, vomiting or significant weight
surgery.
loss), psychiatric symptoms (irritability or depression)
Yet Wernicke’s syndrome diagnosis is only rarely
or neurological symptoms should suggest a thiamine
evoked although gastric bypass surgery is known to
deficiency that must be promptly assessed. Considering
be a risk factor for this condition. Indeed, all types of
the gravity of the sequellae in the case of delayed
bariatric surgery may lead to this complication and
treatment, and without waiting for the results, vitamin
several predisposing risk factors have been identified,
supplementation must be initiated. And lastly, as
i.e. significant initial weight loss and vomiting.9,10
thiamine is necessary for carbohydrate metabolism,
Intravenous glucose administration without thiamine
glucose infusion after bariatric surgery always calls for
was a risk factor in 18% cases of the literature.10 The
thiamine supplementation.
vitamin B1 deficiency after bariatric surgery resulted
According to the French recommendations, a very
in a decrease in acid production by the gastric pouch,
strict clinical, dietary and metabolic follow-up as
a reduction in food intake and repeated episodes
well as vitamin monitoring at regular intervals must
of vomiting. From a neurological perspective,
accompany all bariatric surgical interventions.1,14
Wernicke’s encephalopathy is associated with a
This is necessary for the surgeons to ascertain that
Korsakoff syndrome. Typically, encephalopathy
the patients are complying with proper hygienic and
Clinical Medicine: Case Reports 2009:2
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Richard-Devantoy et al
dietary measures and are taking their multivitamin
3. Folope V, Coëffier M, Déchelotte P. Nutritional deficiencies associated with
supplementation, which may be adjusted as necessary.
bariatric surgery. Gastroenterol Clin Biol. 2007;31(4):369–77.
4. Houdent C, Verger N, Courtois H, Ahtoy P, Ténière P. Wernicke’s
This complication is exceptional in France because the
encephalopathy after vertical banded gastroplasty for morbid obesity.
indication for surgery is taken by a multi-disciplinary
Rev Med Interne. 2003;24(7):476–7.
staff after following the patient for an entire year. The
5. Bozbora A, Coskun H, Ozarmagan S, Erbil Y, Ozbey N, Orham Y. A rare
complication of adjustable gastric banding: Wernicke’s encephalopathy.
post-operative follow-up continues in the long-term
Obes Surg. 2000;10(3):274–5.
involving all the relevant parties (endocrinological
6. Angstadt JD, Bodziner RA. Peripheral polyneuropathy from thiamine
deficiency following laparoscopic Roux-en-Y gastric bypass. Obes Surg.
nutritionist, general practitioner, surgeon, dietician,
2005;15(6):890–2.
and psychiatrist). This highlights the interest of a
7. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on
network of professionals involved in the care of
mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52.
8. Encinosa WE, Bernard DM, Chen CC, Steiner CA. Healthcare utilization
patients undergoing bariatric surgery. Wernicke
and outcomes after bariatric surgery. Med Care. 2006;44(8):706–12.
encephalopathy after bariatric surgery usually occurs
9. Salas-Salvado J, Garcia-Lorda P, Cuatrecasas G, et al. Wernicke’s syndrome
after bariatric surgery. Clin Nutr. 2000;19:371–3.
between 4 and 12 weeks postoperatively, especially
10. Aasheim ET. Wernicke encephalopathy after bariatric surgery: a systematic
in young women with vomiting. Atypical neurologic
review. Ann Surg. 2008;248(5):714–20.
features are common. The diagnosis is mainly
11. Towbin A, Inge TH, Garcia VF, et al. Beriberi after gastric bypass surgery
in adolescence. J Pediatr. 2004;145:263–7.
clinical, because radiographic findings are normal in
12. Singh S, Kumar A. Wernicke encephalopathy after obesity surgery:
some patients. Prospective studies to determine the
a systematic review. Neurology. 2007;68:807–11.
13. Antunez E, Estruch R, Cardenal C, Nicolas JM, Fernandez-Sola J, Urbano-
prevalence of this problem and protocols for preventive
Marquez A. Usefulness of CT and MR imaging in the diagnosis of acute
thiamine supplementation need evaluation.
Wernicke’s encephalopathy. AJR Am J Roentgenol. 1998;171:1131–7.
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Conflict of Interest
No.
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every scientist working in your field can
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