Bariatric Times

JUL 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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9 Letter to the Editor Bariatric Times • July 2017 Dear Bariatric Times Editor: B ariatric surgery is the only long- term successful treatment for morbid obesity. As a result, about 196,000 bariatric surgeries are performed annually in the United States. 1 Laparoscopic sleeve gastrectomy (LSG) is the most commonly procedure performed, followed by laparoscopic Roux-en-Y gastric bypass (RYGB). 1 Outcomes of RYGB and LSG promise perioperative complications rates of less than one percent, and excess weight loss at 69 to 76 percent excess weight loss (EWL). 2 On the contrary, long-term complication rates can be quite high and frequently go undiagnosed. These long-term complications are often related to nutritional deficiencies that mostly occur from malabsorption secondary to bypassing segments of gastrointestinal tract, where the various nutrients are absorbed. Common deficiencies seen include inadequacies in cobalamin (B12), thiamine, folate, zinc, iron, magnesium, selenium, copper, calcium, vitamin D, and protein. As a result of these deficiencies, complications might ensue, including generalized weakness, alopecia, psychiatric disorders, cognitive dysfunction, fatigue, irritability, osteoporosis, Wernicke encephalopathy, iron-deficient and megaloblastic anemias, cardiomegaly, and peripheral neuropathy. 3,4 Bariatric surgeons are aware of these deficiencies, and most patients are placed on oral supplementation immediately after surgery. However, the oral absorption of nutrients is altered significantly after bariatric surgery, and there is a wide variation in the use of supplementation and the performance of diagnostic laboratory tests. Patients are required to take oral supplementation for the rest of t heir lives but often become nonadherent. Physicians may become less diligent about monitoring patients for nutritional deficiencies. 5 Currently, there are no accepted universal guidelines for supplementation or monitoring after bariatric surgery. As such, nutritional deficiencies often go undiagnosed and untreated. One study found that three years after bypass surgery, even with supplementation, as many as 50 percent of patients had iron deficiency and nearly 30 percent had cobalamin deficiency. 6 Intravenous (IV) micronutrient therapy (IMNT) for bypass patients is well researched but underutilized. 7,8 IMNT has its origin in the management of cancer- related issues and fibromyalgia, but is being considered more and more as a prophylactic and therapeutic option for bariatric patients. IV infusion of micronutrients is safe, feasible, reliable, and relatively inexpensive. A basic supplementation regimen of United States Department of Agriculture (USDA) recommended doses of magnesium, calcium, cobalamin, thiamine, iron, and vitamin C on a bi-weekly or monthly basis might serve as an adjunct therapy to a daily oral supplementation regimen. Specific IV infusions for documented deficiencies are also well tolerated and more effective than oral supplementation because of superior absorption via the IV route. 10 With the number of bariatric surgery patients in the United States approaching 10 million, bariatric surgeons and primary care physicians will encounter nutrient deficiencies and associated complications at an increasing rate. The use of IMNT as a prophylactic and therapeutic management tool to prevent and treat these deficiencies should be considered f or this patient population. References 1. American Society for Metabolic and Bariatric Surgey. Estimate of Bariatric Surgery Numbers, 2011- 2015. https://asmbs.org/resources/estim ate-of-bariatric-surgery-numbers. Accessed June 8, 2017. 2. Young MT, Gebhart A, Phelan MJ, Nguyen NT. Use and outcomes of laparoscopic sleeve gastrectomy vs laparoscopic gastric bypass: Analysis of the American College of Surgeons NSQIP. J Am Coll Surg. 2015;220(5):880–885. 3. John S, Hoegerl C. Nutritional deficiencies after gastric bypass surgery. J Am Osteopath Assoc. 2009;109:601–604. 4. Bloomberg RD, Fleishman A, Nalle Je, Herron DM, Kini S. Nutrional deficiencies following bariatric surgery: what have we learned? Obes Surg. 2005;15:145–154. 5. Elkins G, Whitfield P, Marcus J, et al. Noncompliance with behavioral recommendations following bariatric surgery. Obes Surg. 2005;4:546–551. 6. Vargas-Ruiz AG, Hernandez- Rivera G, Herrera MF, Prefalence of iron, folate, and vitamin B12 deficiency after laparoscopic Roux en Y gastric bypass. Obes Surg. 2008;18:288–293. 7. Kotkiewicz A, Donaldson K, Dye C, et al. Anemia and the need for intravenous iron infusion after Roux en Y gastric bypass. Clin Med Insights Blood Disord. 2015;8:9–17. 8. Srikanth M, Payment R, Fox SR, et al. Nutritional resuscitation for acute on chronic malnutrition resulting from chronic noncompliance with supplements after distal gastric bypass. Surg Obes Relat Dis. 2005;1:285-286. 9. Malone M, Barish C, He A, Bregman D. Comparative review of the safety and efficacy of ferric carboxymaltose versus standard medical care for the treatment of iron deficiency anemia in bariatric and gastric surgery patients. Obes Surg. 2013;23(9):1413–1420. With regard, Terrence M. Fullum, MD, MBA, FACS Professor of Surgery, Howard University College of Medicine, Medical Director, Howard University Center for Wellness and Weight Loss Surgery, Washington, DC Funding/financial disclosures: The author has no conflicts of interest relevant to the content of this letter. No funding was received for the preparation of this letter. Address for Correspondence Terrence M. Fullum, MD, MBA, FACS; e-mail: tfullum@Howard.edu INTRAVENOUS MICRONUTRIENT THERAPY (IMNT) FOR GASTRIC BYPASS PATIENTS A Solution to Complications of an Often Unrecognized Problem

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