A kliewer journal_club_anemiaPresentation Transcript
Prevalence of anemia and relateddeficiencies in the first year followinglaparoscopic gastric bypass for morbidobesityAarts, E. O., van Wageningen, B., Janssen, I. M. C.,& Berends, F. J. (2012).Journal of ObesityAllison Kliewer
Literature : Evidence Analysis Manual Accurate assumptions No bias was introduced to the study Appropriate conclusions made No financial ties to disclose No conflict of interests Design: prospective cohort Epidemiological analytical study: class B, Grade I: Good
Background Laparoscopic Roux-en-Y Gastric Bypass (LRBGY)is most common bariatric surgery Anemia associated with iron, folic acid, andvitamin B12 deficiencies after surgery arecommon Restrictive, malabsorptive procedure Bypassing stomach and duodenum, gastricacid, intake
Purpose Limited studies addressing nutrientdeficiencies and anemia Prospective study to investigate the prevalenceof anemia and deficiencies in iron, folate, andvitamin B12 in the first year after laparoscopicgastric bypass (LRYGB) in our patients.
Subjects January 2005 – October 2009 416 pts LRYGB (Rijnstate Hospital, TheNetherlands) N= 377 ( 102: M, 275: F) Average age: 43.4 (18-63) Average wt (kg): 137.5 ± 22.6 Average BMI 46.8 ± 6.3
Inclusion/Exclusion criteria Screened by multidisciplinary team Met NIH Consensus Development ConferencePanel for bariatric surgery Unable to attend standard F/U protocol Pt with laboratory evaluations that surpassedthe 6 & 12 month evaluation by 2-3 monthsrespectively
Methods 30 cc proximal gastric pouch Connect 100-150 cm roux-en-y limb tojejunum 40 cm from the ligament of Treitz 2005-2007 BMI > 40 received 100 cm limb,BMI of >50 (or failing gastric band) received150 cm limb 2007 all pt received 150 cm
Ligament ofTreitz30 cc proximalgastric pouch40 cm100 cm roux-en-limb150 cm roux-en-limbVitamins andMineralsAbsorption sitesbypassed:IronB vitaminsVitamin ACalciumPyridoxinePantothenic acidFolic Acid
Methods F/U at 1,3,6 & 12 months post-op Complete blood count, mean cell volume(MCV) and kidney function pre-op After 6 & 12 months laboratory evaluationsrepeated, plus plasma levels of iron, total ironbinding capacity (TIBC), serum folate levels andserum B12
Post-op Protocol Standard multivitamin 3 x daily 7 mg iron 100 μg of folic acid 0.5 μg B12 Compliance was assessed
Limits Anemia: Hemoglobin (Hb) in men < 8.4mmol/L & Hb women <7.4 mmol/L MCV 80-100 fL normal TIBC > 80% Serum iron < 9.0 μmol/L = Deficient Serum folate < 9.0 nmol/L = Deficient B12 < 150 pmol/L = Deficient
Results: Anemia Pre-op 27 pt had anemia After 12 months 66 pt developed anemia Total prevalence of anemia including pre-op is25% 93 developed anemia within first year
Results: Iron deficiency 33% after one year 61% with anemia de novo 38% vs. 17% (Female vs. Male)
Results: Folic acid 15% of pt 14% of pt with anemia de novo
Results: Vitamin B12 50% of pt 40% of pt with anemia de novo 42 % vs. 21 % (female vs. male)
Results 239/377 (63%) were diagnosed with at leastone of either iron, folic acid, or B12 deficiency Male 45% risk of being diagnosed with iron,folic acid, or B12 deficiency vs. 68% of females AGB prior to RYGB a 24% vs. 39% risk in B12deficiencies
Male vs Female & AGBMale FemaleAnemia 20% 20%Iron deficient 17% 38%B12 deficient 21% 42%Iron, Folate, B12Deficient45% 68%• AGB had lower % of anemia, folic acid, and B12 deficiency
Article Subjects Length Post-op protocol ResultsAarts et al.2012N= 377Male= 102Female= 275January 2005-October 200912 monthspost-opStandard MVI x 3dailyAt least 7 mg iron100 μg folic acid0.5 μg B1266 pt anemia de novo33% iron deficient15% folic acid deficient50% B12 deficientAvgerinos etal.2010RYGBN= 206Male= 41Female= 165January 2003-November200786 wksStandard chewableMVIFerrous sulfatetablets @ 320 mgdailyAnemia= 21 (10.2 %)serum ferritin, TIBC, MCVMenstruating females and pt foundto have marginal ulcer onendoscopy at significantly greaterrisk.Drygalski et al.2011RYGBN= 1125Male= 126Female= 99948 monthspostoperativeDaily MVI with 18mg iron, 400 μg folicacid, 1000 μg B12Calcium citrate withvitamin 1500 mgvitamin DMean Hb lower after 24-48 mSignificantly lower Hb inpremenopausal women than inpostmenopausal women or men.Anemia greater in pre vs postmenopausalFerritin continuously at 24-48mIron @ 24-48 mFolate @ 24-48 mB12 @ 24-48 m
Risk Factors Decreased absorption surface = absorptioncapacity ph due to gastric acid (proton pump inhibitorsand calcium, other meds) Intolerance for red meat and milk Inadequate intake preoperatively Menstruation inflammatory response
Recommendations 40-65 mg/d of elemental iron for males 100 mg/d elemental iron for females + Vitamin C ? 400 μg/d of folic acid or 1 mg/d 300-500 μg/d of B12
Questions? Based on the results from this study, whatprotocol should be followed with patientsundergoing LRYGB? Why would a folate deficiency be of concernfor premenopausal women? Is this information useful?
Application Monitor anemia and deficiencies in ptfollowing gastric bypass Supplementation to avoid deficiency andanemia post-op needs to be determined At risk pts would benefit from a highersupplementation level
ReferencesAarts, E., van Wageningen, B., Janssen, I. & Berends, F. (2012). Prevalenceof anemia and related deficiencies in the first year following laparoscopicgastric bypass for morbid obesity. Journal of Obesity. 1-7.doi:10.1155/2012/193705.Avgerinos, D., Llaguna, O., Seigerman, M., Lefkowitz, A. & Leitman, M.(2010). Incidence and risk factors for the development of anemiafollowing gastric bypass surgery. World Journal of Gastroenterology. 16(15): 1867-1870. doi:10.3748/wjg.v16.i15.1867Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement Online1991 Mar 25-27 [16 October 2012];9(1):1-20.Von Drygalski, A., Andris, D., Nuttleman, P., Jackson, S., Klein, J. & Wallace,J. (2011). Anemia after bariatric surgery cannot be explained by irondeficiency alone: results of large cohort study. Surgery for Obesity andRelated Diseases. 7: 151-156. doi:10.1016/soard.2010.04.008.