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  • Here talk of the “Gold Standard” of LRBGYAlso communicate the use of LRBGY as opposed to other bariatric surgeriesCommunicate what a “malabsorption procedure”
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A kliewer journal_club_anemia A kliewer journal_club_anemia Presentation 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
  • IntroductionBackgroundPurposeSubjectsMethodsResultsOther research
  • 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.