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Journal club anemia


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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”
  • Look up NIH criteria, figure out what that means
  • Figure out better title
  • Transcript

    • 1. Prevalence of anemia and relateddeficiencies in the first yearfollowing laparoscopic gastric bypassfor morbid obesityAarts, E. O., van Wageningen, B.,Janssen, I. M. C., & Berends, F. J. (2012).Journal of ObesityAllison Kliewer
    • 2. Introduction• Background• Purpose• Subjects• Methods• Results• Other research
    • 3. 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• Malabsorption and insufficient intake
    • 4. Purpose• Limited studies addressing nutrientdeficiencies and anemia• Prospective study to investigate theprevalence of anemia and deficiencies iniron, folate, and vitamin B12 in the first yearafter laparoscopic gastric bypass (LRYGB) inour patients.
    • 5. 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
    • 6. 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
    • 7. 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 cmlimb, BMI of >50 (or failing gastric band)received 150 cm limb• 2007 all pt received 150 cm
    • 8. Ligament ofTreitz30 cc proximalgastric pouch40 cm100 cm roux-en-limb150 cm roux-en-limbVitamins andMineralsAbsorption sitesbypassed:IronB vitaminsVitamin ACalciumPyridoxinePantothenic acidFolic Acid
    • 9. 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 levelsand serum B12
    • 10. Post-op Protocol• Standard multivitamin 3 x daily• 7 mg iron• 100 μg of folic acid• 0.5 μg B12• Compliance was assessed
    • 11. Limits• Anemia: Hemoglobin (Hb) in men < 8.4mmol/L & Hb women <7.4 mmol/L• MCV 80-100 fL normal• Serum iron < 9.0 μmol/L = Deficient• TIBC > 80%• Serum folate < 9.0 nmol/L = Deficient
    • 12. Results: Anemia• Pre-op 27 pt had anemia• After 12 months 66 pt developed anemia: 19microcytic• Total prevalence of anemia including pre-op is25%• 93 developed anemia within first year
    • 13. Results: Iron deficiency• 66% of pt• 33% after one year• 61% with anemia de novo• 38% vs. 17% (Female vs. Male)
    • 14. Results: Folic acid• 15% of pt• 14% of pt with anemia de novo
    • 15. Results: Vitamin B12• 50% of pt• 40% of pt with anemia de novo• 2/3 pt developed macrocytic red blood cellswith B12 deficiency• 42 % vs. 21 % (female vs. male)
    • 16. Results• 239/377 (63%) were diagnosed with at leastone of either iron, folic acid, or B12 deficiency• Male 45% risk of being diagnosed withiron, folic acid, or B12 deficiency vs. 68% offemales• AGB prior to RYGB a 24% vs. 39% risk in B12deficiencies
    • 17. Article Subjects Length Post-op protocol ResultsAarts et al. N= 377Male= 102Female= 275January 2005-October 200912 monthspost-opStandard MVI x 3dailyAt least 7 mg iron100 μg folic acid0.5 μg B1266% anemia de novo33% iron ddeficient15% folic acid deficient50% B12 deficientAvgerinos et al. RYGBN= 206Male= 41 (19.9%)Female= 165(80.1 %)Mean age=40.8 (18-60y)January 2003-November2007Standard chewableMVIFerrous sulfatetablets @ 320 mgdailyAnemia= 21 (10.2 %)(serrum ferritin, TIBC,MCVMenstruating females and ptfound to have marginal ulceron endoscopy at significantlygreater risk.Drygalski et al. RYGBN= 1125Male= 126Female= 99948 monthspostoperativeDaily MVI with 18mg iron, 400 μgfolic acid, 1000 μgB12Calcium citrate withvitamin 1500 mgvitamin DMean Hb lower after 24-48 mSignificantly more inpremenopausal women than inpostmenopausal women ormen.Anemia greater in pre vs postmenopausalFerritin continuously at 24-48cIron @ 24-48 mFolate @ 24-48 mB12 @ 24-48 m
    • 18. Risk Factors• Decreased absorption surface = absorptioncapacity• ph due to gastric acid (proton pumpinhibitors and calcium, other meds)• Intolerance for red meat and milk• Inadequate intake preoperatively• Menstruation• inflammatory response
    • 19. Application• Monitor anemia and deficiency in pt followinggastric bypass• Supplementation to avoid deficiency andanemia post-op needs to be determined• At risk pts would benefit from a highersupplementation level
    • 20. Questions?
    • 21. References• Aarts, E., van Wageningen, B., Janssen, I. & Berends, F. (2012). Prevalence of anemiaand related deficiencies in the first year following laparoscopic gastric bypass formorbid obesity. Journal of Obesity. 1-7. doi:10.1155/2012/193705.• Avgerinos, D., Llaguna, O., Seigerman, M., Lefkowitz, A. & Leitman, M. (2010). Incidenceand risk factors for the development of anemia following gastric bypass surgery. WorldJournal of Gastroenterology. 16 (15): 1867-1870. doi:10.3748/wjg.v16.i15.1867• Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement Online 1991Mar 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 explainedby iron deficiency alone: results of large cohort study. Surgery forObesity and Related Diseases. 7: 151-156.doi:10.1016/soard.2010.04.008.