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
  • Journal club anemia

    1. 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. 2. Introduction• Background• Purpose• Subjects• Methods• Results• Other research
    3. 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. 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. 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. 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. 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. 8. Ligament ofTreitz30 cc proximalgastric pouch40 cm100 cm roux-en-limb150 cm roux-en-limbVitamins andMineralsAbsorption sitesbypassed:IronB vitaminsVitamin ACalciumPyridoxinePantothenic acidFolic Acid
    9. 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. 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. 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. 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. 13. Results: Iron deficiency• 66% of pt• 33% after one year• 61% with anemia de novo• 38% vs. 17% (Female vs. Male)
    14. 14. Results: Folic acid• 15% of pt• 14% of pt with anemia de novo
    15. 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. 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. 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. 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. 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. 20. Questions?
    21. 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.

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