Prevalence of anemia and related deficiencies in the first year

following laparoscopic gastric bypass for morbid obesity

Aarts, E. O., van Wageningen, B., Janssen, I. M. C., & Berends, F. J. (2012).

Journal of Obesity

Allison Kliewer

Introduction

• Background

• Purpose

• Subjects

• Methods

• Results

• Other research

Background

• Laparoscopic Roux-en-Y Gastric Bypass (LRBGY) is most common bariatric surgery

• Anemia associated with iron, folic acid, and vitamin B12 deficiencies after surgery are common

• Malabsorption and insufficient intake

Purpose

• Limited studies addressing nutrient deficiencies and anemia

• Prospective study to investigate the prevalence of anemia and deficiencies in iron, folate, and vitamin B12 in the first year after laparoscopic gastric bypass (LRYGB) in our patients.

Subjects

• January 2005 – October 2009

• 416 pts LRYGB (Rijnstate Hospital, The Netherlands)

• 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 Conference Panel for bariatric surgery

• Unable to attend standard F/U protocol

• Pt with laboratory evaluations that surpassed the 6 & 12 month evaluation by 2-3 months respectively

Methods

• 30 cc proximal gastric pouch

• Connect 100-150 cm roux-en-y limb to jejunum 40 cm from the ligament of Treitz

• 2005-2007 BMI > 40 received 100 cm limb, BMI of >50 (or failing gastric band) received 150 cm limb

• 2007 all pt received 150 cm

Ligament of Treitz

30 cc proximal gastric pouch

40 cm

100 cm roux-en-limb

150 cm roux-en-limb

Vitamins and Minerals Absorption sites bypassed:

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 evaluations repeated, plus plasma levels of iron, total iron binding capacity (TIBC), serum folate levels and serum 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 < 8.4 mmol/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

Results: Anemia

• Pre-op 27 pt had anemia

• After 12 months 66 pt developed anemia: 19 microcytic

• Total prevalence of anemia including pre-op is 25%

• 93 developed anemia within first year

Results: Iron deficiency

• 66% of pt

• 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

• 2/3 pt developed macrocytic red blood cells with B12 deficiency

• 42 % vs. 21 % (female vs. male)

Results

• 239/377 (63%) were diagnosed with at least one 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 B12 deficiencies

Article Subjects Length Post-op protocol Results

Aarts et al. N= 377Male= 102Female= 275

January 2005-October 200912 months post-op

Standard MVI x 3 dailyAt least 7 mg iron100 μg folic acid0.5 μg B12

66% anemia de novo33% iron ddeficient15% folic acid deficient50% B12 deficient

Avgerinos et al. RYGBN= 206Male= 41 (19.9%)Female= 165 (80.1 %)Mean age= 40.8 (18-60y)

January 2003-November 2007

Standard chewable MVIFerrous sulfate tablets @ 320 mg daily

Anemia= 21 (10.2 %)(serrum ferritin, TIBC, MCVMenstruating females and pt found to have marginal ulcer on endoscopy at significantly greater risk.

Drygalski et al. RYGBN= 1125Male= 126Female= 999

48 monthspostoperative

Daily MVI with 18 mg iron, 400 μg folic acid, 1000 μg B12Calcium citrate with vitamin 1500 mg vitamin D

Mean Hb lower after 24-48 mSignificantly more in premenopausal women than in postmenopausal women or men.Anemia greater in pre vs post menopausalFerritin continuously at 24-48cIron @ 24-48 mFolate @ 24-48 mB12 @ 24-48 m

Risk Factors

• Decreased absorption surface = absorption capacity

• ph due to gastric acid (proton pump inhibitors and calcium, other meds)

• Intolerance for red meat and milk

• Inadequate intake preoperatively

• Menstruation

• inflammatory response

Application

• Monitor anemia and deficiency in pt following gastric bypass

• Supplementation to avoid deficiency and anemia post-op needs to be determined

• At risk pts would benefit from a higher supplementation level

Questions?

References

• Aarts, E., van Wageningen, B., Janssen, I. & Berends, F. (2012). Prevalence of anemia and related deficiencies in the first year following laparoscopic gastric 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 anemia following gastric bypass surgery. World Journal of Gastroenterology. 16 (15): 1867-1870. doi:10.3748/wjg.v16.i15.1867

• Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement Online 1991 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 iron deficiency alone: results of large cohort study. Surgery for Obesity and Related Diseases. 7: 151-156. doi:10.1016/soard.2010.04.008.