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 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, and vitamin B12 deficiencies after surgery are common

Restrictive, malabsorptive procedure

Bypassing stomach and duodenum, gastric acid, 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

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 is 25%

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 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

Male vs Female & AGB

Male Female

Anemia 20% 20%

Iron deficient 17% 38%

B12 deficient 21% 42%

Iron, Folate, B12Deficient

45% 68%

• AGB had lower % of anemia, folic acid, and B12 deficiency

Article Subjects Length Post-op protocol Results

Aarts et al.

2012

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 pt anemia de novo33% iron deficient15% folic acid deficient50% B12 deficient

Avgerinos et al.

2010

RYGBN= 206Male= 41Female= 165

January 2003-November 200786 wks

Standard chewable MVIFerrous sulfate tablets @ 320 mg daily

Anemia= 21 (10.2 %)serum ferritin, TIBC, MCV

Menstruating females and pt found to have marginal ulcer on endoscopy at significantly greater risk.

Drygalski et al.

2011

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 lower Hb in premenopausal women than in postmenopausal women or men.Anemia greater in pre vs post menopausalFerritin continuously at 24-48mIron @ 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

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, what protocol should be followed with patients undergoing LRYGB?

Why would a folate deficiency be of concern for premenopausal women?

Is this information useful?

Application

Monitor anemia and deficiencies 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

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.