Elsevier

Diabetes & Metabolism

Volume 33, Issue 1, February 2007, Pages 13-24
Diabetes & Metabolism

Review
Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment

https://doi.org/10.1016/j.diabet.2006.11.004Get rights and content

Abstract

In recent years, the recourse to obesity surgery to treat morbid obesities has grown. The number of “malabsorptive” interventions, such as the gastric bypass (RYGB: Roux-en-Y gastric bypass) increases each year. The RYGB, which combines two mechanisms promoting weight loss, restriction and malabsorption, has proven its effectiveness in term of weight loss and improvement of obesity-associated co-morbidities. However this intervention involves a profound change in digestive physiology and is the source of nutritional and metabolic complications. The deficits observed most frequently concern proteins, iron, calcium, vitamin B12 and vitamin D. The deficiencies in vitamin B1 are rare but potentially serious. Multidisciplinary follow-up is essential to ensure prevention, diagnosis and treatment of these complications. Based on an analysis of the literature, this article summarizes the various nutritional complications observed after RYGB and the means to diagnose it. It proposes practical recommendations for follow-up, preventive supplementation and treatment of these deficiencies, both generally and in the more specific case of a pregnancy after RYGB.

Résumé

Carences nutritionnelles après by-pass gastrique : diagnostic, prévention et traitement.

Ces dernières années, le recours à la chirurgie de l'obésité comme traitement des obésités morbides s'est amplifié. Le nombre d'interventions de type « malabsorptives », telles que le gastric bypass (RYGB : Roux-en-Y gastric bypass) augmente chaque année. Le RYGB qui associe deux mécanismes favorisant la perte de poids, la restriction et la malabsorption, a fait preuve de son efficacité en termes de perte de poids et d'amélioration des comorbidités. Cependant, cette intervention entraîne une modification profonde de la physiologie digestive à l'origine de complications nutritionnelles et métaboliques. Les déficits les plus fréquemment observés concernent les protéines, le fer, le calcium, la vitamine B12 et la vitamine D. Les carences en vitamine B1 sont rares mais potentiellement graves. Le suivi multidisciplinaire est indispensable pour assurer le dépistage, le diagnostic et la prise en charge de ces complications. Fondé sur une analyse de la littérature, cet article résume les différentes complications nutritionnelles observées après RYGB et les moyens pour en faire le diagnostic. Il propose des recommandations pratiques de suivi, de supplémentation préventive et de prise en charge des carences avérées, de façon générale et dans le cas plus spécifique d'une grossesse après RYGB.

Introduction

In recent years, surgical treatments of morbid obesity have greatly increased worldwide, notably in France where 17,000 operations a year were performed in 2001–2002, compared to only 2000 in 1995 [2], [3]. Several surgical techniques are available, but in France, gastric banding is the most frequently used [2]. However, due to increasing “malabsorptive” operations, such as RYGB, experts were prompted to develop practical recommendations regarding these procedures [4], [5].

RYGB combines two methods, restriction and malabsorption (Fig. 1). The superior part of the stomach is cut to provide a small additional pocket of 20–30 ml, which in return leads to a quantitative decrease in nutritional intake. The inferior part of the stomach and the duodenum stay in place so they are of no more use to the crossing food, but they still secrete substances important for digestion (chlorhydric acid, pancreatic enzymes, biliary salts, hormones…). This is how a certain degree of food maldigestion and malabsorption contributes to weight loss.

The efficacy of the RYGB technique has been proven in terms of weight loss and improvement of comorbidities [6], [7]. However this intervention is not without risk, and a frequent short-term and long-term follow-up is required for several reasons. Firstly, there are potential surgical complications (leaks, fistula, obstruction, anastomotic stenosis, internal hernia etc.) particularly in the case of patients with acute digestive symptoms. In addition, it is essential to follow-up on comorbidities, and to adapt treatments, in particular antidiabetic ones. Finally, the operation might have a deep psychological and social impact on patients, which then require a multidisciplinary support. In any case, the operation results in important changes in digestive physiology: for example, non acid reflux, exclusion of the inferior gastric pocket, asynergia between the different secretions (enzymes, acids, hormones) and the nutrients, malabsorption. Consequently, the operation might induce iatrogenic pathologic symptoms on the overall digestive tube organs [8], [9]: the mouth, the esophagus, the stomach, the intestine, the pancreas, the liver etc. In particular we notice its damaging effect on dental state and mastication, hypoglycemia by pancreatic cell hyperplasia [10], [11], functional complications (vomiting, bowel disorders, dumping syndrome). Lastly, patients experience short-term and long-term nutritional complications which is the topic of this review.

First we are going to review the nutritional malfunctions and deficiencies observed after RYBP, and how to diagnose them through close monitoring. Then we will suggest ways to prevent and supplement these deficiencies, and finally we will discuss the appropriate course of action in case of pregnancy after RYGB.

Section snippets

Nutritional deficiencies and physiopathology mechanisms

The different mechanisms that explain the observed nutritional deficiencies are illustrated in Fig. 1. First, there is insufficient intake due to dietary restrictions and potential intolerance to certain type of food (meat, milk, fiber) (1). The exclusion of the stomach's inferior part results in a decreased secretion of gastric acid, sometimes required to absorb vitamins and minerals (B12 and iron) (2). Dietary restrictions are also accompanied by duodeno-jejunal malabsorption related to the

Diagnosis of the deficiencies and nutritional follow-up

Taking into account the frequency of the nutritional deficits among obese patients (vitamin D, B12, folates, iron), it is imperative to carry out a complete nutritional assessment before surgery. After surgery, we propose a nutritional check-up after 3 months, then every 6 months in the first 2 years, then at least once per year after 2 years.

The assessment should attempt to seek clinical signs of deficiency (Table 1). An example of the complementary examinations to require and rhythm of

Prevention and treatment of the nutritional deficiencies after RYGB

No controlled trial exists to determine the type of supplements and the dosages to be prescribed after RYGB. The majority of the reviews published on post-RYGB deficiencies recommend a multivitamin supplement providing 100% of the ANC (Table 3) [8], [51].

However, in France, no marketed supplement available covers all the requirements. In addition, one does not know the proportion of each vitamin or minerals introduced which is really absorbed, the principal site of absorption remaining the

Specific nutritional needs during pregnancy and breast feeding [1]

The specific ANCs for pregnant women are detailed in Table 3.

The additional protein contribution necessary for foeto-placental growth is estimated at 11 g/day in the third trimester compared to 1.3 g/day in the first trimester.

The consequences of certain specific deficits deserve to be detailed:

  • in the event of maternal ferriprive anemia, the risks of prematurity and low-weight birth are increased [85], [86];

  • there is a relation between a maternal deficit in vitamin D and the occurrence of

Conclusion

The large increase in the number of gastric surgeries and in particular malabsorptive techniques such as RYGB, as well as the nutritional deficiencies observed after this type of surgery require rigorous medical follow-up and multi-disciplinary collaboration between nutritionists, surgeons, dieticians and obstetricians.

Based on the data in the medical literature, this synthesis suggests practical guidelines for vitamin supplements and post-operative follow-up, but well-designed randomized tests

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