Weight Loss Surgery – Bariatric weight loss case

The complications you may have after weight loss surgery (bariatric surgery) are more likely to hurt you then the surgery itself.

Weight loss surgery was invented about 40 years ago.  It can be a life-saving/life-altering benefit for some people.  Millions of Americans have now had bariatric surgery.  There are several types of bariatric surgery:  Roux-en-Y (less popular now), duodenal switch, gastric sleeve, bypass, lap band, etc.

Of course, we see these complications:  The suture line doesn’t hold together and the patient becomes septic.  The patient has a stricture or a blockage of the digestive tract and ends up in the hospital with a life-threatening condition.

I want to focus on a specific problem which some patients are unaware of:  The risk of a catastrophic nutritional or vitamin deficiency in the weeks after bariatric surgery.  One of the worst of these risks is thiamine deficiency, also known as Wernicke’s Encephalopathy, which often leads to a condition called Korsakoff Syndrome.

The human body stores about 30 to 40 g of thiamine at any given time.  If your reserve of thiamine is not continuously replenished, you can run out of this essential material in as little as three weeks.  Without thiamine, your body can’t properly metabolize carbohydrates and you can suffer a devastating brain injury.  You can even die.

What should the bariatric patient watch out for following the surgery?

Everyone knows that some degree of nausea and vomiting is common after surgery.  If a patient vomits for a day or two and then manages to hold down several square meals, a devastating vitamin deficiency is very unlikely to develop.

The thing to be concerned about is several days on end of relentless vomiting and nausea which make it difficult or impossible for the patient to hold down a balanced meal and the multivitamins which the patient should be taking.  If this happens, go to your emergency room, make sure the emergency room doctor calls your bariatric surgeon to let him or her know what is going on, and insist on having your thiamine level measured.  The last part is really important.

In the general population, with the exception of chronic alcoholics (who are notoriously prone to thiamine deficiency), a serious thiamine deficiency is pretty rare.  (In less-developed parts of the world the disease beriberi is associated with a chronic thiamine deficiency.)  Many doctors, unfortunately, will rarely treat a thiamine deficiency and will not properly test for it.  It just isn’t on their radar.

The bariatric surgical population is very different.  Thiamine deficiencies are not all that uncommon among this patient group because bariatric surgery has a profound effect on the patient’s digestive system.  It can take months or even years for the post-surgical patient to adjust to these effects and compensate for the loss of a portion of the stomach or a portion of the small bowel.  If you find yourself going to a doctor (your family practitioner, internist, OB/GYN, or your friendly neighborhood emergency room doctor) with a complaint that you have been vomiting for days on end a few months after weight loss surgery, you need to do three very specific things to protect yourself:

First, make sure the doctor knows about your weight loss surgery, when it happened, and who the surgeon was.  Make sure that your doctor calls the surgeon to let him or her know what’s going on.

Second, be very specific about how much weight you have lost in the last month or two.  How serious is your nausea?  If it has been days or weeks, literally, since you have been able to hold anything down, you need to let the doctor know just how serious the problem is.

Finally, ask your doctor to test your thiamine level.

What are the warning signs of a serious thiamine deficiency?  The three cardinal symptoms of thiamine deficiency/Wernicke’s  Encephalopathy are:

First, ataxia.  Also known as dizziness.  Leg weakness. Unsteady gait.

Second, involuntary eye movements.  Also sometimes referred to as ocular disturbances or nystagmus.

Third, any signs of mental confusion or delirium.  Is the patient telling stories and not making sense?  Slurring their speech?  Unaware of his or her surroundings?

At the first sign of any of these problems, you need to seek very prompt medical attention.

It doesn’t matter if you don’t look like you are starving.  It doesn’t matter if you still weigh 50 or 150 pounds over your target weight.  You may look perfectly healthy, even obese, and still have a serious nutritional deficit or vitamin deficiency.

We are handling several of these cases.

If you get into the medical literature, here is a typical case:  A young woman undergoes surgery on day one.  By day 30, she has lost 30 pounds.  (A pound a day is not all that unusual following bariatric surgery.  Still, it is something to be careful about because that’s very rapid weight loss.)  She loses another 30 pounds in the next 30 days.  By now, 60 days post-surgery, she is frequently dizzy, unsteady on her feet, and it’s been two or three weeks since she has been able to hold a meal down.  She is taking her vitamins but she throws them up so quickly that they probably don’t do any good.  But she is still 50 pounds overweight.  When she goes to the emergency room, doctors don’t think to check her thiamine levels.  By the time the diagnosis is made two weeks later, the patient has a permanent brain injury and is confined to a wheelchair.  Nobody seemed to notice that for the last couple of weeks she had involuntary rapid eye movement.

One last word of caution:  It’s especially important, if you go to the emergency room or hospital and get a bag of IV fluid, that the fluid contains thiamine.  Just giving the patient a normal IV saline fluid with dextrose and no thiamine supplement will actually make Wernicke’s Encephalopathy worse.

If you have had weight loss surgery in the past and it worked well for you, congratulations.  If you’re thinking about it, these are some things we would recommend to watch out for.