Correspondence
Bariatric Surgery for Morbid Obesity
N Engl J Med 2007; 357:1158-1160September 13, 2007
- Article
To the Editor:
In his review of the surgical treatment of morbid obesity, DeMaria (May 24 issue)1 lists key components of the preoperative medical evaluation; these components include screening for diabetes, hypertension, coronary artery disease, sleep apnea, pulmonary hypertension, and musculoskeletal disease. However, the role of esophagogastroduodenoscopy in this evaluation should also be mentioned. Although its routine use remains controversial,2,3 there is evidence for recommending esophagogastroduodenoscopy with biopsy and assessment of samples for Helicobacter pylori in all patients planning to undergo bariatric surgery, even if they are asymptomatic.4-6 Several arguments provide support for this statement. First, there is a lack of correlation between symptoms and endoscopic findings.4,5 Second, in patients who undergo Roux-en-Y gastric bypass, the bypassed gastric and duodenal mucosa may no longer be within the reach of the endoscope postoperatively, making it more difficult to treat lesions that could have been diagnosed preoperatively.5 Finally, routine esophagogastroduodenoscopy has been shown to have a high diagnostic yield and a relatively low cost.5
6 ReferencesChristoph Gasteyger, M.D.
University of Copenhagen, DK-1958 Frederiksberg, Denmark
chga@life.ku. dk 1
DeMaria EJ . Bariatric surgery for morbid obesity. N Engl J Med 2007;356:2176-2183
Full Text | Web of Science | Medline2
Korenkov M ,Sauerland S ,Shah S ,Junginger T . Is routine preoperative upper endoscopy in gastric banding patients really necessary? Obes Surg 2006;16:45-47
CrossRef | Web of Science | Medline3
Azagury D ,Dumonceau JM ,Morel P ,Chassot G ,Huber O . Preoperative work-up in asymptomatic patients undergoing Roux-en-Y gastric bypass: is endoscopy mandatory? Obes Surg 2006;16:1304-1311
CrossRef | Web of Science | Medline4
Csendes A ,Burgos AM ,Smok G ,Beltran M . Endoscopic and histologic findings of the foregut in 426 patients with morbid obesity. Obes Surg 2007;17:28-34
CrossRef | Web of Science | Medline5
Sharaf RN ,Weinshel EH ,Bini EJ ,Rosenberg J ,Sherman A ,Ren CJ . Endoscopy plays an important preoperative role in bariatric surgery. Obes Surg 2004;14:1367-1372
CrossRef | Web of Science | Medline6
Zeni TM ,Frantzides CT ,Mahr C , et al. Value of preoperative upper endoscopy in patients undergoing laparoscopic gastric bypass. Obes Surg 2006;16:142-146
CrossRef | Web of Science | Medline
To the Editor:
DeMaria describes surgical procedures for obese patients and reviews their potential adverse effects. Obesity is associated with an increased risk of deep venous thrombosis and pulmonary embolism.1 Obese patients who undergo bariatric surgery are at high risk for venous thromboembolism, with pulmonary embolism being one of the most common causes of postoperative death.2 Hence, prophylaxis for venous thromboembolism is a pivotal step to decrease postoperative mortality.
According to previous studies, low-dose unfractionated3 or low-molecular-weight4 heparin injected subcutaneously during the preoperative and postoperative period is safe and effective for the prevention of venous thromboembolism in patients undergoing general surgery. Therefore, we would appreciate it if the author would describe prophylactic antithrombotic strategies for patients undergoing bariatric surgery for morbid obesity.
4 ReferencesRui Chen, M.D.
Union Hospital, Wuhan 430022, ChinaTakashi Takahashi, M.D.
Tsugiyasu Kanda, M.D.
Kanazawa Medical University, Kahoku-gun 920-0293, Japan
kandat@kanazawa-med.ac. jp 1
Goldhaber SZ ,Grodstein F ,Stampfer MJ , et al. A prospective study of risk factors for pulmonary embolism in women. JAMA 1997;277:642-645
CrossRef | Web of Science | Medline2
Westling A ,Bergqvist D ,Bostrom A ,Karacagil S ,Gustavsson S . Incidence of deep venous thrombosis in patients undergoing obesity surgery. World J Surg 2002;26:470-473
CrossRef | Web of Science | Medline3
Collins R ,Scrimgeour A ,Yusuf S ,Peto R . Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med 1988;318:1162-1173
Full Text | Web of Science | Medline4
Mismetti P ,Laporte S ,Darmon JY ,Buchmuller A ,Decousus H . Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg 2001;88:913-930
CrossRef | Web of Science | Medline
To the Editor:
DeMaria does not mention the highly common neurologic abnormalities seen after bariatric surgery. Rates of neurologic complications as high as 9% have been reported.1 Peripheral neuropathies are the most common of these abnormalities.1 Other commonly seen neurologic complications include Wernicke's encephalopathy, subacute combined degeneration of the spinal cord, and optic neuropathies.2 Less common complications include myopathies, seizures, and plexopathies. Neurologic symptoms have been reported as early as 1 month and as late as 18 years after surgery.3
Postoperative copper, thiamine, and vitamin B12 deficiencies are the most common causes of these neurologic disorders, which are of particular significance because they are often irreversible.4 Replacement therapy with a high dose of the appropriate micronutrient may be effective in some cases if the diagnosis is made early. Surgeons and physicians should be aware of these neurologic complications, since early recognition and timely initiation of treatment can increase the likelihood of recovery.
4 ReferencesShailendra Kapoor, M.D.
University of Illinois at Chicago, Chicago, IL 60612
shailendrakapoor@yahoo.com 1
Thaisetthawatkul P ,Collazo-Clavell ML ,Sarr MG ,Norell JE ,Dyck PJ . A controlled study of peripheral neuropathy after bariatric surgery. Neurology 2004;63:1462-1470
Web of Science | Medline2
Berger JR . The neurological complications of bariatric surgery. Arch Neurol 2004;61:1185-1189
CrossRef | Web of Science | Medline3
Juhasz-Pocsine K ,Rudnicki SA ,Archer RL ,Harik SI . Neurologic complications of gastric bypass surgery for morbid obesity. Neurology 2007;68:1843-1850
CrossRef | Web of Science | Medline4
Koffman BM ,Greenfield LJ ,Ali II ,Pirzada NA . Neurologic complications after surgery for obesity. Muscle Nerve 2006;33:166-176
CrossRef | Web of Science | Medline
Author/Editor Response
Gasteyger's comments regarding routine esophagogastroduodenoscopy before bariatric surgery highlight an important current controversy in the field of bariatric surgery. There is no clear correlation between the presence of H. pylori and the postoperative complications of bariatric surgery.1,2 Esophagogastroduodenoscopy clearly offers a high diagnostic yield and is a relatively low-cost procedure, but it remains unclear whether all patients require this screening test before bariatric surgery.
With regard to the comments by Chen and colleagues, great controversy exists regarding the appropriate agents, dosing, and duration of prophylactic anticoagulation to reduce the incidence of venous thromboembolism. It is not possible to make an evidence-based argument regarding these issues at the current time. However, the principle that prophylactic perioperative anticoagulant therapy should be given to every patient undergoing bariatric surgical treatment has become accepted, and it is the subject of a recent position statement by the American Society for Metabolic and Bariatric Surgery.3
Finally, with regard to the comments by Kapoor, it is somewhat unfair to characterize neurologic complications of bariatric surgery as being “highly common” because a single study suggests they occur in as many as 9% of patients,4 particularly since that study included patients treated by means of jejunoileal bypass, a procedure that is no longer used. Neurologic complications after more modern types of bariatric surgery occur in approximately 1% of patients.5 In their review of 18 surgical series between 1976 and 2004, Koffman et al. reported a prevalence of neurologic complications of 1.3% among 9996 patients.6 Despite these observations, I agree that awareness of nutritional deficiencies as a cause of neurologic disorders is essential for early recognition and treatment. Thiamine deficiency is most likely in patients with intractable vomiting after bariatric surgery, and such symptoms are not typical after gastric bypass surgery. Distal malabsorptive procedures such as jejunoileal bypass or its modern modification, biliopancreatic diversion with or without duodenal switch, are characterized by an increased late risk of neurologic and metabolic complications as well as protein-calorie malnutrition. Patients with such complications are often lost to follow-up by the surgical treatment program. Patients should be encouraged to comply with long-term follow-up care in order to prevent such disorders or to allow for early recognition of them.
6 ReferencesEric J. DeMaria, M.D.
Duke University, Durham, NC 27710
eric.demaria@duke. edu 1
Csendes A ,Smok G ,Burgos GM . Endoscopic and histologic findings in the gastric pouch and the Roux limb after gastric bypass. Obes Surg 2006;16:279-283
CrossRef | Web of Science | Medline2
Yang CS ,Lee WJ ,Wang HH ,Huang SP ,Lin JT ,Wu MS . The influence of Helicobacter pylori infection on the development of gastric ulcer in symptomatic patients after bariatric surgery. Obes Surg 2006;16:735-739
CrossRef | Web of Science | Medline3
The Clinical Issues Committee. Position statement on prophylactic measures to reduce the risk of venous thromboembolism in bariatric surgery patients. Gainesville, FL: American Society for Metabolic and Bariatric Surgery, 2007. (Accessed August 23, 2007, at http://www.asbs.org/Newsite07/resources/vte_statement.pdf.)
4
Thaisetthawatkul P ,Collazo-Clavell ML ,Sarr MG ,Norell JE ,Dyck PJ . A controlled study of peripheral neuropathy after bariatric surgery. Neurology 2004;63:1462-1470
Web of Science | Medline5
Chang CG ,Adams-Huet B ,Provost DA . Acute post-gastric reduction surgery (APGARS) neuropathy. Obes Surg 2004;14:182-189
CrossRef | Web of Science | Medline6
Koffman BM ,Greenfield LJ ,Ali II ,Pirzada NA . Neurologic complications after surgery for obesity. Muscle Nerve 2006;33:166-176
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Ismael Court, Aaron Wilson, Peter Benotti, Samuel Szomstein, Raul J. Rosenthal. (2010) T-Tube Gastrostomy as a Novel Approach for Distal Staple Line Disruption after Sleeve Gastrectomy for Morbid Obesity: Case Report and Review of the Literature. Obesity Surgery 20:4, 519-522
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