Nutritional Markers Following Duodenal Switch for Morbid Obesity
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Obesity Surgery, 14, pp-pp Nutritional Markers following Duodenal Switch for Morbid Obesity Robert A. Rabkin MD, FACS; John M. Rabkin, MD, FACS; Barbara Metcalf, RN; Myra Lazo, MS, PA-C; Michael Rossi, PA-C; Lee B. Lehman- Becker, BA Pacific Laparoscopy, San Francisco, CA, USA Background: Laparoscopic duodenal switch with gas- Introduction tric reduction (LapDS) is a minimally invasive hybrid operation combining moderate intake restriction with moderate malabsorption for treatment of morbid obe- The duodenal switch (DS) was first performed by sity. In LapDS, both the quantity of food ingested and Hess 19881 and Marceau et al2 in 1990, and a the efficiency of digestion are reduced. laparoscopic approach (LapDS) was first imple- Methods: A cohort of 589 sequential LapDS mented by the author in 1999.3,4 The DS combines patients had laboratory studies drawn annually. Serum markers for calcium, iron and protein metabo- moderate malabsorption with moderate restriction lism and for hepatic function were analyzed using via reduced stomach capacity, yet preserves normal SAS statistical software. stomach functioning. While quality of life is diffi- Results: There were 95 men and 494 women. Mean cult to study, most postoperative patients report that age was 44 years, mean BMI 50 kg/m2 and mean pre- they continue to be able to ingest normally and operative weight 142 kg. Although mean hemoglobin enjoy eating. decreased below reference and mean parathyroid hormone (PTH) increased above reference, similar to The DS and the LapDS are identical in internal abnormal values reported after Roux-en-y gastric anatomy and are fashioned as shown in Figure 1. bypass, both hemoglobin and calcium in LapDS read- The gastric pouch is constructed after first clearing ily returned to within the reference range following the greater curvature vessels cephalad to 5 cm prox- supplementation with iron and calcium respectively. imal to the pylorus. Serial applications of the linear Mean iron, corrected calcium, alkaline phosphatase, albumin, total protein, aspartate aminotransferase (AST), alanine transaminase (ALT), and bilirubin Cholecystectomy remained within the normal range. Cholangiogram Parietal Conclusion: LapDS is not associated with broad Liver biopsy Gastrectomy nutritional deficiencies. Annual laboratory studies, which are required following any type of bariatric operation, appear to be sufficient to identify unfavor- able trends. In selected patients, additional iron and calcium supplementation are effective when indicat- ed. Biliary limb Enteric limb Key words: Morbid obesity, bariatric surgery, duodenal switch, laparoscopy, serum calcium, parathyroid hor- mone, serum iron, serum protein, liver functions Presented at the 20th Annual Meeting of the American Society Common Channel for Bariatric Surgery, Boston, MA, USA, June 19, 2003. Appendectomy Reprint requests to: Robert A. Rabkin, MD, FACS, 2250 Hayes Street, Third Floor, San Francisco, CA 94117, USA. Fax: (415) 668-2010; e-mail: [email protected] Figure 1. Duodenal switch and concurrent procedures. © FD-Communications Inc. Obesity Surgery, 14, 2004 1 Rabkin et al stapler achieve a vertical division of the stomach, Methods leaving a lesser curvature sleeve configuration of 120 ml and allowing preservation of the pylorus and As summarized in Table 1, 589 sequential LapDS intact vagal innervation. The duodenum is divided patients were operated on over 43 months from 4-5 cm distal to the pylorus and anastomosed to the September 1999 to May 2003. There were 95 men distal 250 cm of ileum, creating a combined enteric and 494 women, with mean age 44 years (median and common limb. The remaining proximal bil- 44, range 18-69 years). The average body mass iopancreatic limb is anastomosed to the distal ileum index (BMI) was 50 kg/m2 (median 49, range 35- 100 cm proximal to the ileocecal valve, thereby 118), with an average preoperative weight of 142 kg delineating a proximal enteric limb and a distal (median 137, range 91-284 kg) and an average common channel. Liver biopsy is routine, and height of 168 cm (median 168, range 147-201 cm). cholecystectomy, appendectomy, and operative The average patient was 74 kg or 209% above cholangiogram are performed when the relevant his/her ideal weight, calculated at an ideal BMI of organs are intact. 24 kg/m2 (medians 69 kg or 203%, ranges 31-284 Sustained weight loss reported after the DS kg or 145-492%, respectively). The heaviest patient exceeds that reported following the Roux-en-Y gas- 5-7 was a woman weighing 284 kg and standing 155 tric bypass. Hess has previously reported mean cm. excess weight loss of 73% maintained at 10 years 1 Hemoglobin, iron, and chemistries measuring following open DS. A sample of 345 consecutive protein and calcium metabolism and hepatic func- patients out of our more recent total series exceed- tion were averaged preoperatively and at 1, 2, and 3 ing 600 LapDS patients shows a mean excess years. Calcium is corrected for normal albumin weight loss of 91% at 24 months (Figure 2). using the following formula: Both the quantities of food ingested and the effi- corrected calcium = calcium level + 0.8(4.0-albumin level). ciency of absorption are affected by the DS. The Our sample size was insufficient to report fraction- bypassed duodenum and jejunum are active in fat- ated alkaline phosphatase results. soluble vitamin and mineral absorption. Conse- A mean, range, and SEM are provided for each quently, routine laboratory studies are employed to time interval; each metabolic deficiency documents identify trends revealing progression to out-of-range a case study of treatment and subsequent results. values and to allow the physician to be proactive Means between the preoperative period and the with respect to those deficiencies. The bariatric sur- postoperative testing intervals taken as a whole and gical team works in conjunction with the primary means between all periods were compared using care physician; patient compliance is essential in Welch’s methodology for a General Linear Model facilitating recognition of potential deficiencies and (GLM) for unbalanced designs, expressed as P1 and enabling successful resolution of potential or actual P2, respectively. We employed a standard GLM problems as identified. when the data met the assumption of homogeneity 100% Table 1. Preoperative data on the 589 consecutive 90% laparoscopic duodenal switch operations September 80% 1999 - May 2003 70% 60% Demographic Mean Median Range 50% 40% Sex (M/F) 95/494 30% Age (years) 44 44 18-69 Mean 20% BMI (kg/m2) 50 49 35-118 Median 10% Height (cm) 168 168 147-201 Mean % Excess Weight Loss Weight Mean % Excess 0% Preoperative weight (kg) 142 137 91-284 0 3 6 9 12 15 18 21 24 Excess weight (kg)* 74 69 31-226 %Excess weight 209 203 145-492 Time postoperative (months) 2 Figure 2. % excess weight loss over time. *Ideal weight calculated at BMI = 24 kg/m 2 Obesity Surgery, 14, 2004 Nutritional Markers following Laparoscopic Duodenal Switch of variance. Outliers were cut beyond 2 standard 180.0 deviations from the mean. The SAS program (The 160.0 140.0 SAS Institute, Cary, NC, USA) was utilized for sta- 120.0 tistical analysis. 100.0 80.0 60.0 40.0 20.0 Results 0.0 Preoperative Year 1 Year 2 Year 3 maximum 124.0 123.0 118.0 126.0 minimum 20.0 9.0 7.0 20.0 Iron Metabolism average 69.4 65.1 61.6 65.2 Two values relating to iron metabolism were tested: Reference Range hemoglobin and serum iron. The normal range for Figure 4. Average, minimum, and maximum iron over hemoglobin is 12-16 g/dl. Average hemoglobin lev- time. els decreased from 13.3 ± 0.05 (range 10-16.7) g/dl pre-operatively to 12.4 ± 0.10 (range 10-16.7) g/dl, diagnosis, the patient was prescribed oral iron, 11.6 ± 0.17 (range 5-15.7) g/dl, and 11.8 ± 0.34 which resulted in a 1st postoperative year hemoglo- (range 9.1-14.4) g/dl at 1, 2, and 3 years, respec- bin of 12.3 g/dl, substantially higher than the preop- tively, with P1 <0.0001 and P2 <0.0001 (Figure 3). erative value. Within a normal range of 26-170 µg/ml, iron aver- ages decreased slightly from 69.4 ± 1.12 (range 20- Calcium Metabolism 124) µg/ml preoperatively to 65.1 ± 1.68 (range 9- Three measures indicating calcium metabolic status 123) µg/ml, to 61.6 ± 2.90 (range 7-118) µg/ml in were tested: adjusted calcium; parathyroid hor- the 1st and 2nd years, and then rebounded from 2nd- mone, intact (PTH); and alkaline phosphatase. The year lows to 65.2 ± 8.764 (range 20-126) µg/ml by normal range for calcium is 8.5-10.0 mg/dl. As the 3rd year, with P1 = 0.0050 and P2 = 0.0373 illustrated in Figure 5, preoperative mean values of µ (Figure 4). 9.2 ± 0.02 (range 8.1-11.2) g/dl decreased to 9.0 ± 0.03 (range 7.9-10.5) µg/dl in the 1st postoperative Case Report year, and then to 8.8 ± 0.04 (range 7.8-10.1) µg/dl D.W., a 54-year-old female, first presented with a and 8.7 ± 0.12 (range 7.9-9.5) µg/dl by the 2nd and BMI of 54 at 171 kg and 178 cm. At the time of her 3rd years, with P1 <0.0001 and P2 <0.0001. PTH May 2002 surgery, she displayed a hemoglobin levels increased from a preoperative mean of 41.5 ± level of 10.8 g/dl. Her level increased to 11.6 g/dl 1.31 (range 11-93) pg/mL to 69.2 ± 2.63 (range 8.3- after the 1st postoperative month, yet decreased 180.0) pg/mL in the 1st year and 74.5 ± 5.20 (range below preoperative levels to 10.2 g/dl by the 6th 16-204) pg/mL in the 2nd year, with P1 <0.0001, P2 postoperative month.