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Sami Harik did not think it was an accident that he was seeing neurological problems in patients who had had gastric bypass surgery.
Harik, chair of the department of neurology at the University of Arkansas for Medical Sciences, got some flak when he told a patient who'd had the weight-reduction procedure that her neurological symptoms were being caused by a vitamin deficiency brought on by the surgery. The patient reported what Harik said to her surgeon, and the surgeon sent Harik a “frosty letter,” challenging Harik to produce data.
Now, Harik and colleagues in the neurology department, including lead investigator Dr. Katalin Juhasz-Pocsine, have published a study based on patients who've been treated by the department for the last 10 years. The results, reported in the May 22 issue of the medical journal “Neurology”: Of the 150 patients who'd had the Roux-en-Y bypass surgery before being treated at UAMS' Neurology Clinic, the symptoms in 26 patients could be directly linked to the surgery.
It started, for Poscine, with a patient in her 30s who came in complaining of tingling in her feet. Poscine ruled out diabetes, which can cause neuropathy in the limbs. Poscine determined she was deficient in vitamin B12 and iron, and began giving her patient IV nutritional supplements and making sure that she was eating. But the patient declined; three months after her first visit, she could no longer walk and, bedridden, required complete care. Her body could not absorb what it needed to repair the problems.
Poscine persuaded the patient to agree to a partial reversal of her bariatric surgery. A section of bowl that had been bypassed was rejoined to the stomach so that more nutrients could be absorbed.
In three more months, she could get out of bed. A year out, she can walk again and is much improved.
Harik said he'd kept a registry of bariatric patients since his earlier experience, and now Poscine went through that and charts of patients of UAMS neurologists Stacy Rudnicki and Robert L. “Lee” Archer, co-authors of the study. “We bent over backwards,” Harik said, “to be very conservative in our interpretation” of the symptoms, omitting all patients whose problems could be explained by other causes.
Bariatric surgeons are aware that the procedure can create nutritional deficits — the stomach and bowel both play a role in the absorption of the vitamins, minerals and micronutrients the body needs to stay healthy. They put their bypass patients on extra vitamins before the surgery and instruct them in the necessity of taking the supplements for the rest of their lives.
Those who ignore doctors' orders, Poscine said, are likely to make up the majority of the population suffering neurological damage. “But a lot were compliant” among the cases she looked at. “One [prescription] doesn't fit all.” Age, drug interactions, variations in nutritional needs may account for why compliant patients suffer problems nevertheless.
“We are not saying patients should not get the surgery,” Poscine said, but that they need individualized supplementation and careful, lifetime follow-up. Harik estimated the percentage of bariatric patients who get into trouble as less than five percent of the population.
Among the patients studied by Poscine, problems cropped up as soon as 4 weeks post-op to as late as 18 years. The most immediate problems — poor memory, hallucinations, incontinence, pain and increasing weakness — can be tracked to (among other things) a vitamin B1 (thiamin) deficiency. Thiamin deficiency causes beriberi (tingling in the limbs, heart problems) and brain abnormalities, like those suffered by alcoholics. B1 can be hard to keep down in large quantities; patients are putting a large capsule into a stomach smaller than a golf ball. If not treated quickly, some of the early problems may become life-long, Poscine said. (Vitamin B1 can make psychotic episodes disappear in a couple of months, she noted. Other problems may take longer to clear up.)
Many years post-op, patients may begin to experience problems with balance, lower body spasticity and incontinence, Poscine said. Vitamin B12 Spinal cord problems were prominent in 12 cases that made up the UAMS study; only three cases could be found in the medical literature. The problem: The surgery was too far out for doctors to make the connection.
It wasn't until 2001 that doctors learned a copper deficiency could cause neuropathy. Persons deficient in B12 — which is absorbed only after it's connected in the stomach to a protein — can bring about pernicious anemia, causing weakness and fatigue. Patients who don't suffer from anemia may still suffer nerve damage from a lack of B12. Advanced B12 deficiency can cause dementia. As people age, their ability to absorb B12 declines. This has implications for gastric bypass patients, some of whom are now entering their 60s. Another age-related problem: Parkinson's is harder to treat in gastric-bypass patients because of malabsorption.
A deficiency in iron, as everyone knows, can cause anemia. Then, there are the 15 or so micronutrients, which are not well understood. You're not going to find them “in Centrum Silver,” Poscine said.
Still, bariatric surgery is growing exponentially, Poscine said, and doctors need to be vigilant to make sure their patients with intentionally compromised digestion get immediate treatment of neurological problems. She is particularly concerned that bariatric surgeons take to heart the results of the study, since, she said, few follow their patients over a long period — and many don't believe the study's premise anyway.