Current Treatment Options in Neurology

, Volume 12, Issue 1, pp 29–36 | Cite as

Prevention and Treatment of Peripheral Neuropathy after Bariatric Surgery

Neuromuscular Disorders

Opinion statement

Given the ever-increasing problem of obesity, it is not surprising that the number of patients who undergo bariatric surgery continues to rise. For patients who have gastric banding, the amount of food they can consume is limited, and nausea and vomiting may further limit nutritional intake early on. More extensive procedures, such as the Roux-en-Y or biliopancreatic diversion with or without a duodenal switch, not only restrict intake but also limit absorption in the small intestine. As a result, deficiencies in vitamins, minerals, and trace elements may develop, leading to a variety of neurologic complications. The peripheral neuropathies best described with a clear-cut cause are an acute, frequently painful neuropathy or polyradiculoneuropathy associated with thiamine deficiency, and an isolated neuropathy or myeloneuropathy associated with deficiencies of either vitamin B12 or copper. Thiamine deficiency tends to occur in the first weeks or months after surgery, vitamin B12 deficiency may develop at any time from a few years to many years after surgery, and copper deficiency tends to be a fairly late complication, developing several years to many years following surgery. Patients who have undergone bariatric surgery may also have an increased risk of developing focal neuropathies, though these are less clearly related to specific nutritional deficiencies.

Ideally, one would like to prevent these neuropathies, but there is no consensus of opinion as to what vitamins and micronutrients need to be taken following bariatric surgery. In addition, many patients who take supplements early on fail to maintain the regimen even though some of the neuropathies can occur fairly late. Supplements frequently recommended include a multivitamin, iron, vitamin D, folic acid, calcium citrate, and vitamin B12. Although thiamine is typically included in a multivitamin, the amount is fairly small, so I recommend adding 100 mg daily for at least the first year. Some have suggested zinc supplementation, but this is potentially problematic because exogenous zinc may interfere with copper absorption. Obtaining blood work every 6 months after surgery will help to identify and treat nutritional deficiencies early.

For those patients who have had a bariatric procedure and then develop a neuropathy, evaluating levels of thiamine, copper, vitamin B12, methylmalonic acid, and homocystine is indicated. In addition, since one deficiency is frequently associated with others, obtaining levels of vitamin A, C, D, K, and E, as well as iron, zinc, selenium, and magnesium is worthwhile. Checking total protein, albumin, and cholesterol also gives a sense of general nutritional status. Occasionally, no clear-cut deficiency of a vitamin, mineral, or trace element can be identified in patients with various peripheral nervous system manifestations. Nevertheless, these patients may have at least some recovery with improving nutritional intake and vitamin supplementation, suggesting that we still do not fully understand how nutritional status affects the peripheral nervous system.

Notes

Disclosure

No potential conflicts of interest relevant to this article were reported.

References and Recommended Reading

Papers of particular importance, recently published, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Centers for Disease Control and Prevention, National Center for Health Statistics: Prevalence of overweight, obesity and extreme obesity among adults: United States, trends 1960–62 through 2005–2006. http://www.cdc.gov/nchs/data/hestat/overweight/overweight_adult.htm#table1. Accessed October 3, 2009.
  2. 2.
    Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clinic Nutr 1992, 55(2 suppl):616S–619S.Google Scholar
  3. 3.
    American Society for Metabolic and Bariatric Surgery: Fact sheet: Metabolic and bariatric surgery. http://www.asbs.org/Newsite07/media/asmbs_fs_surgery.pdf Accessed October 3, 2009.
  4. 4.
    Santry HP, Lauderdale DS, Cagney KA, et al.: Predictors of patient selection in bariatric surgery. Ann Surg 2007, 245:59–67.CrossRefPubMedGoogle Scholar
  5. 5.
    Inge TH, Krebs NF, Skelton JA: Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics 2004, 114:217–223.CrossRefPubMedGoogle Scholar
  6. 6.
    •Aasheim ET, Bjorkman S, Sevik TT, et al.: Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clinic Nutr 2009, 90(1):15–22. This prospective study observed patients with both types of procedures for a year to compare the nutritional deficiencies they developed.CrossRefPubMedGoogle Scholar
  7. 7.
    Coupaye M, Puchaus K, Bogard C, et al.: Nutritional consequences of adjustable gastric banding and gastric bypass: a 1-year prospective study. Obes Surg 2009, 19:56–65.CrossRefPubMedGoogle Scholar
  8. 8.
    Ernst B, Thurnheer M, Schmid SM, Schultes B: Evidence for necessity to systemically assess micronutrient status prior to bariatric surgery. Obes Surg 2009, 19:66–73.CrossRefPubMedGoogle Scholar
  9. 9.
    Gong K, Gagner M, Pomp A, et al.: Micronutrient deficiencies after laparoscopic gastric bypass: recommendations. Obes Surg 2008, 18:1062–1066.CrossRefPubMedGoogle Scholar
  10. 10.
    Koffman BM, Greenfield LJ, Ali II, Pirzada NA: Neurologic complications after surgery for obesity. Muscle Nerve 2005, 33:166–176.CrossRefGoogle Scholar
  11. 11.
    ••Juhasz-Pocsine K, Rudnicki SA, Archer RL, Harik SI: Neurologic complications of gastric bypass surgery for morbid obesity. Neurology 2007, 68:1842–1850. This paper reports on 26 patients who developed both central and peripheral nervous system complications after bariatric surgery; it also reviews the literature.CrossRefGoogle Scholar
  12. 12.
    Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, et al.: A controlled study of peripheral neuropathy after bariatric surgery. Neurology 2004, 63:1462–1470.PubMedGoogle Scholar
  13. 13.
    Abarbanel JM, Berginer VM, Osimani A, et al.: Neurologic complications after gastric surgery for morbid obesity. Neurology 1987, 37:196–200.PubMedGoogle Scholar
  14. 14.
    Matrana MR, Vasireddy S, Davis WE: The skinny on a growing problem: dry beriberi after bariatric surgery. Ann Intern Med 2008, 149:842–844.PubMedGoogle Scholar
  15. 15.
    ••Aashaim ET: Wernicke encephalopathy after bariatric surgery: a systematic review. Ann Surg 2008, 248:714–720. This review of the literature includes 84 patients who developed thiamine deficiency, detailing risk factors, time of onset, outcome, and associated symptoms, including neuropathy.Google Scholar
  16. 16.
    Tanphaichitr V: Thiamin. In Modern Nutrition in Health and Disease, edn 9. Edited by Shils ME, Olson JA, Shike M, Ross AC. Baltimore, MD: Williams and Wilkins; 1999:381–389.Google Scholar
  17. 17.
    Kumar N, Gross JB, Ahlskog JE: Copper deficiency myelopathy produces a clinical picture like subacute combined degeneration. Neurology 2004, 63:33–39.PubMedGoogle Scholar
  18. 18.
    Dunlap WM, James GW, Hume DM: Anemia and neutropenia caused by copper deficiency. Ann Intern Med 1974, 80:470–476.PubMedGoogle Scholar
  19. 19.
    ••Mechanick JI, Kushner RF, Sugerman HJ, et al.: American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis 2008, 4(5 Suppl):S109–S184. This sweeping guideline covers not only the nutritional aspects of bariatric surgery but also essentially all aspects regarding the procedures. It includes nearly 800 references.CrossRefPubMedGoogle Scholar
  20. 20.
    Ukleja A: Dumping syndrome: pathophysiology and treatment. Nutr Clin Pract 2005, 20:517–525.CrossRefPubMedGoogle Scholar
  21. 21.
    Brolin RE, Gorman JH, Groman RC, et al.: Are vitamins B12 and folate deficiency clinically important after roux-en-Y gastric bypass? J Gastrointest Surg 1998, 2:436–442.CrossRefPubMedGoogle Scholar
  22. 22.
    Rowin J, Lewis SL: Copper deficiency myeloneuropathy and pancytopenia secondary to overuse of zinc supplementation. J Neurol Neurosurg Psychiatry 2005, 76:750–751.CrossRefPubMedGoogle Scholar
  23. 23.
    Nations SP, Boyer PJ, Love LA, et al.: Denture cream: an unusual source of excess zinc, leading to hypocupremia and neurologic disease. Neurology 2008, 71:639–643.CrossRefPubMedGoogle Scholar
  24. 24.
    Malone M: Recommended nutritional supplements for bariatric surgery patients. Ann Pharmacother 2008, 42:1851–1858.CrossRefPubMedGoogle Scholar
  25. 25.
    Shahidzadeh R, Sridhar S: Profound copper deficiency in a protein with gastric bypass. Am J Gastroenterol 2008, 103:2660–2662.CrossRefPubMedGoogle Scholar
  26. 26.
    Kumar N: Copper deficiency myelopathy (human swayback). Mayo Clin Proc 2006, 81:1371–1384.CrossRefPubMedGoogle Scholar
  27. 27.
    Brown LM, Rowe AE, Ryle PR, et al.: Efficacy of vitamin supplementation in chronic alcoholics undergoing detoxification. Alcohol Alcohol Suppl 1983, 18:157–166.Google Scholar
  28. 28.
    Tallaksen CM, Bell M, Bøhmer T: Thiamin and thiamin phosphate ester deficiency assessed by high performance liquid chromatography in four clinical cases of Wernicke’s encephalopathy. Alcohol Clin Exp Res 1993, 17:712–716.CrossRefPubMedGoogle Scholar
  29. 29.
    •Sechi G, Serra A: Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol 2007, 6(5):442–455.This paper raises some interesting questions concerning dosing of thiamine.CrossRefPubMedGoogle Scholar
  30. 30.
    Sechi G: Prognosis and therapy of Wernicke’s encephalopathy after obesity surgery. Am J Gastroenterol 2008, 103:3219.CrossRefPubMedGoogle Scholar
  31. 31.
    Traviesa DC: Magnesium deficiency: a possible cause of thiamine refractoriness in Wernicke-Korsakoff encephalopathy. J Neurol Neurosurg Psychiatry 1974, 37:959–962.CrossRefPubMedGoogle Scholar
  32. 32.
    Greenberg SA, Briemberg HR: A neurological and hematological syndrome associated with zinc excess and copper deficiency. J Neurol 2004, 251:111–114.CrossRefPubMedGoogle Scholar
  33. 33.
    Gregg XT, Reddy V, Prchal JT: Copper deficiency masquerading as myelodysplastic syndrome. Blood 2002, 100:1493–1495.CrossRefPubMedGoogle Scholar
  34. 34.
    Kelkar P, Chang S, Muley SA: Response to oral supplementation in copper deficiency myeloneuropathy. J Clin Neuromuscul Dis 2008, 10(1):1–3.CrossRefPubMedGoogle Scholar
  35. 35.
    Provenzale D, Reinhold RB, Golner B, et al.: Evidence for diminished B12 absorption after gastric bypass: oral supplementation does not prevent low plasma B12 levels in bypass patients. J Am Coll Nutr 1992, 11:29–35.PubMedGoogle Scholar
  36. 36.
    Vasconcelos OM, Poehm EH, McCarter RJ, et al.: Potential outcome factors in subacute combined degeneration. J Gen Intern Med 2006, 21:1063–1068.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of Arkansas Medical SchoolLittle RockUSA

Personalised recommendations