Denosumab-Induced Hypocalcemia after Billroth II Gastric Bypass Surgery

Hypocalcemia is a known risk following bariatric surgery and can contribute to the development of osteoporosis. Osteoporosis is commonly treated with denosumab, though denosumab can exacerbate underlying abnormalities in calcium homeostasis. We present the case of a 59-year-old female with severe hypocalcemia who had been treated with denosumab for osteoporosis three months before and had Billroth II gastric bypass surgery 15 years before, for bariatric purposes. Intravenous calcium supplementation was used to correct the initial electrolyte abnormality, and the patient was able to maintain appropriate calcium levels on high doses of oral calcium before discharge. Denosumab-induced hypocalcemia has been previously reported in patients with predisposing conditions including chronic kidney disease, primary sclerosing cholangitis, Crohn’s disease, and a history of sleeve gastrectomy for marginal gastric ulcers. A few cases of hypocalcemia have been reported in patients with a history of bariatric surgery secondary to vitamin D deficiency, but this report is unique in demonstrating denosumab-induced hypocalcemia after bariatric surgery with normal vitamin D levels, suggesting a primary malabsorption of calcium. The risk of severe hypocalcemia should be considered before initiating denosumab to treat osteoporosis in patients with a history of bariatric surgery. If denosumab is initiated, serum calcium levels should be closely monitored, and patients should be educated about the importance of adherence to calcium supplementation.

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Vitamin D and calcium supplementation recommended after gastric bypass surgery

Nature Clinical Practice Endocrinology &#38 Metabolism ◽

10.1038/ncpendmet0238 ◽

2006 ◽

Vol 2 (8) ◽

pp. 422-422

Keyword(s):

Vitamin D ◽

Gastric Bypass ◽

Bypass Surgery ◽

Calcium Supplementation ◽

Gastric Bypass Surgery

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Vitamin D absorption: consequences of gastric bypass surgery

Acta Endocrinologica ◽

10.1530/eje-10-1126 ◽

2011 ◽

Vol 164 (5) ◽

pp. 827-832 ◽

Cited By ~ 37

Author(s):

Edo Aarts ◽

Lenneke van Groningen ◽

Ronald Horst ◽

Darryl Telting ◽

Adriaan van Sorge ◽

...

Keyword(s):

Vitamin D ◽

Gastric Bypass ◽

Bypass Surgery ◽

Gastric Bypass Surgery ◽

Premenopausal Women ◽

Individual Variability ◽

Common Finding ◽

Morbidly Obese ◽

Vitamin D Levels ◽

Laparoscopic Rygb

BackgroundSevere vitamin D deficiency is a common finding in morbid obesity, and the incidence increases markedly after RYGB. Normalization of vitamin D levels after RYGB is difficult to achieve because the degree of surgery-induced malabsorption is not known.ObjectiveTo develop a test that quantifies the changes in intestinal cholecalciferol absorption induced by Roux-en-Y gastric bypass (RYGB) surgery.MethodsAbsorption characteristics of cholecalciferol were studied in 14 morbidly obese, premenopausal women before and 4 weeks after laparoscopic RYGB. Serum cholecalciferol levels were measured at baseline and 1, 2, 3, and 14 days after a single oral dose of 50 000 IU solubilized cholecalciferol.ResultsPeak serum cholecalciferol levels were observed on day 1 in all patients. They were 26.6±3.7% lower after RYGB (P=0.02). Inter-individual variability was high.ConclusionPeak cholecalciferol levels are reduced by about 25% after RYGB. Further analysis suggested that the timing of sampling in the current study was not optimal. This might have caused an underestimation of the true decrease in cholecalciferol absorption induced by RYGB.

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Recurrent Thrombi in an Obese Patient With History of Bariatric Surgery Despite Anti-Xa Therapy

Journal of Pharmacy Practice ◽

10.1177/08971900211004837 ◽

2021 ◽

pp. 089719002110048

Author(s):

Rachel Briggler ◽

Emma Matherne ◽

Chris Johnson ◽

Kaci Boehmer

Keyword(s):

Bariatric Surgery ◽

Gastric Bypass ◽

Bypass Surgery ◽

Clinical Decision Making ◽

Gastric Bypass Surgery ◽

Anticoagulation Therapy ◽

Clinical Decision ◽

International Normalized Ratio ◽

History Of ◽

American Society

Obesity and gastric bypass surgery can complicate anticoagulation therapy. In general, patients post-bariatric surgery are considered to be at a moderate risk for deep venous thromboembolism or pulmonary embolism. American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists guidelines recommend chemical prophylaxis with unfractionated heparin or low molecular weight heparin after surgery until the patient is fully mobile, and for those who require chronic anticoagulation, the International Society of Thrombosis and Haemostasis recommend warfarin if body mass index (BMI) is above 40 kg/m2 or weight is more than 120 kg. Clinical decision making regarding anticoagulation in the following patient case is complicated by multiple factors, most notably the combination of obesity and history of gastric bypass surgery. This patient failed multiple anticoagulation regimens, with apixaban and rivaroxaban therapies each ending in venous thromboemboli and warfarin leading to subtherapeutic International Normalized Ratio (INR)s despite dose adjustment. However, she is currently therapeutic on the combination of enoxaparin and warfarin as shown by INR and anti-Xa level monitoring. In this case and similar instances, there could be a need for anticoagulant dose adjustments, different INR goals, or a combination of different anticoagulants. Providers should take an individualized approach to patients who have had bariatric surgery with elevated BMI as a key factor in anticoagulant selection.

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Internal hernia following total gastrectomy with Roux-en-Y reconstruction

Annals of The Royal College of Surgeons of England ◽

10.1308/147870811x590333 ◽

2011 ◽

Vol 93 (6) ◽

pp. e71-e73 ◽

Cited By ~ 4

Author(s):

JO Larkin ◽

F Cooke ◽

N Ravi ◽

JV Reynolds

Keyword(s):

Gastric Bypass ◽

Small Bowel ◽

Total Gastrectomy ◽

Internal Hernia ◽

Bypass Surgery ◽

Gastric Bypass Surgery ◽

Postoperative Recovery ◽

Entire Small Bowel ◽

History Of ◽

Swirl Sign

Internal herniation is a well-described complication after a gastric bypass, particularly when performed laparoscopically, although it is rarely described following a total gastrectomy. A 55-year-old lady presented with a 24-hour history of vomiting and rigors 10 months after a radical total gastrectomy with Roux-en-Y reconstruction for a gastric adenocarcinoma. Computed tomography (CT) showed a complete small bowel obstruction and a mesenteric swirl sign, indicating a possible internal hernia. The entire small bowel was found at laparotomy to have migrated through the mesenteric defect adjacent to the site of the previous jejunojejunostomy and was dark purple and aperistaltic. The small bowel was reduced through the defect. At a second laparotomy, the small bowel looked healthy and the defect was repaired. Postoperative recovery was unremarkable. Of numerous signs described, the mesenteric swirl sign is considered the best indicator on CT of an internal hernia following Roux-en-Y reconstruction in gastric bypass surgery. A swirl sign on CT in a patient with abdominal pain should always raise the suspicion of an internal hernia.

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Anthropometric Measurements and Correlations to Glucometabolic and Cardiovascular Risk in Obese Patients Undergoing Gastric Bypass Surgery

Journal of Obesity ◽

10.1155/2021/6647328 ◽

2021 ◽

Vol 2021 ◽

pp. 1-6

Author(s):

Erica Aldenbäck ◽

Hans-Erik Johansson

Keyword(s):

Bariatric Surgery ◽

Vitamin D ◽

Gastric Bypass ◽

Fasting Glucose ◽

Gastric Bypass Surgery ◽

Cost Effective ◽

Morbidly Obese ◽

Obese Patients ◽

Inclusion Criteria ◽

Sagittal Abdominal Diameter

Abdominal obesity is associated with hypertension, increased fasting glucose, HbA1c, and cholesterol. Body mass index (BMI) is frequently used to measure and define obesity and as inclusion criteria for bariatric surgery. Sagittal abdominal diameter (SAD) has been suggested to predict the amount of visceral fat, metabolic traits, and cardiometabolic risk superior to BMI. The aim was to test whether SAD has stronger correlations to glucometabolic traits compared to BMI. One hundred and fifty-five (108 women, 47 men) morbidly obese patients undergoing bariatric surgery were evaluated before (baseline), 6 and 12 months after Roux-en-Y gastric bypass (RYGBP). BMI was reduced from 43.7 kg/m2 (baseline) to 31.3 kg/m2 (12 months) and SAD from 32.6 to 23.2 cm (both p <0 .001 ). SAD correlated with CRP ( p = 0.04 ), fasting glucose ( p = 0.008 ), HbA1c ( p = 0.016 ), triglycerides ( p = 0.017 ), systolic blood pressure ( p = 0.032 ), and vitamin D ( p = 0.027 ). BMI correlated with CRP ( p = 0.006 ), triglycerides ( p = 0.016 ), vitamin D ( p = 0.002 ), and magnesium ( p = 0.037 ). Despite RYGBP surgery, vitamin D was significantly increased. Liver enzymes were significantly lowered after RYGBP and the change over time in SAD correlated with gamma-glutamyltransferase. SAD was superior to BMI to predict glucose disturbance and dyslipidemia implying increased use of SAD as it is cost effective and simple to perform in the clinic and could be of value when considering patients for bariatric surgery.

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Roux-en-Y-Bariatric Surgery Reduces Markers of Metabolic Syndrome in Morbidly Obese Patients

Obesity Surgery ◽

10.1007/s11695-019-04190-y ◽

2019 ◽

Vol 30 (2) ◽

pp. 391-400 ◽

Cited By ~ 5

Author(s):

G. Rega-Kaun ◽

C. Kaun ◽

G. Jaegersberger ◽

M. Prager ◽

M. Hackl ◽

...

Keyword(s):

Bariatric Surgery ◽

Metabolic Syndrome ◽

Gastric Bypass ◽

Bypass Surgery ◽

Gastric Bypass Surgery ◽

Morbidly Obese ◽

Diabetic Patients ◽

Obese Patients ◽

C Peptide ◽

Hepatic Insulin Clearance

Abstract Background Obesity is closely linked to increased markers of metabolic syndrome and development of diabetes. Roux-en-Y bariatric surgery reduces hyperinsulinemia and improves insulin sensitivity and hence benefits morbidly obese patients. Aim To determine changes in markers of metabolic syndrome, pancreatic function, and hepatic insulin sensitivity in patients before and 1 year after undergoing Roux-en-Y gastric bypass surgery. Methods We enrolled 43 consecutive patients in a single center. Markers for metabolic syndrome included proinsulin, insulin, C-peptide, liver enzymes, and serum levels of selected microRNAs hsa-miR-122, hsa-miR-130, hsa-miR-132, and hsa-miR-375. Results After surgery, all patients showed a significant 37% drop of body mass index (p < 0.001). Furthermore, proinsulin (59% reduction, p < 0.001), insulin (76% reduction, p < 0.001), and C-peptide (56% reduction, p < 0.001) were all reduced 1 year after surgery. Using the hepatic insulin clearance score, we determined a significant increase in hepatic insulin clearance after surgery (76% increase, p < 0.001). Especially diabetic patients showed a marked 2.1-fold increase after surgery. Hepatic enzymes ALT (35% reduction, p = 0.002) and γGT (48% reduction, p < 0.001) were significantly reduced in all patients with similar improvement in diabetic and non-diabetic patients. miRNAs hsa-miR-122, hsa-miR-130, and hsa-miR-132 were all significantly reduced whereas hsa-miR-375 was increased after gastric bypass surgery (p < 0.001 for all miRNAs). Conclusion Both liver and pancreatic stress parameters were reduced significantly 1 year after Roux-en-Y gastric bypass surgery suggesting an overall amelioration of the metabolic syndrome in all patients regardless of previous health status.

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Association of Circulating Irisin Concentrations with Weight Loss after Roux-en-Y Gastric Bypass Surgery

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph16040660 ◽

2019 ◽

Vol 16 (4) ◽

pp. 660 ◽

Cited By ~ 3

Author(s):

Yeon Lee ◽

Yoonseok Heo ◽

Ji-Ho Choi ◽

Sunghyouk Park ◽

Kyoung Kim ◽

...

Keyword(s):

Bariatric Surgery ◽

Weight Loss ◽

Gastric Bypass ◽

Bypass Surgery ◽

Excess Weight Loss ◽

Gastric Bypass Surgery ◽

Morbidly Obese ◽

Obese Patients ◽

Preoperative Serum ◽

One Year

Irisin is a myokine with potential anti-obesity properties that has been suggested to increase energy expenditure in obese patients. However, there is limited clinical information on the biology of irisin in humans, especially in morbidly obese patients undergoing bariatric surgery. We aimed to assess the association of circulating irisin concentrations with weight loss in obese patients undergoing bariatric surgery. This was a pilot, single-centre, longitudinal observational study. We recruited 25 morbidly obese subjects who underwent Roux-en-Y gastric bypass surgery (RYGBP), and blood samples from 12 patients were taken to measure serum irisin concentrations before, and one and nine months after surgery. Their clinical characteristics were measured for one year. The preoperative serum irisin concentration (mean 1.01 ± 0.23 μg/mL, range 0.73–1.49) changed bidirectionally one month after RYGBP. The mean concentration at nine months was 1.11 ± 0.15 μg/mL (range 0.92–1.35). Eight patients had elevated irisin levels compared with their preoperative values, but four did not. Elevations of irisin levels nine months, but not one month, after surgery, were associated with lower preoperative levels (p = 0.016) and worse weight reduction rates (p = 0.006 for the percentage excess weight loss and p = 0.032 for changes in body mass index). The preoperative serum irisin concentrations were significantly correlated with the percentage of excess weight loss for one year (R2 = 0.612; p = 0.04) in our study. Our results suggest that preoperative circulating irisin concentrations may be at least in part associated with a weight loss effect of bariatric surgery in morbidly obese patients. Further large-scale clinical studies are needed to ratify these findings.

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