Zinc deficiency after nutrient-restricted weight loss surgery, Wernicke's encephalopathy, and routine follow-up

Zinc and vitamin B₁ deficiencies are not common, but they have been reported.

Experimental animal models have shown that pancreatic secretion is related to zinc absorption.

However, Scopinaro et al. found that, one year after the surgery, serum and hair zinc levels were not different in 14 patients who underwent bile-pancreatic diversion compared to morbidly obese patients who did not receive surgical treatment.

Postoperative vitamin B₁ deficiency is also challenging, especially when patients experience chronic vomiting and insufficient food intake.

Wernicke-Korsakoff symptoms are commonly seen in chronic alcoholics and occur in 0.18% of patients after bile-pancreatic diversion surgery.

Although vitamin B₁ deficiency is rare, the consequences can be disastrous if it is not diagnosed and treated promptly and appropriately.

Despite the fact that weight loss surgery, which focuses on restricting nutrient absorption, has been around for 20 years, there are still no guidelines on supplementing vitamins and trace elements.

A survey of 24 surgeons who underwent bile-pancreatic diversion surgery revealed that 95% of the doctors prescribed multivitamin preparations, 95% supplemented with calcium, 67% with iron, 42% used vitamin B₁₂, 58% used vitamin A, and 67% used vitamin D.

Similarly, there is no consensus on how often blood tests should be performed. 46% of doctors recommend that patients have a blood test every 3 months, 33% recommend every 6 months, and 16% recommend once a year.

Surprisingly, 5% of doctors do not usually order blood tests for their patients.

We usually have patients have blood tests every 3 months in the first year after surgery, and every 6 months in the second year. After that, if there are no complications, blood tests are performed once a year. If complications occur, the frequency of blood tests is increased.

During each outpatient follow-up visit, we will understand the changes in the patient's physical condition, assess whether there are symptoms and signs of vitamin and trace element deficiency, and conduct routine laboratory tests.

in conclusion

Postoperative management and nutritional assessment are crucial for the ultimate success of minimally invasive bariatric surgery, which focuses on restricting nutrient absorption.

Such surgeries are not yet widely accepted due to concerns about severe protein and vitamin deficiencies after surgery.

We recommend selecting patients who can adhere to long-term follow-up and have good compliance.

Routine postoperative care for outpatients undergoing restrictive nutrition surgery:

3 weeks post-surgery: Check the wound; start a high-protein, soft diet, gradually transitioning to a normal diet if tolerated; begin vitamin supplementation: multivitamins once daily; Niferex Forte 150mg twice daily; calcium citrate, 2 scoops twice daily; vitamin B₁₂, 100μg every other day; if gallbladder is retained, administer ursodeoxycholic acid, 300mg twice daily for 6 months.

Every 3 months until 1 year post-surgery: routine laboratory tests: complete blood count, blood biochemistry, liver function, complete lipid profile, thyroid-stimulating hormone, iron, B₁₂, folic acid, total protein, albumin, parathyroid hormone, calcium, and vitamin D-25 levels; bone mineral density scan is performed 1 year post-surgery and annually thereafter.

Every 6 months, until 2 years post-surgery: Same as above.

Once a year: Same as above.

Vitamin deficiencies may occur after weight-loss surgery that primarily restricts nutrient absorption:

Non-lipid-soluble: Ca²⁺ deficiency manifests as increased neuromuscular excitability, paresthesia, Chvostek's sign and Trousseau's sign, laryngospasm, tetany, and prolonged QT interval on electrocardiogram in the acute phase; and as muscle spasms, intellectual disability, pseudopapilledema, extrapyramidal signs, personality disorders, dry and rough skin, alopecia, abnormal dentition, and osteoporosis in the chronic phase.

Fe²⁺ deficiency manifests as microcytic hypochromic anemia.

B₁₂ (cobalamin) deficiency manifests as megaloblastic anemia, jaundice, glossitis, anorexia, diarrhea, numbness and paresthesia of the extremities, weakness, ataxia, positive Romberg's sign and Babinski's sign, mental disorder, and confusion.

Early symptoms of vitamin B₁ deficiency include anorexia, irritability, apathy, and physical weakness; chronic deficiency manifests as Wernicke's encephalopathy-level nystagmus, oculomotor palsy, cerebellar ataxia, mental disorders, Wernicke-Korsakoff syndrome, memory loss, and intermittent psychosis.

Zinc deficiency can manifest as immunodeficiency, delayed wound healing, skin diseases, glossitis, photophobia, hair loss, diarrhea, and lethargy.

Fat-soluble: Vitamin D deficiency manifests as signs and symptoms of hypocalcemia and low blood phosphate, rickets (in children), and osteomalacia.

Vitamin E deficiency manifests as loss of reflexes, ataxia gait, decreased vibration and position sense, oculomotor paralysis, skeletal myopathy, and retinitis pigmentosa.

Vitamin A deficiency manifests as hyperkeratosis of the skin, Bitot's spots, night blindness, xerophthalmia, and Sjögren's disease.

Vitamin K deficiency manifests as abnormal blood clotting.