Background

The prevalence of stage 3 obesity (BMI>40kg/m2) has doubled over the past 20 years. There is increasing interest and utilization of biliopancreatic diversion with duodenal switch (BPD-DS), a restrictive and malabsorptive procedure, for management of obesity because it results in the greatest excess weight loss and resolution of comorbidities. While highly effective, BPD-DS has the potential for complications, including malnutrition with vitamin and trace element deficiencies. Despite modifications to technique, extensive long-term follow-up with ongoing supplementation and nutritional support is necessary.

Methods

We report the presentation and management strategies for six individuals who presented to our institution with malnutrition and vitamin deficiency after BPD-DS.

Results

Five women and one man presented with severe malnutrition and nutrient deficiencies, including low plasma concentrations of vitamins A, C, K, B1, B6, B12, folate, and copper. Malnutrition varied in presentation and occurred as soon as 3 months post-operatively; multiple individuals developed peripheral neuropathy with altered sensation and gait disturbance. Other presentations included night blindness and liver failure complicated by bleeding esophageal varices and hepatorenal syndrome with need for hemodialysis. Individuals were treated with a combination of total parenteral and enteral nutrition with vitamin supplementation until nutritional recovery. Five individuals underwent surgical revision - three conversions to Roux-en-Y and two with Braun enteroenterostomies.

Conclusions

While BPD-DS is an important option for the treatment of severe obesity, it is not without significant nutritional risk. It is essential that providers are aware of these risks and can provide nutritional optimization in the setting of malnutrition after BPD-DS.