1. Prevalence of anemia and related
deficiencies in the first year following
laparoscopic gastric bypass for morbid
obesity
Aarts, E. O., van Wageningen, B., Janssen, I. M. C.,
& Berends, F. J. (2012).
Journal of Obesity
Allison Kliewer

2. Introduction
Background
Purpose
Subjects
Methods
Results
Other research

3. Literature : Evidence Analysis Manual
 Accurate assumptions
 No bias was introduced to the study
 Appropriate conclusions made
 No financial ties to disclose
 No conflict of interests
 Design: prospective cohort
 Epidemiological analytical study: class B, Grade I: Good

4. Background
 Laparoscopic Roux-en-Y Gastric Bypass (LRBGY)
is most common bariatric surgery
 Anemia associated with iron, folic acid, and
vitamin B12 deficiencies after surgery are
common
 Restrictive, malabsorptive procedure
 Bypassing stomach and duodenum, gastric
acid, intake

5. Purpose
 Limited studies addressing nutrient
deficiencies and anemia
 Prospective study to investigate the prevalence
of anemia and deficiencies in iron, folate, and
vitamin B12 in the first year after laparoscopic
gastric bypass (LRYGB) in our patients.

6. Subjects
 January 2005 – October 2009
 416 pts LRYGB (Rijnstate Hospital, The
Netherlands)
 N= 377 ( 102: M, 275: F)
 Average age: 43.4 (18-63)
 Average wt (kg): 137.5 ± 22.6
 Average BMI 46.8 ± 6.3

7. Inclusion/Exclusion criteria
 Screened by multidisciplinary team
 Met NIH Consensus Development Conference
Panel for bariatric surgery
 Unable to attend standard F/U protocol
 Pt with laboratory evaluations that surpassed
the 6 & 12 month evaluation by 2-3 months
respectively

8. Methods
 30 cc proximal gastric pouch
 Connect 100-150 cm roux-en-y limb to
jejunum 40 cm from the ligament of Treitz
 2005-2007 BMI > 40 received 100 cm limb,
BMI of >50 (or failing gastric band) received
150 cm limb
 2007 all pt received 150 cm

9. Ligament of
Treitz
30 cc proximal
gastric pouch
40 cm
100 cm roux-en-limb
150 cm roux-en-limb
Vitamins and
Minerals
Absorption sites
bypassed:
Iron
B vitamins
Vitamin A
Calcium
Pyridoxine
Pantothenic acid
Folic Acid

10. Methods
 F/U at 1,3,6 & 12 months post-op
 Complete blood count, mean cell volume
(MCV) and kidney function pre-op
 After 6 & 12 months laboratory evaluations
repeated, plus plasma levels of iron, total iron
binding capacity (TIBC), serum folate levels and
serum B12

11. Post-op Protocol
 Standard multivitamin 3 x daily
 7 mg iron
 100 μg of folic acid
 0.5 μg B12
 Compliance was assessed

12. Limits
 Anemia: Hemoglobin (Hb) in men < 8.4
mmol/L & Hb women <7.4 mmol/L
 MCV 80-100 fL normal
 TIBC > 80%
 Serum iron < 9.0 μmol/L = Deficient
 Serum folate < 9.0 nmol/L = Deficient
 B12 < 150 pmol/L = Deficient

13. Results: Anemia
 Pre-op 27 pt had anemia
 After 12 months 66 pt developed anemia
 Total prevalence of anemia including pre-op is
25%
 93 developed anemia within first year

14. Results: Iron deficiency
 33% after one year
 61% with anemia de novo
 38% vs. 17% (Female vs. Male)

15. Results: Folic acid
 15% of pt
 14% of pt with anemia de novo

16. Results: Vitamin B12
 50% of pt
 40% of pt with anemia de novo
 42 % vs. 21 % (female vs. male)

17. Results
 239/377 (63%) were diagnosed with at least
one of either iron, folic acid, or B12 deficiency
 Male 45% risk of being diagnosed with iron,
folic acid, or B12 deficiency vs. 68% of females
 AGB prior to RYGB a 24% vs. 39% risk in B12
deficiencies

18. Male vs Female & AGB
Male Female
Anemia 20% 20%
Iron deficient 17% 38%
B12 deficient 21% 42%
Iron, Folate, B12
Deficient
45% 68%
• AGB had lower % of anemia, folic acid, and B12 deficiency

19. Article Subjects Length Post-op protocol Results
Aarts et al.
2012
N= 377
Male= 102
Female= 275
January 2005-
October 2009
12 months
post-op
Standard MVI x 3
daily
At least 7 mg iron
100 μg folic acid
0.5 μg B12
66 pt anemia de novo
33% iron deficient
15% folic acid deficient
50% B12 deficient
Avgerinos et
al.
2010
RYGB
N= 206
Male= 41
Female= 165
January 2003-
November
2007
86 wks
Standard chewable
MVI
Ferrous sulfate
tablets @ 320 mg
daily
Anemia= 21 (10.2 %)
serum ferritin, TIBC, MCV
Menstruating females and pt found
to have marginal ulcer on
endoscopy at significantly greater
risk.
Drygalski et al.
2011
RYGB
N= 1125
Male= 126
Female= 999
48 months
postoperative
Daily MVI with 18
mg iron, 400 μg folic
acid, 1000 μg B12
Calcium citrate with
vitamin 1500 mg
vitamin D
Mean Hb lower after 24-48 m
Significantly lower Hb in
premenopausal women than in
postmenopausal women or men.
Anemia greater in pre vs post
menopausal
Ferritin continuously at 24-48m
Iron @ 24-48 m
Folate @ 24-48 m
B12 @ 24-48 m

20. Risk Factors
 Decreased absorption surface = absorption
capacity
 ph due to gastric acid (proton pump inhibitors
and calcium, other meds)
 Intolerance for red meat and milk
 Inadequate intake preoperatively
 Menstruation
 inflammatory response

21. Recommendations
 40-65 mg/d of elemental iron for males
 100 mg/d elemental iron for females
 + Vitamin C ?
 400 μg/d of folic acid or 1 mg/d
 300-500 μg/d of B12

22. Questions?
 Based on the results from this study, what
protocol should be followed with patients
undergoing LRYGB?
 Why would a folate deficiency be of concern
for premenopausal women?
 Is this information useful?

23. Application
 Monitor anemia and deficiencies in pt
following gastric bypass
 Supplementation to avoid deficiency and
anemia post-op needs to be determined
 At risk pts would benefit from a higher
supplementation level

24. References
Aarts, E., van Wageningen, B., Janssen, I. & Berends, F. (2012). Prevalence
of anemia and related deficiencies in the first year following laparoscopic
gastric bypass for morbid obesity. Journal of Obesity. 1-7.
doi:10.1155/2012/193705.
Avgerinos, D., Llaguna, O., Seigerman, M., Lefkowitz, A. & Leitman, M.
(2010). Incidence and risk factors for the development of anemia
following gastric bypass surgery. World Journal of Gastroenterology. 16
(15): 1867-1870. doi:10.3748/wjg.v16.i15.1867
Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement Online
1991 Mar 25-27 [16 October 2012];9(1):1-20.
Von Drygalski, A., Andris, D., Nuttleman, P., Jackson, S., Klein, J. & Wallace,
J. (2011). Anemia after bariatric surgery cannot be explained by iron
deficiency alone: results of large cohort study. Surgery for Obesity and
Related Diseases. 7: 151-156. doi:10.1016/soard.2010.04.008.