Protein-Calorie Malnutrition Requiring Revisional Surgery after One-Anastomosis-Mini-Gastric Bypass (OAGB-MGB): Case Series from the Tehran Obesity Treatment Study (TOTS)

Abstract

Introduction: One-anastomosis-mini-gastric bypass (OAGB-MGB) is the second most popular gastric bypass procedure with remarkable weight loss results and comorbidity resolution rates. However, some concerns remain regarding its postoperative complications, including protein-calorie malnutrition (PCM). We hereby report our experience with patients who returned with severe PCM after OAGB-MGB. Methods: Patients with severe obesity presenting to our referral bariatric center underwent OAGB-MGB surgery using a 200-cm biliopancreatic limb (BPL) by a single surgical team at three university hospitals from March 2014 to February 2016. Results: From 189 patients undergoing OAGB-MGB, seven patients (3.7%), all female, with a mean age of 46.4 ± 8.2 years and initial body mass index (BMI) of 44.2 ± 4.7 kg/m2, were readmitted for signs of PCM. Lower extremity edema, fatigue, excessive weight loss, hypoalbuminemia, anemia, and pancytopenia were the presenting symptoms and lab findings. Revisional surgery was performed at a mean 19 ± 9.7 months after OAGB-MGB after failure of supportive measures. The mean BMI at the time of revision was 22.5 ± 2.6 kg/m2 with an excess weight loss of 109.2 ± 22.1%. After revisional surgery, one patient developed profound liver failure and expired. Another patient developed severe steatohepatitis but ultimately recovered. In the remaining five, edema and fatigue completely resolved at 1 month and hypoalbuminemia and anemia normalized at 2 months. Conclusion: A one-fits-all BPL length of 200 cm is increasingly being questioned as it may result in an inadequate absorptive area and PCM in a subset of patients with shorter total bowel lengths, potentially placing them in danger and depriving them of bariatric surgery benefits.