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. 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
• Malabsorption and insufficient intake

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

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

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

12. Results: Anemia
• Pre-op 27 pt had anemia
• After 12 months 66 pt developed anemia: 19
microcytic
• Total prevalence of anemia including pre-op is
25%
• 93 developed anemia within first year

13. Results: Iron deficiency
• 66% of pt
• 33% after one year
• 61% with anemia de novo
• 38% vs. 17% (Female vs. Male)

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

15. Results: Vitamin B12
• 50% of pt
• 40% of pt with anemia de novo
• 2/3 pt developed macrocytic red blood cells
with B12 deficiency
• 42 % vs. 21 % (female vs. male)

16. 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

17. Article Subjects Length Post-op protocol Results
Aarts et al. 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% anemia de novo
33% iron ddeficient
15% folic acid deficient
50% B12 deficient
Avgerinos et al. RYGB
N= 206
Male= 41 (19.9
%)
Female= 165
(80.1 %)
Mean age=
40.8 (18-60y)
January 2003-
November
2007
Standard chewable
MVI
Ferrous sulfate
tablets @ 320 mg
daily
Anemia= 21 (10.2 %)
(serrum ferritin, TIBC,
MCV
Menstruating females and pt
found to have marginal ulcer
on endoscopy at significantly
greater risk.
Drygalski et al. 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 more in
premenopausal women than in
postmenopausal women or
men.
Anemia greater in pre vs post
menopausal
Ferritin continuously at 24-48c
Iron @ 24-48 m
Folate @ 24-48 m
B12 @ 24-48 m

18. 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

19. Application
• Monitor anemia and deficiency 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

20. Questions?

21. 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.