Postoperative Deficiencies in Protein and Vitamin D

The authors rightly pointed out that “The rapidly rising numbers of patients and operations will soon make it impossible for lifelong follow-up to be provided in specialized centers alone.” For this reason, targeted further education about this topic among primary care physicians is of extraordinary importance.

In the patients of the obesity center of the Helios Weißeritztal Hospitals, protein deficiency and vitamin D deficiency are the most common postoperative deficiencies. The S3 guideline “Surgery for obesity and metabolic disorders” (2) states that because of the small food portions and the catabolic metabolic situation, protein deficiency is common, if not appropriate substitution is provided. The usual recommendations suggest administration of at least 60 g/day of protein powder. In our experience, providing protein-rich foods is usually not sufficient. For this reason, additional administration of protein powder with a high bioavailability is mostly required, dosed according to the individual total protein/albumin concentration. Putting this into practice requires intensive communication with and counseling of the patients.

In some of those affected, inadequate provision of vitamin D and/or calcium can trigger a rise in parathormone (PTH). This should be controlled. Activation of PTH usually indicates substantial deficits in the calcium/vitamin D balance, which require counter measures. Especially in the context of malabsorptive procedures, we have the opinion that bone densitometry should be carried out every two years, so as to detect and prevent potential adverse effects subsequent to bariatric surgery as a result of inadequate substitution.

Fink et al. (1) point out that patients with a one-anastomosis gastric bypass (OAGB, omega loop bypass) can develop acidic as well as bile reflux because of retrograde flow of bile into the gastric pouch in the absence of a Roux anastomosis. Conversion into a Roux-en-Y gastric bypass (RYGB) can be considered, as can the potentially surgically simpler creation of a Braun foot-point anastomosis.