Protein Energy Malnutrition After One-Anastomosis Gastric Bypass with a Biliopancreatic Limb ≤200 cm: A Case Series

Abstract

Background:

Increased popularity of one-anastomosis gastric bypass (OAGB) is associated with increased reports on the procedure-related complications. Protein-energy malnutrition (PEM) is a serious complication that may mandate reversal. The primary outcome of this study is the outcome of surgical management of PEM after OAGB.

Methods:

A retrospective cohort study of patients presented with PEM after OAGB between January 2014 and December 2018. Patients with a biliopancreatic limb (BPL) >200 cm were excluded. PEM was diagnosed based on the Global Leadership Initiative on Malnutrition criteria. Indications for reversal of OAGB due to PEM included failure of conservative measures, intolerable symptoms, and hepatic decompensation.

Results:

Eight patients presented with PEM and were reversed to normal anatomy or Roux-en-Y gastric bypass. The incidence of postoperative 30-day complications in this series was 37.5% (n: 3/7). Postoperative mortality due to hepatic cell failure occurred in 1 patient. Two patients deceased before reversal, one secondary to severe soft tissue infection, whereas the cause of death could not be confirmed for the second.

Conclusion:

Socioeconomic status and thorough preoperative counselling are important to predict patient commitment to postoperative supplementations and laboratory investigations. Bariatric teams should apply innovative methods as telemedicine to make patient compliance easier. The etiology of PEM cannot be purely explained by the BPL length. Revisional surgery is mandatory for resistant, recurrent, or complicated PEM.

Highlights

Protein-energy malnutrition (PEM) is a serious complication after one-anastomosis gastric bypass.

Proper patient choice and strict long-term follow-up are important to avoid PEM.

Etiology of PEM is more complicated than explanation by biliopancreatic limb length.

Revisional surgery is mandatory for resistant, recurrent, or complicated PEM.

Introduction

One-anastomosis gastric bypass (OAGB) has gained acceptance as an effective treatment for morbid obesity worldwide. Recent studies on thousands of patients described the safety and efficacy of OAGB.¹ However, reports on protein-energy malnutrition (PEM) leading to mortality or mandating reversal aroused more concerns about the still controversial procedure.^2,3

PEM after bariatric surgery is an interdisciplinary subject in terms of detection and management. The incidence of PEM is variable according to the type of the procedure performed; being 2% in restrictive procedures as sleeve gastrectomy (SG), 5–15% in Roux-en-Y gastric bypass (RYGB), and 5%–25% in biliopancreatic diversions and single-anastomosis duodeno-ileal bypass.⁴ Multidisciplinary (MD) approach to PEM is crucial for early diagnosis and proper timing of intervention. Few studies have exclusively detailed the reversal of OAGB due to PEM.^2,3 The aim of this study is to present our experience with PEM after OAGB.

Methods

This is a retrospective single-center cohort study of patients who presented with PEM after OAGB between January 2014 and December 2018. The study is conducted in an academic tertiary center. The primary outcome was the success of management of PEM. Secondary outcomes included complications of PEM, readmissions, and patient satisfaction. The study was limited to patients who underwent OAGB with a long gastric tube and a biliopancreatic limb (BPL) ≤200 cm. Referred cases were included if the length of the BPL was confirmed to be ≤200 cm during reversal surgery.

Bariatric surgery was offered to patients with a body mass index (BMI) >40 kg/m² or ≥35 with comorbidities. OAGB was either the patient choice or recommended for patients with uncontrolled diabetes mellitus (DM) with special emphasis on the need for long-term follow-up and lifelong supplementations. Patients with obstructive sleep apnea were prepared by continuous positive airway pressure before surgery. Patients with history of pulmonary embolism received the proper thromboembolic prophylaxis.⁵ Laboratory derangements were corrected before surgery, however, complete glycemic and lipid profile correction was not possible even after months of preparation in some patients.

Postoperative supplements included multivitamins, calcium, and iron on daily basis for the first 6 months and then guided by laboratory investigation. Protein supplementation was prescribed during the first 2 months and the patient was then advised to consume a high-protein diet. The follow-up visits were scheduled every 3 months in the 1st year and then every 6 months. Follow-up laboratory investigations included serum vitamin D 25OH, vitamin B12, total protein, albumin, total and ionized calcium, total iron binding capacity, and complete blood count.

PEM was diagnosed based on the global leadership initiative on malnutrition criteria by combining one phenotypic and one etiologic criterion.⁶ Complications of PEM included recurrent infections, hepatic decompensation, psychological disturbances, sexual dysfunction, recurrent abortion, and preterm labor. The severity of PEM was classified based on the degree of hypoalbuminemia into mild (3–3.5 gm/dL), moderate (2.5–3 gm/dL), or severe (≤2.5 gm/dL).

Once PEM was suspected, hospitalization with intensive nutritional therapy and correction of associated nutritional deficiencies as anemia and hypocupremia was performed. Pancreatic enzyme replacement therapy was administered in case of steatorrhea. Parenteral protein therapy was added in case of moderate to severe hypoalbuminemia. Gradual nutritional replenishment, with bolus dose of thiamine in the 1st day, was adopted to avoid refeeding syndrome.

Upper endoscopy and contrast study were performed to exclude organic causes of PEM. Responsive patients were discharged on instructions to adhere to more frequent follow-up visits and concentrate on high-protein intake. Indications for reversal surgery included failure of conservative measures, intolerable symptoms of PEM, and complicated PEM. The decision of reversal was a MD decision, including bariatric surgeons, dieticians, gastroenterologist, and psychiatrist. The least duration of follow-up after reversal was 1 year.

Patient data were retrieved from a prospectively maintained bariatric database. Retrograde analysis of family data was done to assess the socioeconomic status (SES) of the patient according to the modified Fahmy and El-Sherbini scoring system.⁷ Categorical variables are expressed as group percentages and continuous data are presented as medians with range. Statistical analyses were performed using SPSS version 17 (Chicago, IL).

Results

A total of 692 patients underwent OAGB in the period between January 2014 and December 2018. Sixteen patients (2.3%) presented with PEM and medical treatment was successful in 7 patients. Nine patients (1.3%) presented with PEM and were planned for surgical revision. Another case was referred from another institution and the BPL was confirmed to be 180 cm during reversal surgery. Demographic and preoperative data are summarized in Table 1. The mean operative time of the index surgery was 113.3 (±74.6) minutes with a mean hospital stay of 1.9 (±1.1) days. There was no intra- or postoperative complications in the index surgery of the patients presented with PEM.

Table 1.

Demographic and Preoperative Data

Patient	Age (years)	Sex	SES	BMI (kg/m²)	Comorbidities	History	ASA score	A1c	Preoperative investigations
1	44	F	High	44.5	DM, HTN, DL		3	9.1	↑ TG, ↑ LDL, fatty liver
2	62	F	Medium	41.3	DM, HTN, DL	CT for lymphoma (cured)	3	12	↑ TG, ↑ LDL, ↓ HB, fatty liver
3	48	F	Medium	47.7	DM, HTN, DL, OA		3	10.4	↑ TG, ↑ LDL, ↓ Ca, fatty liver
4	58	F	Low	53.4	DM, HTN, DL, OSA		3	11.2	↑ TG, Fatty liver
5	56	M	Low	63.7	DM, HTN, DL, OSA	Old PE	4	9.3	↑ TG, ↑ LDL, fatty liver
6 (R)	57	F	High	59.3	DM, DL		3	8.7	↑ TG, fatty liver
7	48	F	Medium	41.5	DM, DL		3	8.2	↑ TG, ↑ LDL, ↓ Ca, fatty liver
8	46	F	Low	45.1	DL		3	5	↑ TG, ↑ LDL, fatty liver
9	34	F	Low	50	None	Old PE	3	5.6	Fatty liver, ↓ HB
10	41	F	High	41	DM, HTN, DL		3	8.5	↑ TG, ↑ LDL, fatty liver

A1c, glycosalated hemoglobin; ASA, American Society of Anesthesiologists; BMI, body mass index; Ca, calcium; CT, chemotherapy; DL, dyslipidemia; DM, diabetes mellitus; F, female; HB, hemoglobin; HTN, hypertension; LDL, low density lipoprotein; M, male; OA, osteoarthritis; OSA, obstructive sleep apnea; PE, pulmonary embolism; R, referred case; SES, socioeconomic status; TG, triglyceride.

Etiological and phenotypic criteria of PEM are summarized in Tables 2 and 3. The third patient was admitted many times without consulting the bariatric team until she was referred by a cardiologist to the team. During nutritional preparation for reversal surgery, she deceased after sudden cardiac arrest. The 5th patient was admitted twice and discharged after good response to nutritional support, but 2 weeks later, he had severe soft tissue infection in the upper limb with rapid deterioration to mortality before reaching the hospital.

Table 2.

Protein Energy Undernutrition: Etiological Criteria

Patient	BPL length (cm)	Compliance	OGD	Precipitating factor	Digestive symptoms
1	200	Compliant to supplements, diet, follow-up	Free	None	Chronic diarrhea (5 times/day)
2	150	Compliant to supplements, diet, follow-up	Biliary reflux	None	Biliary reflux with severe nausea and vomiting
2	150	Compliant to supplements, diet, follow-up	Biliary reflux	None	Protein intolerance
3	180	Non compliant	Free	None	Chronic diarrhea (10–15 times/day)
3	180	Referred by a cardiologist to complete follow-up	Free	None	Chronic diarrhea (10–15 times/day)
4	200	Compliant to follow-up only	Free	None	Severe nausea
4	200	Compliant to follow-up only	Free	None	Selective feeding (aversion to protein)
5	180	Compliant to follow-up only	Free	None	Selective feeding (aversion to protein)
6 (R)	180	Compliant to supplements, diet, follow-up	Free	None	Severe nausea and induced vomiting
6 (R)	180	Compliant to supplements, diet, follow-up	Free	None	Protein intolerance
7	180	Compliant to supplements, diet, follow-up	Biliary reflux	None	Biliary reflux with severe nausea and vomiting
7	180	Compliant to supplements, diet, follow-up	Marginal ulcers	None	Protein intolerance
8	200	Compliant to follow-up only	Biliary reflux	None	Protein intolerance
9	200	Compliant to diet and follow-up only	Free	Pregnancy	Chronic diarrhea (5–10 times/day)
9	200	Compliant to diet and follow-up only	Free	Pregnancy	Colonoscopy: ulcerative colitis
10	200	Compliant to supplements, diet, follow-up	Free	None	Chronic diarrhea (5–10 times/day)

BPL, biliopancreatic limb; OGD, oesophagogastroduodenoscopy; R, referred case.

Table 3.

Protein Energy Undernutrition: Phenotypic Criteria

Patient	Interval to presentation (months)	Clinical presentation	BMI (kg/m²)	Complications and associations	Serum albumin (gm/dL)	Laboratory investigations
1	13	Physical weakness	25	Recurrent genitourinary infections	2.6	↓ Vitamin D, ↓ calcium, ↓ ferritin, anemia
1	13	Lower limb edema	25	Psychological depression	2.6	↓ Vitamin D, ↓ calcium, ↓ ferritin, anemia
2	8	Physical weakness	29	Hepatic decompensation	2.2	Elevated liver enzymes
		Generalized anasarca		Recurrent genitourinary infections
		Generalized anasarca		Psychological depression
3	3	Physical weakness	34	Recurrent respiratory infections	1.9	↓ Vitamin D, ↓ calcium, ↓ zinc
3	3	Lower limb edema	34	Psychological depression	1.9	↓ Vitamin D, ↓ calcium, ↓ zinc
4	30	Physical weakness	23	Psychological depression	3.0	↓ Vitamin D, ↓ calcium
5	10	Physical weakness	42	Recurrent respiratory infections	3.1	↑ WBCs
5	10	Lower limb edema	42	Sexual dysfunction	3.1	↑ WBCs
6 (R)	24	Physical weakness	23	Psychological depression	3.0	Anemia
6 (R)	24	Lower limb edema	23	Psychological depression	3.0	Anemia
7	30	Physical weakness	19	Recurrent respiratory infection	2.9	↑ WBCs, ↓ vitamin D, ↓ calcium
7	30	Excessive weight loss	19	Psychological depression	2.9	↑ WBCs, ↓ vitamin D, ↓ calcium
8	6	Physical weakness	32	Recurrent genitourinary infections	2	↑ WBCs, ↓ ferritin, anemia
		Generalized anasarca		Psychological depression and introversion		↓ Vitamin D, ↓ calcium
		Generalized anasarca		Sexual dysfunction		↓ Vitamin D, ↓ calcium
9	14	Physical weakness	26	Sexual dysfunction	2.7	↓ Ferritin, anemia
				Psychological depression
				Preterm labor
10	13	Physical weaknessLower limb edema	23	Sexual dysfunction	2.2	↓ Calcium
10	13	Physical weaknessLower limb edema	23	Psychological depression	2.2	↓ Calcium

BMI, body mass index; R, referred case; WBCs, white blood cells.

Seven patients underwent laparoscopic reversal to normal anatomy. On counseling with the tenth patient, she refused reversal to normal anatomy whenever possible for fear of recurrence of DM. During her reversal surgery, the length of the common limb (CL) was 520 cm and the BPL was 200 cm and this gave a chance for reconstruction of RYGB (alimentary limb: 75 cm, BPL: 75 cm).

The mean operative time was 122.5 (±52.2) minutes with a mean hospital stay of 7.1 (±4.4) days. No blood transfusion was needed except for 1 U in the 2nd patient. The 2nd patient had a grossly cirrhotic liver of hard texture on laparoscopic exploration despite normal appearance during index surgery. The patient developed hepatic encephalopathy 2 weeks after reversal surgery and died of liver cell failure. In the ninth patient, PEM was associated with de novo diagnosis of ulcerative colitis and its treatment was applied during treatment of PEM.

The 7th patient was complicated by internal hemorrhage from the staple line that was uncontrollable by endoscopy and surgical control was performed. The 8th case was complicated by a leakage evident as large epigastric and left subphrenic collection. Leakage was managed by ultrasound guided tube drain and conservative measures till healing of the fistula occurred. The outcome of PEM management is summarized in Table 4.

Table 4.

Management and Outcome of Protein-Energy Undernutrition

Patient	Readmission number	Medical treatment outcome	Preop. albumin (gm/dL)	Indication of reversal	CL length (cm)	Postoperative course	Surgery and outcome in correcting PEM	1-Year follow-up
1	2	Success	3.5	Intolerable symptoms	370		Reversal to normal/success	DM remission: yesPatient satisfaction: noBMI: 32 kg/m²S. albumin: 4.4 gm/dL
2	2	Failure	3.7	Hepatic decompensation	NP		Reversal to normal/mortality (hepatic failure)
3	7	Mortality (sudden arrest)
4	2	Failure	3.0	Failed medical treatment	350		Reversal to normal/success	DM remission: noPatient satisfaction: yesBMI: 30 kg/m²S. albumin: 4.5 gm/dL
5	2	Mortality (necrotizing fasciitis)
6 (R)	2	Success	3.5	Patient desire	350	Postoperative bleeding (surgical control)	Reversal to normal/success	DM remission: noPatient satisfaction: yesBMI: 26 kg/m²S. albumin: 4 gm/dL
7	3	Failure	4.1	Excess weight loss	300	Leakage (conservative)	Reversal to normal/success	DM remission: noPatient satisfaction: yesBMI: 24 kg/m²S. albumin: 3.9 gm/dL
8	4	Failure	2.7	Failed medical treatment	350	Intestinal obstructionAfter 3 months (lap adhesiolysis)	Reversal to normal/success	Non diabeticPatient satisfaction: noBMI: 30 kg/m²S. albumin: 3.8 gm/dL
9	1	Success	3.1	Patient desire	380		Reversal to normal/success	Non diabeticPatient satisfaction: yesBMI: 30 kg/m²S. albumin: 4 gm/dL
10	2	Failure	3.3	Failed medical treatment	520	GB stonesAfter 6 months (lap Chole)	RYGB with BPL 75cm and AL 75 cm/success	DM remission: noPatient satisfaction: noBMI: 27 kg/m²S. albumin: 4 gm/dL

AL, alimentary limb; BMI, body mass index; BPL, biliopancreatic limb; Chole, cholecystectomy; CL, common limb; DM, diabetes mellitus; Lap, laparoscopic; NP, not performed; PEM, protein energy malnutrition; R, referred case; RYGB, Roux-en-Y gastric bypass; S, serum.

Discussion

The search for the ideal bariatric procedure is a dynamic process. Easy reversibility is a criterion of an ideal bariatric procedure.¹ However, frequent need for reversal is a common characteristic of the abandoned historical procedures. The revision rate after OAGB is less than 5% and the most common cause is malnutrition (50%–60%) (Table 5). PEM after OAGB is a multifactorial problem with a prevalence of 0%–10%.¹ The reported prevalence of surgical revision due to PEM in this series is 1.3%, which is comparable to the published studies.

Table 5.

Indications of Late Reoperation and Prevalence of Malnutrition After One-Anastomosis Gastric Bypass

Author/year/country	Total population/study duration	BPL length	Late reoperation (number/indications)	Malnutrition, n (%)	Comments
Rutledge and Walsh¹⁹ (2005) USA	2410 (1997–2004)	180 cm	34 (1.4%)Marginal ulcer (3)Excess weight loss (31)	31 (1.29)	Revision to gastroplasty.
Lee et al.²⁰ (2011) Taiwan	1322 (2001–2009)	200 cm	23 (1.73%)The accumulated rate: 2.7%Intolerance (6)Weight regain (8)Malnutrition (9)	9 (0.68)	Revision to RYGB in 11, SG in 11, and to NA in 2 patients
Noun et al.²¹ (2012) France	1000 (2005–2011)	150 cm (+10 cm for each BMI point >40 kg/m²)	8 (0.8%)Bile reflux (4)Malnutrition (4)	4 (0.4)	Revision to SG (2) and NA (2)
Kular et al.²² (2014) India	1054 (2007–2013)	200 cm	5 (0.47%)Bile reflux (1)Biliary pancreatitis (1)Port site hernia (1)Excessive weight loss (1)Low albumin (1)	2 (0.2)	The BPL was 300 cm in the 2 patients with malnutrition as they were superobese
Chevallier et al.¹⁴ (2015) France	1000 (2006–2013)	200 cm	14 (1.4%)Biliary reflux (7)Ulcer perforation (2)Intestinal obstruction (5)	2 (0.2)	The 2 patients were treated with nutritional and psychiatric therapy. Reversal surgery was planned
Carbajo et al.²³ (2017) Spain	1200 (2002–2008)	1st 209 patients: 200 cmThen: 250–350 cm and for increasing BMIs, additional 10–50 cm are bypassed (no specific formula, with at least 250–300 cm of common channel.)	None	14 (1.1)	All cases of malnutrition were managed by medical treatment
Genser et al.³ (2017) France	2934 (2005–2015	200 cm	NR	26 (0.89)	- Reversal to NA- BPL length was measured in 12 patients and revealed misconstruction in 8 patients with a mean 320 ± 63.9 cm (230–400) length based on the 200 cm normal standard- 9 patients had the whole bowel measured and all had a common limb length ≥4 m
Musella et al.²⁴ (2017) Italy	2678 (2006–2015)	217 ± 13.8 cm (165–260 cm range)	32 (1.19%)Marginal ulcer (5)DGER (12)Malnutrition (3)Internal hernia (1)Weight regain (11)	5 (0.7)	- Three malnutrition cases required surgery (reversal to NA [1], loop resizing [2])- Excessive weight loss correlated with a BPL >250 cm (P < .001)
Taha et al.²⁵ (2017) Egypt	472 (2009–2015)	150–300 cm based on BMI	2 (0.4%)Biliary reflux (1)Malnutrition (1)	1 (0.2)	No details available on the relationship between the BMI and the length of BPL
Alkhalifah et al.²⁶ (2018) Taiwan	1731 (2001–2015)	150–250 cm based on BMI	70 (4%)Malnutrition (43)Weight regain (9)Intolerance (14)Gastrojejunal stricture (2)Gastrogastric fistula (1)Outlet obstruction (1)	43 (2.5)	No details available on the relationship between the BMI and the length of BPL
Apers et al.²⁷ (2018) Netherland	287 (2012–2013)	150–250 cm based BMI (BMI <40 = BPL 150 cm, BMI 40–50 = BPL 200 cm, BMI >50 = BPL 250 cm.)	17 (5.9%)Biliary reflux (8)Internal herniation (1)Steatorrhea and malnutrition (1)Hypoglycemia (1)Incisional hernia (5)Insufficient weight loss (1)	1 (0.3)	Reversal to NA
Hussain et al.⁸ (2019) United Kingdom	925 (2010–2018)	150–300 cm based on the unit/surgeon's technique	19 (2.05%)Diarrhea (5)Afferent loop syndrome (4)GERD (3)GJ stenosis (2)Liver decompensating/failure (2)Protein malnutrition (1)Excessive weight loss (1)Perforated ulcer (1)	9 (0.97)	Malnutrition cases included diarrhea, excess weight loss, protein malnutrition and hepatic decompensation. Malnutrition was managed by reversal to NA (2) or shortening of BPL (7). BPL length ≥200 cm lead to serious complications
Khalaj et al.² (2019) Iran	189 (2014–2016)	200 cm	NR	7 (3.7)	BPL length of 200 cm can lead to an inadequate absorptive area

BMI, body mass index; BPL, biliopancreatic limb; DGER, duodenogastroesophageal reflux; GERD, gastroesophageal reflux disease; GJ, gastrojejunostomy; NA, normal anatomy; NR, not reported; RYGB, Roux-en-Y gastric bypass; SG, sleeve gastrectomy.

Most reports attribute PEM to excess length of the BPL in OAGB.^8,9 Many policies are recommended to avoid this complication, including measurement of the whole bowel length, bypass of a fixed percentage of bowel length, tailoring the BPL according to BMI, and adherence to a maximum of 150–200 cm length of BPL.¹⁰ In this series, all patients presented with PEM had a BPL length ≤200 cm and CL length >300 cm. Similarly, Genser et al. reported a mean CL length of 610 ± 111.7 cm in 9 patients who underwent reversal of OAGB due to PEM.³

Factors contributing to PEM, other than length of BPL, include protein intolerance, steatorrhea, postoperative incompliance, and ethnic variations. Protein intolerance can be attributed to reduced pepsin production, bacterial floral imbalance, reduced amino acid absorption due to proximal jejunal bypass, and changes in the gut hormones.¹¹ Steatorrhea occurs due to deactivation of pancreatic proteolytic enzymes after rerouting to the acidic PH in the gastric pouch.¹²

Informed written consent on long-term follow-up after OAGB can increase commitment to the planned schedule.¹³ However, SES should be evaluated to assess feasibility of commitment. SES roughly reflects patient education, eating habits, hygienic standards, psychosocial support, compliance to supplementations, and financial status.^6,14 Financial disability plays a role that cannot be ignored in compliance to supplementations, healthy high-protein diet, readmissions, good hygienic standards, intensive nutritional therapy, and even in the coverage of reversal surgery.

Also, ethnic variation has a significant role in weight loss after bariatric surgery even with similar caloric intake.¹⁵ Ethnic variations could be due to various social, psychological, biological, and genetic factors. Heterogeneity, underreporting, and infeasibility of large-scale comparative studies keep the ethnic role in PEM in the uncertainty zone. Specific ethnic response to a bariatric procedure should be considered before reproducing the surgical experience from a country to another.

Suspicion of risk of PEM in obese patients is a clinical challenge. This is more difficult after bariatric surgery as the reduced food intake is considered a success. Once the diagnosis is established, gradual nutritional replenishment is mandatory to avoid refeeding syndrome that is a fatal complication due to electrolyte imbalance mainly hypophosphatemia.¹⁶ In this series, 1 patient expired by a sudden cardiac arrest during preoperative preparation and the exact cause of death could not be assessed by autopsy although measures to prevent refeeding syndrome were taken.

Another mortality, in this series, was due to hepatic decompensation in a patient who had noncirrhotic fatty liver during index surgery. The exact mechanism of liver cirrhosis after OAGB is not fully understood. Ahuja et al. suggested that hypoalbuminemia may contribute to nonalcoholic steatohepatitis by increasing portal pressure with subsequent hypertensive enteropathy leading to a viscous cycle of portal hypertension and malabsorption.¹⁷

The decision of revisional surgery is usually difficult. The patient hesitates between the burden of malnutrition and giving a “second chance” for OAGB. The surgeon weighs the operative complexity and risk of weight regain versus complications of PEM. Delay in surgical intervention may lead to irreversible complications, in which any intervention will be a failure.² OAGB can be revised to normal anatomy, RYGB, shortening of the BPL, SG, or vertical gastroplasty. The authors do not recommend SG as a revisional technique in PEM because of the higher prevalence of leakage from the longer staple line in a high pressure tube, and the limitation of further revisions after resection of the residual stomach.^3,18 RYGB is beneficial in case of steatorrhea or biliary reflux.³ Otherwise, reversal to normal anatomy should be the standard surgical management in the authors' opinion.

The limitations of this study are its retrospective nature, the small sample size, and the absence of a control group in terms of management plan and surgical approach. However, PEM is a rare complication and this report provides a structured and detailed description derived from a prospectively maintained bariatric database that can help in future meta-analyses.

In conclusion, SES and thorough preoperative counseling are important to predict patient commitment to postoperative supplementations and laboratory investigations. Bariatric teams should apply innovative methods as telemedicine to make patient compliance easier. The etiology of PEM cannot be purely explained by the BPL length. Factors other than long BPL should not be underestimated during problem analysis by researchers. MD management is crucial, and proper timing of revisional surgery is necessary to avoid irreversible complications.

Footnotes

Disclosure Statement

No conflict of interest to be declared.

Funding Information

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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