Gastrointestinal and Nutritional Complications of Bariatric Surgery

Matt Cave, MD Luis S. Marsano, MD 2011

Case Presentation

A 24 year old white female presents in a coma, one year after gastric bypass surgery. She was non-verbal, made no spontaneous movements, and was ventilator dependent but required no sedation. Her post-operative course had been complicated by nausea and vomiting. She had recently developed a peripheral neuropathy and was undergoing treatment for Guillain Barr syndrome.

Bariatric Surgery Goals

GI Complications Nutritional Complications Role of the internist

Obesity Trends U.S. Adults 2005

15%19%

20%24%

25%29%

30%

Source: Behavioral Risk Factor Surveillance System, CDC.

Diet and Exercise

Bariatric Surgery

Members: 258 in 1998; 2929 in 2007. Procedures: 16,000 in 1990; 200,000 in 2006. Indications: BMI > 40. BMI > 35 with comorbidities.

Int J Obes. 2007 Apr;31(4):569-77.

Centers of Excellence

Ashland: Kings Daughters Medical Center Florence: St. Luke Hospital Georgetown: Georgetown Community Hospital Lexington: Saint Joseph East Louisville: Norton Hospital Sts. Mary and Elizabeth Hospital Bariatric patients admitted to other hospitals with complications will not be at a center for excellence. Hospitalists and medical consultants will provide the majority of their care.

Laparascopic Adjustable Gastric Band

GI Complications Lap Band

Overall 10% complication rate. Symptoms: GERD, abdominal pain, nausea, vomiting, increased appetite, weight gain. Gastric Prolapse: 2%-4%. Band Erosion: < 2%. Obstruction / Esophageal Dilation: <1%. Port Problems

Nutr Clin Pract. 2007 Feb;22(1):29-40.

Gastric Prolapse

Symptoms Heartburn Intolerance of solids, liquids Nausea Vomiting Abdominal, back, shoulder pain Diagnosis History Plain radiographs Contrast esophagram Upper endoscopy

Gastric Prolapse

Band Erosion

Presentation:

Asymptomatic Latent port site infection Lack of restriction Acute abdomen

Index of Suspicion Diagnosis by EGD

Gastroenterol Clin North Am. 200Mar;34(1):105-25.

Obstruction / Esophageal Dilation

Obstruction may be relieved by band deflation. Esophageal dilation may initially be asymptomatic but lead to permanent motility problems. Yearly esophagram is recommended in lap band patients.

Roux-en-Y Gastric Bypass

60 150 cm

GI Complications Gastric Bypass

Abdominal Pain / Nausea Marginal ulcer Obstruction (Nausea / Vomitting / Abdominal Pain) Internal hernia Anastomotic stricture Adhesions Weight Gain Staple line disruption / gastrogastric fistula Diarrhea Dumping syndrome Small bowel bacterial overgrowth Bile acid diarrhea

Nutr Clin Pract. 2007 Feb;22(1):29-40.

Marginal Ulcer

Incidence 3%-15%. Pain, nausea, anemia, rarely bleeding. Causes: Acid (large pouches) Gastrogastric fistula Roux-limb tension Ischemia NSAIDS H. pylori Smoking

Treatment: Risk Factor Modification + Proton Pump Inhibitor (pH < 4) Carafate (pH > 4) Surgery
Gastroenterol Clin North Am. 200Mar;34(1):105-25. Nutr Clin Pract. 2007 Feb;22(1):29-40.

Staple Line Disruption & Gastrogastric Fistula

Related to ulcer. Weight regain. Less frequent in divided stomachs. A reversal method.

Gastroenterol Clin North Am. 200Mar;34(1):105-25. http://www.gastricbypassproblems.org/services.html

Anastomotic Stricture

Incidence 1%-15%. Nausea, vomiting, obstruction. Usually occurs at the GJ. Defined as the inability to pass a 9 mm endoscope. Treatment is dilation with a TTS balloon dilator to 12 mm.

Nutr Clin Pract. 2007 Feb;22(1):29-40.

Anastomotic Stricture

Internal Hernia

Incidence 2%-5%. Intra-abdominal spaces are created during surgery and enlarge with weight loss. The intestine migrates into an intra-abdominal space and obstructs. Variety of presentations. Exploratory surgery.

Nutr Clin Pract. 2007 Feb;22(1):29-40.

Explosion # 1

Diarrhea

Usual causes should be excluded. Dumping Syndrome: Postprandial lightheadedness, flushing, watery diarrhea. Start meals with protein, avoid simple sugars. Octreotide for refractory cases. Small Bowel Bacterial Overgrowth: Postprandial bloating. Breath test or EGD with small bowel aspirate for quantitative culture. Rotating antibiotics. Bile Salt Toxicity: Watery diarrhea. Cholestyramine.

Gastroenterol Clin North Am. 200Mar;34(1):105-25.

GI Complications of Both Lap Band and Gastric Bypass

Gallstones Non-alcoholic Fatty Liver Disease (NAFLD)

Cholelithiasis

25% bariatric patients have had a prior cholecystectomy. 25% have cholelithiasis noted on their pre-operatively. 10%-42% of patients without gallstones will develop them. 32.5% of surgeons perform concomitant cholecystectomy. Ursodiol 600 mg daily for 6 months reduced postoperative gallstone formation from 32% to 2%, but its use is limited by cost ($600 yearly) and non-compliance. ERCP is difficult after gastric bypass and may require laparoscopic access to the stomach.
;

Nutr Clin Pract. 2007 Feb;22(1):29-40. Am J Surg. 1995 Jan;169(1):91-6

NAFLD

Incidence: NAFLD 91% NASH 37% unexpected cirrhosis 1.7% (1-7%) Hepatomegally makes bariatric surgery technically difficult. A pre-operative very low carbohydrate diet may reduce left lobe liver volume making surgery easier. Bariatric surgery can potentially reverse fatty cirrhosis. However, the initial rapid weight loss following bariatric surgery can cause hepatic decompensation in patients with NASH.

J Hepatol. 2006 Oct;45(4):600-6. Surg Endosc. 2007 Mar 1. J Gastroenterol Hepatol. 2007 Apr;22(4):510-4. Dig Dis Sci. 2004 Oct;49(10):1563-8.

Explosion # 2

Malnutrition in Obesity Before Bariatric Surgery

CAUSES:

Over ingestion of low-nutrient high-calorie foods. Low ingestion of high nutrient-density foods (vegetables, dairy, legumes, whole grains, fish, nuts, etc.). High fat diets with low Vitamin A, C, and folate. Low sun-light exposure due to decreased activity causing low vitamin D. Low-grade chronic inflammatory state. Type-II DM increasing renal hyperfiltration with micronutrient loss.

Malnutrition in Obesity Before Bariatric Surgery

Fe deficiency found in 44% (female > male). Vitamin D deficiency (< 20ng/mL) in 91% on winter & 24% on summer.

Worse in African Americans & Hispanics.

Low retinol & beta-carotene (vitamin A) in 12.5% Low vitamin E in 23% Low Folate in 0-6% in USA (folate enriched foods)

but up to 54% in other parts of world.

Malnutrition in Obesity Before Bariatric Surgery

Low vitamin B12 in 18%. Low thiamin (Vitamin B1) in up to 7% in Caucasians, 31% in African Americans, and 47% in Hispanics. Prevalence of low vitamins B2 (Riboflavin) and B6 (Pyridoxine) is not known. Low vitamin C in 36% Low Zinc in up to 28%. Low Selenium was found in 6-58%. Copper deficiency has not been found.

Recommended Studies Before Bariatric Surgery J Clin Endocrinol Metab 95:4823-4843,2010

Complete Hemogram Liver Enzymes Glucose Creatinine Electrolytes Fe, Transferrin, Ferritin Vit B12 Folate

Ca Intact PTH 25-OH D Albumin/Prealbumin Vitamin A Zn Bone Mineral Density & Body composition Consider: thiamine, Se, Vitamin E, Vitamin C.

Nutritional Considerations

Preop

Mandatory 6 month weight loss programs VLCD Correction of nutritional deficiencies. Liquids-- minimize trauma, maximize healing Food intake less than before Well balanced, small portions 64 oz. fluid daily 60-120 grams of protein daily

Immediate Post-Op

Long term

Types of Bariatric Surgeries

Purely Restrictive: affect Fe, Se & B12 absorption

Vertical Banded Gastroplasty Adjustable Gastric Band (AGB and LAGB) Vertical Sleeve Gastrectomy Roux-en-Y Gastric Bypass Jejuno-Ileal Bypass (not done anymore) Bilio-Pancreatic Diversion (anastomosis 50 cm from IC valve) Bilio-Pancreatic Diversion with Duodenal switch (anastomosis 100 cm from IC valve)

Mostly Restrictive (some malabsorption):

Mostly Malabsorptive (some restriction):

Bariatric Surgical Procedures

Vertical Banded Gastroplasty

Adjustable Gastric Band +/- Laparoscopy

Roux-en-Y Gastric Bypass

Gastric Sleeve Gastrectomy

Vertical Sleeve Gastrectomy

Bilio-Pancreatic Diversion with Duodenal Switch (100 cm)

Prevalence (%) of Micronutrient Deficiencies After Bariatric Surgery

LAGB
0 14 10 0-19 48 10-25 30-40 0-11 N/S 0-32 N/A N/A N/A

RYGB
12 10 0-12 33-58 10-50 10-52 30-50 0-22 N/A 25-50 37 3 N/A

BPD+/-DS
0 N/A 5 22 N/A 61-69 40-100 4-5 68 21-26 10-50 14.5 70

Clinical Presentation of Nutritional Deficiencies After Bariatric Surgery

Edema: Protein malnutrition, Vit C. Skin Rash: Vit A, vit B6, Vit B2, Vit C, Zn, Biotin. Hair loss: protein malnutrition, Zn, Biotin. Stomatitis/glossitis: Fe, Folate, Vit B6, vit B2. Altered Taste: Zn, Cu. Night blindness: Vit A, Zn. Diarrhea: Folate, Zn. Anemia: Fe, Vit E, Folate, vit B12, Thiamine, Vit B6, Cu.

Clinical Presentation of Nutritional Deficiencies After Bariatric Surgery

Neuropathy: Vit E, Vit B12, Thiamine, Vit C, Cu, Biotin. Abnormal gait: Thiamine, Vit D, Cu, Biotin. Muscular weakness: Vit D, Vit E, Thiamine, Vit C, Se. Osteomuscular pain: Vit D, Vit C. Depression, Memory problems, Confusion:
Vitamin B12, Folate, Thiamine, Vit B6, Biotin, Zn.

Encephalopathy: Thiamine, vit B12, Cu, Carnitine,

uncovering of Urea Cycle Disorder (ornithine transcarbamylase deficiency)

Cardiomyopathy/ Heart Failure: Thiamine, Se. Poor wound healing: protein malnutrition, Vit C.

Macronutrient Deficiency Post Bariatric Surgery

Dehydration and protein-calorie malnutrition are rare in the absence of vomiting and diarrhea.

First correct any associated anatomical lesion such as an anastomotic stricture.

RYGB with limb < 150 cm rarely causes hypoalbuminemia (< 5%). Hypoalbuminemia is seen after RYGB with limb > 150 cm in 13%, and in BPD+/-DS in up to 18%.

Deficiency causes edema, alopecia, and poor wound healing. Recommend to eat 60-120 gm protein a day with >/= 30 gm in at least 2 meals/d (to initiate protein repletion). Monitor Albumin + Pre-albumin twice a year after RYGB or BPD+/-DS.

Macronutrient Deficiency Post Bariatric Surgery

If protein-calorie malnutrition develop, it is difficult to catch up as patients can not eat or drink quickly in large volumes.

May need temporary TPN

Revisional surgery or even reversal may be necessary for extreme and refractory cases.

Micronutrient Deficiency Post Bariatric Surgery

Micronutrient supplements (Vitamins & Minerals) should NOT be enteric coated.

Tablets are better absorbed after 30 min dissolution in water, or as liquid or chewable preparation.

Micronutrient Deficiency Post Bariatric Surgery

Fe deficiency occurs in 12-47% after RYGB. More frequent after BPD+/-DS.

More frequent in females and in younger age < 25 (79%). Routine Multivitamin/Mineral preparations are NOT enough to correct Fe deficiency; Deficiency may cause weakness, fatigue, headaches, dizziness, pallor, restless legs, brittle nails, sore tongue and dysphagia. Need oral Fe sulfate 325 mg (65 mg Fe) BID or TID with Vitamin C, or IV Fe. Monitor Fe, TIBC, Ferritin twice a year.

Micronutrient Deficiency Post Bariatric Surgery

Vitamin D deficiency in 45% after RYGB (more in BPD+/- DS).

Deficiency causes osteomalacia with aching pain in lower spine, hips, pelvis, legs, and ribs. May give weakness of arm and legs with waddling gait. Prevention: Give Vitamin D3 1000 -5000 IU/d to maintain levels. If deficient, needs 50000 IU/day until normalization, then 5000 IU/d. Monitor plasma 25OH-D twice a year after RYGB or BPD+/-DS

Micronutrient Deficiency Post Bariatric Surgery

Calcium depletion: calcium levels are usually normal but elevated intact PTH is common (29% after RYGB, 63% after BPD+/-DS).

Clinical hypocalcemia is rare because of secondary hypoparathyroidism, which increases bone resorption. Administration of biphosphonates without previous correction of low vitamin D and without Calcium supplements may trigger symptomatic hypocalcemia. Prophylaxis: Oral intake of 1200 2000 mg/d of Ca Citrate is recommended. Monitor intact PTH twice a year after RYGB, & BPD+/-DS.

Micronutrient Deficiency Post Bariatric Surgery

Vitamin A deficiency is rare and mild after RYGB; after BPD+/-DS deficiency occurs in 61-69%.

May cause xerophthalmia, nyctalopia (night blindness) and follicular hyperkeratosis. Supplements of 5000-10000 IU/d are recommended after biliopancreatic diversion. Monitor twice yearly Plasma Retinol after BPD+/-DS. (Normal = 28-86 mcg/dL).

Vitamin A Deficiency:
Follicular Hyperkeratosis

Micronutrient Deficiency Post Bariatric Surgery

Vitamin E deficiency occurs in 7.1% after BPD.

May cause sensory neuropathy, spinocerebellar ataxia, areflexia, skeletal myopathy and hemolytic anemia. Monitor twice yearly plasma alfa-tocopherol after BPD+/-DS (Normal alfa tocopherol > 5mcg/mL or 0.8 mg/g total lipids) Prevention: 400 IU/day after bilio-pancreatic diversion.

Micronutrient Deficiency Post Bariatric Surgery

Vitamin K deficiency occurs in 68% after BPD.

May cause easy bleeding or bruising. Monitor twice yearly PT after BPD+/-DS. Prevention: 1 mg/day after bilio-pancreatic diversion

Micronutrient Deficiency Post Bariatric Surgery

Folic Acid deficiency is rare after Bariatric Surgery, due to bacterial production of folate and use of multivitamins.

Deficiency causes macrocytic anemia, glossitis, diarrhea, depression, confusion, palpitations, fatigue and, in pregnancy, neural tube defects. Recommend 400 mcg/day (in multivitamins). If deficient, give 1 mg/day. Monitor plasma or RBC folic acid and for elevated homocysteine (also affected by B12, B6, renal insufficiency and genetics) twice a year.

Micronutrient Deficiency Post Bariatric Surgery

Vitamin B12 deficiency is common after RYGB (3040%).

Deficiency causes Pernicious Anemia, paresthesias, neuropathy, depression, paranoia, delirium, and dementia. Prevention: Supplement with oral 350 mcg/d, 1000 mcg IM q 3 months, or 1000 mcg/week intranasal. Monitor plasma B12 twice a year after RYGB, or BPD+/-DS. In low-normal values (200-350 pg/mL), an elevated serum Methylmalonic acid supports B12 deficiency (in absence of renal failure). Treatment of symptomatic deficiency: 1000 mcg/d IM x 5 days, then 1000 mcg IM every 3 months, or 1000 mcg/week intranasal.

Micronutrient Deficiency Post Bariatric Surgery

Thiamin or Vitamin B1 deficiency occurs in 18% after RYGB.

May occur after as little of 2 weeks of persistent vomiting or as a result of bypass of the jejunum Deficiency may cause:

Peripheral neuropathy, fatigue, irritability, Wernicke encephalopathy (ophtalmoplegia, nystagmus, ataxia, apathy, coma), Korsakoff psychosis (confusion, dysphonia and confabulation), Dry beriberi (bilateral symmetric, stocking-glove distribution paresthesias, dysesthesias, muscular cramps and muscular wasting) , Wet beriberi (vasodilation, tachycardia, wide pulse, warm skin, lactic acidosis, CHF and shock) and Anemia.

Micronutrient Deficiency Post Bariatric Surgery

Thiamin or Vitamin B1 deficiency

Evaluate by measuring erythrocyte transketolase activity and MRI of brain looking for T2 abnormalities in the dorsomedial thalamic nuclei, periaqueductal grey matter and mamillary bodies (sensitivity 53%, specificity 93%). No monitoring required. Investigate after symptoms. Prevention: 50 mg a day Deficiency: Treat with thiamine 500 mg IV 3 times a day x 3 days, then 250 mg IV daily until improved, followed by 50-100 mg 3 times a day orally thereafter.

Micronutrient Deficiency Post Bariatric Surgery

Vitamin B6 deficiency occurs in 17% after RYGB.

May cause seborrheic dermatitis, glossitis, cheilosis, depression, confusion, EEG abnormalities, and seizures. May also cause anemia (normocytic, microcytic or sideroblastic) Measure plasma pyridoxal-5 phosphate. No monitoring required. Investigate after symptoms.

Vitamin B6 deficiency Seborrheic Dermatitis

Micronutrient Deficiency Post Bariatric Surgery

Vitamin B2 deficiency occurs in 13% after RYGB.

May cause angular stomatitis, cheilosis, seborrheic dermatitis in naso-labia, eyelids, scrotum and labia majora, lacrimation and photophobia. Measure urinary excretion of riboflavin. No monitoring required. Investigate after symptoms.

Riboflavin (B2) Deficiency Stomatitis & Cheilosis

Riboflavin (B2) Deficiency Stomatitis & Cheilosis

Micronutrient Deficiency Post Bariatric Surgery

Vitamin C deficiency occurs in 34% of patients after RYGB

Early manifestations are lassitude, weakness, irritability, weight loss, and vague myalgias and arthralgias. Late manifestations are follicular hyperkeratosis, coiled hair, and perifollicular hemorrhages. Wounds heal poorly. May develop femoral neuropathy, leg edema, and painful joint effusions. Could measure plasma ascorbic acid; levels < 0.6 mg/dL are marginal, and < 0.2 mg/dL are deficient. No monitoring required. Investigate after symptoms. Treatment: standard multivitamins BID should be enough.

Vitamin C Deficiency

Perifollicular Hemorrhage and Corkscrew Hairs

Micronutrient Deficiency Post Bariatric Surgery

Zinc deficiency occurs in 36-51% post-bariatric surgery patients.

Causes acrodermatitis enteropathica rash, abnormal smell and taste, hair loss, diarrhea, night blindness, and altered memory. Diagnosis is by serum Zn levels. No monitoring required. Investigate after symptoms.

Zinc Deficiency Acrodermatitis Enteropathica

Micronutrient Deficiency Post Bariatric Surgery

Selenium deficiency is almost universal after JIB, and is found in 28% after LAGB, and 15% after RYGB.

Deficiency may cause acute severe heart failure due to selenium-deficient dilated cardiomyopathy. May cause muscular weakness and muscular cramps. Diagnosis: Measure RBC glutathione peroxidase activity, and RBC selenium. No monitoring required. Investigate after symptoms.

Micronutrient Deficiency Post Bariatric Surgery

Copper deficiency can occur after gastrectomy, and is found in 15% after RYGB, but is usually mild.

Manifestations are anemia, leukopenia, ageusia, ataxia, myelopathy, and peripheral neuropathy with paresthesias in feet +/- hands. Is diagnosed by serum copper levels. Zn and Fe supplementation may aggravate Cu deficiency. No monitoring required. Investigate after symptoms. Treatment: 6 mg orally daily x 1 week, then 4 mg daily x 1 week, then 2 mg/d thereafter. If oral replacement fails, give IV copper 2 mg/day x 5 days. Then continue oral Cu. Discontinue Zn supplements.

Recommended Periodic Testing After Bariatric Surgery J Clin Endocrinol Metab 95:4823-4843,2010
EVERY 6 MONTHS

OPTIONAL

Complete Hemogram Liver Enzymes Glucose Creatinine Electrolytes Iron/Ferritin/Transferrin Vitamin B12 Folic Acid Calcium Intact PTH 25-OH Vit D Albumin/Prealbumin

Vitamin A Zinc Vitamin B1 (thiamine) Other tests trigger by symptoms (Cu, Se, Cr, )

Vitamins and Minerals

Micronutrient deficiencies are common preoperatively due to a nutrient-poor diet and renal losses from obesity and diabetes associated renal hyper-filtration. Post-operatively, reduced food intake and absorption compound the problem. For example, up to 30% of patients may be zinc deficient pre-operatively. Other key nutrients include: iron, folate, B12, calcium, vitamin D, thiamine.

Neurologic Complications

Experienced by 4.6% of bariatric surgery patients.

Peripheral neuropathy 62%, encephalopathy 31%

B12: 24%-70% (1-7 yr); paresthesias, ataxia, weakness Thiamine: 18% (1 yr); neuropathy, encephalopathy
Pyridoxine: 18% (1 yr); neuropathy, seizures, confusion Vitamin D: osteomalacic myopathy Vitamin E: sensory neuropathy / myopathy Copper: myeloneuropathy, ataxia, neuropathy, ageusia Carnitine: encephalopathy Vitamin C: femoral neuropathy Zinc: night blindness, dysgeusia. Others: Vitamins B3, B5 and B7; chromium.
Am Surg. 2006 Dec;72(12):1196-202; Muscle Nerve. 2006 Feb;33:166-176.

Acute Post Gastric Reduction Surgery Neuropathy Bariatric Beriberi / APGARS Neuropathy

Painful symmetric sensorimotor lower extremity polyneuropathy with objective weakness and often with hyporeflexia, burning feet syndrome, and/or vomiting.

Incidence: 3.6% at 14 months, 4.6% at 20 months. Surgery: gastric bypass > gastric banding. Micronutrient deficiencies: thiamine, B12;

Typically occurs after protracted vomiting (ulcer, stricture). Frequently misdiagnosed as Guillain Barr syndrome.

Treatment: Vitamins, nutrition support +/IV immunoglobulins.

possibly others (B7 Biotin, B6 pyridoxine, B5 pantothenic acid, B3 niacin, vitamin E, copper, chromium, carnitine).

Neurology 1987;37:196-200. Clin Nutr 1986;15:181-184. Obes Surg 2004 14(2):182-9. Muscle & Nerve 2006 33:166-176.

Wernickes Encephalopathy

Arises in the setting of APGARS neuropathy. Requires 2 of 4:

dietary deficiency oculomotor abnormalities cerebellar dysfunction impaired mental status

MRI 53% sensitive and 93% specific Parenteral thiamine

Muscle Nerve. 2006 Feb;33:166-176. Arch Neurol. 2004 Aug;61(8):1185-9. J Neurol Neurosurg Psychiatry. 1997 Jan;62(1):51-60. AJR Am J Roentgenol. 1998 Oct;171(4):1131-7.

Hematologic Complications

Anemia occurs in 37% of patients. It occurs earlier (6 mo vs. 1 yr) and more commonly in menstruating women than men. Iron: 16% (estimate) B12: 24%-70% Folate: 40% Copper, Pyridoxine The most common endoscopic findings: #1 Normal 35% #2 Marginal Ulcer 25%

Gastroenterol Clin North Am. 2005 Mar;34(1):25-33. Obes Surg. 1999 Apr;9(2):150-4. Muscle Nerve. 2006 Feb;33:166-176. Obes Surg. 2006 Sep;16(9):1232-7.

Endocrine Complications

Bypass Bone Disease

Vitamin D deficiency (63% yr 4) & calcium depletion may lead to secondary hyperparathyroidism (50% yr 20) and biopsy proven osteomalacia (20%). Symptoms: diffuse bone pain (microfractures) but may also feature weakness from a proximal myopathy, arthralgia, synovitis.

X-Ray: pseudofractures with Loosers lines

New onset diabetes.

Chromium deficiency.

Gastroenterol Clin North Am. 2005 Mar;34(1):25-33.

Gastrointest Surg. 2004 Jan;8(1):48-55

Cardiac Complications

Non-ischemic Dilated Cardiomyopathy #1 Bariatric Beriberi #2 Keshan Syndrome

Heart Lung Circ. 2007 Apr;16(2):123-6.

Conclusions

The prevalence of obesity is still rising. The number of bariatric surgeries is rising accordingly. Gastrointestinal and nutritional complications of the surgeries are common and may present years later. Given the Center of Excellence model, the internist should be prepared to diagnose and treat these problems. No matter what the presentation, always consider the possibility of nutritional deficiency.