Objective: Alterations of the endocrine system in patients following Roux-en-Y gastric bypass (GBP) are poorly described and have prompted us to perform a longitudinal study of the effects of GBP on serum calcium, 25-hydroxy-vitamin-D (vitamin D), and parathyroid hormone (PTH).
Methods: Prospectively collected data were compiled to determine how GBP affects serum calcium, vitamin D, and PTH. Student t test, Fisher exact test, or linear regression was used to determine significance.
Results: Calcium, vitamin D, and PTH levels were drawn on 243 patients following GBP. Forty-one patients had long-limb bypass (LL-GBP), Roux >100 cm, and 202 had short-limb bypass (SL-GBP), Roux ≤100 cm. The mean (±SD) postoperative follow-up time was significantly longer in the LL-GBP group (5.7 ± 2.5 years) than the SL-GBP group (3.1 ± 3.6 years, P < 0.0001). When corrected for albumin levels, mean calcium was 9.3 mg/dL (range, 8.5–10.8 mg/dL), and no difference existed between LL-GBP and SL-GBP patients. For patients with low vitamin D levels (<8.9 ng/mL), 88.9% had elevated PTH (>65 pg/mL) and 58.0% of patients with normal vitamin D levels (≥8.9 ng/mL) had elevated PTH (P < 0.0001). In individuals with vitamin D levels <30 ng/mL, 55.1% (n = 103) had elevated PTH, and of those with vitamin D levels ≥30 ng/mL 28.5% (n = 16) had elevated PTH (P = 0.0007). Mean vitamin D levels were lower in patients who had undergone LL-GBP as opposed to those with SL-GBP, 16.8 ± 10.8 ng/mL versus 22.7 ± 11.1 ng/mL (P = 0.0022), and PTH was significantly higher in patients who had a LL-GBP (113.5 ± 88.0 pg/mL versus 74.5 ± 52.7 pg/mL, P = 0.0002). There was a linear decrease in vitamin D (P = 0.005) coupled with a linear increase in PTH (P < 0.0001) the longer patients were followed after GBP. Alkaline phosphatase levels were elevated in 40.3% of patients and correlated with PTH levels.
Conclusion: Vitamin D deficiency and elevated PTH are common following GBP and progress over time. There is a significant incidence of secondary hyperparathyroidism in short-limb GBP patients, even those with vitamin D levels ≥30 ng/mL, suggesting selective Ca2+ malabsorption. Thus, calcium malabsorption is inherent to gastric bypass. Careful calcium and vitamin D supplementation and long-term screening are necessary to prevent deficiencies and the sequelae of secondary hyperparathyroidism.
Routine monitoring of 25-OH-vitamin D and parathormone levels at annuals visits for gastric bypass patients disclosed a high incidence of vitamin D insufficiency and secondary hyperparathyroidism. This was progressive over time and was more severe in long-limb Roux-en Y gastric bypass patients.
From the Departments of *Surgery and †Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA. The current address of Dr. DeMaria is Department of Surgery, Duke University School of Medicine, Durham, NC.
Reprints: John M. Kellum, MD, P.O. Box 980519, Department of Surgery, Virginia Commonwealth University, Richmond VA, 23298-0519. E-mail: firstname.lastname@example.org.