First Case Report of Acquired Copper Deficiency Following Revisional Single Anastomosis Duodeno-Ileal Bypass with Sleeve
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LETTER TO THE EDITOR
First Case Report of Acquired Copper Deficiency Following Revisional Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) Leading to Severe Pancytopenia with Refractory Anemia Alyaa Abusabeib 1 & Walid El Ansari 2,3,4
&
Wahiba Elhag 1
Received: 26 July 2020 / Revised: 4 August 2020 / Accepted: 10 August 2020 # The Author(s) 2020
Background Copper, a largely available trace element in the human body, is a cofactor in many enzymatic reactions that are vital for the functioning of the hematologic, vascular, skeletal, antioxidant, and neurologic systems [1, 2]. It is absorbed mainly in the stomach and proximal duodenum [3]. Copper deficiency is extremely unusual in healthy individuals [4]. Bariatric surgical procedures cause anatomical changes of the gastrointestinal tract that could lead to hypocupremia and/ or predispose patients to a range of nutritional deficiencies that can lead to anemia, osteoporosis, and protein malnutrition [5]. Thus, without appropriate supplementation of a range of micro- and macronutrients post-bariatric procedures, patients might develop such deficiencies. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a relatively recent bariatric surgical procedure in which sleeve gastrectomy is followed by end-to-side duodeno-ileal diversion [6]. The elimination of one anastomosis results in decreased surgery time and possibly less surgeryrelated complications [7]. Whilst SADI-S has significant weight loss and positive metabolic outcomes, malabsorptive effects might occur, e.g., albumin, zinc, folate, vitamins A, D, and E, zinc, and copper [6, 7]. The diagnosis of hypocupremia could be challenging due to its rarity and its similar clinical presentation as vitamin B12 deficiency [8]. * Walid El Ansari [email protected] 1
Department of Bariatric Surgery/Bariatric Medicine, Hamad General Hospital, 3050 Doha, Qatar
2
Department of Surgery, Hamad General Hospital, 3050 Doha, Qatar
3
College of Medicine, Qatar University, Doha, Qatar
4
Schools of Health and Education, University of Skovde, Skövde, Sweden
Published reports of the malnutrition outcomes after SADIS are extremely rare [9]. An exception is a study of 97 SADI-S patients, where 12% developed copper deficiency at 1 year and 11% at 3 years post-op [10]. We report a case of severe copper deficiency after revisional SADI-S leading to severe pancytopenia with cellular atypia. To the best of our knowledge, this could be the first case report of severe copper deficiency leading to profound hematological abnormalities postSADI-S.
Case Report Figure 1 depicts the sequence of events over 7 years. A 37-year-old Qatari female presented to our outpatient bariatric clinic (Hamad General Hospital, largest tertiary care institution in Qatar) with a 4-month complaint of generalized fatigability and progressive bilateral lower limbs swelling with occasional numbness of the distal aspects of the lower limbs but no weakness. Her complaints had worsened over time, and were affecting h
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