A GRIM TURN OF OBESITYRELATED SURGERY

WERNICKE'S ENCEPHALOPATHY, SLEEVE GASTRECTOMY GONE WRONG

Abstract

INTRODUCTION/BACKGROUND
Wernicke’s encephalopathy (WE) is a devastating neurologic syndrome resulting from thiamine deficiency, typically affecting those with chronic alcoholism or poor nutrition, and post-bariatric surgery patients. We present a case of WE that developed after 3 months after laparoscopic sleeve gastrectomy.

CASE
A 38-year-old male with morbid obesity (BMI 44 kg/m2) who underwent laparoscopic sleeve gastrectomy in December 2022, was admitted due to development of a gastrocutaneous fistula and resultant intraabdominal sepsis. He was on prolonged nil by mouth and nutritional support was given through total parenteral nutrition. After one month of admission, he developed unsteadiness and blurring of vision. Physical examination noted he appeared confused, with ophthalmoplegia, bilateral horizontal nystagmus, and ataxic gait. Basic blood exams showed hypochromic microcytic anaemia with haemoglobin of 8.3 g/dL. Unfortunately, our centre was unable to provide a test for serum thiamine. Brain MRI showed symmetric hyperintensities in the thalami, mamillary bodies, tectum of the midbrain, and periventricular region, indicating Wernicke’s encephalopathy. Thus, parenteral thiamine replacement was given followed by oral therapy upon discharge. A follow up visit after one month noted complete resolution of symptoms and signs. Sleeve gastrectomy, an intervention for morbid obesity, may result to macro-micronutrient deficiency due to reduced nutrient absorption from gut alterations and reduced food intake post-surgery. Thiamine deficiency can
impact the cardiovascular and nervous system, causing dry or wet beriberi. In severe cases, WE or Wernicke’s Korsakoff Syndrome (WKS) may develop, and the mainstay treatment for this is to administer thiamine to reverse mental changes and prevent disease progression. Despite thiamine replacement, WE and WKS is associated with high morbidity and mortality. Our patient is fortunate to have responded well to treatment.

CONCLUSION
Thiamine deficiency after sleeve gastrectomy may lead to severe neurological impairments. Proactive prophylactic thiamine supplementation can significantly decrease the likelihood of WE and WKS.