OBES SURG (2009) 19:1468–1470
DOI 10.1007/s11695-009-9935-2
CASE REPORT
When the Brakes Came Off: Re-feeding Oedema
after Deflation of a Gastric Band: A Case Report
Royce P. Vincent & Simon J. B. Aylwin &
Carel W. le Roux
Received: 24 February 2009 / Accepted: 30 July 2009 / Published online: 13 August 2009
# Springer Science + Business Media, LLC 2009
Abstract Bariatric surgery is now the treatment of choice for
morbid obesity, but is not without risk. Patients are cared for in
specialised centres, but complications can present to nonspecialised centres. We describe life-threatening re-feeding
oedema in a patient following routine deflation of a gastric
band. Band deflation or removal may be required for various
reasons, but rapid release of the band without additional
supplementation of electrolytes may be dangerous due to
re-feeding syndrome.
Keywords Bariatric surgery . Gastric banding .
Re-feeding oedema
Introduction
Bariatric surgery currently represents the treatment of
choice for morbid obesity. Most surgical procedures are
carried out in low-risk individuals and the perioperative
morbidity and mortality rates are low [1]. However, as
clinical experience expands the spectrum of long-term
complications is becoming evident, nutritional disorders
such as protein-calorie malabsorption [2], vitamin and trace
element deficiencies [3] and post-prandial hypoglycaemia
R. P. Vincent : C. W. le Roux (*)
Department of Chemical Pathology,
King’s College Hospital NHS Foundation Trust,
Denmark Hill,
London SE5 9RS, UK
e-mail: c.leroux@imperial.ac.uk
S. J. B. Aylwin
Department of Endocrinology,
King’s College Hospital NHS Foundation Trust,
Denmark Hill,
London SE5 9RS, UK
[4] are increasingly recognised. In this report, we describe a
patient who developed a nutrition-related disorder—re-feeding
oedema—following routine deflation of a gastric band.
Case Report
A 23-year-old female weighing 120 kg (body mass index
(BMI) of 41 kg/m2) underwent laparoscopic adjustable
gastric banding primarily for reasons of body image
dysphoria. She had no history of an eating disorder prior
to gastric banding. Over the subsequent 12 months, she
experienced reduced appetite and restriction to food
ingestion due to the band and lost 75 kg to a nadir weight
of 56 kg (BMI 19 kg/m2). After weight loss, she developed
bulimic behaviour with binge eating and deliberate purging.
During this time, her menstrual periods became infrequent.
Two years after the procedure, in view of the excessive weight
loss and maladaptive behaviour, she opted to have the band
fully deflated. Following the deflation, her appetite and food
intake increased rapidly and she was able to eat without any
restriction. Five days later, she presented to the emergency
department having gained 12 kg in weight, with bilateral leg
swelling and lower back pain.
Examination revealed severe bilateral pitting oedema of her
legs extending to the abdomen and upper limbs. Biochemical
analysis on admission revealed marked hypophosphataemia
with a serum phosphate of 0.29 mmol/L (normal 0.8–
1.4 mmol/L), an albumin of 34 g/L (35–50 g/L), deranged
liver function tests with an aspartate aminotransferase of
253 IU/L (10–50 IU/L) and gamma glutamic transpeptidase
96 IU/L (1–55 IU/L). Other investigations to exclude a
pathological oedema-forming state were normal including an
echocardiogram, abdominal and pelvic ultrasound scan and
24-h urine protein excretion. Re-feeding syndrome was
OBES SURG (2009) 19:1468–1470
diagnosed, and she made a rapid recovery with diuretic
therapy but without specific nutritional replacement and was
discharged home 5 days later.
Two months following this episode, the gastric band was
removed which resulted in 17 kg weight gain. One year
later, she weighed 75 kg (BMI 32 kg/m2). Currently, she
does not have any symptoms of binge eating and her
menstrual cycle is regular.
Discussion
Gastric banding involves the introduction of an adjustable
silastic band encircling the proximal portion of the stomach
with a subcutaneous port linked to the band [5]. The band
can be adjusted by introducing fluid through the port, thus
leading to more pressure on the gastro-oesophageal
junction and a reduction in appetite [6]. The average excess
weight loss in clinical practise after 2 years following
gastric banding is around 50% [5]. The 136% excess
weight loss in this case is beyond normal expectation and
was probably due to several factors: the restriction of the
band and the abnormal eating behaviour that followed. The
reduction in appetite that occurs with the gastric band is
reversed when the band is deflated and this can contribute
to the excessive drive to consume food [6].
Re-feeding syndrome describes a clinical presentation
that consists of a marked oedema and metabolic
disturbances that occur as a result of reinstitution of
nutrition, amongst patients who are starved or severely
malnourished. Re-feeding oedema was first described in
prisoners of war after the Second World War [7] and
usually occurs within 4 days of re-feeding [8]. Patients can
develop fluid and electrolyte disorders, especially hypophosphataemia, hypokalaemia, hypomagnesaemia along
with neurologic, pulmonary, cardiac, neuromuscular and
haematologic complications which can lead to mortality [8].
Most effects result from a sudden shift from fat to
carbohydrate metabolism after re-feeding in combination
with decreased intracellular phosphate stores.
The investigations performed on admission excluded
hypoalbuminaemia, cardiac failure, renal failure, chronic liver
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disease and obstruction to venous outflow as contributors to
her generalised oedema.
Prolonged starvation leads to low insulin levels, which
are rapidly reversed when carbohydrates are introduced.
During re-feeding, the increased secretion of insulin can
result in significant oedema [9]. Insulin can promote
sodium and potassium re-absorption mainly in the distal
tubule and thick ascending limb of Henle’s loop which have
the greatest density of insulin receptors [9, 10] as well as
increase capillary permeability [10]. Specifically, insulin
promotes the cell surface expression of the epithelial
sodium channel [11] within the glomerular apparatus,
leading to enhanced sodium re-absorption. Glucagon has
also been implicated since glucagon has a natriuretic effect,
and low levels favour an anti-natriuresis effect in the distal
tubule [12]. During re-feeding, production of gonadotrophins, oestrogens and progestogens increase. Oestrogen has
been shown to induce pronounced non-genomic endothelial
dependent nitric oxide mediated vasodilation [13]. Hence,
the pathogenesis of re-feeding oedema is complex.
Phosphate is a major intracellular anion. Serum concentrations do not optimally assess body stores for electrolytes
which are distributed intracellularly. While body stores of
phosphate can be depleted by starvation, serum concentrations may appear normal [14]. Increased insulin secretion
following re-feeding causes an intracellular flux of phosphate. It is also increasingly required for high-energy
phosphate compounds during anabolism, especially when
glucose is the major source of energy. This increased
demand and the depleted phosphorus state due to
starvation contributes to the severe hypophosphataemia seen
in re-feeding syndrome.
The major electrolyte changes that occur with re-feeding
syndrome are summarised in Table 1.
Conclusion
Currently, gastric banding is increasingly used as a
treatment option for severe-morbid obesity. Even though
patients are cared for in specialised centres, complications
can present after banding or reversal of banding. Band
Table 1 Major electrolyte disturbances during re-feeding syndrome
Electrolyte
Serum
concentration
Mechanism
Systems affected
Sodium
Potassium
Increases
Decreases
Increased re-absorption in the kidney
Increased demand and intracellular flux
Phosphate
Magnesium
Decreases
Decreases
Increased demand and intracellular flux
Increased demand and intracellular flux
Cardiovascular,
Cardiovascular,
respiratory
Cardiovascular,
Cardiovascular,
respiratory, neurological
renal, hepatic, gastrointestinal, neuromuscular,
hepatic, neuromuscular, respiratory, haematological
gastrointestinal, neuromuscular
1470
deflation or removal may be required for a variety of reasons:
excessive weight loss, persistent vomiting or the development
of abnormal eating behaviour. Rapid release of the band
without additional supplementation of electrolytes may be
dangerous as re-feeding syndrome represents risk to this
group of patients.
Authors and contributors
Vincent RP: I declare that I participated in the literature search,
drafting of the paper, obtaining written consent from the patient and
that I have seen and approved the final version.
Aylwin SJB: I declare that I participated in drafting of the paper;
critically reviewed its content and that I have seen and approved the
final version.
le Roux CW: I declare that I participated in drafting of the paper;
critically reviewed its content and that I have seen and approved the
final version.
Conflicts of interest None
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