August 2017, VOLUME140 /ISSUE 2

Authors’ Response

  1. Amy Armstrong-Javors, MD
  1. Pediatric Neurology Resident, Massachusetts General Hospital
  1. Janey Pratt, MD
  1. General Surgeon
  1. Sigmund Kharasch, MD
  1. Pediatric Emergency Medicine Physician

Thank you for your thoughtful commentary. Although we agree with most of your discussion, especially your conclusion that adolescent bariatric surgery should be performed in multidisciplinary adolescent centers, there are a few points that we would like to emphasize.

Firstly, most bariatric procedures performed in adolescents in the United States and worldwide today are sleeve gastrectomy (SG) rather than Roux-en-Y gastric bypass (RYGB) procedures. Although there are limited statistical data in adolescents, this transition from bypass to sleeve procedures seems to be mirroring that of the adult population. Although 37% of weight reduction surgeries in 2011 were RYGBs and 18% were SGs, by 2015, only 23% were bypass procedures and 54% were SGs.1

Theoretically, the risk of Wernicke encephalopathy (WE) should be higher after RYGB compared with SG, a restrictive procedure in which the stomach volume is reduced without bypassing the duodenum. There are, however, several reported cases of both adolescent and adult patients developing WE after SG.25 A recent case series demonstrated that preoperative thiamine (Vitamin B1) levels in 7 patients who underwent SG fell significantly postoperatively, although only 2 of these patients developed WE.2 The risk factors for developing WE after RYGB and SG appear similar and include nausea, vomiting, and medication noncompliance. Additionally, the limited reports on WE after SG demonstrate a similar time from surgery to first presentation and variable weight loss at presentation. Thus, impaired absorption of thiamine can occur even in the absence of significant postoperative weight loss.3 Lastly, the significant challenge some adult patients have with medication and dietary compliance underscores the even larger barriers that adolescents face postoperatively.35

We believe that the most important points of this article involve prevention and early recognition of this easily treatable condition. Thiamine supplementation should be used in all adolescent patients before and after bariatric surgery. Furthermore, members of the bariatric team as well as the adolescent and their family should be aware of the symptoms of WE and the need for immediate treatment. Anecdotally, adolescents appear to be at greater risk of postoperative WE than adults. Prevention remains the best therapy for WE in both adolescent and adult weight loss surgery patients.


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  • CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.