Sleeve Gastrectomy and Wernicke Encephalopathy

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To the Editor:
We read with great interest the recent publication by Zheng1 published in the November 2015 issue of the American Journal of Therapeutics which reports a case of Wernicke encephalopathy (WE) 7 weeks after sleeve gastrectomy (SG). The author describes a rare case of WE resulting from thiamine deficiency in a 42-year-old female patient who underwent SG. According to the article, WE was suspected because of the neurological findings, the recent history of bariatric procedure and the abnormal MRI findings. The aforementioned case report is significant due to the fact that it describes not only an uncommon but also a severe complication after SG with markedly increased morbidity and mortality.
According to Zheng1 there are only 8 cases of WE after SG reported in the literature. However, our review of the current literature has found almost the double number of cases.1–5 The unreported cases of WE after SG are equally important as the cases that the author has described due to the early develop of neurological symptoms and the incomplete recovery even after 1-year follow-up. As the unreported cases are concerned, 2 out of them are extremely significant. More specifically, Kröll et al2 published in 2015 a case of a 55-year-old man with an early development of WE with the classic triad of WE and Korsakoff syndrome. Intravenous thiamine was administered, with gradual improvement. However, 24 months after the diagnosis, the patient's neurological status has not yet fully recovered. Moreover, in 2015, Samanta3 reported the youngest patient in the literature who suffered from WE, 2 months after SG. Intravenous thiamine reversed her symptoms, nevertheless the patient needed rehabilitation for neuropathy. The rest of the unreported cases by Zheng's review1 describes approximately similar neurological symptoms of WE due to vitamin B1 deficiency. However, the course of WE after SG varied widely, and it was unpredictable as well.
The contribution of SG to the evolution of bariatric surgery is unquestionable. However, SG is not without complications. The impact of WE after bariatric surgery is significantly underestimated. Due to its increasing clinical application, even if WE was considered as an extremely rare complication that can occur after SG, more and more relevant literature references come to light. Therefore, physicians should be highly suspicious with the diagnosis of WE in cases of rapidly altered mental status occurring in patients with malnutrition or malabsorption as a consequence of prolonged vomiting after bariatric surgery.
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