Reversal of Roux-en-Y Gastric Bypass Fails to Facilitate the Management of Recalcitrant Hypocalcaemia Caused by Primary Hypoparathyroidism

Abstract

Roux-en-Y gastric bypass (RYGB) is thought to reduce calcium absorption from the gut. Here, we report the case of a patient with a RYGB, who developed primary hypoparathyroidism after a total thyroidectomy, leading to recalcitrant hypocalcaemia. Despite aggressive oral calcium and calcitriol supplementation, she remained hypocalcaemic and required intravenous (IV) calcium supplementation to control her symptoms, and to keep calcium serum levels within an acceptable range. Teriparatide treatment improved calcium levels marginally. This treatment, however, was poorly tolerated and ultimately stopped by the patient. As a last resort, reversal of RYGB was performed to improve calciumabsorption from the gut. Unfortunately, IV calcium supplementation remained necessary. This case illustrates that the reversal of RYGB is not always a guarantee for success in managing recalcitrant hypocalcaemia.

Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid Surgery

“…11 Postsurgical hypoparathyroidism with prior gastric bypass often results in recalcitrant hypocalcemia, at times requiring prolonged parenteral calcium, and even reversal of the gastric bypass with varying results. 12,13 Leveraging surgical technologies to prevent PG injury is therefore important.…”

“…Undertreatment of pregnant or breastfeeding patients can lead to maternal hypocalcemia (linked to premature delivery, intrauterine fetal hyperparathyroidism, and fetal death), while overtreatment can result in abortion, stillbirth, perinatal death, and neonatal tetany . Postsurgical hypoparathyroidism with prior gastric bypass often results in recalcitrant hypocalcemia, at times requiring prolonged parenteral calcium, and even reversal of the gastric bypass with varying results . Leveraging surgical technologies to prevent PG injury is therefore important.…”

History of Bariatric Surgery Before Thyroid Surgery: Recommendations for Prevention and Management of Postoperative Hypocalcemia

“…The American Society for Metabolic and Bariatric Surgery have also published recommendations for calcium and vitamin D for all patients after bariatric surgery 13 . Although most of these recommendations focus on perioperative calcium and vitamin D monitoring and supplementation, studies have examined the utility of a staged thyroidectomy or rarely reversal of the bariatric procedure 14‐16 . Gooi et al presented a case series of patients with a history of RYGB who received an initial thyroid lobectomy and isthmusectomy followed by a completion hemithyroidectomy months later.…”

“…13 Although most of these recommendations focus on perioperative calcium and vitamin D monitoring and supplementation, studies have examined the utility of a staged thyroidectomy or rarely reversal of the bariatric procedure. [14][15][16] Gooi et al presented a case series of patients with a history of RYGB who received an initial thyroid lobectomy and isthmusectomy followed by a completion hemithyroidectomy months later. Patients did not develop postoperative hypocalcemia in these cases, so the authors proposed a staged approach to minimize the risk.…”