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Occult Hyperparathyroidism in Body Contouring Patients After Bariatric Surgery: A Plastic Surgeon’s Role

Occult Hyperparathyroidism in Body Contouring Patients After Bariatric Surgery: A Plastic... Massive weight loss after bariatric surgery leaves patients with excessive skin, and body contouring surgery by plastic surgeons is increasingly recognized as essential for improving quality of life and helping maintain weight loss. Weight loss in bariatric surgery is achieved through alterations in the gastrointestinal anatomy, restricting food intake and limiting absorptive capacity for nutrients such as calcium and vitamin D. Roux-en-Y gastric bypass diverts nutrients past portions of the small intestine, limiting the absorptive area for not only calcium but also for fat-soluble vitamin D. Many patients require lifelong supplementation of calcium and vitamin D. Although plastic surgeons are aware of the nutritional deficits in postbariatric body contouring patients, derangements in calcium metabolism are not routinely investigated. Parathyroid hormone (PTH) is chiefly responsible for maintaining calcium homeostasis. Decreasing serum calcium levels stimulate increased PTH secretion and vitamin D activation. Vitamin D facilitates absorption of calcium in the intestine to normalize levels.1 A review of the plastic surgery literature reveals no guidelines for assessing PTH levels, especially if routine labs indicate a normal serum calcium level.2-4 The senior author began collecting preoperative PTH levels in all bariatric surgery patients in 2019 over concern for occult secondary hyperparathyroidism. This practice has since revealed a surprising incidence of occult hyperparathyroidism, with 6 out of 19 patients (31.6%) demonstrating hyperparathyroidism. PTH values ranged as high as 238 pg/mL, over 3 times the upper limit of normal. No patients were found to have low calcium levels, suggesting compensatory bone resorption was occurring. Persistently elevated PTH levels risk the development of osteoporosis and parathyroid hyperplasia. Patients may suffer unexplained fatigue, psychological disturbances, myalgias, and arthralgias.5 Two patients highlight why we believe plastic surgeons should routinely screen postbariatric body contouring patients for hyperparathyroidism. The first presented with unexplained hypercalcemia on preoperative evaluation. They were referred for surgical clearance with the recommendation for PTH testing. Clearance was obtained with no further testing performed and the patient underwent body contouring surgery. After an uneventful postoperative course, the patient reported psychological disturbances and severe anxiety to their personal physician. PTH testing revealed a value twice the upper limit of normal, leading to a hemithyroidectomy to resect the severely hyperplastic adjacent parathyroid gland. For years the patient had reportedly suffered from poor dentition attributable to bone loss, requiring extensive and costly procedures. Another patient found to have hyperparathyroidism complained of debilitating psychological disturbances requiring anxiolytic and antidepressant medications, stating they felt like they were “losing their mind.” In our practice, all patients with hyperparathyroidism are referred to their primary care physician for treatment prior to body contouring surgery. Elevated parathyroid levels alone are not known to significantly influence body contouring surgical outcomes; however, in bariatric surgery patients, plastic surgeons have a unique opportunity to increase the detection of unmanaged hyperparathyroidism. As such, we recommend routine testing of PTH levels in postbariatric surgery patients undergoing body contouring and subsequent treatment if PTH levels are abnormal. This routine screening can help diagnosis and ultimately treat this commonly overlooked disease in the postbariatric surgery population. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and/or publication of this article. REFERENCES 1. Vantour L , Goltzman D. Regulation of calcium homestasis . In: Bilezikian JP, ed. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism , 9th ed. Wiley Blackwell ; 2019 : 163 - 172 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2. Song A , Fernstrom MH. Nutritional and psychological considerations after bariatric surgery . Aesthet Surg J. 2008 ; 28 ( 2 ): 195 - 199 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Sebastian JL . Bariatric surgery and work-up of the massive weight loss patient . Clin Plast Surg. 2008 ; 35 ( 1 ): 11 - 26 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Herman CK , Hoschander AS, Wong A. Post-bariatric body contouring . Aesthet Surg J. 2015 ; 35 ( 6 ): 672 - 687 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Mendonça FM , Neves JS, Silva MM, et al. ; CRIO group. Secondary hyperparathyroidism among bariatric patients: unraveling the prevalence of an overlooked foe . Obes Surg. 2021 ; 31 ( 8 ): 3768 - 3775 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes Dr Moliver is a plastic surgeon in private practice in Webster, TX, USA © 2021 The Aesthetic Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com © 2021 The Aesthetic Society. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Occult Hyperparathyroidism in Body Contouring Patients After Bariatric Surgery: A Plastic Surgeon’s Role

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References (8)

Publisher
Oxford University Press
Copyright
© 2021 The Aesthetic Society.
ISSN
1090-820X
eISSN
1527-330X
DOI
10.1093/asj/sjab361
Publisher site
See Article on Publisher Site

Abstract

Massive weight loss after bariatric surgery leaves patients with excessive skin, and body contouring surgery by plastic surgeons is increasingly recognized as essential for improving quality of life and helping maintain weight loss. Weight loss in bariatric surgery is achieved through alterations in the gastrointestinal anatomy, restricting food intake and limiting absorptive capacity for nutrients such as calcium and vitamin D. Roux-en-Y gastric bypass diverts nutrients past portions of the small intestine, limiting the absorptive area for not only calcium but also for fat-soluble vitamin D. Many patients require lifelong supplementation of calcium and vitamin D. Although plastic surgeons are aware of the nutritional deficits in postbariatric body contouring patients, derangements in calcium metabolism are not routinely investigated. Parathyroid hormone (PTH) is chiefly responsible for maintaining calcium homeostasis. Decreasing serum calcium levels stimulate increased PTH secretion and vitamin D activation. Vitamin D facilitates absorption of calcium in the intestine to normalize levels.1 A review of the plastic surgery literature reveals no guidelines for assessing PTH levels, especially if routine labs indicate a normal serum calcium level.2-4 The senior author began collecting preoperative PTH levels in all bariatric surgery patients in 2019 over concern for occult secondary hyperparathyroidism. This practice has since revealed a surprising incidence of occult hyperparathyroidism, with 6 out of 19 patients (31.6%) demonstrating hyperparathyroidism. PTH values ranged as high as 238 pg/mL, over 3 times the upper limit of normal. No patients were found to have low calcium levels, suggesting compensatory bone resorption was occurring. Persistently elevated PTH levels risk the development of osteoporosis and parathyroid hyperplasia. Patients may suffer unexplained fatigue, psychological disturbances, myalgias, and arthralgias.5 Two patients highlight why we believe plastic surgeons should routinely screen postbariatric body contouring patients for hyperparathyroidism. The first presented with unexplained hypercalcemia on preoperative evaluation. They were referred for surgical clearance with the recommendation for PTH testing. Clearance was obtained with no further testing performed and the patient underwent body contouring surgery. After an uneventful postoperative course, the patient reported psychological disturbances and severe anxiety to their personal physician. PTH testing revealed a value twice the upper limit of normal, leading to a hemithyroidectomy to resect the severely hyperplastic adjacent parathyroid gland. For years the patient had reportedly suffered from poor dentition attributable to bone loss, requiring extensive and costly procedures. Another patient found to have hyperparathyroidism complained of debilitating psychological disturbances requiring anxiolytic and antidepressant medications, stating they felt like they were “losing their mind.” In our practice, all patients with hyperparathyroidism are referred to their primary care physician for treatment prior to body contouring surgery. Elevated parathyroid levels alone are not known to significantly influence body contouring surgical outcomes; however, in bariatric surgery patients, plastic surgeons have a unique opportunity to increase the detection of unmanaged hyperparathyroidism. As such, we recommend routine testing of PTH levels in postbariatric surgery patients undergoing body contouring and subsequent treatment if PTH levels are abnormal. This routine screening can help diagnosis and ultimately treat this commonly overlooked disease in the postbariatric surgery population. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and/or publication of this article. REFERENCES 1. Vantour L , Goltzman D. Regulation of calcium homestasis . In: Bilezikian JP, ed. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism , 9th ed. Wiley Blackwell ; 2019 : 163 - 172 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2. Song A , Fernstrom MH. Nutritional and psychological considerations after bariatric surgery . Aesthet Surg J. 2008 ; 28 ( 2 ): 195 - 199 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Sebastian JL . Bariatric surgery and work-up of the massive weight loss patient . Clin Plast Surg. 2008 ; 35 ( 1 ): 11 - 26 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Herman CK , Hoschander AS, Wong A. Post-bariatric body contouring . Aesthet Surg J. 2015 ; 35 ( 6 ): 672 - 687 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Mendonça FM , Neves JS, Silva MM, et al. ; CRIO group. Secondary hyperparathyroidism among bariatric patients: unraveling the prevalence of an overlooked foe . Obes Surg. 2021 ; 31 ( 8 ): 3768 - 3775 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes Dr Moliver is a plastic surgeon in private practice in Webster, TX, USA © 2021 The Aesthetic Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com © 2021 The Aesthetic Society.

Journal

Aesthetic Surgery JournalOxford University Press

Published: Oct 10, 2021

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