title: Severe fatal protein malnutrition and liver failure in a morbidly obese patient after mini-gastric bypass surgery: Case report.
abstract: BACKGROUND
  Mini-gastric bypass (MGB) is a bariatric surgical technique popular in many centers due to shorter duration, easier technique, and excellent weight loss results. However, it may be associated with postoperative malnutrition. This case describes the clinical course and unfortunate outcome of a morbidly obese patient who underwent MGB and developed malnutrition in the first postoperative year.
  
  
  METHODS
  A 37 year-old female patient with a BMI of 44kg/m2successfully underwent MGB surgery in June 2015 and was discharged uneventfully. She presented with lower extremity edema and generalized weakness 8 months later, with a blood albumin level of 3.1g/dL, compared to a normal preoperative value. She was admitted and received a high-protein diet, and her clinical condition improved. Three months after her discharge, she was readmitted with the same complaints, as well as pancytopenia. She was also hypocupremic. After unsuccessful intensive supportive measures, she finally underwent revisional gastrogastrostomy. However, she developed signs and symptoms of profound liver failure postoperatively (albumin 1.8g/dL; total bilirubin 7.5mg/dL; prothrombin time 34s) and pancytopenia persisted. All resuscitative measures were unsuccessful and she expired in July 2016.
  
  
  CONCLUSIONS
  Multiple factors can contribute to postoperative malnutrition and liver dysfunction after MGB, including the presence of baseline liver disease, inadequate diet supplementation, leaving a too-short common small intestinal channel, and ethnic variations in small bowel length. These factors should also be considered when deciding to perform corrective surgery.
  
  
  CONCLUSIONS
  Careful, individualized treatment and follow-up plans may help to prevent such catastrophic consequences.
authors.affiliation: Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Mohammad Ali Kalantar
authors.initials: MAK
authors.lastname: Motamedi
authors.affiliation: Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Maryam
authors.initials: M
authors.lastname: Barzin
authors.affiliation: Obesity Treatment Center, Department of Surgery, Shahed University, Tehran, Iran.
authors.forename: Mohammadreza
authors.initials: M
authors.lastname: Ebrahimi
authors.affiliation: Obesity Treatment Center, Department of Surgery, Shahed University, Tehran, Iran.
authors.forename: Reza
authors.initials: R
authors.lastname: Ebrahimi
authors.affiliation: Obesity Treatment Center, Department of Surgery, Shahed University, Tehran, Iran. Electronic address: khalaj@totc.ir.
authors.forename: Alireza
authors.initials: A
authors.lastname: Khalaj
keywords: Bariatric surgery; Case report; Liver failure; Malnutrition; Mini-gastric bypass; Morbid obesity