First Case Report of Acquired Copper Deficiency Following Revisional Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) Leading to Severe Pancytopenia with Refractory Anemia

Abstract

Copper, a largely available trace element in the human body, is a cofactor in many enzymatic reactions that are vital for the functioning of the hematologic, vascular, skeletal, antioxidant, and neurologic systems [1, 2]. It is absorbed mainly in the stomach and proximal duodenum [3]. Copper deficiency is extremely unusual in healthy individuals [4]. Bariatric surgical procedures cause anatomical changes of the gastrointestinal tract that could lead to hypocupremia and/or predispose patients to a range of nutritional deficiencies that can lead to anemia, osteoporosis, and protein malnutrition [5]. Thus, without appropriate supplementation of a range of micro- and macronutrients post-bariatric procedures, patients might develop such deficiencies. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a relatively recent bariatric surgical procedure in which sleeve gastrectomy is followed by end-to-side duodeno-ileal diversion [6]. The elimination of one anastomosis results in decreased surgery time and possibly less surgery-related complications [7]. Whilst SADI-S has significant weight loss and positive metabolic outcomes, malabsorptive effects might occur, e.g., albumin, zinc, folate, vitamins A, D, and E, zinc, and copper [6, 7]. The diagnosis of hypocupremia could be challenging due to its rarity and its similar clinical presentation as vitamin B12 deficiency [8]. Published reports of the malnutrition outcomes after SADI-S are extremely rare [9]. An exception is a study of 97 SADI-S patients, where 12% developed copper deficiency at 1 year and 11% at 3 years post-op [10]. We report a case of severe copper deficiency after revisional SADI-S leading to severe pancytopenia with cellular atypia. To the best of our knowledge, this could be the first case report of severe copper deficiency leading to profound hematological abnormalities post-SADI-S.