We describe an interesting case of a 25 year-old female who presents as a specialist tertiary referral with severe refractory secondary hypocalcaemia after total thyroidectomy for a benign goitre. She had also undergone a one anastomosis gastric bypass. Symptoms include tetanic seizures, vertebral compression fracture, dental issues and iron deficiency anaemia. There was excess weight loss from BMI 54.2 to 24 (kg/m2). She underwent full investigations including a barium swallow and follow through, CT abdomen and pelvis, an upper GI endoscopy and a NM parathyroid scan. She was reviewed by the bariatric dietitian and psychiatrist. We then proceeded to diagnostic laparoscopy where we found a 260cm Bilio-pancreatic limb with a total small bowel length of 430cm.
Despite maximal treatment with oral calcium supplements and parathyroid hormone injections, she remained intermittently symptomatic and required recurrent admissions for IV calcium replacement. Following multi-disciplinary team discussion and patient consent, a decision was made to perform a reversal of OAGB after a period of parenteral nutrition and electrolyte correction.
The patient underwent a reversal of OAGB with no immediate complications.
There are several important transferable learning points, (1) active absorption of calcium ions occur at the duodenum and proximal jejunum (2) patients need to be counselled and forewarned about possible complications of total thyroidectomy and duodenal exclusion procedures (3) Close liaison of bariatric and endocrine surgical teams are required in such patients with total thyroidectomy only performed when absolutely necessary (4) Compliance with medication needs close attention.