Articles 8/14/06 1:25 PM Page 1209

Obesity Surgery, 16, 1209-1213

Rhabdomyolysis after Gastric Bypass: Severity and

Outcome Patterns

Joel Faintuch, MD, PhD1; Roberto de Cleva, MD2; Denis Pajecki, MD3;
Arthur B. Garrido Jr, MD4; Ivan Cecconello, MD5

1
Division of Gastrointestinal Surgery; 2Surgical Intensive Care Unit, Department of
Gastroenterology; 3Outpatient Clinic of Obesity Surgery Group; 4Chief, Obesity Surgery Group;
5Professor and Chief, Division of Gastrointestinal Surgery, Hospital das Clínicas and São Paulo

University Medical School, São Paulo, Brazil

Background: Rhabdomyolysis (RML) is a recently rec-
ognized complication of bariatric operations, but it is
not known whether creatine kinase (CK) levels along
with clinical markers are able to define the course and
outcome.
Methods: Bariatric patients (n=324) were reviewed
retrospectively. Substantially elevated plasma CK
after operation was identified in 4.9% (16/324). The
affected population was divided into Group I (n=11,
68.8%) with CK 1050-8000 IU/L and no conspicuous
muscle pain, weakness or swelling, and Group II (n=5,
31.2%) displaying CK >8000 IU/L and severe pain and
dysfunction. The main outcome measures were CK
concentration, frequency of renal failure, need for
hemodialysis and mortality.
Results: Group I subjects compared to Group II were
younger (37.7 ± 10.9 vs 44.0 ± 5.5 years, P<0.05) and
predominantly females (72.7% vs 40.0%, P<0.05). Peak
CK values were definitely lower (2811 ± 952 vs 28136 ±
19000 IU/L, P<0.001), and none progressed to renal
failure (0% vs 40.0%, P<0.05). No difference was detect-
ed regarding preoperative BMI (50.8 ± 8.1 vs 54.6 ± 7.0
kg/m2, NS), duration of operation (5.3 ± 1.6 vs 5.6 ± 2.1
hours, NS) or types of anesthetic drugs (basically fen-
tanyl, nitrogen oxide and halothane/isoflurane).
Conclusions: 1) Demographic features, nominally
gender and age, were different between the two
degrees of RML; 2) Renal failure and hemodialysis
were a danger only in patients with massive CK ele-
vation and muscle pain; 3) Moderate CK increase was
very well tolerated and rarely entailed major clinical
symptoms; 4) Early diagnosis, fluid replenishment
and general supportive therapy probably contributed
to avert mortality.
Reprint requests to: Joel Faintuch, MD, PhD, Hospital das
Clinicas, Haddock Lobo 180/ 111, São Paulo, SP 01414-000,
Brazil. Fax: (5511) 30697560; e-mail: faintuch@net.ipen.br
Key words: Rhabdomyolysis, morbid obesity, bariatric sur-
gery, gastric bypass, renal failure, hemodialysis
Introduction
Rhabdomyolysis (RML) is an unusual but well-
demonstrated complication of bariatric operations.
RML is associated with multiple technical modali-
ties, from restrictive to malabsorptive and mixed
operations, equally involving open and laparoscopic
approaches.1-6 Obese subjects but also those with
normal weight are vulnerable to the same compli-
cation when undegoing other prolonged operations
or when awkward or uncomfortable positions are
required.7-13 The pathophysiology of RML has been
studied extensively, especially because of diverse
and convenient experimental models,14-16 and
includes both local and systemic triggers.
From the surgical point of view, prolonged immo-
bilization, ischemia, acidosis, crushing injury and
compartment syndrome tend to be the most relevant
phenomena. Nevertheless, just localized pressure
over muscle groups of the shoulders, back, buttocks
and lower limbs, generated during several hours by
gravity forcing a massive body against an unyield-
ing surgical table, may be sufficient for damage of
muscle sarcolemma and leakage of intracellular
content into the circulatory system.1,2,6,17,18
Despite a long and respectable history19,20 and
extensive international experience,17,18 not all ques-

© FD-Communications Inc. Obesity Surgery, 16, 2006 1209

Articles 8/14/06 1:25 PM Page 1210
Faintuch et al
tions concerning the course and complications of
RML have been answered. The main uncertainties
concern frequency in bariatric candidates where
clinical studies are fairly scarce, and notably prog-
nostic interpretation of CK findings.
In a retrospective study with a homogeneous popu-
lation submitted to a single operative technique, find-
ings concerning frequency, severity and outcome were
analyzed, aiming to assess prognostic value of CK
concentration, renal complications, and mortality.
Methods
Experimental Design
This was a retrospective observational cohort study
with patients of the Obesity Surgery Group of
Hospital das Clínicas of São Paulo. All bariatric
subjects treated during a 84-month period (February
1999-February 2006) (n=324) were retrospectively
screened for postoperative CK aberrations and sub-
sequent clinical events.
Criteria for Inclusion: Male or female patients
(18-70 years), submitted to open Roux-en-Y gastric
bypass (RYGBP), with or without associated proce-
dures (cholecystectomy, hernia repair, liver biopsy,
etc), were investigated in this study.
Criteria for Exclusion: Excluded were patients
with alcohol abuse, myopathy, malignant hyperther-
mia, seizures , renal disease, any hospitalization for
major surgery, trauma, myocardial infarction or
other ischemic episodes in the last 30 days, incom-
plete medical chart, or lack of CK measurements
confirming the diagnosis of RML.
Methods
Documented variables included demographic infor-
mation, anthropometrics (body mass index, BMI),
general biochemical determinations, serum creatine
kinase (CK), surgical and anesthetic routine, renal
complications, specific therapeutic assistance (flu-
ids and electrolytes, medications) and clinical
course during hospitalization.
Serum CK was measured by immunoenzymofluo-
rimetric technique, using commercial kits and a
Hitachi 747 Analyser (Roche Diagnostics, São Paulo,
Brazil). The upper limit of normal was 204 IU/L for
1210 Obesity Surgery, 16, 2006
males and 173 IU/L for females. For the purposes of
this study, RML was defined as a CK >1050 IU/L.6
Exclusions: There were no exclusions in this pro-
tocol, as the listed criteria are similar to those
employed for bariatric surgery itself.
Stratification: Patients were stratified according to
muscle pain, swelling and dysfunction, as well as to
peak serum CK value, in Group I (n = 11) with tran-
sient or inconspicuous pain and CK <8000 IU/L
(minor rhabdomyolysis), and Group II (n= 5) with
severe shoulder, back or buttock pain, swelling and
weakness and CK >8000 IU/L (extensive RML).11, 21
Surgical Technique: Open RYGBP involved the cre-
ation of a gastric pouch of approximately 30 ml, a
Roux-en-Y jejunal limb of 100 cm, and a biliopan-
creatic limb of 60-80 cm. Drainage was routinely pro-
vided. Operations were performed by residents under
the guidance of senior members of the surgical staff.22
Anesthetic Interventions: Premedication was done
with a diazepam preparation. Anesthesia was usually
induced with fentanyl, and muscular relaxation was
achieved with atracurium. Then, the trachea was intu-
bated, and anesthesia was maintained with isoflurane
or halothane and 50% nitrous oxide in oxygen.
Postoperative analgesia was performed with dipy-
rone, toradol or morphine, depending on complaints.
Postoperative Monitoring: CK assessment was
not obligatory, and measurements were requested
based on suggestive cardiac or peripheral muscular
abnormalities. All CK determinations were accom-
panied by estimation of CK isoenzyme MB fraction,
troponin and electrocardiographic monitoring, in
order to exclude myocardial infarction.
Perioperative Prophylaxis: Padding of the surgi-
cal table was not a routine in this series, nor was any
special fluid or mannitol protocol employed during
the operation. However, if RML was suspected and
elevated CK was confirmed after surgery, continu-
ous intravenous hydration and alkalinization with
sodium bicarbonate was started, and osmotic or
tubular diuretics were complemented if oliguria
ensued, until normalization of enzyme levels.
Statistical Analysis: Numerical findings are
shown as mean ± SD. Comparison between the
groups was done by Student’s t-test and Mann-
Whitney test, as appropriate, whereas qualitative
variables were submitted to Chi-square analysis
with Yates correction or Fischer exact test. A signif-
icance level of P<0.05 was selected.
Articles 8/14/06 1:25 PM Page 1211

Rhabdomyolysis: Severity and Outcome Patterns

Results Table 4. Clinical outcome

Variable Group I Group II Significance

The entire group of 324 subjects was retrospective-
ly screened for postoperative manifestations of Post-op stay 7.0 ± 6.9 9.8 ± 4.2 NS
RML, including acute renal failure or hemodialysis, (days) (4-25) (4-15)
but only 129 (39.8%) had been evaluated with Renal failure 0 40.0% (2/5) P<0.05
Hemodialysis 0* 40.0% (2/5) P<0.05
serum CK after operation. Sixteen patients were Mortality 0 0 NS
diagnosed with RML (4.9% of the total population,
or 12.9% of those with CK evaluation). These were * One patient with arterial hypertension and chronic
divided as 11 minor and 5 major forms. Principal atrial fibrillation was managed by 48 hours of ultrafiltra-
tion for lung edema in the course of postoperative inten-
findings are shown in Tables 1-4.
sive hydration. Her peak CK was only 2.8 mg/dL.
Cases of both minor and major RML received
intravenous hydration and alkalinization with sodi-
um bicarbonate. No patient progressed to compart- ment syndrome or muscle necrosis; thus, decom-
pression maneuvers and surgical debridement were
Table 1. Demographic and general features not necessary. Also, in these patients, no mortality
or sequelae resulted.
Variable Group I Group II Significance

Age(years) 37.7±10.9 44.0±5.5 P<0.05

(34-62) (38-52) Discussion
Gender
(Male/Female) 8F/ 3M 3M/ 2F P<0.05
BMI (kg/m2) 50.8 ± 8.1 54.6 ± 7.0 NS Rhabdomyolysis (RML) after elective surgery is not
(42.1-70.0) (46.6-66.7) a frequent complication. Nevertheless, it occurs more
than generally imagined, because episodes are dis-
Operations: Open RYGBP
persed among many settings and specialties. More
than 50 diseases and conditions can be associated
with this complication, besides dozens of drugs and
Table 2. Principal co-morbidities
assorted herbs.17,18 RML has been estimated to
Variable Group I Group II Significance account for 3-15% of all cases of acute renal failure.16
Predominance of RML in males was noticed some
Arterial 54.5% 60.0% NS years ago, probably because of the larger muscle
hypertension (6/11) ( 3/5)
mass,2,3,17,23 and this association was found here
Diabetes 18.2% 20.0% NS
mellitus (2/11) (1/5) with regard to major RML, but not in the less
Sleep apnea 9.1% 20.0% NS aggressive category.
(1/11) (1/5) Massive BMI1,3,6 as well as operations of long dura-
Hyperlipidemia 9.1% 20.0% NS tion2,3,5,22 are also classical detrimental conditions. In
(1/11) (1/5) this study, no difference could be demonstrated for
these variables, but it must be recognized that all sub-
Table 3. General and biochemical findings jects displayed mean BMI in the range of super-obe-
sity, and suffered very lengthy interventions.23
Variable Group I Group II Significance Minor RML (Group I) did not feature a different
profile from the major alternative. These patients
Operating time 5.3 ± 1.6 5.6 ± 2.1 NS
(hours) (4.5-9.0) (4.0-9.5)
were as severely obese as those in Group II, displayed
Peak serum 2811 ± 952 28136 ± 19000 P<0.001 equivalent co-morbidities and underwent equally pro-
CK (IU/L) (1117-5174) (8754-55010) longed operations. Yet muscle pain and weakness
Day of peak 1.6 ± 1.2 1.4 ± 0.8 NS were virtually absent, kidney function remained
CK (1-4) (1-4) almost undamaged, and outcome was favorable.

Obesity Surgery, 16, 2006 1211

Articles 8/14/06 1:25 PM Page 1212
Faintuch et al
The only significant complication in Group I was
one case of lung edema requiring ultrafiltration for
48 hours, in a patient with previous moderate heart
troubles (Table 4). In retrospect, intravenous hydra-
tion because of CK elevation should have proceed-
ed more slowly in this patient.
A consensus exists that elevations of CK below
five times the upper limit of normal (<5 ULN) are
mostly irrelevant, because drugs, surgical and anes-
thetic manipulations, muscle incisions and multiple
other mechanisms may be responsible for such
oscillations6,17,21,22 CK >10 ULN may be induced by
statins and other lipid-lowering drugs in proportions
of <0.1% of treated patients.24 Uncertainties center
around chances of progression to full-fledged RML,
and the corresponding CK threshold.25
In the current report, dialysis was mandatory on
two occasions of major RML. Other patients with
massive CK elevation suffered little nephrologic
compromise as well as no mortality, thus reinforc-
ing the message that attention to CK determination
whenever suggestive symptoms arise, and appropri-
ate and timely intervention, are the mainstays of
therapeutic success.1-6,11
Less prolonged operations are always advisable
despite lack of statistical differences in this study,
because both current groups remained for many
hours on the operating table.2,3,5,22
One unproven prophylactic measure that is inex-
pensive and harmless, is generous padding.26
Nowadays, surgical tables for patients who weigh
>300 kg can easily be purchased on the internation-
al market, and most models and brands are updating
the mattress, that typically had a thickness of 5 cm
(two inches).2,13 It is our belief that more substantial
physical protection of the patient, with a cushion
three times as thick, would considerably reduce the
incidence of RML in the obese population.
It is debated as to whether CK measurements are
mandatory after bariatric interventions.3,18 As large
population studies are not available, and some expe-
rienced services have not observed a case of RML,
the cost/benefit ratio would seem unfavorable. In
Hospital das Clinicas, the CK test was recently adopt-
ed as routine, because the current study indicated that
the risk for this complication was not negligible.
The most important concept generated by this
protocol is the classification of dangerous versus
minor syndromes based not only on CK values but
1212 Obesity Surgery, 16, 2006
also on pain manifestations. RML followed by
relentless pain and functional impairment is consis-
tent with either extensive cellular necrosis, massive
swelling or a compartment syndrome, which signal
high-risk situations.8,13,21,22
Conclusions
1) Male gender and older age were associated with
higher risk for severe RML. 2) Renal failure was a
danger only in patients with massive CK elevation. 3)
Moderate CK increase was very well tolerated and
rarely entailed major clinical symptoms. 4) Early
diagnosis, fluid replenishment and general supportive
therapy probably contributed to avert mortality. 5)
Classification of RML according to both pain and CK
level is suggested, because of its prognostic value.
References
1. Torres-Villalobos G, Kimura E et al. Pressure-induced
rhabdomyolysis after bariatric surgery. Obes Surg.
2003; 13: 297-301.
2. Khurana RN, Baudendistel TE, Morgan EF et al.
Postoperative rhabdomyolysis following laparoscopic
gastric bypass in the morbidly obese. Arch Surg 2004;
139: 73-6.
3. Bostanjian D, Anthone GJ, Hamoui N et al.
Rhabdomyolysis of gluteal muscles leading to renal
failure: a potentially fatal complication of surgery in
the morbidly obese. Obes Surg 2003; 13: 302-5.
4. Anthone GJ, Lord RVN, DeMeester TR et al The duo-
denal switch operation for the treatment of morbid
obesity. Ann Surg 2003; 238: 618-28.
5. Collier B, Goreja MA, Duke BE 3rd. Postoperative
rhabdomyolysis with bariatric surgery. Obes Surg
2003; 13: 941-3.
6. Mognol P, Vignes S, Chosidow D et al.
Rhabdomyolysis after laparoscopic bariatric surgery.
Obes Surg 2004; 14: 91-4.
7. Cone AM, Schneider M. Massive rhabdomyolysis
following cardiopulmonary bypass. Anesth Intensive
Care 1995; 23: 721-4.
8. Ferreira TA, Pensado A, Dominguez L et al.
Compartment syndrome with severe rhabdomyolysis
in the post-operative period following major vascular
surgery. Anesthesia 1996; 51: 692-4.
Articles 8/14/06 1:25 PM Page 1213
9. Biswas S, Gnanasekaran I, Ivatury RR et al.
Exaggerated lithotomy position-related rhabdomyoly-
sis. Am Surg 1997; 63: 361-4.
10.Lachiewicz PF, Latimer HA. Rhabdomyolysis follow-
ing total hip arthroplasty. J Bone Joint Surg Br 1991;
73: 576-9.
11.Choufane S, Lemogne M, Jacob L. Unexpected rhab-
domyolysis with myoglobinuria in a patient in the
supine position. Eur J Anaesthesiol 1998; 15: 493-6.
12.Hofmann R, Stroller ML. Endoscopic and open sur-
gery in morbidly obese patients. J Urol 1992; 148:
1108-11.
13.Iseri C, Senkul T, Reddy PK. Major urologic surgery
and rhabdomyolysis in two obese patients. Int J Urol
2003; 10: 558-60
14. Perri G, Gorini P. Uremia in the rabbit after injection of
crystaline myoglobin. Br J Exp Path 1952; 33: 440-4.
15.Fernandez-Funez A, Polo FJ, Broseta L et al. Effects
of N-acetylcysteine on myoglobinuric-acute renal
failure in rats. Ren Fail 2002; 24: 725-33.
16.Chander V, Singh D, Chopra K. Reversal of experi-
mental myoglobinuric acute renal failure in rats by
quercetin, a bioflavonoid. Pharmacology 2005; 73:
49-56.
17.Meijer ARD, Fikkers BG, Keijzer MHD et al. Serum
creatine kinase as predictor of clinical course in rhab-
domyolysis: a 5-year intensive care survey. Intensive
Care Med 2003; 7: 1121-5.
18.Singh D, Chander V, Chopra K. Rhabdomyolysis.
Rhabdomyolysis: Severity and Outcome Patterns
Exp Clin Pharmacol 2005; 27: 39-48.
19.Meyer-Betz F. Beobachtungen an einem
Eigentartigen mit Muskellahmungen verbunden fall
von Haemoglobinurie (Observations on an unique
case of hemoglobinuria associated with muscle
injury). Dtsch Arch Klin 1911; 101: 5.
20.Bywaters EGL, Beall D. Crush injuries with impair-
ment of renal function. BMJ 1941; 1: 427-34
21.Bertrand, M, Godet G, Fleron MH et al. Lumbar mus-
cle rhabdomyolysis after abdominal aortic surgery .
Anesth Analg 1997; 85: 11-5.
22.Hiratsuka Y, Ishii T, Takeuchi F et al. Risk of elevat-
ed creatine kinase and myoglobulinemia due to
incised muscles in patients who underwent urological
surgery. J Urol 2003; 170: 119-21.
23.Stroh C, Hohman U, Remmler K et al. Rhabdo-
myolysis after biliopancreatic diversion with duode-
nal switch. Obes Surg 2005; 15: 1347-51.
24.Heart Protection Study Collaborative Group.
MRC/BHF Heart Protection Study of cholesterol low-
ering with simvastatin in 20,536 high-risk individuals:
a randomised placebo-controlled trial. Lancet 2002;
360 (9326): 7-22.
25.Wortmann RL. Lipid-lowering agents and myopathy
Curr Opin Rheumatol 2002; 14: 643-7.
26.Ettinger JEMTM, Filho PVS, Azaro E et al.
Prevention of rhabdomyolysis in bariatric surgery.
Obes Surg 2005; 15: 874-9.
(Received February 14, 2006; accepted April 19, 2006)
Obesity Surgery, 16, 2006 1213