Bariatric Times July/August 2007

Musculoskeletal Perspective Bariatric Times • July/August 2007 Resolution of Fibromyalgia Following Laparoscopic Roux-en-Y Gastric Bypass by Michael J. Boros, MD; Mohamed H. Elgamal, MD; and Alan A. Saber, MD, MS, FACS Dr. Boros is Chief Surgical Resident, Dr. Elgamal is Surgical Resident, and Dr. Saber is Chief of Minimally Invasive Surgery and Bariatric Surgery, Associate Professor of Surgery—All with Michigan State University, Kalamazoo Center for Medical Studies in Kalamazoo, Michigan. INTRODUCTION Fibromyalgia is a clinical syndrome characterized by chronic fatigue, widespread musculoskeletal pain, multiple tender points, skin sensitivity, sleep disturbance, and muscle stiffness. In the United States, 3 to 5 percent suffer from this debilitating disorder.1,2 Treatment of this disorder is a challenge. We herein present a morbidly obese patient with long-standing fibromyalgia that dramatically improved following weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGBP). To our knowledge, there is no previously reported data on the effect of bariatric surgery on fibromyalgia. 120mg, and mycophenolate mofetil 2500mg. In addition, she received human immune globulin at five-week intervals for persistent weakness in the upper extremities, double vision, and difficulty to chew. For the last five years, numerous attempts of dietary and medical treatment for obesity have failed. Due to her obesity, exercise was very difficult to achieve. Physical examination revealed 18 out of 18 positive point of tender. After extensive preoperative workup, she underwent a LRYGBP with a 100cm alimentary limb and a 50cm biliopancreatic limb. The postoperative period was uneventful. At one-year follow-up, she lost 73 pounds and her BMI is now 26.7Kg/m2.This was associated with resolution of her long-standing fibromyalgia as indicated by amelioration of her 18 points of tenderness down to 6. Her need for medications to suppress fibromyalgiarelated symptoms has markedly decreased (prednisone 1mg daily and mycophenolate mofetil 750mg daily). Her exercise tolerance has dramatically improved. This was also accompanied by resolution of her comorbidities. DISCUSSION The American College of Rheumatology criteria for the diagnosis of fibromyalgia include history of widespread pain that has been present for at least three months.3 The pain must be distributed through both sides of the body and both upper and lower parts of the body. Additionally, pain should be found in 11 out of 18 tender points on digital palpation (Table 1). It is 10 times more common in women. However, fibromyalgia is seen in both sexes, all age groups, and all ethnicities.4 Symptoms associated with fibromyalgia include cognitive difficulties with attention and memory, obesity, allergies, series of regional CASE REPORT pains, including noncardiac chest pain, A 38-year-old morbidly obese dyspepsia, headache, abdominal woman, who weighed 232 pounds and cramping (irritable bowel syndrome), had a body mass index (BMI) of temporomandibular pain, and chronic 38.6Kg/m2, had a significant history of pelvic pain, syncope, shortness of fibromyalgia for 13 years. She is also breath, sleep apnea, and urinary suffers from multiple obesity-related frequency and urgency.5 Fibromyalgia comorbidities, including has a significant association with the hypertension, gastroesophageal psychological and psychiatric reflux, obstructive sleep apnea, condition of the patient.6 arthritis, and depression. Her daily There is no known cure for medications for fibromyalgia included fibromyalgia; the current treatment prednisone 5mg, pyridostigmine strategy is chiefly symptomatic.7 The main aspect of patient management is good doctorTABLE 1. American Society of Rheumatology criteria for diagnosis of fibromyalgia patient relationship and the use of cognitive behavioral • Widespread pain for at least three months therapy in order to eliminate • Pain in both sides of the body Pain • Pain above and below the waist stress and develop positive • Axial pain must be present pain beliefs and coping strategies.8 Pharmacologic • Pain on pressure with the approximate force of 4kg in 11 out treatment of fibromyalgia Tender points of 18 points includes the use of anxiolytic/hypnotics, skeletal muscle relaxants, TABLE 2. Treatment of fibromyalgia antidepressants, and • Good doctor patient relationship anticonvulsants.9 • Stress management-relaxation techniques-activity pacingTwenty-four percent of Cognitive/behavioral coping strategies. fibromyalgia patients have a • Proper sleep hygiene body mass index above 30.10 Weight loss through diet and • Massage-heat therapy exercise has been proposed as • Chiropractic manipulation-myofascial release Physical therapy a method to improve • Graded aerobic exercise symptoms of fibromyalgia. • Trigger point injection-acupuncture Loss of five percent of body Weight loss Diet and exercise improve symptoms weight has been associated with mild improvement of CLASS EXAMPLES fibromyalgia symptoms.11 Anxiolytics/hypnotics Alprazolam-clonazepam-zolpidem Bariatric surgery has been Medications Skeletal muscle relaxants Cyclobenzaprine found to improve the Antidepressants Amitriptyline-duloxetine musculoskeletal complaints of Anticonvulsants Gabapentin-pregabalin-topiramate obese patients.12 In general, physical exercise becomes remarkably easier after bariatric surgery with subsequent improvement of the musculoskeletal condition and the general health condition of the patient. Bariatric surgery is known to improve many of the comorbidities associated with fibromyalgia, including depression, musculoskeletal pain, and sleep disturbance (Table 2). CONCLUSION In conclusion, fibromyalgia, as with many other obesity-related comorbidities, could significantly improve or completely resolve after bariatric surgery with marked improvement of quality of life. REFERENCES 1. 2. Reiffenberger DH, Amundson LH. Fibromyalgia syndrome—A review. Is Fam Physician 1996;53(5):1698–712. Gran JT. The epidemiology of chronic generalized musculoskeletal pain. Best Pract Res Clin Rheumatol 2003;17(4): 547–61. Wolfe F, Smyth HA, Yunus MB. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33(2):160–72. Yunus MB. Gender differences in fibromyalgia and other related syndromes. J Gend Specif Med 2002;5(2):42–7. Longley K. Fibromyalgia: Aetiology, diagnosis, symptoms and management. Br J Nurs 2006;15(13):729–33. Bradley LA. Psychiatric comorbidity in fibromyalgia. Curr Pain Headache Rep 2005;9(2):79–86. Lucas HJ, Brauch CM, Settas L. Fibromyalgia: New concepts of pathogenesis and treatment. Curr Pharm Des 2006;12(1):3–9. Garcia J, Simon MA, Duran M, et al. Differential efficacy of a cognitive-behavioral intervention versus pharmacological treatment in the management of fibromyalgic syndrome. Psychol Health Med 2006;11(4):498–506. Baker K, Barkhuizen A. Pharmacologic treatment of fibromyalgia. Curr Pain Headache Rep 2005;9(5):301–6. Mengshoel IS, Haugen M. Health status in fibromyalgia—A follow-up study. J Rheumatol 2001;28(9):2085–9. Shapiro JR, Anderson DA, Danoff-Burg S. A pilot study of the effects of behavioral weight loss treatment on fibromyalgia symptoms. J Psychosom Res 2005;59(5):275–82. Hooper MM, Stellato TA, Hallowell PT. Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery. Int J Obes (Lond) 2007;31(1):114–20. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. CORRESPONDING AUTHOR: Alan A Saber, MD, MS, FACS, Chief of Minimally Invasive Surgery, Michigan State University, Kalamazoo Center for Medical Studies, 1000 Oakland Drive, Kalamazoo, Michigan 49008; Phone: 269-337-6260; Fax: 269-337-6222; E-mail: saber@kcms.msu.edu

Table of Contents Feed for the Digital Edition of Bariatric Times July/August 2007

Cover Editorial Message Table of Contents Editorial Board Letter to the Editor Malpractice Preventative Maintenance: Record Protocols and Happy Lawyers Resolution of Fibromyalgia Following Laparoscopic Roux-en-Y Gastric Bypass University General Hospital Bariatric Program at University General Hospital Journal Watch Category List Trade Name Index Company Index Products and Services

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