Transcript File - adrienne Gebele, rd

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Gastric Bypass
Complications &
Parenteral Nutrition
By: Adrienne Gebele
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What is Bariatric Surgery?

Surgical procedure that
cause weight loss by
restricting the amount of
food the stomach can hold,
causing malabsorption of
nutrients, or by a
combination of both gastric
restriction and
malabsorption.

200,000 Americans get
Bariatric surgery a year
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Bariatric surgery improves
comorbid conditions in morbidly
obese patents such as:
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Coronary artery disease
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Dyslipidemia
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Type 2 diabetes mellitus
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Obstructive sleep apnea
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Hypertension
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Nonalcoholic liver disease
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Degenerative joint disease
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Candidates and Criteria for
Surgery
1.
BMI > 40 or BMI > 35 and at least 2 obesity-related comorbidities.
2.
Pt understands possible risks, benefits, and side effects
3.
Pt is committed to lifestyle changes
4.
Pervious weight loss efforts
5.
No serious medical, psychiatric, or emotional condition
that would limit adherence
6.
Stable for surgery
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Contraindications for Surgery
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Current smoker
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Alcohol abuse
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Cardiac instability
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Clotting disorders
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Severe heart and lung disease
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Active unstable liver disease
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Autoimmune connective tissue disease
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Poorly controlled psychopathology
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Documented non-compliance
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Under the age of 18 years of age
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Pregnancy
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4 Common Types of Bariatric
Surgery:
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Roux-en-Y Gastric Bypass
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Laparoscopic Sleeve Gastrectomy
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Laparoscopic Adjustable Gastric Band
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Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Gastric Bypass
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Roux-en-Y Gastric Bypass (RYGBP)

Considered the ‘gold standard’
of weight loss surgery
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Procedure
1.
Small stomach pouch is created
2.
The first part of the small
intestine is divided and the
bottom end of the divided
small intestine is brought up
and connected
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Advantages
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Disadvantages
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Laparoscopic Sleeve Gastectomy
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Surgically removing approximately
80% of the stomach.

Short term studies show the sleeve
is as effective as the roux-en-Y
gastric bypass in terms of weight
loss and improvement or remission
of diabetes
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Complications fall between
adjustable gastric band and rouxen-Y gastric bypass.
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Advantages
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Disadvantages
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Laparoscopic Adjustable Gastric
Band (LAGB)

Involves an inflatable band
that is placed around the
upper portion of the stomach,
creating a small stomach
pouch above the band, and the
rest of the stomach below the
band.

The size of the stomach
opening can be adjusted by
filling the band with sterile
saline, which is injected
through a port placed under
the skin.
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Advantages
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Disadvantages
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Biliopancreatic Diversion with
Duodenal Switch (BPD/DS) Gastric
Bypass
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A procedure with 2 components:
1.
A small, tubular stomach pouch is
created by removing a portion of the
stomach
2.
A large portion of the small intestine is
bypassed
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Advantages
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Disadvantages
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Common Nutrition Related
Complications
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Anemia
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Metabolic Bone Disease
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Failure to Thrive
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Protein Calorie Malnutrition
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Steatorrhea
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Wernicke Encephalopathy
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Polyneuropathy and Myopathy
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Visual Disturbances
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Skin Rashes
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Dietitian’s Role
“The RD’s role within the multidisciplinary team is
multifaceted. The RD’s responsibilities include pre- and
postoperative education, focusing evaluation and assessment
on nutritional status, screening for clinical issues that require
physician follow-up, assisting the patient in making an
informed decision about the procedure, and assessing and
treating nutritional deficiencies.”

Betsy Lehman, Expert Panal
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Nutrient Supplementation
for Parenteral and Enteral
Nutrition
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2 daily MVI with multitrace
elements
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1200-200 mg Calcium Citrate
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400-800 IU Vitamin D
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400mcg Folate
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40-65mg Elemental Iron
(menstruating women)
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> 350mcg B12
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Following bariatric surgery, most patients
successfully progress to an oral diet designed to
promote weight loss. However, up to 16% of patients
may experience postoperative complications, and in
some cases, oral intake is limited or contraindicated
due to need for prolonged bowel rest or
reoperation.
+ Article One: Application of the A.S.P.E.N. Clinical Guidelines
for Nutrition Support of Hospitalized Adult Patients With
Obesity: A Case Study of Home Parenteral Nutrition
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43 year old women
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Pre Operation
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Weight: 165.2 kg (363lbs)
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Height: 178 cm ( 70in)
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BMI: 52.2
2 weeks Post Operation
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Weight: 153.2 kg (337lbs)
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Height: 178 cm (70in)
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BMI: 48.47
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The Patient’s Journey
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Laparoscopic surgery
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Discharged post operation home day 3
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Readmitted post operation day 6
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Discharged post operation day 8
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Readmitted post operation day 14 (PN begins)
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Post operation day 27
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Post operation day 37
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Post operation day 60 (PN stopped)
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Post operation day 160
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Estimated Needs:
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Calories:
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Mifflin-St Jeor using ABW: 2275 kcals
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For weight loss (50-70% of needs):1138-1600 kcals
Protein:
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Using 2.5g/kg: 175 g protein
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Conclusion
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Further cohort based off of this case study
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This case study demonstrated how hypocaloric, high protein
PN can bridge the gap and reduce the chances of
malnutrition during bariatric malnutrition.
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Further studies should be administered
+ Article Two: Hypocaloric Home Parenteral Nutrition
and Nutrition Parameters in Patients Following
Bariatric Surgery
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N= 23 patients
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How needs were determined:
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BMI <25 received 25-35 kcals/kg ABW and 1.5-2 g protein/kg
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BMI 25-29.9 received 20-25 kcals/kg ABW and 1.3-1.7 g
protein/kg
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BMI 30-34.9 received 15-20 kcals/kg ABW and 1.2-1.6 g
protein/kg
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BMI >35 received 10-15 kcals/kg ABW and 1.1-1.5 g protein
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Frequency of Readmissions
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Conclusion
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First study to evaluate home PN use in morbidly obese
patients after complication in bariatric surgery.
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Many complications of bariatric surgery require NPO for a
long period of time. PN can help prevent malnutrition during
times of complications.
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Nutrition goals of weight loss and visceral protein repletion
can be met providing a hypocaloric PN formula.
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Future studies are needed.
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Questions?
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Works Cited:
Bariatric Surgery Procedures - ASMBS. (n.d.). Retrieved March 10, 2016, from
https://asmbs.org/patients/bariatric-surgery-procedures#bypass
Beebe, M., & Crowley, N. (n.d.). Can Hypocaloric, High-Protein Nutrition Support Be Used
in Complicated Bariatric Patients to Promote Weight Loss? 30(4), 522-529.
Hamilton, C., Dasari, V., Shatnawei, A., Lopez, R., Steiger, E., & Seidner, D. (2011).
Hypocaloric Home Parenteral Nutrition and Nutrition Parameters in Patients Following
Bariatric Surgery. Nutrition in Clinical Practice, 26(5), 577-582.
Isom, K., Andromalos, L., Ariagno, M., Hartman, K., Mogensen, K., Stephanides, K., &
Shikora, S. (2014). Nutrition and Metabolic Support Recommendations for the Bariatric
Patient. Nutrition in Clinical Practice, 29(6), 718-739.
Muller CM, eds. Adult Nutrition Support Core Curriculum, 2nd edition. United States: Society
for Parenteral and Enteral Nutrition; 2012: 610-12
Schiavone, P., Piccolo, K., & Compher, C. (n.d.). Application of the A.S.P.E.N. Clinical
Guideline for Nutrition Support of Hospitalized Adult Patients With Obesity. Nutrition in
Clinical Practice, 29(1), 73-77.
Shankar, Padmini, Mallroy Boylan, and Kristnan Sriram. “Micronutrient deviancies after
bariatric surgery.” Nutrition. 26. (20110): 1031-1037. Print.