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Till Death Do We Part
The Life-long Journey of a Bariatric Surgical
Patient
Tina Musselman MA, RD, CCN
St. James Center for Bariatric Surgery Mind, Body & Wellness Institute, Inc.
Program Coordinator
[email protected]
[email protected]
(708) 846-5816
(708) 679-2717
Obesity…Intervention
BMI
RYGB, AGB (BMI 30),
Duodenal Switch,
Gastric Sleeve
Surgery
35
Phentermine, Meridia, Xenical
(Byetta), Band(?)
Pharmacotherapy
30
Lifestyle Modification
Diet
Physical Activity
25
http://cme.medscape.com/viewarticle/712986?src=cmemp&uac=98478HV
The Reality of Bariatric Surgery
# of bariatric cases grew 400% from 1998-2004
– 13,386 to 121,055 per year
– 220,000 performed in 2008
82% of surgical cases are female
Age
– Ages 18-54 accounted for 85.2% of all surgeries
– FASTEST GROWTH IN BARIATRIC SURGERY IS FOR
AGES 55-64 (20 fold increase)
RD’s can run, but we cannot hide!
Healthcare Cost and Utilization Project, Statistical Brief #23 (January 2007)
Eligibility
BMI
– BMI 35-39.9 with 1 - 2 obesity-related co-morbidities (DM, HTN, dyslipidemia,
severe OA, OSA, Pickwinian Syndrome)
– BMI > 40
– New indications for Lap Band - BMI 30-34.9 (not covered by insurance yet)
Age
– Adults over 18
– Controversy over 65 y.o. - evaluated case by case
– Adolescent trials are currently being done
Growth must be completed
Some insurances may cover it
“Exhausted all non-surgical weight loss options”
CKD/ESRD is NOT a contraindication
Adjustable Gastric Band
(Lap Band® & Realize Band)
1988 approved by FDA in
June 2001
15 ml pouch
Adjustable stoma size
Digestive tract remains in tact
2/2011 - Lap Band approved for
BMI 30-35 + co-morbids
Roux en Y Gastric Bypass
(RYGB)
1971
15-30 ml pouch
Roux limb 75-150 cm
– Longer in Super Obese
Biliopancreatic Limb
– Carries gastric juice
– Bile and Pancreatic juice
– 15-60 cm
Distal Common Channel
– 200-500 cm
– All of the ileum and some jejunum
– Bulk of digestion and absorption
RYGB vs. AGB (Lap Band)
RYGB
AGB
Weight Loss
70% EBW at 1 yr.
20# wt regain around 2 yrs.
Post-op
50% EBW at 2 yrs
Wt loss may stabilize at 4 yrs
post op
Short Term
Complications
1 yr. post op
0.5% mortality
Similar to any surgery
Anastomotic Leak
Stomal Stenosis (4.9%)
Internal Hernia (2.5%)
Gallstones (1.4%)
Suture Line Ulcers (1.4%)
Staple Line Failure (1.0%)
Bleeding (0.9%)
Death (0.6%)
Dehydration
Hair Loss (iron and
Protein)
0.1% mortality
Similar to any surgery
Gallstones
Dehydration
RYGB vs. AGB (Lap Band)
RYGB
Long-Term
Complications
Misc…
AGB
Hypoglycemia
Gastro-gastric Fistula
Stomal Stenosis
Bowel Obstruction
Nutritional (peaks >5 yrs.
post op)
- B12, Folic Acid, Iron,
Calcium, Vit D
Weight Regain
Loss of LBM
Vomiting more common
Gastric prolapse
Obstruction
Esophageal and pouch
dilation
Gastric erosion and
necrosis
Port access problems
Weight regain
Dumping Syndrome
Gradual shift away from
solid food
Treatment and Outcomes, FNCE Pre-symposium Workshop by Chris Eagon, MD; October 2005
5 year comparison
Band has the highest safety profile for all bariatric procedures
The “new kid on the block” in bariatrics
Laparoscopic Sleeve gastrectomy
Partial Gastrectomy (60-80%
removed)
Small bowel remains intact
Founded as part of the first step in a
two step surgical process for the
super obese
New- more to learn about
sustainability and safety
Results similar to RYGB
SG
Weight Loss
Short Term
Complications
1 yr. post op
Long Term
Complications
62-69.4% EBW loss at 18 mos
Similar to any surgery
bleeding
Fistula
Stenosis/obstruction
Staple line leak
GERD (0-83%)
Gerd (5% at 2 yrs)
Nutritional deficiencies ?
?
Chouillard et al. Laparoscopic RYGB vs Sg for morbid obesity: Case controlled study.. SOARD 2011; 7: 500-505.
Micronutrition
Factors common to all procedures that increase
nutritional risk
–
–
–
–
–
Poor eating behaviors,
Decreased nutrient dense foods
Food intolerance
Restricted portion sizes
(Emesis)
Micronutrition - Gastric Bypass
Etiology:
– GERD (PPI’s)
– Emesis
– transit time/diarrhea
Most common deficiencies
– Iron (20-51%): HCl
– B-12 (35%): HCl, IF
– Vit D
– Ca
– Folate (41-47%)
Micronutrition - Gastric Bypass
Etiology:
– GERD (PPI’s)
– Emesis
– transit time/diarrhea
Most common deficiencies
– Iron (20-51%): HCl
– B-12 (35%): HCl, IF
– Vit D
– Ca
– Folate (41-47%)
63% of pts developed nutrition deficiencies (Fe, B12, folate) 2 yrs. Post
RYGB including those who were compliant with the vitamin regimen.
(n=140)
- Brolin, et al 1991
Micronutrition - Sleeve gastrectomy
Etiology
– transit time
– Emesis/Nausea
– GERD (PPI’s)
– HCl
Common nutrient def.
– B12: 18% ?
– Fe: 18% ?
– Zn: 35% ?
– Folic Acid?
– Vit D?
Micronutrition - Sleeve gastrectomy
Little data on micronutrition and SG
1 yr. results without MVI
– 4.9-43% Fe def.
– 9-18.1% B12 def.
– 9.8-22% folate def.
Jacques, J., Goldenberg, L. Nutrition and the sleeve gastrectomy patient: From micronutrients
to dietary patterns. Bariatric Times 2011; 8(6):12-15.
Micronutrition - AGB
Etiology
– po intake
– Food intolerance
– Maladaptive eating
Micronutrition - AGB
Etiology
– po intake
– No alterations to
digestive processes
-“AGB has minor effects on normal physiological digestive
processes and, as a result, selective nutritional deficiencies
are presumed to be unusual…Closer clinical follow up is
more necessary (adjustments) after AGB than RYGB,
whereas the reverse is true for perioperative nutritional
evaluations.”
- Ziegler, O., Sirveaux, MA, et al, Diab. & Met. 2009, p. 544
& 553
Micronutrition - Summary
- very rare
+ rare
+ frequent
++ very frequent
AGB
RYGB
SG
Protein
-
+
-(?)
Iron
+
++
+
B12
+
++
+(?)
Ca/D
- or +
++
-(?)
Folate
+
+
+
B1
+
+
+(?)
Zn/Se
+
++
(?)
A, E, K
-
- or +
-
Vomiting
++
++
+
Ziegler, O., Sirveaux, MA., et al. Medical follow up after bariatric surgery: nutritional and drug issues General
recommendations for the prevention and treatment of nutritional deficiencies. Diab. & Metab 2009; 35: 544-557.
The Standard Supplementation
“There is little agreement on exactly how to manage micronutrition
in post-operative bariatric surgery patients.”
-
Jacqueline Jacques, ND Micronutrition for the Weight Loss Surgery Patient (2006)
Many patients will be malnourished pre-operatively leading to
more aggressive supplementation after surgery
– 51-62% pre-operative Vit D deficiency
Obese individuals may have needs above and beyond normal
recommendations
– Contributing mechanisms
Multiple medications
Years of poor diet
Underlying inflammation
Recommended Supplementation
AGB
Multiple vitamin
1,000 mg Calcium
B complex
Bile salt replacement
RYGB/SG
Multiple vitamin x 2 (100% RDA
including iron)
Sublingual B12
1,500 mg Ca + D
Thiamin (B complex)?
Supplemental iron for menstruating
women?
Bile salt replacement prn
Tablets or capsules can be tolerated 6 mo. and beyond
Multiple Vitamin and Calcium should not be taken together and
should be in divided doses
Common “Bariatric” Eating
Guidelines
1.
Protein and Produce
- At least 60 g. protein/day
- Liquids and “mushy” calories not recommended
- Foods not tolerated well: bread, rice, dry meat, some produce
2.
2-3 meals per day
- breakfast optional
- limited snacking
3.
Avoid eating and drinking at the same time
3.
1200-1400 calories per day long-term
A word about renal disease and bariatrics
Bariatric Surgery improves DM, obesity and HTN, three of the
leading causes of renal disease
“The more earlier we treat CKD in the disease process with
bariatric surgery, the more favorable the impact on the kidney.” Wei-Jei Lee.
Be aware of medical absorption changes
Monitor labs and adjust vitamins/macronutrients as appropriate
Thank You!
Tina Musselman RD, CCN
St. James Center for Bariatric Surgery
Program Coordinator
[email protected]
(708) 679-2717
Mind, Body & Wellness Institute, Inc.
[email protected]
(708) 846-5816