1. Providing Nutrition Support after Bariatric Surgery
Presented by: Aja Stokes
12/19/14

2. Outline of Presentation
Overview of nutrition support
Overview of different bariatric surgeries
Need for nutrition support after bariatric surgery
Medical complications of weight loss procedures
Nutritional complications after bariatric procedures
Estimating nutrition needs for the obese bariatric patient
Indicators to assess nutrition support tolerance
Conclusion

3. Nutrition Support
Nutrition support therapy is needed when patients are unable to eat or take adequate nutrition by mouth, or have GI complications that inhibit the use of the intestinal tract for feeding over an extended amount of time

4. Nutrition Support cont’d
Enteral Nutrition
Parenteral Nutrition
EN involves nutrition therapy via nasogastric tube, orogastric tube, gastrostomy, nasoduodenal or nasoenteric, or jejunostomy
PN involves nutrient admixture administered via an IV into the blood with a catheter placed in a vein

5. Bariatric Surgery
Bariatric procedures promote weight loss through restriction and/or malabsorption
Approved for individuals whose BMI >/= 40
BMI between if accompanied by at least one severe obesity-related comorbidity (i.e., HLD, DM, HTN)
Benefits from surgery include: reduced mortality, increased DM remission, improved beta-cell function, and improved pulmonary function
Mortality- the state of being subject to death
Beta-cells- produce and secrete insulin - the hormone responsible for regulating levels of glucose in the blood

6. Bariatric Surgeries cont’d
Roux-en-Y-gastric bypass (RYGB)
Surgeon creates a small gastric pouch with the capacity of mL from the proximal and attaches it to the roux limb of the jejunum

7. Bariatric Surgeries cont’d
Laproscopic adjustable gastric band (LAGB)
An adjustable silicone ring fits around the gastric cardia to create a 30mL pouch

8. Bariatric Surgeries cont’d
Vertical Sleeve gastrectomy
Cutting the antrum of the stomach 2-6 cm away from the pylorus and forming a tubular pouch
Stomach capacity is reduced by about 80 percent through the removal of the fundus and body

9. Bariatric Surgeries cont’d
Vertical banded gastroplasty
A gastric pouch is created by stapling a vertical line in the upper part of the stomach and placing a band of about 1 cm in diameter at the bottom of the pouch to create a restricted outlet

10. Bariatric Surgeries cont’d
Biliopancreatic diversion (BPD)
The stomach is horizontally resected into a mL pouch
The pouch is anastomosed to the jejunum with a long roux limb and a short common limb
Anastomosis- a cross-connection between adjacent channels, tubes, fibers, or other parts of a network

11. Bariatric Surgeries cont’d
Biliopancreatic diversion with duodenal switch (BPD- DS)
The stomach is resected vertically to preserve the pylorus and about 3 cm of the proximal duodenum

12. Bariatric Surgeries cont’d
Jejunoileal bypass (JIB)
Anastomosis of the jejunum and the ileum resulting in a small area of small bowel for digestion and absorption
Anastomosis- a cross-connection between adjacent channels, tubes, fibers, or other parts of a network

13. Need for Nutrition Therapy after Bariatric Surgery
Indications for EN:
During first 7 days of admission (in well- nourished patients)
Must have functional gastrointestinal tract and ability to safely insert an enteral feeding tube
Enterocutaneous fistula where the enteral feeding tube can be inserted distal to the fistula
Inadequate oral intake to meet metabolic demands (i.e., trauma, burn, or other critically-ill patients)
Significant malnutrition
Enterocutaneous fistula- an abnormal connection that develops between the intestinal tract or stomach and the skin. As a result, contents of the stomach or intestines leak through to the skin
Distal- situated away from the center of the body or from the point of attachment

14. Need for Nutrition Therapy after Bariatric Surgery cont’d
Indications for PN:
Inability to take oral or enteral nutrition for >7- 10 days (5-7 days in ICU setting)
Entercutaneous fistula where the enteral feeding tube can not be inserted distal to the fistula
Ileus
Intestinal obstruction
Intractable vomiting
Intractable diarrhea
Severe gastrointestinal bleeding
Severe malabsorption
Severe malnutrition with inability to obtain enteral access
Contraindication to enteral nutrition
Poor tolerance to enteral nutrition
Ileus- a painful obstruction of the ileum or other part of the intestine

15. Medical Complications
EN Nutrition Complications
Abdominal bloating
Aspiration
Constipation
Dehydration
Diarrhea
Electrolyte disturbances
Feeding tube clog
High gastric residuals
Hyperglycemia
Infection around tube insertion site
Vitamin and mineral deficiency

16. Medical Complications cont’d
PN Nutrition Complications
Catheter-related blood stream infection
Dehydration
Electrolyte disturbances
Essential fatty acid deficiency
Hyperglycemia
Hypoglycemia
Intestinal atrophy
Metabolic bone disease
Parenteral nutrition- associated liver disease
Volume overload
Vitamin and/or trace element deficiencies or excess

17. Medical Complications cont’d
RYGB
LAGB
Gastric remnant distention
Anastomotic leak
Anastomotic stenosis
Marginal ulcer
Hernia
Cholelithiasis
Dumping syndrome
Lowest risk for morbidity, readmission, and reoperation or intervention
Band slippage
Erosion
Esophageal dilatation
Obstruction
Mechanical issues with the hardware
Anastomosis- a cross-connection between adjacent channels, tubes, fibers, or other parts of a network
Dumping syndrome- when too much food/drink (especially simple sugars) is rapidly “dumped” into the intestine at one time, pancreas will over produce insulin that lowers the blood sugar too much
Common symptoms- diarrhea, nausea, cramping, dizziness, weakness, feeling clammy, shaky, sluggish, rapid pulse
Cholelithiasis- gallstones

18. Medical Complications cont’d
Vertical Sleeve Gastrectomy
BPD/BPD-DS
Gastric bleeding
Gastric stenosis
Gastric leak and reflux
Cirrhosis
Malabsorption
Malnutrition
Nephrolithiasis
Cirrhosis- scarring of the liver and poor liver function; final phase of chronic liver disease
Nephrolithiasis- A kidney stone is a solid mass made up of tiny crystals; one or more stones can be in the kidney or ureter at the same time

19. Nutritional Complications
Nutrition-related complications occur in about 30% of patients

20. Procedures Associated Iron
Deficiency
Signs/Symptoms
Recommendation
Procedures Associated
Iron
Anemia, microcytic, hypochromic red blood cells, pallor, fatigue, poor capillary refill
mg/day of elemental iron in two to three divided doses; vitamin C may increase absorption
All procedures
B12
Glossitis, constipation or diarrhea, neurologic changes such as paresthesia of hands and feet, diminished vibration and/or position sense and confusion, anemia, polyneuropathy and myopathy
1000mcg administered daily, weekly, or monthly depending on severity
Folate
Diarrhea or a smooth sore tongue, anemia
Daily supplementation 400mcg; 1000mcg daily for 3 months to replete stores
Calcium/vitamin D
Metabolic bone disease
mg daily; IU
Thiamine
Wernicke encephalopathy, lactic acidosis, protein-energy malnutrition, steatorrhea, polyneuropathy and myopathy
mg in a dextrose-free IV fluid; 100mg/day for 7-10 days
Other (fat-soluble vitamins, zinc, selenium, copper, and essential fatty acids)
Anemia, neuromuscular changes, dysgeusia, hair loss, visual disturbance, skin rash , bleeding, bruising
MVI
BPD, BPD-DS, RYGB
Glossitis- the tongue is swollen and changes color, often making the surface of the tongue appear smooth
Paresthesia- a sensation of burning, numbness, tingling, itching or prickling
Wernicke encephalopathy- presence of neurological symptoms; characterised by the triad ophthalmoplegia (eye movement abnormalities), ataxia (imbalance), and confusion (mental changes)
Steatorrhea- presence of excess fat in feces
Dysgeusia- distortion of the sense of taste

21. Estimating Nutrition Needs
Calculating energy needs
Hypocaloric feeding
11 to 14 kcals/kg ABW
22 to 25 kcals/kg IBW

22. Estimating Nutrition Needs cont’d
Calculating protein needs
2.0g/kg IBW if BMI= 30 to 39.9
2.5g/kg IBW if BMI >/= 40
Calculating fluid needs
No recommendations provided by SCCM/A.S.P.E.N.
Minimum requirement is generally 1.5 L/day

23. Indicators to assess nutrition support tolerance
Lab measures
Fasting glucose
CRP
Prealbumin
Electrolytes
Nitrogen balance
Weight Trends
Gastric residuals
Adequate wound healing
Functional status

24. Conclusion
EN and PN are not often used in the bariatric surgery patient
In general,
Protein intake between 2-2.5g/kg (depending on BMI)
Wound healing
Builds muscle
Maintain lean body mass
Muscle burns calories
May help prevent hair loss
Fights infection
Daily supplementation (MVI, iron, B12, calcium, vitamin D)

25. Conclusion cont’d
Nutrition intervention should be individualized for patients who have undergone bariatric surgery not only in consideration of obesity, but also due to altered gastrointestinal anatomy
RD should work with surgical team to create a nutrition plan to stabilize the patients nutrition status

26. References
Fujioka, K., DiBaise, J. K., and Martindale, R. G. (2011). “Nutrition and Metabolic After Bariatric Surgery and Their Treatment.” Journal of Parenteral and Enteral Nutrition; 35, 52S-59S Kerner, Jennifer. (2014). “Nutrition Support After Bariatric Surgery.” Support Line: A Publication of Dietitians in Nutrition Support; 36(3), 9-21 Mogensen, Kris M. (2010). “Nutrition Support Therapy for the Bariatric Patient.” Weight Management Matters; 7(3), 8-16