PROVIDING NUTRITION SUPPORT AFTER BARIATRIC SURGERY Presented by: Aja Stokes

12/19/14

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

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

Nutrition Support cont’d

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

Enteral Nutrition Parenteral Nutrition

Bariatric Surgery

Bariatric procedures promote weight loss through restriction and/or malabsorption

Approved for individuals whose BMI >/= 40 BMI between 35-40 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

Bariatric Surgeries cont’d

Roux-en-Y-gastric bypass (RYGB) Surgeon creates a

small gastric pouch with the capacity of 20-30mL from the proximal and attaches it to the roux limb of the jejunum

Bariatric Surgeries cont’d

Laproscopic adjustable gastric band (LAGB) An adjustable

silicone ring fits around the gastric cardia to create a 30mL pouch

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

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

Bariatric Surgeries cont’d

Biliopancreatic diversion (BPD) The stomach is

horizontally resected into a 200-250mL pouch

The pouch is anastomosed to the jejunum with a long roux limb and a short common limb

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

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

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

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

Medical 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

EN Nutrition Complications

Medical Complications cont’d

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

PN Nutrition Complications

Medical Complications cont’d

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

RYGB LAGB

Medical Complications cont’d

Gastric bleeding Gastric stenosis Gastric leak and

reflux

Cirrhosis Malabsorption Malnutrition Nephrolithiasis

Vertical Sleeve Gastrectomy

BPD/BPD-DS

Nutritional Complications

Nutrition-related complications occur in about 30% of patients

Deficiency Signs/Symptoms Recommendation Procedures Associated

Iron Anemia, microcytic, hypochromic red blood cells, pallor, fatigue, poor capillary refill

150-200mg/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

All procedures

Folate Diarrhea or a smooth sore tongue, anemia

Daily supplementation 400mcg; 1000mcg daily for 3 months to replete stores

All procedures

Calcium/vitamin D Metabolic bone disease 1200-1500mg daily; 3000-6000 IU

All procedures

Thiamine Wernicke encephalopathy, lactic acidosis, protein-energy malnutrition, steatorrhea, polyneuropathy and myopathy

100-300mg 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

Estimating Nutrition Needs

Calculating energy needs Hypocaloric feeding

11 to 14 kcals/kg ABW 22 to 25 kcals/kg IBW

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

Indicators to assess nutrition support tolerance

Lab measures Fasting glucose CRP Prealbumin Electrolytes Nitrogen balance

Weight Trends Gastric residuals

Adequate wound healing

Functional status

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)

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

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-59SKerner, 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