+ 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

+ Bariatric surgery improves comorbid conditions in morbidly obese patents such as: Coronary artery disease Dyslipidemia Type 2 diabetes mellitus Obstructive sleep apnea Hypertension Nonalcoholic liver disease Degenerative joint disease

+ Candidates and Criteria for Surgery 1. BMI > 40 or BMI > 35 and at least 2 obesity-related co- morbidities. 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

+ Contraindications for Surgery Current smoker Alcohol abuse Cardiac instability Clotting disorders Severe heart and lung disease Active unstable liver disease Autoimmune connective tissue disease Poorly controlled psychopathology Documented non-compliance Under the age of 18 years of age Pregnancy

+ 4 Common Types of Bariatric Surgery: Roux-en-Y Gastric Bypass Laparoscopic Sleeve Gastrectomy Laparoscopic Adjustable Gastric Band Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Gastric Bypass

+ Roux-en-Y Gastric Bypass (RYGBP) Considered the ‘gold standard’ of weight loss surgery 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 Advantages Disadvantages

+ Laparoscopic Sleeve Gastectomy 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 Complications fall between adjustable gastric band and roux- en-Y gastric bypass. Advantages Disadvantages

+ 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. Advantages Disadvantages

+ Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Gastric Bypass 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 Advantages Disadvantages

+ Common Nutrition Related Complications Anemia Metabolic Bone Disease Failure to Thrive Protein Calorie Malnutrition Steatorrhea Wernicke Encephalopathy Polyneuropathy and Myopathy Visual Disturbances Skin Rashes

+ 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

+ Nutrient Supplementation for Parenteral and Enteral Nutrition 2 daily MVI with multitrace elements mg Calcium Citrate IU Vitamin D 400mcg Folate 40-65mg Elemental Iron (menstruating women) > 350mcg B12

+ 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 43 year old women Pre Operation Weight: kg (363lbs) Height: 178 cm ( 70in) BMI: weeks Post Operation Weight: kg (337lbs) Height: 178 cm (70in) BMI: 48.47

+ The Patient’s Journey Laparoscopic surgery Discharged post operation home day 3 Readmitted post operation day 6 Discharged post operation day 8 Readmitted post operation day 14 (PN begins) Post operation day 27 Post operation day 37 Post operation day 60 (PN stopped) Post operation day 160

+ Estimated Needs: Calories: Mifflin-St Jeor using ABW: 2275 kcals For weight loss (50-70% of needs): kcals Protein: Using 2.5g/kg: 175 g protein

+ Conclusion Further cohort based off of this case study This case study demonstrated how hypocaloric, high protein PN can bridge the gap and reduce the chances of malnutrition during bariatric malnutrition. Further studies should be administered

+ Article Two: Hypocaloric Home Parenteral Nutrition and Nutrition Parameters in Patients Following Bariatric Surgery N= 23 patients How needs were determined: BMI <25 received kcals/kg ABW and g protein/kg BMI received kcals/kg ABW and g protein/kg BMI received kcals/kg ABW and g protein/kg BMI >35 received kcals/kg ABW and g protein

+ Frequency of Readmissions

+ Conclusion First study to evaluate home PN use in morbidly obese patients after complication in bariatric surgery. Many complications of bariatric surgery require NPO for a long period of time. PN can help prevent malnutrition during times of complications. Nutrition goals of weight loss and visceral protein repletion can be met providing a hypocaloric PN formula. Future studies are needed.

+ Questions?

+ Works Cited: Bariatric Surgery Procedures - ASMBS. (n.d.). Retrieved March 10, 2016, from Beebe, M., & Crowley, N. (n.d.). Can Hypocaloric, High-Protein Nutrition Support Be Used in Complicated Bariatric Patients to Promote Weight Loss? 30(4), 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), 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), Muller CM, eds. Adult Nutrition Support Core Curriculum, 2 nd edition. United States: Society for Parenteral and Enteral Nutrition; 2012: 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), Shankar, Padmini, Mallroy Boylan, and Kristnan Sriram. “Micronutrient deviancies after bariatric surgery.” Nutrition. 26. (20110): Print.