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 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

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 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

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 Anastomosis- a cross-connection between adjacent channels, tubes, fibers, or other parts of a network

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 Anastomosis- a cross-connection between adjacent channels, tubes, fibers, or other parts of a network

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

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

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

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

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

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

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

Procedures Associated Iron 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 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 1200-1500mg daily; 3000-6000 IU 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 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

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-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