Bariatric Surgery

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Bariatric Surgery

• Christina R Pruemer, B.S.

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Purpose

• To make dietetics professionals aware of the
  types of bariatric surgery, the benefits and
  risks associated with the procedures, and related
  nutrition and weight loss concerns.

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Overview

• Obesity
• History of bariatric surgery
• Types of bariatric surgery
• Complications/nutrition concerns
• benefits/weight loss
• Studies
• Disease states
• Reinvented procedures
• Conclusions

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Defining obesity

• Overweight
• BMI 25
• Obesity
• BMI 30

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Obesity worldwide

• More than 1 billion overweight adults
• 300 million obese adults
• Highest BMIs
• North America
• Europe
• Latin American
• North Africa
• Pacific Island

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Obesity Trends Among U.S. AdultsBRFSS, 1991-2002
(BMI 30, or 30 lbs overweight for 5 4 woman)
2002
No Data 1519 2024 25
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Digestive system
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Bariatrics

• Defined
• Branch of medicine that deals with prevention,
  control, and treatment of obesity
• Bariatric surgery
• Uses surgical means to control and treat obesity

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Where we have been

• 1950s
• Noted that those with short bowel syndrome lost
  weight.
• Led to use in treatment of obesity
• Jejuno-colic bypass
• Fluid and electrolyte imbalances, liver
  dysfunction
• Abandoned

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Where we have been, cont

• 1960s-1970s
• Jejuno-ileal bypass
• Subsequent development of gastric restriction
• Many people are living because of the surgery
• Mortality also resulted
• Largely abandoned in the United States

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Where we have been, cont

• Mid-Late 1970s
• Masons Horizontal gastroplasty
• 1980s
• Ballooning
• Inserted endoscopically and inflated with air
• Weight loss was temporary
• Problems
• Pressure ulcers
• Deflation
• Placement problems

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Selection criteria

• BMI
• 40
• 35 with comorbid conditions
• Diabetes
• Cardiovascular disease
• Others
• Eating disorders
• Pregnancy
• Age(over 18)

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(No Transcript)
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Bariatric Surgery

• 2 types
• Restrictive (15-30ml pouch)
• Vertical Banded Gastroplasty
• Malabsorptive
• Roux-en-Y gastric bypass
• Biliopancreatic diversion
• Goal
• Loss of excess body weight

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Restrictive procedures

• Vertical Banded Gastroplasty

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Vertical Banded Gastroplasty
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Malabsorptive procedures

• Roux-en-Y Gastric Bypass
• Bilipancreatic Diversion

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Masons Roux-en-Y gastric bypass
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Roux-en-Y gastric bypass
Y
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Scopinaros Biliopancreatic diversionBiliopancrea
tic diversion with duodenal switch
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Complications with restrictive procedures

• Overeating
• Pouch stretches
• Staple disruption
• Staple failure significantly reduced with use of
  4 line staple as opposed to single line
• Pouch obstruction
• Death-0.4, reoperation-0.65, wound
  infection-2.13, pulmonary embolism-0.13

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Nutrition for restrictive procedures

• Protein calorie malnutrition
• Only with excessive vomiting or refusal to eat
• Supplements
• Vitamin/mineral supplements sufficient
• No malabsorption of specific nutrients

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Complications with malabsorptive procedures

• Overeating
• Pouch stretches
• Staple line ruptures
• Dumping syndrome
• Abdominal hernia
• Biliopancreatic limb obstruction
• Rare, usually long after initial operation

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Nutrition concernswith malabsorptive procedures

• Protein malnutrition
• Fat malabsorption
• Affects fat soluble vitamins
• Vitamin/mineral deficiencies
• Iron
• B12
• Folate
• Calcium
• Vitamin D
• Malabsorption
• Meat/milk products not well tolerated

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Benefits of restrictive procedures

• Limited malabsorption of nutrients
• Fewer complications (especially long term)

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Benefits of malabsorptive procedures

• Malabsorption of nutrients creates greater weight
  loss
• Resolution of comorbid factors

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Success

• 50 loss of excess body weight, maintained over 5
  years
• Vertical banded gastroplasty
• Average loss of 40 excess weight
• Malabsorptive procedures
• Average loss of 60-70 excess weight
• 30 of patients gain weight at 18 months to 2
  years after surgery

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Studies
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Brolin RE, et al, 1998

• Subjects
• Menstruating women
• 29 experimental, 27 control
• Design
• Prospective, double-blind, randomized study
• All received standard multivitamin
• Given iron supplement or placebo beginning 1
  month after RYGB
• Followed for 2 years
• Tested ferritin, hemoglobin, hematocrit, TIBC

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Results
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Behrns KE, et al, 1994

• Study on Vitamin B12
• 8 patients after RYGB
• Measured cobalamin absorption prior to surgery
  and 6-8 weeks after
• Results
• Postoperative absorption significantly decreased
• Recommendation
• Monthly parenteral injection or
• Daily supplement of non-protein bound cobalamin

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Brolin RE, et al, 1994

• Brolin, et al, 1994
• 138 patients
• 30 VBG
• 108 RYGB

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Brolin, 1994, cont

• Brolin, cont.
• Nutritional deficiencies
• VBG 0
• RYGB
• 30 cases B12
• 30 cases iron
• 2 cases folate
• Oral supplements
• 2 iron deficiencies required injection
• Weight loss
• VBG 40 success rate
• RYGB 92 success rate

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Skroubis G, et al, 2002

• Subjects
• 79 RYGB
• 95 BPD (modified)
• All received multivitamin supplement
• Looked at weight loss of patients in follow-up
  over 5 years

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Skroubis G, cont
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Skroubis G, cont

• Other results
• Low ferritin
• RYGP-37.7
• BPD-15.2
• Estimate B12 deficiencies most likely at 10.7
  months following RYGB and 7.9 following BPD
• Folic acid was not supplemented, was not
  deficient
• Does folic acid require supplementation?

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Moize V, et al, 2003

• Calorie and protein intake in 93 patients who had
  RYGB, taking multivitamin, iron, and calcium
• Results
• Drastic reduction in calories (increased over 12 months
• Insufficient protein intake over 12 months
• No significant changes in albumin, vitamin B12,
  hemoglobin, or mean corpuscular volume
• Iron levels increased from 3-12 months
• Anemia
• 3 months 5 patients
• 6 months 6 patients
• 12 months 5 patients

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Moize V, cont

• Food intolerances
• Meat/eggs
• Rice/pasta/bread
• Vegetables
• Milk
• Higher food intolerances led to decreased intake
• Discussion
• Modular protein supplementation

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Martinez MJ, et al, 2003

• Subjects
• 15 RYGB
• 47 BPD
• TPN (38 patients) and no nutritional support (24
  patients)
• Compared serum albumin, length of hospital stay,
  number of infections
• Results
• No difference in nutritional status or infection
• Hospital stay was decreased with no parenteral
  nutrition

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Disease states
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General benefits of weight loss

• Improvements in
• Blood glucose control for Type 2 DM
• Lipid profiles
• Hypertension
• Arthritis
• Cardiac function
• Respiratory function
• Urinary stress incontinence
• Sleep apnea
• Decreased health care costs

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Reinvented procedures

• Intragastric balloon
• Gastric banding

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BioEnterics Intragastric Balloon
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Totté E, et al, 2001

• 126 patients, 500ml saline inflation, 800 Kcal
  diet restriction, removed after 3-6 months
• Complications
• Severe nausea (up to 1 month post)
• 76
• Treated with anti-emetic drugs
• Intolerant to device
• 4
• Gastric perforation along greater curvature of
  stomach
• 4

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Totté, cont

• Weight loss
• 48.6 excess weight at 3 months
• 50.8 total maximum loss
• Mean loss of 18 kg with dietary compliance
• Mean loss of 9.6 kg without dietary compliance
• Satisfaction was very low
• 8.8 unsatisfied
• 40 very unsatisfied

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Gastric Banding
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Conclusions

• Supplement all procedures with multivitamin
• Supplement malabsorptive procedures with iron,
  B12, and Calcium at least
• Thoroughly educate patients on diet regimen
• Make sure patients understand the
  results/consequences
• Noncompliance will result is decreased weight
  loss, nausea/vomiting, possible need for plastic
  surgery, and others
• Follow a multi-disciplinary approach

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Diet regimen

• Start with clear liquids for lunch next day
• Soft blended diet for next two weeks as tolerated
• Advance to textured food over next 10 weeks as
  tolerated
• Take multivitamin, iron, calcium supplements

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Conclusions, cont

• Future
• Increase in obesity
• Increase in bariatric surgery
• This is not a miracle cure for obesity

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Questions?