till death do we part the life-long journey of a bariatric surgical patient tina musselman ma, rd,...
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Till Death Do We PartTill Death Do We PartThe Life-long Journey of a Bariatric The Life-long Journey of a Bariatric
Surgical PatientSurgical Patient
Tina Musselman MA, RD, CCN
St. James Center for Bariatric Surgery
Program Coordinator
(708) 679-2717
Mind, Body & Wellness Institute, Inc.
(708) 846-5816
Obesity…InterventionObesity…Intervention
DietDiet Physical ActivityPhysical Activity
Lifestyle ModificationLifestyle Modification
PharmacotherapyPharmacotherapy
SurgerySurgery
BMI
25
30
35
http://cme.medscape.com/viewarticle/712986?src=cmemp&uac=98478HV
Phentermine, Meridia, Xenical (Byetta), Band(?)
RYGB, AGB (BMI 30), Duodenal Switch,
Gastric Sleeve
The Reality of Bariatric SurgeryThe Reality of Bariatric Surgery
# of bariatric cases grew 400% from 1998-2004– 13,386 to 121,055 per year– 220,000 performed in 2008
82% of surgical cases are female
Age– Ages 18-54 accounted for 85.2% of all surgeries– FASTEST GROWTH IN BARIATRIC SURGERY
IS FOR AGES 55-64 (20 fold increase)
RD’s can run, but we cannot hide!Healthcare Cost and Utilization Project, Statistical Brief #23 (January 2007)
EligibilityEligibility BMI
– BMI 35-39.9 with 1 - 2 obesity-related co-morbidities (DM, HTN, dyslipidemia, severe OA, OSA, Pickwinian Syndrome)
– BMI > 40 – New indications for Lap Band - BMI 30-34.9 (not covered by
insurance yet)
Age– Adults over 18 – Controversy over 65 y.o. - evaluated case by case – Adolescent trials are currently being done
Growth must be completedSome insurances may cover it
“Exhausted all non-surgical weight loss options”
CKD/ESRD is NOT a contraindication
Adjustable Gastric BandAdjustable Gastric Band(Lap Band® & Realize Band)(Lap Band® & Realize Band)
1988 approved by FDA inJune 2001
15 ml pouch
Adjustable stoma size
Digestive tract remains in tact
2/2011 - Lap Band approved for BMI 30-35 + co-morbids
Roux en Y Gastric Bypass Roux en Y Gastric Bypass (RYGB)(RYGB)
1971
15-30 ml pouch
Roux limb 75-150 cm – Longer in Super Obese
Biliopancreatic Limb– Carries gastric juice– Bile and Pancreatic juice– 15-60 cm
Distal Common Channel– 200-500 cm– All of the ileum and some jejunum– Bulk of digestion and absorption
RYGB vs. AGB (Lap Band)RYGB vs. AGB (Lap Band)
RYGB AGB
Weight Loss 70% EBW at 1 yr. 20# wt regain around 2 yrs. Post-op
50% EBW at 2 yrsWt loss may stabilize at 4 yrs post op
Short Term Complications1 yr. post op
0.5% mortality Similar to any surgery Anastomotic Leak Stomal Stenosis (4.9%) Internal Hernia (2.5%) Gallstones (1.4%) Suture Line Ulcers (1.4%) Staple Line Failure (1.0%) Bleeding (0.9%) Death (0.6%)DehydrationHair Loss (iron and Protein)
0.1% mortalitySimilar to any surgeryGallstonesDehydration
RYGB AGB
Long-Term Complications Hypoglycemia
Gastro-gastric Fistula Stomal Stenosis Bowel Obstruction Nutritional (peaks >5 yrs. post op) - B12, Folic Acid, Iron, Calcium, Vit D Weight RegainLoss of LBM
Vomiting more common Gastric prolapse Obstruction Esophageal and pouch dilation Gastric erosion and necrosis Port access problems Weight regain
Misc… Dumping Syndrome Gradual shift away from solid food
RYGB vs. AGB (Lap Band)RYGB vs. AGB (Lap Band)
Treatment and Outcomes, FNCE Pre-symposium Workshop by Chris Eagon, MD; October 2005
5 year comparison5 year comparison
Band has the highest safety profile for all bariatric procedures
The “new kid on the block” in The “new kid on the block” in bariatrics bariatrics
Laparoscopic Sleeve Laparoscopic Sleeve gastrectomygastrectomy Partial Gastrectomy (60-80%
removed)
Small bowel remains intact
Founded as part of the first step in a two step surgical process for the super obese
New- more to learn about sustainability and safety
Results similar to RYGB
SG
Weight Loss 62-69.4% EBW loss at 18 mos
Short Term Complications1 yr. post op
Similar to any surgery bleedingFistulaStenosis/obstructionStaple line leakGERD (0-83%)
Long Term Complications
Gerd (5% at 2 yrs)Nutritional deficiencies ??
Chouillard et al. Laparoscopic RYGB vs Sg for morbid obesity: Case controlled study.. SOARD 2011; 7: 500-505.
Micronutrition Micronutrition
Factors common to all procedures that increase nutritional risk
– Poor eating behaviors,– Decreased nutrient dense foods– Food intolerance– Restricted portion sizes– (Emesis)
Micronutrition - Gastric Micronutrition - Gastric BypassBypass
Etiology:– GERD (PPI’s)– Emesis transit time/diarrhea
Most common deficiencies– Iron (20-51%): HCl– B-12 (35%): HCl, IF– Vit D– Ca– Folate (41-47%)
Micronutrition - Gastric Micronutrition - Gastric BypassBypass
Etiology:– GERD (PPI’s)– Emesis transit time/diarrhea
Most common deficiencies– Iron (20-51%): HCl– B-12 (35%): HCl, IF– Vit D– Ca– Folate (41-47%)
63% of pts developed nutrition deficiencies (Fe, B12, folate) 2 yrs. Post RYGB including those who were compliant with the vitamin regimen. (n=140)
- Brolin, et al 1991
Micronutrition - Sleeve Micronutrition - Sleeve gastrectomygastrectomy
Etiology transit time – Emesis/Nausea– GERD (PPI’s) HCl
Common nutrient def.– B12: 18% ?– Fe: 18% ? – Zn: 35% ?– Folic Acid?– Vit D?
Micronutrition - Sleeve Micronutrition - Sleeve gastrectomygastrectomy
Little data on micronutrition and SG
1 yr. results without MVI– 4.9-43% Fe def. – 9-18.1% B12 def.– 9.8-22% folate def.
Jacques, J., Goldenberg, L. Nutrition and the sleeve gastrectomy patient: From micronutrients to dietary patterns. Bariatric Times 2011; 8(6):12-15.
Micronutrition - AGBMicronutrition - AGB
Etiology po intake– Food intolerance– Maladaptive eating
Micronutrition - AGBMicronutrition - AGB
Etiology po intake– No alterations to digestive processes
-“AGB has minor effects on normal physiological digestive processes and, as a result, selective nutritional deficiencies are presumed to be unusual…Closer clinical follow up is more necessary (adjustments) after AGB than RYGB, whereas the reverse is true for perioperative nutritional evaluations.”
- Ziegler, O., Sirveaux, MA, et al, Diab. & Met. 2009, p. 544 & 553
Micronutrition - SummaryMicronutrition - Summary
AGB RYGB SG
Protein - + -(?)
Iron + ++ +
B12 + ++ +(?)
Ca/D - or + ++ -(?)
Folate + + +
B1 + + +(?)
Zn/Se + ++ (?)
A, E, K - - or + -
Vomiting ++ ++ +
- very rare
+ rare
+ frequent
++ very frequent
Ziegler, O., Sirveaux, MA., et al. Medical follow up after bariatric surgery: nutritional and drug issues General recommendations for the prevention and treatment of nutritional deficiencies. Diab. & Metab 2009; 35: 544-557.
The The Standard SupplementationStandard Supplementation“There is little agreement on exactly how to manage
micronutrition in post-operative bariatric surgery patients.”
- Jacqueline Jacques, ND Micronutrition for the Weight Loss Surgery Patient (2006)
Many patients will be malnourished pre-operatively leading to more aggressive supplementation after surgery– 51-62% pre-operative Vit D deficiency
Obese individuals may have needs above and beyond normal recommendations– Contributing mechanisms
Multiple medications Years of poor diet Underlying inflammation
Recommended SupplementationRecommended Supplementation
AGB RYGB/SG
Multiple vitamin1,000 mg CalciumB complexBile salt replacement
Multiple vitamin x 2 (100% RDA including iron)Sublingual B121,500 mg Ca + DThiamin (B complex)?Supplemental iron for menstruating women?Bile salt replacement prn
Tablets or capsules can be tolerated 6 mo. and beyond
Multiple Vitamin and Calcium should not be taken together and
should be in divided doses
Common “Bariatric” Eating Common “Bariatric” Eating Guidelines Guidelines
1. Protein and Produce- At least 60 g. protein/day- Liquids and “mushy” calories not recommended- Foods not tolerated well: bread, rice, dry meat, some produce
2. 2-3 meals per day- breakfast optional- limited snacking
3. Avoid eating and drinking at the same time
3. 1200-1400 calories per day long-term
A word about renal disease and bariatrics
Bariatric Surgery improves DM, obesity and HTN, three of the leading causes of renal disease
“The more earlier we treat CKD in the disease process with bariatric surgery, the more favorable the impact on the kidney.” - Wei-Jei Lee.
Be aware of medical absorption changes
Monitor labs and adjust vitamins/macronutrients as appropriate
Thank You!Thank You!
St. James Center for Bariatric SurgeryProgram Coordinator
[email protected](708) 679-2717
Mind, Body & Wellness Institute, Inc.
(708) 846-5816
Tina Musselman RD, CCN