Till Death Do We Part Till Death Do We Part The Life-long Journey of a The Life-long Journey of a Bariatric Surgical Patient Bariatric Surgical Patient Tina Musselman MA, RD, CCN St. James Center for Bariatric Surgery Program Coordinator [email protected](708) 679-2717 Mind, Body & Wellness Institute, Inc. [email protected](708) 846-5816
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Till Death Do We Part The Life-long Journey of a Bariatric Surgical Patient Tina Musselman MA, RD, CCN St. James Center for Bariatric Surgery Program Coordinator.
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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
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
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
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