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Amanda Lambrechts

Illinois State Univ. Dietetic Intern

Review of bariatric surgeries


Research

MNT for bariatric patients


Malnutrition diagnosis
Introduction of case study patient
Timeline of patient hospitalization
MNT snapshot of patient

68%
EWL*
Laparoscopic Roux-en-Y Gastric Bypass
Laparoscopic Adjustable Gastric Banding (LAP-BAND)
Laparoscopic Vertical Sleeve Gastrectomy

50%
EWL*

*Excess Weight Loss (Evidence Analysis Library)


Pictures from Memorial Health System website.

Purely restrictive procedure


Stomach restricted by being divided and stapled

vertically

Remaining stomach shaped like a sleeve

Nerves and valves intact


Often used as first step of bariatric surgery
Typical hospital day post-op=2-3 days
Follow-up care important

Picture from Memorial Health System website.

Koren et al. 2014


Efficacy of LSG for morbid obesity and associated

diseases
54 LSG procedures between March 2008 to April 2014
Avg wt loss of 44.1kg, reduction of BMI by 15.2 kg/m2, and

% excess wt loss of nearly 75% and reductions of DM and


HTN (2 yr period)

Jawed et al. 2014


10 LSG patients
Avg BMI reduction of 17.87kg/m2, 1 complication of

bleeding, & 2 wound infections

Picture from Koren et al. 2014 study.

Ballsmider et al. 2015


Examined anatomical integrity of vagal nerve innervation of GI tract after sleeve

gastrectomy and Roux-en-Y Gastric Bypass

Sleeve gastrectomy may induce hyperexcitation of NTS synapses

Matthew et al. 2015.


Effects of intensive precondition and close follow-up evaluated
Superior outcomes of wt loss, comorbidities and quality of life in those in intensive

preconditioning

2 weeks after discharge


Fluid/Liquid Needs:
Women: 24 oz. full liquids + 24 oz. clear liquids/day
Men: 30 oz. of full liquids+ 30 oz. clear liquids/day

Vitamins/Minerals:
2 complete MVI in AM (chewable)
1 calcium at lunch and 1 at dinner (chewable or liquid)
1 vitamin B-12 anytime (under tongue)
3,000 IU Vitamin D3 anytime

Stage 1
Waterusually initiated within a day of surgery
1 oz/hr

Stage 2
Clear liquids
1 oz./15 mins, slowly increasing to goal of 8 oz./hr.

Stage 3
Liquid Protein
Aim of 1 oz./hr of liquid protein + 5-7 oz. clear liquids/hr

Stage 4
Soft Protein
Avoid fluids with solids; sip between meals

Stage 5
General

Two levels of severity:


262: Other Severe Protein Calorie Malnutrition

263.0: Malnutrition of Moderate Degree

Three Typical Etiologies:


Acute Illness/Injury: Severe acute inflammation
Chronic Illness: Mild to moderate chronic inflammation
Social/Environmental Circumstances: without inflammation

Six Characteristics (a minimum of 2 recommended for diagnosis)


Weight loss
Insufficient energy intake

Loss of subcutaneous fat


Loss of muscle mass
Localized or generalized fluid accumulation
Diminished functional status (measured by hand-grip strength)

Name: S.V.
Age: 56 y.o.

Unit: General
Height: 67 (57)
Admit Wt: 115kg (253#)

BMI: 39.7 kg/m2


IBW: 61kg
%IBW: 203%
AdjBW: 77kg (169#)

Lap
Band

Lap sleeve
gastrectomy

Lap Band removal

Admitted
with
malnutrition
MI

Assessed
by RD

Difficulty tolerating and keeping food down

Labs

Only taking chicken broth and clear protein drinks

K+: 3.4 mmol/L (low)

K+ IVF 2x/wk

CO2: 17mmol/L (low)

Orders for RD to manage TPN


Pt at risk of refeeding syndrome

Wt same as pre-surgery

BUN: <5 mg/dL (low)


Cr: 0.6 mG/dL (low)

Estimated Needs:
1925kcals/day (25kcal/kg AdjBW)
100gm protein/day (1.3 gm/kg AdjBW)

Nutrition Diagnosis:
Altered GI function (NC 1.4) RT sleeve gastrectomy AEB inability to tolerate any food &

nausea.
Impaired nutrient utilization (NC 2.1) RT sleeve gastrectomy AEB need for vitamin and
mineral supplementation.
Inadequate oral intake (NI 2.1) RT inability to tolerate food AEB NPO diet Rx.
TPN Bag #1:
Standard macros of 1 gm/kg AA, 2.5 gm/kg dextrose and 100ml 20% lipids to provide

1164kcal and 77 gm protein.


Thiamine 200mg added x10days.

EDG in
afternoon to
determine
NG tube
placement

TPN Bag #2:


Same as
first
TF Recs:
Osmolite 1.5 @10ml/hr.
Advance 10ml q12 hr to
goal of 60ml/hr
w/ 3 Beneprotein packets

1965kcals,
97gm pro,
960ml free
fluid

Failed
keofed
placement
Keofed
placement
in IR

TPN Bag
#3:
Same

RD manage
TF orders

Pt removed
keofed

TPN Bag #4:


Same but w/
increased P to
18mmol

Bariatric
Stage 3
TPN Bag #5:
Increased
macros slightly
w/ same lytes.

Tolerating
Bariatric Stage 3
PO intake
TPN Bag #6:
Same but
increased mg to
12 mEq, chloride
acetate to 30/70.

TPN to d/c
after current
infusion

Pt d/cd on
Bariatric Stage
3
FU in 1 wk w/
RD & bariatric
MD

11/18

11/19

11/20

11/21

11/22

11/23

11/24

Na (mmol/L)

139

139

140

140

137

137

--

K (mmol/L)

3.4

3.8

3.8

4.0

4.0

4.2

--

Cl (mmol/L)

110

109

107

104

102

--

CO2 (mmol/L)

17

24

27

28

26

26

--

BUN (mg/dL)

<5

<5

<5

<5

--

Cr (0.6 mg/dL)

0.6

0.4

0.4

0.5

0.4

0.4

--

Ca (mg/dL)

8.4

8.4

8.0

8.3

8.4

8.3

--

Mg (mg/dL)

1.7

1.8

2.0

2.1

2.2

2.1

2.2

4.2

4.1

3.5

4.2

4.2

4.4

Phos (mg/dL)

**Yellow shaded boxes indicate low labs

Bariatric procedures
Bariatric MNT
Malnutrition diagnosis
TPN management
Electrolytes

Questioned why receiving MgSO4 and KPO3 when labs wdl


Provided handouts to the patient
Discussed with MD plans after discharge

AND Evidence Analysis Library. (2009). Weight loss and weight regain expected after procedure. Retrieved from

https://www.andeal.org/topic.cfm?cat=3845&conclusion_statement_id=251158&highlight=bariatric&home=1. Accessed Nov 29, 2015.

Ballsmider, L. A., Vaughn, A. C., David, M., Hajnal, A., Di Lorenzo, P. M., & Czaja, K. (2015). Sleeve gastrectomy and roux-en-y gastric

bypass alter the gut-brain communication. Neural Plasticity; 2015:1-9.

Jawed, M., Khan, M. I., Shakih, U., Iqbal, P., & Shaikh, S. U. (2015). Sleeve gastrectomy. Professional Medical Journal; 22(1):000-000.
Koren, R., Marko, L., & Vladovic, P. (2014). Our experience with laparoscopic sleeve gastrectomy in the therapy of morbid obesity. Acta

Medica Martiniana; 14(2): 31-41.

Matthew, B., Flesher, M., Sampath, S., Nguyen, N., Alizadeh-Pasdar, N., & Barclay, K. (2015). The effect of intensive preconditioning and

close follow-up on bariatric surgery outcomes: Does multidisciplinary care contribute to positive results whether a gastric bypass or
sleeve gastrectomy is performed? BC Medical Journal; 57(6):238-243.

Memorial Health System. (2015). Bariatric procedures. Retrieved from https://www.memorialmedical.com/Medical-Services/Bariatric-

Services/Our-Program/Bariatric-Procedures. Accessed Nov 28, 2015.

Nutrition Care Manual. (2015). Bariatric vitamin and mineral supplements. Retrieved from

https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=357. Accessed Nov 28, 2015.

Nutrition Care Manual. (2015). Malnutrition coding. Retrieved from

https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=11&ncm_toc_id=144942&ncm_heading=Resources&ncm_content_id=
111000#Malnutrition. Accessed Nov 28, 2015.

Nutrition Care Manual. (2015). Roux-en-y gastric bypass/sleeve gastrectomy discharge nutrition therapy. Retrieved from

https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=339. Accessed Nov 28, 2015.