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 Mind, Body & Wellness Institute, Inc.
Program Coordinator
Tmusselman26@yahoo.com
Tina.musselman@ssfhs.org
(708) 846-5816
(708) 679-2717
Obesity…Intervention
BMI
RYGB, AGB (BMI 30),
Duodenal Switch,
Gastric Sleeve
Surgery
35
Phentermine, Meridia, Xenical
(Byetta), Band(?)
Pharmacotherapy
30
Lifestyle Modification
Diet
Physical Activity
25
http://cme.medscape.com/viewarticle/712986?src=cmemp&uac=98478HV
The 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)
Eligibility
 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 completed
 Some insurances may cover it
 “Exhausted all non-surgical weight loss options”
 CKD/ESRD is NOT a contraindication
Adjustable Gastric Band
(Lap Band® & Realize Band)
 1988 approved by FDA in
June 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
(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
AGB
Weight Loss
 70% EBW at 1 yr.
 20# wt regain around 2 yrs.
Post-op
 50% EBW at 2 yrs
Wt loss may stabilize at 4 yrs
post op
Short Term
Complications
1 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%)
Dehydration
Hair Loss (iron and
Protein)
0.1% mortality
Similar to any surgery
Gallstones
Dehydration
RYGB vs. AGB (Lap Band)
RYGB
Long-Term
Complications
Misc…
AGB
 Hypoglycemia
Gastro-gastric Fistula
 Stomal Stenosis
 Bowel Obstruction
 Nutritional (peaks >5 yrs.
post op)
- B12, Folic Acid, Iron,
Calcium, Vit D
 Weight Regain
Loss of LBM
 Vomiting more common
 Gastric prolapse
 Obstruction
 Esophageal and pouch
dilation
 Gastric erosion and
necrosis
 Port access problems
 Weight regain
 Dumping Syndrome
 Gradual shift away from
solid food
Treatment and Outcomes, FNCE Pre-symposium Workshop by Chris Eagon, MD; October 2005
5 year comparison
Band has the highest safety profile for all bariatric procedures
The “new kid on the block” in bariatrics
Laparoscopic Sleeve gastrectomy
 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
Short Term
Complications
1 yr. post op
Long Term
Complications
 62-69.4% EBW loss at 18 mos
Similar to any surgery
 bleeding
Fistula
Stenosis/obstruction
Staple line leak
GERD (0-83%)
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
 Factors common to all procedures that increase
nutritional risk
–
–
–
–
–
Poor eating behaviors,
Decreased nutrient dense foods
Food intolerance
Restricted portion sizes
(Emesis)
Micronutrition - Gastric Bypass
 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 Bypass
 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 gastrectomy
 Etiology
–  transit time
– Emesis/Nausea
– GERD (PPI’s)
–  HCl
 Common nutrient def.
– B12: 18% ?
– Fe: 18% ?
– Zn: 35% ?
– Folic Acid?
– Vit D?
Micronutrition - Sleeve gastrectomy
 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 - AGB
 Etiology
–  po intake
– Food intolerance
– Maladaptive eating
Micronutrition - 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 - Summary
- very rare
+ rare
+ frequent
++ very frequent
AGB
RYGB
SG
Protein
-
+
-(?)
Iron
+
++
+
B12
+
++
+(?)
Ca/D
- or +
++
-(?)
Folate
+
+
+
B1
+
+
+(?)
Zn/Se
+
++
(?)
A, E, K
-
- or +
-
Vomiting
++
++
+
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 Standard 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 Supplementation
AGB
Multiple vitamin
1,000 mg Calcium
B complex
Bile salt replacement
RYGB/SG
Multiple vitamin x 2 (100% RDA
including iron)
Sublingual B12
1,500 mg Ca + D
Thiamin (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
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!
Tina Musselman RD, CCN
St. James Center for Bariatric Surgery
Program Coordinator
Tina.musselman@ssfhs.org
(708) 679-2717
Mind, Body & Wellness Institute, Inc.
tmusselman26@yahoo.com
(708) 846-5816