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Clinical Nutrition 3 > Bariatric Surgery > Flashcards

Bariatric Surgery Flashcards

1
Q

Why is obesity and bariatric surgery recognized for federal coverage?

A

Due to it’s increased mortality from cancer

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2
Q

Name 5 health implications from obesity

A
  • Hypertension
  • Coronary heart disease
  • Type 2DM
  • Gallbladder disease
  • Osteoarthiritis
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3
Q

What are some factors influencing obesity?

A
  • Social
  • Individual psychology
  • Individual activity
  • Food productions, foods available
  • Biology
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4
Q

Discuss obesity trends in Canada

A
  • Has increased

- Self-reported obesity is always less reported than measured obesity

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5
Q

Why do obesity rates increased with age, then sharply decline in the elderly?

A

Due to earlier death associated with obesity

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6
Q

What is the economic burden of obesity in Canada?

A

4.7-7.1 billion alone

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7
Q

Worldwide obesity has ____ since 1980

A

doubles

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8
Q

More than ____ children <5 years were overweight in 2011

A

40 million

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9
Q

What is the BMI Classification for bariatric patients?

A

BMI >/= to 35

Class II and above

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10
Q

What is bariatric surgery?

A

The surgical treatment of obesity

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11
Q

What is the purpose of BS? What is NOT it’s purpose?

A
  • To promote significant weight loss and assist/improve weight-related comorbidities
  • NOT related to lower weight for aesthetics
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12
Q

Why is bariatric surgery considered “metabolic surgery”

A

As many metabolic issues, such as type II diabetes may be resolved with these surgeries

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13
Q

Indications for BS?

A

1) BMI >40 is an immediate candidate

2) BMI 35-40 with significant obesity-related co-morbidities

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14
Q

For patients with a BMI of 35-40, what are the significant obesity-related co-morbidites needed to qualify for BS?

A
  • T2DM
  • Hypertension
  • NAFLD (NOT cirrhosis)
  • HyperTGs
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15
Q

In addition to BMI and co-morbidities, what else must candidates possess?

A
  • Acceptable operative risk
  • Failure of non-surgical weight-loss
  • Well informed, compliant and motivated patient
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16
Q

What is the failure rate of dieting? BS?

A

-95%-50%

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17
Q

Contraindications to BS?

A
  • Active substance use
  • Uncontrolled psychiatric illness
  • Cirrhosis
  • Pulmonary hypertension
  • Severe cardiac or respiratory disease
  • Active pregnancy
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18
Q

Is binge-eating a contraindication to BS?

A

No

-however, the surgery will not change or reverse an ED

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19
Q

How will binge-eating change after BS?

A

-They cannot physically fit all the food into their stomach, but may consume the same amount of food over a longer period of time (grazing), and can cause weight re-gain

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20
Q

What are the two restrictive procedures?

A

1) Adjustable gastric band (AGB)

2) Vertical sleeve gastrectomy (VSG)

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21
Q

What are the two restrictive and malabsorptive procedures?

A

1) Roux-en-Y gastric bypass (RYGB)

2) Biliopancreatic diversion with duodenal switch (BPD/DS)

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22
Q

Discriminate between restrictive and malabsorptive

A
  • Restrictive refers to restricting the stomach size, allowing less food into stomach
  • Malabsorption means bypassing a certain length of the SI, therefore less food in AND less food absorbed
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23
Q

Discuss the AGB

A
  • Reversible
  • Rapid satiety
  • Requires frequent adjustments
  • Unknown durability of the band
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24
Q

Is the AGB successful?

A

Lowest success rate, low enough to no longer be covered by the government or offered in the private sector

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25
Q

How does the AGB work?

A

We have a port on the outside of the body, where if we inject with saline it will feed into the band, which will expand and then restrict the stomach

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26
Q

Discuss the Sleeve gastrectomy

A
  • Most of the fundus is removed (70-80%)
  • Pyloric sphincter and intestines remain intact
  • Rapid satiety
  • There is no bypass of absorption
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27
Q

Is there likely to be dumping syndrome with the sleeve gastrectomy

A

No, the pyloric sphincter is still intact

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28
Q

Discuss Roux-en-Y gastric bypass

A
  • New gastric pouch is created, excluding the fundus

- Bypass of intestines, causing malabsorption

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29
Q

Discuss how RYGB alters GI architecture

A
  • The smaller upper part of the resected stomach is attached to the top of the duodenum.
  • The larger (fundus) part of the resected stomach is attached to the proximal jejunum
  • There is no pyloric sphincter
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30
Q

What comprises the alimentary limb in RYGB?

A
  • Where the food goes through
  • Small resection of stomach and the duodenum
  • No absorption occurs here
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31
Q

What comprises the pancreatic limb in RYBG?

A
  • Where pancreatic and gastric enzymes reach

- Resected larger portion of the stomach which reached the proximal jejunum at the anastomosis

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32
Q

What meets at the common channel in RYBG?

A
  • The alimentary and pancreatic limb

- Absorption will take place in the distal jejunum

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33
Q

Discuss the BPD/DS

A
  • Sleeve gastrectomy and bowel resection
  • The common limb is only 100 cm of the ileum
  • More malabsorption than the RYGB
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34
Q

Which surgery may be done in 2 procedures?

A

BPD/DS

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35
Q

Discuss how BPD/DS alter the GI architecture

A
  • The fundus is removed (similar to sleeve), no pylorus.
  • Start of duodenum is resected, and attached to gallbladder and pancreas
  • Other end of duodenum will be attached to resected stomach
  • Common channel meets at ileum
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36
Q

What isa key concept of weight loss outcomes with BS?

A

We measure excess weight-loss, not total weight loss

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37
Q

%EWL =

A

(Pre-op BW - CBW) / (Pre-op BW - IBW) x100

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38
Q

What is important to communicate about weight to a BS candidate

A
  • That by BMI, they still may be considerd as “obese”

- However, the are likely to have great metabolic improvements

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39
Q

Who may lose more than the average BS patient? Who is the average BS patient?

A
  • Men, younger, and those of lower pre-op weight

- Woman, >40 y/o

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40
Q

What is the significance of the metabolic improvements seen with BS?

A
  • 5-10% weight loss is known to have metabolic improvements

- BS results in 45-70% of excess weight lost

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41
Q

How will diabetes be resolved only 24-hours after BS surgery despite no weight loss yet?

A

Change in gut-hormones, such as an increased GLP-1

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42
Q

Why does surgery for bariatric patients have a good risk:benefit ratio?

A

Obese patients often have a higher rate succumbing to their weight within 5 years rather than the surgery itself

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43
Q

AGB %EWL?

A

46%

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44
Q

AGB resolution of DM2?

A

58%

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45
Q

SG %EWL?

A

50-60%

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46
Q

SG resolution of DM2?

A

60%

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47
Q

RYGB %EWL?

A

60%

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48
Q

RYGB resolution of DM2?

A

71%

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49
Q

BPD-DS %EWL?

A

64-70%

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50
Q

BPD-DS resolution of DM2?

A

96%

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51
Q

What is the reduction in mortality after 5 years pot RYGN?

A

89%

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52
Q

What are the weight-loss outcomes after 12 months post-op?

A
  • rapid weight loss occurs over the first 12 months post-op

- However, the most significant weight loss is seen in the first 6 months post-op

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53
Q

What is the significance of most weight loss occurring within 1 year post-op?

A
  • The surgery doesn’t grant an indefinite period of weight loss
  • After this initial loss, the surgery has “done its work” and the rest is on the patient
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54
Q

What is the goal outcome in BS?

A

Weight reduction to improve overall health

55
Q

What are the 3 key mechanisms which promote weight-loss post-op?

A

1) Gastric restriction
2) Common-limb length
- Gut hormones

56
Q

Which surgeries cause gastric restriction?

A

All of them

57
Q

Which surgeries result in a common limb, of varying lenghts?

A
  • RYGB

- BPD-DS

58
Q

Which surgeries result in an alteration of gut hormones?

A
  • RYGB
  • Sleeve
  • BPD-DS
59
Q

Discuss how common limb length can result in weight-loss

A

-Only are where pancreatic/gastric juices will mix with foods - therefore the only length where absorption is possible

60
Q

Which gut hormones change?

A
  • Decrease in ghrelin

- Increase in leptin

61
Q

Why does ghrelin decrease?

A

Due to the removal of the gastric fundus, which contain the parietal cells which secrete ghrelin

62
Q

What do we need to consider when a patient indicates that they are hungry

A

Where is this “hunger” coming from? Is it psychological or is it true hunger?

63
Q

Common early complications (<30 days post-op?)

A
  • Bleeding
  • Anastomotic leak
  • Infections
  • Strictures
  • Obstructions
64
Q

What is an anastomotic leak?

A

The anastomosis (surgical stitches have not fused properly with the tissue, causing a leak which can be fatal

65
Q

What is a stricture?

A

When tissue heals, it tightens. If it tightens too much is can create a stricture

66
Q

Common late complications (>30 days post-op?)

A
  • Nutritional deficiencies
  • Dumping syndrome
  • Weight-regain or weight los failure
  • Malnutrition
  • Ulcer
  • Stricture
  • Psychological complications
67
Q

Discuss the pre-op nutritional guidelines

A
  • Very low calorie diet 2 weeks prior to surgery (800-900 kcal)
  • Low carb (<100g/day), high protein and moderate fat
  • Will induce ketosis
68
Q

What is the rationale behind the pre-op nutritional guidelines?

A
  • Reduce the size of the liver by decrease intrahepatic fat
  • Improve visibility for surgeons
  • Reduce surgical risks
69
Q

Nutritional guide-lines post-op?

A
  • CF (1-3 days)
  • FF/Puree (5 wks)
  • Solids (for life)
  • With portion progression
70
Q

What is the rational behind the pos-op nutritional guidelines?

A
  • Reduce vomiting and allow healing of anastomosis

- Portion control to habituate patient to their new gastric pouch

71
Q

What is the portion progression?

A
  • 1/2 cup to start

- Increase to 1 cup portions per meal/snack

72
Q

Discuss why vitamin and mineral deficiencies are common post-op

A
  • Reduced dietay intake
  • Removal of fundus –> less parietal cells –> less HCl
  • Bypassed intestines
  • tolerance issues
73
Q

Which nutrients are of particular concern when HCL is reduced?

A
  • Calcium
  • Iron
  • No activation of IF, less B12
74
Q

Key nutrient absorbed in the duodenum?

A

-Calcium

0Iron

75
Q

Key nutrients absorbed in the jejunum and proximal ileum?

A
  • Folate
  • Vitamin D
  • Fat soluble vitamins
  • Copper
  • Zinc
76
Q

Ke nutrients absorbed in the terminal ileum?

A
  • Vitamin B12

- Bile salts

77
Q

What is the issue with nutrient deficiencies and lab work?

A

-We are often not testing for copper or zinc, therefore we may have to rely on physical signs

78
Q

Which surgery has a greater risk of deficiencies of fat soluble vitamins?

A
  • BPD/DS

- Common channel doesnt form until after the proximal ileum

79
Q

Why would we prefer using calcium citrate instead of calcium carbonate after the bariatric surgery?

A
  • There is less HCl produced
  • Calcium citrate will be more absorbed as the citrate is acidic, thus allowing for the breakdown and absorption of calcium
80
Q

Why is vitamin B1 (thiamine) important to supplement?

A

-Has a short half-life, rapidly depleted

81
Q

What are the two kinds of protein deficiencies observed after BS?

A

-Primary and secondary protein-malnutrition (PM) or protein-energy malnutrition (PEM)

82
Q

Discuss primary PM and PEM

A
  • Rare, but at risk in all BS
  • Due to decreased oral intake an volume restriction
  • Significant loss of LBM
83
Q

Discuss secondary PM and PEM

A
  • Rare in RYGB, uncommon in BPD/DS

- Due to malabsorption

84
Q

What may aggravate PM/PEM in a BS patient?

A

-BS patients often have a “diet-mindset” and will only fill their plates with veggies, however we need to switch them to a “protein” mindset

85
Q

When does most LBM occur? Why?

A
  • Within 3-months post-op
  • Patients are adjusting to new intakes, may be experiencing nausea, vomiting, discomfort and issues tolerating foods and incorporating protein
86
Q

What is the significance of reduced LBM?

A

-Will lead to reduced RMR, muscle strength and physical function

87
Q

What is the goal within the context of LBM?

A

-Inevitable loss, put try to preserve as much LBM as possible

88
Q

Why do protein needs increase for some surgeries?

A

Not because their true requirement is higher, but their absorption is lower

89
Q

Protein for band, sleeve or RYGB?

A
  1. 0-1.5 g/kg/day

- 60-120 g/day

90
Q

Protein for BPD/DS?

A

1.5-2.0 g/kg/day

91
Q

Key recommendation with protein?

A
  • Focus on high biological value and high quality proteins

- High PDCAAs

92
Q

Example of high PDCAAS?

A
  • Egg white
  • Casein
  • Whey
  • Soy
93
Q

Low PDCAAS?

A
  • Collage

- Gelatin

94
Q

Why may some people choose low PDCAAS?

A
  • Tastes better

- Less volume for same amount of protein

95
Q

Most common equation to estimate energy needs?

A

Mifflin-St-Jeor

96
Q

What is the issue with MFSJ?

A

-Often severely overestimates after surgery, and severely underestimates after surgery

97
Q

What is the main issue with tolerance post-op?”

A

People are not tolerating normal foods

  • HCl decreases
  • No more stomach churning/grinding
  • No pyloric sphincter (dumping, diarrhea)
  • Constipation
  • Dysgeusia
  • Food intolerances
  • Smaller portion sizes, delaying fluids
98
Q

What is an important recommendation regarding chewing foods?

A
  • Post-op, stomach does not have same churning activity

- Chew thoroughly until food is consistency of applesauce prior to swallowing

99
Q

Discuss delaying fluids and dehydration post op

A
  • Easy to become dehydrated after sx as we must delay fluids

- Only small sips throughout the day and cannot drink with meals

100
Q

How much water can the stomach tolerate?

A

Less than 1 cup

101
Q

What may induce diarrhea

A
  • Lactose
  • Dumping syndrome
  • Sugar alcohols (often found in diet products, low-sugar products)
102
Q

Dietary modifications?

A
  • Limit liquid calories, but hydrate (delay fluids)
  • 1/2 pro, 1/4 veg, 1/4 grains
  • Reduce eating out
  • Decrease processed foods/simple sugars
  • Decrease high fat foods
103
Q

Behaviour modification?

A
  • No skipped meals
  • Prolong meals (cut in 1/2, but must eat later)
  • Chew well
  • Portion control
  • Pay attention to satiety signals, mindful eating
  • Avoid drinking with meals/snakcs
104
Q

Guidelines for delaying fluids?

A

No fluids:

  • 15 minutes before meals
  • 30 minutes after meals
105
Q

Case: Patient 6wk S/P gastric bypass presents with vomiting. What do you rule out?

A
  • Esophageal dysphagia

- Structure

106
Q

how could we investigate esophageal dysphagia?

A
  • Are they chewing well?
  • Are you overeating?
  • Are you eating too quickly??
  • What kind of textures are you eating?
  • What kind of preparation methods are you using?
107
Q

If esophageal stricture is rules out, how should we proceed?

A
  • Suspect possible stricture

- Need to see doctor or nurse to rule out a stenosis - investigate via gastroscopy and ballon dilation

108
Q

Nutritional intervention within the case of a stricture?

A
  • Suggest liquid meal replacement

- Supplements, shakes, protein water

109
Q

Case: Patient S/P 1 year gastric bypass, presents with shakiness, sweats, nausea and feeling unwell 3-4 days/week. What is your impression?

A
  • Rule out hypoglycemia and it’s sources

- Investigate possible dumping syndrome

110
Q

How could we rule of hypoglycemia?

A

-Check blood glucose levels, consider if diabetic

111
Q

How can we investigate dumping syndrome?

A
  • Onset of symptoms as related to last meal/snack
  • Type of food consumed
  • Presence of diarrhea
112
Q

Questions to investigate dumping syndrome?

A
  • What kind of meal are you eating?
  • Does it happen at a certain moment?
  • What types of foods? Simple sugars?
113
Q

When is dumping syndrome most common?

A

In those surgeries where the pyloric sphincter is removed, with RYGM

114
Q

What is the early phase of dumping syndrome?

A
  • Occurs 10-30 mins PC
  • Due to the rapid transit of hyperosmotic food into the jejunum (usually simple sugars)
  • Symptoms include dizziness, nausea, weakness, rapid pulse and diarrhea
115
Q

What is the late phase of dumping syndrome?

A
  • Occurs 1-3 hours PC

- Reactive hypoglycemia due to an exaggerated release of insulin

116
Q

(T/F) Dumping syndrome is typically only caused by eating simple sugars (candies, desserts, ice cream etc)

A

F

Could be seen with an excess of fruit with an absence of fibre, fat or protein (smoothies, juice etc)

117
Q

Is dumping syndrome seen with CHOs, such as bread, potatoes and whole fruit?

A

Not usually

118
Q

Why does reactive hypoG occur in the late phase?

A

When undigested food touches our bowel, our body will send out an untitrated surge of insulin which will elicit the hypoG response

119
Q

What would be our nutritional intervention within the context of dumping syndrome?

A
  • Healthy snacking, label reading
  • Avoidance of trigger foods, limiting simple sugars
  • Label reading, net carbs (= 25 g of absorbable carbs)
120
Q

Case: Patient S/P gastric bypass 1 yea, reports shakiness, sweats, nausea and feeling unwell 3-4 times per week. His diet is not indicative of dumping syndrome (high carb, low protein lunch, but no simple sugars? What is your impresion?

A
  • Diet not likely inicative of dumping syndrome

- Rule out possible nesidioblastosis

121
Q

What is nesidioblastosis?

A

Hyperinsulinemic hypoglycemia
-Many BS patients have insulin resistance, and the concentration os insulin will remain the same even though their resistance has improve with the weight los

122
Q

Nutritional intervention with nesidioblastosis?

A

Increase protein:carb ratio at lunch with PM snack

If no improvements, refer to endocrinologist

123
Q

Case: Patient S/P surgery 4 mo and complains of hair loss. What is your impression?

A
  • Likely “shock loss” due to catabolic stress of Sx (telogen effluvium)
  • Occurs between 3-6 mo post op
  • Check adequate protein and vitamin/mineral compliance
124
Q

Case: Patient S/P BPD-DS 2 yr has been losing lots of hair over the last two months. What is your impression?

A
  • Hair loss at this stage in rare
  • Investigate via dietary assessment and bloodwork
  • Ensure proper protein intake, and also verify vitamin and mineral supplements (i.e. not al MVs will be adequate)
125
Q

What is the prevalence of inc deificiency in post-op BPD-DS patients?

A

70%

126
Q

What are the symptoms of zinc deficiency?

A
  • Hair loss

- Dysgeusia

127
Q

What is the zinc supplementation recommendation post BPD-DS?

A

16-22 mg of zinc sulfate/day

128
Q

When may we suspect zinc deficiency?

A
  • hair loss begins >6-9 months post-op
  • Attaining protein needs
  • Insufficient zinc supplement
129
Q

Nutrition intervention for zinc deficiency?

A
  • Supplement 60 mg of zinc BID
  • Monitor plasma zinc in bloodwork
  • Suggest complete multivitamin to patient
130
Q

Case: A patient returns to see you 14 months after surgery, she has regained 25lbs, C/O of always being hungry, can tolerate more food and is discouraged. What is your impression

A
  • Likely not delaying fluids

- Review dietary and drinking habits

131
Q

What are causes for weight regain which is not habit based?

A
  • Poorly controlled thyroid
  • New medications (antidepressants)
  • Stopped exercising
  • Surgical reasons, such as fistulas
132
Q

Case: Patient has gained 60lbs, and is not making changes despite counselling and nutritional intervention. What is your next course of action?

A
  • Suggest benefits of seeing a psychologist for better management of her emtions, and dietary counselling has not provided a solution to her emotional eating thus far.
133
Q

Case 5: A patient is admitted to the hospital with an anastomotic leak (can be fatal, as the gastric contents leak into the abdomen). What is your intervention?

A
  • TPN

- No EN, as the bowel needs to be at rest to encourage the healing process

Clinical Nutrition 3 (30 decks)

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