Obesity / Appetite

Question 1

Bariatric surgery and malnutrition

Answer 1

Bariatric surgery and malnutrition

• leads to nutritional deficiencies due to reduced intake, malabsorption, inadequate supplementation

Types of surgery

• gastric balloon - insertion of silicone baloon in stomach in preparation for gastric surgery (sleeve, banding, bypass), can stay in situ for up to 9months
• Sleeve gastrectomy (resection of greater curvature + fundus of stomach, leading to rapid emptying). Reduced ghrelin, which reduces the effects of hunger over the first year or two. Can lead to nutrient deficiencies if inadequately managed.
• Laparoscopic adjustable gastric band (LABG) is less commonly performed, and pts can resume normal diet afterwards, followed by 4-6weekly band tightening. Lowest risk of nutrient def^ys but highest rate of re-operation
• Vertical banded gastroplasty: combination of staples and a band to create the pouch. There is a dime-sized opening at the bottom of the “new” stomach that opens into the rest of the larger stomach. Plastic tissue or mesh is wrapped around the opening to help prevent the opening from stretching.
• Roux-en-Y Gastric bypass (RYGB - small pouch is made from the top section of the stomach and is connected to a loop of jejunum, bypassing the duodenum and the first part of the jejunum). This is commonly associated with micronutrient malabsorption (need lifelong supplements). Leads to food intolerances (vegetarian diet is better tolerated), dumping syndrome (nausea, weakness, diarrhoea, worse with refined sugars).
• Laparoscopic Biliopancreatic diversion with duodenal switch (BPD/DS) is a 2step procedure. First, a sleeve gastrectomy is done. Then, duodenum is detached just beyond the pylorus; a large portion of the small intestine (duodenum, jejunum) is bypassed; the ileum is joined to the resection section beyond the pylorus; then the duodenum is attached to the distal ileum (to permit passage of pancreatobiliary contents that aid digestion). This is the least commonly performed, and very commonly associated with micronutrient malabsorption. This commonly leads to osteoporosis (from malabsorption of Ca2+ / vit D), offensive stools/diarrhoea (from vitamin/ca/iron/protein malabsorption), dumping syndrome. Requires lifelong supplementation. [https://columbiasurgery.org/conditions-and-treatments/duodenal-switch-bpd-ds]

Management

• should correct and nutrient deficiencies prior to surgery (obese ppl at risk for nutritional deficiencies)
• Early post op diet: clear liquids until day 3 –> free liquids (protein rich, low sugar) until day 10 –> soft diet until 1month post op –> salads, fruit/veg, high protein, this phase lasts for months until they reach maintenace weight –> then stage 4 diet, they can eat healthy solid foods, with vitamin and mineral supp daily
• Supplementation: protein (46g/day); carbs; fats; fat soluble vitamin ADEK (fat soluble); Vit D (3000IU/day), calcium, iron (primarily absorbed in duodenum; 18mg/day males, 45-60mg/day menstruating females); vitamin B’s; folate; zinc; copper; selenium
  https: //asmbs.org/patients/bariatric-surgery-procedures