Gastric Bypass surgery (roux-en-y)

1
Gastric Bypass surgery (roux-en-y)

• Sami Beilke
• Concordia College, Moorhead, MN

2
Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
3
Obesity Trends Among U.S. AdultsBRFSS, 1986
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
4
Obesity Trends Among U.S. AdultsBRFSS, 1987
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
5
Obesity Trends Among U.S. AdultsBRFSS, 1988
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
6
Obesity Trends Among U.S. AdultsBRFSS, 1989
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
7
Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
8
Obesity Trends Among U.S. AdultsBRFSS, 1991
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
9
Obesity Trends Among U.S. AdultsBRFSS, 1992
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
10
Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
11
Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
12
Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
13
Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
14
Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
15
Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
16
Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
17
Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
18
Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
19
Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
20
Obesity Trends Among U.S. AdultsBRFSS, 2003
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
21
Obesity Trends Among U.S. AdultsBRFSS, 2004
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
22
Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
23
Obesity Trends Among U.S. AdultsBRFSS, 2006
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
24
Obesity Trends Among U.S. AdultsBRFSS, 2007
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
25
Obesity Trends Among U.S. AdultsBRFSS, 2008
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
26
Obesity Trends Among U.S. AdultsBRFSS, 1990,
1999, 2008
(BMI ?30, or about 30 lbs. overweight for 54
person)
1999
1990
2008
No Data lt10 1014
1519 2024 2529
30
27
Obesity Epidemic

• According to the National Health and Nutrition
  Examination Survey (NHANES), in 2003-2004
• about 66.3 of U.S. adults are overweight or
  obese (BMI gt 25 kg/m2)
• 32.2 are obese (BMI gt 30 kg/m2)
• 4.8 are morbidly obese (BMI gt 40 kg/m2)
• Also, from 1986 to 2000, the prevalence of
  morbidly obese individuals has increased twice as
  fast as the prevalence of obesity

28
Assessment of obesity

• BMI
• Overweight 25-29
• Obese 30-39.9
• Morbidly obese gt40
• Waist circumference should be used to assess
  proportion of body fat
• High risk men gt40 in. and women gt35 in.

29
Contributing factors to obesity

• Genes
• Metabolism
• Behavior
• Environment
• Culture
• Socioeconomic status
• Some medications

30
Comorbidities of obesity

• Type II diabetes
• Coronary heart disease
• Hyperlipidemia
• Hypertension
• Sleep apnea
• Pulmonary dysfunction
• Ischemic stroke
• Gallbladder disease
• Cancer

31
obesity Continued

• Obesity and obesity related health problems cost
  the nation 92.6 billion in health care per year
• According to the ADA, current data on lifestyle
  weight loss interventions (eating a well balanced
  diet and exercising) indicate that overweight and
  obese individuals produce low levels of sustained
  weight loss
• Weight losses remaining after 4-5 years are only
  about 3 to 6 of initial body weight

32
WE ARE NEEDED!

• Dieticians, along with a medical doctor,
  psychiatrist, and nurse play a pivotal role in
  determining if bariatric surgery is the best
  decision for an obese individual trying to lose
  weight.

33
OBJECTIVES

• Be able to define Roux-en-Y gastric bypass
  surgery and gain knowledge on the procedure
• Describe the nutrition assessment and care of
  patients undergoing Roux-en-Y gastric bypass
  surgery
• Identify recommended medical nutrition therapy
  for Roux-en-Y gastric bypass surgery
• Recognize ethical issues concerning Roux-en-Y
  gastric bypass surgery

34
ROUx-en-y Gastric Bypass Surgery

• Gastric bypass surgery is the most common type of
  bariatric surgery which changes the digestive
  system to limit the amount of food a patient can
  eat and digest.
• Weight loss is achieved by restricting the amount
  of food that the patients stomach can hold and
  by reducing the amount of calories that are
  absorbed.
• Surgeries can be performed laparoscopically (most
  common) or some surgeries require an open
  approach.

35
procedure of Roux-en-y Gastric Bypass Surgery
36
Gastric Bypass Surgery who is it for?

• Not for everyone
• Requires permanent lifestyle changes
• Patient unable to maintain healthy weight through
  diet and exercise

• BMI of 40 or higher
• BMI of 35 to 39.9 plus a serious health related
  problem

37
Veteran Affairs study

• May 2002-April 2004 40 VA patients underwent
  laparoscopic RYGB
• All fit the guidelines for bariatric surgery
• Average age of 49.9 years and an average BMI of
  48.1
• Results
• 3 patients converted to an open procedure
• No mortalities
• Immediate complications were present in 9
  patients requiring re-operation in 3 patients

38
VA Study (cont.)

• Result (cont.)
• Late complications developed in 8 patients
• In 23 patients who were followed up for more than
  3 months, DM resolved in 79 and improved in 21
  of the patients.
• Conclusions
• Laparoscopic RYGB can be performed with
  acceptable morbidity with good short-term results
  in a VA hospital setting
• Safadi, B.Y., Kieran, J.A., Hall, R.G., Morton,
  J.M., Bellatorre, N., Shinoda, E., et al. (2004).
  Introducing laparoscopic Roux-en-Y gastric
  bypass at a Veterans Affairs medical facility.
  American Journal of Surgery, 188(1), 606-610.

39
Preoperative Nutrition Care

• Candidates must go through an extensive screening
  process
• Physician, dietician, psychologist, nurse, and
  surgeon evaluate to see if surgery is appropriate
  
• Patient must be compliant in making appropriate
  lifestyle changes in diet and exercise and
  discontinuing tobacco and alcohol use
• Patient should be motivated to accept the
  responsibility for sustaining lifestyle changes
  to maintain weight loss and decrease
  post-operative complications

40
Preoperational Assessment

• Anthropometric measurements
• Weight history
• Medical history
• Psychological history
• Alcohol/drug use
• 24 hr. dietary intake recall
• Physical activity
• Psychosocial

41
Pre-op Nutrition Education

• Importance of taking personal responsibility for
  self-care and lifestyle choices
• Pre-op diet preparation
• Discuss postoperative dietary intake

• Common complaints
• Dehydration
• nausea/vomiting
• Return of hunger
• Dumping syndrome

42
Video of Roux-en-y Gastric Bypass Surgery

• http//www.mayoclinic.com/health/gastric-bypass/MM
  00703

43
Post operational Assessment

• Anthropometric measurements
• Biochemical
• Medication review
• Vitamin/mineral supplementation
• Dietary intake

44
Post-op Laboratory values for nutritional status

• Hemoglobin
• normal (M) 14-18 g/dl (F) 12-16 g/dl
• B12- serum B12
• normal
• Serum iron- ferritin
• males 15-200 ng/mL females 12-150 ng/mL
• Hematocrit
• Normal (M) 40-54 ml/dl (F) 37-47 ml/dl

• Fasting blood glucose
• Normal gt126 mg/dl
• Visceral protein status
• Serum albumin
• Normal 3.5-5.0 g/dl
• Prealbumin
• Normal 19-43 mg/dl

Nelms, M., Sucher, K., Long, S. (2007).
Nutrition Therapy and Pathophysiology.
Belmont Thomson Brooks and Cole.
45
Nutrient deficiencies

• Iron (320 mg twice daily)
• Calcium (1200-1500 mg/ day)
• Calcium citrate vs calcium carbonate (poor
  absorption with gastric bypass surgery)
• Vitamin D (400 IU/ day)
• Folate (400 µg/ day)
• Vitamin B12 (500 µg/ day)
• Protein
• Multivitamin supplementation is needed to ensure
  that daily needs of each nutrient is met

Aillis, L., Blankenship, J., Buffington, C.,
Furtado, M. (2008). Bariatric Nutrition
Suggestions for the Surgical Weight Loss Patient.
Journal of the Society for Metabolic and
Bariatric Surgery, 4(45), 1-25.
46
Dietary guidelines post-op

• No standardized nutritional guidelines for
  bariatric surgery
• The guidelines vary from health care facilities

Marcason, W. (2004). What are the dietary
guidelines following bariatric surgery? Journal
of the American Dietetic Association,
104(3), 487-488.
47
DIET Texture and progression

• First- adequate energy and nutrients are required
  to support tissue and healing after surgery
• Second, the foods and beverages consumed after
  surgery must minimize reflux, early satiety, and
  dumping syndrome while maximizing weight loss and
  weight maintenance
• Initial gastric capacity is generally 30 to 60 mL
  with a progression up to 120 to 150 mL
• Marcason, W. (2004). What are the dietary
  guidelines following bariatric surgery? Journal
  of the American Dietetic Association,
  104(3),487-488.

48
Clear liquid diet

• 1-2 days after surgery
• Sugar-free or low sugar clear liquids
• Liquids should leave a minimal amount of GI
  residue

• Diet is nutritionally inadequate over 24-48 hrs
• Clear liquid nutritional supplement

Aillis, L., Blankenship, J., Buffington, C.,
Furtado, M. (2008). Bariatric Nutrition
Suggestions for the Surgical Weight Loss Patient.
Journal of the Society for Metabolic and
Bariatric Surgery, 4(45), 1-25.
49
Full liquid diet

• 2-16 days after surgery
• Sugar-free or low-sugar full liquids
• Milk, milk products, liquids that contain solutes

• Increased gastric residue
• Protein supplements may be added to diet

Aillis, L., Blankenship, J., Buffington, C.,
Furtado, M. (2008). Bariatric Nutrition
Suggestions for the Surgical Weight Loss Patient.
Journal of the Society for Metabolic and
Bariatric Surgery, 4(45), 1-25.
50
Pureed diet

• 16-30 days after surgery
• Foods that have been blended or liquefied with
  adequate fluid
• milkshake to mash potato consistency
• Fruits and vegetables can be included
• Emphasis on protein rich foods
• Scrambled eggs and canned fish
• Additional tolerance in gastric residue and gut
  tolerance of solute and fiber

Aillis, L., Blankenship, J., Buffington, C.,
Furtado, M. (2008). Bariatric Nutrition
Suggestions for the Surgical Weight Loss Patient.
Journal of the Society for Metabolic and
Bariatric Surgery, 4(45), 1-25.
51
Mechanically altered soft diet

• 30-60 days after surgery
• Food are texture modified
• Requires minimal chewing

• Lots of chopping, grinding, mashing, flaking

Aillis, L., Blankenship, J., Buffington, C.,
Furtado, M. (2008). Bariatric Nutrition
Suggestions for the Surgical Weight Loss Patient.
Journal of the Society for Metabolic and
Bariatric Surgery, 4(45), 1-25.
52
Regular diet

• Usually started more than 8 weeks (60 days) after
  the RYGB surgery
• Recommended foods to avoid
• Sugar, sugar-containing foods
• Carbonated beverages
• Fruit juices
• High-saturated fats, fried foods
• Soft breads, pastas, rice
• Tough, dry, red meat
• Caffeine
• Alcohol

Aillis, L., Blankenship, J., Buffington, C.,
Furtado, M. (2008). Bariatric Nutrition
Suggestions for the Surgical Weight Loss
Patient. Journal of the Society for Metabolic
and Bariatric Surgery, 4(45), 1-25.
53
Calories and fluid

• 800-1000 kcal per day
• For 6-8 months

• 2 liters or 64 ounces per day of fluids

54
Beverage requirements

• Avoid consuming liquids 20-30 minutes before,
  during, and after meals
• No alcohol
• Fluids should not include carbonation, calories,
  or caffeine

55
Protein Requirements

• 55-75 grams of protein per day
• Patients should aim for about 20-22 grams of
  protein per meal
• Supplements help achieve protein amount
• Protein supplements should be taken until patient
  is able to get adequate protein in their diet
• Suggested protein supplements Whey protein,
  Beneprotein, Unjury, Juven, Soy protein
• Walters, L., Willie, M. (2008). Pre-surgical
  Bariatric Patient Class. St. Josephs Area
  Health Services.

56
Other daily recommendations

• Fat 35-40 grams
• Trans fat 2.5 grams
• Saturated fat 6 grams
• Sodium 2,300 mg
• About 10 CHO choices
• varies depending on patient

• Fiber 25 grams
• Cholesterol 200 mg
• LDL lt100 mg
• HDL
• Men gt40-60 mg
• Women gt50-60 mg

57
Other dietary considerations

• Avoid lying down after eating
• Consider functional fibers
• Delay gastric emptying
• Slowly progress to 5 or 6 small meals each day
• Containing protein

58
Lifelong need for vitamins

• Multivitamin is recommended two times per day
• Preferably chewable
• Centrum select chewable
• Flintstones Complete Chewables
• Calcium vitamins should also be taken two times a
  day
• Calcium citrate

59
Complications to RYGB Surgery

• Dumping syndrome
• increased osmolar load enters the small intestine
  too quickly from the stomach
• When pyloric portion of stomach is bypassed, the
  rate of gastric emptying is increased
• Cramping, abdominal pain, hypermotility, and
  diarrhea

• Early dumping occurs 10 to 20 min after eating
• Intermediate dumping occurs 20 to 30 min after
  eating
• Late dumping occurs anywhere from 1 to 3 hours
  after eating
• Common after consuming simple CHOs
• Possible hypoglycemia

60
Weight regain after rygb

• Wanted to identify factors producing post-RYGB
  weight regain
• Literature survey of metabolic changes in very
  obese
• Review of diet-induced obese RYGB rat model data
  was done
• Results
• Weight regain suggests an imbalance in
  physiological mechanisms regulating appetite and
  metabolic rate
• Weight regain occurred in 25 of the studys rats
  and returned to pre-op energy intake levels

61
Weight Regain study (cont.)

• Results (cont.)
• The 75 of rats that sustained their weight loss
  secreted a significantly larger amount of peptide
  YY (PYY) while suppressing leptin secretion
• The 25 that failed were unable to develop or
  sustain a sufficiently large plasma PYY to leptin
  ratio.
• Conclusions
• Weight regain after RYGB occurs in about 20 of
  patients and constitutes a serious complication
• Weight regain can be pointed toward a failure to
  sustain elevated plasma PYY concentrations

62
Weight regain study (cont.)

• Conclusions (cont.)
• Combining RYGB with pharmacologic stimulation of
  PYY secretion may increase long-term success or
  weight reduction

Meguid, M.M., Glade, M.J., Middleton,F.A.
(2008). Weight regain after Roux-en-Y A
significant 20 complication related to PYY.
Journal of Nutrition, 24(1), 832-842.
63
Insurance reimbursement

• Providers and patients are rarely reimbursed for
  the cost of weight-management services
• The situation may change as concerns about
  obesity increase
• Recent changes in the federal tax code allow
  individuals to deduct the cost of behavioral or
  nutritional counseling, as well as
  pharmacotherapy and surgery, to treat weight
  related illness
• Medicare and Medicaid also have reversed their
  previous policy that did not consider obesity to
  be a disease. This change may facilitate payment
  for weight management, because private insurers
  often follow the lead of public payers regarding
  covered services.

Tsai, A.D., Asch, D.A., Wadden, T.A. (2006).
Insurance Coverage for Obesity Treatment.
Journal of the American Dietetic Association,
106(10), 1651- 1665.
64
Reimbursement (cont.)

• Survey of five MN insurers
• Most companies paid for dietary counseling (as
  well as medications, surgery, and physician
  visits to discuss weight), but not for other
  forms of lifestyle modification, such as
  behavioral therapy, physical activity programs,
  or commercial interventions.
• Survey of Medicaid organizations in 14 states
• Dietary counseling for obesity was consistently
  reimbursed only if the patient had a
  weight-related diagnosis (MNT usually reimbursed)
• Medicaid managed-care plans paid for counseling
  more often than fee-for-service plans

Tsai, A.D., Asch, D.A., Wadden, T.A. (2006).
Insurance Coverage for Obesity Treatment. Journal
of the American Dietetic Association, 106(10),
1651-1665.
65
ETHICAL ISSUES

• Should insurance policies include more money
  allocated for long-term nutrition maintenance
  services?
• Before and after surgery

• Should children and adolescents be given the
  opportunity to under-go the RYGB surgery?

Xanthakos, S.A. (2008). Bariatric surgery for
extreme adolescent obesity Indications,
outcomes, and physiologic effects on
the gut-brain axis. Pathophysiology, 15(2),
135-146.
66
References

• Aillis, L., Blankenship, J., Buffington, C.,
  Furtado, M. (2008). Bariatric Nutrition
  Suggestions for the Surgical Weight Loss
  Patient. Journal of the Society for Metabolic
  and Bariatric Surgery, 4(45), 1-25.
• Brethauer, S.A., Chand, B., Schauer, P.R.
  (2006). Risks and benefits of bariatric surgery
  Current evidence. Cleveland Clinic Journal of
  Medicine, 73(11), 1-15.
• Cummings, S., Parham, E.S., Strain, G.W. (2005).
  Position of the American Dietetic Association
  Weight management. Journal of the American
  Dietetic Association, 102(8), 1145-1155.
• Harrington, L. (2006). Postoperative care of
  patients undergoing bariatric surgery. Medsurg
  Nursing,15(6), 357-363.
• Kaser, N.J., Kukla, A. (2009). Weight-loss
  Surgery. Online Journal of Issues in Nursing,
  14(1), 10.
• Marcason, W. (2004). What are the Dietary
  Guidelines Following Bariatric Surgery? Journal
  of the American Dietetic Association, 104(3),
  487-488.
• Marema, R.T., Perez, M., Buffington, C.K. (2005).
  Comparison of the benefits and complications
  between laparoscopic and open Roux-en-Y gastric
  bypass surgeries. Journal of Surgical Endoscopy,
  30(19), 525-530.
• Mayo Clinic Staff. (2007). Gastric bypass
  surgery Who is it for? Mayo Foundation for
  Medical Education and Research, 1-4.
• Meguid, M.M., Glade, M.J., Middleton, F.A.
  (2008). Weight regain after Roux-en-Y A
  significant 20 complication related to PYY.
  Journal of Nutrition, 24(1), 832-842.
• Nelms, M., Sucher, K., Long, S. (2007). Nutrition
  Therapy and Pathophysiology. Belmont Thomson
  Brooks and Cole.
• Ogden, C.L., Carroll, M.D., McDowell, M.A.,
  Fegal, K.M. (2007). Obesity among adults in the
  United States. Centers for Disease and Control
  and Prevention. National Center for Health
  Statistics. Data Report, 1, 1-8.
• Safadi, B.Y., Kieran, J.A., Hall, R.G., Morton,
  J.M., Bellatorre, N., Shinoda, E., et al. (2004).
  Introducing laparoscopic Roux-en-Y gastric bypass
  at a Veterans Affairs medical facility. American
  Journal of Surgery, 188(1), 606-610.
• Scheier, L. (2004). Bariatric Surgery
  Life-Threatening Risk or Life-Saving Procedure?
  Journal of the American Dietetic Association,
  104(9), 1338-1340.

67
References (cont.)

• Shah, M., Simha, V., Garg, A. (2006). Review
  Long-Term Impact of Bariatric Surgery on Body
  Weight, Comorbidities, and Nutritional Status.
  The Journal of Clinical Endocrinology and
  Metabolism, 91(11), 4223-4231.
• Tice, J.A., Karliner, L., Walsh, J., Petersen,
  A.J., Feldman, M.D. (2008). Gastric Banding or
  Bypass? A Systematic Review Comparing the Two
  Most Popular Bariatric Procedures. The American
  Journal of Medicine, 121(10), 885-893.
• Tsai, A.G., Asch, D.A., Wadden, T.A. (2006).
  Insurance Coverage for Obesity Treatment.
  Journal of the American Dietetic Association,
  106(10), 1651-1655.
• Walters, L., Willie, M. (2008). Pre-surgical
  Bariatric Patient Class. St. Josephs Area
  Health Services.
• Xanthakos, S.A. (2008). Bariatric surgery for
  extreme adolescent obesity Indications,
  outcomes, and physiologic effects on the
  gut-brain axis. Pathophysiology, 15(2), 135-146.
  

68
Questions?