2. Outline
2
Overview of the Patient
Sleeve Gastrectomy Surgery
Medical Nutrition Therapy for Bariatric Surgery
Nutrition Care Process of the Patient
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Monitoring/Evaluation
Follow-Ups
3. Patient Overview
3
58-year-old female
Past Medical History:
Current Medical History:
s/p Gastric Sleeve Surgery
(July 2013)
Persistent Leakage
Gastric Stenting
Left Upper Quadrant
Abscess
Nausea and Vomiting
Leukocytosis
Morbid Obesity (BMI 45
pre-surgery)
Hypertension
Hyperlipidemia
GERD
Cholecystectomy
Hysterectomy
5. Laparoscopic Sleeve Gastrectomy Overview
5
Removes 60-80% of the stomach
Shrinks stomach capacity to ≤300 mL
Weight loss mechanism = gastric restriction and
possible decreased levels of ghrelin
Ghrelin = appetite stimulating hormone primarily produced in
fundus and with small amounts produced in the pancreas
Potential nutritional risk factors = nutrient
deficiencies due to:
Decreased intake
Removal of the majority of parietal cells
Decreased hydrochloric acid and intrinsic factor (B12)
6. Who is a Candidate for Bariatric Surgery?
6
BMI ≥ 40 or 35-39.9 with comorbidities:
Type 2 diabetes
Sleep apnea
Hypertension
Cardiovascular disease
Osteoarthritis
Age 16-70 (some exceptions possible)
Failed attempts at diet and exercise
Have been obese for at least 5 years
Free of substantial psychological disease, drug or alcohol
dependency
Candidates must be able to understand surgery and postsurgery lifestyle requirements
Motivated and well-informed
7. Outcomes of Sleeve Gastrectomy
7
Weight Loss Outcomes for
average % of excess body
weight:
1 month: 18-30%
3 months: 37-41%
6 months: 54-61%
1 year: 58-70%
2 years: 61.5%
5 years: no long-term data
Potential Complications:
Nausea/Vomiting
GERD
Anemia
Leakage along the staple line
causing peritonitis or abscess
Sleeve Stricture
Bowel Obstruction
Pneumonia
Deep Venous Thrombosis
(DVT)
Acute Kidney Injury
Liver Failure
8. Post-Bariatric Surgery Behavior
8
Eat slowly and chew thoroughly – at least 25 times!
Avoid concentrated sugars, especially in liquid form
Limit fats and fried foods
Shrink your portions – do NOT overeat!
Do not drink liquids with a meal – try not to drink
30 minutes before and after a meal or snack
If you can no longer tolerate diary – try a lactose-free
diary source
Exercise – after 2 months more strenuous exercise
can be tolerated
9. MNT for Sleeve Gastrectomy
9
Typical Diet Progression:
Bariatric Phase I: Clear Liquids (begins post-op for 2-3 days)
Bariatric Phase II: Full Liquid (advance as tolerated)
Bariatric Phase III: Pureed/Home Soft Diet (progress as
tolerated, usually begins 1 week post-op)
Bariatric Phase IV: Solids (progress as tolerated, usually begins
1 month post-op)
Protein Needs:
No set standard – typically 80-120g/day or 1-1.5 g/kg IBW
CAMC Weight Loss Center = 1.5 g protein/kg of IBW
Adequate Hydration – goal 64 oz. day
Rule of Thumb: Sip 1-2 ounces every 15 minutes
10. Sample Menu for 1 Month Post Op
(Bariatric Home Soft Diet)
10
8:00AM Breakfast:
¼ - ½ cooked cereal
¼ - ½ cup skim plus milk
10:00AM Snack:
½ cup protein supplement
12:00PM Lunch:
¼ - ½ cup sugar free yogurt
¼ cup pureed fruit
2:00PM Snack:
¼ - ½ cup unsweetened applesauce
1 sugar free popsicle
6:00PM Dinner:
¼-1/2 cup blended soup with protein
¼ cup pureed fruit
11. MNT Life-Long Bariatric Diet
11
High protein
Low in refined carbohydrates
Ideally, choose protein first, then fruits and
vegetables, and then whole grains
Maintain adequate hydration
12. Vitamin and Supplement Rx
12
First 3 Weeks Post-Op:
Chewable multi-vitamin
Chewable calcium
Vitamin D – only if levels are low
Vitamin B12 – if needed
Protein supplements
Must be high in protein (15-25g/serving) and low in sugar (less than 10g/serving)
After 3 Weeks Post-Op:
Multi-vitamin
Calcium Citrate (1200 mg)
Vitamin B12- if needed
Vitamin D – only if levels are low
Iron – only if prescribed by MD
Protein Supplements – if unable to consume 50-70g protein/day
Ursodiol – “Gall Bladder Pills” only for the first 6 months
Helps prevent gallstones due to rapid weight loss
14. Nutrition Assessment (11/12)
14
Secondary To:
TPN protocol consult
Current Medical History:
s/p sleeve gastrectomy, persistent gastric leak, morbid obesity,
HTN, hypokalemia, tachycardia
Past Medical History:
HTN, hyperlipidemia, GERD, cholecystectomy, partial
hysterectomy
15. Bariatric Past Medical History
15
7/8/2013: Laparoscopic Sleeve Gastrectomy
N/V started 2 weeks post-op
8/9/2013: Upper GI Endoscopy – found mild stricture in the
opening of the gastroplasty (between esophagus and stomach),
performed balloon dilation
8/15/2013: Admitted to ER with N/V, HTN, leukocytosis, lactic
acidosis – conducted CT scan to find left upper quadrant abscess
and left pleural effusion
8/16/2013: Transferred to Cleveland Clinic and had abscess drained
8/19/2013: Re-drained abscess
8/23/2013: Re-drained abscess, placed gastric sleeve stent, resealed the leak at the staple line
8/29/2013: Endoscopic exploration found stent partially collapsed
so it was adjusted
9/2/2013: Double stenting placed to correct the collapse stent
11/02/2013: Transferred from Cleveland Clinic to CAMC
16. Patient Medications and Supplements
16
Medication Name
Reason
Protonix
PPI to decrease stomach acid to treat GERD
Mylanta
Neutralizes existing stomach acid to treat GERD
Reglan
Reduces nausea, vomiting, and GERD
Phenergan
Helps treat existing nausea and vomiting
Zofran
Helps prevent nausea and vomiting
Metoprolol
Beta-blocker to lower blood pressure
Lasix
Loop diuretic to lower blood pressure
Dilaudid
Treats pain
Folic Acid
Individuals post bariatric surgery are at an increased risk for
deficiency – used to prevent deficiency
Vitamin B6
Vitamin B12
Thiamine
18. Nutrient Needs
18
Current Diet Order (11/12):
Vivonex RTF @ goal rate of 60ml/hr to provide 1440kcal, 72g
protein, and 1224ml free H2O
NG tube
Bariatric Phase I - Clear Liquids
Estimated Needs Per Kg of IBW
Per Day
Energy (kcal)
18 – 22 kcal
1278 – 1562 kcal
Protein
1 – 1.5 grams
71 – 106 grams
Fluid
Per MD
Per MD
19. Subjective Information (11/12)
19
Patient was consuming ~50% of clear liquid diet and
tube feeding was up to 40ml/hour
Very nauseous
Vomits multiple times a day and has since 2 weeks
post-surgery in July
Patient has had nothing but clear liquids and tube
feedings since surgery
20. Patient Labs
20
11/11
Potential Reasons for Abnormalities
Glucose (74-106)
127
Stress, insulin resistance
Na (136-145)
135
K (3.5-5.1)
3.4
BUN (7-18)
21
Creatinine (0.6-1.3)
1.4
eGFR (>60)
47
Based on creatinine levels – potential decrease in kidney
function
Albumin (3.4-5)
1.6
Sign of inflammation with potential protein/energy
deficiency
Occurs with prolonged vomiting
Potential decrease in kidney function or dehydration
21. Nutrition Diagnosis
21
Altered GI function related
to persistent gastric leak and
stent placement as
evidenced by intolerance to
tube feed
Notes:
High risk for refeeding syndrome
due to minimal intake:
Advance feedings slowly
Monitor electrolyte values
closely
Watch for low potassium,
phosphate, magnesium levels
22. Nutrition Intervention (11/12)
22
d/c tube feeding and bariatric clear liquid diet
Due to persistent N/V
PICC line placement was ordered by MD and x-ray
was used to verify correct placement
Initiate TPN @ 8:00PM (11/12) per CAMC protocol
TPN was discussed with Physician, who determined the initial
rate to be 75 ml/hour
Nursing staff was notified
IPOC
25. Monitoring and Evaluation
25
Goals:
Improve protein status
Provision of adequate nutrition via nutrition support
Stabilize blood glucose levels
Monitoring:
High Risk – F/U in 5 days
Will follow daily
Will monitor weight, labs, and TPN/PPN tolerance
27. Follow-Up Assessment (11/14)
27
Subjective Information:
Patient was tolerating full liquid diet and a Boost Glucose Control
with lunch and dinner
Patient was still nauseated but had only vomited once today
Patient preferences of cream of chicken, tomato, chicken noodle soup
were recorded
Plan for Patient:
Spoke with social worker and determined that the patient must be on
12-hour cyclic TPN prior to discharge in order to be accepted into a
skilled nursing facility
Plan to start cycling on Monday (11/18)
Patient will require an stent placement – per MD notes, date planned
for 11/20
28. Follow-Up Assessment (11/19)
28
Nutrition Orders:
11/17: TPN d/c due to lost access secondary to multiple blood
clots
Bariatric Phase II – Full Liquid with Boost Glucose Control w/
lunch and dinner
Subjective:
Patient was tolerating full liquid diet and consuming the
majority of the supplement
Vomiting frequency has decreased but nausea still persist
29. Follow-Up Assessment (11/19) Cont.
29
Significant Lab Changes:
Alkphos (39-117): 306
ALT (17-67): 127
AST (15-65): 181
Suggestive of potential hepatic dysfunction and
common with TPN
30. Updates
30
11/20: Gastric stent placed
11/22: Restarted TPN
11/24: Started to cycle TPN – due to SNF
requirements
11/27: Reached cyclic goal of 12 hours
11/28: Switched TPN back to continuous due to
acute renal failure
TPN providing an average of 1,314 kcal
12/2: Bariatric Phase III – Pureed/Soft with Boost
Glucose Control and continuous TPN
32. References
32
Snyder-Marlow G, Taylor D, Lenhard MJ. Nutrition
care for patients undergoing laparoscopic sleeve
gastrectomy for weight loss. J Am Diet Assoc.
2010;110(4):600-607. doi: 10.1016/j.jada.
CAMC Standards of Practice
http://www.cornellweightlosssurgery.org/pdf/dietar
y_guidelines_sleeve_gastrectomy.pdf
http://www.camc.org/surgicalweightloss
Leaves the stomach shaped like a sleeve or similar to a bananaGhrelin – appetite stimulating hormone, produced in the fundus which is removed during surgeryIntrinsic factor – helps absorb B12Hydrochloric Acid = kills bacteria and helps denature the proteins in our food, making them more vulnerable to attack by pepsinSnyder-Marlow G, Taylor D, Lenhard MJ. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc. 2010;110(4):600-607. doi: 10.1016/j.jada.
Snyder-Marlow G, Taylor D, Lenhard MJ. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc. 2010;110(4):600-607. doi: 10.1016/j.jada.
% of excess body weight lossSnyder-Marlow G, Taylor D, Lenhard MJ. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc. 2010;110(4):600-607. doi: 10.1016/j.jada.
Snyder-Marlow G, Taylor D, Lenhard MJ. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc. 2010;110(4):600-607. doi: 10.1016/j.jada.
Snyder-Marlow G, Taylor D, Lenhard MJ. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc. 2010;110(4):600-607. doi: 10.1016/j.jada.
Vivonex = elemental EN formula
Gastroplasty = gastrectomyLeukocytosis = high WBC countLactic acidosis (carbohydrate meals leads to excess short chain fatty acid to colon which lowers colonic pH levels and increase Gram positive anerobes which produce lactate, humans lack lactate dehydrogenase and it is absorbed into the circulation.Pleural effusion = fluid in lung from leakage
With TPN: If Triglycerides read 450 then limit lipids– if 600-700 then d/c lipids
Worked with RD to calculateEDIT Based on Standards of Care – only show discrepancies!
With TPN: If Triglycerides read 450 then limit lipids– if 600-700 then d/c lipids