Manual of Clinical Nutrition

Nutrition Management in Bariatric Surgery

Manual of Clinical Nutrition Management B- 31 Copyright © 2013 Compass Group, Inc.

Patients who do not appropriately modify their behavior and patients who have anatomical complications
may experience constant postprandial vomiting. Because of a complete lack of nutrition, these patients can
develop complications such as protein-energy malnutrition and thiamin deficiency, which can lead to
Wernicke-Korsakoff syndrome (1,17,22,26). A 3% to 5% incidence of hospitalization for treatment of protein-
energy malnutrition after biliopancreatic diversion procedures has been reported (17,26). If prolonged
vomiting or projectile vomiting occurs, the patient should be clinically assessed for medical complications,
such as thiamin deficiency, and treated for dehydration or thiamin deficiency, if indicated (1). Patients should
be evaluated for enteral or parenteral nutrition support whenever necessary to prevent complications
associated with malnutrition or nutritional deficiencies (1). Enteral feedings can be provided by using a small-
caliber nasogastric tube placed into the distal stomach or remaining small bowel. An isotonic elemental
formula given slowly with a pump over a 24-hour period may promote greater tolerance (26). With any
feeding regimen, the clinician should be alert for refeeding syndrome (17,19,26) by carefully monitoring serum
levels of phosphorus, potassium, and magnesium (19). If parenteral nutrition is indicated, the initial 24-hour
infusion should contain only 50% of the estimated energy needs and 50% of the estimated fluid volume. A
hypocaloric feeding with adequate protein, such as 14 to 18 kcal/kg of ideal body weight and 1.5 to 2.0 g of
protein per kg of ideal body weight, is often recommended in the literature (10,19). (Refer to Section B:
Specialized Nutrition Support for additional information on refeeding syndrome.) Patients who experience
prolonged vomiting may develop acute neurological deficits 1 to 3 months after restrictive gastric surgery
(1,26). Symptoms of these neurological deficits include double vision, ataxia, nystagmus, bilateral facial
weakness, acute polyneuropathy with paralysis, reduced deep tendon reflex, and mental confusion.
Wernicke-Korsakoff syndrome related to thiamin deficiency has also been observed in this population.
Patients who manifest neurological symptoms should be treated with 100 mg of thiamin that is intravenously
or intramuscularly administered for 7 to 14 days, followed by oral administration of 100 mg/day of thiamin
until the patient fully recovers or neurologic symptoms resolve (1).

Skeletal and mineral homeostasis, including nephrolithiasis, is common after Roux-en-Y gastric bypass,
biliopancreatic diversion, and biliopancreatic diversion with duodenal switch (1). Laboratory tests to evaluate
calcium and vitamin D metabolism and metabolic bone disease are recommended for all patients who have
these procedures. Treatment with orally administered calcium, ergocalciferol (vitamin D 2 ), or cholecalciferol
(vitamin D 3 ) is indicated in these patients to prevent or minimize secondary hyperparathyroidism without
inducing hypercalcuria (1). The bone density of these patients should be evaluated to assess for the
development of osteoporosis (1). Orally administered bisphosphonates for bariatric surgery patients with
osteoporosis include: alendronate (70 mg/week), risedronate (35 mg/week or two tablets of 75 mg/month),
and ibandronate (150 mg/month) (1). Oral phosphate supplementation may be provided for mild to
moderate hypophosphatemia (1.5 to 2.5 mg/dL), which is usually due to vitamin D deficiency (1). The
management of oxalosis and calcium oxalate stones includes avoidance of dehydration and adoption of a low-
oxalate meal plan and oral calcium and potassium citrate therapy (1). Probiotics that contain Oxalobacter
formigenes improve renal oxalate excretion and are a treatment option (1).

References:

1. Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH,
   Brolin R, Sarwer DB, Anderson WA, Dixon J. Executive summary of the recommendations of the American Association of Clinical
   Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical
   practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract.
   2008;14: 318 - 336.


2. National Heart, Lung, and Blood Institute Obesity Education Initiative Expert Panel. Clinical Guidelines on the Identification,
   Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, Md: National Institutes of Health;
   1998. NIH Publication No. 98-4083. Available at: http://nhlbi.nih.gov/nhlbi/htm. Accessed February 19, 2009.


3. Gastrointestinal Surgery for Severe Obesity. Consensus Statement. NIH Consensus Development Conference, March 25-27, 1991.
   Bethesda, Md: US Public Health Service, National Institutes of Health, Office of Medical Applications of Research.


4. Position of the American Dietetic Association: weight management. J Am Diet Assoc. 2009;109:330-346.


5. Bariatric surgery. In: Nutrition Care Manual. Academy of Nutrition and Dietetics; Updated annually. Available at:
   http://www.nutritioncaremanual.org. Accessed January 15, 2009.


6. Fujioka K. Follow-up of nutritional and metabolic problems after bariatric surgery. Diabetes Care. 2005;28:481-484.


7. Shikora A. The nutritional consequences of gastric restrictive surgery. Presented at: ASPEN 22nd Clinical Congress; January 20,
   1998; Lake Buena Vista, Fla.


8. Sjostrom L, Narbo K, Sjostrom CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C,
   Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindross A-K, Lonroth H, Naslund I, Olbers T, Stenolf K, Torgerson J, Agren G.
   Effects of bariatric surgery on mortality in Swedish obese subjects. N Eng J Med. 2007;357: 741-752.


9. Adams TD, Gress RD, Smith SC, Halverson RC, Simper SC, Rosamond WD, LaMonte MJ, Stroup AM, Hunt SC. Long-term mortality
   after gastric bypass surgery. N Eng J Med. 2007;357: 753-761.


10. Shah MV. Nutrition support in the complicated bariatric patient. Support Line. 2007; 29(6): 7-11.


11. Weinsier RL, Ullmann DO. Gallstone formation and weight loss. Obes Res. 1993;1:51-56.


12. Gebhard RL, Prigge WF, Ansel HJ, Schlasner L, Ketover SR, Sande D, Holtmeier K, Peterson FJ. The role of gallbladder emptying in
    gallstone formation during diet-induced rapid weight loss. Hepatology. 1996;24:544-548.