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The Advisor
An Advisors Consulting News Bulletin

Special Considerations for Patients Undergoing Gastric Bypass Surgery

gastric bypass surgery The prevalence of Class III obesity (body mass index of 40 kgs/m or greater) has tripled over the past decade. Traditional methods of weight loss including dietary restriction, behavior modification, exercise and medication have not proven successful in the long run for the morbidly obese (body mass index of 40 kgs/m or greater). In 2004, the number of bariatric surgeries performed was approximately 141,000 which represented an increase of 123% over 2002. According to the American Society of Bariatric Surgery, approximately 170, 000 surgeries were projected to be performed in 2005. 3 At this time bariatric surgical methods are primarily either gastric banding or the Roux-en-Y (RYGB) method which is a combination of elements of gastric resection and selective malabsorption. , The increase in numbers of bariatric surgery is due to the effectiveness of losing weight, celebrity endorsement, advertising, the improved surgical techniques, and the increase of centers performing the procedures. 4

The complexity of bariatric surgery and the life-long changes necessary for successful weight loss require that surgical candidates be well-informed regarding the benefits, risks, and need for long-term compliance. Surgical candidates require pre-screening for appropriateness, pre- and post-operative education on the physical and nutritional aspects of the surgery, and long-term follow-up to address problems, concerns, and compliance issues. 2, 3

It is postulated that patient non-compliance may be the most important factor contributing to the development and persistence of post-RYGB metabolic deficiencies. 2 Because non-compliance and complications can be life threatening, selection of patients must be cautious, and patient emphasis pre-surgically should emphasize the need for regular follow-up and compliance with dietary advice, making patients fully aware of their responsibility for the outcomes of the surgery. 2

Bariatric surgery success is defined as a loss of 50% of excess body weight. Weight loss after surgery is reported to be approximately 60% of excess weight during the first 2 years, and then becoming stable after time. Some studies have shown sustained weight loss up to 14 years after surgery. 3 The National Institute of Health Consensus Development Conference on gastrointestinal surgery for severe obesity states that the greatest weight loss after bariatric surgery occurs within the first 18 to 24 months with some regain of weight by five years. 2 It is reported that for patients who have undergone a RYGB, an average weight loss of 100 pounds after one year is feasible with low mortality and morbidity rates. Speculation regarding a reasonable time for weight loss post-operatively for a RYGB procedure seems to be as follows. For the first three months post-operatively weight loss should be less than what is expected with total starvation and closer to what is expected with very low calorie diets. 4 It is estimated between 32 - 57% of bariatric surgery candidates have an underlying eating disorder which may lead to weight loss failure.2 Non-compliance with dietary restrictions may also result in 3:
• failure of weight loss
• dehydration
• protein-calorie malnutrition

Deficits of nutrients following bariatric surgery may cause:
• anemia,
• osteoporosis,
• metabolic bone disease, and
• severe protein caloric malnutrition.

Criteria for malnutrition are the presence of three or more of the following objective findings: hypoalbuminemia, anemia, inability to walk, or difficulty performing simple tasks. 4


Common post-operative complaints , 2, include:
• nausea
• vomiting
• abdominal pain
• constipation

Long term sequelae may include food aversions resulting in anger, frustration, anxiety, and fear when eating. 5 Patients with a pre-operative history of eating disorders are more likely to have difficulty adjusting to the changes in eating habits. 5

Dietary deficits may include:
• Iron deficiency; this is the most common mineral deficit
• Folate deficient; women who become pregnant and is folate deficient could result in
neural tube defect in the fetus.
• Vitamin B12 (most common vitamin deficit with bariatric surgery).
• Deficits of fat soluble vitamins, calcium, and thiamine resulting in serious complications such as Wernicke’s encephalopathy, beriberi, and night blindness. Thiamine deficiency presents with disturbances of vision, gait and polyneuropathy.
• Carnitine deficiencies may lead to polyneuropathy.

There are currently no standardized nutritional guidelines for bariatric surgery. 3, 4 Patient education however should stress the need for life-long alterations in eating patterns, and to prevent complications such as emesis, dumping syndrome, and dehydration as well as the need for life-long vitamin and mineral supplementation. 3

Case managers and life care planners working with patients who are considering or have had gastric bypass surgery must be cognizant of the special requirements and needs of this population.

Patients that are preparing to undergone gastric bypass surgery require education and a team approach to alleviate many of the post-operative complications that may ensue following this type of surgery. Team members must be cognizant of nutritional deficits and symptomotology. In addition, due to the many underlying psychosocial problems associated in particular with this population, early recognition of potential barriers to successful outcomes of gastric bypass surgery is essential.

Post-operatively the following should be considered by the case manager and/or life care planner:
• Medical – surgical follow up
• Nutritionist consultation
• Dietary supplements
• EKG
• Diagnostic laboratory studies
• Exercise and physical therapy
• Counseling


Hirscheld, L. & Stoernell, C. Nutritional Considerations in Bariatric Surgery. Plastic Surgical
Nursing 24 (3), 102 – 106

Collene, A. & Hertzler, S. Metabolic Outcomes of Gastric Bypass. Nutrition in Clinical
Practice 18 (2), 136 – 140.

McKee, J. S. & Tassinari, S. Nutrition in Bariatric Surgery: The Role of Nursing in Reducing
Liability. Journal of Legal Nurse Consulting 17 (1), 7 – 10.

Shuster, M. & Vazquez, J. Nutritional Concerns Related to Roux-en-Y Gastric Bypass: What
Every Clinician Needs to Know. Critical Care Nursing Quarterly 28, (3), 227-260.

Boan, J. Post-op Management for Bariatric Surgery. The Clinical Advisor 8 (4), 30 – 35.

Voelker, M. Assessing Quality of Life in Gastric Bypass Clients. Journal of PeriAnesthesia
Nursing 19 (2), 89-104.


Consider the addition of Rehabilitation Advisors, Inc. to your team for case management or life care planning of your clients with gastric bypass surgery. For further information on the benefits of medical case management, vocational counseling, and life care planning, contact Betty Reid, RN at: rehabilitationadvisors@bellsouth.net

 

Rehabilitation Advisors
4545 Edgewater Drive
Orlando, Florida  32804
Toll Free (800) 432-0704
 Florida (407) 294-2082
Fax (407) 294-7220
email:
rehabadvisors@bellsouth.net