Special
Considerations for Patients
Undergoing 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
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