A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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November 2016 • Supplement B • Bariatric Times B27 FIRST INTERNATIONAL CONSENSUS CONFERENCE ON DUODENAL SWITCH ASMBS guidelines (Table 1). 5 The bias of severe m alabsorption is left over from the days of the Jejunoileal Bypass or some studies that have reported high rates of nutritional d eficiencies for the BPD-DS. In many instances these are the results of studies that have not compared preoperative to postoperative values or have supplemented patients inadequately by not giving them the water soluble analogues of fat soluble vitamins. However, studies from experienced centers demonstrate reasonable rates and easily managed nutritional deficiencies with low chances of needing enteral nutrition or TPN (4%) as a temporary measure and reoperation in only 1.5% of patients. 6 Patients who present with malnutrition should undergo a complete history and physical. Warning signs may include excessive nausea and vomiting, diarrhea, or excessive weight loss. A dietary history to elicit compliance with nutrition and vitamin intake is important. Bowel obstruction, strictures of the stomach or of the anastomoses should be ruled out. Physical examination should include examination for signs of malnutrition. Laboratory investigations should include a complete blood count, chemistry profile and levels of vitamins and minerals per ASMBS guidelines. 5 Excessive nausea/vomiting. If the patients are complaining of excessive nausea or vomiting, the workup must exclude stricture of the sleeve or bowel obstruction. A history and physical, computerized axial tomography, upper gastrointestinal series with oral contrast, and endoscopy can help make the diagnosis. A stricture may be treated by performing balloon dilation, strictureplasty, 7 gastro-gastrostomy or occasionally a conversion to a Roux-en-Y gastric bypass. Bowel obstructions may need lysis of adhesions and occasionally a Braun entero- enterostomy, if the distal anastomosis is strictured. Occasionally, if the position of the alimentary limb is retro colic, it may be compressed extrinsically due to dense scar tissue in the mesocolic tunnel. Occasionally, the nausea and vomiting are unrelated to an anatomic problem and are metabolic in nature, like the nausea associated with pregnancy. The use of antiemetics, such as diphenhydramine or ondansetron, and periodic small meals may help ameliorate these symptoms. If this does not work, enteral nutrition using an elemental formula through a nasojejunal tube or parenteral nutrition, for a short period may help overcome the nausea. Rarely a surgical feeding tube is needed and should be placed laparoscopically in the biliary limb to allow the biliary and pancreatic enzymes to adequately Table 2. Other Vitamin and Mineral of Importance V ITAMIN/MINERAL NORMAL RANGE C OMMENTS B 1 (thiamin) 1 0-64 ng/mL More common with chronic nausea and vomiting R ecommend 100 mg IV when rehydrating patients 10-30 mg/day orally for less severe deficiency states B6 (pyridoxine) 5-24 ng/mL Supplement toally B12 (cyanocobalamin) 200-1,000 pg./mL Less common with BPD-DS compared to RYGB Supplemental B12 – at least 350 μg sublingual daily, 500 μg weekly nasal spray or 1,000 μg IM injection monthly Folate (Folic Acid) 280-791 ng/mL 400 mcg daily recommended dose Copper Copper: 70 - 145 μg/dL Ceruloplasmin: 27 - 37 mg/dL Rare, may coexist with B12 deficiency Maybe associated with excessive intake of zinc 1-3 mg po as copper sulfate Selenium 70-150 ng/mL Daily intake of 55 μg is recommended Important for conversion of thyroid hormone to active form and deficiency states mimic hypothyroidism Based on to Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis. 2013;9(2):159–191.