Roux-en-Y Gastric Bypass Surgery and Nutritional Concerns

Bariatric surgery is performed for patients who have chronic problems and difficulties losing weight, in order to be of a healthy body mass index for their individual size and frame. Weight loss surgery is a major surgery, yet it is safe and effective. It is not considered a cosmetic operation. It is considered to be permanent. One particular bariatric surgery, that I have noticed more common compared to other procedures, is the Roux-en-Y Gastric Bypass procedure.

Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. In this procedure, stapling creates a small (15-30cc) stomach pouch. The outlet from this newly formed pouch bypasses most of the stomach and several feet of the small intestine, preventing your body from absorbing all the calories and nutrients from the foods you eat. By combining the smaller stomach and the malabsorption feature, this surgery produces more weight loss than operations that only decrease the intake of food. The malabsorption of nutrients, especially calcium, iron, and Vitamin B12 can be managed through proper diet and vitamin supplements. An excess intake of sugar and fat may trigger a condition known as “dumping syndrome.” The results can be extremely unpleasant and can include nausea, weakness, abdominal cramping, and diarrhea.

Reasons for the procedure

Obesity lowers quality of life. This can result in poor overall health, and contribute to a higher risk for depression. Your doctor may suggest a RYGB surgery if you have a body mass index (BMI) of 40 or more or if you have a BMI of 35 and also suffer from serious obesity-related health problems such as diabetes, coronary heart disease, sleep apnea, high blood pressure, or severe arthritis.

Doctors generally recommend the weight-loss surgery only if you are severely obese. That means about 100 pounds overweight for men and 80 pounds for women. They also usually don’t recommend it unless you haven’t been able to lose a large amount of weight and keep it off through diet, exercise, and changes in lifestyle.

Before the procedure

It’s important that your weight-loss surgery be arranged at a qualified bariatric center, where you will complete an extensive educational and preparatory program before surgery. Your doctor can obtain a referral from the American Society for Metabolic and Bariatric Surgery (ASMBS).

  • Your doctor will typically test you for nutritional deficiencies and prescribe supplements to correct any problems before the operation. Your surgeon may ask you to have tests and visits with other health care providers before surgery such as a dietitian and a psychologist.
  • Because smoking slows recovery and increases risks of surgery, your doctor will suggest you stop smoking for good several weeks before surgery. Tell your doctor or nurse if you need help quitting.
  • You’ll want to check with your health insurance provider to make sure bariatric surgery is covered in your health insurance plan, as many plans will not pay for it.
  • Let your doctor know about any prescription or over-the-counter drugs, vitamins, and herbs you are taking. In the week before surgery you may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), and any other blood-thinning drugs. Ask what drugs you can take on the day of your surgery.
  • Let your doctor know if you have had any trouble with anesthesia in the past.

During the Procedure

With either open or laparoscopic RYGB surgery, you will be given general anesthesia for the procedure. Initially your doctors will start an IV and may deliver medications to help you relax. Your anesthesiologist will use a drug or combination of drugs to control pain and make you unaware of the procedure.

When you reach the operating room, your medical team will use routine monitoring equipment throughout the procedure or longer, depending on your health conditions.

The surgery to create the stomach pouch and the bypass usually takes several hours.

After the Procedure

You may stay in the hospital for two to four days after the procedure. You will typically only have liquids or puréed foods for at least three to six weeks after surgery. Rarely, you may have a catheter, or tube, from the larger bypassed part of your stomach that will come out of your side to drain excess fluids from your abdomen for four or more weeks.

Your RD may slowly add soft food and then regular food to your diet about a month after surgery. You will be instructed to chew slowly and completely and not to drink 30 minutes before or after you eat food.

Talk with your doctor, surgeon, and RD about proper wound care, the type of pain-relieving drugs that are safe to take, and when you can resume physical activities. Your surgeon will tell you how often to change the dressing on your incision.

You should inform your doctor immediately if you develop a fever or if your wound becomes painful or hot to the touch or has a foul-smelling drainage. Also look for any coughing or difficulty breathing, vomiting and diarrhea, pain in the abdomen, chest, shoulder, or legs, or any other unusual symptoms.

Your initial weight-loss may occur quickly, so it’s important to get all of the nutrition and vitamins you need as you recover. Your doctor will prescribe certain vitamin and mineral supplements that your body may no longer absorb well from food alone.

Recommendations for the following supplements to prevent nutritional deficiencies after recovery from surgery are:

  • Daily vitamin D and calcium supplements. Vitamin D deficiency is common in people who have had this kind of gastric bypass. Multivitamins containing 1,200 mg of daily calcium citrate and 400 to 800 IU of vitamin D don’t appear to provide enough protection for bone health, studies suggest. Some experts have had success stopping bone loss by increasing vitamin D intake to 1,600 to 2,000 IU daily. Additional calcium supplementation of 1,600 mg daily is also suggested.
  • Multivitamins. You should take a daily multivitamin that contains 200% of the daily values. Wait two hours to take a calcium supplement after your multivitamin.
  • Vitamin B12 supplements. Doctors recommend vitamin B12 supplementation for all weight-loss surgery patients to help prevent bone fractures. You may need to give yourself B12 injections for the rest of your life.
  • Oral vitamin D supplementation if a deficiency is detected. Your doctor may prescribe 50,000 IU of vitamin D2 taken orally once a week for 8 weeks, some people require lifelong vitamin D supplementation.
  • Iron supplements. Research suggests that after RGBY surgery, the amount of iron contained in a standard multivitamin may not be enough to prevent anemia. Teens and menstruating women may require the amount of iron found in two multivitamins, along with 50 to 100 mg of elemental iron a day.

Because nutritional deficiencies are so common after this surgery, RDs recommend that your blood be tested every 6 months for the rest of your life to ensure that you are getting the right amount of vitamins and minerals.

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What is the Braden Scale?

The Braden Scale for Predicting Pressure Sore Risk was developed during a Robert Wood Johnson Teaching Nursing Home project and while writing an NIH proposal to study pressure ulcer risk factors. The scale is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom and the purpose of the scale is to health help professionals assess a patient’s risk of developing a pressure ulcer.

The Braden Scale is a scale made up of six subscales, which measure elements of risk which contribute to both higher intensity and duration of pressure, or lower tissue tolerance for pressure. These subscales are: sensory perception, moisture, activity, mobility, friction, and shear. Each item is scored between 1 and 4, with each score accompanied by a descriptor. The lower the score, the greater the risk for a pressure ulcer a patient is at-risk for.

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The Burlodge Multigen III

Who is Burlodge?

Burlodge is a kitchen equipment company originating from Italy but has companies and factories in the United Kingdom, Italy, France, United States of America, and Canada. The headquarters in the US in based out of Winston-Salem, North Carolina.

What is the Multigen III 105 Series?

This piece of kitchen equipment is a revolutionary dual-oven technology that is used is a variety of patient foodservice systems around the world. The Multigen series allows foodservice professionals to re-thermalize products of different densities and textures to a consistent heat, insuring optimum food quality every time. Another beneficial characteristic of the Multigen series is the adaptability of the oven compartment which can be configured to various sizes to accommodate different meal arrangements. Basically, this piece of equipment is a multi-portion point of service trolley that is intended for cook-serve, cook-chill, and cook-freeze foodservice applications.

I was trained how to use this equipment yesterday at my patient foodservice rotation. The representative who trained the kitchen staff was a Registered Dietitian from Nashville, TN who worked for Burlodge.

The Burlodge equipment is broken down by different categories of major kitchen equipment:

          Tray Systems

          Bulk Systems

          Tray Assembly Systems

          Trayware

          Support Equipment

The Multigen III 105 Series falls in the Bulk Systems category and is a two compartment cart consisting of oven and refrigeration settings. The equipment is used in locations that cook, hold, and deliver food to other parts of the facility that are physically farther away than ideal. For example if a hospital setting had a nursing home attached, foodservice workers would be able to cart their Burlodge Multigen III over to the connecting facility, while the meals for service were cooking. Then, serve these meals without compromising the food safety of the meal.

Features of the equipment include:

          The Multigen III uses convection heat (Competitors use conduction heat)

          Reaches temperature in less time

          Heating time reduced and food re-thermed at a lower temperature

          Distributes heat evenly

          Saves energy

          The cart can be programmed to wake itself up and begin cooking

The daily cleaning procedures include:

1.      Removing racks and shelves from cart

2.      Using a hot soapy solution, wipe compartments, exterior stainless steel panels, shelves, and hot top; then rinse with a separate cloth and plain water. Allow to dry.

3.      Allow heavily soiled surfaces to soak for about 15 minutes.

4.      The hot top should also be sanitized as this surface may come in direct contact with food.

5.      Clean the sneeze screen with a soft cloth and a suitable hard surface/glass cleaner. Do not use abrasive pads or cleaners as these will damage the screen surface.

6.      Clean the control panel with a damp cloth only.

Burlodge USA

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Post-Transplant Diabetes Mellitus (PTDM)

What is Post-Transplant Diabetes Mellitus (PTDM)?

PTDM is the new onset of diabetes in patients who previously received an organ transplant. Specific predisposing factors play a role in the development of PTDM like:

          Age

          Body Mass Index (BMI)

          Hepatitis C virus (HCV) infection

          Various immunosuppressive therapies

          Ethnicity

Post-transplant diabetes mellitus (PTDM) is a complication which takes place after a solid organ transplant, and its incidence is widely variable, ranging from 2% to 53%. Specific types of immunosuppressive regimens (steroids) are related to the highest risk of for developing PTDM like, tacrolimus and corticosteroid. One of the major effects of the transplant is hyperglycemia.

Non-Modifiable Risk Factors:

          Ethnicity

          Age

          Gender of Recipient

          Donor’s Gender

          Family History of Diabetes

 

Modifiable Risk Factors Include:

          Immunosuppressive Therapy

o   Tacrolimus

o   Cyclosporine

o   Corticosteroid

o   Sirolimus

          Obesity

          Metabolic Syndrome

 

Potentially Modifiable Risk Factors:

          Infections

o   HCV

o   CMV

          Impaired Glucose Tolerance: IGT (pre-transplantation)

Every patient in the pre-transplant period must be examined for glucose intolerance and diabetes. The clinical history of the patient will also be important for the identification of risk factors and co-morbidities. The clinical management of patients with PTDM is normally the same as recommended for patients with type 2 diabetes (T2DM).

American Diabetes Association Guidelines

          A1C: 7%

          A1C may also be reported as eAG: 154 mg/dl

          Before a meal (preprandial plasma glucose): 70–130 mg/dl

          1-2 hours after beginning of the meal (Postprandial plasma glucose): Less than 180 mg/dl

          LDL Cholesterol: Less than 100 mg/dl

          HDL Cholesterol: Higher than 40 mg/dl for men and 50 mg/dl for women is good, but an HDL 50 mg/dl or higher helps everyone lower their risk for heart disease.

          Triglycerides: Less than 150 mg/dl

          Blood Pressure: 120/80

          Body Weight Control

Patients with PTDM have a higher risk of cardiovascular disease and infections compared to the general population and these problems could compromise the survival period and transplant durability. PTDM is a significant cause of morbidity in transplant patients. The early identification of this condition in addition to a thorough treatment of diabetes and its co morbidities will definitely determine its development.

ADA Glucose

ADA Cholesterol

ADA Blood Pressure

PTDM Journal Article

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Small Bowel Obstruction in CF Patients

Small bowel obstruction means the small intestine is partially or totally blocked. When this happens, the contents of the intestine cannot properly get out of the body. Stools, fluid, and gas build up inside the intestine. This is a potentially serious condition that requires urgent medical care.

Symptoms

The symptoms for “mechanical” small bowel obstruction include:

          Abdominal fullness and/or excessive gas

          Abdomen feels stretched out more than normal (abdominal distention)

          Pain and cramps in stomach area

          Vomiting

          Constipation (cannot pass gas or stool)

          Diarrhea

          Bad breath

The symptoms of paralytic ileus include:

          Abdominal fullness and/or excessive gas

          Abdominal distention

          Vomiting after eating

          Pain is often less severe than in “mechanical” small bowel obstruction

The diagnosis of a small bowel obstruction is initially performed through a physical exam. The exam will include listening for bowel sounds in your stomach. Very high pitched bowel sounds heard through a stethoscope suggest mechanical bowel obstruction, whereas paralytic ileus often produces no bowel sounds. Your doctor may recommend that you see a gastroenterologist or surgeon depending on the suspected diagnosis. These tests include:

  • CT scan
  • Abdominal ultrasound
  • Abdominal X-ray

For patients with cystic fibrosis, small bowel obstructions are much more common and potentially more dangerous. In cystic fibrosis, the build-up of thick, sticky mucus blocks the ducts leading from your pancreas to your bowel. When this happens, the amount of insulin that your body produces is reduced and digestive enzymes are stopped from aiding your digestion. Without these enzymes, you may not be able to digest enough essential nutrients and you may find it difficult to gain weight. Malnutrition can lead to poor growth, physical weakness and delayed puberty in children. Your feces may contain excess fat making them oily, smelly, large and difficult to flush away.

NYU Langone Medical Center

Bupa Health Center

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Diabetic Ketoacidosis (DKA)

As part of my Medical Nutrition Therapy (MNT) rotation, my preceptor has asked me to create a summary sheet of certain illnesses and complications associated with various disease states. One of which, is diabetic ketoacidosis (DKA).

What is DKA?

DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones.
It develops when your body is unable to produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as an alternate fuel. This process produces a buildup of toxic acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

What causes DKA?

1. Not enough insulin

2. Not enough food

3. Low blood glucose

When cells don’t get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood and appear in the urine when your body doesn’t have enough insulin. They are a warning sign that your diabetes is out of control or that you are getting sick. High levels of ketones can poison the body. When levels get too high, you can develop DKA. DKA may happen to anyone with diabetes, though it is rare in people with type 2. Treatment for DKA usually takes place in the hospital. But you can help prevent it by learning the warning signs and checking your urine and blood regularly. DKA usually develops slowly. But when vomiting occurs, this is life-threatening and can develop in a few hours.

Sugar is a main source of energy for the cells that make up your muscles and other tissues. Normally, sugar enters your cells with the help of insulin. If you don’t have enough insulin in your body, your body won’t be able to use sugar properly for energy. This prompts the release of hormones that break down fat as an alternate fuel. In turn, this process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually “spill over” into the urine.

Early symptoms include:

– Polydypsia (increase of thirst)

– Polyuria (frequent urination)

– Hyperglycemia (high blood glucose levels)

– High level of ketones in the urine

– Fatigue, dry skin, nausea, difficulty breathing, fruity odor on the breath (caused from the presence of ketones)

When diagnosing DKA, a healthcare provider should pay close attention to the following lab values:

Blood Glucose: If there isn’t enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise.

Ketone level: When your body breaks down fat and protein for energy, toxic acids known as ketones enter your bloodstream.

Blood acidity: If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of various organs throughout your body.

– Blood electrolyte tests, Urinalysis, Chest X-ray, and an Electrocardiogram (ECG)

The treatment for DKA involves a three-pronged approach:

1. Fluid Replacement: receive fluids, orally or intravenously, until rehydrated. These fluids will replace those that have been lost through excessive urination and dilute the excess sugar in the blood.

2. Electrolyte Replacement: Electrolytes are minerals in your blood that carry an electric charge, such as sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in your blood. You’ll receive electrolytes through your veins to help keep your heart, muscles and nerve cells functioning normally.

3. Insulin Therapy: Insulin reverses the processes that cause diabetic ketoacidosis. Along with fluids and electrolytes, you’ll receive insulin therapy — usually through a vein. When your blood sugar level falls below 240 mg/dL (13.3 mmol/L) and your blood is no longer acidic, you may be able to stop intravenous insulin therapy and resume your normal subcutaneous insulin therapy.

Diabetic ketoacidosis is usually triggered by an illness or insulin therapy.

An infection or other illness can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol. Unfortunately, these hormones work against insulin — sometimes triggering an episode of diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits.

Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering an episode of diabetic ketoacidosis.

Other possible triggers of DKA could include:

– Stress

– Physical or emotional stress

– High fever

– Surgery

– Heart attack

– Alcohol or drug abuse, specifically cocaine

While DKA is being treated, there are complications that patients and healthcare providers need to be aware of as well. Complications could include:

Hypoglycemia: Insulin allows sugar to enter your cells. This causes your blood sugar level to drop. If your blood sugar level drops too quickly, you may develop low blood sugar.

Hypokalemia: Fluids and insulin used to treat diabetic ketoacidosis may cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles and nerves.

Cerebral Edema: Adjusting your blood sugar level too quickly can produce swelling in your brain. This complication appears to be more common in children, especially those with newly diagnosed diabetes.

American Diabetes Association- DKA

Mayo Clinic- DKA

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