Bariatric Notes

Types of surgery:
● Gastric Bypass (RGB), “Gold standard” of WLS
○ A small stomach pouch, approximately one ounce or 30 milliliters in
volume, is created by dividing the top of the stomach from the rest of the
stomach. Next, the first portion of the small intestine is divided, and the bottom
end of the divided small intestine is brought up and connected to the newly
created small stomach pouch. The procedure is completed by connecting the top
portion of the divided small intestine to the small intestine further down so that
the stomach acids and digestive enzymes from the bypassed stomach and first
portion of small intestine will eventually mix with the food
○ The newly created stomach pouch is considerably smaller and facilitates
significantly smaller meals, which translates into less calories consumed.
Additionally, because there is less digestion of food by the smaller stomach
pouch, and there is a segment of small intestine that would normally absorb
calories as well as nutrients that no longer has food going through it, there is
probably to some degree less absorption of calories and nutrients. Most
importantly, the rerouting of the food stream produces changes in gut hormones
that promote satiety, suppress hunger, and reverse one of the primary
mechanisms by which obesity induces type 2 diabetes
○ Pros
■ Produces significant long-term weight loss (60 to 80 percent excess
weight loss)
■ Restricts the amount of food that can be consumed
■ Typical maintenance of >50% excess weight loss
○ Cons
■ Is technically a more complex operation than the AGB or LSG and
potentially could result in greater complication rate
■ Can lead to long-term vitamin/mineral deficiencies particularly deficits in
vitamin B12, iron, calcium, and folate
■ Requires adherence to dietary recommendations, life-long vitamin/mineral
supplementation, and follow-up compliance
○ Special Additional Notes
■ Gut hormone changes are major factor w/ GB
■ Changes in ghrelin (hunger, lowered) and leptin (appetite, increased
satiety) aide w/ weight loss
■ Best for managing DM b/c GLP-1 is affected which decreases glucagon
function
● Insulin use is definitely lowered, but not always able to come off
especially if you’ve been on insulin for 8+ years (pancreas is
dependent)
Bariatric Notes

● Sleeve Gastrectomy (sleeve, LSG)

○ Laparoscopic
○ Removes 80% of the stomach, remaining part shaped like a banana
○ The new stomach pouch holds a considerably smaller volume than the
normal stomach and helps to significantly reduce the amount of food (and thus
calories) that can be consumed. The greater impact, however, seems to be the
effect the surgery has on gut hormones that impact a number of factors including
hunger, satiety, and blood sugar control.
○ Pros
■ Restricts amount of food the stomach can hold
■ Induces rapid and significant weight loss
■ Requires no foreign objects (AGB), and no bypass or re-routing
of the food stream (RYGB)
○ Cons
■ Non-reversible
■ Long term vitamin deficiencies
○ Special Additional Notes
■ Some people go from sleeve to GB because of inadequate weight loss or
reflux issues (tend to have more reflux w/ sleeve)
■ OK to start w/ sleeve if really high BMI (ex: 74) to assist w/ weight loss
then change to bypass since it’s “safer”
■ Bad reflux/barrett's esophagus (cx) = no sleeve
● Gastric Band (AGB)
○ “The band”, not used as much anymore
○ With the smaller stomach pouch, eating just a small amount of food will
satisfy hunger and promote the feeling of fullness
○ The size of the stomach opening can be adjusted by filling the band with
sterile saline, which is injected through a port placed under the skin
○ The clinical impact of the band seems to be that it reduces hunger,
which helps the patients to decrease the amount of calories that are consumed
○ Pros
■ Induces excess weight loss of approximately 40 – 50 percent
■ Involves no cutting of the stomach or rerouting of the intestines
■ Is reversible and adjustable
■ Has the lowest risk for vitamin/mineral deficiencies
○ Cons
■ Slower and less early weight loss than other surgical procedures
■ Requires a foreign device to remain in the body
■ Can result in possible band slippage or band erosion into the stomach in
a small percentage of patients
■ Highest rate of re-operation
○ Special Additional Notes
■ More common to be taken out then switch to GBP/LSG d/t maintenance
of the band/slippage/erosion, etc.
Bariatric Notes

■ Important to at least maintain weight or lose and not gain w/ the band b/c
things change once the band is removed
■ Banded Plication
● “During adjustable gastric banding with gastric plication, the
procedure begins with the surgeon partially cutting the tissue and
vascular attachments to the stomach along the greater curve
(outside part of stomach) exposing the front and back of the
stomach. The surgeon then inserts the adjustable gastric banding.
Once the band is inserted, the surgeon then folds the stomach
below the band in on itself and uses stitches to keep the fold in
place. This procedure reduces the volume of the stomach, which
reduces the capacity of the stomach for food.”
● Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
○ Duodenal switch, barely used d/t complications/complexity
○ First, a smaller, tubular stomach pouch is created by removing a portion
of the stomach, very similar to the sleeve gastrectomy. Next, a large portion of
the small intestine is bypassed.
○ Pros
■ Results in greater weight loss than RYGB, LSG, or AGB, i.e. 60 –
70% percent excess weight loss or greater, at 5 year follow up
■ Allows patients to eventually eat near “normal” meals
■ Reduces the absorption of fat by 70 percent or more
■ Causes favorable changes in gut hormones to reduce appetite
and improve satiety
■ Is the most effective against diabetes compared to RYGB, LSG, and AGB
○ Cons
■ Has higher complication rates and risk for mortality than the AGB, LSG,
and RYGB
■ Requires a longer hospital stay than the AGB or LSG
■ Has a greater potential to cause protein deficiencies and long-term
deficiencies in a number of vitamin and minerals, i.e. iron, calcium, zinc,
fat-soluble vitamins such as vitamin D
■ Compliance with follow-up visits and care and strict adherence to dietary
and vitamin supplementation guidelines are critical to avoiding serious
complications from protein and certain vitamin deficiencies
○ Special notes
■ Can go from sleeve to DS
■ Greater need for ADEK vitamins
■ Bad reflux = no DS
● New surgeries/devices to watch for
○ Apollo suturing technique
■ “”OverStitch” is a procedure done after previous weight loss surgery. It
uses an innovative device to reduce (revise) your pouch back to its
previous size”
Bariatric Notes

○ Orbera balloon
■ “The gastric balloon system consists of one or two balloons placed in
your stomach through a tube inserted through your mouth. Your doctor or
nurse will give you a sedative before the procedure. Once the balloons
are in your stomach, doctors inflate them with salt water so they take up
space in your stomach and help you feel fuller”
■ Removed after 6 months
○ “Aspire assist”
■ Port located on front of abdomen. Eat a meal, then 20-30 minutes later,
hook up a drain to the port over the toilet and drain remaining stomach
contents, FWF, then drain more
■ Resembles bulimia w/o the vomiting
■ https://www.cnbc.com/2016/06/14/the-fda-approved-a-weight-loss-device-
that-sucks-food-out-of-your-stomach.html
○ “The Tantulus” “Transcend”
■ “The “electrical stimulation system” uses a device implanted in your
abdomen, by way of laparoscopic surgery, that blocks nerve activity
between your stomach and brain. The device works on the vagus nerve,
which helps signal the brain that the stomach feels full or empty”
○ Stomach Intestinal Pylorus Sparing (SIPS) surgery
■ “Remove the stretchy, upper portion of your stomach: What remains is a
small stomach pouch that is a fraction of the size of a normal stomach
■ Reroute your intestines: After leaving the stomach pouch, food skips over
(bypasses) a portion of the small intestine”
○ Bariatric Arteriale Embolization (“BAE”)
■ “Interventional radiologists thread a catheter through the wrist or groin to
gain access to specific blood vessels in a precise area of the stomach.
Once they zero in on their target, they inject microscopic beads to block
the blood supply to this spot where the body’s "hunger hormone" ghrelin
is produced.
■ The decrease in blood flow leads to what’s being reported as an 80
percent decrease in hunger. And the beads have already been safely
used in heart and uterine procedures for decades.”

Websites:
https://asmbs.org/patients/bariatric-surgery-procedures
https://www.sciencedirect.com/science/article/pii/S0002822309020914?via%3Dihub

Diet Guidelines:
● 1-2 weeks before: liquid diet
○ 5 Atkins shakes/d (20g protein) q2-3 hours
○ 800 kcal/d
○ CLD (broths, jello, etc.)
Bariatric Notes

○ Premier (30g) not recommended at this time b/c pts don’t need that much protein
■ Extra protein = more likely to get dehydrated and constipated
● Ensure surgical night before and 2 hours pre-op
● Post surgery: CLD for 24 hours
○ Occurs while in house
○ Food tray w/ beneprotein, healthy shot, Ensure max protein & CL items
■ Not required to eat it all (may be hard to tolerate)
■ Drink as much as you can tolerate
● Football, to ping pong, to marble
● 1 week after: Liquid diet (~60 g pro)
○ Will take hours to drink even 1 drink, but try to sip every 5-10 min
■ May not even be possible to consume 2 drinks in first 2 days
■ Stomach and GI tract may be swollen
○ Premier drinks recommended b/c 1 can has 30g of pro so 2 = rec amt.
○ Keep up w/ fluid intake as much as possible
■ Sip every 5-10 minutes
● 2 weeks after: Pureed (>60 g pro)
○ Baby food consistency
○ Yogurt, cottage cheese, pureed veggies, oatmeal, cream of wheat
○ OK to start vitamins at this point (for tolerance)
● 3 weeks after: soft foods (>60 g pro)
○ Eggs, ground meats, can still continue yogurt, soft cooked vegetables
● 4 weeks after: “regular” diet (>60 g pro)
○ Chicken, pork, beef, meat
○ Stray from breads, pastas, rice
○ Make sure meat/food is moist to help it go down
■ But don’t drink water at the same time

Things of Note:
● American Society for Metabolic and Bariatric Surgery
● Metabolic Surgery and Bariatric Care
● Adult candidates: (SHP = serious health problem)
○ Start appointments w/ RD 6 mos. prior to surgery and need clearance (6 appts,
1st initial appt. doesn’t usually count even though it should)
○ BMI >40
○ BMI >35 w/ SHP linked to obesity (T2DM, HD, etc.)
○ BMI >30 w/ SHP linked to obesity (**band only)
○ Higher BMI is more likely to be recommended to get GB → lose more weight
■ Ultimately pt decides even if surgeon recommends something different
● Teen candidates
○ BMI >35 w/ SHP (T2DM or SA)
○ BMI >40 w/ SHP (HBP or high cholesterol)
○ **Peds wt. Management clinic lost funding at Loyola so no teens
Bariatric Notes

● After 3 no call/no show or same day cancellations, pts are kicked out of program and not
allowed back
● Some insurances cover costs if certain criteria is met and doctor’s recs have to show
you have been unable to lose weight via another program
○ Otherwise surgery costs between $15,000-$20,000
○ Insurances only cover costs of certain surgeries
■ Newer ones not so much right now but could change
● Surgical Pathway Colors at GMH
○ Green: can see any provider in any order
○ Red: Significant medical hx - needs to see the MD first then can see another
provider
○ Yellow: Significant psych hx - needs to see psychologist first then can see
another provider
○ Orange: Significant medical and psych hx - needs to see MD and psych first
before RD or surgeon
○ Purple: Past hx of a bariatric procedure - needs a GI and EGD then a visit w/
surgeon before any other provider
○ Brown: Pt interested in another technique - Orbera balloon or Apollo suturing (out
of pocket only) Need to see surgeon before any other provider
● On vitamin supplements for life after surgery (super important!!!)
○ Recommended amounts:
○ MVI, Iron, B12, vitamin A, vitamin D, calcium citrate (w/ vit. D) and zinc?
■ Stool softener and reflux meds optional & prn
■ Citrate doesn’t need stomach acid to absorb/digest
■ Bypass → no carbonate b/c no stomach acid
■ Most important vits: vit D, iron and B12
○ For bypass: need supplementation d/t malabsorption, bypassing a major area in
intestines for absorption
○ OK to wait to take MVI/vitamins till 1 week post-op d/t tolerance
■ Chewable ones recommended for ~1st month b/c capsules may be
harder to swallow
■ Then able to switch to capsules if preferred
■ MVI = tums consistency, calcium = starburst consistency
○ Special MVI made for bariatric patients (b/c of increased needs, Celebrate brand)
■ Recommended so there’s less pills to take since it meets increased
needs
■ OTC/gummy vitamins NOT recommended - not nearly high enough in
needs for bariatric patients and will cause pts to have to take more pills to
make up for deficits
■ Celebrate usually 2/d for chewable, pills are 3/d
○ Patches NOT recommended (not enough absorption through skin)
○ SHOULD NOT take iron/MVI at the same time as calcium
■ Inhibits absorption of each other
■ 2+ hours between
Bariatric Notes

○ Calcium can only be absorbed ~500-600 mg at a time

■ 500 mg 3x/d also 2+ hours apart for proper absorption
○ Labs checked monthly-yearly to monitor any deficiencies
○ Don’t want to start in the hole w/ deficiencies pre-surgery so may need to
supplement before (vit. D or iron most common deficiencies)
● Nausea can occur when taking MVI or iron
○ Especially in the morning on an empty stomach
○ Can take at night before bed
● If extremely obese, need to lose weight before surgery to lessen the risk of surgery
○ May be prescribed a weight loss drug to help suppress appetite (see meds
sheet)
■ Phentermine most popular - need EKG & no HBP before being prescribed
○ “Combo” meds may be prescribed separately d/t insurance costs
○ Some meds may cause dry mouth so fluid intake increases (ex: phentermine)
○ Sometimes prescribed at least 1 year post-op
● NSAIDS should be avoided post-op
○ Increased chance of developing ulcers which are harder to treat post-op
● EGD performed pre-op
○ If h. Pylori is found, need to get it removed (take abx)
○ Common in most people and they had no idea they were even there
○ Also check for Barrett’s esophagus → can lead to cx down the line
■ Not a candidate for sleeve then b/c of increased reflux
● APC (endoscopic)
○ “Argon plasma coagulation of gastrojejunal anastomosis for weight regain after
gastric bypass”
○ Ex: woman had it done then ate solids too soon after & had to have an EGD
○ To alter the anastomosis
■ “An anastomosis is a connection or opening between two things that are
normally diverging or branching, such as between blood vessels, leaf
veins, or streams”
● Sleep study, EGD, and psych visit performed pre-op
● Liquid diet before surgery to shrink the liver so it’s easier to access the stomach
○ 1 week for BMI <50
○ 2 weeks for BMI >50
● Drink ensure surgical the night before and 2 hours before surgery
○ 50% CHO to “carb load” for surgery since it’s a lot
○ Tastes like watered down slightly thickened coffee
● Eating and drinking at the same time not allowed/recommended post-surgery
○ No liquids 30 min before, none during, and none 30 min after meals/eating
○ Stomach can only handle so much at once
○ Don’t want liquids to push food out faster
● Increase fluids (water)
○ 64+ oz (probably need more)
○ No juice, limit coffee to small or none (NAS)
Bariatric Notes

○ No sugar/calorie drinks ok (powerade, propel)

■ To get them to drink something (besides plain water)
○ Crystal light OK too
● Protein needs increase post surgery
○ Proteins are absorbed mainly in the jejunum and mid-ileum. The procedures that
bypass these gut areas increase the risk of protein malnutrition
○ 60+ g/d
■ Premier protein shakes (30g/drink)
● Iron deficiency also very common post-op
○ “Decreased ability to convert the dietary Fe3+ into the more absorbable Fe2+
form (due to low gastric acid production) and the bypassing of the duodenum and
proximal jejunum (which are the main sites of iron absorption) are the primary
mechanisms leading to iron deficiency”
○ Women tend to be lower in iron
● “Stomach acid helps to release B12 from food, and another substance that is made by
the stomach – Intrinsic Factor –is essential for B12 absorption
○ Gastric bypass and vertical sleeve gastrectomy make B12 absorption more
difficult for these reasons
○ Often people who have these procedures will be required to take additional B12
as an injection, intranasal spray or sublingual tablet”
● Insulin resistance
○ “The hormone insulin helps control the amount of sugar (glucose) in the blood.
With insulin resistance, the body's cells don't respond normally to insulin.
Glucose can't enter the cells as easily, so it builds up in the blood. This can
eventually lead to type 2 diabetes.”
● Meal tracking super important
○ Monitor protein intake and kcals
○ My fitness pal recommended most or paper journals
● Dumping syndrome can occur
○ Watch sugar intake carefully, avoid added sugar
■ “Single digit” sugar content; if first 3 ingredients are sugar don’t eat
○ Can lead to “instant” diarrhea
○ Mostly occurs w/ bypass d/t changes in GI route
● Food intolerances can occur post-surgery
○ Milk/lactose common, esp. after bypass
○ Steak/beef/pork seems to be not tolerated sometimes as well but chicken OK
○ Pasta, bread, & rice recommended on lower end or none at all
● Alcohol not advised post-op
○ 100 cals/5 oz of wine, 100 cal/shot
○ Can cause dumping, especially if too soon post-op (even in sleeve)
○ Can cause pts to get drunk faster but also leave system faster
● Post surgery visits are important to monitor labs and weight
○ RD visits: 1 mo, 6 mo, 12 mo, 18 mo, then “yearly”
○ Appetite can creep back up as time goes on - won’t feel the same as first post-op
Bariatric Notes

○ Pts feel like they can eat certain items again or more than before as time goes on
so they may indulge more
○ Labs to monitor deficiencies
○ As time goes on and weight loss continues, RMR decreases & calorie needs
decrease so weight loss can slow down → exercise is important to widen the gap
since it’s “closing in”
● Revisions are possible post-op
○ Because the desired results were not produced, stomach stretched out,
● Hair loss can be common for 3-6 mos. post-op or even a year
○ Usually d/t stress in the beginning, not nutrition related
○ If longer than that, may be deficient in iron and zinc
● Women should wait to get pregnant till at least 1-2 years post-op
○ Ex: pt who had surgery in early 2000’s got pregnant right away and was still
losing weight so it was a high risk pregnancy
○ Women think they may not be fertile but with body/hormone changes and weight
loss, fertility increases so may be more likely to be pregnant after (but should
wait)
○ May also even be safer to get pregnant after d/t less risk of obesity
● IF a pt needs TF, the tube will be placed in the remnant of the stomach
○ https://www.rippeinfoservices.com/conagra-
nutrition/pdf/Webinar_050615_bariatric.pdf
○ https://www.researchgate.net/publication/301340968_Nutrition_support_therapy_
for_the_bariatric_surgery_patient
● %excess body weight
○ Starting body weight (SBW) is the weight taken at the H&P visit which is w/in one
month of surgery
○ SBW - IBW = excess body weight
○ Patients generally never get to 100% (nearly impossible) and that’s OK

Medical Weight Loss Patients

● Reasons for these pts to be seen by RD:
○ MD referral (PCP)
○ Pt is not eligible for weight loss meds
○ Pt is not eligible for surgery but still needs weight loss
■ Failed pre-tests (EGD, sleep study, etc.)
■ Other comorbidities interfering
○ Pts who don’t want surgery can try this route first to lose weight
■ A lot of pts probably should have surgery though
○ Some pts personally seek out RD help