This document provides an overview of a 58-year-old female patient who underwent a sleeve gastrectomy surgery in July 2013 and experienced complications including a persistent gastric leak. It discusses her medical and surgical history, the nutrition care process being followed including assessments, diagnosis of altered GI function, interventions of initiating TPN and monitoring, and follow-up evaluations showing tolerance of TPN and a full liquid diet. The summaries provide the high-level details about the patient's history, surgery, complications, nutrition care and progress.

1. Bariatric Surgery Complications
NUTRITION CASE STUDY
WENDY THOMPSON
WVU DIETETIC INTERN
D E C E M B E R 2 ND, 2 0 1 3

2. Outline
2
 Overview of the Patient
 Sleeve Gastrectomy Surgery
 Medical Nutrition Therapy for Bariatric Surgery
 Nutrition Care Process of the Patient
 Nutrition Assessment
 Nutrition Diagnosis
 Nutrition Intervention
 Monitoring/Evaluation
 Follow-Ups

3. Patient Overview
3
 58-year-old female
 Past Medical History:
 Current Medical History:

s/p Gastric Sleeve Surgery
(July 2013)


Persistent Leakage
 Gastric Stenting
 Left Upper Quadrant
Abscess



Nausea and Vomiting
Leukocytosis




Morbid Obesity (BMI 45
pre-surgery)
Hypertension
Hyperlipidemia
GERD
Cholecystectomy
Hysterectomy

4. What is a Laparoscopic Sleeve
Gastrectomy?

5. Laparoscopic Sleeve Gastrectomy Overview
5
 Removes 60-80% of the stomach
 Shrinks stomach capacity to ≤300 mL
 Weight loss mechanism = gastric restriction and
possible decreased levels of ghrelin

Ghrelin = appetite stimulating hormone primarily produced in
fundus and with small amounts produced in the pancreas
 Potential nutritional risk factors = nutrient
deficiencies due to:


Decreased intake
Removal of the majority of parietal cells

Decreased hydrochloric acid and intrinsic factor (B12)

6. Who is a Candidate for Bariatric Surgery?
6
 BMI ≥ 40 or 35-39.9 with comorbidities:
 Type 2 diabetes
 Sleep apnea
 Hypertension
 Cardiovascular disease
 Osteoarthritis
 Age 16-70 (some exceptions possible)
 Failed attempts at diet and exercise
 Have been obese for at least 5 years
 Free of substantial psychological disease, drug or alcohol
dependency
 Candidates must be able to understand surgery and postsurgery lifestyle requirements
 Motivated and well-informed

7. Outcomes of Sleeve Gastrectomy
7
 Weight Loss Outcomes for
average % of excess body
weight:






1 month: 18-30%
3 months: 37-41%
6 months: 54-61%
1 year: 58-70%
2 years: 61.5%
5 years: no long-term data
 Potential Complications:
 Nausea/Vomiting
 GERD
 Anemia
 Leakage along the staple line
causing peritonitis or abscess
 Sleeve Stricture
 Bowel Obstruction
 Pneumonia
 Deep Venous Thrombosis
(DVT)
 Acute Kidney Injury
 Liver Failure

8. Post-Bariatric Surgery Behavior
8
 Eat slowly and chew thoroughly – at least 25 times!
 Avoid concentrated sugars, especially in liquid form
 Limit fats and fried foods
 Shrink your portions – do NOT overeat!
 Do not drink liquids with a meal – try not to drink
30 minutes before and after a meal or snack
 If you can no longer tolerate diary – try a lactose-free
diary source
 Exercise – after 2 months more strenuous exercise
can be tolerated

9. MNT for Sleeve Gastrectomy
9
 Typical Diet Progression:
 Bariatric Phase I: Clear Liquids (begins post-op for 2-3 days)
 Bariatric Phase II: Full Liquid (advance as tolerated)
 Bariatric Phase III: Pureed/Home Soft Diet (progress as
tolerated, usually begins 1 week post-op)
 Bariatric Phase IV: Solids (progress as tolerated, usually begins
1 month post-op)
 Protein Needs:
 No set standard – typically 80-120g/day or 1-1.5 g/kg IBW
 CAMC Weight Loss Center = 1.5 g protein/kg of IBW
 Adequate Hydration – goal 64 oz. day
 Rule of Thumb: Sip 1-2 ounces every 15 minutes

10. Sample Menu for 1 Month Post Op
(Bariatric Home Soft Diet)
10
 8:00AM Breakfast:
 ¼ - ½ cooked cereal
 ¼ - ½ cup skim plus milk
 10:00AM Snack:
 ½ cup protein supplement
 12:00PM Lunch:
 ¼ - ½ cup sugar free yogurt
 ¼ cup pureed fruit
 2:00PM Snack:
 ¼ - ½ cup unsweetened applesauce
 1 sugar free popsicle
 6:00PM Dinner:
 ¼-1/2 cup blended soup with protein
 ¼ cup pureed fruit

11. MNT Life-Long Bariatric Diet
11
 High protein
 Low in refined carbohydrates
 Ideally, choose protein first, then fruits and
vegetables, and then whole grains
 Maintain adequate hydration

12. Vitamin and Supplement Rx
12
 First 3 Weeks Post-Op:
 Chewable multi-vitamin
 Chewable calcium
 Vitamin D – only if levels are low
 Vitamin B12 – if needed
 Protein supplements

Must be high in protein (15-25g/serving) and low in sugar (less than 10g/serving)
 After 3 Weeks Post-Op:
 Multi-vitamin
 Calcium Citrate (1200 mg)
 Vitamin B12- if needed
 Vitamin D – only if levels are low
 Iron – only if prescribed by MD
 Protein Supplements – if unable to consume 50-70g protein/day
 Ursodiol – “Gall Bladder Pills” only for the first 6 months

Helps prevent gallstones due to rapid weight loss

13. Nutrition Care Process

14. Nutrition Assessment (11/12)
14
 Secondary To:
TPN protocol consult
 Current Medical History:
 s/p sleeve gastrectomy, persistent gastric leak, morbid obesity,
HTN, hypokalemia, tachycardia
 Past Medical History:
 HTN, hyperlipidemia, GERD, cholecystectomy, partial
hysterectomy


15. Bariatric Past Medical History
15
 7/8/2013: Laparoscopic Sleeve Gastrectomy
 N/V started 2 weeks post-op
 8/9/2013: Upper GI Endoscopy – found mild stricture in the







opening of the gastroplasty (between esophagus and stomach),
performed balloon dilation
8/15/2013: Admitted to ER with N/V, HTN, leukocytosis, lactic
acidosis – conducted CT scan to find left upper quadrant abscess
and left pleural effusion
8/16/2013: Transferred to Cleveland Clinic and had abscess drained
8/19/2013: Re-drained abscess
8/23/2013: Re-drained abscess, placed gastric sleeve stent, resealed the leak at the staple line
8/29/2013: Endoscopic exploration found stent partially collapsed
so it was adjusted
9/2/2013: Double stenting placed to correct the collapse stent
11/02/2013: Transferred from Cleveland Clinic to CAMC

16. Patient Medications and Supplements
16
Medication Name
Reason
Protonix
PPI to decrease stomach acid to treat GERD
Mylanta
Neutralizes existing stomach acid to treat GERD
Reglan
Reduces nausea, vomiting, and GERD
Phenergan
Helps treat existing nausea and vomiting
Zofran
Helps prevent nausea and vomiting
Metoprolol
Beta-blocker to lower blood pressure
Lasix
Loop diuretic to lower blood pressure
Dilaudid
Treats pain
Folic Acid
Individuals post bariatric surgery are at an increased risk for
deficiency – used to prevent deficiency
Vitamin B6
Vitamin B12
Thiamine

17. Anthropometric Measurements
17
Height
165.1 cm (5’5”)
Weight
112 kg (10/30 – Bed Scale)
IBW
57 kg
% IBW
196%
Adjusted/Feeding Weight
71 kg
BMI
41.1 (Class III Obesity)

18. Nutrient Needs
18
 Current Diet Order (11/12):

Vivonex RTF @ goal rate of 60ml/hr to provide 1440kcal, 72g
protein, and 1224ml free H2O


NG tube
Bariatric Phase I - Clear Liquids
Estimated Needs Per Kg of IBW
Per Day
Energy (kcal)
18 – 22 kcal
1278 – 1562 kcal
Protein
1 – 1.5 grams
71 – 106 grams
Fluid
Per MD
Per MD

19. Subjective Information (11/12)
19
 Patient was consuming ~50% of clear liquid diet and
tube feeding was up to 40ml/hour
 Very nauseous
 Vomits multiple times a day and has since 2 weeks
post-surgery in July
 Patient has had nothing but clear liquids and tube
feedings since surgery

20. Patient Labs
20
11/11
Potential Reasons for Abnormalities
Glucose (74-106)
127 
Stress, insulin resistance
Na (136-145)
135 
K (3.5-5.1)
3.4 
BUN (7-18)
21 
Creatinine (0.6-1.3)
1.4 
eGFR (>60)
47 
Based on creatinine levels – potential decrease in kidney
function
Albumin (3.4-5)
1.6 
Sign of inflammation with potential protein/energy
deficiency
Occurs with prolonged vomiting
Potential decrease in kidney function or dehydration

21. Nutrition Diagnosis
21
 Altered GI function related
to persistent gastric leak and
stent placement as
evidenced by intolerance to
tube feed
 Notes:

High risk for refeeding syndrome
due to minimal intake:
Advance feedings slowly
 Monitor electrolyte values
closely
 Watch for low potassium,
phosphate, magnesium levels


22. Nutrition Intervention (11/12)
22
 d/c tube feeding and bariatric clear liquid diet
 Due to persistent N/V
 PICC line placement was ordered by MD and x-ray
was used to verify correct placement
 Initiate TPN @ 8:00PM (11/12) per CAMC protocol


TPN was discussed with Physician, who determined the initial
rate to be 75 ml/hour
Nursing staff was notified
 IPOC

23. Parenteral Nutrition Invention
23
 PICC Line
 Start: subclavian vein
 End: superior vena cava

24. Parenteral Nutrition Intervention
24
 Initial TPN Order - 11/12
 Rate: 75ml/hour
 Macronutrients:
 Amino Acids: 50g of 15%
 Dextrose: 75g of 70%
 Lipids (M/W/F only) = 0g
 Total Calories: 455 kcal
 Electrolytes:
 Sodium: 140 mEq
 Potassium: 30 mEq
 Calcium: 10 mEq
 Magnesium: 8 mEq
 Phosphate: 6 mEq
 MVI: Standard
 Ascorbic Acid: 125mg
 Thiamine: 50mg
 Trace Elements: None
 Insulin: None
 Pepcid: None (on Protonix)

25. Monitoring and Evaluation
25
 Goals:
Improve protein status
 Provision of adequate nutrition via nutrition support
 Stabilize blood glucose levels
 Monitoring:
 High Risk – F/U in 5 days
 Will follow daily
 Will monitor weight, labs, and TPN/PPN tolerance


26. TPN Monitoring and Evaluation
26
Check labs per TPN protocol:
 Every 6 hours:






Glucose
 Daily:

 Weekly (unless abnormal):
Basic Metabolic Panel (BMP)
Sodium
Potassium
Calcium
Chloride






Complete Metabolic Panel
(CMP)
Triglyceride
Magnesium
Phosphorus
Ionized Calcium
Pre-albumin
Liver panel

27. Follow-Up Assessment (11/14)
27
 Subjective Information:



Patient was tolerating full liquid diet and a Boost Glucose Control
with lunch and dinner
Patient was still nauseated but had only vomited once today
Patient preferences of cream of chicken, tomato, chicken noodle soup
were recorded
 Plan for Patient:

Spoke with social worker and determined that the patient must be on
12-hour cyclic TPN prior to discharge in order to be accepted into a
skilled nursing facility


Plan to start cycling on Monday (11/18)
Patient will require an stent placement – per MD notes, date planned
for 11/20

28. Follow-Up Assessment (11/19)
28
 Nutrition Orders:
 11/17: TPN d/c due to lost access secondary to multiple blood
clots
 Bariatric Phase II – Full Liquid with Boost Glucose Control w/
lunch and dinner
 Subjective:
 Patient was tolerating full liquid diet and consuming the
majority of the supplement
 Vomiting frequency has decreased but nausea still persist

29. Follow-Up Assessment (11/19) Cont.
29
 Significant Lab Changes:
 Alkphos (39-117): 306 
 ALT (17-67): 127 
 AST (15-65): 181 
 Suggestive of potential hepatic dysfunction and
common with TPN

30. Updates
30
 11/20: Gastric stent placed
 11/22: Restarted TPN
 11/24: Started to cycle TPN – due to SNF
requirements
 11/27: Reached cyclic goal of 12 hours
 11/28: Switched TPN back to continuous due to
acute renal failure

TPN providing an average of 1,314 kcal
 12/2: Bariatric Phase III – Pureed/Soft with Boost
Glucose Control and continuous TPN

31. Questions?
31

32. References
32
 Snyder-Marlow G, Taylor D, Lenhard MJ. Nutrition
care for patients undergoing laparoscopic sleeve
gastrectomy for weight loss. J Am Diet Assoc.
2010;110(4):600-607. doi: 10.1016/j.jada.
 CAMC Standards of Practice
 http://www.cornellweightlosssurgery.org/pdf/dietar
y_guidelines_sleeve_gastrectomy.pdf
 http://www.camc.org/surgicalweightloss

33. Appendix: Patient Labs
33
11/11
11/13
11/14
11/15
11/16
11/17
11/18
Glucose (74106)
127 
120 
140 
112 
106
135 
117 
Na (136-145)
135 
137
139
139
143
140
139
K (3.5-5.1)
3.4 
3.3 
3.3 
3.7
3.5
3.4 
3.5
BUN (7-18)
21 
27 
31 
37 
44 
50 
60 
Creat (0.6-1.3)
1.4 
2.0 
2.0 
1.9 
1.6 
1.6 
1.7 
GFR (>60)
47 
31 
31 
33 
40 
40 
37 
2.5
2.3 
3.1
3.6
Phosphorus
(2.5-4.9)
Albumin (3.45)
3.4
1.6 
1.7 
Pre-Alb. (2040)
Triglycerides
(50-200)
1.6 
1.8 
15.5 
224 