The Prevalence of Anastomotic Stenosis Post Laparoscopic Gastric Bypass Surgery and the Efficacy of Medical Nutrition Therapy
Bariatric surgery has grown in popularity coinciding with a steady increase of obese individuals. Globally obesity has nearly tripled since 1975. More than 1.9 billion adults were overweight in 2016. Of these over 650 million were obese (“Obesity and Overweight” 2017). Before a person is evaluated for qualification by a bariatric surgeon, a person must show unsuccessful efforts of weight lost. Insurance companies generally require patients to complete a medical weight loss management program for 4-6 months before a claim for surgery is even considered for approval. The guidelines for determining if a person would qualify for surgery are as follows: body mass index (BMI) is 40kg/m2 or higher, BMI is 35kg/m2 or more and have a serious weight-related health problem, such as type 2 diabetes and a person may still qualify if BMI is 30 to 35kg/m2 with serious related health concerns. A team of health professionals including a doctor, dietitian, psychologist and surgeon will elevate the suitability of gastric bypass with weight loss goals per individual case (“Gastric Bypass Surgery”, 2017). Insurance companies will then approve or deny the claim for surgery. Insurance companies require in some cases, patients meet a specific percentage of weight loss at 5-15% (Insurance-Mandated, 2019). Bariatric surgery for the morbidly is considered the next steps on the weight loss ladder. After surgery is completed, the patient will then begin their weight loss journey. For a patient to reach those top steps of the ladder, success is attainable through medical compliance, compliance to diet, engaging in physical activity and coping with behavioral factors. Bariatric surgery is a life-long change that is needed to be reverberated to ensure the patient can make permanent lifestyle changes for successful weight loss. These lifestyle patterns will be new terrain for many patients and should require mandated education hours. Follow-up after surgery requires an interdisciplinary approach from numerous care team members that deliver expertise in their specialized areas of medical care. While the patient is responsible for compliance the care team is expected to educate, coordinate and monitor care.
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The Roux-en-Y via laparoscopy is a major surgery although less invasive than open surgery. Stomach, intestines and organs are all pushed out of place and cut and stapled where necessary. The surgeon creates a small upper pouch and a much larger lower remnant pouch of the stomach with the small intestine rearranged to connect to both. All major procedures have risks involved. In comparison, complications following gastric bypass can be vast. Complications can arise from a surgical standpoint and behavioral, both are common. After undergoing bariatric surgery, 10-30% of patients will require follow-up operations from complications. The most common complications are gastrojejunal anastomotic stenosis(stricture) and marginal ulcers with incidence rates up to 35% and up to 16% respectively. Gallstones may develop and lead to the need of a cholecystectomy. This occurs in more than 33% of bariatric surgery recipients. Rapid and substantial weight loss increases the risk of developing gallstones. Also, nearly 30% of patients who have gastric bypass develop nutritional deficits leading to osteoporosis, anemia and metabolic bone disease. Consuming a lifelong multivitamin daily is a way to avoid these deficiencies (“Obesity Surgery”). Complications at the gastrojejunal anastomosis after Roux-en-Y are frequent and potentially life-threatening. They usually appear within 1-3 months, up to several years following surgery. Stenosis is noted to occur most frequently to occur when a patient has attempted to advance the postoperative diet from full liquid to semi-solid. Patients may complain of the inability to advance diet due to symptoms including dysphagia, abdominal pain, nausea, or vomiting. These symptoms must be taken seriously and investigated early. Stenosis or marginal ulcers are successfully diagnosed and treated nonoperatively in most cases. Smoking, alcohol consumption and use of NSAIDs are key players to produce the serious complications stated above. These risks and complications should be reiterated preoperatively.
Roux-en-Y decreases stomach size to just between 15-30mL from an average stomach size of 300mL, which reduces the amount of food that can be ingested. This surgery significantly alters many important physical properties and gastrointestinal functions. During the initial consultation with a dietitian, life-long diet modifications are discussed along with specific weight loss goals. The risk for malnutrition is serious and should be defined in pre-operative education. The dietitian’s role of follow-up education is the most important facet for safe weight loss and prevention of weight gain. Currently, patients are given a set of guidelines or rules rather than a detailed eating pattern. The nutritional guidelines succeeding gastric bypass are, NPO until passed oral gastografin study; clear liquids anywhere from 2-14 days until a week after surgery; full liquids 2-3 weeks advancing to semisolid food within 4 weeks of surgery; follow by eating solid foods by 3 months after surgery. Patients are to consume 64 ounces of fluid each day and a minimum of 65 grams of protein each day. The optimal amount of protein gastric bypass patients should consume each day is still unknown. Obese patients may ignore the potential risks associated with not following eating guidelines and focus considerable attention on losing weight quickly. For many, hearing one potential risk of surgery could be losing too much weight might sound like a blessing, not a chronic and incapacitating condition that can lead to hospitalization or even death. The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition collaborated in 2009 to set standards to diagnose malnutrition. Undiagnosed malnutrition may lead to longer length of hospital stays, decreased quality of life and increased health care costs. Unfortunately, there is no single lab test can be used to diagnose malnutrition. For malnutrition to be determinable, two or more of the following six characteristics must be met: insufficient or poor oral intake; moderate or severe weight loss; muscle wasting, subcutaneous fat loss, edema and diminished functional status measured by a dynamometer (Marcason,2017). Following a stenosis diagnosis, a patient should be examined for severe protein calorie malnutrition. Enteral or Parenteral nutrition should be considered for patients that are unable to orally consume nutrients for several days or weeks due to the severity of the symptoms from stenosis. Gastric bypass patients are at grave risk if unable to maintain hydration and take a daily multivitamin. Using parenteral and enteral nutrition support related to preventing or minimizing the effects of stenosis on the body remains poorly researched at this time, no protocol or guideline found.
Shuster et al transcribed a continuing education article that pointed out the protein calorie malnutrition signs are not always crystal clear. Pories et al reported, from the 397 patients in their Greenville gastric bypass study, 4% were diagnosed with malnutrition and dehydration. MacLean et al. used body composition analysis, while analyzing multiple techniques to assess the incidence of protein calorie malnutrition after gastric bypass. The reported findings were, postoperative 16-34 months, 47 patients or 25% were diagnosed with malnutrition. Patients that underwent the Roux-en-Y procedure lost more weight and developed malnutrition earlier than other types of bariatric surgery. Curiously, most if not all, of those patients that contributed to the percentages above had also developed stenosis. Also, Faintauch et al studied the prevalence of malnutrition after Roux-en-Y in a series of 236 consecutive patients over a 68-month period. There were 23 patients or 10% had developed protein calorie malnutrition. Postoperatively 63% of the patients had external events that caused the development of malnutrition. Anastomotic stenosis was the most common complication. Poor intake and edema were other events presented that preceded malnutrition in this study. Patients who were malnourished were treated with a combination of oral, enteral, or parenteral nutrition which required an average of 3-4 months of nutrition therapy.
Recently Serrato et aldescribed obesity as a “multifactorial disease” generating a public health crisis. Genotype and environmental factors are considered most relevant to contributing to obesity. An obese person will undoubtedly experience significant health comorbidities. When medical weight loss programs that include pharmacological with psychological therapies prove to be non-effective, a person may choose to undergo bariatric surgery. However, there are risks and complications correlating with gastric bypass surgery. Stenosis is the most common complication. In addition, the mechanism behind why stenosis occurs is not well understood. Ischemia of the suture, stomal ulcers, reflux or retraction of scar tissue is thought to contribute to these cases of severe stenosis. As well as, diet advancing from liquid to semi-solid foods at the 4-6 week point following surgery may contribute to lesions, which commonly causes that narrowing leading to stenosis. A study conducted by Nguyen et al. have shown that the stenosis complication is more common with laparoscopic Roux-en-Y procedure, 11.4% comparatively to open hand sewn procedure respectively at 2.6%.
A case study was used to determine the association between a Roux-en-Y procedure leading to stenosis complications and nutritional deficits. A 37-year-old with a BMI of 45 kg/m2 was followed retrospectively. The patient suffered from GERD and hypertension preoperative gastric bypass. After surgery, barium transit showed no anastomotic leakage and the patient was able to tolerate clear liquid diet moving on to full liquids thereafter. Post-op 2-months, the patient had symptoms that accelerated weight loss to an unsafe percentage. Gastrointestinal distress with nausea and vomiting were the main symptoms which correlated to poor intake and nutritional status. Stenosis should be suspected when patients are showing signs of nausea, vomiting and/or dysphagia following surgery. Excessive vomiting could lead to malnutrition and vitamin deficiencies, particularly B vitamins. Enteral nutrition was required for several weeks following the diagnosis of severe stenosis determined by endoscopy. Pneumatic dilation was used as treatment with no complications. It should be noted that this case study patient had their comorbidities disappear 2 years post gastric bypass.
Garcia-Garcia et al clarified that there are over 30 different gastric bypass surgery techniques. For a gastric bypass surgery to be deemed safe, it must have less than 10% morbidity and less than 1% mortality. The surgery must offer a good quality of life and minimum side effects. The gold standard technique is deemed to be the laparoscopic Roux-en-Y. This is because it has been shown to have few and manageable complications as compared to other techniques. However, stenosis is the most common early complication and is far from a trivial complication. Endoscopy is essential for diagnosis and treating almost all cases without the need for surgical repair. As this type of surgery increases, specialists must be able to assist and seek answers for the prevention of complications. Subsequently, when complications arise, the multidisciplinary team must recognize and treat complications post-surgery.
The article conducted a retrospective study looking at 280 patients that underwent gastric bypass at general and digestive surgery departments at J.M. Morales Meseguer University General Hospital. Patients had a mean age of 44 years old and had a BMI equal or greater than 40kg/m2 or BMI equal or greater than 35kg/m2 with several comorbidities. Follow-up care was maintained through the clinical guidelines regarding medical, nursing and nutritional aspects. From the 280 patients, 265 patients received Roux-en-Y preformed using no. 21 autosuture instrument (circular mechanical anastomosis). There were 15 patients that received this surgery, preformed using GIA 45 reload beige (linear side-to-side mechanical anastomosis). From circular mechanical anastomosis group 20 patients (7.1%) developed stenosis presented against no cases from linear side-to-side mechanical anastomosis. The authors concluded this study met publishing averages and determined that from no reported stenosis cases in the linear technique group, it is plausible to lower the complication incidence of stenosis following gastric bypass surgery by using linear anastomosis.
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Goitein et al studied the occurrence of stenosis after Roux-en-Y. The article hypothesized the pathophysiological mechanisms for stenosis formation to ischemia; with or without ulceration causing scarring at the anastomotic junction, non-ischemia related scarring and inadequate technique with the formation of a tight anastomosis or angulation. The method of constructing gastrojejunal anastomosis may as well play a role in complications. Circular staplers appear lead to a higher percentage of postoperative stenosis in comparison to linear staplers or completely hand sewn. Unfortunately, these hypothesized mechanisms are lacking scientific investigation. Contingent on the severity of stenosis, dehydration and malnutrition are significant misfortunes the patient will endure following an endoscopy. Prompt recognition of stenosis and appropriate management are essential in order to prevent severe protein malnutrition and muscle wasting.
A retrospective analysis of 369 patients that underwent Roux-en-Y procedures were used in the article conducted by Goitein et al. All patients were followed up on a standard schedule in the bariatric surgery center by a team of physicians, physician assistants and a dietitian. Of the 369 patients, 19 developed anastomotic stenosis (5.1%). These patients suffered from postprandial nausea, vomiting and dysphagia consistent with stenosis symptoms. All were referred to endoscopy. The mean time of the development of stenosis was 32 days post gastric bypass. Stenosis following Roux-en-Y procedure leads to patient dissatisfaction with substantial morbidity. Of the 19 patients that developed stenosis only six received nutritional support in the form of protein shakes, enteral nutrition or a brief course of parenteral nutrition. One patient was noted to have protein malnutrition and proximal weakness.
The pathophysiological mechanisms that cause stenosis are not understood or studied enough to have a definite answer or solution to halt the prevalence. Much research has confidence in stating the technique of the surgery as well as scarring factors support stenosis to form after gastric bypass surgery. All the studies above used retrospective analysis of patients that had undergone a Roux-en-Y procedure. The variances astray at which technique was performed during the operation. The lack of information behind each study’s bariatric program made for it to be undeterminable what the nutrition practices or protocols were in place preoperative and postoperative. There has been little new research on this topic and the studies are not able to be randomized thus far.
Nutrition after bariatric surgery has not been abundantly researched. Presently, hospitals use standard postoperative oral intake guidelines based on protocols from previous gastric surgeries. Preventative measures for undesirable conditions like dumping syndrome, is the justification behind these guidelines. Losing weight after gastric bypass is affected by the degree of compliance with dietary and physical activity but has not been adequately researched. It is believed that many patients after surgery want to lose excess weight as fast as possible and purposely avoid eating or consuming fluids. The ideal oral intake following Roux-en-Y is unidentified. There is a great probability for inadequate nutrient intake following gastric bypass because patients are not given set targets to meet. Patients receive diet advancement steps to follow which allows for intake to be rather variable. More research is needed to determine the optimal diet composition post Roux-en-Y that inhibit nutritional complications while sustaining controlled weight loss. The snapshot of how much nutrition support is used following gastric bypass is not readily available. This may be due to patients being followed closely for the first 30 days after surgery and then moving into less routine follow-up visits. The care team must develop therapeutic plans to combat dehydration, electrolyte disorders and malnutrition. In addition, clinical research is needed to determine if diet composition postoperative can prevent stenosis entirely. By closely following a patient post Roux-en-Y with a diagnosis of stenosis, it is possible to limit undiagnosed malnutrition as well the effects or symptoms.
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