BARIATRIC SURGERY

BY-
ABHILASHA CHUM
CLINICAL NUTRITIONIST
 INTRODUCTION
Bariatrics, is the branch of medicine that deals with the
causes, treatment, and prevention of obesity. Weight-loss
(bariatric) surgery helps you lose weight and lowers your
risk of medical problems associated with obesity
It is the surgery on the stomach and/or intestines to help a
person with extreme obesity lose weight.
Bariatric surgery is an option for people who have a body mass
index (BMI) above 40.
Surgery is also an option for people with a body mass index
between 35 and 40 who have health problems like type
2 diabetes or heart disease.
 Bariatric surgery improves quality of life and co morbid
conditions and decreases overall cost of care.
 Patients who undergo surgery will likely increase the
length of their lives due to improvement in diabetes and
heart disease and decreased risk of cancer.
 Long-term bariatric follow-up requires a team approach
and attention to several aspects of care.
 Nutrition is the most important aspect of follow-up to
safely maximize weight loss and prevent weight gain.
 Exercise helps to maintain weight loss.
 Complications need to be identified early and can result
from improper behavior or from surgical complications.
Emotional difficulties occur in many patients.
Bariatric surgery contributes to weight loss in two main
ways:
 Restriction. Surgery is used to physically limit the
amount of food the stomach can hold, which limits the
number of calories one eats.
 Malabsorption. Surgery is used to shorten or bypass
part of the small intestine, which reduces the amount
of calories and nutrients the body absorbs.
TYPES OF WEIGHT-LOSS SURGERY
Four common are:
 Roux-en-Y gastric bypass
 Laparoscopic adjustable gastric banding
 Sleeve gastrectomy
 Duodenal switch with biliopancreatic diversion
LAPAROSCOPIC ADJUSTABLE GASTRIC
BANDING
 In the laparoscopic adjustable
gastric banding procedure, a band
containing an inflatable balloon is
placed around the upper part of the
stomach and fixed in place. This
creates a small stomach pouch
above the band with a very narrow
opening to the rest of the stomach.
 Gastric banding restricts the
amount of food that your stomach
can hold, so you feel full sooner,
but it doesn't reduce the absorption
of calories and nutrients.
 SLEEVE GASTRECTOMY
 In a sleeve gastrectomy, part of
the stomach is separated and
removed from the body. The
remaining section of the stomach
is formed into a tube like
structure. This smaller stomach
cannot hold as much food. It also
produces less of the appetite-
regulating hormone ghrelin,
which may lessen desire to eat.
However, sleeve gastrectomy does
not affect the absorption of
calories and nutrients in the
intestines.
 ROUX-EN-Y GASTRIC BYPASS
 In Roux-en-Y gastric bypass, the
surgeon creates a small pouch at the top
of the stomach. The pouch is the only
part of the stomach that receives food.
This greatly limits the amount that you
can comfortably eat and drink at one
time.
 The small intestine is then cut a short
distance below the main stomach and
connected to the new pouch. Food
flows directly from the pouch into this
part of the intestine. The main part of
the stomach, however, continues to
make digestive juices. The portion of
the intestine still attached to the main
stomach is reattached farther down.
This allows the digestive juices to flow
to the small intestine. Because food
now bypasses a portion of the small
intestine, fewer nutrients and calories
are absorbed.
 BILIOPANCREATIC DIVERSION WITH

DUODENAL SWITCH
Doctors create a small, tube shaped stomach
pouch, and the rest of the stomach is
removed
 The small intestine is divided into two parts
 The end of the small intestine is connected
to the small pouch, so that food travels
directly from the pouch into the last segment
of the small intestine (bypassing ¾ of the
small intestine)
 The bypassed part of the small intestine,
which carries important digestive enzymes,
is reconnected to the last part of the small
intestine
 Enzymes mix with the food from the pouch
to help complete digestion
 Patients eat less food, digest more
efficiently, and hormonal signals are
changed
 Typical outcomes include weight loss and
improvement in metabolic syndrome and
overall health and well-being
 BARIATRIC SURGERY BENEFITS
 Weight loss — Immediately following procedures, most people
lose weight rapidly and continue to do.
 Improved health — Weight loss surgery may improve
many obesity-related health conditions, including:
 Diabetes
 High blood pressure
 High cholesterol
 Sleep apnea
BARIATRIC SURGERY RISKS,
COMPLICATIONS AND SIDE EFFECTS
 Acid reflux
 Anesthesia-related risks
 Chronic nausea and vomiting
 Dilation of esophagus
 Inability to eat certain foods
 Infection
 Obstruction of stomach
 Weight gain or failure to lose weight
BARIATRIC SURGERY LONG-TERM
RISKS
 Dumping syndrome, a condition that can lead to symptoms
like nausea and dizziness
 Low blood sugar
 Malnutrition
 Vomiting
 Ulcers
 Bowel obstruction
 Hernias
 COMMON NUTRIENT DEFICIENCIES
 Gastric Bypass:
 Most common: Iron, Vitamin B-12, Folic acid, Fat soluble
Vitamins A, D, & E
 Thiamin
 Calcium
 Protein malnutrition
 Gastric Banding:
 Nutrition deficiencies are less commonly seen post gastric
banding
 Sleeve Gastrectomy
 Possible B-12
SITE OF ABSOPTION NUTRIENTS

DUODENUM Calcium, magnesium, iron, fat-soluble vitamins A

and D, glucose,copper,zinc

JEJUNUM Fat, sucrose, lactose, fat-soluble vitamins A and

D, water-soluble vitamins like folic acid, proteins
and amino acids, glucose

ILEUM Last part of the small intestine (leads to large

bowel): Proteins and amino acids, water-soluble
vitamins like folic acid, vitamin B12.
 NUTRITION
 The final aim of gastric sleeve surgery is to achieve weight
loss and after surgery that starts and with a diet after surgery.
 Thus, the diet post gastric sleeve surgery is designed to
achieve this optimum results while helping new patients
speed up recovery.
 The principles include a high protein and low
carbohydrate and fat diet, avoidance of refined sugars,
avoidance of alcohol, liberal fluid intake, minimal or no
‘junks.’

High protein diet will help reduce muscle breakdown and

accelerates healing, while low carbohydrate will help
reduce weight. Refined sugars are high in calories and
deficient in nutrients and therefore affect the adequacy
of the nutrients in your diet.
 Due to some hormonal changes following gastric sleeve
surgery, the appetite reduces, and you may be tempted not
to eat. This may also be reinforced by the false belief that
avoiding meals post op will speed up the weight loss.
However, not eating following gastric sleeve surgery
may make you malnourished and possibly slow down
your recovery.

 Our surgeon will determine when it is safe for you to eat.

Usually, the oral intake post gastric sleeve is commenced
with clear liquid (sips of water) followed by a gradual
transition to a liquid diet, and later to semi-solid and solid
food. Here is the sample plan of our post-op diet.
WHY DOES DEHYDRATION OCCUR
AFTER GASTRIC SLEEVE SURGERY?

 After bariatric surgery of any kind, patients find that they

often experience fewer sensations of hunger and thirst as a
direct result of a smaller stomach.
 In turn, patients tend to end up eating and drinking less,
which is great for their weight loss, but not so good for their
hydration efforts.
 As patients recover from their Gastric Sleeve surgery, they
must be careful to stay hydrated and pay attention to their
bodies so that dehydration and nutritional deficiencies don’t
occur. Additionally, since it is not recommended to eat and
drink at the same time, it’s vital that drinking occurs outside
of meal times.
GUIDELINES FOR POST OPERATIVE DIET
STAGES FIRST EIGHT WEEKS
 Do not chew gum
 Do not use a straw
 Avoid carbonated beverages (unless flat, diet, and caffeine-free)
 No juice or sweetened beverages
 No honey, sugar, syrup
 Avoid protein bars, rice, fresh bread, lettuce, nuts, seeds
 Avoid skin and seeds of fruit (because of nuts)
 Avoid spicy and acidic foods, drinks for 8 weeks, including:
 Pineapple Juice
 Grapefruit Juice
 Orange Juice
 Hot Sauce
 Peppers
 Tomato, Vegetables Juice
 Tomato Sauce, Soup
 GASTRIC SLEEVE POST-OP DIET STAGES
 There are five regular stages of the postoperative diet for
gastric sleeve:
 Clear Liquids Diet – Phase, Stage 1 (while in hospital)

 Protein-Based Liquids – Phase, Stage 2 (2-3 days post

surgery, 2-week duration)

 Pureed Foods – Phase, Stage 3 (day 15, weeks 3 and 4)

 Soft Foods – Phase, Stage 4 (weeks 5 and 6)

 Regular Foods – Phase, Stage 5 (week 7 and beyond)

STAGE 1: CLEAR LIQUIDS

 Duration: While in Hospital

 In this phase, the goal is to sip 1 ounce of fluid over 15
minutes. Which means taking only small sips of liquid over
15 minutes. In the stage 1 diet the only foods, drinks
allowed are:
 Water
 Coconut water
 Clear dal soup/Clear vegetable soup/Clear chicken soup
 Tea/Coffee(without milk)
 Calorie-free, non-carbonated, caffeine-free or decaffeinated
beverages
 DIET PHASE, STAGE 2: PROTEIN-
BASED LIQUIDS
 Duration: Starts 2 or 3 days after surgery, lasts during 1 and 2
weeks
 Phase Goals: 60 to 80 grams per day .The first week is
characterized by thin liquid foods. Begin with sips and gradually
increase it. It is advisable that you take at least 3 liters of liquid diet
per day to avoid getting dehydrated and to prevent constipation.
The quantity of these foods should be as prescribed by surgeon.
 Drinks allowed are:
 Buttermilk, curd, yogurt(skimmed/low fat and unsweetened)
 Dal soup, vegetable soup, fruit juices(unsweetened)
 Skimmed milk
 Protein supplement
 DIET PHASE, STAGE 3: PUREE
(BLENDERIZED)
 Duration: Starts on day 15 after surgery, lasts during 3 and 4 weeks
 Phase Goals: 60 to 80 grams per day .During the 2nd-3rd week post-
surgery, the diet should be composed of soft foods with no lumps.
Examples include fats free yogurt, milk based
dalia/porridges/oats(blended,), khichdi, well cooked chicken and fish,
cooked egg whites, thick and smooth soups, cottage cheese, low fat
puddings
 General Guidelines of Diet Stage 3:
 Introduce one new food at a time
 Start with 1/8 to 1/4 cup portions
 Aim for 3 to 4 servings of food per day with liquids in-between
 No liquids 20-30 minutes before or after foods
 Do not eat while distracted
 Start taking calcium with D and B12 supplements
 You may begin taking whole pills, capsules, and multivitamins.
DIET PHASE, STAGE 4: SOFT FOODS

 Duration: Starts on day 29 after surgery, lasts during 5 and 6 weeks

 Phase Goals: 60 to 80 grams
 Foods soft diet for gastric sleeve surgery include beans, cooked
vegetables, fish, eggs, etc. can be considered during this stage.
 Food Allowed:
 All foods in phases 1, 2 and 3
 Finely chopped, moist and soft foods
 Well cooked dals/rice
 Beans, lentils, bean soups
 Low-fat cheese
 Boiled eggs, mashed chicken
 Hot cereals
 Well-cooked vegetables
 Boil potatoes without the skin
 Soft fruits without skin ( banana, peaches, pears)
 DIET PHASE, STAGE 5: REGULAR
DIET AFTER SURGERY
 Duration: Starts on day 50 after surgery, lasts the rest of
life
 Phase Goals: 60 to 80 grams .Eating protein and high fiber foods
help you feel fuller longer.You will be able to eat a variety of foods
– but low fat, low sugar, and in smaller portions.
Food Allowed:
 Well cooked dals
 Thin chapati, well cooked rice
 Vegetables peeled, chopped, cookies until soft without seeds
 Raw vegetables/salad small pieces, chewed well
 Soft low sugar fruits like papaya, apple, watermelons and melons
 Skimmed milk/soya milk, low fat sugar free yogurt
 One slice of whole wheat bread
 Well cooked chicken/fish, boiled eggs
 NUTRITION FOLLOW-UP
The main goals after any bariatric gastric surgery are threefold: (1) to
maximize weight loss and absorption of nutrients, (2) to maintain
adequate hydration, and (3) to avoid vomiting and dumping syndrome.
 Mealtime guidelines are provided to encourage fluid intake and to
maximize satiety between meals. Five guidelines for fluid consumption
are as follows:
 No liquids at meals; wait at least 30 minutes after a meal to start fluids. It
is important to avoid overfilling and stretching the stomach pouch.
 Sip beverages; do not use a straw, which increases swallowed air.
 The daily goal is at least 1.4 L (6 cups) of fluids. This should include
high-protein liquid supplement, skim milk, and sugar-free noncarbonated
beverages. Decaffeinated coffee or tea is preferred.
 Stop eating and drinking when a full feeling occurs. Overfilling the
stomach pouch will cause it to stretch, which often leads to increased
intake.
 Avoid carbonated beverages, as the gas bubbles may stretch the pouch.
 SUPPLEMENTATION
Multivitamins (vitamins B12, vitamin D) and mineral
supplements (zinc, iron, and calcium) may be essential in the
early postoperative period of the gastric sleeve as you may be
struggling to eat and your diet may not supply the
appropriate quantity of those micronutrients. However, as
your meals become more regular, you may no longer need
those supplements.
 COMMON NUTRITIONAL PROBLEMS
 Nausea and vomiting
 Chronic malnutrition
 Lactose intolerance
 Temporary hair loss
 Dehydration
 Dumping syndrome
 Constipation
 RECOMMENDATIONS
Micronutrients Supplementation Repletion recommendation
Recommendation
Iron 45-60 mg of elemental iron 150-200 mg of elemental iron daily
daily or intravenous
Calcium 1,000-1,200 mg daily 1,200-1,500 mg daily
Vitamin D 60,000 IU weekly Injectable
Vitamin B12 350-500 µg daily 500 µg alternate days x 5 days
Vitamin B1 (Thiamin) 12 mg or 50 mg from Oral therapy: 100 mg orally 2-3
multivitamin BD times daily until symptoms resolve or
IV infusion
Zinc 8-22 mg daily Insufficient evidence to make a dose
related recommendation for
repletion
Copper 2 mg daily 2-4 mg /- day of intravenous copper

Folate (Folic acid) 400-800 mcg oral folate daily Oral dose of 100 cg daily
 CONCLUSION
Follow-up after bariatric surgery is critical and requires a team
approach.

For most patients, the benefits greatly outweigh the risks, and
they are likely to have better and longer lives after surgery.

Patients need to know that the surgery is a tool and that losing
weight and keeping it off requires some work on their part
particularly with regard to diet and exercise.

For the best long-term results, follow-up is key.