SURGERY

• Bariatric Surgery – Preoperativ
• Bariatric Surgery – Postoperative
• Ileostomy
• Intermaxillary Fixation
• Preoperative and Postoperative Care

 

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Bariatric Surgery – Preoperative

Adults

 

General information:

Diet is an important part of the total care for the bariatric surgery patient. Treatment of bariatric surgery patients should preferably be multidisciplinary. In addition, lifelong follow-up care must be taken into account for this patient population.

Criteria to be taken into consideration in whether an individual may have the surgery:

• BMI ≥ 40 kg/m2 or ≥ 35 kg/m2 + at least 1 comorbidity related to obesity
• unsuccessful previous medical treatments for obesity
• healthy enough to undergo anesthesia and surgery
• motivated, well informed and without significant psychological disorders
• willing to remain under the long-term supervision of a specialized medical team
• preferably people in the ages between 18-65
• for patients with a BMI > 50 kg/m2 (super obese), bariatric surgery can be considered as first-line treatment.
• dieting history

 

Best time to refer to the dietician:

• in the case of at least one of the following:

• pre-operative screening
• preoperative patient education on diet and lifestyle following bariatric surgery

 

Relevant information for the dietician:

• Diagnosis: morbid obesity, any comorbid diseases
• Laboratory tests: blood work-up, vitamins B1, B12 and D, PTH, calcium and iron
• Medication: weight control drugs or medications that affect weight loss (such as psychopharmaceutical drugs), vitamin and mineral supplements, medication needed for treatment of comorbid diseases, medication that affects the absorption or digestion of foods (such as metformin and antacids), corticosteroids and thyroid hormones
• Other: height, (changes in) weight, BMI, eating disorders, rule out lipedema, inquire whether patient has been under treatment with a psychologist or psychiatrist.

 

Aims of the diet:

• to assess whether the patient is a suitable candidate for bariatric surgery
• to assess which surgical procedure could be most successful
• to maintain/improve nutritional status, specifically aimed at preventing/treating nutrient deficiencies
• to prepare the patient well for life after the surgery through an educational program around diet and lifestyle.

 

Characteristics of the diet:

• If necessary, for 2-6 weeks preoperatively, stay on a Very Low Calorie Diet (VLCD) to shrink the liver, which will facilitate the operation.
• multivitamin and mineral supplements for any nutrient deficiencies that may already be present.

 

Treatment time:

• Care level 2, see “Dietician’s working methods.”

 

References:

Aills L, Blankenship J et al. ASMBS Allied Health Nutritional Guidelines for surgical weight loss patient. Surgery for Obesity and Related Diseases 2008; 4(5):73-108

 

Greve JWM, Janssen IMC, Ramshorst B van. Maagverkleining bij volwassenen met morbide obesitas in Nederland. Nederlands Tijdschrift voor Geneeskunde 2007; 151(20):1116-20

 

CBO. Richtlijn Diagnostiek en behandeling van obesitas bij volwassenen en kinderen. Alphen aan de Rijn: Uitgever Van Zuiden Communications B.V. 2008

 

Mechanick JI, Kushner RF et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient. Surgery for Obesity and Related Diseases 2008;4(5):109-184

 

SAGES Guidelines Committee. SAGES guideline for clinical application of laparoscopic bariatric surgery. Surgery for Obesity and Related Diseases 2009; 5(3):387-405

 

Bariatric Surgery – Preoperative was compiled by Henny Jansen, dietician at the Leveste site of Scheper Ziekenhuis, Emmen, writing also on behalf of the Netwerk Diëtisten Bariatrische Chirurgie (NDBC).

 

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Bariatric Surgery – Postoperative

Adults

 

General information:

Diet is an important part of the total care for the bariatric surgery patient. The treatment of bariatric surgery patients should preferably be multidisciplinary. In addition, lifelong follow-up care must be taken into account for this patient population.

 

Bariatric surgery includes various procedures. Gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy and duodenal switch are covered in this Guide.

 

Best time to refer to the dietician:

• follow-up: within 2 weeks after the surgery
• when at least one of the following is present after the surgery:

• limited weight loss or unwanted weight gain
• too rapid or too much weight loss
• if the patient is suspected to be undereating
• frequent vomiting
• passage symptoms
• malabsorption symptoms
• pregnancy (desire for)
• desire for plastic surgery because of excess flesh
• when other care providers identify problems in integrating the recommendations into daily life

Gastric band

• if the patient cannot eat any solid food
• if an injection of more fluid is intended

 

Relevant information for the dietician:

• Diagnosis:

Gastric band

• gastric banding, surgery date and institution where the gastric band was placed, type, how much fluid was injected, any comorbid conditions.

Roux-en-Y gastric bypass

• surgery date, whether it was a conversion operation or not, length of intestine between the gastric pouch and the anastomosis to the biliary limb, any comorbid conditions.

sleeve gastrectomy

• surgery date, whether it was a conversion operation or not; if it was a conversion operation, then the diameter of the endotube used in the surgery (French bougie or Charrière), any comorbid conditions.

duodenal switch

• surgery date, whether it was a second stage operation or not, in the case of a second stage

operation also information on the sleeve gastrectomy and how much weight loss has already been achieved, the length of the common channel, any comorbid conditions.

• Symptoms: perioperative or postoperative complications

gastric band

• passage symptoms, such as slippage

Roux-en-Y gastric bypass

• passage symptoms (such as dumping syndrome, diarrhea), malabsorption symptoms (such as fatigue, irritability, hair loss, reduced immunity).

sleeve gastrectomy

• symptoms of malabsorption (such as fatigue, irritability, hair loss, reduced immunity).

duodenal switch

• symptoms of malabsorption (such as fatigue, irritability, hair loss, reduced immunity, osteoporosis)

• Laboratory tests:

Roux-en-Y gastric bypass

• blood work-up, electrolytes, vitamins B1, B12 (or MMA, Hcy) and D, PTH, calcium and iron, any other relevant measurements that analyze malabsorption.

sleeve gastrectomy

• blood work-up, electrolytes, vitamins B1 (or MMA, Hcy) and folic acid, any other relevant measurements that analyze malabsorption.

duodenal switch

• blood work-up, electrolytes, vitamins B1, B12 (or MMA, Hcy) and D, PTH, calcium and iron, any other relevant measurements that analyze malabsorption.

• Medication/Treatment:

Gastric band

• medication that affects weight loss (e.g. psychopharmaceuticals), use of nutritional supplements, medication required for treating comorbid conditions.

Roux-en-Y gastric bypass

• medication that affects absorption of vitamin B12, bone metabolism and weight loss (psychopharmaceuticals), use of nutritional supplements, medication required for treating comorbid conditions.

sleeve gastrectomy

• medication that affects absorption of vitamin B12, weight loss (e.g. psychopharmaceuticals), use of nutritional supplements, medication required for treating comorbid conditions.

duodenal switch

• medication that affects absorption of vitamin B12, bone metabolism and weight loss (e.g. psychopharmaceuticals), use of nutritional supplements, medication required for treating comorbid conditions.

• Other: height, (changes in) weight, BMI, psychological factors

 

Aims of the diet:

• to reduce weight and maintain the target weight:

gastric band

• > 45% Excess Weight Loss (EWL) is attainable

Roux-en-Y gastric bypass/sleeve gastrectomy

• > 60% EWL is attainable

duodenal switch

• >70% EWL is attainable

• maintain/improve nutritional status, specifically aimed at preventing/treating nutrient deficiencies
• reduce/prevent comorbidity
• reduce/prevent physical and/or psychological symptoms.

 

Characteristics of the diet:

• Initial postoperative nutrition varies from one institution to another. Usually the patient is started on (clear) liquid meals, and the diet is then built up gradually.
• based on national Nutritional Guidelines, with an emphasis on adequate fluids and fibers
• Energy-restricted
• Protein: at least 60 g, but aim for a daily intake of 90 g (Roux-en-Y gastric bypass / duodenal switch)
• regular eating pattern, frequent (small) meals
• chew well and take time eating a meal
• separate fluids and solid foods during the meals (Roux-en-Y gastric bypass, sleeve gastrectomy, duodenal switch)
• stop eating when satiated and/or nauseous
• multivitamin supplements:

gastric band/sleeve gastrectomy

• Advise taking 1 x multivitamin with 100% RDA, with at least 2/3 of the nutrients represented in the supplement; be sure the supplement does contain B vitamins, zinc and selenium, and 100% RDA of iron and folic acid.

Roux-en-Y gastric bypass/duodenal switch

• advise taking 2 x multivitamin with 100% RDA with at least 2/3 of the nutrients represented in the supplement; be sure the supplement does contain B vitamins, zinc and selenium, and 100% RDA of iron and folic acid. If necessary supplement calcium and vitamin D.

 

Treatment time:

• Care level 2*, see “Dietician’s working methods.”

 

Specific remarks:

• slow release medication must be avoided (Roux-en-Y gastric bypass/duodenal switch)
• keep an interval of at least 2 hours between consuming calcium and iron supplements or multivitamins containing iron.

 

References:

Aills L, Blankenship J et al . ASMBS Allied Health Nutritional Guidelines for surgical weight loss patient. Surgery for Obesity and Related Diseases 2008; 4(5):73-108

 

Elder KA, Wolfe BM. Bariatric Surgery: A review of procedures and Outcomes. Gastroenterology 2007;132(6) 2253-71

 

Mathus-Vliegen L. Gewichtsbeheersing en het metabolisme: feiten en fabels. Nederlands Tijdschrift voor Diëtisten 2005;(50):5-9

 

Janssen IMC, Ramshorst B van. Maagverkleining bij volwassenen met morbide obesitas in Nederland. Nederlands Tijdschrift voor Geneeskunde 2007; 151(20):1116-20

 

Kushner RF et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient. Surgery for Obesity and Related Diseases 2008;4(5):109-184

 

Schweitzer DH. Mineral metabolism and bone disease after bariatric surgery and ways to optimize bone health. Obesity surgery. 2007;(17)1510-16

 

Schweitzer DH, Posthuma EF. Prevention of Vitamin and Mineral Deficiencies After Bariatric Surgery: Evidence and Algorithms. Obesity surgery 2008;(18):1485-88

 

Wezel BJ van. 09 Adipositas. Dieetbehandelingsrichtlijnen. Maarssen: Elsevier Gezondheidszorg 2008

 

Bariatric Surgery – Postoperative was compiled by Nienke ten Hoor-Aukema, dietician at “Bon Appétit” Leidschendam, Henny Jansen, dietician at the Leveste location of Scheperziekenhuis Emmen, and Ilse Scholten, dietician at Ziekenhuis Gelderse Vallei, writing also on behalf of the Netwerk Diëtisten Bariatrische Chirurgie (NDBC).

 

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Ileostomy

 

Best time to refer to the dietician:

• after ileostomy surgery

 

Relevant information for the dietician:

• Diagnosis: underlying etiology, complications, any comorbid conditions
• Symptoms:

• that could indicate underhydration: thirst, drowsiness, fatigue, reduced appetite
• that could indicate a sodium deficiency: fatigue, dizziness, irritability, insomnia, difficulty concentrating, muscle cramps, rapid weight loss
• caused by food: gas, stains and odors from the feces.
• medications: anti-diarrheal drugs, anti-inflammatory drugs, bile salt binders, bulking agents, sodium capsules, oral rehydration solution (ORS), antacids, laxatives

• Other: height, (changes in) weight, length/location of resected bowel, temporary or permanent ileostomy, the volume and consistency of stoma production.

 

Aims of the diet:

• stabilize/improve the fluid and electrolyte balance
• prevent passage disorders of the digestive tract / obstruction due to food wast
• prevent unwanted weight gain and weight loss
• maintain/improve nutritional status
• ensure appropriate consumption of foods or products that can cause constipation, gas, stains and odors.

 

Characteristics of the diet:

• Follow national Nutritional Guidelines, with the exception of fluids and sodium:

• 2-2.5 L fluid per day: fluid intake should be increased if there are symptoms of dehydration, the urine has a dark color and urine output is low (less than one liter). (Does not apply to high output ileostomy.)
• High sodium: if symptoms caused by sodium deficiency occur

• Draw attention to:

• avoiding unwanted weight gain and weight loss
• eating slowly and chewing foods well, especially high-fiber foods
• products that can cause gas, stains and odor formation
• fecal consistency
• increased loss of fluid and salt.

 

Treatment time:

• Care level 2, see “Dietician’s working methods.”

 

Specific remarks:

• The use of salt capsules may be necessary.

 

References:

Welink-Lamberts B.J. Dieetbehandelingsrichtlijn Ileostoma. Maarssen: Elsevier, 2007

 

 Ileostomy was updated by Bertine Welink-Lamberts, dietician at Universitair Medisch Centrum Groningen (UMCG), Rianne Vehof, dietician at Universitair Medisch Centrum Nijmegen (UMCN) and Marjan Mullers, dietician at Maastricht Universitair Medisch Centrum

(MUMC), also writing on behalf of the Chirurgisch Overleg Diëtisten Academische

Ziekenhuizen (CHIODAZ).

 

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Intermaxillary Fixation

 

Best time to refer to the dietician:

• before performing intermaxillary fixation, if possible

 

Relevant information for the dietician:

• Diagnosis: underlying disease, any comorbid conditions
• Symptoms: nausea, pain in the mouth
• Medication: if applicable
• Other: height, (changes in) weight, the expected time period of intermaxillary fixation, elimination pattern.

 

Aims of the diet:

• maintain/improve nutritional status
• restore elimination to a normal pattern

 

Characteristics of the diet:

• liquid consistency
• in accordance with national Nutritional Guidelines, with attention to adequate caloric, protein, dietary fiber, and fluid intake
• equal distribution of food and drinking fluids over the course of the day
• use caution with hot spices and acid products when there is mouth pain.

 

Treatment time:

• Care level 1, see “Dietician’s working methods.”

 

References:

Jansma J, Schoen PJ et al. Operatieve kaakorthopedie. Stegenga B, Vissink A, editors. In: Mondziekten en Kaakchirurgie. Assen: Van Gorcum & Comp. BV; 2000

 

Jong-Kampherbeek EH de, Remijnse-Meester TA, Meeteren NL van. Diëtetische zorg bij patiënten na maxillofaciaal trauma. Ned Tijdschr Tandheelkd 1997;104 (11): 448-50

 

 Intermaxillary Fixation (formerly called Wired Jaw) was updated by Annemieke Kok, dietician at Universitair Medisch Centrum (UMC) Utrecht.

 

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Preoperative and Postoperative Care

Adults

 

General information:

Diet makes up an important part of the complete care of the surgical patient. In order to prepare the patient for surgery as thoroughly as possible, improving the nutritional status may be necessary before the surgery. After the surgery, the nutritional status may deteriorate rapidly as a result of disease activity and/or the surgical procedure, due to reduced food intake, reduced absorption, significant losses and/or an increased need for nutrients. This in turn increases the risk of developing postoperative complications. The patient’s diet may also need to change because of the surgery. Feeding by mouth can be resumed quickly after most surgeries, and built up to a nutritionally complete diet within a short period of time. Following extensive surgery, however, the period during which the patient cannot feed themselves adequately or at all may be substantially longer. Early identification of at-risk patients is of prime importance. so that adequate dietary treatment can be initiated in a timely manner (pre-operatively, if necessary).

 

Best time to refer to the dietician (preoperatively, if possible):

• if unwanted weight loss exceeds 5% in a 1-month period or 10% in a 6-month period and/or the patient is underweight (ages 18-65: BMI < 18.5 kg/m² and over age 65 BMI < 20 kg/m², to be measured preoperatively, if possible)
• if there is (a risk of) malnutrition, measured with a validated screening tool
• prior to operations that could adversely affect food intake
• if symptoms are experienced which seriously hinder food intake and/or absorption, and if these symptoms persist for longer than one week
• in the case of surgery after which extra dietary measures are indicated, as in the case of major abdominal surgery
• if the patient has questions about the relationship between food and the surgery

 

Relevant information for the dietician:

• Diagnosis: underlying disease, treatment, type of surgery, any comorbid conditions
• Medication: if applicable
• Other: height, (changes in) weight

 

Aims of the diet:

• maintain/improve nutritional status
• reduce symptoms

 

Characteristics of the diet:

• Energy-enriched: basal metabolism (Harris & Benedict) + extra allowances (30% for preoperative and 50% for preoperative if weight gain is desired)
• Protein-enriched: preoperatively: 1.5-1.7 g/kg body weight; postoperatively: 1.2-1.7 g/kg body weight. In intensive care, a diet of 1.2-1.5 g/kg body weight is adequate. Calculate the protein requirement based on the actual weight. Ensure adequate amounts of vitamins/minerals, depending on the pathology.
• Ensure adequate fluids, a minimum of 1.5 to 2 L per day, correcting for significant losses and fever (350 ml per degree).
• For malnutrition: see “Malnutrition”

 

Treatment time:

• Care level 2, see “Dietician’s working methods.”

 

Specific remarks:

• The diet is evaluated and, if necessary, fine-tuned based on the patient’s weight and fluid balance. The grip strength (GS) can be used in assessing the changes in muscle strength and thus fat-free mass (FFM). Basing it on the GS alone will not result in adjustment of the diet. Maintenance of or increase in the GS is positive.

 

References:

CBO. Richtlijn Perioperatief voedingsbeleid. Utrecht: 2007

 

Preoperative and Postoperative Care was updated by Gertien Ligthart-Melis, dietician at the VU medisch centrum (VUmc) and Myriam van Zandvoort, dietician at Leids Universitair Medisch Centrum (LUMC), writing also on behalf of Chirurgisch Overleg Diëtisten Academische Ziekenhuizen (CHIODAZ).