Abstract
Contemporary laparoscopic malabsorptive bariatric procedures are mostly of the biliopancreatic diversion type, either the Scopinaro procedure with a distal gastrectomy and a gastroileal anastomosis or the duodenal switch procedure with a sleeve gastrectomy and a duodenoileostomy. Aside from surgical complications, nutritional complications related to these procedures are particular and mandate careful attention and follow-up in the perioperative period to address preexisting nutritional derangements and maintain the benefits in the long term after surgery. Because the number of bariatric procedures involving gastrointestinal reconfiguration has increased dramatically, it is important for clinicians involved in the care of bariatric patients to be familiar with a variety of nutritional conditions associated with BPD surgery over time to allow for prompt recognition and management of potentially serious postoperative complications, including a few nutritional emergencies. This chapter reviews important early and late nutritional complications specific to laparoscopic biliopancreatic diversion with or without duodenal switch.
Keywords
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.
Demaria EJ, Jamal MK. Surgical options for obesity. Gastroenterol Clin North Am. 2005;34(1):127–42.
Anthone GJ, Lord RV, DeMeester TR, Crookes PF. The duodenal switch operation for the treatment of morbid obesity. Ann Surg. 2003;238(4):618–27. discussion 27-8.
Scopinaro N. Thirty-five years of biliopancreatic diversion: notes on gastrointestinal physiology to complete the published information useful for a better understanding and clinical use of the operation. Obes Surg. 2012;22(3):427–32.
Marceau P, Biron S, Bourque RA, Potvin M, Hould FS, Simard S. Biliopancreatic Diversion with a New Type of Gastrectomy. Obes Surg. 1993;3(1):29–35.
Marceau P, Hould FS, Simard S, Lebel S, Bourque RA, Potvin M, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22(9):947–54.
Nguyen NT, Masoomi H, Magno CP, Nguyen XM, Laugenour K, Lane J. Trends in use of bariatric surgery, 2003-2008. J Am Coll Surg. 2011;213(2):261–6.
Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg. 2013;216(2):252–7.
Buchwald H, Oien DM. Metabolic/Bariatric Surgery Worldwide 2011. Obes Surg. 2013;23(4):427–36.
Dumon KR, Murayama KM. Bariatric surgery outcomes. Surg Clin North Am. 2011;91(6):1313–38. x.
Colles SL, Dixon JB, O'Brien PE. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity (Silver Spring). 2008;16(3):615–22.
Kruseman M, Leimgruber A, Zumbach F, Golay A. Dietary, weight, and psychological changes among patients with obesity, 8 years after gastric bypass. J Am Diet Assoc. 2010;110(4):527–34.
Ernst B, Thurnheer M, Schmid SM, Schultes B. Evidence for the necessity to systematically assess micronutrient status prior to bariatric surgery. Obes Surg. 2009;19(1):66–73.
Botella Romero F, Milla Tobarra M, Alfaro Martinez JJ, Garcia Arce L, Garcia Gomez A, Salas Saiz MA, et al. [Bariatric surgery in duodenal switch procedure: weight changes and associated nutritional deficiencies]. Endocrinol Nutr. 2011;58(5):214–8.
Ashton K, Heinberg L, Windover A, Merrell J. Positive response to binge eating intervention enhances postoperative weight loss. Surg Obes Relat Dis. 2011;7(3):315–20.
Wadden TA, Faulconbridge LF, Jones-Corneille LR, Sarwer DB, Fabricatore AN, Thomas JG, et al. Binge eating disorder and the outcome of bariatric surgery at one year: a prospective, observational study. Obesity (Silver Spring). 2011;19(6):1220–8.
Scholtz S, Bidlake L, Morgan J, Fiennes A, El-Etar A, Lacey JH, et al. Long-term outcomes following laparoscopic adjustable gastric banding: postoperative psychological sequelae predict outcome at 5-year follow-up. Obes Surg. 2007;17(9):1220–5.
Aasheim ET, Bjorkman S, Sovik TT, Engstrom M, Hanvold SE, Mala T, et al. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clin Nutr. 2009;90(1):15–22.
Scopinaro N, Gianetta E, Adami GF, Friedman D, Traverso E, Marinari GM, et al. Biliopancreatic diversion for obesity at eighteen years. Surgery. 1996;119(3):261–8.
Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, et al. Duodenal switch: long-term results. Obes Surg. 2007;17(11):1421–30.
Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, et al. Duodenal switch improved standard biliopancreatic diversion: a retrospective study. Surg Obes Relat Dis. 2009;5(1):43–7.
Scopinaro N, Marinari G, Camerini G, Papadia F. Biliopancreatic diversion for obesity: state of the art. Surg Obes Relat Dis. 2005;1(3):317–28.
Barbosa-Silva MC. Subjective and objective nutritional assessment methods: what do they really assess? Curr Opin Clin Nutr Metab Care. 2008;11(3):248–54.
Biertho L, Biron S, Hould FS, Lebel S, Marceau S, Marceau P. Is biliopancreatic diversion with duodenal switch indicated for patients with body mass index <50 kg/m2? Surg Obes Relat Dis. 2010;6(5):508–14.
Scopinaro N, Adami GF, Marinari GM, Gianetta E, Traverso E, Friedman D, et al. Biliopancreatic diversion. World J Surg. 1998;22(9):936–46.
Mattar SG, Velcu LM, Rabinovitz M, Demetris AJ, Krasinskas AM, Barinas-Mitchell E, et al. Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome. Ann Surg. 2005;242(4):610–7. discussion 8-20.
Kral JG, Thung SN, Biron S, Hould FS, Lebel S, Marceau S, et al. Effects of surgical treatment of the metabolic syndrome on liver fibrosis and cirrhosis. Surgery. 2004;135(1):48–58.
Baltasar A, Serra C, Perez N, Bou R, Bengochea M. Clinical hepatic impairment after the duodenal switch. Obes Surg. 2004;14(1):77–83.
Castillo J, Fabrega E, Escalante CF, Sanjuan JC, Herrera L, Hernanz F, et al. Liver transplantation in a case of steatohepatitis and subacute hepatic failure after biliopancreatic diversion for morbid obesity. Obes Surg. 2001;11(5):640–2.
Grimm IS, Schindler W, Haluszka O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastroenterol. 1992;87(6):775–9.
Geerts A, Darius T, Chapelle T, Roeyen G, Francque S, Libbrecht L, et al. The multicenter Belgian survey on liver transplantation for hepatocellular failure after bariatric surgery. Transplant Proc. 2010;42(10):4395–8.
D’Albuquerque LA, Gonzalez AM, Wahle RC, de Oliveira Souza E, Mancero JM, de Oliveira e Silva A. Liver transplantation for subacute hepatocellular failure due to massive steatohepatitis after bariatric surgery. Liver Transpl. 2008; 14(6): 881–5.
Scopinaro N. Invited Commentary. Obes Surg. 1994;4(3):291–2.
Greco M, De Micheli E, Lonardo A. Multifactorial hepatopathy in a patient with biliopancreatic diversion. Ann Ital Med Int. 2003;18(2):99–103.
Papadia F, Marinari GM, Camerini G, Adami GF, Murelli F, Carlini F, et al. Short-term liver function after biliopancreatic diversion. Obes Surg. 2003;13(5):752–5.
van Dongen JL, Michielsen PP, Van den Eynden GG, Pelckmans PA, Francque SM. Rapidly evolving liver decompensation with some remarkable features 14 years after biliopancreatic derivation: a case report and literature review. Acta Gastroenterol Belg. 2010;73(1):46–51.
Mechanick JI, Youdim A, Jones DB, Timothy Garvey W, Hurley DL, Molly McMahon M, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient–2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis. 2013;9(2):159–91.
Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes Surg. 1999;9(2):150–4.
Cook JD, Dassenko SA, Whittaker P. Calcium supplementation: effect on iron absorption. Am J Clin Nutr. 1991;53(1):106–11.
Lonnerdal B. Calcium and iron absorption–mechanisms and public health relevance. Int J Vitam Nutr Res. 2010;80(4–5):293–9.
Brolin RE, Gorman JH, Gorman RC, Petschenik AJ, Bradley LB, Kenler HA, et al. Prophylactic iron supplementation after Roux-en-Y gastric bypass: a prospective, double-blind, randomized study. Arch Surg. 1998;133(7):740–4.
Stabler SP. Clinical practice. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149–60.
Provenzale D, Reinhold RB, Golner B, Irwin V, Dallal GE, Papathanasopoulos N, et al. Evidence for diminished B12 absorption after gastric bypass: oral supplementation does not prevent low plasma B12 levels in bypass patients. J Am Coll Nutr. 1992;11(1):29–35.
Brolin RE. Gastric bypass. Surg Clin North Am. 2001;81(5):1077–95.
Brolin RE, Gorman JH, Gorman RC, Petschenik AJ, Bradley LJ, Kenler HA, et al. Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass? J Gastrointest Surg. 1998;2(5):436–42.
Berghella V, Buchanan E, Pereira L, Baxter JK. Preconception care. Obstet Gynecol Surv. 2010;65(2):119–31.
Kumar N, Ahlskog JE, Gross Jr JB. Acquired hypocupremia after gastric surgery. Clin Gastroenterol Hepatol. 2004;2(12):1074–9.
Goldberg ME, Laczek J, Napierkowski JJ. Copper deficiency: a rare cause of ataxia following gastric bypass surgery. Am J Gastroenterol. 2008;103(5):1318–9.
Tan JC, Burns DL, Jones HR. Severe ataxia, myelopathy, and peripheral neuropathy due to acquired copper deficiency in a patient with history of gastrectomy. JPEN J Parenter Enteral Nutr. 2006;30(5):446–50.
Rudnicki SA. Prevention and treatment of peripheral neuropathy after bariatric surgery. Curr Treat Options Neurol. 2010;12(1):29–36.
de Luis DA, Pacheco D, Izaola O, Terroba MC, Cuellar L, Martin T. Zinc and copper serum levels of morbidly obese patients before and after biliopancreatic diversion: 4 years of follow-up. J Gastrointest Surg. 2011;15(12):2178–81.
Balsa JA, Botella-Carretero JI, Gomez-Martin JM, Peromingo R, Arrieta F, Santiuste C, et al. Copper and zinc serum levels after derivative bariatric surgery: differences between Roux-en-Y Gastric bypass and biliopancreatic diversion. Obes Surg. 2011;21(6):744–50.
Juhasz-Pocsine K, Rudnicki SA, Archer RL, Harik SI. Neurologic complications of gastric bypass surgery for morbid obesity. Neurology. 2007;68(21):1843–50.
King JC, Shames DM, Woodhouse LR. Zinc homeostasis in humans. J Nutr. 2000;130(5S Suppl):1360S–6S.
Hambidge KM. Zinc and diarrhea. Acta Paediatr Suppl. 1992;381:82–6.
Slater GH, Ren CJ, Siegel N, Williams T, Barr D, Wolfe B, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8(1):48–55. discussion 4-5.
Dolan K, Hatzifotis M, Newbury L, Lowe N, Fielding G. A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch. Ann Surg. 2004;240(1):51–6.
Bal BS, Finelli FC, Shope TR, Koch TR. Nutritional deficiencies after bariatric surgery. Nat Rev Endocrinol. 2012;8(9):544–56.
Lonsdale D. A review of the biochemistry, metabolism and clinical benefits of thiamin(e) and its derivatives. Evid Based Complement Alternat Med. 2006;3(1):49–59.
Victor M, Adams RD, Collins GH. The Wernicke-Korsakoff syndrome. A clinical and pathological study of 245 patients, 82 with post-mortem examinations. Contemp Neurol Ser. 1971;7:1–206.
Aasheim ET. Wernicke encephalopathy after bariatric surgery: a systematic review. Ann Surg. 2008;248(5):714–20.
Lakhani SV, Shah HN, Alexander K, Finelli FC, Kirkpatrick JR, Koch TR. Small intestinal bacterial overgrowth and thiamine deficiency after Roux-en-Y gastric bypass surgery in obese patients. Nutr Res. 2008;28(5):293–8.
Bozbora A, Coskun H, Ozarmagan S, Erbil Y, Ozbey N, Orham Y. A rare complication of adjustable gastric banding: Wernicke's encephalopathy. Obes Surg. 2000;10(3):274–5.
Davies DJ, Baxter JM, Baxter JN. Nutritional deficiencies after bariatric surgery. Obes Surg. 2007;17(9):1150–8.
Loh Y, Watson WD, Verma A, Chang ST, Stocker DJ, Labutta RJ. Acute Wernicke's encephalopathy following bariatric surgery: clinical course and MRI correlation. Obes Surg. 2004;14(1):129–32.
Smets RM, Waeben M. Unusual combination of night blindness and optic neuropathy after biliopancreatic bypass. Bull Soc Belge Ophtalmol. 1999;271:93–6.
Ocon J, Cabrejas C, Altemir J, Moros M. Phrynoderma: a rare dermatologic complication of bariatric surgery. JPEN J Parenter Enteral Nutr. 2012;36(3):361–4.
Stroh C, Weiher C, Hohmann U, Meyer F, Lippert H, Manger T. Vitamin A deficiency (VAD) after a duodenal switch procedure: a case report. Obes Surg. 2010;20(3):397–400.
Lee WB, Hamilton SM, Harris JP, Schwab IR. Ocular complications of hypovitaminosis a after bariatric surgery. Ophthalmology. 2005;112(6):1031–4.
Booth SL. Roles for vitamin K beyond coagulation. Annu Rev Nutr. 2009;29:89–110.
Shearer MJ. Vitamin K, metabolism and nutriture. Blood Rev. 1992;6(2):92–104.
Eerdekens A, Debeer A, Van Hoey G, De Borger C, Sachar V, Guelinckx I, et al. Maternal bariatric surgery: adverse outcomes in neonates. Eur J Pediatr. 2010;169(2):191–6.
Bersani I, De Carolis MP, Salvi S, Zecca E, Romagnoli C, De Carolis S. Maternal-neonatal vitamin K deficiency secondary to maternal biliopancreatic diversion. Blood Coagul Fibrinolysis. 2011;22(4):334–6.
Kopic S, Geibel JP. Gastric acid, calcium absorption, and their impact on bone health. Physiol Rev. 2013;93(1):189–268.
Gosch M, Jeske M, Kammerlander C, Roth T. Osteoporosis and polypharmacy. Z Gerontol Geriatr. 2012;45(6):450–4.
Scibora LM, Ikramuddin S, Buchwald H, Petit MA. Examining the link between bariatric surgery, bone loss, and osteoporosis: a review of bone density studies. Obes Surg. 2012;22(4):654–67.
Goldner WS, O'Dorisio TM, Dillon JS, Mason EE. Severe metabolic bone disease as a long-term complication of obesity surgery. Obes Surg. 2002;12(5):685–92.
Marceau P, Biron S, Lebel S, Marceau S, Hould FS, Simard S, et al. Does bone change after biliopancreatic diversion? J Gastrointest Surg. 2002;6(5):690–8.
Sinha N, Shieh A, Stein EM, Strain G, Schulman A, Pomp A, et al. Increased PTH and 1.25(OH)(2)D levels associated with increased markers of bone turnover following bariatric surgery. Obesity (Silver Spring). 2011;19(12):2388–93.
Balsa JA, Botella-Carretero JI, Peromingo R, Caballero C, Munoz-Malo T, Villafruela JJ, et al. Chronic increase of bone turnover markers after biliopancreatic diversion is related to secondary hyperparathyroidism and weight loss. Relation with bone mineral density. Obes Surg. 2010;20(4):468–73.
Halverson JD, Haddad JG, Bergfeld M, Teitelbaum SL. Spontaneous healing of jejunoileal bypass-induced osteomalacia. Int J Obes (Lond). 1989;13(4):497–504.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Review Questions and Answers
Review Questions and Answers
Questions
-
Question 1: Which of the following statements about perioperative nutritional management of the bariatric patient is true?
-
1.
Malabsorptive procedures are limited to the biliopancreatic diversion, and only patients awaiting this surgery need preoperative assessment with a multidisciplinary team that includes a dietitian.
-
2.
Currently, there is strong conclusive evidence that addressing preexisting conditions such as eating disorders and vitamin deficiencies preoperatively is associated with improved postoperative outcomes after malabsorptive surgery.
-
3.
Initiating the therapeutic process preoperatively for patients seeking biliopancreatic diversion surgery offers many advantages such as an opportunity to address preexisting eating disorders and vitamin deficiencies and assess patient compliance and candidacy for surgery.
-
4.
Multidisciplinary teams have little role in the assessment of patients receiving malabsorptive surgery as long as a dietitian is involved in the preoperative assessment and preparation of patients with the surgeon.
-
1.
-
Question 2: Protein energy malnutrition is an important potential complication of malabsorptive procedures. Which of the following regarding protein-calorie malnutrition after biliopancreatic diversion is true?
-
1.
Protein-calorie malnutrition is a rare but serious complication of biliopancreatic diversion surgery and is not encountered in the duodenal switch variant of the procedure.
-
2.
The presence of edema may underestimate the degree of weight loss, clouding the diagnosis and influencing the treatment of protein-calorie malnutrition.
-
3.
Regardless of when protein malabsorption presents in the postoperative period after biliopancreatic diversion surgery, the condition consistently resolves with increasing the administration of enteral protein, without needing to revise the procedure.
-
4.
Protein malnutrition is associated with the intestinal bypass component of malabsorptive surgery and not related to the type of gastrectomy performed.
-
1.
-
Question3: The management of nutritional anemia after malabsorptive surgery involves:
-
1.
Giving all patients supplemental folate in addition to the folate present in a single complex multivitamin tablet because folate levels consistently decrease with time after biliopancreatic diversion with duodenal switch.
-
2.
The routine administration of oral vitamin B12 on a daily or monthly basis, since vitamin B12 deficiency is an important cause of anemia after biliopancreatic diversion and prevention involves.
-
3.
Empiric oral iron therapy for patients with low hemoglobin, recognizing that iron deficiency anemia is the only important anemia resulting in clinical symptoms warranting investigation and therapy after bariatric surgery.
-
4.
The routine administration of oral iron supplementation postoperatively to minimize the incidence of iron deficiency anemia, given that it is the most common form of nutritional anemia encountered after bariatric surgery
-
1.
Answers
-
Q1: #3
-
Q2: #2
-
Q3: #4
Rights and permissions
Copyright information
© 2015 Springer Science+Business Media New York
About this chapter
Cite this chapter
Moustarah, F., Hould, FS. (2015). 35 Laparoscopic Malabsorption Procedures: Management of Nutritional Complications After Biliopancreatic Diversion. In: Brethauer, S., Schauer, P., Schirmer, B. (eds) Minimally Invasive Bariatric Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1637-5_35
Download citation
DOI: https://doi.org/10.1007/978-1-4939-1637-5_35
Published:
Publisher Name: Springer, New York, NY
Print ISBN: 978-1-4939-1636-8
Online ISBN: 978-1-4939-1637-5
eBook Packages: MedicineMedicine (R0)