Nutrition Intervention After Gastric Bypass Revision

Transcription

1 Nutrition Intervention After Gastric Bypass Revision With an Anastomotic Leak Ali Fox- Montana Dietetic Intern

2 Objectives 1. Describe the etiology of anastomotic leak post Roux-en-Y gastric bypass (G.B.) 2. Identify the medical nutrition therapy after gastric bypass with an anastomotic leak 3. Identify indications for initiating nutrition support after surgery 4. Demonstrate the role of the registered dietitian (RD) with both coordination and collaboration of care

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4 Anastomotic Leak and its Severity Anastomosis- A surgical connection between two structures ¹ The most commonly reported location for gastrointestinal leak after G.B. is at the gastrojejunal anastomosis. ² Anastomotic leaks after a Roux-en-Y G.B. range from 0-5.2%. ³ Anastomotic leaks are the second leading cause of death after a G.B. surgery, and are often difficult to diagnose. ³

5 Case Study: General Information 51 year old female Morbidly obese Lives with spouse Non smoker/ non drinker Admitted for complications after gastric bypass surgery

6 Surgical History Underwent gastric bypass surgery in 2006 Admitted for chronic anastomotic ulcer, non responsive to medication- 1/9/2018 Laparoscopic revision of gastric bypass to remove ulcer- 1/29/2018 Discharged home

7 Anastomotic Leak Readmitted for complications- 2/7/2018 Abdominal pain Left shoulder pain Slight nausea Anastomotic leak found Laparoscopic repair of anastomotic leak- 2/8/2018-2/25/18 Nasogastric tube- gastric pouch Gastrostomy tube- remnant stomach

8 Initial Nutrition Assessment 2/12/18- Initial visit Poor intake for 2 weeks 2 oz of protein drink every few hours No other oral intake No vitamin supplementation

9 Anthropometrics Height: 165 cm (65 in) Weight: kg (270 lb) BMI: 44.9 kg/m2 (class 2 obesity)⁴ Ideal Body Weight: kg (125 pounds)⁴

10 Estimated Energy Needs Needs: Calories: calories based on kcal/kg body weight⁵ Protein: grams based on grams/kg ideal body weight ⁵

11 Diagnosis Increased nutrient needs (protein) related to abdominal abscess and recent metabolic surgery as evidenced by poor intake for 15 days and higher protein needs post surgery.⁷

12 Initiating Nutrition Support Continued monitoring output from NG and G-tube Supplementation: Receiving Multi-vitamin concentrate (MVI) 100 mg thiamine Glucose infusion rate: less than 2 mg/kg/minute 2/13/18 Consult to initiate parenteral nutrition via PICC line Rate started at 65 ml/hr, 200 g Dex, 115 g AA, advanced next day to goal ⁶ Resistant to nutrition support Collaborated with pharmacist, physician's assistant (PA) and nurse (RN)

13 Nutrition Support Continued Continued to monitor output from NG and G-tube CPN continued at goal rate 350 G Dex, 100 g AA, 250 ml 20% lipids 1x/week 1670 calories, 120 grams protein 2/16/18 initiated trickle tube feed via G-tube ⁶ Very high protein content 10 ml/hr 240 calories, 22 grams protein Total nutrition: 1910 calories and 142 grams protein

14 Nutrition Support Continued EN advancement: Advanced on 2/24 to 30 ml/hr- felt full Reduced tube feed on 2/24 to 25 ml/hr 2/22/18 diet advanced clear liquids with protein shakes

15 Discontinuing Nutrition Support CPN stopped on 2/24/18, ran for 11 days Trickle feeds stopped on 2/25/18, ran for 9 days RD provided education on G.B. diet guidelines Discharged home on clear liquid diet with protein shakes

16 Monitor and Evaluate ⁷ Body composition: weight trends Electrolyte profile: Sodium, Potassium, Magnesium, Phosphorus Enteral nutrition: initiation, formula, rate, tolerance volume, duration Parenteral nutrition: access, initiation, rate, volume, duration Nutrition physical exam findings: diarrhea, nausea, vomiting, bloating, abdominal pain.

17 Summary of Action Taken: Initiated parenteral feeding through PICC line using a very high protein solution Initiated tube feeding through gastrostomy tube Provided extensive education regarding home nutrition plan for a G.B. diet handout⁸ Vitamin and mineral deficiency Importance of the RD role Support system Working with all team members is critical

18 Questions? Questions?

19 Works Cited: 1. "Anastomosis." Medline Plus, medlineplus.gov/ency/article/ htm. Accessed "Prevention and Detection of Gastrointestinal Leak." The American Society for Metabolic and Bariatric Surgery, May 2015, asmbs.org/resources/prevention-and-detection-of-gastrointestinal-leak. 3. Ballesta, Carlos, et al. "Management of Anastomotic Leaks After Laparoscopic Roux-en-Y Gastric Bypass." Obesity Surgery, vol. 18, no. 6, June 2008, pp , link-springer-com.proxybz.lib.montana.edu:3443/article/ /s Accessed 1 Mar Green pocket book 5. The aspen adult nutrition support core curriculum edition 3 published 2017 pg Matarese, Laura E., et al., editors. The Health Professional's Guide to Gastrointestinal Nutrition. Academy of Nutrition and Dietetics, International Dietetics and Nutrition Terminology (IDNT) reference Manual 4. 4th ed., "Roux-En-Y Gastric Bypass/Sleeve Gastrectomy Discharge Nutrition Therapy." Nutrition Care Manual, Academy of Nutrition and Dietetics, 2018,

20 Works Cited Cont. (pictures) "Roux-En-Y (REY) Gastric Bypass Surgery." A Lighter Me, 2018, Roux-en-Y Gastric Bypass Procedure. Dec. 2011, Correct Placement of NG Tube. Gastrostomy.