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35 Laparoscopic Malabsorption Procedures: Management of Nutritional Complications After Biliopancreatic Diversion

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Minimally Invasive Bariatric Surgery

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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.

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Authors and Affiliations

  1. Department of Surgery, Advanced Laparoscopy, Bariatric and Metabolic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Laval University, 2725, Chemin Sainte-Foy, Québec City, QC, Canada, G1V-4G5

    Fady Moustarah MD, MPH (Clin Epi), FRCS (C) & Frédéric-Simon Hould M.D.

Authors
  1. Fady Moustarah MD, MPH (Clin Epi), FRCS (C)
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  2. Frédéric-Simon Hould M.D.
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Corresponding author

Correspondence to Fady Moustarah MD, MPH (Clin Epi), FRCS (C) .

Editor information

Editors and Affiliations

  1. Cleveland Clinic Lerner College of Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio, USA

    Stacy A. Brethauer

  2. Cleveland Clinic Lerner College of Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio, USA

    Philip R. Schauer

  3. Department of Surgery, Health Sciences Center, University of Virginia Health System, Charlottesville, Virginia, USA

    Bruce D. Schirmer

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. 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. 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. 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. 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.

  • 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. 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. 2.

      The presence of edema may underestimate the degree of weight loss, clouding the diagnosis and influencing the treatment of protein-calorie malnutrition.

    3. 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. 4.

      Protein malnutrition is associated with the intestinal bypass component of malabsorptive surgery and not related to the type of gastrectomy performed.

  • Question3: The management of nutritional anemia after malabsorptive surgery involves:

    1. 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. 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. 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. 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

Answers

  • Q1: #3

  • Q2: #2

  • Q3: #4

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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

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