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Complications After Bariatric Surgery: Survey Evaluating Impact on the Practice of Specialized Nutrition Support  
* Vanderbilt University Medical Center, Nashville,
Tennessee; Correspondence: Vanessa J. Kumpf, Vanderbilt University Medical Center, Center for Human Nutrition, 1121 21st Ave S, 514 Medical Arts Bldg, Nashville, TN 37232. Electronic mail may be sent to vanessa.kumpf{at}vanderbilt.edu. Background: The rapid growth of obesity rates has affected the practice of specialized nutrition support in various ways. One area that deserves special consideration is the impact that bariatric surgery, in particular complications resulting from bariatric surgery, has made on nutrition support practice. A descriptive survey was designed to evaluate this impact and to assess the various approaches to nutrition assessment and interventions in the postoperative bariatric surgery patient. Methods: A web-based survey consisting of 17 questions was administered in April 2006 to American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) members with available e-mail addresses. Participants were queried about professional background, primary practice setting, and various issues related to their involvement in the care of bariatric surgery patients. Results: There were 467 responses returned out of 3400 surveys delivered (14% response rate). Sixty percent of responders estimated they were consulted to see 1–10 patients requiring specialized nutrition support over the previous year as a result of complications of bariatric surgery. The most common indications for specialized nutrition support in these patients were anastomotic leak/fistula (49%) and chronic nausea/vomiting (27%). When estimating calorie goals, 62% used an adjusted body weight, 15% used ideal body weight, and 14% used actual weight. When estimating protein goals, 56% used an adjusted body weight, 29% used ideal body weight, and 8% used actual weight. Conclusion: These observations provide impetus for guideline development and highlight the priority for further research regarding the best practices to ensure that postoperative bariatric surgery patients receive safe and appropriate nutrition support. Accompanying the alarming rate of obesity in the United States is a dramatic increase in the number of bariatric surgeries performed to assist patients with weight loss. Bariatric surgery has gained wide spread acceptance because it can be associated with sustainable weight loss and reduced comorbidities for many morbidly obese individuals. Data obtained from the largest all-payer discharge database in the United States from 1990 to 2000 shows that the national annual rate of bariatric surgery increased nearly 6-fold, from 2.3 to 14.1 per 100,000 adults.1 The number of bariatric surgical procedures in 2003 was approximately 103,000,2 and estimates for 2006 have been 175,000–200,000.3 Along with an ongoing growth in the overall number of bariatric procedures is an increasing trend favoring gastric bypass procedures that have restrictive and malabsorptive components in preference to purely restrictive procedures and a shift from open to laparoscopic surgeries. Gastric bypass procedures have increased from 55% of all bariatric procedures in 1990 to 95% of all procedures in 2000.1 A recent national audit of bariatric surgery being performed at U.S. academic centers reported that laparoscopy was used in 76% of gastric bypass procedures and in 92% of restrictive procedures.4 These evolving trends in bariatric surgery are likely to have implications with regard to associated complications and nutrition concerns. Despite the potential long-term benefits of bariatric surgery, there are complications that can occur during the immediate postoperative period or over the long term. It has been unclear what impact the care of the postoperative bariatric surgery patient has on the practice of specialized nutrition support. These patients present unique challenges related to nutrition support assessment due to their massive body size, rapid weight loss, and unusual nutrient deficiencies. There are also challenges in delivering nutrition interventions to the postoperative bariatric surgery patient due to difficulties in gaining enteral or vascular access, as well as the risks of developing metabolic complications, such as refeeding syndrome and hyperglycemia. This survey was designed to evaluate the current impact that managing these patients has on the practice of nutrition support in the United States and to assess the various approaches to nutrition assessment and interventions.
A questionnaire was developed to obtain information about general characteristics of the postoperative bariatric surgery patients that nutrition support practitioners are consulted to manage and to assess the nutrition support interventions in these patients. The survey instrument was reviewed by an expert panel and evaluated for comprehension and readability by a focus group of practitioners. An electronic version of the survey was then pilot tested. The final web-based electronic survey consisted of 17 multiple-choice questions. This anonymous survey was granted exempt status by the Vanderbilt University institutional review board. In April 2006, it was electronically distributed to 3700 domestic members of A.S.P.E.N. who provided e-mail addresses. A follow-up survey reminder was electronically sent to those who did not initially respond. Participants were queried about professional background, primary practice setting, the number of postoperative bariatric surgery patients seen who require specialized nutrition support, indications for specialized nutrition support, and various issues related to the nutrition assessment and management of bariatric surgery patients. Throughout the survey, specialized nutrition support was noted to reflect parenteral or enteral nutrition.
Three hundred surveys out of 3700 were returned as undeliverable. Of the 3400 individuals who received the survey, 1156 (34%) opened the survey link and 467 (14%) returned a survey response. The questionnaire and survey results are presented in Table 1. The majority of respondents (74%) were dietitians, followed by pharmacists (10%). The time respondents spent engaged in specialized nutrition support practice varied considerably. Hospitals (teaching, nonteaching, and community) were the most common practice setting (82%), and there were 9% of respondents from the home care setting. Almost 60% of those who responded worked in an institution that performed bariatric surgery. Of those, 60% reported their institution performed >100 cases/year.
Patient Characteristics (Questions 6–8)
Nutrition Counseling (Questions 9–10)
Nutrition Assessment/Intervention (Questions 11–17) Methods used for assessing calorie and protein requirements in this patient population varied greatly (Figure 2). When provided with an example postoperative bariatric surgery patient case, a broad range of estimated calorie and protein requirements was provided by respondents. The length of time specialized nutrition support was required for the postoperative bariatric surgery patient also varied considerably. The final survey question asked who provided specialized nutrition support assessments and interventions for the bariatric surgery patients in their institution. The clinicians most often identified with providing this care were dietitians, physicians, and pharmacists.
The major serious complications of bariatric surgery include leaks from breakdown of the suture or staple line, wound infection, stomal obstruction or stenosis, pulmonary embolism, respiratory failure, bleeding, and death. Patients may experience persistent vomiting and are at risk for dumping syndrome. The overall complication rate, during the initial surgical stay, including all intraoperative and postoperative complications, was reported between 10% and 20%.4,5 Due to extensive changes in gastrointestinal anatomy and altered absorption of nutrients resulting from bariatric surgery, especially surgeries with a malabsorptive component, patients may develop nutrition deficiencies and metabolic abnormalities.6–8 Iron deficiency is one of the most common nutrient deficiencies that occurs after bariatric surgery and has been reported in 20%–49% of bariatric surgery patients, depending on the type of surgery performed.8 Malabsorption of vitamins may also occur, including folate, vitamin B12, and thiamine.6–8 In addition, patients may be at risk of developing osteoporosis due to impaired absorption of calcium and vitamin D.6 Patients may also develop protein malnutrition due to compromised protein intake and malabsorption. Maintaining adequate protein intake and oral supplementation of specific vitamins and minerals is necessary in the postoperative bariatric surgery patient to minimize risk of developing nutrient deficiency states. Noncompliance with micronutrient supplementation, as well as noncompliance with necessary dietary restrictions after surgery, may result in complications. Growing numbers of postoperative bariatric surgery patients require hospitalization for evaluation and management of these postoperative complications. Use of inpatient services for patients receiving gastric bypass surgery in California hospitals from 1995 to 2004 showed a substantially increased frequency of hospitalization in the first year after surgery compared with the year before surgery (19.3% vs 7.9%, respectively).9 Another nationwide study evaluating safety outcomes and resource use within the 6-month period after bariatric surgery found a complication rate of 39.6%, and many of these patients required a postoperative visit to the hospital.5 As the number of patients receiving bariatric surgery continues to grow, nutrition support practitioners are faced with the challenge of caring for more patients with postoperative complications that necessitate the use of parenteral or enteral nutrition. The purpose of this survey was to characterize the impact that complications of bariatric surgery is having on the practice of specialized nutrition support and to identify current nutrition support assessment and intervention methods being used by nutrition support practitioners for these patients.
Identifying a representative sample of the nutrition support practitioner population is difficult. A convenience sample of domestic A.S.P.E.N. membership was selected for distribution of the survey due to electronic access. The overall response rate of 14% represents an adequate but not necessarily representative sample of nutrition support practitioners. The proportion of respondents by discipline is not entirely reflective of domestic A.S.P.E.N. membership. Physician respondents (9%) were lower than membership (13% in 2006), pharmacist respondents (10%) were lower than membership (13% in 2006), and dietitian respondents (74%) were higher than membership (66% in 2006). Reflective of the growing number of bariatric surgeries being performed in the United States, the majority of respondents (almost 60%) worked in an institution that performed bariatric surgery. There was wide variability by respondents in the number of postoperative bariatric surgery patients they were asked to provide specialized nutrition support for. However, almost all respondents (80%) reported some involvement in providing parenteral or enteral nutrition to this patient population over the past year. The most common indications for requiring specialized nutrition support in these patients included anastomotic leak, chronic nausea and vomiting, and severe malabsorption. Some patients required parenteral or enteral nutrition for 90 days or longer. Because only a small fraction of the respondents (9%) were practitioners from the home infusion setting, the use of long-term parenteral and enteral nutrition in the postoperative bariatric surgery patient may not be fully represented. An area of particular concern is the wide variability among respondents in the manner in which calorie and protein requirements were estimated. There was no consensus among respondents as to the appropriate body weight to use for assessing these requirements (ie, adjusted weight, ideal weight, or actual weight). This variability resulted in a broad range of protein and calorie recommendations for a sample patient. Practice guidelines for determining optimal calorie, protein, and micronutrient requirements in these patients are lacking and the wide variability in survey responses reflects lack of consensus regarding many aspects of nutrition assessment and intervention. Outcome studies that compare standardized methods of nutrition assessment and intervention within a consistent type of bariatric surgical patient population requiring specialized nutrition support are needed to guide appropriate practice. Measurable clinical outcomes of interest include markers of nutrition status, complication rate, length of hospital stay, hospital readmissions, and length of time requiring specialized nutrition support. Despite limitations in obtaining a representative sample of the provider population and the subjective nature of questions asked, these preliminary findings serve to highlight a number of relevant concerns. It appears likely that practitioners will be consulted for specialized nutrition support for growing numbers of bariatric surgery patients with complications. Great variability in approaches to assessment and intervention were reported. Further research is needed to develop practice guidelines to ensure safe and appropriate nutrition support for these patients.
Nutrition in Clinical Practice, Vol. 22, No. 6,
673-678 (2007)
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