Roux-en-Y Gastric Bypass with

anastomotic leak
Case Study
Vicky Pehling
Dietetic Intern
July 27, 2017
 Learning Objectives

1. Participants will be able to describe the disease

process of a anastomotic leak post Roux-En-Y
laparoscopic procedure

2. Participants will be able to identify at least one

nutrition intervention for patients post Roux-En-Y
with anastomotic leak
 Meet the Patient

Jon Snow
 33 year old
 Caucasian
 Male
 Married with young children
 Height: 6’ 1”
 Admit weight: 402 Ibs
 o1/5/2017 admitted for Roux-
En-Y gastric bypass for morbid
obesity
Disease Overview
 Roux-En-Y procedure
 The Roux-En-Y gastric
bypass procedure involves
creating a stomach pouch
out of a small portion of the
stomach and attaching it
directly to the jejunum,
bypassing a large part of the
stomach and duodenum.1
Not only is the stomach
pouch too small to hold
large amounts of food, but
by skipping the duodenum,
fat absorption is
substantially reduced 1
https://www.youtube.com/watch
?v=x_w4CdEl67s
 Roux-En-Y nutrition status
 Protein
 Deficiency related to decreased intake
 Aim for 60 g to 80 g per day6
 Calcium
 Deficiency related to bypassing site of primary absorption
(duodenum and proximal jejunum)
 Supplement with 1,200-1,500 mg calcium citrate6
 Iron
 Deficiency related to bypassing site of primary absorption
(duodenum and proximal jejunum)
 Supplement with 18 to 27 mg/d of elemental iron 6
 Roux-En-Y nutrition status

 Vitamin B12
 Deficiency related to inadequate contact with intrinsic factor,
decreased gastric acid and low intake of foods rich in Vitamin B12
 Physician should monitor B12 and prescribe supplementation as
needed6
 Folate
 Etiology of deficiency is unknown
 Suggest daily MVI6
 Vitamin D-3
 Deficiency related to decreased amount of gastric acid
 Physician should monitor and prescribe supplement as needed6
Who qualifies for bariatric surgery?

 Be well-informed, compliant and motivated

 Have a BMI > 40 -or-
 Have a BMI >35 with comorbidities such as diabetes,
sleep apnea, obesity-related cardiomyopathy, or
severe joint disease
 Have failed previous non-surgical weight loss, 3, 6
 Contraindication

 Untreated major depression or psychosis

 Binge eating disorder
 Current drug or alcohol abuse
 Severe cardiac disease with prohibited anesthetic risks
 Severe coagulopathy
 Inability to comply with nutritional requirements including
life-long vitamin replacement 6
 Bariatric surgery in advanced age (above 65) or very young
age (under 18) is controversial 3
 Weight Loss Outcomes

Procedure % initial weight loss (% % initial weight loss (%

excess body weight) excess body weight
2 year post surgery6 10 year post surgery6

Vertical banded 25 (50) 16 (32)

gastroplasty
Gastric Banding 20 (40) 14 (28)
Roux-En-Y gastric 32 (64) 25 (50)
banding
Sleeve Gastrectomy 30 (60) No data
 Comorbidity Outcomes

Percentage of patients who achieved comorbidity remission or significant

improvement 1 year after operation 6

Roux-En-Y bypass(%) Sleeve (%) Band (%)

Type 2 Diabetes 83 55 44
Hypertension 79 68 44
Hyperlipidemia 66 35 33
Sleep Apnea 66 62 38
GERD 70 55 64
 Surgical risks

 10 to 20 percent of patients who have weight loss

operations require follow-up operations to correct
complications. 5
 Abdominal hernias are the most common complications
requiring follow-up surgery.5
 Other complications include leakage through staples or
sutures, bowel obstruction, ulcers in the stomach or small
intestine, recurring vomiting, abdominal pain, inflammation
of the gallbladder and failure to lose weight5
 Anastomotic leak

 Anastomotic or staple line leaks are the

most dreaded and potentially
devastating complication of this
procedure, with a mortality rate of nearly
50%4
 Incidence of ASL is relatively low at 0.4%–
5.2%. 4
 Anastomotic leaks occur most frequently
at the gastrojejunal anastomosis4
 The etiology of ASL is multiple but
generally falls into mechanical/tissue
causes or ischemic causes, both of which
involve intraluminal pressure that
exceeds the strength of the tissue and/or
staple line 7
 Anastomotic leak

 Clinical signs and symptoms5

 Persistent tachycardia HR <120
 Increasing abdominal pain
 Fever
 Tachypnea
 Hypoxia
 Oliguria
 Quality of drain output (blue dye, amaylase)
 Increase WBC
 Anastomotic leak

 Diagnostic and Radiographic tests

 Upper GI
 Huge number of false negatives and false positives
 Negative UGI does not rule out leak4, 5
 Surgery is the only definitive test
 The diagnosis of ASL is typically based on clinical
grounds, with or without the help of radiographic
studies 4
 Anastomotic leak
 Early operative management is the mainstay of
treatment for ASLs following LRYGB.
 The operative goals are to confirm and repair the ASL,
remove GI contents from the abdominal cavity and
place closed suction drains4
 Placement of a feeding gastrostomy into the gastric
remnant or a feeding jejunostomy could also be
considered, as this would allow for continued enteral
nutrition while bowel rest is maintained at the site of
the ASL.4
Nutrition Care Process
 Nutrition Assessment

 Food and Nutrition Related History

 Referred by Unasource Weight Control Center
 Patient reports long history of obesity
 Has tried various weight loss plans under the supervision
of medical doctor without long term success
 Patient's wife had Roux-En-Y procedure 3 years prior
without complications
 Patient instructions on pre-operative diet to help with
liver size and intra abdominal fat given
 Nutrition Assessment

 Medical History
 Type 2 Diabetes Mellitus
 Hypertension
 Obstructive sleep apnea
 Hypercholesterolemia
 Vitamin D deficiency
 B12 deficiency
 Elevated liver function tests
 Microalbuminuria
 Nutrition Assessment

 Home medications prior to admission

 Lipitor (40 mg by mouth at bedtime)
 Lisinopril (40 mg by mouth)
 MetFormin (500 mg by mouth twice daily before breakfast
and dinner)
 B complex vitamins (by mouth daily)
 Cholecalciferol (2000 units by mouth daily)
 Multivitamin-iron-mineral-folic acid (centrum silver), take 1
tablet by mouth daily
 Omega-3 Fatty Acids 1,200 mg by mouth daily
 Nutrition Assessment
laboratory data
 Labs prior to admission
 HgbA1c
 Reference range: 4.0 - 5.6 %
 6.5% (5/3/2016)
 Vitamin B12:
 Reference range: 271 - 870 pg/mL
 245 (5/3/2016)
 306 (9/29/2016)
 Vit D-25 OH:
 Reference Range 25 - 80 ng/mL
 13 (on 5/3/2016)
 34 (on 8/17/2016)
 Nutrition Assessment

 Physical Activity prior to admission

 Visiting a outpatient physical therapist in Sept 2016 for
sprain of right rotator cuff capsule
 Otherwise functional
 Works at a factory, lifts 50 Ibs
Anthropometric Measurements

• Height • Ideal body weight

• 6'1" (185.4 cm) • Based on Hamwi equation:
•Weight history [106+ (13x6)]/2.2 = 83.63 kg
• 1/5/2017 181 kg (399 Ib) •% ideal body weight
• 12/06/216 185.165 kg (401 Ib) • 216%
• 11/282016 182.8 kg (403 Ib)
• 06/21/2016 177.356 kg (391 Ib)
•BMI
• 52.66 kg/m2
Anthropometrics Measurements

• Estimated Energy Needs

• 11-14 kcal/kg actual weight based on ASPEN guidelines/Obesity
• 1991-2534 kcals day
• Estimated Protein Needs
• 2.0-2.5 gm/kg using ideal body weight per ASPEN for obese
• 167-209 gm protein/day
• Estimated Fluid Needs
• 1991-2534 mL/day based on 1mL/kcal or per fluid status
Nutrition Focused Physical Exam

From NSS on 1/12/2017

 Wounds

 1/24/2016 per plastics note

 Open unstageable pressure ulcer, sacrococcygeal
extending to bilateral buttocks
 Open unstageable pressure ulcer/deep tissue injury, left
hip/abdominal fold
 Unstageable pressure ulcer/deep tissue injury, right heel
 Unstageable pressure ulcer, right ear
 Clinical Course Part 1

 o1/5/2017
 Admitted for Roux-En-Y gastric bypass for morbid obesity by Dr. Chengelis
 1/7/2017
 Complaints of abdominal pain, elevated HR 120s, elevated WBC, negative UGI,
febrile episodes , low urine output
 Exploratory laparotomy repair of gastrojejunostomy anastomotic leak with
omental patch, decompression of small bowel and pack of open abdomen.
 1/13/2017
 Exploratory laparotomy
 JP drained placed and wound vac placed
 TPN started
 1/16/2017
 Exploratory laparotomy. Rous limb found to be necrotic. Entire rous limb and
gastric pouch removed.
 A jejunostomy was created in the biliopancreatic limb
Laboratory Data and Clinical Symptoms
 WBC on 1/6/2017
 WBC: 19.2 (high)
 Heart Rate on 1/6/2017
 Per RN, intermittent tachycardia, going as high as 140.
 Upper GI study on 1/6/2017
 Postsurgical changes of patent gastrojejunostomy, with
end to side afferent jejunal loop, and no evidence of an
anastomotic leak.
 Uncontrolled pain on 1/7/2017
 Per RN, pt inquiring about more pain meds
 Decreased Urine Ouput on 1/7/2016
 Per RN, 100cc concentrated urine output
 Increasing oxygen requirements on 1/7/2017
 Clinical Course Part 2
 2/4 TPN Dc'd and TF via initiated J tube
 2/8 patient had abdominal closure with Vicryl mesh.
 2/13 pt complains of loose BMs, Imodium given.
 2/16 C.diff negative.
 2/18 Per Dr. Chengelis "Increase protein and reduce carbohydrate as
weight loss is now part of our goal set."
 3/22 Per surgery, started premier protein tubefeeds via J tube for high
protein, low carbohydrate diet goal 5 cartons per/day
 3/24 patient had split thickness skin graft to the anterior abdominal
wall.
 4/8 patient had first sensitive excisional debridement of his sacral acute
ulcer. The sacral acute ulcer became both infected and necrotic and
required multiple significant debridements between 4/8 and 5/31.
 5/23 still complains of loose stools
 7/11 admitted into IPR
 Nutrition Diagnosis

 Obese, class III related to lifestyle choices as evidenced by BMI

greater than 40

 Inadequate enteral nutrition infusion related to altered

absorption of nutrients as evidenced by diarrhea
 Nutrition Intervention Part 1
 1/13 TPN initiated
 2/4 EN initiated TF regimen: Semi-elemental, high calorie Peptamen 1.5
@ 55 mL/hr + protein bolus x4/day
 TF regimen provided: 2200 kcals, 142g protein
 2/13 TF regimen adjusted r/t loose stools. Imodium given
 Held liquid protein modulars, increased rate to 60 mL/hr
 2/16 Continues to c/o of loose stools. TF formula changed to
positively affect bowel function
 Semi Elemental low cal/high protein VHP at goal rate of 70mL/hr
 TF regimen provides: 1680 calories, 156g protein, 1411 mL free H2O
 2/21 Continues to c/o of loose stools. Decreased TF rate and added
soluble fiber
 VHP @ 50mL/hr soluble fiber bolus x4/d
 TF regimen provides: 1200 calories, 110g protein, 1008mL free h2o
 Nutrition Intervention Part 2
 3/22 premier protein TF initiated per MD Chengelis/Baker
resident for high protein/low CHO diet for weight loss
 TF Goal of 5 cartons daily (70 mL/hr)
 TF regimen will provide: 800 kcals, 150 gm protein, 20 gm CHO
 4/14 increased TF rate to 82 mL/ hr (6 cartons daily)
 TF Regimen provides: 960 kcals, 180 mg protein, and 24gm CHO.
 Diet clear liquid for comfort (~63% caloric & 86% protein assessed
needs per RD)
 5/24 still complains of loose sto0ls
 Added powdered fiber modulars
 5/26 Tolerating TF. Increased to 1200 calories per MD orders
 Increased to 7 premier protein containers/day running at 95 mL/day + 5
scoops fiber powder daily
 TF regimen provides: 1195 calorie, 210 gm protein, 15gm fiber, 48 gm
CHO (~80% calorie and 100% of protein needs based on ASPEN)
 Nutrition Intervention Part 3
 7/6 After discussing with surgery resident
 TF order changed to Peptamen Intense VHP @ goal rate 110mL/hr x 12 hrs( 6pm
to 6AM) + additional 60 gm liquid protein modular
 TF regimen provdies: 1720 kcalories, 181 gm protein, 1109 bmL free h2o
 Pt also started back on MVI, vitamin C, Vitamin D, zinc
 7/8 pt & spouse requesting to change back to previous tube feed
regimen due to increase diarrhea/loose stools.
 Most likely cause of diarrhea may have been if liquid protein is not properly diluted
can cause osmotic diarrhea -directions for each liquid protein is to dilute 4:1.
 New orders have been entered into EPIC for previous tube feed regimen, Premier
Protein at 110 mL/hr.
 7/11 . Changed TF orders after discussion with patient
 VHP @ 50mL/hour to goal rate 110mL/hour X 16 hours (4pm to 8am
only) + 5 scoops powdered fiber daily
 No liquid proteins at this time
 TF regimen will provide: 1760 cals; 162 g protein; 1478 mL free h2o; 22
g fiber
 Dietary Counseling

 01/6 (1 day post op)

 Provided written and verbal nutrition education on Gastric
Bypass Diet and dehydration prevention
 Response: pt expressed understanding. Pt's wife had bariatric
surgery 3 years ago and is familiar with diet
 Pt has protein shake from Unasource at home.
 PT has MVI, Vitamin D, B12 at home. Still needs to purchase
calcium and iron supplements
 RD’s discussed with pt various TF products, nutrient
modulars and troubleshooting tolerance issues throughout
stay
 Pt will likely go home on PEJ feeding, likely needs education
prior to discharge
Post-0p diet plan after bariatric
surgery3

Day Diet
Day of surgery Ice chips only
Day 2 Clear liquid or full liquid diet
Day 3-13 (rest of 1st and 2nd week) Full liquid diet
Day 14-27 (3rd and 4th week) Pureed foods diet
Day 28-41 (5th and 6th week) Soft foods diet

Day 42 (7th week and on) Regular diet

 Dietary Counseling Bariatric
Eating Principles
 Meal timing:
 Eat approximately every 3-4 hours3
 Portions:
 The gastric bypass pouch is approximately 1 ounce in size
 In the early post operative period, the portions will range
between ½ to 1 cup depending on the consistency of the
food3
 Eating mindfully:
 Eat slowly and chew well
 Up food into small pieces the size of a pea, chew each
bite 10-15 times
 It should take approximately 20-30 minutes to eat a meal 3
 Dietary Counseling Bariatric
Eating Principles
 Protein
 At each meal, eat protein foods first and supplement with
fruits and vegetables
 Wait to add starches such as bread, rice and pasta until 6
months post op3
 Fluids
 Drink a minimum of 64 ounces of calorie-free liquids per
day.
 Avoid drinking with meal. Stop drinking 30 minutes
before and 30 minutes after a meal3
 Vitamins and minerals
 Take a complete multivitamin/mineral supplement 2x/day
 Minimum of 1000 mg of calcium daily
 A minimum of 29 mg of iron daily3
 Dietary Counseling Bariatric
Eating Principles
 Dumping syndrome3
 Occurs when foods, especially sugar, moves from the
stomach to the small bowel too quickly.
 Most people develop signs and symptoms such as
abdominal cramps and diarrhea, within 10 to 30 minutes
after eating. Some have symptoms 3 hours later
 Take preventative measures, such as eating smaller
meals and limiting high-sugar foods
 Steatorrhea3
 Since food will bypass the small intestine, this can cause
malabsorption of fat, leading to fat in stools
 To avoid steatorrhea, cut back on eating high fat foods,
such as fried foods and fast foods.
 Monitoring and Evaluation
 Nutrition Goals
 Patient to meet TF goal volume for 24 hours- not met,
ongoing
 Difficulty meeting this goal related to altered GI function
and loose stools
 Patient to meet estimated nutritional needs via TF
regimen not met- ongoing
 Physician wanted to underfed patient for weight loss using
premier protein/low CHO & high protein diet
 Patient to show signs of wound healing met, ongoing
 Difficulty related to underfeeding total energy needs
 Did eventually start healing per plastics note
 Monitoring and Evaluation

Jon Snow
450
402
400
342
350 329
299
300 276
Weight (Ibs.)

250 239

200

150

100

50

0
1/5/2017 2/8/2017 3/1/2017 4/20/2017 6/9/2017 7/22/2017

Date

Jon Snow
 Literature Review

 Mainstays of laparoscopic or open re-exploration follow the

principles of drainage, creation of a controlled fistula with
drains, antimicrobial therapy, and parenteral nutrition or
enteral nutrition with consideration of feeding access of the
jejunum either with a nasoenteric catheter placed beyond
the area of leak or a gastrostomy tube placed in the gastric
remnant. 7
 More research examining the energy and protein
requirements of obese patients needing nutrition support
following bariatric surgery is urgently required 11
 Literature Review

 ASPEN guidelines for the provision and assessment of

nutrition support therapy in adult critically ill patient
 For all classes of obesity where BMI is >30, the goal of the
EN regimen should not exceed 60-70% of target energy
requirement or 11-14 kcal/kg actual body weight per day or
22-25 kcal/kg ideal body weight per day.9
 Protein should be provided in range of >2.0g/kg ideal body
weight per day for class I and II patients (30-40). >2.5g/kg
ideal body weight per day for class III (greater than BMI
40). 9
 Summary

• Despite decreased incidence, anastomotic leak remains an important

cause of overall morbidity and mortality post Roux-En-Y procedure
• The etiology of ASL is multiple but generally falls into
mechanical/tissue causes or ischemic causes, both of which involve
intraluminal pressure that exceeds the strength of the tissue and/or
staple line
• Treatment includes parenteral nutrition or enteral nutrition with
consideration of feeding access of the jejunum either with a
nasoenteric catheter placed beyond the area of leak or a gastrostomy
tube placed in the gastric remnant.
• Continuous monitoring and re-evaluating of TF tolerance is important
for reaching estimated energy and protein needs
 References
1. Rogers, Anne. "Roux-en-Y Stomach Surgery for Weight Loss." MedlinePlus
Medical Encyclopedia Image. U.S. National Library of Medicine, 31 Mar. 15. Web. 25
July 2017.
2. Meilahn, John, and Rita Sather. "Risks of Gastric Bypass Surgery: Anastomotic
Leaking."Risks of Gastric Bypass Surgery: Anastomotic Leaking. University of
Rochester Medical Center Rochester, n.d. Web. 25 July 2017.
3. "Bariatric Surgical Weight Loss." Bariatric Surgical Weight Loss. Beaumont
Health, n.d. Web. 25 July 2017.
4. Griffith, P. Sahle, Daniel W. Birch, Arya M. Sharma, and Shahzeer Karmali.
"Managing Complications Associated with Laparoscopic Roux-en-Y Gastric
Bypass for Morbid Obesity." Canadian Journal of Surgery. Canadian Medical
Association, Oct. 2012. Web. 25 July 2017.
5. Choi, Jenny J. "Leak After Gastric Bypass: Early Detection and Treatment."
Society of American Gastrointestinal and Endoscopic Surgeons. Boston. Mar.
2016. Web.
6. "Bariatric Sugery." Nutrition Care Manual. Academy of Nutrition and Dietetics,
n.d. Web. 25 July 2017.
7. "Prevention and Detection of Gastrointestinal Leak." American Society for
Metabolic and Bariatric Surgery. ASMBS Executive Council, May 2015. Web. 25 July
2017
8. Podnos, Yale D., J. C. Jimenez, S. E. Wilson, C. M. Stevens, and N. T. Nguyen.
"Complications After Laparoscopic Gastric Bypass." Archives of Surgery. American
Medical Association, 01 Sept. 2003. Web. 25 July 2017.
9. Choban, P., R. Dickerson, A. Malone, P. Worthington, C. Compher, and N. U.
American. "A.S.P.E.N. Clinical Guidelines: Nutrition Support of Hospitalized Adult
Patients with Obesity." JPEN. Journal of Parenteral and Enteral Nutrition. U.S.
National Library of Medicine, Nov. 2013. Web. 25 July 2017.
10. Isom, Kellene A., and Kris M. Mogensen. "Nutrition Support for the Bariatric
Surgery Patient: When and Why Nutrition Supported Is Needed." Nutri-Bites
Webinar Series. Lecture.
11. Seagran, Ella. "Provision of Nutritional Support to Those Experiencing
Complications Following Bariatric Surgery." Proceedings of the Nutrition Society 69
(2010): 536-42. Print.