Conclusions and Postoperative Management Routine of Nutritionally Restrictive Bariatric Surgery

in conclusion

Biliary-pancreatic diversion (BPD), whether or not duodenal transposition (DS) is performed, has significant long-term weight loss effects and improves obesity-related complications.

There is still relatively limited experience in using laparoscopic techniques for this type of surgery, and the technical difficulty is quite challenging.

Current data reports that laparoscopic BPD surgery is technically feasible, and if cases are selected appropriately, the complications and mortality rates are acceptable.

Since open and laparoscopic surgeries are similar in terms of surgical methods, it is reasonable to expect similar long-term weight loss results after surgery.

The relative risks and benefits of laparoscopic BPD surgery are comparable to other bariatric surgeries, such as RYGB and adjustable gastric banding, although no prospective study has yet compared these procedures.

Restrictive laparoscopic bariatric surgery: Postoperative management and nutritional assessment

Minimally invasive surgical procedures that primarily restrict the absorption of nutrients in the gastrointestinal tract, such as bile-pancreatic diversion (BPD) pioneered by Scopinaro et al. and duodenal transposition (DS) popularized by Marceau et al. and Hess et al., can effectively reduce the weight of obese patients. However, in terms of technical difficulty, complication rate, and mortality, they exceed those of laparoscopic adjustable gastric banding (LAGB) and laparoscopic Y-type gastric bypass (RYGB).

In addition, weight loss surgery that restricts nutrient absorption has a high incidence of nutritional disorders, such as protein deficiency and vitamin deficiency.

Because of these high-risk factors, postoperative patient management and nutritional monitoring is a lifelong task.

Nutrient-restrictive minimally invasive weight loss surgery is a newly developed treatment method, but long-term follow-up data is still limited.

However, the numerous open abdominal surgeries that restrict nutrient absorption have shown that nutritional and vitamin disorders are a fatal postoperative complication.

Therefore, doctors should be highly vigilant during each follow-up visit.

This section introduces the routine postoperative management after minimally invasive weight loss surgery that restricts nutrient absorption.

Postoperative management of hospitalized patients

Due to the complexity and severity of postoperative complications in these patients, careful and meticulous postoperative monitoring and management are crucial for the success of the surgery.

The routine postoperative monitoring during hospitalization is listed in the table.

Patients are encouraged to bring their usual continuous positive airway pressure (CPAP) device to the hospital on the day of surgery for use in the post-anesthesia recovery room.

Once the patient is fully conscious, they are transferred back to a regular ward and monitored post-operatively by nurses from the bariatric surgery department.

Another procedure involves monitoring the patient in the ICU the night after surgery, especially after open surgery.

During the first 12 hours after surgery, pain medication (usually morphine or pethidine) is administered as needed by the patient.

Ketorheic acid was administered in three doses within 24 hours post-surgery.

After the patient is able to eat orally, oral analgesics are administered.

And actively use antiemetics, such as ondansetron, to avoid nausea and vomiting.

Patients are encouraged to get out of bed and move around early, and intermittent barotrauma devices are used to prevent deep vein thrombosis.

A survey by the American College of Bariatric Surgeons reported that 50% of surgeons use unfractionated heparin, 33% use pneumatic compression devices, 13% use low molecular weight heparin, and 38% use a combination of various methods to prevent deep vein thrombosis.

However, we believe there is insufficient evidence to support the routine use of heparin and other prophylactic treatments after surgery.

In addition to early ambulation, we insist on postoperative CPAP use for patients with sleep apnea to prevent pulmonary complications.

However, this has not been widely accepted due to concerns that blowing gas into the stomach and small intestine could increase the probability of gastric fistulas, although most studies have not found this to be the case.

Although some surgeons like to use nasogastric tubes and abdominal drainage after surgery, we do not do it routinely.

Clinical evidence in this area varies, and no consensus has been reached.

If the patient's condition is stable after the operation, the urinary catheter can be removed the following morning.

Water-soluble contrast agents were used for upper gastrointestinal contrast studies to rule out anastomotic leakage.

There is still debate regarding the supporting evidence for whether or not to perform upper gastrointestinal radiological examinations postoperatively.

Some doctors believe that postoperative radiological examinations are used to diagnose early complications, while others believe that routine radiological examinations do not offer any additional benefit and recommend that they be performed only when there is a clinical indication.

Our experience shows that routine upper gastrointestinal contrast studies performed early after surgery help to identify anastomotic leakage at an early stage, and this examination can also serve as a control for subsequent examinations.

If no abnormalities are found during an upper gastrointestinal contrast study, a liquid diet can be started, and oral analgesics can be given.

When taking oral medications, the tablets need to be crushed.

We usually instruct patients which pills can be crushed before taking.

And constantly emphasize to the patient that they should get out of bed and move around more.

The patient can begin a concentrated diet on the second day after surgery.

Our nutritionists provide postoperative dietary counseling and guidance to each patient before discharge to help them develop proper eating habits. They also inform patients about the importance of postoperative food choices and vitamin supplementation, and emphasize the importance of adequate hydration (the goal is to consume at least 60 ounces of fluids per day).

In addition, the importance of a high-protein diet is emphasized. Patients should consume 60-80g of protein per day in the early postoperative period, and then increase it to 80-100g per day.

Most patients can be discharged from the hospital the day after surgery with their own oral analgesics.

Patients should be instructed to maintain a concentrated diet after surgery until their first follow-up visit 3 weeks post-surgery.