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137

incorrect eating habits or inadequate physical

activity.

Regarding excessive weight loss, please

refer to 7 Chap. 12.

13.5 Morbidity andMortality

Compared to the most common bariatric pro-

cedures (sleeve gastrectomy and Roux-en-Y

gastric bypass), BPD-DS is associated with

signicantly increased perioperative morbid-

ity and mortality. In the literature, compli-

cation rates of up to 38% for a single-stage

procedure (Ren etal. 2000) and up to 30% for

a two-stage procedure (Silecchia etal. 2009)

have been reported, although these are partly

due to the learning curve.

The most frequent complications are, as

with the other bariatric procedures, stulas of

the staple suture, anastomotic insufciencies,

abscesses or (post-) bleeding.

Duodenal switch is accompanied by

complications such as pancreatic stulas or

truncated duodenal insufciency due to the

preparation at the pancreatic head and the

cutting of the duodenum; especially the latter

is associated with high mortality. If a duode-

nal truncation insufciency is suspected, if it is

fresh, it should be reapplied and, if necessary,

a T-drain system should be installed to reduce

the secretion load. In the case of chronic stu-

las, targeted drainage is often the only option.

With regard to complication management,

reference is made to the recommendations in

7 Chap. 12.

In the case of a two-stage procedure,

attention must be paid to the risks of vascular

or hollow organ injury when the pneumoperi-

toneum is applied or—in the case of a second

procedure—during adhesiolysis.

In the case of duodenodenal or ileoileal

anastomosis insufciency or post-bleeding,

an urgent relaparoscopy and revision should

be performed. Duodenoileostomy can also be

performed gastroscopically with a stent, clip

or vacuum; preferably if a local target drain-

age is still present.

In the long-term course, the reoperation

rates according to BPD-DS are compara-

tively low. Strong attention must be paid to

deciency symptoms, which can occur in over

90% of cases despite substitution (Homan

etal. 2015). According to BPD-DS, substitu-

tion should be carried out with special prepa-

rations such as those available for conditions

following gastric bypass. Commercially avail-

able multivitamin tablets from discounters are

not recommended.

Please refer to 7 Chap. 12 for recommen-

dations on how to avoid deciencies and com-

plications.

Practical Tip

Since the duodenal switch can often lead to

deciency symptoms due to its pronounced

malabsorption, consistent substitution and

aftercare is required especially in these

patients, which also requires appropriate

compliance.

References

Buchwald H, Oien DM (2013) Metabolic/bariatric sur-

gery worldwide 2011. Obes Surg 23:427–436

Buchwald H, Kellogg TA, Leslie DB, Ikramuddin S

(2008) Duodenal switch operative mortality and

morbidity are not impacted by body-mass-index.

Ann Surg 248:541–548

Gagner M, Gumbs AA (2007) Gastric banding: conver-

sion to sleeve, bypass, or DS.Surg Endosc 21:1931–

1935

Gumbs AA, Pomp A, Gagner M (2007) Revisional bar-

iatric surgery for inadequate weight loss. Obes Surg

17:1137–1145

Hedberg J, Sundström J, Sundbom M (2014) Duodenal

switch versus Roux-en-Y gastric bypass for mor-

bid obesity: systematic review and meta-analysis of

weight results, diabetes resolution and early com-

plications in single-centre comparisons. Obes Rev

15:555–563

Hess DS, Hess DW (1998) Biliopancreatic diversion with

a duodenal switch. Obes Surg 8:267–282

Homan S, Betzel B, Aarts EO etal (2015) Vitamin and

mineral deciencies after biliopancreatic diver-

sion and biliopancreatic diversion with duodenal

switch—the rule rather than the exception. Obes Surg

25:1626–1632

Kim WW, Gagner M, Kini S, Inabnet WB, Quinn T,

Herron D, Pomp A (2003) Laparoscopic vs. open bil-

iopancreatic diversion with duodenal switch: a com-

parative study. J Gastrointest Surg 7:552–557

Biliopancreatic Diversion withDuodenal Switch

138

Manger T, Hohmann U, Stroh C (2009) Surgical tech-

nique and outcome in metabolic and bariatric

surgery: biliopancreatic diversion. Zentralbl Chir

134:38–42

Prachand VN, Davee RT, Alverdy JC (2006) Duodenal

switch provides superior weight loss in the super-

obese (BMI ≥ 50 kg/m

) compared with gastric

bypass. Ann Surg 244:611–619

Ren CJ, Patterson E, Gagner M (2000) Early results of

laparoscopic biliopancreatic diversion with duodenal

switch: a case series of 40 consecutive patients. Obes

Surg 10:514–523

Risstad H, Søvik TT, Engström M etal (2015) Five-year

outcomes after laparoscopic gastric bypass and lapa-

roscopic duodenal switch in patients with body- mass-

index of 50–60: a randomized clinical trial. JAMA

Surg 150:352–361

Sánchez-Pernaute A, Rubio MÁ, Conde M, Arrue E,

Pérez-Aguirre E, Torres A (2015) Single- anastomosis

duodenoileal bypass as a second step after sleeve gas-

trectomy. Surg Obes Relat Dis 11:351–355

Silecchia G, Rizzello M, Casella G, Fioriti M, Soricelli E,

Basso N (2009) Two-stage laparoscopic biliopancre-

atic diversion with duodenal switch as treatment of

high-risk super-obese patients: analysis of complica-

tions. Surg Endosc 23:1032–1037

Weiner R (2010) Indications and principles of metabolic

surgery. Chirurg 81:379–395

14.1.1 First Stage

In the rst and second postoperative week it is

recommended to offer liquid food. On the rst

and second day after the operation, only small

amounts of liquids should be drunk, i.e., sips

of unsweetened tea and non-carbonated

water. If these quantities are well tolerated,

the uid intake can be increased and broth can

be added (Dieckmann 2013). If well tolerated,

the patient can be given protein- containing

meals from the third day onwards, such as

unsweetened milk or natural yoghurt dishes as

well as protein supplements. In addition, nely

pureed vegetable soups, mashed potatoes and

nely pureed fruit, such as banana and apple,

are usually well tolerated by patients. Due to

the low stomach volume after the procedure,

4–6 meals per day are recommended, whereby

a meal volume of 100–200 ml should not be

exceeded during the rst stage (Hellbardt

2013). To achieve an early feeling of satiety, it

is recommended to separate eating and drink-

ing. The following overview gives the eating

behaviour rules after bariatric interventions

for all time periods modied according to

Moizé etal. (2010).

Eating Behaviour Rules After Bariatric

Interventions (Mod. According to Moizé

etal. 2010)

5 5–6 meals, 3 main meals and 2–3 snacks

per day

5 Avoidance of carbonated drinks

5 Chew your food properly, eat in small

bites

5 Portion small quantities onto the plate

5 Eat consciously, consider the feeling of

satiety

5 Eat slowly, allow at least 20min

5 Separate drinking and eating, drink

30 min before and only again 30 min

after eating

5 Take daily vitamin and mineral supple-

ments and protein supplements if nec-

essary

14.1.2 Second Stage

The second stage of the dietary regimen aims

at the transition from liquid food to soft food.

In the second to fourth postoperative week,

the patient is offered pureed or soft meals.

Depending on the patient’s tolerance, slowly

more solid foods (. Table 14.1) are added

to the diet. A high-protein, low-fat and low-

sugar diet is the basis for the choice of food.

Postoperative Management ofBariatric Surgery Patients

142

. Table 14.1 Exemplary food selection of

pureed and soft foods (2–4weeks after bariatric

surgery)

Food group Food examples

Beverages Non-carbonated water, unsweetened

tea

Fruit and

vegetables

Bananas, apples (low acidity

varieties), pears

carrots, zucchini, broccoli, other

non-atulent vegetables (initially

better tolerated: steamed or

pureed)

Cereals

(products)

and

potatoes

Toast, rusk, cereal products made

from wheat, maize, oats, e.g. our,

starch or semolina, boiled potatoes,

mashed potatoes (lactose-free if

necessary)

Milk and

dairy

products

Low-fat variants of milk, natural

yoghurt, quark, cheese (maximum

30% in dry matter), (lactose-free if

necessary)

Meat, sh,

egg and

sausages

Lean meat: veal, chicken

Egg, prepared low-fat

Lean sausage: cooked ham

(without fat rim), poultry sausage

Fats and

oils

Vegetable oils, e.g. rapeseed oil,

margarine

Spices No pungent spices

. Table 14.2 Foods that can cause complaints

after bariatric surgery

Food group Food examples

Beverages Coffee, alcohol, sugary and

carbonated drinks

Fruit and

vegetables

Pineapple, bananas,

rhubarb

Mushrooms, asparagus,

cabbage, green beans

Cereals (products)

and potatoes

White bread, rusk, noodles,

rice, fried products

Milk and dairy

products

Milk, high-fat dairy

products

Meat, sh, egg

and sausages

Beef, seafood, raw ham

Food rich in fat

and sugar

Sweets, fried food, etc.

14.1.3 Third Stage

The third stage is the transition from pureed

or soft food to light diet. From the fourth

postoperative week onwards, if the previous

diet is well tolerated, more solid foods can be

carefully added to the diet. The third stage is

therefore the transition to long-term nutri-

tion after bariatric surgery (see also 7 Sect.

14.2). Special attention should be paid to

the foods (. Table 14.2), which can cause

discomfort, for example, due to insufcient

chewing, solid or brous structures or unin-

tentional swallowing. By recording them in

a diet and complaints diary, patients can be

sensitised to specic intolerances and sensible

avoidance strategies can be discussed in the

consultation.

14.2 Long-Term Nutrition After

Bariatric Surgery

H.Berger

Long-term nutrition after bariatric surgery is

the form of nutrition that is permanently rec-

ommended after the initial postoperative diet

regimen. Just like in the three stages explained

above, it is intended to prevent the develop-

ment of malnutrition and nutrition-related

complaints. The rules of eating behaviour

(7 Sect. 14.1) have to be observed constantly.

So far, only a few authors have dealt with long-

term nutrition after bariatric surgery. Moizé

etal. (2010) have developed a nutrition pyra-

mid (. Fig. 14.1) for gastric bypass patients

based on a diet low in fat and rich in protein

and bre. The use of this pyramid as nutri-

tional advice for patients undergoing other

bariatric procedures, such as a sleeve gastrec-

tomy, should be investigated in future studies.

Dietary complications can occur both

during the initial postoperative diet regimen

and—to a lesser extent—during long-term

nutrition at a later stage. Complications are,

for example

H. Berger et al.

143

. Fig. 14.1 Food pyramid for patients undergoing gastric bypass surgery. (Mod. according to Moizé etal. 2010)

5 Dumping syndrome,

5 Nausea and vomiting,

5 Meteorism,

5 Diarrhea,

5 Constipation,

5 Food intolerances,

5 Dehydration.

Recurring complaints require further diag-

nostics and therapeutic measures, in which

renewed nutritional advice in particular plays

a decisive role.

14.3 Supplementation

H.Berger

In obese patients, a lack of vitamins or miner-

als may already exist before bariatric interven-

tions due to unbalanced nutrition (Saltzmann

and Karl 2013). Possible deciency symptoms

should be diagnosed and compensated for in

advance of bariatric surgery. Depending on

the surgical procedure, anatomical changes of

the digestive tract may occur, resulting in dif-

ferent degrees of malabsorptive effects.

In restrictive procedures, such as sleeve

gastrectomy, deciency symptoms occur less

frequently after surgery than in malabsorp-

tive procedures, such as gastric bypass surgery

and biliopancreatic diversion (Handzlik-Orlik

et al. 2014). In addition, low food intake,

intolerances and developing aversions to

certain foods or groups of foods can lead

to the development of nutrient deciencies.

The deciency of macro- and micronutri-

ents can persist in bariatric patients and thus

make lifelong supplementation necessary (see

also 7 Sect. 14.5.2). To avoid a protein de-

ciency, the intake of 60–120 g of protein per

day is recommended. If possible, this should

Postoperative Management ofBariatric Surgery Patients

144

be ensured by a protein-rich diet. In cases

of deciency, however, oral, enteral or even

parenteral nutrition is indicated for therapy,

depending on the severity of the malnutrition.

14.4 Surgical Aftercare

J.Ordemann

Obesity is a chronic disease and cannot be

treated curatively. Thus, surgically treated

obesity patients remain chronically (obese) ill

and require lifelong therapy, even if they have

lost weight signicantly and their secondary

diseases have improved. Aftercare should not

only focus on weight development but also

on changes in secondary diseases, nutritional

deciencies, complications and quality of life.

Studies show that patients who receive

professional aftercare are signicantly better

able to lose weight and maintain their weight

loss in the long term than patients who do not

receive this aftercare.

It is crucial that competent obesity phy-

sicians coordinate this follow-up care and

refer patients to other specialists (plastic

surgeons, cardiologists, pulmonologists) if

necessary. Patients who signal avoidance of

aftercare already preoperatively or who do

not acknowledge the necessity of aftercare

should be critically evaluated with regard to

the indication for surgery.

There is no generally excepted aftercare

scheme. The frequency of follow-up appoint-

ments depends on the procedure, the intensity

of weight loss and the possible occurrence of

complications.

The rst surgical follow-up is on the tenth

postoperative day. During this follow-up

visit, wound healing, presence of pain, and

problems with the initial postoperative diet

regimen are assessed in order to rule out early

postoperative complications. Since weight

loss is most pronounced in the rst year after

the operation, it is advisable to carry out the

aftercare at regular intervals every 3 months.

In the second year, follow-up every 6months

is sufcient. From the third year postopera-

tively, annual follow-up is supposed to be suf-

cient (. Table14.3). If, however, internal or

psychosomatic complications or complaints

arise, the aftercare should be carried out more

closely again (7 Sects. 14.5 and 14.6).

Surgical follow-up should assess the clini-

cal condition of the patient. In particular,

BMI and excess body weight loss should be

carefully recorded. It is important to con-

. Table 14.3 Aftercare scheme

10days

postop.

Week

Month

Yearly

Sur-

geon,

nutri-

tionist

X x x x x x x x x x x

Inter-

nist,

endo-

cri-

nolo-

gist

x x x x x x

Psy-

cholo-

gist

if necessary

H. Berger et al.

145

tinuously document these data in order to be

able to react early on to a renewed increase in

weight. The core task of surgical aftercare is

to identify complications. Depending on the

surgical procedure (gastric banding, sleeve

gastrectomy or gastric bypass), the symptoms

vary and require adequate diagnostics and

therapy (7 Sect. 14.7).

Practical Tip

All medical information should be care-

fully recorded as part of the follow-up care

and inserted into a database of obesity

surgery quality assurance.

14.5 Internal Aftercare

U.Elbelt

The task of internal aftercare is the adjustment

of the pre-existing medication during postoper-

ative weight reduction, the early identication

of nutrition-related deciencies, the appropri-

ate treatment of obesity-related pre-existing

diseases as well as the treatment of additional

cardiovascular risk factors, which mostly

occur in the context of a metabolic syndrome.

Following the postoperative phase of “effort-

less” weight reduction, further care is aimed

at preventing renewed weight gain. At each

presentation, the patient’s current complaints,

eating habits, weight development, changes in

existing comorbidities and current life circum-

stances should be assessed. In addition, weight

measurement and a careful physical examina-

tion are required. Aftercare has to be provided

throughout the patient’s postoperative life.

14.5.1 Follow-Up intheEarly

Postoperative Phase

The initial postoperative dietary regimen is

described in detail in 7 Sect. 14.1. In the early

postoperative phase, the internal follow-up

focuses on complaints with food intake and

the adjustment of the pre-existing medication.

The medical history should specically ask

about pain associated with food intake and the

frequency of vomiting. Should vomiting occur

repeatedly, a (renewed) detailed nutritional

consultation and, if necessary, a psychoso-

matic presentation is necessary. Surgical com-

plications (7 Sect. 14.7) have to be ruled out

beforehand. Immediately before surgery, oral

antidiabetics (especially metformin and insuli-

notropic substances with the potential to cause

hypoglycaemia) should be discontinued if type

2 diabetes mellitus is present. In the case of

pre-existing insulin therapy, the administration

of basal insulin should be at least halved post-

operatively; prandial insulin administration

should rst be paused. In order to be able to

react appropriately to the early drop in insu-

lin requirements (within the rst postoperative

week), a 4-point daily blood glucose prole

should be carried out regularly during the

inpatient stay. Postoperatively elevated blood

glucose levels should be compensated for by

short-acting insulin in a reduced dose.

Practical Tip

These recommendations must not be

applied to patients with diabetes mellitus

type 1. In these patients, too, there is usu-

ally a drastic reduction in insulin require-

ments. Changes in basal insulin coverage,

modication of daytime dependent insu-

lin/carbohydrate-ratios and reduction of

the insulin correction factor should be dis-

cussed in detail with the patient and the

treating diabetologist prior to surgery.

Furthermore, in this phase, the therapy with

diuretics has to be adjusted to avoid dehydra-

tion and hypokalemia. An antihypertensive

medication should also be reduced, if necessary.

14.5.2 Aftercare During theWeight

Loss Phase (‘Honeymoon

Phase’)

The “honeymoon phase”covers the rst 18

(up to max. 24) months postoperatively. Its

Postoperative Management ofBariatric Surgery Patients

146

end is marked by renewed weight gain or no

further weight loss.

The weight loss is most pronounced in the

rst 6 postoperative months. In this phase,

the reduction of antihypertensive therapy and

also a possible pre-existing therapy with thy-

roid hormones is of particular importance.

During this time, a drug therapy to prevent

gallstone formation with ursodeoxycholic acid

in a dosage of at least 500mg/day for a period

of 6months should be administered. Whether

a drug prophylaxis for prevention of gout

attacks is necessary is still a matter of debate.

In our centre, this is only done in a targeted

manner.

During this phase, the psychosomatic

symptom burden is generally reduced and the

psychosocial level of function improves. As a

result, the psychosomatic aftercare offer is no

longer perceived necessary by most patients,

so that potential psychological problems

have to be assessed as part of internal after-

care. Especially for women who have under-

gone surgery, the temporary increased hair

loss that occurs in the third month after the

operation is very stressful. This usually lasts

for 3–6 months. Treatment with biotin and

consistent iron supplementation are recom-

mended. The topical constant application of

hair tonic containing minoxidil (and estra-

diol) is effective after a latency period. Being

cold is also often reported to be very unpleas-

ant. With continued weight loss, the burden

of skin sagging increases. These should be

inspected in order to prevent inammatory

skin changes and to initiate therapy at an

early stage. Careful documentation is particu-

larly important for justifying the necessity of

plastic surgery that is planned in the further

course of weight loss. However, these opera-

tions should generally only be performed after

weight reduction has been completed in a

phase of weight stability (usually not until the

18th postoperative month). Due to the change

in appearance and lifestyle, partnership con-

icts can often occur in this phase.

Some patients are burdened by the occur-

rence of diarrhoea and associated faecal

incontinence. Since this is often not reported

out of shame, it should be specically asked

for. Differential diagnoses include gastroin-

testinal infections (which are favoured by the

postoperative lack of an acid barrier in the

stomach), bacterial colonisation of the small

intestine and relative lactose intolerance. It is

helpful to carry out targeted medical investi-

gations.

With regard to the use of medication,

altered absorption should be considered,

especially after gastric bypass surgery.

Especially the therapy with oral anticoagu-

lants and anticonvulsants should be closely

monitored. Women have to be informed of

the reduced effectiveness of oral contracep-

tives. Alternative contraceptive methods

should therefore be used for safe contracep-

tion. Overall, liquid pharmaceutical prepa-

rations appear to be more favourable with

regard to absorption. In this context, the

postoperative higher alcohol sensitivity due

to faster absorption should also be pointed

out. The consumption of alcohol should be

assessed and discussed at every follow-up

visit.

Especially after gastric bypass surgery,

the avoidance of macro- and micronutrient

deciencies is of central importance in inter-

nal aftercare. While to our experience a pro-

tein deciency tends to be a minor problem,

special attention should be paid to the avoid-

ance of hypovitaminosis D

with subsequent

development of secondary hyperparathy-

roidism, iron deciency anaemia and hypovi-

taminosis B

To avoid deciencies, consistent postop-

erative supplementation and regular labora-

tory testing should be carried out for an early

detection. The symptoms of a micronutrient

deciency can be very diverse. For this reason,

a (previously overlooked) deciency should

always be considered for differential diagnosis

in the case of reported complaints or conspic-

uous clinical ndings.

Supplementation should include multi-

vitamin administration, additional intake of

calcium, vitamin D

and iron, and parenteral

administration of vitamin B

Hypovitaminosis D

is often present preop-

eratively and should be compensated for prior

to the operation. Postoperatively, the need for

supplementation is increased and after gas-

tric bypass surgery it may often be necessary

H. Berger et al.

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References

Further Readings

14.1.1 First Stage

14.1.2 Second Stage

14.1.3 Third Stage

14.3 Supplementation

14.4 Surgical Aftercare

14.5 Internal Aftercare