The following communication is an invited discussion of the article “Potential Impacts of Nutritional Deficiency of Postbariatric Patients on Body Contouring Surgery” but it was not received in time to be printed in the December issue.
In their December 2008 article “Potential Impacts of Nutritional Deficiency of Postbariatric Patients in Body Contouring Surgery” (Plast Reconstr Surg. 2008;122:1901–1914), Agha-Mohammadi and Hurwitz present the results of their extensive review of the literature on post–bariatric surgery nutritional deficiency and identify the physiologic effect of select nutrients on wound healing and immune response. The authors highlight the importance of nutritional optimization before body contouring surgery with respect to both macronutrients and micronutrients. These nutrients, including vitamins, minerals, and amino acids, have been demonstrated in the literature to clinically promote wound healing and have a positive effect on the immune response. The authors attempt to relate this pool of data to the perioperative care of the post–bariatric surgery patient. An extensive chart review is provided that breaks down the primary nutrient deficiency and its potential effects (Table 2). The authors discuss the mechanisms of nutritional deficiency of bariatric surgery and present the common nutritional protocol during the weight loss period. The article culminates in the presentation of two nutritional supplements that the authors have used with anecdotal success in this population. The supplement components are broken down in table form in the article (Table 3). ProCare (Nutressential, Wilmington, Calif.) and Promend [Bariatric Advantage (discontinued, a division of Catalina Lifesciences, Inc., Irvine, Calif.] are 10- to 20-g protein per serving powder form supplements that are enriched with vitamin B complex, arginine, and glutamine, and micronutrients such as zinc, iron, and selenium. It is recommended that the supplement be taken three times per day starting 3 weeks before the surgical procedure until complete healing, with the regimen presented in the article. The focus of the article is lost with the discussion of the authors’ supplement at the extended Conclusion of the article, and almost seems to be the real emphasis of the article masked by a semiscientific but extensive literature review of post–bariatric surgery nutrition.
Bariatric surgery can either restrict caloric intake, decrease absorption, or combine both effects.1–3 This inherently allows for weight loss in the majority of patients; however, the surgery can leave the patient in a persistent malabsorptive state, with protein-calorie malnutrition and a catabolic state, which is not conducive to wound healing in post–bariatric surgery body contouring.4 With the number of bariatric procedures increasing yearly, the plastic surgeon is being presented with patients desiring extensive surgery to remove excess skin.5,6 These operations are commonly multisite operations that create wounds that are, if calculated on a burn scale, approximately 20 percent total body surface area. Although these wounds are closed during the operation, they can incite a large stress response for which the post–bariatric surgery patient may not be able to compensate if not preoperatively optimized. The authors should be commended for highlighting the importance of not just protein but also other nutrients that are vital in wound healing and the normal immune response. Replacement of these factors may be an important component in the successful outcome of post–bariatric surgery body contouring suggested by the authors’ experience; however, only anecdotal data are presented to support the major objective in this article and provide an incomplete assessment of their recommended supplement.
The supplement presented in the Conclusion of the article is bolstered with increased levels of amino acids, specifically, arginine and glutamine, which have been linked to improved wound healing.7 Arginine, a semiessential amino acid that is a precursor for proline during collagen synthesis, likely is rapidly depleted in situations of stress or injury and has been postulated clinically to improve wound healing and immune response with oral supplementation.8 Glutamine, the most abundant amino acid, may also be depleted with injury, and efficacy has been demonstrated in some clinical situations.9 These nutritional additions may be of some clinical benefit, although the authors have not included important details about the relative cost savings, the calorie and sugar content, protein type, and taste. Promend, ironically, is no longer available commercially. It was approximately $1.80 per serving. Procare (Nutressential, Wilmington, Calif.), a 110-kcal and 20-g per serving whey protein supplement sweetened with stevia, a natural plant-based sweetener, is $2.50 per serving. Three servings are recommended, and the total cost per day can be upward of $8.00, which may be consumed for over 60 days. The question one should ask is whether it is more effective than mere vitamin supplementation and a whey or soy protein supplement. The authors do not adequately answer this question, which is not the stated purpose of the article, and we are sure further studies will follow.
First and foremost, if patients are to benefit from nutritional supplementation, just as with any other medication, they must be compliant with the product. We have found that beneficial supplements need to be in a palatable form, either liquid or solid; also, the volume of nutritional supplement has to be small to be tolerated in a restrictive foregut. These products should also not contain high levels of sugars, which can promote dumping syndromes in some bariatric anatomies. In addition, dairy-based supplements are poorly tolerated in this population. There are numerous commercial sources directed to the post–bariatric surgery patient that contain a multitude of choices for these patients and, provided that a daily protein requirement is met, it is up to the patient to maintain an increased level of nutrition before any post–bariatric surgery body contouring. Protein loading is generally started over 1 month in advance and monitored and/or gauged by measuring the prealbumin level at 3 months and 3 weeks preoperatively. Vitamin supplementation is prevalent in this population, although variable levels of anemia are still commonly encountered. Typically, additional vitamin B12 supplementation and iron can help reduce anemia and may be necessary to be administered in intravenous form. In general, many supplements do contain increased levels of micronutrients, although absorption and serum monitoring is difficult: this poses the question regarding how much is enough and how much extra do these patients need. This is the answer for which most plastic surgeons and surgeons dealing with large wounds have likely been searching and, after reviewing this article, for which we are still searching. Nutrition does play a large role in post–bariatric surgery safety and success. This should be initiated at the initial consultation and followed through to complete postoperative healing. A bariatric internist and/or nutritionist and the bariatric surgeon can be used as consultants to manage difficult patients. Deficiencies are expected preoperatively, although supplementation and replacement are only successful with patient compliance. We generally recommend a non–dairy-based, low-calorie, low-volume, high-potency protein supplement with an iron-fortified multivitamin. Protein and to some extent vitamin supplementation can be followed and titrated to optimal levels, although micronutrients cannot. This, combined with general physical optimization, a sound operative plan with a procedure planned for less than 6 hours with preventative measures taken to prevent hypothermia, and perioperative venous thromboembolism prophylaxis can potentiate safety and success in this very challenging but expanding patient population.10
The authors should be commended for presenting their review of the data. However, the article highlights the fact that there are more questions than answers in this expanding field of post–bariatric surgery body contouring.
Andrew P. Trussler, M.D.
Jeffrey M. Kenkel, M.D.
University of Texas Southwestern Medical Center
1. Kenkel JM. Body contouring surgery after massive weight loss. Plast Reconstr Surg.
2. Buchwald H, Avidor Y, Braunnald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA
3. Matarasso A, Roslin MS, Kurian M. Bariatric surgery: An overview of obesity surgery. Plast Reconstr Surg.
4. Agha-Mohammadi S, Hurwitz DJ. Nutritional deficiency of post-bariatric surgery body contouring patients: What every plastic surgeon should know. Plast Reconstr Surg
5. American Society for Metabolic and Bariatric Surgery. Available at: http://www.asbs.org/Newsite07/resources/press_release_8202007.pdf
6. American Society of Plastic Surgeons. Procedural Statistics, 2006. Body contouring after massive weight loss. Available at: http://www.plasticsurgery.org/media
7. Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg.
8. Barbul A, Wasserkrug HL, Yoshimura N, Tao R, Efron G. High arginine levels in intravenous hyperalimentation abrogate post-traumatic immune suppression. J Surg Res.
9. Peng X, Yan H, You Z, Wang P, Wang S. Clinical and protein metabolic efficacy of glutamine granules-supplemented enteral nutrition in severely burned patients. Burns
10. Rubin PJ, Nguyen V, Schwentker A. Perioperative management of the post-gastric-bypass patient presenting for body contour surgery. Clin Plast Surg.
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