Intravenous nutritional support in pregnancy. Experience following biliopancreatic diversion

For whom the bell tolls? It is time to retire the classic BPD (bilio-pancreatic diversion) operation

With the culture of safety and lowering risks that took place 20 years ago, sleeve gastrectomy has emerged as a procedure of choice. Hence, for super- and super-super-obese patients, there is a tendency these days to perform surgeries in 2 stages, and sleeve is the procedure of choice. Because sleeve is not part of a classic bilio-pancreatic diversion, it is unlikely that this operation will be done as a second stage, making this operation obsolete.

Safety of home parenteral nutrition during pregnancy

BACKGROUND & AIMS

Few studies have examined the effect of total parenteral nutrition which is lipid-based given throughout pregnancy to patients unable to obtain adequate nutrition by the oral route. In this study we examined the use of lipid-based home parenteral nutrition (HPN) in 7 pregnant women, commenced either before or during pregnancy, and their intra-pregnant course as well as a 2-year follow-up of their offspring is described.

METHODS

HPN was formulated on an individual basis and protein administered in a dose of 0.8-1.1 g/kg during the three trimesters. Lipid emulsions included long chain triglycerides or olive-oil based formulae and all patients received trace elements. Data were collected during the course of pregnancy and at birth while infants were followed for a period of between 6 months and 2 years using medical records and questionnaires.

RESULTS

In total, we studied 9 pregnancies (in 7 women). HPN was administered for a median of 9 months (range 3-9 months). The mean energy provided during the 1st, 2nd and 3rd trimester was 9297 ± 2797 kcal/week, 9148 ± 2629 kcal/week and 8564 ± 4059 kcal/week resp. The mean increase in weight during the pregnancy was 9 ± 5 Kg. The only complications noted during the pregnancy consisted of 3 episodes of catheter-related infections which were successfully treated by antibiotics. The infants were born after a mean of 38.00 ± 1.55 weeks of gestation, with a mean first minute Apgar score of 8.7 ± 1.8 which increased to 9.8 ± 0.4 after 10 min. The mean infant birth weight was 2.45 ± 0.37 kg. No complications were noted at birth apart from one infant who suffered from torticollis which resolved spontaneously. During follow up, a decrease in hemoglobin related to low iron levels was noted in 1 infant, 2 infants were noted to be allergic to pollen and one underwent a scrotal hernia reduction. No developmental problems have been observed, neither physiological nor psychomotor, over the 2-year follow-up period.

CONCLUSIONS

The authors suggest, based on, the current study, that lipid-based HPN for pregnant women is a safe method for meeting the nutritional demands of both mother and fetus, and may be administered throughout the pregnancy.

Pregnancy and foetal outcome after bariatric surgery: a review of recent studies

It is well known that maternal obesity has adverse effects on the health of offspring, causing immediate and long-term morbidities. The various types of procedure coming under the heading of bariatric surgery have proved effective in preventing some maternal and foetal complications in morbidly obese pregnant women. This review aims to assess the role, the risks and the benefits of bariatric surgery for mothers and offspring. According to recent findings, pregnancy and neonatal outcomes in morbidly obese women who have undergone bariatric surgery depend to some extent on the type of surgery used. Maternal complications, nutritional defects and intestinal obstruction are more frequently reported after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) than after laparoscopic adjustable gastric banding (LAGB) procedures, whereas caesarean section, preterm delivery and neonatal death are more commonly reported after RYGB than after LAGB. The authors of the only long-term follow-up study conducted on this subject reported that the rate of obesity in the children dropped by 52% after bariatric surgery for the mother, and the cases of severe obesity decreased by 45%. Data on pregnancy and bariatric surgery confirm that the procedure is more effective than dietary measures alone in morbidly obese women, and that pregnancy outcome is generally favorable after surgery. Some studies have indicated, nonetheless, that pregnancies after bariatric surgery are at higher risk: the women affected require special medical attention, particularly as concerns gastrointestinal symptoms and vitamin deficiencies, warranting nutritional/dietary counselling by a multidisciplinary team before, during and after pregnancy.

Obesity in pregnancy: risks and management

Maternal obesity is now considered one of the most commonly occurring risk factors seen in obstetric practice. Compared with women with a healthy pre-pregnancy weight, women with obesity are at increased risk of miscarriage, gestational diabetes, preeclampsia, venous thromboembolism, induced labour, caesarean section, anaesthetic complications and wound infections, and they are less likely to initiate or maintain breastfeeding. Babies of obese mothers are at increased risk of stillbirth, congenital anomalies, prematurity, macrosomia and neonatal death. Intrauterine exposure to obesity is also associated with an increased risk of developing obesity and metabolic disorders in childhood. This article reviews the prevalence of obesity in pregnancy and the associated maternal and fetal complications. Recommendations and suggestions for pre-conception, antenatal and postnatal care of women with obesity are presented, and current research in the UK and future research priorities are considered.

Reproductive outcome after bariatric surgery: a critical review

BACKGROUND

After many cycles of weight loss and weight gain, more and more morbidly obese patients undergo bariatric surgery, like gastric banding or gastric bypass, as the ultimate treatment for their obesity-problem. Since women of reproductive age are candidates for bariatric surgery, concerns arise regarding the potential impact on future pregnancy.

METHODS

English-language articles were identified in a PUBMED search from 1982 to January 2008 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding.

RESULTS

The few reported case-control and cohort studies clearly show improved fertility and a reduced risk in obstetrical complications, including gestational diabetes, macrosomia and hypertensive disorders of pregnancy, in women after operatively induced weight loss when compared with morbidly obesity women. The incidence of intrauterine growth restriction (IUGR) appears to be increased, however. No conclusions can be drawn concerning the risk for preterm labour and miscarriage, although these risks are probably increased compared with controls matched for body mass index. Operative complications are not uncommon with bariatric surgery and several cases have pointed to the increased risk for intestinal hernias and nutritional deficiencies in subsequent pregnancy. Deficiencies in iron, vitamin A, vitamin B(12), vitamin K, folate and calcium can result in both maternal complications, such as severe anaemia, and fetal complications, such as congenital abnormalities, IUGR and failure to thrive.

CONCLUSIONS

Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient's individual requirements can help to prevent nutrition-related complications and improve maternal and fetal health, in this high-risk obstetric population.

Biliopancreatic diversion in the surgical treatment of morbid obesity

Biliopancreatic diversion is a malabsorptive technique of bariatric surgery that has gained wide acceptance in the Western world. It is performed in one of two ways: In its classic form it consists of partial gastrectomy with a Roux-en-Y gastroenterostomy; in its duodenal switch form a vertical sleeve gastrectomy is combined with a duodenoenterostomy. Both techniques realize diversion of biliopancreatic juice, thereby creating a mild form of malabsorption. Weight loss has been approximately 70% of initial excess weight, exceeding that obtained with most other bariatric procedures. Iron, calcium, and vitamin deficiencies may occur, especially with classic biliopancreatic diversion, and must be prevented with adequate supplements during vigorous follow-up. Weight loss is followed by a substantial reduction in the co-morbidities that are present in many morbidly obese patients. Biliopancreatic diversion should be included in each obesity clinic program and be proposed for morbidly obese patients who are having difficulty with the prospect of continuous restraint of food intake or problems due to failed gastric restrictive interventions. The postoperative results in such patients have been good and have substantially improved quality of life and self-esteem in this category of morbidly obese patients.