The Use of Total Parenteral Nutrition in Patients Following Bariatric Surgery

Kevin D Helling, MD, Kamran Samakar, MD, Eric Sheu, MD, PhD, Malcolm Robinson, MD, Scott A Shikora, MD, Ashley Vernon, MD, David Spector, MD, Ali Tavakkoli, MD. Brigham and Women’s Hospital

Introduction: While the safety of bariatric surgery has increased significantly, complications do arise which necessitate the use of Total Parenteral Nutrition (TPN). The safety of TPN in this patient cohort is not studied. We therefore studied the outcomes of a group of patients who required TPN following bariatric surgery.

Methods and Procedures: The TPN database at our institution was queried and 24 consecutive cases of TPN usage identified. All patients had bariatric surgery between 12/2008 and 10/2010. Patient demographics, type of operation performed, indications for and duration of TPN therapy, as well complications arising from TPN administration were recorded.

Results: Twenty-two of the 24 patients underwent revisionary bariatric operations prior to initiation of TPN. Two patients underwent primary bariatric operations, both with significant non-bariatric surgical history requiring extensive adhesiolysis at the time of bariatric operation. Fifteen patients required subsequent operations following the index procedure. Of those, 8 patients needed one additional operation, 3 patients underwent two subsequent operations, and 4 patients required four additional operations.

Complications leading to TPN use included anastomotic leak (10), gastric perforation from band erosion (2), pancreatitis (2), ulcer (3), GI bleed (2), small bowel internal herniation (1), omental necrosis and chronic abdominal pain (1), and an inability to tolerate diet (1). Both primary operation patients developed enterocutaneous fistulae (2).

Average duration of TPN use was 55 days (6-299). Average length of time between the inciting operation and initiation of TPN was 19 days.

TPN was given via PICC line in 21 patients and temporary indwelling central venous catheters in 3 patients. Of PICC line patients, 6 developed line infections (29%). Three experienced upper extremity venous thrombosis (14%). No line related complications occurred in the central line patients.

Conclusion: In this group of bariatric TPN patients, all underwent complex high risk bariatric operations. The most common complication requiring the use of TPN was anastomotic leak. Many of the patients required subsequent operations after the index procedure. TPN use with indwelling peripheral line was a risk factor for line infection and upper extremity venous thrombosis. Further study of the risk factors for, and consequences of TPN usage in the bariatric surgery patient population is warranted.

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