10/14/2014 PRIMARY CARE OF THE GOALS BARIATRIC SURGERY PATIENT 1. - PDF document

10/14/2014 PRIMARY CARE OF THE GOALS BARIATRIC SURGERY PATIENT 1. Who is right for bariatric surgery? 2. Know the early post-op complications MICHELLE GUY, MD ASSOCIATE PROFESSOR 3. Know the late post-op DIVISION OF GENERAL INTERNAL MEDICINE complications, including weight DEPARTMENT OF MEDICINE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO regain FULL DISCLOSURE OBESITY IS A CHRONIC DISEASE 2013 2012 1998 • 33% of American adults are obese (BMI > 30) • Approximately 150, 000 weight loss surgeries being performed in US /year • Bariatric surgery can provide: • Sustained weight loss • Resolution of Type 2 Diabetes • Reduced cardiovascular morbidity • Reduce all cause mortality 1

10/14/2014 OBESITY COMORBIDITIES THAT CAN IMPROVE OR RESOLVE WITH BARIATRIC SURGERY Pre-op • Migraines • Diabetes • Pseudotumor Cerebri • Urinary Stress Incontinence Early • • Depression Venous Stasis • Obstructive Sleep Apnea • Cellulitis post-op • Asthma • DVT/PE • • Hypertension Hernias • Cardiovascular Disease • PCOS • Dyslipidemia • Infertility Late • GERD • DJD/ Chronic pain/ Arthritis • Fatty Liver • Cancer (colon, prostate, uterine, breast) post-op • Metabolic Syndrome • Quality of Life Diminished WHO IS ELIGIBLE FOR SURGERY? CONTRAINDICATIONS TO SURGERY BMI (kg/m2) RISK • The NIH Consensus Panel recommends that: • Untreated major depression or psychosis UNDERWEIGHT < 18.5 INCREASED • Patients have a Body Mass Index > 40 kg/m 2 • Binge-eating disorders • 100 lbs. or more overweight NORMAL 18.5-24.9 NORMAL • Patients have a Body Mass Index between 35 and • Current drug or alcohol abuse OVERWEIGHT 25.0-29.9 INCREASED 40 kg/m 2 with significant comorbidities OBESITY CLASS I 30.0-34.9 HIGH • Severe cardiac disease with high risk for • Patient have failed other medically managed weight-loss programs anesthesia OBESITY CLASS II 35.0-39.9 VERY HIGH • Severe coagulopathy (MODERATE OBESITY) 6% of the U.S. adult population (over 12 million people) OBESITY CLASS III 40.0-49.9 EXTREMELY HIGH • Inability to comply with post op diet and meet these criteria (SEVERE OR EXTREME OBESITY) supplementations OBESITY CLASS IV > 50.0 MAY BE TOO HIGH (SUPEROBESITY) 2

10/14/2014 PRE-OP EVALUATION PRE-OPERATIVE LABS • Pre-op tests CO MORBID DISEASE NUTRITIONAL CAUSATIVE OR • DEFICIENCIES COMPLICATION Weight loss • • CBC • • Parathyroid Hormone (PTH) Cardio/pulmonary evaluation Magnesium • Electrolytes • Prolactin • Phosphate • Nutrition Evaluation and Counseling • Liver panel • Cortisol • Iron, ferritin, and TIBC • Calcium • TSH • Psychologist clearance • B-12 • • BUN and creatinine LDH and CPK • Vitamin D • • Glucose and hemoglobin A1C Prothrombin time • Folate • Lipid panel • H. pylori Laparoscopic Weight Loss Surgery SURGICAL CONSIDERATIONS • Restrictive vs Malabsorptive • Open vs Closed • Surgeon’s Experience 3

10/14/2014 Laparoscopic Adjustable Gastric Banding (LAGB) Lap Band Sleeve Gastrectomy Gastric Bypass An adjustable band around the top of the stomach like a belt, creating a 1-2 oz pouch. A port implanted under the skin near the belly button is used to inflate a ballon inside the band with saline, narrowing the entry to the stomach and limiting the amount of food consumed. Restrictive Only Ideal Candidate • BMI 35-40 kg/m2 • Wants to lose 50-100 pounds • Is not comfortable with stapling • Can maintain a post-op diet of < 1300 cal/day Benefits • Safest and least invasive procedure; fewer early risks than other procedures • One hour procedure • Fully Reversible/Removable • Lowest risk of vitamin deficiencies Considerations/Risks • Average excess weight loss (EWL) is 50% • 10-year removal or reoperation rate is 25% • Slower weight loss (1-2lbs/week) compared to other surgeries • Appetite suppression and a comfortable feeling of fullness may be difficult to achieve • Least effective for resolving diabetes Sleeve Gastrectomy (Sleeve or Vertical Gastrectomy) Roux en Y Gastric Bypass (RNY or Bypass) A large volume of stomach is removed creating a 1-2 oz “sleeve.” The removed A small 1 oz pouch—about the size of an egg—is created. The rest of the stomach is stapled off, portion of the stomach is the more pliable portion and contains the Ghrelin cells; preventing food from entering it but allowing digestive juices to empty into the small intestine. The thereby reducing appetite. The stomach that remains has intact stretch and pressure small stomach pouch is then connected to a limb of the intestine (the Roux limb) receptors. Both Restrictive and Malabsorptive Restriction and Resection Most common procedure performed Ideal Candidate Ideal Candidate • BMI 35-55 kg/m2 • BMI 35-55 kg/m2 • Wants to lose 80-150 lbs • Wants to lose 100- 150 + lbs • Can maintain a post-op diet of < 1300 cal /day • May have severe or prolonged medical conditions • Benefits Weight maintenance diet < 1300 cal/day • Average EWL 70-90% Benefits • 1-2 hour procedure • EWL 70-90% • • 2 hour procedure Recovery ranges from days to weeks • Patients report early and lasting fullness • Recovery of days to weeks • Very effective for curing diabetes • Intestines stay intact—No malabsorption • Approximately 100-200 calories per day lost through malabsorption • May cure diabetes • Procedure is reversible Considerations/ Risks Considerations/Risks • Removal of a portion of the stomach is permanent • Greater risk for vitamin deficiencies • The remaining pouch may expand over time • Dumping syndrome • Smoking, EtOH, NSAIDS use may lead to ulcers 4

10/14/2014 A sleeve gastrectomy with a 2-4 oz pouch + a malabsorption component. The pouch is connected to the enteric limb, diverting food and preventing it from mixing with digestive juices. Food bypasses 40-60% of the intestine. DUODENAL SWITCH Restriction, Resection and Malabsortion Pre-op Ideal Candidate • BMI > 60 kg/m2 • Poorly controlled diabetic • Weight maintenance diet < 1500-2000 cal/day Benefits Early • Has the highest cure rate for diabetes • EWL 80-90%. Most effective weight loss surgery • post-op 3-4 hour procedure with 1-2 night stay • Recovery days to weeks • Patients report lasting fullness • 200-400 calories may be lost through malabsorption Late Considerations/Risks • Not offered by most surgeons (including UCSF) • Preoperative weight loss is usually required post-op • Stomach removal is permanent. Bypass may be reversed • Highest risk for vitamin and protein deficiencies, diarrhea and intestinal blockages PHYSIOLOGIC CHANGES AFTER SURGERY What happens in the hospital? remove bladder catheter remove abdominal drain • Avoid delayed, enteric-coated and extended- start clear liquids BYPASS or SLEEVE OPERATION transition to oral pain meds release preparations after malabsorption meet nutritionist procedures home meet pharmacist • Attempt to use immediate-release, crushed, 7am noon 7pm 7am noon 7pm 7am noon liquid or chewable preparations Day 0 Day 1 Day 2 • Some meds require gastric acidity for dissolution • Patient are often discharged from the hospital remove bladder catheter off HTN and DM meds start clear liquids • If meds are needed in diabetics use immediate transition to oral pain meds BAND OPERATION meet nutritionist release Metformin and/or sliding scale insulin meet pharmacist home • Diuretics are discontinued in the hospital • LAGB slower resolution of diabetes 7am noon 7pm 7am noon 7pm 7am noon • Attempt to avoid NSAIDS Day 0 Day 1 Day 2 5

10/14/2014 MORE POST-OP COMPLICATIONS POST-OPERATIVE COMPLICATIONS • Mood Changes GASTRIC BANDING SLEEVE GASTRECTOMY BYPASS SURGERY • Excessive Vomiting Phase WEEKS Leaks along staple line • Stomal obstruction • Slippage of the band • Phase 1 Weeks 1 to 6 • Gas Postoperative bleeding • • Nausea and vomiting • Band erosion • Small bowel obstruction Phase 2 Weeks 7 to 12 leading to dehydration Gastrointestinal leak • • Dumping Syndrome • Port infection • Abdominal pain • Deep vein thrombosis Phase 3 Weeks 13 to 12 Months Splenectomy Wound problems • • Injury to adjacent • • Pulmonary embolus • • Bleeding Hair loss organs • Protein-calorie malnutrition Narrowing or Stenosis • • Dumping Syndrome • Death within 30 days • Reflux • Death within 30 days • Patulous Eustachian Tube (<1% of Death within 30 days • (<0.5% of • patients) Dysfunction (<1% of patients) patients) POST-OPERATIVE DIET DIET AND EXERCISE PROGRESSION—KEY POINTS • Liquid amnesia • Maladaptive Eating DAY 31 AND BEYOND DAYS 1-14 DAYS 15-30 • How much can you eat? • • Thin fluids only Start thick liquids and soft foods • Regular foods as tolerated • No solid food • 32-60 oz fluids • Meats and other foods should be tender, cut and chewed well and eaten slowly • 32-60 oz fluids per day • 600 calories per day • 60+ oz fluids • 400-600 calories per day • 50-70 grams of protein • 600 calories per day • 50-70 grams of protein • Minimal carbs and fats • Walk 5-10 minutes every hour • 50-70 grams of protein • Start cardio exercises and light weight • Wake and walk after 8 hours lifting • Increase physical activity 6