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

10/14/2014 1 PRIMARY CARE OF THE BARIATRIC SURGERY PATIENT

MICHELLE GUY, MD ASSOCIATE PROFESSOR DIVISION OF GENERAL INTERNAL MEDICINE DEPARTMENT OF MEDICINE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

GOALS

• 1. Who is right for bariatric surgery?
• 2. Know the early post-op

complications

• 3. Know the late post-op

complications, including weight regain

FULL DISCLOSURE

1998 2012 2013

OBESITY IS A CHRONIC DISEASE

• 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

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OBESITY COMORBIDITIES THAT CAN IMPROVE OR RESOLVE WITH BARIATRIC SURGERY

• Migraines
• Pseudotumor Cerebri
• Depression
• Obstructive Sleep Apnea
• Asthma
• Hypertension
• Cardiovascular Disease
• Dyslipidemia
• GERD
• Fatty Liver
• Metabolic Syndrome
• Diabetes
• Urinary Stress Incontinence
• Venous Stasis
• Cellulitis
• DVT/PE
• Hernias
• PCOS
• Infertility
• DJD/ Chronic pain/ Arthritis
• Cancer (colon, prostate, uterine, breast)
• Quality of Life Diminished

Pre-op Early post-op Late post-op

WHO IS ELIGIBLE FOR SURGERY?

BMI (kg/m2) RISK UNDERWEIGHT < 18.5 INCREASED NORMAL 18.5-24.9 NORMAL OVERWEIGHT 25.0-29.9 INCREASED OBESITY CLASS I 30.0-34.9 HIGH OBESITY CLASS II

(MODERATE OBESITY)

35.0-39.9 VERY HIGH OBESITY CLASS III

(SEVERE OR EXTREME OBESITY)

40.0-49.9 EXTREMELY HIGH OBESITY CLASS IV

(SUPEROBESITY)

> 50.0 MAY BE TOO HIGH

• The NIH Consensus Panel recommends that:
• Patients have a Body Mass Index > 40 kg/m2
• 100 lbs. or more overweight
• Patients have a Body Mass Index between 35 and

40 kg/m2 with significant comorbidities

• Patient have failed other medically managed

weight-loss programs 6% of the U.S. adult population (over 12 million people) meet these criteria

CONTRAINDICATIONS TO SURGERY

• Untreated major depression or psychosis
• Binge-eating disorders
• Current drug or alcohol abuse
• Severe cardiac disease with high risk for

anesthesia

• Severe coagulopathy
• Inability to comply with post op diet and

supplementations

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PRE-OP EVALUATION

• Pre-op tests
• Weight loss
• Cardio/pulmonary evaluation
• Nutrition Evaluation and Counseling
• Psychologist clearance

PRE-OPERATIVE LABS

CO MORBID DISEASE

• CBC
• Electrolytes
• Liver panel
• Calcium
• BUN and creatinine
• Glucose and hemoglobin A1C
• Lipid panel

NUTRITIONAL DEFICIENCIES

• Magnesium
• Phosphate
• Iron, ferritin, and TIBC
• B-12
• Vitamin D
• Folate

CAUSATIVE OR COMPLICATION

• Parathyroid Hormone (PTH)
• Prolactin
• Cortisol
• TSH
• LDH and CPK
• Prothrombin time
• H. pylori

SURGICAL CONSIDERATIONS

• Restrictive vs Malabsorptive
• Open vs Closed
• Surgeon’s Experience

Laparoscopic Weight Loss Surgery

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Sleeve Gastrectomy Lap Band Gastric Bypass

Laparoscopic Adjustable Gastric Banding (LAGB)

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)

A large volume of stomach is removed creating a 1-2 oz “sleeve.” The removed portion of the stomach is the more pliable portion and contains the Ghrelin cells; thereby reducing appetite. The stomach that remains has intact stretch and pressure receptors. Restriction and Resection Ideal Candidate

• BMI 35-55 kg/m2
• Wants to lose 80-150 lbs
• Can maintain a post-op diet of < 1300 cal /day

Benefits

• Average EWL 70-90%
• 1-2 hour procedure
• Recovery ranges from days to weeks
• Patients report early and lasting fullness
• Intestines stay intact—No malabsorption
• May cure diabetes

Considerations/ Risks

• Removal of a portion of the stomach is permanent
• The remaining pouch may expand over time

Roux en Y Gastric Bypass (RNY or Bypass)

A small 1 oz pouch—about the size of an egg—is created. The rest of the stomach is stapled off, preventing food from entering it but allowing digestive juices to empty into the small intestine. The small stomach pouch is then connected to a limb of the intestine (the Roux limb) Both Restrictive and Malabsorptive Most common procedure performed Ideal Candidate

• BMI 35-55 kg/m2
• Wants to lose 100- 150 + lbs
• May have severe or prolonged medical conditions
• Weight maintenance diet < 1300 cal/day

Benefits

• EWL 70-90%
• 2 hour procedure
• Recovery of days to weeks
• Very effective for curing diabetes
• Approximately 100-200 calories per day lost through malabsorption
• Procedure is reversible

Considerations/Risks

• Greater risk for vitamin deficiencies
• Dumping syndrome
• Smoking, EtOH, NSAIDS use may lead to ulcers

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DUODENAL SWITCH

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. Restriction, Resection and Malabsortion Ideal Candidate

• BMI > 60 kg/m2
• Poorly controlled diabetic
• Weight maintenance diet < 1500-2000 cal/day

Benefits

• Has the highest cure rate for diabetes
• EWL 80-90%. Most effective weight loss surgery
• 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

Considerations/Risks

• Not offered by most surgeons (including UCSF)
• Preoperative weight loss is usually required
• Stomach removal is permanent. Bypass may be reversed
• Highest risk for vitamin and protein deficiencies, diarrhea and

intestinal blockages

Pre-op Early post-op Late post-op

BYPASS or SLEEVE OPERATION

remove bladder catheter start clear liquids

What happens in the hospital?

7am noon 7pm 7am noon 7pm 7am noon

Day 0 Day 1 Day 2

transition to oral pain meds meet nutritionist meet pharmacist remove abdominal drain home

BAND OPERATION 7am noon 7pm 7am noon 7pm 7am noon

Day 0 Day 1 Day 2

remove bladder catheter start clear liquids transition to oral pain meds meet nutritionist meet pharmacist home

PHYSIOLOGIC CHANGES AFTER SURGERY

• Avoid delayed, enteric-coated and extended-

release preparations after malabsorption procedures

• Attempt to use immediate-release, crushed,

liquid or chewable preparations

• Some meds require gastric acidity for

dissolution

• Patient are often discharged from the hospital
• ff HTN and DM meds
• If meds are needed in diabetics use immediate

release Metformin and/or sliding scale insulin

• Diuretics are discontinued in the hospital
• LAGB slower resolution of diabetes
• Attempt to avoid NSAIDS

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POST-OPERATIVE COMPLICATIONS

GASTRIC BANDING

• Slippage of the band
• Band erosion
• Port infection
• Injury to adjacent
• rgans
• Death within 30 days
• (<0.5% of

patients) SLEEVE GASTRECTOMY

• Leaks along staple line
• Nausea and vomiting

leading to dehydration

• Abdominal pain
• Wound problems
• Bleeding
• Narrowing or Stenosis
• Reflux
• Death within 30 days

(<1% of patients)

BYPASS SURGERY

• Stomal obstruction
• Postoperative bleeding
• Small bowel obstruction
• Gastrointestinal leak
• Deep vein thrombosis
• Splenectomy
• Pulmonary embolus
• Protein-calorie malnutrition
• Dumping Syndrome
• Death within 30 days

(<1% of patients)

MORE POST-OP COMPLICATIONS

Phase WEEKS Phase 1 Weeks 1 to 6 Phase 2 Weeks 7 to 12 Phase 3 Weeks 13 to 12 Months

• Mood Changes
• Excessive Vomiting
• Gas
• Dumping Syndrome
• Hair loss
• Patulous Eustachian Tube

Dysfunction

DIET AND EXERCISE PROGRESSION—KEY POINTS

DAYS 1-14

• Thin fluids only
• No solid food
• 32-60 oz fluids per day
• 400-600 calories per day
• 50-70 grams of protein
• Walk 5-10 minutes every hour
• Wake and walk after 8 hours

DAYS 15-30

• Start thick liquids and soft foods
• 32-60 oz fluids
• 600 calories per day
• 50-70 grams of protein
• Minimal carbs and fats
• Start cardio exercises and light weight

lifting

DAY 31 AND BEYOND

• Regular foods as tolerated
• Meats and other foods should be tender,

cut and chewed well and eaten slowly

• 60+ oz fluids
• 600 calories per day
• 50-70 grams of protein
• Increase physical activity

POST-OPERATIVE DIET

• Liquid amnesia
• Maladaptive Eating
• How much can you eat?

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KEYS TO SUCCESS

DO THIS

• Start each meal with protein, Goal 60+ g/day
• Eat 3 meals per day, Goal 600 cal/day
• Chew Chew Chew
• Drink water between meals
• Drink 64 oz fluids per day
• Measure and Track all intake
• Weigh weekly
• Take your vitamins

DON’T DO THAT

• Eat sweets or excessive carbohydrates
• Overeat or Graze
• Drink through a straw
• Drink within 30 minutes of eating
• Drink Carbonated Beverages
• Drink Caffeine and Alcohol
• Eat soft or high calorie foods
• Exceed 1000 calories per day

WHAT TYPE OF RESULTS TO EXPECT?

Months Post-op Pounds Lost 6 months 75 6-9 months 100 9-12 months 100-150 > 12 months > 150

POST-OPERATIVE FOLLOW-UP

TIME FOLLOW-UP PLAN 1-3 WEEKS Review speed of weight loss, wound check, Dietician follow-up to help advance diet 3 MONTHS Verify weight loss is on track, Review diet and exercise, labs 6 MONTHS Review weight and make specific plans to achieve goal weight, labs 9 MONTHS Verify weight loss is on track, Review diet and exercise, labs 1 YEAR Review outcome, check labs, consider GI Xrays YEARLY Discuss maintenance, Check labs, Reinforce support

RECOMMENDED FOLLOW-UP LABS

BASIC LABS

• CBC
• Electrolytes
• BUN and creatinine
• Liver panel
• Lipid panel
• Glucose and A1C

DEFICIENCIES

• Folate
• Iron, ferritin, and TIBC
• B-12
• Calcium
• Vitamin D

ALSO CONSIDER

• Magnesium
• Phosphorus
• B6
• Thiamine (B1)
• Zinc
• Copper
• Vitamin A

28

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POST-SURGICAL VITAMIN SUPPLEMENTATION

LAP BAND SLEEVE OR BYPASS DUODENAL SWITCH Multivitamin Multivitamin Multivitamin Calcium (Citrate) +Mg Calcium (Citrate) +Mg Calcium (Citrate) +Mg Vitamin D 400-2000 IU Vitamin D 400-2000 IU Vitamin D 400-2000 IU B-Complex B-Complex B-Complex PPI PPI PPI B-12, 500 mcg B-12, 500 mcg Iron 325mg + Vitamin C Iron 325 mg + Vitamin C Vitamin A 25, 000 IU

PREGNANCY AND WEIGHT-LOSS SURGERY

• Fertility is enhanced after surgery
• Use non oral forms of birth control
• Delay pregnancy for 12 to 18

months after surgery

• Avoid oral glucose challenge after

gastric bypass

Pre-op Early post-op Late post-op

WEIGHT RE-GAIN

Swedish Obesity Study

• 2000 surgical vs non

surgical obese patients

• Greater initial weight

loss

• Improved outcomes at

two, six and ten years

N Engl J Med 2007; 357:741-752August 23, 2007

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HONEYMOON PERIOD

“it’s a new starting point to resume the battle” “It’s a tool” “Don’t fall asleep at the wheel”

KEYS TO SUCCESS—”IT’S A TOOL”

NEW ADDICTIONS MAY DEVELOP

Addiction

Cigarettes Shopping Alcohol Drugs

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MANAGING EXCESS SKIN TAKE HOME POINTS

• Screen all your patients for overweight and obesity
• Most obesity related comorbidities can resolve or improve with successful weight loss

surgery

• Consider gastric bypass surgery for patients with more than 100 lbs to lose and/or
• diabetes. Consider sleeve gastrectomy for others
• Potential complications are many but overall surgical mortality is low
• Surgery is only a tool. Patients will need long term follow, support and tracking

Sleeve Gastrectomy: Lost 93 lbs in 7 months Special thanks to Gregg Jossart, MD and Stanley Rogers, MD

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THE OBESITY EPIDEMIC

Percent of Obese (BMI >30) in U.S. Adults

WHO IS ELIGIBLE FOR SURGERY?

• The NIH Consensus Panel recommends that:
• Patients have a Body Mass Index > 40 kg/m2
• 100 lbs. or more overweight
• Patients have a Body Mass Index between 35 and

40 kg/m2 with significant comorbidities

• Patient have failed other medically managed

weight-loss programs 6% of the U.S. adult population (over 12 million people) meet these criteria

Bariatric surgery and comorbidity resolution

courtesy of ASMBS

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 Prospective, controlled trial 2010 patients underwent surgery 2037 matched patients underwent conventional Rx  Mean 11 years of follow-up  99% of patients were followed  129 deaths in control group  101 deaths in surgery group

All-cause mortality was reduced by 40% 7 years after RYGB

 Decreased mortality was from decreased myocardial infarction and cancer

EFFECTS OF BARIATRIC SURGERY ON MORTALITY IN SWEDISH OBESE SUBJECTS

INSURANCE COVERAGE CALCULATING PERCENT EXCESS WEIGHT LOSS

 Percent of Excess Weight Loss (EWL) is used as an outcome measure for

bariatric surgery. A percentage is used rather than the absolute number

• f pounds lost to allow comparison of weight loss between persons or

between types of bariatric procedures. A person's Ideal Body Weight (IBW) is based on the Metropolitan Life Insurance Company standard height and weight tables for men and women.

 A sustained EWL of ≥ 50% is considered successful by insurance

providers and accrediting organizations.

Ideal Body Weight is a calculation based on height and gender Estimate Ideal body weight(IBW) in (kg): Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet. Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet. Starting Weight– Ideal Body Weight = EWL Weight loss / EWL x 100 = % EWL Example: If IBW = 130lbs and starting weight = 245lbs then EWL = 115lbs If person loses 90 lbs then EWL % is 90/ 115 x 100 = 78 %

OTHER PROCEDURES

• Cholecystectomy
• Hiatal hernia repair
• Liver biopsy

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REVISION SURGERIES

yp

stricture of gastrojejunostomy (2-3%) treatment: dilation during endoscopy staple line leak (1-4%) treatment: reoperation, stent placement, feeding tube placement, drain placement, or some combination thereof acute pouch obstruction (0- 10%) treatment: nasogastric tube marginal ulceration (3-5%) treatment: antacids sleeve stricture (1-4%) treatment: reoperation, conversion to gastric bypass band erosion (0-7%) treatment: surgery to remove band gallstone disease (2% with prevention) prevention: ursodiol for 6 months treatment: remove gallbladder gallstone disease (2% with prevention) prevention: ursodiol for 6 months treatment: remove gallbladder gallstone disease (2% with prevention) prevention: ursodiol for 6 months treatment: remove gallbladder internal hernias / obstruction (0-5%) treatment: surgery gastroesophageal reflux (10- 40%) treatment: acid blocking medications, conversion to gastric bypass in extreme cases port infection (0.3-9%) treatment: surgery to remove port dumping syndrome (0-10%) treatment: limit simple sugars, high protein diet, complex carbs, high fiber, smaller more frequent meals dumping syndrome (0-10%) treatment: limit simple sugars, high protein diet, complex carbs, high fiber, smaller more frequent meals band slippage (2-30%) treatment: surgery to remove/reposition band port or tubing malfunction (0.4- 7%) treatment: surgery to fix malfunction psychological intolerance (0- 5%) treatment: removal of band

LATE LATE LATE

MG1

Post Surgical Vitamin Supplementation

Bypass or Sleeve Band multivitamin daily multivitamin daily

• meprazole 20mg daily
• meprazole 20mg daily

calcium + D 500mg 3x daily calcium + D 500mg 3x daily Iron sulfate 325mg daily + Vitamin C 500mg daily (menstruating women only) vitamin B12 500mcg daily

Slide 50 MG1 Michelle Guy, 8/3/2013