10/25/2013 Bariatric Surgery: Who Gets It, What are the Results, - - PowerPoint PPT Presentation

▶
10 25 2013
SMART_READER_LITE
LIVE PREVIEW

10/25/2013 Bariatric Surgery: Who Gets It, What are the Results, - - PowerPoint PPT Presentation

Dec 11, 2022 292 likes •434 views

10/25/2013 Bariatric Surgery: Who Gets It, What are the Results, Case Presentation: Rachelle and Can It Improve Ob-Gyn Outcomes? 35 year-old woman with morbid obesity. 51 236 lbs BMI 44.5 2,000 B.C. 2,000 A.D. PMHx: mild depression

slide-1
SLIDE 1

10/25/2013 1

Bariatric Surgery: Who Gets It, What are the Results, and Can It Improve Ob-Gyn Outcomes?

Jonathan Carter, MD and Michael Sutker, MD No disclosures

2,000 B.C. 2,000 A.D.

Case Presentation: Rachelle

35 year-old woman with morbid obesity. 5’1” 236 lbs BMI 44.5 PMHx: mild depression

  • bstructive sleep apnea (AHI 42, on CPAP)

asthma polycystic ovarian syndrome gastroesophageal reflux disease Diet attempts: Weight Watchers Atkins HerbaLife South Beach

Case Presentation: Rachelle Case Presentation: Rachelle

Intervention: ??????? PMHx: mild depression RESOLVED

  • bstructive sleep apnea (AHI 42, on CPAP) RESOLVED

asthma RESOLVED polycystic ovarian syndrome NO MEDS gastroesophageal reflux disease RESOLVED

Weight versus time

100 120 140 160 180 200 220 240 260 5 10 15 20 25 30 35 time (months) weight (pounds)

slide-2
SLIDE 2

10/25/2013 2

Case Presentation: Rachelle Obesity Trends* Among U.S. Adults BRFSS, 1990

  • Obesity Trends* Among U.S. Adults

BRFSS, 1991

  • Obesity Trends* Among U.S. Adults

BRFSS, 1992

slide-3
SLIDE 3

10/25/2013 3

Obesity Trends* Among U.S. Adults BRFSS, 1993

  • Obesity Trends* Among U.S. Adults

BRFSS, 1994

  • Obesity Trends* Among U.S. Adults

BRFSS, 1995

  • Obesity Trends* Among U.S. Adults

BRFSS, 1996

slide-4
SLIDE 4

10/25/2013 4

Obesity Trends* Among U.S. Adults BRFSS, 1997

  • Obesity Trends* Among U.S. Adults

BRFSS, 1998

  • Obesity Trends* Among U.S. Adults

BRFSS, 1999

  • Obesity Trends* Among U.S. Adults

BRFSS, 2000

slide-5
SLIDE 5

10/25/2013 5

Obesity Trends* Among U.S. Adults BRFSS, 2001

  • !"#$%&'(%$)

*+((,,

Obesity Trends* Among U.S. Adults BRFSS, 2003

  • Obesity Trends* Among U.S. Adults

BRFSS, 2004

slide-6
SLIDE 6

10/25/2013 6

Obesity Trends* Among U.S. Adults BRFSS, 2005

  • Obesity Trends* Among U.S. Adults

BRFSS, 2006

  • Obesity Trends* Among U.S. Adults

BRFSS, 2007

  • Obesity Trends* Among U.S. Adults

BRFSS, 2008

slide-7
SLIDE 7

10/25/2013 7

Obesity Trends* Among U.S. Adults BRFSS, 2009

  • Obesity Trends* Among U.S. Adults

BRFSS, 2010

  • Why is obesity unhealthy?

Mechanick et al. SOARD 2008

CARDIOVASCULAR Hypertension Congestive Heart Failure Cor pulmonale Varicose veins Pulmonary embolism Coronary artery disease ENDOCRINE Metabolic syndrome Type 2 diabetes Dyslipidemia Polycystic ovary syndrome Amenorrhea, infertility, menstrual disorders MUSCULOSKELETAL Gout Osteoarthritis Lower back pain Carpal tunnel syndrome SKIN dermatoliposclerosis lymphedema cellulitis intertrigo hidradenitis suppurativa RESPIRATORY

  • bstructive sleep apnea

Pickwickian syndrome asthma GASTROINTESTINAL GERD Fatty liver disease / NASH Hernia Colon cancer GENITOURINARY Urinary stress incontinence Obesity-related glomerulonephropathy Hypogonadism Breast and uterine cancer Pregnancy complications NEUROLOGIC Stroke Idiopathic intracranial hypertension Meralgia paresthetica Dementia PSYCHOLOGIC Depression Low self-esteem Body image disturbance Social stigmatization

Obesity reduces life expectancy

Years of lost life expectancy in women

25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

BODY MASS INDEX

10 8 6 4

slide-8
SLIDE 8

10/25/2013 8

Gastric bypass anatomy

BMI > 40 = candidate for bariatric surgery

consider surgery if BMI>40

  • r

BMI >35 with metabolic disease

<20 20-25 26-29 30-40

Annals of Surgery, 2000

50 40 30 20 BMI time 48 28 Change in BMI after gastric bypass 30 mos start

  • bese

controls bypass number of patients

Bariatric surgery has a durable effect on weight

slide-9
SLIDE 9

10/25/2013 9

courtesy of ASMBS

Metabolic benefits

  • f

bariatric surgery

courtesy of ASMBS

Metabolic benefits

  • f

bariatric surgery

impaired fasting glucose diet controlled diabetics

  • ral agent

diabetics insulin dependent diabetics

HbA1C (%)

8.2% before bypass 5.5% after bypass

6.0 5.0 7.6 8.3 8.7 5.5 6.0 5.2

March 26, 2012

slide-10
SLIDE 10

10/25/2013 10

Bariatric surgery and comorbidity resolution

courtesy of ASMBS

RYGB dropped percentage of dyslipidemic patients from 95% to 28% Number taking medication dropped to 15%

  • 7%
  • 22%

40%

  • 27%

Total cholesterol LDL cholesterol HDL cholesterol Triglycerides Percent change from baseline preoperative value

Change in lipid profile 2 years after gastric bypass

surgery

  • bese controls

Lancet July, 2009 Bariatric surgery reduces risk of: colon cancer endometrial cancer breast cancer prostate cancer

  • varian cancer

CANCER INCIDENCE

Prospective, controlled trial 2010 patients underwent bariatric surgery 2037 matched patients underwent conventional Rx Mean 11 years of follow-up 99% of patients were followed

Decrease mortality was from decrease in incidence of myocardial infarction and cancer

slide-11
SLIDE 11

10/25/2013 11

Safety: Complications

Sleeve Band Bypass

Review of 30 day outcomes

  • f 28,616 patients undergoing

bariatric surgery reported to the American College of Surgeons

...so can bariatric surgery improve Ob-Gyn outcomes?

Michael Sutker, M.D.

  • Do obese pregnant patients have higher risk of:

– Pre-eclampsia? – Pregnancy-induced hypertension? – Gestational diabetes? – Macrosomia?

  • Can bariatric surgery mitigate these risks?
  • When to get pregnant after bariatric surgery?
  • How do I manage the pregnant bariatric patient?
slide-12
SLIDE 12

10/25/2013 12

Hogan, J et al. “Body mass index and hypertensive disorders of pregnancy.” Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health. 2 (2012) 28-31

  • Prospective observational study
  • 2230 women

– 16.8% obese

BMI Category Normal (BMI 18.5-24.9) Overweight (BMI 25- 30) Obese (BMI > 30)

Pre-eclampsia

2.5% 3.9% 5.1

Pregnancy-Induced Hypertension

1.8% 2.6% 8%

Burke, A et al. “Reduced Incidence of Gestational Diabetes with Bariatric Surgery.” Journal of the American College of Surgery. 2 (2010) 169-175.

  • 1193 women
  • Bariatric

surgical procedure and delivery or pregnancy loss

Can bariatric surgery mitigate the risks of obesity in pregnancy? Abodeely, A et al. “Pregnancy outcomes after bariatric surgery: maternal, fetal, and infant complications.” Surgery for Obesity and Related Diseases. 4 (2008) 464-471

  • Review of 31 studies
  • 730 women and 1093 pregnancies

“Complication” RYGB General Population Obese Caesarean section 22.6% 27% 1.5-3x risk Gestational Diabetes 3.7% 2% 1.4-20x risk Pregnancy-Induced HTN 4.3% 5-10% 15-20% Pre-eclampsia 0% 5-8% 12-19% Macrosomia 6% 9% 30-35% Small for Gestational Age 8.1% 5-10% 3-7%

Can bariatric surgery mitigate the risks of obesity in pregnancy? Ducarme, G et al. “Obstetric outcome following laparoscopic adjustable gastric banding.” International Journal of Gynecology and

  • Obstetrics. 98 (2007) 244-247.
  • Retrospective case-control
  • 427 obese women (13

underwent LAGB) Can bariatric surgery mitigate the risks of obesity in pregnancy?

slide-13
SLIDE 13

10/25/2013 13

Sheiner, E et al. “Pregnancy after bariatric surgery is not associated with adverse perinatal outcome.” American Journal of Obstetrics and

  • Gynecology. 190 (2004) 1335-1340.
  • Population-based study
  • 1988-2002
  • 298 deliveries to patients after bariatric

surgery

– 159,120 total

Can bariatric surgery mitigate the risks of obesity in pregnancy? Sheiner, E et al. “Pregnancy after bariatric surgery is not associated with adverse perinatal outcome.” American Journal of Obstetrics and

  • Gynecology. 190 (2004) 1335-1340.

Can bariatric surgery mitigate the risks of obesity in pregnancy? Dao, T et al. “Pregnancy outcomes after gastric-bypass surgery.” The American Journal of Surgery. 192 (2006) 762-766.

  • Retrospective review
  • 2001-2004

Cohorts:

  • Early group (<1 year after surgery)
  • Late group (>1 year after surgery)

Can bariatric surgery mitigate the risks of obesity in pregnancy? Dao, T et al. “Pregnancy outcomes after gastric-bypass surgery.” The American Journal of Surgery. 192 (2006) 762-766.

  • Weight gain

– Early group: +4 (-70 to +45) – Late group: +34 (+13 to +75)

  • BMI at delivery

– Early group: 35 – Late group: 28

  • No difference in preterm birth, type of

delivery, pregnancy complications

Can bariatric surgery mitigate the risks of obesity in pregnancy?

slide-14
SLIDE 14

10/25/2013 14

Sheiner, E et al. “Pregnancy outcome of patients who conceive during

  • r after the first year following bariatric surgery.” American Journal of

Obstetrics & Gynecology. 204:50 (2011) e1-6.

  • Retrospective population-based study
  • 104 pregnancies during the first year after

bariatric surgery

  • 385 pregnancies after the first year after

bariatric surgery

  • No difference in hypertensive disorders,

diabetes, perinatal outcomes

Can bariatric surgery mitigate the risks of obesity in pregnancy? Robinson, J et al. “Obesity and hormonal contraceptive efficacy.” Women’s Health. 9:5 (2013) 453-466. When to get pregnant after bariatric surgery ?

Nutritional Deficiencies after Gastric Bypass Surgery

Nutrient

Risk of deficiency Diagnosis Treatment

Protein

<5% Hypoalbuminemia Dietary diary <60g Prophy: dietary training >60g Rx: Protein shakes

Calcium / vitamin D

0.9% hypocalcemia 30% secondary HPTH Serum calcium Serum PTH Vitamin D level Prophy: Ca 500mg + vit D 200IU TID Rx: vit D 100,000 IU IM weekly until 25-OHD levels normalize

Essential fatty acids

Rare Dry scaly skin, hair loss Triene:tetraene ratio >0.2 Prophy: soy protein Rx: soy protein, safflower oil

Vits ADEK

Rare A - Night blindness E - Eczematous rash K - Coagulopathy D - Osteomalacia Rx: ADEK tablet daily vitamin A 4,000 IU vitamin D 400 IU vitamin E 150 IU vitamin K 0.15mg (also contains folate, thiamine, B vits)

Iron

Up to 50% of women without supplements Anemia Prophy: FeSO4 325mg daily + vit C Rx: mild: FeSO4 TID severe: Iron dextran IV

Vitamin B12

Up to 33% if only taking multivitamin Anemia Neuropathy Prophy: vit B12 500ug SL daily Rx: 1000uG IM monthly until normal

Folate

Rare if taking MVI Hyperhomocysteinemia Anemia Neural tube defects of preg Prophy: MVI Rx: folate acid supplementation

Thiamine (vit B1)

Rare, unless severe nausea and vomiting Wernicke-Korsakoff Peripheral neuropathy Beriberi <erythrocyte transketolase activity Prophy: MVI Rx: thiamine 100mg/day IV

Harris, A et al. “Specialized Care for Women Pregnant After Bariatric Surgery.” Journal of Midwifery & Women’s Health. 55 (2010) 529-540.

  • Avoid NSAIDs, aspirin, oral bisphosphonates
  • Check these q2 months:

CBC, iron, ferritin, folate, LFTs, albumin, B12,calcium, vit D, electrolytes, glucose.

  • Give the patient these:

MVI 2 tabs daily, calcium + D 500/200 TID, iron 325 daily, vit C 500mg daily, vit B12 500mcg daily.

  • Refer to a bariatric surgeon for nutritional

monitoring, eating advice.

How do I manage the pregnant bariatric patient?