Obesity & Related Surgical Procedures

1. Obesity & Related Surgical Procedures RNSG 1247

2. Obesity and Overweight • Obesity is an abnormal increase in the proportion of fat cells • Primarily occurs in the visceral and subcutaneous tissues of the body

3. Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, 1971-2006 *Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category. Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05.

4. Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, 1960-2006† *Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population.Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.

5. Etiology and Pathophysiology • Genetic/Biologic basis • Environmental factors • Psychological factors ** Most common form considered to be polygenic, arising from the interaction of multiple genetic and environmental factors

6. Hormones & Peptides that Interact with Hypothalamus to Effect Obesity Fig. 41-3

7. Classification of Body Weight and Obesity • Primary obesity (majority of obese) • Excess caloric intake for the body’s metabolic demands • Secondary obesity • Results from various congenital anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and disorders

8. Classification of Body Weight and Obesity • Body mass index (BMI) • Used to classify underweight, healthy (normal) weight, overweight, or obese • Common clinical index of obesity or altered body fat distribution • Uses weight-to-height ratios

9. BMI chart

10. Weight for height chart

11. Classification of Body Weight and Obesity • Waist-to-hip ratio (WHR) • Preferred tool when predominantly muscular • Waist measurement/hip measurement = ratio • WHR <0.80 is optimal • Visceral fat increases risk for cardiovascular disease and metabolic syndrome

12. Visceral Fat

13. Subcutaneous Fat

14. Classification of Body Shapes • Apple-shaped body • Fat located primarily in the abdominal area • At greater risk for obesity-related complications • Android obesity • Pear-shaped body • Fat located primarily in upper legs • Gynoid obesity

15. Classification of Body Shapes . . Fig. 41-5

16. Health Risks Associated with Obesity • Problems occur at higher rates for obese patients • Mortality rate rises as obesity increases • Especially with increased visceral fat • Obese patients have a decreased quality of life • Most conditions improve with weight loss

17. Health Risks Associated with Obesity Fig. 41-6

18. Nursing Problems • Imbalanced nutrition • Chronic low self-esteem • Others related to complications

19. Planning • Modify eating patterns • Participate in a regular physical activity program • Achieve weight loss to a specified level • Maintain weight loss at a specified level • Minimize or prevent health problems related to obesity

20. Management: Non-surgical • Nutrition • Exercise • Behavior modification • Support groups • Drug therapy

21. Nutrition

22. Exercise

23. Trends in Prevalence (%) of High School Students Attending PE Class Daily, by Grade, US, 1991-2007 Source: Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008.

24. Behavior modification Basic techniques include • Self monitoring • Stimulus control • Rewards – short term vs long term, what’s acceptable vs unacceptable

25. Support groups

26. Drug Therapy • Appetite-suppressing drugs or Sympathomimetic drugs for _____ term use • Decrease food intake through nonadrenergic or serotonergic mechanisms in the CNS • Phentermine – most commonly prescribed; causes appetite ___________ and _________ food intake • Other exs: Diethylpropion, Phendimetrazine

27. Drug Therapy • Appetite-suppressing drugs or Sympathomimetic drugs for ______ term use • Mixed nonadrenergic–serotonergic agents • Do not stimulate release of serotonin • Sibutramine (Meridia) – works by increasing _____________

28. Drug Therapy • Nutrient absorption-blocking drugs (GI lipase inhibitors) • Work by blocking fat breakdown and absorption in intestine • Orlistat (Xenical)

29. Drug Therapy Drugs that ↑ energy expenditure are not approved by the FDA. Ex: Ephedrine Appetite-suppressing drugs removed from market • fenfluramine (Pondimin) • dexfenfluramine (Redux)

30. Bariatric Surgery • Used to treat morbid obesity • Currently the only treatment found to have a successful and lasting impact for sustained weight loss

31. Bariatric Surgery • Must meet all of the following criteria to be considered an ideal candidate • BMI ≥40 kg/m2 with one or more obesity-related complication • 18 years or older • Understands the risks and benefits • Has been obese for >5 years • Has tried and failed to lose weight

32. Bariatric Surgery • Criteria to be considered an ideal candidate (cont’d) • Has no serious endocrine problems • Has psychiatric and social stability • Availability of a team of health care providers • Surgery would ↓ or eradicate high-risk conditions

33. Bariatric Surgery • Three broad categories • Restrictive • Malabsorptive • Combination of restrictive and malabsorptive

34. Restrictive Surgery • Reduces the size of a stomach to 30 ml or less • Causes patient to feel full quicker • Normal stomach digestion and intestinal absorption of food • ↓ Risk of anemia and cobalamin deficiency

35. Restrictive Surgery • Vertical banded gastroplasty • Partitions stomach into a small pouch in upper portion • Small pouch drastically limits capacity • Stoma opening to rest of stomach is banded to delay emptying of solid food from proximal pouch

36. Restrictive Surgery • Adjustable gastric banding (AGB) • Also referred to as the LapBand • Stomach size is limited by an inflatable band placed around fundus of stomach • Band is connected to a subcutaneous port • Can be inflated or deflated to change stoma size

37. Restrictive Surgery • AGB (cont’d) • Can be done laparoscopically and can be modified or reversed • Better choice for patients who are surgical risks • Weight loss is slower than in other procedures

38. Restrictive Surgeries Fig. 41-7A

39. Malabsorptive Surgeries • Biliopancreatic diversion (BPD) • Removes ~3/4 of stomach to ↓ food intake and ↓ acid output • Remaining 1/4 of stomach is connected to lower portion of small intestine • Pancreatic enzymes and bile enter final segment of intestine • Nutrients pass without being digested

40. Malabsorptive Surgeries • Biliopancreatic diversion with duodenal switch • Variation of BPD • By including duodenal switch, surgeons leave a larger portion of the stomach intact • Helps prevent dumping syndrome

41. BPD with or w/o doudenal switch

42. Bariatric Surgeries • How is weight loss accomplished? • What are the specific nutritional risks or adverse effects? • What should be monitored to avoid complications? • What is/are the advantage/s over other procedures?

43. Combination of Restrictive and Malabsorptive Surgery • Roux-en-Y surgical procedure • Has low complication rates • Excellent patient tolerance • Stomach size is ↓ with a gastric pouch anastomosis that empties directly into jejunum

44. Combination of Restrictive and Malabsorptive Surgery • Roux-en-Y surgery (cont’d) • Variations • Stapling stomach without transection to create a small 20- to 30-ml gastric pouch • Creating an upper and lower gastric pouch and totally disconnecting the pouches • Creating an upper gastric pouch and completely removing the lower pouch

45. Restrictive Surgery Fig. 41-7D

46. Cosmetic Surgeries • Ideal candidates have • Achieved weight reduction • Excess skinfolds or fat • Chooses surgery for cosmetic reasons • Lipectomy • Liposuction

47. Preoperative Care • Patients who are obese are likely to suffer other comorbidities, such as • Diabetes, altered cardiorespiratory function, abnormal metabolic function, atherosclerosis • An interdisciplinary team approach may be necessary

48. Preoperative Care • Have room ready for patient prior to arrival • Larger size BP cuff, gown • Bariatric wheelchair • Or a wheelchair with removable arms • Strongly reinforced trapeze bar over bed for movement and positioning

49. Preoperative Care • Obtaining venous access may be complicated • Assistance may be needed • Multiple tourniquets • May need a longer catheter inserted far enough into the vein

50. Preoperative Care • Obesity can make breathing shallow and rapid • Instruct patient in proper • Coughing techniques, deep, diaphragmatic breathing • Methods of turning and positioning to prevent pulmonary complications