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The Medical Complications of Bariatric Surgery

The Medical Complications of Bariatric Surgery. Jeanette Newton Keith MD Associate Professor University of Alabama at Birmingham Department of Nutrition Sciences Department of Internal Medicine (www.eatright.uab.edu). Background.

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The Medical Complications of Bariatric Surgery

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  1. The Medical Complications of Bariatric Surgery Jeanette Newton Keith MD Associate Professor University of Alabama at Birmingham Department of Nutrition Sciences Department of Internal Medicine (www.eatright.uab.edu)

  2. Background • More than one million people are classified as morbidly obese in the United States • Bariatric surgery has emerged as a definitive therapy for long-term treatment of obesity • The three to five year success rate is 54-75% for surgery versus a 6-8% three-year success rate with medical weight management programs

  3. Background • Between 1990 to 1997, 12,203 people underwent bariatric surgery • The annual rate has increased from 2.7 per 100,000 people (1990) to 6.3 per 100,000 people (1997) • In 2006, approximately 177,600 cases were performed per the American Society for Bariatric Surgery • Some estimate that > 205,000 surgeries will be performed this year (Source: American Society for Metabolic and Bariatric Surgery)

  4. “To Cut or Not To Cut” • Medical Therapy 5-10% excess weight loss • Pharmacologic Intervention 8-10% EWL • Bariatric Surgery 60-80% EWL

  5. Bariatric Surgery • Indications for Bariatric Surgery: Failure of medical therapy-3-5 yr attempt Life-threatening complications of obesity Severe obesity (BMI >40 or >35 with complications) • Monitoring pre-surgery: Minimum of 6 months medical therapy Followed by MD, DO or FNP ∆Wt, Food logs, exercise, psych Blue Cross Blue Sheild of IL

  6. Types of Bariatric Procedures • Malabsorptive: Jejuno-ileal bypass Biliopancreatic Diversion Duodenal Switch (DS), no bypass • Restrictive: Vertical banded gastric bypass Laproscopic adjustable gastric banding • Restrictive and Malabsorptive: Roux-en Y gastric bypass Distal gastric bypass with DS

  7. Surgical Advantages ofPureGastric Restriction • 50% excess weight loss at 1 year • Minimal nutrition complications • Can be used in populations that are high risk for RYGB

  8. Surgical Advantages ofCombined Gastric Restriction & Malabsorption • Advantages of Gastric Bypass: 60% of excess weight lost in year 1 Maintains a weight loss of 50% for 25 years Rapid resolution of metabolic syndrome Improvement in obesity-related complications • Advantages of the Duodenal Switch: 60-80% of excess weight lost in year 1 Most effective therapy for super obese

  9. Combined Gastric Restriction & Malabsorption • Operative Risks: (vs. cholecystectomy) Perioperative Mortality 1-2% vs. 0.2-0.8% Early Complications 10% vs. 2.9% Late Complications 20% vs. 1-2% • Limitations: Widening of (unbanded) gastrojejunostomy Expansion of gastric pouch 25% with nearly 100% weight regain*** Adaptation of limb that receives the food

  10. Combined gastric restriction & malabsorption • Potential complications: 1) severe dumping syndrome - rapid rush of liquid/soft high caloric food “dumping” into limb of small intestine….discomfort, nausea, bloating, diarrhea, weakness 2) Abnormalities in iron, calcium, B12, and possibly magnesium homeostasis 3) Profound rapid weight loss

  11. Weight Loss Benefits vs.Nutritional Risk

  12. Risk of Deficiencies • Determined by the type of surgical intervention • Restrictive Minimal risk • Malabsorptive Moderate risk • Combination High risk • Risk increases as: • the length of the common channel decreases, and • the degree of malabsorption increases

  13. Risk of deficiencies

  14. Risk of deficiencies

  15. Other Nutrition Complications • Refractory Hypoglycemia • Vitamin C Deficiency • Selenium deficiency • Copper deficiency

  16. Other Nutrition Complications • Severe Protein Calorie Malnutrition • Functional Pancreatic Insufficiency • Accelerated Weight Loss • Hepatic Failure • Dehydration

  17. Other Post-surgical Complications • Anastomotic leak or bleeding (1-2%) • Strictures (10-15%) • Fistula formation • Severe diarrhea • Intusseption

  18. Other Post-surgical Complications • Short Bowel Syndrome • Abdominal pain • Intestinal ischemia • Gastric erosions or ulceration • Hernias- Hiatal, Incisional

  19. Non-Nutritional Psychosocial Complications • Depression • Suicide • Alcoholism • Night Eating Syndrome • Binge Eating Syndrome Zwaan et al Int J Eat Disord 2006 Adams et al NEJM 2007 Hsu et al Psychosom Med 1998

  20. Types of Bariatric Procedures • Malabsorptive: Jejuno-ileal bypass Biliopancreatic Diversion Duodenal Switch (DS), no bypass • Restrictive: Vertical banded gastric bypass Laproscopic adjustable gastric banding • Restrictive and Malabsorptive: Roux-en Y gastric bypass Distal gastric bypass with DS

  21. Laproscopic Adjustable Banding • Nutritional Deficiencies: Protein • Endoscopic limits: Depends on lumen Retroflexion • Increased risk of ischemia and necrosis

  22. Roux-en Y Gastric Bypass • Nutritional deficiencies: Vitamin B12 Calcium Iron Protein • Endoscopic limits: Retroflexion ERCP

  23. Distal Roux-en Y Gastric BP • Nutritional deficiencies: Vitamin B12 Calcium Iron Protein • Endoscopic limits: Retroflexion ERCP

  24. Duodenal Switch, with RYGB • Pylorus and D1-sparing • Nutritional deficiencies: Protein Magnesium Vitamin B12 Iron Calcium • Endoscopic limits: ERCP

  25. Anti-obesity Surgery and Co-morbidities J Kral 1995, >1000 patients

  26. Suggested Monitoring Monitoring Guidelines • Frequent (no less than every 3 months) • Weight (more often in first 6 months) • CBC, Electrolytes, BUN, Cr, Ca, Mg, P • Glucose, Liver Tests, Albumin • Fat soluble vitamins-A,D.E and K • Vitamin B12, B1 • Iron studies • Vitamin C, Selenium, Zinc, Copper • Pre-albumin (or Transferrin if renal disease)

  27. Suggested Monitoring • Occasional (at least annually) • Measured Height • Bone Mineral Density • PTH, 1,25-OH Vitamin D, Zinc, 24 hour urine calcium

  28. Post Surgical Monitoring • Weight loss progression* • Goal: not more than 1-2 lbs/d in 1st mo • Adequate Protein Intake • Fluid status Presutti et al, Mayo Clin Proc 2004

  29. Goal Nutrient Intake • Protein (1-2 grams per kg of adjusted weight) • 60 gram Gastric bypass • 75 grams Duodenal Switch • Fat • 25% total calories • Carbohydrate • 15-30 grams per serving day in 4-6 servings • Fluid • 64 ounces

  30. Potential Nutritional Limitations • Meat and dairy intolerance • Nutrient malabsorption • Vomiting, especially with over-consumption • Constipation • Dehydration Dolan, Ann Surg 2004 Elliott Crit Care Nurs Q 2003

  31. Post-surgical Supplementation • Prenatal multivitamin or Flintstone chewable MVI with minerals (2/day) • Iron Polysaccharide 150 mg po BID for women • Calcium Carbonate 500 mg po TID • Vitamin D 400 IU po qD • Vitamin B12 500 mcg po qD Forse et al, Current Opin Endo Diabete 2000 Alvarez-Leite, Current Opin Clin Metab Care 2004

  32. Nutrient Deficiencies • Preventable with supplementation • Require lifelong compliance with supplements • Minimized by regular and routine monitoring

  33. Nutrition Monitoring Challenges • Few randomized protocols to address nutrition monitoring • How often and for how long patients are to be followed is debated due to $$$ • Timing of follow-up visits not clear • Routine vitamin replacement not covered by many carriers

  34. Take Home • Bariatric surgery can be life-saving for the right patient • Attention to adequate nutrition and vitamin supplementation is key • Lifelong monitoring is essential

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