1 / 55

The Family Physician’s Role in Managing the Bariatric Surgery Patient

The Family Physician’s Role in Managing the Bariatric Surgery Patient. B. Wayne Blount, M.D., MPH. Objectives. Discuss non-surgical and surgical weight management options

niel
Download Presentation

The Family Physician’s Role in Managing the Bariatric Surgery Patient

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Family Physician’s Role in Managing the Bariatric Surgery Patient B. Wayne Blount, M.D., MPH

  2. Objectives • Discuss non-surgical and surgical weight management options • Identify appropriate surgical candidates and counsel patients about the importance of compliance with the post-operative regimen • Review the current surgical treatment options and their effectiveness including possible side effects and complications • Discuss follow-up care and long-term management of the post-bariatric surgical patient

  3. The Obesity Epidemic • 67% are overweight or obese • $117 billion spent in 2000 to treat the medical consequences of overweight and obesity • 112,000 deaths/year attributed to obesity* *Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual cause of death in the United States. Journal of the American Medical Association, 291 (10), 1238-1245.

  4. The Obesity Epidemic • “CLINICIANS SHOULD SCREEN ALL ADULT PATIENTS FOR OBESITY AND OFFER INTENSIVE COUNSELLING & BEHAVIORAL INTERVENTIONS TO PROMOTE SUSTAINED WEIGHT LOSS FOR OBESE PATIENTS” • B Recommendation • USPSTF

  5. The Obesity Epidemic • Use : • BMI : tables • Waist Circumference : • Measured @ narrowest part of waist between lower rib cage & unbilicus

  6. Health Burden • Type 2 diabetes • Hypertension • Cardiovascular disease • Stroke • Dyslipidemias • Osteoarthritis • Cancers • Sleep apnea • Gall bladder disease • Female infertility • Psychological issues

  7. The Current Interventions • Popular diets: reduce caloric intake by restricting certain foods and limiting portions, i.e. by counting calories, fat or carbs • Medically supervised diets • Very Low Calorie Diets (VLCD) • Liquid Fasts • Referral to a nutritionist or dietician • Exercise regimens • Medications (sibutramine, orlistat) • Cognitive Behavioral Training • Bariatric Surgery

  8. The Current Interventions

  9. Effect of 4 Diets on Wgt Loss • Atkins, Ornish, Wgt Watchers, & Zone • 1 year • 25% with adequate adherence • 4.6 to 7.3 # loss @ 1 yr in those 25% • Which diet didn’t matter • Exercise did matter

  10. Why Diets Often Fail • Require lot of time and energy • Cause feelings of deprivation • Don’t address why people overeat • Disrupt metabolism

  11. Bariatric Surgery • Number of procedures performed has increased 10-fold • 14,000 in 1993 • 140,000 in 2004 • > 200,000 in 2005 • > 300,000 in 2007

  12. Bariatric Surgery Evidenced Based Recommendation: • Bariatric surgery leads to sustainable long-term weight loss and may reduce obesity-related comorbities such as diabetes mellitus and obstructive sleep apnea. It is not clear which surgical procedure is the safest and most effective. • Recommendation B • From The Cochrane Database of Systematic Reviews available at ttp://www.cochrane.org/reviews/en/ab003641.html 5

  13. The Family Physician’s Role • Assist their patients in their weight management efforts • Identify potential surgical candidates • Counsel patients about their options and the risks and outcomes of each • Understand the post-surgical dietary regimen • Monitor patients for short and long-term complications of bariatric surgery

  14. Indications • Body Mass Index of 40 kg per m2 • Body Mass Index of 35 kg per m2 with significant comorbities • Type 2 diabetes • Obstructive sleep apnea • Coronary artery disease • Debilitating arthritis • Online BMI calculator available @ http://familydoctor.org Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus .nih.gov/1991/1991GISurgeryobesity084html.htm.

  15. Indications (continued) • Previous failed weight loss attempts using an integrated weight loss program including: • Dietary modification • Behavioral support • Appropriate exercise • Appropriate motivation and psychological stability to understand risks and benefits of the procedure • The commitment to lifelong postoperative lifestyle changes and medical surveillance Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus .nih.gov/1991/1991GISurgeryobesity084html.htm.

  16. Contraindications • Poor surgical candidates – inadequate cardiopulmonary reserve, drug or alcohol dependency, impaired intellectual capacity • Unable or unwilling to comply with post-op lifestyle changes, diet, supplementation, f/u • Unstable psychiatric illness or eating disorders • Uncontrolled coagulation problems or cannot be removed from coagulation therapy • For Lap Band – Intra-abdominal adhesions or potential for inadequate pneumoperitoneum

  17. Pre-Op Evaluation • Patients should be evaluated by a team – medical surgical, psychiatric and nutritional experts to determine whether they are candidates for bariatric surgery • Pre-op physical and evaluation Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus .nih.gov/1991/1991GISurgeryobesity084html.htm.

  18. Pre-Op Evaluation (continued) Studies may include: • EKG • CXR • Echocardiogram • Cardiac cath • Polysomnography/sleep study • Gallbladder ultrasound • UGI or EGD • Possible cardiac, pulmonary and psychiatry consultations

  19. Pre-Op Evaluation (continued) Labs may include: • Fasting comprehensive metabolic panel • LFTs including albumin • Lipid panel • CBC • UA • Hgb A1C • Oral glucose tolerance test • Fasting insulin • Transferrin • TFTs • Beta HCG for females of childbearing age

  20. Surgical Options • Based on 1 of 2 mechanisms for weight loss: • 1. Gastric restriction : • Vertical Banded Gastroplasty • Sleeve Gastrectomy • Adjustable gastric banding • 2. Intestinal malabsorption : • Roux-en-Y • Duodenal Switch

  21. What are the procedures available for weight loss? • The Malabsorptive Procedures • The malabsorptive procedures bypass a large amount of intestine and weight loss is achieved by creating nutritional inefficiency • DUODENAL SWITCH • TheRestrictiveProcedures • These procedures restrict the size of the stomach near the esophagus by creating a restrictive pouch. which will hold a volume of approximately 40cc. • GASTRIC BYPASS Lap-Band • Sleeve Gastrectomy

  22. The Malabsorptive ProceduresDuodenal Switch • Fat Malabsorption Primary Mechanism • Malnutrition an issue • Fat Souluble Vitamins • Protein malnutrtion • Frequent foul smelling stools • Up to seven per day • Hepatotoxicity • Elevated liver enzymes • Potential for Liver Failure • Hypoalbuminemia • Hypoproteinemia • VERY EFFECTIVE WEIGHT LOSS

  23. The Restrictive ProceduresLap-Band • Pure Restrictive Mechanism • Requires Frequent Surgical Followvup • Monthly to Every 6 weeks • Requires Significant Dietary Changes • Major Complications • Band Slippage – Reoperation • Band Erosion – Removal • No Malabsorption Risk • Reversible • Low Risk • Outpatient Surgery

  24. The Restrictive ProceduresSleeve Gastrectomy • Permanent Partial Gastrectomy • Resection of body of stomach • Resection of fundus of stomach • Resection of Antrum of stomach • Unproven – experimental • Becoming more common • Not covered by Insurance

  25. Combined ProceduresGastric Bypass • Most commonly performed bariatric procedure in U.S. • Creates a small Gastric pouch • Creates a short Roux Limb • Combined Procedure • Small Malabsorptive limb • Restrictive gastric pouch • Difficult to Reverse

  26. Results of Gastric Bypass • Average BMI 43.5 • 82% Female 18% male • Conversions to open – 2% • Admissions to ICU post op 4% • 3% sleep apnea observation • 1% unexpected secondary to conversion to open • Average Length of Stay – 2.2 days • Outliers – 1% > 10 days

  27. Results of Gastric Bypass • Anastomotic leaks -2% • Internal Hernia requiring reoperation – 4% • Death – < 3 % • Anastomotic Leak Sudden Cardiac Death

  28. Outcomes – Gastric Bypass • Effective Weight Loss • 1 year 68% • 2 year 74% • 3 year 72%

  29. LAGB Weight LossSystematic Review World Literature-ASERNIP-S • Mean % Excess Weight Loss: *Not statistically significance Surgery 2004;135:326-51 J Lap Adv Surg Tech 2003;13:265-70

  30. LAGB Weight Loss A comparison of percentage of excess weight loss following LAGB and RYGB surgery. Published series with baseline numbers greater than 501 1 Surgery 2004;135:326-51

  31. Career Experience – Gastric Bypass1152 Cases – Major Complications • Death 3 patients • Anastomotic Leak – 1 patient post op day 3 • Sudden Cardiac Death – 2 patients • No Leak • No PE • Internal Hernia Requiring Reoperation • 6 patients • Ischemic Bowel – Reoperation/Resection • 2 patients • Venous Stasis/Thrombosis/Congestion – 1 • Arterial Thrombosis/Hypercoagulopathy -1

  32. Career Experience – Gastric Bypass1152 Cases – Major Complications • Pulmonary Embolism – (No Deaths) • Post Op Day 1-14 NONE • Post Op Day 14-30 3 • Rx – Prophylactic IVC Filter Pre-Op - (One) - Post Op Heparin/Coumadin – (Two)

  33. Surgical Options • Roux-en-Y is most common procedure • Lap-Band Increasing in popularity • Sleeve Gastrectomy – Experimental • Duodenal Switch – • Laparoscopic pts have less; • Time in hospital, • Lost work • Pain • Incisional hernias (vs 25% in open)

  34. Life-Threatening Complications • 80% of deaths in the first 30 days are due to: • Pulmonary embolism • Anastomotic leaks • Respiratory failure

  35. Life-Threatening Complications Pulmonary Embolism • Leading cause of death • Risk factors • BMI => 60 kg/m2 • Chronic lower extremity edema • Obstructive sleep apnea • h/o pulmonary embolism • Prophylaxis • low-molecular-weight heparin and compression stockings • Early Ambulation (laparoscopic) • Consider Pre-operative IVC Filter Geerts, W.H., Pineo, g.F., Heit, J.A. et al. (2004). Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3 suppl), S338-400.

  36. Life-Threatening Complications Anastomotic leaks – Signs and Symptoms • Sustained tachycardia, severe abdominal pain, fever, rigors, hypotension • Respiratory failure • Work-up: UGI or CT scan with contrast – • May be negative • DON’T DELAY SURGICAL CONSULT • Urgent surgical consultation • Exploratory surgery if equivocal signs • “Leak Until Proven Otherwise” post op day 1-14 Identify complications early and educate patients about reporting symptoms

  37. Life-Threatening Complications • Internal Hernia • Partial Small Bowel Obstruction through internal mesenteric defects • Usually following RYGB or Duodenal Switch procedures • Patients complain of severe pain • Intermittent • Out of proportion to physical findings • Usually NOT vomiting • CT findings usually negative • Abdominal series usually negative • Usually occur 12 months or greater post op • Usually occur after >100 pounds weight loss • Surgical Consultation • Diagnostic laparoscopy and repair of hernia • Delay in diagnosis can be life threatening

  38. Short-Term Complications 1-6 weeks post-op: • Wound infections • Less Common in Laparoscopic Group • Open Group may lead to incisional hernia • Stomal stenosis • Nausea, Vomiting inability to advance diet • Usually requires EGD and dilation • Marginal ulceration • Usually ischemic • Rarely secondary to Acid production • PPI (Prevacid Solutab), Carafate suspension • Constipation • Poor PO Fluid intake

  39. Long-Term Complications • Nausea, Bloating Abdominal Discomfort • Think Biliary Dyskinesia or Symptomatic Cholelithiasis • Workup • Abdominal Ultrasound – Gallstones? • HIDA WITH Biliary Ejection Fraction – Dyskinesia? • Up to 50% due to rapid weight loss • Consider prophylactic cholecystectomy at the time of surgery • Consider bile salt therapy – Daily for 6 months post op

  40. Long-Term Complications • Nausea, Bloating Abdominal Discomfort, Malaise, Fatigue, Hair loss etc • Think Nutritional Deficiency • B vitamins • Thiamin, Riboflavin, Niacin, Folate, B6, B12, biotin and pantothenic acid. • Fat Soluble Vitamins • A,D,E,K • Vitamin C • Compliance? • Only 30-35% patients are vitamin compliant

  41. Long-Term Complications • Nutritional Deficiencies • Especially with malabsorptive procedures (RYGB, biliopancreatic diversion) • Prevention • Adherence to high protein diet • Lifelong supplementation • High potency • MVI with iron • Vitamin B12, 1000mcg IM q mo or 100mcg po qd • Calcium 1200 mg q d • Menstruating women may require parenteral iron infusions Halverson, J.D., (1992).Metabolic risk of obesity surgery and lon-term follow-up. American Journal of Clinical Nutrition, 55, S602-605.

  42. Post-Op • Usually surgeons have their own specific dietary transitions & anticoagulation methods • Some recommended ones can be found @ “UpToDate” • Be aware that in the perioperative period, many obesity-related medical co-morbidities change dramatically; e.g. HTN, DM, GERD

  43. Post-Op Monitoring Virji, A., Murr, M. (2006). Caring for patients after bariatric surgery. American Family Physician, 73 (8), 1403-1408.

  44. Long-Term ComplicationsCompliance Issues • Dumping Syndrome • Procholinergic symptoms from influx of undigested carbohydrate into the jejunum • Side effect of malabsorptive procedures – RYBG and biliopancreatic diversion • Symptoms • Nausea, vomiting, diarrhea, tachycardia, salivation, dizziness • Results from poor dietary compliance; may serve as reinforcement • Subsides 1-2 hours after sugar or foods high in simple carbohydrate

  45. Long-Term ComplicationsCompliance Issues • Persistent vomiting due to pouch distention • More common with purely restrictive procedures VBG and adj. lap band • Due to non-adherence to dietary recommendations • Small portions • Chewing thoroughly • Eating slowly • Waiting one hour after eating before drinking • Other causes of vomiting – pain meds, vitamins, dehydration, gastroenteritis Bohn, M., Way, M., Jemieson, A. (1993). The effects of practical dietary counseling on food variety and regurgitation frequency after gastroplasty for obesity. Obesity Surgery, 3, 23-28.

  46. Compliance Issues - Pregnancy • Pregnancy is contraindicated for at least 18 months after surgery due to rapid weight loss and nutritional requirements • Provide appropriate contraception

  47. Long-Term Complications • Protein-calorie malnutrition months to years after surgery due to anastomotic stricture or food phobias • Repeated episodes of nausea and vomiting • Multiple hospitalizations for dehydration, renal insufficiency and liver failure • Treat with aggressive TPN, dilation of stricture • Surgical Consultation for Revision or Reversal

  48. Long-Term ComplicationsSide Effects – Skin Issues Panniculitis • Severe infection of the excess abdominal skin • Treat with antibiotics and skin hygiene • Consider excision of the excess skin

  49. Results • Clinical Improvement/Resolution : • Diabetes : 64-100% • HTN : 62-69% • O.S.Apnea : 85% • Dyslipidemia : 60-100% • Nonalcoholic fatty liver dz : 90%

  50. Results • Cholelithiasis : 22% • Overall mortality (after 9 yrs) : • With surgery : 9% • Without surgery : 28%

More Related