Bariatric Procedures, Complications and Follow up

1. Bariatric Procedures, Complications and Follow up Mr Pratik Sufi Consultant Bariatric & Upper GI Surgeon Spire Bushey Hospital

2. Balancing Activity Levels with Food • One small chocolate chip cookie (50 calories) is equivalent to walking briskly for 10 minutes. • The difference between a large gourmet chocolate chip cookie and a small chocolate chip cookie could be about 40 minutes of raking leaves (200 calories). • One hour of walking at a moderate pace (20 min/mile) uses about the same amount of energy that is in one jelly filled doughnut (300 calories). • A fast food "meal" containing a double patty cheeseburger, extra-large fries and a 24 oz. soft drink is equal to running 2½ hours at a 10 min/mile pace (1500 calories). • One tspsugar (20cal) ≈ 4 minwalk • One can coke (160cal) ≈ 30 minwalk

3. Dietary Change

4. Obesity Associated Co-morbidities • Pulmonary Disease • Abnormal Function • Obstructive Sleep Apnea • Hypoventilation Syndrome • Asthma • Cerebral • Idiopathic Intracranial Hypertension • Stroke Cataracts • Hepato-pancreato-biliary Disease • Steatosis (NALD) • Steatohepatitis (NASH) • Cirrhosis • Gall Bladder Disease • Pancreatitis • Coronary Heart Disease • Diabetes • Dyslipidemia • Hypertension • CCF • GI • GORD & Hiatus Hernia • Herniae • Umbilical • Ventral • Inguinal • Cancer • Breast, Uterus, Cervix, • Colon, Esophagus, Pancreas, • Kidney, Prostate • Gynecologic Abnormalities • Abnormal Menses • Infertility • Polycystic Ovarian Syndrome • Vascular • Phlebitis / DVT • Venous stasis • Leg ulcers Obesity OnLine Slide Presentation. Accessed May 17, 2007. Accessible as slide #5 at http://www.obesityonline.org/slides/slide01.cfm?tk=33. • Musculoskeletal • Osteoarthritis • Gout • Skin • Dermatitis • Leg ulcers

5. 30 25 Percentage 20 15 10 20 25 30 35 40 BMI Impact of Obesity on GP Consultations Brown WJ et al. Int J Obes 1998;22:520-528. • Low BMI was associated with fewer physical health problems than mid-level or higher BMI. • Indicators of health care use showed a J-shaped relationship with BMI for general practitioners (>5 GP Consultations). • Prevalence of medical problems (for example, hypertension OR 6x and diabetes OR 6x), surgical procedures (cholecystectomy OR 7x and hysterectomy OR 2x) and symptoms (for example, back pain OR 40% and constant tiredness OR 70%) increased monotonically with BMI.

6. Effect of Diet and Surgery on Weight & Mortality • Diet & exercise effective up to 6m • 60% failure at 1 yr. • 80% failure at 2 yrs. • 100% failure at 5 yrs. • Surgery effective long-term (80%) Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects N Engl J Med 2007;357:741-52.

7. Abandoned Surgery Surgery EndolumenalObesity Diet/ Drugs Low Risk Primary Obesity Options Today More Effective Less Effective Gastric Balloon POSE Endosheath 20-60% Low efficacy – less durable weight loss Moderate risk / efficacy – intermediate durability Effective but unacceptable risk High efficacy – durable weight loss 40-95% Lap Band Sleeve Gastrectomy Gastric Bypass BPD/DS VBG Jejuno-Ileal Bypass High Risk

8. Procedure Comparison

9. Referral - Minimal Dataset • Age • Weight & BMI • Co-morbidity esp. • cardiovascular • respiratory • endocrine • GI and • musculo-skeletal • Medication • Previous attempts at weight loss • Other concerns like • Untreated eating disorders • Psychiatric history NICE: BMI≥35 ASMBS: BMI≥30 Asians: BMI 2 points lower

10. Pre-operative Liver Shrinkage Diet Slimfast –900 kcal/d approximately Food-based – 900 kcal/d approx. Two (2) weeks Four (4) weeks

11. Pre-operative Special Considerations • Hypertension control • ACE Inhibitors • AT2 receptor antagonists • Glycaemic control • Oral hyperglycaemic agents • Insulin • Anticoagulation • Warfarin • Clopidogrel • Aspirin • OSA • CPAP • GORD • PPI • NAFLD / NASH • Liver shrinkage diet

12. Post-operative Regime • Liquids only for 2-3 weeks • Soft blended food for 2-3 weeks • Resume solids after 4-6 weeks • Small mouthfuls • Chew well • Eat slowly • Separate eating and drinking by ½ hour • Avoid fizzy / sugary drinks or sugary food • Medication – liquid / soluble (crushed) • Supplements • Iron • Calcium and vitamin D • Vitamin B12 • Folic acid • Vitamin B1 • Recommended Multivitamin and minerals: • Chewable versions: • Bassett’s Adult Chewablemultivitamins with prebiotics & minerals • Wellkid Smart / Sanatogen A-Z Kids Chewable • Haliborange Chewable multivitamins • Whole tablet: • Sanatogen Gold or Centrum (after 3 months) • Plus • Chewable Calcium – 1000mg calcium /day • Liquid iron or iron drops - 50mg of iron/day

13. Post-operative – Suitable Fluids D0-W2 • Milk - Aim for at least two pints (1.2L) of milk or a milk alternative a day • Milk can be flavoured with Nesquick or low calorie hot chocolate • Slimming drinks e.g. Slimfast or chemist/supermarket own brand • Complan or Build-up shakes or soups • Yogurt drinks and smoothies • Still mineral water, if taking the flavoured types make sure they are low sugar • Still low-sugar squashes • Smooth soups e.g. cream of tomato or chicken; or oxtail • Tea and coffee without sugar • Unsweetened pure fruit juice

14. Post-operative Special Considerations • Diet • Not allowed to eat and drink together • Eat slowly, chew well – at least 20-30 minutes • Liquids for 24-48hours after band adjustment • Return to work • Change in medications • Restrictions on tablets – soluble, liquids or crushed tablets • Change in co-morbidity • Antihypertensive • Oral hyperglycaemic agents • Insulin • Change in absorption • Warfarin • Oral contraceptives • Avoid pregnancy for 18 months • Risk to mother • Risk to foetus

15. Long-term Follow-up • Pins and needles (B12, B1) • Frequent falls (B12, B1, Fe) • Tiredness (anaemia, hypoglycaemia) • Generalised pain (PTH) • Abdominal pain (ulcer, gallstones / hernia / kidney stones) • Reflux / regurgitation/ N&V / persistent cough (band slippage, over-tight band, ulcer, hiatus hernia) • Calcium supplements- 1000mg calcium / day. Liquid or effervescent tablets • Ferrous Sulphate/ ferrous fumarate or sodium feredetate – drops, syrup or sugar free elixir. 50mg of iron/day • Hydroxocobalamin Vitamin B12 injections – 1mg every 3 months

16. Nutritional Deficiencies

17. An Endocrine Society Clinical Practice Guideline

18. Schedule for Clinical and Biochemical Monitoring Xa – Tests should only be performed after RYGB, BPD, or BPD/DS. X – Tests suggested for patients submitted to restrictive surgery where frank deficiencies are less common. An Endocrine Society Clinical Practice Guideline

19. Post-Bariatric Surgery Complications • Cerebrovascular Disease • Wernicke’s Encephalopathy (Beriberi) • Stroke / TIA Pulmonary Disease Pneumonia / Atelectasis Malnutrition Glossitis, stomatitis Hair loss • CV Disease • MI • DVT / PE • Beriberi • HPB Disease • Hepatitis (trauma) • Pancreatitis (trauma) • Cholecystitis • GI Disease • Bleeding • GORD & Hiatus Hernia • Ulcer • Bloating / Obstruction • Diarrhoea / Constipation • Malabsorption • Renal Disease • Kidney stones • Gynecologic Abnormalities • Amenorrhoea • Fertility – failure of contraception • Bone Disease • Osteomalacia • Malnutrition • Dermatitis • Neuropathy • Ataxia

20. Immediate post-operative – infection, bleed, thromboembolism Tiredness, pain, ulcers, dry skin, pins and needles, hair loss etc. (Nutritional deficiency – Iron, Calcium, Vitamin D, Folate, Vitamin B12, Vitamin B1, Zinc) Nausea, vomiting (Slipped band, over-restriction, hiatus hernia, gallstones, anastomotic ulcer, GLP-1 excess, internal /port-site hernia etc.) Hernia – port-site, incisional General complications

21. Slippage (Pain, N&V) Erosion (Pain, N&V, loss of restriction) Oesophageal dilation (Regurgitation, N&V, persistent cough) Infection (Pain, local inflammation, systemic sepsis) Nutritional deficiency (tiredness, hair loss) Gallstones (Pain, N&V, Jaundice) Hiatus hernia / GORD (Regurgitation, heartburn, dysphagia) Band Complications

22. Sleeve Gastrectomy Complications Staple line leak (pain, N&V, sepsis) Staple line bleed Reflux (regurgitation, heartburn, dysphagia) Sleeve dilation (weight regain) Nutritional deficiency (tiredness, hair loss, pain) Gallstones (pain, dyspepsia, N&V, jaundice)

23. Gastric Bypass Complications Staple line leak (pain, N&V, sepsis) Staple line bleed Ulcer (pain, N&V, dysphagia) Stenosis (dysphagia, pain, N&V, regurgitation, excessive weight loss) Dumping (giddiness, tiredness, tachycardia, cramps) Internal hernia (cramps, bloating, constipation) Gallstones (pain, N&V, Jaundice) Nutritional deficiency (tiredness, hair loss, pins and needles, pain, ulcers)

24. Balloon Complications Intolerance (nausea & vomiting, cramps) Ulcer (epigastric pain) Deflation and migration (bowel obstruction)

25. POSE Complications Perforation Bleeding Intolerance (nausea & vomiting, cramps) Ulcer (epigastric pain)

26. Pain Gallstones Pancreatitis Anastomotic ulcer Perforation / Anastomotic leak Gastric band erosion Slipped gastric band Dumping syndrome Anastomotic stricture Small bowel obstruction Gastro-gastric fistula

27. Nausea & Vomiting Pregnancy! Gastroenteritis Gastric balloon intolerance Over-restricted gastric band Anastomotic ulcer Anastomotic / Sleeve gastrectomy stricture Gallstones / Pancreatitis Hiatus hernia Internal hernia / Small bowel obstruction

28. Diarrhoea Gastroenteritis Bacterial overgrowth Clostridium difficile Fat malabsorption Dumping syndrome Lactose intolerance

29. Case Study 1 Thiamine Deficiency • Beriberi • Wernicke’s encephalopathy • Confusion, irritability, memory loss, nervousness, speech difficulties • SoB, orthopnoea, tachycardia • Constipation, digestive problems, loss of appetite • Numbness of hands and feet, pain sensitivity, poor coordination, weakness, absent knee and tendon reflexes, paralysis • Mr A, 32 year old publican, gastric bypass 3 year ago, lost 85% excess body weight • Tripping over repeatedly – 4 months.Nausea and vomiting, pins and needles in hands and feet • Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine? • GP referred patient to neurologist • Differential diagnosis: Thiamine / Vitamin B12 deficiency • Investigation: RBC thiamine / Serum Vit B12 + ECHO + MRI brain • Treatment: Thiamine 100mg bd for 12 weeks

30. Case Study 2 Band slippage • Epigastric pain • Dysphagia • Weight regain Band erosion • Epigastric pain • Loss of restriction • Weight regain • Band infection • Mrs B, 42 year old housewife, gastric band 2 years ago, lost 64% excess body weight • Sudden onset epigastric painand dysphagia • Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine? • Differential diagnosis: • Band slippage • Band erosion • Investigate: • Contrast swallow • CT abdomen • OGD • Band slippage – Emergency band deflation + reposition / removal

31. Case Study 3 Anastomotic ulcer • Epigastric pain, heartburn Gallstones • Epigastric / RUQ pain, N&V, Pancreatitis Internal hernia • Abdominal cramps after eating, constipation, bloating, acute abdomen • Mrs X, 37 year old writer, gastric bypass 6 months ago, lost 45% excess body weight • Intermittent epigastric pain and nausea • Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine? • Differential diagnosis: • Anastomotic ulcer • Gallstones • Internal hernia • Investigate: • USS, Contrast swallow, CT abdomen, OGD • Diagnosis: Gallstone cholecystitis • Treatment: Laparoscopic cholecystectomy

32. Case Study 4 Bacterial overgrowth • Abdominal cramps, diarrhoea, borborygmi Malabsorption • SoB, orthopnoea, tachycardia Internal hernia • Abdominal cramps after eating, constipation, bloating • Mr Y, 27 year old computer analyst, gastric bypass 3 years ago, lost 75% excess body weight • Abdominal pain, bloating, nausea and diarrhoea • Refer to hospital – Emergency / Urgent / Routine? • Differential diagnosis: • Bacterial overgrowth • Malabsorption • Internal hernia • Investigate: • Bloods, ABG, CT abdomen, D-Xylose test, Hydrogen breath test, Stool culture, Faecal fat • Diagnosis: Bacterial overgrowth • Treatment: Correct nutritional deficiencies and Metronidazole + Live yogurt / Neomycin + Rifampicin

33. Case Study 5 Over-restricted band • Cough, reflux and water brash • Unable to tolerate solids • Unable to lie down without coughing Band slippage • Epigastric pain • Intolerant to solids / liquids • Weight regain • Ms Q, 42 year old teacher, gastric band 2004, lost 60% excess body weight • Cough, reflux and water brash for the last 3 weeks. • Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine? • GP started her on Amoxicillin and referred for an OGD • Differential diagnosis: RTI, band slippage, over-restricted band • Investigation: Gastrograffin swallow + OGD • Treatment: Band volume reduction - defill

34. Take Home Message • Bariatric surgery is a cost-effective treatment for obesity which leads to resolution of co-morbidities, improved quality of life and increased life expectancy • However, patients need lifelong follow-up after surgery in order to avoid harm – this can be performed by their surgical team and by the primary care. • Patients can present with nausea, vomiting, dysphagia, reflux, abdominal pain and neurological symptoms. • Common things are common! • Nutritional deficiencies are common and easily preventable.

35. Thank you!