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Post-Surgical Care of the Bariatric Patient

Post-Surgical Care of the Bariatric Patient. Eve L. Olson, MD Medical Director St. Francis Weight Loss Center Indianapolis, Indiana 317-782-7525. Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008. (*BMI  30, or about 30 lbs. overweight for 5’4” person). 1999. 1990. 2008.

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Post-Surgical Care of the Bariatric Patient

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  1. Post-Surgical Care of the Bariatric Patient Eve L. Olson, MD Medical Director St. Francis Weight Loss Center Indianapolis, Indiana 317-782-7525

  2. Obesity Trends* Among U.S. AdultsBRFSS,1990, 1999, 2008 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1999 1990 2008 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  3. ↑ 1000% ↑ 500% ↑ 300%

  4. Number of Bariatric Operations performed in the US from 1992-2006 NEJM, R. Steinbrook, 2004/ ASBS

  5. Who Qualifies for Weight-Loss Surgery? Clinical Terms Used to Describe Various Levels of Body Fat Normal Weight (BMI 18.5 to 24.9) Overweight(BMI 25 to 29.9) Obese(BMI 30 to 34.9) Severely Obese(BMI 35 to 39.9 ) Morbidly Obese(BMI 40 or more) BMI>40 BMI 25-29.9 BMI 30-34.9 BMI 35-39.9 BMI 18.5-24.9

  6. Bariatric Surgery IndicationsNIH Criteria • BMI > 40 • BMI > 35 with Co-morbidities • Type II Diabetes • Obstructive Sleep Apnea • Coronary Artery Disease • Cardiomyopathy • Hypertension • Dyslipidemia

  7. Restrictive Procedures Gastric Banding Sleeve Gastrectomy

  8. Restrictive + MalabsorptiveProcedures Roux-en-Y Gastric Bypass Biliopancreatic Diversion with Duodenal Switch

  9. Efficacy of Bariatric Surgery for Weight Loss • Mean percentage excess weight loss: • 61.2% - All Patients • 47.5% - Gastric Banding • 61.6% - Gastric Bypass • 70.1% - BPD or duodenal switch *Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004

  10. Weight Maintenance after Bariatric Surgery Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

  11. Comparing Weight-Loss Results Gastric Bypass LAP-BAND Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Surgery, ANZ J Surg, 2004; 74: 200-204.

  12. Long-term Survival with Bariatric Surgery Rel. Risk = 0.11 (.04-.27) 89% reduction in risk ofdeath over 5 years % Mortality Christou et al. Ann Surg 2004;240:416-424

  13. 0 50 100 150 200 250 300 350 400 450 500 550 600 650 Relationship Between Surgical Experience and Perioperative Mortality in Gastric Bypass Surgery 7% 6% 5% 4% 3% 2% 1% 0% 125 case lifetime bariatric surgery experience Thirty Day Mortality Chronological case order per surgeon D Flum et al. J Am Coll Surg 199:543, 2004

  14. Mortality rates after common operations in U.S. hospitals Variable Repair of CABG Pancreatic Hip Replacement ASMBS BSCOE AAA Surgery surgery surgery bariatric surgery Hospitals 2485 1036 1302 3445 235 operation (n) Avg. mortality 3.9 3.5 8.3 0.3 0.36 rate (%) Average hospital 30 491 8 24 280 caseload Is Bariatric Surgery Safe? Adapted from Dimick J.B., Welch H.G., Birkmeyer, J.D. Surgical mortality as an indicator of hospital quality. JAMA 2004; 292:847-51.

  15. Patient outcomes for all Bariatric Surgeries at 235 SRC Full Approval BSCOE Hospitals

  16. Recognizing Complications • Over-medication • Anti-hypertensives • Diabetic Medications • Under-medication • Anti-seizure • Dehydration • Most common first two weeks post-op • No Thirst

  17. Postoperative Complications Common to all Procedures • General Complications • Pulmonary embolism • Incisional hernia • Gallstone formation • Major wound infection and seroma • Abdominal fluid collection • Subphrenic abscess • Peritonitis

  18. Procedure-Specific Complications (RYGB) • Anastomotic or staple-line leak • Acute gastric distention • Staple-line disruption • Stomal stenosis • Stomal ulceration • Small-bowel obstruction • Occlusion of Roux limb • Dumping

  19. Procedure-Specific Complications( gastric banding) • band slippage • esophageal dilatation • erosion of the band into the stomach • band or port infections • balloon or system leaks that can diminish weight loss

  20. Band Erosions Partial Complete

  21. Normal Absorption

  22. Risk of Vitamin and Mineral Deficiencies Post-op • Calcium and Vitamin D • Reduced absorption d/t bypassed duodenum, proximal jejunum (R-en-Y) • Life-long supplements mandatory • Iron • Absorption decreased d/t decreased contact of food with gastric acid; reduced conversion of iron from ferrous to ferric form (MVI) • Vitamin B12 • Absorption decreased d/t decreased contact with intrinsic factor • 60% of patients require long term supplementation of B12 • Thiamine • Connection to Wernicke’s syndrome • Cases not well documented

  23. Question and Comments

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