Complications and Benefits of Bariatric Surgery

1. Complications and Benefits of Bariatric Surgery Tracy Robinson PAS 646 Advisor: Dr. Hadley

2. Objectives • Obesity Statistics • Bariatric Surgery options • Post-surgical complicatioins • Nutritional consequences • Improvements in co-morbidities • Psychological and QOL improvements • Why do PAs need to be aware?

3. Obesity Statistics • 33% US population is obese (BMI ≥ 30 kg/m2) • 8 million people in US morbidly obese (BMI ≥ 40 kg/m2) • Between 1986 and 2000…… • Obesity doubled • Morbid obesity quadrupled • Super obesity (BMI ≥ 50 kg/m2) increased five-fold

4. Obesity Statistics cont….. • Men > 50% overweight = double mortality • Men > 50% overweight + DM = 5x mortality • Women > 50% overweight = 2x mortality • Women > 50% overweight + DM = 8x mortality • 5% total healthcare costs • US $60 billion

5. Bariatric Surgery • 1990 – 2000 → 4925 to 41,000 • 2005 → 130,000 • 2010 → 218,000 • Bariatric surgery criteria • BMI ≥ 40 kg/m2 without co-morbid disease • BMI ≥ 35 kg/m2 with concurrent co-morbid disease

6. Roux-en-Y Gastric Bypass • 15 to 25 ml gastric pouch with 1 cm outlet • Bypass distal stomach, duodenum, first segment of jejunum • Bypass 75 -150+ cm jejunum • 65% -70% EBW loss • Decrease BMI 35% www.obesitycenter.org/ images/bg_roux2.gif

7. LAP-BAND • No physiological changes or resections • Band around upper stomach creates 15 ml pouch • Port of adjustment attached to abdominal wall • Inflate/deflate 6 times a year • 50% EBW loss www.weighlite.com/images/ content/gastric-diag.jpg

8. Post-surgical Complications • Anastomosis leaks or staple line leaks • PE or DVT • Cholelithiasis • Stomal ulceration • Dumping syndrome • Constipation

9. Anastamosis Leaks • Up to 7-10 days after surgery • Most common at gastrojejunostomy, enteroenterostomy, Roux limb stump, staple line • Can lead to peritonitis, sepsis, possible death • Presentation • Tachycardia, tachypnea • Fever • Ab pain/back pain • Pelvic pressure or rebound tenderness

10. Anastamosis Leaks • Order Gastrograffin upper GI series • Subclinical cases • Bowel rest • Parenteral nutrition • IV antibiotic if H. pylori • Clinically suspect leak • Laparoscopic evaluation and leak repair Failure to evaluate is the most common cause of preventable, major long-term disability or death in bariatric surgical patients

11. Pulmonary Embolism • Sudden cause of death up to one month after surgery • 20%-30% mortality rate • High risk may have vena cava filter placement prior to surgery • Prophylaxis with compression stockings and LMWH • Early ambulation imperitive

12. Pulmonary Embolism • Presentation • Profound hypoxia • Hypotension • Signs of sepsis • Immediate spiral chest CT • Abdominal exploration if too large for machine • No pathology start anticoagulation • Too large…….NO SURGERY

13. Cholelithiasis • Up to 36% of patients within 6 months post-op • Bile stasis leads to increased sludge and gallstones • Prophylactic cholecystectomy prior to surgery if evidence of existing sludge or stones • Prevent post-operative disease with concurrent bariatric surgery and cholecystectomy • Prophylactic use of urosidol • Expensive and unpalatable

14. Stomal Ulceration • 12%-15% within 2-4 mos. Post-surgery • Etiology • Overabundant acid in pouch leads to excessive acid passing through stoma • Pouch tension and staple line breakdown • NSAID use • Presentation • Dyspepsia, vomiting • Epigastric or retrosternal pain

15. Stomal Ulceration • Treatment • PPI, carafate • Antibiotics if H. Pylori • Avoid NSAIDS, alcohol, smoking • If no response to treatment • Endoscopy • Back to surgery for pouch revision or staple line repair

16. Dumping Syndrome • More than 15% patients • Hypotention • Tachycardia • Lightheadedness, syncope • Flushing • Abdominal cramping and diarrhea • Nausea and vomiting

17. Dumping Syndrome • Occurs with high dose simple sugar ingestion • Sugar in small intestine causes osmotic overload and fluid shift from blood to intestine • Increased intestinal volume leads to watery diarrhea • Decreased blood volume leads to systemic changes • Patient education • Eat slowly • Avoid drinking before, during and not until 30 minutes after meals.

18. Constipation • Most common complaint • Causes • Dehydration and decreased fluid intake post-operatively • Increased metabolic water needs • Calcium and iron supplement use following surgery • Treat with increased fluids and stool softeners

19. Nutritional Consequences • Iron deficiency anemia • B12 deficiency • Folate deficiency • Calcium and Vitamin D deficiency • Not seen with purely restrictive surgeries

20. Iron deficiency and anemia • Common following RYGB • As high as 49% of patients • Multifactorial cause • Low gastric acid levels prohibit iron cleavage from food • Absorption inhibited because no nutrient exposure to duodenum or proximal jejunum • Decrease in iron-rich food consumption due to intolerance • Treat with oral supplementation of ferrous sulfate or ferrous gluconate

21. Vitamin B12 deficiency • Up to 70% of patients • Lack of hydrochloric acid and pepsin in stomach • Prevents B12 cleavage from food • Affects secretion of intrinsic factor, thus B12 absorption • Intolerance to meat and milk • Oral supplementation usually adequate, otherwise, IM injections used

22. Folate Deficiency • 40% of gastric bypass patients • Complete absorption requires B12 • Absorption dependent on HCl and upper 1/3 stomach • Deficiency generally caused by decreased consumption • Oral supplementation

23. Vitamin D and Calcium Deficiency • Vitamin D deficiency is common among obese people • Calcium absorption decreased because duodenum is bypassed • Intolerance to dairy, foods high in calcium • Vitamin D is required for Ca++ absorption • Prolonged deficiencies lead to • Bone resorption, osteomalacia, osteoporosis • Treat with calcium citrate supplementation and 2 weekly doses of Vitamin D

24. Improvements of Co-morbidities • Type 2 diabetes mellitus • Hypertension • Hyperlipidemia • Degenerative joint disease • Sleep apnea • GERD • 5% to 10% weight reduction is associated with significant decrease in risk • Weight loss from surgery reduces or eliminates medications • Improves severity or resolves co-morbid disease

25. Improvements of Co-morbidities • 2 years after surgery diabetes mellitus was resolved in 83% of pre-operative diabetic patients (Sugerman et. al 2005) • 2 years following surgery 69% had resolution of hypertension • 8 years post-surgery there was complete relapse in those with gastric banding • 25% decrease in total cholesterol and 40% decrease in triglycerides 6 to 12 months after surgery

26. Psychological and Psychosocial Improvements • Depression • Low self-esteem and self-appraisal • Poor interpersonal relationships • Feelings of failure and dissatifaction with life • Subject to prejudice and discrimination

27. Psychological and Psychosocial Improvements “ Most obese patients consider impaired QOL the most crippling aspect of their disease, and after surgery consider enhanced QOL the greatest benefit” (Puzziferri 2005). “Obese individuals would rather have a normal weight with a severe disability such as be deaf, have heart disease, have an amputation and others rather than be obese without any of these conditions” (Livingston 2003).

28. Psychological and Psychosocial Improvements • Significant improvement in QOL with all types of surgery • New vocational and social activities • Improved interpersonal relationships • Better moods, self-esteem • More employable, get paid more, work more and take less sick days.

29. Why do PAs need to know this? • We will be the long-term healthcare provider • Consequences and complications last a lifetime • Initial provider assessing signs and symptoms • Track improvements • Medication changes • Stay educated in all specific needs and concerns of bariatric surgery patient!