Transcript 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
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
↑ 1000%
↑ 500%
↑ 300%
Medical Complications of Obesity:
Almost every organ system is affected
Pulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
steatosis
steatohepatitis
cirrhosis
Gall bladder disease
Gynecologic abnormalities
abnormal menses
infertility
polycystic ovarian syndrome
Osteoarthritis
Idiopathic intracranial hypertension
Stroke
Cataracts
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Severe pancreatitis
Cancer
breast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Skin
Gout
Phlebitis
venous stasis
Number of Bariatric Operations performed in
the US from 1992-2006
200,000
180,000
160,000
140,000
120,000
100,000
# Bariartric
80,000
Surgeries
60,000
40,000
20,000
0
1992 1994 1996 1998 2000 2002 2004 2006
NEJM, R. Steinbrook, 2004/ ASBS
Who Qualifies for Weight-Loss
Surgery?
Clinical Terms Used to Describe Various Levels of Body
Fat
Normal Weight
(BMI 18.5 to 24.9)
BMI 18.5-24.9
Overweight
(BMI 25 to 29.9)
Obese
(BMI 30 to 34.9)
BMI 25-29.9
BMI 30-34.9
Severely Obese
(BMI 35 to 39.9 )
BMI 35-39.9
Morbidly Obese
(BMI 40 or more)
BMI>40
Bariatric Surgery Indications
NIH Criteria
• BMI > 40
• BMI > 35 with Co-morbidities
– Type II Diabetes
– Obstructive Sleep Apnea
– Coronary Artery Disease
– Cardiomyopathy
– Hypertension
– Dyslipidemia
Restrictive Procedures
Gastric Banding
Sleeve Gastrectomy
Restrictive + Malabsorptive
Procedures
Roux-en-Y Gastric Bypass
Biliopancreatic Diversion with
Duodenal Switch
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
Weight Maintenance after Bariatric Surgery
Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26
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.
Long-term Survival with Bariatric Surgery
7
Rel. Risk = 0.11 (.04-.27)
% Mortality
6
89% reduction in risk of
death over 5 years
5
4
3
2
1
0
Control
Christou et al. Ann Surg 2004;240:416-424
Bariatric Surgery
Relationship Between Surgical Experience and
Perioperative Mortality in Gastric Bypass Surgery
7%
Thirty Day Mortality
6%
5%
125 case lifetime bariatric
surgery experience
4%
3%
2%
1%
0%
0
50 100 150 200 250 300 350 400 450 500 550 600 650
Chronological case order per surgeon
D Flum et al. J Am Coll Surg 199:543, 2004
Is Bariatric Surgery Safe?
Mortality rates after common operations in U.S. hospitals
Variable
Repair of
AAA
CABG
Surgery
Pancreatic
surgery
Hip Replacement
ASMBS BSCOE
surgery
bariatric surgery
Hospitals
operation (n)
2485
1036
1302
3445
235
Avg. mortality
rate (%)
3.9
3.5
8.3
0.3
0.36
8
24
280
Average hospital
caseload
30
491
Adapted from Dimick J.B., Welch H.G., Birkmeyer, J.D. Surgical mortality as an
indicator of hospital quality. JAMA 2004; 292:847-51.
Patient outcomes for all Bariatric Surgeries at
235 SRC Full Approval BSCOE Hospitals
4000
4.86 %
# of events
3000
2000
2.21 %
1000
0.13 %
0.16 %
0.07 %
0.36 %
In-patient
mortality
Post-discharge
30 day
mortality
31-90 day
mortality
Total mortality
(< 90 days)
0
Re-admissions Re-operations
within 30 days within 30 days
Recognizing Complications
• Over-medication
– Anti-hypertensives
– Diabetic Medications
• Under-medication
– Anti-seizure
• Dehydration
– Most common first two weeks post-op
– No Thirst
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
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
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
Band Erosions
Partial
Complete
Normal
Absorption
Risk of Vitamin and Mineral
Deficiencies Post-op
•
•
•
•
Calcium and Vitamin D
– Reduced absorption d/t bypassed duodenum, proximal jejunum (Ren-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
Question and Comments