Transcript bariatric - Pilgrims Hospital

Bariatric Surgery
Mr Peter O’Leary
History
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Greek
 Baros
= weight
 Iatros = physician
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Kremen & Linner
 1954
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Jejuno-ileal Bypass
Mason
 1967
Gastric Bypass
 Failure to gain weight post
partial gastrectomy for peptic
ulcer disease
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Recognised as a general surgical sub-speciality by
 American
College of Surgeons
 American Medical Association
Mrs. KG (48)
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Referred by Orthopaedics re Gastric bypass for:
 Weight
reduction prior to hip replacement (OA)
 Improvement of mobility
 Seeking procedure for 4 year
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Current status
Weight
Height
BMI
135kg
1.75m
47
HxPC
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>9st until mid 20s
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Gained weight since the birth of her children
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Weight reduction measures
 Weight watchers
 Dieticians
 Appetite suppressants
 All effective short term
MedHx
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Osteoarthritis B/L hip
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Hypertension
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Hypercholestrolaemia
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Sleep apnoea
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Reflux and heart burn
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NIDDM
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Family Hx
 Nil
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of note
Drug Hx
 NKDA
 Metformin
 Atenolol
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SHx
 Non-smoker
 No
alcholo
 Shop assistant
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RoS
 Nil
of note
On Examination
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Looked well but obese
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Vitals normal
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MSS
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CVS, RS, Neuro - NAD
Fixed flexion R knee
Joint line tender medially
Crepitus +
Pre-op Advice
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Advised about Procedure
Possible complication
Post-op recovery
Endocrine assessment
No pre-op consultation with Dietician
No pre-op psychological evaluation
Indications
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BMI > 40 (> 35 with co-morbid conditions)
 sleep apnea
 cardiomyopathy
 diabetes mellitus
 musculoskeletal
 body size severely impacting on function
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No medical or anaesthetic contraindications
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No previous major upper abdominal surgery
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No active drug or alcohol addiction history
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No major psychiatric history
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Well informed, motivated, and acceptable operative risks
Pre-op Considerations
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Endocrinologist
 Pituitary
 Thyroid
 Adrenal
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Dietician
 Eating behaviour modification
 Post op diet adjustment, vitamin and
mineral supplementation
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Psychological evaluation
 Psychiatric co-morbidities
 Change in relationship with food
 Behaviour modification techniques
Please help…!
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Bariatric surgery
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weight reduction surgery for morbidly
obese
1.BMI >40 (basically, >100 pounds above ideal
body weight).
2.BMI >35 with a medical problem related to
morbid obesity.
Surgical options
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Stapling off of small
gastric pouch
(restrictive) roux-en-Y
limb to gastric pouch
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Mechanism of gastric by pass
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1. Creates a small gastric
reservoir
2. Causes dumping
symptoms when a patient
eats too much food or
high calorie foods, the
food is dumped into the
roux-en-Y limb
3. Bypass of small bowel
by roux-en-Y limb
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Dose gastric by pass work?
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Weight loss 50% of
excess weight
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Postop Complications
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Early (1 to 6 weeks)
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Postoperative bleeding
Anastomosis leak
Bowel perforation
Bowel obstruction
Wound infections
Intermediate (7 to 12 weeks)
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Prolonged vomiting
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Dietary indiscretions
Bulimia
Stricture at gastrojejunal anastomosis (4.6%)
Marginal ulcer
Dumping syndrome (50% after roux en y)
Late (13 weeks to 12 months)
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Cholelithiasis
Small bowel obstruction (adhesions)
Secondary hyperparathyroidism
Leak after
gastric
bypass on
upper
gastrointestinal
series
Long term eating habits
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Initially, the stomach tolerates 30 cc at one time
3 months, patients are ingesting ~1000 kcal in three to
six meals per day
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Six months, should be on 3 meals a day
Food aversions develop esp if prolonged vomiting
associated with eating
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Dietary advice important at this stage
Such patients often express "buyers remorse" and may request
extensive investigations for problems with the gastric pouch
Eating habits change compared to preoperative eating
habits
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Fresh fruits and vegetables are tolerated without a problem
Some patients have continuing food intolerances, especially to
red meat, and become vegetarian
Changes post surgery
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Weight loss
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Rapid in the first six months
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Averages 4 to 7 Kg per month
Slows 2 to 3 Kg after 6 months
Total weight loss peaks at 12 months
Weight regain 18-24 months post op
Nutritional Deficiencies
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Inadequate intake of nutrients
Alterations in the digestive anatomy
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lack of intrinsic factor – B12 def
Lack of acid in new pouch (R en Y) – Poor absorption of iron
Ca and Vit D absorption decreased after surgery – Secondary
Hyperthyroidism
Thiamine def due to recurrent vomiting
Little evidence available on the amount of supplementation required
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Cosmetic
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After 12 months, patients seek info about plastic surgery to
remove abdominal pannus
Insurance companies will not cover it - cosmetic
Exception if abdominal pannus becomes infected or excoriated
Case series suggested that delaying panniculectomy until after
weight loss is safer and more effective
Physical function
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Fatigue improves, increased energy
Exercise habits improve
 increase in activities of daily living and recreational activities
Musculoskeletal and back pain improves or resolves in the
majority of patients
Osteoarthritis improves to a lesser degree
 Dependent on the degree of underlying bone and cartilage
damage
Sleep apnea improves
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Psychological
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Lethargy, depression, and other psychopathology
Food used for emotional reasons, pre-op
Grieve the loss of food
Several studies have shown increases in self-esteem, selfconfidence, assertiveness, and expressiveness
Improvements seen in social interaction, sexual activity, and
work performance
Pregnancy
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Greater fertility with weight loss
Surgery not associated with adverse perinatal outcomes
Pregnancy complications eg gestational diabetes, hypertension, and
macrosomia
Period of rapid weight loss
Gastric band may need to be adjusted
nutritional deficiencies
"un poco con la cabeza de
Maradona y otro poco con la mano
de Dios"