Transcript Complications and Benefits of Bariatric Surgery

Complications and
Benefits of Bariatric
Surgery
Tracy Robinson
PAS 646
Advisor: Dr. Hadley
Objectives
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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?
Obesity Statistics
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33% US population is obese (BMI ≥ 30
kg/m2)
8 million people in US morbidly obese (BMI ≥
40 kg/m2)
Between 1986 and 2000……
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Obesity doubled
Morbid obesity quadrupled
Super obesity (BMI ≥ 50 kg/m2) increased fivefold
Obesity Statistics cont…..
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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
Bariatric Surgery
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1990 – 2000 → 4925 to 41,000
2005 → 130,000
2010 → 218,000
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Bariatric surgery criteria
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BMI ≥ 40 kg/m2 without co-morbid disease
BMI ≥ 35 kg/m2 with concurrent co-morbid
disease
Roux-en-Y Gastric Bypass
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www.obesitycenter.org/ images/bg_roux2.gif
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%
LAP-BAND
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www.weighlite.com/images/ content/gastric-diag.jpg
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
Post-surgical Complications
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Anastomosis leaks or staple line leaks
PE or DVT
Cholelithiasis
Stomal ulceration
Dumping syndrome
Constipation
Anastamosis Leaks
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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
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Tachycardia, tachypnea
Fever
Ab pain/back pain
Pelvic pressure or rebound tenderness
Anastamosis Leaks
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Order Gastrograffin upper GI series
Subclinical cases
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Bowel rest
Parenteral nutrition
IV antibiotic if H. pylori
Clinically suspect leak
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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
Pulmonary Embolism
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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
Pulmonary Embolism
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Presentation
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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
Cholelithiasis
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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
Stomal Ulceration
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12%-15% within 2-4 mos. Post-surgery
Etiology
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Overabundant acid in pouch leads to
excessive acid passing through stoma
Pouch tension and staple line breakdown
NSAID use
Presentation
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Dyspepsia, vomiting
Epigastric or retrosternal pain
Stomal Ulceration
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Treatment
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PPI, carafate
Antibiotics if H. Pylori
Avoid NSAIDS, alcohol, smoking
If no response to treatment
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Endoscopy
Back to surgery for pouch revision or staple
line repair
Dumping Syndrome
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More than 15% patients
Hypotention
Tachycardia
Lightheadedness, syncope
Flushing
Abdominal cramping and diarrhea
Nausea and vomiting
Dumping Syndrome
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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
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Eat slowly
Avoid drinking before, during and not until 30 minutes after
meals.
Constipation
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Most common complaint
Causes
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Dehydration and decreased fluid intake postoperatively
Increased metabolic water needs
Calcium and iron supplement use following
surgery
Treat with increased fluids and stool
softeners
Nutritional Consequences
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Iron deficiency anemia
B12 deficiency
Folate deficiency
Calcium and Vitamin D deficiency
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Not seen with purely restrictive surgeries
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Iron deficiency and anemia
Common following RYGB
As high as 49% of patients
Multifactorial cause
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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
Vitamin B12 deficiency
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Up to 70% of patients
Lack of hydrochloric acid and pepsin in
stomach
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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
Folate Deficiency
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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
Vitamin D and Calcium
Deficiency
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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
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Bone resorption, osteomalacia, osteoporosis
Treat with calcium citrate supplementation and 2
weekly doses of Vitamin D
Improvements of
Co-morbidities
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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
Improvements of
Co-morbidities
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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
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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
Psychological and
Psychosocial Improvements
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Depression
Low self-esteem and self-appraisal
Poor interpersonal relationships
Feelings of failure and dissatifaction with life
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Subject to prejudice and discrimination
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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).
Psychological and
Psychosocial Improvements
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Significant improvement in QOL with all types
of surgery
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New vocational and social activities
Improved interpersonal relationships
Better moods, self-esteem
More employable, get paid more, work more
and take less sick days.
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Why do PAs need to know
this?
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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!