Transcript Bariatric Surgery Basics

Obesity:
prevalence, influences and challenges
Canadian
Medical
Association
recognizes
obesity as a
chronic disease
(October 2015).
4-fold increase in
morbid obesity
over the last 20
years
Source: Katzmarzyk PT, Mason C. Prevalence of class I, II and III obesity in
Canada. CMAJ. 2006 Jan 17;174(2):156-7.
80-90% of patients with T2DM overweight or
obese*
Some antihyperglycemic therapies contribute to
weight gain
Higher BMI increases mortality
Modest weight loss (5-10% total body weight) can
improve metabolic parameters
*Wing
RR. Weight loss in the management of type 2 diabetes. In: Gerstein HC, Haynes B
editor(s). Evidence-Based Diabetes Care. Ontario, Canada: B.C. Decker, Inc, 2000:252–76.
Interdisciplinary weight management programs to prevent weight gain
and achieve and maintain a lower, healthy body weight (Grade A, Level
1A).
Recognize the effect of anti-hyperglycemic agents on body weight.
(Grade D, consensus).
Bariatric surgery may be considered when lifestyle interventions are
inadequate in achieving healthy weights in patients with type 2
diabetes and class II or III obesity (Grade B, Level 2).
*A.Sharma
and D. Lau (2013). Weight Management in Diabetes. Can J Diabetes 37: S82-S86.
Weight management is not a simple equation
Goals around weight management:
- Preventing weight gain
- Preventing weight regain
- Understanding best weight
Weight Management Strategies
Age ≥ 18 years
Body Mass Index (BMI) ≥ 40
BMI ≥ 35 with significant co-morbidities
Heart disease, Type 2 diabetes, Hypertension, Sleep Apnea,
GERD
History of prior weight management attempts
Motivation and engagement in lifestyle modifications
* Ontario Bariatric Network
Active substance use, including nicotine and alcohol,
<6 months prior to surgery.
Medical or surgical conditions that may make surgery a
high risk to perform.
Severe or poorly controlled current psychiatric illness or
undertreated symptoms.
* Ontario Bariatric Network
NSAIDS are contraindicated for gastric bypass
Significantly increased risk of GI bleeding
Avoidance (pre / post op) : nicotine, caffeine
Potential detrimental effect on anastomoses and GI
lining
Weight loss
52-77% excess body weight loss maintained at 10
yrs
All cause mortality lowered 29-40%
CAD 49%, cancer 60%
Diseases improved or remission (60-80%)
Diabetes, lipids, BP, liver disease, MSK pain
Sleep apnea resolves 95%
Improved Quality of Life
TD Adames et al. (2007). Long-term mortality after gastric bypass surgery. N Engl J Med. 357: 753-761.
Impressive outcomes:
Metabolic – STAMPEDE trial of 150 moderately obese
patients showed that 42% of patients with RNY had A1C <
6% compared to 12% of a medical therapy group
Metabolic outcomes are independent of weight loss
Reduced truncal fat and increased beta cell function
Improved insulin sensitivity
Reduction / elimination of medications: insulin, oral
antihyperglycemics, antihypertensives, statins
ALL surgeries have a risk of death
Studies show 0.2-2.0% mortality for RYGB
<2 deaths per 100 operations
The most common causes of death:
Pulmonary embolism (blood clot in the lung)
Leak in staple lines made during surgery
Early complications
Nausea / Vomiting
Diarrhea / Dumping
Heart and lung problems
Blood Clots
Stricture
Blockage
Leaks
Infection
Organ failure
Death
Later complications
Constipation
Nutrient deficiencies
Protein malnutrition
Hair loss
Gallbladder disease
Mental health problems
Higher incidence of post prandial hypoglycemia
post bariatric surgery
Can occur months to years after surgery
Causes related to rapid transit of food between
stomach and small intestine
Carbohydrates absorbed much quicker producing
an acute spike in glucose provoking a strong
hyperinsulinemia.
Responsive to dietary modification with small
frequent low carb meals
Some patients require medical therapy such as
acarbose to reduce carbohydrate absorption
More severe cases require partial pancreatectomy.
Lifestyle and weight management
• Understanding influences on
weight management
• Encourage awareness and
application of healthy
behaviours
• Building confidence in managing
lifestyle change
• Accepting best weight
Emotions & Coping
Strategies
Sleep
Biology, hormones +
more
Medications
Weight loss and
weight cycling
Mental Health
Portion Management
Understanding
nutrients and
Inadequacies
Disorganized eating
Environments: family,
work, social
Beverage
Consumption
Planning and Goal
Setting
Plate method
Nutrient
Supplements
Mindful Eating
Physical Activity
Balanced plate
Balanced plate after bariatric surgery
Compromised: food and fluid volumes, nutrient absorption, surface area
Risks: nutrient deficiencies, appetite irregularity, disorganized eating, absorption
Diet progression
• 5 stages
• Progress to normal
diet
Nutrient supplements
• Multivitaminmineral
• Vit B12, Vit D,
Calcium citrate
• Others
Lifelong lifestyle
• Mindful
• Coping
• Accepting
Ideal Body Weight
Desired Body Weight
Best Weight
Weight will continue to
change through the
course of our life.
Bariatric Surgery shows
the greatest total
weight loss even over
years of follow-up.
Manage
Stress
Journaling
Problem
Solving/Goal
Setting
Selfmonitoring
Mindfulness
Motivational
Techniques
Social support
Wadden TA, Foster GD Med Clin North Am 2000: 84(2) 441-461, vii. Review
Supported by the Ministry of Health and LongTerm Care and South East Local Health
Integration Network
Only bariatric assessment service between
Ottawa and Toronto
Means easier access to care closer to home
Committed to providing patient and family
centered care for obese and morbidly obese
patients
Provide pre-surgical assessment and post
surgical follow-up services
Surgeries performed at Toronto East General
Hospital and St. Michael’s Hospital
Medical Lead
Program Manager
2 Nurse Practitioners
1 Registered Nurse
3 Registered Dietitians (1 FT, 0.8 FT, 0.5 PT)
2 Social Workers
3 Medical Secretaries / Data Coordinators
Referral to Bariatric Registry
from Family Doctor/Nurse Practitioner
Referral received by RATC
Package mailed to patient
Orientation Session
Patient questionnaire returned
Patient Questionnaire
Initial Assessment
Baseline Bloodwork
Tests ordered as applicable
Deferred from RATC
Transfer to surgical site
Booked with Dietitian
and Social Worker
Referred for
further
medical/psychiatric
evaluation
Required attendance at orientation session
Patient to make informed decision about
continuing the process
Pre-operatively patients assessed by each
member of the team
Required to complete tests relevant to their
pre-surgical screening
Follow-up includes multiple visits with team
members starting at 1 week post-operatively
Follow-up at 1,3,6,9, and 12 months
Support groups offered bi-weekly
Annual follow-up for 5 years
Glycemic Optimization Clinic:
Provides support to pre-op bariatric candidates
with elevated blood glucose levels
Endocrinologist and CDE support once weekly
Surgical/General Medicine Clinic:
Dr. Robertson providing consultation to complex
bariatric surgical patients once monthly
Sleep Apnea Assessment/ Respirology clinic
Dr. Aaron Aggarwal providing support for preoperative bariatric patients requiring sleep
study assessment
Internal Medicine Clinic
• Clinics run weekly
• Optimize patients’ chronic health conditions
Ontario Bariatric Network (OBN) :
http://www.ontariobariatricnetwork.ca/
Public Health Agency of Canada (2011). Obesity in Canada. Accessed at
https://secure.cihi.ca/free_products/Obesity_in_canada_2011_en.pdf
Mechanick et al (2013) Clinical practice guidelines for the Perioperative Nutritional,
Metabolic and Nonsurgical support of the bariatric surgical patient. Surgery for
Obesity and Related Diseases. 9: 159-191.
Isom et al (2014). Nutrition and Metabolic Support Recommendations for the Bariatric
Patient. Accessed online at www.ncp.sagepub.com
Ontario Bariatric Network www.ontariobariatricnetwork.ca
Canadian Obesity Network www.obesitynetwork.ca