Transcript Bariatric Surgery

ASSESSMENT AND TREATMENT OF ABDOMINAL
PAIN IN THE BARIATRIC PATIENT
PRESENTED BY
ANGELA CHRISTOPHERSON CNP
DISCLOSURES
• I am a fulltime employee of Regional Health
TOPICS
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Prevalence of Bariatric Surgery
Expected outcomes
Obtaining a history
Gastric banding
Sleeve Gastrectomy
Roux en Y Gastric Bypass
PREVALENCE OF BARIATRIC SURGERY
2011
2012
2013
Roux en-Y
Gastric Bypass
36.7%
37.5%
34.2%
Sleeve
Gastrectomy
17.8%
33.0%
42.1%
Gastric Banding
35.4%
20.2%
14.0%
Total
158,000
173,000
179,000
Reference:
American Society for Metabolic Surgery (2014). New procedure estimates for bariatric surgery: What the numbers
reveal. Retrieved from http://connect.asmbs.org/may-2014-bariatric-surgery-growth.html
EXPECTED OUTCOMES
EWL
Roux en-Y
Gastric Bypass
61.2%
Sleeve Gastrectomy
55.4%
Gastric Banding
47.5%
Reference:
Forse, A & Apovian, C. (2016). Bariatric Surgery: What Every Provider
Needs to Know. Thorofare, NJ: SLACK; 79-109.
LAPAROSCOPIC ADJUSTABLE GASTRIC
BANDING (LAGB)
Placement of an adjustable band
on the upper portion of the
stomach creating a small stomach
pouch above the band
Reduces hunger and creates
fullness allowing patients to eat
fewer calories (ASMBS, 2014).
Reference
ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from
http://asmbs.org/patients/bariatric-surgery-procedures
GASTRIC BAND
ADVANTAGES
Reduces the amount of food the stomach can hold
Does not involve cutting the stomach or intestines
Shorter hospital stay (outpatient or 1 night stay)
Is reversible and adjustable
Has the lowest risk of early complications and
mortality among bariatric procedures
• Has the lowest risk of vitamin/mineral deficiencies
• Expected 40-50% excess weight loss
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Reference
ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from
http://asmbs.org/patients/bariatric-surgery-procedures
DISADVANTAGES
• Requires foreign object to be placed in the body
• Requires strict adherence of post operative diet
recommendations
• Possibility for mechanical problems of the band
• Possibility of slippage, erosion or infection of the port
or band
• Slower weight loss than other procedures
Reference
ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from
http://asmbs.org/patients/bariatric-surgery-procedures
EARLY POST OPERATIVE CONCERNS
• Most common post operative concerns include
nausea and dehydration
• Mortality is 0.1%-most often attributed to cardiac
event or pulmonary emboli
• Rarely: bleeding, infection or internal organ
injury….Consider these if patient presents with fever
and pain
Reference:
Forse, A & Apovian, C. (2016). Bariatric Surgery: What Every Provider
Needs to Know. Thorofare, NJ: SLACK; 79-109.
LONG TERM CONCERNS
• Device malfunction: port migration, port infection, tubing
disconnection, tubing kink or port leak
• Band Erosion: often happens years after implantation although
can happen earlier. Patient often asymptomatic but can present
with lack of satiety despite optimal adjustment or with cellulitis
over the access port. Diagnosed with endoscopy and requires
band explantation.
• Band Slip (Pouch Enlargement): Presents with heartburn, reflux,
dysphagia or intolerance to food. Caused by portion of the
pouch lying dependent over the band resulting in improper
emptying. Diagnosed with barium swallow esophagram.
Treatment includes loosening of the band and PPI or sucralfate.
Often needing surgical revision.
• Esophageal Dilation: Presents with dysphagia. Diagnosed on
esophagram. Treated with band deflation.
Reference:
Forse, A & Apovian, C. (2016). Bariatric Surgery: What Every Provider
Needs to Know. Thorofare, NJ: SLACK; 79-109.
CASE STUDY #1
-45 year old female with h/o lap band presents with
dysphagia for 4 months. She reports she has been
waking up at night coughing for the past two weeks
occasionally vomiting. She noticed yesterday that
when she vomited at 2am her morning medications
came up.
WORK UP
Assess: When and where was the lap band placed?
1. When was the last time the patient had any adjustments to her lap
band?
2. What is she eating? Quantity? How quickly?
3. How close to bedtime is she eating her last meal?
4. Daytime reflux? Taking PPI? Abdominal pain or fever?
DDX: Maladaptive eating, reflux, overly tightened lap band, lap band slip
Treatment: Refer patient to bariatric surgeon who performed her surgery if
possible or nearest professional trained in lap band adjustments. Patient will
likely have fluid removed from her band and possible barium esophogram
to verify location of band
CASE STUDY #2
56 year old male presents with c/o heartburn for 3
months worsening over the last month. He states that
in the last week he has vomited daily. He has lost over
100 pounds with lap band surgery and has not
needed to see his bariatric surgeon in over 1 year. He
is very resistant to having fluid removed from his lap
band because he has done so well with maintaining
his weight.
WORK UP
Assess: When and where was lap band placed?
Intake: what, when and how much is he eating? Is he
taking any OTC medications for his symptoms?
DDX: GERD, pouch dilatation, lap band slip,
maladaptive eating
Treat: Refer to patients bariatric surgeon or nearest
professional trained in lap band adjustments. May
consider starting PPI but patient most likely needs
some fluid removed from his band
CASE STUDY # 3
38 year old female presents with redness and
tenderness over her lap band port. Denies having her
port recently accessed and is not having any
nausea, vomiting or heart burn.
WORK UP
Assess: Infection localized? Difficulty eating?
Adequate restriction?
DDX: port site infection, lap band erosion
Treat: May start oral antibiotics. Send referral for
endoscopy to r/o erosion
LAPAROSCOPIC SLEEVE GASTRECTOMY
(LSG)
Is performed by removing 80% of the
stomach creating a tubular stomach
pouch
Causes weight loss by restriction of food
intake (fewer calories in) and also
because of changes in hormones
causing decreased hunger, earlier
satiety and better control of blood
sugars
Reference
ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from
http://asmbs.org/patients/bariatric-surgery-procedures
ADVANTAGES
• Restricts the amount of food the stomach can hold
• Causes rapid weight loss with comparable to the
gastric bypass (>50% EWL)
• Does not require a foreign object to be placed in
the body
• Short hospital stay (typically 1 night)
• Changes gut hormones causing decreased hunger,
suppresses appetite and causes earlier satiety
Reference
ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from
http://asmbs.org/patients/bariatric-surgery-procedures
DISADVANTAGES
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Is non reversible
Can cause long term vitamin deficiencies
Higher complication rate than gastric banding
Can have complication such as:
• Leakage
• Bleeding
• Stricture
Reference
ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from
http://asmbs.org/patients/bariatric-surgery-procedures
IMMEDIATE CONCERNS
• Gastric Staple line leak- Typically present with
unexplained elevated WBC, tachycardia, fever,
abdominal pain or persistent hiccups. Imaging
includes CT scan of Chest and abdomen with IV/PO
contrast or surgical re-exploration (ASMBS, 2015)
• GI Bleed- Presents with drop in hct, tachycardia,
hypotension. Low incidence.
• Gastric outlet obstruction
• Early stricture
• Surgical Site infection
• Early postop Small Bowel Obstruction
References:
ASMBS (2015). Prevention and Detection of Gastrointestinal Leaks.
Retrieved from https://asmbs.org/resources/prevention-and-detection-of-gastrointestinal-leak
LONG TERM CONCERNS
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Leak or fistula
Stricture
Gastric outlet obstruction
Portal/mesenteric vein thrombosis
Gallstones
Severe GERD
LSG CASE STUDY #1
42 year old female presents with fatigue, reported
inability to get fluids down and decreased urine
output. She reports bariatric surgery 5 days ago. She
states she is able to sip on fluids but doesn’t feel like
she is getting in enough fluids. She also reports some
nausea but denies vomiting. She reports she is
passing gas and had a small BM 2 days ago. Patient
is afebrile, B/P 136/64, HR 96, RR 18
PE: Abdomen obese, soft, BS+. Incisions healing
without signs of infection.
WORK UP
Assess- What type of surgery did the patient have? Is
patient tolerating any fluids? Does she have Rx for
antiemetic, is she using them? Is she having pain?
Incisional vs. Visceral. Bowel function? Abdominal
assessment. Has patient contacted bariatric
surgeon?
Treat: Check CBC, CMP. IV LR or NS 1-2liters. IV
antiemetic vs. Oral dissolving. Contact Bariatric
surgeon.
LSG CASE STUDY #2
38 year old male presents with generalized
abdominal pain. He is 1 week s/p bariatric surgery. He
reports he has been able to get small amounts of
liquids down and feels a little bloated. He denies
fever, has been taking his pain medications routinely
for pain. VS: 120/84, HR 122, RR 18, T 98.6
WORK UP
Assess: What type of bariatric surgery did he have?
How much liquid is he tolerating? Last BM? Abd
exam? Has he contacted his surgeon?
Diagnostics: CBC, CRP. CT with IV and water-soluble
PO contrast. Contact bariatric surgeon!! Avoid
endoscopy if patient <4 weeks post-op.
LSG CASE STUDY #3
23 year old female 4 months s/p bariatric surgery
presents with nausea and vomiting. She has lost 70
pounds since her surgery. She had been tolerating
solid food until the last month. She reports she can
tolerate liquids without difficulty but vomits most
solids. She reports some constipation. She is not
having any pain. Her VS are unremarkable.
WORK UP
Assess: What type of bariatric surgery did he have?
How much liquid is she tolerating? Last BM? Abd
exam?
Treat: Increase fluids, laxatives, fiber, activity.
Consider endoscopy to r/o stricture.
GASTRIC BYPASS (GB)
First a small stomach pouch is created
by dividing the top of the stomach
from the rest of the stomach. Next the
intestines are divided and connected
to the new stomach pouch
Works by allowing less intake, the
change in the intestines causes less
absorption of calories and nutrients
and changes in the way food moves
through the stomach and intestine.
Changes in gut hormones producing
earlier satiety, suppressing huger and
changing the way obesity induces
type 2 diabetes
Reference
ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from
http://asmbs.org/patients/bariatric-surgery-procedures
ADVANTAGES
• Produces significant long term weight loss (60-80%
EWL)
• Restricts the amount of food that is consumed
• Produces changes in gut hormones that cause
satiety and reduces appetite
Reference
ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from
http://asmbs.org/patients/bariatric-surgery-procedures
DISADVANTAGES
• More complex surgery than the Gastric band and
sleeve, with more complications
• Can lead to long term vitamin/mineral deficiencies
• Longer hospital stay
• Requires adherence to strict dietary
recommendation
• Requires lifelong adherence to vitamin and mineral
supplementation
Reference
ASMBS (2014).Bariatric surgery procedures. Retrieved from
http://asmbs.org/patients/bariatric-surgery-procedures
IMMEDIATE CONCERNS (1-4 WEEKS)
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Anastomotic leak
GI bleed
Early stricture
Surgical site infection
Early small bowel infection
LONG TERM CONCERNS (>30 DAYS)
• Internal herniation and SBO-SBO is often caused by
internal herniation.
• Stricture-Typically occur at 4-6 weeks post op (can
be later) noted with progressive intolerance to solids
• Marginal Ulcer-Most common in smokers and NSAID
use. Common symptoms include epigastric pain
with eating or spontaneous perforation.
Reference:
Martin, Matthew. (n.d.). Acute Care Surgery Emergencies in the Bariatric Patient: Syllabus. Retrieved from
https://webcache.googleusercontent.com/search?q=cache:CYw5VMFde8kJ:https://www.east.org/content/documents
/43_bariatric_syllabus.pdf+&cd=1&hl=en&ct=clnk&gl=us
INTERNAL HERNIATION
• Most commonly occurring through the mesenteric
defect of the jejunjejunostomy or at Peterson’s
defect (potential space posterior to a
gastrojejunosotmy)
• Symptoms can be mild and non specific. Not
always identifiable on CT scan.
• Can occur at any time after surgery
Reference:
De Bakker, J. K., van Namen, Y. W. B., Bruin, S. C., & de Brauw, L. M. (2012). Gastric Bypass and Abdominal Pain: Think
of Petersen Hernia. JSLS : Journal of the Society of Laparoendoscopic Surgeons, 16(2), 311–313.
http://doi.org/10.4293/108680812X13427982376581
STRICTURE
• Present at >4 weeks post-op
• Presentation usually includes progressive
intolerance to solids but will often tolerate liquids
• EGD is diagnostic of choice
Reference:
Martin, Matthew. (n.d.). Acute Care Surgery Emergencies in the Bariatric Patient: Syllabus. Retrieved from
https://webcache.googleusercontent.com/search?q=cache:CYw5VMFde8kJ:https://www.east.org/content/documents
/43_bariatric_syllabus.pdf+&cd=1&hl=en&ct=clnk&gl=us
MARGINAL ULCER
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Ulceration at the gastrojejunosotomy.
Incidence 2-15%
Typical presentation of epigastric pain with eating
Typically heal with acid suppression and cessation of
smoking and NSAID use.
• Patients can present with abdominal pain, nausea,
vomiting, hematemesis, stomal obstruction or perforation
• Medical management includes PPI and sucralfate for 3
to 6 months. Also rule out of H. Pylori infection and
treatment if indicated.
Reference:
Martin, Matthew. (n.d.). Acute Care Surgery Emergencies in the Bariatric Patient: Syllabus. Retrieved from
https://webcache.googleusercontent.com/search?q=cache:CYw5VMFde8kJ:https://www.east.org/content/documents
/43_bariatric_syllabus.pdf+&cd=1&hl=en&ct=clnk&gl=us
KEY CONSIDERATIONS
• Identify the type of surgery the patient had as
bariatric procedures often get referred to as gastric
bypass.
• Identify patient eating behaviors. Maladaptive
eating can contribute to many abdominal
complaints after bariatric surgery.
• The patients bariatric surgeon should be contacted
with concerns. They are your best resources when
dealing with many abdominal complaints.
CONT…
• Significant weight loss contributes to occurrence of
gallbladder disease. Consider this in your differential.
• Constipation is a common problem in patients s/p
bariatric surgery as the patients diets are typically low in
fiber and high in protein. Calcium supplementation and
decreased fluid intake can also contribute.
• Not all health conditions are associated to a patients
surgical procedure. Common problems still occur in
these patients.
• If the patient is less than 4 weeks s/p bariatric
surgery think “LEAK” either anastomotic or staple
line. Mild elevation in WBC’s, tachycardia and fever
can all indicate a leak.
• Many abdominal complaints with the adjustable
gastric band can be relieved with deflation of the
band!!
OTHER CONSIDERATIONS
• Vitamin and mineral deficiencies: B12, thiamine,
iron, Vitamin A,E,D,K, Zinc and Copper. Can occur
acute or chronically.
• Consider psychological differentials.
Thank You!!