Transcript Bariatric Procedures, Complications and Follow up 2014

Spire Bushey Hospital
Mr Pratik Sufi
Consultant Bariatric & Upper GI Surgeon
Balancing Activity Levels with Food
Physical Activity
3.
4.
5.
6.
Walking leisurely @ 2mph
85
Walking briskly @ 4mph
170
Gardening
135
Raking leaves
145
Dancing
190
Bicycling leisurely @ 10mph
205
Swimming laps, medium level
240
Jogging @ 5mph
275
Energy Utilisation in Human Metabolism
One small chocolate chip cookie (50 calories) is equivalent to walking briskly for 10 minutes.
The difference between a 80%
large gourmet chocolate chip cookie and a small chocolate chip cookie could be
70%
about 40 minutes of raking leaves (200 calories).
60%
One hour of walking at a moderate
pace (20 min/mile) uses about the same amount of energy that is in one
50%
Physical activity
jelly filled doughnut (300 calories).
40%
A fast food "meal" containing a double patty cheeseburger, extra-large fries Thermic
and effect
a 24 oz. soft drink is equal
Resting metabolism
30%
to running 2½ hours at a 1020%
min/mile pace (1500 calories).
One tsp sugar (20cal) ≈ 4 min
walk
10%
One can coke (160cal) ≈ 30 0%
min walk
% of Energy Use
1.
2.
Calories Burnt /
30 minutes
Low activity
Moderate activity
Activity Level
High activity
Dietary Change
Obesity Associated Co-morbidities
Pulmonary Disease
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•
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Abnormal Function
Obstructive Sleep Apnea
Hypoventilation Syndrome
Asthma
Hepato-pancreato-biliary Disease
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•
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•
•
Steatosis (NALD)
Steatohepatitis (NASH)
Cirrhosis
Gall Bladder Disease
Pancreatitis
Herniae
• Umbilical
• Ventral
• Inguinal
Gynecologic Abnormalities
• Abnormal Menses
• Infertility
• Polycystic Ovarian Syndrome
Musculoskeletal
• Osteoarthritis
• Gout
Cerebral
• Idiopathic Intracranial Hypertension
• Stroke
Cataracts
Coronary Heart Disease
•
•
•
•
Diabetes
Dyslipidemia
Hypertension
CCF
GI
• GORD & Hiatus Hernia
Cancer
• Breast, Uterus, Cervix,
• Colon, Esophagus, Pancreas,
• Kidney, Prostate
Vascular
• Phlebitis / DVT
• Venous stasis
• Leg ulcers
Skin
• Dermatitis
• Leg ulcers
Obesity OnLine Slide
Presentation. Accessed May
17, 2007. Accessible as
slide #5 at
http://www.obesityonline.or
g/slides/slide01.cfm?tk=33.
Impact of Obesity on GP Consultations
Brown WJ et al. Int J Obes 1998;22:520-528.
20
25
30
35
40
BMI
• Low BMI was associated with fewer physical health problems than mid-level or higher BMI.
• Indicators of health care use showed a J-shaped relationship with BMI for general practitioners (>5 GP
Consultations).
• Prevalence of medical problems (for example, hypertension OR 6x and diabetes OR 6x), surgical procedures
(cholecystectomy OR 7x and hysterectomy OR 2x) and symptoms (for example, back pain OR 40% and
constant tiredness OR 70%) increased monotonically with BMI.
Effect of Diet and Surgery on Weight & Mortality
•Diet & exercise effective up to 6m
•60% failure at 1 yr.
•80% failure at 2 yrs.
•100% failure at 5 yrs.
•Surgery effective long-term (80%)
Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects N Engl J Med 2007;357:741-52.
Low Risk
Primary Obesity Options Today
More Effective
Less Effective
Diet/
Drugs
Endolumenal
Obesity
Gastric
Balloon
POSE
Endosheath
20-60%
Low efficacy – less durable weight loss
Moderate risk / efficacy – intermediate durability
Effective but unacceptable risk
High efficacy – durable weight loss
40-95%
Surgery
Abandoned
Surgery
VBG
Jejuno-Ileal
Bypass
High Risk
Lap
Band
Sleeve
Gastrectomy
Gastric
Bypass
BPD/DS
Procedure Comparison
Procedure
Mechanism of
action
EBWL
(2 year)
Invasiveness /
Durability
Follow-up
Gastric balloon
Restrictive
10-20%
Minimal/Short-term
Intensive/6-24m
POSE
Restrictive
20-40%
Minimal/Long-term
Minimal/12-24m
Endosheath
Diversion
30-50%
Minimal/Short-term
Intensive/12-24m
Gastric band
Restrictive +
Neurostimulation
50-60%
Moderate/Long-term
Intensive/Life-long
Gastric plication
Restrictive
40-60%
High/Unknown
Modest/Life-long
Sleeve
Restrictive +
Endocrine
60-80%
High/Long-term
Modest/Life-long
Gastric bypass
Restrictive +
Bypass-Diversion +
Malabsorption
70-90%
High/Long-term
Intensive/Life-long
Duodenal switch
Restrictive +
Bypass-Diversion +
Malabsorption
90-100% Very high/Long-term
Intensive/Life-long
Referral - Minimal Dataset
 Age
 Weight & BMI
 Co-morbidity esp.
 cardiovascular
 respiratory
 endocrine
 GI and
 musculo-skeletal
 Medication
 Previous attempts at weight loss
 Other concerns like
 Untreated eating disorders
 Psychiatric history
NICE: BMI≥35
ASMBS: BMI≥30
Asians: BMI 2 points lower
Pre-operative Liver Shrinkage Diet
Slimfast –900 kcal/d approximately
Meal/Snack
Product
Amount
Calories
Protein (g)
Breakfast
Slimfast shake
1 serving
220 / 230
14 / 15
Morning snack
Slimfast shake
1 serving
220 / 230
14 / 15
Food-based – 900 kcal/d approx.
Food group
No of servings
Fruit
2
or Slimfast meal
Vegetables
3
replacement bar
Carbohydrates
3
Lunch
Slimfast shake
1 serving
220 / 230
14 / 15
Dairy
2
Dinner
Slimfast shake
1 serving
220 / 230
14 / 15
Protein
3
Totals
880-920
56-60
Fats
2
Two (2) weeks
Four (4) weeks
Pre-operative Special Considerations
 Hypertension control
 ACE Inhibitors
 AT2 receptor antagonists
 Glycaemic control
 Oral hyperglycaemic agents
 Insulin
 Anticoagulation
 Warfarin
 Clopidogrel
 Aspirin
 OSA
 CPAP
 GORD
 PPI
 NAFLD / NASH
 Liver shrinkage diet
Post-operative Regime
 Liquids only for 2-3 weeks
 Soft blended food for 2-3 weeks
 Resume solids after 4-6 weeks
 Small mouthfuls
 Chew well
 Eat slowly
 Separate eating and drinking by ½ hour
 Avoid fizzy / sugary drinks or sugary food
 Medication – liquid / soluble (crushed)
 Supplements
 Iron
 Calcium and vitamin D
Recommended Multivitamin and minerals:
 Vitamin B12
Chewable versions:
•
Bassett’s Adult Chewable multivitamins with prebiotics & minerals
 Folic acid
•
Wellkid Smart / Sanatogen A-Z Kids Chewable
•
Haliborange Chewable multivitamins
 Vitamin B1
Whole tablet:
•
•
•
Sanatogen Gold or Centrum (after 3 months)
Plus
Chewable Calcium – 1000mg calcium /day
Liquid iron or iron drops - 50mg of iron/day
Post-operative – Suitable Fluids D0-W2
 Milk - Aim for at least two pints (1.2L) of milk or a milk
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alternative a day
Milk can be flavoured with Nesquick or low calorie hot
chocolate
Slimming drinks e.g. Slimfast or chemist/supermarket own
brand
Complan or Build-up shakes or soups
Yogurt drinks and smoothies
Still mineral water, if taking the flavoured types make sure
they are low sugar
Still low-sugar squashes
Smooth soups e.g. cream of tomato or chicken; or oxtail
Tea and coffee without sugar
Unsweetened pure fruit juice
Post-operative Special Considerations
 Diet
 Not allowed to eat and drink together
 Eat slowly, chew well – at least 20-30 minutes
 Liquids for 24-48hours after band adjustment
 Return to work
 Change in medications
 Restrictions on tablets – soluble, liquids or crushed tablets
 Change in co-morbidity
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Antihypertensive
Oral hyperglycaemic agents
Insulin
 Change in absorption
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
Warfarin
Oral contraceptives
 Avoid pregnancy for 18 months
 Risk to mother
 Risk to foetus
Long-term Follow-up
 Pins and needles (B12, B1)
 Frequent falls (B12, B1, Fe)
 Tiredness (anaemia, hypoglycaemia)
 Generalised pain (PTH)
 Abdominal pain (ulcer, gallstones / hernia / kidney stones)
 Reflux / regurgitation/ N&V / persistent cough (band slippage, over-tight
band, ulcer, hiatus hernia)
Calcium supplements- 1000mg calcium / day. Liquid or effervescent tablets
Ferrous Sulphate/ ferrous fumarate or sodium feredetate – drops, syrup or
sugar free elixir. 50mg of iron/day
Hydroxocobalamin Vitamin B12 injections – 1mg every 3 months
Nutritional Deficiencies
Mechanism
Prevalence
Clinical
Protein
Intake, absorption,
Distal RYGB 6-13%
Standard RYGB 0%
Peak 1-2 yrs
Loss of muscle,
weakness, oedema, etc.
Iron
Intake, Acid
exposure,
absorption
2 yr: 33%
Anaemia, tinnitus, hair
loss
Vitamin B12
(cobalamin)
Reduced acid,
?IF link
1 yr: 12 – 70%
Within 2yrs: 25%
Anaemia, macrocytosis
Calcium &
Vitamin D
Intake, absorption,
HyperPTH
Distal RYGB:
2yr Ca 10%,
MBD –
Osteomalacia,
osteoporosis
Vit D 51%
BPD
Ca 25-50%, Vit D 17 – 50%
Liposoluble
Vitamins (A, E,
K)
Reduced fat
breakdown
RYGB: very low
BPD (4yr): A-69%, K-68%, E-4%
A: night blindness
Zinc
Absorption –
dependent on lipids
Surgical stress
RYGB: rare
BPD: 10 – 50%
Hair loss
Diagnosis and Treatment of Nutritional Deficiencies
Deficiency
Symptoms
and signs
Confirmation
Treatment
first phase
Treatment
second phase
Protein
malnutrition
Weakness, decreased
muscle mass, brittle hair,
generalized oedema
Hypocalcaemia, tetany,
tingling, cramping,
metabolic bone disease
Serum albumin and
prealbumin levels,
serum creatinine
Total and ionized
calcium levels, intact
PTH, 25-D, urinary Ntelopeptide, bone
densitometry
Blood cell count,
vitamin B12 levels
Protein supplements
Enteral or parenteral
nutrition; reversal of
surgical procedure
Calcitriol oral vitamin
D 1,000 IU/d
Oral crystalline B12
350 mg/d
1,000 –2,000
mg/2–3 months im
Cell blood count,
folic acid levels,
homocysteine
Blood cell count, serum
iron, iron binding
capacity, ferritin
Oral folate, 400 mg/d
(included in
multivitamin)
Ferrous sulphate 300
mg 2–3 times/d,
taken with vitamin C
Oral folate, 1,000
mg/d
Vitamin A levels
Oral vitamin A,
5,000–10,000 IU/d
Oral vitamin A,
50,000 IU/d
Calcium/
Vitamin D
Vitamin B12
Folic acid
Iron
Vitamin A
Pernicious anaemia,
tingling in fingers and
toes, depression,
dementia
Macrocytic anaemia,
palpitations, fatigue,
neural tube defects
Decreased work ability,
palpitations, fatigue,
koilonychia, pica,
brittle hair, anaemia
Xerophthalmia, loss
of nocturnal vision,
decreased immunity
Calcium citrate
1,200–2,000 mg,
oral vitamin D
50,000 IU/d
Parenteral iron
administration
An Endocrine Society Clinical Practice Guideline
Schedule for Clinical and Biochemical Monitoring
TESTS
Pre-operative
1 month
3 months
6 months
Complete blood count
X
X
X
X
X
X
X
X
LFTs
X
X
X
X
X
X
X
X
Glucose
Creatinine
Electrolytes
Iron/ferritin
X
X
X
X
X
X
X
X
X
X
X
X
X
Xa
X
X
X
Xa
X
X
X
Xa
X
X
X
Xa
X
X
X
Xa
Vitamin B12
X
Xa
Xa
Xa
Xa
Xa
Folate
Calcium
Intact PTH
25-D
Albumin/prealbumin
X
X
X
X
X
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Xa
Vitamin A
X
Optional
Optional
Zinc
X
Optional
Optional
Optional
Xa
Xa
Xa
Optional
Optional
Bone mineral density and
body composition
Vitamin B1
Optional
X
Optional
Optional
12 months 18 months 24 months
Optional
Optional
Xa – Tests should only be performed after RYGB, BPD, or BPD/DS.
X – Tests suggested for patients submitted to restrictive surgery where frank deficiencies are less common.
An Endocrine Society Clinical Practice Guideline
Annually
Post-Bariatric Surgery Complications
Pulmonary Disease
Pneumonia / Atelectasis
Cerebrovascular Disease
• Wernicke’s Encephalopathy (Beriberi)
• Stroke / TIA
Malnutrition
Glossitis, stomatitis
Hair loss
HPB Disease
• Hepatitis (trauma)
• Pancreatitis (trauma)
• Cholecystitis
Renal Disease
• Kidney stones
Gynecologic Abnormalities
• Amenorrhoea
• Fertility – failure of contraception
CV Disease
• MI
• DVT / PE
• Beriberi
GI Disease
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•
•
•
•
•
Bleeding
GORD & Hiatus Hernia
Ulcer
Bloating / Obstruction
Diarrhoea / Constipation
Malabsorption
Bone Disease
• Osteomalacia
Malnutrition
• Dermatitis
• Neuropathy
• Ataxia
General complications
 Immediate post-operative – infection, bleed, thromboembolism
 Tiredness, pain, ulcers, dry skin, pins and needles, hair loss etc. (Nutritional deficiency –
Iron, Calcium, Vitamin D, Folate, Vitamin B12, Vitamin B1, Zinc)
 Nausea, vomiting (Slipped band, over-restriction, hiatus hernia, gallstones, anastomotic
ulcer, GLP-1 excess, internal /port-site hernia etc.)
 Hernia – port-site, incisional
Band Complications
 Slippage (Pain, N&V)
 Erosion (Pain, N&V, loss of restriction)
 Oesophageal dilation (Regurgitation, N&V, persistent cough)
 Infection (Pain, local inflammation, systemic sepsis)
 Nutritional deficiency (tiredness, hair loss)
 Gallstones (Pain, N&V, Jaundice)
 Hiatus hernia / GORD (Regurgitation, heartburn, dysphagia)
Sleeve Gastrectomy Complications
 Staple line leak (pain, N&V, sepsis)
 Staple line bleed
 Reflux (regurgitation, heartburn, dysphagia)
 Sleeve dilation (weight regain)
 Nutritional deficiency (tiredness, hair loss, pain)
 Gallstones (pain, dyspepsia, N&V, jaundice)
Gastric Bypass Complications
 Staple line leak (pain, N&V, sepsis)
 Staple line bleed
 Ulcer (pain, N&V, dysphagia)
 Stenosis (dysphagia, pain, N&V, regurgitation, excessive weight loss)
 Dumping (giddiness, tiredness, tachycardia, cramps)
 Internal hernia (cramps, bloating, constipation)
 Gallstones (pain, N&V, Jaundice)
 Nutritional deficiency (tiredness, hair loss, pins and needles, pain, ulcers)
Balloon Complications
 Intolerance (nausea & vomiting, cramps)
 Ulcer (epigastric pain)
 Deflation and migration (bowel obstruction)
POSE Complications
 Perforation
 Bleeding
 Intolerance (nausea & vomiting, cramps)
 Ulcer (epigastric pain)
Pain
 Gallstones
 Pancreatitis
 Anastomotic ulcer
 Perforation / Anastomotic leak
 Gastric band erosion
 Slipped gastric band
 Dumping syndrome
 Anastomotic stricture
 Small bowel obstruction
 Gastro-gastric fistula
Nausea & Vomiting
 Pregnancy!
 Gastroenteritis
 Gastric balloon intolerance
 Over-restricted gastric band
 Anastomotic ulcer
 Anastomotic / Sleeve gastrectomy stricture
 Gallstones / Pancreatitis
 Hiatus hernia
 Internal hernia / Small bowel obstruction
Diarrhoea
 Gastroenteritis
 Bacterial overgrowth
 Clostridium difficile
 Fat malabsorption
 Dumping syndrome
 Lactose intolerance
Case Study 1
 Mr A, 32 year old publican, gastric
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bypass 3 year ago, lost 85% excess
body weight
Tripping over repeatedly – 4 months.
Nausea and vomiting, pins and
needles in hands and feet
Investigate / Treat / Refer to hospital
– Emergency / Urgent / Routine?
GP referred patient to neurologist
Differential diagnosis: Thiamine /
Vitamin B12 deficiency
Investigation: RBC thiamine / Serum
Vit B12 + ECHO + MRI brain
Treatment: Thiamine 100mg bd for
12 weeks
Thiamine Deficiency
 Beriberi
 Wernicke’s encephalopathy
 Confusion, irritability,
memory loss, nervousness,
speech difficulties
 SoB, orthopnoea,
tachycardia
 Constipation, digestive
problems, loss of appetite
 Numbness of hands and
feet, pain sensitivity, poor
coordination, weakness,
absent knee and tendon
reflexes, paralysis
Case Study 2
 Mrs B, 42 year old housewife,
gastric band 2 years ago, lost
64% excess body weight
 Sudden onset epigastric pain and
dysphagia
 Investigate / Treat / Refer to
hospital – Emergency / Urgent /
Routine?
 Differential diagnosis:
 Band slippage
 Band erosion
 Investigate:
 Contrast swallow
 CT abdomen
 OGD
 Band slippage – Emergency
band deflation + reposition /
removal
Band slippage
 Epigastric pain
 Dysphagia
 Weight regain
Band erosion
 Epigastric pain
 Loss of restriction
 Weight regain
 Band infection
Case Study 3
 Mrs X, 37 year old writer, gastric
bypass 6 months ago, lost 45% excess
body weight
 Intermittent epigastric pain and
nausea
 Investigate / Treat / Refer to hospital
– Emergency / Urgent / Routine?
 Differential diagnosis:
 Anastomotic ulcer
 Gallstones
 Internal hernia
 Investigate:
 USS, Contrast swallow, CT abdomen,
OGD
 Diagnosis: Gallstone cholecystitis
 Treatment: Laparoscopic
cholecystectomy
Anastomotic ulcer
 Epigastric pain, heartburn
Gallstones
 Epigastric / RUQ pain, N&V,
Pancreatitis
Internal hernia
 Abdominal cramps after eating,
constipation, bloating, acute
abdomen
Case Study 4
 Mr Y, 27 year old computer analyst,
gastric bypass 3 years ago, lost 75%
excess body weight
 Abdominal pain, bloating, nausea
and diarrhoea
 Refer to hospital – Emergency /
Urgent / Routine?
 Differential diagnosis:
 Bacterial overgrowth
 Malabsorption
 Internal hernia
 Investigate:
 Bloods, ABG, CT abdomen, D-Xylose
test, Hydrogen breath test, Stool
culture, Faecal fat
 Diagnosis: Bacterial overgrowth
 Treatment: Correct nutritional
deficiencies and Metronidazole +
Live yogurt / Neomycin + Rifampicin
Bacterial overgrowth
 Abdominal cramps, diarrhoea,
borborygmi
Malabsorption
 SoB, orthopnoea, tachycardia
Internal hernia
 Abdominal cramps after eating,
constipation, bloating
Case Study 5
 Ms Q, 42 year old teacher, gastric
band 2004, lost 60% excess body
weight
 Cough, reflux and water brash for
the last 3 weeks.
 Investigate / Treat / Refer to
hospital – Emergency / Urgent /
Routine?
 GP started her on Amoxicillin and
referred for an OGD
 Differential diagnosis: RTI, band
slippage, over-restricted band
 Investigation: Gastrograffin
swallow + OGD
 Treatment: Band volume
reduction - defill
Over-restricted band
 Cough, reflux and water brash
 Unable to tolerate solids
 Unable to lie down without
coughing
Band slippage
 Epigastric pain
 Intolerant to solids / liquids
 Weight regain
Take Home Message
 Bariatric surgery is a cost-effective treatment for
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obesity which leads to resolution of co-morbidities,
improved quality of life and increased life expectancy
However, patients need lifelong follow-up after surgery
in order to avoid harm – this can be performed by their
surgical team and by the primary care.
Patients can present with nausea, vomiting, dysphagia,
reflux, abdominal pain and neurological symptoms.
Common things are common!
Nutritional deficiencies are common and easily
preventable.
Thank you!