Transcript Bariatric Surgery - An Opportunity for Changex

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Define the extent of the problem
Discuss which weight loss methods are available
Determine who is a good candidate for bariatric
surgical procedures
Describe bariatric surgical procedures; differentiate
between bariatric surgical procedures in regard to
invasiveness, potential complications,
adjustability, and reversibility
Discuss the improvement and resolution of
comorbidities of obesity after bariatric surgery
Define the NP’s role in providing post-operative
support and management
According to the CDC (2011):
* Approximately 195 million Americans are
overweight – that’s 63% of the total population
* About half of these people are considered
obese
* 8-12 million are “morbidly obese”
* Obesity-related conditions include heart
disease, stroke, type 2 diabetes and certain
types of cancer - some of the leading causes of
preventable death.
* In 2008, medical costs associated with
obesity were estimated at $147 billion
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Calculated using height and weight
BMI is calculated by weight in pounds
multiplied by 703 and divided by height in
inches squared
BMI < 19 is considered under a healthy weight,
BMI 19-24 is healthy weight, BMI 25-29 is
overweight, BMI 30-34 is obese I, BMI 35-39 is
obese II, BMI 40 or greater is obese III
V Codes for billing by BMI category is V85.00V85.40
BMI controversial - but the best we have for
ease, price and accepted universal description
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We no longer have to gather, hunt for, or
prepare our own food
We no longer build our own shelter or walk to
get to one place or another
We are at the top of the food chain; we no
longer have to run from predators
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Increased Portion Size
Stress Eating
Socioeconomic Aspect
Comfort Foods
Fats and Carbohydrates are very satisfying
Quick energy boost from high calorie
sweeteners
No knowledge of how to prepare foods
Bad foods hidden behind good labels
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We no longer need to walk
Sedentary Leisure Activities
Sedentary Jobs
P.E. class
“Exercise used to go by another name – it was
called survival” - David Katz
Type 2 Diabetes
Cancer
Hypertension
Degenerative Joint Disease
Heart Disease
Infertility/PCOS
High Cholesterol
Pseudotumor Cerebri
Reflux Disease
Incontinence
Sleep Apnea
Psychosocial Problems
Venous Stasis Disease
Injuries
First Line : Basic Intake and Exercise
* Decease caloric intake/day; 1200/day for women
and 1600/day for men
* Better food choices; decrease carbohydrates,
eliminate fats, cut down on sodium
* Menus and food choice lists very helpful
* Increase zero and low-calorie fluid intake; at least
64 ounces/day
* Exercise; walking, combo of cardio and
strength/resistance training
* Gym membership, YMCA, community centers,
civic groups, parks, community pools, home
exercise equipment/videos, or no equipment at all
Second line: Diets and Medications
* Diets that incorporate all food groups; Weight
Watchers, South Beach, Mediterranean
* Diets that incorporate weigh-ins, ‘buddy’ support,
and meetings
* Rx and OTC medications: Amphetamines,
Phentermine (Adipex, Fastin, Pondimen), Xenical
(Orlistat), Meridia (Sibutramine), HCG, Prozac,
Wellbutrin
***Keep in mind that this may be the first time you see
the patient in the primary care setting. So much
information is available commercially and on-line that
they are only there to see you for a prescription.
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They don’t work very well for very long
3-5% of people succeed in long term weight
loss by diet and exercise alone
They don’t cure the comorbidities
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Laparoscopic Adjustable Gastric Band (LAGB)
Laparoscopic Sleeve Gastrectomy or Gastric
Sleeve Resection (GSR)
Vertical Banded Gastroplasty (VBG)
Roux-en-Y Gastric Bypass (RYGB)
Gastric Balloon Procedure – used mostly in
Europe and Asia. Not FDA approved in US,
although clinical trials are being performed in
the US (Houston)
Gastric
Gastric
Gastric
Banding
Bypass
Sleeve
Gastric Banding
Gastric Bypass
Gastric Sleeve
Invasiveness
Minimally invasive, no
rerouting or partial removal of intern.organs
Stomach stapling and
rerouting of the
intestines are required
Stapling and removal
of part of the stomach
are required
Adjustability
Yes
No
No
Reversibility
 Chart
but extremely
Yes
No
of comparison
of Yes,
bariatric
surgeries
difficult
Restrictive/
Malabsorptive
Restrictive
Restrictive and
Malabsorptive
Restrictive and
Malabsorptive
Short Term
Complications;
(within 30 days)
Bleeding (0.6-4%),
wound infection (315%), PE & DVT, CV
(12.5-17.6) and Pulm
(3-7%) complications,
acute stomal
obstruction (<1-14%)
Bleeding (0.6-4%),
wound infection (315%), PE & DVT, CV
(12.5-17.6) and
pulmonary (3-7%)
complications, Leaks
(1-6%)
Bleeding (0.6-4%),
wound infection (315%), PE & DVT, CV
(12.5-17.6) and
pulmonary (3-7%)
complications, Leaks
(1-6%)
Long Term
Complications;
(after 30 days)
Band erosion, band
slippage or prolapse,
port infection, port
tubing or band
malfunction,
esophagitis, cholelithiasis, esophageal or
pouch dilation, hiatal
hernia
GI bleeding due to
marginal ulcers,
stomal stenosis,
hernias, cholelithiasis,
short bowel and
dumping syndromes,
micronutrient
deficiencies, renal
failure, changes in
GI bleeding at staple
line, stenosis  gastric
outlet obstruction,
GERD, Leaks,
dumping syndrome,
micronutrient
deficiencies (not
enough long-term data
to rule out other
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Wants to look better in a bikini?
Wants to shed a few excess holiday pounds?
Knows several people/relatives who have had
bariatric surgery and wants to try it too?
Wants to quickly get in shape for the class reunion
next month?
Wants to use up funds in their health savings
account or flex-spending account at the end of the
year?
Has lots of money and doesn’t know what else to
do with it?
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Those who wish to decrease the risk of dying
Those whose risk of dying, illness, and/or
disability is higher than the risks of the
operation
Those who wish to improve their quality of life
and decrease costs of living
To reduce pain and suffering due to
comorbidities
Those who have seriously considered and
accept necessary lifestyle modifications and
risk of operative and long-term complications
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BMI equal or greater than 40
BMI equal or greater than 35 with 1 or more
comorbidities
BMI equal or greater than 30 with 2 or more
comorbidities
Those who have multiple documented
attempts at weight loss through
diet/exercise/medication
Those who are psychologically stable with no
substance abuse
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Complete H&P
PMH, Family Medical Hx, Social Hx,
(including drugs, ETOH, smoking), Allergies,
Medications, Wt Loss Hx, Surgical Hx, Typical
Eating and Exercise Hx, PE
Diagnostics
Lab Studies, Mallampati, EKG, PFT, Epworth
Sleepiness Scale, Oximetry. If clinically indicated:
Sleep Study, EGD, CXR
Consults
Psych, Cardiology, Pulmonary, Hematology
(not routine – only if clinically/PMH indicated)
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Patients on immunosuppression s/p organ
transplant; routine steroid Rx for
COPD/arthritis on a case by case basis
Schizophrenia
Scleroderma
Significant esophageal dysmotility syndrome
as evidenced by abnormal manometry studies
Significant prior GI surgery as in resection for
PUD/tumor; failure of prior RYGB, VBG, or
GSR on a case by case basis for possible GB
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Inability to ambulate (WC or bedbound)
Untreated substance abuse
Untreated eating disorders
Severe anxiety disorder
Crohn’s disease
Untreated OSA
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Success in long-term weight loss is 50-80%
depending on the procedure selected.
Expected Improvement in:
Diabetes II
50-95%
Hypertension
60-92%
GERD
80-98%
Dislipidemia
76-97%
OSA
65-75%
Stress Urinary Incontinence
45-87%
Degenerative Joint Disease
42-82%
Primary Care
Practitioner
Exercise
Physiologist,
Nutritionist,
Registered Dietician
Lifestyle
Counselor
Surgical Team
Medical Consultants:
Cardiologist,
Endocrinologist, GI,
Sleep Specialist,
Psychologist,
Psychiatrist
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Reinforce proper eating and exercise behaviors;
these must change permanently for success
Food tolerances may change
Dumping Syndrome with ingestion of sweets
and carbohydrates
Body image changes and relationship changes
are stressful and may lead to depression and
anxiety; new lifestyle changes may strain even
previously healthy family/social relationships
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Patient should avoid caffeine, alcohol and
carbonated beverages
Do not drink for 30 minutes before or after a meal
Drink slowly – fast may stimulate vomiting
No drinking through a straw
A meal should be no more than a cup (8 oz) of
food
Gastric Bypass and Sleeve patients should avoid a
large amount of carbohydrates or sweets at one
time
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All medications ordered post-op must be
chewable, liquid, capsules that can be opened,
tablets that are very small (no bigger than a baby
aspirin) or tablets that can be cut to that size
Must take MVI and possible supplementation with
Ca, Fe, B vitamins, Vitamin D, and protein to avoid
such issues as hair loss/thinning, muscle loss, bone
loss, low body iron stores, and/or tiredness
People may still be unhappy with physical
appearance – sagging skin, stretch marks
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The primary care NP has the unique
opportunity to be the first practitioner that the
patient comes to with GI and psychosocial
issues. Do not hesitate to call on the bariatric
team, psychologists, nutritionists and other
specialists to assist with the healthcare
problems that may arise.
There are risks of serious operative
complications, especially when a patient is not
compliant. Please be on the lookout for these
and alert the bariatric team/ED as necessary.