Transcript Shedding Health risks with Bariatric Weight Loss Surgery

Shedding Health Risks with
Bariatric Weight Loss Surgery
By Susan Gallagher Camden, RN, CBN,
MSN, PhD
Nursing2009, January 2009
2.5 ANCC/AACN contact hours
Online: www.nursingcenter.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
Bariatric weight loss surgery
(BWLS)
 Patients having BWLS in the U.S. grew
644% from 1995 to 2005
 400,000 had the surgery in 2008
 One reason is growing awareness of
obesity’s effect on morbidity and
mortality
How BWLS combats diabetes
 Obesity is a major independent risk
factor for type 2 diabetes
 In the U.S., most people diagnosed with
diabetes are overweight
 Research shows that 90% of patients
who have BWLS no longer need
medication for diabetes
Who’s a candidate for BWLS?
 National guidelines set forth criteria
- body mass index of 40 kg/m2 or more
- 35 to 39.9 kg/m2 with severe
comorbidities
 Insurance reimbursement looks for
documentation of 3 unsuccessful
attempts at weight-loss programs
Who’s a candidate for BWLS?
 Physical exam to include health and
weight history
 Screening of physical or emotional
disorders
Not considered a candidate if:
 Unstable cardiac or pulmonary condition
 Prader-Willi syndrome
 Known endocrine disease
 Unresolved psychological issues
Typical screening protocol
Preoperative evaluation compromises two
main parts:
 psychological testing
 clinical interview
Psychological testing
 Typically, Minnesota Multiphasic
Personality Inventory-2
 Includes family and social situation
 Any eating disorders or psychological
issues must be addressed
 Patients must be made aware of
commitment to weight loss, exercise,
changes in eating habits postoperatively
Clinical interview
 Consists of comprehensive assessment
of patient’s medical, surgical,
psychiatric, and psychosocial history
 Drug or food allergies
 Alcohol and tobacco use and medication
history
Sorting out surgical options
 Roux-en-Y gastric bypass combines
gastric restriction and malabsorption
strategies, is most common weight loss
procedure performed in U.S.
 Surgeon creates small gastric pouch
with an anastomosis to the jejunum
 Food bypasses 90% of stomach and
duodenum so fewer calories are
absorbed
Sorting out surgical options
 When high-calorie foods reach this limb
of the small intestine, a feeling of satiety
or even discomfort may result, helping
curb the appetite
 Can be done laparoscopically; reduces
consumption and absorption, leading to
weight loss
Sorting out surgical options
 Laparoscopic adjustable gastric
banding: stomach size is limited by
inflatable band placed around fundus of
stomach. Band is connected to SC port
and monitored to ensure regulation of
stoma size to meet patient’s weight and
nutritional needs
Sorting out surgical options
 Primary advantage is that a reduced
amount of well-chewed food enters and
passes through the digestive tract in the
usual manner
 Banding can be performed
laparoscopically, making it less invasive
and a better choice for some patients
Sorting out surgical options
 Biliopancreatic diversion (BPD)
involves removing 75% of stomach and
dividing intestine, with one end attached
to the stomach (alimentary limb)
 Bile and pancreatic juices move though
biliopancreatic limb, which supplies
digestive juices to common limb;
surgeon is able to adjust length of limb
to regulate malabsorptive qualities
Sorting out surgical options
 Adverse reactions: flatus, loose or foulsmelling stools, stomal ulcers, and
severe malnutrition, especially protein,
vitamin, and mineral malnutrition
 Adding duodenal switch to traditional
BPD procedure results in a BPD/DS
procedure, where part of the stomach
is resected, creating a smaller stomach
pouch
Sorting out surgical options
 Distal part of small intestine is then
connected to pouch, bypassing
duodenum and jejunum
 As with any weight loss surgery, protein,
vitamin, and mineral supplements
become part of patient’s everyday life
 Risks for malnutrition are greater with
malabsorptive surgeries, especially BPD
and BPD/DS
Vertical sleeve gastrectomy
 Sometimes called sleeve gastrectomy,
greater curvature gastrectomy, parietal
gastrectomy, gastric reduction, or
vertical gastroplasty
 Restrictive form of weight loss surgery;
approximately 85% of stomach is
removed
 Sleeve-shaped stomach that remains
has capacity of 60 to 150 mL
Vertical sleeve gastrectomy
 In contrast to other forms of bariatric
surgery, outlet valve and nerves to
stomach remain intact; although
stomach is drastically reduced, function
is preserved
 Because pylorus is retained, problem of
dumping is avoided
 Not reversible
Vertical sleeve gastrectomy
 Greatest advantage: doesn’t include
bypass of intestinal tract, avoiding
complications (intestinal obstruction,
anemia, osteoporosis, vitamin and
protein deficiency)
 Because new stomach continues to
function normally, patients face fewer
restrictions on foods they can eat
Vertical sleeve gastrectomy
 Removing most of stomach virtually
eliminates hormones produced within
stomach that stimulate hunger.
 Best suited to patients who are either
extremely obese or who have medical
conditions such as Crohn’s disease that
would rule out intestinal bypass surgery
Vertical sleeve gastrectomy
 Usually a one-step procedure that can
be performed laparoscopically
 Doesn’t provide malabsorption so some
experience disappointing weight loss or
even weight regain
 Patients with high body mass index
often require follow-up weight loss
surgery to achieve goals
Vertical sleeve gastrectomy
 Two-procedure option not only produces
results that patient wants but may also
provide lower overall risk
 Because procedure requires stapling of
stomach, patients run risk of leakage
and other complications directly related
to stapling
 Patients may experience additional
complications (postop bleeding, smallbowel obstruction, pneumonia, death)
Preparing the patient
Patient/family teaching to include:
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early ambulation postoperatively
spirometry for increased lung expansion
pain management
wound care
nutrition instruction (including frequent
small meals and fluids in between)
Postoperative care
 Preventing respiratory complications is a
priority
 Prevention of increased risk of VTE
 Monitor fluid and electrolyte balance
 Monitor nutrition
Long-term implications
 Patient must commit to lifetime monitoring
of height, weight, and nutritional status
 Women should not become pregnant up to
18 months after surgery
 Encourage patient to join a support group
to celebrate and cope with weight loss