Obesity & Related Surgical Procedures
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Transcript Obesity & Related Surgical Procedures
Obesity & Related Surgical
Procedures
RNSG 1247
Obesity and Overweight
Obesity is an abnormal increase in the
proportion of fat cells
Primarily occurs in the visceral and
subcutaneous tissues of the body
Trends in Obesity* Prevalence (%), Children
and Adolescents, by Age Group, US, 19712006
20
18
17
16
16
Prevalence (%)
15
12
11
11
10
10
7
5
7
5
6
5
4
5
0
2 to 5 years
6 to 11 years
NHANES I (1971-74)
NHANES II (1976-80)
NHANES 1999-2002
NHANES 2003-2006
12 to 19 years
NHANES III (1988-94)
*Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sexspecific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight”
to describe youth in this BMI category.
Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National
Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al.
High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05.
Trends in Obesity* Prevalence (%), By
Gender, Adults Aged 20 to 74, US,
†
1960-2006
45
40
35
Prevalence (%)
34
33
35
34 35
36
32
31
28
30
26
23
25
21
20
15
13
16 17
15 15
11
17
12 13
10
5
0
Both sexes
Men
NHES I (1960-62)
NHANES I (1971-74)
NHANES II (1976-80)
NHANES 1999-2002
NHANES 2003-2004
NHANES 2005-2006
Women
NHANES III (1988-94)
*Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population. Source:
National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980,
1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 20032004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National
Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.
Etiology and Pathophysiology
Genetic/Biologic basis
Environmental factors
Psychological factors
** Most common form considered to be
polygenic, arising from the interaction of
multiple genetic and environmental factors
Hormones & Peptides that Interact
with Hypothalamus to Effect Obesity
Fig. 41-3
Classification of Body Weight and
Obesity
Primary obesity (majority of obese)
Excess
caloric intake for the body’s metabolic
demands
Secondary obesity
Results
from various congenital anomalies,
chromosomal anomalies, metabolic problems,
or CNS lesions and disorders
Classification of Body Weight and
Obesity
Body mass index (BMI)
Used
to classify underweight, healthy
(normal) weight, overweight, or obese
Common clinical index of obesity or altered
body fat distribution
Uses weight-to-height ratios
BMI chart
Weight for height chart
Classification of Body Weight and
Obesity
Waist-to-hip ratio (WHR)
Preferred
tool when predominantly muscular
Waist measurement/hip measurement = ratio
WHR <0.80 is optimal
Visceral fat increases risk for cardiovascular
disease and metabolic syndrome
Visceral Fat
Subcutaneous Fat
Classification of Body Shapes
Apple-shaped
body
Fat
located primarily in the abdominal area
At greater risk for obesity-related complications
Android obesity
Pear-shaped
Fat
body
located primarily in upper legs
Gynoid obesity
Classification of Body Shapes
.
Fig. 41-5
Health Risks Associated with
Obesity
Problems occur at higher rates for obese
patients
Mortality rate rises as obesity increases
Especially with increased visceral fat
Obese patients have a decreased quality
of life
Most conditions improve with weight loss
Health Risks Associated with
Obesity
Fig. 41-6
Nursing Problems
Imbalanced nutrition
Chronic low self-esteem
Others related to complications
Planning
Modify eating patterns
Participate in a regular physical activity
program
Achieve weight loss to a specified level
Maintain weight loss at a specified level
Minimize or prevent health problems
related to obesity
Management: Non-surgical
Nutrition
Exercise
Behavior modification
Support groups
Drug therapy
Nutrition
Exercise
Trends in Prevalence (%) of High School
Students Attending PE Class Daily, by
Grade, US, 1991-2007
70
60
Prevalence (%)
50
9th
40
10th
30
11th
20
12th
10
0
1991
1993
1995
1997
1999
2001
2003
2005
2007
Year
Source: Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007
National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and
Prevention, 2008.
Behavior modification
Basic techniques include
Self monitoring
Stimulus control
Rewards – short term vs long term, what’s
acceptable vs unacceptable
Support groups
Drug Therapy
Appetite-suppressing drugs or
Sympathomimetic drugs for _____ term
use
Decrease
food intake through nonadrenergic
or serotonergic mechanisms in the CNS
Phentermine – most commonly prescribed;
causes appetite ___________ and _________
food intake
Other
exs: Diethylpropion, Phendimetrazine
Drug Therapy
Appetite-suppressing drugs or
Sympathomimetic drugs for ______ term
use
Mixed
Do
nonadrenergic–serotonergic agents
not stimulate release of serotonin
Sibutramine (Meridia) – works by increasing
_____________
Drug Therapy
Nutrient absorption-blocking drugs (GI
lipase inhibitors)
Work
by blocking fat breakdown and
absorption in intestine
Orlistat (Xenical)
Drug Therapy
Drugs that ↑ energy expenditure are not
approved by the FDA. Ex: Ephedrine
Appetite-suppressing drugs removed from
market
fenfluramine
(Pondimin)
dexfenfluramine (Redux)
Bariatric Surgery
Used to treat morbid obesity
Currently the only treatment found to
have a successful and lasting impact for
sustained weight loss
Bariatric Surgery
Must meet all of the following criteria to
be considered an ideal candidate
BMI
≥40 kg/m2 with one or more
obesity-related complication
18 years or older
Understands the risks and benefits
Has been obese for >5 years
Has tried and failed to lose weight
Bariatric Surgery
Criteria to be considered an ideal
candidate (cont’d)
Has
no serious endocrine problems
Has psychiatric and social stability
Availability of a team of health care providers
Surgery would ↓ or eradicate high-risk
conditions
Bariatric Surgery
Three broad categories
Restrictive
Malabsorptive
Combination
of restrictive and malabsorptive
Restrictive Surgery
Reduces the size of a stomach to 30 ml or
less
Causes patient to feel full quicker
Normal stomach digestion and intestinal
absorption of food
↓
Risk of anemia and cobalamin deficiency
Restrictive Surgery
Vertical banded gastroplasty
Partitions
stomach into a small pouch in upper
portion
Small pouch drastically limits capacity
Stoma opening to rest of stomach is banded
to delay emptying of solid food from proximal
pouch
Restrictive Surgery
Adjustable gastric banding (AGB)
Also
referred to as the LapBand
Stomach size is limited by an inflatable band
placed around fundus of stomach
Band is connected to a subcutaneous port
Can be inflated or deflated to change stoma
size
Restrictive Surgery
AGB (cont’d)
Can
be done laparoscopically and can be
modified or reversed
Better choice for patients who are surgical
risks
Weight loss is slower than in other procedures
Restrictive Surgeries
Fig. 41-7A
Malabsorptive Surgeries
Biliopancreatic diversion (BPD)
Removes
~3/4 of stomach to ↓ food intake
and ↓ acid output
Remaining 1/4 of stomach is connected to
lower portion of small intestine
Pancreatic enzymes and bile enter final
segment of intestine
Nutrients pass without being digested
Malabsorptive Surgeries
Biliopancreatic diversion with duodenal
switch
Variation
of BPD
By including duodenal switch, surgeons leave
a larger portion of the stomach intact
Helps prevent dumping syndrome
BPD with or w/o doudenal switch
Bariatric Surgeries
How is weight loss accomplished?
What are the specific nutritional risks or
adverse effects?
What should be monitored to avoid
complications?
What is/are the advantage/s over other
procedures?
Combination of Restrictive and
Malabsorptive Surgery
Roux-en-Y surgical procedure
Has
low complication rates
Excellent patient tolerance
Stomach size is ↓ with a gastric pouch
anastomosis that empties directly into
jejunum
Combination of Restrictive and
Malabsorptive Surgery
Roux-en-Y surgery (cont’d)
Variations
Stapling
stomach without transection to create a
small 20- to 30-ml gastric pouch
Creating an upper and lower gastric pouch and
totally disconnecting the pouches
Creating an upper gastric pouch and completely
removing the lower pouch
Restrictive Surgery
Fig. 41-7D
Cosmetic Surgeries
Ideal candidates have
Achieved
weight reduction
Excess skinfolds or fat
Chooses surgery for cosmetic reasons
Lipectomy
Liposuction
Preoperative Care
Room and equipment should consider
patient size prior to arrival
Obtaining IV access maybe complicated
Proper breathing techniques, positioning
Hygiene and skin care prior to admission
Prevention of wound infection and
dehiscence
Postoperative Care
During transfer ensure that patient’s
Airway
is stabilized
Pain is managed
Early __________ is essential
Patients undergoing bariatric surgery are
often in considerable _________ ____
Patient is now _______ ______ due to
anatomic changes
Ambulatory and Home Care
Diet prescribed is generally
High protein
Low in carbohydrates fats & roughage
6 small feedings
Fluids not to be ingested with meals :
< 1000 ml/day
first 24 hrs post-op = water, sugar-free liquids Q 2hrs WA
Day 1 to 2 wks = high protein liquids Q 2hrs WA
2-4 wks = pureed at frequent intervals
4-6 wks = transition diet w/solids & pureed
Ambulatory and Home Care
Possible complications from surgery
Anemia
Vitamin
deficiencies
Diarrhea
Psychiatric problems
Peptic ulcer formation
Dumping syndrome
Small bowel obstruction
Evaluation
Expected outcomes
Long-term
weight loss
Improvement in obesity-related comorbidities
Integration of healthy practices into lifestyle
Monitoring possible adverse side effects
Improved self-image
Gerontologic Considerations
Number of older obese persons has risen
More common in women than men
Decreased energy expenditure and loss of
muscle mass are important contributors
Exacerbates age-related problems
Metabolic Syndrome
A group of risk factors that increase an
individual’s chance of developing
cardiovascular disease and diabetes
mellitus
Metabolic Syndrome
Risk factors:
abdominal obesity, insulin resistance
Diagnostic criteria:
1.
2.
3.
4.
5.
Waist circumference
Triglycerides
HDL
BP
Fasting glucose