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

Support groups
Drug Therapy

Classified into two categories

Drugs that ↑ energy expenditure are not
approved by the FDA
Drug Therapy

Appetite-suppressing drugs
 Decrease
food intake through nonadrenergic
or serotonergic mechanisms in the central
nervous system (CNS)
 Examples of nonadrenergic drugs
 Phentermine
 Diethylpropion
 Phendimetrazine
Drug Therapy

Appetite-suppressing drugs (cont’d)
 Serotonergic
drugs ↑ release of serotonin or ↓
its uptake thus ↓ metabolism
 fenfluramine
(Pondimin)
 dexfenfluramine (Redux)
Drug Therapy

Appetite-suppressing drugs (cont’d)
 Mixed
 Do
nonadrenergic–serotonergic agents
not stimulate release of serotonin
 Sibutramine (Meridia)
Drug Therapy

Nutrient absorption-blocking drugs
 Work
by blocking fat breakdown and
absorption in intestine
 Orlistat (Xenical)

Purchasing over-the-counter drugs should
be discouraged
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
Fig. 41-7A
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 Surgery
Fig. 41-7B
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
Malabsorptive Surgery
Fig. 41-7C
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

Patients who are obese are likely to suffer
other comorbidities, such as
 Diabetes,
altered cardiorespiratory function,
abnormal metabolic function, atherosclerosis

An interdisciplinary team approach may be
necessary
Preoperative Care

Have room ready for patient prior to
arrival
 Larger
size BP cuff, gown
 Bariatric wheelchair
 Or
a wheelchair with removable arms
 Strongly
reinforced trapeze bar over bed for
movement and positioning
Preoperative Care
Wound infection is one of the most
common complications
 Skin preparation is important
 Ask patient to bathe or shower frequently
for a few days before admission

Preoperative Care
Obesity can make breathing shallow and
rapid
 Instruct patient in proper

 Coughing
techniques
 Deep, diaphragmatic breathing
 Methods of turning and positioning to prevent
pulmonary complications
Preoperative Care

Obtaining venous access may be
complicated
Assistance may be needed
 Multiple tourniquets
 May need a longer catheter inserted far
enough into the vein

Preoperative Care

Patients undergoing anesthesia have an
increased risk of failing to wean from
mechanical ventilation
Postoperative Care

During transfer ensure that patient’s
 Airway
is stabilized
 Pain is managed
Postoperative Care
Early ambulation is essential
 Patients undergoing bariatric surgery are
often in considerable abdominal pain
 Patient is now reduced intake due to
anatomic changes

Ambulatory and Home Care

Diet prescribed is generally
 High
protein
 Low carbohydrates
 Low fats
 Low roughage
 6 small feedings
 Fluids not to be ingested with meals
 <1000
ml/day
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
