WHAT HAPPENS WHEN ALL ELSE

FAILS? BariatricsFrontiers in Medicine

February 8, 2014

Mary MacGuire, M.D., F.A.C.S.

Your Role

• Advice preop

▫ The effectiveness of diets

▫ Long term result of diets

• Care Postop

▫ Postop Complications

▫ Long Term Metabolic Problems

▫ Every Operation is Different

Preop Choices

Where to go

What operation

Postop Care

frequency

cost

• Helping Your Super Obese Patient

Considerations in Choosing

Surgery• Insurance status

• BMI > 40kg/m2 or uncontrollable metabolic problems with BMI 35 or more

• Ambulatory, Able to travel

• Age, adolescents finished with growth spurt

• Ability to survive surgery

• Comorbidities

• Willingness to make big changes

• Addiction free…..drugs, alcohol, tobacco

Most Important

• Motivation

• Intelligence

• Understanding

• Support

Does it really work

and, does it really matter?• Life expectancy

• Cancer risk

• Lifetime cost of care for comorbidities

▫ Diabetes

▫ Hypertension

▫ Degenerative joint disease

Why is it so hard to lose weight?

• 1. “thrifty” gene

• 2. other genetic and environmental factors

• 3. social and familial pressures

• 4. ghrelin production

• 5. high quality abundant food supply

• 6. decreased activity level

• 7. brain set, hunger/caloric intake

Types of Surgeries

Restrictive Malabsorptive

• Lap band

• Sleeve Gastrectomy

• Vertical banded gastroplasty

� Roux-en-Y gastric bypass

� Biliopancreaticdiversion with duodenal switch

Restrictive vs. Malabsorptive

• Decreased gastric volume

• Delayed emptying

• Divert nutrient flow

• Decrease absorptive surface

• Hormonally alter satiety

All operations can be overcome

• Ingestion of high calorie liquids

▫ Milk

▫ Ice cream

▫ Juice

▫ Soda pop

▫ Alcohol

• Patients unwilling to abstain from these liquids should not be referred for surgery

Calculating Risk

• 1 point each for

▫ Male gender

▫ BMI>50 kg/m2

▫ HTN

▫ Risk of PE

▫ Age > 45

• 4-5 risk ff=mort 7.6%

• 2-3 risk ff=mort 1.9%

• 0-1 risk ff=mort 0.31%

Laparoscopic Adjustable Band

Laparoscopic Adjustable Band

Advantages Disadvantages

• Widely available

• No metabolic complications

• Lowest M&M

• No anastomoses

• Reversible

▫ Pregnancy

▫ Chemotherapy

• Not for the super-obese

• Requires frequent adjustment

• Close follow-up correlates directly with success

• GERD, erosion, slippage

Best for

• Patients without geographic and financial limitations to their access to care

• Patients without severe diabetes

• Patients with a lower BMI

Use is decreasing worldwide

• More bands are removed than are placed worldwide

• Sleeve resection more effective with lower maintenance

Laparoscopic Roux-en-Y

Gastric Bypass

Removes the duodenum and pylorus from the food stream and has 2 anastomoses

Advantages Disadvantages

• Mortality rate < 1 %

• Proven record of long term weight loss

• Deficiencies in Iron, Calcium and B12

• Internal hernias

• Gastric Remnant excluded

• Malabsorption

• Diarrhea, flatulence and dehydration

Laparoscopic biliary pancreatic diversion,

duodenal sw

itch

Sometimes done as a staged procedure in the superobeseRemoves the greater curvature of the stomach, has multiple staple lines

Advantages Disadvantages

• Excellent weight loss, especially for the superobese, BMI>70

• No dumping

• Less risk of marginal ulcer

• Increased food intake does not interfere with weight loss

• Highest complication rate

• Protein and fat soluble vitamin malabsorption

• Iron deficiency

• Diarrhea and flatulence

• Internal hernias

• osteoporosis

Laparoscopic Sleeve Gastrectomy

Probably the most popular bariatric surgery worldwide in the past year

Advantages Disadvantages

• Pylorus and duodenum are still in the food stream

• Safer, shorter surgery

• Increased satiety

• Decreased ghrelin levels

• Significant postop nausea and vomiting requiring medication

• Less wt loss

• Long staple line which may leak and cause a fistula

Especially Beneficial for

Patients with

▫ iron deficiency anemia

▫ on steroids

▫ transplant

▫ arthritis dependent on NSAIDs

▫ autoimmune connective tissue disorder

▫ pre-existing vitamin deficiency

▫ unable to comply with frequent follow-up

Postop Complications

Early Late

• PE

• Leak

• Wound/port infections

• Dumping

• SBO

• Marginal ulcer

• Stomal stenoses

• Vitamin and Mineral deficiencies

• Gallbladder disease

• Weight regain

Pulmonary Embolus

• Leading cause of postop death

• Can occur post-discharge

• Can be confused with leak

• Tachycardia

• Spiral CT angio if not too big for scanner,

• Otherwise, image/explore for leak then anticoagulate

LEAK

• Tachycardia >120 is an emergency, can be PE, leak, infection

• 20% of pts with leaks die, 2nd cause of mort

• Pt may not have fever, guarding or tenderness

• Requires immediate surgical intervention and may require return to bariatric center

Dumping

• Diaphoresis, nausea, diarrhea after eating

• Usually means the pt is consuming high sugar liquids like juice or soda pop

• Advise pt to stop high calorie liquids or their operation will fail

• Increase the protein and fiber in the diet

Cholelithiasis

• 28% of pts need ESLC within 3 years

• Ursodiol for 6 months postop

• ESLC at the time of surgery for all patients with ultrasound-proven gallstones

Weight Regain

• 25-30% of patients at 2-5 years

• Lower with the malabsorptive procedures

• Frequently related to high calorie liquids

• May require surgical revision

Jejunoileal bypass

• An old operation first performed in the 50’s

• Many done in the late 60’s and 70’s

• Require reversal and another bariatric procedure because the operation causes portal hypertension

Wernicke’s Encephalopathy

• Acute on chronic vomiting

• May be slowly progressive

• Any patient who has had a bariatric procedure and who develops nausea and vomiting should be hydrated intravenously and given thiamine

Be willing to treat

• Protein-calorie Malnutrition, esp with the malabsorptive procedures

• Thiamine, calcium and fat-soluble vitamin deficiencies

• Depression

• Iron deficiency anemia

▫ Fe gluconate is absorbed in a non-acid environment

Be Aware that

• The death rate for bariatric surgery patients is 4.6% for the first year, less with youth and restrictive procedures

• The failure rate is 10% for enough wt loss to resolve obesity comorbidities

• Mortality is directly related to patient age and center experience

• <2% of eligible patients have surgery annually

Weight Loss

in a Morbidly Obese Person• Confers a 30-40% reduction in 10 year mortality

• Decreases risk of cardiovascular and neoplastic disease, esp in women

• Is rarely achieved at a level that will change metabolism with CHO or fat restricted low calorie diets

• The increase in ghrelin 6 months after a significant weight loss leads to regain in the majority of dieters

Insurance

• Frequently requires documentation of failure of medically supervised weight loss

• This has no correlation with bariatric surgery success

• Places a barrier many patients do not surmount in order to have surgery

Preop

• A low carbohydrate diet for 2 weeks preopdecreases the size of the liver and makes it more likely that the proposed surgery can be achieved laparoscopically, with lower morbidity and a shorter hospital stay

Questions?