Medical management

post Bariatric Surgery

Case Study Teaching Workshop

- Severe long-standing obesity with a BMI >50 kg/m2

- Insulin-treated T2DM requiring >100 units of insulin per day

- Arterial hypertension controlled by 3 drugs

- Severe OSA treated by C-PAP

- Divorced, living alone, mildly depressed

- Nibbling during the day, sometimes night eating

- Moderate-to-high alcohol intake at dinner

- Shortness of breath at minimal exertion

- Complete sedentariness

The case of Gianpietro

- Severe long-standing obesity with a BMI >50 kg/m2

- Insulin-treated T2DM requiring >100 units of insulin per day

- Arterial hypertension controlled by 3 drugs

- Severe OSA treated by C-PAP

- Divorced, living alone, mildly depressed

- Nibbling during the day, sometimes night eating

- Moderate-to-high alcohol intake at dinner

- Shortness of breath at minimal exertion

- Complete sedentariness

The case of Gianpietro

Question 1. What are the critical points in T2DM management

in the pre-, peri-, and post-operative phases?

Medical management post BS: T2DM

Medical management post BS: Clinical Case T2DM

• Surgical stress is associated with exacerbation of hyperglycemia in patients with type 2 diabetes and with “stress hyperglycemia” in non-diabetic patients.

• Among hospitalised patients, adverse outcomes (hospital mortality, infection, heart failure after myocardial infarction, need for ICU admission, and increased length of hospital stay) are more frequent in patients with hyperglycemia compared to those with normal glucose levels [Moghissi ES. Addressing hyperglycemia from hospital admission to discharge. Curr Med Res Opin 2010;26:589-98].

• Both before and after adjustment for several possible confounding variables, an HbA1c level of more than 7% was found to be associated with a two-fold increased rate of infectious complications (pneumonia,wound infection, urinary tract infection, or sepsis) in 490 diabetic patients undergoing several types of surgical procedures at a tertiary referral US centre [Dronge AS, Perkal MF, Kancir S, et al. Long-term glycemic control and postoperative infectious complications. Arch Surg 2006;141:375-80].

Peri-operative complications related to type 2 diabetes

Main goals for glucose controls in bariatric patients

Pre-operative phase

Identification of patients with type 2 diabetesOptimisation of metabolic control

HbA1c value of 6.5%-7.0% or less, a fasting blood glucose level of ≤110 mg/dL, and a 2-hour postprandial blood glucose concentration of ≤140 mg/dl.

More liberal preoperative targets, such as a HbA1c of 7-8%, should be considered in patients with advanced micro-vascular or macro-vascular complications, extensive co-morbid conditions, or long-standing diabetes in which the general goal has been difficult to attain despite intensive efforts.

AACE/TOS/ASMBS. Obesity 2013;21:S1-S27.

Medical management post BS: Clinical Case T2DM

Medical Management of T2DM post BS

• Peri- and Post-operative phase

Adjustment of glucose-lowering to the news therapeutic needs

Continued surveillance and preventive diabetes care

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Medical Management of T2DM post BS

Medical Management of T2DM post BS

Algorithm for basal-bolus insulin after surgery

Medical Management of T2DM post BS

For cardiovascular disease, the very high risk that diabetes imparts is unlikely to be

modified quickly, if ever, by amelioration of hyperglycemia, particularly if the usual

coexisting risk factors are still present.

Buse JB et al. Diab Care 2009;32:2133

Medical Management of T2DM post BS

Medical Management of T2DM post BS

Medical Management of T2DM post BS

Medical Management of T2DM post BS

Question 2. What are the critical points in HYPERTENSION management

in the pre-, peri-, and post-operative phases?

Medical management post BS: HYPERTENSION

Sjöström L. New Engl J Med 2004;351:2683

Medical management post BS: HYPERTENSION

Lifestyle, Diabetes, andCardiovascular Risk Factors10 years after Bariatric Surgery

Medical management post BS: HYPERTENSION

Question 3. What are the critical points in OSAS management

in the pre-, peri-, and post-operative phases?

Medical management post BS: SLEEP APNEA

Medical Management post BS: SLEEP APNOEA

Peri-operative complications related to sleep apnoea

LABS Consortium. N Engl J Med 2009;361:445

Medical Management post BS: SLEEP APNOEA

Pre-operative phase

Clinical practice guidelines for the perioperative support of the bariatric surgery recommend standard preoperative management of overweight/obese patients with OSA using continuous positive airway pressure (CPAP), with early resumption of non-invasive ventilation (NIV) in the post-op recovery period.

AACE/TOS/ASMBS. Obesity 2013;21:S1-S27.

Management of OSA in bariatric patients

STOP-BANG questionnaire

S = Snoring. Do you snore louder than talking or loud enough to be heard

through closed doors?

T = Tiredness. Do you often feel tired. Fatigued, or sleepy during daytime?

O = Observed apnea. Has anyone observed you stop breathing during your sleep?

P = Pressure. Do you have or are you being treated for high blood pressure?

B = BMI > 40 kg/m2

A = Age > 50 years

N = Neck circumference > 40 cm

G = Male gender

High risk of OSA is considering if answering yes to three or more questions of the questionnaire.

Medical Management post BS: SLEEP APNOEA

Medical Management post BS: SLEEP APNOEA

Thanks for yourattention !!!

luca.busetto@unipd.it

Luca Busetto

@busetto_luca