Obesity and Bariatric Surgery

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Objectives

• Describe what obesity is and the co-mobidities associated with obesity.

• Explain why losing weight is so difficult for some and how weight loss surgery can help.

• Discuss the differences between the 4 most common bariatric surgeries performed: adjustable gastric band, sleeve gastrectomy, roux-en-y bypass, duodenal switch.

• List potential complications of bariatric surgery and the signs and symptoms.

• Describe the post op pathway of the bariatric surgical patient and identify key factors for success.

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Obesity Facts

• Morbid obesity is the first epidemic of the 21st century

• It is the second leading cause of preventable deaths in the United States second only to cigarette smoking.

• Approximately 300,000 deaths per year are associated with obesity compared to 400,000 deaths annually from cigarette smoking.

U.S. Department of Health and Human Services 2001: Medsurg Nursing June 2006

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Obesity Defined

• Obesity is a disease characterized by Body Mass Index (BMI)

BMI = body weight (kg)

height (meters) 2

• Class I Obesity BMI 30-34.5• Class II Obesity BMI 35-39.9• Class III Obesity BMI >40

Typically over 100 lbs over ideal body weight

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Conditions affected by obesity

• Gastroesophageal reflux

• Depression• Infertility• Increased cancer

risk• Degenerative joint

disease

• Diabetes• Coronary artery

disease• Hypertension• Obstructive sleep

apnea• High cholesterol

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Who is a candidate for surgery?

• BMI >40 or BMI >35 with related medical conditions (diabetes, HTN, sleep apnea)

• Healthy enough for surgery

• Support system from family/friends

• Understanding of bariatric surgery and its risks

• Motivated to make long term changes in lifestyle.

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Why Surgery?

• Most effective tool to achieve and maintain weight loss in most patients.

• Resolves potentially fatal co-morbid conditions such as diabetes and hypertension.

• Improves quality of life.

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Who is a candidate for surgery?

• Willing and able to participate in long-term follow up care

• No chemical or alcohol dependency

• Smoking cessation prior to surgery 6 months

• No active hepatitis C

• Avoid pregnancy for 1-2 years

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Pathway for surgery

Consultations

•Psychology

(1-3 sessions)•Dietitian

(2-5 sessions)•Pharmacist•Exercise program

Pre-op goals

•10% weight loss•Begin liquid diet•Start exercise program

Medical Evaluation

•Consultation with surgeon•If GERD – endoscopy•If gallstones - ultrasound•Primary Care ProviderSleep Study

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Surgical Options

Restrictive:

•Adjustable gastric band

•Vertical sleeve gastrectomy

Malabsorptive and Restrictive

•Roux-en-y gastric bypass

•Duodenal switch

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Adjustable Gastric Banding

• Band placed around upper stomach• Port inserted under the skin that

allows the size of the band to be adjusted therefore slowing the passage of food.

• Gives the sensation that the stomach is full.

• No change in how food is absorbed in the intestines.

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Sleeve Gastrectomy

• Creation of gastric “sleeve” by removing a portion of the stomach.

• Gives you a decreased hunger sensation.

• Food is absorbed normally in the rest of the digestive tract.

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Roux en Y Gastric Bypass

• Creation of a “pouch.”• Intestine is divided and reattached.• Food goes down the esophagus and

into the new pouch and bypasses approximately 150cm of the small intestine.

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Duodenal Switch

• Creation of a gastric “sleeve” which is connected to the lower part of the digestive tract.

• Less absorption of calories and nutrients.

• Higher risk of malnutrition.

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Perioperative Considerations

Obesity hypoventilation syndrome (also known as Pickwickian syndrome)•Severely overweight people tend to breathe shallow and not rapidly enough (hypoventilation)•Increased C02 levels (hypercapnia)•Many also with obstructive sleep apnea•Increased heart strain and can lead to heart failure.•Associated symptoms may include depression and hypertension. •Cor pulmonale: can occur in up to 1/3 of all OHS patients (peripheral edema, ascities, exertional chest pain, heart murmur, hepatomegaly)

AORN Journal July 2008 Vol 88 No 1

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Perioperative Considerations

Medication absorption concerns

It may take more medication to attain and maintain proper levels of anesthesia due to: •Fat tissue delays absorption of medication•Fat tissue stores medications

AORN Journal July 2008 Vol 88 No 1

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Perioperative Considerations

Airway Challenges

•Failed intubation: greatest risk – difficult airway cart readily available. Consider: fiber optic intubation, Glidescope, rapid induction, blankets under shoulders to achieve “sniffing” position.

•Low chance for successful mask ventilation

•Reduced oxygen reserve – decompensates quickly

•High rates of oxygen consumption

•Difficult vocal cord visualization

•Decreased neck mobility

•OSA – use home CPAP in PACU

•I.S – begin in PACU

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Perioperative Considerations

Vascular System

•Prone to cardiac disease (due to HTN, diabetes, hyperlipidemia)

•Increased incidence of DVT

•Veins may be difficult to access

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Perioperative Considerations

Musculoskeletal and Nervous System•Obese patients are more prone to positioning injuries – due to strain that excessive weight places on their musculoskeletal system.•Pressure points well padded.•Intra-abdominal view – may need reverse trendelenburg or lateral tilting.

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Perioperative Considerations

Moving and Transferring Obese Patients

•Focus on patient and staff safety

•Using available devices: hovermatt, lifts, appropriate slings, stand assists etc.

•Chairs & tables (all positions) that can handle the weight of the patient.

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Postoperative Care in the Hospital

Day of Surgery•Strict NPO

•Ambulate q2hrs

•Sequential sleeves and subcutaneous heparin

•I.S q1hr while awake

•Continuous oximetry overnight

•Home CPAP overnight if applicable.

•Manage nausea – IV Zofran, S.L. Levsin, Scopolamine patch, Compazine.

•Manage pain – IV Dilaudid/Morphine and IV Ativan., ice packs, abd binder when up.

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Postoperative Care in the Hospital

Day of Surgery (continued)

•Antiulcer agents: Pepcid, Protonix, Prevacid.

•Anti-hypertensives as needed

•Sliding Scale insulin as needed.

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Upper GI early post op day 1 –water soluble esophagram

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Post op Day 1

Upper GI early AM•Assess for any obstruction or leak•If UGI ok: begin ½ oz sips of water slowly advancing to once ounce of bariatric clear liquids. •Home later that day if tolerating clears and co-morbid conditions stable ie: HTN and blood sugars etc.

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Follow up

• F/u call by nurse coordinator first week post op

• Community paramedic visits x 2. One 30 minute visit 1-2 days after discharge. One 15 minute visit 2nd or 3rd week post discharge.

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Follow upImportant Appointments After Surgery:•Community paramedic visit 1-3 days after discharge•1 week after surgery- See your surgeon for a postoperative visit. 763-780-6699•4 weeks after surgery-See your surgeon for follow up •5-6 weeks after surgery-See the Bariatric Nurse Coordinator and Dietitian. This is important prior to starting a regular diet to review how to advance your diet and for meal planning. •3 months-Follow up with Coordinator•6 months –Follow up with Surgeon•9 months-Follow up with Coordinator•12 months-Follow up with Surgeon•Yearly follow up for the rest of your life!

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Risks of Surgery

• Operative mortality in 1-30 days after surgery is 0.25%

*Often associated with type of surgery• Surgical complications

* Blood clots (PE/DVT) * Pneumonia

* Heart attack/stroke * Wound infection

* Dehydration * Leak

CALL SURGEON if severe shoulder pain, fast heart rate or difficulty breathing occur

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Risks and Benefits of SurgeryASMBS – American Society for Metabolic and Bariatric

Surgery

30 day mortality

Leak Re-operation

Decrease in BMI after one year

Sleeve 0.08% 0.3% 1.5% 30%

RYGB 0.14% 0.4% 7.7% 40%

Band 0.03% 15.3% 20%

• Risk of death about 0.1% - overall likelihood of major complication is 4%

• Mortality and complication rates lower than typically associated with hip replacement surgery.

• One study compared sleeve and RYGB –no difference in weight loss after two and five years.

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QUESTIONS?