Post-Surgical Care of the Bariatric

Patient

Eve L. Olson, MDMedical Director

St. Francis Weight Loss CenterIndianapolis, Indiana

317-782-7525

1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2008

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2008

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

↑ 1000%

↑ 500%

↑ 300%

Medical Complications of Obesity: Almost every organ system is affected

Phlebitisvenous stasis

Coronary heart disease

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Gall bladder disease

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Gout

Stroke

Diabetes

Osteoarthritis

Cancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostate

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

HypertensionDyslipidemia

Cataracts

Skin

Idiopathic intracranial hypertension

Severe pancreatitis

Number of Bariatric Operations performed in the US from 1992-2006

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

# Bariartric Surgeries

1992 1994 1996 1998 2000 2002 2004 2006

NEJM, R. Steinbrook, 2004/ ASBS

Who Qualifies for Weight-Loss Surgery?

Clinical Terms Used to Describe Various Levels of Body Fat

Normal Weight (BMI 18.5 to 24.9)

Overweight(BMI 25 to 29.9)

Obese(BMI 30 to 34.9)

Severely Obese(BMI 35 to 39.9 )

Morbidly Obese(BMI 40 or more)

BMI 18.5-24.9 BMI 25-29.9 BMI 30-34.9 BMI 35-39.9 BMI>40

Bariatric Surgery IndicationsNIH Criteria

• BMI > 40

• BMI > 35 with Co-morbidities– Type II Diabetes– Obstructive Sleep Apnea– Coronary Artery Disease– Cardiomyopathy– Hypertension– Dyslipidemia

Restrictive Procedures

Gastric Banding Sleeve Gastrectomy

Restrictive + MalabsorptiveProcedures

Roux-en-Y Gastric Bypass Biliopancreatic Diversion with

Duodenal Switch

Efficacy of Bariatric Surgery for Weight Loss

• Mean percentage excess weight loss:– 61.2% - All Patients– 47.5% - Gastric Banding– 61.6% - Gastric Bypass– 70.1% - BPD or duodenal switch

*Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004

Weight Maintenance after Bariatric Surgery

Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

Comparing Weight-Loss Results

Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Surgery, ANZ J Surg, 2004; 74: 200-204.

Gastric Bypass

LAP-BAND

0

1

2

3

4

5

6

7

Control Bariatric Surgery

Long-term Survival with Bariatric Surgery

Rel. Risk = 0.11 (.04-.27)

89% reduction in risk ofdeath over 5 years

Christou et al. Ann Surg 2004;240:416-424

% M

ort

alit

y

D Flum et al. J Am Coll Surg 199:543, 2004

Thi

rty

Day

Mor

talit

yRelationship Between Surgical Experience and Relationship Between Surgical Experience and Perioperative Mortality in Gastric Bypass Surgery Perioperative Mortality in Gastric Bypass Surgery

7%

6%

5%

4%

3%

2%

1%

0%0 50 100 150 200 250 300 350 400 450 500 550 600 650

Chronological case order per surgeon

125 case lifetime bariatric 125 case lifetime bariatric surgery experiencesurgery experience

Is Bariatric Surgery Safe?Is Bariatric Surgery Safe?

Mortality rates after common operations in U.S. hospitalsMortality rates after common operations in U.S. hospitals

Variable Repair of CABG Pancreatic Hip Replacement ASMBS BSCOE

AAA Surgery surgery surgery bariatric surgeryVariable Repair of CABG Pancreatic Hip Replacement ASMBS BSCOE

AAA Surgery surgery surgery bariatric surgery

Hospitals 2485 1036 1302 3445 235operation (n)

Avg. mortality 3.9 3.5 8.3 0.3 0.36rate (%)

Average hospital 30 491 8 24 280caseload

Hospitals 2485 1036 1302 3445 235operation (n)

Avg. mortality 3.9 3.5 8.3 0.3 0.36rate (%)

Average hospital 30 491 8 24 280caseload

Adapted from Dimick J.B., Welch H.G., Birkmeyer, J.D. Surgical mortality as an indicator of hospital quality. JAMA 2004; 292:847-51.Adapted from Dimick J.B., Welch H.G., Birkmeyer, J.D. Surgical mortality as an indicator of hospital quality. JAMA 2004; 292:847-51.

0

1000

2000

3000

4000

Re-admissionswithin 30 days

Re-operationswithin 30 days

In-patientmortality

Post-discharge30 day

mortality

31-90 daymortality

Total mortality(< 90 days)

# o

f ev

ents

4.86 %

2.21 %

0.13 % 0.16 % 0.07 % 0.36 %

0

1000

2000

3000

4000

Re-admissionswithin 30 days

Re-operationswithin 30 days

In-patientmortality

Post-discharge30 day

mortality

31-90 daymortality

Total mortality(< 90 days)

# o

f ev

ents

0

1000

2000

3000

4000

Re-admissionswithin 30 days

Re-operationswithin 30 days

In-patientmortality

Post-discharge30 day

mortality

31-90 daymortality

Total mortality(< 90 days)

# o

f ev

ents

4.86 %

2.21 %

0.13 % 0.16 % 0.07 % 0.36 %

Patient outcomes for all Bariatric Surgeries at 235 SRC Full Approval BSCOE Hospitals

Patient outcomes for all Bariatric Surgeries at 235 SRC Full Approval BSCOE Hospitals

Recognizing Complications

• Over-medication– Anti-hypertensives– Diabetic Medications

• Under-medication– Anti-seizure

• Dehydration– Most common first two weeks post-op– No Thirst

Postoperative Complications Common to all Procedures

• General Complications– Pulmonary embolism– Incisional hernia– Gallstone formation– Major wound infection and seroma– Abdominal fluid collection– Subphrenic abscess– Peritonitis

Procedure-Specific Complications (RYGB)

• Anastomotic or staple-line leak• Acute gastric distention• Staple-line disruption• Stomal stenosis• Stomal ulceration• Small-bowel obstruction• Occlusion of Roux limb• Dumping

Procedure-Specific Complications( gastric banding)

• band slippage

• esophageal dilatation

• erosion of the band into the stomach

• band or port infections

• balloon or system leaks that can diminish weight loss

Band Erosions

Partial Complete

Normal

Absorption

Risk of Vitamin and Mineral Deficiencies Post-op

• Calcium and Vitamin D– Reduced absorption d/t bypassed duodenum, proximal jejunum (R-

en-Y)– Life-long supplements mandatory

• Iron– Absorption decreased d/t decreased contact of food with gastric

acid; reduced conversion of iron from ferrous to ferric form (MVI)• Vitamin B12

– Absorption decreased d/t decreased contact with intrinsic factor– 60% of patients require long term supplementation of B12

• Thiamine– Connection to Wernicke’s syndrome– Cases not well documented

Question and Comments