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Till Death Do We Part The Life-long Journey of a Bariatric Surgical
Patient
Tina Musselman MA, RD, CCN
St. James Center for Bariatric Surgery
Program Coordinator
(708) 679-2717
Mind, Body & Wellness Institute, Inc.
(708) 846-5816
Obesity…Intervention
Diet Physical Activity
Lifestyle Modification
Pharmacotherapy
Surgery
BMI
25
30
35
http://cme.medscape.com/viewarticle/712986?src=cmemp&uac=98478HV
Phentermine, Meridia, Xenical
(Byetta), Band(?)
RYGB, AGB (BMI 30),
Duodenal Switch,
Gastric Sleeve
The Reality of Bariatric Surgery
# of bariatric cases grew 400% from 1998-2004
– 13,386 to 121,055 per year
– 220,000 performed in 2008
82% of surgical cases are female
Age
– Ages 18-54 accounted for 85.2% of all surgeries
– FASTEST GROWTH IN BARIATRIC SURGERY IS FOR
AGES 55-64 (20 fold increase)
RD’s can run, but we cannot hide! Healthcare Cost and Utilization Project, Statistical Brief #23 (January 2007)
Eligibility BMI
– BMI 35-39.9 with 1 - 2 obesity-related co-morbidities (DM, HTN, dyslipidemia, severe OA, OSA, Pickwinian Syndrome)
– BMI > 40
– New indications for Lap Band - BMI 30-34.9 (not covered by insurance yet)
Age
– Adults over 18
– Controversy over 65 y.o. - evaluated case by case
– Adolescent trials are currently being done
Growth must be completed
Some insurances may cover it
“Exhausted all non-surgical weight loss options”
Adjustable Gastric Band
(Lap Band® & Realize Band)
1988 approved by FDA in
June 2001
15 ml pouch
Adjustable stoma size
Digestive tract remains in tact
2/2011 - Lap Band approved for
BMI 30-35 + co-morbids
Roux en Y Gastric Bypass
(RYGB)
1971
15-30 ml pouch (getting smaller)
Roux limb 75-150 cm
– Longer in Super Obese
Biliopancreatic Limb
– Carries gastric juice
– Bile and Pancreatic juice
– 15-60 cm
Distal Common Channel
– 200-500 cm
– All of the ileum and some jejunum
– Bulk of digestion and absorption
RYGB vs. AGB (Lap Band)
RYGB AGB
Weight Loss
70% EBW at 1 yr.
20# wt regain around 2 yrs.
Post-op
50% EBW at 2 yrs
Wt loss may stabilize at 4 yrs
post op
Short Term
Complications
1 yr. post op
0.5% mortality
Similar to any surgery
Anastomotic Leak
Stomal Stenosis (4.9%)
Internal Hernia (2.5%)
Gallstones (1.4%)
Suture Line Ulcers (1.4%)
Staple Line Failure (1.0%)
Bleeding (0.9%)
Death (0.6%)
Dehydration
Hair Loss (iron and
Protein)
0.1% mortality
Similar to any surgery
Gallstones
Dehydration
RYGB AGB
Long-Term
Complications Hypoglycemia
Gastro-gastric Fistula
Stomal Stenosis
Bowel Obstruction
Nutritional (peaks >5 yrs.
post op)
- B12, Folic Acid, Iron,
Calcium, Vit D
Weight Regain
Loss of LBM
Vomiting more common
Gastric prolapse
Obstruction
Esophageal and pouch
dilation
Gastric erosion and
necrosis
Port access problems
Weight regain
Misc… Dumping Syndrome
Gradual shift away from
solid food
RYGB vs. AGB (Lap Band)
Treatment and Outcomes, FNCE Pre-symposium Workshop by Chris Eagon, MD; October 2005
5 year comparison
Band has the highest safety profile for all bariatric procedures
The “new kids on the block” in bariatrics
Laparoscopic Sleeve Gastrectomy
Gastric Plication
Laparoscopic Sleeve gastrectomy
Partial Gastrectomy (60-80% removed)
Small bowel remains intact
Founded as part of the first step in a two step surgical process for the super obese
New- more to learn about sustainability and safety
Results similar to RYGB
SG
Weight Loss 62-69.4% EBW loss at 18 mos
Short Term
Complications
1 yr. post op
Similar to any surgery
bleeding
Fistula
Stenosis/obstruction
Staple line leak
GERD (0-83%)
Long Term
Complications
Gerd (5% at 2 yrs)
Nutritional deficiencies ?
?
Chouillard et al. Laparoscopic RYGB vs Sg for morbid obesity: Case controlled study.. SOARD 2011; 7: 500-505.
Micronutrition Concerns
Malnutrition is “any disorder of nutrition status including disorders resulting from
a deficiency of nutrient intake, impaired nutrient metabolism, or over nutrition.” - Tucker et al., Med Clin N Am, p. 499
– Obesity is a form of malnutrition
Other contributors to pre-op deficiency
– Overfed but undernourished
– Polypharmacy
– Fat sequesters fat soluble vitamins
– Comorbidities create greater nutritional demands
Micronutrition
Factors common to all procedures that increase
nutritional risk
– Poor eating behaviors,
– Decreased nutrient dense foods
– Food intolerance
– Restricted portion sizes
– (Emesis)
Micronutrition - Gastric Bypass
Etiology:
– GERD (PPI’s)
– Emesis
– transit time/diarrhea
Most common deficiencies
– Iron (20-51%): HCl
– B-12 (35%): HCl, IF
– Vit D
– Ca
– Folate (41-47%)
Micronutrition - Gastric Bypass
Etiology:
– GERD (PPI’s)
– Emesis
– transit time/diarrhea
Most common deficiencies
– Iron (20-51%): HCl
– B-12 (35%): HCl, IF
– Vit D
– Ca
– Folate (41-47%)
63% of pts developed nutrition
deficiencies (Fe, B12, folate) 2 yrs.
Post RYGB including those who
were compliant with the vitamin
regimen. (n=140)
- Brolin, et al 1991
Micronutrition - Sleeve gastrectomy
Etiology
– transit time
– Emesis/Nausea
– GERD (PPI’s)
– HCl
Common nutrient def.
– B12: 18% ?
– Fe: 18% ?
– Zn: 35% ?
– Folic Acid?
– Vit D?
Micronutrition - Sleeve gastrectomy
Little data on micronutrition and SG
1 yr. results without MVI
– 4.9-43% Fe def.
– 9-18.1% B12 def.
– 9.8-22% folate def.
Jacques, J., Goldenberg, L. Nutrition and the sleeve gastrectomy patient: From micronutrients
to dietary patterns. Bariatric Times 2011; 8(6):12-15.
Micronutrition - AGB
Etiology
– po intake
– Food intolerance
– Maladaptive eating
Micronutrition - AGB
Etiology
– po intake
– No alterations to
digestive processes
-“AGB has minor effects on normal physiological
digestive processes and, as a result, selective
nutritional deficiencies are presumed to be
unusual…Closer clinical follow up is more
necessary (adjustments) after AGB than RYGB,
whereas the reverse is true for perioperative
nutritional evaluations.”
- Ziegler, O., Sirveaux, MA, et al, Diab. & Met. 2009, p. 544 & 553
Micronutrition - Summary
AGB RYGB SG
Protein - + -(?)
Iron + ++ +
B12 + ++ +(?)
Ca/D - or + ++ -(?)
Folate + + +
B1 + + +(?)
Zn/Se + ++ (?)
A, E, K - - or + -
Vomiting ++ ++ +
- very rare
+ rare
+ frequent
++ very frequent
Ziegler, O., Sirveaux, MA., et al. Medical follow up after bariatric surgery: nutritional and drug issues General
recommendations for the prevention and treatment of nutritional deficiencies. Diab. & Metab 2009; 35: 544-557.
The Standard Supplementation
“There is little agreement on exactly how to manage micronutrition
in post-operative bariatric surgery patients.” - Jacqueline Jacques, ND Micronutrition for the Weight Loss Surgery Patient (2006)
Many patients will be malnourished pre-operatively leading to
more aggressive supplementation after surgery
– 51-62% pre-operative Vit D deficiency
Obese individuals may have needs above and beyond normal
recommendations
– Contributing mechanisms
Multiple medications
Years of poor diet
Underlying inflammation
Recommended Supplementation
AGB RYGB/SG
Multiple vitamin
1,500 mg Calcium
B complex
Bile salt replacement
Multiple vitamin x 2 (100% RDA
including iron)
Sublingual B12
2,000 mg Ca + D
Thiamin (B complex)?
Supplemental iron for menstruating
women?
Bile salt replacement prn
Tablets or capsules can be tolerated 6 mo. and beyond
Multiple Vitamin and Calcium should not be taken together and
should be in divided doses
Bariatric AND Metabolic Surgery
Diabetes &
Comorbidity
Improvement + =
A “CURE” for Diabetes
% improved/resolved
All procedures
78.1%
60% at 2 yrs post op
RYGB 75% @ 6 mos
86% @ 18 mos
SG 48% @ 6 mos
62% @ 18 mos
AGB 72% @ 2yrs
40% remission @ 5yrs
32% improved @ 5 yrs.
Surgical Impact on Gut Hormones
Mechanism of Action RYGB SG
Ghrelin
Hunger & Appetite
Insulin Sensitivity
PYY Hunger
Satiety
Gastric emptying
HCl
insulin sensitivity
beta cell fxn
GLP1 Hunger
Satiety
Gastric emptying
insulin release
insulin sensitivity
beta cell fxn
Medical Therapy vs RYGB vs SG
Medical Therapy
N=41
RYGB
N=50
SG
N=49
% EBW loss 13% 88%* 81%*
HgA1c < 6.0% 12% 42%*
37%*
Pre-op >3 Rx
Postop >3 Rx
61%
72%
52%
0%*
47%
10%*
STAMPEDE trial 12 months
(Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently)
Average disease duration > 8 yrs and HgA1c 8.9-9.5% pre intervention
F/u with diabetes specialist q 3 months
Schaur, P. et al. Bariatric surgery vs. intensive medical therapy in obese patients with diabetes. N Engl J Med 2012. Doi 10.1056/NEJMoa12002255.
Long-term Diabetes Resolution Remission depends on
– Duration of the disease prior to surgery
The earlier on in the disease state the patient receives treatment, the greater chance for remission
– Beta Cell Function
– Sustenance of lifestyle change and diet
Long-term - remission is weight dependent
“Diabetes is resolved for, on average 10 years after bariatric surgery.” - J. Dixon
“There is emerging evidence that body weight is defended by powerful physiological mechanisms making long-term maintenance of weight loss difficult” - IDF statement, 2011
?
Where the Rubber Meets the Road
Surgery is not a miracle, it is a tool
20-30% of patients fail to reach the typical post operative
weight loss goal
The most successful patients after ANY procedure make the
lifestyle changes
Plateau or Weight Regain
“Stress with clients that they will rarely be able to attain
a weight lower than their minimum adult weight.”
Maintain 48-74% of initial loss 5 years s/p surgery
Maintain 50% initial weight loss at 15 years s/p surgery
- Nancy Bradley, FNCE October 2005
600 RYGB pt’s with a 96% f/u rate
– 14 years post op mean EBW lost exceeded 50%
– AORN Journal May 2004 vol. 79(5).
Rules of the Road
1. Eat slowly… but not too slow
- Use smaller plates, consume what a 2-5 yr. old would eat
- Practice mindful eating
2. Avoid eating and drinking at the same time
- most caloric beverages should be avoided
- No juices, even if they are 100%
- “coffee” is no longer coffee
3. Choose PROTEIN and PRODUCE
- Nutrient dense, low calorie foods
- Whole grains and other low glycemic load
carbohydrates should be chosen last
- Increase Fiber Intake
- Diet about 1200-1400 calories/day
4. Eat only when hungry: avoid snacks
- Snacking is typically associated with junk food
- Snacking can turn into snacking, grazing picking.
Rules of the Road
5. Choose nutrient dense foods
- Low in calories and contribute to calorie deficit
- Nutritional powerhouses
- “Undiet” the patient
- Ask yourself “What is in this food that is making me healthy?”
Rules of the Road
To Choose
Nutrient Dense Foods
To Avoid
Empty Calorie Foods
- Apples/Fruit
- Sugar Free Yogurt
- Low-fat Dairy
- Vegetables
- Protein Bar (no sugar)
- White meat poultry
- Broccoli
- Non-fried fish
- Lean ground beef
- Eggs
- Salad
- Pretzels
- Sugar free ice cream
- Sugar free cookies
- Chex Mix or trail mixes
- Bread
- 100 calorie pack
- Stuffing
- Mashed potatoes
- Chips
- Rice cakes
- Most “diet” foods
Rules of the Road
6. Increase physical activity
- Increases insulin sensitivity
- Increases PYY and GLP1
- Focus on increasing activities of
daily living
- Consistent “intentional” physical
activity
- Allow non-sugar starches only if the
patient is active enough to burn
them off.
RMR
(50-65%)
Thermogetic Effect of Food
Planned Activity
NEAT
(Non-exercise Activity
Thermogenesis)
15-50%
To
tal D
aily E
ne
rgy E
xp
en
dit
ure
Movement and Activity Pyramid
Incidental movement
Low impact – long
time walking
Aerobic
Elite
high impact
Many people over the age of
30 who exercise regularly at
the gym etc. use less energy
than their “unfit” colleagues
because they “compensate”
with a decrease in incidental
movement
Weight re-gain…where do I start?
Have patient keep a 3-5 day food log or 1 day recall
– Maladaptive Eating/Soft Calorie Syndrome?
– High fat?
– High calorie?
– High in simple carbohydrates?
– Choosing nutrient dense foods?
Review beverage intake
– Eating and drinking at the same time?
– High caloric beverages?
Review meal patterns
– Grazing, picking or snacking?
Assessment of physical activity
Consult with surgeon to ensure integrity of the surgery
Behavioral health consultation (CBT) or support group
Adult Obesity…Relapse Prevention
Obese and reduced obese must accept that obesity requires
life-long management
– Acknowledge dysfunctional fat cells and propensity to gain
weight
Weight regainers
– Burned 800 fewer calories per week
– Decrease in food restraint
Obesity…Intervention
Diet Physical Activity
Lifestyle Modification
Pharmacotherapy
Surgery
BMI
25
30
35
http://cme.medscape.com/viewarticle/712986?src=cmemp&uac=98478HV
Phentermine, Meridia,
Xenical (Byetta)
RYGB, AGB, Duodenal
Switch, Gastric Sleeve
Despite all we know about obesity
and what we still have to
uncover…there is no magic bullet.
Long-term weight loss will come
from burning more calories than is
consumed. What we CAN do is
help individuals find the tools to
make successful and enduring
change.
Thank You!
St. James Center for Bariatric Surgery
Program Coordinator
(708) 679-2717
Mind, Body & Wellness Institute, Inc.
(708) 846-5816
Tina Musselman RD, CCN
Gastric Plication
Dr. Vafa Shayani ,FASBMS
Bariatric Institute of Greater Chicago
Medical Director St. James Center for Bariatric Surgery
Chicagobanding.com
Greater Curvature Gastric Plication
Mobilization of the greater curvature of the stomach
May mimic SG restriction with fewer risks
Infolding/imbricating the stomach to achieve gastric restriction
Does NOT involve gastric resection, intestinal bypass, implantation of a foreign
device
Unlikely that ghrelin levels are altered
Greater Curvature Gastric Plication May lead to increased speed of gastric emptying - J. Dixon
Complications
– Mild to moderate nausea - short term
– Fold disruption
– Suture line leak
– Prepyloric perforation
– “kinking of the stomach”
– No late complications noted
Summary of % EBW loss
– 1 mo: 20 - 21.4%
– 1 yr: 61 - 69.6%
– 18 mo: 62%
– 2 yrs: 60%
– 3 yrs: 57%
Brethauer, S., et al. Laparoscopic gastric plication for treatment of severe obesity.
Surgery for Obesity and Related Diseases 2011; 7: 15-22.
4 studies available of < 300 patients
“this could potentially provide a lower risk alternative that will appeal to patients and referring physicians.”
Procedures should be considered investigational and should be performed under a study protocol and IRB or other third party oversight
Greater Curvature Gastric Plication
ASMBS Policy Statement
ASMBS Executive Council. ASMBS policy statement on gastric plication. Surg Obes Relat Dis 2011; 7:262.
LAGB + Plication: Preliminary Results
LAGBP = Laparoscopic Adjustable Gastric Banded
Plication
– Can be a primary or “salvage” procedure for failure
with AGB
n=26 (16 female, 10 male)
BMI of 39.4 + 4 kg/m2
Used the Swedish Adjustable
Gastric Band
Huang, C.-K. et al. Novel bariatric technology: Laparoscopic adjustable gastric banded plication:
technique and preliminary results. Surg Obes Relat Dis 2012; 8:41-47.
Band was adjusted only 1 time
Complications
– 1 pt c prolonged emesis
rehydrated in ER resolved 1 wk
post op
– 1 gastrogastric intussusception
– 1 subQ tube kinking
Benefits
– Quicker wt loss than AGB alone
– Reversible
– nutritional risk vs RYGB or SG
“findings similar to Sleeve
Gastrectomy”
LAGB + Plication: Preliminary Results
% EBW Loss s/p LAGBP
21.9
31.9
41.3
53.2
59.5
0
10
20
30
40
50
60
70
1 mo.
(n=26)
3 mo.
(n=24)
6 mo
(n=18)
9 mo
(n=10)
12 mo
(n=5)
Time
% E
BW
lo
ss
Huang, C.-K. et al. Novel bariatric technology: Laparoscopic adjustable gastric banded plication:
technique and preliminary results. Surg Obes Relat Dis 2012; 8:41-47.
Thank You!
Dr. V. Shayani [email protected]