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Shedding Health Risks with Bariatric Weight Loss Surgery
By Susan Gallagher Camden, RN, CBN, MSN, PhD
Nursing2009, January 20092.5 ANCC/AACN contact hoursOnline: www.nursingcenter.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
Bariatric weight loss surgery (BWLS)
Patients having BWLS in the U.S. grew 644% from 1995 to 2005
400,000 had the surgery in 2008
One reason is growing awareness of obesity’s effect on morbidity and mortality
How BWLS combats diabetes Obesity is a major independent risk
factor for type 2 diabetes
In the U.S., most people diagnosed with diabetes are overweight
Research shows that 90% of patients who have BWLS no longer need medication for diabetes
Who’s a candidate for BWLS?
National guidelines set forth criteria- body mass index of 40 kg/m2 or more- 35 to 39.9 kg/m2 with severe comorbidities
Insurance reimbursement looks for documentation of 3 unsuccessful attempts at weight-loss programs
Who’s a candidate for BWLS?
Physical exam to include health and weight history
Screening of physical or emotional disorders
Not considered a candidate if: Unstable cardiac or pulmonary condition
Prader-Willi syndrome
Known endocrine disease
Unresolved psychological issues
Typical screening protocol
Preoperative evaluation compromises two main parts:
psychological testing
clinical interview
Psychological testing Typically, Minnesota Multiphasic
Personality Inventory-2
Includes family and social situation
Any eating disorders or psychological issues must be addressed
Patients must be made aware of commitment to weight loss, exercise, changes in eating habits postoperatively
Clinical interview Consists of comprehensive assessment
of patient’s medical, surgical, psychiatric, and psychosocial history
Drug or food allergies
Alcohol and tobacco use and medication history
Sorting out surgical options
Roux-en-Y gastric bypass combines gastric restriction and malabsorption strategies, is most common weight loss procedure performed in U.S.
Surgeon creates small gastric pouch with an anastomosis to the jejunum
Food bypasses 90% of stomach and duodenum so fewer calories are absorbed
Sorting out surgical options
When high-calorie foods reach this limb of the small intestine, a feeling of satiety or even discomfort may result, helping curb the appetite
Can be done laparoscopically; reduces consumption and absorption, leading to weight loss
Sorting out surgical options
Laparoscopic adjustable gastric banding: stomach size is limited by inflatable band placed around fundus of stomach. Band is connected to SC port and monitored to ensure regulation of stoma size to meet patient’s weight and nutritional needs
Sorting out surgical options
Primary advantage is that a reduced amount of well-chewed food enters and passes through the digestive tract in the usual manner
Banding can be performed laparoscopically, making it less invasive and a better choice for some patients
Sorting out surgical options
Biliopancreatic diversion (BPD) involves removing 75% of stomach and dividing intestine, with one end attached to the stomach (alimentary limb)
Bile and pancreatic juices move though biliopancreatic limb, which supplies digestive juices to common limb; surgeon is able to adjust length of limb to regulate malabsorptive qualities
Sorting out surgical options Adverse reactions: flatus, loose or foul-
smelling stools, stomal ulcers, and severe malnutrition, especially protein, vitamin, and mineral malnutrition
Adding duodenal switch to traditional BPD procedure results in a BPD/DS procedure, where part of the stomach is resected, creating a smaller stomach pouch
Sorting out surgical options Distal part of small intestine is then
connected to pouch, bypassing duodenum and jejunum
As with any weight loss surgery, protein, vitamin, and mineral supplements become part of patient’s everyday life
Risks for malnutrition are greater with malabsorptive surgeries, especially BPD and BPD/DS
Vertical sleeve gastrectomy
Sometimes called sleeve gastrectomy, greater curvature gastrectomy, parietal gastrectomy, gastric reduction, or vertical gastroplasty
Restrictive form of weight loss surgery; approximately 85% of stomach is removed
Sleeve-shaped stomach that remains has capacity of 60 to 150 mL
Vertical sleeve gastrectomy
In contrast to other forms of bariatric surgery, outlet valve and nerves to stomach remain intact; although stomach is drastically reduced, function is preserved
Because pylorus is retained, problem of dumping is avoided
Not reversible
Vertical sleeve gastrectomy
Greatest advantage: doesn’t include bypass of intestinal tract, avoiding complications (intestinal obstruction, anemia, osteoporosis, vitamin and protein deficiency)
Because new stomach continues to function normally, patients face fewer restrictions on foods they can eat
Vertical sleeve gastrectomy
Removing most of stomach virtually eliminates hormones produced within stomach that stimulate hunger.
Best suited to patients who are either extremely obese or who have medical conditions such as Crohn’s disease that would rule out intestinal bypass surgery
Vertical sleeve gastrectomy
Usually a one-step procedure that can be performed laparoscopically
Doesn’t provide malabsorption so some experience disappointing weight loss or even weight regain
Patients with high body mass index often require follow-up weight loss surgery to achieve goals
Vertical sleeve gastrectomy
Two-procedure option not only produces results that patient wants but may also provide lower overall risk
Because procedure requires stapling of stomach, patients run risk of leakage and other complications directly related to stapling
Patients may experience additional complications (postop bleeding, small-bowel obstruction, pneumonia, death)
Preparing the patient
Patient/family teaching to include:
early ambulation postoperatively spirometry for increased lung expansion pain management wound care nutrition instruction (including frequent
small meals and fluids in between)
Postoperative care Preventing respiratory complications is a
priority
Prevention of increased risk of VTE
Monitor fluid and electrolyte balance
Monitor nutrition
Long-term implications
Patient must commit to lifetime monitoring of height, weight, and nutritional status
Women should not become pregnant up to 18 months after surgery
Encourage patient to join a support group to celebrate and cope with weight loss