bariatric surgery for the primary care physician - the family
TRANSCRIPT
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The Family Physician’s Role in Managing the Bariatric Surgery Patient
B. Wayne Blount, M.D., MPH
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Objectives
Discuss non-surgical and surgical weight management options
Identify appropriate surgical candidates and counsel patients about the importance of compliance with the post-operative regimen
Review the current surgical treatment options and their effectiveness including possible side effects and complications
Discuss follow-up care and long-term management of the post-bariatric surgical patient
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The Obesity Epidemic
67% are overweight or obese
$117 billion spent in 2000 to treat the medical consequences of overweight and obesity
112,000 deaths/year attributed to obesity*
*Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual cause of death in the United States. Journal of the American Medical Association, 291 (10), 1238-1245.
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The Obesity Epidemic
“CLINICIANS SHOULD SCREEN ALL ADULT PATIENTS FOR OBESITY AND OFFER INTENSIVE COUNSELLING & BEHAVIORAL INTERVENTIONS TO PROMOTE SUSTAINED WEIGHT LOSS FOR OBESE PATIENTS”
B Recommendation USPSTF
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The Obesity Epidemic
Use : BMI : tables Waist
Circumference : Measured @
narrowest part of waist between lower rib cage & unbilicus
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Health Burden
Type 2 diabetes Hypertension Cardiovascular disease Stroke Dyslipidemias Osteoarthritis Cancers Sleep apnea Gall bladder disease Female infertility Psychological issues
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Popular diets: reduce caloric intake by restricting certain foods and limiting portions, i.e. by counting calories, fat or carbs
Medically supervised diets Very Low Calorie Diets (VLCD) Liquid Fasts
Referral to a nutritionist or dietician Exercise regimens Medications (sibutramine, orlistat) Cognitive Behavioral Training Bariatric Surgery
The Current Interventions
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The Current Interventions
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Effect of 4 Diets on Wgt Loss
Atkins, Ornish, Wgt Watchers, & Zone 1 year 25% with adequate adherence 4.6 to 7.3 # loss @ 1 yr in those 25% Which diet didn’t matter Exercise did matter
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Why Diets Often Fail
Require lot of time and energy
Cause feelings of deprivation
Don’t address why people overeat
Disrupt metabolism
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Bariatric Surgery
Number of procedures performed has increased 10-fold 14,000 in 1993 140,000 in 2004 > 200,000 in 2005 > 300,000 in 2007
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Bariatric Surgery
Evidenced Based Recommendation:
Bariatric surgery leads to sustainable long-term weight loss and may reduce obesity-related comorbities such as diabetes mellitus and obstructive sleep apnea. It is not clear which surgical procedure is the safest and most effective.
Recommendation B
From The Cochrane Database of Systematic Reviews available at ttp://www.cochrane.org/reviews/en/ab003641.html
5
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The Family Physician’s Role
Assist their patients in their weight management efforts
Identify potential surgical candidates Counsel patients about their options and the
risks and outcomes of each Understand the post-surgical dietary regimen Monitor patients for short and long-term
complications of bariatric surgery
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Indications
Body Mass Index of 40 kg per m2
Body Mass Index of 35 kg per m2 with significant comorbities Type 2 diabetes Obstructive sleep apnea Coronary artery disease Debilitating arthritis
Online BMI calculator available @ http://familydoctor.org
Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus .nih.gov/1991/1991GISurgeryobesity084html.htm.
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Indications (continued)
Previous failed weight loss attempts using an integrated weight loss program including: Dietary modification Behavioral support Appropriate exercise
Appropriate motivation and psychological stability to understand risks and benefits of the procedure
The commitment to lifelong postoperative lifestyle changes and medical surveillance
Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus .nih.gov/1991/1991GISurgeryobesity084html.htm.
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Contraindications
Poor surgical candidates – inadequate cardiopulmonary reserve, drug or alcohol dependency, impaired intellectual capacity
Unable or unwilling to comply with post-op lifestyle changes, diet, supplementation, f/u
Unstable psychiatric illness or eating disorders Uncontrolled coagulation problems or cannot
be removed from coagulation therapy For Lap Band – Intra-abdominal adhesions or
potential for inadequate pneumoperitoneum
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Pre-Op Evaluation
Patients should be evaluated by a team – medical surgical, psychiatric and nutritional experts to determine whether they are candidates for bariatric surgery
Pre-op physical and evaluation
Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus .nih.gov/1991/1991GISurgeryobesity084html.htm.
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Pre-Op Evaluation (continued)
Studies may include: EKG CXR Echocardiogram Cardiac cath Polysomnography/sleep study Gallbladder ultrasound UGI or EGD Possible cardiac, pulmonary and psychiatry
consultations
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Pre-Op Evaluation (continued)
Labs may include: Fasting comprehensive metabolic panel LFTs including albumin Lipid panel CBC UA Hgb A1C Oral glucose tolerance test Fasting insulin Transferrin TFTs Beta HCG for females of childbearing age
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Surgical Options
Based on 1 of 2 mechanisms for weight loss: 1. Gastric restriction :
Vertical Banded Gastroplasty Sleeve Gastrectomy Adjustable gastric banding
2. Intestinal malabsorption : Roux-en-Y Duodenal Switch
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What are the procedures available for weight loss? The Malabsorptive Procedures
The malabsorptive procedures bypass a large amount of intestine and weight loss is achieved by creating nutritional inefficiency
DUODENAL SWITCH The Restrictive Procedures
These procedures restrict the size of the stomach near the esophagus by creating a restrictive pouch. which will hold a volume of approximately 40cc.
GASTRIC BYPASS Lap-Band Sleeve Gastrectomy
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The Malabsorptive ProceduresDuodenal Switch
Fat Malabsorption Primary Mechanism•Malnutrition an issue
•Fat Souluble Vitamins•Protein malnutrtion
•Frequent foul smelling stools•Up to seven per day
•Hepatotoxicity•Elevated liver enzymes•Potential for Liver Failure
•Hypoalbuminemia•Hypoproteinemia
•VERY EFFECTIVE WEIGHT LOSS
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The Restrictive ProceduresLap-Band
•Pure Restrictive Mechanism•Requires Frequent Surgical Followvup
•Monthly to Every 6 weeks•Requires Significant Dietary Changes •Major Complications
•Band Slippage – Reoperation•Band Erosion – Removal
•No Malabsorption Risk•Reversible •Low Risk•Outpatient Surgery
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The Restrictive ProceduresSleeve Gastrectomy
Permanent Partial Gastrectomy•Resection of body of stomach•Resection of fundus of stomach•Resection of Antrum of stomach
•Unproven – experimental•Becoming more common•Not covered by Insurance
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Combined ProceduresGastric Bypass
• Most commonly performed bariatric procedure in U.S.
• Creates a small Gastric pouch• Creates a short Roux Limb• Combined Procedure
•Small Malabsorptive limb•Restrictive gastric pouch
• Difficult to Reverse
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Results of Gastric Bypass
Average BMI 43.5 82% Female 18% male Conversions to open – 2% Admissions to ICU post op 4%
3% sleep apnea observation 1% unexpected secondary to conversion to open
Average Length of Stay – 2.2 days Outliers – 1% > 10 days
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Results of Gastric Bypass
Anastomotic leaks -2%
Internal Hernia requiring reoperation – 4%
Death – < 3 % Anastomotic Leak Sudden Cardiac Death
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Outcomes – Gastric Bypass
Effective Weight Loss1 year 68%2 year 74%3 year 72%
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LAGB Weight LossSystematic Review World Literature-ASERNIP-S
Mean % Excess Weight Loss:
Surgery 2004;135:326-51J Lap Adv Surg Tech 2003;13:265-70
Procedure 36
months
48
months
60
months
LAGB(range)
# Reports
55%
(38-64)
52%
(44-68)
56%*
(53-60)
RYGB(range)
# Reports
69%
(58-89)
58%
(56-63)
59%*
(55-62)
*Not statistically significance
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A comparison of percentage of excess weight loss following LAGB and RYGB surgery. Published series with baseline numbers greater than 501
0
10
20
30
40
50
60
70
80
6 12 18 24 36 48 60 72 84 96 108 120
Months
RYGB (n=5160)
Lap-Band (n=6242)
1 Surgery 2004;135:326-51
LAGB Weight Loss
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Career Experience – Gastric Bypass1152 Cases – Major Complications Death 3 patients
Anastomotic Leak – 1 patient post op day 3 Sudden Cardiac Death – 2 patients
No Leak No PE
Internal Hernia Requiring Reoperation 6 patients
Ischemic Bowel – Reoperation/Resection 2 patients
Venous Stasis/Thrombosis/Congestion – 1 Arterial Thrombosis/Hypercoagulopathy -1
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Career Experience – Gastric Bypass1152 Cases – Major Complications
Pulmonary Embolism – (No Deaths) Post Op Day 1-14 NONE Post Op Day 14-30 3
Rx – Prophylactic IVC Filter Pre-Op - (One)
- Post Op Heparin/Coumadin – (Two)
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Surgical Options
Roux-en-Y is most common procedure Lap-Band Increasing in popularity Sleeve Gastrectomy – Experimental Duodenal Switch – Laparoscopic pts have less;
Time in hospital, Lost work Pain Incisional hernias (vs 25% in open)
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Life-Threatening Complications
80% of deaths in the first 30 days are due to: Pulmonary embolism Anastomotic leaks Respiratory failure
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Life-Threatening Complications
Pulmonary Embolism Leading cause of death Risk factors
BMI => 60 kg/m2
Chronic lower extremity edema Obstructive sleep apnea h/o pulmonary embolism
Prophylaxis low-molecular-weight heparin and compression
stockings Early Ambulation (laparoscopic) Consider Pre-operative IVC Filter
Geerts, W.H., Pineo, g.F., Heit, J.A. et al. (2004). Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3 suppl), S338-400.
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Life-Threatening Complications
Anastomotic leaks – Signs and Symptoms Sustained tachycardia, severe abdominal pain, fever,
rigors, hypotension Respiratory failure
Work-up: UGI or CT scan with contrast – May be negative DON’T DELAY SURGICAL CONSULT
Urgent surgical consultation Exploratory surgery if equivocal signs
“Leak Until Proven Otherwise” post op day 1-14
Identify complications early and educate patients about reporting symptoms
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Life-Threatening Complications
Internal Hernia• Partial Small Bowel Obstruction through internal mesenteric defects• Usually following RYGB or Duodenal Switch procedures• Patients complain of severe pain
• Intermittent• Out of proportion to physical findings• Usually NOT vomiting• CT findings usually negative• Abdominal series usually negative• Usually occur 12 months or greater post op• Usually occur after >100 pounds weight loss
• Surgical Consultation • Diagnostic laparoscopy and repair of hernia• Delay in diagnosis can be life threatening
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Short-Term Complications
1-6 weeks post-op:
Wound infections Less Common in Laparoscopic Group Open Group may lead to incisional hernia
Stomal stenosis Nausea, Vomiting inability to advance diet Usually requires EGD and dilation
Marginal ulceration Usually ischemic Rarely secondary to Acid production PPI (Prevacid Solutab), Carafate suspension
Constipation Poor PO Fluid intake
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Long-Term Complications
Nausea, Bloating Abdominal Discomfort Think Biliary Dyskinesia or
Symptomatic Cholelithiasis Workup
Abdominal Ultrasound – Gallstones? HIDA WITH Biliary Ejection Fraction – Dyskinesia?
Up to 50% due to rapid weight loss Consider prophylactic cholecystectomy at the time of
surgery Consider bile salt therapy – Daily for 6 months post op
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Long-Term Complications
Nausea, Bloating Abdominal Discomfort, Malaise, Fatigue, Hair loss etc Think Nutritional Deficiency
B vitamins Thiamin, Riboflavin, Niacin, Folate, B6, B12,
biotin and pantothenic acid. Fat Soluble Vitamins
A,D,E,K Vitamin C
Compliance? Only 30-35% patients are vitamin compliant
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Long-Term Complications
Nutritional Deficiencies Especially with malabsorptive procedures (RYGB,
biliopancreatic diversion) Prevention
Adherence to high protein diet Lifelong supplementation
High potency MVI with iron Vitamin B12, 1000mcg IM q mo or 100mcg po qd Calcium 1200 mg q d Menstruating women may require parenteral iron
infusions
Halverson, J.D., (1992).Metabolic risk of obesity surgery and lon-term follow-up. American Journal of Clinical Nutrition, 55, S602-605.
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Post-Op
Usually surgeons have their own specific dietary transitions & anticoagulation methods
Some recommended ones can be found @ “UpToDate”
Be aware that in the perioperative period, many obesity-related medical co-morbidities change dramatically; e.g. HTN, DM, GERD
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Post-Op Monitoring
Follow-up Lab Tests
Every 3 months for the first year
CBC, glucose, creatinine
Every 6 months for the first year
LFTs, protein and albumin, iron, TIBC, ferritin, vitamin B12, folic acid, calcium, parathyroid hormone (if hypercalcemic)
Every year after the first year
All of the above
Virji, A., Murr, M. (2006). Caring for patients after bariatric surgery. American Family Physician, 73 (8), 1403-1408.
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Long-Term ComplicationsCompliance Issues Dumping Syndrome
Procholinergic symptoms from influx of undigested carbohydrate into the jejunum
Side effect of malabsorptive procedures – RYBG and biliopancreatic diversion
Symptoms Nausea, vomiting, diarrhea, tachycardia, salivation,
dizziness Results from poor dietary compliance; may serve as
reinforcement Subsides 1-2 hours after sugar or foods high in
simple carbohydrate
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Long-Term ComplicationsCompliance Issues Persistent vomiting due to pouch distention
More common with purely restrictive procedures VBG and adj. lap band
Due to non-adherence to dietary recommendations Small portions Chewing thoroughly Eating slowly Waiting one hour after eating before drinking
Other causes of vomiting – pain meds, vitamins, dehydration, gastroenteritis
Bohn, M., Way, M., Jemieson, A. (1993). The effects of practical dietary counseling on food variety and regurgitation frequency after gastroplasty for obesity. Obesity Surgery, 3, 23-28.
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Compliance Issues - Pregnancy
Pregnancy is contraindicated for at least 18 months after surgery due to rapid weight loss and nutritional requirements
Provide appropriate contraception
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Long-Term Complications
Protein-calorie malnutrition months to years after surgery due to anastomotic stricture or food phobias
Repeated episodes of nausea and vomiting Multiple hospitalizations for dehydration, renal
insufficiency and liver failure Treat with aggressive TPN, dilation of stricture Surgical Consultation for Revision or Reversal
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Long-Term ComplicationsSide Effects – Skin Issues
Panniculitis Severe infection of the excess abdominal skin Treat with antibiotics and skin hygiene Consider excision of the excess skin
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Results
Clinical Improvement/Resolution :
Diabetes : 64-100% HTN : 62-69% O.S.Apnea : 85% Dyslipidemia : 60-100% Nonalcoholic fatty
liver dz : 90%
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Results
Cholelithiasis : 22% Overall mortality (after 9 yrs) :
With surgery : 9% Without surgery : 28%
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F. P. ‘ s Role in F/U
COUNSELLING PT ON LIFE STYLE CHANGES AND EXPECTATIONS **
DIETARY CHANGES : AMT, LIQUIDS, PROTEIN
SUPPLEMENTS CHANGE IN CHRONIC ILLNESSES
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Manage Changes In Chronic Illnesses
DIABETES HYPERTENSION GERD DYSLIPIDEMIAS
WHEN ?
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Bibliography
Virji A, Murr MM. caring for patients After Bariatric Surgery. AFP 2006;73:1403-8.
http://www.hamptonbariatric.com USPSTF. Screening for obesity in adults. AFP April
15, 2004; UpToDate CARING FOR PATIENTS AFTER BARIATRIC
SURGERY. CME BULLETIN. AAFP. JUNE 2006. MAYO CLINIC PROCEEDINGS. SUPPLEMENT TO
OCT. 2006, VOL 81.
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Bibliography
American Dietetic Assoc Position of ADA. 2002. J Am Dietetic Assn. 102:1145-55.
May M. Am I Hungry? What To Do When Diets Don’t Work. Phoenix: Nourish publishing
Vega GL. Obesity,The Metabolic Syndrome, & Cardiovascular Disease. Am Heart J, 142:1108-16.
Wadden, TA. (ed). Handbook of Obesity Treatment. 2002. Ny: Guilford Press.
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Thank You!
? Questions?