Top Ten Things You Need to Know About Bariatric Surgery Patients

Laura Dyck, M.S., R.D., LDNComprehensive Weight Management

Center,Kingsport, TN

Top Ten Things You Need to Know About Bariatric Surgery Patients

1) Who qualifies?2) Surgery options3) Who benefits?4) Who may NOT be

a good candidate?5) How safe is the surgery?

6) Where should I refer candidates for surgery?

7) Post-Op diet8) Supplements/Lab Monitoring 9) Post-Op exercise10) Other potential issues related to bariatric surgery

1) Who Qualifies?

BMI of 35-39.9 with co-morbid conditions OR >40 without co- morbid conditions

Documented failed attempts at weight loss

Weight Class

BMI (kg/m2)

Normal Weight

18.5-24.9

Overweight 25.0-29.9

Obesity (Class I)

30.0-34.9

Obesity (Class II)

35.0-39.9

Morbid Obesity (Class III)

>40.0

Who Qualifies?

Able to comprehend, and motivated for, lifelong lifestyle changes

Committed to lifelong medical monitoring

Willing to give up tobacco, NSAIDs Age range (typical) ~18 - 65 years Able to obtain psychological

clearance for surgery.

Who Qualifies?

Many insurances cover surgery (Medicare and Medicaid do cover)- Must complete insurance company requirements (medical weight management, weight loss requirements, etc.)

PCP and/or FNP may provide medical weight management (designated number of consecutive monthly appts., solely to discuss diet, exercise and behavior change)

2) Common Surgical Options for Weight Loss

Restrictive- Gastric banding & sleeve gastrectomy (sleeve can be Part One of 2 part procedure)

Malabsorptive- Biliopancreatic diversion & biliopancreatic diversion with duodenal switch

Combination- Roux-en-Y gastric bypass

Common Surgical Options for Weight Loss- Gastric Banding

Images Courtesy of Ethicon

Common Surgical Options for Weight Loss- Sleeve Gastrectomy

Image Courtesy of Ethicon

Common Surgical Options for Weight Loss- Gastric Bypass

Image Courtesy of Ethicon

Common Surgical Options for Weight Loss- Comparison

Gastric Banding

35-50 % Weight Loss*

In 2-3 years

Sleeve Gastrectomy

50-70 % Weight Loss*

In 12 months

Gastric Bypass

70-75 % Weight Loss*

In 9-12 months*%ages refer to “Excess

Weight” Lost

Common Surgical Options for Weight Loss- Which is Best?

Depends on many individual factors: How much weight to lose? Which is safest given body shape/size? Compliance with dietary changes? Work/family schedule? Geographic location?

3) Who Benefits?

Obese patients with: GBP1 Sleeve2 Band11) Diabetes

2) Hypertension

3) High Cholesterol

4) Sleep Apnea

Resolved 83.7%

Resolved 67.5%

Improved 94.9%

Resolved 80.4%

R- 56%

R- 49%

R- 43%

R- 60%

R- 47.8%

R- 43.2%

I- 78.3%

R 94.6%

Improvements/Resolution also seen with:

-GERD3 -Depression4 -Osteoarthritis/Joint Pain4

-Stress Urinary Incontinence4 -Menstrual dysfunction d/t PCOS5

-Ovulation and Fertility Restored5 -Quality of Life/Increased Activity1

4) Who may NOT be a Good Candidate for Surgery?

Have other untreated medical conditions that may have caused obesity

Psychological or cognitive limitations that jeopardize informed consent and cooperation with long term follow-up

Immobility Medical issues that make surgery too

risky

Who may NOT be a Good Candidate for Surgery?

Unwilling to give up tobacco & NSAIDs Hepatic cirrhosis with impaired liver

function Active Drug/Alcohol Abuse Not willing to/motivated to make

lifelong lifestyle changes Patient is pregnant

5) How Safe is Surgery?

Bariatric surgery holds no more risk than gallbladder or hip replacement surgery- the risks of surgery are lower than long term risks of living with obesity (increasing risks of dying due to heart disease, diabetes, etc. daily)6

How Safe is Surgery?

Bariatric surgery is now endorsed by the:

American Heart Association American Diabetes Association International Diabetes Federation American Association of Clinical

Endocrinologists

Risks and Complications

Dumping Syndrome (a blessing & a curse!) Bleeding Infections Complications with anesthesia Blood clots Injury to stomach, esophagus, surrounding

organs Leaks or blockages at site where tissue has

been sewn or stapled

6) Where should I refer candidates for surgery?

Look for a: Bariatric Surgery Center of Excellence

Where should I refer candidates for surgery?

The American Society for Metabolic and Bariatric Surgery (ASMBS) + the American College of Surgeons (ACS)= Metabolic and Bariatric Surgery

Accreditation and Quality Improvement Program

(MBSAQIP)

Holding a Center of Excellence Designation Means Centers Are:

Accountable for the quality and safety of surgery in their center

Participating in ongoing data collection/analysis

Going through a site inspection/approval process every 3 years

Stressing safety, proficiency and volume

Holding a Center of Excellence Designation Means Centers Are:

Requiring a multidisciplinary team for appropriate patient care

Hosting monthly support group meetings for patients

Dedicated to long term follow-up (Patients should be followed by their bariatric surgeon for LIFE!)

QUIZ TIME!

Which foods will I need to avoid after gastric bypass surgery?

a. Alcoholb. Carbonated beveragesc. Sugard. All of the above

Which foods will I need to avoid after gastric bypass surgery?

a. Alcoholb. Carbonated beveragesc. Sugard. All of the above

After surgery I will need to:

a. Chew my food thoroughlyb. Take 30-60 minutes to eat a mealc. Eat and drink at the same timed. a & b

After surgery I will need to:

a. Chew my food thoroughlyb. Take 30-60 minutes to eat a mealc. Eat and drink at the same timed. a & b

Xylitol, Lactitol and Sorbitol found in foods are classified as:

a. Sugarb. Sugar Alcoholsc. Fatd. Preservatives

Xylitol, Lactitol and Sorbitol found in foods are classified as:

a. Sugarb. Sugar Alcoholsc. Fatd. Preservatives

Chewing gum is not allowed. If you do chew it and swallow it you might have which complication?

a. Ulcer formationb. Headachec. Diarrhead. Outlet obstruction of your gastric

pouch

Chewing gum is not allowed. If you do chew it and swallow it you might have which complication?

a. Ulcer formationb. Headachec. Diarrhead. Outlet obstruction of your

gastric pouch

Dumping Syndrome after gastric bypass (and possibly sleeve gastrectomy) can occur by eating foods high in:

a. Fatb. Sugarc. Sugar Alcoholsd. All of the above

Dumping Syndrome after gastric bypass (and possibly sleeve gastrectomy) can occur by eating foods high in:

a. Fatb. Sugarc. Sugar Alcoholsd. All of the above

7) Post-Op Diet

“Phases” are slowly progressed through for ~8-12 weeks after surgery

Diet for life is a low fat, sugar free, balanced diet with smaller serving sizes

60-75 grams of Protein/day

Post-Op Diet

STOP when full- otherwise, will lead to N/V

CHEW WELL- otherwise, will lead to N/V

Dumping Syndrome with high fat and/or high sugar foods after Gastric Bypass (and mild dumping is possible after sleeve gastrectomy)

Post-Op Diet

Separate foods/fluids by at least 30 minutes

Fluid goals: 6-8 cups/day, SF, non-carbonated, caffeine free, non-caloric

Avoid Alcohol- ESPECIALLY GBP patients

8) Post-Op Supplements/Lab Monitoring

Sleeve Gastrectomy/Gastric Banding MVI/Mineral Supplement daily Calcium Citrate- 1200-1500 mg/day

Gastric Bypass MVI/Mineral Supplement daily Vitamin B12- 500 mcg/day sublingual or

1000mcg IM injection/month Calcium Citrate- 1200-1500 mg/day Iron (for menstruating women or if directed by

MD or FNP)- 200-325 mg of Ferrous Sulfate daily

Post-Op Labs to Monitor/Check

CMP (electrolytes, albumin, etc.) CBC Serum B12 (especially with GBP) Ferritin/Iron Profile Lipid Panel 25-hydroxyvitamin D or ionized

Calcium

9) Post-Op Exercise

Is an absolute MUST!!!

Patients should gradually work up to goal of 45 minutes- 1 hour of exercise most days of the week.

Should have education pre-operatively and resources, if needed

Post-Op Exercise

Support groups are great places to build on exercise knowledge

Utilize community resources (parks, rec centers, senior’s centers, gyms, Med Fit Center, etc) and nationally offered resources (National Institute on Aging, Go4Life Exercise and Physical Activity Books/DVD)

10) Other Potential Issues Related to Bariatric Surgery

Ulcers/Reflux (Don’t smoke/Avoid NSAIDs) Incisional hernias (especially if open

procedure) Loose skin Hypoglycemia Strictures Addiction Transfer Syndrome Weight Regain (~10% regain is normal)

References

1. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery. A systematic review and meta-analysis. JAMA. 2004;292:1724-1737.

2. EES summary of data contained in review article: Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis. 2009;5:469-475.

3. Wittgrove A, Clark G. Laparoscopic gastric bypass, Roux-en-Y---500 patients: technique and results, with 3-60 month follow-up. Obes Surg. 2000;10(3):233-239.

4. Schauer P, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515-529.

5. Eid GM, Cottam DR, Velcu LM, et al. Effective treatment of polycystic ovarian syndrome with roux-en-Y gastric byapss. Surg Obes Related Dis. 2005;2:77-80.

6. The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. N Engl J Med. 2009;361:445-454.

QUESTIONS?