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?