Complications and Benefits of Bariatric

Surgery

Tracy Robinson

PAS 646

Advisor: Dr. Hadley

Objectives

Obesity Statistics Bariatric Surgery options Post-surgical complicatioins Nutritional consequences Improvements in co-morbidities Psychological and QOL improvements Why do PAs need to be aware?

Obesity Statistics

33% US population is obese (BMI ≥ 30 kg/m2)

8 million people in US morbidly obese (BMI ≥ 40 kg/m2)

Between 1986 and 2000…… Obesity doubled Morbid obesity quadrupled Super obesity (BMI ≥ 50 kg/m2) increased five-fold

Obesity Statistics cont…..

Men > 50% overweight = double mortality Men > 50% overweight + DM = 5x mortality Women > 50% overweight = 2x mortality Women > 50% overweight + DM = 8x

mortality

5% total healthcare costs US $60 billion

Bariatric Surgery

1990 – 2000 → 4925 to 41,000 2005 → 130,000 2010 → 218,000

Bariatric surgery criteria BMI ≥ 40 kg/m2 without co-morbid disease BMI ≥ 35 kg/m2 with concurrent co-morbid

disease

Roux-en-Y Gastric Bypass

15 to 25 ml gastric pouch with 1 cm outlet

Bypass distal stomach, duodenum, first segment of jejunum

Bypass 75 -150+ cm jejunum

65% -70% EBW loss Decrease BMI 35%

www.obesitycenter.org/ images/bg_roux2.gif

LAP-BAND

No physiological changes or resections

Band around upper stomach creates 15 ml pouch

Port of adjustment attached to abdominal wall

Inflate/deflate 6 times a year

50% EBW losswww.weighlite.com/images/ content/gastric-diag.jpg

Post-surgical Complications

Anastomosis leaks or staple line leaks PE or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy,

enteroenterostomy, Roux limb stump, staple line Can lead to peritonitis, sepsis, possible death Presentation

Tachycardia, tachypnea Fever Ab pain/back pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H. pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable, major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery

20%-30% mortality rate High risk may have vena cava filter

placement prior to surgery Prophylaxis with compression stockings and

LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for

machine No pathology start anticoagulation Too large…….NO SURGERY

Cholelithiasis

Up to 36% of patients within 6 months post-op Bile stasis leads to increased sludge and

gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent

bariatric surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12%-15% within 2-4 mos. Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia, vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI, carafate Antibiotics if H. Pylori Avoid NSAIDS, alcohol, smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple

line repair

Dumping Syndrome

More than 15% patients Hypotention Tachycardia Lightheadedness, syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload

and fluid shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before, during and not until 30 minutes after

meals.

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively

Increased metabolic water needs Calcium and iron supplement use following

surgery Treat with increased fluids and stool

softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49% of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to

duodenum or proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70% of patients Lack of hydrochloric acid and pepsin in

stomach Prevents B12 cleavage from food Affects secretion of intrinsic factor, thus B12

absorption Intolerance to meat and milk Oral supplementation usually adequate,

otherwise, IM injections used

Folate Deficiency

40% of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 1/3

stomach Deficiency generally caused by decreased

consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people

Calcium absorption decreased because duodenum is bypassed

Intolerance to dairy, foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption, osteomalacia, osteoporosis Treat with calcium citrate supplementation and 2

weekly doses of Vitamin D

Improvements of Co-morbidities

Type 2 diabetes mellitus Hypertension Hyperlipidemia Degenerative joint disease Sleep apnea GERD

5% to 10% weight reduction is associated with significant decrease in risk

Weight loss from surgery reduces or eliminates medications

Improves severity or resolves co-morbid disease

Improvements of Co-morbidities

2 years after surgery diabetes mellitus was resolved in 83% of pre-operative diabetic patients (Sugerman et. al 2005)

2 years following surgery 69% had resolution of hypertension 8 years post-surgery there was complete relapse

in those with gastric banding 25% decrease in total cholesterol and 40%

decrease in triglycerides 6 to 12 months after surgery

Psychological and Psychosocial Improvements

Depression Low self-esteem and self-appraisal Poor interpersonal relationships Feelings of failure and dissatifaction with life

Subject to prejudice and discrimination

Psychological and Psychosocial Improvements

“ Most obese patients consider impaired QOL the most crippling aspect of their disease, and after surgery consider enhanced QOL the greatest benefit” (Puzziferri 2005).

“Obese individuals would rather have a normal weight with a severe disability such as be deaf, have heart disease, have an amputation and others rather than be obese without any of these conditions” (Livingston 2003).

Psychological and Psychosocial Improvements

Significant improvement in QOL with all types of surgery

New vocational and social activities Improved interpersonal relationships Better moods, self-esteem More employable, get paid more, work more

and take less sick days.

Why do PAs need to know this?

We will be the long-term healthcare provider Consequences and complications last a

lifetime Initial provider assessing signs and

symptoms Track improvements Medication changes Stay educated in all specific needs and

concerns of bariatric surgery patient!