Mitigating surgical risk in the

morbidly obese:

A System by System Approach in the Bariatric Patient

Jessica Folek, MD

Disclosure:

I have no actual or potential conflict of interest related to this program/presentation

Objectives

Identify cardiac, pulmonary endocrine, and hematologic risk factors more prevalent in obese patients

Describe testing and interventions to mitigate identified risk factors before surgery to help optimize patient

Learn about postoperative considerations specific to bariatric surgery patients

Obesity Epidemic

One out of every three adults and one in 6 children are obese.

Obesity contributes to increased costs, ~150 billion dollars per year - approaching 10% national medical budget

Disease has reached epidemic proportions and is a major cause of morbidity

Greater percentage of all surgical

patients, not solely bariatric, are obese

Case Study 50 F presents for bariatric surgery

consultation, BMI 63

PMHx-

DM2, last HGA1c 10.3

HTN

Hypercholesterolemia

Fatty liver disease

DJD

Depression

Smoker

PreOp Eval Starts with:

Comprehensive H&P, physical exam, labs

Patients should be evaluated for causes and complications of obesity, in particular those that affect recommendation for surgery (Mechanick et.al, 2008)

Screen for thyroid dysfunction

Check lipid panel

Check Vitamin levels- D, B1, B12, Folate

Check albumin

Nicotine and metabolites if hx recent use

Action plan: Would obtain Chemical stress test /

Stress echo

Cardiac testing - typically highest priority.

Follow AHA advisory/guidelines Risk Factors affecting cardiac assessment (Poirier et.al, 2011)

CAD

Heart failure

HTN

Pulmonary HTN (secondary to OSA)

Poor exercise capacity

Cardiac dysrhythmias (particularly A-fib)

History of PE, Deep venous thrombosis

Obesity Surgery Mortality Risk Score (OS-MRS)- 4431 pts

(DeMaria et. al, 2007)

Action plan cont’d Smoking Cessation

Smoking identified as independent preoperative risk factor in bariatric pts and was associated with significant postoperative complications. (Livingston et.al,2006)

Minimum four weeks of abstinence reduces respiratory complications (Wong et al,2012)

Abstinence of 3-4 weeks reduces wound-healing complications.

Short-term cessation no significant effect on respiratory complications.

Smoking associated with marginal ulcer

Action plan cont’d

Target HgA1c of 6.5 – 7-

Optimize preop glycemic control

Recent guidelines recommend HgA1c of 7.2 or less prior to surgery.(Mechanick et.al, 2008)

Preop weight loss 5-10% TBW - Decreases liver size (Colles et.al,2006) Improves BP control (Aucott et. al, 2005) Improves glycemic control (Wing 2007),

Decreased rate of postop complications (Benotti et. al, 2009)

Liver Shrinking Diet

Colles et al

Action plan (cont’d) Screen for obstructive sleep apnea

Obesity a leading cause for OSA

10% increase in BMI results in 32% increase in AHI index (Demaria et al,2007)

OSA is an independent risk factor for 30 day morbidity and mortality following bariatric surgery (Flum et al, 2009)

Modest weight loss can improve OSA and can optimize patient risk related to OSA in the perioperative period.

Action plan (cont’d) Retrievable IVC filter placement

High risk pt- super morbid obesity, known hx of VTE, hypercoagulopathy immobility, poor pulmonary reserve

Incidence of VTE .3-5.0%, up to 30% of these with PE (Becattini et al,2012)

No current consensus on use of rIVC in addition to chemoprophylaxis

Recent ASMBS/AACE guidelines from 2008 do recommend the use of rIVC in select high risk pts (Mechanick et.al,2008)

Postoperative Considerations Adjust BP and DM meds after surgery

NSAIDS, ASA contraindicated post LRYGB

Ensure patient is compliant with recommended vitamin regimen: MVI, B12, Calcium Citrate, Vitamin D, Iron in post RYGB in particular. They are most at risk for vitamin deficiencies.

Annual labwork to check for deficiencies if patient decides to f/u with PCP one year out from surgery.

Communication with bariatric surgeon regarding any GI complaints.

Thank You!

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