Mr Pratik Sufi Consultant Bariatric & Upper GI Surgeon Spire Bushey Hospital.
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Transcript of Mr Pratik Sufi Consultant Bariatric & Upper GI Surgeon Spire Bushey Hospital.
Bariatric Procedures, Complications and Follow up
Mr Pratik SufiConsultant Bariatric & Upper GI Surgeon
Spire Bushey Hospital
Balancing Activity Levels with Food
1. One small chocolate chip cookie (50 calories) is equivalent to walking briskly for 10 minutes. 2. The difference between a large gourmet chocolate chip cookie and a small chocolate chip cookie
could be about 40 minutes of raking leaves (200 calories). 3. One hour of walking at a moderate pace (20 min/mile) uses about the same amount of energy that is
in one jelly filled doughnut (300 calories). 4. A fast food "meal" containing a double patty cheeseburger, extra-large fries and a 24 oz. soft drink is
equal to running 2½ hours at a 10 min/mile pace (1500 calories).5. One tsp sugar (20cal) ≈ 4 min walk6. One can coke (160cal) ≈ 30 min walk
Physical Activity Calories Burnt / 30 minutes
Walking leisurely @ 2mph 85
Walking briskly @ 4mph 170
Gardening 135
Raking leaves 145
Dancing 190
Bicycling leisurely @ 10mph 205
Swimming laps, medium level 240
Jogging @ 5mph 275
Energy Utilisation in Human Metabolism
0%
10%
20%
30%
40%
50%
60%
70%
80%
Low activity Moderate activity High activity
Activity Level
% o
f Ene
rgy
Use
Physical activity
Thermic eff ect
Resting metabolism
Dietary Change
Pulmonary Disease• Abnormal Function• Obstructive Sleep Apnea• Hypoventilation Syndrome• Asthma
Hepato-pancreato-biliary Disease• Steatosis (NALD)• Steatohepatitis (NASH)• Cirrhosis• Gall Bladder Disease• Pancreatitis
Coronary Heart Disease• Diabetes• Dyslipidemia• Hypertension• CCF
Gynecologic Abnormalities• Abnormal Menses• Infertility• Polycystic Ovarian
SyndromeMusculoskeletal• Osteoarthritis• Gout
Skin• Dermatitis• Leg ulcers
Cancer• Breast, Uterus, Cervix,• Colon, Esophagus, Pancreas,• Kidney, Prostate
Vascular• Phlebitis / DVT• Venous stasis• Leg ulcers
Herniae• Umbilical• Ventral• Inguinal
Cerebral• Idiopathic Intracranial Hypertension• Stroke
Cataracts
Obesity OnLine Slide Presentation. Accessed May 17, 2007. Accessible as slide #5 at http://www.obesityonline.org/slides/slide01.cfm?tk=33.
Obesity Associated Co-morbidities
GI• GORD & Hiatus Hernia
Impact of Obesity on GP Consultations
BMI
Perc
en
tag
e
20 25 30 35 40
15
10
20
25
30 Brown WJ et al. Int J Obes 1998;22:520-528.
• Low BMI was associated with fewer physical health problems than mid-level or higher BMI.
• Indicators of health care use showed a J-shaped relationship with BMI for general practitioners (>5 GP Consultations).
• Prevalence of medical problems (for example, hypertension OR 6x and diabetes OR 6x), surgical procedures (cholecystectomy OR 7x and hysterectomy OR 2x) and symptoms (for example, back pain OR 40% and constant tiredness OR 70%) increased monotonically with BMI.
Effect of Diet and Surgery on Weight & Mortality
•Diet & exercise effective up to 6m• 60% failure at 1 yr.• 80% failure at 2 yrs.• 100% failure at 5 yrs.
•Surgery effective long-term (80%)
Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects N Engl J Med 2007;357:741-52.
High Risk
Low efficacy – less durable weight loss
High efficacy – durable weight loss
Effective but unacceptable risk
Low Risk
Primary Obesity Options Today
Diet/ Drugs
Surgery
EndolumenalObesity
Moderate risk / efficacy – intermediate durability
Abandoned Surgery
LapBand
GastricBalloon
POSEEndosheath
Less Effective More Effective
SleeveGastrectomy
GastricBypass BPD/DS
VBG
Jejuno-IlealBypass
20-60%
40-95%
Procedure ComparisonProcedure Mechanism of
actionEBWL (2 year)
Invasiveness / Durability
Follow-up
Gastric balloon Restrictive 10-20%
Minimal/Short-term
Intensive/6-24m
POSE Restrictive 20-40%
Minimal/Long-term
Minimal/12-24m
Endosheath Diversion 30-50%
Minimal/Short-term
Intensive/12-24m
Gastric band Restrictive + Neurostimulation
50-60%
Moderate/Long-term
Intensive/Life-long
Gastric plication
Restrictive 40-60%
High/Unknown Modest/Life-long
Sleeve Restrictive + Endocrine
60-80%
High/Long-term Modest/Life-long
Gastric bypass Restrictive + Bypass-Diversion +Malabsorption
70-90%
High/Long-term Intensive/Life-long
Duodenal switch
Restrictive + Bypass-Diversion +Malabsorption
90-100%
Very high/Long-term
Intensive/Life-long
Referral - Minimal DatasetAgeWeight & BMICo-morbidity esp.
cardiovascularrespiratoryendocrineGI and musculo-skeletal
MedicationPrevious attempts at weight lossOther concerns like
Untreated eating disordersPsychiatric history
NICE: BMI≥35ASMBS: BMI≥30Asians: BMI 2 points lower
Pre-operative Liver Shrinkage Diet
Food group No of servings
Fruit 2
Vegetables 3
Carbohydrates 3
Dairy 2
Protein 3
Fats 2
Meal/Snack Product Amount Calorie
s
Protein
(g)
Breakfast Slimfast
shake
1
serving
220 /
230
14 / 15
Morning
snack
Slimfast
shake or
Slimfast meal
replacement
bar
1
serving
220 /
230
14 / 15
Lunch Slimfast
shake
1
serving
220 /
230
14 / 15
Dinner Slimfast
shake
1
serving
220 /
230
14 / 15
Totals 880-
920
56-60
Slimfast –900 kcal/d approximately
Food-based – 900 kcal/d approx.
Two (2) weeks
Four (4) weeks
Pre-operative Special ConsiderationsHypertension control
ACE Inhibitors AT2 receptor antagonists
Glycaemic control Oral hyperglycaemic agents Insulin
Anticoagulation Warfarin Clopidogrel Aspirin
OSA CPAP
GORD PPI
NAFLD / NASH Liver shrinkage diet
Post-operative RegimeLiquids only for 2-3 weeksSoft blended food for 2-3 weeksResume solids after 4-6 weeks
Small mouthfulsChew wellEat slowlySeparate eating and drinking by ½ hourAvoid fizzy / sugary drinks or sugary food
Medication – liquid / soluble (crushed)Supplements
IronCalcium and vitamin DVitamin B12Folic acidVitamin B1
Recommended Multivitamin and minerals: Chewable versions:• Bassett’s Adult Chewable multivitamins with prebiotics & minerals • Wellkid Smart / Sanatogen A-Z Kids Chewable• Haliborange Chewable multivitaminsWhole tablet:• Sanatogen Gold or Centrum (after 3 months)
Plus• Chewable Calcium – 1000mg calcium /day• Liquid iron or iron drops - 50mg of iron/day
Post-operative – Suitable Fluids D0-W2Milk - Aim for at least two pints (1.2L) of milk or a milk
alternative a dayMilk can be flavoured with Nesquick or low calorie hot
chocolateSlimming drinks e.g. Slimfast or chemist/supermarket
own brandComplan or Build-up shakes or soupsYogurt drinks and smoothiesStill mineral water, if taking the flavoured types make
sure they are low sugarStill low-sugar squashes Smooth soups e.g. cream of tomato or chicken; or oxtailTea and coffee without sugarUnsweetened pure fruit juice
Post-operative Special Considerations
Diet Not allowed to eat and drink together Eat slowly, chew well – at least 20-30 minutes Liquids for 24-48hours after band adjustment
Return to workChange in medications
Restrictions on tablets – soluble, liquids or crushed tabletsChange in co-morbidity
Antihypertensive Oral hyperglycaemic agents Insulin
Change in absorption Warfarin Oral contraceptives
Avoid pregnancy for 18 months Risk to mother Risk to foetus
Long-term Follow-up Pins and needles (B12, B1) Frequent falls (B12, B1, Fe) Tiredness (anaemia, hypoglycaemia) Generalised pain (PTH) Abdominal pain (ulcer, gallstones / hernia / kidney stones) Reflux / regurgitation/ N&V / persistent cough (band slippage,
over-tight band, ulcer, hiatus hernia)
Calcium supplements- 1000mg calcium / day. Liquid or effervescent tablets Ferrous Sulphate/ ferrous fumarate or sodium feredetate – drops, syrup or sugar free elixir. 50mg of iron/day Hydroxocobalamin Vitamin B12 injections – 1mg every 3 months
Mechanism Prevalence Clinical
Protein Intake, absorption,
Distal RYGB 6-13%Standard RYGB 0%Peak 1-2 yrs
Loss of muscle, weakness, oedema, etc.
Iron Intake, Acid exposure, absorption
2 yr: 33% Anaemia, tinnitus, hair loss
Vitamin B12 (cobalamin)
Reduced acid, ?IF link
1 yr: 12 – 70%Within 2yrs: 25%
Anaemia, macrocytosis
Calcium & Vitamin D
Intake, absorption, HyperPTH
Distal RYGB: 2yr Ca 10%, Vit D 51%
BPD Ca 25-50%, Vit D 17 – 50%
MBD –Osteomalacia, osteoporosis
Liposoluble Vitamins (A, E, K)
Reduced fat breakdown
RYGB: very lowBPD (4yr): A-69%, K-68%, E-4%
A: night blindness
Zinc Absorption – dependent on lipidsSurgical stress
RYGB: rareBPD: 10 – 50%
Hair loss
Nutritional Deficiencies
Diagnosis and Treatment of Nutritional Deficiencies Deficiency Symptoms
and signs Confirmation Treatment
first phase Treatment second phase
Protein malnutrition
Weakness, decreased muscle mass, brittle hair, generalized oedema
Serum albumin and prealbumin levels, serum creatinine
Protein supplements
Enteral or parenteral nutrition; reversal of surgical procedure
Calcium/Vitamin D
Hypocalcaemia, tetany, tingling, cramping, metabolic bone disease
Total and ionized calcium levels, intact PTH, 25-D, urinary N-telopeptide, bone densitometry
Calcium citrate 1,200–2,000 mg,oral vitamin D50,000 IU/d
Calcitriol oral vitamin D 1,000 IU/d
Vitamin B12 Pernicious anaemia, tingling in fingers and toes, depression, dementia
Blood cell count, vitamin B12 levels
Oral crystalline B12350 mg/d
1,000 –2,000 mg/2–3 months im
Folic acid Macrocytic anaemia, palpitations, fatigue, neural tube defects
Cell blood count, folic acid levels, homocysteine
Oral folate, 400 mg/d (included in multivitamin)
Oral folate, 1,000 mg/d
Iron Decreased work ability, palpitations, fatigue, koilonychia, pica, brittle hair, anaemia
Blood cell count, serum iron, iron binding capacity, ferritin
Ferrous sulphate 300 mg 2–3 times/d, taken with vitamin C
Parenteral iron administration
Vitamin A Xerophthalmia, loss of nocturnal vision, decreased immunity
Vitamin A levels Oral vitamin A, 5,000–10,000 IU/d
Oral vitamin A, 50,000 IU/d
An Endocrine Society Clinical Practice Guideline
Schedule for Clinical and Biochemical Monitoring
An Endocrine Society Clinical Practice Guideline
TESTSPre-operative
1 month
3 months
6 months 12
months 18
months 24
months Annually
Complete blood count X X X X X X X X
LFTs X X X X X X X X
Glucose X X X X X X X X Creatinine X X X X X X X X Electrolytes X X X X X X X X Iron/ferritin X Xa Xa Xa Xa Xa
Vitamin B12 X Xa Xa Xa Xa Xa
Folate X Xa Xa Xa Xa Xa
Calcium X Xa Xa Xa Xa XaIntact PTH X Xa Xa Xa Xa Xa
25-D X Xa Xa Xa Xa XaAlbumin/prealbumin X Xa Xa Xa Xa Xa
Vitamin A X Optional Optional
Zinc X Optional Optional Optional Optional
Bone mineral density and body composition
X
Xa
Xa Xa
Vitamin B1 Optional Optional Optional Optional Optional Optional
Xa – Tests should only be performed after RYGB, BPD, or BPD/DS. X – Tests suggested for patients submitted to restrictive surgery where frank deficiencies are less common.
Pulmonary DiseasePneumonia / Atelectasis
HPB Disease• Hepatitis (trauma)• Pancreatitis
(trauma)• Cholecystitis
CV Disease• MI• DVT / PE• Beriberi
Gynecologic Abnormalities• Amenorrhoea• Fertility – failure of
contraception
Bone Disease • Osteomalac
ia
Malnutrition• Dermatitis• Neuropathy• Ataxia
Cerebrovascular Disease• Wernicke’s Encephalopathy (Beriberi)• Stroke / TIA
MalnutritionGlossitis, stomatitisHair loss
Post-Bariatric Surgery Complications
GI Disease• Bleeding• GORD & Hiatus
Hernia• Ulcer• Bloating /
Obstruction• Diarrhoea /
Constipation• Malabsorption
Renal Disease• Kidney
stones
Immediate post-operative – infection, bleed, thromboembolism Tiredness, pain, ulcers, dry skin, pins and needles, hair loss etc. (Nutritional
deficiency – Iron, Calcium, Vitamin D, Folate, Vitamin B12, Vitamin B1, Zinc) Nausea, vomiting (Slipped band, over-restriction, hiatus hernia, gallstones,
anastomotic ulcer, GLP-1 excess, internal /port-site hernia etc.) Hernia – port-site, incisional
General complications
Slippage (Pain, N&V) Erosion (Pain, N&V, loss of restriction) Oesophageal dilation (Regurgitation, N&V, persistent cough) Infection (Pain, local inflammation, systemic sepsis) Nutritional deficiency (tiredness, hair loss) Gallstones (Pain, N&V, Jaundice) Hiatus hernia / GORD (Regurgitation, heartburn, dysphagia)
Band Complications
Sleeve Gastrectomy Complications Staple line leak (pain, N&V, sepsis) Staple line bleed Reflux (regurgitation, heartburn, dysphagia) Sleeve dilation (weight regain) Nutritional deficiency (tiredness, hair loss, pain) Gallstones (pain, dyspepsia, N&V, jaundice)
Gastric Bypass Complications Staple line leak (pain, N&V, sepsis) Staple line bleed Ulcer (pain, N&V, dysphagia) Stenosis (dysphagia, pain, N&V, regurgitation, excessive
weight loss) Dumping (giddiness, tiredness, tachycardia, cramps) Internal hernia (cramps, bloating, constipation) Gallstones (pain, N&V, Jaundice) Nutritional deficiency (tiredness, hair loss, pins and needles,
pain, ulcers)
Balloon Complications
Intolerance (nausea & vomiting, cramps) Ulcer (epigastric pain) Deflation and migration (bowel obstruction)
POSE Complications
Perforation Bleeding Intolerance (nausea & vomiting,
cramps) Ulcer (epigastric pain)
Pain
GallstonesPancreatitisAnastomotic ulcerPerforation / Anastomotic leakGastric band erosionSlipped gastric bandDumping syndromeAnastomotic strictureSmall bowel obstructionGastro-gastric fistula
Nausea & Vomiting
Pregnancy!GastroenteritisGastric balloon intoleranceOver-restricted gastric bandAnastomotic ulcerAnastomotic / Sleeve gastrectomy strictureGallstones / PancreatitisHiatus herniaInternal hernia / Small bowel obstruction
Diarrhoea
GastroenteritisBacterial overgrowthClostridium difficileFat malabsorptionDumping syndromeLactose intolerance
Case Study 1 Mr A, 32 year old publican,
gastric bypass 3 year ago, lost 85% excess body weight
Tripping over repeatedly – 4 months. Nausea and vomiting, pins and needles in hands and feet
Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?
GP referred patient to neurologist
Differential diagnosis: Thiamine / Vitamin B12 deficiency
Investigation: RBC thiamine / Serum Vit B12 + ECHO + MRI brain
Treatment: Thiamine 100mg bd for 12 weeks
Thiamine DeficiencyBeriberiWernicke’s encephalopathy
Confusion, irritability, memory loss, nervousness, speech difficulties
SoB, orthopnoea, tachycardia
Constipation, digestive problems, loss of appetite
Numbness of hands and feet, pain sensitivity, poor coordination, weakness, absent knee and tendon reflexes, paralysis
Case Study 2 Mrs B, 42 year old housewife,
gastric band 2 years ago, lost 64% excess body weight
Sudden onset epigastric pain and dysphagia
Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?
Differential diagnosis: Band slippage Band erosion
Investigate: Contrast swallow CT abdomen OGD
Band slippage – Emergency band deflation + reposition / removal
Band slippageEpigastric painDysphagiaWeight regainBand erosionEpigastric painLoss of restrictionWeight regainBand infection
Case Study 3 Mrs X, 37 year old writer, gastric
bypass 6 months ago, lost 45% excess body weight
Intermittent epigastric pain and nausea
Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?
Differential diagnosis: Anastomotic ulcer Gallstones Internal hernia
Investigate: USS, Contrast swallow, CT
abdomen, OGD Diagnosis: Gallstone cholecystitis Treatment: Laparoscopic
cholecystectomy
Anastomotic ulcerEpigastric pain, heartburnGallstonesEpigastric / RUQ pain, N&V,
PancreatitisInternal herniaAbdominal cramps after
eating, constipation, bloating, acute abdomen
Case Study 4 Mr Y, 27 year old computer
analyst, gastric bypass 3 years ago, lost 75% excess body weight
Abdominal pain, bloating, nausea and diarrhoea
Refer to hospital – Emergency / Urgent / Routine?
Differential diagnosis: Bacterial overgrowth Malabsorption Internal hernia
Investigate: Bloods, ABG, CT abdomen, D-
Xylose test, Hydrogen breath test, Stool culture, Faecal fat
Diagnosis: Bacterial overgrowth Treatment: Correct nutritional
deficiencies and Metronidazole + Live yogurt / Neomycin + Rifampicin
Bacterial overgrowthAbdominal cramps,
diarrhoea, borborygmiMalabsorptionSoB, orthopnoea,
tachycardiaInternal herniaAbdominal cramps after
eating, constipation, bloating
Case Study 5 Ms Q, 42 year old teacher,
gastric band 2004, lost 60% excess body weight
Cough, reflux and water brash for the last 3 weeks.
Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?
GP started her on Amoxicillin and referred for an OGD
Differential diagnosis: RTI, band slippage, over-restricted band
Investigation: Gastrograffin swallow + OGD
Treatment: Band volume reduction - defill
Over-restricted bandCough, reflux and water
brashUnable to tolerate solidsUnable to lie down
without coughingBand slippageEpigastric pain Intolerant to solids /
liquidsWeight regain
Take Home MessageBariatric surgery is a cost-effective treatment
for obesity which leads to resolution of co-morbidities, improved quality of life and increased life expectancy
However, patients need lifelong follow-up after surgery in order to avoid harm – this can be performed by their surgical team and by the primary care.
Patients can present with nausea, vomiting, dysphagia, reflux, abdominal pain and neurological symptoms.
Common things are common!Nutritional deficiencies are common and
easily preventable.
Thank you!