CE 25 HOURS Continuing Education

Outcomes and

Complications After Bariatric Surgery Five of the most common procedures and nursing implications for pre- and postoperative care

OVERVIEW Bariatric surgery is an effective and increasingly common treatment for obesity and obesity-related comorbidities There are currently two major categories of such surgery grouped according to the predominant mechanism of action restrictive procedures such as vertical banded gastroplasty and adjust-able gastric banding and malabsorptive procedures with a restrictive component such as Roux-en-Y gas-tric bypass vertical sleeve gastrectomy and biliopancreatic diversion with duodenal switch In general the more complex the procedure the better the results in terms of weight loss but therersquos evidence that more complex procedures also have higher morbidity and mortality rates This article outlines five of the most common procedures discusses the outcomes and complications of bariatric surgery and describes the nursing implications for pre- and postoperative patient care

Keywords bariatric surgery obesity weight loss surgery weight reduction

If you havenrsquot already cared for a patient who has undergone bariatric surgery itrsquos likely that at some point in your nursing career you will

Obesity has been shown to adversely affect all body systemsmdashand prevalence rates for obesity and over-weight stand at record highs in this country Recent data from the National Health and Nutrition Ex-amination Survey yield an estimated prevalence for

obesity of 39 while that for overweight and obesity combined is 68 1 (For precise definitions of obesity and overweight see Terms Defined2) People who are obese are at greater risk for numer-ous illnesses including type 2 diabetes hyperten-sion coronary heart disease stroke osteoarthritis cholelithiasis sleep apnea and certain types of cancers among others3 4 Obesity may also have

26 AJN September 2012 Vol 112 No 9 ajnonlinecom

By Lauren E Gagnon BSN RN and Emily J Karwacki Sheff MS FNP-BC CMSRN

psychological and psychosocial consequences For example people who are obese often experience prejudice discrimination and psychological abuse from coworkers family members friends and strangers making it harder for them to maintain personal relationships5 6 They are also at higher risk for anxiety and depression7-9

Probably for all of these reasons and more bar-iatric surgery is becoming increasingly popular In 1998 an estimated 13365 bariatric procedures were performed in the United States by 2007 that num-ber had increased to approximately 20000010 The American College of Physicians recommends that surgical intervention be considered for patients with a body mass index (BMI) of 40 kgm2 or greater who have had previous unsuccessful attempts at weight loss and have obesity-related comorbidities11

Furthermore the American Diabetes Association rec-ommends that patients with a BMI of 35 kgm2 or greater and type 2 diabetes also be considered for bariatric surgery especially if the diabetes has not been well controlled with lifestyle changes and phar-macotherapy12 This article outlines five of the most common procedures discusses the outcomes and complications of bariatric surgery and describes the nursing implications for pre- and postoperative pa-tient care

for older patients because of their higher risk of complications bariatric surgery has been shown to be safe for many patients over the age of 6021 22

Bariatric surgery may be contraindicated for people who have extremely high operative risk factors such as severe congestive heart failure or unstable angina Patients who are unable to understand the surgical risks and postoper-ative maintenance requirements those who are active substance abusers those with sig-nificant psychopathology (such as psychosis) and those with under- or untreated depression also may not be candidates23

TYPES OF BARIATRIC SURGERY There are currently two major categories of bariatric surgery grouped according to the predominant mechanism of action restrictive

In 1998 an estimated 13365 bariatric procedures were

performed in the United States by 2007 that number

had increased to approximately 200000

Candidates for surgery Many people who opt for bariatric surgery have already tried numerous other weight loss strategies without success When diet exercise psychotherapy and pharmacotherapy have failed bariatric surgery has been shown to be an ef-fective treatment for obesity and obesity-related co-morbidities13-18 A majority of patients seeking bariatric surgery are female (83) white (60) and have pri-vate insurance (78)19 In one large study the aver-age age of patients was 42 but adolescents and older adults also undergo bariatric surgical procedures20

While elective surgery is generally contraindicated

procedures such as vertical banded gastro-plasty (VBG) and adjustable gastric banding (AGB) and malabsorptive procedures with a restrictive component such as Roux-en-Y gastric bypass (RYGB) vertical sleeve gastrec-tomy (VSG) and biliopancreatic diversion with duodenal switch (BPD-DS) Itrsquos also not uncommon for a surgeon to use a combina-tion of both restrictive and malabsorptive procedures In general the more complex the procedure the better the results in terms of weight loss but therersquos evidence that more

ajnwolterskluwercom AJN September 2012 Vol 112 No 9 27

28 AJN September 2012 Vol 112 No 9 ajnonlinecom

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imag

es c

ourt

esy

of E

thic

on E

ndo-

Surg

ery

Inc

Vertical sleeve gastrectomy VSG (often simply called sleeve gastrectomy) was originally used as the first step in the BPD-DS procedure but itrsquos begin-ning to be used as a stand-alone procedure for bariatric surgery in high-risk patients with severe obesity (BMI of 50 kgm2 or greater)28 29 The surgery which is irreversible involves removal of 80 to 90 of the stomach leav-ing only a gastric ldquosleeverdquo30 The surgery both restricts intake and slows diges-tion and absorption Usually performed laparoscopically this procedure has lower risks of mortality and of major complications compared with RYGB and BPD-DS28-31 although long-term outcomes need further evaluation29 Moreover VSG has been shown to significantly improve or resolve hypertension and diabetes29 31 32

Roux-en-Y gastric bypass RYGB (often simply called gastric bypass) is the most commonly per-formed bariatric procedure in the United States accounting for between 71 and 81 of all bariatric surgeries19 25 Open RYGB was first per-formed in the United States in the 1960s laparo-scopic RYGB was introduced in the early 1990s26

The surgery which is irreversible involves cre-ating a small stomach pouch and attaching it directly to the small intestine using a Y-shaped limb of the small bowel the larger stomach portion and the duodenum are bypassed Thus the procedure works both by restricting intake and by slowing the digestion and absorption of food Although itrsquos usually performed laparo-scopically open RYGB is still performed in some cases13 19 25 27 such as in patients who have adhe-sions from previous abdominal surgeries22 RYGB has been shown to have lower peri- and intra-operative risks than some other procedures24 more research is needed to establish the risks relative to AGB25 27

Biliopancreatic diversion with du-odenal switch BPD-DS is usually considered for patients with severe obesity The surgery which is irrevers-ible is a variation on biliopancreatic

diversion (the original surgery is now rarely performed) BPD-DS involves removing 65 to 70 of the stomach leaving the pyloric valve intact The remaining portion of the stomach is then connected to the proximal portion of the ileum The surgery both restricts intake and slows di-gestion and absorption as digestive enzymes cannot mix with food until food reaches the distal ileum33 BPD-DS has demonstrated substantial reductions in excess body weight and in the severity of associated comorbidities34 One study by Iaconelli and colleagues showed a 100 remission rate for type 2 diabetes within one year of surgery35 The authors also found significant reductions in hypertension hyper-lipidemia and cardiovascular disease

ajnwolterskluwercom AJN September 2012 Vol 112 No 9 29

Adjustable gastric banding is the second most common bariatric procedure performed in the United States19 25 The procedure which is restrictive and reversible was initially devel-oped in the 1980s as an alternative to major surgery36 A laparoscopic AGB device (the Lap-Band) first won US Food and Drug Adminis-tration (FDA) approval in 2001 and since then its use has increased dramatically indeed one source notes that between 2004 and 2007 its use increased from 7 to 2314 With a second AGB device (the REALIZE band) re-ceiving FDA approval in 2007 and with AGB considered to be ldquothe safest of the currently available surgical optionsrdquo further increases are expected14

The procedure involves placing an adjust-able silicone band around an upper portion of the stomach to form a small pouch leaving a small stoma to the larger lower portion of the stomach Food passes first into the small pouch where it begins digestion The digested food then moves through the small stoma into

the lower stomach portion and on through the remainder of the gastrointestinal tract Food intake is restricted by the small pouch capacity and because of the small stoma size emptying of food into the lower stomach portion is also delayed During surgery the band is also connected through tubing to a port placed under the patientrsquos skin The tightness of the band can then be adjusted depending on the patientrsquos tolerance by instilling or removing fluid through the port Adjustments are usually made by the physician on an outpatient basis Both the band and port are usually placed laparoscopically The procedure can be done in an ambulatory surgical setting and patients generally go home within a few hours of surgery37

The FDA has approved the use of adjustable gastric bands for obese adults ages 18 and older and is reportedly considering approval for adolescents as young as 1438 Studies have found the associated mortality rate to be between 0 and 0114 39 making it the safest of the available procedures14 AGB is a good option for obese patients who need bariatric surgery and want to avoid permanent rerouting of the gastrointestinal tract39

Vertical banded gastroplasty VBG some-times called ldquostomach staplingrdquo was devel-oped in 1982 itrsquos a restrictive and reversible procedure The surgeon first cuts a small hole into the stomach a few inches below the esophagus Then the surgeon places a line of staples from the hole toward the esophagus to section off a small portion of the upper stomach creating a small pouch This pouch is then anchored distally by a prosthetic band The band slows digestion by allowing smaller-than-normal amounts of food through to the remainder of the gas-trointestinal tract Both the reduced stom-ach capacity and the delayed emptying give the patient a feeling of early satiety Rates of mortality and major complications are low40

Repr

inte

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m D

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r G

A e

t al

Am J

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t 200

710

2(11

)257

1-80

by

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issio

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May

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ajnwolterskluwercom AJN September 2012 Vol 112 No 9 29

Adjustable gastric banding is the second most common bariatric procedure performed in the United States19 25 The procedure which is restrictive and reversible was initially devel-oped in the 1980s as an alternative to major surgery36 A laparoscopic AGB device (the Lap-Band) first won US Food and Drug Adminis-tration (FDA) approval in 2001 and since then its use has increased dramatically indeed one source notes that between 2004 and 2007 its use increased from 7 to 2314 With a second AGB device (the REALIZE band) re-ceiving FDA approval in 2007 and with AGB considered to be ldquothe safest of the currently available surgical optionsrdquo further increases are expected14

The procedure involves placing an adjust-able silicone band around an upper portion of the stomach to form a small pouch leaving a small stoma to the larger lower portion of the stomach Food passes first into the small pouch where it begins digestion The digested food then moves through the small stoma into

the lower stomach portion and on through the remainder of the gastrointestinal tract Food intake is restricted by the small pouch capacity and because of the small stoma size emptying of food into the lower stomach portion is also delayed During surgery the band is also connected through tubing to a port placed under the patientrsquos skin The tightness of the band can then be adjusted depending on the patientrsquos tolerance by instilling or removing fluid through the port Adjustments are usually made by the physician on an outpatient basis Both the band and port are usually placed laparoscopically The procedure can be done in an ambulatory surgical setting and patients generally go home within a few hours of surgery37

The FDA has approved the use of adjustable gastric bands for obese adults ages 18 and older and is reportedly considering approval for adolescents as young as 1438 Studies have found the associated mortality rate to be between 0 and 0114 39 making it the safest of the available procedures14 AGB is a good option for obese patients who need bariatric surgery and want to avoid permanent rerouting of the gastrointestinal tract39

Vertical banded gastroplasty VBG some-times called ldquostomach staplingrdquo was devel-oped in 1982 itrsquos a restrictive and reversible procedure The surgeon first cuts a small hole into the stomach a few inches below the esophagus Then the surgeon places a line of staples from the hole toward the esophagus to section off a small portion of the upper stomach creating a small pouch This pouch is then anchored distally by a prosthetic band The band slows digestion by allowing smaller-than-normal amounts of food through to the remainder of the gas-trointestinal tract Both the reduced stom-ach capacity and the delayed emptying give the patient a feeling of early satiety Rates of mortality and major complications are low40

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inte

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m D

ecke

r G

A e

t al

Am J

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710

2(11

)257

1-80

by

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issio

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May

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30 AJN September 2012 Vol 112 No 9 ajnonlinecom

complex procedures also have higher morbidity and mortality rates24

OUTCOMES Weight loss The overall success of a patientrsquos bariatric surgery and the rate and amount of weight lost post-operatively vary based on the patient and the type of surgery performed One study defined success as a loss of more than 50 of excess body weight and failure as a loss of less than 30 of excess body weight at one year after surgery41

Patients who have undergone BPD-DS have lost an average of 80 of their excess body weight at two years after surgery and an average of 70 at eight years out34 Patients who have undergone VSG have lost from 59 to 68 of their excess body weight at 18 months to two years after surgery respectively28 42

Patients who have undergone VBG have lost from 50 to 57 of their excess body weight at one to

studies have shown that bariatric surgery increases pulmonary functioning and decreases the severity of asthma and sleep apnea48-51 Indeed one study found that of 29 obese patients with sleep apnea who used continuous positive airway pressure therapy preoper-atively only four required it at two years after bariat-ric surgery50

Cardiovascular disease Multiple studies have shown an increased risk of coronary heart disease in patients who are obese The Nursesrsquo Health Study found that the relative risk of coronary heart disease was 36 times greater for women with a BMI above 29 kgm252 Similarly the Framingham Heart Study found that obesity was an important long-term pre-dictor of cardiovascular disease53 The incidence of coronary heart disease in men younger than 50 years was doubled in the heaviest group among women younger than 50 years the incidence was 24 times greater in the heaviest group

Many people who opt for bariatric surgery have already tried

numerous other weight loss strategies without success

five years after surgery40 But itrsquos important to note that up to 15 of patients have eventually required revision of their surgery to RYGB or BPD-DS due to weight regain and vomiting24 Patients who have un-dergone RYGB have lost from 60 to 76 of their excess body weight at one or more years after sur-gery15 43 Patients who have undergone AGB have lost from 50 to 82 of their excess body weight at one or more years after surgery14 44

Type 2 diabetes One of the most encouraging out-comes of bariatric surgery is the reduced severity and even the elimination of type 2 diabetes15 24 Overall re-mission has been seen in 50 to 85 of all patients who have undergone bariatric surgery although re-mission is ldquoless likelyrdquo in older patients and in those who have had type 2 diabetes for a longer period of time12 One study by Wool and colleagues even re-ported remission rates of 87 to 9022 Remission rates have been highest in patients who underwent either biliopancreatic diversion or BPD-DS followed by RYGB then laparoscopic AGB and VBG12 Studies have found that 72 to 81 of patients with type 2 diabetes have been able to stop using diabetes medi-cations at one year follow-up17 18

Sleep apnea asthma and other respiratory prob-lems are frequently seen in people who are obese45 46

The loss of abdominal and intrathoracic fat reduces restriction of the lower airway while the loss of ex-cess fat around the neck reduces obstruction of the upper airway thus enhancing breathing47 Several

Related conditions such as hypertension and hy-perlipidemia have been shown to improve in patients who undergo bariatric surgery17 18 In one study of people with severe obesity 86 of patients with hy-perlipidemia and 81 of those with hypertension no longer required medications for these conditions at 12 months after bariatric surgery17

Musculoskeletal problems are common in people with obesity Some candidates for bariatric surgery will have already undergone surgery to repair or re-place weight-bearing joints Weight loss reduces the strain on the bodyrsquos muscles and weight-bearing joints thus easing joint and muscle pain Weight loss result-ing from bariatric surgery has also been shown to im-prove the severity of lower back pain and to improve overall functionality16

COMPLICATIONS Bariatric surgery like other surgeries carries some risk of complications A study by Cawley and colleagues found that preexisting obesity-related comorbidities were significantly associated with the likelihood of de-veloping certain complications after bariatric surgery54

The two comorbidities most predictive of postop-erative complications were sleep apnea and gastro-esophageal reflux disease others included diabetes hyperlipidemia and hypertension

lsquoDumpingrsquo syndrome a common complication refers to a group of symptoms that can occur when calorically dense carbohydrates are ingested and

ajnwolterskluwercom AJN September 2012 Vol 112 No 9 31

Terms Defined2

Overweight is defined as a body mass index (BMI) of 25 to 299 kgm2

Obesity is defined as a BMI of 30 kgm2 or greater Three subcategories of obesity are also recognized bull Class I a BMI of 30 to 349 kgm2 bull Class II a BMI of 35 to 399 kgm2 bull Class III a BMI of 40 kgm2 or greater

when the stomach ldquorapidly and without regulation empties its contents into the small intestinerdquo55 Symp-toms which can arise 15 minutes to two hours after eating and generally last about 30 minutes may in-clude tachycardia dizziness sweating nausea vomit-ing bloating abdominal cramping and diarrhea33 55

Patients should be instructed which foods to avoid in order to avoid this complication Dumping syndrome occurs more often with RYGB than with BPD-DS probably because the latter procedure preserves more of the stomach including the pyloric valve34 Patients who undergo laparoscopic RYGB56 and patients who have preexisting hyperlipidemia or gastroesophageal reflux disease appear to be at especially high risk for dumping syndrome54

Cholelithiasis The development of gallstones is a complication related to postoperative weight loss rather than the surgery itself However since choleli-thiasis occurs in about one-third of patients who un-dergo bariatric surgery it deserves mention57 Both obesity and rapid weight loss increase a patientrsquos propensity to develop gallstones especially among women57-59 Studies indicate that 22 to 45 of pa-tients who undergo bariatric surgery will develop gall-stones within the first few months after surgery58-61 In earlier years it wasnrsquot uncommon for a prophylactic cholecystectomy to be performed along with bariatric surgery with the advent of laparoscopic bariatric sur-gery this is no longer recommended Moreover stud-ies have also shown that in many cases the gallstones resolve on their own59 the off-label prophylactic ad-ministration of ursodiol has also been shown to help prevent gallstone formation62 63

Pulmonary embolism and deep vein thrombosis Patients who undergo bariatric surgery are at higher risk for deep vein thrombosis and pulmonary em-bolism64 As a result physicians often recommend early and frequent ambulation following surgery65

Some physicians may order the administration of low-molecular-weight or low-dose heparin after surgery65 66 For patients who are at very high risk for pulmonary embolism deep vein thrombosis or stroke some physicians may opt to place a temporary

inferior vena cava filter65 67 Compression stockings and pneumatic sequential compression devices are also frequently ordered for deep vein thrombosis prophylaxis65

Anastomotic leak Postoperative leaking at the anastomotic sites in RYGB BPD-DS and VSG is a serious complication that can be life threatening Anastomotic leak has been reported in 012 to 20 of patients undergoing open or laparoscopic RYGB13 28 42 66 68 The signs and symptoms of anasto-motic leak can be subtle or absent they include ab-dominal pain nausea and vomiting tachycardia fever hypotension and oliguria66

Some physicians may order a swallowing study to evaluate for leaks on postoperative day 1 or 266

Snyder and colleagues have reported that robotic-assisted RYGB resulted in fewer anastomotic leaks and other major complications compared with lap-aroscopic RYGB hospital stays were also shortened69

Death Although bariatric surgery is generally safe there is always a risk of death Overall death occurs in 015 to 064 of patients who undergo bariatric surgery13 19 70 71 Mortality rates vary somewhat by sur-gery type For patients who undergo VBG itrsquos approx-imately 1624 Among patients who have undergone either traditional biliopancreatic diversion or BPD-DS the mortality rate is approximately 1224 Frezza and colleagues have noted that VSG has a mortality rate of 0542 The mortality rate for the adjustable gastric band is approximately 0 to 0114 39 A meta-analysis found that among patients undergoing RYGB mortality rates were 044 and 016 for open and laparoscopic procedures respectively72

Although bariatric surgery

is generally safe there is

always a risk of death

The top three causes of death in people who un-dergo bariatric surgery are pulmonary embolism (15 to 32) cardiac complications or arrest (13 to 18) and sepsis (18)19 71 Other causes of death can include anastomotic leak (15) gastrointestinal bleeding or hemorrhage (8) bypass obstruction (5) and small bowel obstruction (3)71

Complications unique to AGB Although this pro-cedure presents with far fewer risks than other bar-iatric procedures14 unique complications can occur27

Among the most common are port disconnections or rupture port displacement and stomach slippage with pouch dilatation73 74 others include band rupture

32 AJN September 2012 Vol 112 No 9 ajnonlinecom

band erosion port blockage port infection and tubing-related malfunctions14 73-75 Studies have found that 12 to 20 of patients require additional sur-gery within one to 12 years after AGB73 76 77 In the event of minor complications the band can be de-flated or removed if necessary If major complications arise further surgery may be required

NURSING IMPLICATIONS Preoperative evaluation and patient teaching As be-fore any surgery the nurse must obtain a thorough history perform a physical assessment and obtain baseline vital signs For patients considering bariatric surgery comprehensive preoperative evaluation by a psychiatrist or psychologist may also be indicated or the patientrsquos insurer may require it In a consensus statement the American Society for Bariatric Surgery (now known as the American Society for Metabolic and Bariatric Surgery) noted that such evaluation ldquois not routinely needed but should be available if indicatedrdquo78 The purpose is to help identify psycho-logical factors that might disqualify a patient from or delay surgery such as untreated depression or a lack of understanding about the risks of surgery and the necessary postoperative regimen23

Itrsquos essential for nurses to be aware of their own attitudes and behaviors regarding obesity and bariat-ric surgery Many people who are obese have been the victims of discrimination and abuse33 They may feel ashamed or embarrassed that theyrsquove been un-able to lose weight by other means and thus require surgery Some may have fears about the operation it-self or about how life might change afterward some may worry that even after surgery theyrsquoll fail to lose weight Nurses need to be able to support a patientrsquos decision to have surgery acknowledge the patientrsquos fears and strive to maintain the patientrsquos dignity

Itrsquos important to discuss

realistic goals for weight loss

with patients prior to surgery

Help patients know what to expect Itrsquos important to explain to patients beforehand what to expect upon awakening from surgery This will likely include receiving IV fluids and having in place a urinary cathe-ter pneumatic sequential compression devices and antiembolism compression stockings33 The patient may also have a nasogastric tube or a wound drain at the incision site Methods of postoperative pain control should be discussed before surgery Patients

should know that the use of a patient-controlled anal-gesia pump after surgery is common13 and that they may be prescribed additional analgesics as needed for breakthrough pain33 Antiemetics may also be pre-scribed The importance of early and frequent ambu-lation in preventing deep vein thrombosis pulmonary embolism bowel obstruction atelectasis pneumonia skin breakdown and even discomfort should be ex-plained79-81

Itrsquos also important to discuss realistic goals for weight loss with patients prior to surgery Many pa-tients have unrealistic ideas about what bariatric sur-gery can do Some may expect to lose nearly 100 of their excess body weight indeed one study found that patientsrsquo average ldquodreamrdquo weight (ldquoa weight you would choose if you could weigh whatever you wantedrdquo) was equivalent to 89 plusmn 8 of their ex-cess body weight lossmdashabout 40 higher than what most bariatric surgeons consider to be a successful outcome82 Another study found that women whites and patients with higher preoperative BMIs were more likely to have unrealistic expectations of bar-iatric surgery83 Patients whose expectations are un-realistic are more likely to be nonadherent to the postoperative plan of care84 and thus are at higher risk for regaining weight

Patients must be able to identify healthy behaviors that lead to successful weight loss For example one study found that attending postoperative support group meetings being able to control food urges being more physically active and following up with a physician were all significant factors in successful weight loss85 Both before and after bariatric surgery then patients should be encouraged to participate in support groups and individual counseling for help in learning and implementing relevant coping and life-style management techniques85

Lastly patients should be prepared for certain aes-thetic changes Rapid weight loss following bariatric surgery can result in an excess of stretched skin which can cause both physical and mental discomfort Sur-gical removal of this skin is usually the only option Such surgery can be risky in particular abdomino-plasty has a rate of complications as high as 5086

Most insurance companies will not cover surgery to remove excess skin unless the skin causes significant obstruction to movement or frequent infections of the skin folds occur Patients should be informed that the denial rate for such surgeries is reportedly 40 to 5087 But itrsquos also worth noting that a majority of patients who undergo abdominoplasty after bar-iatric surgery report an improved quality of life88

Postoperative assessment and patient teaching As with any surgery vital signs must be monitored closely for the first few hours after the procedure and at regular intervals thereafter The following are con-cerns specific to bariatric surgery

ajnwolterskluwercom AJN September 2012 Vol 112 No 9 33

Respiratory function Patients who undergo bariat-ric surgery are at risk for postoperative respiratory complications as intrathoracic and abdominal fat can restrict lung expansion and decrease reserve volumes Respiratory complications can also occur as a result of anesthesia or the use of opioids for postoperative pain management Respiratory function should be as-sessed periodically using pulse oximetry some patients may require continuous monitoring Encouraging cough and deep breathing is essential to preventing at-electasis and pneumonia Some physicians may order the use of incentive spirometry devices although their therapeutic efficacy is still under scrutiny89-91

sliding-scale insulin regimen after surgery for the treatment of hyperglycemia Hypoglycemia is also common after bariatric surgery Recognition and treatment of hypoglycemia must be swift Many physicians will order glucose IV or glucagon IM be-cause patients are typically on NPO orders and to avoid dumping syndrome which can occur with oral ingestion of glucose gel or juice

Nutrition and hydration After bariatric surgery patients are kept on NPO pending evaluation with a Gastrografin swallow study or an abdominal X-ray these tests are performed to rule out anastomotic leak and gastric dilatation or obstruction usually on

Because intake capacity has been reduced to as little as

15 to 30 mL after surgery the nurse should explain the importance

of taking small sips of fluid to reduce nausea and vomiting

Skin care Because their weight puts excess pressure on boney prominences patients who are obese are more likely to develop pressure ulcers Frequent re-positioning and ambulation should be encouraged Special mattresses or inflatable mattress overlays may be used to prevent pressure ulcers Patients who are obese are also more likely to develop yeast infections under skin folds These areas must be kept clean and dry if a patient does develop a yeast infection anti-fungal creams may be applied Careful inspection and care of incisions are critical as well If the surgeon has placed a drain monitoring the amount and type of drainage should be done at least once per shift33

Warmth redness pain and drainage at the incision site can indicate infection and should be reported Patients should be instructed on how to splint their incisions during coughing and movement in order to prevent dehiscence33

Abdomen and bowel sounds Abdominal rigidity or pain absent bowel sounds lack of flatus lack of bowel movements nausea or a combination of these can indicate possible bowel obstruction and warrant immediate attention Postoperative nausea and vom-iting must also be managed For example vomiting after AGB can cause band slippage which may re-quire reoperation Patients are often prescribed anti-emetics and proton pump inhibitors after surgery as a preventive measure66

Blood glucose levels must be monitored closely in patients with diabetes or who are on NPO orders (pa-tients who have bariatric surgery are kept on NPO [non per os or nothing by mouth] at least on postoperative day 1) Patients with diabetes may be placed on a

postoperative day 113 66 92 Patients are kept hydrated with IV solutions Once patients are cleared by the evaluation most can begin to take fluids orally be-ginning with water then clear liquids then full liquids as tolerated Because intake capacity has been dras-tically reduced to as little as 15 to 30 mL92 the nurse should explain the importance of taking small sips in order to reduce nausea and vomiting Fluids should be sugar free caffeine free and noncarbonated High-protein supplements or shakes may also be prescribed Once the patient is able to tolerate oral fluids IV hy-dration can be discontinued Strict management of intake and close monitoring of urine output are essen-tial for determining fluid volume status33 Advance-ment of the patientrsquos diet from liquids to solids will vary Generally patients consume a liquid diet for a few weeks after surgery and then progress to a low-fat low-carbohydrate high-protein diet Concentrated sweets and carbonated beverages should be avoided

Nutritional deficiencies are common after bariatric surgery and patients are often prescribed a multivita-min regimen One study found that among patients who had undergone RYGB more than half were defi-cient in vitamin B12 vitamin D3 beta carotene and hemoglobin and more than one-quarter were defi-cient in zinc ferritin magnesium and iron93 Protein deficiency is also common after bariatric surgery94

Supplemental protein has been shown to help patients reach their daily protein intake goal94

Patients at risk for dumping syndrome will need instruction regarding how and what to eat to prevent this complication Recommendations include eating five or six smaller meals rather than three large ones

34 AJN September 2012 Vol 112 No 9 ajnonlinecom

eating slowly and chewing well avoiding fluids with meals and avoiding fried foods and foods high in fat or sugar content95

The postoperative regimen Several studies have shown that adherence to postoperative recommenda-tions and attendance at follow-up visits and support groups are associated with more successful weight loss after surgery96-98 Among patients who fail to achieve their weight loss goals nonadherence to the postoperative plan of care is often a major factor One study found that frequent snacking not exercis-ing and not attending support groups were the most frequently cited areas of nonadherence to postoper-ative recommendations99 Another study identified several factors associated with nonadherence includ-ing emotionally triggered eating or ldquograzingrdquo impul-sivity binge eating and having a ldquoprimary affective disorderrdquo84 Similarly binge eating tendencies low self esteem physical inactivity and a lack of social support have been associated with lower chances of postoperative success in losing or maintaining weight loss85 100

Extensive teaching regarding diet physical activity and lifestyle is vital in helping patients to make the necessary changes achieve and maintain weight loss and adjust to life after surgery Indications that a pa-tient might be nonadherent to the postoperative plan of care include a history of binge eating a history of mood or anxiety disorders missing preoperative appointments and nonadherence to preoperative recommendations for weight loss and exercise98 101

Although itrsquos ultimately up to each patient to follow her or his plan of care nurses should address any of these warning signs and discuss possible solutions with the patient

Discharge teaching should include verbal and writ-ten instructions about the dietary progression the medication regimen incision care signs and symp-toms that must be reported to the physician follow-up appointments (including those with the patientrsquos surgeon primary care provider and nutrition coun-selor) contact information for postoperative support groups and any restrictions on driving and other ac-tivities The nurse should ensure that the patient un-derstands the importance of periodic assessment for nutritional deficits One study found that during the first postoperative year some patients demonstrated an inadequate intake of nutrients such as protein cal-cium and iron102 The value of regular physical activ-ity and participation in support groups should also be reiterated

For 79 additional continuing nursing education articles on surgical topics go to wwwnursingcenter comce

Lauren E Gagnon is a nurse on the cardiovascular surgical unit at Catholic Medical Center in Manchester NH where Emily J Karwacki Sheff is the nursing practice and standards coordina-tor Karwacki Sheff is also a clinical instructor in the School of Nursing at MGH Institute of Health Professions in Boston Con-tact author Emily J Karwacki Sheff esheffcmc-nhorg The authors have disclosed no potential conflicts of interest financial or otherwise

REFERENCES 1 Flegal KM et al Prevalence and trends in obesity among

US adults 1999-2008 JAMA 2010303(3)235-41

2 National Heart Lung and Blood Institute (NHLBI) Obesity Education Initiative Expert Panel on the Identification Eval-uation and Treatment of Overweight and Obesity in Adults Clinical guidelines on the identification evaluation and treatment of overweight and obesity in adults the evidence report Bethesda MD National Institutes of Health 1998 Sep httpwwwnhlbinihgovguidelinesobesityob_gdlns pdf

3 National Heart Lung and Blood Institute (NHLBI) What are the health risks of overweight and obesity National Institutes of Health 2010 httpswwwnhlbinihgovhealth health-topicstopicsoberiskshtml

4 Weight-control Information Network Do you know the health risks of being overweight National Institute of Dia-betes and Digestive and Kidney Diseases National Institutes of Health 2007 httpwinniddknihgovpublications health_riskshtm

5 Gortmaker SL et al Social and economic consequences of overweight in adolescence and young adulthood N Engl J Med 1993329(14)1008-12

6 Rand CS Macgregor AM Morbidly obese patientsrsquo per-ceptions of social discrimination before and after surgery for obesity South Med J 199083(12)1390-5

7 Ashmore JA et al Weight-based stigmatization psycho-logical distress and binge eating behavior among obese treatment-seeking adults Eat Behav 20089(2)203-9

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