Pre & Post Operative Nursing Care of the

Bariatric Patient

Jacinta Velt

Registered Nurse

Melbourne Gastro Oesophageal Surgery | Melbourne Weight Loss Surgery

Drivers of Obesity

UK Government (2018), Foresight Obesity Map, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/296290/obesity-map-full-hi-res.pdf

Drivers of Obesity

UK Government (2017), Foresight Obesity Map, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/295153/07-1177-obesity-system-atlas.pdf

Stigma Obesity

Latner J, O’brien K.S etal., (2008) Weighing Obesity Prejudice: The Relative Strength of Different Forms of Prejudice. International Journal of Obesity 32, https://www.nature.com/articles/ijo200853

OBESITY RACE SEXUALITY

NO QUICK FIX, surgery is a TOOL

Patient Responsibility

• Accountability • Maintain & monitor baseline weight

• Dietary choices

• Lifestyle behaviours

• Exercise Behaviours

• Engage in life long follow up

Obesity

Bariatric Surgical Registry

MWLS

Op time Hosp Stay Recovery Minor Cx Major Cx Weight loss

Sleeve 45min 2 30 4% <1% 75%

RYGB 65min 2 30 8% 2% 90%

OAGB 55min 2 30 9% 4% 76%

Band 35min 1 30 7% 0% 20%

Makary et al, Arch Surg. 2010;145(8):726-731.

Surgical outcomes

Surgical Pathway

Initial Surgical Consultation

Preparation

Surgery

Hospital Care

Discharge

GP/ Specialist review

Nursing Pathway

Headspace

Medications

Hospital Care

Discharge

Education

Gastroscopy

Pathology

Dietetics

Pre-Surgery Diet

• OptiFast meal replacement product & low calories vegetables

• Typically 2 weeks

• Compliance

Post Operative Diet

Post Operative Diet

• Less ghrelin = less hunger

• Initially minimal hunger

• Meals ‘opportunity for nutrition’

• Pt’s described ‘I’m no longer constantly thinking about food

16

Moize. Obesity Surgery. 2010. Nutritional Pyramid for Post-gastric Bypass Patients

Long Term Bariatric Food Pyramid

Post OP Follow Up

1 week

1 week

1 month

3 months

6 months

9 months

Discharge12 months

Life long follow up(at MWLS)

MWLS Post Op ComplicationsSleeve RYGB SAGB

Wound haematoma 0.2%

Wound infection 0.2%

Thromboembolic event

0.2%

Anastomotic stricture 1.9%

Anastomotic leak 0.5% 1.9%

Pneumonia 0.2% 0.9%

Bleeding 0.6% 2.7%

Atelectasis 0.6% 2.3% 1.9%

N & V 2.2% 4.1% 7.4%

Malabsorption

Underweight/ Undernourished

• Very uncommon to become underweight due to weight loss surgery

• As weight drops, energy output drops too

• Eventually hit a weight plateau

Input

Output

Weight-Loss Plateau/ Homeostasis

InputOutput

Case Study

Case Study

• Respiratory: CPAP

• Orthopaedic: family history osteoarthritis*Pt 3/7 kick boxing, cycling 7 swiming

• Gastrointestinal:Band 2002, 151 kg lost 40kg, back up. Band out 2011Multiple fad diets.Failed medical management

• Psychology:Weight issue since childhood traumaStress Eating↑ post quitting smoking

• Cardiovascular:Family history : hyptertension, hyperlipidemia.

• EndocrineCurrently freezing eggsGoal: pregnancy

41 year old femaleBMI 60.2 (height 168cm, weight 170kg)

Guyenet et al Regulation of Food Intake, Energy Balance, and Body Fat Mass: Implications for the Pathogenesis and Treatment of Obesity J Clin Endocrinol Metab, March 2012, 97(3):745–755.

WeightStabilised

Lap Band Lap band failure

↑ stress eating/ snacking

• Pathology

• Gastroscope

• Fatty liver

• +/- Interventions

• +/- Physician/ Specialist Review

• Bariatric Psychologist

RYGB

Post OP Recovery

1 week Dietitian

1 week Nurse

1 monthDietitian & Nurse

3 monthsSurgeon &Dietitian

6 monthsDietitian & Nurse

9 monthsDietitian & Nurse

Portion sizes Eating time

N& VHair loss

(expected)

Hospital & Discharge

Weight Loss

13.7% 18.2%22.5%

32.5%

52.5%

Post Operative Care

• Pt coming up to 12 months post op• Pathology• USS Gall Bladder• Swap MV to Elevit• Headspace• Review diet & eating behaviours• Exercise• Commence IVF post surgical review

Questions