The Medical Complications of Bariatric Surgery

Jeanette Newton Keith MDJeanette Newton Keith MDAssociate Professor Associate Professor

University of Alabama at BirminghamUniversity of Alabama at BirminghamDepartment of Nutrition SciencesDepartment of Nutrition SciencesDepartment of Internal MedicineDepartment of Internal Medicine

(www.eatright.uab.edu)(www.eatright.uab.edu)

Background More than one million people are classified as More than one million people are classified as

morbidly obese in the United Statesmorbidly obese in the United States

Bariatric surgery has emerged as a definitive Bariatric surgery has emerged as a definitive therapy for long-term treatment of obesitytherapy for long-term treatment of obesity

The three to five year success rate is 54-75% for The three to five year success rate is 54-75% for surgery versus a 6-8% three-year success rate with surgery versus a 6-8% three-year success rate with medical weight management programsmedical weight management programs

Background Between 1990 to 1997, Between 1990 to 1997, 12,20312,203 people underwent bariatric people underwent bariatric

surgerysurgery

The annual rate has increased from 2.7 per 100,000 people The annual rate has increased from 2.7 per 100,000 people (1990) to 6.3 per 100,000 people (1997)(1990) to 6.3 per 100,000 people (1997)

In 2006, approximately 177,600 cases were performed per In 2006, approximately 177,600 cases were performed per the American Society for Bariatric Surgerythe American Society for Bariatric Surgery

Some estimate that > 205,000 surgeries will be performed Some estimate that > 205,000 surgeries will be performed this year (Source: American Society for Metabolic and this year (Source: American Society for Metabolic and Bariatric Surgery)Bariatric Surgery)

“To Cut or Not To Cut”

Medical Therapy 5-10% excess weight lossMedical Therapy 5-10% excess weight loss

Pharmacologic Intervention 8-10% EWLPharmacologic Intervention 8-10% EWL

Bariatric SurgeryBariatric Surgery 60-80% EWL60-80% EWL

Bariatric Surgery Indications for Bariatric Surgery: :

Failure of medical therapy-3-5 yr attemptFailure of medical therapy-3-5 yr attempt Life-threatening complications of obesity Life-threatening complications of obesity Severe obesity Severe obesity (BMI >40 or >35 with complications(BMI >40 or >35 with complications))

Monitoring pre-surgery:Monitoring pre-surgery:Minimum of 6 months medical therapyMinimum of 6 months medical therapyFollowed by MD, DO or FNPFollowed by MD, DO or FNP∆∆Wt, Food logs, exercise, psychWt, Food logs, exercise, psych

Blue Cross Blue Sheild of IL

Types of Bariatric Procedures Malabsorptive:Malabsorptive:

Jejuno-ileal bypassJejuno-ileal bypassBiliopancreatic DiversionBiliopancreatic DiversionDuodenal Switch (DS), no bypassDuodenal Switch (DS), no bypass

Restrictive:Restrictive:Vertical banded gastric bypassVertical banded gastric bypass Laproscopic adjustable gastric banding Laproscopic adjustable gastric banding

Restrictive and Malabsorptive:Restrictive and Malabsorptive:Roux-en Y gastric bypassRoux-en Y gastric bypassDistal gastric bypass with DSDistal gastric bypass with DS

Surgical Advantages of Pure Gastric Restriction

50% excess weight loss at 1 year50% excess weight loss at 1 year

Minimal nutrition complicationsMinimal nutrition complications

Can be used in populations that are high Can be used in populations that are high risk for RYGBrisk for RYGB

Surgical Advantages of Combined Gastric Restriction & Malabsorption

Advantages of Gastric BypassAdvantages of Gastric Bypass: : 60% of excess weight lost in year 1 60% of excess weight lost in year 1 Maintains a weight loss Maintains a weight loss of 50% for 25 years Rapid resolution of metabolic of 50% for 25 years Rapid resolution of metabolic syndrome Improvement in obesity-related syndrome Improvement in obesity-related

complicationscomplications

Advantages of the Duodenal Switch: Advantages of the Duodenal Switch: 60-80% of excess weight lost in year 160-80% of excess weight lost in year 1

Most effective therapy for super obese

Combined Gastric Restriction & Malabsorption Operative Risks: (vs. cholecystectomy)Operative Risks: (vs. cholecystectomy)

Perioperative Mortality Perioperative Mortality 1-2%1-2% vs. 0.2-0.8% vs. 0.2-0.8% Early Complications Early Complications 10% 10% vs. 2.9%vs. 2.9%Late ComplicationsLate Complications 20%20% vs. 1-2%vs. 1-2%

Limitations:Limitations:Widening of (unbanded) gastrojejunostomyWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch Expansion of gastric pouch 25% with nearly 100% weight regain***25% with nearly 100% weight regain***Adaptation of limb that receives the food Adaptation of limb that receives the food

Combined gastric restriction & malabsorption

Potential complications:Potential complications:1) severe dumping syndrome - rapid 1) severe dumping syndrome - rapid

rush of liquid/soft high caloric food rush of liquid/soft high caloric food “dumping” into limb of small “dumping” into limb of small intestine….discomfort, nausea, bloating, intestine….discomfort, nausea, bloating, diarrhea, weaknessdiarrhea, weakness

2) 2) Abnormalities in iron, calcium, B12, and Abnormalities in iron, calcium, B12, and possibly magnesium homeostasispossibly magnesium homeostasis

3) Profound rapid weight loss3) Profound rapid weight loss

Weight Loss Benefits vs. Nutritional Risk

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Band Gastroplasty GBP DS

EWLMortalityB12 def

Risk of Deficiencies Determined by the type of surgical interventionDetermined by the type of surgical intervention

Restrictive Restrictive Minimal riskMinimal risk MalabsorptiveMalabsorptive Moderate riskModerate risk CombinationCombination High riskHigh risk

Risk increases as: Risk increases as: the length of the common channel decreases, and the length of the common channel decreases, and the degree of malabsorption increasesthe degree of malabsorption increases

Risk of deficienciesDeficiencyDeficiency RYGBPRYGBP DSDS

ProteinProtein 4.7%4.7% 3-5%3-5%

CalciumCalcium 15-43%15-43% 15-57% 1 yr15-57% 1 yr

63% 4 yr63% 4 yr

IronIron 33-50% 1 yr33-50% 1 yr

49-52% 3yr49-52% 3yr

35-74% 3 yr35-74% 3 yr

FerritinFerritin 44-50%44-50% 44-50%44-50%

AlbuminAlbumin 2%2% 2%2%

AnemiaAnemia 35-74% 5 yr35-74% 5 yr 35-74% 5 yr35-74% 5 yr

Risk of deficienciesDeficiencyDeficiency RYGBPRYGBP DSDS

B12B12 12-33%12-33% 33%33%

ThiamineThiamine ““Common”Common” ““Common”Common”

FolateFolate 12%12% 12%12%

Vitamins A and Vitamins A and EE

““Frequent”Frequent” A- 69% E-4%A- 69% E-4%

K- 68%K- 68%

Vitamin DVitamin D >30%>30% 30 -63%30 -63%

ZincZinc ““Frequent”Frequent” ““Frequent”Frequent”

Other Nutrition Complications

Refractory HypoglycemiaRefractory Hypoglycemia

Vitamin C DeficiencyVitamin C Deficiency

Selenium deficiencySelenium deficiency

Copper deficiencyCopper deficiency

Other Nutrition Complications Severe Protein Calorie MalnutritionSevere Protein Calorie Malnutrition

Functional Pancreatic InsufficiencyFunctional Pancreatic Insufficiency

Accelerated Weight LossAccelerated Weight Loss

Hepatic FailureHepatic Failure

DehydrationDehydration

Other Post-surgical Complications Anastomotic leak or bleeding (1-2%)Anastomotic leak or bleeding (1-2%)

Strictures (10-15%)Strictures (10-15%)

Fistula formationFistula formation

Severe diarrheaSevere diarrhea

IntusseptionIntusseption

Other Post-surgical Complications Short Bowel SyndromeShort Bowel Syndrome

Abdominal painAbdominal pain

Intestinal ischemiaIntestinal ischemia

Gastric erosions or ulcerationGastric erosions or ulceration

Hernias- Hiatal, IncisionalHernias- Hiatal, Incisional

Non-Nutritional Psychosocial Complications

DepressionDepression

SuicideSuicide

AlcoholismAlcoholism

Night Eating SyndromeNight Eating Syndrome

Binge Eating SyndromeBinge Eating Syndrome Zwaan et al Int J Eat Disord 2006Adams et al NEJM 2007Hsu et al Psychosom Med 1998

Types of Bariatric Procedures Malabsorptive:Malabsorptive:

Jejuno-ileal bypassJejuno-ileal bypassBiliopancreatic DiversionBiliopancreatic DiversionDuodenal Switch (DS), no bypassDuodenal Switch (DS), no bypass

Restrictive:Restrictive:Vertical banded gastric bypassVertical banded gastric bypass Laproscopic adjustable gastric banding Laproscopic adjustable gastric banding

Restrictive and Malabsorptive:Restrictive and Malabsorptive:Roux-en Y gastric bypassRoux-en Y gastric bypassDistal gastric bypass with DSDistal gastric bypass with DS

Laproscopic Adjustable Banding

Nutritional Deficiencies:Nutritional Deficiencies:ProteinProtein

Endoscopic limits:Endoscopic limits:Depends on lumenDepends on lumen

RetroflexionRetroflexion

Increased risk of Increased risk of ischemia and necrosisischemia and necrosis

Roux-en Y Gastric Bypass

Nutritional dNutritional deficiencies:eficiencies:Vitamin B12Vitamin B12CalciumCalciumIronIronProteinProtein

Endoscopic limits:Endoscopic limits:RetroflexionRetroflexion ERCPERCP

Distal Roux-en Y Gastric BP

Nutritional deficiencies: Nutritional deficiencies: Vitamin B12Vitamin B12CalciumCalcium IronIron

ProteinProtein

Endoscopic limits:Endoscopic limits:RetroflexionRetroflexion ERCPERCP

Duodenal Switch, with RYGB Pylorus and D1-sparingPylorus and D1-sparing

Nutritional deficiencies:Nutritional deficiencies:ProteinProteinMagnesiumMagnesium Vitamin Vitamin B12B12 IronIron

CalciumCalcium

Endoscopic limits:Endoscopic limits:ERCPERCP

Anti-obesity Surgery and Co-morbidities

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Hypert

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Diabete

sLipids

Asthma

Heart

Failure

Sleep Apnea

Improve

Cure

J Kral 1995, >1000 patients

Suggested Monitoring

Monitoring GuidelinesMonitoring Guidelines Frequent (no less than every 3 months)Frequent (no less than every 3 months)

Weight (more often in first 6 months)Weight (more often in first 6 months) CBC, Electrolytes, BUN, Cr, Ca, Mg, PCBC, Electrolytes, BUN, Cr, Ca, Mg, P Glucose, Liver Tests, AlbuminGlucose, Liver Tests, Albumin Fat soluble vitamins-A,D.E and KFat soluble vitamins-A,D.E and K Vitamin B12, B1Vitamin B12, B1 Iron studiesIron studies Vitamin C, Selenium, Zinc, CopperVitamin C, Selenium, Zinc, Copper Pre-albumin (or Transferrin if renal disease)Pre-albumin (or Transferrin if renal disease)

Suggested Monitoring

Occasional (at least annually)Occasional (at least annually) Measured HeightMeasured Height Bone Mineral DensityBone Mineral Density PTH, 1,25-OH Vitamin D, Zinc, 24 hour PTH, 1,25-OH Vitamin D, Zinc, 24 hour

urine calciumurine calcium

Post Surgical Monitoring

Weight loss progression* Weight loss progression* Goal: not more than 1-2 lbs/d in 1Goal: not more than 1-2 lbs/d in 1stst mo mo

Adequate Protein IntakeAdequate Protein Intake

Fluid statusFluid status

Presutti et al, Mayo Clin Proc 2004

Goal Nutrient Intake ProteinProtein

(1-2 grams per kg of adjusted weight)(1-2 grams per kg of adjusted weight) 60 gram Gastric bypass60 gram Gastric bypass 75 grams Duodenal Switch75 grams Duodenal Switch

FatFat 25% total calories25% total calories

CarbohydrateCarbohydrate 15-30 grams per serving day in 4-6 servings15-30 grams per serving day in 4-6 servings

FluidFluid 64 ounces64 ounces

Potential Nutritional Limitations Meat and dairy intoleranceMeat and dairy intolerance

Nutrient malabsorptionNutrient malabsorption

Vomiting, especially with over-consumptionVomiting, especially with over-consumption

ConstipationConstipation

Dehydration Dehydration Dolan, Ann Surg 2004Elliott Crit Care Nurs Q 2003

Post-surgical Supplementation

Prenatal multivitamin or Flintstone Prenatal multivitamin or Flintstone chewable MVI with minerals (2/day)chewable MVI with minerals (2/day)

Iron Polysaccharide 150 mg po BID for Iron Polysaccharide 150 mg po BID for womenwomen

Calcium Carbonate 500 mg po TIDCalcium Carbonate 500 mg po TID

Vitamin D 400 IU po qDVitamin D 400 IU po qD Vitamin B12 500 mcg po qDVitamin B12 500 mcg po qDForse et al, Current Opin Endo Diabete 2000

Alvarez-Leite, Current Opin Clin Metab Care 2004

Nutrient Deficiencies

Preventable with supplementationPreventable with supplementation

Require lifelong compliance with Require lifelong compliance with supplementssupplements

Minimized by regular and routine Minimized by regular and routine monitoringmonitoring

Nutrition Monitoring Challenges Few randomized protocols to address nutrition Few randomized protocols to address nutrition

monitoringmonitoring

How often and for how long patients are to be How often and for how long patients are to be followed is debated due to $$$followed is debated due to $$$

Timing of follow-up visits not clearTiming of follow-up visits not clear

Routine vitamin replacement not covered by Routine vitamin replacement not covered by many carriers many carriers

Take Home

Bariatric surgery can be life-saving for the Bariatric surgery can be life-saving for the right patientright patient

Attention to adequate nutrition and vitamin Attention to adequate nutrition and vitamin supplementation is keysupplementation is key

Lifelong monitoring is essentialLifelong monitoring is essential