BARIATRIC SURGERY – AN OPPORTUNITY FOR CHANGE

IDA DIAMOND APRN, GNP, FNP

Objectives

Define the extent of the problem Discuss which weight loss methods are available Determine who is a good candidate for bariatric

surgical procedures Describe bariatric surgical procedures;

differentiate between bariatric surgical procedures in regard to invasiveness, potential complications, adjustability, and reversibility

Discuss the improvement and resolution of comorbidities of obesity after bariatric surgery

Define the NP’s role in providing post-operative support and management

Obesity – The Problem

According to the CDC (2011): * Approximately 195 million Americans are

overweight – that’s 63% of the total population * About half of these people are considered

obese * 8-12 million are “morbidly obese” * Obesity-related conditions include heart

disease, stroke, type 2 diabetes and certain types of cancer - some of the leading causes of preventable death.

* In 2008, medical costs associated with obesity were estimated at $147 billion

Body Mass Index Calculated using height and weight BMI is calculated by weight in pounds

multiplied by 703 and divided by height in inches squared

BMI < 19 is considered under a healthy weight, BMI 19-24 is healthy weight, BMI 25-29 is overweight, BMI 30-34 is obese I, BMI 35-39 is obese II, BMI 40 or greater is obese III

V Codes for billing by BMI category is V85.00-V85.40

BMI controversial - but the best we have for ease, price and accepted universal description

Why are we obese?

We no longer have to gather, hunt for, or prepare our own food

We no longer build our own shelter or walk to get to one place or another

We are at the top of the food chain; we no longer have to run from predators

Food Issues

Increased Portion Size Stress Eating Socioeconomic Aspect Comfort Foods Fats and Carbohydrates are very

satisfying Quick energy boost from high calorie

sweeteners No knowledge of how to prepare foods Bad foods hidden behind good labels

Exercise Issues

We no longer need to walk Sedentary Leisure Activities Sedentary Jobs P.E. class “Exercise used to go by another name – it

was called survival” - David Katz

Obesity Related Comorbidities

Type 2 Diabetes Cancer

Hypertension Degenerative Joint Disease

Heart Disease Infertility/PCOS

High Cholesterol Pseudotumor Cerebri

Reflux Disease Incontinence

Sleep Apnea Psychosocial Problems

Venous Stasis Disease Injuries

***Breather***

What Can We Do?

First Line : Basic Intake and Exercise * Decease caloric intake/day; 1200/day for women

and 1600/day for men * Better food choices; decrease carbohydrates,

eliminate fats, cut down on sodium * Menus and food choice lists very helpful * Increase zero and low-calorie fluid intake; at least

64 ounces/day * Exercise; walking, combo of cardio and

strength/resistance training * Gym membership, YMCA, community centers,

civic groups, parks, community pools, home exercise equipment/videos, or no equipment at all

What Else Can We Do?

Second line: Diets and Medications * Diets that incorporate all food groups; Weight

Watchers, South Beach, Mediterranean * Diets that incorporate weigh-ins, ‘buddy’ support,

and meetings * Rx and OTC medications: Amphetamines,

Phentermine (Adipex, Fastin, Pondimen), Xenical (Orlistat), Meridia (Sibutramine), HCG, Prozac, Wellbutrin

***Keep in mind that this may be the first time you see the patient in the primary care setting. So much information is available commercially and on-line that they are only there to see you for a prescription.

All have one thing in common…

They don’t work very well for very long 3-5% of people succeed in long term

weight loss by diet and exercise alone They don’t cure the comorbidities

So, Let’s look at Bariatric Surgery

Bariatric Surgical Options

Laparoscopic Adjustable Gastric Band (LAGB) Laparoscopic Sleeve Gastrectomy or Gastric

Sleeve Resection (GSR) Vertical Banded Gastroplasty (VBG) Roux-en-Y Gastric Bypass (RYGB) Gastric Balloon Procedure – used mostly in

Europe and Asia. Not FDA approved in US, although clinical trials are being performed in the US (Houston)

Images of Major Bariatric Surgeries

Gastric

Banding

Gastric Bypass

Gastric Sleeve

Chart of comparison of bariatric surgeries

Gastric Banding

Gastric Bypass

Gastric Sleeve

Invasiveness Minimally invasive, no rerouting or partial re- moval of intern.organs

Stomach stapling and rerouting of the intestines are required

Stapling and removal of part of the stomach are required

Adjustability Yes No No

Reversibility Yes Yes, but extremely difficult

No

Restrictive/ Malabsorptive

Restrictive Restrictive and Malabsorptive

Restrictive and Malabsorptive

Short Term Complications;(within 30 days)

Bleeding (0.6-4%), wound infection (3-15%), PE & DVT, CV (12.5-17.6) and Pulm (3-7%) complications, acute stomal obstruction (<1-14%)

Bleeding (0.6-4%), wound infection (3-15%), PE & DVT, CV (12.5-17.6) and pulmonary (3-7%) complications, Leaks (1-6%)

Bleeding (0.6-4%), wound infection (3-15%), PE & DVT, CV (12.5-17.6) and pulmonary (3-7%) complications, Leaks (1-6%)

Long Term Complications;(after 30 days)

Band erosion, band slippage or prolapse, port infection, port tubing or band malfunction, esophagitis, choleli-thiasis, esophageal or pouch dilation, hiatal hernia

GI bleeding due to marginal ulcers, stomal stenosis, hernias, cholelithiasis, short bowel and dumping syndromes, micronutrient deficiencies, renal failure, changes in bowel habits, leaks

GI bleeding at staple line, stenosis gastric outlet obstruction, GERD, Leaks, dumping syndrome, micronutrient deficiencies (not enough long-term data to rule out other complications)

Who Is a Candidate for Bariatric Surgery?

Wants to look better in a bikini? Wants to shed a few excess holiday pounds? Knows several people/relatives who have had

bariatric surgery and wants to try it too? Wants to quickly get in shape for the class

reunion next month? Wants to use up funds in their health savings

account or flex-spending account at the end of the year?

Has lots of money and doesn’t know what else to do with it?

NO!

Who is really a candidate for Bariatric Surgery?

Those who wish to decrease the risk of dying Those whose risk of dying, illness, and/or

disability is higher than the risks of the operation

Those who wish to improve their quality of life and decrease costs of living

To reduce pain and suffering due to comorbidities

Those who have seriously considered and accept necessary lifestyle modifications and risk of operative and long-term complications

Clinical Prerequisites

BMI equal or greater than 40 BMI equal or greater than 35 with 1 or

more comorbidities BMI equal or greater than 30 with 2 or

more comorbidities Those who have multiple documented

attempts at weight loss through diet/exercise/medication

Those who are psychologically stable with no substance abuse

Pre-Operative Assessment

Complete H&P PMH, Family Medical Hx, Social Hx, (including drugs, ETOH, smoking), Allergies, Medications, Wt Loss Hx, Surgical Hx, Typical Eating and Exercise Hx, PE Diagnostics Lab Studies, Mallampati, EKG, PFT, Epworth Sleepiness Scale, Oximetry. If clinically indicated: Sleep Study, EGD, CXR Consults Psych, Cardiology, Pulmonary, Hematology (not routine – only if clinically/PMH indicated)

Surgical Contraindications

Patients on immunosuppression s/p organ transplant; routine steroid Rx for COPD/arthritis on a case by case basis

Schizophrenia Scleroderma Significant esophageal dysmotility syndrome

as evidenced by abnormal manometry studies

Significant prior GI surgery as in resection for PUD/tumor; failure of prior RYGB, VBG, or GSR on a case by case basis for possible GB

Surgical Contraindications(continued)

Inability to ambulate (WC or bedbound) Untreated substance abuse Untreated eating disorders Severe anxiety disorder Crohn’s disease Untreated OSA

Expected Improvement and Resolution of Obesity and Comorbidities

Success in long-term weight loss is 50-80% depending on the procedure selected.

Expected Improvement in: Diabetes II 50-95% Hypertension 60-92% GERD 80-98% Dislipidemia 76-97% OSA 65-75% Stress Urinary Incontinence 45-87% Degenerative Joint Disease 42-82%

Multidisciplinary Team Approach

Primary Care Practitioner

Exercise Physiologist, Nutritionist, Registered Dietician

Surgical Team

Lifestyle Counselor

Medical Consultants: Cardiologist,

Endocrinologist, GI, Sleep Specialist,

Psychologist, Psychiatrist

Things the Nurse Practitioner Should Know About the Post-op

Bariatric Patient Reinforce proper eating and exercise

behaviors; these must change permanently for success

Food tolerances may change Dumping Syndrome with ingestion of

sweets and carbohydrates Body image changes and relationship

changes are stressful and may lead to depression and anxiety; new lifestyle changes may strain even previously healthy family/social relationships

How to Help Care for the Post-op Bariatric Patient (cont’d)

Patient should avoid caffeine, alcohol and carbonated beverages

Do not drink for 30 minutes before or after a meal

Drink slowly – fast may stimulate vomiting No drinking through a straw A meal should be no more than a cup (8 oz)

of food Gastric Bypass and Sleeve patients should

avoid a large amount of carbohydrates or sweets at one time

How to Help Care for the Post-op Bariatric Patient (cont’d)

All medications ordered post-op must be chewable, liquid, capsules that can be opened, tablets that are very small (no bigger than a baby aspirin) or tablets that can be cut to that size

Must take MVI and possible supplementation with Ca, Fe, B vitamins, Vitamin D, and protein to avoid such issues as hair loss/thinning, muscle loss, bone loss, low body iron stores, and/or tiredness

People may still be unhappy with physical appearance – sagging skin, stretch marks

How to Help Care for the Post-op Bariatric Patient (cont’d)

The primary care NP has the unique opportunity to be the first practitioner that the patient comes to with GI and psychosocial issues. Do not hesitate to call on the bariatric team, psychologists, nutritionists and other specialists to assist with the healthcare problems that may arise.

There are risks of serious operative complications, especially when a patient is not compliant. Please be on the lookout for these and alert the bariatric team/ED as necessary.

Almost Done…Only the Questions Remain