bariatric perioperative

8/6/2019 Bariatric perioperative

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! Perioperative of the Bariatric Surgery



Benefits of bariatric surgery



Type of bariatric

surgery• Restrictive procedures

• Vertical banded gastroplasty (VBG)

• laparoscopic adjustable gastric banding (LAGB)

• Sleeve gastrectomy (SG)



Vertical banded gastroplasty

Less complex and lower risk of micronutrient deficiencies



Laparoscopic adjustable gastricbanding (LAGB)

Silicone band, can

be adjusted byaddition or removal

of saline



Sleeve gastrectomy (SG)

Remaining size is about60-100 mL

For who high risk of performing a

gastric bypass orduodenal switch



Type of bariatric

surgery• Malabsorptive procedures

• Biliopancreatic diversion (BPD)

• Duodenal switch operation (BPD/DS)

• Combination or mixed procedures

• Roux-en-Y gastric bypass (RYGB)



Biliopancreatic diversion (BPD)

Creating a smaller

stomach

Distal part of smallintestine is connected

Bypassing duodenum and

jejunum.



Biliopancreaticdiversion with

duodenal switch

Upper part of smallintestine are reattached at75–100 cm from colon



Roux-en-Y stomachsurgery for weight loss

Stomach pouch is created with astapler device

Connected to the distal small

intestine.

Reattached inY-shaped



Metabolic complications

of bariatric surgery• Acid-base disorder

• Bacterial overgrowth (primarily with BPD, BPD/DS)

• Electrolyte abnormalities (primarily with BPD, BPD/DS)

• Fat-soluble vitamin deficiency

• Folic acid deficiency Iron deficiency

• Osteoporosis Oxalosis

• Secondary hyperparathyroidism

• Thiamine deficiency (vitamin B1) Vitamin B12deficiency



Executive summary of

recommendations• Which patients should be offered bariatric surgery?

• Which bariatric surgical procedure should be

offered?

• How should potential candidates for bariatricsurgery be managed preoperatively?

• System-oriented approach to medical clearance forbariatric surgery

• Early postoperative care (5 days)

• Late postoperative management (> 5 days)



Which patients should be offered

bariatric surgery?



Which patients should be offered

bariatric surgery?

• Depends on the available local-regional expertise

• Insufficient conclusive evidence to recommendspecific bariatric surgical procedures (Grade D)

• Should caution when recommending BPD, BPD/ DS, or related procedures (Grade C)

• Laparoscopic bariatric procedures are preferred



How should potential candidates for bariatric

surgery be managed preoperatively?

• Discussion risks and benefits, procedural options

• Provided with educational and access to

preoperative educational sessions.

• Diabetes

• Targets HbA1c < 7.0% ,FBS < 110 mg/dL , 2hrPostprandrial <140 mg/dL

• Thyroid : routine screening not recommend



• PCOS and fertility

• Minimize risk of pregnancy for at least 12mo

• Estrogen should be discontinued beforebariatric surgery

• 1 cycle :premenopausal

• 3 wks of HRT in postmenopausal

women) reduced thromboembolism

• Women with PCOS their fertility statusmay be improved postoperatively



• Exclusion of endocrine causes of obesity

• Routine laboratory testing :not cost-effective and notrecommended, should based on Hx and PE

• Cardiology and hypertension

• Pt with heart disease should have cardiologyconsultation

• At risk for heart disease should undergo evaluation forperioperative beta-adrenergic blockade (Grade A)

• Pulmonary and sleep apnea

• Patients with intrinsic lung disease or disordered sleep

patterns• ABG and polysomnography,

• Stop smoking at least 8 weeks before bariatric surgery



• Venous disease

• Risk or Hx of DVT or cor pulmonaleshould undergo diagnostic evaluationfor DVT (Grade D).

• Prophylactic vena caval filter (Grade C)

• Hx of prior PE, prior iliofemoral DVT

• Hypercoagulable state

• Increased right-sided heart pressures



• Psychiatric

• Psychosocial-behavioral evaluation,which assesses environmental,familial, and behavioral factors

• Evaluation ability to incorporatenutritional and behavioral changesbefore and after bariatric surgery



Early postoperativecare



• Clear liquid meal program can usually be initiatedwithin 24 hours after any of the bariatric procedures

• Protein intake average 60 to 120 g daily (Grade D).

• Concentrated sweets should be avoided after RYGB tominimize symptoms of the dumping syndrome

• Nutritional supplementation

• 1-2 multivitamin-mineral supplements

• iron, 1200 to 1500 mg/d of calcium, and vitaminB-complex.

• PN should be considered in high-risk patients



• Diabetes

• Insulin secretagogue drugs should be discontinued

• Maintain postprandial values below 180 mg/dL

• FBS maintained 80-110 mg/dL with the use of a long-acting insulin analogue

• In the ICU glucose levels should maintained 80-110 byintravenous insulin infusion (Grade A)



• Pulmonary

• Aggressive pulmonary toilet and incentive spirometry, avoid hypoxemia,and early institution CPAP when clinically indicated

• Prophylaxis against DVT is recommended for all patients (Grade B; BEL

2 [randomized]) and may be continued until patients are ambulatory(Grade D). Early ambulation is encouraged (Grade C; BEL 3).

• Prophylactic regimens

• sequential compression devices

• UFH or LMWH 3 days before and after bariatric surgery

• IVC filter placement in patients at high risk for mortality after PE orDVT



• Monitoring for surgical complications

• New sustained PR>120 beats/min for longer than4 hours should raise suspicion anastomotic leak

• In clinically stable: meglumine diatrizoate(Gastrografin) upper gastrointestinal studies or CTmay identify anastomotic leaks

• Exploratory laparotomy in high clinical suspicionfor anastomotic leaks despite a negative study



Late postoperativemanagement



• Inadequate weight loss

• Loss of integrity of the gastric pouch in

gastroplasty or RYGB procedures

• Poorly adjusted gastric band

• Development of maladaptive eatingbehaviors or psychologic complications



• Metabolic and nutritional management

• Routine metabolic and nutritional monitoring is recommendedafter all bariatric procedures (Grade A)

• advised to increase physical activity to a minimum 30 min/day aswell as increase physical activity

• Association of malabsorptive surgical procedureswith nutritional deficiencies

• recommended empiric vitamin and mineral supplementationafter malabsorptive bariatric surgery

• Protein depletion and supplementation

• Protein intake 80 -120 g/d for BPD or BPD/DS and 60 g/d ormore for RYGB



Skeletal and mineral

homeostasis, nephrolithiasis• Recommended evaluation Ca and Vit D metabolism

and metabolic bone disease in patients who have

undergone RYGB, BPD, or BPD/DS

• Ca, D2, D3 is indicated to prevent or minimizesecondary hyperparathyroidism without inducingfrank hypercalciuria

• Severe vitamin D malabsorption, may need D2 orD3 as high as 50,000 to 150,000 U daily



• Bisphosphonates consideration in patients with Tscore 2.5 or below for the hip or spine only after therapy

for Ca and vitamin D insufficiency.

• Normal PTH level

• 25-OH D level of 30-60 ng/mL

• Normal Ca and PO4

• Urine24-hr Ca excretion 70-250 mg/24 h.

• Recommended dosages

• alendronate, 70 mg/ wk;

• risedronate, 35 mg/wk or two 75-mg tablets/mo; or• ibandronate, 150 mg/mo.

• zoledronic acid, 5 mg once a year



Diagnostic testing and management

for skeletal and mineral disorders



• Insufficient data to recommend empiric supplementationMg : 300 mg in women and 400 mg in men)

• Oral phosphate supplementation hypophosphatemia (1.5to 2.5 mg/dL), which is usually due to vitamin Ddeficiency

• Management of oxalosis and calcium oxalate stones

• avoidance of dehydration

• low oxalate meal plan

• oral calcium and potassium citrate therapy

• Probiotics containing Oxalobacter formigenes have beenshown to improve renal oxalate excretion and improvesupersaturation levels and may therefore be used as well



Roux-en-Y gastric bypass

• Every 3-6 mo then Annually

• CBC, platelets, Electrolytes, Glucose, Lipid profile

• Iron studies, ferritin

• Thiamine RBC folate

• Vitamin B12 (MMA, HCy optional)

• Liver function (GGT optional)

• 25-Hydroxyvitamin D

• PTH



Biliopancreatic diversion (+/-duodenalswitch)

• Every 3 mo Every 3-6 mo depending on symptoms

• Same + Fat-soluble vitamins (6-12 mo)

• Vitamin A, 25-OH D, Vit E, Vit K1 and INR

• Metabolic stone evaluation (annually) 24-Hour urinecalcium, citrate, uric acid, and oxalate

• Trace elements (annually or as needed)

• Zinc

• Selenium

• Miscellaneous (as needed)

• Carnitine Essential fatty acid chromatography



Fat and fat-soluble

vitamin malabsorption• Routine supplementation of vitamin A is usually not

necessary after RYGB or purely restrictive procedures

• Routine screening for Vit A def is recommended

• Supplementation is often needed after malabsorptivebariatric procedures (BPD or BPD/DS)

• Routine screening for vitamin E or K deficiencies hasnot been documented for any bariatric procedure

• Fat-soluble vitamin deficiency

• Hepatopathy, coagulopathy, or osteoporosis

• Assessment of a vitamin K1 level should beconsidered



Routine nutrient supplementationafter bariatric surgery



Iron, Vitamin B12, Folic acid, andSelenium deficiencies

• Iron

• Should be monitored in all bariatric patients

• Ferrous sulfate, fumarate, or gluconate (320 mgbid) may be needed to prevent in malabsorptiveprocedure(Grade A)

• Vit C supplementation should be considered inrecalcitrant iron deficiency



• Vitamin B12

• Evaluation Vit B12 deficiency in all patients

• Supplementation Vit B12 dosage of 350 mcg/d

• Parenteral supplementation if cant by oral

• 1000 mcg monthly or

• 1000 to 3000 mcg every 6 to 12 months



• Folic acid

• Supplementation 400 mcg/d

• Should be provided in all women of childbearing age (Grade A)

• Nutritional anemia• should evaluate protein, copper, and

selenium if B12, folic and iron study isnormal

• Unexplained anemia or fatigue, persistent diar-rhea, cardiomyopathy, or metabolic bonedisease selenium levels should be checked



• Zinc and thiamine• Inadequate evidence to empiric zinc

supplementation after bariatric surgery

• All bariatric patients should oralsupplement multivitamin that containsthiamine

• Protracted vomiting should screenedthiamine deficiency



Gastrointestinal complications

• Diarrhea

• EGD with small bowel biopsies and aspirates

gold standard in the evaluation of celiac sprueand bacterial overgrowth

• Colonoscopy if the presence of Clostridiumdifficile colitis is suspected

• Persistent steatorrhea after BPD or BPD/DS shouldevaluation for nutrient deficiencies




• Stomal stenosis or ulceration after bariatricsurgery

• NSAIDS should be avoided

• H pylori testing• Anastomotic ulcers treated H2 blockers, PPI, sucralfate

• Persistent symptoms of GERD, chronic cough, orrecurrent aspiration pneumonia after LAGB suggestive

•

Band being too tight• Development of an abnormally large gastric

pouch above the band

• Immediate referral back to the surgeon




• Gallbladder disease

• Ursodiol 300 mg bid x 6 months postoperatively may beconsidered in patients not undergoing a prophylacticcholecystectomy (Grade A)

• No consensus need to perform cholecystectomy at the time of bariatric operations

• Bacterial overgrowth

• Suspected bacterial over-growth after BPD or BPD/DS should

be treated empirically with metronidazole

• For antibiotic-resistant cases : probiotic therapy withLactobacillus plantarum 299v and Lactobacillus GG mayconsidered (Grade D)



Criteria for hospital admissionafter bariatric surgery

• Severe PEM should hospital admission for initiation of nutritionalsupport

• If not dehydrated, most patients can undergo endoscopic stomaldilation for stricture as an outpatient procedure

• Revision of a bariatric surgical procedure

• Complications from surgical procedure and not amenableor responsive to medical therapy

• Inadequate weight loss or weight regain in patients with

persistent weight-related comorbidities (restrictiveprocedure)

• Reversal of a bariatric surgical procedure is recommendedwhen serious complications cannot be managed medicallyand are not amenable to surgical revision



! Thank you

bariatric perioperative

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