Bariatric Procedures, Complications and Follow up

Mr Pratik SufiConsultant Bariatric & Upper GI Surgeon

Spire Bushey Hospital

Balancing Activity Levels with Food

1. One small chocolate chip cookie (50 calories) is equivalent to walking briskly for 10 minutes. 2. The difference between a large gourmet chocolate chip cookie and a small chocolate chip cookie

could be about 40 minutes of raking leaves (200 calories). 3. One hour of walking at a moderate pace (20 min/mile) uses about the same amount of energy that is

in one jelly filled doughnut (300 calories). 4. A fast food "meal" containing a double patty cheeseburger, extra-large fries and a 24 oz. soft drink is

equal to running 2½ hours at a 10 min/mile pace (1500 calories).5. One tsp sugar (20cal) ≈ 4 min walk6. One can coke (160cal) ≈ 30 min walk

Physical Activity Calories Burnt / 30 minutes

Walking leisurely @ 2mph 85

Walking briskly @ 4mph 170

Gardening 135

Raking leaves 145

Dancing 190

Bicycling leisurely @ 10mph 205

Swimming laps, medium level 240

Jogging @ 5mph 275

Energy Utilisation in Human Metabolism

0%

10%

20%

30%

40%

50%

60%

70%

80%

Low activity Moderate activity High activity

Activity Level

% o

f Ene

rgy

Use

Physical activity

Thermic eff ect

Resting metabolism

Dietary Change

Pulmonary Disease• Abnormal Function• Obstructive Sleep Apnea• Hypoventilation Syndrome• Asthma

Hepato-pancreato-biliary Disease• Steatosis (NALD)• Steatohepatitis (NASH)• Cirrhosis• Gall Bladder Disease• Pancreatitis

Coronary Heart Disease• Diabetes• Dyslipidemia• Hypertension• CCF

Gynecologic Abnormalities• Abnormal Menses• Infertility• Polycystic Ovarian

SyndromeMusculoskeletal• Osteoarthritis• Gout

Skin• Dermatitis• Leg ulcers

Cancer• Breast, Uterus, Cervix,• Colon, Esophagus, Pancreas,• Kidney, Prostate

Vascular• Phlebitis / DVT• Venous stasis• Leg ulcers

Herniae• Umbilical• Ventral• Inguinal

Cerebral• Idiopathic Intracranial Hypertension• Stroke

Cataracts

Obesity OnLine Slide Presentation. Accessed May 17, 2007. Accessible as slide #5 at http://www.obesityonline.org/slides/slide01.cfm?tk=33.

Obesity Associated Co-morbidities

GI• GORD & Hiatus Hernia

Impact of Obesity on GP Consultations

BMI

Perc

en

tag

e

20 25 30 35 40

15

10

20

25

30 Brown WJ et al. Int J Obes 1998;22:520-528.

• Low BMI was associated with fewer physical health problems than mid-level or higher BMI.

• Indicators of health care use showed a J-shaped relationship with BMI for general practitioners (>5 GP Consultations).

• Prevalence of medical problems (for example, hypertension OR 6x and diabetes OR 6x), surgical procedures (cholecystectomy OR 7x and hysterectomy OR 2x) and symptoms (for example, back pain OR 40% and constant tiredness OR 70%) increased monotonically with BMI.

Effect of Diet and Surgery on Weight & Mortality

•Diet & exercise effective up to 6m• 60% failure at 1 yr.• 80% failure at 2 yrs.• 100% failure at 5 yrs.

•Surgery effective long-term (80%)

Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects N Engl J Med 2007;357:741-52.

High Risk

Low efficacy – less durable weight loss

High efficacy – durable weight loss

Effective but unacceptable risk

Low Risk

Primary Obesity Options Today

Diet/ Drugs

Surgery

EndolumenalObesity

Moderate risk / efficacy – intermediate durability

Abandoned Surgery

LapBand

GastricBalloon

POSEEndosheath

Less Effective More Effective

SleeveGastrectomy

GastricBypass BPD/DS

VBG

Jejuno-IlealBypass

20-60%

40-95%

Procedure ComparisonProcedure Mechanism of

actionEBWL (2 year)

Invasiveness / Durability

Follow-up

Gastric balloon Restrictive 10-20%

Minimal/Short-term

Intensive/6-24m

POSE Restrictive 20-40%

Minimal/Long-term

Minimal/12-24m

Endosheath Diversion 30-50%

Minimal/Short-term

Intensive/12-24m

Gastric band Restrictive + Neurostimulation

50-60%

Moderate/Long-term

Intensive/Life-long

Gastric plication

Restrictive 40-60%

High/Unknown Modest/Life-long

Sleeve Restrictive + Endocrine

60-80%

High/Long-term Modest/Life-long

Gastric bypass Restrictive + Bypass-Diversion +Malabsorption

70-90%

High/Long-term Intensive/Life-long

Duodenal switch

Restrictive + Bypass-Diversion +Malabsorption

90-100%

Very high/Long-term

Intensive/Life-long

Referral - Minimal DatasetAgeWeight & BMICo-morbidity esp.

cardiovascularrespiratoryendocrineGI and musculo-skeletal

MedicationPrevious attempts at weight lossOther concerns like

Untreated eating disordersPsychiatric history

NICE: BMI≥35ASMBS: BMI≥30Asians: BMI 2 points lower

Pre-operative Liver Shrinkage Diet

Food group No of servings

Fruit 2 

Vegetables 3 

Carbohydrates 3 

Dairy 2 

Protein 3 

Fats 2 

Meal/Snack Product Amount Calorie

s

Protein

(g)

Breakfast Slimfast

shake

1

serving

220 /

230

14 / 15

Morning

snack

Slimfast

shake or

Slimfast meal

replacement

bar

1

serving

220 /

230

14 / 15

Lunch Slimfast

shake

1

serving

220 /

230

14 / 15

Dinner Slimfast

shake

1

serving

220 /

230

14 / 15

    Totals 880-

920

56-60

Slimfast –900 kcal/d approximately

Food-based – 900 kcal/d approx.

Two (2) weeks

Four (4) weeks

Pre-operative Special ConsiderationsHypertension control

ACE Inhibitors AT2 receptor antagonists

Glycaemic control Oral hyperglycaemic agents Insulin

Anticoagulation Warfarin Clopidogrel Aspirin

OSA CPAP

GORD PPI

NAFLD / NASH Liver shrinkage diet

Post-operative RegimeLiquids only for 2-3 weeksSoft blended food for 2-3 weeksResume solids after 4-6 weeks

Small mouthfulsChew wellEat slowlySeparate eating and drinking by ½ hourAvoid fizzy / sugary drinks or sugary food

Medication – liquid / soluble (crushed)Supplements

IronCalcium and vitamin DVitamin B12Folic acidVitamin B1

Recommended Multivitamin and minerals: Chewable versions:• Bassett’s Adult Chewable multivitamins with prebiotics & minerals • Wellkid Smart / Sanatogen A-Z Kids Chewable• Haliborange Chewable multivitaminsWhole tablet:• Sanatogen Gold or Centrum (after 3 months)

Plus• Chewable Calcium – 1000mg calcium /day• Liquid iron or iron drops - 50mg of iron/day   

Post-operative – Suitable Fluids D0-W2Milk - Aim for at least two pints (1.2L) of milk or a milk

alternative a dayMilk can be flavoured with Nesquick or low calorie hot

chocolateSlimming drinks e.g. Slimfast or chemist/supermarket

own brandComplan or Build-up shakes or soupsYogurt drinks and smoothiesStill mineral water, if taking the flavoured types make

sure they are low sugarStill low-sugar squashes Smooth soups e.g. cream of tomato or chicken; or oxtailTea and coffee without sugarUnsweetened pure fruit juice

Post-operative Special Considerations

Diet Not allowed to eat and drink together Eat slowly, chew well – at least 20-30 minutes Liquids for 24-48hours after band adjustment

Return to workChange in medications

Restrictions on tablets – soluble, liquids or crushed tabletsChange in co-morbidity

Antihypertensive Oral hyperglycaemic agents Insulin

Change in absorption Warfarin Oral contraceptives

Avoid pregnancy for 18 months Risk to mother Risk to foetus

Long-term Follow-up Pins and needles (B12, B1) Frequent falls (B12, B1, Fe) Tiredness (anaemia, hypoglycaemia) Generalised pain (PTH) Abdominal pain (ulcer, gallstones / hernia / kidney stones) Reflux / regurgitation/ N&V / persistent cough (band slippage,

over-tight band, ulcer, hiatus hernia)

Calcium supplements- 1000mg calcium / day. Liquid or effervescent tablets Ferrous Sulphate/ ferrous fumarate or sodium feredetate – drops, syrup or sugar free elixir. 50mg of iron/day Hydroxocobalamin Vitamin B12 injections – 1mg every 3 months

Mechanism Prevalence Clinical

Protein Intake, absorption,

Distal RYGB 6-13%Standard RYGB 0%Peak 1-2 yrs

Loss of muscle, weakness, oedema, etc.

Iron Intake, Acid exposure, absorption

2 yr: 33% Anaemia, tinnitus, hair loss

Vitamin B12 (cobalamin)

Reduced acid, ?IF link

1 yr: 12 – 70%Within 2yrs: 25%

Anaemia, macrocytosis

Calcium & Vitamin D

Intake, absorption, HyperPTH

Distal RYGB: 2yr Ca 10%, Vit D 51%

BPD Ca 25-50%, Vit D 17 – 50%

MBD –Osteomalacia, osteoporosis

Liposoluble Vitamins (A, E, K)

Reduced fat breakdown

RYGB: very lowBPD (4yr): A-69%, K-68%, E-4%

A: night blindness

Zinc Absorption – dependent on lipidsSurgical stress

RYGB: rareBPD: 10 – 50%

Hair loss

Nutritional Deficiencies

Diagnosis and Treatment of Nutritional Deficiencies Deficiency Symptoms

and signs Confirmation Treatment

first phase Treatment second phase

Protein malnutrition

Weakness, decreased muscle mass, brittle hair, generalized oedema

Serum albumin and prealbumin levels, serum creatinine

Protein supplements

Enteral or parenteral nutrition; reversal of surgical procedure

Calcium/Vitamin D

Hypocalcaemia, tetany, tingling, cramping, metabolic bone disease

Total and ionized calcium levels, intact PTH, 25-D, urinary N-telopeptide, bone densitometry

Calcium citrate 1,200–2,000 mg,oral vitamin D50,000 IU/d

Calcitriol oral vitamin D 1,000 IU/d

Vitamin B12 Pernicious anaemia, tingling in fingers and toes, depression, dementia

Blood cell count, vitamin B12 levels

Oral crystalline B12350 mg/d

1,000 –2,000 mg/2–3 months im

Folic acid Macrocytic anaemia, palpitations, fatigue, neural tube defects

Cell blood count, folic acid levels, homocysteine

Oral folate, 400 mg/d (included in multivitamin)

Oral folate, 1,000 mg/d

Iron Decreased work ability, palpitations, fatigue, koilonychia, pica, brittle hair, anaemia

Blood cell count, serum iron, iron binding capacity, ferritin

Ferrous sulphate 300 mg 2–3 times/d, taken with vitamin C

Parenteral iron administration

Vitamin A Xerophthalmia, loss of nocturnal vision, decreased immunity

Vitamin A levels Oral vitamin A, 5,000–10,000 IU/d

Oral vitamin A, 50,000 IU/d

An Endocrine Society Clinical Practice Guideline

Schedule for Clinical and Biochemical Monitoring

An Endocrine Society Clinical Practice Guideline

TESTSPre-operative

1 month

3 months

6 months 12

months 18

months 24

months Annually

Complete blood count X X X X X X X X

LFTs X X X X X X X X

Glucose X X X X X X X X Creatinine X X X X X X X X Electrolytes X X X X X X X X Iron/ferritin X     Xa Xa Xa Xa Xa

Vitamin B12 X     Xa Xa Xa Xa Xa

Folate X     Xa Xa Xa Xa Xa

Calcium X     Xa Xa Xa Xa XaIntact PTH X     Xa Xa Xa Xa Xa

25-D X     Xa Xa Xa Xa XaAlbumin/prealbumin X     Xa Xa Xa Xa Xa

Vitamin A X           Optional Optional

Zinc X     Optional Optional   Optional Optional

Bone mineral density and body composition

X      

Xa 

Xa Xa

Vitamin B1     Optional Optional Optional Optional Optional Optional

Xa – Tests should only be performed after RYGB, BPD, or BPD/DS. X – Tests suggested for patients submitted to restrictive surgery where frank deficiencies are less common.

Pulmonary DiseasePneumonia / Atelectasis

HPB Disease• Hepatitis (trauma)• Pancreatitis

(trauma)• Cholecystitis

CV Disease• MI• DVT / PE• Beriberi

Gynecologic Abnormalities• Amenorrhoea• Fertility – failure of

contraception

Bone Disease • Osteomalac

ia

Malnutrition• Dermatitis• Neuropathy• Ataxia

Cerebrovascular Disease• Wernicke’s Encephalopathy (Beriberi)• Stroke / TIA

MalnutritionGlossitis, stomatitisHair loss

Post-Bariatric Surgery Complications

GI Disease• Bleeding• GORD & Hiatus

Hernia• Ulcer• Bloating /

Obstruction• Diarrhoea /

Constipation• Malabsorption

Renal Disease• Kidney

stones

Immediate post-operative – infection, bleed, thromboembolism Tiredness, pain, ulcers, dry skin, pins and needles, hair loss etc. (Nutritional

deficiency – Iron, Calcium, Vitamin D, Folate, Vitamin B12, Vitamin B1, Zinc) Nausea, vomiting (Slipped band, over-restriction, hiatus hernia, gallstones,

anastomotic ulcer, GLP-1 excess, internal /port-site hernia etc.) Hernia – port-site, incisional

General complications

Slippage (Pain, N&V) Erosion (Pain, N&V, loss of restriction) Oesophageal dilation (Regurgitation, N&V, persistent cough) Infection (Pain, local inflammation, systemic sepsis) Nutritional deficiency (tiredness, hair loss) Gallstones (Pain, N&V, Jaundice) Hiatus hernia / GORD (Regurgitation, heartburn, dysphagia)

Band Complications

Sleeve Gastrectomy Complications Staple line leak (pain, N&V, sepsis) Staple line bleed Reflux (regurgitation, heartburn, dysphagia) Sleeve dilation (weight regain) Nutritional deficiency (tiredness, hair loss, pain) Gallstones (pain, dyspepsia, N&V, jaundice)

Gastric Bypass Complications Staple line leak (pain, N&V, sepsis) Staple line bleed Ulcer (pain, N&V, dysphagia) Stenosis (dysphagia, pain, N&V, regurgitation, excessive

weight loss) Dumping (giddiness, tiredness, tachycardia, cramps) Internal hernia (cramps, bloating, constipation) Gallstones (pain, N&V, Jaundice) Nutritional deficiency (tiredness, hair loss, pins and needles,

pain, ulcers)

Balloon Complications

Intolerance (nausea & vomiting, cramps) Ulcer (epigastric pain) Deflation and migration (bowel obstruction)

POSE Complications

Perforation Bleeding Intolerance (nausea & vomiting,

cramps) Ulcer (epigastric pain)

Pain

GallstonesPancreatitisAnastomotic ulcerPerforation / Anastomotic leakGastric band erosionSlipped gastric bandDumping syndromeAnastomotic strictureSmall bowel obstructionGastro-gastric fistula

Nausea & Vomiting

Pregnancy!GastroenteritisGastric balloon intoleranceOver-restricted gastric bandAnastomotic ulcerAnastomotic / Sleeve gastrectomy strictureGallstones / PancreatitisHiatus herniaInternal hernia / Small bowel obstruction

Diarrhoea

GastroenteritisBacterial overgrowthClostridium difficileFat malabsorptionDumping syndromeLactose intolerance

Case Study 1 Mr A, 32 year old publican,

gastric bypass 3 year ago, lost 85% excess body weight

Tripping over repeatedly – 4 months. Nausea and vomiting, pins and needles in hands and feet

Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?

GP referred patient to neurologist

Differential diagnosis: Thiamine / Vitamin B12 deficiency

Investigation: RBC thiamine / Serum Vit B12 + ECHO + MRI brain

Treatment: Thiamine 100mg bd for 12 weeks

Thiamine DeficiencyBeriberiWernicke’s encephalopathy

Confusion, irritability, memory loss, nervousness, speech difficulties

SoB, orthopnoea, tachycardia

Constipation, digestive problems, loss of appetite

Numbness of hands and feet, pain sensitivity, poor coordination, weakness, absent knee and tendon reflexes, paralysis

Case Study 2 Mrs B, 42 year old housewife,

gastric band 2 years ago, lost 64% excess body weight

Sudden onset epigastric pain and dysphagia

Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?

Differential diagnosis: Band slippage Band erosion

Investigate: Contrast swallow CT abdomen OGD

Band slippage – Emergency band deflation + reposition / removal

Band slippageEpigastric painDysphagiaWeight regainBand erosionEpigastric painLoss of restrictionWeight regainBand infection

Case Study 3 Mrs X, 37 year old writer, gastric

bypass 6 months ago, lost 45% excess body weight

Intermittent epigastric pain and nausea

Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?

Differential diagnosis: Anastomotic ulcer Gallstones Internal hernia

Investigate: USS, Contrast swallow, CT

abdomen, OGD Diagnosis: Gallstone cholecystitis Treatment: Laparoscopic

cholecystectomy

Anastomotic ulcerEpigastric pain, heartburnGallstonesEpigastric / RUQ pain, N&V,

PancreatitisInternal herniaAbdominal cramps after

eating, constipation, bloating, acute abdomen

Case Study 4 Mr Y, 27 year old computer

analyst, gastric bypass 3 years ago, lost 75% excess body weight

Abdominal pain, bloating, nausea and diarrhoea

Refer to hospital – Emergency / Urgent / Routine?

Differential diagnosis: Bacterial overgrowth Malabsorption Internal hernia

Investigate: Bloods, ABG, CT abdomen, D-

Xylose test, Hydrogen breath test, Stool culture, Faecal fat

Diagnosis: Bacterial overgrowth Treatment: Correct nutritional

deficiencies and Metronidazole + Live yogurt / Neomycin + Rifampicin

Bacterial overgrowthAbdominal cramps,

diarrhoea, borborygmiMalabsorptionSoB, orthopnoea,

tachycardiaInternal herniaAbdominal cramps after

eating, constipation, bloating

Case Study 5 Ms Q, 42 year old teacher,

gastric band 2004, lost 60% excess body weight

Cough, reflux and water brash for the last 3 weeks.

Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?

GP started her on Amoxicillin and referred for an OGD

Differential diagnosis: RTI, band slippage, over-restricted band

Investigation: Gastrograffin swallow + OGD

Treatment: Band volume reduction - defill

Over-restricted bandCough, reflux and water

brashUnable to tolerate solidsUnable to lie down

without coughingBand slippageEpigastric pain Intolerant to solids /

liquidsWeight regain

Take Home MessageBariatric surgery is a cost-effective treatment

for obesity which leads to resolution of co-morbidities, improved quality of life and increased life expectancy

However, patients need lifelong follow-up after surgery in order to avoid harm – this can be performed by their surgical team and by the primary care.

Patients can present with nausea, vomiting, dysphagia, reflux, abdominal pain and neurological symptoms.

Common things are common!Nutritional deficiencies are common and

easily preventable.

Thank you!