Preoperative evaluation of the Bariatric patient.

William Bakhos,MD

Preoperative Focus Multidirectional

Concomitant patient educationInformed consentMedical evaluation for risk assessmentStrategies for risk reduction

Patient Education Content

Health risks and medical hazards associated with obesity.

Quality of life issues. Low probability of success with dietary or other

non-surgical weight control programs. Weight loss results of surgery, including failure

rates of the different types of procedures Impact of weight loss. Necessity for long-term follow-up.

Patient Education Content

Possible complications Mechanisms for weight loss Post-operative alcohol restriction Available and accepted operations for obesity

treatment,results,advantages,disadvantages, operative risks and complications

Mortality rate (broken down by BMI and severe medical problems)

Contraindications to Surgery

High medical risk. Unable to understand the operation. Unrealistic expectations. Unresolved emotional illness. Drug abuse/alcoholism. Unwilling to sign follow-up contract. Does not have a support person.

Initial Screening

H&P- Medical and Surgical History Family History/Social History Medications/Allergies Diet History Physical Exam- HT, WT, BMI, VS

Initial Screening

Labs Chemistry, liver function, renal function Lipid Profile CBC Iron Profile- TIBC, total iron, saturation B-1, B-12 levels HbA1c H-Pylori Drug Screen (optional)

Initial Screening

Radiology U/S liver/GB CXR UGI Swallow Study (optional)

Cardiac EKG Venous Doppler Studies (optional)

Preoperative Evaluations

ASBS and SAGES Guidelines For Surgical Treatment –Bariatric Surgery, Published in 2000:

The multidisciplinary approach includes Medical management of comorbidities Dietary instruction, Exercise training, Specialized nursing care and psychological

assistance as needed. Having a multidisciplinary team who can address these

necessary components of bariatric patients’ needs is imperative.

Preoperative Behavior Change

Preoperative exercise program.

Patients sometimes asked to maintain body weight or lose weight prior to surgery.

Patients asked to quit smoking prior to surgery.

Reduces risk, establishes healthy habits,and tests motivaiton and commitment.

Dietary Evaluation

Registered Dietitian Address dietary concerns and begin making

changes now Avoid the Last Supper Syndrome Diabetes Education

Exercise Evaluation

Preoperative exercise program. Assessment . Mobility Issues. Physical Conditioning. Education. Motivation.

Gastro-Intestinal Evaluation.

Endoscopy. Ulcers (Helicobacter pylori). Esophageal Disorders. Irritable Bowel Syndrome. Crohn’s Disease.

Birth control counseling.

Absence of pregnancy. Birth control. Risky pregnancy in the early post-op. period (1-2

years). Weight loss may improve fertility.

Cardiac Risk & Complication Rate

One point assigned per risk factor:

1- CAD

2- CHF

3- CVD

4- High-risk surgery

5- Diabetic requiring insulin

6- Pre-op creatinine >2.0 mg/dl

Risk Class/ complication rate

Class I Zero 0.4%

Class II One 0.9%

Class III Two 6.6%

Class IV Three 11.0%

Lee TH, et al. Circulation. 1999;100:1043-49

Cardiac Risk Assessment.

Stress Testing Echocardiogram Medication adjustment Cardiac Clearance

Beta BlockadeMajor criteria

Use Beta-blockers in patients meeting any of the following criteria

History of MI,current angina Or use of sublingual nitroglycerine Positive exercise test results Q waves on ECG Patients who have undergone PTCA or CABG and who have chest

pain History of TIA or CVA Diabetes mellitus requiring insulin therapy Chronic renal insufficiency, defined as a baseline creatinine level of

at least 2.0 mg/dL (177 µmol/L)

Lee TH et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043-1049.

Beta BlockadeMinor Criteria

Use Beta -blockers in patients meeting any 2 of the

following criteria: Aged 65 years or older Hypertension Current smoker Serum cholesterol concentration at least 240 mg/dL (6.2

mmol/L) Diabetes mellitus not requiring insulin therapy

Mangano et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery: Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996;335:1713-1720.

Pulmonary Evaluation.

Obstructive Sleep Apnea (testing and treatment).

Asthma.

Smokers.

Endocrine Evaluation

Diabetes Management.

Diabetes Education.

Thyroid disease.

DVT Prophylaxis

Early ambulation Elastic stockings Intermittent pneumatic compression devices – IPC Inferior vena caval filters Low Dose Unfractionated Heparin Low Molecular Weight Heparin (LMWH)

IVC Filter placement

Preoperative vena caval filter placement should be

considered in bariatric patients with

Prior pulmonary embolus

Prior deep venous thrombosis

Evidence of venous stasis

Known hypercoagulable state.

Keeling WB et al..Current indications for preoperative inferior vena cava filter insertion in

patients undergoing surgery for morbid obesity. Obes Surg. 2005 Aug;15(7):1009-12

Pre-Operative Visit

Physical Exam. Changes to medications, condition, VS, WT, BMI. Check all Consult Notes. Photographs (optional). Educational Assessment Tools. Consents.

Pre-Operative Visit

Preoperative Instructions Verbal and Written

Be Explicit Bowel Prep

Pre-Operative Visit Patient Education

Pre-admission orders including any bowel preparation,meal restrictions, NPO instructions

When to arrive at the hospital and what to bring What will take place prior to surgery Waking up in the PACU after the operation and the

importance of early ambulation Pain management

Introduction of fluids and diet progression

Pre-Operative Visit Patient Education

Maximizes the patient’s success potential.

Decreases stress from lack of knowledge

Helps Set appropriate expectations.

Pre-Operative Visit Prophylactic ABx

First Generation cephalosporin before induction and 12 hours post-op.

Vancomycin if allergic to penicillin.

Same as any UGI Procedure.

Pre-Operative Visit Preo-op Diet

Low calorie,Low carb,High protein liquids for 2 weeks pre-op.

Helps control blood sugar peri-op.

Technically helps with the size of the liver.

Information Meetings/Support Groups.

Help consolidate the informations about peri-op expectations and care.

Focus on the change in lifestyle and commitment for better results.

Sharing personal experience.

Psychological Evaluation

The psychological evaluation can be used to identify psychiatric disorders, provide treatment referrals, and flag any contraindications for surgery.

It also provides an opportunity to educate patients, resolve ambivalence, and build motivation.

Psychological Evaluation

Accountability Stability - Will surgery

disrupt it? Situational vs. clinical

depression(treated/untreated)

pre op treatment) History of eating

disorders

Anorexia/Bulimia

Absence of mental illness

Setting goals & realistic expectations

Support system Ability & willingness to

make lifetime changes Safe setting

(domestic dynamics) Substance abuse Suicide attempts

Psychological EvaluationPatient History

History of any psychiatric problems. History of dieting and binge eating. Results of any previous evaluations or treatment. Previous weight loss attempts. Relevant personal and family information. Medication and dietary supplements.

Psychological Evaluation Patient Knowledge Gaps

A significant minority of patients

- Believe that surgery makes it impossible to overeat (25%).

- Have unrealistic weight loss expectations (19% high and 30% low).

- Do not know the symptoms of dumping (>20%).

- Believe there is no need to worry if depression occurred in the postoperative period (27%).

Gonder-Frederick et. al., Bariatric Times, Nov./Dec. 2004

Psychological Evaluation Possible contraindications for surgery

Concerns about patient’s ability to give informed consent or comply with behavior changes required after operation.

Current severe or uncontrolled psychopathology such as alcoholism, schizophrenia, or bipolar disorder

Psychological Evaluation Possible contraindications for surgery

patients who have ever had an Axis I clinical disorder, especially mood or anxiety, exhibit poorer weight outcomes 6 months after gastric bypass than those who have never had an Axis I

disorder.

Kalarchian MA et al..Surg Obes Relat Dis. 2008 Jul-Aug;4(4):544-9

Psychological Evaluation Patient Goals and Expectations

Some patients may have unrealistic goals and expectations for weight loss.

Personal goals and expectations may affect success at long-term weight control.

The behavioral health provider may provide psychoeducation, foster realistic expectations, and build motivation.

Psychological Evaluation Treatment Recommendations

Empirically supported treatments exist for many psychiatric disorders potentially relevant to the bariatric surgery patient.

Eating disorders (e.g., binge eating). Mood disorders (e.g., depression). Anxiety disorders. Borderline personality disorder.

Psychological Evaluation What Psychologists can do ?

Screen out inappropriate patients. Evidence not promising; research is needed Active substance abuse, psychiatric personality

disorder, suicide ideation Teaching candidates to be good patients.

Attend support groups, reading, learning What constitutes a “good patient?”

Psychological Evaluation Possible Complicating Factors

Poorly managed psychopathology Depression, Anxiety, Bi-polar, Bulimia etc..

Borderline personality disorder Active alcohol or substance abuse Recent hospitalization (mental disorder) History of postoperative complications

Psychological Evaluation Possible Positive Predictors or Factors

Social/Emotional support network Family, Friends.

Optimism, positive attitude Humor Knowledge of surgery, diet, etc.. Compliance may be the best indicator of

successful outcome

Psychological Evaluation What “Pre-Ops” Want ?

Self-esteem Energy Happiness, optimism Depression Physical symptoms Medications

Patients Report Dramatic Changes After Surgery

Able to breathe easily. Able to sleep & wake up

refreshed. Free from snoring & apnea. Off most pre-op meds. Free from joint pain. More active and less

fatigued Resolution of chronic

issues like skin rashes.

Relief from depression Excited to start a new day Happy to look in the mirror

when getting ready for work

Experienced improvement in work arena, i.e. promotion, new duties, raises etc.

Able to pursue new hobbies and interests.

Self confident.

Psychological Evaluation What “Post-ops” Get ?

Positives: Psychological Self esteem Happiness, optimism Body image Emotional access Depression Food obsession

Psychological Evaluation What “Post-ops” Get ?

Positives: Social Going out, trying new activities Socializing Intimacy Sex, libido Dating, flirting

Psychological Evaluation What “Post-ops” Get ?

Positives: Physical Health (general) Energy Mobility (activities of daily living) Physical symptoms (sleep dsrpt, arthritis)

Clothing

Psychological Evaluation Psychosocial Outcomes

Improvements in social relations and employment.

Reductions in depression and anxiety.

Decreases in binge eating.

Herpertz et. al, 2003; Bocchieri et. al, 2002

ConclusionClinical Decision Making

There are no well-established predictors of surgery outcome.

There are few alternative treatments for individuals who qualify for surgery

Conclusion Decisional Balance

CONS Potential for

complications. Careful medical

monitoring for life Miss time from work Feeling like a failure.

PROS Long-term weight

control. I’ll have a tool to help.

me eat less food at each meal.

Perform better at my job.

Helps improve my diabetes and reduce my medications.

Postoperative Eating Problems

Although surgery has a positive impact overall,some patients do experience the onset of eating disorders after bariatric surgery (or other behavioral health concerns).

Eating disorders may be most common among those who had binge eating or other eating problems prior to operation.