update: bariatric surgery

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Bariatric Surgery: An Overview for the Internist Andrea Cherrington November 20, 2007

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Page 1: Update: Bariatric Surgery

Bariatric Surgery:An Overview for the InternistAndrea Cherrington

November 20, 2007

Page 2: Update: Bariatric Surgery

Case vignette

26 yo white female 2 weeks progressive lower extremity

weakness, blurred vision, urinary incontinence “Sluggish,” mild personality change PMHx:

Roux-en-Y gastric bypass150 lb weight loss since surgeryMultiple admissions for N&V, IV hydration

Page 3: Update: Bariatric Surgery

Case vignette

Physical examNormal vital signs

(+) Horizontal nystagmus

(+) Bilateral ophthalmoplegia

Unable to walk

Lower extremity exam: 2/5 strength, areflexia

Upper extremities exam normal

Page 4: Update: Bariatric Surgery

Case vignette

What is on the differential diagnosis? What would you do next?

Laboratory tests? Imaging studies?

What are the most common complications after bariatric surgery?

What can we do in primary care to prevent complications?

Page 5: Update: Bariatric Surgery

Outline

Bariatric surgeryBackground information

Who and when to refer Long-term follow-up

Potential complicationsRecommendations for management

Page 6: Update: Bariatric Surgery

Obesity epidemic

Obesity is an epidemic condition in the United States and around the world.

Associated with increased risk of hypertension, diabetes, hyperlipidemia, sleep apnea, coronary heart disease and stroke.

Increase in rates of obesity could lead to decline in overall life expectancy in the United States.

Page 7: Update: Bariatric Surgery

Obesity Trends* Among U.S. AdultsBRFSS, 1990

*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person

No Data <10% 10%–14%

http://www.cdc.gov/nccdphp/dnpa/obesity/

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Obesity Trends* Among U.S. AdultsBRFSS, 1998

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

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Obesity Trends* Among U.S. AdultsBRFSS, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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Obesity epidemic

Factors influencing weight:Behavior (diet, exercise)

Personal characteristics Environment Cultural attitudes Financial situation

Genetic Helps determine susceptibility

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Obesity epidemic

Treatment optionsLifestyle modification

Diet Exercise

MedicationBariatric Surgery

Increasing interest

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Number of weight loss operations performed in the United States

0

10000

20000

30000

40000

50000

60000

70000

80000

1993 1998 2002

JAMA. 2005;294:1909-1917.

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Bariatric Surgery: Definition

Procedure to reduce

caloric intake by modifying

the GI tract Three categories

RestrictiveMalabsorptiveMixed

Page 14: Update: Bariatric Surgery

Restrictive procedures

Limit food intake by creating small gastric reservoir with narrow outlet (<10%)

Procedures include:Gastric stapling (gastroplasty)Adjustable gastric banding

Wrapping a synthetic, inflatable band around the stomach to create a small pouch

Page 15: Update: Bariatric Surgery

N Engl J Med. May 24 2007;356(21):2176-2183.

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Malabsorptive procedures

Bypass varying portions of the small intestine where nutrient absorption occurs (>90%)Jejunoileal bypass (JIB)

Resulted in significant weight loss Abandoned secondary to severe metabolic

consequences

Jejunocolonic bypass (JCB)

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Mixed procedures

Combine malabsorption and restrictionProximal Roux-en-Y (RYGB)

Most commonly performed bypass procedure in the United States

Weight loss occurs from reduction in gastric volume with restricted intake, dumping syndrome, and a degree of malabsorption

Biliopancreatic diversion (BPD)BPD-Duodenal switch

Page 18: Update: Bariatric Surgery

Bariatric Surgery: Mixed

N Engl J Med. May 24 2007;356(21):2176-2183

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Bariatric Surgery: Evidence

No large, RCTs comparing surgery with medical management

2005 Cochrane Review: Identified 2 small RCTs, 3 cohort studiesWeight loss of 20 to 50kg with surgery vs.

modest weight gain with medical treatment.Weight loss greater with malabsorptive

procedures than restrictive procedures.

N Engl J Med. May 24 2007;356(21):2176-2183

Page 20: Update: Bariatric Surgery

Bariatric Surgery: Evidence

Swedish Obese Subjects Trial (SOS)Only large, well-controlled prospective study

2,010 surgically treated patients vs

2,037 control subjects

Weight change greater for surgical patients 23% of body weight lost vs 0.1% gain (2 yrs) 16% of body weight lost vs 1.6% gain (10 yrs)

N Engl J Med. May 24 2007;356(21):2176-2183

Page 21: Update: Bariatric Surgery

Bariatric Surgery: Evidence

Improvements seen in conditions associated with obesityDiabetes, hyperlipidemia, hypertension,

sleep apnea Benefits diminish over time but still

significant2yrs vs 10 yrs

Page 22: Update: Bariatric Surgery

Referral for surgery: Who & when

“A 44-year old obese woman has seen her primary care physician for the past 10 years for management of DM, HTN and GERD. Despite her best efforts to lose weight, her body mass index has increased from 40.0 to 46.6. During a routine office visit, she asks her physician whether bariatric surgery might be a treatment option for her. The physician does not recommend referral for surgical evaluation, citing concerns about variable effectiveness of the procedure, associated risks and lack of long term outcome data. The patient then seeks a specialist in bariatric surgery for evaluation, without the assistance of her physician.”

Duke Weight Loss Surgery Center, NEJM 356:21

Page 23: Update: Bariatric Surgery

Referral for surgery: Who & when

Criteria: BMI > 40

Almost 5% of adults in the U.S. BMI > 35 + high risk condition

Severe sleep apnea Obesity-related cardiomyopathy Severe diabetes mellitus

Additional: Failure of medical weight control Absence of medical or psychologic contraindications Strong patient motivation to comply with postsurgical regimen

Page 24: Update: Bariatric Surgery

Referral for surgery: Who & when

Comprehensive weight and nutrition history Weight trends, previous weight loss efforts

Determine current weight, height and BMI Medication history

Antidepressants, OCPs, oral hypoglycemics Evaluation for conditions associated with obesity

Diabetes, hypertension, hyperlipidemia, coronary disease sleep apnea, pulmonary hypertension

Psychological evaluation

Page 25: Update: Bariatric Surgery

Referral for surgery: Who & when

Psychological evaluation Patients with Axis I or II disorder less likely to

lose weight after surgery Other psychosocial factors associated with

suboptimal surgical outcomes include: Disturbed eating habits, (e.g. binge eating) Substance abuse Low socioeconomic status Limited social support Unrealistic expectations of surgery.

Page 26: Update: Bariatric Surgery

Referral for surgery: Who & when

Prior to undergoing surgery Preoperative education, including realistic

expectations Comprehensive long-term plan necessary Increases chances of safety and success

Do not proceed with surgery if Plan for systematic follow-up not in place Patient does not agree to the plan up front

Page 27: Update: Bariatric Surgery

Who is this man?

Page 28: Update: Bariatric Surgery

Acute complications of BS

In 2002, Charlie Weis, the 330lb offensive coordinator for the New England Patriots underwent gastric stapling.

An acute bleed led to an ICU stay and a 2 week coma.

Charlie sued the hospital and physicians but was unsuccessful.

Page 29: Update: Bariatric Surgery

Acute complications of BS

Mortality rates 0.1 – 2.0% Common causes of death

Pulmonary embolism Anastomotic leak

Non-fatal peri-operative complications Venous thromboembolism Anastomotic leaks Wound infection Bleeding Incisional and internal hernias Early small bowel obstruction

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Long Term Complications: Nausea & Vomiting Occurs in 30% of all bariatric patients Occurs in 50% of patients undergoing restrictive

procedure Dehydration, electrolyte imbalance Protein-calorie malnutrition Thiamine deficiency with neurological sequelae

Page 31: Update: Bariatric Surgery

Long Term Complications: Nausea & Vomiting Common causes after bariatric surgery:

Inadequate chewing Overdistension of pouch by fluid Large volume meals Food intolerance (red meat, lactose) Stomal outlet stenosis/obstruction Marginal ulceration Intestinal obstruction Gastroesophageal reflux disease Symptomatic gallstones Medications Dumping syndrome

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Long Term Complications: Diarrhea Can occur as a result of

Food sensitivity Lactose intolerance Malabsorption Bacterial overgrowth and infection Dumping syndrome

Can lead to dehydration and electrolyte imbalance

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Long Term Complications: Dumping syndrome Occurs in more than 75% of patients after Roux-

en-Y Neurohormonal: facial flushing, light-headed,

palpitations, fatigue and diarrhea Triggered by ingestion of concentrated sugars Generally subsides after 12-18 months Prevention: small, frequent meals, avoid foods with

high sugar content. Chew food thoroughly, eat slowly

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Long Term Complications: Nutritional Deficiencies Iron Folate Vitamin B12 Calcium Deficiency of fat soluble vitamins (D,E,A,K) Thiamine (vitamin B1) Zinc Protein malnutrition (after long limb or distal

bypass)

Page 35: Update: Bariatric Surgery

Long Term Complications: Nutritional Deficiencies

Severity and pattern depend on Presence of pre-operative deficiencies Type of procedure performed Degree of restriction Length of bypassed intestine Modification of eating behavior Development of complications (ex. emesis) Compliance with oral MVI & mineral supplements

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Review: what gets absorbed where?

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Long Term Complications: Nutritional Deficiencies Occur more commonly with malabsorptive and

mixed procedures Nutritional deficiencies are uncommon with

purely restrictive procedures unless Eating habits are excessively restricted or

complications occur (emesis) Folate is the most common deficiency after restrictive

procedures

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Long Term Complications: Post-surgical Additional

complications include: Bowel obstruction Anastomotic leaks Strictures Erosions

Ulcers Adhesions Hernias Cholelithiasis

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Long Term Complications: Post-surgical Common complications of gastric banding:

Gastric prolapse 5-10% Gastroesophageal dilation 5-10% Band erosion 0-2%

Symptoms include nausea & vomiting, also heartburn, nocturnal reflux, dysphagia

After RYGB, 4-20% of patients develop stenosis of the gastrojejunostomy

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Recommended management

Key to management of complications is prevention when possible

Dietary recommendationsFailure to modify eating habits will results in

vomiting and discomfort Life-long multivitamin and mineral supplements

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Recommended management

Dietary modification Reduce food volume consumed, chew food very

well, slow pace of eating Do not consume fluids with food

30 minutes before or after meal Protein rich-food should be major component of

each meal Cheese, fish, poultry, eggs & meat 40-60g/day after RYGB 60-90g/day after BPD-DS

Avoid empty calories

Page 42: Update: Bariatric Surgery

Recommended management

Dietary supplements All patients should receive

Multivitamin with iron Vitamin B12, B complex with thiamine Vitamin C Calcium

Additional supplements may be needed for menstruating or pregnant women

Depending on procedure, patient may need fat soluble vitamin supplements (BPD)

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Recommended management

Am J Med Sci. Apr 2006;331(4):219-225.

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Case vignette

Routine lab tests: NL Low

Vitamin B12 Vitamin B6 Vitamin C Vitamin D

Very low Thiamine

Other vitamin/mineral levels were normal

Page 45: Update: Bariatric Surgery

Case vignette

Wernicke’s encephalopathy Thiamine deficiency Potential complication of bariatric surgery Presents with ocular changes (nystagmus,

ophthalmoplegia), ataxia, mental status change After several months on MVI, daily thiamine,

patient’s ophthalmoplegia and nystagmus resolved, lower extremity weakness improved somewhat.

Page 46: Update: Bariatric Surgery

Additional information

For additional information on Impact of bariatric surgery on CVDz Psychosocial impact of bariatric surgery; before

and after Financial impact of bariatric surgery

Check out Medical Clinics of North America, 91(2007)

Thanks to Jeanette Keith and Andrea Braun

Page 47: Update: Bariatric Surgery

References1. Allen JW. Laparoscopic gastric band complications. Med Clin North Am. May

2007;91(3):485-497, xii.2. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med. May 24

2007;356(21):2176-2183.3. Lopez PP, Patel NA, Koche LS. Outpatient complications encountered following Roux-

en-Y gastric bypass. Med Clin North Am. May 2007;91(3):471-483, xii.4. Malinowski SS. Nutritional and metabolic complications of bariatric surgery. Am J Med

Sci. Apr 2006;331(4):219-225.5. Markel TA, Mattar SG. Management of gastrointestinal disorders in the bariatric patient.

Med Clin North Am. May 2007;91(3):443-450, xi.6. Mathier MA, Ramanathan RC. Impact of obesity and bariatric surgery on cardiovascular

disease. Med Clin North Am. May 2007;91(3):415-431, x-xi.7. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in

the United States in the 21st century. N Engl J Med. Mar 17 2005;352(11):1138-1145.8. Powers KA, Rehrig ST, Jones DB. Financial impact of obesity and bariatric surgery. Med

Clin North Am. May 2007;91(3):321-338, ix.9. Tucker ON, Szomstein S, Rosenthal RJ. Nutritional consequences of weight-loss

surgery. Med Clin North Am. May 2007;91(3):499-514, xii.10. Wadden TA, Sarwer DB, Fabricatore AN, Jones L, Stack R, Williams NS. Psychosocial

and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin North Am. May 2007;91(3):451-469, xi-xii.