Medical Management of the Bariatric Surgery Patient

Transcription

1 Medical Management of the Bariatric Surgery Patient Jennifer Dooley, MD, FACP Assistant Professor, Internal Medicine Department Diplomat of the American Board of Obesity Medicine

2 No disclosures

3 Objectives Understand the benefits of and who qualifies for bariatric surgery Pre-Operative Assessment of the Obese Patient Review Types of Bariatric surgery with early and late complications General Follow-up Post-Op Including nutritional and supplement needs Poor weight loss or weight re-gain after surgery

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5 Gupta, Wang Treatment satisfaction with different weight loss methods among respondents with obesity. Clin Obes Apr;6(2):161-70

6 Adams. Weight and Metabolic Outcomes 12 Years after Gastric Bypass NEJM Sept

7 Mortality rate when performed at a Bariatric Surgery Center of Excellence: Bariatric Surgery: DeMaria Baseline data from ASMBS designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database. Surgery for Obeisty and Related Diseases. Dolan, et al The National Mortality Burden and Significant Factors Associated with Open and Laparoscopic Cholecystectomy: J Gastro Surg 2009: 13: Lie SA, et al. Early postoperative mortality rate after total hip replacements Acta Ortho (4): Ricciardi, et al. Volume Outcome Relationship for CABG in an Era of Decreasing Volume. Arch Surg 2008: 143(4):

8 Adams, et al, Long-Term Mortality after Gastric Bypass Surgery NEJM 2007

9 Ikramuddin S, Korner J, Lee W, et al. Lifestyle Intervention and Medical Management With vs Without Roux-en-Y Gastric Bypass and Control of Hemoglobin A 1c, LDL Cholesterol, and Systolic Blood Pressure at 5 Years in the Diabetes Surgery Study. JAMA. 2018;319(3):

10 Schauer, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5-Year Outcomes NEJM 2017

11 Who is eligible? BMI >40 kg/m 2 BMI >35 kg/m 2 with comorbidity Diabetes Hypertension Obstructive Sleep Apnea / Obesity Hypoventilation Syndrome Nonalcoholic Fatty Liver Disease (NAFLD) or Nonalcoholic Steatohepatitis (NASH Pseudotumor Cerebri Debilitating Arthritis Prior weight loss attempts

12 Other Bariatric Seminar Insurance coverage for bariatric surgery Most require documentation of obesity for over 5 years Most require documented weight loss attempts for over 6 months Tobacco free at least 6 weeks Nutrition/Dietitian evaluation Psychological evaluation No substance abuse within 6 months No uncontrolled psych disorders Compliant, competent, and motivated to change

13 Medical Preoperative Assessment Glycemic Control: A1c <8% Labs CBC, CMP, FLP, B12, Fe, Folate Vit D, Ca, +/- TSH Medication review Stop OCPs and HRT 1 month before surgery BP and DM med review Tobacco cessation Sleep screening F/U polysomnography if positive GI evaluation, if symptoms Esophagram, endoscopy +/- H. pylori testing Counseled to avoid pregnancy Routine cancer screenings up to date Weight loss pre-op Liquid diet 2 weeks prior to surgery Cardiac evaluation

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15 Morgenstern. Prevalence of OSA in USA Railway Workers. American Sleep Apnea Society

16 R. Carter III, D.E. Watenpaugh / Pathophysiology 15 (2008) 71 77

17 Pre-op Clearance Request Stress Test Weight Limit Comments Exercise Treadmill lbs Ability to exercise may be impaired Adenosine SPECT (Thallium, sestamibi) 400 lbs Difficult to interpret due to false positives (artifacts) Expensive Dobutamine Echo 700 lbs Limited Echo Windows Less Expensive Gives info on LVH, EF, diastolic function and right heart pressures Adapted from Butsch. Bariatric Surgery. Blackburn Course in Obesity Medicine 2016

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19 Sjöström Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007; 357:

20 Laparoscopic Adjustable Gastric Band Purely restrictive Highest weight regain May be appropriate in those who want less invasive surgery or less weight loss Multiple adjustments needed, high reoperation rate Complications Early: Reflux Band migration DVT Complications Late: Reflux Pouch enlargement Esophageal dysmotility/dilation Band leakage Band erosion

21 Sleeve Gastrectomy Restrictive and metabolic Currently the most common bariatric surgery Avoid if pre-existing severe reflux Nausea and reflux Complications Early GI Leak Reflux Nausea DVT Complications Late: Reflux Gastric dilation Stricture B12 deficiency

22 Roux-En-Y Gastric Bypass Restrictive and malabosorptive Gold Standard Complications Early: Stricture Marginal Ulcer DVT most common cause of mortality in perioperative period Thiamine Deficiency With persistent nausea and vomiting Anastomotic Leak Unexplained Tachycardia +/- Shoulder Pain Complications Late: Dumping Syndrome Vasovagal symptoms high carb meals Bowel obstruction Hernia Marginal Ulcer Enteroenteric fistulas Bacterial Overgrowth Oxalate Nephropathy Gallstones Vitamin deficiencies with

23 T. Biliopancreatic Diversion with/without Duodenal Switch Malabsorptive Least commonly performed due to severe long term side effects Complications Early GI Leak Roux limb obstruction Complications Late Diarrhea and flatulence Dumping Syndrome Electrolyte abnormalities Liver failure Gallstones Renal stones Highest risk for nutritional deficiencies: B12, Folate, Fe Ca, Vit D Vitamins ADEK Zinc, Copper, Selenium, Thiamine

24 Postoperative Points Nutrition Comorbidities/Medication Follow-up Supplements Lab Follow-up Physical Activity

25 Nutrition A minimal protein intake of 60 g/d and up to 1.5 g/kg ideal body weight per day should be adequate Concentrated sweets should be eliminated from the diet after RYGB to minimize symptoms of the dumping syndrome Crushed or liquid rapid-release medications should be used instead of extended-release medications to maximize absorption in the immediate postoperative period Fluids should be consumed slowly, preferably at least 30 minutes after meals to prevent gastrointestinal symptoms, and in sufficient amounts to maintain adequate hydration (more than 1.5 liters daily)

26 Dumping Syndrome Early Dumping Can occur in up to 50% of RYGB patients Rapid onset, usually within 15 minutes Results from rapid emptying of food into the small intestine and due to the hyperosmolality of the food, rapid fluid shifts from the plasma into the bowel occur, resulting in hypotension and a sympathetic nervous system response Patients often present with vasovagal symptoms, nausea, tachycardia, colicky abdominal pain, diarrhea Late Dumping (Postprandial Hyperinsulinemic Hypoglycemia [PHH]) Rare complication, occurs in % of patients Occurs 1-3 hours after a carbohydrate-rich meal, months to years after surgery The pathophysiology of PHH is not fully understood but likely includes alterations in multiple hormonal and glycemic patterns such as increase in incretin levels. Symptoms same as above and documented hypoglycemia Most patients can avoid by limiting carbohydrate intake each meal Late dumping refractory to dietary modification may require need medication (ex. nifedipine, octreotide)

27 Comorbidity/Medication Follow-up Diabetes Regular close follow-up, as bariatric surgery is effective in some cases to cure diabetes Immediately post-op, all medication should be adjusted due to liquid diet and risk for hypoglycemia (ex hold insulin secretagogues such as sulfonylureas) Hypertension Regular medication review with each visit Needs may decrease with weight loss, variable with patients Caution diuretics in immediate post-op period Hyperlipidemia Lipid levels and need for lipid-lowering medications should be periodically evaluated Sleep apnea may be reassessed with a sleep study in 6 to 12 months after surgery to reassess the continuous positive airway pressure (CPAP) requirement. NSAID avoidance

28 Routine Supplementation for RYGB and Sleeve Multivitamins (MV) with iron Bariatric form 200% of daily recommend value or 2 OTC Complete MV Chewable but NOT GUMMY VITAMINS Calcium Citrate 1200 to 1500 mg in divided doses 2 hours apart from iron supplementation Vitamin B12 (sublingual 500 mcg/day, intranasal 500 mcg/week, intramuscular 1,000 mcg/month or later oral 1000mcg/day) Vitamin D 3000 IU titrated to therapeutic 25- hydroxyvitamin D levels Iron 36 mg elemental Fe/day in MVs, sufficient for most mg needed for menstruating women and those at risk for anemia Ferrous sulfate 325mg daily (65mg elemental Fe) or Ferrous fumarate two 27 mg chewable tabs daily Supplements should be chewable/easily absorbable the first 3 to 6 months

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30 Water Soluble Vitamins Vitamin Thiamine (B1) Cobalamin (B12) Clinical Findings of Deficiency Absorption Test Supplements Replacement Other Wernicke-Korsakoff: Proximal Serum Thiamine Multivitamin 500 mg IV TID 2 confabulation, Jejunum < 80mcg with 100% RDA days then 250 mg ophthalmoplegia, ataxia IV/IM daily for 5 Wet Beriberi: days then 100mg Cardiomegaly, CHF, daily tachycardia Dry Beriberi: peripheral polyneuropathy Peripheral and central neuropathy Pernicious anemia Paresthesias Unsteady gait Delusions Terminal ileum Gastric acid detaches B12 from binding protein and IF required for absorption B12 < 250pg/mL MMA > 40mmol/L If severe N/V, can be quickly precipitated mcg daily 1000 mcg IM PPIs and metformin increase deficiency risk Folate Biotin Glossitis, stomatitis Diarrhea, malabsorption Alopecia seborrheic dermatitis nausea and vomiting depression glossitis Duodenum and Decreased RBC Multivitamin jejunum folate with 100% RDA Duodenum Serum biotin levels Multivitamin jejunum not reliable marker with 100% RDA colon 800 mcg/day mcg/day Many patients will take for hair loss High doses not associated with toxicity Katz. Nutrition in Clinical Practice 3rd Edition Wolters Kluwer 2015 Butch. Nutrition Assessment and Therapy. Blackburn Obesity Board Review 2016 Parrott. ASMBS Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients

31 Fat Soluble Vitamins Vitamin Vitamin A Vitamin D Clinical Findings of Deficiency Absorption Test Supplements Replacement Other Night blindness Duodenum Plasma Retinol < 25mg/dL Multivitamin 5,000-10, ,000 IU can Follicular hyperkeratosis jejunum IU daily result in toxicity (HA, vomiting, hepatic injury, birth defect) Osteomalacia: bone pain, proximal muscle weakness Small bowel 25-OH Vitamin < 32m g/dl 2, IU 50,000 IU weekly Vitamin E Hyporeflexia, gait disturbance, muscle weakness, decreased proprioception, ophthalmoplegia, nystagmus, hemolytic anemia Duodenum jejunum Vitamin K Ecchymoses and Bleeding small and large intestine Plasma alpha tocopherol < 5 mg/dl Multivitamin mg daily Prolonged PT Multivitamin 1 mg/d Katz. Nutrition in Clinical Practice 3rd Edition Wolters Kluwer 2015 Butch. Nutrition Assessment and Therapy. Blackburn Obesity Board Review 2016 Parrott. ASMBS Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients Interferes with Vit K metabolism and can prolong PT at higher doses

32 Minerals Mineral Clinical Findings of Deficiency Absorption Test Supplements Replacement Other Calcium Iron Zinc Copper Osteoporosis Hypoparathyroidism Muscles cramps Tetany Paresthesia Microcytic Anemia Pallor Fatigue Pica Glossitis Restless Leg Impaired taste and smell Poor wound healing Dry, scaly, hperpigmented skin Cellular immune deficiency Anemia Neutropenia Menke s kinky hair Poor wound healing Myeloneuropathy Duodenum and proximal jejunum Duodenum and proximal jejunum Duodenum and proximal jejunum Stomach and Duodenum Decreased Calcium Increased PTH Decreased Ferritin (acute phase reactant) Low Fe Elevated TIBC Serum zinc level not reliable but can be checked Serum Copper < 70 mcg/dl mg/d in divided doses mg/d 36 mg elemental Fe/day (the amount found in 2 MVs) mg needed for menstruating women and those at risk for anemia Take iron and Calcium 2 hours apart Multivitamin with 60 mg zinc Multivitamin with 2-4 mg copper IV if symptomatic mg of elemental iron daily If unresponsive to oral therapy, IV infusion should be administered Insufficient evidence to make a dose-related recommendation for repletion Estimated dose 60 mg elemental zinc (eg 220mg zinc sulfate) orally BID 2.5mg IV x 5 days Calcium Citrate is preferred early post-op as it is chewable and does not need HCl for absorption Ferrous sulfate 325mg daily (65mg elemental Fe) Ferrous fumarate 27 mg elemental Fe chewable tabs 2 daily Niferex 150mg elemental iron per capsule Chronic intake of zinc may lead to copper deficiency Supplement 1 mg copper for every 8 15 mg of elemental zinc to prevent copper deficiency Katz. Nutrition in Clinical Practice 3rd Edition Wolters Kluwer 2015 Butch. Nutrition Assessment and Therapy. Blackburn Obesity Board Review 2016 Parrott. ASMBS Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients

33 Lab follow-up ASMBS Recommendations: CBC, CMP each visit FLP 6-12 months based on risk and therapy B12 Q3-6 months for the 1 st year then annually 25-vitamin D, PTH, iron studies, folic acid (RBC folic acid optional) Q3-6 months for the 1 st year then annually Vitamin A if BPD (optional with RYGB) Q3-6 months for 1 st year then annually Copper, zinc, thiamine only with specific findings DEXA at 2 years

34 Physical Activity Exercise Goals: 150 minutes (30 minutes, 5 days/week) has been shown to be effective for weight maintenance 300 minutes (60 minutes, 5 days/week) has been shown to be effective for weight loss Incorporate strength training 2 to 3 days/week Erlanger Metabolic & Bariatric Surgery Center Patient Manual 2018

35 Other Avoid pregnancy for 1 year post-op Fertility increases post-op (PCOS improves) Gout May be exacerbated after RYGB Alcohol accelerated alcohol absorption after RYGB and LSG Mental Health Depression may improve or worsen SSRI absorption decreased after RYGB Support group encouraged Hamad, et al. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors.. Am J Psychiatry Mar;169(3):256-63

36 Weight Regain Nutrition Physical Activity Pharmacotherapy

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38 Medications Approved by the Food and Drug Administration for Long-Term Weight Management Heymsfield SB, Wadden TA. N Engl J Med 2017;376:

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40 References 1. Gupta, Wang Treatment satisfaction with different weight loss methods among respondents with obesity. Clin Obes Apr;6(2): Accessed April Adams. Weight and Metabolic Outcomes 12 Years after Gastric Bypass NEJM Sept Mortality rate when performed at a Bariatric Surgery Center of Excellence: Bariatric Surgery: DeMaria Baseline data from ASMBS designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database. Surgery for Obesity and Related Diseases. 5. Dolan, et al The National Mortality Burden and Significant Factors Associated with Open and Laparoscopic Cholecystectomy: J Gastro Surg 2009: 13: Lie SA, et al. Early postoperative mortality rate after total hip replacements Acta Ortho (4): Ricciardi, et al. Volume Outcome Relationship for CABG in an Era of Decreasing Volume. Arch Surg 2008: 143(4): Adams, et al, Long-Term Mortality after Gastric Bypass Surgery NEJM Ikramuddin S, Korner J, Lee W, et al. Lifestyle Intervention and Medical Management With vs Without Roux-en-Y Gastric Bypass and Control of Hemoglobin A 1c, LDL Cholesterol, and Systolic Blood Pressure at 5 Years in the Diabetes Surgery Study. JAMA. 2018;319(3): Schauer, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes 5-Year Outcomes NEJM Accessed Oct Morgenstern. Prevalence of OSA in USA Railway Workers. American Sleep Apnea Society 2016 via R. Carter III, D.E. Watenpaugh / Pathophysiology 15 (2008) Butsch. Bariatric Surgery. Blackburn Course in Obesity Medicine Sjöström Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007; 357: Accessed Oct Katz. Nutrition in Clinical Practice 3rd Edition Wolters Kluwer Butch. Nutrition Assessment and Therapy. Blackburn Obesity Board Review Parrott. ASMBS Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients 20. Erlanger Metabolic & Bariatric Surgery Center Patient Manual Hamad, et al. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors.. Am J Psychiatry Mar;169(3): Apovian C, et al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2015; 100 (2): Machineni S. Pharmacotherapy. Blackburn Course in Obesity Medicine Leslie. Weight gain as an adverse effect of some commonly prescribed drugs: a systematic review. QJM 2007: 100(7): Heymsfield SB, Wadden TA. N Engl J Med 2017;376: