10/28/11. Bariatric Surgery: What the Primary Care Provider Should Know. Case Presentation: Rachelle

Size: px

Start display at page:

Download "10/28/11. Bariatric Surgery: What the Primary Care Provider Should Know. Case Presentation: Rachelle"

Maud Reeves
5 years ago
Views:

Bariatric Surgery: What the Primary Care Provider Should Know 2,000 B.C. 2,000 A.D.

5 PMHx: mild depression obstructive sleep apnea (AHI 42, on CPAP) asthma polycystic ovarian syndrome gastroesophageal reflux

Rachelle Case Presentation: Rachelle Intervention:?

1 Bariatric Surgery: What the Primary Care Provider Should Know 2,000 B.C. 2,000 A.D. Case Presentation: Rachelle 35 year-old woman with morbid obesity lbs BMI 44.5 PMHx: mild depression obstructive sleep apnea (AHI 42, on CPAP) asthma polycystic ovarian syndrome gastroesophageal reflux disease Diet attempts: Weight Watchers Atkins HerbaLife South Beach Jonathan Carter, MD No disclosures Case Presentation: Rachelle Case Presentation: Rachelle Intervention:??????? Weight versus time weight (pounds) time (months) PMHx: mild depression RESOLVED obstructive sleep apnea (AHI 42, on CPAP) RESOLVED asthma RESOLVED polycystic ovarian syndrome NO MEDS gastroesophageal reflux disease RESOLVED 1

2 Case Presentation: Rachelle BRFSS, 1990 No Data <10% 10% 14% BRFSS, 1991 BRFSS, 1992 No Data <10% 10% 14% 15% 19% No Data <10% 10% 14% 15% 19% 2

3 BRFSS, 1993 BRFSS, 1994 No Data <10% 10% 14% 15% 19% No Data <10% 10% 14% 15% 19% BRFSS, 1995 BRFSS, 1996 No Data <10% 10% 14% 15% 19% No Data <10% 10% 14% 15% 19% 3

4 BRFSS, 1997 BRFSS, 1998 No Data <10% 10% 14% 15% 19% 20% No Data <10% 10% 14% 15% 19% 20% BRFSS, 1999 BRFSS, 2000 No Data <10% 10% 14% 15% 19% 20% No Data <10% 10% 14% 15% 19% 20% 4

5 BRFSS, 2001 BRFSS, 2002 No Data <10% 10% 14% 15% 19% 20% 24% 25% No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2003 BRFSS, 2004 No Data <10% 10% 14% 15% 19% 20% 24% 25% No Data <10% 10% 14% 15% 19% 20% 24% 25% 5

6 BRFSS, 2005 BRFSS, 2006 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, 2007 BRFSS, 2008 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 6

women, BMI >45 took off 8 years of life expectancy Mechanick et al.

7 Why is obesity bad? Obesity reduces life expectancy For young men, BMI >45 took off 13 years of life expectancy For young women, BMI >45 took off 8 years of life expectancy Mechanick et al. SOARD 2008 Randomly assigned 811 patients to 4 groups: low fat, low protein high fat, high protein low fat, high protein high fat, low protein Intensive group/individual instructional sessions Intensive follow-up to 2 years Katan, NEJM

< 25 Overweight 25-29.9 Obese, class 1 30-34.

8 Medicines for the treatment of obesity Robert H. Eckel, MD INDICATIONS FOR BARIATRIC SURGERY Gastric bypass anatomy Definition BMI Normal < 25 Overweight Obese, class Obese, class Obese, class Superobese 60+ with co-morbidity SURGERY 8

9 Annals of Surgery, 2000 Change in BMI after gastric bypass BMI time Change in weight (%) Metabolic benefits of bariatric surgery Years courtesy of ASMBS 9

The effect is durable, at least for 15 years.

10 After gastric bypass, DM2 commonly resolves within days or weeks, before any significant weight loss has occurred. After gastric bypass, 83% of diabetics and 97% of patients with impaired glucose tolerance will normalize their fasting blood glucose, HbA1c, and insulin levels. The effect is durable, at least for 15 years. Metabolic benefits of bariatric surgery blood glucose insulin courtesy of ASMBS fasting blood glucose diabetic <5 years diabetic 6-10 years diabetic >10 years impaired fasting glucose diet controlled diabetics oral agent diabetics insulin dependent diabetics HbA1C (%) diabetic <5 years diabetic 6-10 years diabetic >10 years diet controlled diabetics impaired fasting glucose oral agent diabetics insulin dependent diabetics 10

11 WHY DOES DIABETES RESOLVE? By direct calorie restriction / weight-loss: % using medication for diabetes control oral agent diabetics insulin dependent diabetics fat mass adiponectin insulin sensitivity caloric intake insulin requirement = beta cell rest Specific to gastric bypass (and not LapBand or other restrictive procedures) ghrelin adiponectin, blocks hepatic insulin signaling, glucagon nutrients to ileum GLP-1 insulin, glucagon, insulin sensitivity beta-cell mass, beta-cell apoptosis nutrients to ileum peptide YY caloric intake nutrients to duodenum??? insulin sensitivity GHRELIN Bariatric surgery and comorbidity resolution Cummings, NEJM 2002 courtesy of ASMBS 11

systolic BP 50% of the morbidly obese have HTN About 40% of those on antihypertensives will be able to wean off medications completely. About 50% of undiagnosed hypertensives will resolve completely.

12 systolic BP 50% of the morbidly obese have HTN About 40% of those on antihypertensives will be able to wean off medications completely. About 50% of undiagnosed hypertensives will resolve completely. diastolic BP Bariatric surgery and comorbidity resolution BMI courtesy of ASMBS About 70% of morbidly obese patients have sleep apnea. About 90% will come off CPAP completely Bariatric surgery Apnea-hypopnea index oxygen saturation sleepiness and comorbidity resolution courtesy of ASMBS 12

CANCER INCIDENCE Lancet July, 2009 1 year after RYGB 2 years

from 95% to 28% Number taking medication dropped to 15%

cancer breast cancer prostate cancer ovarian cancer obese

underwent bariatric surgery 2037 matched patients underwent

were followed Decrease mortality was from decrease in

13 CANCER INCIDENCE Lancet July, year after RYGB 2 years after RYGB RYGB dropped percentage of dyslipidemic patients from 95% to 28% Number taking medication dropped to 15% Bariatric surgery reduces risk of: colon cancer endometrial cancer breast cancer prostate cancer ovarian cancer obese controls surgery Prospective, controlled trial 2010 patients underwent bariatric surgery 2037 matched patients underwent conventional Rx Mean 11 years of follow-up 99% of patients were followed Decrease mortality was from decrease in incidence of myocardial infarction and cancer Safety: Early Complications 13

14 Bypass Band Safety: Late Complications Bypass Band stricture of gastrojejunostomy (2-3%) acute pouch outlet obstruction (0-10%) treatment: dilation during endoscopy treatment: nasogastric tube marginal ulceration (3-5%) band erosion (0-7%) treatment: antacids treatment: surgery to remove band gallstone disease (2% with prevention) gallstone disease (2% with prevention) prevention: ursodiol for 6 months prevention: ursodiol for 6 months treatment: remove gallbladder treatment: remove gallbladder internal hernias with obstruction (0-5%) port infection (0.3-9%) treatment: surgery treatment: surgery to remove port dumping syndrome (0-10%) band slippage (2-14%) treatment: limit simple sugars, high protein diet, treatment: surgery to remove/reposition band complex carbs, high fiber, smaller more frequent meals port or tubing malfunction (0.4-7%) treatment: surgery to fix malfunction acid reflux or esophageal dilation (0-10%) treatment: antacids or band removal psychological intolerance (0-5%) treatment: removal of band LATE REOPERATION (5-10%) LATE REOPERATION (up to 50%) Nutritional Deficiencies after Gastric Bypass Surgery Nutrient Risk of deficiency Diagnosis Treatment Protein <5% Hypoalbuminemia Dietary diary <60g Calcium / vitamin D Essential fatty acids Rare 0.9% hypocalcemia 30% secondary HPTH Serum calcium Serum PTH Vitamin D level Dry scaly skin, hair loss Triene:tetraene ratio >0.2 Vits ADEK Rare A - Night blindness E - Eczematous rash Iron Vitamin B12 Up to 50% of women without supplements Up to 33% if only taking multivitamin K - Coagulopathy D - Osteomalacia Anemia Anemia Neuropathy Folate Rare if taking MVI Hyperhomocysteinemia Anemia Thiamine (vit B1) Rare, unless severe nausea and vomiting Neural tube defects of preg Wernicke-Korsakoff Peripheral neuropathy Beriberi <erythrocyte transketolase activity Prophy: dietary training >60g Rx: Protein shakes Prophy: Ca 500mg + vit D 200IU TID Rx: vit D 100,000 IU IM weekly until 25-OHD levels normalize Prophy: soy protein Rx: soy protein, safflower oil Rx: ADEK tablet daily vitamin A 4,000 IU vitamin D 400 IU vitamin E 150 IU vitamin K 0.15mg (also contains folate, thiamine, B vits) Prophy: FeSO4 325mg daily + vit C Rx: mild: FeSO4 TID severe: Iron dextran IV Prophy: vit B12 500ug SL daily Rx: 1000uG IM monthly until normal Prophy: MVI Rx: folate acid supplementation Prophy: MVI Rx: thiamine 100mg/day IV 14

Nutrition after bariatric surgery Nutritional monitoring after bariatric surgery Gastric bypass Multivitamin 2 tablets daily (need 400 mcg/d folate) omeprazole 20mg daily Calcium citrate 500mg and

15 Nutrition after bariatric surgery Nutritional monitoring after bariatric surgery Gastric bypass Multivitamin 2 tablets daily (need 400 mcg/d folate) omeprazole 20mg daily Calcium citrate 500mg and vitamin D 200 IU, 3x daily Iron sulfate 325mg daily (women) vitamin B12 500mcg SL daily LapBand multivitamin daily omeprazole 20mg daily calcium + D 500mg 3x daily GET THESE LABS YEARLY CBC Serum Iron / Ferritin Serum Folate (optional: thiamine) LFTs Albumin Vitamin B12 Serum calcium / vitamin D (optional: PTH) Electrolytes / glucose Cholesterol panel Fasting blood sugar Sleeve gastrectomy The Future. 15

16 Surgery for the primary treatment of diabetes?!? 16

6/23/2011. Bariatric Surgery: What the Primary Care Provider Should Know. Case Presentation: Rachelle

6/23/2011. Bariatric Surgery: What the Primary Care Provider Should Know. Case Presentation: Rachelle Bariatric Surgery: What the Primary Care Provider Should Know 2,000 B.C. 2,000 A.D. Case Presentation: Rachelle 35 year-old woman with morbid obesity. 5 1 236 lbs BMI 44.5 PMHx: mild depression obstructive