METABOLIC COMPLICATIONS OF BARIATRIC SURGERY. Aleksandr Shteynberg Downstate Medical Center July 7, 2006
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1 METABOLIC COMPLICATIONS OF BARIATRIC SURGERY Aleksandr Shteynberg Downstate Medical Center July 7, 2006
2 Case presentation 55 year old female was transferred to Downstate Medical Center on March 31, 2006 for management of metabolic encephalopathy and pancreatitis following gastric bypass procedure performed in January 2006
3 Case presentation HPI: Nausea, vomiting and RUQ pain x 3 days Altered mental status: disoriented x 10 days Patient was not compliant with medications and medical follow up Patient was treated in referring hospital for pancreatitis and encephalopathy
4 Case presentation PMH: Morbid obesity Pancreatitis Cholelythiasis Hypertension DM Sleep apnea Hyperlipedemia Osteoarthritis
5 Case presentation PSH: Gastric bypass (January 2006) All: NKA Meds: Metochlopramide Roxicet Protonix Amitriptyline
6 Case presentation Vital Signs T = 97.3 B/P = 116/73 Pulse = 79 PE significant findings Lethargic, confused, impaired short term memory No neurological deficits Morbid obesity
7 Case presentation Labs: Ca = 9, Mg = 1.6, P = 3 Alb = 3.1, AST/ALT = 25/41, AP = 63, TB = 3 Amy = 134, Lip = 433
8 Case presentation Labs microelements: Vit B1 = 22 nmol/l (87-280) Vit B6 = 3 ng/ml (2-26) Vit B12 = 852 pg/ml ( ) FA = 3.5ng/ml (3-16) Zn 905 mcg/l ( )
9 Case presentation Imaging CT head no acute changes CTA chest negative for PE
10 Case presentation Hospital course complications: RUE DVT, likely secondary to PICC line, LGIB due to stercoral ulcer and anticoagulation Bacteremia and fungemia Renal failure Aspiration pneumonitis, intubation Sepsis
11 Case presentation Treatment Vitamin, nutritional supplements ICU management for respiratory, renal and septic complications
12 BARIATRIC SURGERY AND POSTOPERATIVE METABOLIC COMPLICATIONS
13 Obesity Epidemic million morbidly obese Americans Percentage of obese people in US is the highest in the world BMI of obese people in US higher than in Europe 35% of adolescents in US are obese Obesity is the second leading cause of preventable death in the United States after tobacco use ( deaths per year)
14 Common Complications of Obesity Osteoarthritis, joint degeneration 50% HTN 30% Asthma 25% Diabetes 20% GERD 20%
15 Morbid Obesity Definition Morbid obesity is defined as being either 100 pounds above ideal body weight, twice ideal body weight, or having a body mass index (BMI, measured as weight in kilograms divided by height in meters squared) of 40 kg/m 2.
16 Obesity Classification BMI > 25 overweight BMI > 30 obesity BMI > 35 severe obesity BMI > 40 morbid obesity
17 Pathophysiology of Obesity Genetic: Leptin receptor (LEPR) gene and melanocortin 4 receptor (MC4R) mutation Hormonal disbalance CCK and Ghrelin regulate satiety Environmental: Food availability Decreased physical activity
18 Bariatric Surgery "Baros" greek word meaning weight "Iatrike" meaning treatment 1889 by an OB/GYN surgeon at John s Hopkins, who performed lipectomies on women during routine surgical procedures used word bariatric surgery
19 History of Bariatric Surgery 1895 Anton Eiselsberg (Billroth s student) made a notice of weight loss in patients after gastric or small bowel resection 1950 s Jejunoilieal Bypass the first Bariatric procedure was presented to a peer reviewed surgical society.
20 History of Bariatric Surgery Malabsorbtive procedured 1 st generation 1953: Varco et al described Jejunoileal Bypass Excellent weight loss Complications: Gas bloat syndrome Diarrhea Electrolyte imbalance Hepatic fibrosis and failure Nephrolithiasis Cutaneous eruption Impaired mentation
21 History of Bariatric Surgery Malabsorbtive procedures 2 nd generation 1970s: Biliopancreatic diversion (BPD) Nicola Scopinaro 1990s: Duodenal switch No segment of intestine left without flow Biliary limb Enteric limb Common channel
22 History of Bariatric Surgery Biliopancreatic diversion (BPD) Partial horizontal gastrectomy Closure of duodenal stamp Gastrojejunostomy with long Roux limb Enteric anastomosis 50 cm from ileocecal valve
23 History of Bariatric Surgery Biliopancreatic diversion (BPD) IEWL (initial excess weight loss)at 1 yr 70% Maintained for 20 yrs Complications: Diarrhea Flatulence Anemia Stomal ulcer Bone demineralization Protein malabsorption
24 History of Bariatric Surgery Duodenal switch introduced by Marceau Lesser curvature gastric tube Vertical resection of 2/3 of the stomach Preserving pylorus Anastomosing enteric limb to proximal duodenum Cross-stapling the distal duodenum with division Common channel 100 cm
25 History of Bariatric Surgery Duodenal switch IEML at 18 mo 80% Complications Flatulence Malodorous stools Iron and calcium malabsorption
26 History of Bariatric Surgery Malabsorptive/restrictive procedures 1960: combination of malabsorption and restriction elements 1966: Mason and Ito introduced Gastric Bypass (GB) 1977: Griffen published results of Roux modification
27 History of Bariatric Surgery Malabsorptive/restrictive procedures GB Restrictive element 30 ml gastric pouch Malabsorptive element Jejunal loop reconstruction Roux limb gastrojejunostomy
28 History of Bariatric Surgery Malabsorptive/restrictive procedures Long limb GB Roux limb 150 cm (vs. standard 75 cm) Used for super obese patients (>= 200 lbs overweight) IEWL 64% at 24 mo
29 History of Bariatric Surgery Malabsorptive/restrictive procedures Laparoscopic GB Most common laparoscopic bariatric surgery in US IEWL 80% at 1 year
30 History of Bariatric Surgery GB: laparoscopic vs. open Nguyen et al., Laparoscopic vs. open gastric bypass. Ann Surg 232 (2000), pp
31 History of Bariatric Surgery Restrictive procedures 1971: Mason and Printen performed first gastroplasty Horizontal gastric division Greater curvature conduit 1980: Mason: Vertical gastroplasty with Marlex mesh around outlet channel
32 History of Bariatric Surgery Restrictive procedures 1981: Fabito 1 st stapled vertical banded gastroplasty 1994: Hess and Hess Laparoscopic vertical banded gastroplasty
33 History of Bariatric Surgery Restrictive procedures 1978: Wilkinson and Peloso Gastric banding 1986: Kusmak Inflatable band with subcutaneous port
34 History of Bariatric Surgery Restrictive procedures 1993: Forsell Laparoscopic placement of adjustable gastric band
35 History of Bariatric Surgery Gastric banding Italian Collaborative Study Group (2001) 5 year experience with 1,265 patients BMI reduction 30.8% at 2 years Operative mortality 0.55% Conversion rate 1.7% Pouch dilation 5.2% Band erosion 1.9%
36 History of Bariatric Surgery Other procedures Stereotaxic stimulation of sites in lateral hypothalamus (Quaade at el, 1974) Gastric and vagal pacing Preliminary human trials Device reduces circulating levels of cholecystokinin, somatostatin, GLP-1, and leptin
37 Indications for bariatric surgery BMI > 40 kg/m 2 or BMI > 35 kg/m 2 with associated medical comorbidity exacerbated by obesity Failed dietary therapy Psychiatrically stable Knowledgeable about operation and its sequelae Motivated Medical problems do not preclude likely survival from surgery
38 Contraindication for bariatric surgery Active substance abuse Noncompliance with previous medical care Active peptic ulcer disease
39 Metabolic Complications Anemia Vitamin B12 deficiency Folate deficiency Iron deficiency Vitamin D deficiency Wernicke s encephalopathy Vitamin A deficiency
40 Metabolic Complications of Different Bariatric Procedures VBG, gastric banding Gastric bypass BPD Excess body weight lost 40% 50% 65% 75% 70% 80% Protein malnutrition No Rare Yes Anemia No Yes Yes Vitamin deficiency No Yes Yes Iron deficiency No Yes Yes Calcium deficiency No No Yes Follow-up labs None CBC, iron studies, B12, folate CBC, iron studies, B12, folate, albumin, electrolytes, fatsoluble vitamins, PTH, INR Standard supplements None Multivitamin, iron Multivitamin, iron, calcium, vitamins A and D
41 Anemia 36.8 % (post GB) 3.5% require transfusion Iron deficiency 20-49% Decreased stomach acid No exposure of nutrients to duodenum and proximal jejunum B12 deficiency 26-70% Decreased intake Diminished intrinsic factor secretion Folate deficiency 9-35%
42 Anemia Prevention Folate deficiency MVI Higher doses for reproductive age women B µg crystalline oral Vit B12 IM supplementation
43 Vitamin D deficiency Parathyroid axis abnormalities in obese patients Increased PTH and 1,25 hydroxy-vitamin D Decreased 25 hydroxy-vitamin D After weight loss procedure Decreased absorption of Ca and Vit D Alteration in mechanical load of the skeleton
44 Vitamin D deficiency Osteomalatia Microfractures, diffuse bone pain Proximal myopathy Prevention Daily 1200 mg of Ca, and IU Vit D
45 Wernicke s Encephalopathy Thiamine (Vit B1) deficiency Water soluble vitamin Absorbed in small intestine By cases reported after GB
46 Wernicke s Encephalopathy Clinical triad Nystagmus and ocular nerve palsies Ataxia Apathetic mental confusion MRI findings Injury to mamillary body Treatment Thiamine 100 mg Q8 hr
47 Vitamin A deficiency Reported only after BPD 69% by 4 years after surgery Occasionally symptomatic Resolution of symptoms after supplementation
48 Metabolic Complications Recommendations for prevention Outpatient semi-annual follow-up Serum iron Hct 25 hydroxy-vitamin D Parathyroid hormone VitB12 VitA
49 Metabolic Complications Recommendations for prevention Supplements MVI Folate 400 µg Vit B µg Ca 1500 mg 25 hydroxy-vitamin D IU Thiamine parenterally for patients with poor intake
50 Future of Bariatric Surgery An algorithm is needed for selecting the most appropriate operation for a given patient to take into consideration Weight Age Gender Comorbidities Race Nationality Outcomes expectations Body habitus Operative safety Side effects Long-term complications.
51 Summary Morbid obesity reached epidemic level in US. Presently bariatric surgery is the most effective treatment option available Metabolic benefits of bariatric surgery significantly outweigh complications.
52 Summary Prevention and early medical intervention essential to avoid metabolic complications of bariatric surgery Integrated medical team care necessary for the management of bariatric patient
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