Bariatric Surgery Work Up, Patient Selection and Follow Up

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1 Bariatric Surgery Work Up, Patient Selection and Follow Up A/Professor Tania Markovic Metabolism & Obesity Services, RPAH Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders

2 SLHD Bariatric Surgery Programme 1. NSW Health Recommended Criteria for Eligibility for Bariatric Surgery, NSW Obesity Management Plan (2009) 2. National Institute for Health and Clinical Excellence (NICE) Guideline 43: Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children (2006) 3. AACE/TOS/ASMBS Guidelines 2009

3 Eligibility criteria at SLHD Aged between Pregnancy not anticipated in first two years post surgery Initial BMI 40 with an associated obesity illness which will improve with weight loss Body weight does not exceed weight limits of equipment necessary for patient care pre, or immediately post operatively Obesity related morbidity

4 Edmonton Obesity Staging Sysyem (EOSS) Cardiometabolic Disease Stage Description Management 0 No apparent obesity-related risk factor 1 Presence of obesity-related subclinical risk factors - Borderline HPT, IFG, LFTs 2 Presence of established obesityrelated chronic disease - HPT, T2DM, PCOS, NASH Identification of factors contributing to increased body weight. Lifestyle counseling. Investigations for other (non weight related) contributors to risk factors. More intense lifestyle intervention. Monitoring of risk factors. Initiation of obesity treatments incl behavioural/pharm/surgery. Management of comorbidities 3 Established end-organ damage - Myo infarction, heart failure, cerebrovasc dis, diabetic complications, cirrhosis 4 Severe (potentially end stage) disabilities - Renal failure, PVD/amputation, hepatic failure/hcc More intensive treatment incl pharm/surgery. Aggressive management of comorbidities. Aggressive obesity management as deemed feasible. Palliative measures may be more appropriate. Sharma AM & Kushner RF Int J Obes 2009;33:

5 Sunil D et al, Curr Opin Endocrinol Diabetes Obes 2013; 20(5):

6 EOSS predicts outcomes better than BMI Analysis of National Health and Nutrition Examination Surveys (NHANES) data NHANES III ( ) n = 4367 NHANES n = 3600 EOSS score assigned to those with BMI > 25 Padwal RS et al, CMAJ, 2011

7 Padwal RS et al, CMAJ, 2011

8 Eligibility criteria at SLHD Absence of other medical conditions that would increase the morbidity or mortality risk of bariatric surgery Comprehensively assessed as fit for surgery by specialist physician, endocrinologist, anaesthetist and bariatric surgeon Psychological profile Undergone comprehensive psychosocial evaluation, and free of acute psychiatric issues, or drug dependency problems Proven to be able to comply with and adhere to the behavioural changes required after surgery Capacity to understand the associated risks and commitment Well-informed and motivated

9

10 SLHD Bariatric surgery criteria: Commitment Regular attendance at one of the weight management programs in SLHD or SWSLHD for at least 12 months Has adhered to lifestyle prescriptions during the period of time attending the weight management programme Expectation that patient will adhere to postoperative care including attending follow-up visits with physician(s) and team members and following instructions/advice provided

11 % weight loss pre surgery vs post surgery 6 months p = 0.6

12 % weight loss pre surgery vs post surgery 48 months p = 0.06

13 SLHD Bariatric surgery criteria Irreversible endocrine or other disorders that can cause obesity Current drug or alcohol abuse Uncontrolled, severe psychiatric illness Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes required with bariatric surgery Inability to attend post surgical follow up appointments

14 Important questions How did you come to make this decision about having surgery? What are your reasons for undertaking this procedure? What is your understanding of what this procedure involves? What is your understanding of the risks involved in this procedure? How will surgery affect your lifestyle in the future? Expectations- Goals for your weight loss post- surgery and anticipated time-frame? It is important patient understands the surgery they will have, and that they have realistic outcome expectations

15 What to expect post surgery Improved health 40% or greater excess weight loss Annual blood test, BMD review as necessary Daily multivitamin lifelong Adhere to a reduced kcal intake (approx 1/3 of usual intake) Abstain from liquid calories, and abstain from snacking Eat slowly, include balanced meals & small portions Include daily structured exercise

16 Bariatric surgery referral process 12 months of lifestyle program and fulfilment of inclusion criteria Reviewed by endocrinologist at Metabolism & Obesity Services Reviewed by Clinical Psychologist Metabolism & Obesity Services If therapist, endocrinologist and psychologist agree that surgery is indicated patient is referred to the Sydney Local Health District Bariatric review committee (monthly meeting) If surgery approved appointment with surgeon Discussion regarding appropriate surgery type Additional weight may need to be lost, further investigations may need to be attended Surgeon approves surgery

17 Pre surgery requirements All patients scheduled for bariatric surgery are to adhere to a full Very Low Energy Diet (VLED) for a minimum of two weeks prior to surgery. THIS IS COMPULSORY AND IS FUNDED BY THE PATIENT

18 Medications Post bypass- extended release medication are not to be used

19 Why is follow up important?

20 All bariatric surgeries are weight loss tools and will not work long term if diet and exercise prescription are not followed

21 Diet transitioning time frames post bariatric surgery Sleeve Gastrectomy Week 1-2 Week 3-4 Week 5-8 Week 9 onwards Fluids Puree Diet Soft Diet Solid Diet Minimum yearly appointments afterwards

22 Post surgery diet regimen Sleeve Gastrectomy Bariatric plate size 50% meal vegetables/ salad 50% lean protein &1 tbsn carbohydrates (not essential) 1 teaspoon per Average plate size minute Take small mouthfuls Chew everything thoroughly Eat slowly DO NOT drink with meals Pictures: Portion perfection for bands and sleeves - Amanda Clark

23 Post surgery diet regimen Solid diet from week 8 DO Daily NOT GRAZE intake BETWEEN MEALS SHOULD NEVER EXCEED Avoid soft food when onto solids. More volume can be consumed in one go compared to solid food Kilojoules / 24hours If you have not finished your meal within 30 minutes either throw the rest away or put it in the fridge for your next meal. ( Calories) POST SURGERY ½ cup protein ½ cup vegetable portions Should avoid soft foods & liquid calories

24 Prioritise Protein and Vegetables

25 DO NOT CONSUME CARBONATED BEVERAGES The bubbly nature of carbonated drinks, can cause gas pain and increase the pressure in your stomach

26 It is the patient s responsibility to: Choose the correct food Make healthy choices Follow post surgery diet & exercise prescription THE SURGERY IS NOT A POLICE OFFICER. IT WILL NOT STOP YOU BREAKING THE RULES. We will support patients, but it is their choice how they eat post surgery

27 Post surgical complications Surgery type Early complications Late Complication Band/ Sleeve/ Bypass Wound infection Clot in leg or lung Dysphagia Gastrointestinal bleeding Incisional hernia Micronutrient deficiency Abdominal pain require investigation Reflux, regurgitation or dysphagia Inconsistent or inadequate weight loss Sleeve/ Bypass Enteric Leak from surgical wounds Functional or mechanical obstruction of stomach Osteoporosis and anaemia Anastomotic Stricture (0-6%) Food impaction related to altered gastric motility Gastric Sleeve Pouch dilation (results from consistent over eating) Gastric bypass Dumping syndrome Dumping syndrome Adjustable Gastric Band Reoperation rate at 10 years 10-20% Band/ gastric slippage Band erosion Oesophageal dilatation Tubing and port- related problems

28 Dumping Syndrome Occurs in 10% of patients post bypass Two types of dumping: 1. Early dumping (30-60 minutes after meals) 2. Late dumping (1-3 hours after eating) To reduce effects of dumping: Try increasing meal frequency and reducing meal size Avoid foods and drinks containing high sugar levels. Sugar is emptied rapidly from the stomach causing symptoms

29 Nutrient deficiencies Most at risk Iron, vitamin B12, folate, calcium, vitamin D, thiamine, fat-soluble vitamins By pass > SG >LAGB 1. Reduced quantity 2. Reduced quality (intolerances/fads) 3. Maldigestion/reduced bioavailability (acid, pepsin; reduced length of common channel-by pass) 4. Malabsorption (by pass absorption site) 5. Increased losses (vomiting)

30 Follow up therapy sessions It is believed those who do not attend follow up post-surgery do worse than those who continue being reviewed by their bariatric team 3 monthly OR 6 monthly OR Yearly

31 Weight loss (kg): regular vs irregular follow up Mixed Model 1 Comparison of predicted mean differences of weight change from baseline (kg) between regular and irregular follow-up by visits adjusted for sex and age at surgery No difference in weight change between regular and irregular follow-up groups

32 Post operative Medical Review- Annual Yearly Co morbid review Biochemical monitoring of nutritional status Bone Mineral Density This is dependent on the patients pre surgical result every 2-5 years For the rest of your life

33 MOS post bariatric surgery form

34 MOS patient flow

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