12/12/14. Primary Care of the Bariatric Surgery Patient. Goals

Transcription

1 Primary Care of the Bariatric Surgery Patient Goals Michelle Guy, MD Associate Professor Division of General Internal Medicine University of California, san Francisco How many post- bariatric surgery pa8ents do you have in your panel? 1. Zero (0) 2. One Five (1-5) 3. Six Ten (6-10) 4. Eleven FiMeen (11-15) 5. More than FiMeen (15+) How many post- bariatric surgery pa8ents do you have in your panel? 1. Zero (0) 2. One Five (1-5) 3. Six Ten (6-10) 4. Eleven FiMeen (11-15) 5. More than FiMeen (15+) 1

2 Full Disclosure Obesity Is A Chronic Disease % of American adults are obese (BMI > 30) Approximately 150, 000 weight loss surgeries being performed in US /year Bariatric surgery can provide: Sustained weight loss Resolu8on of Type 2 Diabetes Reduced cardiovascular morbidity Reduce all cause mortality Pre-op Post-op Maintenance 2

3 Who is Eligible For Surgery? BMI (kg/m2) RISK UNDERWEIGHT < 18.5 INCREASED NORMAL NORMAL OVERWEIGHT INCREASED OBESITY CLASS I HIGH OBESITY CLASS II (MODERATE OBESITY) OBESITY CLASS III (SEVERE OR EXTREME OBESITY) OBESITY CLASS IV (SUPEROBESITY) VERY HIGH EXTREMELY HIGH > 50.0 MAY BE TOO HIGH Who is Eligible For Surgery? The NIH Consensus Panel recommends that: Pa8ents have a Body Mass Index > 40 kg/m lbs. or more overweight Pa8ents have a Body Mass Index between 35 and 40 kg/m 2 with significant comorbidi8es Pa8ent have failed other medically managed weight- loss programs 6% of the U.S. adult populazon (over 12 million people) meet criteria for Class III Obesity Contraindications to Surgery Pre-op Evaluation Severe cardiac disease with high risk for anesthesia Severe coagulopathy Untreated major depression or psychosis Binge- ea8ng disorders Current drug or alcohol abuse Inability to comply with post op diet and supplementa8ons 3

4 12/12/14 Pre-op Evaluation Complete H & P (obesity- related co- morbidi8es, causes of obesity, weight/bmi, weight loss history, commitment, and exclusions related to surgical risk) RouZne labs (fas8ng glucose and lipid panel, kidney func8on, liver profile, urine analysis, prothrombin 8me, blood type, CBC) Nutrient screening (Iron, ferri8n, and TIBC, B- 12, Vitamin D, Folate, Magnesium, Phosphate) Cardiopulmonary (sleep apnea screening, ECG, CXR, echocardiography if cardiac disease or pulmonary hypertension suspected, DVT evalua8on if clinically indicated) GI evaluazon (H pylori screening in high- prevalence areas; gallbladder evalua8on and upper endoscopy if Surgical considerations Surgeon s Experience Restrictive vs Malabsorptive Open vs Closed clinically indicated) Endocrine evaluazon (A1c, TSH, androgens with PCOS suspicion (total/bioavailable testosterone, DHEAS, Δ4- androstenedione); screening for Cushing s syndrome if clinically suspected (1 mg overnight dexamethasone test, 24- hour urinary free cor8sol, 11 PM salivary cor8sol) Appropriate healthcare maintenance cancer screening based on age Psychosocial- behavioral and Clinical nutrizon evaluazon Smoking cessazon counseling Laparoscopic Weight Loss Surgery Lap Band Sleeve Gastrectomy Gastric Bypass 4

5 12/12/14 Laparoscopic Adjustable Gastric Banding (LAGB) Sleeve Gastrectomy (VerZcal Gastrectomy) RestricZve Only RestricZon and ResecZon Ideal Candidate BMI kg/m2 Wants to lose pounds Benefits Fewer early risks than other procedures One hour procedure Fully Reversible/Removable Lowest risk of vitamin deficiencies ConsideraZons/Risks Excess Weight Loss (EWL) 50% 10- year removal or reopera8on rate is >25% Slower weight loss (1-2lbs/week) compared to other surgeries Appe8te suppression may be difficult to achieve Least effec8ve for resolving diabetes Roux en Y Gastric Bypass (RNY or Bypass) RestricZve and MalabsorpZve Most common procedure performed Ideal Candidate BMI kg/m2 Wants to lose lbs May have severe or prolonged medical condi8ons Benefits Excess Weight Loss 70-90% 2 hour procedure Recovery of days to weeks Very effec8ve for curing diabetes Approximately calories per day lost through malabsorp8on Procedure is reversible ConsideraZons/Risks Greater risk for vitamin deficiencies Dumping syndrome Smoking, EtOH, NSAIDS use may lead to ulcers Ideal Candidate BMI kg/m2 Wants to lose lbs Benefits Excess Weight Loss 70-90% 1-2 hour procedure Recovery ranges from days to weeks Pa8ents report early and las8ng fullness Intes8nes stay intact No malabsorp8on May cure diabetes ConsideraZons/ Risks Removal of a por8on of the stomach is permanent The remaining pouch may expand over 8me Duodenal switch RestricZon, ResecZon and MalabsorZon Ideal Candidate BMI > 60 kg/m2 Poorly controlled diabe8c Benefits Has the highest cure rate for diabetes Excess Weight Loss 80-90%. 3-4 hour procedure cal lost from malabsorp8on ConsideraZons/Risks Not offered by most surgeons Stomach removal is permanent but bypass may be reversed Highest risk for vitamin and protein deficiencies, diarrhea and intes8nal blockages 5

6 Physiologic changes after surgery Post-op Pre-op Maintenance DiureZcs are disconznued in the hospital Afempt to use immediate- release, crushed, liquid or chewable preparazons PaZent are ohen discharged from the hospital off HTN and DM meds If meds are needed in diabezcs use immediate release Mejormin and/or sliding scale insulin Avoid delayed, enteric- coated and extended- release preparazons aher malabsorpzon procedures Some meds require gastric acidity for dissoluzon Avoid NSAIDS, EtOH and Smoking as it can cause ulcers Days 1-14 Thin fluids only No solid food oz fluids per day calories per day grams of protein Walk 5-10 minutes every hour Wake and walk amer 8 hours Diet and Exercise Progression Days Start thick liquids and som foods oz fluids 600 calories per day grams of protein Minimal carbs and fats Start cardio exercises and light weight liming Day 31 and beyond Regular foods as tolerated Meats and other foods should be tender, cut and chewed well and eaten slowly 60+ oz fluids 600 calories per day grams of protein Increase physical ac8vity Gastric Banding Band Slippage Band Erosion Port infec8on Injury to adjacent organs Death within 30 days (<0.5% of pa8ents) Post-operative Complications Sleeve Gastrectomy Leakage Bleeding Abdominal pain Poor wound healing Narrowing/Stenosis Reflux Death within 30 days (<1% of pa8ents) Bypass Surgery Leakage Bleeding Stoma obstruc8on Small bowel obstruc8on DVT Protein- calorie malnutri8on Death within 30 days (<1% of pa8ents) 6

7 More Post-Operative Complications Mood Changes Excessive VomiZng Gas Dumping Syndrome Hair loss Patulous Eustachian Tube DysfuncZon TIME 1-3 WEEKS Post- OperaZve Follow- Up FOLLOW- UP PLAN Review speed of weight loss, wound check, DieZcian follow- up to help advance diet 3 MONTHS Verify weight loss is on track, Review diet and exercise, labs 6 MONTHS Review weight and make specific plans to achieve goal weight, labs 9 MONTHS Verify weight loss is on track, Review diet and exercise, labs 1 YEAR Review outcome, check labs, consider GI Xrays YEARLY Discuss maintenance, Check labs, Reinforce support Recommended Follow-Up Labs Post-Surgical Vitamin Supplementation Basic labs CBC Electrolytes BUN and creaznine Liver panel Lipid panel Glucose and A1C Deficiencies Folate Iron, ferrizn, and TIBC B- 12 Calcium Vitamin D Also consider Magnesium Phosphorus B6 Thiamine (B1) Zinc Copper Vitamin A LAP BAND SLEEVE OR BYPASS DUODENAL SWITCH MulZvitamin MulZvitamin MulZvitamin Calcium (Citrate) +Mg Calcium (Citrate) +Mg Calcium (Citrate) +Mg Vitamin D IU Vitamin D IU Vitamin D IU B- Complex B- Complex B- Complex PPI PPI PPI B- 12, 500 mcg B- 12, 500 mcg Iron 325mg + Vitamin C Iron 325 mg + Vitamin C Vitamin A 25, 000 IU 27 7

8 Pregnancy and Weight- Loss Surgery FerZlity is enhanced aher surgery Delay pregnancy for 12 to 18 months aher surgery Use non- oral forms of birth control Avoid oral glucose challenge aher gastric bypass What Type of Results to Expect? MONTHS POST- OP POUNDS LOST 6 MONTHS MONTHS MONTHS > 12 MONTHS > 150 Weight Re-Gain Post-op Pre-op MAINTENANCE Swedish Obesity Subjects (SOS) Trial, surgical vs non surgical obese patients Greater initial weight loss Improved outcomes at two, six and ten years N Engl J Med 2007; 357: August 23,

9 Post-operative Diet Liquid Amnesia Maladaptive Eating How much can you eat? Keys to Success DO THIS Protein first, Goal 60+ g/day Eat 3 meals per day, Goal 600 cal/ day Chew Chew Chew Drink water between meals Drink 64 oz fluids per day Measure and Track all intake Exercise 30 to 60 minutes daily Weigh weekly Take your vitamins DON T DO THIS Eat sweets or excessive carbohydrates Overeat or Graze Drink within 30 minutes of ea8ng Drink Carbonated Beverages Drink through a straw Drink Caffeine and Alcohol Eat som or high calorie foods Exceed calorie limits per day New Addictions May Develop Drugs Cigareues Addic8on Alcohol Shopping 9

10 Managing Excess Skin TAKE HOME POINTS Screen all your pa8ents for overweight and obesity Most obesity related comorbidi8es can resolve or improve with successful weight loss surgery Consider gastric bypass surgery for pa8ents with more than 100 lbs to lose and/or diabetes. Consider sleeve gastrectomy for others Poten8al complica8ons are many but overall surgical mortality is low Surgery is only a tool. Pa8ents will need long term follow- up, support and tracking Thanks! 10