Obese Patients & Bariatric Surgery

Transcription

1 Obese Patients & Bariatric Surgery Jenny Bramhall, Consultant Nurse Pre-Operative Assessment Heart of England Foundation Trustcurrently on secondment to the NHS Institute of Innovation & Improvement

2 What will be covered Prevalence of obesity and treatment Eligibility gb for weight eg loss osssugey surgery The set up at Heart of England Hospitals - pre The set up at Heart of England Hospitals pre & post op care

3 WHO classification of obesity BMI = weight(kg)/height(m)2 WHO Classification BMI Risk of Comorbidity Underweight Below 18.5 Low Healthy weight Average Overweight (grade 1 obesity) Mild increase Obese (grade 2 obesity) Moderate/severe Morbid/severe obesity (grade 3) 40.0 and above Very severe World Health Organisation. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO, 1997

4 Prevalence In England around 43% of men and 33% of women are overweight (BMI 25-30kg/m²) An additional 22% of men and 23% of women are obese (BMI >30kg/m²) Overweight and obesity increase with age About 31% of men and women aged But 77% of men and 71% women aged More prevalent in lower socioeconomic groups especially in women Ref: Health Survey for England 2003

5 Medical Complications of Obesity: Almost every organ system is affected Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis

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8 Benefits of 10% Weight Loss Mortality Blood pressure >20% fall in total mortality >30% fall in diabetes related deaths >40% fall in obesity related deaths fall of 10mmHg systolic and diastolic pressure Diabetes 50% fall in fasting glucose Lipidsid 10% dec. total t cholesterol l Jung % dec. in LDL 30% dec. in triglycerides 8% inc. in HDL

9 Patients eligible for weight loss surgery NIH Guidelines 1991 BMI >40 BMI > 35 with significant ifi co-morbidities Hypertension, diabetes, sleep apnoea, polycystic ovarian syndrome, musculoskeletal problems Adopted universally by IFSO (International Federation for Obesity Surgery) National Organisations followed suit (BOSS) British Obesity Surgery Society.

10 NICE Obesity Guideline No When to consider surgery People with BMI>40kg/m² or between 35-40kg/m² with other significant disease and Achieved or nearly achieved physiological i l maturity (not generally recommended d for children or young people) Tried all appropriate non-surgical measures but failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months. Receiving or will receive intensive specialist management Generally fit enough to have an anaesthetic and surgery Commit to the need for long-term follow-up Consider surgery as first-line option for adults with a BMI >50kg/m² where appropriate (Before performing surgery a comprehensive assessment of any psychological or clinical factors that could affect adherence to postoperative care needs should be carried out)

11 Surgical Treatments Restrictive Restricts the amount of food eaten so total energy intake decreases but all calories + nutrients are digested and absorbed Malabsorptive Not all the calories + nutrients are completely digested and absorbed from food and drink consumed Combination Other Procedures

12 Laparoscopic Surgery

13 Adjustable gastric band

14 Adjustable Gastric Band

15 Adjustability

16 Diet is Key for Optimal Results In all cases dietary habits MUST be changed For restrictive procedures a healthy low fat, low sugar diet gives best results For malabsorptive procedures compliance with a high protein diet with vitamin and mineral supplementation is essential

17 The Heart of England Experience

18 The Set Up 2 Specialist Weight Management Clinics Patients from local area referred mainly with BMIs > 40kg/m² (Patients with BMI > 50kg/m² - surgical clinic ) Patients assessed by Consultant physician, seen by dietitians and possibly psychologist Try weight reducing diets with Orlistat, Sibutramine or Rimonobant (withdrawn June 08) as appropriate If no success may be referred for Surgery

19 The Core Bariatric Surgery Team Consultant Surgeons; Mr P Super (lead), Mr M Richardson and Mr H Kumar Consultant Radiologists; Dr J Ferrando and Dr A Pallan Consultant Anaesthetists Specialist Bariatric Dietician Pre-Operative Assessment staff Nursing Staff in theatre, Ward 5 and Ward 12 (surgery/gastroenterology)

20 Our Care Pathway Before Surgery (gastric banding) External Referral Internal Information Information Weight Management clinic (medical + surgical) Wait for funding Set Date for Surgery (2 3 months) Telephone Contact Consultant Surgeon DIETITIAN Pre-operative Assessment Telephone Contact OPERATION

21 Before the Operation 1 st appointment SURGICAL WEIGHT MANAGEMENT CLINIC Surgeon discusses: Most appropriate p operation, results and complications Pre-operative weight loss necessary Reasons explained! ( visceral fat and liver size) then Dietician i discusses: Re-iterate what the surgeon has said Answer all the questions that patient was afraid to ask Brief detail of pre-op diet options, length of time etc Overview given of what to expect Emphasise that band/any operation is a helping hand not a magic cure. Hard work is needed on long-term lifestyle change Give patient leaflet on gastric banding with contact details

22 Before the Operation While patients are waiting for funding they are encouraged to contact the Dietitian with any queries about diet, operation, procedures... Patients are encouraged to find out as much as possible about the operation. Make appointment with GP to discuss medications. Referred to (British Obesity patient assoc) Patients can make contact with a local support group Patients can make contact with a local support group or speak with others who have had gastric banding

23 Before the Operation Pre-op diet dependent on BMI BMI > 60kg/m² months Low Calorie Diet BMI 50-60kg/m² months Low Calorie Diet BMI 40-50kg/m² - 2 weeks 1 month Low CD Adi diet tthat thas worked dbefore eg Weight Watchers, Slimming World, Atkins.. Meal Replacements eg Slimfast Healthy Eating Plan + portion control to achieve at least 1000kcal deficit

24 Before the Operation 2 weeks to go the liver shrinking diet Phone to encourage, motivate, cajole etc! Reduce intake to kcal/day, low fat and relatively low carbohydrate Options given: Real food smaller portions Meal replacement eg Slimfast, Tesco Ultraslim etc Continue with Cambridge plan Milk and yogurt Plenty of water (at least 2 litres/day) One-a-day multivitamin/mineral

25 Pre-Operative Assessment Same as for all pts Full patient history Review systems Perform Heart & Lung examination Baseline observations including BMI (girth measured on TCI) ECG VTE Assessment U&E s only unless co-morbidity, then appropriate tests MRSA swabs

26 Pre-Operative Assessment Inform theatres, ward, manual handling of patients BMI Specialist bed/theatre table needed Patients treated as day case, some overnight stay Written information discussed and given Advised to continue diet and ensure medication is in liquid form if possible Refer to Anaesthetist if necessary, usual Consultant Anaesthetist

27 Our Care Pathway After Surgery (gastric banding) Telep phone con tact as req quired (by DIETITIA AN) < 1 week 6 weeks 3 months 4-5 months 6 months 7-8 months 12 months 18 months 24 months Telephone contact Weight Management clinic X-ray controlled Band Fill Weight Management clinic X-ray controlled Band Fill Weight Management clinic Weight Management clinic Weight Management clinic Weight Management clinic DIETITIAN Consultant Surgeon Consultant Radiologist As above Consultant Radiologist As above As above As above As above

28 Dietary Care Pathway - After Surgery ( gastric banding) 1 st month Liquids 2 nd month Pureéd/Soft food (drinks separate) 3 rd month Solid textured food of a drier consistency (drinks separate) After each band adjustment 1 week liquids, 1 week pureéd/soft food then solid Long term the best band eating gplan Medication should be in liquid, crushable or chewable form for 1 year after operation

29 Crisps Biscuits Cakes Chocolate Smoothies Ice cream Sweets GRAZERS and SNACKERS BEWARE! The Band doesn t stop these! Won t feel full High calorie foods Tempted to eat more Easily consumed rapidly Soft foods High calorie drinks

30 Assessment for Band fills Weight loss slowing Able to eat larger quantities Minimal regurgitation Increased hunger between meals Food texture Eating pattern Drinks separate from meals

31 FOOD SOLID foods of drier consistency work best with the band Forget sauce, gravy and sloppy or soft foods - these pass through h and the patient t will soon be hungry and tempted to eat more or snack on high calorie foods Drinks should be low calorie or NO calorie Learn band fullness and STOP eating Avoid getting overfull or oesophagus can stretch and sensitivity to fullness may be lost

32 MONITORING Encourage self monitoring weigh weekly, take measurements, record comments Food and exercise diaries Think thin Learn relapse control Seek out support Manage expectations patients unlikely to reach ideal body weight (BMI 25) Emphasize health gains rather than aesthetic considerations

33 But I no longer take medication for diabetes or hypertension, can walk upstairs without getting out of breath and don t snore at night!