3/30/12 Weight Loss Surgery What Every GI Nurse Needs to Know Kenneth A Cooper, D.O. March 31, 2012 Outline Define Morbid Obesity & its Medical Consequences Treatments for Obesity Bariatric (Weight-loss) Surgery Common Complications handled by the GI service Summary, FAQs and Questions 1
Morbid Obesity Lifelong progressive disease of excess fat storage Clinically Severe Obesity at which point serious medical conditions occur as a direct result of the obesity Defined as a body mass index (BMI) of 40 Body Mass Index Calculated as follows: Weight/Height² Lowest mortality = BMI < 25 kg/m² Highest mortality = BMI > 40 kg/m² BMI > 40 = approximately 100 lbs. over ideal body weight Hypertension Hyperlipidemia Diabetes OSA Urinary incontinence Cardiac disease Reflux Arthritis Infertility Depression (70-90%) Comorbidity 2
Obesity Related Cancers Esophageal Colon Prostate Thyroid Breast Cervical Uterine Ovarian Herra 1999 Carrol 1998 Everhart 1993 Research has shown that both genetics and the environment play a significant role as underlying causes of morbid obesity Treatment Options Behavior Modification Diet Exercise Diet Pills Weight Loss Surgery 3
NIH Consensus Conference 1991 Surgery is the only approach that provides consistent, permanent weight loss for morbidly obese patients Surgery indicated in patients with: BMI of >40 BMI of 35-40 with significant co-morbidity documented dietary attempts ineffective Sources: Eliosoff, 1997; Sjostrom, 2000 Patient Profile 80% women, 20% men Mostly age 25 to 55 (range 18 65) Often overweight since childhood Tried multiple (10+) diets and exercise programs 4
Surgical Options Malabsorptive biliopancreatic diversion with duodenal switch Restrictive adjustable gastric banding Sleeve gastrectomy Combination of Restriction and Malabsorption Roux-en-Y gastric bypass Laparoscopic Band Restrictive Good results in Europe and Australia (12 years) There are two different types of gastric bands available: The Realize Gastric Band (Ethicon) and The Lap Band (Allergen) US results show 60% EBW loss in 3 years Very simple and very safe Normal placement 5
Outcomes of Banding Significant weight loss (60% at 3 years) Improvement in diabetes (73%) Improvement in hypertension and other comorbidities Complications of Banding Essentially no chance of gastrointestinal leak Low chances of DVT and PE Low chance of slippage Low chance of erosion (confirmed by endoscopy) Low chance of infection Capsular stricture after band removal Erosion seen at endoscopy 6
Sleeve Gastrectomy Restrictive Weight loss results similar to band and bypass Reduces Ghrelin production 34 French Bougie used for sizing during surgery Complications of sleeve gastrectomy DVT, PE, MI, etc. Staple line leak is most feared early complication Stricture is late complication Antral dilatation rare 7
Treatment of sleeve complications Leak confirmed by gastrograffin swallow Can attempt primary repair surgically Stent for refractory leaks 8
Roux en Y Gastric Bypass Combination Most frequently performed surgery First done in 1967 Safe and effective 75% EBW loss at 5 years >50% EBW 14yr followup ASBS Complications of Bypass seen by GI Leak Stricture Ulcer Anastomotic dilatation 9
Stent across leak Marginal Ulcer Symptoms of MU Pain with eating vomiting hematemesis 10
Stricture Stricture Management Confirm with endoscopy serial baloon dilatations (usually several sessions over several weeks) rarely needs surgical revision 11
Anastomotic dilatation Weight regain loss of satiety? endoscopic management endoscopic plication Significant Results and durable of Bariatric weight surgery loss (60 75% EBW) Improvement of other health issues High Blood Pressure (90%) Type 2 Diabetes (95%) High Cholesterol (97%) GERD (98%) Sleep Apnea (75%) Osteoarthritis (82%) Stress Incontinence (87%) Improvement in Cardiac Function (95%) Long term improvement in health and physical functioning 12
3/30/12 Questions? 13