Bariatric Surgery and Post Operative Patient Care Alisha M. Fuller DNP, CBN, FNP BC Tristate Bariatrics Clinical Director, NP Manager Presentation Objectives Causes of Obesity Measuring Obesity Medical/Psychological/Social Implications of Obesity Treating Obesity Surgical Options and Complications Dietary Guidelines Post operative Management What Causes Obesity? Genetic predisposition Twin studies Adopted children Obesity gene Physiologic Leptin Decreased stretch receptors Loss of satiety mechanism (hypothalamus) Evolutionary Behavioral Family tradition Food to comfort child Addiction 3 Gender (80% women) Higher fat component Socioeconomic High/low income classes Cultural views Psychosocial Coping mechanism (i.e. stress, abuse) Societal Technology has decreased energy expenditure Elevators, power windows, food delivery, remote controls, computers, Sony playstation, TV, cars, cell phones 1
Body Mass Index (BMI) Used to measure obesity based on height & weight One aspect to determine eligibility for surgery Normal Weight (BMI* 18.5 to 24.9) Overweight (BMI 25 to 29.9) Obese (BMI 30 to 34.9) Severely Obese (BMI 35 to 39.9 ) Morbidly Obese (BMI 40 or more) BMI Chart Obesity Multifactorial Genetic (Epigenetic) Environmental Behavioral 2
Impact of Obesity Comorbid Diseases Premature Death Disability OBESITY Reduced QOL Medical Costs 8 Psychological Impact of Obesity Depression Low self esteem Social isolation Uncomfortable in public Lack intimacy Decreased libido 9 3
Social Implications of Obesity Unable to/have difficulty with Going to the movies Sitting on bus or in theater/plane seat Use of seat belt Fit through turnstile Play/pick up children Maintain adequate hygiene Buy stylish clothes 10 Obesity: the last bastion of discrimination Weight Loss Approaches Diet Exercise Behavioral Modifications Pharmacotherapy Bariatric Surgery Treatment for Severe Obesity Diets, exercise, and behavioral change Up to 10% weight loss Ineffective long term Pharmacotherapy Some recent improvements with medication,? Long term Minimal sustained weight loss Bariatric surgery Only evidence based efficacy with increasing safety 12 4
The Problem with Exercise Lose 1 pound = 3800 calories Lose 100+ pounds = 380,000 calories Strenuous exercise = 10 calories per minute 30 min. exercise = 300 calories burned 1 candy bar = 200 300 calories Caloric restriction causes weight loss Exercise maintains weight loss 13 Weight Loss Medications Phentermine Anorectic On the market since the 50s, Class IV Not covered by insurance plans (cash pay $3 25.00 per month) Only short term (3 months) Contraindicated in patients with HTN Stimulant Lorcaserin HCL Serotonin 2C Receptor Agonist Class IV Twice daily Caution with Psych meds and Diabetics Weight Loss Medications Naltrexone HCI/bupropion HCI Titrated dose high dose is 2 in am 2 in pm Do not use in uncontrolled HTN, Seizure D/O, Methadone/Opioid use Liraglutide GLP 1 Injectable Contraindicated in patients with MTC/MEN 2 Not covered by Medicare/Medicaid Can be used long term Phentermine and Topiramate Schedule IV Can be used long term Must have monthly pregnancy tests in child bearing age women 5
Indications for Surgery Clinically Severe Obesity BMI > 40 BMI > 35 with associated co morbidities BMI 30 35 under certain circumstances Failed weight loss with non surgical therapies Well informed, Highly motivated Accepts surgical risks Age >18, <? 16 Contraindications for Surgery Unstable coronary artery disease Severe pulmonary disease Portal hypertension Substance Abuse Inability to understand or carry out lifestyle changes necessary to achieve and maintain weight loss after surgery 17 Surgical Options to Treat Obesity Types of weight loss surgeries Malabsorptive procedures shorten the digestive tract Biliopancreatic diversion with/without duodenal switch (BPD/DS) Restrictive procedures reduce how much the stomach can hold Vertical Banded Gastroplasty (VBG) Laparoscopic Adjustable Gastric Band (LAGB) Gastric Balloon Sleeve Gastrectomy Combined procedures shorten the digestive tract and reduce how much the stomach can hold Roux en Y Gastric Bypass (RYGB) 18 6
Surgery Statistics 2011 158,000 surgeries performed 17.8% Sleeve Gastrectomy 36.7% RNY 35.4% LAGB 0.90% BPD DA 2017 228, 000 surgeries performed 60% Sleeve Gastrectomy 18% RNY 2.77% LAGB 0.70% BPD DS 2.75% Balloon Death rate 0.13% with in 30 days (1 in 1000) Normal GI System Balloon 7
Vertical Banded Gastroplasty BPD Biliopancreatic Diversion 24 Advantages Greatest amount of initial weight loss due to the high levels of malabsorption Can eat larger meals because of larger stomach pouch Higher total average weight loss reporter than with VBG, Gastric Bypass or LAGB Disadvantages Requires cutting/stapling of stomach and bowel More operative complications than with LAGB Lifelong monitoring for protein malnutrition, anemia and bone disease Highly complex procedure Nonadjustable Dumping syndrome can occur Higher mortality rate than LAGB, VBG and Gastric Bypass 8
Lapband Surgical Options Sleeve Gastrectomy Gastric Bypass Gastric Bypass How it promotes weight loss Restrictive hunger Afferent Vagal Nerve / Hypothalamus Hormone GLP & other gut hormones Malabsorptive diges on / absorp on Surgical Time 1hr 15min 1hr 30min Recovery Time 3 4 wks Average weight loss 2 3 lbs / wk % EWL (excess weight loss) 1 yr 70% 5 yr 58% Improvement / Resolution Type II Diabetes 90% High Blood Pressure 65% Sleep Apnea 90% 26 Gastric Bypass 9
Gastric Bypass Advantages Rapid initial weight loss Minimally invasive approach is possible Longer experience in USA Minimal diet restrictions Disadvantages Cutting and stapling of stomach and bowel is required More operative complications than with LAGB Dumping syndrome can occur Portion of digestive tract is bypassed, reducing absorption of essential nutrients Nonadjustable Higher mortality rate than LAGB or VBG procedures Technically complex Can be difficult to reverse 28 Gastric Bypass Long Term Complications Dumping Vitamin Deficiencies Marginal Ulcer Hernia Internal Hernia Bowel Obstruction 29 Sleeve Gastrectomy How it promotes weight loss Restrictive hunger Afferent Vagal Nerve / Hypothalamus Hormone Ghrelin Surgical Time 45 60 minutes Recovery Time 2 3 wks Average weight loss 1 2 lbs / wk % EWL (excess weight loss) 1 yr 50 60 % 5 yr 60% Improvement / Resolution Type II Diabetes 80% High Blood Pressure 60% Sleep Apnea 90% 30 10
Sleeve Gastrectomy Sleeve Gastrectomy Long Term Complications Dehydration Gastric Strictures Gastroesophageal Reflux Ulcers Leak Dilated Pouch 32 Dilated Sleeve Gastrectomy 11
Lap Band How it promotes weight loss Restriction hunger Afferent Vagal Nerve / Hypothalamus Surgical Time 30 minutes Recovery Time 1 2 wks Average weight loss 1 2 lbs / wk % EWL (excess weight loss) 1 yr 45% 5 yr 55% 15 year 41% Improvement / Resolution Type II Diabetes 60% High Blood Pressure 55% Sleep Apnea 90% 34 Lap Band Laparoscopic Adjustable Gastric Band 36 Advantages 10x safer than Gastric Bypass* Adjustable customized per patient Least invasive option No stomach stapling, cutting or intestinal rerouting Reversible Lowest operative complication rate no leaks Low malnutrition risk Satiety-inducing procedure OR time = 1 hour or less Same day Disadvantages Implant Some dietary restrictions Routine follow-up required 12
Slipped Lap Band Lapband Adjustment Adjusting the diameter of the band around the stomach Adjustments are done in the office Ultrasound guided adjustment to access the Lapband port with a special needle Normal saline is added or removed to change the size of the band Choice of Foods Proper nutrition will be key to success both before & after surgery Advise to practice making better food choices now to begin the weight loss journey 13
Dietary Guidelines Very Low Calorie Diet Protein Vital nutrient needed by all parts of the body Promotes healing Prevents excessive muscle loss & slowing metabolism Fruits Good source of fiber, vitamins, & minerals Vegetables Contain important vitamins & minerals Good source of fiber Nonstarchy vegetables are ideal Water Water or very low calorie liquid (>5cal/serving) Crystal Light, Tea, Diet Iced Tea 64 oz or more per day is recommended Carbohydrates Carbohydrates vs Protein Breakdown of carbohydrates Sugar Elimination of major Carbohydrates All forms of bread, pasta, rice, oatmeal, potatoes, cakes, cookies, chips, crackers, ice cream, cereals, juices, milk, flavored waters with sugar Protein Drinks Extremely important & necessary immediately after surgery for healing Highly recommended during the weight loss process Used as a meal replacement 14
After Surgery (Post Op) The stomach will need time to heal after bariatric surgery. The following phases are guidelines to ensure adequate nutrition for healing and ongoing weight loss following surgery. Phase I Phase 2 Phase 2.5 Phase 3 Phase I 2 weeks duration 3 protein drinks a day 64oz of very low calorie beverages per day Phase II 2 4 weeks duration Semi soft foods or pureed / smooth consistency 3 meal per day with 1 meal being semi soft food 2 meal replacements 64oz of very low calorie beverages per day 15
Phase 2.5 2 4 weeks duration Mushy/shredded food consistency 3 meal per day with 1 meal being semi soft food 2 meal replacements Phase III Solid foods 3 meals per day with 1 meal being solid food 2 meal replacements 64oz of very low calorie beverages per day Vitamins & Minerals Lapband Sleeve Gastric Bypass Gastrectomy Multivitamin X X X Calcium X X X Citrate B12 X X Iron X X Taking vitamins after surgery (forever) is an extremely important requirement along with having blood levels tested at specific intervals. 16
Important Guidelines to Eating Healthy Choose fresh unprocessed foods Do NOT eat high fat or sugary foods Eat protein first Eat slowly 30 minutes per meal Chew thoroughly 15 20 times for each bite of food Stop eating just before you feel full Important Guidelines to Eating Healthy Small plate/toddler fork/spoon Keep foods moist Drink only very low calorie; non carbonated drinks Do NOT eat & drink at the same time Do NOT drink for 30 min after eating Reading labels Avoid stress or distractions when eating Exercise Everyday Physical Activity Cardiovascular Walking, swimming, biking Strength Training Free weights Flexibility Yoga, stretching 51 17
Lifestyle Changes Hunger physical vs mental hunger Journaling Food/Emotions/Water/Exercise Structure /Consistency Pre planning: food, exercise, support, reading labels Inspiration Set goals Emotional Impact Timing of Surgery Support System Family Friends Support Groups Co workers Professional Staff Realistic Expectations Weight loss does not eliminate everyday problems Emotional Impact Potential for transfer of addiction Spending Money / Shopping Drugs Alcohol Sex Gambling Counseling CBT Learning how to cope without seeking food for comfort is necessary 18
Additional Considerations Smoking Stop smoking 6 weeks prior to surgery & do not return to smoking Drugs Illegal drugs Special consideration for medical marijuana Alcohol Strongly discouraged for all bariatric procedures Gastric bypass pts will physically absorb alcohol quicker Pregnancy Strongly discouraged for at least first 2yrs Most bariatric pts will need to be followed by an Obstetrician specializing in high risk pregnancy Long Term Weight Loss Losing and maintaining weight after surgery is truly based on lifestyle changes for the long term success Food choices Exercise Ongoing support Follow up care with bariatric program Avoid Grazing (unnecessary snacking) Overeating: risk of damaging size of stomach/ pouch / esophagus NP Role in Bariatrics Pre op History and Physicals Post op care Education, education, education Band adjustments Hospital Rounds Surgical Assist (RNFA) Call coverage Medical management of co morbidities 57 19
Weight Loss Surgery is Not a Cure But a TOOL to a Healthier Life Questions? 20