Bariatric Surgery for the Primary Care Physician - The Family ...

The Family Physician’s Role in Managing the Bariatric Surgery Patient

B. Wayne Blount, M.D., MPH

Objectives

Discuss non-surgical and surgical weight management options

Identify appropriate surgical candidates and counsel patients about the importance of compliance with the post-operative regimen

Review the current surgical treatment options and their effectiveness including possible side effects and complications

Discuss follow-up care and long-term management of the post-bariatric surgical patient

The Obesity Epidemic

67% are overweight or obese

$117 billion spent in 2000 to treat the medical consequences of overweight and obesity

112,000 deaths/year attributed to obesity*

*Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual cause of death in the United States. Journal of the American Medical Association, 291 (10), 1238-1245.


“CLINICIANS SHOULD SCREEN ALL ADULT PATIENTS FOR OBESITY AND OFFER INTENSIVE COUNSELLING & BEHAVIORAL INTERVENTIONS TO PROMOTE SUSTAINED WEIGHT LOSS FOR OBESE PATIENTS”

B Recommendation USPSTF


Use : BMI : tables Waist

Circumference : Measured @

narrowest part of waist between lower rib cage & unbilicus

Health Burden

Type 2 diabetes Hypertension Cardiovascular disease Stroke Dyslipidemias Osteoarthritis Cancers Sleep apnea Gall bladder disease Female infertility Psychological issues

Popular diets: reduce caloric intake by restricting certain foods and limiting portions, i.e. by counting calories, fat or carbs

Medically supervised diets Very Low Calorie Diets (VLCD) Liquid Fasts

Referral to a nutritionist or dietician Exercise regimens Medications (sibutramine, orlistat) Cognitive Behavioral Training Bariatric Surgery

The Current Interventions

The Current Interventions

Effect of 4 Diets on Wgt Loss

Atkins, Ornish, Wgt Watchers, & Zone 1 year 25% with adequate adherence 4.6 to 7.3 # loss @ 1 yr in those 25% Which diet didn’t matter Exercise did matter

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Don’t address why people overeat

Disrupt metabolism

Bariatric Surgery

Number of procedures performed has increased 10-fold 14,000 in 1993 140,000 in 2004 > 200,000 in 2005 > 300,000 in 2007

Bariatric Surgery

Evidenced Based Recommendation:

Bariatric surgery leads to sustainable long-term weight loss and may reduce obesity-related comorbities such as diabetes mellitus and obstructive sleep apnea. It is not clear which surgical procedure is the safest and most effective.

Recommendation B

From The Cochrane Database of Systematic Reviews available at ttp://www.cochrane.org/reviews/en/ab003641.html

5

The Family Physician’s Role

Assist their patients in their weight management efforts

Identify potential surgical candidates Counsel patients about their options and the

risks and outcomes of each Understand the post-surgical dietary regimen Monitor patients for short and long-term

complications of bariatric surgery

Indications

Body Mass Index of 40 kg per m2

Body Mass Index of 35 kg per m2 with significant comorbities Type 2 diabetes Obstructive sleep apnea Coronary artery disease Debilitating arthritis

Online BMI calculator available @ http://familydoctor.org

Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus .nih.gov/1991/1991GISurgeryobesity084html.htm.

Indications (continued)

Previous failed weight loss attempts using an integrated weight loss program including: Dietary modification Behavioral support Appropriate exercise

Appropriate motivation and psychological stability to understand risks and benefits of the procedure

The commitment to lifelong postoperative lifestyle changes and medical surveillance


Contraindications

Poor surgical candidates – inadequate cardiopulmonary reserve, drug or alcohol dependency, impaired intellectual capacity

Unable or unwilling to comply with post-op lifestyle changes, diet, supplementation, f/u

Unstable psychiatric illness or eating disorders Uncontrolled coagulation problems or cannot

be removed from coagulation therapy For Lap Band – Intra-abdominal adhesions or

potential for inadequate pneumoperitoneum

Pre-Op Evaluation

Patients should be evaluated by a team – medical surgical, psychiatric and nutritional experts to determine whether they are candidates for bariatric surgery

Pre-op physical and evaluation


Pre-Op Evaluation (continued)

Studies may include: EKG CXR Echocardiogram Cardiac cath Polysomnography/sleep study Gallbladder ultrasound UGI or EGD Possible cardiac, pulmonary and psychiatry

consultations

Pre-Op Evaluation (continued)

Labs may include: Fasting comprehensive metabolic panel LFTs including albumin Lipid panel CBC UA Hgb A1C Oral glucose tolerance test Fasting insulin Transferrin TFTs Beta HCG for females of childbearing age

Surgical Options

Based on 1 of 2 mechanisms for weight loss: 1. Gastric restriction :

Vertical Banded Gastroplasty Sleeve Gastrectomy Adjustable gastric banding

2. Intestinal malabsorption : Roux-en-Y Duodenal Switch

What are the procedures available for weight loss? The Malabsorptive Procedures

The malabsorptive procedures bypass a large amount of intestine and weight loss is achieved by creating nutritional inefficiency

DUODENAL SWITCH The Restrictive Procedures

These procedures restrict the size of the stomach near the esophagus by creating a restrictive pouch. which will hold a volume of approximately 40cc.

GASTRIC BYPASS Lap-Band Sleeve Gastrectomy

The Malabsorptive ProceduresDuodenal Switch

Fat Malabsorption Primary Mechanism•Malnutrition an issue

•Fat Souluble Vitamins•Protein malnutrtion

•Frequent foul smelling stools•Up to seven per day

•Hepatotoxicity•Elevated liver enzymes•Potential for Liver Failure

•Hypoalbuminemia•Hypoproteinemia

•VERY EFFECTIVE WEIGHT LOSS

The Restrictive ProceduresLap-Band

•Pure Restrictive Mechanism•Requires Frequent Surgical Followvup

•Monthly to Every 6 weeks•Requires Significant Dietary Changes •Major Complications

•Band Slippage – Reoperation•Band Erosion – Removal

•No Malabsorption Risk•Reversible •Low Risk•Outpatient Surgery

The Restrictive ProceduresSleeve Gastrectomy

Permanent Partial Gastrectomy•Resection of body of stomach•Resection of fundus of stomach•Resection of Antrum of stomach

•Unproven – experimental•Becoming more common•Not covered by Insurance

Combined ProceduresGastric Bypass

• Most commonly performed bariatric procedure in U.S.

• Creates a small Gastric pouch• Creates a short Roux Limb• Combined Procedure

•Small Malabsorptive limb•Restrictive gastric pouch

• Difficult to Reverse

Results of Gastric Bypass

Average BMI 43.5 82% Female 18% male Conversions to open – 2% Admissions to ICU post op 4%

3% sleep apnea observation 1% unexpected secondary to conversion to open

Average Length of Stay – 2.2 days Outliers – 1% > 10 days

Results of Gastric Bypass

Anastomotic leaks -2%

Internal Hernia requiring reoperation – 4%

Death – < 3 % Anastomotic Leak Sudden Cardiac Death

Outcomes – Gastric Bypass

Effective Weight Loss1 year 68%2 year 74%3 year 72%

LAGB Weight LossSystematic Review World Literature-ASERNIP-S

Mean % Excess Weight Loss:

Surgery 2004;135:326-51J Lap Adv Surg Tech 2003;13:265-70

Procedure 36

months

48

months

60

months

LAGB(range)

# Reports

55%

(38-64)

52%

(44-68)

56%*

(53-60)

RYGB(range)

# Reports

69%

(58-89)

58%

(56-63)

59%*

(55-62)

*Not statistically significance

A comparison of percentage of excess weight loss following LAGB and RYGB surgery. Published series with baseline numbers greater than 501

0

10

20

30

40

50

60

70

80

6 12 18 24 36 48 60 72 84 96 108 120

Months

RYGB (n=5160)

Lap-Band (n=6242)

1 Surgery 2004;135:326-51

LAGB Weight Loss

Career Experience – Gastric Bypass1152 Cases – Major Complications Death 3 patients

Anastomotic Leak – 1 patient post op day 3 Sudden Cardiac Death – 2 patients

No Leak No PE

Internal Hernia Requiring Reoperation 6 patients

Ischemic Bowel – Reoperation/Resection 2 patients

Venous Stasis/Thrombosis/Congestion – 1 Arterial Thrombosis/Hypercoagulopathy -1

Career Experience – Gastric Bypass1152 Cases – Major Complications

Pulmonary Embolism – (No Deaths) Post Op Day 1-14 NONE Post Op Day 14-30 3

Rx – Prophylactic IVC Filter Pre-Op - (One)

- Post Op Heparin/Coumadin – (Two)

Surgical Options

Roux-en-Y is most common procedure Lap-Band Increasing in popularity Sleeve Gastrectomy – Experimental Duodenal Switch – Laparoscopic pts have less;

Time in hospital, Lost work Pain Incisional hernias (vs 25% in open)

Life-Threatening Complications

80% of deaths in the first 30 days are due to: Pulmonary embolism Anastomotic leaks Respiratory failure


Pulmonary Embolism Leading cause of death Risk factors

BMI => 60 kg/m2

Chronic lower extremity edema Obstructive sleep apnea h/o pulmonary embolism

Prophylaxis low-molecular-weight heparin and compression

stockings Early Ambulation (laparoscopic) Consider Pre-operative IVC Filter

Geerts, W.H., Pineo, g.F., Heit, J.A. et al. (2004). Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3 suppl), S338-400.


Anastomotic leaks – Signs and Symptoms Sustained tachycardia, severe abdominal pain, fever,

rigors, hypotension Respiratory failure

Work-up: UGI or CT scan with contrast – May be negative DON’T DELAY SURGICAL CONSULT

Urgent surgical consultation Exploratory surgery if equivocal signs

“Leak Until Proven Otherwise” post op day 1-14

Identify complications early and educate patients about reporting symptoms


Internal Hernia• Partial Small Bowel Obstruction through internal mesenteric defects• Usually following RYGB or Duodenal Switch procedures• Patients complain of severe pain

• Intermittent• Out of proportion to physical findings• Usually NOT vomiting• CT findings usually negative• Abdominal series usually negative• Usually occur 12 months or greater post op• Usually occur after >100 pounds weight loss

• Surgical Consultation • Diagnostic laparoscopy and repair of hernia• Delay in diagnosis can be life threatening

Short-Term Complications

1-6 weeks post-op:

Wound infections Less Common in Laparoscopic Group Open Group may lead to incisional hernia

Stomal stenosis Nausea, Vomiting inability to advance diet Usually requires EGD and dilation

Marginal ulceration Usually ischemic Rarely secondary to Acid production PPI (Prevacid Solutab), Carafate suspension

Constipation Poor PO Fluid intake

Long-Term Complications

Nausea, Bloating Abdominal Discomfort Think Biliary Dyskinesia or

Symptomatic Cholelithiasis Workup

Abdominal Ultrasound – Gallstones? HIDA WITH Biliary Ejection Fraction – Dyskinesia?

Up to 50% due to rapid weight loss Consider prophylactic cholecystectomy at the time of

surgery Consider bile salt therapy – Daily for 6 months post op


Nausea, Bloating Abdominal Discomfort, Malaise, Fatigue, Hair loss etc Think Nutritional Deficiency

B vitamins Thiamin, Riboflavin, Niacin, Folate, B6, B12,

biotin and pantothenic acid. Fat Soluble Vitamins

A,D,E,K Vitamin C

Compliance? Only 30-35% patients are vitamin compliant


Nutritional Deficiencies Especially with malabsorptive procedures (RYGB,

biliopancreatic diversion) Prevention

Adherence to high protein diet Lifelong supplementation

High potency MVI with iron Vitamin B12, 1000mcg IM q mo or 100mcg po qd Calcium 1200 mg q d Menstruating women may require parenteral iron

infusions

Halverson, J.D., (1992).Metabolic risk of obesity surgery and lon-term follow-up. American Journal of Clinical Nutrition, 55, S602-605.

Post-Op

Usually surgeons have their own specific dietary transitions & anticoagulation methods

Some recommended ones can be found @ “UpToDate”

Be aware that in the perioperative period, many obesity-related medical co-morbidities change dramatically; e.g. HTN, DM, GERD

Post-Op Monitoring

Follow-up Lab Tests

Every 3 months for the first year

CBC, glucose, creatinine

Every 6 months for the first year

LFTs, protein and albumin, iron, TIBC, ferritin, vitamin B12, folic acid, calcium, parathyroid hormone (if hypercalcemic)

Every year after the first year

All of the above

Virji, A., Murr, M. (2006). Caring for patients after bariatric surgery. American Family Physician, 73 (8), 1403-1408.

Long-Term ComplicationsCompliance Issues Dumping Syndrome

Procholinergic symptoms from influx of undigested carbohydrate into the jejunum

Side effect of malabsorptive procedures – RYBG and biliopancreatic diversion

Symptoms Nausea, vomiting, diarrhea, tachycardia, salivation,

dizziness Results from poor dietary compliance; may serve as

reinforcement Subsides 1-2 hours after sugar or foods high in

simple carbohydrate

Long-Term ComplicationsCompliance Issues Persistent vomiting due to pouch distention

More common with purely restrictive procedures VBG and adj. lap band

Due to non-adherence to dietary recommendations Small portions Chewing thoroughly Eating slowly Waiting one hour after eating before drinking

Other causes of vomiting – pain meds, vitamins, dehydration, gastroenteritis

Bohn, M., Way, M., Jemieson, A. (1993). The effects of practical dietary counseling on food variety and regurgitation frequency after gastroplasty for obesity. Obesity Surgery, 3, 23-28.

Compliance Issues - Pregnancy

Pregnancy is contraindicated for at least 18 months after surgery due to rapid weight loss and nutritional requirements

Provide appropriate contraception


Protein-calorie malnutrition months to years after surgery due to anastomotic stricture or food phobias

Repeated episodes of nausea and vomiting Multiple hospitalizations for dehydration, renal

insufficiency and liver failure Treat with aggressive TPN, dilation of stricture Surgical Consultation for Revision or Reversal

Long-Term ComplicationsSide Effects – Skin Issues

Panniculitis Severe infection of the excess abdominal skin Treat with antibiotics and skin hygiene Consider excision of the excess skin

Results

Clinical Improvement/Resolution :

Diabetes : 64-100% HTN : 62-69% O.S.Apnea : 85% Dyslipidemia : 60-100% Nonalcoholic fatty

liver dz : 90%

Results

Cholelithiasis : 22% Overall mortality (after 9 yrs) :

With surgery : 9% Without surgery : 28%

F. P. ‘ s Role in F/U

COUNSELLING PT ON LIFE STYLE CHANGES AND EXPECTATIONS **

DIETARY CHANGES : AMT, LIQUIDS, PROTEIN

SUPPLEMENTS CHANGE IN CHRONIC ILLNESSES

Manage Changes In Chronic Illnesses

DIABETES HYPERTENSION GERD DYSLIPIDEMIAS

WHEN ?

Bibliography

Virji A, Murr MM. caring for patients After Bariatric Surgery. AFP 2006;73:1403-8.

http://www.hamptonbariatric.com USPSTF. Screening for obesity in adults. AFP April

15, 2004; UpToDate CARING FOR PATIENTS AFTER BARIATRIC

SURGERY. CME BULLETIN. AAFP. JUNE 2006. MAYO CLINIC PROCEEDINGS. SUPPLEMENT TO

OCT. 2006, VOL 81.

Bibliography

American Dietetic Assoc Position of ADA. 2002. J Am Dietetic Assn. 102:1145-55.

May M. Am I Hungry? What To Do When Diets Don’t Work. Phoenix: Nourish publishing

Vega GL. Obesity,The Metabolic Syndrome, & Cardiovascular Disease. Am Heart J, 142:1108-16.

Wadden, TA. (ed). Handbook of Obesity Treatment. 2002. Ny: Guilford Press.

Thank You!

? Questions?

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