Care of the Post Bariatric Surgery PatientBRADLEY HAVINS MD, FAAFPASSISTANT PROFESSOR TOURO UNIVERSITY NEVADADIPLOMATE, AMERICAN BOARD OF FAMILY MEDICINEDIPLOMATE, AMERICAN BOARD OF OBESITY MEDICINE

Disclosures

I have no financial or other conflicts of interest to disclose.

Outline/Objectives Review of Types of Bariatric Surgery

Review of Guidelines

Acute Complications

Long Term Complications

Preventing Weight Regain

2 Worlds Separated by a Common Language Medical Weight Loss

Expresses weight loss as a percentage of total body weight

Surgical Weight Loss Expresses weight loss as a percentage of EXCESS body weight lost

Total Body Weight- Ideal Body Weight = Excess Body Weight

Types of Bariatric Surgery Restrictive Procedures

Malabsorptive Procedures

Beyond the scope of this talk Newer invasive procedures for weight loss

Gastric Balloons AspireAssist VBLOC- Vagus Nerve Stimulator Duodenal Endoluminal Sleeve Transpyloric Shuttle

Why Do Bariatric Surgery?

The August 23, 2007 edition of The New England Journal of Medicine publishes a landmark long term study regarding reduction in mortality

Sjostrom et al in the Swedish Obesity Study (SOS) show a 29% reduction in death at average follow-up of 10.9 years

Adams et al in a retrospective study of 7900 patients at 7.1 years, 40% reduction in mortality; 60% in cancer death; 92% in DM death

The Evidence Continues to Mount Weight and Metabolic Outcomes 12 Years after Gastric Bypass (NEJM 2017)

1156 patients divided into 3 distinct study groups; Roux-en-y group, sought but did not get Roux-en-y group, and never sought surgery group

At 12 years Roux-en-y group had 35kg weight loss, sought surgery group was 2.9kg weight loss, and never sought surgery group was 0kg

The Evidence Continues to Mount Weight and Metabolic Outcomes 12 Years after Gastric Bypass (NEJM 2017)

Metabolic Improvements Roux-en-y Group- Type 2 DM resolved in 66 of 88 patients (75%) at 2 years and 43 of 84

(51%) patients at 12 years Sought Surgery Group- Type 2 DM occurred in 42 of 164 (26%) of patients Never Sought Surgery Group- Type 2 DM occurred in 47 of 184 (26%) of patients

Lipid and Blood Pressure measurements also improved in the surgery group

The Evidence Continues to Mount STAMPEDE Trial 5-Year Outcomes (NEJM 2017) Specifically looked at glycemic control between three groups (endpoint A1c <6)

Roux-en-y Group- 14 of 49 patients achieved remission of DM

Gastric Sleeve Group- 11 of 47 patients achieved remission of DM

Intensive Medical Therapy Group- 2 of 38 patients achieved remission of DM

The Evidence Continues to Mount STAMPEDE Trial 5-Year Outcomes (NEJM 2017)

Restrictive ProceduresLaparoscopic adjustable gastric banding

Most common WLS procedure world wide until the late 2000’s

Purely restrictive

In the U.S., two bands available - Realize® and LAP-BAND®

Sleeve gastrectomy Fastest growing option in the USA (2013/14–most common procedure in

U.S.)

Restrictive (Minimal malabsorption)

Malabsorptive Procedures Gastric bypass (Roux-en-y)

Was the most common WLS procedure done in the USA

Mostly restrictive, some malabsorption

Long-limb GBP and duodenal switch (or BPD) Much more rare (<1%)

Mainly malabsorptive

Laparoscopic Adjustable Gastric BandingCreates a small pouch that fills with food

Food squeezes the stomach, producing the sensation of fullness

Helps suppress appetite

Low mortality and complication rate

Sleeve Gastrectomy aka Gastric Sleeve Used initially as a “first-stage” procedure for patients with severe

obesity. Promotes weight loss making subsequent surgery less risky.

Second stage then a “bypass-type” procedure

Now used as a primary weight-loss procedure

Removes 75-80% of the greater curvature of the stomach. Leaves a “lesser curve based” tubular stomach pouch. Preserves the pylorus

Stomach is 60 ml – 100 ml, about the size and shape of a medium banana

Sleeve Gastrectomy• Works by decreasing Ghrelin levels

• Ghrelin is the hormone responsible for hunger

• Greater curve of the stomach removed• Stomach is where ghrelin is produced

• Minimal Malabsorption

• Anatomy remains nearly intact

• Fastest growing type of gastric surgery, became most popular in U.S. in 2014, now is almost 60% of all surgical weight loss procedures

• Full recovery from surgery in 2-3 weeks

• Average weight loss = 60-70% EBW

Gastric bypass (Roux-en-y)• The stomach is reduced to the size of an egg

• The ilium is attached to the stomach pouch, called the Roux limb

• A blind pouch is created called the hepatobillary limb

• Weight loss occurs as only small volumes of food can be consumed, and the food consumed is only partially absorbed

• Becoming a less popular option as of 2011

• 2nd most common weight loss procedure in 2017, just barely more common than a revision surgery

Bariatric Surgery by the Numbers

Clinical Practice Guidelines

Multiple Organizations and Entities Publish CPG with regards to Bariatric Surgery Patients

These guidelines are often incongruent or directly opposed to each other.

Personally Recommended Resources with regard to CPG Practical Recommendations of the Obesity Management Task Force of

the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management

VA/DOD Clinical Practice Guidelines on Obesity

American Society for Metabolic and Bariatric Surgery

VA/DOD Clinical Practice Guidelines Offer bariatric surgery, as an adjunct to comprehensive lifestyle

intervention, for weight loss in adult patients with a body mass index (BMI) >40 kg/m2 or those with BMI 35.0‐39.9 kg/m2 with one or more obesity‐associated conditions. [A]

Offer bariatric surgery, as an adjunct to comprehensive lifestyle intervention, to improve some obesity‐ associated conditions in adult patients with a body mass index (BMI) >35.0 kg/m2. [A]

Current evidence is insufficient to assess the balance of benefits and harms of offering bariatric surgery as an adjunct to comprehensive lifestyle intervention, for weight loss or to improve some obesity‐associated conditions, to patients over age 65 or with a body mass index (BMI) <35 kg/m2. [I]

VA/DOD Clinical Practice Guidelines Engage all patients who are candidates for bariatric surgery in a

general discussion of the benefits and potential risks. If more detailed information is requested by the patient to assist in the decision‐making process, a consultation with a bariatric surgical team should occur. [EO]

Provide lifelong follow‐up after bariatric surgery to monitor adverse effects and complications, dietary restrictions, adherence to weight management behaviors and psychological health. [EO]

VA/DOD Clinical Practice Guidelines

Acute Complications Defined as anything 30 days or less from date of surgery Not necessarily a issue with the technical procedure Never hesitate to contact the patient’s surgeon for guidance of

acute complications

Acute Complications- Surgical RiskGastric Bypass Laparoscopic Adjustable

Gastric BandSleeve Gastrectomy

Death (1:500) Death (1:1000) Death (1:500)

Leak (1:100) Leak (1:500) Leak (1:50-100)

Wound Infection (1:50) Wound Infection (1:100) Wound Infection (1:100)

DVT/PE (1:50-100) DVT/PE (1:100) DVT/PE (1:100)

Nausea, Vomiting, Dehydration (1:50)

Nausea, Vomiting, Dehydration (1:100)

Nausea, Vomiting, Dehydration (1:50-100)

.

Acute Complications- Surgical RiskGastric Bypass Laparoscopic Adjustable

Gastric BandSleeve Gastrectomy

Death (1:500) Death (1:1000) Death (1:500)

Leak (1:100) Leak (1:500) Leak (1:50-100)

Wound Infection (1:50) Wound Infection (1:100) Wound Infection (1:100)

DVT/PE (1:50-100) DVT/PE (1:100) DVT/PE (1:100)

Nausea, Vomiting, Dehydration (1:50)

Nausea, Vomiting, Dehydration (1:100)

Nausea, Vomiting, Dehydration (1:50-100)

Acute Complications-Thiamine Deficiency Nausea, Vomiting, Dehydration

Be aware of Thiamine Deficiency Absorption reduced due to decreased acid and duodenal exclusion in

gastric bypass patients Symptoms include lower extremity weakness, peripheral neuropathy and

nystagmus/ dipoplia Peripheral neurologic symptoms can occur within weeks Wet and Dry Beriberi Wernicke’s encephalopathy reported as early as three (3) months Central Pontine Myelinolysis Parenteral supplementation if neurologic symptoms with 100mg/day for 7-14

days, then 10mg daily

Acute Complications- Marginal Ulcer Anastomotic/ Marginal Ulcers (Can also be a chronic complication)

Up to 20% early after gastric bypass (can be asymptomatic)

Commonly complaints of pinpoint abdominal pain, nausea, vomiting, GI bleeding, free perforation

Risk Factors include NSAIDS, Smoking, Steroids

DX is confirmed by upper endoscopy

Treat with PPI, Sucralfate, improved nutrition, smoking cessation

Acute Complications- Marginal Ulcer Anastomotic/ Marginal Ulcers (Can also be a chronic complication)

Acute Complications- Anastomotic Leak Anastomotic Leak (aka Sleeve leak)

0-2% after Gastric Bypass, 1-2% after Gastric Sleeve

Almost always occurs very early, rare after two (2) weeks

Symptoms include tachycardia, abdominal pain, left sided chest pain, leukocytosis, fever, decreased urine output, and feelings of doom

Diagnosed by Upper GI, or CT scan + High Index of Suspicion Left Pleural Effusion should be a tip off to look for anastomotic leak

If contained, may require drainage

If free, will likely require surgery

Acute Complications- Anastomotic Leak

Long Term Complications Defined as any complication that occurs >30 days after surgery

Practically speaking most of these occur months to years after surgery

Some of these are due to poor compliance with recommendations

Long Term ComplicationsGastric Bypass LAGB Sleeve Gastrectomy

Peptic Ulcer (3-5%) Band Slippage (3-5%) Stenosis (1-2%)

Small Bowel Obstruction (1%)

Gastric Pouch or Esophageal Dilation (3-5%)

Sleeve Dilation (Unknown)

Internal Hernia (1-2%) Band Erosion (1%) New or Worsening GERD (Unknown)

Incisional Hernia (0.8%) Port/Device Problem (2-5%)

Stenosis or Stricture (2%) Need for Revision Surgery or Removal (15-30%)

Vitamin/Nutrient Malnutrition (15-40%)

Long Term Complications Internal Hernia

Months to years after procedure Roux-en-y most common

Abdominal pain and obstruction syndromes, acute or intermittent

Can result in bowel necrosis, sepsis or death

X-Rays and CT may be negative

Endoscopy can be helpful

Have a low index of suspicion and send for laparoscopic surgery

Case courtesy of Radswiki, Radiopaedia.org, rID: 11527

Long Term ComplicationsCalcium, Vitamin D, and Fracture Risk

Calcium and Vitamin D Supplementation Roux-en-y patients are susceptible to multiple vitamin and nutrient

deficiencies compared to gastric sleeve

Theoretic Risk for Secondary Hyperparathyroidism after Gastric Bypass due to poor absorption of Calcium

Use Calcium Citrate instead of Calcium Carbonate (easier to absorb)

No data exists to recommend ideal Vitamin D and Calcium regimen

Long Term ComplicationsCalcium, Vitamin D, and Fracture Risk

The DEXA and Fracture Risk Controversy VA/DOD Clinical Practice Guidelines recommend Annual DEXA after

Roux-en-y

ASMBS recommends against routine DEXA in bariatric surgery patients

Evidence demonstrates fracture risk increases after Roux-en-y. Fracture pattern changes from obesity related to osteoporosis associated fractures

Fracture risk increases after gastric bypass, independent of amount of weight lost, regardless of Calcium or Vitamin D supplementation (poor data)

Overall fracture risk after Gastric Bypass is 10.1 in patients with diabetes and 7.7 in patients without diabetes per 1000 patient years

ASMBS= American Society of Metabolic and Bariatric Surgeons

Long Term ComplicationsPregnancy

Majority of patients undergoing bariatric surgery are female 80% of Females undergoing bariatric surgery are of child bearing

age Pregnancy is NOT RECOMMENDED for 12-18 months after bariatric

surgery Pregnancy after an appropriate waiting period is considered safe Fertility is usually increased after bariatric surgery by improvement in

sex hormone profile

Long Term ComplicationsPregnancy

Long Term ComplicationsPregnancy and Screening

Post bariatric surgery status should be considered a risk factor for IUGR

Routine ultrasounds at 12 and 20 weeks should be performed (European Guideline)

A1C should be measured in 1st trimester to screen for pre-existing DM Glucose Tolerance Test as a screen for Gestational Diabetes is ill

advised in these patients (dumping syndrome)- use serial pre and post prandial finger sticks as an alternative

Abdominal Pain in the pregnant female presents a unique problem, and evaluation by both an obstetrician and a bariatric surgeon should be offered

Prevention of Weight Regain General Recommendations

Behavioral Reasons

Medication Choices

Psychosocial Factors

Prevention of Weight RegainGeneral Recommendations

Support recommendations made by surgeon Usually a low carb, high protein diet is recommended Any diet that is “low energy” will provide weight loss

Beware of liquid calories

Use patient 1st language, avoid use of the word “Obese”

Encourage “Physical Activity”, avoid use of the word “Exercise”

Use of weight loss medication in addition to bariatric surgery not well studied

Ensure compliance with multivitamin and supplement regimen

Prevention of Weight RegainBehavioral Reasons

Increased frequency of eating/ grazing

Consuming calorie dense foods and liquid calories

Overcoming dumping syndrome

NO SURGERY CAN DEFEAT M&M’s

Prevention of Weight RegainMedication Choices

Disease Avoid Choose

Depression Paroxetine AmitryptilineNortryptilineMirtazapine

Bupropion, Escitalopram,Citalopram Fluoxetine, Sertraline ImipramineTrazodone, Duloxetine,Venlafaxine

Anti‐Epileptic Drugs Valproic Acid (5‐10%) Gabapentin (2.2 kg) Divalproex Carbamazepine (1.5 kg)

Wt Loss: Felbamate, topiramate, zonisamide

Wt Neutral: Lamotrigine, Levetiracetam, phenytoin

Anti‐psychotics Olanzapine (30% wt gain) Quetiapine (16%)Risperidone (14%)Perphenazine (12%) Clozapine (.9‐9.5 kg)

Aripiprazole Ziprasidone(7%)Consider offset with metformin or topiramate (off‐ label)

Prevention of Weight RegainMedication Choices

Disease Avoid Choose

Acute Pain Prednisone, etc. (4‐8%) NSAID, etanercept

Anti‐Histamines Sedating:Cyproheptadine Diphenhydramine

Non‐sedating: Loratadine, Fexofenadine, Cetirizine

Diabetes Insulin (10 kg)Pioglitazone (3 kg),Rosiglitazone Sulfonylureas (10 kg)

Metformin (‐2.1 kg), GLP‐1,DPP‐4 SGLT‐2 Inhibitors, acarbose, miglitol,pramlintide

Hypertension Beta‐blockers (1.2 kg)(Carvedilol and nebivolol are the best choices)

Ace‐I , ARB, CCB

Contraception Injectables including Depo‐ medroxyprogesteroneAcetate

Oral Contraceptive Pills (ifnot contraindicated)

Prevention of Weight RegainPsychosocial Factors

Obese patients undergoing significant weight loss have a change in identity. This change can be ego dystonic

Patients may sabotage their weight loss to ease this distress

Counseling and psychiatric support is crucial to avoid this

Bariatric Surgery Support Groups Small study of 17 patients showed group CBT in the post-bariatric surgery

patient improved psychological wellbeing

Improved scores on the Obesity Adjustment Survey, Outcome Questionnaire-45, and Kessler Psychological Distress Scale

No data from this study regarding impact on weight loss

References Adams et al. Weight and Metabolic Outcomes 12 Years after Gastric Bypass. New England Journal of

Medicine. 2017; 377;12 1143-1155

Axelsson KF, Werling M, Eliasson B, Szabo E, Näslund I, Wedel H, et al. Fracture Risk After Gastric Bypass Surgery: A Retrospective Cohort Study. Journal of Bone and Mineral Research. 2018;33(12):2122–31.

Beaulac J, Sandre D. Impact of a CBT psychotherapy group on post-operative bariatric patients. SpringerPlus. 2015;4(1).

Busetto L, Dicker D, Azran C, Batterham RL, Farpour-Lambert N, Fried M, et al. Obesity Management Task Force of the European Association for the Study of Obesity Released “Practical Recommendations for the Post-Bariatric Surgery Medical Management.” Obesity Surgery. 2018Apr;28(7):2117–21.

Chakhtoura MT, Nakhoul N, Akl EA, Mantzoros CS, Fuleihan GAEH. Guidelines on vitamin D replacement in bariatric surgery: Identification and systematic appraisal. Metabolism. 2016;65(4):586–97.

Estimate of Bariatric Surgery Numbers, 2011-2017 https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers

Gagnon C, Schafer AL. Bone Health After Bariatric Surgery. JBMR Plus. 2018Mar30;2(3):121–33.

Issa H, Al-Saif O, Al-Momen S, Bseiso B, Al-Salem A. Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: the value of laparoscopic gastroduodenoscopy. Annals of Saudi Medicine. 2010;30(1):67-69. doi:10.4103/0256-4947.59382.

References Lazarus, OMA Annual Meeting 2016 Kim J, Brethauer S. Metabolic bone changes after bariatric surgery. Surgery for Obesity and

Related Diseases. 2015;11(2):406–11. Nieuwenhove YV, Ceelen W, Renterghem KV, Putte DVD, Henckens T, Pattyn P. Conversion

from Band to Bypass in Two Steps Reduces the Risk for Anastomotic Strictures. Obesity Surgery. 2010;21(4):501-505. doi:10.1007/s11695-010-0331-8.

Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients. Surgery for Obesity and Related Diseases. 2017;13(5):727–41.

Schauser et al. Bariatric Surgery vs Intensive Medical Therapy for Diabetes- 5-Year Outcomes. New England Journal of Medicine 2017.376:641-651

Sjöström L, Narbro K, Sjöström CD, et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. New England Journal of Medicine. 2007;357(8):741-752. doi:10.1056/nejmoa066254.

VA/DoD Clinical Practice Guidelines. Management of Obesity and Overweight (OBE) (2014) - VA/DoD Clinical Practice Guidelines. http://www.healthquality.va.gov/guidelines/cd/obesity/. Accessed February 1, 2017.

Questions?