Laparoscopic Adjustable Gastric Banding BioEnterics Lap-Band, Inamed Corporation

Sandy McCoy, RN, MSN, CBN, FNP-BC

Post Operative Care/Considerations of the Bariatric Patient in Primary Care

ObjectivesIdentify obesity as a major health problemDescribe the socio-economic impact on people who suffer from morbid obesityDiscuss the surgical options for obesity.Identify key components to the pre-operative evaluation of bariatric patients.Discuss the after care of the surgical bariatric patient including laboratory and GI testsDiscuss post operative complications that may appear in the primary care office.

Weight CountsSlightly underweight insects, fish, reptiles, birds, mammals and people live longer than the overweight.

To lengthen thy life, lessen thy meals.Benjamin FranklinWhat Is Obesity?Obesity- over ideal weight by 30% or BMI over 30

Morbid Obesity- Clinically severe obesity-point where serious medical conditions occur as a direct result of the obesity Defined as >200% of ideal weight, >100 lb overweight, or a body mass index of 40

What is Causing Obesity?Eating out/ordering in & foods not healthyPortion sizes increased (soda 6 oz to 20oz)Consumption of soft drinks (600 12 oz/pp/per year, males 12y-29y=1/2 gal/d or 160 gal/yr)Rushed mealsJunk food is advertised, cheap and availableNo time to exerciseTechnology especially for childrenUnrealistic expectations

Body Mass Index (BMI)BMI = Formula: weight (lb) / [height (in)]2 x 703 Calculate BMI by dividing weight in pounds (lbs) by height in inches (in) squared and multiplying by a conversion factor of 703. Example: Weight = 150 lbs, Height = 55 (65")Calculation: [150 (65)2] x 703 = 24.96W.H.O. ClassificationBMIIdeal Weight20 24.9Overweight25 29.9Moderate Obesity 30 34.9Severe Obesity 35 39.9Morbid Obesity 40 49.9Super Obesity50+++(MenWaist 40 inches Women Waist 35 inches)More adverse health effects with increased fat inside the abdominal cavity.

Obesity FactsWorld epidemic of obesityEstimated about 1.7 billion people25% of industrialized world

97 million Americans (> 2/3 population) are overweight/obese. Has tripled in last 20 years.

Obesity costs in US about $100 billion/yr in direct health care expenses/lost productivity.

300,000 deaths annually in US obesity related.1 in 6 morbidly obese people will die within 10 years. (from research Ohio State University)

Less than 2% morbidly obese people will succeed in loosing and keeping off weight with diet and exercise on their own.

Obesity Related Co-Morbidities% of patients presenting w/ condition prior to bariatric surgeryDiabetes15-30%Hypertension20-55%Hyperlipidemia35-53%Cardiac disease10-20%Respiratory disease15-20%Sleep apnea Syndrome 50-65%Arthritis70-90%Depression50-65%Stress Incontinence30-45%Menstrual irregularity 50-65%Metabolic Syndrome 40% >age 60Table 7 Bariatric Literatre reviewObesity Related Co-Morbidities% of patients presenting w/ condition prior to bariatric surgeryDiabetes 15-30%Hypertension 20-55%Hyperlipidemia 35-53%Cardiac disease 10-20%Respiratory disease 15-20%Sleep apnea Syndrome 50-65%Arthritis 70-90%Depression 50-65%Stress Incontinence 30-45%Menstrual irregularity 50-65%Table 7 Bariatric Literatre reviewEconomic and Social Co-Morbidities

DiscriminationStudies show society has low respect for morbidly obeseMany have limited number of friendsMany obese individuals report being treated disrespectfully by an M.D. Social isolation, depression & low esteemWhat WLS Will and Will Not do for youWeight loss surgery is not a magic pill.It will not make you suddenly slim, happy, & beautiful or give you a perfect life.It is a tool to assist you and is a part of an entire program to help you lose the your excess weight. WLS can make you healthier and decrease your risk of early death associated with obesity.Surgical ProceduresLaparoscopic duodenal switch

Laparoscopic RNY Gastric Bypass

Laparoscopic Adjustable Gastric Band

Laparoscopic Sleeve Gastrectomy

Revision surgery - Conversion from band to RNY or Sleeve - Conversions from VBG to RNY - Failed previous RNY

Surgical ProceduresRoux-en-Y Gastric BypassMost durable technique, been performed in some variations since 1967Most studied, best understood good programs will provide best long-term maintenanceRequires modification of food preferences enforced by dumping syndromeLaparoscopic versions preferred, much easier on patient75-80% EWL at three yearsIt is reversible

Negatives: higher initial complication rate (lower late complication rate), need to supplement vitamins and minerals for life, potential for malnutrition with non-compliance

Complications of Gastric BypassEarly (any abdominal pain, get CT scan)Staple line leak (0.25-3%), most occur 3-12 days post-op, rare after 3 weeks.GI bleeding - (0.5-5%), usually from staple linesDilated loops (2-5%), ileus, SBO, internal hernia, kinks; worry is perforation of bypassed stomachDeath (0.2%) first 30 days either PE or bowel leakLong term complications Gastric BypassVitamin deficient Common are Vitamin B12, Calcium, Folic Acid

Some food intolerance & alcohol - more rapidly absorbed and can lead to early intoxication. Dumping syndrome-especially after large amounts of sugar. Symptoms=heart racing, sweating, nausea, stomach cramps, diarrhea, fatigue

Bowel obstructions - 1%+Caused by Internal Hernia CT Scan for dx. dilated bypassed stomach, dilated small bowel, deviated SMA vessels dx laparoscopy

Stricture/Stenosis (2-8%), if cannot keep down H20 suspect stricture diagnosed by UGI, EGD (rare after 3 months unless smoker)

Ulcers of pouch - 1% (Smokers), double with NSAID use, diagnose with EGD

Cholelithiasis gallbladder sonogram (5 - 25%), rare before 6 weeks post-op, increases w/ excessive fats or dairy in diet (Ursodial)

Long Term Positive Results of Gastric BypassAverage weight loss of 77% at one year.After 10-14 years approx. 70% patients have maintained approximately 70% of their weight loss.96% of patients saw a reduction or resolution of co-morbidities.

Band SurgeryRestrictive (limits amount of food eaten)Adjustable can adapt to changing needsLow immediate complication rate (higher later complication rate)Easy on patient outpatient surgery Less dependent upon supplementationSlow but steady weight loss 1-2 lbs. per week, average 40-60% EWL at three yearsNegatives Half of patients only reach 50% EWL mark, requires lots of maintenance, doesnt reinforce food choices; frequent adjustments needed, slip, erosion, esophageal dilatation, and port problems

Normal Band (X-Ray View)

Complications of BandsSlippage (Prolapse) 2 10%Port Problem 2 7%Erosion 0.5 1%Esophageal Dilation 1 2%Death 1 IN 1500 from pulmonary emboliGreater Chance re-operationPersistent dysphagiaUp to 25% of bands being removed after 5 yrs.

Complications of Gastric SleeveBleeding from suture line (0-6.4%)Gastric leak from suture line (1-1.4%)Excess narrowing or post op stricture (1-2%)Pouch dilatation over time (5-10%)Post op nausea (usually goes away in 2 weekPost op heartburn (