Till Death Do We Part The Life-long Journey of a Bariatric Surgical

Patient

Tina Musselman MA, RD, CCN

St. James Center for Bariatric Surgery

Program Coordinator

Tina.musselman@ssfhs.org

(708) 679-2717

Mind, Body & Wellness Institute, Inc.

mindbodywellness@yahoo.com

(708) 846-5816

Obesity…Intervention

Diet Physical Activity

Lifestyle Modification

Pharmacotherapy

Surgery

BMI

25

30

35

http://cme.medscape.com/viewarticle/712986?src=cmemp&uac=98478HV

Phentermine, Meridia, Xenical

(Byetta), Band(?)

RYGB, AGB (BMI 30),

Duodenal Switch,

Gastric Sleeve

The Reality of Bariatric Surgery

# of bariatric cases grew 400% from 1998-2004

– 13,386 to 121,055 per year

– 220,000 performed in 2008

82% of surgical cases are female

Age

– Ages 18-54 accounted for 85.2% of all surgeries

– FASTEST GROWTH IN BARIATRIC SURGERY IS FOR

AGES 55-64 (20 fold increase)

RD’s can run, but we cannot hide! Healthcare Cost and Utilization Project, Statistical Brief #23 (January 2007)

Eligibility BMI

– BMI 35-39.9 with 1 - 2 obesity-related co-morbidities (DM, HTN, dyslipidemia, severe OA, OSA, Pickwinian Syndrome)

– BMI > 40

– New indications for Lap Band - BMI 30-34.9 (not covered by insurance yet)

Age

– Adults over 18

– Controversy over 65 y.o. - evaluated case by case

– Adolescent trials are currently being done

Growth must be completed

Some insurances may cover it

“Exhausted all non-surgical weight loss options”

Adjustable Gastric Band

(Lap Band® & Realize Band)

1988 approved by FDA in

June 2001

15 ml pouch

Adjustable stoma size

Digestive tract remains in tact

2/2011 - Lap Band approved for

BMI 30-35 + co-morbids

Roux en Y Gastric Bypass

(RYGB)

1971

15-30 ml pouch (getting smaller)

Roux limb 75-150 cm

– Longer in Super Obese

Biliopancreatic Limb

– Carries gastric juice

– Bile and Pancreatic juice

– 15-60 cm

Distal Common Channel

– 200-500 cm

– All of the ileum and some jejunum

– Bulk of digestion and absorption

RYGB vs. AGB (Lap Band)

RYGB AGB

Weight Loss

70% EBW at 1 yr.

20# wt regain around 2 yrs.

Post-op

50% EBW at 2 yrs

Wt loss may stabilize at 4 yrs

post op

Short Term

Complications

1 yr. post op

0.5% mortality

Similar to any surgery

Anastomotic Leak

Stomal Stenosis (4.9%)

Internal Hernia (2.5%)

Gallstones (1.4%)

Suture Line Ulcers (1.4%)

Staple Line Failure (1.0%)

Bleeding (0.9%)

Death (0.6%)

Dehydration

Hair Loss (iron and

Protein)

0.1% mortality

Similar to any surgery

Gallstones

Dehydration

RYGB AGB

Long-Term

Complications Hypoglycemia

Gastro-gastric Fistula

Stomal Stenosis

Bowel Obstruction

Nutritional (peaks >5 yrs.

post op)

- B12, Folic Acid, Iron,

Calcium, Vit D

Weight Regain

Loss of LBM

Vomiting more common

Gastric prolapse

Obstruction

Esophageal and pouch

dilation

Gastric erosion and

necrosis

Port access problems

Weight regain

Misc… Dumping Syndrome

Gradual shift away from

solid food

RYGB vs. AGB (Lap Band)

Treatment and Outcomes, FNCE Pre-symposium Workshop by Chris Eagon, MD; October 2005

5 year comparison

Band has the highest safety profile for all bariatric procedures

The “new kids on the block” in bariatrics

Laparoscopic Sleeve Gastrectomy

Gastric Plication

Laparoscopic Sleeve gastrectomy

Partial Gastrectomy (60-80% removed)

Small bowel remains intact

Founded as part of the first step in a two step surgical process for the super obese

New- more to learn about sustainability and safety

Results similar to RYGB

SG

Weight Loss 62-69.4% EBW loss at 18 mos

Short Term

Complications

1 yr. post op

Similar to any surgery

bleeding

Fistula

Stenosis/obstruction

Staple line leak

GERD (0-83%)

Long Term

Complications

Gerd (5% at 2 yrs)

Nutritional deficiencies ?

?

Chouillard et al. Laparoscopic RYGB vs Sg for morbid obesity: Case controlled study.. SOARD 2011; 7: 500-505.

Micronutrition Concerns

Malnutrition is “any disorder of nutrition status including disorders resulting from

a deficiency of nutrient intake, impaired nutrient metabolism, or over nutrition.” - Tucker et al., Med Clin N Am, p. 499

– Obesity is a form of malnutrition

Other contributors to pre-op deficiency

– Overfed but undernourished

– Polypharmacy

– Fat sequesters fat soluble vitamins

– Comorbidities create greater nutritional demands

Micronutrition

Factors common to all procedures that increase

nutritional risk

– Poor eating behaviors,

– Decreased nutrient dense foods

– Food intolerance

– Restricted portion sizes

– (Emesis)

Micronutrition - Gastric Bypass

Etiology:

– GERD (PPI’s)

– Emesis

– transit time/diarrhea

Most common deficiencies

– Iron (20-51%): HCl

– B-12 (35%): HCl, IF

– Vit D

– Ca

– Folate (41-47%)

Micronutrition - Gastric Bypass

Etiology:

– GERD (PPI’s)

– Emesis

– transit time/diarrhea

Most common deficiencies

– Iron (20-51%): HCl

– B-12 (35%): HCl, IF

– Vit D

– Ca

– Folate (41-47%)

63% of pts developed nutrition

deficiencies (Fe, B12, folate) 2 yrs.

Post RYGB including those who

were compliant with the vitamin

regimen. (n=140)

- Brolin, et al 1991

Micronutrition - Sleeve gastrectomy

Etiology

– transit time

– Emesis/Nausea

– GERD (PPI’s)

– HCl

Common nutrient def.

– B12: 18% ?

– Fe: 18% ?

– Zn: 35% ?

– Folic Acid?

– Vit D?

Micronutrition - Sleeve gastrectomy

Little data on micronutrition and SG

1 yr. results without MVI

– 4.9-43% Fe def.

– 9-18.1% B12 def.

– 9.8-22% folate def.

Jacques, J., Goldenberg, L. Nutrition and the sleeve gastrectomy patient: From micronutrients

to dietary patterns. Bariatric Times 2011; 8(6):12-15.

Micronutrition - AGB

Etiology

– po intake

– Food intolerance

– Maladaptive eating

Micronutrition - AGB

Etiology

– po intake

– No alterations to

digestive processes

-“AGB has minor effects on normal physiological

digestive processes and, as a result, selective

nutritional deficiencies are presumed to be

unusual…Closer clinical follow up is more

necessary (adjustments) after AGB than RYGB,

whereas the reverse is true for perioperative

nutritional evaluations.”

- Ziegler, O., Sirveaux, MA, et al, Diab. & Met. 2009, p. 544 & 553

Micronutrition - Summary

AGB RYGB SG

Protein - + -(?)

Iron + ++ +

B12 + ++ +(?)

Ca/D - or + ++ -(?)

Folate + + +

B1 + + +(?)

Zn/Se + ++ (?)

A, E, K - - or + -

Vomiting ++ ++ +

- very rare

+ rare

+ frequent

++ very frequent

Ziegler, O., Sirveaux, MA., et al. Medical follow up after bariatric surgery: nutritional and drug issues General

recommendations for the prevention and treatment of nutritional deficiencies. Diab. & Metab 2009; 35: 544-557.

The Standard Supplementation

“There is little agreement on exactly how to manage micronutrition

in post-operative bariatric surgery patients.” - Jacqueline Jacques, ND Micronutrition for the Weight Loss Surgery Patient (2006)

Many patients will be malnourished pre-operatively leading to

more aggressive supplementation after surgery

– 51-62% pre-operative Vit D deficiency

Obese individuals may have needs above and beyond normal

recommendations

– Contributing mechanisms

Multiple medications

Years of poor diet

Underlying inflammation

Recommended Supplementation

AGB RYGB/SG

Multiple vitamin

1,500 mg Calcium

B complex

Bile salt replacement

Multiple vitamin x 2 (100% RDA

including iron)

Sublingual B12

2,000 mg Ca + D

Thiamin (B complex)?

Supplemental iron for menstruating

women?

Bile salt replacement prn

Tablets or capsules can be tolerated 6 mo. and beyond

Multiple Vitamin and Calcium should not be taken together and

should be in divided doses

Bariatric AND Metabolic Surgery

Diabetes &

Comorbidity

Improvement + =

A “CURE” for Diabetes

% improved/resolved

All procedures

78.1%

60% at 2 yrs post op

RYGB 75% @ 6 mos

86% @ 18 mos

SG 48% @ 6 mos

62% @ 18 mos

AGB 72% @ 2yrs

40% remission @ 5yrs

32% improved @ 5 yrs.

Surgical Impact on Gut Hormones

Mechanism of Action RYGB SG

Ghrelin

Hunger & Appetite

Insulin Sensitivity

PYY Hunger

Satiety

Gastric emptying

HCl

insulin sensitivity

beta cell fxn

GLP1 Hunger

Satiety

Gastric emptying

insulin release

insulin sensitivity

beta cell fxn

Medical Therapy vs RYGB vs SG

Medical Therapy

N=41

RYGB

N=50

SG

N=49

% EBW loss 13% 88%* 81%*

HgA1c < 6.0% 12% 42%*

37%*

Pre-op >3 Rx

Postop >3 Rx

61%

72%

52%

0%*

47%

10%*

STAMPEDE trial 12 months

(Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently)

Average disease duration > 8 yrs and HgA1c 8.9-9.5% pre intervention

F/u with diabetes specialist q 3 months

Schaur, P. et al. Bariatric surgery vs. intensive medical therapy in obese patients with diabetes. N Engl J Med 2012. Doi 10.1056/NEJMoa12002255.

Long-term Diabetes Resolution Remission depends on

– Duration of the disease prior to surgery

The earlier on in the disease state the patient receives treatment, the greater chance for remission

– Beta Cell Function

– Sustenance of lifestyle change and diet

Long-term - remission is weight dependent

“Diabetes is resolved for, on average 10 years after bariatric surgery.” - J. Dixon

“There is emerging evidence that body weight is defended by powerful physiological mechanisms making long-term maintenance of weight loss difficult” - IDF statement, 2011

?

Where the Rubber Meets the Road

Surgery is not a miracle, it is a tool

20-30% of patients fail to reach the typical post operative

weight loss goal

The most successful patients after ANY procedure make the

lifestyle changes

Plateau or Weight Regain

“Stress with clients that they will rarely be able to attain

a weight lower than their minimum adult weight.”

Maintain 48-74% of initial loss 5 years s/p surgery

Maintain 50% initial weight loss at 15 years s/p surgery

- Nancy Bradley, FNCE October 2005

600 RYGB pt’s with a 96% f/u rate

– 14 years post op mean EBW lost exceeded 50%

– AORN Journal May 2004 vol. 79(5).

Rules of the Road

1. Eat slowly… but not too slow

- Use smaller plates, consume what a 2-5 yr. old would eat

- Practice mindful eating

2. Avoid eating and drinking at the same time

- most caloric beverages should be avoided

- No juices, even if they are 100%

- “coffee” is no longer coffee

3. Choose PROTEIN and PRODUCE

- Nutrient dense, low calorie foods

- Whole grains and other low glycemic load

carbohydrates should be chosen last

- Increase Fiber Intake

- Diet about 1200-1400 calories/day

4. Eat only when hungry: avoid snacks

- Snacking is typically associated with junk food

- Snacking can turn into snacking, grazing picking.

Rules of the Road

5. Choose nutrient dense foods

- Low in calories and contribute to calorie deficit

- Nutritional powerhouses

- “Undiet” the patient

- Ask yourself “What is in this food that is making me healthy?”

Rules of the Road

To Choose

Nutrient Dense Foods

To Avoid

Empty Calorie Foods

- Apples/Fruit

- Sugar Free Yogurt

- Low-fat Dairy

- Vegetables

- Protein Bar (no sugar)

- White meat poultry

- Broccoli

- Non-fried fish

- Lean ground beef

- Eggs

- Salad

- Pretzels

- Sugar free ice cream

- Sugar free cookies

- Chex Mix or trail mixes

- Bread

- 100 calorie pack

- Stuffing

- Mashed potatoes

- Chips

- Rice cakes

- Most “diet” foods

Rules of the Road

6. Increase physical activity

- Increases insulin sensitivity

- Increases PYY and GLP1

- Focus on increasing activities of

daily living

- Consistent “intentional” physical

activity

- Allow non-sugar starches only if the

patient is active enough to burn

them off.

RMR

(50-65%)

Thermogetic Effect of Food

Planned Activity

NEAT

(Non-exercise Activity

Thermogenesis)

15-50%

To

tal D

aily E

ne

rgy E

xp

en

dit

ure

Movement and Activity Pyramid

Incidental movement

Low impact – long

time walking

Aerobic

Elite

high impact

Many people over the age of

30 who exercise regularly at

the gym etc. use less energy

than their “unfit” colleagues

because they “compensate”

with a decrease in incidental

movement

Weight re-gain…where do I start?

Have patient keep a 3-5 day food log or 1 day recall

– Maladaptive Eating/Soft Calorie Syndrome?

– High fat?

– High calorie?

– High in simple carbohydrates?

– Choosing nutrient dense foods?

Review beverage intake

– Eating and drinking at the same time?

– High caloric beverages?

Review meal patterns

– Grazing, picking or snacking?

Assessment of physical activity

Consult with surgeon to ensure integrity of the surgery

Behavioral health consultation (CBT) or support group

Adult Obesity…Relapse Prevention

Obese and reduced obese must accept that obesity requires

life-long management

– Acknowledge dysfunctional fat cells and propensity to gain

weight

Weight regainers

– Burned 800 fewer calories per week

– Decrease in food restraint

Obesity…Intervention

Diet Physical Activity

Lifestyle Modification

Pharmacotherapy

Surgery

BMI

25

30

35

http://cme.medscape.com/viewarticle/712986?src=cmemp&uac=98478HV

Phentermine, Meridia,

Xenical (Byetta)

RYGB, AGB, Duodenal

Switch, Gastric Sleeve

Despite all we know about obesity

and what we still have to

uncover…there is no magic bullet.

Long-term weight loss will come

from burning more calories than is

consumed. What we CAN do is

help individuals find the tools to

make successful and enduring

change.

Thank You!

St. James Center for Bariatric Surgery

Program Coordinator

Tina.musselman@ssfhs.org

(708) 679-2717

Mind, Body & Wellness Institute, Inc.

mindbodywellness@yahoo.com

(708) 846-5816

Tina Musselman RD, CCN

Gastric Plication

Dr. Vafa Shayani ,FASBMS

Bariatric Institute of Greater Chicago

Medical Director St. James Center for Bariatric Surgery

Drshayani@chicagobanding.com

Chicagobanding.com

Greater Curvature Gastric Plication

Mobilization of the greater curvature of the stomach

May mimic SG restriction with fewer risks

Infolding/imbricating the stomach to achieve gastric restriction

Does NOT involve gastric resection, intestinal bypass, implantation of a foreign

device

Unlikely that ghrelin levels are altered

Greater Curvature Gastric Plication May lead to increased speed of gastric emptying - J. Dixon

Complications

– Mild to moderate nausea - short term

– Fold disruption

– Suture line leak

– Prepyloric perforation

– “kinking of the stomach”

– No late complications noted

Summary of % EBW loss

– 1 mo: 20 - 21.4%

– 1 yr: 61 - 69.6%

– 18 mo: 62%

– 2 yrs: 60%

– 3 yrs: 57%

Brethauer, S., et al. Laparoscopic gastric plication for treatment of severe obesity.

Surgery for Obesity and Related Diseases 2011; 7: 15-22.

4 studies available of < 300 patients

“this could potentially provide a lower risk alternative that will appeal to patients and referring physicians.”

Procedures should be considered investigational and should be performed under a study protocol and IRB or other third party oversight

Greater Curvature Gastric Plication

ASMBS Policy Statement

ASMBS Executive Council. ASMBS policy statement on gastric plication. Surg Obes Relat Dis 2011; 7:262.

LAGB + Plication: Preliminary Results

LAGBP = Laparoscopic Adjustable Gastric Banded

Plication

– Can be a primary or “salvage” procedure for failure

with AGB

n=26 (16 female, 10 male)

BMI of 39.4 + 4 kg/m2

Used the Swedish Adjustable

Gastric Band

Huang, C.-K. et al. Novel bariatric technology: Laparoscopic adjustable gastric banded plication:

technique and preliminary results. Surg Obes Relat Dis 2012; 8:41-47.

Band was adjusted only 1 time

Complications

– 1 pt c prolonged emesis

rehydrated in ER resolved 1 wk

post op

– 1 gastrogastric intussusception

– 1 subQ tube kinking

Benefits

– Quicker wt loss than AGB alone

– Reversible

– nutritional risk vs RYGB or SG

“findings similar to Sleeve

Gastrectomy”

LAGB + Plication: Preliminary Results

% EBW Loss s/p LAGBP

21.9

31.9

41.3

53.2

59.5

0

10

20

30

40

50

60

70

1 mo.

(n=26)

3 mo.

(n=24)

6 mo

(n=18)

9 mo

(n=10)

12 mo

(n=5)

Time

% E

BW

lo

ss

Huang, C.-K. et al. Novel bariatric technology: Laparoscopic adjustable gastric banded plication:

technique and preliminary results. Surg Obes Relat Dis 2012; 8:41-47.

Thank You!

Dr. V. Shayani Drshayani@chicagobanding.com