PREOPERATIVE MANAGEMENT FOR BARIATRIC PATIENTS. Adrienne R. Gomez, MD Bariatric Physician St. Vincent Bariatric Center of Excellence

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1 PREOPERATIVE MANAGEMENT FOR BARIATRIC PATIENTS Adrienne R. Gomez, MD Bariatric Physician St. Vincent Bariatric Center of Excellence

2 BARIATRIC SURGERY Over 200,000 bariatric surgical procedures are performed in the US per year (2009) Laparoscopic roux en Y gastric bypass (RYGB), adjustable gastric band & sleeve gastrectomy are the most common Surgery is currently the only obesity treatment method proven to achieve long-term weight reduction It is estimated that 80% of diabetics will show major improvement of Type 2 diabetes control after bariatric surgery (varies by procedure) Many of the recommendations made for management before and after bariatric surgery are based on expert opinion; further studies are needed to develop more evidence-based guidelines

3 Guide for Selecting Obesity Treatment BMI Category (kg/m 2 ) Treatment >40 Diet, Exercise, Behavior Tx Pharmacotherapy Surgery With comorbidities With comorbidities + The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub. No

4 Medical Considerations Co-morbid conditions are present in the majority of bariatric surgery candidates Those which may have the biggest impact on surgery include Type 2 DM, HTN, OSA, GERD, CAD, psychological disorders, non-alcoholic liver disease, and cholelithiasis Patients with unstable coronary artery disease, portal hypertension with varices, active substance abuse, or untreated psychiatric disorder should not be considered for surgery

5 Preoperative Medical Management Most surgeons recommend a HgbA1c <8% prior to bariatric surgery Blood pressure should be optimally treated Rule out secondary causes of obesity Perform a sleep study if OSA symptoms are present, and begin treatment as early as possible if OSA is diagnosed Evaluate for possible liver dysfunction; perform liver ultrasound if indicated

6 Preoperative Medical Management (cont d) Smoking cessation should be initiated ASAP Evaluate for possible chemical or alcohol dependency, and refer for treatment Perform routine preventive care, if not upto-date (colonoscopy, Pap smear, mammogram) Patients who are diagnosed with co-morbid conditions during the preoperative period should initiate treatment immediately

7 Nutritional Considerations Deficiencies common before and after bariatric surgery include iron, vitamin D, B12, folate, and thiamine Protein intake may not be adequate Consider the following labs: CBC, CMP, TSH, lipids, pre-albumin, vitamin D, B-12, and folate Bone density and calcium intake should be evaluated prior to bariatric surgery, especially in women

8 Preoperative Treatment: Goals Reduction in liver size Improved control of co-morbid conditions Smoking cessation Psychological and dietary evaluations Reduce risk for perioperative complications Maximize patient s nutritional status Patient education

9 Surgical Complication Risk Mortality risk may be increased with BMI>50, male gender, open procedure, Type 2 DM, age >60 (discharge summary analysis of 105,387 patients in academic centers from ) A significant number of conversions from laparoscopic to open procedures are related to hepatomegaly Several retrospective (Class III) studies have indicated that acute weight loss (5-10%) prior to surgery resulted in fewer complications

10 Preoperative Management: Primary Care Perspective Identify those patients who may benefit from bariatric surgery Aggressively manage co-morbid conditions and assess nutritional status prior to surgery Recognize potential need for more intensive behavioral intervention Educate the patient regarding the procedure and long-term health considerations Provide documentation of weight history along with a letter of medical necessity

11 Team Approach Patients are often very engaged, excited, curious, and eager for bariatric surgery Many questions arise during the months before surgery Support, encouragement, and guidance provided during this period can have an impact on short and long-term outcomes The bariatric surgery center team strongly emphasizes the importance of close followup with a primary care physician

12 Preoperative Medically Supervised Weight Loss Program Required by most 3 rd party payers prior to approval for bariatric surgery coverage Generally 6 months duration, although can be 3-18 months Can be provided by primary care physician Must include the components of diet, exercise, and behavior modification Must be 6 consecutive months

13 Initial Assessment of the Pre-Surgical Patient Complete history and physical Laboratory studies (CBC, CMP, iron, ferritin, 25-OH vitamin D, B-12, TSH, HgbA1c) Medication and supplement review Assessment of family and social support Address patient questions, concerns

14 Dietary Prescription Recommendations regarding calorie intake, portions, food choices (there is no standardized regimen that is currently recommended) Introduce Foods to Avoid list RD visit(s) Begin nutritional supplements (MVI, Vitamins D3 and B-Complex, calcium citrate) Patients should keep a daily food and activity journal

15 Very Low Calorie Diets (VLCDs) Prior to Bariatric Surgery Many surgeons recommend patients to use a short-term VLCD (<800 kcal/day) in the 2-4 weeks immediately preceding surgery There are currently no standardized recommendations regarding this treatment Benefits may include reduction of liver size, lower BMI, improved blood sugars Liquid protein supplements are used to help prevent extreme catabolism (usually 3-5 protein shakes/day)

16 Liver Reduction Diet Similar to VLCDs, but in some cases used for longer periods of time prior to surgery, particularly in patients with a BMI >50 Typically limits carbohydrates to <100g/day Eliminates refined carbohydrates May reduce glycogen, water, and fatty stores in the liver, reducing its overall size (same effect as VLCDs) May also help with other co-morbid conditions, including Type 2 DM, and HTN

17 Registered Dietician Visit At least one visit is required for assessment (more may be beneficial) Patients should bring a completed food journal Ideally the visit(s) should be with an RD that has experience with bariatric surgery All visits should be carefully documented

18 Physical Activity Recommendations highly variable based on individual ability, preference, and access Start slow and advance as tolerated Emphasize the potential benefit of improved cardiovascular health and endurance as surgery approaches Encourage pedometer use

19 Behavior Modification Self-monitoring (food and activity journal, self-weighing, hunger rating scale, etc.) Monthly bariatric support group attendance Discussions regarding post-surgery lifestyle changes, guidelines, and follow-up Patients who self-monitor, attend bariatric support groups, and follow up with the bariatric surgery team may achieve greater long-term weight loss results

20 Patient FAQs What is my insurance company looking for? What if I lose too much weight? Do you think surgery is a good idea for me? Is it possible to gain weight after bariatric surgery? Will I ever eat normal food again?

21 Preoperative Patient Education Patients can develop a better understanding of the procedure itself, the post-operative course, and expected long-term outcomes It is important for patients to understand that bariatric surgery is a tool that requires effort and diligence to be successful Strong emphasis should be placed on adherence to post-op guidelines, including long-term follow-up

22 Insurance Approval Documentation, documentation, documentation! Components of each monthly visit note should include: diet and exercise recommendations, and discussion of behavior modification Psychological evaluation (performed by a psychologist) Bariatric surgery support group attendance required

23 Why Do Insurance Companies Require Preoperative Weight Loss Programs? Confirms the patient s inability to lose weight through diet and exercise Potentially lowers morbidity and mortality Improves long-term surgical outcomes Reduces potential for complications Also increases wait time and patient attrition

24 Preoperative Weight Loss Programs: ASMBS Perspective the requirement for documentation of prolonged preoperative diet efforts before health insurance carrier approval of bariatric surgery services is inappropriate, capricious, and counter-productive given the complete absence of reasonable level of medical evidence to support this practice. (ASMBS Position Statement on Preoperative Supervised Weight Loss Requirements, 2011)

25 Measurable Impact of Pre-Surgical Weight Loss Programs Several studies (mostly Class III) have been conducted regarding preoperative weight loss programs and the effect on complication rates, operating time, overall weight loss, and hospital stay Results have been inconclusive, with many examples of contradictory outcomes Most bariatric specialists still recommend weight loss prior to bariatric surgery due to the potential improvements in co-morbid conditions and perioperative risks

26 Multidisciplinary Management of the Preoperative Patient Primary care physicians play a crucial role in helping patients navigate the bariatric surgery process There is the potential to lower perioperative risk by aggressively managing co-morbid conditions prior to surgery Preoperative weight loss programs are often required prior to insurance approval for surgery, and can be done in the primary care office with the help of an experienced dietician

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