10/14/2014 PRIMARY CARE OF THE BARIATRIC SURGERY PATIENT GOALS OBESITY IS A CHRONIC DISEASE FULL DISCLOSURE

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1 PRIMARY CARE OF THE BARIATRIC SURGERY PATIENT MICHELLE GUY, MD ASSOCIATE PROFESSOR DIVISION OF GENERAL INTERNAL MEDICINE DEPARTMENT OF MEDICINE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO GOALS 1. Who is right for bariatric surgery? 2. Know the early post-op complications 3. Know the late post-op complications, including weight regain FULL DISCLOSURE OBESITY IS A CHRONIC DISEASE 33% of American adults are obese (BMI > 30) Approximately 150, 000 weight loss surgeries being performed in US /year Bariatric surgery can provide: Sustained weight loss Resolution of Type 2 Diabetes Reduced cardiovascular morbidity Reduce all cause mortality 1

2 OBESITY COMORBIDITIES THAT CAN IMPROVE OR RESOLVE WITH BARIATRIC SURGERY Pre-op Migraines Pseudotumor Cerebri Depression Obstructive Sleep Apnea Asthma Hypertension Cardiovascular Disease Dyslipidemia GERD Fatty Liver Metabolic Syndrome Diabetes Urinary Stress Incontinence Venous Stasis Cellulitis DVT/PE Hernias PCOS Infertility DJD/ Chronic pain/ Arthritis Cancer (colon, prostate, uterine, breast) Quality of Life Diminished Early post-op Late post-op WHO IS ELIGIBLE FOR SURGERY? CONTRAINDICATIONS TO SURGERY BMI (kg/m2) RISK UNDERWEIGHT < 18.5 INCREASED NORMAL NORMAL OVERWEIGHT INCREASED OBESITY CLASS I HIGH OBESITY CLASS II VERY HIGH (MODERATE OBESITY) OBESITY CLASS III EXTREMELY HIGH (SEVERE OR EXTREME OBESITY) OBESITY CLASS IV (SUPEROBESITY) > 50.0 MAY BE TOO HIGH The NIH Consensus Panel recommends that: Patients have a Body Mass Index > 40 kg/m lbs. or more overweight Patients have a Body Mass Index between 35 and 40 kg/m 2 with significant comorbidities Patient have failed other medically managed weight-loss programs 6% of the U.S. adult population (over 12 million people) meet these criteria Untreated major depression or psychosis Binge-eating disorders Current drug or alcohol abuse Severe cardiac disease with high risk for anesthesia Severe coagulopathy Inability to comply with post op diet and supplementations 2

3 PRE-OP EVALUATION PRE-OPERATIVE LABS Pre-op tests Weight loss Cardio/pulmonary evaluation Nutrition Evaluation and Counseling Psychologist clearance CO MORBID DISEASE CBC Electrolytes Liver panel Calcium BUN and creatinine Glucose and hemoglobin A1C Lipid panel NUTRITIONAL DEFICIENCIES Magnesium Phosphate Iron, ferritin, and TIBC B-12 Vitamin D Folate CAUSATIVE OR COMPLICATION Parathyroid Hormone (PTH) Prolactin Cortisol TSH LDH and CPK Prothrombin time H. pylori SURGICAL CONSIDERATIONS Laparoscopic Weight Loss Surgery Restrictive vs Malabsorptive Open vs Closed Surgeon s Experience 3

4 Lap Band Sleeve Gastrectomy Gastric Bypass Laparoscopic Adjustable Gastric Banding (LAGB) An adjustable band around the top of the stomach like a belt, creating a 1-2 oz pouch. A port implanted under the skin near the belly button is used to inflate a ballon inside the band with saline, narrowing the entry to the stomach and limiting the amount of food consumed. Restrictive Only Ideal Candidate BMI kg/m2 Wants to lose pounds Is not comfortable with stapling Can maintain a post-op diet of < 1300 cal/day Benefits Safest and least invasive procedure; fewer early risks than other procedures One hour procedure Fully Reversible/Removable Lowest risk of vitamin deficiencies Considerations/Risks Average excess weight loss (EWL) is 50% 10-year removal or reoperation rate is 25% Slower weight loss (1-2lbs/week) compared to other surgeries Appetite suppression and a comfortable feeling of fullness may be difficult to achieve Least effective for resolving diabetes Sleeve Gastrectomy (Sleeve or Vertical Gastrectomy) A large volume of stomach is removed creating a 1-2 oz sleeve. The removed portion of the stomach is the more pliable portion and contains the Ghrelin cells; thereby reducing appetite. The stomach that remains has intact stretch and pressure receptors. Restriction and Resection Ideal Candidate BMI kg/m2 Wants to lose lbs Can maintain a post-op diet of < 1300 cal /day Benefits Average EWL 70-90% 1-2 hour procedure Recovery ranges from days to weeks Patients report early and lasting fullness Intestines stay intact No malabsorption May cure diabetes Considerations/ Risks Removal of a portion of the stomach is permanent The remaining pouch may expand over time Roux en Y Gastric Bypass (RNY or Bypass) A small 1 oz pouch about the size of an egg is created. The rest of the stomach is stapled off, preventing food from entering it but allowing digestive juices to empty into the small intestine. The small stomach pouch is then connected to a limb of the intestine (the Roux limb) Both Restrictive and Malabsorptive Most common procedure performed Ideal Candidate BMI kg/m2 Wants to lose lbs May have severe or prolonged medical conditions Weight maintenance diet < 1300 cal/day Benefits EWL 70-90% 2 hour procedure Recovery of days to weeks Very effective for curing diabetes Approximately calories per day lost through malabsorption Procedure is reversible Considerations/Risks Greater risk for vitamin deficiencies Dumping syndrome Smoking, EtOH, NSAIDS use may lead to ulcers 4

5 DUODENAL SWITCH A sleeve gastrectomy with a 2-4 oz pouch + a malabsorption component. The pouch is connected to the enteric limb, diverting food and preventing it from mixing with digestive juices. Food bypasses 40-60% of the intestine. Restriction, Resection and Malabsortion Ideal Candidate BMI > 60 kg/m2 Poorly controlled diabetic Weight maintenance diet < cal/day Benefits Has the highest cure rate for diabetes EWL 80-90%. Most effective weight loss surgery 3-4 hour procedure with 1-2 night stay Recovery days to weeks Patients report lasting fullness calories may be lost through malabsorption Considerations/Risks Not offered by most surgeons (including UCSF) Preoperative weight loss is usually required Stomach removal is permanent. Bypass may be reversed Highest risk for vitamin and protein deficiencies, diarrhea and intestinal blockages Pre-op Early post-op Late post-op What happens in the hospital? remove bladder catheter remove abdominal drain start clear liquids BYPASS or SLEEVE OPERATION transition to oral pain meds meet nutritionist meet pharmacist home 7am noon 7pm 7am noon 7pm 7am noon Day 0 Day 1 Day 2 remove bladder catheter start clear liquids transition to oral pain meds BAND OPERATION meet nutritionist meet pharmacist home 7am noon 7pm 7am noon 7pm 7am noon Day 0 Day 1 Day 2 PHYSIOLOGIC CHANGES AFTER SURGERY Avoid delayed, enteric-coated and extendedrelease preparations after malabsorption procedures Attempt to use immediate-release, crushed, liquid or chewable preparations Some meds require gastric acidity for dissolution Patient are often discharged from the hospital off HTN and DM meds If meds are needed in diabetics use immediate release Metformin and/or sliding scale insulin Diuretics are discontinued in the hospital LAGB slower resolution of diabetes Attempt to avoid NSAIDS 5

6 POST-OPERATIVE COMPLICATIONS MORE POST-OP COMPLICATIONS GASTRIC BANDING Slippage of the band Band erosion Port infection Injury to adjacent organs Death within 30 days (<0.5% of patients) SLEEVE GASTRECTOMY Leaks along staple line Nausea and vomiting leading to dehydration Abdominal pain Wound problems Bleeding Narrowing or Stenosis Reflux Death within 30 days (<1% of patients) BYPASS SURGERY Stomal obstruction Postoperative bleeding Small bowel obstruction Gastrointestinal leak Deep vein thrombosis Splenectomy Pulmonary embolus Protein-calorie malnutrition Dumping Syndrome Death within 30 days (<1% of patients) Mood Changes Excessive Vomiting Gas Dumping Syndrome Hair loss Patulous Eustachian Tube Dysfunction Phase WEEKS Phase 1 Weeks 1 to 6 Phase 2 Weeks 7 to 12 Phase 3 Weeks 13 to 12 Months DIET AND EXERCISE PROGRESSION KEY POINTS DAYS 1-14 DAYS DAY 31 AND BEYOND Thin fluids only Start thick liquids and soft foods Regular foods as tolerated No solid food oz fluids Meats and other foods should be tender, oz fluids per day cut and chewed well and eaten slowly 600 calories per day calories per day 60+ oz fluids grams of protein grams of protein 600 calories per day Minimal carbs and fats Walk 5-10 minutes every hour grams of protein Start cardio exercises and light weight Wake and walk after 8 hours lifting Increase physical activity POST-OPERATIVE DIET Liquid amnesia Maladaptive Eating How much can you eat? 6

7 KEYS TO SUCCESS WHAT TYPE OF RESULTS TO EXPECT? DO THIS Start each meal with protein, Goal 60+ g/day Eat 3 meals per day, Goal 600 cal/day Chew Chew Chew Drink water between meals Drink 64 oz fluids per day Measure and Track all intake Weigh weekly Take your vitamins DON T DO THAT Eat sweets or excessive carbohydrates Overeat or Graze Drink through a straw Drink within 30 minutes of eating Drink Carbonated Beverages Drink Caffeine and Alcohol Eat soft or high calorie foods Exceed 1000 calories per day Months Post-op Pounds Lost 6 months months months > 12 months > 150 POST-OPERATIVE FOLLOW-UP RECOMMENDED FOLLOW-UP LABS TIME FOLLOW-UP PLAN 1-3 WEEKS Review speed of weight loss, wound check, Dietician follow-up to help advance diet 3 MONTHS Verify weight loss is on track, Review diet and exercise, labs 6 MONTHS Review weight and make specific plans to achieve goal weight, labs 9 MONTHS Verify weight loss is on track, Review diet and exercise, labs 1 YEAR Review outcome, check labs, consider GI Xrays YEARLY Discuss maintenance, Check labs, Reinforce support BASIC LABS CBC Electrolytes BUN and creatinine Liver panel Lipid panel Glucose and A1C DEFICIENCIES Folate Iron, ferritin, and TIBC B-12 Calcium Vitamin D ALSO CONSIDER Magnesium Phosphorus B6 Thiamine (B1) Zinc Copper Vitamin A 28 7

8 POST-SURGICAL VITAMIN SUPPLEMENTATION PREGNANCY AND WEIGHT-LOSS SURGERY LAP BAND SLEEVE OR BYPASS DUODENAL SWITCH Multivitamin Multivitamin Multivitamin Calcium (Citrate) +Mg Calcium (Citrate) +Mg Calcium (Citrate) +Mg Vitamin D IU Vitamin D IU Vitamin D IU B-Complex B-Complex B-Complex PPI PPI PPI B-12, 500 mcg B-12, 500 mcg Iron 325mg + Vitamin C Iron 325 mg + Vitamin C Vitamin A 25, 000 IU Fertility is enhanced after surgery Use non oral forms of birth control Delay pregnancy for 12 to 18 months after surgery Avoid oral glucose challenge after gastric bypass Pre-op WEIGHT RE-GAIN Early post-op Late post-op Swedish Obesity Study 2000 surgical vs non surgical obese patients Greater initial weight loss Improved outcomes at two, six and ten years N Engl J Med 2007; 357: August 23,

9 HONEYMOON PERIOD it s a new starting point to resume the battle It s a tool Don t fall asleep at the wheel KEYS TO SUCCESS IT S A TOOL NEW ADDICTIONS MAY DEVELOP Cigarettes Drugs Addiction Shopping Alcohol 9

10 MANAGING EXCESS SKIN TAKE HOME POINTS Screen all your patients for overweight and obesity Most obesity related comorbidities can resolve or improve with successful weight loss surgery Consider gastric bypass surgery for patients with more than 100 lbs to lose and/or diabetes. Consider sleeve gastrectomy for others Potential complications are many but overall surgical mortality is low Surgery is only a tool. Patients will need long term follow, support and tracking Special thanks to Gregg Jossart, MD and Stanley Rogers, MD Sleeve Gastrectomy: Lost 93 lbs in 7 months 10

11 THE OBESITY EPIDEMIC Percent of Obese (BMI >30) in U.S. Adults WHO IS ELIGIBLE FOR SURGERY? The NIH Consensus Panel recommends that: Patients have a Body Mass Index > 40 kg/m lbs. or more overweight Patients have a Body Mass Index between 35 and 40 kg/m 2 with significant comorbidities Patient have failed other medically managed weight-loss programs Bariatric surgery and comorbidity resolution 6% of the U.S. adult population (over 12 million people) meet these criteria courtesy of ASMBS 11

12 EFFECTS OF BARIATRIC SURGERY ON MORTALITY IN SWEDISH OBESE SUBJECTS Prospective, controlled trial 2010 patients underwent surgery 2037 matched patients underwent conventional Rx Mean 11 years of follow-up 99% of patients were followed 129 deaths in control group 101 deaths in surgery group All-cause mortality was reduced by 40% 7 years after RYGB INSURANCE COVERAGE Decreased mortality was from decreased myocardial infarction and cancer CALCULATING PERCENT EXCESS WEIGHT LOSS OTHER PROCEDURES Percent of Excess Weight Loss (EWL) is used as an outcome measure for bariatric surgery. A percentage is used rather than the absolute number of pounds lost to allow comparison of weight loss between persons or between types of bariatric procedures. A person's Ideal Body Weight (IBW) is based on the Metropolitan Life Insurance Company standard height and weight tables for men and women. A sustained EWL of 50% is considered successful by insurance providers and accrediting organizations. Ideal Body Weight is a calculation based on height and gender Estimate Ideal body weight(ibw) in (kg): Males: IBW = 50 kg kg for each inch over 5 feet. Females: IBW = 45.5 kg kg for each inch over 5 feet. Starting Weight Ideal Body Weight = EWL Weight loss / EWL x 100 = % EWL Example: If IBW = 130lbs and starting weight = 245lbs then EWL = 115lbs If person loses 90 lbs then EWL % is 90/ 115 x 100 = 78 % Cholecystectomy Hiatal hernia repair Liver biopsy 12

13 REVISION SURGERIES MG1 yp stricture of gastrojejunostomy (2-3%) treatment: dilation during endoscopy marginal ulceration (3-5%) treatment: antacids staple line leak (1-4%) treatment: reoperation, stent placement, feeding tube placement, drain placement, or some combination thereof sleeve stricture (1-4%) treatment: reoperation, conversion to gastric bypass acute pouch obstruction (0-10%) treatment: nasogastric tube band erosion (0-7%) treatment: surgery to remove band gallstone disease (2% with prevention) gallstone disease (2% with prevention) gallstone disease (2% with prevention) prevention: ursodiol for 6 months prevention: ursodiol for 6 months prevention: ursodiol for 6 months treatment: remove gallbladder treatment: remove gallbladder treatment: remove gallbladder internal hernias / obstruction (0-5%) treatment: surgery gastroesophageal reflux (10-40%) treatment: acid blocking medications, conversion to gastric bypass in extreme cases port infection (0.3-9%) treatment: surgery to remove port dumping syndrome (0-10%) dumping syndrome (0-10%) band slippage (2-30%) treatment: limit simple sugars, high protein diet, complex carbs, high fiber, smaller more frequent meals treatment: limit simple sugars, high protein diet, complex carbs, high fiber, smaller more frequent meals treatment: surgery to remove/reposition band port or tubing malfunction (0.4-7%) treatment: surgery to fix malfunction psychological intolerance (0-5%) treatment: removal of band LATE LATE LATE Post Surgical Vitamin Supplementation Bypass or Sleeve multivitamin daily omeprazole 20mg daily calcium + D 500mg 3x daily Band multivitamin daily omeprazole 20mg daily calcium + D 500mg 3x daily Iron sulfate 325mg daily + Vitamin C 500mg daily (menstruating women only) vitamin B12 500mcg daily 13

14 Slide 50 MG1 Michelle Guy, 8/3/2013