How To Care For An Obese Patient In Surgery

Transcription

1 TITLE The Bariatric Patient in Surgery An Online Continuing Education Activity A Continuing Nursing Education Activity Sponsored by Funding provided by COVIDIEN 1

2 Welcome to The Bariatric Patient in Surgery (An Online Continuing Education Activity) CONTINUING EDUCATION INSTRUCTIONS This educational activity is being offered online and may be completed at any time. STEPS FOR SUCCESSFUL COURSE COMPLETION To earn continuing education credit, the participant must complete the following steps: 1. Read the overview and objectives to ensure consistency with your own learning needs and objectives. At the end of the activity, you will be assessed on the attainment of each objective. 2. Review the content of the activity, paying particular attention to those areas that reflect the objectives. 3. Complete the test questions. Missed questions will offer the opportunity to re-read the question and answer choices. You may also revisit relevant content. 4. For additional information on an issue or topic, consult the references. 5. To receive credit for this activity complete the evaluation and registration form. 6. A certificate of completion will be available for you to print at the conclusion. Pfiedler Enterprises will maintain a record of your continuing education credits and provide verification, if necessary, for 7 years. Requests for certificates must be submitted in writing by the learner. If you have any questions, please call: CONTACT INFORMATION 2014 All rights reserved Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado Phone: Fax: Covidien All rights reserved. Contents of materials presented or distributed by Covidien may not be reproduced in any form without the written permission of Covidien. 2

3 OVERVIEW The Bariatric Patient in Surgery Obesity is a multi-factorial disease which results in a body mass index that greatly exceeds established physical standards and is associated with numerous comorbidities. It is considered to be both an epidemic and a public health concern in the United States and around the world. The clinical evidence has clearly demonstrated that patients classified as obese have the best long-term success with and can be safely treated through individualized surgical interventions as compared to other non-surgical weight loss programs (dieting). In order to safely care for the bariatric patient throughout the surgical weight loss journey, perioperative personnel should understand the unique challenges presented by the obese patient. This continuing education activity will provide an overview of key perioperative considerations in the care of the patient undergoing bariatric surgery. OBJECTIVES Upon completion of this continuing education activity, the participant should be able to: 1. Define the terminology describing body size. 2. Describe the world-wide trends in obesity. 3. Differentiate the various bariatric surgical procedures. 4. Review electrosurgical safety considerations for bariatric patients. 5. Discuss perioperative considerations during the care of the bariatric patient. INTENDED AUDIENCE This continuing education activity is intended for surgeons, perioperative nurses, and other healthcare team members who provide patient care during surgery or other invasive procedures. CREDIT/CREDIT INFORMATION State Board Approval for Nurses Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for 2.0 contact hour(s). Obtaining full credit for this offering depends upon completion, regardless of circumstances, from beginning to end. Licensees must provide their license numbers for record keeping purposes. 3

4 The certificate of course completion issued at the conclusion of this course must be retained in the participant s records for at least four (4) years as proof of attendance. IACET Pfiedler Enterprises has been accredited as an Authorized Provider by the International Association for Continuing Education and Training (IACET). CEU Statements As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs that qualify under the ANSI/IACET Standard. Pfiedler Enterprises is authorized by IACET to offer 0.2 CEUs for this program. RELEASE AND EXPIRATION DATE This continuing education activity was planned and provided in accordance with accreditation criteria. This material was originally produced in August, 2014 and can no longer be used after August, 2016 without being updated; therefore, this continuing education activity expires in August, DISCLAIMER Accredited status as a provider refers only to continuing nursing education activities and does not imply endorsement of any products. SUPPORT Funds for the development of this activity were provided by Covidien. AUTHORS/PLANNING COMMITTEE/REVIEWER Chad Edmonson, CST Certified Surgical Technologist/Reviewer Sky Ridge Medical Center Lone Tree, Colorado Peter B. Graves, BSN, RN, CNOR Manager, Professional Nursing Education Covidien Surgical Solutions. Kari King, BS, RN, CNOR Manager, Professional Nursing Education Covidien Surgical Solutions Julia A. Kneedler, RN, MS, EdD Chief Executive Officer/Reviewer Pfiedler Enterprises Dallas, Texas Boulder, Colorado Aurora, Colorado 4

5 Judith I. Pfister, RN, BSN, MBA President/Planner Pfiedler Enterprises Carol J. Wilcox, MT (ASCP), MA, BS Consultant/Reviewer Pfiedler Enterprises Aurora, Colorado Aurora, Colorado DISCLOSURE OF RELATIONSHIPS WITH COMMERCIAL ENTITIES FOR THOSE IN A POSITION TO CONTROL CONTENT FOR THIS ACTIVITY Pfiedler Enterprises has a policy in place for identifying and resolving conflicts of interest for individuals who control content for an educational activity. Information listed below is provided to the learner, so that a determination can be made if identified external interests or influences pose a potential bias of content, recommendations or conclusions. The intent is full disclosure of those in a position to control content, with a goal of objectivity, balance and scientific rigor in the activity. Disclosure includes relevant financial relationships with commercial interests related to the subject matter that may be presented in this educational activity. Relevant financial relationships are those in any amount, occurring within the past 12 months that create a conflict of interest. A commercial interest is any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Activity Planning Committee/Authors/Reviewers: Chad Edmonson, CST No conflict of interest Peter B. Graves, BSN, RN, CNOR Employee of grant provider Kari King, BS, RN, CNOR Employee of grant provider Julia A. Kneedler, RN, MS, EdD Co-owner of company that receives grant funds from commercial entities Judith I. Pfister, RN, BSN, MBA Co-owner of company that receives grant funds from commercial entities Carol J. Wilcox, MT (ASCP), MA, BS No conflicts of interest 5

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7 INTRODUCTION Obesity and being overweight are defined as an abnormal or excessive fat accumulation and storage that may impair an individual s health and quality of life. Further, obesity is now considered to be an epidemic by numerous governmental and recommending bodies worldwide. These conditions are placing enormous cost burdens upon payers and society in general. 2, 3 The currently accepted clinical assessment tool used to define obesity is a person s Body Mass Index (BMI). 4 While some may argue that the BMI is not the ideal criteria to classify an individual s weight and obesity status, it is nonetheless the measurement modality being universally accepted. 5 The BMI is a proportional measure of an adult s weight in relation to his or her height. To determine an individual s BMI, the patient s weight in kilograms is divided by his or her height in meters squared. 4, 6 Overweight is defined as a BMI equal to or greater than 25 and obesity is defined as a BMI equal to or greater than 30. While these cut-off points provide a benchmark for individual assessment, there is evidence that risk of chronic disease in the population increases progressively from a BMI of Table 1 outlines the World Health Organization s (WHO) standard classification of obesity. 7

8 WHO Standard Classification BMI The current surgical literature uses additional classification terms to distinguish and describe severe obesity. 5 In this continuing education activity, a BMI of greater than 40 is defined as severe obesity; 1 a BMI of is termed morbid obesity; 3, 4, 7 and a BMI of greater than 50 is described as super obese. 8, 9 Clinicians should remember that although BMI correlates with the amount of body fat, BMI does not directly measure body fat. 7 For example, some people, such as athletes and those of certain descents, may have a BMI that defines them as overweight, even though they do not have excess body fat. There are additional methods available to the clinician who may use these assessment tools to estimate body fat and body fat distribution. These include, but are not limited to, measurements of skin fold thickness and waist circumference, 5 calculation of waist-to-hip circumference ratios, and techniques such as ultrasound, computed tomography, and magnetic resonance imaging (MRI). 7 PREVALENCE OF OBESITY In the United States, there is growing concern with the rapidly increasing number of overweight and obese individuals. Prevalence rates for Americans considered to be overweight or obese are currently being measured in the millions: OVERWEIGHT (BMI 25) Over two-thirds of adults (> 20 years old) are considered overweight or obese: 2, 4, 10, 11 All adults: 68% o Women: 64.1% o Men: 72.3% OBESE (BMI 30) Over one-third of adults are obese: 2, 4, 10, 11 All adults: 33.8% 8

9 o Women: 35.5% o Men: 32.2% MORBID OBESITY (BMI 40) A smaller percentage of U.S. adults (5.7%) are severely obese. 10 Obesity is also a growing concern for children of all ages. The National Health and Nutrition Examination Survey (NHANES) data from and , respectfully, demonstrate that the prevalence of childhood obesity is rapidly increasing in every age group. Below is the prevalence trend by age group: 4, 10 In children aged 2 5 years, the prevalence rate increased from 5.0% to 12.4% In children aged 6 11 years, the prevalence rate increased from 6.5% to 17.0% In adolescents aged years, the prevalence rate increased from 5.0% to 17.6% In addition to decreasing the individual s quality of life, obesity also significantly increases a person s risk for many serious chronic diseases and premature death. When comparing health data, obese individuals have a 10% to 50% greater risk of death from all causes, compared with healthy-weight individuals. It has been suggested that obesity may be the leading cause for a reduction in the average life span of Americans. 12 PREVALENCE IN THE UNITED STATES The United States obesity trends are a serious cause for concern as there has been an extraordinary increase in obesity over the past 20 years. 11 The Centers for Disease Control and Prevention (CDC) reported that in 1990, 10 states had a prevalence of obesity less than 10% and no states had prevalence equal to or greater than 15%. By 1999, no state had prevalence less than 10%; 18 states had a prevalence of obesity between 20% 24%; and no state had prevalence equal to or greater than 25%. In 2010, as shown in figure 1, no state had a prevalence of obesity less than 20%. Thirty-three states had a prevalence equal to or greater than 25%; nine states had a prevalence of obesity equal to or greater than 30%. 11 Figure 1 State by State obesity rates CDC. U.S. Obesity Trends. Trends by State

10 PREVALENCE WORLDWIDE Obesity is also quickly increasing throughout the rest of the world. The most recent estimates by the World Health Organization (WHO) indicate that globally, in 2005, approximately 1.6 billion adults (age 15+) were overweight, and at least 400 million adults were obese. 3 WHO further projects that by 2015, an estimated 2.3 billion adults will be overweight, and more than 700 million will be obese. 3 Moreover, being overweight or obese, which was once considered a problem only in high-income countries, is now significantly on the rise in low- and middle-income countries, especially in urban settings. The global increases seen in overweight and obesity are attributable to a number of factors, such as: A global shift in diet towards a higher intake of energy- dense foods that are high in fat and sugars, but low in vitamins, minerals, and other micronutrients; 3 A trend towards decreased physical activity due to environmental and behavioral changes brought about by economic development, modernization, and urbanization. Factors include the following: o the increasingly sedentary nature of many types of work (e.g., use of technology due to computerization); o an increase in the use of elevators, escalators, and automatic doors; o an increase in computer and video game use and in watching television; o changing transportation modes (e.g., the rise in car ownership, which decreases walking or cycling as a method of transportation). 3 WEIGHT REDUCTION STRATEGIES In order to lose weight, an individual must have a sustained negative energy balance (i.e., energy output must exceed energy input.) 3, 5, 10, 13 There are numerous strategies for weight loss, including but not limited to: Behavior modification (e.g., self-monitoring of eating habits, stress management, stimulus control); Fitness and exercise programs; Appropriate pharmacotherapy; Specialized low-calorie and lower-fat diets. Unfortunately, many of these medical and behavioral management weight loss programs have not demonstrated long-term effectiveness in reducing weight in severely obese patients Those individuals treated in behavioral weight-loss programs generally lose only about 10% of their body weight. In contrast, bariatric surgical patients typically lose about 25% of their initial body weight within the first 12 months postoperatively. As a result of the demonstrated differences in weight loss, bariatric surgery is considered the most effective method for achieving long-term weight loss

11 HISTORICAL DEVELOPMENT OF BARIATRIC SURGERY Bariatric surgery, also called weight reduction or weight loss surgery, is the surgical treatment of obesity. 18 The historical development of bariatric surgery is summarized in Table Obesity surgery began in 1954 at the University of Minnesota where Dr. A. J. Kremen and colleagues performed and published reports of a jejunoileal bypass procedure in which the upper small intestine was anastomosed to the lower small intestine in an attempt to bypass much of the small intestine and decrease absorption. 20 Table 2 Historical Development of Bariatric Surgery During the 1960s, investigators published reports of 10 jejunalocolic shunt procedures in which the upper small intestine was anastomosed to the colon. This was done in order to bypass more of the gastrointestinal tract, thus decreasing nutrient absorption. Unfortunately, patients developed complications (e.g. severe diarrhea, dehydration, electrolyte imbalance) and the shunts were converted to jejunoileostomies in which the upper portion of the jejunum was anastomosed to the lower portion of the ileum. 21 In 1966, gastric bypass was developed and introduced at the University of Iowa by Dr. Edward E. Mason. Dr. Mason applied the principles of partial gastrectomy to women who were obese and found that they lost weight. He created a partition across the upper portion of the stomach using surgical staples and then anastomosed this pouch to the small intestine. Complications of this early procedure lead to further development and refinement of gastroplasty in the late 1960s and early 1970s. 14 In the mid-1970s, horizontal gastroplasties were introduced in an attempt to simplify gastric restriction. With this procedure, the stomach was vertically partitioned (i.e., vertical gastroplasty) creating a gastric pouch. By the late 1970s, biliopancreatic diversion was developed in Italy. This procedure produced significant weight loss by restricting food intake by means of a partial gastrectomy and bypassing a portion of the small intestine which 11

12 resulted in malabsorption. Weight loss is maintained by a tolerable degree of malabsorption of starches and fats in the common limb. The biliopancreatic diversion creates the greatest amount of weight loss of any of the bariatric procedures, but requires surgical expertise and rigorous long-term follow-up care. 14 In the 1970s and 1980s, gastric banding was advanced as another method of restricting food intake. The restricting band is placed near the upper end of the stomach, just below the gastro-esophageal junction. Early attempts were largely unsuccessful because arterial grafting materials were used for banding; later bands specifically for this procedure as well as techniques to measure and gauge stoma size were developed. In the late 1980s, the adjustable gastric band, made of a hollow band with an inflatable balloon in its lining, was developed and introduced. 22 Until the 1990s, open procedures were the norm for virtually all bariatric procedures. A dramatic shift has occurred during the last decade where minimally invasive laparoscopic surgery has become the technique of choice for most bariatric procedures. In addition to the minimally invasive procedures in use today, natural orifice approaches that offer additional options for the bariatric patient are being introduced. Table 3 Total Number of Performed by Year Year Number of Surgeries Performed SURGICAL OPTIONS FOR THE BARIATRIC PATIENT As the techniques and products for bariatric surgery continue to evolve and the benefits of surgical weight loss are reported, the interest in bariatric surgery continues to dramatically rise, as shown in Table 3. Figure 2 Gastrointestinal Anatomy 12

13 ANATOMY Before a discussion of bariatric surgical procedures can proceed, it is helpful to briefly review the anatomy of the stomach and small intestine as shown in Figure 2. The stomach is a specialized organ which appears expanded, hollow, and J-shaped and lies between the esophagus and the duodenum (the first part of the small intestine); it is stabilized indirectly by the lower portion of the esophagus and directly by its attachment to the duodenum. 18 The stomach is divided into three parts, as shown in Figure 3: the fundus, the body, and the antrum; the convex or lower margin of the stomach is known as the greater curvature; the upper margin is called the lesser curvature. Figure 3 Stomach Anatomy The stomach has several functions: Acceptance and storage of ingested food; Mechanical and chemical digestion through the production of various gastric enzymes; Peristaltic waves, which both mix and propel the stomach contents, or chyme, into the duodenum. The small intestine, the longest part of the digestive tract, begins at the pylorus and ends at the ileocecal valve. It is divided into three parts: The duodenum is approximately 25 cm long and 5 cm in diameter. The duodenum follows a C-shaped path as it passes in front of the kidney and the upper three lumbar vertebrae. A common landmark of the duodenum is the ligament of Treitz, which is used by surgeons for anatomical orientation. 18 The duodenum receives the ingested food and digestive juices from the stomach as well as bile and pancreatic juices which aide in digestion and absorption of micronutrients. These functions are largely controlled by hormones (i.e. secretin and cholecystokinin) that are produced by cells in the duodenum which stimulate the liver and the gallbladder to release bile, as well as the pancreas to secrete enzymes (lipase, amylase and trypsin) into the duodenum. 23 The jejunum measures about 8 feet in length and begins near the ligament of Treitz, terminating at the ileum. The jejunum contains the slightly acidic mixture of digested food from the stomach and duodenum. The jejunum functions by absorbing the broken down fats, proteins, nutrients, and carbohydrates into the blood stream. The ileum makes up the remaining length of the small intestine. The ileum allows for the absorption of vitamin B12, vitamins dissolved in fatty liquids, electrolytes, bile salts and water. The ileum terminates at the ileocecal valve. At this point in the digestive tract, the contents have the consistency of a paste. 13

14 There are three categories of bariatric surgical procedures with various adaptations or combinations restrictive, malabsorption, and combination procedures. 18,24 RESTRICTIVE PROCEDURES With restrictive procedures, the size of the gastric reservoir is reduced and the overall anatomical structure and capacity of the stomach is altered. This does not affect the normal digestive processes of the GI tract; thus the caloric and nutrient absorption are not affected. Upon completion of this procedure, the patient will feel full sooner (i.e. satiety) due to the significantly reduced capacity of the stomach ultimately reducing the total volume of calorie intake. Gastric emptying is also delayed, thus prolonging the feeling of satiety. Gastric Banding Gastric banding is one type of restrictive weight loss surgery. Restrictive procedures alter the basic anatomy of the stomach without affecting normal digestion. By design, these types of procedures produce a small gastric pouch (i.e., reduce the size of the stomach to limit total food volume). Gastric banding reduces calorie consumption and delays gastric emptying, which prolongs feelings of satiety. There are two types of gastric banding procedures: vertical banded gastroplasty and adjustable gastric banding. 19, Vertical Banded Gastroplasty (VBG) With vertical banded gastroplasty (VBG), the stomach is partitioned vertically along the lesser curvature of the stomach using staples with the creation of a circular window to form a pouch like structure as shown in Figure 4. Once the pouch is developed, a constricting ring or band is applied. Various types of restrictive devices (e.g., polypropylene mesh bands, adjustable sphincters, and silicone rings) have been developed to slow the passage of food and to prevent stretching of the newly formed gastric outlet. The bands are placed at the stomal outlet in order to prevent or limit stomal stretching and subsequent weight gain Figure 4 Vertical Banded Gastroplasty Slightly better weight loss has been achieved with vertical banded gastroplasty (VBG) versus gastric banding with only a band or ring. Rates of weight loss success with VBG do vary significantly, particularly in the super-obese patient populations. Approximately 50% of VBG patients achieve success in losing weight (positive success, 50% weight loss). Weight loss with the VBG patient population peaks at about 1 year post procedure. 29 It has been reported that many VBG patients will regain their lost weight within 3-5 years. This is a result of the stomach stretching over time to accommodate the eating of larger meals or increased frequency of food intake. In Europe, this procedure has declined in favor of the adjustable gastric banding procedure

15 Adjustable Gastric Banding One of the most popular weight loss surgeries being performed today is the laparoscopic adjustable gastric band (LAGB) as shown in Figure 5. 19, 24, In 2008, there were roughly 77,000 patients treated with the AGB. Dr. Kuzmak, who adapted the AGB for clinical use in 1986, found that patients with the adjustable band had significantly better weight loss results along with fewer complications when compared to those with the non-adjustable silicone band. 31 The mechanism of action that the LAGB produces is that patients have a sense of fullness (satiety) and thus eat less often and a reduced volume. 32 If patients overeat the pouch s capacity, they will likely develop pain, nausea, and vomiting. Figure 5 Adjustable Gastric Banding The inflatable silicone adjustable gastric band is laparoscopically inserted approximately 3 cm below the gastro-esophageal juncture, around the upper portion of the stomach as shown in Figure 5. Proper placement is vital for overall patient success. Once this adjustable gastric band is in place, adjustments are complete; it is then fixated in place with suture. The LAGB acts by constricting the upper portion of the stomach, leaving only a small pouch with a constricted passageway which controls and limits the passage of food into the larger, lower section of the stomach. A small port/reservoir is then placed under the patient s skin in the upper abdomen on the anterior rectus sheath. 32 The port is connected to the inflatable adjustable gastric band. Inflation of the adjustable band is accomplished by injection or withdrawal of saline from this reservoir. This allows for an individualized degree of gastric restriction and can be adjusted in the physician s office. It is reported that adjustable gastric band patients lose weight slower after surgery than those having a gastric bypass or biliopancreatic diversion (BPD). Weight loss with the LAGB is optimized at approximately 3-4 years. 32 While the LAGB can be removed, this is not a common event. Sleeve Gastrectomy Sleeve gastrectomy is a non-reversible, restrictive bariatric surgery procedure. 33 With this procedure, a smaller, tube-shaped stomach or sleeve is created, as pictured in Figure 6, by removing approximately 75% of the stomach using gastric staples over a bougie dilator. Weight loss is achieved by limiting the 15

16 amount of food required to feel full due to the significantly reduced capacity. By removing the significant portion of the stomach, it may reduce production of the hormone Ghrelin, which controls hunger. 34 The stomach will continue to function in a normal manner after this procedure. Figure 6 Sleeve Gastrectomy Expected weight loss from sleeve gastrectomy surgery is 60%- 80% of the patient s excess weight. As with the VBG, over time, the stomach may expand and stretch with increased food intake. A low rate of complications and the ability to maintain the normal GI continuity without a malabsorption component are some of the reported benefits of a sleeve gastrectomy. 35 MALABSORPTIVE PROCEDURES Malabsorptive procedures are more technically complex and are geared toward bypassing portions of the proximal small intestine to produce malabsorption. This procedure results in an incomplete digestion process and diminishes the amount of calories and nutrients the body can effectively absorb due to the shortened exposure time in the small intestine. Biliopancreatic Diversion (BPD) World-wide, biliopancreatic diversion (BPD) is one of the most effective and commonly performed malabsorptive procedures today. 36 The BPD surgery alters both the intestines and the stomach. A partial gastrectomy is performed where approximately 60%-75% of the stomach is removed. The surgeon creates a gastroileal anastomosis which will result in a diminished stomach volume while also producing fewer digestive acids. The anastomosis is created by the construction of a long Roux-en-y limb (approximately 200 cm) with a common channel (50 cm). As a result of this diversion, as shown in Figure 7, the body will selectively absorb fewer calories from fat and starch while allowing for longerterm weight maintenance. 19,

17 Figure 7 Biliopancreatic Diversion (BPD) The amount of excess weight loss after the BPD surgery has been reported to be around 75%, with weight loss in some patients persisting up to 20 years. 39 However, as is the case with all bariatric procedures, the percentage of excess weight lost varies depending on many factors, including body type, the length and quality of medical follow-up, and the initial weight of the patient. Because BPD is a malabsorptive procedure, the bariatric patient will require life-long medical follow-up. Biliopancreatic Diversion with Duodenal Switch (BPD-DS) BPD-DS was first described by Hess and Marceau simultaneously in This procedure combines a sleeve vertical gastrectomy with a duodenal switch. Initially the duodenum is transected below the pyloric valve (sparing the pyloric valve). This 150-cm alimentary limb is created by anastomosing the distal ileum to the duodenum. A 100-cm common channel is created using the distal ileum. As shown in Figure 8, this technique has reduced many of the complications commonly encountered with the BPD alone. 40, 41 Figure 8 Biliopancreatic Diversion with Duodenal Switch (BPD-DS) Some surgeons may prefer to initially perform a sleeve gastrectomy prior to the BPD-DS. This might be considered for heavier, male, and at-risk patients or those who would benefit from that initial weight loss. When weighing the potential increased risks associated with a single-stage procedure versus the risks of 17

18 sleeve gastrectomy first, followed by the malabsorptive procedure after an initial weight loss, some controversy does exist. 41 While there may be limited evidence in regards to the procedure s effectiveness, current case studies have demonstrated weight loss of 70%-80% with the BPD-DS. It has been suggested that the super-obese (BMI 50 kg/m2) may experience the greatest benefits from this procedure. 39 COMBINATION PROCEDURE These procedures have both restrictive and malabsorption features as described above. Specific surgical procedures are described below. Roux-en-Y Gastric Bypass The Roux-en-Y gastric bypass combines both the restrictive and malabsorption techniques and is preformed approximately 132,000 times per year in the United States. It reduces the volume of food that can be ingested while also reducing the total calories that can be absorbed by bypassing the digestive structures. 14 As a non-reversible treatment modality, the Roux-en-Y procedure is seen as one of the top surgical methods to treat clinically severe obesity. 19, 42 Figure 9 Roux-en-Y Gastric Bypass In the course of the Roux-en-Y procedure, the surgeon divides the stomach into two compartments. The small upper section of the stomach (the pouch) is only capable of holding about 30 to 60 cc of food. The larger, lower compartment of the stomach, which comprises approximately 90% of the original stomach, no longer stores food. It does, however, continue to secrete digestive juices necessary for digestion and absorption, which continue to flow into the duodenum. The jejunum is transected from the duodenum and is brought up and anastomosed to the upper pouch. This allows for ingested food to travel from the newly created upper pouch directly into the lower portion of the small intestine, bypassing the lower stomach and the duodenum altogether, as portrayed in Figure 9. The lower end of the jejunum is anastomosed to the biliopancreatic limb. This allows for the gastric and other digestive juices to be delivered and combined with the ingested food, thus allowing for some absorption to take place. The amount of absorption will depend upon the length of the Roux limb as well as the point of anastomosis forming the common channel. The reduction in the amount of absorption which takes place is a direct result of the reduced exposure time to the digestive juices and the food mixture (e.g. chyme) as it passes through the small intestine. 18

19 Many patients can lose up to 80% of their excess weight and maintain this weight reduction indefinitely, provided that patients comply with dietary and other lifestyle guidelines. Long term follow-up in this patient population is very important due to potential micronutrient malabsorption potential. COSTS The annual cost of managing obesity in the United States alone amounts to approximately $100 billion; approximately $52 billion of this total are direct costs of healthcare. This amounts to approximately 5.7% of all US health expenditures. 5 The cost of lost productivity due to obesity is approximately $3.9 billion, and an additional $33 billion is spent annually on weight-loss products and services. 5 With the ever increasing emphasis by payers, both private and governmental, to control the spiraling cost of healthcare, managing the obesity epidemic is a global priority. Table 4 Volume of Bariatric 2008 (United States) Volume Table 4 outlines the volume of the different types of bariatric surgical procedures performed in Bariatric surgery is a complex process. The cost for the various types of procedures often range from $18,000 to $35,000, which includes the preoperative lab and radiology fees, as well as those of the anesthesia provider, facility, and surgeon. 44 These fees can vary significantly based on the extent of the procedure and the length of recovery, location, and other confounding issues. There may be additional postoperative costs which are not always included in these costs. These may include, but are not limited to, individualized dietary plans, a fitness regimen, behavioral modification, nutritional supplements, and body contouring procedures which may be required to remove excess skin after weight loss. Most cases of chronic morbid obesity (BMI 40 kg/m 2 ) with comorbidities are covered by insurance if medical necessity is indicated and all appropriate documentation, including records of physician-supervised 19

20 attempts at nonsurgical weight loss methods, are provided. Insurance coverage for bariatric procedures is more likely to occur if the physician documents the presence of obesity-related comorbidities, such as diabetes or heart disease. PERIOPERATIVE CONSIDERATIONS IN BARIATRICS PREOPERATIVE CONSIDERATIONS Perioperative practitioners should be aware that patients undergoing bariatric surgery commonly have associated co-morbidities which increase their risk for injury or adverse outcome. Preplanning with the entire care team is a key component of a successful patient experience. In addition to the perioperative consideration as shown in Table 5, a thorough patient assessment should be conducted to further individualize their plan of care. Table 5 Preoperative Preoperative Considerations PREOPERATIVE AND ONGOING PHYSIOLOGICAL CONSIDERATIONS IN THE BARIATRIC PATIENT Obesity is commonly associated with one or more serious comorbidities such as cardiopulmonary disease, diabetes, hypertension, and obstructive sleep apnea (OSA). 5 For the morbidly obese patient, a thorough patient assessment is warranted with careful attention paid to the following concerns: 6 Cardiopulmonary abnormalities The patient should receive a thorough cardiac assessment according to the established guidelines. Additionally, he/she should also be evaluated for preexisting cardiac disease and related comorbidities (e.g., chronic pulmonary disease, peripheral vascular disease, diabetes). 20

21 Abnormal airway issues Obese patients often present with a history of obstructive sleep apnea (OSA). Therefore, special attention should be given to patients who have a history of snoring, apnic episodes, and frequent arousal during sleep, morning headaches, and daytime somnolence. The physical examination should include airway evaluation, nasopharyngeal features, neck circumference, tonsil size, and tongue volume. Airway evaluation is very important in order to determine the possibility of a difficult endotracheal intubation and post-operative complications (e.g. OSA). Sleep studies are often performed to assess the risk for OSA. Nervous system dysfunction Preoperative evaluation of the neurologic system includes determination of central nervous system or peripheral nervous system dysfunction, including motor system (gait, grip strength), sensory system (physical distinction of pain, vibration, and touch on the hands, feet, and limbs), muscle reflexes, cranial nerve abnormalities, and mental status and speech pattern. INTRAOPERATIVE PATIENT CARE NEEDS There are several areas of special consideration during the intraoperative phase of care for bariatric surgery patients, as shown in Table 6. Table 6 Intraoperative Considerations Intraoperative Hemostasis o Electrosurgery o Vessel fusion/sealing o Ultrasonic o Mechanical Anesthesia and monitoring equipment o Airway Equipment o Oximetry o BIS index monitoring o Cardiovascular o Blood pressure (invasive and non-invasive) o Fluid management Deep vein thrombosis (DVT) prevention o Sequential compression devices Positioning equipment o OR Table designed to support patient s weight o Mechanical transfer aides designed for bariatric patients o Adequate personnel for lifting/positioning o Positioning aides Temperature management 21

22 HEMOSTASIS o Electrosurgery Electrosurgery presents a challenge for the perioperative team caring for the bariatric patient. Due to the high impedance of these patients, perioperative practitioners may have trouble placing the patient in circuit and selecting appropriate power settings for the procedure. This section reviews basic concepts of electrosurgery relative to the bariatric patient and suggests interventions designed to maximize patient safety and facilitate surgery. Basics of electricity Knowledge of the five variables associated with electricity as shown in Table 7 will assist the perioperative practitioner providing a safe patient care environment during the use of electrosurgery for the bariatric procedure. 22

23 Table 7 Variables of Electricity Current Flow of electrons during a period of time, measured in amperes. Circuit Pathway for the uninterrupted flow of electrons. Whether monopolar or bipolar electrosurgery, the patient is part of the electrosurgery circuit. Impedance The opposition to the flow of the electrical current. Impedance is measured in ohms. In the operating room, particularly with bariatric patients, one source of resistance or impedance would be the patient s tissue, particularly adipose tissue. Muscle and blood have the lowest resistance and easily pallow the flow of current. Voltage The force that will cause one amp of current to flow through one ohm of impedance. Voltage is measured in volts. The voltage in an electrosurgical generator provides the force that pushes the electrons through the circuit. Depending on the type of generator, and how it is used, electrosurgery generators may produce up to 10,000 volts. Power Energy produced and measured in watts. A watt is the amount of energy produced by one volt multiplied by one ampere of current. Electrosurgical generator power settings can be displayed on an LED screen in watts, or a percent of the watts is demonstrated on a numerical dial setting. Most electrosurgical generators have a maximum coagulation output of 120 watts, and a maximum vaporization or cut output of 300 watts. Ulmer, B. Electrosurgery Self-Study Guide Boulder, CO: Covidien Energy-Based Devices, 2010, p. 8. Circuit As shown in Figures 10 and 11, the patient becomes part of the circuit when the surgeon uses monopolar or bipolar electrosurgery. Monopolar electrosurgery may potentially increase the patient s risk for an adverse outcome due to the use of high voltages which is related to high impedance secondary to the patient body mass and the distance of the patient return electrode from the operative site, or the use of a capacitive mat, which may require higher voltages. In addition, the use of long monopolar duty cycles to achieve the desired tissue effect poses another potential risk to the patient, including undesired thermal spread at the active electrode site and heat accumulation underneath the patient return electrode. When choosing bipolar electrosurgery (Figure 11) the patient becomes part of the circuit as the surgeon grasps the target tissue with the bipolar device (i.e., bipolar forceps or vessel fusion hand piece) and activates the generator. When used according to the manufacturer s instructions, bipolar electrosurgery equipment has the potential to reduce the patient s risk for adverse outcomes related to electrosurgery because the low impedance tissue grasped between the bipolar 23

24 instrument tines or jaws only requires low voltage to achieve the desired tissue effect. Figure 11: Bipolar circuit Impedance, Voltage and Power The electrosurgical mode used, type of target tissue, technique required to accomplish the desired electrosurgical effect, and patient impedance determine the power required for a surgical procedure. A bariatric patient, as a result of the increased amount of body fat, will increase the level of impedance. As a result of this increased impedance, power settings will often be increased to achieve the desired surgical effect. As the amount of voltage delivered increases, the risk for thermal leakage, and capacitance, particularly if a capacitor is used in the electrosurgical circuit, may also increase. In the bariatric patient, selecting an optimal monopolar power setting for the procedure may present a challenge because of the high impedance levels related to increased body fat. Power settings commonly used for lower impedance patients may not provide the voltage necessary to achieve the desired surgical affect. When selecting the monopolar power setting for a bariatric patient, always start with the lowest power setting that will achieve the desired surgical affect. In addition to monopolar power settings, the higher impedance level of the bariatric patient may lead to difficulties when placing the patient in circuit with the electrosurgery generator. Patient return electrode Technology available for placing the patient in circuit during monopolar electrosurgery is called return electrode contact quality monitoring (RECQM). It offers the patient the safest alternative when the surgeon uses monopolar electrosurgery. RECQM system continuously measures the impedance at the patient return electrode site and compares it to a safe impedance range, thus eliminating intermittent false alarms that could result from small changes in impedance. 24

25 Some patients present with extremes in impedance that affect the pad-to-patient interface such as morbid obesity, emaciation, edema, ascites, and burns. Consequently, the impedance at the pad-to-patient interface may fall close to the higher limits defined by the generator, or exceed these limits, and thus require the application of a second patient return electrode as shown in Figure 12. Laparoscopic Procedures and Bariatric Patients All patients undergoing laparoscopic procedures are at risk for these potential adverse outcomes during laparoscopic procedures, including direct coupling, insulation-failure, capacitive coupling, and burns secondary to residual heat (Table 8). Bariatric patients potentially have more risk because of high impedance that may require higher power settings and voltage. Higher voltage increases the potential for insulation failure and capacitive coupling. By remaining diligent, perioperative practitioners can avoid direct coupling and residual heat burns. The perioperative practitioner can reduce the patients risk for an injury secondary to insulation failure and capacitive coupling by using lower power settings, employing short activations, avoiding open circuit activation of the active electrode, and using technologies such as tissue response, tissue sensing energy generators, vessel fusion, and active electrode monitoring (AEM). 25

26 Table 8 Potential Adverse Outcomes Related to Laparoscopic Procedures DDiDDrect Direct couplingirect Coupling The condition that occurs when one electrical conductor (the active electrode) comes into contact with a secondary conductor (scopes, graspers). Electrical current will flow from the first conductor into the secondary one and energize it. Capacitive coupling The condition that occurs when energy is coupled from one circuit to another through an electric field. This is most likely to happen when the impedance of the source circuit is high. Insulation failure The condition that occurs when the insulation barrier around an electrical conductor is breached. As a result, current will travel outside the intended circuit. Residual heat Radiofrequency electrosurgery devices produce heat instantaneously to achieve quick hemostasis. Once used the active electrode tips do not cool instantaneously. There is enough heat remaining in an active electrode tip to produce a tissue effect just after the tip has been deactivated. Ulmer, B (2011). Evidence-based Practices for Minimally Invasive Procedures. Boulder, CO. p. 21; Ulmer, B (2010). Electrosurgery Self-Study Guide. Boulder, CO, pp Tissue response generators reduce capacitive coupling in the low voltage (cut) waveform. Newer tissue sensing energy generators reduce capacitive coupling across all electrosurgery modes cut, blend, and coagulation. Vessel fusion technology offers the safety of bipolar 26

27 thus eliminating the risks of insulation - failure and capacitive coupling and has the ability to fuse vessels and tissue bundles up to 7 mm in size. 45, 46 To function correctly, tissue response and tissue sensing energy generators require the use of a RECQM patient return electrode. 45, 46 Facilities that use active electrode monitoring (AEM) technology can reduce the potential for insulation-failure and capacitive coupling injuries during laparoscopic procedures. When used according to the manufacturer s instructions, the system continuously monitors and actively shields against stray electrosurgical current. The AEM system is one of the most effective means of minimizing potential patient injuries due to insulation failure or capacitive coupling. 47 Bariatric and other high impedance patients present a challenge to the perioperative practitioner using monopolar electrosurgery for open and laparoscopic procedures. Table 9 Tissue Fusion Knowledge of the variables of electricity, the relationship of the variables, and electrosurgery safety innovations will enable the perioperative practitioner to safely care for the high impedance patient during surgical procedures that use monopolar electrosurgery. o Vessel Fusion Tissue/vessel fusion employs a unique combination of pressure and energy which reliably seals vessels and tissue bundles for surgical ligation in both open and laparoscopic procedures. 48, 49 Through the unique combination of pressure and energy as described in Table 9, the device melts the collagen and elastin in the vessel walls, reforming it into a permanent, custom seal. 50 In contrast to other energy-based ligation methods as shown in Figure 13, which shrink the vessel walls and rely on the formation of a proximal thrombus for hemostasis, vessel fusion technology obliterates the lumen of the vessel as demonstrated in Figure

28 Figure 13: Proximal Thrombus The vessel fusion system reduces and/or eliminates the need for sutures, clips, and staples. Patient safety is greatly increased since the bipolar-like design of the system does not require a patient return electrode. Pacemakers, implants, scar tissue and jewelry are not affected by the vessel fusion current. 51 Figure 14: Vessel Sealing o Ultrasonic Ultrasonic instruments provide excellent transection and hemostasis during bariatric procedures as shown in Figure 15. Figure 15: Ultrasonic Devices An ultrasonic scalpel controls bleeding by coaptive coagulation at low temperatures, ranging from 50º C to 100º C. The vessels are coapted or tamponaded and sealed by this sticky protein coagulum. Figure 16 demonstrates how coagulation occurs by means of protein denaturation when the blade, vibrating at a high frequency (55,000 Hz), 52 combines with protein, denaturing it to form a coagulum that seals small coapted vessels. Greatest at the tip 28

29 Perioperative practitioners should be aware that ultrasonic devices do produce a vapor and aerosols, and due to a potentially lower tissue temperature, may potentially carry infectious materials. 53 Surgeons and perioperative practitioners should be aware that even though ultrasonic devices may operate at lower temperatures than electrosurgical devices, the ultrasonic device s blade can produce and retain enough heat to cause thermal spread or injury to adjacent tissues. 54 o Mechanical Devices For laparoscopic and open bariatric procedures as shown in Figures 17 and 18, various mechanical devices such as linear and circular staples, clips, and sutures are available. A linear stapler that creates two, and preferably three, rows of staples on each side of the transected tissue is useful for many bariatric procedures. This device can be used to transect hollow viscera (e.g. the stomach), divide highly vascular tissue (e.g., the mesentery), and create an anastomosis. These staplers can be reloaded for use in tissues of varying thicknesses. A circular endoluminal stapler, with two rows of circular staples and an inner circular knife, can also be used to create a circular anastomosis. Additionally, there are endoscopic staplers available that are preloaded with fully integrated, synthetic absorbable tissue reinforcement in every firing; these devices are designed to improve hemostasis, pneumostasis and burst pressure in various endoscopic stapling applications. Endomechanical instrumentation for laparoscopic procedures has become very specialized for the bariatric patient. Common laparoscopic instrumentation for bariatric s include graspers, dissectors, suturing devices, and staplers as shown in Figure 18. Most manufacturers make longer versions of their instrumentation for bariatric surgical applications. Figure 18: Common bariatric laparoscopic devices 29

30 Because the abdominal wall is much thicker in obese patients, a long veress needle (e.g., 150 mm) may be required to establish pneumoperitoneum and extra-long trocars should be of sufficient length to reach the peritoneal cavity without excessive disruption of the abdominal fascia, as seen in Figure 19. Figure 19: Trocar and veress needle o ANESTHESIA AND PHYSIOLOGICAL MONITORING Obese patients present a unique set of challenges for the anesthesia provider. Body size alone can make managing the airway difficult. As a result of these predictable challenges, the anesthesia provider should anticipate and be prepared with appropriately sized supplies and equipment for the obese patient. o Cardiovascular Both basic and advanced intraoperative monitoring that meets the specific needs of the patient should be used. For example, selection of the electrocardiogram leads as shown in Figure 20 should facilitate detection of myocardial ischemia and other arrhythmias (i.e., leads II and V5). Figure 20: Disposable EKG leads The use of central venous and pulmonary artery catheters should also be considered in patients undergoing extensive procedure or those with serious cardiorespiratory disease. 55 o Blood pressure Non-invasive blood pressure monitoring - an extra-large thigh cuff can be used on either the upper arm or the lower leg; a regular-size or large cuff can be used on the forearm over the radial artery until arterial cannulation is accomplished for invasive monitoring. 30

31 o Bispectral Index Monitoring (BIS) The use of BIS monitoring, as shown in Figure 21, may be employed as an adjunct to clinical training and experience to assist the anesthesia provider in assessing the level of sedation and anesthesia during the case on the obese patient. It has been reported that the use of BIS monitoring with the morbidly obese surgical patient has statistically reduced the recovery times and sevoflurane consumption. 56 Figure 21: Bispectral Index Monitoring o Airway In addition to the monitoring supplies, an important part of the airway management is to ensure that all required equipment and personnel are readily available to intubate and ventilate the obese patient. Various masks, laryngoscope blades and handles, oral and nasopharyngeal airways, endotracheal tubes, and stylets should be assembled and available. Figure 22 shows various endotracheal tube styles available for use with the bariatric patient. Figure 22: Endotracheal tubes o Fluids Anesthesia fluid management during bariatric surgery has been historically guided by blood pressure, heart rate, and urine output measurement. It is important to note that, despite the augmentation of circulatory fluid in the morbidly obese patient; the estimated blood volume is actually reduced and therefore may not require excessive fluids. 57 Fat, which contains 8%- 10% water, contributes less fluid to total body water than an equivalent amount of muscle. The total body water in a normal weight adult is 60%-65%; in the severely obese patient, it is 31

32 decreased to 40%. As a result, the calculation of estimated blood volume should be 45 to 55 ml/kg of actual body weight rather than the 70 ml/kg apportioned in non-obese adults; the use of reduced parameters for volume replacement and avoidance of rapid rehydration diminish cardiopulmonary compromise. 55 o DEEP VEIN THROMBOSIS PREVENTION Deep vein thrombus (DVT) and pulmonary embolism (PE) are serious and common complications for the bariatric patient. Figure 23 shows a variety of sequential compression devices designed for the obese patient which when used, reduce the risk for DVT/PE in the bariatric population. In addition, sequential compression sleeves can be used in combination with or without compression stocking, on the leg with compression hose, or as a foot cuff. o Sequential Compression Devices Figure 23: Sequential compression sleeve, controller, and compression hose o POSITIONING THE BARIATRIC PATIENT It is crucial for the perioperative team to acknowledge that the bariatric patient is significantly different from that of other normal-sized patients, and thus should recognize that special precautions and considerations will be required to safely transfer, position, and care for the patient. Initially, the perioperative nurse should conduct an assessment to determine specific positioning needs of the bariatric patient. This assessment should be communicated to, and input solicited from, the entire team (e.g., anesthesia provider, surgeon, perioperative team) with the goal of developing a collaborative plan of care, focusing upon the establishment of an optimal patient outcome, and maintaining a safe journey throughout the continuum of care. Part of this plan of care should be focused upon the collaborative and individualized positioning needs of the patient. Considerations for the bariatric patient should include, but not be limited to, the following: 32

33 o Safe transfer of the bariatric patient Transfer of the bariatric patient can be physically challenging within the operating room. Ideally, transfer of the bariatric patient should take place from a bed rather than a gurney or stretcher, since many gurneys/stretchers are both uncomfortable and may not safely accommodate the weight of the bariatric patient. 58 In addition, perioperative team members should know the maximum patient weight rating of the chosen bed to facilitate safe transfer. Some patients could exceed the maximum weight rating of the chosen bed or gurney as shown in Figure 24. Figure 24: Bariatric bed It should also be noted that some bed manufacturers have written instructions for use that specify their bariatric bed should not be used for patient transfer or repositioning when the bed is occupied. 58 In the operating room, the bariatric patient is usually transferred from a bariatric bed to the procedure bed due to safety concerns. The safety of the OR procedure table is equally important and must be able to accommodate the patient s height and weight, desired surgical position(s), necessary surgical equipment, and accessories. Numerous procedural tables are available which are designed and tested to safely accommodate bariatric patients with maximum weights of pounds. 19, 59 Proper body mechanics, adequate staffing, and the use of transfer devices should be available and used with bariatric patients. This will reduce the risk for injuries to both staff members and patients. Additionally, positioning needs should be identified and available prior to attempting the bariatric patient transfer, allowing for the safest method of patient transfer. As part of the transfer and positioning of the bariatric patient, use of adequately sized padding and positioning devices, as shown in Figure 25, should be selected and used to avoid potential injuries, pressure ulcers, or neuromuscular circulation and optimizing proper body alignment. The perioperative team should recognize that bariatric patient has an increased risk of developing injuries and should plan accordingly. 60, 61 33

34 Figure 25: Padding and positioning devices o Temperature Management Temperature control is another important consideration for the obese patient. Equipment used to maintain normothermia (e.g., bed-warming devices, fluid warmers, and warm air flow blankets) should also be used. 55 POSTOPERATIVE CONSIDERATIONS Postoperative care is based on the identified risks and anticipation of potential complications; prompt recognition, clear communication, education, and targeted interventions may minimize the risk of potential complications. 62, 63 Postoperative care considerations for the obese patient are outlined in Table 10. Table 10 Postoperative Considerations Postoperative (acute and long term) Continuously monitor for potential post-operative complications o Respiratory o Cardiovascular Deep vein thrombosis, pulmonary emboli o Fluid dynamics o Skin and wound care o Hemorrhage o Pain o Anastomotic leak o Cholelithiasis o Emotional changes o Hyperglycemia o Nutritional deficiencies o Neurological complications o Pressure ulcer and skin breakdown o Pregnancy o Venous thromboembolism (VTE)/Pulmonary embolism (PE)/Respiratory failure Wound infection Death 34

35 o o Respiratory A direct correlation exists between the incidence rate of postoperative pulmonary complications and the degree of obesity. This is a primary concern in the immediate postoperative phase. Obstructive sleep apnea, severe deconditioning (i.e., shortness of breath on minimal exertion), obesity hypoventilation syndrome (Pickwickian Syndrome), and asthma are several of the pre-existing conditions that may indicate potential difficulties with airway management. Positioning can be a valuable tool for improving arterial oxygenation. In the PACU, the obese patient should be cared for in a semi-fowler s position unless cardiovascular instability exists. Cardiovascular Because the obese patient has a higher incidence rate of hypertension, coronary artery disease, myocardial infarction, and cardiomegaly, careful cardiac and electrocardiographic monitoring should be used. o Fluid dynamics Alterations in fluid requirements are likely to occur in obese patients because their body water is about 40% of total weight (in a healthy person, body water is 65%). Therefore, calculations of fluid requirements should be adjusted to compensate for this reduction in total body water. Urine collection, as shown in Figure 26, and output should be monitored and documented. Figure 26. Urine collection bag o Skin/Wound Care Observe the skin areas and folds for redness, excoriation, or breakdown to detect and treat potential problems. Apply an abdominal binder to prevent wound dehiscence. Use absorbent padding between skin folds to prevent pressure areas, especially where tubing or catheters are in close contact with the skin. 35

36 o Hemorrhage The stapling, suturing, and alterations in the structure of the GI tract may present both direct and indirect risks of acute hemorrhage. o Pain Adequate pain management is vital for bariatric patients in order to promote early ambulation; a patient-controlled analgesia (PCA) pump is typically used for up to 48 hours postoperatively. Potential Long-Term Complications Regardless of the type of bariatric procedure, the change in the basic structure and physiology of the GI tract can have wide-ranging effects. Because the surgical procedure does not correct the underlying cause of the patient s eating or metabolic disorders that resulted in obesity, a program of both short-term and long-term follow-up and behavior modification is essential. Further, the more extensive the gastric bypass surgery, the greater the risk for complications and nutritional deficiencies. The bariatric patient is at risk for a combination of physiologic, psychologic, and metabolic challenges and potential complications. In general, the immediate operative mortality rate is relatively low. In the late postoperative period, other problems may arise and may require reoperation, which is associated with higher morbidity and mortality rates than those of primary procedures. Potential complications are outlined below. 14, 24, 62 o Anastomotic leak Patients typically present with signs and symptoms of anastomotic leak within seven to 14 days postoperatively. Various signs and symptoms indicative of an anastomotic leak include shoulder, abdominal, and pelvic pain; vague changes in heart rate or sustained tachycardia; hypotension; and unexplained changes in urinary output. Combined, pulmonary embolus (PE), anastomotic leak, and respiratory failure account for approximately 80% of all deaths in the first 30 day postoperatively. 64 o Cholelithiasis Bariatric surgery patients have a greater rate of gall stone formation, presumably due to an increase in cholesterol excretion. After bariatric surgery, cholesterol further increases as does the level of biliary protein which promotes stone formation. As a result, it is anticipated that nearly 30% of all bariatric patients will eventually develop gall stones postoperatively. o Emotional changes It is essential that support addressing the patient s psychological, emotional, and behavioral needs begins with the initial consultation and continues throughout the entire course of the patient s weight loss journey. As previously noted, surgery does not change the behavioral eating disorders that originally lead to obesity. Obese patients are often subjected to 36

37 discrimination, prejudice, and stigmatization, leading to feelings of low self-esteem and other forms of compulsive and dysfunctional behaviors, including overeating. Postoperatively, the psychosocial functioning of the patient is improved. Nursing care should provide dignity, safety, and attention to the patient s specific personal needs in order to support the holistic healing process. Education, counseling, behavioral therapy, and support groups are also effective interventions for the emotional and psychological care of the patient, both preoperatively and postoperatively. o Nutritional deficiencies Many bariatric surgical patients experience nutritional deficiencies due to the complex metabolic derangements present in the morbidly obese patient. The combination of intentional malabsorption and significant restrictions in dietary intake results in deficiencies of key nutrients. Deficiencies in protein, iron, fat-soluble vitamins (A, D, E, K) and the B vitamins are most commonly reported. 65 Bariatric patients will require guided and essential multivitamin supplementation to promote healing and address the potential imbalances. Frequent lab tests are recommended as shown in Table 11. Table 11 Common Lab Tests on the Post-Operative Bariatric Patient CBC Liver panel Glucose and hemoglobin A1C Calcium Parathyroid Hormone (PTH) Lipid panel Electrolytes BUN and creatinine Prothrombin time Phosphate Iron, ferritin, and TIBC TSH LDH and CPK B-12 Folate Magnesium Vitamin D Others as deemed necessary o Neurologic complications Neurologic complications are not uncommon and are reported as a result of the metabolic and nutritional deficiencies, including B1, B12, folic acid, niacin, and copper. These complications, identified in as many as 5% to 10% of bariatric patients, can manifest in almost any area of the nervous system. Patient assessment and nutritional supplementation are needed to prevent these complications. 37

38 o Pressure ulcers and skin breakdown The reduced blood supply to adipose tissue is a contributing factor to the patient s risk for skin and wound problems. Skin folds around the breasts, abdomen, back, and perineum are at higher risk due to moisture and bacteria accumulation because they are difficult to reach and clean. Proper cleansing, provision of routine skin care, frequent repositioning and ambulation are essential to maintaining the patient s skin integrity. o Pregnancy Female patients of childbearing age should avoid becoming pregnant immediately after bariatric surgery because of the risks associated with rapid weight loss and the potential nutritional deficiencies noted above that may cause harm to the fetus. Once the patient has reached a stable, lower weight, she may consider pregnancy months postoperatively. o Venous thromboembolism (VTE)/pulmonary embolism (PE)/respiratory failure Venous thromboembolism (VTE) is a serious complication that can lead to pulmonary embolism (PE) and respiratory failure. Extreme obesity increases the known risks of PE and respiratory failure; however patients with a BMI 60, with chronic lower extremity edema, obstructive sleep apnea and prior history of PE are also at higher risk. The risk is increased by the elevation of numerous clotting factors in the morbidly obese; surgery further increases this risk due to hemostatic shifts, venous stasis, and immobility. o Wound infection Postoperative wound infection can develop as a result of numerous risk factors commonly associated with surgery; the rate of infection is approximately 7% for open procedures and 2.9% for laparoscopic procedures. 66 Signs and symptoms include pain, purulent drainage, redness, and swelling at or near the incision site(s). o Death The risk of death associated with initial bariatric procedures is less than 1%; this approaches 2% for reoperative gastric bypass surgery. Prior abdominal or gastric surgery further complicates the procedure as well as the risk associated with reoperation. 38

39 SUMMARY The literature clearly demonstrates that the number of overweight, obese, and morbidly obese individuals has been and continues to steadily increase both in the United States and the world. As a result of this increasing population, obesity now represents a rapidly growing public health concern. Surgical treatment has proven the best method to achieve long-term weight control for the morbidly obese. Advancements in bariatric surgical procedures have led to new treatment options which the perioperative team should be cognizant of. Specialized equipment, energy-based modalities (e.g. monopolar, bipolar, and ultrasonic), and other devices require the perioperative health care provider to follow the manufacturer s instructions for use so patient safety may be optimized. The bariatric patient quickly benefits by experiencing significant and rapid weight loss and the subsequent reduction or elimination of many of their health problems (comorbidities) associated with obesity. Complications from weight loss surgery, while low, as with any major surgical procedure, can be significant. All members of the perioperative team play a vital role in caring for the patient during his/her surgical journey. Through understanding of the significant and unique special needs of obese patients and continued awareness of the associated perioperative challenges presented by this patient population, perioperative team members will serve as valuable patient advocates, whereby promoting positive outcomes. 39

40 GLOSSARY Adjustable Band Gastroplasty Anastomosis Band Bariatric Surgery Biliopancreatic diversion (BPD) Biliopancreatic limb Body Mass index (BMI) Comorbidity Dumping Syndrome A bariatric surgical procedure in which an inflatable silicone band is placed around the stomach to create a small proximal pouch joined to a larger distal pouch by a narrow stoma. The surgical connection of two tubular structures, such as blood vessels or intestine. The structures can be connected end-to-end, side-to-side, or side-to-end. The connection can be accomplished using sutures, surgical staples, or a combination of both. A prosthetic device placed around the upper portion of the stomach, usually through laparoscopic surgical technique. This device restricts the movement of food from the stomach. Any surgical procedure performed for the purpose of producing weight loss; derived from the Greek root word baro, meaning weight. A malabsorptive procedure in which both the Roux limb and the biliopancreatic limb of the small bowel are long with a shortened common channel where digestion takes place. The segment of small bowel connecting the bile duct to the distal end of the Roux limb. This segment follows the Roux limb and is the bile-carrying limb. A mathematical calculation used to determine whether a patient is overweight. BMI is calculated using a metric formula dividing the person s body weight in kilograms by his or her height in meters squared (kg/m²). BMI allows the categorization of weight ranges and is both an economic and efficient screening tool. One or more coexisting disease or condition(s) in addition to the condition that is the subject of study. The uncomfortable feeling of nausea, lightheadedness, upset stomach, diarrhea that is associated with the ingestion of sweets, high-calorie liquids, or dairy products. 40

41 Gastric Banding Malabsorption A form of bariatric surgery in which a band of special material is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach. The small outlet delays the emptying of food from the pouch and causes a feeling of fullness. Imperfect, inadequate, or otherwise disordered intake of nutrients from the small intestine, caused by lesions of the small intestine, lack of digestive enzymes, or surgical procedures. Morbid Obesity Having a BMI greater than 40 with or without comorbidities. Obesity Having a BMI equal to or greater than 30. Overweight Having a BMI equal to or greater than 25. Pouch A surgically created portion of the stomach that serves as a reservoir for food immediately after food exits the esophagus. Restrictive Roux-en-Y Gastric Bypass Roux limb Sleeve Gastrectomy Decreasing or limiting the amount of food intake. The most common gastric bypass procedure, involving the creation of a small stomach pouch by stapling or by vertical banding to restrict food intake. A y-shaped section of the small intestine is connected to the pouch to allow food to bypass the duodenum as well as the first portion of the jejunum. The segment of small bowel where food exits the stomach and enters the bowel. The Roux limb starts where food enters and ends where the biliopancreatic limb joins to form the common channel. A bariatric procedure in which approximately 75% of the stomach is removed, creating a smaller, tube-shaped stomach or sleeve. Super Obese Having a BMI of greater than 50. Vertical Banded Gastroplasty A surgical treatment for extreme obesity that uses a band and a vertical row of staples to construct a small pouch in the stomach that empties through a narrow opening into the distal stomach and duodenum. 41

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