Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2007 (*BMI 30, or about 30 lbs. overweight for 5 4 person) 1990 1998 The Bariatric and Metabolic Center of Colorado Bariatric Surgery: Options, Care and Outcomes Parker Adventist Hospital 2007 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% Source: CDC behavioral Risk Factor Surveillance System. Using the Body Mass Index (BMI) Used to determine if you qualify for surgery Measures obesity based on weight and height What is Morbid Obesity? Clinically defined as: 200% of ideal weight > 100 lbs overweight Body Mass Index (BMI) of -- > 40 -- > 35 + presence of co-morbidity Health Risks & Increased Risk of Mortality Bariatric Surgery Mortality Rate Relative 400 350 300 250 200 150 100 50 0 16 19 22 25 28 31 34 37 40 45 BMI (kg/m 2 ) Diabetes High risk Hypertension Medium risk Sleep apnea Low risk Depression Joint Pain Infertility Cancer GERD Asthma Estimated 220,000 in 2008 15 million people in US are morbidly Obese Only 1% that are clinically eligible have bariatric surgery (1) Avg cost $10,000-$25,000 Can improve or resolve >30 obesity-related conditions long-term mortality rate from diabetes, coronary artery disease, and cancer at 7 years after gastric bypass had decreased by 92%, 56%, and 60% (2) ~85% resolve sleep apnea ~73-83% resolution of T2DM In 2009, ADA recommended that bariatric surgery be considered for adults with a BMI of 35 and Type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy.(3) 1.American Society for Metabolic and Bariatric Surgery. Bariatric Surgery Fact Sheet, Available from: http:// www.asbs.org/newsite07/media/fact-sheet1_bariatric-surgery.pdf. Accessed January 24, 2009. 2.Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357:753 761. CrossRef 3.American Diabetes Association. Standards of Medical Care in Diabetes 2009. Diabetes Care, Volume 32, Supplement 1. January 2009. Source: The Surgeon General s Call to Action to Prevent Overweight and Obesity & NIH, NEJM, 1995. 1
Metabolic Woman Bariatric surgery is known to be one of the most effective and longest lasting treatments for morbid obesity. It can also positively affect the following obesity-related conditions: Reprinted with permission of The Cleveland Clinic Center for Medical Art & Photography 2007. All Rights Reserved Bariatric Surgery Not a CURE for obesity Tool to treat or control obesity, to be used in conjunction with changes in eating and exercise habits Considered the only treatment that has resulted in long-term weight loss Improve life expectancy by 89% (1) Risk of death from Diabetes 92%, Cancer 60%, CAD 56% (2) Risk of death from Bariatric surgery ~ 0.1% (3) patients who are morbidly obese, well informed, motivated, and acceptable operative risks. 1. Christou, NV et al. Surgery Decreases Long-Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Ann Surg 2004; 240: 416-24. 2. Adams TD. Long-Term Mortality after Gastric Bypass Surgery. N Engl J Med 2007; 357:741-52 3. Agency for Healthcare Research and Quality (AHRQ). Statistical Brief #23. Bariatric Surgery Utilization and Outcomes in 1998 and 2004. January 2007. BARIATRIC WEIGHT LOSS SURGERY AT PARKER GASTRIC RESTRICTION Adjustable banding (LAP-BAND) Sleeve Gastrectomy GASTRIC RESTRICTION and MALABSORPTION Roux-en-Y Gastric Bypass (RNYGB) LAP BAND -Restricts size of stomach -Adjustable -No dumping -No malabsorption Lap Band-expected Outcome Gradual weight loss 1-2 pounds per week Weight loss goal reached between 2-3 years Strong dedication to lifestyle changes: diet, exercise and vitamins Band is adjusted every 4 weeks or PRN with huber needle % Excess Body weight 40-50% over 5 years 2
Surgery Pouch Diet Hospital Stay LAP BAND Gastric Band 35-60 minutes 100% Laproscopic Some restriction post-op 2-4 oz with fills Week 1 &2- straw diet Week 3 & 4-Sugar free pureed foods Week 4 & 5- Regular diet ( high protein) 24 hours or less Lap Band Hospital Course 3 day clear liquid diet pre-op Day of surgery- out patient mainly Time in hospital-pt should be: Walking Full Liquids On IV fluids and antibiotics (if overnight) On Lovenox q 12 while in house IV pain medication and nausea medication PRNcan do PO medications Lap Band Hospital Course Lap Band Complications Discharge Instructions Can remove TP tape Steri strips will fall off in ~1 week- -absorbable sutures under skin No lifting over 10 Lbs for 2 wks then lift weight as body allows Port site will be very sore- ice pack Sip water all day long Follow diet per nutrition class Minor Vomiting- to tight? Eating correct things? Chewing? Reflux- to tight? Coughing? Night reflux? Major Slipped band Erosion Esophagus Dilated What should I be watching for in my patient after LapBand surgery? Roux-En-Y Gastric Bypass Fever >101 Difficulty breathing DVT sx Severe nausea- prolapse? Inflammation? Incisional infections Restrictive and Malabsorptive 3
Roux-en-Y Gastric Bypass (RNYGB)-expected outcomes 1-2 oz pouch after surgery, 8-10 oz 1 year post-op Average weight loss 1 lb per day for first month then it gradually slows Maximum weight loss usually at 1 year Lifestyle changes: diet, exercise and vitamins % Excess Body weight loss-48 to 74 % in 5 years Hospital Care of the Bariatric Patient Post Op Day #1 Average of about 2 day stay Day of surgery needs Ambulate as soon as able Bariatric clear liquids- NO JUICE OR SODA! Goal is 4-1 oz cups an hour Pain Control PCA Routine orders always include- PT, OT, Pepcid IV, I&O s, VS, Labs in AM, Antibx IV, Lovenox, some home meds, O2 Typically DC foley Ambulate Drink 4 1 oz cups of clear liquids/hour DC IVF if adequate PO intake Oral pain control vs PCA- DC if able Gas pains 5-6 incisions absorbable sutures- can take TP tape off Change Pepcid to PO Titrate O2 as able Post Op day #2 Potential Complications of Bariatric Surgery May shower 48 hours after surgery Ambulate often Make sure they are drinking fluids Lovenox teaching if BMI> 50 Home O2? If o2 sat<90 s resting or very low with ambulation Generally go home Early complications intestinal leakage (contained vs not contained) -contained-usually known during surgery -NPO, Swallow, ~1 week stay -not contained-surgery ASAP! -Sx-Tachy, Poor UOP, looks bad -Others=low BP, WBC, temp not as indicative 4
5/9/2012 Potential Complications of Bariatric Surgery Potential Complications of Bariatric Surgery Roux-en-Y obstruction repeatedly vomiting with intake- no resolution Bad abdominal pain- closed loop obstruction CT or UGI UGI, keep NPO NPO, possible return to OR Cardiopulmonary (ie, MI, PE, pneumonia) Chest pain, tachy, looks bad, SOB send for arteriogram with a CT to R/O PE and leak or Troponins to R/O MI Late complications Stricture, nutritional deficiencies, marginal ulcers, ulcers SBO 5
5/9/2012 The Future Sleeve Gastrectomy Diabetes treatment BMI <35 Cohen et al 37 patients BMI 32-35 with T2DM RNYGB- all resolved diabetes r/t duodenal bypass day of surgery Diabetes may be an operable intestinal disease 2009 study in the American Journal of Medicine found overall 86.6 percent of patients improved or resolved their Type 2 diabetes after bariatric surgery Gastric Sleeve- the in-between procedure Cohen R, Pinheiro JS, Correa JL, Schiavon CA. Laproscopic Roux-en-Y gastric bypass for BMI<35kg/m2: a tailored approach. Surg Obes Rel Dis. 2006; 2:401-404 Henry Buchwald, et al. Weight and Type 2 Diabetes after Bariatric Surgery: Systematic Review and Meta-Analysis. The American Journal of Medicine. March 2009. [Cited 2009 April 27]. 6
Gastric Sleeve Outcomes Hospital course for sleeve Average weight loss ½-1 lb per day for first month then it gradually slows Maximum weight loss usually at 1 year Lifestyle changes: diet, exercise and vitamins % excess weight loss 33 85%, with an overall mean of 55%. Brethauer SA, Hammel J, Schauer PR. Systematic review of sleeve gastrectomy as a staging and primary bariatric operation. Surg Obes Relat Dis 2009;5:469 75. Average stay ~1 night Diet- same as lap band Full liquid diet while in hospital- preferably sugar free 5 incisions-one may be more sore than the others due to removal of stomach Absorbable stitches Can remove TP tape on day 1 Steris stay on for 1 week Shower 48 hours after surgery Gas pains- ambulate and IS machine IV fluids- DC when adequate PO intake What should I be watching for in my patient after Gastric Sleeve surgery? If you ever have questions Fever >101 Difficulty breathing DVT sx Severe nausea- Inflammation? Obstruction? ti Incisional infections Bleeding Please call me at office 303.269.4370 Page me at 303-203-5326 any time 7