ESPEN Congress Geneva 2014 LLL LIVE COURSE: NUTRITION IN OBESITY Pre-operative medical assessment, post-operative follow-up and clinical outcome in bariatric surgery patients A. Thorell (SE)
Nutrition in obesity Pre-operative medical assessment, postoperative follow-up and clinical outcome in bariatric surgical patients Anders Thorell MD, PhD Karolinska Institutet & Department of Surgery, Ersta Hospital Stockholm, Sweden
Ethical dilemmas Bioethical principles Application of bioethical principles to Nutrition at the end-of-life The decision-making process
Outline Treatment modalities Indications for bariatric surgery Bariatric surgical procedures Preoperative assessement Postop follow-up Clinical outcome
Obesity - Treatment modalities Diet regimens Behavioural therapy Physical activity Pharmacological Surgical (Bariatric surgery)
Bariatric surgery- indications BMI > 40 kg/m 2 or BMI > 35 kg/m 2 with comorbidity Earlier serious weight-reducing attempts No major eating disorders BED (Binge eating disorder) AN (Anorexia nervosa) Well informed Well motivated
Bariatric surgical procedures Restrictive Vertical banded gastroplasty Adjustable gastric banding Sleeve gastrectomy Gastroplication Malabsorptive Biliopancreatic diversion Biliopancreatic diversion with duodenal switch Combined Roux-en-Y gastric bypass
Vertical banded gastroplasty
Adjustable Gastric Banding
Sleeve resection
Gastroplication 11
Gastroplication 12
Biliopancreatic diversion
Biliopancreatic diversion with duodenal switch
Roux-en-Y Gastric bypass
Bariatric procedures trends Worldwide: 146 000 344 000 340 000 Europe: 33 000 67 000 113 000 % procedures 70 60 50 40 30 20 10 0 Gastric Band Gastric Bypass Sleeve Gastrectomy BPD/DS Mini GB 2003 2008 2011 Buchwald & Oien, Obes Surg 2013
Preoperative assessment Aim to ensure that: Comorbidities are identified and optimized Patients are well informed regarding: Expected outcome/risks Importance of adherence to postop regimens Well motivated and willing
Preoperative assessment Multidisciplinary team: Bariatric surgeon Internist Anaesthesist Dietician Specialist nurse Psychologist/Psychiatrist
Preoperative assessment General Identify risk factors that increase risk: Cariovascular Iscaemic heart disease Thromboembolic events Unregulated hypertension Metabolic disease (diabetes) Previous surgery (adhesions)
Preoperative assessment Procedure specific: RYGB Inflammatory Bowel Disease Premalignant gastric conditions H.Pylori Sleeve gastrectomy Gastroesophageal reflux disease
Early Postoperative Follow-up - Complications Postoperative complications Late Anastomotic leak Bleeding Infections Thromboembolic events Complications Internal herniation Stomal ulcers Chronic pain Nutitional deficiencies
Early complications (< 1 week) Symptoms Abdominal pain Tachycardia Fever Nausea/vomiting Respiratory distress Actions Blood sampling Upper endoscopy Radiology Immediate surgical intervention
Long term follow up 6 weeks, 6 months, annually Athropometrics Blood sampling Prescription of supplementation: Multivitamin Cobolamine (Vitamin B12) Calcium Citrate Vitamin D Iron (Menstruating women) Councelling Dietary Lifestyle
Long term follow up Procedure specific Band Adjustment (AGB) VBG, Sleeve: only multivitamin supplementation Malabsorptive: More extensive laboratory checks Outcome dependent on adherence to follow-up!
Outcome after bariatric surgery Weight (SOS) Sjöström L et al. NEJM 2007
Outcome after bariatric surgery Diabetes incidence (SOS) Odds ratio: 0.14 0.25 95% CI: 0.08-0.24 0.17-0.38 N control 1402 539 N surgery 1489 517 Sjöström L et al NEJM 2004;351:2683-2693
Outcome after bariatric surgery Diabetes remission (SOS) Sjöström L et al NEJM 2004;351:2683-2693
Outcome after bariatric surgery HbA1c (Randomized) Schauer et al NEJM 2014
Outcome after bariatric surgery Cardiovascular disease (MI) 8 Cumulative incidence, % 6 4 2 0 Individuals with MI, n Control 87 Surgery 64-28.5% HR = 0.715 95% CI: 0.518 to 0.987 P= 0.0411 0 2 4 6 8 10 12 14 16 Years of follow up Sjöström et al NEJM 2006 Schauer et al NEJM 2014
Outcome after bariatric surgery - Mortality (SOS) 8-28.5% 6 4 HR = 0.715 95% CI: 0.518 to 0.987 P= 0.0411 2 0 0 2 4 6 8 10 12 14 Years of follow up Sjöström L et al NEJM 2004;351:2683-2693
Outcome after bariatric surgery - Kidney function 8 6 4 HR = 0.715 95% CI: 0.518 to 0.987 P= 0.0411 2 0 0 2 4 6 8 10 12 Years of follow up Iaconelli et al. Diabetes Care 2011
Summary Volumes of bariatric surgery increasing Effects on: Weight Co-morbidities Quality of life Mortality Invasive procedures (risks) Pre- and postop assessment crucial Life-long follow up mandatory