Transcript
Bariatric Surgery:An Overview for the InternistAndrea Cherrington
November 20, 2007
Case vignette
26 yo white female 2 weeks progressive lower extremity
weakness, blurred vision, urinary incontinence “Sluggish,” mild personality change PMHx:
Roux-en-Y gastric bypass150 lb weight loss since surgeryMultiple admissions for N&V, IV hydration
Case vignette
Physical examNormal vital signs
(+) Horizontal nystagmus
(+) Bilateral ophthalmoplegia
Unable to walk
Lower extremity exam: 2/5 strength, areflexia
Upper extremities exam normal
Case vignette
What is on the differential diagnosis? What would you do next?
Laboratory tests? Imaging studies?
What are the most common complications after bariatric surgery?
What can we do in primary care to prevent complications?
Outline
Bariatric surgeryBackground information
Who and when to refer Long-term follow-up
Potential complicationsRecommendations for management
Obesity epidemic
Obesity is an epidemic condition in the United States and around the world.
Associated with increased risk of hypertension, diabetes, hyperlipidemia, sleep apnea, coronary heart disease and stroke.
Increase in rates of obesity could lead to decline in overall life expectancy in the United States.
Obesity Trends* Among U.S. AdultsBRFSS, 1990
*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person
No Data <10% 10%–14%
http://www.cdc.gov/nccdphp/dnpa/obesity/
Obesity Trends* Among U.S. AdultsBRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity epidemic
Factors influencing weight:Behavior (diet, exercise)
Personal characteristics Environment Cultural attitudes Financial situation
Genetic Helps determine susceptibility
Obesity epidemic
Treatment optionsLifestyle modification
Diet Exercise
MedicationBariatric Surgery
Increasing interest
Number of weight loss operations performed in the United States
0
10000
20000
30000
40000
50000
60000
70000
80000
1993 1998 2002
JAMA. 2005;294:1909-1917.
Bariatric Surgery: Definition
Procedure to reduce
caloric intake by modifying
the GI tract Three categories
RestrictiveMalabsorptiveMixed
Restrictive procedures
Limit food intake by creating small gastric reservoir with narrow outlet (<10%)
Procedures include:Gastric stapling (gastroplasty)Adjustable gastric banding
Wrapping a synthetic, inflatable band around the stomach to create a small pouch
N Engl J Med. May 24 2007;356(21):2176-2183.
Malabsorptive procedures
Bypass varying portions of the small intestine where nutrient absorption occurs (>90%)Jejunoileal bypass (JIB)
Resulted in significant weight loss Abandoned secondary to severe metabolic
consequences
Jejunocolonic bypass (JCB)
Mixed procedures
Combine malabsorption and restrictionProximal Roux-en-Y (RYGB)
Most commonly performed bypass procedure in the United States
Weight loss occurs from reduction in gastric volume with restricted intake, dumping syndrome, and a degree of malabsorption
Biliopancreatic diversion (BPD)BPD-Duodenal switch
Bariatric Surgery: Mixed
N Engl J Med. May 24 2007;356(21):2176-2183
Bariatric Surgery: Evidence
No large, RCTs comparing surgery with medical management
2005 Cochrane Review: Identified 2 small RCTs, 3 cohort studiesWeight loss of 20 to 50kg with surgery vs.
modest weight gain with medical treatment.Weight loss greater with malabsorptive
procedures than restrictive procedures.
N Engl J Med. May 24 2007;356(21):2176-2183
Bariatric Surgery: Evidence
Swedish Obese Subjects Trial (SOS)Only large, well-controlled prospective study
2,010 surgically treated patients vs
2,037 control subjects
Weight change greater for surgical patients 23% of body weight lost vs 0.1% gain (2 yrs) 16% of body weight lost vs 1.6% gain (10 yrs)
N Engl J Med. May 24 2007;356(21):2176-2183
Bariatric Surgery: Evidence
Improvements seen in conditions associated with obesityDiabetes, hyperlipidemia, hypertension,
sleep apnea Benefits diminish over time but still
significant2yrs vs 10 yrs
Referral for surgery: Who & when
“A 44-year old obese woman has seen her primary care physician for the past 10 years for management of DM, HTN and GERD. Despite her best efforts to lose weight, her body mass index has increased from 40.0 to 46.6. During a routine office visit, she asks her physician whether bariatric surgery might be a treatment option for her. The physician does not recommend referral for surgical evaluation, citing concerns about variable effectiveness of the procedure, associated risks and lack of long term outcome data. The patient then seeks a specialist in bariatric surgery for evaluation, without the assistance of her physician.”
Duke Weight Loss Surgery Center, NEJM 356:21
Referral for surgery: Who & when
Criteria: BMI > 40
Almost 5% of adults in the U.S. BMI > 35 + high risk condition
Severe sleep apnea Obesity-related cardiomyopathy Severe diabetes mellitus
Additional: Failure of medical weight control Absence of medical or psychologic contraindications Strong patient motivation to comply with postsurgical regimen
Referral for surgery: Who & when
Comprehensive weight and nutrition history Weight trends, previous weight loss efforts
Determine current weight, height and BMI Medication history
Antidepressants, OCPs, oral hypoglycemics Evaluation for conditions associated with obesity
Diabetes, hypertension, hyperlipidemia, coronary disease sleep apnea, pulmonary hypertension
Psychological evaluation
Referral for surgery: Who & when
Psychological evaluation Patients with Axis I or II disorder less likely to
lose weight after surgery Other psychosocial factors associated with
suboptimal surgical outcomes include: Disturbed eating habits, (e.g. binge eating) Substance abuse Low socioeconomic status Limited social support Unrealistic expectations of surgery.
Referral for surgery: Who & when
Prior to undergoing surgery Preoperative education, including realistic
expectations Comprehensive long-term plan necessary Increases chances of safety and success
Do not proceed with surgery if Plan for systematic follow-up not in place Patient does not agree to the plan up front
Who is this man?
Acute complications of BS
In 2002, Charlie Weis, the 330lb offensive coordinator for the New England Patriots underwent gastric stapling.
An acute bleed led to an ICU stay and a 2 week coma.
Charlie sued the hospital and physicians but was unsuccessful.
Acute complications of BS
Mortality rates 0.1 – 2.0% Common causes of death
Pulmonary embolism Anastomotic leak
Non-fatal peri-operative complications Venous thromboembolism Anastomotic leaks Wound infection Bleeding Incisional and internal hernias Early small bowel obstruction
Long Term Complications: Nausea & Vomiting Occurs in 30% of all bariatric patients Occurs in 50% of patients undergoing restrictive
procedure Dehydration, electrolyte imbalance Protein-calorie malnutrition Thiamine deficiency with neurological sequelae
Long Term Complications: Nausea & Vomiting Common causes after bariatric surgery:
Inadequate chewing Overdistension of pouch by fluid Large volume meals Food intolerance (red meat, lactose) Stomal outlet stenosis/obstruction Marginal ulceration Intestinal obstruction Gastroesophageal reflux disease Symptomatic gallstones Medications Dumping syndrome
Long Term Complications: Diarrhea Can occur as a result of
Food sensitivity Lactose intolerance Malabsorption Bacterial overgrowth and infection Dumping syndrome
Can lead to dehydration and electrolyte imbalance
Long Term Complications: Dumping syndrome Occurs in more than 75% of patients after Roux-
en-Y Neurohormonal: facial flushing, light-headed,
palpitations, fatigue and diarrhea Triggered by ingestion of concentrated sugars Generally subsides after 12-18 months Prevention: small, frequent meals, avoid foods with
high sugar content. Chew food thoroughly, eat slowly
Long Term Complications: Nutritional Deficiencies Iron Folate Vitamin B12 Calcium Deficiency of fat soluble vitamins (D,E,A,K) Thiamine (vitamin B1) Zinc Protein malnutrition (after long limb or distal
bypass)
Long Term Complications: Nutritional Deficiencies
Severity and pattern depend on Presence of pre-operative deficiencies Type of procedure performed Degree of restriction Length of bypassed intestine Modification of eating behavior Development of complications (ex. emesis) Compliance with oral MVI & mineral supplements
Review: what gets absorbed where?
Long Term Complications: Nutritional Deficiencies Occur more commonly with malabsorptive and
mixed procedures Nutritional deficiencies are uncommon with
purely restrictive procedures unless Eating habits are excessively restricted or
complications occur (emesis) Folate is the most common deficiency after restrictive
procedures
Long Term Complications: Post-surgical Additional
complications include: Bowel obstruction Anastomotic leaks Strictures Erosions
Ulcers Adhesions Hernias Cholelithiasis
Long Term Complications: Post-surgical Common complications of gastric banding:
Gastric prolapse 5-10% Gastroesophageal dilation 5-10% Band erosion 0-2%
Symptoms include nausea & vomiting, also heartburn, nocturnal reflux, dysphagia
After RYGB, 4-20% of patients develop stenosis of the gastrojejunostomy
Recommended management
Key to management of complications is prevention when possible
Dietary recommendationsFailure to modify eating habits will results in
vomiting and discomfort Life-long multivitamin and mineral supplements
Recommended management
Dietary modification Reduce food volume consumed, chew food very
well, slow pace of eating Do not consume fluids with food
30 minutes before or after meal Protein rich-food should be major component of
each meal Cheese, fish, poultry, eggs & meat 40-60g/day after RYGB 60-90g/day after BPD-DS
Avoid empty calories
Recommended management
Dietary supplements All patients should receive
Multivitamin with iron Vitamin B12, B complex with thiamine Vitamin C Calcium
Additional supplements may be needed for menstruating or pregnant women
Depending on procedure, patient may need fat soluble vitamin supplements (BPD)
Recommended management
Am J Med Sci. Apr 2006;331(4):219-225.
Case vignette
Routine lab tests: NL Low
Vitamin B12 Vitamin B6 Vitamin C Vitamin D
Very low Thiamine
Other vitamin/mineral levels were normal
Case vignette
Wernicke’s encephalopathy Thiamine deficiency Potential complication of bariatric surgery Presents with ocular changes (nystagmus,
ophthalmoplegia), ataxia, mental status change After several months on MVI, daily thiamine,
patient’s ophthalmoplegia and nystagmus resolved, lower extremity weakness improved somewhat.
Additional information
For additional information on Impact of bariatric surgery on CVDz Psychosocial impact of bariatric surgery; before
and after Financial impact of bariatric surgery
Check out Medical Clinics of North America, 91(2007)
Thanks to Jeanette Keith and Andrea Braun
References1. Allen JW. Laparoscopic gastric band complications. Med Clin North Am. May
2007;91(3):485-497, xii.2. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med. May 24
2007;356(21):2176-2183.3. Lopez PP, Patel NA, Koche LS. Outpatient complications encountered following Roux-
en-Y gastric bypass. Med Clin North Am. May 2007;91(3):471-483, xii.4. Malinowski SS. Nutritional and metabolic complications of bariatric surgery. Am J Med
Sci. Apr 2006;331(4):219-225.5. Markel TA, Mattar SG. Management of gastrointestinal disorders in the bariatric patient.
Med Clin North Am. May 2007;91(3):443-450, xi.6. Mathier MA, Ramanathan RC. Impact of obesity and bariatric surgery on cardiovascular
disease. Med Clin North Am. May 2007;91(3):415-431, x-xi.7. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in
the United States in the 21st century. N Engl J Med. Mar 17 2005;352(11):1138-1145.8. Powers KA, Rehrig ST, Jones DB. Financial impact of obesity and bariatric surgery. Med
Clin North Am. May 2007;91(3):321-338, ix.9. Tucker ON, Szomstein S, Rosenthal RJ. Nutritional consequences of weight-loss
surgery. Med Clin North Am. May 2007;91(3):499-514, xii.10. Wadden TA, Sarwer DB, Fabricatore AN, Jones L, Stack R, Williams NS. Psychosocial
and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin North Am. May 2007;91(3):451-469, xi-xii.
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