Post Operative Care/Considerations of the Bariatric Patient in
Primary Care
Slide 3
Identify obesity as a major health problem Describe the
socio-economic impact on people who suffer from morbid obesity
Discuss the surgical options for obesity. Identify key components
to the pre-operative evaluation of bariatric patients. Discuss the
after care of the surgical bariatric patient including laboratory
and GI tests Discuss post operative complications that may appear
in the primary care office.
Slide 4
Slightly underweight insects, fish, reptiles, birds, mammals
and people live longer than the overweight. To lengthen thy life,
lessen thy meals. Benjamin Franklin
Slide 5
Obesity- over ideal weight by 30% or BMI over 30 Morbid
Obesity- Clinically severe obesity-point where serious medical
conditions occur as a direct result of the obesity Defined as
>200% of ideal weight, >100 lb overweight, or a body mass
index of 40
Slide 6
Eating out/ordering in & foods not healthy Portion sizes
increased (soda 6 oz to 20oz) Consumption of soft drinks (600 12
oz/pp/per year, males 12y-29y=1/2 gal/d or 160 gal/yr) Rushed meals
Junk food is advertised, cheap and available No time to exercise
Technology especially for children Unrealistic expectations
Slide 7
Body Mass Index (BMI) BMI = Formula: weight (lb) / [height
(in)]2 x 703 Calculate BMI by dividing weight in pounds (lbs) by
height in inches (in) squared and multiplying by a conversion
factor of 703. Example: Weight = 150 lbs, Height = 55 (65")
Calculation: [150 (65)2] x 703 = 24.96 W.H.O. Classification BMI
Ideal Weight 20 24.9 Overweight 25 29.9 Moderate Obesity 30 34.9
Severe Obesity 35 39.9 Morbid Obesity 40 49.9 Super Obesity 50+++
(MenWaist 40 inches Women Waist 35 inches) More adverse health
effects with increased fat inside the abdominal cavity.
Slide 8
World epidemic of obesity - Estimated about 1.7 billion people
- 25% of industrialized world 97 million Americans (> 2/3
population) are overweight/obese. Has tripled in last 20 years.
Obesity costs in US about $100 billion/yr in direct health care
expenses/lost productivity. 300,000 deaths annually in US obesity
related.1 in 6 morbidly obese people will die within 10 years.
(from research Ohio State University) Less than 2% morbidly obese
people will succeed in loosing and keeping off weight with diet and
exercise on their own.
Discrimination Studies show society has low respect for
morbidly obese Many have limited number of friends Many obese
individuals report being treated disrespectfully by an M.D. Social
isolation, depression & low esteem
Slide 12
Weight loss surgery is not a magic pill. It will not make you
suddenly slim, happy, & beautiful or give you a perfect life.
It is a tool to assist you and is a part of an entire program to
help you lose the your excess weight. WLS can make you healthier
and decrease your risk of early death associated with obesity.
Slide 13
Laparoscopic duodenal switch Laparoscopic RNY Gastric Bypass
Laparoscopic Adjustable Gastric Band Laparoscopic Sleeve
Gastrectomy Revision surgery - Conversion from band to RNY or
Sleeve - Conversions from VBG to RNY - Failed previous RNY
Slide 14
Slide 15
Most durable technique, been performed in some variations since
1967 Most studied, best understood good programs will provide best
long-term maintenance Requires modification of food preferences
enforced by dumping syndrome Laparoscopic versions preferred, much
easier on patient 75-80% EWL at three years It is reversible
Negatives: higher initial complication rate (lower late
complication rate), need to supplement vitamins and minerals for
life, potential for malnutrition with non-compliance
Slide 16
Early (any abdominal pain, get CT scan) Staple line leak
(0.25-3%), most occur 3-12 days post-op, rare after 3 weeks. GI
bleeding - (0.5-5%), usually from staple lines Dilated loops
(2-5%), ileus, SBO, internal hernia, kinks; worry is perforation of
bypassed stomach Death (0.2%) first 30 days either PE or bowel
leak
Slide 17
Vitamin deficient Common are Vitamin B12, Calcium, Folic Acid
Some food intolerance & alcohol - more rapidly absorbed and can
lead to early intoxication. Dumping syndrome-especially after large
amounts of sugar. Symptoms=heart racing, sweating, nausea, stomach
cramps, diarrhea, fatigue Bowel obstructions - 1%+Caused by
Internal Hernia CT Scan for dx. dilated bypassed stomach, dilated
small bowel, deviated SMA vessels dx laparoscopy Stricture/Stenosis
(2-8%), if cannot keep down H20 suspect stricture diagnosed by UGI,
EGD (rare after 3 months unless smoker) Ulcers of pouch - 1%
(Smokers), double with NSAID use, diagnose with EGD Cholelithiasis
gallbladder sonogram (5 - 25%), rare before 6 weeks post-op,
increases w/ excessive fats or dairy in diet (Ursodial)
Slide 18
Average weight loss of 77% at one year. After 10-14 years
approx. 70% patients have maintained approximately 70% of their
weight loss. 96% of patients saw a reduction or resolution of
co-morbidities.
Slide 19
Restrictive (limits amount of food eaten) Adjustable can adapt
to changing needs Low immediate complication rate (higher later
complication rate) Easy on patient outpatient surgery Less
dependent upon supplementation Slow but steady weight loss 1-2 lbs.
per week, average 40-60% EWL at three years Negatives Half of
patients only reach 50% EWL mark, requires lots of maintenance,
doesnt reinforce food choices; frequent adjustments needed, slip,
erosion, esophageal dilatation, and port problems
Slide 20
Slide 21
Slippage (Prolapse) 2 10% Port Problem 2 7% Erosion 0.5 1%
Esophageal Dilation 1 2% Death 1 IN 1500 from pulmonary emboli
Greater Chance re-operation Persistent dysphagia Up to 25% of bands
being removed after 5 yrs.
Slide 22
Slide 23
Bleeding from suture line (0-6.4%) Gastric leak from suture
line (1-1.4%) Excess narrowing or post op stricture (1-2%) Pouch
dilatation over time (5-10%) Post op nausea (usually goes away in 2
week Post op heartburn (27 with one co-morbidity Do not use
preg./breast feeding, glaucoma, hyperthyroid Phendimetrazine
(Bontril) 35mg/ 2-3 x daySame as phenteramine
Slide 29
Skin hygiene-document with pictures in the medical record
Proper nutrition (60 grams of protein and 60 oz of fluids/day)
Proper vitamins- if hospitalized then use a banana bag daily
Medicines should be taken one at a time with plenty of water
in-between. Avoid NSAIDS and aspirin but if have to take aspirin it
should be chewable. Checking laboratory data periodically as
recommended. Never put down an NG tube Encourage pt not to
smoke!
Slide 30
Slide 31
36 y/o female presents to your office with 2 year history of
gastric banding c/o dry cough especially at night when lying down,
heart burn, GERD for last 2 weeks. Now c/o productive cough with
temperatures of 100.6. VS 144/90-100.8-100-28. pulse ox=94%. CBC
shows WBC of 14.3 with slight shift to left. PE unremarkable except
rales at left base. Had a fill 3 weeks ago. What is the most likely
diagnosis? What do you think is going on? What is your plan of
care?
Slide 32
You order a chest x-ray and is shows pneumonia which you treat
with antibiotics, rest and plenty of fluids. You ask her to follow
up in one week. What is the next step in the care of this
patient?
Slide 33
48 y/o female with history of gastric bypass 18 months ago and
has done very well with losing over 110 lbs and is now at her goal
weight. She presents to your office with persistent abdominal pain
that is worse after eating and occurs almost every time after
eating for the last 3 weeks and progressively getting worse.
Occasional waive of nausea but no vomiting and bowels are moving
normally maybe slightly slower but no constipation. PE is normal
except tenderness at mid to left abdominal pain above the umbilicus
VS wnl. CBC, CMP, UA all normal What is your next step? What do you
think is going on?
Slide 34
You first order a gallbladder sonogram which is normal. Then
you order a CT scan of the abdomen and it shows an internal hernia.
What is your next step and what usually will be done in this
case?
Slide 35
32 y/o female presents to the officewith abdominal pain and
distention, nausea and vomiting and no BM for 3 days. She is 9
months post op gastric bypass. VS-138/88- 98.8-94-24 What test
should be ordered? What do you think is going on?
Slide 36
You order a obstruction series and it shows a small bowel
obstruction. What would be your next step?? What would normally
happen with this patient??
Slide 37
Obesity is a chronic disease Modest weight loss (5% -10% of
body weight) can have considerable medical benefits Lifestyle
change (diet behavioral changes and physical activity) is the
cornerstone of therapy Pharmacotherapy can be useful in properly
selected patients Bariatric surgery is the most effective therapy
for obesity