BARIATRIC SURGERY EVALUATION AND PRE-OP ASSESSMENT CAMERON SIDDENS PGY-2

OVERVIEW Bariatric Surgery Surgical Options Risks and Benefits Choosing the Patient Pre-Op Evaluation

BARIATRIC SURGERY Hendrikson First Surgery Mason 1960s- Gastric Bypass 1991 NIH Consensus Statement

ROUX-EN-Y

GASTRIC SLEEVE

GASTRIC BAND(LAGB)

DUODENAL SWITCH (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)

BENEFITS Weight loss- 61% reduction after 3 years Hypertension-61% become normotensive DM2- 77% normalized A1C DLD- 70% normalized lipids OSA- 85% cure rate Mortality- NEJM 2007 showed significant risk reduction from deaths caused by DM2, Cardiac Disease, HTN.

RISKS Short Term Outcomes -conversion to open, bleeding, infection, anastomotic leak Long Term Outcomes - Vitamin deficiencies, cholelithasis, Dumping syndrome, Hernias, Stomach perforation Mortality risk - patients >65 around 4%

WHO TO CHOOSE Unlikely to lose weight or keep it off over the long term using other methods? Well informed about the surgery and treatment effects? Aware of the risks and benefits of surgery? Ready to lose weight and improve his or her health? Aware of how life may change after the surgery? (For example, patients need to adjust to side effects, such as the need to chew food well and the loss of ability to eat large meals.) Aware of the limits on food choices, and occasional failures? Committed to lifelong healthy eating and physical activity, medical follow- up, and the need to take extra vitamins and minerals?

CRITERIA FOR SURGERY BMI is still the gold standard for objectively measuring obesity BMI> or = 40 BMI> or =35 + co morbidities(HTN, DM2, OSA) BMI 30 to 35 -FDA approved in 2013 *All patients must have gone through life style modifications before surgical consideration.

PRE-OP EVAL History and Physical Examination - rule out secondary causes -past procedures, reactions to anesthesia -recent infections -chronic conditions -social/psychological Laboratory/Imaging Assessment - tailor it to your patient (cbc, cmp, U/A, TSH, cortisol, Coag’s, CXR, EKG)

PRE-OP EVAL Pulmonary Assessment -All patients referred for Bariatric Surgery will be considered “high-risk” given their obesity status -PFTs, CXR Nutritional Assessment -Albumin <3.2

CARDIAC EVALUATION ACC and AHA recommend all patients undergo cardiac risk assessment for non- cardiac procedures. -3 Main Factors: The Patient, exercise capacity and the Surgery -Surgery (low, intermediate, high risk) ~around 1-5% chance of Cardiac Event -+/- EKG, TTE depending on patient’s cardiac history

OBESITY SURGERY MORTALITY RISK(OS-MRS) OS-MRS is the first validated risk scoring system in bariatric surgery Risk factorPoints Age > 45 years1 Hypertension1 Male sex1 Risk factors for pulmonary embolism 1 Body mass index ≥ 50 kg per m 2 1 Total:––––––––––– Obesity Surgery Mortality Risk Score SCORE Low 0-1 Intermediate 2-3 High 4-5

OTHER CONSIDERATIONS Know your patient Insurance – BCBS, Medicare, Medicaid, Self-Pay Post Surgery and Beyond -HTN, DM, DLD, GERD, nutritional defiencies

SOURCES Uptodate NIDDK website Fajnwaks P, Ramirez A, Martinez P, Arias E, Szomstein S, Rosenthal R (May 2008). "P46: Outcomes of bariatric surgery in patients with BMI less than 35 kg/m2". Surgery for Obesity and Related Diseases 4 (3): 329"P46: Outcomes of bariatric surgery in patients with BMI less than 35 kg/m2" MODIFIED FROM GOODNEY PP, SIEWERS AE, STUKEL TA, LUCAS FL, WENNBERG DE, BIRKMEYER JD. IS SURGERY GETTING SAFER?NATIONAL TRENDS IN OPERATIVE MORTALITY. J AM COLL SURG 2002; 195:219–227. BARIATRIC SURGERY DATA FROM FLUM DR, SALEM L, ELROD JA, DELLINGER LP, CHEADLE A, CHAN L. EARLY MORTALITY AMONG MEDICAREBENEFICIARIES UNDERGOING BARIATRIC SURGICAL PROCEDURES. JAMA 2005; 294:1903–1908. Macpherson DS, Lofgren RP. Outpatient internal medicine preoperative evaluation: a randomized clinical trial. Med Care. 1994;32:498–507. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr 1992;55:Suppl 2:615S-619S The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361: ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery