Complications and Benefits of Bariatric Surgery Tracy Robinson PAS 646 Advisor: Dr. Hadley

Objectives Obesity Statistics Bariatric Surgery options Post-surgical complicatioins Nutritional consequences Improvements in co-morbidities Psychological and QOL improvements Why do PAs need to be aware?

Obesity Statistics 33% US population is obese (BMI ≥ 30 kg/m2) 8 million people in US morbidly obese (BMI ≥ 40 kg/m2) Between 1986 and 2000…… Obesity doubled Morbid obesity quadrupled Super obesity (BMI ≥ 50 kg/m2) increased five-fold

Obesity Statistics cont….. Men > 50% overweight = double mortality Men > 50% overweight + DM = 5x mortality Women > 50% overweight = 2x mortality Women > 50% overweight + DM = 8x mortality 5% total healthcare costs US $60 billion

Bariatric Surgery 1990 – 2000 → 4925 to 41,000 2005 → 130,000 2010 → 218,000 Bariatric surgery criteria BMI ≥ 40 kg/m2 without co-morbid disease BMI ≥ 35 kg/m2 with concurrent co-morbid disease

Roux-en-Y Gastric Bypass 15 to 25 ml gastric pouch with 1 cm outlet Bypass distal stomach, duodenum, first segment of jejunum Bypass 75 -150+ cm jejunum 65% -70% EBW loss Decrease BMI 35% www.obesitycenter.org/ images/bg_roux2.gif

www.weighlite.com/images/ content/gastric-diag.jpg LAP-BAND No physiological changes or resections Band around upper stomach creates 15 ml pouch Port of adjustment attached to abdominal wall Inflate/deflate 6 times a year 50% EBW loss www.weighlite.com/images/ content/gastric-diag.jpg

Post-surgical Complications Anastomosis leaks or staple line leaks PE or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks Up to 7-10 days after surgery Most common at gastrojejunostomy, enteroenterostomy, Roux limb stump, staple line Can lead to peritonitis, sepsis, possible death Presentation Tachycardia, tachypnea Fever Ab pain/back pain Pelvic pressure or rebound tenderness

Anastamosis Leaks Order Gastrograffin upper GI series Subclinical cases Bowel rest Parenteral nutrition IV antibiotic if H. pylori Clinically suspect leak Laparoscopic evaluation and leak repair Failure to evaluate is the most common cause of preventable, major long-term disability or death in bariatric surgical patients

Pulmonary Embolism Sudden cause of death up to one month after surgery 20%-30% mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism Presentation Immediate spiral chest CT Profound hypoxia Hypotension Signs of sepsis Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too large…….NO SURGERY

Cholelithiasis Up to 36% of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric surgery and cholecystectomy Prophylactic use of urosidol Expensive and unpalatable

Stomal Ulceration 12%-15% within 2-4 mos. Post-surgery Etiology Overabundant acid in pouch leads to excessive acid passing through stoma Pouch tension and staple line breakdown NSAID use Presentation Dyspepsia, vomiting Epigastric or retrosternal pain

Stomal Ulceration Treatment If no response to treatment PPI, carafate Antibiotics if H. Pylori Avoid NSAIDS, alcohol, smoking If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome More than 15% patients Hypotention Tachycardia Lightheadedness, syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education Eat slowly Avoid drinking before, during and not until 30 minutes after meals.

Constipation Most common complaint Causes Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery Treat with increased fluids and stool softeners

Nutritional Consequences Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency Not seen with purely restrictive surgeries

Iron deficiency and anemia Common following RYGB As high as 49% of patients Multifactorial cause Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or proximal jejunum Decrease in iron-rich food consumption due to intolerance Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency Up to 70% of patients Lack of hydrochloric acid and pepsin in stomach Prevents B12 cleavage from food Affects secretion of intrinsic factor, thus B12 absorption Intolerance to meat and milk Oral supplementation usually adequate, otherwise, IM injections used

Folate Deficiency 40% of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 1/3 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is bypassed Intolerance to dairy, foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to Bone resorption, osteomalacia, osteoporosis Treat with calcium citrate supplementation and 2 weekly doses of Vitamin D

Improvements of Co-morbidities Type 2 diabetes mellitus Hypertension Hyperlipidemia Degenerative joint disease Sleep apnea GERD 5% to 10% weight reduction is associated with significant decrease in risk Weight loss from surgery reduces or eliminates medications Improves severity or resolves co-morbid disease

Improvements of Co-morbidities 2 years after surgery diabetes mellitus was resolved in 83% of pre-operative diabetic patients (Sugerman et. al 2005) 2 years following surgery 69% had resolution of hypertension 8 years post-surgery there was complete relapse in those with gastric banding 25% decrease in total cholesterol and 40% decrease in triglycerides 6 to 12 months after surgery

Psychological and Psychosocial Improvements Depression Low self-esteem and self-appraisal Poor interpersonal relationships Feelings of failure and dissatifaction with life Subject to prejudice and discrimination

Psychological and Psychosocial Improvements “ Most obese patients consider impaired QOL the most crippling aspect of their disease, and after surgery consider enhanced QOL the greatest benefit” (Puzziferri 2005). “Obese individuals would rather have a normal weight with a severe disability such as be deaf, have heart disease, have an amputation and others rather than be obese without any of these conditions” (Livingston 2003).

Psychological and Psychosocial Improvements Significant improvement in QOL with all types of surgery New vocational and social activities Improved interpersonal relationships Better moods, self-esteem More employable, get paid more, work more and take less sick days.

Why do PAs need to know this? We will be the long-term healthcare provider Consequences and complications last a lifetime Initial provider assessing signs and symptoms Track improvements Medication changes Stay educated in all specific needs and concerns of bariatric surgery patient!