1. Weight Loss Surgery for the Primary Care Provider
Vanessa Hurta, FNP-BC

2. Objectives
Identify commonly performed bariatric surgeries and procedures
Describe effects of bariatric surgery on weight loss and comorbidities
Identify patients who may be appropriate candidates for bariatric surgery
Recognize complications of bariatric surgery
Recall considerations for follow-up care of the patient post bariatric surgery

3. Who is a surgical candidate?
No or limited success with diet
Issues over a period of time
Obesity related comorbidities with BMI 35+
40+ BMI
Is there a better surgery for a particular patient?
Consider functional status, comorbidities (especially GERD and DM), need for steroids or NSAIDs

4. Gastric bypass (Roux-en-Y)
Malabsorptive (less absorbed by small intestine) and restrictive (smaller meals)
Stomach pouch is created (1 oz or 30 mL). Then the bottom of duodenum is brought up to to new pouch.
Large portion of stomach and duodenum is bypassed
Changes in hormones suppress hunger and allow for faster satiety
Can be reversed

5. Roux-en-Y Gastric Bypass Cont’d
60-80% excess weight loss, but people usually maintain > 50%
Due to malabsorption, vitamin and mineral deficiencies are more common

6. Comparison
Gastric sleeve
Gastric Bypass

7. Sleeve gastrectomy Primarily restrictive
Large portion (80%) of stomach is removed
Restrictive (smaller stomach)
Also affects hormones that suppress hunger and promote satiety
Some studies show weight loss similar to RYGB, some a little less, but generally people can maintain > 50% excess weight loss
Non-reversible
May cause or worsen GERD
Can also cause deficiencies but less likely

8. Balloons and bands
Bands falling out of favor due to issues with esophagus
An inflatable band is placed around the upper portion of the stomach
Inflated or deflated with saline through a port
Band can erode into stomach
Highest rate of reoperation
Intragastric Balloons
Saline filled silicone
Nausea and pain (usually short term), perforation
Not covered by insurance

9. Comparison
Gastric balloon
Gastric band

10. The bariatric process Usually about six months Seminar
Initial visit with provider
Lab screening (and treatment)
Nutrition visits
Mental health
Exercise
Pre-operative class
Pre-op exam with surgeon
Operation
Post operative visits

11. For some: Sleep apnea evaluation and treatment
Smoking and drug cessation
Cardiac or renal clearance
H pylori treatment
Household contacts

12. Initial recovery Most done laparoscopically
Stay 1-3 nights at hospital
Discharged on liquid diet
Short term complications include leaks (within first 30 days), stenosis (can be acute or delayed)
Hydration and walking are most important things to do post-operatively

13. Exercise requirement Recommendations follow national recommendations
If having trouble with lower extremities usually can still find a routine
Will be necessary for maintenance
Can start walking right away, clear routine with surgeon at 2 week post-op visit
Weight training

14. Major Complications Leaks Stenosis/strictures Ulcers
Internal hernias **
Always refer/consult for abdominal pain
Incisional hernias

15. Leaks
First few weeks
Pain, temperature, distension
Surgical revision

16. Stenosis/stricture Inability to tolerate food and drink
Problems swallowing
Pain/fullness
Nausea/vomiting
Treatment is to dilate

17. Marginal ulcers Common Treatment/prophylaxis Risk factors
Pain after eating, nausea, vomiting
Treatment/prophylaxis
Risk factors
Smoking
Alcohol
Medications
Diabetes

18. Medicines to avoid post-op
Oral/IV steroids
NSAIDS
aspirin
Immunomodulatory therapy
Biphosphonates
Certain forms of medications

19. Fertility Women often become more fertile
Recommend against pregnancy in first months post-op
Level 3 from MMWR no oral contraceptive pills or combined oral contraceptive pills for RYGB
Glucose screening test shouldn’t be done in post- RYGB or in other bariatric patients who get dumping syndrome

20. Bone loss and DEXA screening
Bone loss is found after bariatric surgery
May be good idea to screen at baseline
Treatment
Vitamin D and Ca++
Consider IV over PO biphosphonates if needed

21. Dumping syndrome
Goes from pouch to small intestine without being digested
Can be right after eating or delayed (see next slide)
Symptoms include cramping, nausea, flushing, tachycardia, diaphoresis, diarrhea, need to lie down
Usually after ingesting sugary beverages or food. Sometimes dairy or fat can cause symptoms.

22. Hyperinsulinemic Hypoglycemia
Delayed onset
In terms of years s/p bypass and time after meal
Postprandial, not fasting
Have neurological symptoms
Treatment
Eat more protein and fiber and less carbohydrates
Small frequent meals
Acarbose and nifedipine

23. Eating behaviors Small amounts, slowly increasing
Concentration on protein, can add some complex carbs after 6 months
Separating food and fluid
Chewing food
Food aversions
Pain and discomfort

24. What is the diet? Advancing stages
Minimal alcohol-weight and absorption changes
Maintenance diet
Very much a “normal” healthy diet emphasizing lean protein sources and small amounts of complex carbs
No carbonated beverages (even soda water)

25. Supplementation Multi-vitamins Vitamin B12 Vitamin D Calcium
Others as needed- zinc, vitamin A, thiamin

26. Protein supplementation
Protein requirements
At least 60 g for women and 80 g for men
Shakes, bars, drinks
Types of protein
Pitfalls of emphasis

27. Hair loss Expected due to acute weight loss and post surgery
Less likely due to deficiencies when in first year
Biotin, protein, iron

28. Deficiencies Thiamin deficiency Vitamin A deficiency
Peripheral nerve damage or Wernicke-Korsakoff
Nausea, headache, abdominal pain
Vitamin A deficiency
Blindness

29. Medical weight loss Many options Can refer before or after surgery
Medicines or shakes
Can refer before or after surgery

30. Outcomes Diabetes remission Sleep apnea Hypertension Hyperlipidemia
Gastric bypass
Sleep apnea
Hypertension
Hyperlipidemia
Quality of life
Outcomes can be mediated by weight loss, hormonal changes or a combination of both

31. Reoperations
Reoperations may be due to complications or weight regain (revision)
Complications
Weight regain
How do we define success?
Cholecystectomy
Weight loss can cause gallstone formations
Success should also be defined by the patient or could be a resolution or improvement in certain comorbidities

32. Sources https://asmbs.org
ASMBS Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 update: Micronutrients, Parrott, Julie et al., SOARD, volume 13, Issue 5,
Clinical Practice GuidelinesforthePerioperativeNutritional,Metabolic,and NonsurgicalSupportoftheBariatricSurgeryPatient—2013Update:CosponsoredbyAmericanAssociationofClinicalEndocrinologists, TheObesitySociety,andAmericanSocietyforMetabolic &BariatricSurgery , Mechanick et al., SOARD, volume 9,