1. The Medical Complications of Bariatric Surgery Jeanette Newton Keith MD Associate Professor University of Alabama at Birmingham Department of Nutrition Sciences Department of Internal Medicine (www.eatright.uab.edu)

2. Background More than one million people are classified as morbidly obese in the United States More than one million people are classified as morbidly obese in the United States Bariatric surgery has emerged as a definitive therapy for long-term treatment of obesity Bariatric surgery has emerged as a definitive therapy for long-term treatment of obesity The three to five year success rate is 54-75% for surgery versus a 6-8% three-year success rate with medical weight management programs The three to five year success rate is 54-75% for surgery versus a 6-8% three-year success rate with medical weight management programs

3. Background Between 1990 to 1997, 12,203 people underwent bariatric surgery Between 1990 to 1997, 12,203 people underwent bariatric surgery The annual rate has increased from 2.7 per 100,000 people (1990) to 6.3 per 100,000 people (1997) The annual rate has increased from 2.7 per 100,000 people (1990) to 6.3 per 100,000 people (1997) In 2006, approximately 177,600 cases were performed per the American Society for Bariatric Surgery In 2006, approximately 177,600 cases were performed per the American Society for Bariatric Surgery Some estimate that > 205,000 surgeries will be performed this year (Source: American Society for Metabolic and Bariatric Surgery) Some estimate that > 205,000 surgeries will be performed this year (Source: American Society for Metabolic and Bariatric Surgery)

4. “To Cut or Not To Cut” Medical Therapy 5-10% excess weight loss Medical Therapy 5-10% excess weight loss Pharmacologic Intervention 8-10% EWL Pharmacologic Intervention 8-10% EWL Bariatric Surgery60-80% EWL Bariatric Surgery60-80% EWL

5. Bariatric Surgery : Failure of medical therapy-3-5 yr attempt Life-threatening complications of obesity Severe obesity (BMI >40 or >35 with complications ) Indications for Bariatric Surgery : Failure of medical therapy-3-5 yr attempt Life-threatening complications of obesity Severe obesity (BMI >40 or >35 with complications ) Monitoring pre-surgery: Monitoring pre-surgery: Minimum of 6 months medical therapy Followed by MD, DO or FNP ∆Wt, Food logs, exercise, psych Blue Cross Blue Sheild of IL

6. Types of Bariatric Procedures Malabsorptive: Jejuno-ileal bypass Biliopancreatic Diversion Duodenal Switch (DS), no bypass Malabsorptive: Jejuno-ileal bypass Biliopancreatic Diversion Duodenal Switch (DS), no bypass Restrictive: Vertical banded gastric bypass Laproscopic adjustable gastric banding Restrictive: Vertical banded gastric bypass Laproscopic adjustable gastric banding Restrictive and Malabsorptive: Roux-en Y gastric bypass Distal gastric bypass with DS Restrictive and Malabsorptive: Roux-en Y gastric bypass Distal gastric bypass with DS

7. Surgical Advantages of Pure Gastric Restriction 50% excess weight loss at 1 year 50% excess weight loss at 1 year Minimal nutrition complications Minimal nutrition complications Can be used in populations that are high risk for RYGB Can be used in populations that are high risk for RYGB

8. Surgical Advantages of Combined Gastric Restriction & Malabsorption Advantages of Gastric Bypass : 60% of excess weight lost in year 1 Maintains a weight loss of 50% for 25 years Rapid resolution of metabolic syndrome Improvement in obesity-related complications Advantages of Gastric Bypass : 60% of excess weight lost in year 1 Maintains a weight loss of 50% for 25 years Rapid resolution of metabolic syndrome Improvement in obesity-related complications Advantages of the Duodenal Switch: 60-80% of excess weight lost in year 1 Advantages of the Duodenal Switch: 60-80% of excess weight lost in year 1 Most effective therapy for super obese

9. Combined Gastric Restriction & Malabsorption Operative Risks: (vs. cholecystectomy) Operative Risks: (vs. cholecystectomy) Perioperative Mortality 1-2%vs. 0.2-0.8% Early Complications10% vs. 2.9% Late Complications20%vs. 1-2% Limitations: Limitations: Widening of (unbanded) gastrojejunostomy Expansion of gastric pouch 25% with nearly 100% weight regain*** Adaptation of limb that receives the food

10. Combined gastric restriction & malabsorption Potential complications: 1) severe dumping syndrome - rapid rush of liquid/soft high caloric food “dumping” into limb of small intestine….discomfort, nausea, bloating, diarrhea, weakness 2) Abnormalities in iron, calcium, B12, and possibly magnesium homeostasis Potential complications: 1) severe dumping syndrome - rapid rush of liquid/soft high caloric food “dumping” into limb of small intestine….discomfort, nausea, bloating, diarrhea, weakness 2) Abnormalities in iron, calcium, B12, and possibly magnesium homeostasis 3) Profound rapid weight loss

11. Weight Loss Benefits vs. Nutritional Risk

12. Risk of Deficiencies Determined by the type of surgical intervention Determined by the type of surgical intervention  Restrictive Minimal risk  MalabsorptiveModerate risk  CombinationHigh risk Risk increases as: Risk increases as:  the length of the common channel decreases, and  the degree of malabsorption increases

13. Risk of deficienciesDeficiencyRYGBPDS Protein4.7%3-5% Calcium15-43% 15-57% 1 yr 63% 4 yr Iron 33-50% 1 yr 49-52% 3yr 35-74% 3 yr Ferritin44-50%44-50% Albumin2%2% Anemia 35-74% 5 yr

14. Risk of deficienciesDeficiencyRYGBPDS B1212-33%33% Thiamine“Common”“Common” Folate12%12% Vitamins A and E “Frequent” A- 69% E-4% K- 68% Vitamin D >30% 30 -63% Zinc“Frequent”“Frequent”

15. Other Nutrition Complications Refractory Hypoglycemia Refractory Hypoglycemia Vitamin C Deficiency Vitamin C Deficiency Selenium deficiency Selenium deficiency Copper deficiency Copper deficiency

16. Other Nutrition Complications Severe Protein Calorie Malnutrition Severe Protein Calorie Malnutrition Functional Pancreatic Insufficiency Functional Pancreatic Insufficiency Accelerated Weight Loss Accelerated Weight Loss Hepatic Failure Hepatic Failure Dehydration Dehydration

17. Other Post-surgical Complications Anastomotic leak or bleeding (1-2%) Anastomotic leak or bleeding (1-2%) Strictures (10-15%) Strictures (10-15%) Fistula formation Fistula formation Severe diarrhea Severe diarrhea Intusseption Intusseption

18. Other Post-surgical Complications Short Bowel Syndrome Short Bowel Syndrome Abdominal pain Abdominal pain Intestinal ischemia Intestinal ischemia Gastric erosions or ulceration Gastric erosions or ulceration Hernias- Hiatal, Incisional Hernias- Hiatal, Incisional

19. Non-Nutritional Psychosocial Complications Depression Depression Suicide Suicide Alcoholism Alcoholism Night Eating Syndrome Night Eating Syndrome Binge Eating Syndrome Binge Eating Syndrome Zwaan et al Int J Eat Disord 2006 Adams et al NEJM 2007 Hsu et al Psychosom Med 1998

20. Types of Bariatric Procedures Malabsorptive: Jejuno-ileal bypass Biliopancreatic Diversion Duodenal Switch (DS), no bypass Malabsorptive: Jejuno-ileal bypass Biliopancreatic Diversion Duodenal Switch (DS), no bypass Restrictive: Vertical banded gastric bypass Laproscopic adjustable gastric banding Restrictive: Vertical banded gastric bypass Laproscopic adjustable gastric banding Restrictive and Malabsorptive: Roux-en Y gastric bypass Distal gastric bypass with DS Restrictive and Malabsorptive: Roux-en Y gastric bypass Distal gastric bypass with DS

21. Laproscopic Adjustable Banding Nutritional Deficiencies: Protein Nutritional Deficiencies: Protein Endoscopic limits: Depends on lumen Retroflexion Endoscopic limits: Depends on lumen Retroflexion Increased risk of ischemia and necrosis Increased risk of ischemia and necrosis

22. Roux-en Y Gastric Bypass Nutritional d eficiencies: Vitamin B12 Calcium Iron Protein Nutritional d eficiencies: Vitamin B12 Calcium Iron Protein Endoscopic limits: Retroflexion ERCP Endoscopic limits: Retroflexion ERCP

23. Distal Roux-en Y Gastric BP Nutritional deficiencies: Vitamin B12 Calcium Iron Protein Nutritional deficiencies: Vitamin B12 Calcium Iron Protein Endoscopic limits: Retroflexion ERCP Endoscopic limits: Retroflexion ERCP

24. Duodenal Switch, with RYGB Pylorus and D1-sparing Pylorus and D1-sparing Nutritional deficiencies: Protein Magnesium Vitamin B12 Iron Calcium Nutritional deficiencies: Protein Magnesium Vitamin B12 Iron Calcium Endoscopic limits: ERCP Endoscopic limits: ERCP

25. Anti-obesity Surgery and Co-morbidities J Kral 1995, >1000 patients

26. Suggested Monitoring Monitoring Guidelines Frequent (no less than every 3 months) Frequent (no less than every 3 months)  Weight (more often in first 6 months)  CBC, Electrolytes, BUN, Cr, Ca, Mg, P  Glucose, Liver Tests, Albumin  Fat soluble vitamins-A,D.E and K  Vitamin B12, B1  Iron studies  Vitamin C, Selenium, Zinc, Copper  Pre-albumin (or Transferrin if renal disease)

27. Suggested Monitoring Occasional (at least annually) Occasional (at least annually)  Measured Height  Bone Mineral Density  PTH, 1,25-OH Vitamin D, Zinc, 24 hour urine calcium

28. Post Surgical Monitoring Weight loss progression* Weight loss progression*  Goal: not more than 1-2 lbs/d in 1 st mo Adequate Protein Intake Adequate Protein Intake Fluid status Fluid status Presutti et al, Mayo Clin Proc 2004

29. Goal Nutrient Intake Protein Protein (1-2 grams per kg of adjusted weight)  60 gram Gastric bypass  75 grams Duodenal Switch Fat Fat  25% total calories Carbohydrate Carbohydrate  15-30 grams per serving day in 4-6 servings Fluid Fluid  64 ounces

30. Potential Nutritional Limitations Meat and dairy intolerance Meat and dairy intolerance Nutrient malabsorption Nutrient malabsorption Vomiting, especially with over-consumption Vomiting, especially with over-consumption Constipation Constipation Dehydration Dehydration Dolan, Ann Surg 2004 Elliott Crit Care Nurs Q 2003

31. Post-surgical Supplementation Prenatal multivitamin or Flintstone chewable MVI with minerals (2/day) Prenatal multivitamin or Flintstone chewable MVI with minerals (2/day) Iron Polysaccharide 150 mg po BID for women Iron Polysaccharide 150 mg po BID for women Calcium Carbonate 500 mg po TID Calcium Carbonate 500 mg po TID Vitamin D 400 IU po qD Vitamin D 400 IU po qD Vitamin B12 500 mcg po qD Vitamin B12 500 mcg po qD Forse et al, Current Opin Endo Diabete 2000 Alvarez-Leite, Current Opin Clin Metab Care 2004

32. Nutrient Deficiencies Preventable with supplementation Preventable with supplementation Require lifelong compliance with supplements Require lifelong compliance with supplements Minimized by regular and routine monitoring Minimized by regular and routine monitoring

33. Nutrition Monitoring Challenges Few randomized protocols to address nutrition monitoring Few randomized protocols to address nutrition monitoring How often and for how long patients are to be followed is debated due to $$$ How often and for how long patients are to be followed is debated due to $$$ Timing of follow-up visits not clear Timing of follow-up visits not clear Routine vitamin replacement not covered by many carriers Routine vitamin replacement not covered by many carriers

34. Take Home Bariatric surgery can be life-saving for the right patient Bariatric surgery can be life-saving for the right patient Attention to adequate nutrition and vitamin supplementation is key Attention to adequate nutrition and vitamin supplementation is key Lifelong monitoring is essential Lifelong monitoring is essential