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Jarrod Phelps PA-C Surgical Associates

Grinnell, IA

Good Afternoon!!

Objectives

1)  Recognize common issues after bariatric surgery

2)  Recognize the most serious clinical situations

3)  Identify & describe treatment for the various conditions

Bariatric Terminology �  IBW: Ideal Body Weight:

Men: IBW = 50 kg + 2.3 kg/inch >5ft.

Women: IBW = 45.5 kg + 2.3 kg/inch >5ft v  If the actual body weight is greater than 30%

of the calculated IBW, calculate the adjusted body weight (ABW): ABW = IBW + 0.4(actual weight - IBW)

�  BMI: Body Mass Index

Bariatric Terminology

�  EBW: Excess Body Weight � EBW = Current weight – IBW � %EBWL: Percent excess body weight

lost

Obesity By Definition

BMI >30

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Calculating BMI

� U.S. BMI Formula = (weight in pounds * 703 ) height in inches²

Or

� Metric Formula= (weight in kilograms) height in meters²

BMI Categories

� BMI <18.5: Underweight � BMI 18.5-24.9: Healthy weight � BMI 25-29.9: Overweight � BMI 30-34.9: Obese (OB I) � BMI 35-39.9: Morbid Obesity (OB II) � BMI >40: Super Morbid Obesity (OB III)

Obesity Epidemic �  Three in five

Americans are overweight/obese

�  Among adults has doubled since 1980, among adolescents has tripled

�  300,000+ premature deaths annually

�  75% of obese children become morbidly obese adults

Obesity Mortality As your BMI increases your

mortality risk grows exponentially!!

Obesity Demographics- 1985 Obesity Demographics- 2009

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Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.

Prevalence of Self-Reported Obesity Among U.S. Adults

by State and Territory, BRFSS, 2014

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.

Obesity % By State- 2014 1: Arkansas 2: West Virginia 3: Mississippi 4: Louisiana 5: Alabama 6: Oklahoma 7: Indiana 8: Ohio 9. North Dakota 10: South Carolina 11: Texas 12: Kentucky 13: Kansas 14: (tie) Tennessee & Wisconsin 16: Iowa 17: (tie) Delaware & MIchigan 19: Georgia 20: (tie) Missouri, Nebraska, Pennsylvania 23: South Dakota 24: (tie) Alaska & North Carolina 26: Maryland

27: Wyoming 28: Illinois 29: (tie) Arizona & Idaho 31: Virginia 32: New Mexico 33: Puerto Rico 34: Maine 35: Oregon 36: Nevada 37: Minnesota 38: New Hampshire 39: Washington 40: (tie) New York & Rhode Island 42: New Jersey 43: Montana 44: Connecticut 45: Florida 46: Utah 47: Vermont 48: California 49: Massachusetts 50: Hawaii 51: District of Columbia 52: Colorado

Health Care Costs Of Obesity

• $200 billion obesity-related costs annually

• 9.4% of national health budget • 33% increase in inpatient and

outpatient spending • 77% increase in medication use • High cost drivers: Co-morbidities

with Obesity

Psychological Impact of Obesity

• Depression • Low self-esteem • Social isolation • Uncomfortable in public • Lack intimacy • Decreased libido

Social Implications of Obesity

• Unable or Difficult to: – Go to movies – Sit on bus or in theater/plane seat – Use seat belt – Fit through turnstile – Play/pick up children – Maintain adequate hygiene – Buy stylish clothes

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Obesity Consequences �  With BMI > 30

– 55% increase in mortality – 70% increase in coronary artery disease – 75% increase in stroke – 400% increase in diabetes

�  Morbidly obese males between 25 and 35 have 12x the chance of mortality as normal weight men

�  A morbidly obese adult has a 33% chance of living to age 65 as that of a normal weight person

Common Comorbidities Hypertension Sleep Apnea Osteoarthritis Hyperlipidemia Coronary Artery

Disease Diabetes Mellitus GERD PCOS Metabolic Syndrome

Stroke DVT/PE Depression Venous insufficiency Joint and Back Pain Skin ulcers & infections Infertility Hypoventilation

Syndrome

Metabolic Syndrome Metabolic Syndrome

Obesity Treatment Options

• No Medical Intervention (most common) • Behavioral Therapy • Pharmaceutical • Hypnosis • Diet • Endoscopic • Surgical (Increasing Awareness and

Popularity)

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Non-Operative Treatment • Combinations of medical, dietary,

behavioral, pharmacologic, and exercise –majority of studies of short duration – average weight loss less than 20-25 lbs

– combined dietary/behavioral therapy – sustained weight reduction uncommon (<5%)

– lifelong behavior modification required

Non-Operative Treatment • Diet control works well for people not morbidly

obese – ie 20-50 pounds over ideal body weight – “yo-yo” effect poses health risks in decreased immunity

– 95% of patients regain all or more weight than was lost

In general, ineffective (and often harmful) for morbidly obese patients

• Traditional bariatric surgery – Effective, but very low utilization; 1:300 to 1:500 (Improving)

Hormonal Obesity Factors GOAL of Bariatric Surgery

• Significant and Sustained Weight Reduction

• Improve Health • Improve Quality of Life • Increase Lifespan • Not Cosmetic—this is only a desired

additional effect

Comorbidity Improvement Evolution of Obesity

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Criteria for Surgery

• BMI > 40 kg/m2 and/or • BMI >35 kg/m2 with co-morbidities • Patient has made attempts at non-

operative weight loss • Patient willing to make healthy lifestyle

changes

Bariatric Program Requirements

Surgical Options • Types of weight loss surgeries A) Malabsorptive procedures shorten the

digestive tract 1) Biliopancreatic diversion with/without duodenal switch aka BPD/DS

B) Restrictive procedures reduce how much the stomach can hold

1) LAP-BAND 2) Sleeve Gastrectomy C) Combined procedures shorten the digestive tract and reduce how much the stomach can hold

1) Roux-en Y Gastric Bypass

Biliopancreatic Diversion with Duodenal Switch The Duodenal Switch procedure (also called vertical gastrectomy with duodenal switch, biliopancreatic diversion with duodenal switch, DS or BPD-DS) is performed by approximately 50 surgeons worldwide. It generates weight loss by restricting the amount of food that can be eaten (removal of stomach or vertical gastrectomy) and by limiting the amount of food that is absorbed into the body (intestinal bypass or duodenal switch). It is more controversial because it has a significant component of malabsorption (bypass of the intestinal tract), which seems to augment and help maintain long-term weight loss. Of the procedures that are currently performed for the treatment of obesity, it seems to be the most powerful and effective, but may also have more complications associated with it. Because of this, some insurance companies will not authorize it and consider it investigational. Most surgeons do not perform this procedure because of concerns about the long term effects of malabsorption.

Common Side Effects after BPD/DS Increased incidence of nutritional deficiencies Increased protein deficiencies

Where are Nutrients Absorbed? Area Between the lines indicate the bypassed portion of the

digestive system after BPD/DS

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Roux en Y Gastric Bypass Roux-en-Y gastric bypass surgery: a 15-30 mL gastric pouch is created and is anastomosed end-to-side to a Roux limb to create the Roux limb, the surgeon transects the jejunum at approximately 30 cm from the ligament of Treitz. The Roux limb is measured 75 cm distally, or 150 cm distally for the massively obese patient, and a stapled side-to-side anastomosis is created with the proximal jejunal limb. The enterotomy sites are stapled closed, and the mesenteric defects of the jejunum and transverse colon are sutured closed. The Roux limb can be brought to the pouch through or anterior relative to the transverse mesocolon and is either ante- or retrogastric. Food no longer goes to the larger portion of the stomach. Because none of the original stomach is removed, its secretions can travel to the duodenum. The divided portion of the jejunum is reconnected distally.

Normal vs Roux en Y

Acute Postop surgical issues/ Early complications �  Serious

�  Anastomotic Leak �  Internal Hernias �  PE/DVT �  Acute Hemorrhagic

Anemia �  Acute Respiratory

Failure �  Gastric Outlet

Obstruction

Others �  Pneumonia �  Atelectasis �  Superficial Wound

Infections �  Gastric Outlet

Stricture/Edema �  Deep Space

Infections �  Dehydration

UGI

Gastric Outlet Stricture before and during balloon Dilatation Late Complications

�  Internal Hernia � Marginal Ulcers � Gastrogastric Fistula � Dumping Syndrome � Weight Regain � Vitamin Deficiencies

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Peterson’s Internal Hernia Marginal Ulcer

Gastrogastric Fistula

Dumping Syndrome Symptoms

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Vitamin Deficiencies �  Vitamin B12 �  Iron �  Folate �  Thiamin �  Copper �  Pyridoxine (B6) �  Vitamin A �  Vitamin K �  Vitamin E

�  Zinc �  Magnesium �  Vitamin D �  Niacin �  Selenium �  Calcium �  Protein

Vitamin Supplementation �  Sleeve/Lap Band �  Roux en Y

�  1 MVI with Folic Acid Daily

�  2 MVI Daily with

Folic Acid

B12 Supplementation

�  500 mcg-1 mg po q day �  If compliant and still deficient consider

increasing to 2 mg po q day or 1000mcg IM injections q week x 8 weeks, then 1000 mcg injection q month

Thiamin Supplementation

� B-Complex Multivitamin Daily

�  If Neuro Symptoms- 100 mg IV and may need repeat doses

Iron Supplementation

� Encourage MVI choice with high Iron content

� May need additional FeSO4 325 mg po BID or Elemental Iron 65 mg po BID

� Consider Fe Infusions for refractory Fe Deficient patients

Calcium & Vitamin D Supplementation

� Vitamin D 800-2000 IU Daily �  Take 300-600 po tid �  If refractory increase to 50,000 IU q week

� Calcium 1500-2000 mg daily recommendation �  Take 500-600 mg po tid

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Protein Supplementation

�  60-80 grams per day Sleeve Gastrectomy

Sleeve gastrectomy is a purely restrictive procedure. It can be used as a primary weight loss operation or as a first-stage operation in a 2-stage approach in patients who are extremely obese and may carry significant risks to undergo a one step definitive surgical approach. The sleeve gastrectomy is an operation in which the left side of the stomach is surgically removed. This results in a new stomach which is roughly the size and shape of a banana.

Lap Band

A gastric band with a small balloon inside is attached around the top portion of your stomach, forming a smaller “gastric pouch”. The placement of the band creates a small pouch at the top of the stomach that holds up to approximately 30 ml, which works out to about 1/8 cup. You are inclined to eat less because the pouch holds less food than the whole stomach. As the upper part of the stomach registers itself as being full, it sends a message to the brain saying that the entire stomach is full. This is the main principle behind the lap band procedure

Normal vs Lap Band Lap Band

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WTF? – What To look For!! Slipped Lap Band

Repair of Slipped Lap Band Repair Slipped Lap Band

Lap Band Tubing Causing Bowel Obstruction

Help Fight Obesity

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Sources Scopinaro N, Gianetta E, Pandolfo N, et al. Biliopancreatic bypass. Proposal and preliminary experimental study of a new type of operation for the functional surgical treatment of obesity. Minerva Chir. 1976;31:560–566.- retrieved 3/14/2016 Scopinaro N, Gianetta E, Adami GF, et al. Biliopancreatic diversion at eighteen years. Surgery. 1996;119:261–268- retrieved 3/14/2016 Hatzifotis M, Dolan K, Fielding G. Vitamin A deficiency following biliopancreatic diversion. Obes Surg. 2003.- retrieved 3/14/2016 Cho M, Pinto D, Carrodeguas L, et al. Frequencyand management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: Review of 1400 consecutive cases. SOARD 2006;2(2):87–91.- retrieved 3/15/2016

Sources Aills L, Blankenship J, Buffington C, et al. Allied Health Sciences Section Ad Hoc Nutrition Committee. ASMBS Allied Health Nutritional Guidelines for the surgical weight loss patient. Surg Obes Relat Dis. 2008;4(Suppl):S73–108. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468646/table/t1-0550329/- retrievded 3/16/2016 Taylor K. Metabolic and bariatric surgery [fact sheet]. American Society for Metabolic & Bariatric Surgery Web site. http://www.asbs.org/Newsite07/media/asmbs_fs_surgery.pdf.- retrieved 3/15/2016 http://springerplus.springeropen.com/articles/10.1186/s40064-015-1556-8- retrieved 3/16/2016 Iannelli A, Buratti MS, Novellas S, et al. Internal hernia as a complication of laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007;17:1283–1286

Sources D'Haeninck A, De LP, Swinnen F. Internal herniation after Roux-en-Y gastric bypass: case reports and a review of the literature. Acta Chir Belg. 2009;109:385–391 Nguyen NT, DeMaria E, Ikramuddin S, et al., editors. The SAGES Manual: A Practical Guide to Bariatric Surgery. New York: Springer; 2008. Papasavas PK, Caushaj PF, McCormick JT, et al. Laparoscopic management of complications following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc. 2003;17:610–4. Marshall JS, Srivastava A, Gupta SK, et al. Roux-en-Y gastric bypass leak complications. Arch Surg. 2003;138:520–3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468646/figure/f6-0550329/- retrieved 3/16/2016 Christou NV, Look D, Maclean LD. Weight gain after short and long limb gastric bypass in patients followed for longer than 10 years. Ann Surg. 2006;244:734–40.

Sources Eckhauser A, Torquati A, Youssef Y, et al. Internal hernia: Postoperative complication of Roux-en-Y gastric bypass surgery. Amer Surg 2006 Christou NV, Look D, Maclean LD. Weight gain after short and long limb gastric bypass in patients followed for longer than 10 years. Ann Surg. 2006;244:734–40. Odom J, Zalesin KC, Washington TL, et al. Behavioral predictors of weight regain after bariatric surgery. Obes Surg. 2010;20:349–56. Lopez PP, Patel NA, Koche LS. Outpatient complications encountered following Roux-en-Y gastric bypass. Med Clin North Am. 2007;91:471–83.