Presentation on theme: "Mr Pratik Sufi Consultant Bariatric & Upper GI Surgeon Spire Bushey Hospital."— Presentation transcript:
Mr Pratik Sufi Consultant Bariatric & Upper GI Surgeon Spire Bushey Hospital
Balancing Activity Levels with Food 1.One small chocolate chip cookie (50 calories) is equivalent to walking briskly for 10 minutes. 2.The difference between a large gourmet chocolate chip cookie and a small chocolate chip cookie could be about 40 minutes of raking leaves (200 calories). 3.One hour of walking at a moderate pace (20 min/mile) uses about the same amount of energy that is in one jelly filled doughnut (300 calories). 4.A fast food "meal" containing a double patty cheeseburger, extra-large fries and a 24 oz. soft drink is equal to running 2½ hours at a 10 min/mile pace (1500 calories). 5.One tsp sugar (20cal) 4 min walk 6.One can coke (160cal) 30 min walk Physical ActivityCalories Burnt / 30 minutes Walking leisurely @ 2mph85 Walking briskly @ 4mph170 Gardening135 Raking leaves145 Dancing190 Bicycling leisurely @ 10mph205 Swimming laps, medium level240 Jogging @ 5mph275
Pulmonary Disease Abnormal Function Obstructive Sleep Apnea Hypoventilation Syndrome Asthma Hepato-pancreato-biliary Disease Steatosis (NALD) Steatohepatitis (NASH) Cirrhosis Gall Bladder Disease Pancreatitis Coronary Heart Disease Diabetes Dyslipidemia Hypertension CCF Gynecologic Abnormalities Abnormal Menses Infertility Polycystic Ovarian Syndrome Musculoskeletal Osteoarthritis Gout Skin Dermatitis Leg ulcers Cancer Breast, Uterus, Cervix, Colon, Esophagus, Pancreas, Kidney, Prostate Vascular Phlebitis / DVT Venous stasis Leg ulcers Herniae Umbilical Ventral Inguinal Cerebral Idiopathic Intracranial Hypertension Stroke Cataracts Obesity OnLine Slide Presentation. Accessed May 17, 2007. Accessible as slide #5 at http://www.obesityonline.or g/slides/slide01.cfm?tk=33. Obesity Associated Co-morbidities GI GORD & Hiatus Hernia
Impact of Obesity on GP Consultations BMI Percentage 2025303540 15 10 20 25 30 Brown WJ et al. Int J Obes 1998;22:520-528. Low BMI was associated with fewer physical health problems than mid-level or higher BMI. Indicators of health care use showed a J-shaped relationship with BMI for general practitioners (>5 GP Consultations). Prevalence of medical problems (for example, hypertension OR 6x and diabetes OR 6x), surgical procedures (cholecystectomy OR 7x and hysterectomy OR 2x) and symptoms (for example, back pain OR 40% and constant tiredness OR 70%) increased monotonically with BMI.
Effect of Diet and Surgery on Weight & Mortality Diet & exercise effective up to 6m 60% failure at 1 yr. 80% failure at 2 yrs. 100% failure at 5 yrs. Surgery effective long-term (80%) Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects N Engl J Med 2007;357:741-52.
High Risk Low efficacy – less durable weight loss High efficacy – durable weight lossEffective but unacceptable risk Low Risk Primary Obesity Options Today Diet/ Drugs Surgery Endolumenal Obesity Moderate risk / efficacy – intermediate durability Abandoned Surgery Lap Band Gastric Balloon POSE Endosheath Less Effective More Effective Sleeve Gastrectomy Gastric Bypass BPD/DS VBG Jejuno-Ileal Bypass 20-60% 40-95%
Referral - Minimal Dataset Age Weight & BMI Co-morbidity esp. cardiovascular respiratory endocrine GI and musculo-skeletal Medication Previous attempts at weight loss Other concerns like Untreated eating disorders Psychiatric history NICE: BMI35 ASMBS: BMI30 Asians: BMI 2 points lower
Pre-operative Special Considerations Hypertension control ACE Inhibitors AT2 receptor antagonists Glycaemic control Oral hyperglycaemic agents Insulin Anticoagulation Warfarin Clopidogrel Aspirin OSA CPAP GORD PPI NAFLD / NASH Liver shrinkage diet
Post-operative Regime Liquids only for 2-3 weeks Soft blended food for 2-3 weeks Resume solids after 4-6 weeks Small mouthfuls Chew well Eat slowly Separate eating and drinking by ½ hour Avoid fizzy / sugary drinks or sugary food Medication – liquid / soluble (crushed) Supplements Iron Calcium and vitamin D Vitamin B12 Folic acid Vitamin B1 Recommended Multivitamin and minerals: Chewable versions: Bassetts Adult Chewable multivitamins with prebiotics & minerals Wellkid Smart / Sanatogen A-Z Kids Chewable Haliborange Chewable multivitamins Whole tablet: Sanatogen Gold or Centrum (after 3 months) Plus Chewable Calcium – 1000mg calcium /day Liquid iron or iron drops - 50mg of iron/day
Post-operative – Suitable Fluids D0-W2 Milk - Aim for at least two pints (1.2L) of milk or a milk alternative a day Milk can be flavoured with Nesquick or low calorie hot chocolate Slimming drinks e.g. Slimfast or chemist/supermarket own brand Complan or Build-up shakes or soups Yogurt drinks and smoothies Still mineral water, if taking the flavoured types make sure they are low sugar Still low-sugar squashes Smooth soups e.g. cream of tomato or chicken; or oxtail Tea and coffee without sugar Unsweetened pure fruit juice
Post-operative Special Considerations Diet Not allowed to eat and drink together Eat slowly, chew well – at least 20-30 minutes Liquids for 24-48hours after band adjustment Return to work Change in medications Restrictions on tablets – soluble, liquids or crushed tablets Change in co-morbidity Antihypertensive Oral hyperglycaemic agents Insulin Change in absorption Warfarin Oral contraceptives Avoid pregnancy for 18 months Risk to mother Risk to foetus
MechanismPrevalenceClinical Protein Intake, absorption,Distal RYGB 6-13% Standard RYGB 0% Peak 1-2 yrs Loss of muscle, weakness, oedema, etc. Iron Intake, Acid exposure, absorption 2 yr: 33%Anaemia, tinnitus, hair loss Vitamin B12 (cobalamin) Reduced acid, ?IF link 1 yr: 12 – 70% Within 2yrs: 25% Anaemia, macrocytosis Calcium & Vitamin D Intake, absorption, HyperPTH Distal RYGB: 2yr Ca 10%, Vit D 51% BPD Ca 25-50%, Vit D 17 – 50% MBD – Osteomalacia, osteoporosis Liposoluble Vitamins (A, E, K) Reduced fat breakdown RYGB: very low BPD (4yr): A-69%, K-68%, E-4% A: night blindness Zinc Absorption – dependent on lipids Surgical stress RYGB: rare BPD: 10 – 50% Hair loss Nutritional Deficiencies
Diagnosis and Treatment of Nutritional Deficiencies Deficiency Symptoms and signs Confirmation Treatment first phase Treatment second phase Protein malnutrition Weakness, decreased muscle mass, brittle hair, generalized oedema Serum albumin and prealbumin levels, serum creatinine Protein supplements Enteral or parenteral nutrition; reversal of surgical procedure Calcium/ Vitamin D Hypocalcaemia, tetany, tingling, cramping, metabolic bone disease Total and ionized calcium levels, intact PTH, 25-D, urinary N- telopeptide, bone densitometry Calcium citrate 1,200–2,000 mg, oral vitamin D 50,000 IU/d Calcitriol oral vitamin D 1,000 IU/d Vitamin B12 Pernicious anaemia, tingling in fingers and toes, depression, dementia Blood cell count, vitamin B12 levels Oral crystalline B12 350 mg/d 1,000 –2,000 mg/2–3 months im Folic acid Macrocytic anaemia, palpitations, fatigue, neural tube defects Cell blood count, folic acid levels, homocysteine Oral folate, 400 mg/d (included in multivitamin) Oral folate, 1,000 mg/d Iron Decreased work ability, palpitations, fatigue, koilonychia, pica, brittle hair, anaemia Blood cell count, serum iron, iron binding capacity, ferritin Ferrous sulphate 300 mg 2–3 times/d, taken with vitamin C Parenteral iron administration Vitamin A Xerophthalmia, loss of nocturnal vision, decreased immunity Vitamin A levelsOral vitamin A, 5,000–10,000 IU/d Oral vitamin A, 50,000 IU/d An Endocrine Society Clinical Practice Guideline
Schedule for Clinical and Biochemical Monitoring An Endocrine Society Clinical Practice Guideline TESTSPre-operative1 month3 months6 months12 months18 months24 monthsAnnually Complete blood countXXXXXXXX LFTsXXXXXXXX GlucoseXXXXXXXX CreatinineXXXXXXXX ElectrolytesXXXXXXXX Iron/ferritinX Xa Vitamin B12X Xa FolateX Xa CalciumX Xa Intact PTHX Xa 25-DX Xa Albumin/prealbuminX Xa Vitamin AX Optional ZincX Optional Bone mineral density and body composition X Xa Vitamin B1 Optional Xa – Tests should only be performed after RYGB, BPD, or BPD/DS. X – Tests suggested for patients submitted to restrictive surgery where frank deficiencies are less common.
Pulmonary Disease Pneumonia / Atelectasis HPB Disease Hepatitis (trauma) Pancreatitis (trauma) Cholecystitis CV Disease MI DVT / PE Beriberi Gynecologic Abnormalities Amenorrhoea Fertility – failure of contraception Bone Disease Osteomalacia Malnutrition Dermatitis Neuropathy Ataxia Cerebrovascular Disease Wernickes Encephalopathy (Beriberi) Stroke / TIA Malnutrition Glossitis, stomatitis Hair loss Post-Bariatric Surgery Complications GI Disease Bleeding GORD & Hiatus Hernia Ulcer Bloating / Obstruction Diarrhoea / Constipation Malabsorption Renal Disease Kidney stones
Case Study 1 Mr A, 32 year old publican, gastric bypass 3 year ago, lost 85% excess body weight Tripping over repeatedly – 4 months. Nausea and vomiting, pins and needles in hands and feet Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine? GP referred patient to neurologist Differential diagnosis: Thiamine / Vitamin B12 deficiency Investigation: RBC thiamine / Serum Vit B12 + ECHO + MRI brain Treatment: Thiamine 100mg bd for 12 weeks Thiamine Deficiency Beriberi Wernickes encephalopathy Confusion, irritability, memory loss, nervousness, speech difficulties SoB, orthopnoea, tachycardia Constipation, digestive problems, loss of appetite Numbness of hands and feet, pain sensitivity, poor coordination, weakness, absent knee and tendon reflexes, paralysis
Case Study 2 Mrs B, 42 year old housewife, gastric band 2 years ago, lost 64% excess body weight Sudden onset epigastric pain and dysphagia Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine? Differential diagnosis: Band slippage Band erosion Investigate: Contrast swallow CT abdomen OGD Band slippage – Emergency band deflation + reposition / removal Band slippage Epigastric pain Dysphagia Weight regain Band erosion Epigastric pain Loss of restriction Weight regain Band infection
Case Study 3 Mrs X, 37 year old writer, gastric bypass 6 months ago, lost 45% excess body weight Intermittent epigastric pain and nausea Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine? Differential diagnosis: Anastomotic ulcer Gallstones Internal hernia Investigate: USS, Contrast swallow, CT abdomen, OGD Diagnosis: Gallstone cholecystitis Treatment: Laparoscopic cholecystectomy Anastomotic ulcer Epigastric pain, heartburn Gallstones Epigastric / RUQ pain, N&V, Pancreatitis Internal hernia Abdominal cramps after eating, constipation, bloating, acute abdomen
Case Study 4 Mr Y, 27 year old computer analyst, gastric bypass 3 years ago, lost 75% excess body weight Abdominal pain, bloating, nausea and diarrhoea Refer to hospital – Emergency / Urgent / Routine? Differential diagnosis: Bacterial overgrowth Malabsorption Internal hernia Investigate: Bloods, ABG, CT abdomen, D-Xylose test, Hydrogen breath test, Stool culture, Faecal fat Diagnosis: Bacterial overgrowth Treatment: Correct nutritional deficiencies and Metronidazole + Live yogurt / Neomycin + Rifampicin Bacterial overgrowth Abdominal cramps, diarrhoea, borborygmi Malabsorption SoB, orthopnoea, tachycardia Internal hernia Abdominal cramps after eating, constipation, bloating
Case Study 5 Ms Q, 42 year old teacher, gastric band 2004, lost 60% excess body weight Cough, reflux and water brash for the last 3 weeks. Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine? GP started her on Amoxicillin and referred for an OGD Differential diagnosis: RTI, band slippage, over-restricted band Investigation: Gastrograffin swallow + OGD Treatment: Band volume reduction - defill Over-restricted band Cough, reflux and water brash Unable to tolerate solids Unable to lie down without coughing Band slippage Epigastric pain Intolerant to solids / liquids Weight regain
Take Home Message Bariatric surgery is a cost-effective treatment for obesity which leads to resolution of co-morbidities, improved quality of life and increased life expectancy However, patients need lifelong follow-up after surgery in order to avoid harm – this can be performed by their surgical team and by the primary care. Patients can present with nausea, vomiting, dysphagia, reflux, abdominal pain and neurological symptoms. Common things are common! Nutritional deficiencies are common and easily preventable.