Presentation is loading. Please wait.

Presentation is loading. Please wait.

Perioperative Care of the Bariatric Patient Mark Kadowaki, MD, FACS Wellmont Surgical Services Kingsport, Tenessee.

Similar presentations


Presentation on theme: "Perioperative Care of the Bariatric Patient Mark Kadowaki, MD, FACS Wellmont Surgical Services Kingsport, Tenessee."— Presentation transcript:

1 Perioperative Care of the Bariatric Patient Mark Kadowaki, MD, FACS Wellmont Surgical Services Kingsport, Tenessee

2 Objectives Be familiar with the perioperative concerns that face the bariatric patient Be familiar with the perioperative concerns that face the bariatric patient Be aware of the signs of complications after bariatric surgery Be aware of the signs of complications after bariatric surgery Plan for initial management and stabilization of the patient suffering postoperative complications Plan for initial management and stabilization of the patient suffering postoperative complications

3 Bariatric Procedures

4 Bariatric Surgery: Postoperative Concerns nts/Guidelines/asbs_bspc.pdf Bariatric Surgery: Postoperative Concerns nts/Guidelines/asbs_bspc.pdf nts/Guidelines/asbs_bspc.pdf nts/Guidelines/asbs_bspc.pdf Emergency Care of the Bariatric Patient Emergency Care of the Bariatric Patient ASMBS_ER_Poster pdf ASMBS_ER_Poster pdf Download the poster for your Emergency Department or Acute Care Clinic

5 Pre-Surgical Psychological Assessment Pre-Surgical Psychological Assessment nes/PsychPreSurgicalAssessment.pdf nes/PsychPreSurgicalAssessment.pdf nes/PsychPreSurgicalAssessment.pdf nes/PsychPreSurgicalAssessment.pdf Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient nes/aace-tos-asmbs.pdf nes/aace-tos-asmbs.pdf nes/aace-tos-asmbs.pdf nes/aace-tos-asmbs.pdf ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient nes/bgs_final.pdf nes/bgs_final.pdf nes/bgs_final.pdf nes/bgs_final.pdf

6 Non-Emergent Concerns

7 RNY Gastric Bypass and Dumping Syndrome Common “side effect” (85%) Common “side effect” (85%) Essentially a known result of the anatomic changes associated with the surgery Essentially a known result of the anatomic changes associated with the surgery Can range from mild to severe Can range from mild to severe Rapid emptying of the gastric pouch of refined sugars (HFCS) or other high glycemic carbohydrates or other osmotically concentrated foods, such as dairy products and some fats such as fried foods Rapid emptying of the gastric pouch of refined sugars (HFCS) or other high glycemic carbohydrates or other osmotically concentrated foods, such as dairy products and some fats such as fried foods

8 “Benefit” of Dumping Syndrome Negative feedback Negative feedback Causative foods will interfere with success of long-term weight loss Causative foods will interfere with success of long-term weight loss Patient is less likely to eat the same foods again Patient is less likely to eat the same foods again

9 Bad effects of Dumping Symptomatically uncomfortable Symptomatically uncomfortable Confusion with other etiologies Confusion with other etiologies Can be difficult to manage Can be difficult to manage May have short-term physiological consequences May have short-term physiological consequences

10 Two Types of Dumping Early: Early: minutes minutes Duration up to 60 minutes Duration up to 60 minutes Osmotic symptoms: Osmotic symptoms: sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lay down, upper abdominal fullness, nausea, diarrhea, cramping, active, audible bowel sounds sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lay down, upper abdominal fullness, nausea, diarrhea, cramping, active, audible bowel sounds Caused by release of gut hormones with vasoactive effects Caused by release of gut hormones with vasoactive effects

11 Two Types of Dumping Late: Late: 1-3 hours after eating 1-3 hours after eating Reactive hypoglycemia symptoms: Reactive hypoglycemia symptoms: Sweating, shakiness, loss of concentration, hunger, fainting and passing out Sweating, shakiness, loss of concentration, hunger, fainting and passing out Related to insulin surge overshooting glucose levels Related to insulin surge overshooting glucose levels

12 Diagnosis of Dumping Syndrome History: History: Classic symptoms related to food intake Classic symptoms related to food intake

13 Management of Dumping Syndrome Early Early Dietary compliance with an appropriate diet Dietary compliance with an appropriate diet Late Late Dietary compliance Dietary compliance Intake of a small amount of sugar (1/2 glass juice) 1 hour after a meal Intake of a small amount of sugar (1/2 glass juice) 1 hour after a meal Acarbose or Somastostatin in resistant cases Acarbose or Somastostatin in resistant cases Rule out rare causes such as insulinoma Rule out rare causes such as insulinoma

14 Bowel Function after Bariatric Surgery Diarrhea Diarrhea Most common with Duodenal Switch procedures Most common with Duodenal Switch procedures Less common with RNY gastric bypass Less common with RNY gastric bypass Uncommon with Sleeve gastrectomy or Gastric banding Uncommon with Sleeve gastrectomy or Gastric banding Caused by FAs, undigested foods and Sorbitol (occurs naturally in fruits) Caused by FAs, undigested foods and Sorbitol (occurs naturally in fruits)

15 Management of Diarrhea Dietary: Dietary: Avoidance of fats Avoidance of fats Identify other trigger foods Identify other trigger foods Evaluate for previously unmasked lactose intolerance: eliminate dairy completely Evaluate for previously unmasked lactose intolerance: eliminate dairy completely Medical: Medical: Imodium or Lomotil Imodium or Lomotil Probiotics Probiotics Cholestyramine to bind bile salts Cholestyramine to bind bile salts

16 C diff Colitis Can occur up to 3 months after surgery Can occur up to 3 months after surgery Severe cramping, especially watery diarrhea, extremely foul flatus Severe cramping, especially watery diarrhea, extremely foul flatus Treat with Flagyl Treat with Flagyl Relapses common Relapses common Follow up with probiotics Follow up with probiotics

17 Constipation Common after bariatric surgery Common after bariatric surgery Causes: Causes: Insufficient intake of water Insufficient intake of water Insufficient intake of fiber Insufficient intake of fiber Diuretics (caffeine?) Diuretics (caffeine?) Nutritional supplements with Calcium and Iron Nutritional supplements with Calcium and Iron Narcotics Narcotics Management: Management: Increased water and fiber intake Increased water and fiber intake Avoidance of aggravating agents Avoidance of aggravating agents

18 Bowel Changes after Bariatric Surgery Caveat: Caveat: Don’t assume that all bowel function problems are related to bariatric surgery Don’t assume that all bowel function problems are related to bariatric surgery Recent changes in a previously stable patient Recent changes in a previously stable patient

19 Postoperative Dysphagia Most commonly associated with restriction procedures Most commonly associated with restriction procedures Symptoms: chest pressure or tightness in the throat Symptoms: chest pressure or tightness in the throat May be functional: May be functional: Eating too fast Eating too fast Eating too much Eating too much Not chewing well enough Not chewing well enough Tough foods Tough foods Breads, rice and pastas Breads, rice and pastas Overcooked steak or dry chicken breast Overcooked steak or dry chicken breast

20 Postoperative Dysphagia Treatment Treatment Better eating habits Better eating habits Failure to respond or severe symptoms Failure to respond or severe symptoms Band adjustment (loosening) or endoscopic dilation Band adjustment (loosening) or endoscopic dilation

21 Postoperative Nutrition Purely restrictive procedures Purely restrictive procedures Gastric Banding, Sleeve Gastrectomy, Vertical Banded Gastroplasty Gastric Banding, Sleeve Gastrectomy, Vertical Banded Gastroplasty Daily multivitamin Daily multivitamin Monitor protein intake Monitor protein intake 1 gm protein/kg ideal body weight/day 1 gm protein/kg ideal body weight/day

22 Postoperative Nutrition Primarily Restrictive with some malabsorption Primarily Restrictive with some malabsorption Gastric Bypass Gastric Bypass Calcium, Iron and B-complex vitamins supplemented at higher than daily recommended levels Calcium, Iron and B-complex vitamins supplemented at higher than daily recommended levels Prioritize protein intake Prioritize protein intake

23 Postoperative Nutrition Primarily Malabsorptive Procedures Primarily Malabsorptive Procedures BPD +/- DS BPD +/- DS Calcium, Iron Calcium, Iron Protein Protein Fat Soluble Vitamins (A, D, E, K) Fat Soluble Vitamins (A, D, E, K) Hydration Hydration Deficiencies can be resistant to therapy! Deficiencies can be resistant to therapy!

24 Nutritional Deficiencies Protein: Protein: Hair loss, Fatigue, Leg swelling Hair loss, Fatigue, Leg swelling Calcium Calcium Bone pain Bone pain Iron Iron Fatigue Fatigue Zinc Zinc Brittle nails Brittle nails Vit A Vit A Decreased night vision Decreased night vision

25 Nutritional Deficiencies Vit E Vit E Poor wound healing Poor wound healing Vit K Vit K Easy bruising Easy bruising Vit B1 (thiamine) Vit B1 (thiamine) Numbness and tingling in hands and feet Numbness and tingling in hands and feet Vit B12 (Methylcobalamin) Vit B12 (Methylcobalamin) fatigue fatigue

26 Exercise IMPERATIVE IMPERATIVE Weight loss will not occur without it Weight loss will not occur without it 40 minutes per day, 6 days per week, strenuous enough to breathe deeply but still able to converse 40 minutes per day, 6 days per week, strenuous enough to breathe deeply but still able to converse Light resistance training a benefit Light resistance training a benefit Some patients may be “exercise naïve” or even “alienated” Some patients may be “exercise naïve” or even “alienated”

27 Emergent Concerns

28 Emergency Presentations Unstable Vital Signs: Unstable Vital Signs: Fever > 102 F Fever > 102 F Hypotension Hypotension Remember incidence of hypertension Remember incidence of hypertension Tachycardia >120 bpm X 4 hours Tachycardia >120 bpm X 4 hours Tachypnea Tachypnea Hypoxia Hypoxia Decreased urinary output Decreased urinary output

29 Emergency Presentations Bleeding Bleeding Per mouth or rectum or drainage Per mouth or rectum or drainage Abdominal pain or colic > 4 hours Abdominal pain or colic > 4 hours Nausea + Emesis > 4 hours Nausea + Emesis > 4 hours Emesis + Abdominal pain Emesis + Abdominal pain

30 Principles of Management Critical Time Frames: Critical Time Frames: Diagnosis within 6 hours Diagnosis within 6 hours To OR in hours To OR in hours Critical Warnings Critical Warnings Alert Bariatric Surgeon Alert Bariatric Surgeon Patients typically have less physiologic reserve Patients typically have less physiologic reserve Avoid blind placement NG tube Avoid blind placement NG tube Avoid NSAIDs, ASA, Plavix, Steroids Avoid NSAIDs, ASA, Plavix, Steroids Use PPIs routinely Use PPIs routinely Be mindful of small volume of gastric pouch Be mindful of small volume of gastric pouch

31 Initial Assessment Serial PE and Vitals Serial PE and Vitals Labs: Labs: CBC, CMP, Amylase CBC, CMP, Amylase Imaging: Imaging: Chest Xray Chest Xray CT of Chest CT of Chest CT of Abdomen CT of Abdomen Upper GI Upper GI

32 Initial Management: FAST HUG Food: establish nutritional support early Food: establish nutritional support early Analgesia Analgesia Sedation: if on ventilator Sedation: if on ventilator Thrombo-embolism prophylaxis Thrombo-embolism prophylaxis Mechanical and Medical Mechanical and Medical Head of Bed: elevated 30 deg (aspiration) Head of Bed: elevated 30 deg (aspiration) Ulcer Prophylaxis: PPIs Ulcer Prophylaxis: PPIs Glucose Control: <150 Glucose Control: <150

33 Bleeding < 48 hours: staple line < 48 hours: staple line > 48 hours: marginal ulcer > 48 hours: marginal ulcer Oral: gastric pouch Oral: gastric pouch Melena or rectal blood: duodenal ulcer, bypassed stomach or bowel source Melena or rectal blood: duodenal ulcer, bypassed stomach or bowel source EGD: consider GA in OR EGD: consider GA in OR Increased risk of perforation with intervention Increased risk of perforation with intervention

34 Leaks and Sepsis Presentation: unstable VSs within 72 hours of bariatric surgery Presentation: unstable VSs within 72 hours of bariatric surgery Persistent or progressive tachycardia is most sensitive Persistent or progressive tachycardia is most sensitive Similar presentation to PE Similar presentation to PE Imaging can be negative Imaging can be negative

35 Obstruction Presentation: Presentation: Abdominal pain > 4 hours associated with vomiting Abdominal pain > 4 hours associated with vomiting Do NOT place NG tube Do NOT place NG tube Diagnostics: Diagnostics: CT abdo with contrast or UGI CT abdo with contrast or UGI Increased risk for aspiration due to small volume of stomach Increased risk for aspiration due to small volume of stomach Consider EGD prior to anesthesia to R/O GOO and empty contrast material to decrease risk of aspiration Consider EGD prior to anesthesia to R/O GOO and empty contrast material to decrease risk of aspiration

36 Obstruction Special Concerns : Special Concerns : Acute bleed causing obstruction secondary to clots Acute bleed causing obstruction secondary to clots Internal hernias after gastric bypass Internal hernias after gastric bypass Evaluation/imaging / PE may be negative Evaluation/imaging / PE may be negative Dilated distal stomach or contrast in remnant Dilated distal stomach or contrast in remnant High risk for closed loop obstruction High risk for closed loop obstruction Bowel ischemic necrosis within 6 hours Bowel ischemic necrosis within 6 hours Immediate surgical exploration Immediate surgical exploration

37 Internal hernias A. Transverse Mesocolon B. Petersen Hernia: Beneath Roux limb C. Mesentery defect created by jejunojejonostomy

38 Pulmonary Embolism Extremely high risk patients Extremely high risk patients Unstable vitals associated with chest pain and tachypnea Unstable vitals associated with chest pain and tachypnea Evaluation with Chest CT Evaluation with Chest CT Can mimic acute intra-abdominal complication Can mimic acute intra-abdominal complication

39 Vomiting + Abdominal Pain Gastric Banding Gastric Banding AXR: assess orientation of band AXR: assess orientation of band Deflate band Deflate band Huber needle Huber needle Similar to a Portacath Similar to a Portacath Reassess Reassess Does not usually require surgery Does not usually require surgery

40 Adjustable Gastric Band Normal Band orientation 2:00-8:00 Normal orientation but too tight

41 Adjustable Gastric Band Slips Anterior Slip: Band rotated counterclockwise Posterior Slip: Band rotated clockwise Note: enlarged pouch flopping over slip

42 Vomiting + Abdominal Pain Unstable: Unstable: Immediate surgical exploration Immediate surgical exploration Stable: Stable: Evaluate per obstruction Evaluate per obstruction Barium swallow most useful Barium swallow most useful

43 Abdominal Compartment Syndrome Respiratory failure Respiratory failure Renal failure Renal failure Other end organ failure Other end organ failure Elevated bladder pressure (> 25 mmHG) Elevated bladder pressure (> 25 mmHG) Emergent abdominal decompression Emergent abdominal decompression

44 “George, how often do you have a leak? “Never had one” “In how many cases?” “Oh, I’ve never done one.....” Surgery for Obesity and Related Diseases 7 (2011) 668

45 Summary Complications are unavoidable but disasters are often avoidable Complications are unavoidable but disasters are often avoidable Be familiar with the perioperative concerns that face the bariatric patient Be familiar with the perioperative concerns that face the bariatric patient Be aware of the signs of complications after bariatric surgery Be aware of the signs of complications after bariatric surgery Plan for initial management and stabilization of the patient facing postoperative complications Plan for initial management and stabilization of the patient facing postoperative complications Early involvement of a Bariatric Surgeon Early involvement of a Bariatric Surgeon Work with a certified Center of Excellence Work with a certified Center of Excellence ASMBS or ACS ASMBS or ACS


Download ppt "Perioperative Care of the Bariatric Patient Mark Kadowaki, MD, FACS Wellmont Surgical Services Kingsport, Tenessee."

Similar presentations


Ads by Google