Bariatric Procedures, Complications and Follow up Bariatric surgery holds out the promise of a healthier and a better quality life to those who have failed to maintain a healthy weight through diet, exercise and medication! Patients will generally live longer and have better health. However, these operations are also associated with risks and complications! Spire Bushey Hospital Mr Pratik Sufi Consultant Bariatric & Upper GI Surgeon

Balancing Activity Levels with Food Physical Activity Calories Burnt / 30 minutes Walking leisurely @ 2mph 85 Walking briskly @ 4mph 170 Gardening 135 Raking leaves 145 Dancing 190 Bicycling leisurely @ 10mph 205 Swimming laps, medium level 240 Jogging @ 5mph 275 One small chocolate chip cookie (50 calories) is equivalent to walking briskly for 10 minutes. 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). 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). 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). One tsp sugar (20cal) ≈ 4 min walk One can coke (160cal) ≈ 30 min walk

Dietary Change

Obesity Associated Co-morbidities Pulmonary Disease Abnormal Function Obstructive Sleep Apnea Hypoventilation Syndrome Asthma Cerebral Idiopathic Intracranial Hypertension Stroke Cataracts Hepato-pancreato-biliary Disease Steatosis (NALD) Steatohepatitis (NASH) Cirrhosis Gall Bladder Disease Pancreatitis Coronary Heart Disease Diabetes Dyslipidemia Hypertension CCF Herniae Umbilical Ventral Inguinal GI GORD & Hiatus Hernia Cancer Breast, Uterus, Cervix, Colon, Esophagus, Pancreas, Kidney, Prostate Gynecologic Abnormalities Abnormal Menses Infertility Polycystic Ovarian Syndrome Vascular Phlebitis / DVT Venous stasis Leg ulcers Obesity OnLine Slide Presentation. Accessed May 17, 2007. Accessible as slide #5 at http://www.obesityonline.org/slides/slide01.cfm?tk=33. Musculoskeletal Osteoarthritis Gout Skin Dermatitis Leg ulcers 4

Impact of Obesity on GP Consultations BMI Percentage 20 25 30 35 40 15 10 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.

Primary Obesity Options Today Low Risk Less Effective More Effective Diet/ Drugs EndolumenalObesity Gastric Balloon POSE Endosheath 20-60% Low efficacy – less durable weight loss Moderate risk / efficacy – intermediate durability Effective but unacceptable risk High efficacy – durable weight loss Surgery Abandoned Surgery 40-95% Lap Band Sleeve Gastrectomy Gastric Bypass BPD/DS VBG Jejuno-Ileal Bypass High Risk

Procedure Comparison Procedure Mechanism of action EBWL (2 year) Invasiveness / Durability Follow-up Gastric balloon Restrictive 10-20% Minimal/Short-term Intensive/6-24m POSE 20-40% Minimal/Long-term Minimal/12-24m Endosheath Diversion 30-50% Intensive/12-24m Gastric band Restrictive + Neurostimulation 50-60% Moderate/Long-term Intensive/Life-long Gastric plication 40-60% High/Unknown Modest/Life-long Sleeve Restrictive + Endocrine 60-80% High/Long-term Gastric bypass Restrictive + Bypass-Diversion + Malabsorption 70-90% Duodenal switch 90-100% Very high/Long-term

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: BMI≥35 ASMBS: BMI≥30 Asians: BMI 2 points lower

Pre-operative Liver Shrinkage Diet Slimfast –900 kcal/d approximately Food-based – 900 kcal/d approx. Meal/Snack Product Amount Calories Protein (g) Breakfast Slimfast shake 1 serving 220 / 230 14 / 15 Morning snack Slimfast shake or Slimfast meal replacement bar Lunch Dinner   Totals 880-920 56-60 Food group No of servings Fruit 2  Vegetables 3  Carbohydrates Dairy Protein Fats Two (2) weeks Four (4) weeks

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: Bassett’s 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

Long-term Follow-up Pins and needles (B12, B1) Frequent falls (B12, B1, Fe) Tiredness (anaemia, hypoglycaemia) Generalised pain (PTH) Abdominal pain (ulcer, gallstones / hernia / kidney stones) Reflux / regurgitation/ N&V / persistent cough (band slippage, over-tight band, ulcer, hiatus hernia) Calcium supplements- 1000mg calcium / day. Liquid or effervescent tablets Ferrous Sulphate/ ferrous fumarate or sodium feredetate – drops, syrup or sugar free elixir. 50mg of iron/day   Hydroxocobalamin Vitamin B12 injections – 1mg every 3 months

Nutritional Deficiencies Mechanism Prevalence Clinical 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

Diagnosis and Treatment of Nutritional Deficiencies  Deficiency Symptoms and signs  Confirmation Treatment first phase 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, 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 levels Oral vitamin A, 5,000–10,000 IU/d An Endocrine Society Clinical Practice Guideline

Schedule for Clinical and Biochemical Monitoring TESTS Pre-operative 1 month 3 months 6 months 12 months 18 months 24 months Annually Complete blood count X LFTs Glucose Creatinine Electrolytes Iron/ferritin   Xa Vitamin B12 Folate Calcium Intact PTH 25-D Albumin/prealbumin Vitamin A Optional Zinc Bone mineral density and body composition Vitamin B1 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. An Endocrine Society Clinical Practice Guideline

Post-Bariatric Surgery Complications Pulmonary Disease Pneumonia / Atelectasis Cerebrovascular Disease Wernicke’s Encephalopathy (Beriberi) Stroke / TIA Malnutrition Glossitis, stomatitis Hair loss CV Disease MI DVT / PE Beriberi HPB Disease Hepatitis (trauma) Pancreatitis (trauma) Cholecystitis GI Disease Bleeding GORD & Hiatus Hernia Ulcer Bloating / Obstruction Diarrhoea / Constipation Malabsorption Renal Disease Kidney stones Gynecologic Abnormalities Amenorrhoea Fertility – failure of contraception Bone Disease Osteomalacia Malnutrition Dermatitis Neuropathy Ataxia 19

General complications Immediate post-operative – infection, bleed, thromboembolism Tiredness, pain, ulcers, dry skin, pins and needles, hair loss etc. (Nutritional deficiency – Iron, Calcium, Vitamin D, Folate, Vitamin B12, Vitamin B1, Zinc) Nausea, vomiting (Slipped band, over-restriction, hiatus hernia, gallstones, anastomotic ulcer, GLP-1 excess, internal /port-site hernia etc.) Hernia – port-site, incisional

Band Complications Slippage (Pain, N&V) Erosion (Pain, N&V, loss of restriction) Oesophageal dilation (Regurgitation, N&V, persistent cough) Infection (Pain, local inflammation, systemic sepsis) Nutritional deficiency (tiredness, hair loss) Gallstones (Pain, N&V, Jaundice) Hiatus hernia / GORD (Regurgitation, heartburn, dysphagia)

Sleeve Gastrectomy Complications Staple line leak (pain, N&V, sepsis) Staple line bleed Reflux (regurgitation, heartburn, dysphagia) Sleeve dilation (weight regain) Nutritional deficiency (tiredness, hair loss, pain) Gallstones (pain, dyspepsia, N&V, jaundice)

Gastric Bypass Complications Staple line leak (pain, N&V, sepsis) Staple line bleed Ulcer (pain, N&V, dysphagia) Stenosis (dysphagia, pain, N&V, regurgitation, excessive weight loss) Dumping (giddiness, tiredness, tachycardia, cramps) Internal hernia (cramps, bloating, constipation) Gallstones (pain, N&V, Jaundice) Nutritional deficiency (tiredness, hair loss, pins and needles, pain, ulcers)

Balloon Complications Intolerance (nausea & vomiting, cramps) Ulcer (epigastric pain) Deflation and migration (bowel obstruction)

POSE Complications Perforation Bleeding Intolerance (nausea & vomiting, cramps) Ulcer (epigastric pain)

Pain Gallstones Pancreatitis Anastomotic ulcer Perforation / Anastomotic leak Gastric band erosion Slipped gastric band Dumping syndrome Anastomotic stricture Small bowel obstruction Gastro-gastric fistula

Nausea & Vomiting Pregnancy! Gastroenteritis Gastric balloon intolerance Over-restricted gastric band Anastomotic ulcer Anastomotic / Sleeve gastrectomy stricture Gallstones / Pancreatitis Hiatus hernia Internal hernia / Small bowel obstruction

Diarrhoea Gastroenteritis Bacterial overgrowth Clostridium difficile Fat malabsorption Dumping syndrome Lactose intolerance

Case Study 1 Thiamine Deficiency 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 Wernicke’s 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 Band slippage Epigastric pain Dysphagia Weight regain 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 Loss of restriction Band infection

Case Study 3 Anastomotic ulcer Epigastric pain, heartburn Gallstones 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 Bacterial overgrowth 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 Over-restricted band Cough, reflux and water brash 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.

Thank you!