1. Obesity and Bariatric Surgery

2. 2 Objectives Describe what obesity is and the co-mobidities associated with obesity. Explain why losing weight is so difficult for some and how weight loss surgery can help. Discuss the differences between the 4 most common bariatric surgeries performed: adjustable gastric band, sleeve gastrectomy, roux-en-y bypass, duodenal switch. List potential complications of bariatric surgery and the signs and symptoms. Describe the post op pathway of the bariatric surgical patient and identify key factors for success.

3. 3 Obesity Facts Morbid obesity is the first epidemic of the 21 st century It is the second leading cause of preventable deaths in the United States second only to cigarette smoking. Approximately 300,000 deaths per year are associated with obesity compared to 400,000 deaths annually from cigarette smoking. U.S. Department of Health and Human Services 2001: Medsurg Nursing June 2006

4. 4 Obesity Defined Obesity is a disease characterized by Body Mass Index (BMI) BMI = body weight (kg) height (meters) 2 Class I Obesity BMI 30-34.5 Class II Obesity BMI 35-39.9 Class III Obesity BMI >40 Typically over 100 lbs over ideal body weight

5. 5 Conditions affected by obesity Gastroesophageal reflux Depression Infertility Increased cancer risk Degenerative joint disease Diabetes Coronary artery disease Hypertension Obstructive sleep apnea High cholesterol

6. 6 Who is a candidate for surgery? BMI >40 or BMI >35 with related medical conditions (diabetes, HTN, sleep apnea) Healthy enough for surgery Support system from family/friends Understanding of bariatric surgery and its risks Motivated to make long term changes in lifestyle.

7. 7 Why Surgery? Most effective tool to achieve and maintain weight loss in most patients. Resolves potentially fatal co-morbid conditions such as diabetes and hypertension. Improves quality of life.

8. 8 Who is a candidate for surgery? Willing and able to participate in long- term follow up care No chemical or alcohol dependency Smoking cessation prior to surgery 6 months No active hepatitis C Avoid pregnancy for 1-2 years

9. 9 Pathway for surgery Consultations Psychology (1-3 sessions) Dietitian (2-5 sessions) Pharmacist Exercise program Pre-op goals 10% weight loss Begin liquid diet Start exercise program Medical Evaluation Consultation with surgeon If GERD – endoscopy If gallstones - ultrasound Primary Care Provider  Sleep Study

10. 10 Surgical Options Restrictive: Adjustable gastric band Vertical sleeve gastrectomy Malabsorptive and Restrictive Roux-en-y gastric bypass Duodenal switch

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12. 12 Adjustable Gastric Banding Band placed around upper stomach Port inserted under the skin that allows the size of the band to be adjusted therefore slowing the passage of food. Gives the sensation that the stomach is full. No change in how food is absorbed in the intestines.

13. 13 Sleeve Gastrectomy Creation of gastric “sleeve” by removing a portion of the stomach. Gives you a decreased hunger sensation. Food is absorbed normally in the rest of the digestive tract.

14. 14 Roux en Y Gastric Bypass Creation of a “pouch.” Intestine is divided and reattached. Food goes down the esophagus and into the new pouch and bypasses approximately 150cm of the small intestine.

15. 15 Duodenal Switch Creation of a gastric “sleeve” which is connected to the lower part of the digestive tract. Less absorption of calories and nutrients. Higher risk of malnutrition.

16. 16 Perioperative Considerations Obesity hypoventilation syndrome (also known as Pickwickian syndrome) Severely overweight people tend to breathe shallow and not rapidly enough (hypoventilation) Increased C02 levels (hypercapnia) Many also with obstructive sleep apnea Increased heart strain and can lead to heart failure. Associated symptoms may include depression and hypertension. Cor pulmonale: can occur in up to 1/3 of all OHS patients (peripheral edema, ascities, exertional chest pain, heart murmur, hepatomegaly) AORN Journal July 2008 Vol 88 No 1

17. 17 Perioperative Considerations Medication absorption concerns It may take more medication to attain and maintain proper levels of anesthesia due to: Fat tissue delays absorption of medication Fat tissue stores medications AORN Journal July 2008 Vol 88 No 1

18. 18 Perioperative Considerations Airway Challenges Failed intubation: greatest risk – difficult airway cart readily available. Consider: fiber optic intubation, Glidescope, rapid induction, blankets under shoulders to achieve “sniffing” position. Low chance for successful mask ventilation Reduced oxygen reserve – decompensates quickly High rates of oxygen consumption Difficult vocal cord visualization Decreased neck mobility OSA – use home CPAP in PACU I.S – begin in PACU

19. 19 Perioperative Considerations Vascular System Prone to cardiac disease (due to HTN, diabetes, hyperlipidemia) Increased incidence of DVT Veins may be difficult to access

20. 20 Perioperative Considerations Musculoskeletal and Nervous System Obese patients are more prone to positioning injuries – due to strain that excessive weight places on their musculoskeletal system. Pressure points well padded. Intra-abdominal view – may need reverse trendelenburg or lateral tilting.

21. 21 Perioperative Considerations Moving and Transferring Obese Patients Focus on patient and staff safety Using available devices: hovermatt, lifts, appropriate slings, stand assists etc. Chairs & tables (all positions) that can handle the weight of the patient.

22. 22 Postoperative Care in the Hospital Day of Surgery Strict NPO Ambulate q2hrs Sequential sleeves and subcutaneous heparin I.S q1hr while awake Continuous oximetry overnight Home CPAP overnight if applicable. Manage nausea – IV Zofran, S.L. Levsin, Scopolamine patch, Compazine. Manage pain – IV Dilaudid/Morphine and IV Ativan., ice packs, abd binder when up.

23. 23 Postoperative Care in the Hospital Day of Surgery (continued) Antiulcer agents: Pepcid, Protonix, Prevacid. Anti-hypertensives as needed Sliding Scale insulin as needed.

24. 24 Upper GI early post op day 1 –water soluble esophagram

25. 25 Post op Day 1 Upper GI early AM Assess for any obstruction or leak If UGI ok: begin ½ oz sips of water slowly advancing to once ounce of bariatric clear liquids. Home later that day if tolerating clears and co-morbid conditions stable ie: HTN and blood sugars etc.

26. 26 Follow up F/u call by nurse coordinator first week post op Community paramedic visits x 2. One 30 minute visit 1-2 days after discharge. One 15 minute visit 2 nd or 3 rd week post discharge.

27. 27 Follow up Important Appointments After Surgery: Community paramedic visit 1-3 days after discharge 1 week after surgery- See your surgeon for a postoperative visit. 763-780-6699 4 weeks after surgery-See your surgeon for follow up 5-6 weeks after surgery-See the Bariatric Nurse Coordinator and Dietitian. This is important prior to starting a regular diet to review how to advance your diet and for meal planning. 3 months-Follow up with Coordinator 6 months –Follow up with Surgeon 9 months-Follow up with Coordinator 12 months-Follow up with Surgeon Yearly follow up for the rest of your life!

28. 28 Risks of Surgery Operative mortality in 1-30 days after surgery is 0.25% *Often associated with type of surgery Surgical complications * Blood clots (PE/DVT) * Pneumonia * Heart attack/stroke * Wound infection * Dehydration * Leak CALL SURGEON if severe shoulder pain, fast heart rate or difficulty breathing occur

29. 29 Risks and Benefits of Surgery ASMBS – American Society for Metabolic and Bariatric Surgery 30 day mortality LeakRe- operatio n Decrease in BMI after one year Sleeve0.08%0.3%1.5%30% RYGB0.14%0.4%7.7%40% Band0.03%15.3%20% Risk of death about 0.1% - overall likelihood of major complication is 4% Mortality and complication rates lower than typically associated with hip replacement surgery. One study compared sleeve and RYGB –no difference in weight loss after two and five years.

30. 30 QUESTIONS?