1. Shedding Health Risks with Bariatric Weight Loss Surgery By Susan Gallagher Camden, RN, CBN, MSN, PhD Nursing2009, January 2009 2.5 ANCC/AACN contact hours Online: www.nursingcenter.com © 2009 by Lippincott Williams & Wilkins. All world rights reserved.

2. Bariatric weight loss surgery (BWLS)  Patients having BWLS in the U.S. grew 644% from 1995 to 2005  400,000 had the surgery in 2008  One reason is growing awareness of obesity’s effect on morbidity and mortality

3. How BWLS combats diabetes  Obesity is a major independent risk factor for type 2 diabetes  In the U.S., most people diagnosed with diabetes are overweight  Research shows that 90% of patients who have BWLS no longer need medication for diabetes

4. Who’s a candidate for BWLS?  National guidelines set forth criteria - body mass index of 40 kg/m2 or more - 35 to 39.9 kg/m2 with severe comorbidities  Insurance reimbursement looks for documentation of 3 unsuccessful attempts at weight-loss programs

5. Who’s a candidate for BWLS?  Physical exam to include health and weight history  Screening of physical or emotional disorders

6. Not considered a candidate if:  Unstable cardiac or pulmonary condition  Prader-Willi syndrome  Known endocrine disease  Unresolved psychological issues

7. Typical screening protocol Preoperative evaluation compromises two main parts:  psychological testing  clinical interview

8. Psychological testing  Typically, Minnesota Multiphasic Personality Inventory-2  Includes family and social situation  Any eating disorders or psychological issues must be addressed  Patients must be made aware of commitment to weight loss, exercise, changes in eating habits postoperatively

9. Clinical interview  Consists of comprehensive assessment of patient’s medical, surgical, psychiatric, and psychosocial history  Drug or food allergies  Alcohol and tobacco use and medication history

10. Sorting out surgical options  Roux-en-Y gastric bypass combines gastric restriction and malabsorption strategies, is most common weight loss procedure performed in U.S.  Surgeon creates small gastric pouch with an anastomosis to the jejunum  Food bypasses 90% of stomach and duodenum so fewer calories are absorbed

11. Sorting out surgical options  When high-calorie foods reach this limb of the small intestine, a feeling of satiety or even discomfort may result, helping curb the appetite  Can be done laparoscopically; reduces consumption and absorption, leading to weight loss

12. Sorting out surgical options  Laparoscopic adjustable gastric banding: stomach size is limited by inflatable band placed around fundus of stomach. Band is connected to SC port and monitored to ensure regulation of stoma size to meet patient’s weight and nutritional needs

13. Sorting out surgical options  Primary advantage is that a reduced amount of well-chewed food enters and passes through the digestive tract in the usual manner  Banding can be performed laparoscopically, making it less invasive and a better choice for some patients

14. Sorting out surgical options  Biliopancreatic diversion (BPD) involves removing 75% of stomach and dividing intestine, with one end attached to the stomach (alimentary limb)  Bile and pancreatic juices move though biliopancreatic limb, which supplies digestive juices to common limb; surgeon is able to adjust length of limb to regulate malabsorptive qualities

15. Sorting out surgical options  Adverse reactions: flatus, loose or foul- smelling stools, stomal ulcers, and severe malnutrition, especially protein, vitamin, and mineral malnutrition  Adding duodenal switch to traditional BPD procedure results in a BPD/DS procedure, where part of the stomach is resected, creating a smaller stomach pouch

16. Sorting out surgical options  Distal part of small intestine is then connected to pouch, bypassing duodenum and jejunum  As with any weight loss surgery, protein, vitamin, and mineral supplements become part of patient’s everyday life  Risks for malnutrition are greater with malabsorptive surgeries, especially BPD and BPD/DS

17. Vertical sleeve gastrectomy  Sometimes called sleeve gastrectomy, greater curvature gastrectomy, parietal gastrectomy, gastric reduction, or vertical gastroplasty  Restrictive form of weight loss surgery; approximately 85% of stomach is removed  Sleeve-shaped stomach that remains has capacity of 60 to 150 mL

18. Vertical sleeve gastrectomy  In contrast to other forms of bariatric surgery, outlet valve and nerves to stomach remain intact; although stomach is drastically reduced, function is preserved  Because pylorus is retained, problem of dumping is avoided  Not reversible

19. Vertical sleeve gastrectomy  Greatest advantage: doesn’t include bypass of intestinal tract, avoiding complications (intestinal obstruction, anemia, osteoporosis, vitamin and protein deficiency)  Because new stomach continues to function normally, patients face fewer restrictions on foods they can eat

20. Vertical sleeve gastrectomy  Removing most of stomach virtually eliminates hormones produced within stomach that stimulate hunger.  Best suited to patients who are either extremely obese or who have medical conditions such as Crohn’s disease that would rule out intestinal bypass surgery

21. Vertical sleeve gastrectomy  Usually a one-step procedure that can be performed laparoscopically  Doesn’t provide malabsorption so some experience disappointing weight loss or even weight regain  Patients with high body mass index often require follow-up weight loss surgery to achieve goals

22. Vertical sleeve gastrectomy  Two-procedure option not only produces results that patient wants but may also provide lower overall risk  Because procedure requires stapling of stomach, patients run risk of leakage and other complications directly related to stapling  Patients may experience additional complications (postop bleeding, small- bowel obstruction, pneumonia, death)

23. Preparing the patient Patient/family teaching to include:  early ambulation postoperatively  spirometry for increased lung expansion  pain management  wound care  nutrition instruction (including frequent small meals and fluids in between)

24. Postoperative care  Preventing respiratory complications is a priority  Prevention of increased risk of VTE  Monitor fluid and electrolyte balance  Monitor nutrition

25. Long-term implications  Patient must commit to lifetime monitoring of height, weight, and nutritional status  Women should not become pregnant up to 18 months after surgery  Encourage patient to join a support group to celebrate and cope with weight loss