1. Obesity & Related Surgical Procedures RNSG 1247

2. Obesity and Overweight Obesity is an abnormal increase in the proportion of fat cells Obesity is an abnormal increase in the proportion of fat cells Primarily occurs in the visceral and subcutaneous tissues of the body Primarily occurs in the visceral and subcutaneous tissues of the body

3. Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, 1971- 2006 *Body mass index (BMI) at or above the sex-and age-specific 95 th percentile BMI cutoff points from the 2000 sex- specific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category. Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05.

4. Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, 1960-2006 † *Obesity is defined as a body mass index of 30 kg/m 2 or greater. † Age adjusted to the 2000 US standard population. Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003- 2004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.

5. Etiology and Pathophysiology Genetic/Biologic basis Genetic/Biologic basis Environmental factors Environmental factors Psychological factors Psychological factors ** Most common form considered to be polygenic, arising from the interaction of multiple genetic and environmental factors ** Most common form considered to be polygenic, arising from the interaction of multiple genetic and environmental factors

6. Hormones & Peptides that Interact with Hypothalamus to Effect Obesity Fig. 41-3

7. Classification of Body Weight and Obesity Primary obesity (majority of obese) Primary obesity (majority of obese) Excess caloric intake for the body’s metabolic demands Excess caloric intake for the body’s metabolic demands Secondary obesity Secondary obesity Results from various congenital anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and disorders Results from various congenital anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and disorders

8. Classification of Body Weight and Obesity Body mass index (BMI) Body mass index (BMI) Used to classify underweight, healthy (normal) weight, overweight, or obese Used to classify underweight, healthy (normal) weight, overweight, or obese Common clinical index of obesity or altered body fat distribution Common clinical index of obesity or altered body fat distribution Uses weight-to-height ratios Uses weight-to-height ratios

9. BMI chart

10. Weight for height chart

11. Classification of Body Weight and Obesity Waist-to-hip ratio (WHR) Waist-to-hip ratio (WHR) Preferred tool when predominantly muscular Preferred tool when predominantly muscular Waist measurement/hip measurement = ratio Waist measurement/hip measurement = ratio WHR <0.80 is optimal WHR <0.80 is optimal Visceral fat increases risk for cardiovascular disease and metabolic syndrome Visceral fat increases risk for cardiovascular disease and metabolic syndrome

12. Visceral Fat

13. Subcutaneous Fat

14. Classification of Body Shapes Apple-shaped body Apple-shaped body Fat located primarily in the abdominal area Fat located primarily in the abdominal area At greater risk for obesity-related complications At greater risk for obesity-related complications Android obesity Android obesity Pear-shaped body Pear-shaped body Fat located primarily in upper legs Fat located primarily in upper legs Gynoid obesity Gynoid obesity

15. Classification of Body Shapes.. Fig. 41-5

16. Health Risks Associated with Obesity Problems occur at higher rates for obese patients Problems occur at higher rates for obese patients Mortality rate rises as obesity increases Mortality rate rises as obesity increases Especially with increased visceral fat Especially with increased visceral fat Obese patients have a decreased quality of life Obese patients have a decreased quality of life Most conditions improve with weight loss Most conditions improve with weight loss

17. Health Risks Associated with Obesity Fig. 41-6

18. Nursing Problems Imbalanced nutrition Imbalanced nutrition Chronic low self-esteem Chronic low self-esteem Others related to complications Others related to complications

19. Planning Modify eating patterns Modify eating patterns Participate in a regular physical activity program Participate in a regular physical activity program Achieve weight loss to a specified level Achieve weight loss to a specified level Maintain weight loss at a specified level Maintain weight loss at a specified level Minimize or prevent health problems related to obesity Minimize or prevent health problems related to obesity

20. Management: Non-surgical Nutrition Nutrition Exercise Exercise Behavior modification Behavior modification Support groups Support groups Drug therapy Drug therapy

21. Nutrition

22. Exercise

23. Trends in Prevalence (%) of High School Students Attending PE Class Daily, by Grade, US, 1991-2007 Source: Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008.

24. Behavior modification Basic techniques include Self monitoring Self monitoring Stimulus control Stimulus control Rewards Rewards

25. Support groups

26. Drug Therapy Classified into two categories Classified into two categories Drugs that ↑ energy expenditure are not approved by the FDA Drugs that ↑ energy expenditure are not approved by the FDA

27. Drug Therapy Appetite-suppressing drugs Appetite-suppressing drugs Decrease food intake through nonadrenergic or serotonergic mechanisms in the central nervous system (CNS) Decrease food intake through nonadrenergic or serotonergic mechanisms in the central nervous system (CNS) Examples of nonadrenergic drugs Examples of nonadrenergic drugs Phentermine Phentermine Diethylpropion Diethylpropion Phendimetrazine Phendimetrazine

28. Drug Therapy Appetite-suppressing drugs (cont’d) Appetite-suppressing drugs (cont’d) Serotonergic drugs ↑ release of serotonin or ↓ its uptake thus ↓ metabolism Serotonergic drugs ↑ release of serotonin or ↓ its uptake thus ↓ metabolism fenfluramine (Pondimin) fenfluramine (Pondimin) dexfenfluramine (Redux) dexfenfluramine (Redux)

29. Drug Therapy Appetite-suppressing drugs (cont’d) Appetite-suppressing drugs (cont’d) Mixed nonadrenergic–serotonergic agents Mixed nonadrenergic–serotonergic agents Do not stimulate release of serotonin Do not stimulate release of serotonin Sibutramine (Meridia) Sibutramine (Meridia)

30. Drug Therapy Nutrient absorption-blocking drugs Nutrient absorption-blocking drugs Work by blocking fat breakdown and absorption in intestine Work by blocking fat breakdown and absorption in intestine Orlistat (Xenical) Orlistat (Xenical) Purchasing over-the-counter drugs should be discouraged Purchasing over-the-counter drugs should be discouraged

31. Bariatric Surgery Used to treat morbid obesity Used to treat morbid obesity Currently the only treatment found to have a successful and lasting impact for sustained weight loss Currently the only treatment found to have a successful and lasting impact for sustained weight loss

32. Bariatric Surgery Must meet all of the following criteria to be considered an ideal candidate Must meet all of the following criteria to be considered an ideal candidate BMI ≥40 kg/m 2 with one or more obesity-related complication BMI ≥40 kg/m 2 with one or more obesity-related complication 18 years or older 18 years or older Understands the risks and benefits Understands the risks and benefits Has been obese for >5 years Has been obese for >5 years Has tried and failed to lose weight Has tried and failed to lose weight

33. Bariatric Surgery Criteria to be considered an ideal candidate (cont’d) Criteria to be considered an ideal candidate (cont’d) Has no serious endocrine problems Has no serious endocrine problems Has psychiatric and social stability Has psychiatric and social stability Availability of a team of health care providers Availability of a team of health care providers Surgery would ↓ or eradicate high-risk conditions Surgery would ↓ or eradicate high-risk conditions

34. Bariatric Surgery Three broad categories Three broad categories Restrictive Restrictive Malabsorptive Malabsorptive Combination of restrictive and malabsorptive Combination of restrictive and malabsorptive

35. Restrictive Surgery Reduces the size of a stomach to 30 ml or less Reduces the size of a stomach to 30 ml or less Causes patient to feel full quicker Causes patient to feel full quicker Normal stomach digestion and intestinal absorption of food Normal stomach digestion and intestinal absorption of food ↓ Risk of anemia and cobalamin deficiency ↓ Risk of anemia and cobalamin deficiency

36. Restrictive Surgery Vertical banded gastroplasty Vertical banded gastroplasty Partitions stomach into a small pouch in upper portion Partitions stomach into a small pouch in upper portion Small pouch drastically limits capacity Small pouch drastically limits capacity Stoma opening to rest of stomach is banded to delay emptying of solid food from proximal pouch Stoma opening to rest of stomach is banded to delay emptying of solid food from proximal pouch

37. Restrictive Surgery Fig. 41-7A

38. Restrictive Surgery Adjustable gastric banding (AGB) Adjustable gastric banding (AGB) Also referred to as the LapBand Also referred to as the LapBand Stomach size is limited by an inflatable band placed around fundus of stomach Stomach size is limited by an inflatable band placed around fundus of stomach Band is connected to a subcutaneous port Band is connected to a subcutaneous port Can be inflated or deflated to change stoma size Can be inflated or deflated to change stoma size

39. Restrictive Surgery AGB (cont’d) AGB (cont’d) Can be done laparoscopically and can be modified or reversed Can be done laparoscopically and can be modified or reversed Better choice for patients who are surgical risks Better choice for patients who are surgical risks Weight loss is slower than in other procedures Weight loss is slower than in other procedures

40. Restrictive Surgery Fig. 41-7B

41. Malabsorptive Surgeries Biliopancreatic diversion (BPD) Biliopancreatic diversion (BPD) Removes ~3/4 of stomach to ↓ food intake and ↓ acid output Removes ~3/4 of stomach to ↓ food intake and ↓ acid output Remaining 1/4 of stomach is connected to lower portion of small intestine Remaining 1/4 of stomach is connected to lower portion of small intestine Pancreatic enzymes and bile enter final segment of intestine Pancreatic enzymes and bile enter final segment of intestine Nutrients pass without being digested Nutrients pass without being digested

42. Malabsorptive Surgeries Biliopancreatic diversion with duodenal switch Biliopancreatic diversion with duodenal switch Variation of BPD Variation of BPD By including duodenal switch, surgeons leave a larger portion of the stomach intact By including duodenal switch, surgeons leave a larger portion of the stomach intact Helps prevent dumping syndrome Helps prevent dumping syndrome

43. Malabsorptive Surgery Fig. 41-7C

44. Combination of Restrictive and Malabsorptive Surgery Roux-en- Y surgical procedure Roux-en- Y surgical procedure Has low complication rates Has low complication rates Excellent patient tolerance Excellent patient tolerance Stomach size is ↓ with a gastric pouch anastomosis that empties directly into jejunum Stomach size is ↓ with a gastric pouch anastomosis that empties directly into jejunum

45. Combination of Restrictive and Malabsorptive Surgery Roux-en- Y surgery (cont’d) Roux-en- Y surgery (cont’d) Variations Variations Stapling stomach without transection to create a small 20- to 30-ml gastric pouch Stapling stomach without transection to create a small 20- to 30-ml gastric pouch Creating an upper and lower gastric pouch and totally disconnecting the pouches Creating an upper and lower gastric pouch and totally disconnecting the pouches Creating an upper gastric pouch and completely removing the lower pouch Creating an upper gastric pouch and completely removing the lower pouch

46. Restrictive Surgery Fig. 41-7D

47. Cosmetic Surgeries Ideal candidates have Ideal candidates have Achieved weight reduction Achieved weight reduction Excess skinfolds or fat Excess skinfolds or fat Chooses surgery for cosmetic reasons Chooses surgery for cosmetic reasons Lipectomy Lipectomy Liposuction Liposuction

48. Preoperative Care Patients who are obese are likely to suffer other comorbidities, such as Patients who are obese are likely to suffer other comorbidities, such as Diabetes, altered cardiorespiratory function, abnormal metabolic function, atherosclerosis Diabetes, altered cardiorespiratory function, abnormal metabolic function, atherosclerosis An interdisciplinary team approach may be necessary An interdisciplinary team approach may be necessary

49. Preoperative Care Have room ready for patient prior to arrival Have room ready for patient prior to arrival Larger size BP cuff, gown Larger size BP cuff, gown Bariatric wheelchair Bariatric wheelchair Or a wheelchair with removable arms Or a wheelchair with removable arms Strongly reinforced trapeze bar over bed for movement and positioning Strongly reinforced trapeze bar over bed for movement and positioning

50. Preoperative Care Wound infection is one of the most common complications Wound infection is one of the most common complications Skin preparation is important Skin preparation is important Ask patient to bathe or shower frequently for a few days before admission Ask patient to bathe or shower frequently for a few days before admission

51. Preoperative Care Obesity can make breathing shallow and rapid Obesity can make breathing shallow and rapid Instruct patient in proper Instruct patient in proper Coughing techniques Coughing techniques Deep, diaphragmatic breathing Deep, diaphragmatic breathing Methods of turning and positioning to prevent pulmonary complications Methods of turning and positioning to prevent pulmonary complications

52. Preoperative Care Obtaining venous access may be Obtaining venous access may be complicated complicated Assistance may be needed Assistance may be needed Multiple tourniquets Multiple tourniquets May need a longer catheter inserted far May need a longer catheter inserted far enough into the vein enough into the vein

53. Preoperative Care Patients undergoing anesthesia have an increased risk of failing to wean from mechanical ventilation Patients undergoing anesthesia have an increased risk of failing to wean from mechanical ventilation

54. Postoperative Care During transfer ensure that patient’s During transfer ensure that patient’s Airway is stabilized Airway is stabilized Pain is managed Pain is managed

55. Postoperative Care Early ambulation is essential Early ambulation is essential Patients undergoing bariatric surgery are often in considerable abdominal pain Patients undergoing bariatric surgery are often in considerable abdominal pain Patient is now reduced intake due to anatomic changes Patient is now reduced intake due to anatomic changes

56. Ambulatory and Home Care Diet prescribed is generally Diet prescribed is generally High protein High protein Low carbohydrates Low carbohydrates Low fats Low fats Low roughage Low roughage 6 small feedings 6 small feedings Fluids not to be ingested with meals Fluids not to be ingested with meals <1000 ml/day <1000 ml/day

57. Ambulatory and Home Care Possible complications from surgery Possible complications from surgery Anemia Anemia Vitamin deficiencies Vitamin deficiencies Diarrhea Diarrhea Psychiatric problems Psychiatric problems Peptic ulcer formation Peptic ulcer formation Dumping syndrome Dumping syndrome Small bowel obstruction Small bowel obstruction

58. Evaluation Expected outcomes Expected outcomes Long-term weight loss Long-term weight loss Improvement in obesity-related comorbidities Improvement in obesity-related comorbidities Integration of healthy practices into lifestyle Integration of healthy practices into lifestyle Monitoring possible adverse side effects Monitoring possible adverse side effects Improved self-image Improved self-image

59. Gerontologic Considerations Number of older obese persons has risen Number of older obese persons has risen More common in women than men More common in women than men Decreased energy expenditure and loss of muscle mass are important contributors Decreased energy expenditure and loss of muscle mass are important contributors Exacerbates age-related problems Exacerbates age-related problems