Post Operative
Care/Considerations
of the Bariatric
Patient in Primary
Care
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Identify obesity as a major health problem
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Describe the socio-economic impact on people who
suffer from morbid obesity
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Discuss the surgical options for obesity.
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Identify key components to the pre-operative
evaluation of bariatric patients.
•
Discuss the after care of the surgical bariatric
patient including laboratory and GI tests
•
Discuss post operative complications that may
appear in the primary care office.
Slightly underweight insects, fish, reptiles, birds,
mammals and people live longer than the
overweight.
“To lengthen thy life, lessen thy meals.”
—Benjamin Franklin
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Obesity- over ideal weight by 30% or BMI over
30
Morbid Obesity- Clinically severe obesity-point
where serious medical conditions occur as a
direct result of the obesity
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Defined as >200% of ideal weight, >100 lb
overweight, or a body mass index of 40
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Eating out/ordering in & foods not healthy
Portion sizes increased (soda 6 ½ oz to 20oz)
Consumption of soft drinks (600 12 oz/pp/per
year, males 12y-29y=1/2 gal/d or 160 gal/yr)
Rushed meals
Junk food is advertised, cheap and available
No time to exercise
Technology especially for children
Unrealistic expectations
BMI = Formula: weight (lb) / [height (in)]2 x 703 Calculate BMI by dividing
weight in pounds (lbs) by height in inches (in) squared and multiplying by a
conversion factor of 703.
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Example: Weight = 150 lbs, Height = 5’5” (65")
Calculation: [150 ÷ (65)2] x 703 = 24.96
W.H.O. Classification
Ideal Weight
Overweight
Moderate Obesity
Severe Obesity
Morbid Obesity
Super Obesity
BMI
20 – 24.9
25 – 29.9
30 – 34.9
35 – 39.9
40 – 49.9
50+++
(Men–Waist 40 inches Women – Waist 35 inches)
More adverse health effects with
increased fat inside the abdominal cavity.
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World epidemic of obesity
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Estimated about 1.7 billion people
25% of industrialized world
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97 million Americans (> 2/3 population) are
overweight/obese. Has tripled in last 20 years.
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Obesity costs in US about $100 billion/yr in direct
health care expenses/lost productivity.
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300,000 deaths annually in US obesity related.1 in 6
morbidly obese people will die within 10 years. (from
research Ohio State University)
Less than 2% morbidly obese people will succeed in
loosing and keeping off weight with diet and exercise
on their own.
Diabetes
Hypertension
Hyperlipidemia
Cardiac disease
Respiratory disease
Sleep apnea Syndrome
Arthritis
Depression
Stress Incontinence
Menstrual irregularity
Metabolic Syndrome
15-30%
20-55%
35-53%
10-20%
15-20%
50-65%
70-90%
50-65%
30-45%
50-65%
40% >age 60
Table 7 Bariatric Literatre review
Diabetes
Hypertension
Hyperlipidemia
Cardiac disease
Respiratory disease
Sleep apnea Syndrome
Arthritis
Depression
Stress Incontinence
Menstrual irregularity
15-30%
20-55%
35-53%
10-20%
15-20%
50-65%
70-90%
50-65%
30-45% Table 7 Bariatric Literatre review
50-65%
Discrimination
•Studies show society has low respect for
morbidly obese
•Many have limited number of friends
•Many obese individuals report being treated
disrespectfully by an M.D.
•Social isolation, depression & low esteem
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Weight loss surgery is not a “magic pill.”
It will not make you suddenly slim, happy, &
beautiful or give you a perfect life.
It is a “tool” to assist you and is a part of an
entire program to help you lose the your excess
weight.
WLS can make you healthier and decrease your
risk of early death associated with obesity.
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Laparoscopic duodenal switch
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Laparoscopic RNY Gastric Bypass
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Laparoscopic Adjustable Gastric Band
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Laparoscopic Sleeve Gastrectomy
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Revision surgery
- Conversion from band to RNY or Sleeve
- Conversions from VBG to RNY
- Failed previous RNY
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Most durable technique, been
performed in some variations since
1967
Most studied, best understood –
good programs will provide best
long-term maintenance
Requires modification of food
preferences – enforced by
“dumping syndrome”
Laparoscopic versions preferred,
much easier on patient
75-80% EWL at three years
It is reversible
Negatives: higher initial
complication rate (lower late
complication rate), need to
supplement vitamins and minerals
for life, potential for malnutrition
with non-compliance
Early (any abdominal pain, get CT scan)
Staple line leak – (0.25-3%), most occur 3-12
days post-op, rare after 3 weeks.
GI bleeding - (0.5-5%), usually from staple
lines
Dilated loops – (2-5%), ileus, SBO, internal
hernia, kinks; worry is perforation of bypassed
stomach
Death (0.2%) first 30 days either PE or bowel
leak
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Vitamin deficient – Common are Vitamin B12, Calcium, Folic Acid
Some food intolerance & alcohol - more rapidly absorbed and can lead to early
intoxication. “Dumping” syndrome-especially after large amounts of sugar.
Symptoms=heart racing, sweating, nausea, stomach cramps, diarrhea, fatigue
Bowel obstructions - 1%+Caused by Internal Hernia CT Scan for dx.
dilated bypassed stomach, dilated small bowel, deviated SMA vessels dx
laparoscopy
Stricture/Stenosis – (2-8%), if cannot keep down H20 suspect stricture diagnosed
by UGI, EGD (rare after 3 months unless smoker)
Ulcers of pouch - 1% (Smokers), double with NSAID use, diagnose with EGD
Cholelithiasis – gallbladder sonogram (5 - 25%), rare before 6 weeks post-op,
increases w/ excessive fats or dairy in diet (Ursodial)
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Average weight loss of 77% at one year.
After 10-14 years approx. 70% patients have
maintained approximately 70% of their weight
loss.
96% of patients saw a reduction or resolution of
co-morbidities.
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Restrictive (limits amount of food
eaten)
Adjustable – can adapt to changing
needs
Low immediate complication rate
(higher later complication rate)
Easy on patient – outpatient surgery
Less dependent upon
supplementation
Slow but steady weight loss – 1-2
lbs. per week, average 40-60% EWL
at three years
Negatives – Half of patients only
reach 50% EWL mark, requires lots
of maintenance, doesn’t reinforce
food choices; frequent adjustments
needed, slip, erosion, esophageal
dilatation, and port problems
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Slippage (Prolapse) 2 – 10%
Port Problem 2 – 7%
Erosion 0.5 – 1%
Esophageal Dilation 1 – 2%
Death 1 IN 1500 from pulmonary emboli
Greater Chance re-operation
Persistent dysphagia
Up to 25% of bands being removed after 5
yrs.
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Bleeding from suture line (0-6.4%)
Gastric leak from suture line (1-1.4%)
Excess narrowing or post op stricture (1-2%)
Pouch dilatation over time (5-10%)
Post op nausea (usually goes away in 2 week
Post op heartburn (<5%)
Pulmonary emboli (0.1-0.2%)
Slimming (<1%)
Strategies for Success; Bariatric Surgery
1.
THREE MEALS PER DAY
a. NO grazing but plan protein snacks if nec.
b. Protein first (60grams/day, then complex
carbs, veg. Avoid fruits/salads)
2.
4-8 OUNCES OF SOLIDS BY WEIGHT PER MEAL
3.
SOLID FOODS ARE BETTER CHOICES THAN SOFT
FOODS
a. Natural foods better than prepared foods
b. AVOID white carbohydrates
c. High protein, low fat, very low carbohydrate
4.
TAKE AT LEAST 30 MINUTES TO EAT
5.
NO CARBONATED BEVERAGES & AVOID EMPTY
LIQUID CALORIES
6.
DO NOT DO ANYTHING ELSE WHILE EATING
7.
DO NOT DRINK AND EAT AT THE SAME TIME;
Do not drink for 10 min before, 30 min. after
a. Chew very well to avoid food getting stuck
b. Fork down between tiny bites
c. Use saucers
a. Avoid distractions
b. Make every bite a conscience choice
a. Drink at least 64 ounces of calorie-free
liquid every day between meals
8.
Activate your body-plan exercise, weigh often
9.
YOU ARE IN CONTROL OF YOUR WEIGHT
a. Choose wisely “space is limited”
10.
RENEW YOU COMMITMENT Each MEAL (think thin),
attend support meetings, and keep doctors appts.
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Assess their physical needs, but emotional needs as well so be sure to schedule
enough time for these patients.
Be sure to have larger gowns and blood pressure cuffs in your office and make
sure your chairs in the waiting room, exam table, and scales can accommodate a
larger person. Toilets floor mounted Take height, weight, BMI, and waist
measurements.
Empathy important with good listening skills. Support and encouragement
essential-never chastise the patient for not losing weight. Set mini goals and
always follow up (make an appointment before they leave the office).
Can offer same tools as with post op requirements-no sodas/sugary drinks,
smaller portions (1 c/meal), small bites, chew well, high protein snacks, not eating
and drinking together, eating at table, food diary, exercise (5 x week) & support
groups. 60 grams protein, 60 oz calorie free liquids per day.
Evaluate triggers like stressors or current meds that may cause weight gain-SSRI’s
(Paxil), Tricyclic Antidepressants, Insulins, sulfonyureas, steroids, & beta blockers
Utilize dieticians and psychologists.
Offer medications like Wellbutrin, Phenteramine, Phendimetrazine, Topamax, ,
or Qysemia.
Band patients:
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Needs a chewable or liquid multivitamin every day and calcium 500mg with vitamin D
twice a day
After 50 lbs weight loss needs CBC, CMP, Lipids, TSH, Iron, Vitamin B12, Vitamin D 25
hydroy then annually
If weight loss over 100 lbs do bone density
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Bypass/Sleeve patients:
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2 chewable or liquid MVI’s daily, 2 calcium citrate 500 mg with vitamin D daily, vitamin
B12 2500 mcg 1-2 sublingual every week, Vitamin D3 5000IU daily, iron (Ferrous
Fumarate) 19-29 mg daily.
Check CBC, CMP, Lipids, TSH, Iron, TIBC, Ferritin, B12, Folic Acid, Vitamin D 25
hydroxy, PTH at 3 months and 9 months. (Add Vitamin A, thiamine & magnesium at 9
months and annually for bypass patients)
Bone Density study first couple of years until stable or while losing weight.
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Duodenal Switch:
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2 chewable or liquid MVI, 4 calcium citrate 500mg/vitamin D, vitamin B 12 2500 mcg
sublingual 2-3 times a week, Vitamin A 10,000 IU daily, Vitamin D3 2000 IU daily, iron
19-29 mg elemental iron daily, Vitamin K 300 mcg daily.
Check CBC, CMP, Lipids, TSH, Iron, TIBC, Ferritin, B12, Folic Acid, Vitamin D 25
hydroxy, Vitamin A, thiamine, PTH, magnesium at 3 months, 9 months and annually.
Bone Density every year.
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All patients need frequent visits at least quarterly
while losing weight with a height, weight, BMI and Waist
measurement.
Generic Name
Phenteramine/
Topiramate
Orlistat
Trade
Names
DEA
Schedule
Approved
Use
Year
Approved
Qsymia
IV
Long-term
2012
Xenical
None
Long-term
1999
Sibutramine
Meridia
IV
Long-term
1997
Off market
Diethylpropion
Tenuate
IV
Short-term
1973
Phentermine
Adipex,
lonamin
IV
Short-term
1973
Phendimetrazine
Bontril
III
Short-term
1961
Benzphetamine
Didrex
III
Short-term
1960
Drug
Dosage
Side effects
Cautions
Phenteramine
(Adipex)
15-37.5mg/day on Dry mouth,
empty stomach
anxious,
insomnia,
elevated BP
Don’t use severe
anxiety, glaucoma,
uncontrolled HTN,
previous stroke,
hyperthyroid, heart
disease, preg./brst feed
Bupropion
(Wellbutrin)
*Off label
300-400mg/day
(usually XL 150
BID)
Headache, dry
mouth, diarrhea
and dizziness
Don’t use if seizures
liver failure, suicide,
preg/brst feed.
Caution w/ BB or
antiarrythmias
Phenteramine/
Topiramate
combination
(Qsymia)
3.75 mg/23 mg
daily x 14 days
then 75mg/46mg
a day
Elevated BP,
anxious, urticaria,
dry mouth,
tremors
BMI/30 or >27 with
one co-morbidity
Do not use
preg./breast feeding,
glaucoma,
hyperthyroid
Phendimetrazine
(Bontril)
35mg/ 2-3 x day
Same as
phenteramine
Same as phenteramine
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Skin hygiene-document with
pictures in the medical record
Proper nutrition (60 grams of
protein and 60 oz of fluids/day)
Proper vitamins- if hospitalized
then use a banana bag daily
Medicines should be taken one
at a time with plenty of water
in-between.
Avoid NSAIDS and aspirin but
if have to take aspirin it should
be chewable.
Checking laboratory data
periodically as recommended.
Never put down an NG tube
Encourage pt not to smoke!
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36 y/o female presents to your office with 2 year
history of gastric banding c/o dry cough especially
at night when lying down, heart burn, GERD for
last 2 weeks. Now c/o productive cough with
temperatures of 100.6. VS 144/90-100.8-100-28.
pulse ox=94%. CBC shows WBC of 14.3 with
slight shift to left. PE unremarkable except rales at
left base. Had a fill 3 weeks ago.
What is the most likely diagnosis?
What do you think is going on?
What is your plan of care?
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You order a chest x-ray and is shows
pneumonia which you treat with antibiotics,
rest and plenty of fluids. You ask her to follow
up in one week.
What is the next step in the care of this patient?
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48 y/o female with history of gastric bypass 18 months ago
and has done very well with losing over 110 lbs and is now
at her goal weight.
She presents to your office with persistent abdominal pain
that is worse after eating and occurs almost every time after
eating for the last 3 weeks and progressively getting worse.
Occasional waive of nausea but no vomiting and bowels are
moving normally maybe slightly slower but no constipation.
PE is normal except tenderness at mid to left abdominal
pain above the umbilicus VS wnl. CBC, CMP, UA all
normal
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What is your next step?
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What do you think is going on?
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You first order a gallbladder sonogram which
is normal.
Then you order a CT scan of the abdomen and
it shows an internal hernia.
What is your next step and what usually will
be done in this case?
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32 y/o female presents to the officewith
abdominal pain and distention, nausea and
vomiting and no BM for 3 days. She is 9
months post op gastric bypass. VS-138/8898.8-94-24
What test should be ordered? What do you
think is going on?
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You order a obstruction series and it shows a
small bowel obstruction.
What would be your next step??
What would normally happen with this
patient??
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Obesity is a chronic disease
Modest weight loss (5% -10% of body
weight) can have considerable medical
benefits
Lifestyle change (diet behavioral changes
and physical activity) is the cornerstone
of therapy
Pharmacotherapy can be useful in
properly selected patients
Bariatric surgery is the most effective
therapy for obesity
.