Update: Bariatric Surgery


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  • A 26 year old woman present to walk in clinic complaining of 2 weeks of progressive lower extremity weakness, blurred vision and urinary incontinence. She reports feeling inreasingly sluggish. Family has noticed mild personality changes. Past medical history significant for a roux-en-y gastric bypass 4 months ago with a subsequent 150lb weight loss. Since surgery, she has had multiple admissions for nausea, vomiting and IV hydration.
  • On physical exam, vital signs were normal. She was noted to horizontal nystagmus and bilateral ophthalmoplegia. She could not walk and lower extremity strength was 2/5, reflexes were absent.
  • This talk is meant to be an overview and so I’ll cover a few different areas. I want to start with a little background regarding the obesity epidemic and then describe bariatric surgery as a treatment option. I then want to touch on who and when to refer patients for surgery. Finally, I want to discuss long term management including potential complications and recommendations for prevention.
  • As everyone in this room is aware, obesity is an epidemic condition in the United states and around the world.
  • The data shown in the next few slides was collected through the CDC’s Behavioral Risk Factor Surveillance System, a telephone survey administered each year by state health departments. The first map represents obesity trends for the year 1990. Obesity is defined as BMI > 30. In 1990, 10 states had a prevalence of obesity less than 10%, and no states had a prevalence of 15% or greater.
  • By 1998, no state had a prevalence less than 10%, seven states had a prevalence between 20 and 24%, no state had a prevalence of 25% or greater.
  • In 2006, only four states had a prevalence of less than 20%. Twenty-two states had a prevalence of 25% or greater, and two states (Mississippi and West Virginia) had a prevalence of obesity greater than or equal to 30%.
  • There are a number of different factors that work together to influence an individual’s weight. They can be grouped broadly into behavior related factors and genetics factors. When we talk about behavioral risk factors for obesity, we are really talking about diet and physical activity. These activities are in turn influenced by factors such as personal characteristics, environment, culture and finances. Personal characteristics includes things like health beliefs, perceived risks and benefits and confidence. For example, if I don’t believe that being a little overweight is that unhealthy, or alternatively if I don’t believe that changing my diet will result in weight loss, I’ll be less inclined to put much effort in. I think the other categories are a little more self-explanatory. If there are an abundance of fast food restaurants in my neighborhood with little to no options for healthy food that is convenient and affordable, I will be less likely to select healthy options. Cultural influences are also important, in many cultures, being too thin is associated with being sick. And finally, an individual living in an unsafe neighborhood faces different challenges than an individual who lives in a more upscale neighborhood or who can afford to join a gym and have a personal trainer.
  • Treatment options for obesity or overweight include lifestyle modification, medication and bariatric surgery. The rest of the talk will focus on this last option, bariatric surgery, in which there has been an increasing interest over the last 10 to 15 years.
  • This slide represents graphically the number of weight loss operations performed in the United States from the years 1993 to 2002. As you can see, in 1993, there were fewer than 10,000 procedures performed. By 2002, that number had increased to around 70,000 and the numbers have continued to increase. As these numbers continue to increase, it is becoming increasingly important that we, as internists, understand how best to manage patients following these procedures. How should we monitor them and what complications are they most likely to encounter?
  • Basically, bariatric surgery refers to any procedure that’s goal is to reduce caloric intake by modifying the GI tract. Procedures are classified as restrictive, malabsorptive or a mix of the two.
  • Options include gastric stapling, sleeve gastrectomy and laparoscpic adjustable banding.
  • These pictures illustrate two of those options. Laparoscopic adjustable gastric banding is a relatively new procedure that includes the insertion of a subcutaneous resevoir so gastric restriction can be adjusted by means of saline injections Vertical restrictive or sleeve gastrectomy is another recently developed procedure in which resection leaves a narrow tube of a stomach in place.
  • The second category consists of the purely malabsorptive procedures. In these, the surgery bypasses varying portions of the small intestine where nutriet absorption occurs. The jejunoileal bypass was one such procedure- it resulted ibn significant weight loss but was abandoned due to severe metabolic consequences, including intractable diarrhea, electrolyte disturbances, severe protein-calorie malnutrition, hypocalcemia, vitamin deficiencies and liver dysfunction progressing to cirrhosis and liver failure.
  • The last category consists of procedures that combine restrictive and malabsorptive features. The primary example of a mixed procedure is the roux en y gastric bypass. This procedure is the most commonly perfromed procedure in the US (follwed closed by laperascopic adjustible gastric banding). In 2004, it accounted for 92% of bariatric procedures. With roux en y, weight loss occurs..
  • These pictures provide examples of mixed procedures. As you can see, proximal roux-en-y gastric bypass is a combination procedure that involves stapling of the stomach to create a 30cc upper gastric pouch. The small intestine is then divided at the mid-jejunum and the distal portion is anastomosed to the gastric pouch. Food comes in contact with pancreatic and biliary secretions only below the anastomoses in a segment of the small intestine termed the common channel. The shorter the common channel the less nutritional absorption will occur. The biliopancreatic diversion with duodenal switch, seen here on the left, is another malabsorptive procedure that typically introduces less gastric restriction and greater intestinal bypass.
  • So we know that bariatric surgery is increasing in popularity and frequency, but what about the evidence for its effectiveness. What is the state of the science? In a word, it is emerging. It is important to note that to date, there have been no large randomized controlled trials of head to head comparison between surgery and medical management. Most of the data comes from observational studies or case control studies. The problem is, as anyone who has tried to refer a patient for bariatric surgery knows, there is a pretty intense selection process that surgical candidates have to pass through. So the data is from sort of “best case scenarios” rather than all comers. In 2005, a comprehensive cochrane review identified 2 small rcts and 3 cohort studies, each were considered to have a high risk of bias in their design. Based on these studies, they found that typical weight loss with surgery was between 20 to 50 kg while medically treated patients had a modest weight gain. Weight loss with malapsorbitve procedures generally greater than weight loss with restrictive procedures alone.
  • In 2004, a group in Sweden published the SOS or Swedish Obese Subjects trial. This is the only large, well controlled prospective study that included 2,010 surgically treated patients vs 2,037 control subjects. In this study, they demonstrated a loss of 23% body weight among surgical patients at 2 years compared to a 0.1% gain among controls. At 10 years, surgical patients had maintained a 16% body weight loss vs a 1.6% gain for controls.
  • The SOS study also, demonstrated improvements in conditions associated with obesity. Benefits were noted to diminish over time but remained statistically significant.
  • The following example was used in the October issue of New England Journal of Medicine to introduce an overview on bariatric surgery. READ I think this case underscores a very important point, and that is, that individuals who have struggled with being obese and with unsuccessful attempts at weight loss are in some ways a vulnerable population. Bariatric surgery seems like a definitive option for many. People may not really know the risks involved, or alternativeley, be so frustrated that they do not care. A couple of different studies have looked at what sorts of information is available to patients on the internet and elsewhere, patients often come in with very unrealistic expectations. Often, these patients either don’t make it through the screening process or if they do, they are at risk for worse outcomes. Our job is to help our patients make an informed decision- part of that is knowing who is eligible, what risks are involved and also educating patients about the life-long, post-operative requirements that this surgery will entail.
  • So what are the actual requirements for referral?
  • Prior to undergoing surgery, each candidate will undergo an extension evaluation consisting of several components.
  • The psychologic evaluation is one of the most important and difficult elements of the pre-operative assessment. A majority of patients presenting for bariatric surgery have one or more psychiatric disorders, some studies suggest that patients with an Axis I or II disorder are less likely to lose weight after surgery. Other psychosocial factors that have been associated with suboptimal surgical outcomes include disturbed eating habits, (e.g. binge eating), substance abuse, low socioeconomic status, limited social support, and unrealistic expectations of surgery.
  • I’d like to transition to a slightly different topic at this point. Would anyone like to identify this gentleman?
  • There are several potential complications associated with bariatic surgery in the immediate setting. Mortality rates range from 0.1 to 2.0%. For a patient, that can be described as up to a 1 in 50 chance of dying during or right after surgery. The most common causes of death include PE and anastomotic leak. Other complications include… Like any other complicated procedure, complication rates vary with experience of the surgeon and also the hospital. For this reason, there has been a move to performing bariatric surgery within specified centers of excellence.
  • Now I want to move from acute complications to complications that may occur any time after surgery. Probably the most common complication from bariatric surgery is nausea and vomiting. This has been noted to occur in approximately 30% of all bariatric patients, and is more common when there is a restrictive component, occuring in 50% of those patients. Nausea and vomiting can result in several additional complications in its own right, among them dehydration and electrolyte imbalance, protein-calorie malnutrition, and thiamine deficiency.
  • There are a number of potential causes of nausea and vomiting to consider in the post-bariatric patient.
  • Another common complication of baritric surgery is diarrhea.
  • I want to spend a couple of extra minutes on dumping syndrome because it is so common- occurring in approximately 75% of patients after a roux en Y procedure. Dumping syndrome is a neurohormonal phenomenon, characterized by facial flushing, light-headedness, palpitations, fatigue and diarrhea. It is triggered by the ingestion of concentrated, simple sugars. Though it generally subsides after about 12-18 months there are prophylatic measures that one can recommend to patients, including small, frequent meals, avoiding meals with high sugar content, and chewing food slowly and thoroughly.
  • The next category of complications I’d like to cover is that of nutritional deficiencies. A myriad of nutritional deficiencies have been noted following bariatric surgery and these include..
  • Severity and pattern depends on a combination of factors. The presence of pre-operative deficiencies. Patients may have a diet consisting of high calorie foods of little to no nutritional value. Type of procedure- restricitve vs those with a malabsorptive component. Degree of restrictyion and/or length of bypassed intestine. Modification of eating behavior- is it extremely restricted?
  • I wanted to give a very general review of which macro and micro nutrients get absorbed where. This picture represents normal sites of absorption but in the context of a roux en y gastric bypass. First, the macronutrients. 50% of protein absorption occurs in the duodenum, by midjejunum, the majority of protein absorption is complete. Carbohydrate absorption also begins in the duodenum and is complete within the first 100cm of the small intestine. 93% of dietary lipids are absorbed in the proximal 2/3 of the jejunum, however fat absorption, including fat soluble vitamins A,E,D &K can take place throughout the small intestine. Absorption of water soluble vitamins occurs in the proximal small bowel, mainly the jejunum. B12 bears special mention. Cobalamin, or B12 containing foods like meat, eggs and milk, undergo acid and peptic hydrolysis in the stomach to liberate the B12. It then passes into the duodenum where it binds to intrinsic factor produced by gastric parietal cells. The complex is then absorbed in the terminal ileum. Surgical procedures that resect portions of the stomach can cause B12 deficiency by decreasing acid or peptic hydolysis or decreasing the production of intrinsic factor. Other essential minerals and trace elements are also absorbed in the small intestine.
  • So as you may have guessed, nutritional deficiencies occur more commonly with malabsorptive and mixed procedures.
  • Finally, I just wanted to mention some additional complications that can arise, mostly mechanical in nature
  • Of patients who undergo gastric banding, 5 to 10% will develop gastric prolapse, where a portion of the stomach slides up through the gastric band and gets stuck. Another 5 to 10% will develop gastroesophageal dilation and can be related to for example, stenosis or a tight band. 2% or fewer will develop erosions. Any of these can present as N & V, heartburn, reflux and dysphagia. Of patients who undergo roux-en-y gastric bypass, somewhere between 4 and 20% will develop stenosis of the gastrojejunostomy. Symptoms are similar.
  • To date, there is really not good evidence to support recommendation for management, most of it comes from expert consensus.
  • This is an example of recommended laboratory monitoring that should be performed at 3 month intervals for the first two years and then annually.
  • So this young woman was diagnosed with wernicke’s encephalopathy. This is a condition due to extreme thiamine deficiency and as we have mentioned, is a recognised complication of bariatric surgery. Patients typically present much as this patient did, with ocular changes, ataxia, and mental status changes. This patient was treated with thiamine and after several months, her ocular symptoms had resolved, her lower extremity weakness improved.
  • Update: Bariatric Surgery

    1. 1. Bariatric Surgery: An Overview for the Internist Andrea Cherrington November 20, 2007
    2. 2. Case vignette <ul><li>26 yo white female </li></ul><ul><li>2 weeks progressive lower extremity weakness, blurred vision, urinary incontinence </li></ul><ul><li>“ Sluggish,” mild personality change </li></ul><ul><li>PMHx: </li></ul><ul><ul><li>Roux-en-Y gastric bypass </li></ul></ul><ul><ul><li>150 lb weight loss since surgery </li></ul></ul><ul><ul><li>Multiple admissions for N&V, IV hydration </li></ul></ul>
    3. 3. Case vignette <ul><li>Physical exam </li></ul><ul><ul><li>Normal vital signs </li></ul></ul><ul><ul><li>(+) Horizontal nystagmus </li></ul></ul><ul><ul><li>(+) Bilateral ophthalmoplegia </li></ul></ul><ul><ul><li>Unable to walk </li></ul></ul><ul><ul><li>Lower extremity exam: 2/5 strength, areflexia </li></ul></ul><ul><ul><li>Upper extremities exam normal </li></ul></ul>
    4. 4. Case vignette <ul><li>What is on the differential diagnosis? </li></ul><ul><li>What would you do next? </li></ul><ul><ul><li>Laboratory tests? </li></ul></ul><ul><ul><li>Imaging studies? </li></ul></ul><ul><li>What are the most common complications after bariatric surgery? </li></ul><ul><li>What can we do in primary care to prevent complications? </li></ul>
    5. 5. Outline <ul><li>Bariatric surgery </li></ul><ul><ul><li>Background information </li></ul></ul><ul><li>Who and when to refer </li></ul><ul><li>Long-term follow-up </li></ul><ul><ul><li>Potential complications </li></ul></ul><ul><ul><li>Recommendations for management </li></ul></ul>
    6. 6. Obesity epidemic <ul><li>Obesity is an epidemic condition in the United States and around the world. </li></ul><ul><li>Associated with increased risk of hypertension, diabetes, hyperlipidemia, sleep apnea, coronary heart disease and stroke. </li></ul><ul><li>Increase in rates of obesity could lead to decline in overall life expectancy in the United States. </li></ul>
    7. 7. Obesity Trends* Among U.S. Adults BRFSS, 1990 *BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person No Data <10% 10%–14% http://www.cdc.gov/nccdphp/dnpa/obesity/
    8. 8. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%
    9. 9. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
    10. 10. Obesity epidemic <ul><li>Factors influencing weight: </li></ul><ul><ul><li>Behavior (diet, exercise) </li></ul></ul><ul><ul><ul><li>Personal characteristics </li></ul></ul></ul><ul><ul><ul><li>Environment </li></ul></ul></ul><ul><ul><ul><li>Cultural attitudes </li></ul></ul></ul><ul><ul><ul><li>Financial situation </li></ul></ul></ul><ul><ul><li>Genetic </li></ul></ul><ul><ul><ul><li>Helps determine susceptibility </li></ul></ul></ul>
    11. 11. Obesity epidemic <ul><li>Treatment options </li></ul><ul><ul><li>Lifestyle modification </li></ul></ul><ul><ul><ul><li>Diet </li></ul></ul></ul><ul><ul><ul><li>Exercise </li></ul></ul></ul><ul><ul><li>Medication </li></ul></ul><ul><ul><li>Bariatric Surgery </li></ul></ul><ul><ul><ul><li>Increasing interest </li></ul></ul></ul>
    12. 12. Number of weight loss operations performed in the United States JAMA. 2005;294:1909-1917.
    13. 13. Bariatric Surgery: Definition <ul><li>Procedure to reduce </li></ul><ul><li>caloric intake by modifying </li></ul><ul><li>the GI tract </li></ul><ul><li>Three categories </li></ul><ul><ul><li>Restrictive </li></ul></ul><ul><ul><li>Malabsorptive </li></ul></ul><ul><ul><li>Mixed </li></ul></ul>
    14. 14. Restrictive procedures <ul><li>Limit food intake by creating small gastric reservoir with narrow outlet (<10%) </li></ul><ul><li>Procedures include: </li></ul><ul><ul><li>Gastric stapling (gastroplasty) </li></ul></ul><ul><ul><li>Adjustable gastric banding </li></ul></ul><ul><ul><ul><li>Wrapping a synthetic, inflatable band around the stomach to create a small pouch </li></ul></ul></ul>
    15. 15. N Engl J Med. May 24 2007;356(21):2176-2183.
    16. 16. Malabsorptive procedures <ul><li>Bypass varying portions of the small intestine where nutrient absorption occurs (>90%) </li></ul><ul><ul><li>Jejunoileal bypass (JIB) </li></ul></ul><ul><ul><ul><li>Resulted in significant weight loss </li></ul></ul></ul><ul><ul><ul><li>Abandoned secondary to severe metabolic consequences </li></ul></ul></ul><ul><ul><li>Jejunocolonic bypass (JCB) </li></ul></ul>
    17. 17. Mixed procedures <ul><li>Combine malabsorption and restriction </li></ul><ul><ul><li>Proximal Roux-en-Y (RYGB) </li></ul></ul><ul><ul><ul><li>Most commonly performed bypass procedure in the United States </li></ul></ul></ul><ul><ul><ul><li>Weight loss occurs from reduction in gastric volume with restricted intake, dumping syndrome, and a degree of malabsorption </li></ul></ul></ul><ul><ul><li>Biliopancreatic diversion (BPD) </li></ul></ul><ul><ul><li>BPD-Duodenal switch </li></ul></ul>
    18. 18. Bariatric Surgery: Mixed N Engl J Med. May 24 2007;356(21):2176-2183
    19. 19. Bariatric Surgery: Evidence <ul><li>No large, RCTs comparing surgery with medical management </li></ul><ul><li>2005 Cochrane Review: </li></ul><ul><ul><li>Identified 2 small RCTs, 3 cohort studies </li></ul></ul><ul><ul><li>Weight loss of 20 to 50kg with surgery vs. modest weight gain with medical treatment. </li></ul></ul><ul><ul><li>Weight loss greater with malabsorptive procedures than restrictive procedures. </li></ul></ul>N Engl J Med. May 24 2007;356(21):2176-2183
    20. 20. Bariatric Surgery: Evidence <ul><li>Swedish Obese Subjects Trial (SOS) </li></ul><ul><ul><li>Only large, well-controlled prospective study </li></ul></ul><ul><ul><ul><li>2,010 surgically treated patients vs </li></ul></ul></ul><ul><ul><ul><li>2,037 control subjects </li></ul></ul></ul><ul><ul><li>Weight change greater for surgical patients </li></ul></ul><ul><ul><ul><li>23% of body weight lost vs 0.1% gain (2 yrs) </li></ul></ul></ul><ul><ul><ul><li>16% of body weight lost vs 1.6% gain (10 yrs) </li></ul></ul></ul>N Engl J Med. May 24 2007;356(21):2176-2183
    21. 21. Bariatric Surgery: Evidence <ul><li>Improvements seen in conditions associated with obesity </li></ul><ul><ul><li>Diabetes, hyperlipidemia, hypertension, </li></ul></ul><ul><ul><li>sleep apnea </li></ul></ul><ul><li>Benefits diminish over time but still significant </li></ul><ul><ul><li>2yrs vs 10 yrs </li></ul></ul>
    22. 22. Referral for surgery: Who & when <ul><li>“ A 44-year old obese woman has seen her primary care physician for the past 10 years for management of DM, HTN and GERD. Despite her best efforts to lose weight, her body mass index has increased from 40.0 to 46.6. During a routine office visit, she asks her physician whether bariatric surgery might be a treatment option for her. The physician does not recommend referral for surgical evaluation, citing concerns about variable effectiveness of the procedure, associated risks and lack of long term outcome data. The patient then seeks a specialist in bariatric surgery for evaluation, without the assistance of her physician.” </li></ul>Duke Weight Loss Surgery Center, NEJM 356:21
    23. 23. Referral for surgery: Who & when <ul><li>Criteria: </li></ul><ul><ul><li>BMI > 40 </li></ul></ul><ul><ul><ul><li>Almost 5% of adults in the U.S. </li></ul></ul></ul><ul><ul><li>BMI > 35 + high risk condition </li></ul></ul><ul><ul><ul><li>Severe sleep apnea </li></ul></ul></ul><ul><ul><ul><li>Obesity-related cardiomyopathy </li></ul></ul></ul><ul><ul><ul><li>Severe diabetes mellitus </li></ul></ul></ul><ul><li>Additional: </li></ul><ul><ul><li>Failure of medical weight control </li></ul></ul><ul><ul><li>Absence of medical or psychologic contraindications </li></ul></ul><ul><ul><li>Strong patient motivation to comply with postsurgical regimen </li></ul></ul>
    24. 24. Referral for surgery: Who & when <ul><li>Comprehensive weight and nutrition history </li></ul><ul><ul><li>Weight trends, previous weight loss efforts </li></ul></ul><ul><li>Determine current weight, height and BMI </li></ul><ul><li>Medication history </li></ul><ul><ul><li>Antidepressants, OCPs, oral hypoglycemics </li></ul></ul><ul><li>Evaluation for conditions associated with obesity </li></ul><ul><ul><li>Diabetes, hypertension, hyperlipidemia, coronary disease sleep apnea, pulmonary hypertension </li></ul></ul><ul><li>Psychological evaluation </li></ul>
    25. 25. Referral for surgery: Who & when <ul><li>Psychological evaluation </li></ul><ul><li>Patients with Axis I or II disorder less likely to lose weight after surgery </li></ul><ul><li>Other psychosocial factors associated with suboptimal surgical outcomes include: </li></ul><ul><ul><li>Disturbed eating habits, (e.g. binge eating) </li></ul></ul><ul><ul><li>Substance abuse </li></ul></ul><ul><ul><li>Low socioeconomic status </li></ul></ul><ul><ul><li>Limited social support </li></ul></ul><ul><ul><li>Unrealistic expectations of surgery. </li></ul></ul>
    26. 26. Referral for surgery: Who & when <ul><li>Prior to undergoing surgery </li></ul><ul><ul><li>Preoperative education, including realistic expectations </li></ul></ul><ul><ul><li>Comprehensive long-term plan necessary </li></ul></ul><ul><ul><li>Increases chances of safety and success </li></ul></ul><ul><li>Do not proceed with surgery if </li></ul><ul><ul><li>Plan for systematic follow-up not in place </li></ul></ul><ul><ul><li>Patient does not agree to the plan up front </li></ul></ul>
    27. 27. Who is this man?
    28. 28. Acute complications of BS <ul><li>In 2002, Charlie Weis, the 330lb offensive coordinator for the New England Patriots underwent gastric stapling. </li></ul><ul><li>An acute bleed led to an ICU stay and a 2 week coma. </li></ul><ul><li>Charlie sued the hospital and physicians but was unsuccessful. </li></ul>
    29. 29. Acute complications of BS <ul><li>Mortality rates 0.1 – 2.0% </li></ul><ul><li>Common causes of death </li></ul><ul><ul><li>Pulmonary embolism </li></ul></ul><ul><ul><li>Anastomotic leak </li></ul></ul><ul><li>Non-fatal peri-operative complications </li></ul><ul><ul><li>Venous thromboembolism </li></ul></ul><ul><ul><li>Anastomotic leaks </li></ul></ul><ul><ul><li>Wound infection </li></ul></ul><ul><ul><li>Bleeding </li></ul></ul><ul><ul><li>Incisional and internal hernias </li></ul></ul><ul><ul><li>Early small bowel obstruction </li></ul></ul>
    30. 30. Long Term Complications: Nausea & Vomiting <ul><li>Occurs in 30% of all bariatric patients </li></ul><ul><li>Occurs in 50% of patients undergoing restrictive procedure </li></ul><ul><ul><li>Dehydration, electrolyte imbalance </li></ul></ul><ul><ul><li>Protein-calorie malnutrition </li></ul></ul><ul><ul><li>Thiamine deficiency with neurological sequelae </li></ul></ul>
    31. 31. Long Term Complications: Nausea & Vomiting <ul><li>Common causes after bariatric surgery: </li></ul><ul><ul><li>Inadequate chewing </li></ul></ul><ul><ul><li>Overdistension of pouch by fluid </li></ul></ul><ul><ul><li>Large volume meals </li></ul></ul><ul><ul><li>Food intolerance (red meat, lactose) </li></ul></ul><ul><ul><li>Stomal outlet stenosis/obstruction </li></ul></ul><ul><ul><li>Marginal ulceration </li></ul></ul><ul><ul><li>Intestinal obstruction </li></ul></ul><ul><ul><li>Gastroesophageal reflux disease </li></ul></ul><ul><ul><li>Symptomatic gallstones </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Dumping syndrome </li></ul></ul>
    32. 32. Long Term Complications: Diarrhea <ul><li>Can occur as a result of </li></ul><ul><ul><li>Food sensitivity </li></ul></ul><ul><ul><li>Lactose intolerance </li></ul></ul><ul><ul><li>Malabsorption </li></ul></ul><ul><ul><li>Bacterial overgrowth and infection </li></ul></ul><ul><ul><li>Dumping syndrome </li></ul></ul><ul><li>Can lead to dehydration and electrolyte imbalance </li></ul>
    33. 33. Long Term Complications: Dumping syndrome <ul><li>Occurs in more than 75% of patients after Roux-en-Y </li></ul><ul><ul><li>Neurohormonal: facial flushing, light-headed, palpitations, fatigue and diarrhea </li></ul></ul><ul><ul><li>Triggered by ingestion of concentrated sugars </li></ul></ul><ul><ul><li>Generally subsides after 12-18 months </li></ul></ul><ul><ul><li>Prevention: small, frequent meals, avoid foods with high sugar content. Chew food thoroughly, eat slowly </li></ul></ul>
    34. 34. Long Term Complications: Nutritional Deficiencies <ul><li>Iron </li></ul><ul><li>Folate </li></ul><ul><li>Vitamin B12 </li></ul><ul><li>Calcium </li></ul><ul><li>Deficiency of fat soluble vitamins (D,E,A,K) </li></ul><ul><li>Thiamine (vitamin B1) </li></ul><ul><li>Zinc </li></ul><ul><li>Protein malnutrition (after long limb or distal bypass) </li></ul>
    35. 35. Long Term Complications: Nutritional Deficiencies <ul><li>Severity and pattern depend on </li></ul><ul><li>Presence of pre-operative deficiencies </li></ul><ul><li>Type of procedure performed </li></ul><ul><li>Degree of restriction </li></ul><ul><li>Length of bypassed intestine </li></ul><ul><li>Modification of eating behavior </li></ul><ul><li>Development of complications (ex. emesis) </li></ul><ul><li>Compliance with oral MVI & mineral supplements </li></ul>
    36. 36. Review: what gets absorbed where?
    37. 37. Long Term Complications: Nutritional Deficiencies <ul><li>Occur more commonly with malabsorptive and mixed procedures </li></ul><ul><li>Nutritional deficiencies are uncommon with purely restrictive procedures unless </li></ul><ul><ul><li>Eating habits are excessively restricted or complications occur (emesis) </li></ul></ul><ul><ul><li>Folate is the most common deficiency after restrictive procedures </li></ul></ul>
    38. 38. Long Term Complications: Post-surgical <ul><li>Additional complications include: </li></ul><ul><ul><li>Bowel obstruction </li></ul></ul><ul><ul><li>Anastomotic leaks </li></ul></ul><ul><ul><li>Strictures </li></ul></ul><ul><ul><li>Erosions </li></ul></ul><ul><ul><li>Ulcers </li></ul></ul><ul><ul><li>Adhesions </li></ul></ul><ul><ul><li>Hernias </li></ul></ul><ul><ul><li>Cholelithiasis </li></ul></ul>
    39. 39. Long Term Complications: Post-surgical <ul><li>Common complications of gastric banding: </li></ul><ul><ul><li>Gastric prolapse 5-10% </li></ul></ul><ul><ul><li>Gastroesophageal dilation 5-10% </li></ul></ul><ul><ul><li>Band erosion 0-2% </li></ul></ul><ul><li>Symptoms include nausea & vomiting, also heartburn, nocturnal reflux, dysphagia </li></ul><ul><li>After RYGB, 4-20% of patients develop stenosis of the gastrojejunostomy </li></ul>
    40. 40. Recommended management <ul><li>Key to management of complications is prevention when possible </li></ul><ul><li>Dietary recommendations </li></ul><ul><ul><li>Failure to modify eating habits will results in vomiting and discomfort </li></ul></ul><ul><li>Life-long multivitamin and mineral supplements </li></ul>
    41. 41. Recommended management <ul><li>Dietary modification </li></ul><ul><li>Reduce food volume consumed, chew food very well, slow pace of eating </li></ul><ul><li>Do not consume fluids with food </li></ul><ul><ul><li>30 minutes before or after meal </li></ul></ul><ul><li>Protein rich-food should be major component of each meal </li></ul><ul><ul><li>Cheese, fish, poultry, eggs & meat </li></ul></ul><ul><ul><li>40-60g/day after RYGB </li></ul></ul><ul><ul><li>60-90g/day after BPD-DS </li></ul></ul><ul><li>Avoid empty calories </li></ul>
    42. 42. Recommended management <ul><li>Dietary supplements </li></ul><ul><li>All patients should receive </li></ul><ul><ul><li>Multivitamin with iron </li></ul></ul><ul><ul><li>Vitamin B12, B complex with thiamine </li></ul></ul><ul><ul><li>Vitamin C </li></ul></ul><ul><ul><li>Calcium </li></ul></ul><ul><li>Additional supplements may be needed for menstruating or pregnant women </li></ul><ul><li>Depending on procedure, patient may need fat soluble vitamin supplements (BPD) </li></ul>
    43. 43. Recommended management Am J Med Sci. Apr 2006;331(4):219-225 .
    44. 44. Case vignette <ul><li>Routine lab tests: NL </li></ul><ul><li>Low </li></ul><ul><ul><li>Vitamin B12 </li></ul></ul><ul><ul><li>Vitamin B6 </li></ul></ul><ul><ul><li>Vitamin C </li></ul></ul><ul><ul><li>Vitamin D </li></ul></ul><ul><li>Very low </li></ul><ul><ul><li>Thiamine </li></ul></ul><ul><li>Other vitamin/mineral levels were normal </li></ul>
    45. 45. Case vignette <ul><li>Wernicke’s encephalopathy </li></ul><ul><ul><li>Thiamine deficiency </li></ul></ul><ul><ul><li>Potential complication of bariatric surgery </li></ul></ul><ul><ul><li>Presents with ocular changes (nystagmus, ophthalmoplegia), ataxia, mental status change </li></ul></ul><ul><li>After several months on MVI, daily thiamine, patient’s ophthalmoplegia and nystagmus resolved, lower extremity weakness improved somewhat. </li></ul>
    46. 46. Additional information <ul><li>For additional information on </li></ul><ul><ul><ul><li>Impact of bariatric surgery on CVDz </li></ul></ul></ul><ul><ul><ul><li>Psychosocial impact of bariatric surgery; before and after </li></ul></ul></ul><ul><ul><ul><li>Financial impact of bariatric surgery </li></ul></ul></ul><ul><ul><li>Check out Medical Clinics of North America, 91(2007) </li></ul></ul><ul><li>Thanks to Jeanette Keith and Andrea Braun </li></ul>
    47. 47. References <ul><li>1. Allen JW. Laparoscopic gastric band complications. Med Clin North Am. May 2007;91(3):485-497, xii. </li></ul><ul><li>2. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med. May 24 2007;356(21):2176-2183. </li></ul><ul><li>3. Lopez PP, Patel NA, Koche LS. Outpatient complications encountered following Roux-en-Y gastric bypass. Med Clin North Am. May 2007;91(3):471-483, xii. </li></ul><ul><li>4. Malinowski SS. Nutritional and metabolic complications of bariatric surgery. Am J Med Sci. Apr 2006;331(4):219-225. </li></ul><ul><li>5. Markel TA, Mattar SG. Management of gastrointestinal disorders in the bariatric patient. Med Clin North Am. May 2007;91(3):443-450, xi. </li></ul><ul><li>6. Mathier MA, Ramanathan RC. Impact of obesity and bariatric surgery on cardiovascular disease. Med Clin North Am. May 2007;91(3):415-431, x-xi. </li></ul><ul><li>7. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. Mar 17 2005;352(11):1138-1145. </li></ul><ul><li>8. Powers KA, Rehrig ST, Jones DB. Financial impact of obesity and bariatric surgery. Med Clin North Am. May 2007;91(3):321-338, ix. </li></ul><ul><li>9. Tucker ON, Szomstein S, Rosenthal RJ. Nutritional consequences of weight-loss surgery. Med Clin North Am. May 2007;91(3):499-514, xii. </li></ul><ul><li>10. Wadden TA, Sarwer DB, Fabricatore AN, Jones L, Stack R, Williams NS. Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin North Am. May 2007;91(3):451-469, xi-xii. </li></ul>