Bariatric Surgery for the Primary Care Physician - The Family ...


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  • Obesity is recognized as a chronic, debilitating and potentially fatal disease. Obesity has approached smoking as a leading cause of preventable death. Obesity and excess weight are associated with: Type 2 Diabetes (wt gain of 11-18 # increases risk x2) Hypertension (High Blood Pressure) – 2X more common Cardiovascular Disease (Heart Attack and Stroke) Stroke High Cholesterol (Incrs Trig, decrs HDL) Osteoarthritis (Every 2# incrs in wt = 9-13% incrs in arthritis) Sleep Apnea Gallbladder Disease Certain Types of Cancer (endomet,colon,GB,prost,kidny,breast) Female Infertility Obese individuals have a 50 to 100% incrsd risk of premat death Overwt adolescents have 70% chance of becoming overwt adults 300,000 deaths calculated, due to diet and sedentary lives
  • Physicians know that even a 5 to 10% weight loss can produce significant health benefits, yet we recognize that many of our patients have difficulty achieving permanent weight loss. Our patients want to lose the weight and are desperate for a quick fix, making them easy targets for this billion-dollar industry. Current popular interventions include diets based on limiting caloric intake by counting calories, fat grams, or by restricting certain foods such as carbohydrates. Another option is medically supervised very low calorie diets or liquid fasts. Prescription and non-prescription weight loss medications remain in high demand despite reports of significant complications. There has been resurgence in popularity of bariatric surgery due to media attention. Exercise regimens remain an important part of most weight loss programs. Interventions recommended by the National Heart, Lung and Blood Institute Clinical Guidelines include low calorie diets, increased physical activity, and behavior therapy. Weight loss medications and surgical interventions may be appropriate for carefully selected patients.
  • Bariatric Surgery for the Primary Care Physician - The Family ...

    1. 1. The Family Physician’s Role in Managing the Bariatric Surgery Patient B. Wayne Blount, M.D., MPH
    2. 2. Objectives <ul><li>Discuss non-surgical and surgical weight management options </li></ul><ul><li>Identify appropriate surgical candidates and counsel patients about the importance of compliance with the post-operative regimen </li></ul><ul><li>Review the current surgical treatment options and their effectiveness including possible side effects and complications </li></ul><ul><li>Discuss follow-up care and long-term management of the post-bariatric surgical patient </li></ul>
    3. 3. The Obesity Epidemic <ul><li>67% are overweight or obese </li></ul><ul><li>$117 billion spent in 2000 to treat the medical consequences of overweight and obesity </li></ul><ul><li>112,000 deaths/year attributed to obesity* </li></ul>*Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual cause of death in the United States. Journal of the American Medical Association, 291 (10), 1238-1245.
    5. 5. The Obesity Epidemic <ul><li>Use : </li></ul><ul><ul><li>BMI : tables </li></ul></ul><ul><ul><li>Waist Circumference : </li></ul></ul><ul><ul><ul><li>Measured @ narrowest part of waist between lower rib cage & unbilicus </li></ul></ul></ul>
    6. 6. Health Burden <ul><li>Type 2 diabetes </li></ul><ul><li>Hypertension </li></ul><ul><li>Cardiovascular disease </li></ul><ul><li>Stroke </li></ul><ul><li>Dyslipidemias </li></ul><ul><li>Osteoarthritis </li></ul><ul><li>Cancers </li></ul><ul><li>Sleep apnea </li></ul><ul><li>Gall bladder disease </li></ul><ul><li>Female infertility </li></ul><ul><li>Psychological issues </li></ul>
    7. 7. <ul><li>Popular diets: reduce caloric intake by restricting certain foods and limiting portions, i.e. by counting calories, fat or carbs </li></ul><ul><li>Medically supervised diets </li></ul><ul><ul><li>Very Low Calorie Diets (VLCD) </li></ul></ul><ul><ul><li>Liquid Fasts </li></ul></ul><ul><li>Referral to a nutritionist or dietician </li></ul><ul><li>Exercise regimens </li></ul><ul><li>Medications (sibutramine, orlistat) </li></ul><ul><li>Cognitive Behavioral Training </li></ul><ul><li>Bariatric Surgery </li></ul>The Current Interventions
    8. 8. The Current Interventions
    9. 9. Effect of 4 Diets on Wgt Loss <ul><li>Atkins, Ornish, Wgt Watchers, & Zone </li></ul><ul><li>1 year </li></ul><ul><li>25% with adequate adherence </li></ul><ul><li>4.6 to 7.3 # loss @ 1 yr in those 25% </li></ul><ul><li>Which diet didn’t matter </li></ul><ul><li>Exercise did matter </li></ul>
    10. 10. Why Diets Often Fail <ul><li>Require lot of time and energy </li></ul><ul><li>Cause feelings of deprivation </li></ul><ul><li>Don’t address why people overeat </li></ul><ul><li>Disrupt metabolism </li></ul>
    11. 11. Bariatric Surgery <ul><li>Number of procedures performed has increased 10-fold </li></ul><ul><ul><li>14,000 in 1993 </li></ul></ul><ul><ul><li>140,000 in 2004 </li></ul></ul><ul><ul><li>> 200,000 in 2005 </li></ul></ul><ul><ul><li>> 300,000 in 2007 </li></ul></ul>
    12. 12. Bariatric Surgery <ul><li>Evidenced Based Recommendation: </li></ul><ul><li>Bariatric surgery leads to sustainable long-term weight loss and may reduce obesity-related comorbities such as diabetes mellitus and obstructive sleep apnea. It is not clear which surgical procedure is the safest and most effective. </li></ul><ul><li>Recommendation B </li></ul><ul><li>From The Cochrane Database of Systematic Reviews available at ttp:// </li></ul>5
    13. 13. The Family Physician’s Role <ul><li>Assist their patients in their weight management efforts </li></ul><ul><li>Identify potential surgical candidates </li></ul><ul><li>Counsel patients about their options and the risks and outcomes of each </li></ul><ul><li>Understand the post-surgical dietary regimen </li></ul><ul><li>Monitor patients for short and long-term complications of bariatric surgery </li></ul>
    14. 14. Indications <ul><li>Body Mass Index of 40 kg per m 2 </li></ul><ul><li>Body Mass Index of 35 kg per m 2 with significant comorbities </li></ul><ul><ul><li>Type 2 diabetes </li></ul></ul><ul><ul><li>Obstructive sleep apnea </li></ul></ul><ul><ul><li>Coronary artery disease </li></ul></ul><ul><ul><li>Debilitating arthritis </li></ul></ul><ul><ul><li>Online BMI calculator available @ </li></ul></ul>Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus
    15. 15. Indications (continued) <ul><li>Previous failed weight loss attempts using an integrated weight loss program including: </li></ul><ul><ul><li>Dietary modification </li></ul></ul><ul><ul><li>Behavioral support </li></ul></ul><ul><ul><li>Appropriate exercise </li></ul></ul><ul><li>Appropriate motivation and psychological stability to understand risks and benefits of the procedure </li></ul><ul><li>The commitment to lifelong postoperative lifestyle changes and medical surveillance </li></ul>Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus
    16. 16. Contraindications <ul><li>Poor surgical candidates – inadequate cardiopulmonary reserve, drug or alcohol dependency, impaired intellectual capacity </li></ul><ul><li>Unable or unwilling to comply with post-op lifestyle changes, diet, supplementation, f/u </li></ul><ul><li>Unstable psychiatric illness or eating disorders </li></ul><ul><li>Uncontrolled coagulation problems or cannot be removed from coagulation therapy </li></ul><ul><li>For Lap Band – Intra-abdominal adhesions or potential for inadequate pneumoperitoneum </li></ul>
    17. 17. Pre-Op Evaluation <ul><li>Patients should be evaluated by a team – medical surgical, psychiatric and nutritional experts to determine whether they are candidates for bariatric surgery </li></ul><ul><li>Pre-op physical and evaluation </li></ul>Gastrointestinal surgery for severe obesity. Consensus Statement 1991;9:1-20. Available online at http://consensus
    18. 18. Pre-Op Evaluation (continued) <ul><li>Studies may include: </li></ul><ul><li>EKG </li></ul><ul><li>CXR </li></ul><ul><li>Echocardiogram </li></ul><ul><li>Cardiac cath </li></ul><ul><li>Polysomnography/sleep study </li></ul><ul><li>Gallbladder ultrasound </li></ul><ul><li>UGI or EGD </li></ul><ul><li>Possible cardiac, pulmonary and psychiatry consultations </li></ul>
    19. 19. Pre-Op Evaluation (continued) <ul><li>Labs may include: </li></ul><ul><li>Fasting comprehensive metabolic panel </li></ul><ul><li>LFTs including albumin </li></ul><ul><li>Lipid panel </li></ul><ul><li>CBC </li></ul><ul><li>UA </li></ul><ul><li>Hgb A1C </li></ul><ul><li>Oral glucose tolerance test </li></ul><ul><li>Fasting insulin </li></ul><ul><li>Transferrin </li></ul><ul><li>TFTs </li></ul><ul><li>Beta HCG for females of childbearing age </li></ul>
    20. 20. Surgical Options <ul><li>Based on 1 of 2 mechanisms for weight loss: </li></ul><ul><li>1. Gastric restriction : </li></ul><ul><ul><li>Vertical Banded Gastroplasty </li></ul></ul><ul><ul><li>Sleeve Gastrectomy </li></ul></ul><ul><ul><li>Adjustable gastric banding </li></ul></ul><ul><li>2. Intestinal malabsorption : </li></ul><ul><ul><li>Roux-en-Y </li></ul></ul><ul><ul><li>Duodenal Switch </li></ul></ul>
    21. 21. What are the procedures available for weight loss? <ul><li>The Malabsorptive Procedures </li></ul><ul><ul><li>The malabsorptive procedures bypass a large amount of intestine and weight loss is achieved by creating nutritional inefficiency </li></ul></ul><ul><ul><ul><li>DUODENAL SWITCH </li></ul></ul></ul><ul><li>The Restrictive Procedures </li></ul><ul><ul><li>These procedures restrict the size of the stomach near the esophagus by creating a restrictive pouch. which will hold a volume of approximately 40cc. </li></ul></ul><ul><ul><ul><li>GASTRIC BYPASS Lap-Band </li></ul></ul></ul><ul><ul><ul><li>Sleeve Gastrectomy </li></ul></ul></ul>
    22. 22. The Malabsorptive Procedures Duodenal Switch <ul><li>Fat Malabsorption Primary Mechanism </li></ul><ul><li>Malnutrition an issue </li></ul><ul><ul><li>Fat Souluble Vitamins </li></ul></ul><ul><ul><li>Protein malnutrtion </li></ul></ul><ul><li>Frequent foul smelling stools </li></ul><ul><ul><li>Up to seven per day </li></ul></ul><ul><li>Hepatotoxicity </li></ul><ul><ul><li>Elevated liver enzymes </li></ul></ul><ul><ul><li>Potential for Liver Failure </li></ul></ul><ul><li>Hypoalbuminemia </li></ul><ul><li>Hypoproteinemia </li></ul><ul><li>VERY EFFECTIVE WEIGHT LOSS </li></ul>
    23. 23. The Restrictive Procedures Lap-Band <ul><li>Pure Restrictive Mechanism </li></ul><ul><li>Requires Frequent Surgical Followvup </li></ul><ul><ul><li>Monthly to Every 6 weeks </li></ul></ul><ul><li>Requires Significant Dietary Changes </li></ul><ul><li>Major Complications </li></ul><ul><ul><li>Band Slippage – Reoperation </li></ul></ul><ul><ul><li>Band Erosion – Removal </li></ul></ul><ul><li>No Malabsorption Risk </li></ul><ul><li>Reversible </li></ul><ul><li>Low Risk </li></ul><ul><li>Outpatient Surgery </li></ul>
    24. 24. The Restrictive Procedures Sleeve Gastrectomy <ul><li>Permanent Partial Gastrectomy </li></ul><ul><ul><li>Resection of body of stomach </li></ul></ul><ul><ul><li>Resection of fundus of stomach </li></ul></ul><ul><ul><li>Resection of Antrum of stomach </li></ul></ul><ul><ul><li>Unproven – experimental </li></ul></ul><ul><ul><ul><li>Becoming more common </li></ul></ul></ul><ul><ul><ul><li>Not covered by Insurance </li></ul></ul></ul>
    25. 25. Combined Procedures Gastric Bypass <ul><li>Most commonly performed bariatric procedure in U.S. </li></ul><ul><li>Creates a small Gastric pouch </li></ul><ul><li>Creates a short Roux Limb </li></ul><ul><li>Combined Procedure </li></ul><ul><ul><li>Small Malabsorptive limb </li></ul></ul><ul><ul><li>Restrictive gastric pouch </li></ul></ul><ul><li>Difficult to Reverse </li></ul>
    26. 26. Results of Gastric Bypass <ul><li>Average BMI 43.5 </li></ul><ul><li>82% Female 18% male </li></ul><ul><li>Conversions to open – 2% </li></ul><ul><li>Admissions to ICU post op 4% </li></ul><ul><ul><li>3% sleep apnea observation </li></ul></ul><ul><ul><li>1% unexpected secondary to conversion to open </li></ul></ul><ul><li>Average Length of Stay – 2.2 days </li></ul><ul><ul><li>Outliers – 1% > 10 days </li></ul></ul>
    27. 27. Results of Gastric Bypass <ul><li>Anastomotic leaks -2% </li></ul><ul><li>Internal Hernia requiring reoperation – 4% </li></ul><ul><li>Death – < 3 % </li></ul><ul><ul><li>Anastomotic Leak Sudden Cardiac Death </li></ul></ul>
    28. 28. Outcomes – Gastric Bypass <ul><li>Effective Weight Loss </li></ul><ul><ul><li>1 year 68% </li></ul></ul><ul><ul><li>2 year 74% </li></ul></ul><ul><ul><li>3 year 72% </li></ul></ul>
    29. 29. LAGB Weight Loss Systematic Review World Literature-ASERNIP-S <ul><li>Mean % Excess Weight Loss: </li></ul>Surgery 2004;135:326-51 J Lap Adv Surg Tech 2003;13:265-70 *Not statistically significance Procedure 36 months 48 months 60 months LAGB (range) # Reports 55% (38-64) 52% (44-68) 56%* (53-60) RYGB (range) # Reports 69% (58-89) 58% (56-63) 59%* (55-62)
    30. 30. A comparison of percentage of excess weight loss following LAGB and RYGB surgery. Published series with baseline numbers greater than 50 1 1 Surgery 2004;135:326-51 LAGB Weight Loss
    31. 31. Career Experience – Gastric Bypass 1152 Cases – Major Complications <ul><li>Death 3 patients </li></ul><ul><ul><li>Anastomotic Leak – 1 patient post op day 3 </li></ul></ul><ul><ul><li>Sudden Cardiac Death – 2 patients </li></ul></ul><ul><ul><ul><li>No Leak </li></ul></ul></ul><ul><ul><ul><li>No PE </li></ul></ul></ul><ul><li>Internal Hernia Requiring Reoperation </li></ul><ul><ul><li>6 patients </li></ul></ul><ul><li>Ischemic Bowel – Reoperation/Resection </li></ul><ul><ul><li>2 patients </li></ul></ul><ul><ul><ul><li>Venous Stasis/Thrombosis/Congestion – 1 </li></ul></ul></ul><ul><ul><ul><li>Arterial Thrombosis/Hypercoagulopathy -1 </li></ul></ul></ul>
    32. 32. Career Experience – Gastric Bypass 1152 Cases – Major Complications <ul><li>Pulmonary Embolism – (No Deaths) </li></ul><ul><ul><li>Post Op Day 1-14 NONE </li></ul></ul><ul><ul><li>Post Op Day 14-30 3 </li></ul></ul><ul><ul><ul><li>Rx – Prophylactic IVC Filter Pre-Op - (One) </li></ul></ul></ul><ul><ul><ul><li>- Post Op Heparin/Coumadin – (Two) </li></ul></ul></ul>
    33. 33. Surgical Options <ul><li>Roux-en-Y is most common procedure </li></ul><ul><li>Lap-Band Increasing in popularity </li></ul><ul><li>Sleeve Gastrectomy – Experimental </li></ul><ul><li>Duodenal Switch – </li></ul><ul><li>Laparoscopic pts have less; </li></ul><ul><ul><li>Time in hospital, </li></ul></ul><ul><ul><li>Lost work </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Incisional hernias (vs 25% in open) </li></ul></ul>
    34. 34. Life-Threatening Complications <ul><li>80% of deaths in the first 30 days are due to: </li></ul><ul><ul><li>Pulmonary embolism </li></ul></ul><ul><ul><li>Anastomotic leaks </li></ul></ul><ul><ul><li>Respiratory failure </li></ul></ul>
    35. 35. Life-Threatening Complications <ul><li>Pulmonary Embolism </li></ul><ul><li>Leading cause of death </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>BMI => 60 kg/m 2 </li></ul></ul><ul><ul><li>Chronic lower extremity edema </li></ul></ul><ul><ul><li>Obstructive sleep apnea </li></ul></ul><ul><ul><li>h/o pulmonary embolism </li></ul></ul><ul><li>Prophylaxis </li></ul><ul><ul><li>low-molecular-weight heparin and compression stockings </li></ul></ul><ul><ul><li>Early Ambulation (laparoscopic) </li></ul></ul><ul><ul><li>Consider Pre-operative IVC Filter </li></ul></ul>Geerts, W.H., Pineo, g.F., Heit, J.A. et al. (2004). Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3 suppl), S338-400 .
    36. 36. Life-Threatening Complications <ul><li>Anastomotic leaks – Signs and Symptoms </li></ul><ul><ul><li>Sustained tachycardia, severe abdominal pain, fever, rigors, hypotension </li></ul></ul><ul><ul><li>Respiratory failure </li></ul></ul><ul><li>Work-up: UGI or CT scan with contrast – </li></ul><ul><ul><li>May be negative </li></ul></ul><ul><ul><li>DON’T DELAY SURGICAL CONSULT </li></ul></ul><ul><li>Urgent surgical consultation </li></ul><ul><li>Exploratory surgery if equivocal signs </li></ul><ul><ul><li>“ Leak Until Proven Otherwise” post op day 1-14 </li></ul></ul><ul><li>Identify complications early and educate patients about reporting symptoms </li></ul>
    37. 37. Life-Threatening Complications <ul><li>Internal Hernia </li></ul><ul><li>Partial Small Bowel Obstruction through internal mesenteric defects </li></ul><ul><li>Usually following RYGB or Duodenal Switch procedures </li></ul><ul><li>Patients complain of severe pain </li></ul><ul><ul><li>Intermittent </li></ul></ul><ul><ul><li>Out of proportion to physical findings </li></ul></ul><ul><ul><li>Usually NOT vomiting </li></ul></ul><ul><ul><li>CT findings usually negative </li></ul></ul><ul><ul><li>Abdominal series usually negative </li></ul></ul><ul><ul><li>Usually occur 12 months or greater post op </li></ul></ul><ul><ul><li>Usually occur after >100 pounds weight loss </li></ul></ul><ul><li>Surgical Consultation </li></ul><ul><ul><li>Diagnostic laparoscopy and repair of hernia </li></ul></ul><ul><ul><li>Delay in diagnosis can be life threatening </li></ul></ul>
    38. 38. Short-Term Complications <ul><li>1-6 weeks post-op: </li></ul><ul><li>Wound infections </li></ul><ul><ul><li>Less Common in Laparoscopic Group </li></ul></ul><ul><ul><li>Open Group may lead to incisional hernia </li></ul></ul><ul><li>Stomal stenosis </li></ul><ul><ul><li>Nausea, Vomiting inability to advance diet </li></ul></ul><ul><ul><li>Usually requires EGD and dilation </li></ul></ul><ul><li>Marginal ulceration </li></ul><ul><ul><li>Usually ischemic </li></ul></ul><ul><ul><li>Rarely secondary to Acid production </li></ul></ul><ul><ul><li>PPI (Prevacid Solutab), Carafate suspension </li></ul></ul><ul><li>Constipation </li></ul><ul><ul><li>Poor PO Fluid intake </li></ul></ul>
    39. 39. Long-Term Complications <ul><li>Nausea, Bloating Abdominal Discomfort </li></ul><ul><li>Think Biliary Dyskinesia or </li></ul><ul><li>Symptomatic Cholelithiasis </li></ul><ul><ul><li>Workup </li></ul></ul><ul><ul><ul><li>Abdominal Ultrasound – Gallstones? </li></ul></ul></ul><ul><ul><ul><li>HIDA WITH Biliary Ejection Fraction – Dyskinesia? </li></ul></ul></ul><ul><ul><li>Up to 50% due to rapid weight loss </li></ul></ul><ul><ul><li>Consider prophylactic cholecystectomy at the time of surgery </li></ul></ul><ul><ul><li>Consider bile salt therapy – Daily for 6 months post op </li></ul></ul>
    40. 40. Long-Term Complications <ul><li>Nausea, Bloating Abdominal Discomfort, Malaise, Fatigue, Hair loss etc </li></ul><ul><ul><li>Think Nutritional Deficiency </li></ul></ul><ul><ul><ul><li>B vitamins </li></ul></ul></ul><ul><ul><ul><ul><li>Thiamin, Riboflavin, Niacin, Folate, B6, B12, biotin and pantothenic acid. </li></ul></ul></ul></ul><ul><ul><ul><li>Fat Soluble Vitamins </li></ul></ul></ul><ul><ul><ul><ul><li>A,D,E,K </li></ul></ul></ul></ul><ul><ul><ul><li>Vitamin C </li></ul></ul></ul><ul><li>Compliance? </li></ul><ul><ul><li>Only 30-35% patients are vitamin compliant </li></ul></ul>
    41. 41. Long-Term Complications <ul><li>Nutritional Deficiencies </li></ul><ul><ul><li>Especially with malabsorptive procedures (RYGB, biliopancreatic diversion) </li></ul></ul><ul><li>Prevention </li></ul><ul><ul><li>Adherence to high protein diet </li></ul></ul><ul><ul><li>Lifelong supplementation </li></ul></ul><ul><ul><ul><li>High potency </li></ul></ul></ul><ul><ul><ul><li>MVI with iron </li></ul></ul></ul><ul><ul><ul><li>Vitamin B 12 , 1000mcg IM q mo or 100mcg po qd </li></ul></ul></ul><ul><ul><ul><li>Calcium 1200 mg q d </li></ul></ul></ul><ul><ul><ul><li>Menstruating women may require parenteral iron infusions </li></ul></ul></ul>Halverson, J.D., (1992).Metabolic risk of obesity surgery and lon-term follow-up. American Journal of Clinical Nutrition, 55, S602-605 .
    42. 42. Post-Op <ul><li>Usually surgeons have their own specific dietary transitions & anticoagulation methods </li></ul><ul><li>Some recommended ones can be found @ “UpToDate” </li></ul><ul><li>Be aware that in the perioperative period, many obesity-related medical co-morbidities change dramatically; e.g. HTN, DM, GERD </li></ul>
    43. 43. Post-Op Monitoring Virji, A., Murr, M. (2006). Caring for patients after bariatric surgery. American Family Physician, 73 (8), 1403-1408 . Follow-up Lab Tests Every 3 months for the first year CBC, glucose, creatinine Every 6 months for the first year LFTs, protein and albumin, iron, TIBC, ferritin, vitamin B12, folic acid, calcium, parathyroid hormone (if hypercalcemic) Every year after the first year All of the above
    44. 44. Long-Term Complications Compliance Issues <ul><li>Dumping Syndrome </li></ul><ul><ul><li>Procholinergic symptoms from influx of undigested carbohydrate into the jejunum </li></ul></ul><ul><ul><li>Side effect of malabsorptive procedures – RYBG and biliopancreatic diversion </li></ul></ul><ul><li>Symptoms </li></ul><ul><ul><li>Nausea, vomiting, diarrhea, tachycardia, salivation, dizziness </li></ul></ul><ul><li>Results from poor dietary compliance; may serve as reinforcement </li></ul><ul><li>Subsides 1-2 hours after sugar or foods high in simple carbohydrate </li></ul>
    45. 45. Long-Term Complications Compliance Issues <ul><li>Persistent vomiting due to p ouch distention </li></ul><ul><ul><li>More common with purely restrictive procedures VBG and adj. lap band </li></ul></ul><ul><ul><li>Due to non-adherence to dietary recommendations </li></ul></ul><ul><ul><ul><li>Small portions </li></ul></ul></ul><ul><ul><ul><li>Chewing thoroughly </li></ul></ul></ul><ul><ul><ul><li>Eating slowly </li></ul></ul></ul><ul><ul><ul><li>Waiting one hour after eating before drinking </li></ul></ul></ul><ul><li>Other causes of vomiting – pain meds, vitamins, dehydration, gastroenteritis </li></ul>Bohn, M., Way, M., Jemieson, A. (1993). The effects of practical dietary counseling on food variety and regurgitation frequency after gastroplasty for obesity. Obesity Surgery, 3, 23-28 .
    46. 46. Compliance Issues - Pregnancy <ul><li>Pregnancy is contraindicated for at least 18 months after surgery due to rapid weight loss and nutritional requirements </li></ul><ul><li>Provide appropriate contraception </li></ul>
    47. 47. Long-Term Complications <ul><li>Protein-calorie malnutrition months to years after surgery due to anastomotic stricture or food phobias </li></ul><ul><li>Repeated episodes of nausea and vomiting </li></ul><ul><li>Multiple hospitalizations for dehydration, renal insufficiency and liver failure </li></ul><ul><li>Treat with aggressive TPN, dilation of stricture </li></ul><ul><li>Surgical Consultation for Revision or Reversal </li></ul>
    48. 48. Long-Term Complications Side Effects – Skin Issues <ul><li>Panniculitis </li></ul><ul><ul><li>Severe infection of the excess abdominal skin </li></ul></ul><ul><ul><li>Treat with antibiotics and skin hygiene </li></ul></ul><ul><ul><li>Consider excision of the excess skin </li></ul></ul>
    49. 49. Results <ul><li>Clinical Improvement/Resolution : </li></ul><ul><ul><li>Diabetes : 64-100% </li></ul></ul><ul><ul><li>HTN : 62-69% </li></ul></ul><ul><ul><li>O.S.Apnea : 85% </li></ul></ul><ul><ul><li>Dyslipidemia : 60-100% </li></ul></ul><ul><ul><li>Nonalcoholic fatty </li></ul></ul><ul><ul><li>liver dz : 90% </li></ul></ul>
    50. 50. Results <ul><li>Cholelithiasis : 22% </li></ul><ul><li>Overall mortality (after 9 yrs) : </li></ul><ul><ul><li>With surgery : 9% </li></ul></ul><ul><ul><li>Without surgery : 28% </li></ul></ul>
    51. 51. F. P. ‘ s Role in F/U <ul><li>COUNSELLING PT ON LIFE STYLE CHANGES AND EXPECTATIONS ** </li></ul><ul><ul><li>DIETARY CHANGES : AMT, LIQUIDS, PROTEIN </li></ul></ul><ul><ul><li>SUPPLEMENTS </li></ul></ul><ul><ul><li>CHANGE IN CHRONIC ILLNESSES </li></ul></ul>
    52. 52. Manage Changes In Chronic Illnesses <ul><li>DIABETES </li></ul><ul><li>HYPERTENSION </li></ul><ul><li>GERD </li></ul><ul><li>DYSLIPIDEMIAS </li></ul><ul><li>WHEN ? </li></ul>
    53. 53. Bibliography <ul><li>Virji A, Murr MM. caring for patients After Bariatric Surgery. AFP 2006;73:1403-8. </li></ul><ul><li> </li></ul><ul><li>USPSTF. Screening for obesity in adults. AFP April 15, 2004; </li></ul><ul><li>UpToDate </li></ul><ul><li>CARING FOR PATIENTS AFTER BARIATRIC SURGERY. CME BULLETIN. AAFP. JUNE 2006. </li></ul><ul><li>MAYO CLINIC PROCEEDINGS. SUPPLEMENT TO OCT. 2006, VOL 81. </li></ul>
    54. 54. Bibliography <ul><li>American Dietetic Assoc Position of ADA. 2002. J Am Dietetic Assn. 102:1145-55. </li></ul><ul><li>May M. Am I Hungry? What To Do When Diets Don’t Work. Phoenix: Nourish publishing </li></ul><ul><li>Vega GL. Obesity,The Metabolic Syndrome, & Cardiovascular Disease. Am Heart J, 142:1108-16. </li></ul><ul><li>Wadden, TA. (ed). Handbook of Obesity Treatment. 2002. Ny: Guilford Press. </li></ul>
    55. 55. Thank You! ? Questions?