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Sandy McCoy, RN, MSN, CBN, FNP-BC

Sandy McCoy, RN, MSN, CBN, FNP-BC. Post Operative Care/Considerations of the Bariatric Patient in Primary Care. Objectives. Identify obesity as a major health problem Describe the socio-economic impact on people who suffer from morbid obesity Discuss the surgical options for obesity.

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Sandy McCoy, RN, MSN, CBN, FNP-BC

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  1. Sandy McCoy, RN, MSN, CBN, FNP-BC Post Operative Care/Considerations of the Bariatric Patient in Primary Care

  2. Objectives • Identify obesity as a major health problem • Describe the socio-economic impact on people who suffer from morbid obesity • Discuss the surgical options for obesity. • 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.

  3. Weight Counts Slightly underweight insects, fish, reptiles, birds, mammals and people live longer than the overweight. “To lengthen thy life, lessen thy meals.” —Benjamin Franklin

  4. What Is Obesity? • 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 • Defined as >200% of ideal weight, >100 lb overweight, or a body mass index of 40

  5. What is Causing Obesity? • 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

  6. Body Mass Index (BMI) 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. Example: Weight = 150 lbs, Height = 5’5” (65")Calculation: [150 ÷ (65)2] x 703 = 24.96

  7. Obesity Facts • World epidemic of obesity • Estimated about 1.7 billion people • 25% of industrialized world • 97 million Americans (> 2/3 population) are overweight/obese. Has tripled in last 20 years. • Obesity costs in US about $100 billion/yr in direct health care expenses/lost productivity. • 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.

  8. Diabetes 15-30% Hypertension 20-55% Hyperlipidemia 35-53% Cardiac disease 10-20% Respiratory disease 15-20% Sleep apnea Syndrome 50-65% Arthritis 70-90% Depression 50-65% Stress Incontinence 30-45% Menstrual irregularity 50-65% Metabolic Syndrome 40% >age 60 Obesity Related Co-Morbidities% of patients presenting w/ condition prior to bariatric surgery Table 7 Bariatric Literatre review

  9. Obesity Related Co-Morbidities% of patients presenting w/ condition prior to bariatric surgery Diabetes 15-30% Hypertension 20-55% Hyperlipidemia 35-53% Cardiac disease 10-20% Respiratory disease 15-20% Sleep apnea Syndrome 50-65% Arthritis 70-90% Depression 50-65% Stress Incontinence 30-45% Menstrual irregularity 50-65% Table 7 Bariatric Literatre review

  10. Economic and Social Co-Morbidities 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

  11. What WLS Will and Will Not do for you • Weight loss surgery is not a “magic pill.” • It will notmake 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.

  12. Surgical Procedures • Laparoscopic duodenal switch • Laparoscopic RNY Gastric Bypass • Laparoscopic Adjustable Gastric Band • Laparoscopic Sleeve Gastrectomy • Revision surgery - Conversion from band to RNY or Sleeve - Conversions from VBG to RNY - Failed previous RNY

  13. Surgical Procedures

  14. Roux-en-Y Gastric Bypass • 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

  15. Complications of Gastric Bypass 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

  16. Long term complications Gastric Bypass • 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)

  17. Long Term Positive Results of Gastric Bypass • 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.

  18. Band Surgery • 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

  19. Normal Band (X-Ray View)

  20. Complications of Bands • 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.

  21. Complications of Gastric Sleeve • 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%)

  22. Post op success rules

  23. Office Visit’s • 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.

  24. Clinical Follow up • Band patients: • 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 • Bypass/Sleeve patients: • 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. • Duodenal Switch: • 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. • All patients need frequent visits at least quarterly while losing weight with a height, weight, BMI and Waist measurement.

  25. Drugs Approved by FDA for Treating Obesity

  26. Most Frequently Used in Adults

  27. Other Medical Considerations • 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!

  28. Case Studies

  29. Case Study #1 • 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?

  30. Case Study #1 Continued • 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?

  31. Case Study #2 • 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 • What is your next step? • What do you think is going on?

  32. Case Study #2 continued • 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?

  33. Case Study #3 • 32 y/o female presents to the officewithabdominal pain and distention, nausea and vomiting and no BM for 3 days. She is 9 months post op gastric bypass. VS-138/88-98.8-94-24 • What test should be ordered? What do you think is going on?

  34. Case Study #3 Continued • 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??

  35. Conclusions • 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

  36. Weight Loss Surgery is not the easy way out, it is only a tool to help the patient. The patient will still have much work for the rest of their life!

  37. Questions ? .

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