Top Ten Things You Need to Know About Bariatric Surgery Patients

1. Top Ten Things You Need to Know About Bariatric Surgery Patients Laura Dyck, M.S., R.D., LDN Comprehensive Weight Management Center, Kingsport, TN

2. 1) Who qualifies? 2) Surgery options 3) Who benefits? 4) Who may NOT be a good candidate? 5) How safe is the surgery? 6) Where should I refer candidates for surgery? 7) Post-Op diet 8) Supplements/Lab Monitoring 9) Post-Op exercise 10) Other potential issues related to bariatric surgery Top Ten Things You Need to Know About Bariatric Surgery Patients

3. 1) Who Qualifies? • BMI of 35-39.9 with co-morbid conditions OR >40 without co- morbid conditions • Documented failed attempts at weight loss

4. Who Qualifies? • Able to comprehend, and motivated for, lifelong lifestyle changes • Committed to lifelong medical monitoring • Willing to give up tobacco, NSAIDs • Age range (typical) ~18 - 65 years • Able to obtain psychological clearance for surgery.

5. Who Qualifies? • Many insurances cover surgery (Medicare and Medicaid do cover)- Must complete insurance company requirements (medical weight management, weight loss requirements, etc.) • PCP and/or FNP may provide medical weight management (designated number of consecutive monthly appts., solely to discuss diet, exercise and behavior change)

6. 2) Common Surgical Options for Weight Loss • Restrictive- Gastric banding & sleeve gastrectomy (sleeve can be Part One of 2 part procedure) • Malabsorptive- Biliopancreatic diversion & biliopancreatic diversion with duodenal switch • Combination- Roux-en-Y gastric bypass

7. Common Surgical Options for Weight Loss- Gastric Banding Images Courtesy of Ethicon

8. Common Surgical Options for Weight Loss- Sleeve Gastrectomy Image Courtesy of Ethicon

9. Common Surgical Options for Weight Loss- Gastric Bypass Image Courtesy of Ethicon

10. Common Surgical Options for Weight Loss- Comparison Gastric Bypass 70-75 % Weight Loss* In 9-12 months *%ages refer to “Excess Weight” Lost Gastric Banding 35-50 % Weight Loss* In 2-3 years Sleeve Gastrectomy 50-70 % Weight Loss* In 12 months

11. Common Surgical Options for Weight Loss- Which is Best? • Depends on many individual factors: • How much weight to lose? • Which is safest given body shape/size? • Compliance with dietary changes? • Work/family schedule? • Geographic location?

12. 3) Who Benefits? Obese patients with: GBP1Sleeve2Band1 1) Diabetes 2) Hypertension 3) High Cholesterol 4) Sleep Apnea Resolved 83.7% Resolved 67.5% Improved 94.9% Resolved 80.4% R- 56% R- 49% R- 43% R- 60% R- 47.8% R- 43.2% I- 78.3% R 94.6% Improvements/Resolution also seen with: -GERD3 -Depression4 -Osteoarthritis/Joint Pain4 -Stress Urinary Incontinence4 -Menstrual dysfunction d/t PCOS5 -Ovulation and Fertility Restored5 -Quality of Life/Increased Activity1

13. 4) Who may NOT be a Good Candidate for Surgery? • Have other untreated medical conditions that may have caused obesity • Psychological or cognitive limitations that jeopardize informed consent and cooperation with long term follow-up • Immobility • Medical issues that make surgery too risky

14. Who may NOT be a Good Candidate for Surgery? • Unwilling to give up tobacco & NSAIDs • Hepatic cirrhosis with impaired liver function • Active Drug/Alcohol Abuse • Not willing to/motivated to make lifelong lifestyle changes • Patient is pregnant

15. 5) How Safe is Surgery? Bariatric surgery holds no more risk than gallbladder or hip replacement surgery- the risks of surgery are lower than long term risks of living with obesity (increasing risks of dying due to heart disease, diabetes, etc. daily)6

16. How Safe is Surgery? Bariatric surgery is now endorsed by the: • American Heart Association • American Diabetes Association • International Diabetes Federation • American Association of Clinical Endocrinologists

17. Risks and Complications • Dumping Syndrome (a blessing & a curse!) • Bleeding • Infections • Complications with anesthesia • Blood clots • Injury to stomach, esophagus, surrounding organs • Leaks or blockages at site where tissue has been sewn or stapled

18. 6) Where should I refer candidates for surgery? Look for a: Bariatric Surgery Center of Excellence

19. Where should I refer candidates for surgery? The American Society for Metabolic and Bariatric Surgery (ASMBS) + the American College of Surgeons (ACS)= Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)

20. Holding a Center of Excellence Designation Means Centers Are: • Accountable for the quality and safety of surgery in their center • Participating in ongoing data collection/analysis • Going through a site inspection/approval process every 3 years • Stressing safety, proficiency and volume

21. Holding a Center of Excellence Designation Means Centers Are: • Requiring a multidisciplinary team for appropriate patient care • Hosting monthly support group meetings for patients • Dedicated to long term follow-up (Patients should be followed by their bariatric surgeon for LIFE!)

22. QUIZ TIME!

23. Which foods will I need to avoid after gastric bypass surgery? • Alcohol • Carbonated beverages • Sugar • All of the above

24. Which foods will I need to avoid after gastric bypass surgery? • Alcohol • Carbonated beverages • Sugar • All of the above

25. After surgery I will need to: • Chew my food thoroughly • Take 30-60 minutes to eat a meal • Eat and drink at the same time • a & b

26. After surgery I will need to: • Chew my food thoroughly • Take 30-60 minutes to eat a meal • Eat and drink at the same time • a & b

27. Xylitol, Lactitol and Sorbitol found in foods are classified as: • Sugar • Sugar Alcohols • Fat • Preservatives

28. Xylitol, Lactitol and Sorbitol found in foods are classified as: • Sugar • Sugar Alcohols • Fat • Preservatives

29. Chewing gum is not allowed. If you do chew it and swallow it you might have which complication? • Ulcer formation • Headache • Diarrhea • Outlet obstruction of your gastric pouch

30. Chewing gum is not allowed. If you do chew it and swallow it you might have which complication? • Ulcer formation • Headache • Diarrhea • Outlet obstruction of your gastric pouch

31. Dumping Syndrome after gastric bypass (and possibly sleeve gastrectomy) can occur by eating foods high in: • Fat • Sugar • Sugar Alcohols • All of the above

32. Dumping Syndrome after gastric bypass (and possibly sleeve gastrectomy) can occur by eating foods high in: • Fat • Sugar • Sugar Alcohols • All of the above

33. 7) Post-Op Diet • “Phases” are slowly progressed through for ~8-12 weeks after surgery • Diet for life is a low fat, sugar free, balanced diet with smaller serving sizes • 60-75 grams of Protein/day

34. Post-Op Diet • STOP when full- otherwise, will lead to N/V • CHEW WELL- otherwise, will lead to N/V • Dumping Syndrome with high fat and/or high sugar foods after Gastric Bypass (and mild dumping is possible after sleeve gastrectomy)

35. Post-Op Diet • Separate foods/fluids by at least 30 minutes • Fluid goals: 6-8 cups/day, SF, non-carbonated, caffeine free, non-caloric • Avoid Alcohol- ESPECIALLY GBP patients

36. 8) Post-Op Supplements/Lab Monitoring • Sleeve Gastrectomy/Gastric Banding • MVI/Mineral Supplement daily • Calcium Citrate- 1200-1500 mg/day • Gastric Bypass • MVI/Mineral Supplement daily • Vitamin B12- 500 mcg/day sublingual or 1000mcg IM injection/month • Calcium Citrate- 1200-1500 mg/day • Iron (for menstruating women or if directed by MD or FNP)- 200-325 mg of Ferrous Sulfate daily

37. Post-Op Labs to Monitor/Check • CMP (electrolytes, albumin, etc.) • CBC • Serum B12 (especially with GBP) • Ferritin/Iron Profile • Lipid Panel • 25-hydroxyvitamin D or ionized Calcium

38. 9) Post-Op Exercise Is an absolute MUST!!! • Patients should gradually work up to goal of 45 minutes- 1 hour of exercise most days of the week. • Should have education pre-operatively and resources, if needed

39. Post-Op Exercise • Support groups are great places to build on exercise knowledge • Utilize community resources (parks, rec centers, senior’s centers, gyms, Med Fit Center, etc) and nationally offered resources (National Institute on Aging, Go4Life Exercise and Physical Activity Books/DVD)

40. 10) Other Potential Issues Related to Bariatric Surgery • Ulcers/Reflux (Don’t smoke/Avoid NSAIDs) • Incisional hernias (especially if open procedure) • Loose skin • Hypoglycemia • Strictures • Addiction Transfer Syndrome • Weight Regain (~10% regain is normal)

41. References • Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery. A systematic review and meta-analysis. JAMA. 2004;292:1724-1737. • EES summary of data contained in review article: Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis. 2009;5:469-475. • Wittgrove A, Clark G. Laparoscopic gastric bypass, Roux-en-Y---500 patients: technique and results, with 3-60 month follow-up. Obes Surg. 2000;10(3):233-239. • Schauer P, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515-529. • Eid GM, Cottam DR, Velcu LM, et al. Effective treatment of polycystic ovarian syndrome with roux-en-Y gastric byapss. Surg Obes Related Dis. 2005;2:77-80. • The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. N Engl J Med. 2009;361:445-454.

42. QUESTIONS?