Perioperative Care of the Bariatric Patient

1. Perioperative Care of the Bariatric Patient Mark Kadowaki, MD, FACS Wellmont Surgical Services Kingsport, Tenessee

2. Objectives • Be familiar with the perioperative concerns that face the bariatric patient • Be aware of the signs of complications after bariatric surgery • Plan for initial management and stabilization of the patient suffering postoperative complications

3. Bariatric Procedures

4. WWW.ASMBS.ORG • Bariatric Surgery: Postoperative Concernshttp://s3.amazonaws.com/publicASMBS/GuidelinesStatements/Guidelines/asbs_bspc.pdf • Emergency Care of the Bariatric Patient http://s3.amazonaws.com/publicASMBS/ASMBS_Store/ASMBS_ER_Poster9-20-10.pdf Download the poster for your Emergency Department or Acute Care Clinic

5. Pre-Surgical Psychological Assessment • http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/Guidelines/PsychPreSurgicalAssessment.pdf • Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient • http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/Guidelines/aace-tos-asmbs.pdf • ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient • http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/Guidelines/bgs_final.pdf

6. Non-Emergent Concerns

7. RNY Gastric Bypass and Dumping Syndrome • Common “side effect” (85%) • Essentially a known result of the anatomic changes associated with the surgery • Can range from mild to severe • Rapid emptying of the gastric pouch of refined sugars (HFCS) or other high glycemic carbohydrates or other osmotically concentrated foods, such as dairy products and some fats such as fried foods

8. “Benefit” of Dumping Syndrome • Negative feedback • Causative foods will interfere with success of long-term weight loss • Patient is less likely to eat the same foods again

9. Bad effects of Dumping • Symptomatically uncomfortable • Confusion with other etiologies • Can be difficult to manage • May have short-term physiological consequences

10. Two Types of Dumping • Early: • 30-60 minutes • Duration up to 60 minutes • Osmotic symptoms: • sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lay down, upper abdominal fullness, nausea, diarrhea, cramping, active, audible bowel sounds • Caused by release of gut hormones with vasoactive effects

11. Two Types of Dumping • Late: • 1-3 hours after eating • Reactive hypoglycemia symptoms: • Sweating, shakiness, loss of concentration, hunger, fainting and passing out • Related to insulin surge overshooting glucose levels

12. Diagnosis of Dumping Syndrome • History: • Classic symptoms related to food intake

13. Management of Dumping Syndrome • Early • Dietary compliance with an appropriate diet • Late • Dietary compliance • Intake of a small amount of sugar (1/2 glass juice) 1 hour after a meal • Acarbose or Somastostatin in resistant cases • Rule out rare causes such as insulinoma

14. Bowel Function after Bariatric Surgery • Diarrhea • Most common with Duodenal Switch procedures • Less common with RNY gastric bypass • Uncommon with Sleeve gastrectomy or Gastric banding • Caused by FAs, undigested foods and Sorbitol (occurs naturally in fruits)

15. Management of Diarrhea • Dietary: • Avoidance of fats • Identify other trigger foods • Evaluate for previously unmasked lactose intolerance: eliminate dairy completely • Medical: • Imodium or Lomotil • Probiotics • Cholestyramine to bind bile salts

16. C diff Colitis • Can occur up to 3 months after surgery • Severe cramping, especially watery diarrhea, extremely foul flatus • Treat with Flagyl • Relapses common • Follow up with probiotics

17. Constipation • Common after bariatric surgery • Causes: • Insufficient intake of water • Insufficient intake of fiber • Diuretics (caffeine?) • Nutritional supplements with Calcium and Iron • Narcotics • Management: • Increased water and fiber intake • Avoidance of aggravating agents

18. Bowel Changes after Bariatric Surgery • Caveat: • Don’t assume that all bowel function problems are related to bariatric surgery • Recent changes in a previously stable patient

19. Postoperative Dysphagia • Most commonly associated with restriction procedures • Symptoms: chest pressure or tightness in the throat • May be functional: • Eating too fast • Eating too much • Not chewing well enough • Tough foods • Breads, rice and pastas • Overcooked steak or dry chicken breast

20. Postoperative Dysphagia • Treatment • Better eating habits • Failure to respond or severe symptoms • Band adjustment (loosening) or endoscopic dilation

21. Postoperative Nutrition • Purely restrictive procedures • Gastric Banding, Sleeve Gastrectomy, Vertical Banded Gastroplasty • Daily multivitamin • Monitor protein intake • 1 gm protein/kg ideal body weight/day

22. Postoperative Nutrition • Primarily Restrictive with some malabsorption • Gastric Bypass • Calcium, Iron and B-complex vitamins supplemented at higher than daily recommended levels • Prioritize protein intake

23. Postoperative Nutrition • Primarily Malabsorptive Procedures • BPD +/- DS • Calcium, Iron • Protein • Fat Soluble Vitamins (A, D, E, K) • Hydration • Deficiencies can be resistant to therapy!

24. Nutritional Deficiencies • Protein: • Hair loss, Fatigue, Leg swelling • Calcium • Bone pain • Iron • Fatigue • Zinc • Brittle nails • Vit A • Decreased night vision

25. Nutritional Deficiencies • Vit E • Poor wound healing • Vit K • Easy bruising • Vit B1 (thiamine) • Numbness and tingling in hands and feet • Vit B12 (Methylcobalamin) • fatigue

26. Exercise • IMPERATIVE • Weight loss will not occur without it • 40 minutes per day, 6 days per week, strenuous enough to breathe deeply but still able to converse • Light resistance training a benefit • Some patients may be “exercise naïve” or even “alienated”

27. Emergent Concerns

28. Emergency Presentations • Unstable Vital Signs: • Fever > 102 F • Hypotension • Remember incidence of hypertension • Tachycardia >120 bpm X 4 hours • Tachypnea • Hypoxia • Decreased urinary output

29. Emergency Presentations • Bleeding • Per mouth or rectum or drainage • Abdominal pain or colic > 4 hours • Nausea + Emesis > 4 hours • Emesis + Abdominal pain

30. Principles of Management • Critical Time Frames: • Diagnosis within 6 hours • To OR in 12-24 hours • Critical Warnings • Alert Bariatric Surgeon • Patients typically have less physiologic reserve • Avoid blind placement NG tube • Avoid NSAIDs, ASA, Plavix, Steroids • Use PPIs routinely • Be mindful of small volume of gastric pouch

31. Initial Assessment • Serial PE and Vitals • Labs: • CBC, CMP, Amylase • Imaging: • Chest Xray • CT of Chest • CT of Abdomen • Upper GI

32. Initial Management:FAST HUG • Food: establish nutritional support early • Analgesia • Sedation: if on ventilator • Thrombo-embolism prophylaxis • Mechanical and Medical • Head of Bed: elevated 30 deg (aspiration) • Ulcer Prophylaxis: PPIs • Glucose Control: <150

33. Bleeding • < 48 hours: staple line • > 48 hours: marginal ulcer • Oral: gastric pouch • Melena or rectal blood: duodenal ulcer, bypassed stomach or bowel source • EGD: consider GA in OR • Increased risk of perforation with intervention

34. Leaks and Sepsis • Presentation: unstable VSs within 72 hours of bariatric surgery • Persistent or progressive tachycardia is most sensitive • Similar presentation to PE • Imaging can be negative

35. Obstruction • Presentation: • Abdominal pain > 4 hours associated with vomiting • Do NOT place NG tube • Diagnostics: • CT abdo with contrast or UGI • Increased risk for aspiration due to small volume of stomach • Consider EGD prior to anesthesia to R/O GOO and empty contrast material to decrease risk of aspiration

36. Obstruction • Special Concerns: • Acute bleed causing obstruction secondary to clots • Internal hernias after gastric bypass • Evaluation/imaging / PE may be negative • Dilated distal stomach or contrast in remnant • High risk for closed loop obstruction • Bowel ischemic necrosis within 6 hours • Immediate surgical exploration

37. Internal hernias • A. Transverse Mesocolon • B. Petersen Hernia: • Beneath Roux limb • C. Mesentery defect created by jejunojejonostomy

38. Pulmonary Embolism • Extremely high risk patients • Unstable vitals associated with chest pain and tachypnea • Evaluation with Chest CT • Can mimic acute intra-abdominal complication

39. Vomiting + Abdominal Pain • Gastric Banding • AXR: assess orientation of band • Deflate band • Huber needle • Similar to a Portacath • Reassess • Does not usually require surgery

40. Adjustable Gastric Band • Normal Band orientation • 2:00-8:00 • Normal orientation but too tight

41. Adjustable Gastric Band Slips • Anterior Slip: • Band rotated counterclockwise • Posterior Slip: • Band rotated clockwise • Note: enlarged pouch flopping over slip

42. Vomiting + Abdominal Pain • Unstable: • Immediate surgical exploration • Stable: • Evaluate per obstruction • Barium swallow most useful

43. Abdominal Compartment Syndrome • Respiratory failure • Renal failure • Other end organ failure • Elevated bladder pressure (> 25 mmHG) • Emergent abdominal decompression

44. “George, how often do you have a leak? • “Never had one” • “In how many cases?” • “Oh, I’ve never done one . . . . .” • Surgery for Obesity and Related Diseases 7 (2011) 668

45. Summary • Complications are unavoidable but disasters are often avoidable • Be familiar with the perioperative concerns that face the bariatric patient • Be aware of the signs of complications after bariatric surgery • Plan for initial management and stabilization of the patient facing postoperative complications • Early involvement of a Bariatric Surgeon • Work with a certified Center of Excellence • ASMBS or ACS