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Gastric Bypass Patient Education. Treatment of Obesity. Obesity Classification. Obesity has reached epidemic proportions in the U.S. over the past 20 years¹. U.S. Pop. BMI. Classification. Overweight > 25.0 64 %

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Obesity classification
Obesity Classification

Obesity has reached epidemic proportions in the U.S. over the past 20 years¹

U.S. Pop

BMI

Classification

Overweight > 25.0 64 %

Obese (Class I) 30.0 - 34.921 %

Obese (Class II) 35.0 - 39.9

Clinically Severe

Obesity (Class III) > 40.0 6 %

1 CDC: www.cdc.gov - accessed 2002

BMI: Body Mass Index = weight/(height)2 kg/m2


Obesity 1 trends among u s adults

<10%

10%-14%

15%-19%

20%

Obesity1 Trends Among U.S. Adults

1BMI > 30, or ~ 30 lbs. overweight for 5’4” person


Multifactorial disease

Genetic

Environmental

Behavioral

Multifactorial Disease


Obesity is associated with significant comorbidities

Osteoarthritis

Hypertension

GERD

Urinary Stress Incontinence

Gallbladder Disease

Depression

Diabetes

Hyperinsulinemia

Asthma

Sleep Apnea

Congestive Heart Failure

Anemia

Neoplasia

Dyslipidemia

Obesity is Associated with Significant Comorbidities


Comorbid conditions
Comorbid Conditions

  • Almost 80% of obese adults have one of the following:

    • Diabetes

    • Dyslipidemia

    • Coronary Artery Disease, Hypertension

    • Gallbladder Disease

    • Osteoarthritis

  • Almost 40% have two or more of the above conditions


Obesity increases mortality
Obesity Increases Mortality

“Taken together, the diseases associated with morbid obesity markedly reduce the odds of attaining an average life span and raise annual mortality tenfold or more.”

American College of Surgeons, Recommendations for facilities performing bariatric surgery, ST-34, Bull Am Col Surg, 2000;85:


Non surgical treatment
Non-Surgical Treatment

  • Medication

  • Diet and exercise

  • Behavior modification

    • Weight loss is not substantial for 90 – 95 % of patients with clinically severe obesity using these methods.

    • Weight is usually regained within five years.


Medical treatment of obesity
Medical Treatment of Obesity

Medical Complications of Pharmacotherapy


Why surgery for the treatment of the clinically severe obese
Why Surgery for the Treatment of the Clinically Severe Obese?

  • “Only surgery has proven effective over the long term for most patients with clinically severe obesity.” NIH Consensus Conference Statement, 1991

  • Surgery for the treatment of clinically severe obesity is endorsed by:

    The National Institutes of Health

    The American Medical Association

    The National Institute of Diabetes and Digestive and Kidney Diseases

    American Association of Family Practitioners


Who is eligible for bariatric surgery
Who is Eligible for Bariatric Surgery? Obese?

The NIH Consensus Panel recommends that:

  • Patients have a Body Mass Index > 40 kg/m2

    • 100 lbs. or more overweight

  • Patients have a Body Mass Index between 35 and 40 kg/m2 with significant comorbidities

  • Patients have failed other medically managed weight-loss programs

6% of the U.S. Adult Population(Over 10 Million People)Meet These Criteria


Ineligible patients
Ineligible patients Obese?

Exclusion Criteria:

  • Obesity related to a metabolic or endocrine disorder

  • History of substance abuse or untreated major psychiatric disease

  • Surgery contraindicated or high risk

  • Women who want to become pregnant within the next 18 months



Review of the digestive system
Review of the Digestive System Obese?

  • Esophagus

  • Stomach

  • Small Intestine

    (Duodenum, Jejunum, Ileum)

  • Large Intestine


Bariatric surgery today

Malabsorptive Obese?

Restrictive

Combination

Adjustable Band Gastroplasty

Biliopancreatic Diversion w/ Duodenal Switch

Roux en Y Gastric Bypass

Bariatric Surgery Today

Three Types of Most Commonly Performed Bariatric Surgery Procedures


Restrictive surgery

Relatively easy surgical procedure Obese?

Less dietary deficiencies

Less weight loss

More late failures due to dilation

Less effective with sweet eaters

Significant dietary compliance

Restrictive Surgery

Adjustable Band Gastroplasty


Malabsorptive surgery

Greater sustained weight loss with less dietary compliance Obese?

Increased risk of malnutrition and vitamin deficiency

Constant follow–up to monitor increased risk

Intermittent diarrhea

Malabsorptive Surgery

Biliopancreatic Diversion w/ Duodenal Switch


Roux en y gastric bypass

Long term sustained weight loss Obese?

No protein-calorie malabsorption

Little vitamin or mineral deficiencies

Technically difficult procedure

Roux-en-Y Gastric-Bypass

Roux en Y Gastric Bypass


The roux en y gastric bypass
The Roux-en-Y Gastric Bypass Obese?

1. A small, 15 to 20 cc, pouch is created at the top of the stomach.

2. The small bowel is divided. The biliopancreatic limb is reattached to the small bowel.

3. The other end is connected to the pouch, creating the Roux limb.

The small pouch releases food slowly, causing a sensation of fullness with very little food.

The biliopancreatic limb preserves the action of the digestive tract.



Evolution of laparoscopic technique in bariatric surgery

Open Obese?

Increased post op pain, longer hospitalizations

Increased incidence of wound complications - infections, hernias, seromas

Return to work in 4-8 weeks

Laparoscopic

Less post op pain, early mobility

Wound complications may be significantly reduced

2-3 day hospital stay

Return to work in 1-3 weeks

Evolution of Laparoscopic Technique in Bariatric Surgery


Sustained weight loss
Sustained Weight Loss Obese?

% Excess Weight Loss as a function of time

Pories et al. Ann Surg 1998 May;227(5):637-43; discussion 643-4

Schauer et al Ann Surg 2000 Oct;232(4):515-29

Wittgrove et al Obes Surg 2000 Jun;10(3):233-9



Bariatric surgery as a tool
Bariatric Surgery as a Tool Obese?

Bariatric surgery will not work alone. Commitment to diet, exercise and support are intricate parts of your weight loss success.


Resolution of comorbidities

47 Obese?

41

47

41

33

63

33

63

24

72

24

72

18

70

18

70

19

74

19

74

29

57

29

57

55

41

55

41

39

44

39

44

69

13

69

13

18

82

18

82

35.1%

55.7%

35.1%

55.7%

90.8%

90.8%

Improved or Resolved

Improved or Resolved

Resolution of Comorbidities

Number

N= 104

Prior to

%

% No -

%

%

1 year post-op

Surgery

Worse

Change

Improved

Resolved

Osteoarthritis

64

2

10

Hypercholesterimia

62

0

4

GERD

58

0

4

Hypertension

57

0

12

Sleep Apnea

44

2

5

Hypertriglyceridemia

43

0

14

Peripheral Edema

31

0

4

Stress Incontinence

18

6

11

Asthma

18

6

12

Diabetes

18

0

0

Average

1.6%

7.6%

Schauer, et al, Ann Surg 2000 Oct;232(4):515-29


Open and laparosopic roux en y bypass complication rates
Open and Laparosopic Roux-en-Y Obese?Bypass Complication Rates

Meta Analysis

Lap

Open

Mortality < 1.5 % < 1.5 %

Leak Rate < 3.1 % < 3.0 %

PE Rate < 0.6 % < 1.5 %

Hernia Rate 6.6 - 18 % < 1.8%

Wound Infection Rate 5 - 18% < 2%

Schauer and Ikramuddin, Surg Clin North Am, 2001 Oct;81(5):1145-79

Kral, Clin Per Gastroenterology 2001 Sep/Oct:295-305

Nguyen et al. Ann Surg, 2001;234(3)279-291


Possible complications
Possible Complications Obese?

(may lead to short or long term hospitalization and/or re-operation)

  • Infection, bleeding or leaking at suture/staple lines

  • Blockage of the intestines or pouch

  • Dehydration

  • Blood clots in legs or lungs

  • Vitamin and mineral deficiency

  • Protein malnutrition

  • Incisional hernia

  • Death


Possible side effects
Possible Side Effects Obese?

  • Nausea and vomiting

  • Gas and bloating

  • Dumping syndrome

  • Lactose intolerance

  • Temporary hair thinning

  • Depression and psychological distress

  • Changes in bowel habits such as diarrhea, constipation, gas and/or foul smelling stool


Post operative summary
Post-Operative Summary Obese?

On average, Gastric-bypass patients . . .

  • Will find that they have lost 65- 80% of their excess body weight, the majority of it in the first 18 to 24 months after surgery.

  • May have rapid improvements in the morbid side effects of their obesity, such as type 2 diabetes, high blood pressure, sleep apnea, and high cholesterol levels.



Pathway to bariatric surgery
Pathway to Bariatric Surgery Obese?

  • Patient Responsibilities

    • Honesty, Responsibility, Cooperation

  • Bariatric Program Responsibilities

    • Honesty, Responsibility, Cooperation


What will your care pathway look like

Initial Contact Obese?

Pre-Op Information Exchange

Preoperative Evaluation

Surgery

Post-Op Follow-up and Support

What will your care pathway look like?


Who is my dedicated team
Who is my dedicated team ? Obese?

  • Surgeon

  • Registered Nurse Coordinator

  • Registered Dietitian

  • Psychologist / Social Worker

  • Exercise Specialist

  • Insurance Coordinator

  • Administrative Assistant


What medical specialists are involved
What Medical Specialists are Involved? Obese?

  • Gynecology

  • Gastroenterology

  • Anesthesiology

  • Reconstructive Surgery

  • Pulmonology

  • Internal Medicine

  • Cardiology

  • Endocrinology

Multidisciplinary Approach


Support groups the heart of the program
Support groups – the heart of the program Obese?

  • Create fellowship through a common bond

  • Provide a source of up-to-date information about surgery and latest developments

  • Educate in nutrition, exercise, and post-op needs

  • Promote networking

  • Increase bariatric surgery success

  • Support life-style changes




Pre operative diet goals
Pre-operative Diet Goals Obese?

Begin creating healthy nutritional patterns:

  • Multivitamin and mineral intake

  • Adequate fluid intake

  • Quality versus quantity

  • Avoiding the last supper syndrome


Diet Obese?

  • Stage I: A low sugar, clear liquid diet, started two to three days after surgery. It essentially provides hydration during the initial post-operative phase.


Diet cont
Diet (cont.) Obese?

  • Stage II: A full liquid diet providing all the essential requirements for the first post-operative month. Patients go home from the hospital on the stage II diet.

  • Stage III: A modified solid diet. The surgeon instructs the patient when to advance to this diet. Introducing semi-solid food or solid diet too early may lead to obstruction and vomiting. It may also unduly stress the anastomosis.


Foods that may be difficult to tolerate
Foods that may be difficult to tolerate Obese?

  • Bread products

  • Cow milk products

  • Pasta products

  • Fatty foods and fried foods

  • Candy, chocolate, any sugary foods and beverages

  • Bran cereal and other bran products

  • Corn, whole beans, and peas

  • Dried fruits and skins of fresh fruit

  • Coconut

  • Carbonated beverages


Fluids
Fluids Obese?

  • Recommended fluid intake: min. 2 Liters/day

  • Non-carbonated

  • Non-calorie

  • Not during meals

  • Continually sip water throughout the day to ensure adequate hydration

  • Avoid caffeinated beverages

  • Avoid straws


Vitamins minerals and supplements
Vitamins, Minerals and Supplements Obese?

  • Liquid protein supplements required to reach 75 grams of protein per day

  • Multivitamin with Iron morning and evening

  • 1000 mg of folate/day

  • B-12 supplementations

  • 500 mg of Calcium Citrate three times per day

  • Other supplements on an individual need basis

  • Periodic blood levels must be taken to ensure adequate nutrition


Dumping syndrome
Dumping Syndrome Obese?

Dumping Syndrome

  • Early: immediately associated with food intake (GI symptoms)

  • Late: delayed onset, usually 1 ½ to 2 hours after food intake (neurological symptoms)

  • Some patients never experience Dumping Syndrome

    Some surgeons consider dumping syndrome to be a beneficial effect of Gastric Bypass surgery. It provides a quick and reliable negative feedback for intake in the “wrong” foods.


Long term diet goals
Long-term Diet Goals Obese?

  • Avoid concentrated sweets due to high calorie content and the possibility of dumping

  • Low fat, heart healthy diet

  • Maintain adequate water intake



Your role before surgery
Your Role Before Surgery Obese?

  • Commit to improving your health (diet, exercise, mental readiness)

  • Discuss your health history with your surgeon

  • Ask questions and vocalize concerns that you may have about surgery or your care

  • Commit to following all instructions on nutrition, activity and other care after surgery


Your commitment
Your Commitment Obese?

  • Adhere to diet

  • Exercise daily

  • Commit to lifelong follow-up

  • Attend at least 2 support group meetings pre-op and participate regularly post-op.

  • Buy and take in vitamin and mineral supplements for the rest of your life

  • Avoid tobacco products lifelong and alcohol for at least 1 year post-op.


Questions
Questions? Obese?



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