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Systems Based Approach to Obesity and Bariatric Surgery

Systems Based Approach to Obesity and Bariatric Surgery. Michel Murr, MD, FACS John Paul Gonzalvo, DO, FACS. Introduction. Great New Beginning. Celebrating 15 yeas of Excellence. Patient-Centered Hypothesis-Driven Outcomes-Focused Thought Leaders. Patient Journey.

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Systems Based Approach to Obesity and Bariatric Surgery

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  1. Systems Based Approach to Obesity and Bariatric Surgery Michel Murr, MD, FACS John Paul Gonzalvo, DO, FACS

  2. Introduction • Great New Beginning

  3. Celebrating 15 yeas of Excellence • Patient-Centered • Hypothesis-Driven • Outcomes-Focused • Thought Leaders

  4. Patient Journey • Preparation for Surgery • Surgery • After Surgery Care

  5. Patient Journey • Patient take 2 years to make the commitment • Research, ask friends or patients, and they talk to their physicians

  6. Primary Care Physicians Role • Identify patients that are at risk • BMI greater than 30 • Identify and treat the associated medical problems • Diabetes • Obstructive Sleep Apnea • Atherosclerosis • Hypertension • Hyper-Lipidemia

  7. Prevalence of Co-morbidities

  8. Decision making process

  9. Decision making process • Realize there is a Problem • Weight and associated medical problems are effecting their life • Shortens their life expectancy • Permanent weight loss is difficult

  10. Decision making process • Choose the people • Family and friends • Bariatric patients • Primary Care Physician / Specialist

  11. Resources for the Process • Internet • There is a lot bad information • Good resources • tgh.org/weight.htm • asmbs.org • aace.com/publications • obesityaction.org

  12. Resources for the Process • Books • Weight Loss Surgery For Dummies • The Weight Loss Surgery Workbook: Deciding on Bariatric Surgery, Preparing for the Procedure, and Changing Habits for Post-Surgery Success • Before & After, Second Revised Edition: Living and Eating Well After Weight-Loss Surgery • Weight Loss Surgery - Everything You Wanted To Know - Before and After

  13. Physician’s Role • Give the patient an alternative • Try non-surgical weight loss strategy • Low calorie • Low carbohydrate • Low fat • Cut out the bad food or drinks • Many phone applications

  14. Physician’s Role • Values that are being traded off • How their excess weight is effecting their lives • Medical problems that are worse because of their obesity • Reduced quality of life / quantity of life

  15. Primary Care Physicians Role • For patient not responding to medical weight loss • BMI >35 with medical co-morbidities • BMI>40 • Well Informed and motivated • Acceptable surgical risk • These patient will see surgery as an option

  16. Patient wants Surgery What Now? • Document 6 month diet history • Monthly visit • Current weight • Diet plan • Atkins, Weight Watchers, South Beach, Calorie Counting • Progress

  17. FREE Information Session • Effects of obesity of health • Different surgery options • Process of preparing for Surgery • Insurance requirements

  18. Wellness Assessment • Assessment of current medical condition • Psychological Assessment • Nutrition Assessment • Exercise Assessment

  19. Medical Assessment • Goals • To evaluate for co-morbidities & minimize their risk of peri-operative complications. • Educate on the different bariatric procedures, risks, benefits, & on pre/post-operative requirements.

  20. Medical Assessment • Include a complete history & physical examination, BMI determination, result review of laboratory tests and appropriate health screening tests. • Diagnostic studies such as EKG, pulmonary function test, and bone density study may also be done.

  21. Medical Assessment • Referrals to respective medical specialists for pre-operative risk assessments, evaluation & management of co-morbidities. • With or without medical clearance, patient receives a written list of medical recommendations.

  22. Medical Assessment • Clearance Barriers • Access to medical records • Access to medical specialists • Time- consuming diagnostic tests such as sleep study

  23. Medical Assessment • Clearance: How do we facilitate? • Referrals to Medical Specialist, as needed • Electronic Medical Record • Continued medical optimization with PCP • 60 day follow-up visit • Bariatric Registrar • Bariatric Financial Specialist

  24. Psychological Assessment • Common components include: • Behavioral • Cognitive/Emotional • Developmental • Current life situation • Motivation • Expectations

  25. Psychological Assessment • Emotionally stable • Adequately informed • risk for a psychiatric episode • emotional crisis • Mental health action plan in place

  26. Psychological Assessment • History • Psychiatric history • major affective and psychotic disorders • Self-destructive or suicidal behavior • Psychiatric hospitalizations • Psychotherapy • Psychotropic medications

  27. Psychological Assessment • 6 consecutive months of good stabilization • Contraindications • Active substance abuse • Psychosis • Relative Contraindications • Low intellectual functioning • Recent history of severe depression, multiple suicide attempts, psychiatric hospitalizations and/or borderline personality disorder

  28. Psychological Assessment • Treat prior to Surgery • Disordered eating behaviors • Untreated Axis I disorder • Unstability social environment • Lack of adherence, lack of understanding

  29. Nutrition Assessment • Medical history – dietary compliance • Previous weight loss attempts • Readiness for lifestyle change • Food log review • 30-60 minutes of nutrition counseling • Overview of Bariatric Nutrition Guidelines & Lifestyle Modifications • Clearance vs. On-going Nutrition Follow-up

  30. Nutrition Assessment • Permanent changes in eating behaviors post op • Reduced volume of stomach • Potential for dehydration after surgery • Importance of chewing • Vomiting • Dumping syndrome • Greater risk of nutrient deficiency and potential long-term consequences • Necessity of supplements for vitamins and minerals after surgery • Permanent changes

  31. Nutrition Follow-up • Weight monitoring • Assess compliance • Food log • Behavior change • Self monitoring • Nutrition education and counseling • Tailored to their food- /nutrition- related knowledge deficits • Clearance vs. On-going Nutrition Follow-up

  32. Nutrition Classes • Monthly group classes • Includes weight monitoring • Class topics vary • basic nutrition • nutrition guidelines for surgery • weight loss strategies • Focus on how to implement their new way of eating in real life

  33. Exercise Assessment

  34. Common Stumbling Blocks • Diet history Documentation • We provide diet classes to help fulfill the requirements • Undiagnosed or under-treated medical problems • We bring the specialist to the center • Pulmonary, Cardiology, Endocrine • Financial • We offer Care Credit We offer a concierge service with a Bariatric Registrar to help guide the patients through the process

  35. Preparation for Surgery • Encourage Pre-op Support group participation • Honest and Frank dialogue • First hand account of problems and struggles • Incorporates new patients into support group

  36. Is the Patient Ready for Surgery? • Best medical condition • Ready to make the appropriate mental changes • Ready to eat correctly • Mobilizing and moving

  37. Is the Patient Ready for Surgery • When the answer is Yes • See the surgeon to discuss surgery options

  38. Surgical options • Restrictive • Malabsorptive • Combination

  39. Restrictive Procedures • A small pouch is created, which limits the food patients can eat • Pouch fills quickly, feel satisfied • Examples of restrictive bariatric procedures: • Gastric Banding • Sleeve Gastrectomy

  40. Malabsorptive procedures • Rarely performed • High long term complications

  41. Combination procedures • Small pouch, limiting the amount of food a patient can eat • Small intestine is rerouted, food bypass some small intestine • Absorb fewer calories. • Examples of combination bariatric procedures: • Gastric bypass • Biliopancreatic diversion with doudenal switch

  42. Adjustable Gastric Band • Laparoscopic • Second most frequently performedbariatric procedure • Mean excess weight loss at 1 yearof 42%1 • Requires implanted medical device • Lowest rate of complications • Buchwald, H. et al., JAMA. 2004; 292:1724-37.

  43. What are the risks and complications of the Adjustable Gastric Band • Migration of implant (band erosion, band slippage, port displacement) • Tubing-related complications (port disconnection, tubing kinking) • Band leak • Port-site infection • Esophageal spasm • Gastroesophageal reflux disease (GERD) • Inflammation of the esophagus or stomach

  44. Vertical Sleeve Gastrectomy Laparoscopic May be an option for carefullyselected patients, including high-risk or super-super-obese patients1. Mean excess weight loss at 1 yearof 59%2 No implanted medical device • ASMBS, Position Statement on Sleeve Gastrectomy as a Bariatric Procedure. June 17, 2007. • Lee CM, et al. Surg Endosc (2007) 21: 1810–1816

  45. Risks and complications of the vertical sleeve gastrectomy • Bleeding • Blood Clots • Infection • Leak from staple line • Vomiting and nausea • Dehydration • Gastric Outlet Obstruction • Stretching of the Sleeve

  46. Roux-en-Y Gastric Bypass Combination procedure Laparoscopic Most frequently performedbariatric procedure Mean excess weight loss at 1 yearof 67%1 No implanted medical device Low rate of complications2 • Buchwald, H. et al., JAMA. 2004; 292:1724-37. • Buchwald H. 2004 ASBS Consensus Conference Statement, Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third party payers. SOARD 2005;(1):371-8.

  47. Risks and complications of the Gastric Bypass • Bleeding • Blood Clots • Infection • Leaks from staple lines • Ulcers / Strictures • Internal Hernia • Bowel Obstruction • Dumping syndrome • Inability to access or fully evaluate the stomach, duodenum, and parts of the small intestine • Nutritional Deficiencies • Increased gas

  48. Choosing the right procedure Considerations • Age • Health Risk (depending on comorbidities) • Amount of weight to lose • Lifestyle • Eating behaviors Mutual decision between patient and surgeon • Discuss with surgeon during initial consultation • Discuss with family and friends

  49. Setting your expectations % Excess Weight Loss at 5 Years1,2 Average Weight Loss (% Total)1,2 Treatment • Eliosoff 1997 • SjostromNEJM 2004, • Lee C M, Cirangle P T, Jossart G H, Vertical gastrectomy for morbid obesity in 216 patients: report of two year results. SurgEndosc (2007) 21: 1810-1816 Placebo 4-6% 0% Diet/behavior modification 8-12% 1.6% (10 Years) Drug therapy <10% 10% Laparoscopic adjustablegastric banding 45-50% 56% Laparoscopic vertical sleeve gastrectomy 60% N/A Gastric bypass surgery 65-85% Up to 100% Average hospital stay for laparoscopic gastric bypass surgery is 2.8 ±1.4 days; for laparoscopic gastric banding, 1.2 ±0.7 days; and for laparoscopic sleeve gastrectomy, 1.9 ± 1.2 days3.

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