Post-Surgical Care of the Bariatric Patient

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Post-Surgical Care of the Bariatric Patient

• Eve L. Olson, MD
• Medical Director
• St. Francis Weight Loss Center
• Indianapolis, Indiana
• 317-782-7525

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Obesity Trends Among U.S. AdultsBRFSS, 1990,
1999, 2008
(BMI ?30, or about 30 lbs. overweight for 54
person)
1999
1990
2008
No Data lt10 1014
1519 2024 2529
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? 1000
? 500
? 300
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Number of Bariatric Operations performed in the
US from 1992-2006
NEJM, R. Steinbrook, 2004/ ASBS
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Who Qualifies for Weight-Loss Surgery?

• Clinical Terms Used to Describe Various Levels of
  Body Fat

Normal Weight (BMI 18.5 to 24.9)
Overweight(BMI 25 to 29.9)
Obese(BMI 30 to 34.9)
Severely Obese(BMI 35 to 39.9 )
Morbidly Obese(BMI 40 or more)
BMIgt40
BMI 25-29.9
BMI 30-34.9
BMI 35-39.9
BMI 18.5-24.9
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Bariatric Surgery IndicationsNIH Criteria

• BMI gt 40
• BMI gt 35 with Co-morbidities
• Type II Diabetes
• Obstructive Sleep Apnea
• Coronary Artery Disease
• Cardiomyopathy
• Hypertension
• Dyslipidemia

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Restrictive Procedures
Gastric Banding
Sleeve Gastrectomy
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Restrictive MalabsorptiveProcedures
Roux-en-Y Gastric Bypass
Biliopancreatic Diversion with

Duodenal Switch
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Efficacy of Bariatric Surgery for Weight Loss

• Mean percentage excess weight loss
• 61.2 - All Patients
• 47.5 - Gastric Banding
• 61.6 - Gastric Bypass
• 70.1 - BPD or duodenal switch

• Buchwald H, et al. Bariatric Surgery A
  Systematic Review and Meta-analysis. JAMA,
  141724-37, 2004

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Weight Maintenance after Bariatric Surgery
Sjöström L, Lindroos AK, Peltonen M et al. N
Engl J Med. 200435126
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Comparing Weight-Loss Results
Gastric Bypass
LAP-BAND
Source OBrien et al. Obesity is a Surgical
Disease Overview of Obesity and Bariatric
Surgery, ANZ J Surg, 2004 74 200-204.
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Long-term Survival with Bariatric Surgery
Rel. Risk 0.11 (.04-.27)
89 reduction in risk ofdeath over 5 years
Mortality
Christou et al. Ann Surg 2004240416-424
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Relationship Between Surgical Experience and
Perioperative Mortality in Gastric Bypass
Surgery
7 6 5 4 3 2 1 0
125 case lifetime bariatric surgery experience
Thirty Day Mortality
Chronological case order per surgeon
D Flum et al. J Am Coll Surg 199543, 2004
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Is Bariatric Surgery Safe?
Adapted from Dimick J.B., Welch H.G., Birkmeyer,
J.D. Surgical mortality as an indicator of
hospital quality. JAMA 2004 292847-51.
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Patient outcomes for all Bariatric Surgeries at
235 SRC Full Approval BSCOE Hospitals
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Recognizing Complications

• Over-medication
• Anti-hypertensives
• Diabetic Medications
• Under-medication
• Anti-seizure
• Dehydration
• Most common first two weeks post-op
• No Thirst

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Postoperative Complications Common to all
Procedures

• General Complications
• Pulmonary embolism
• Incisional hernia
• Gallstone formation
• Major wound infection and seroma
• Abdominal fluid collection
• Subphrenic abscess
• Peritonitis

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Procedure-Specific Complications (RYGB)

• Anastomotic or staple-line leak
• Acute gastric distention
• Staple-line disruption
• Stomal stenosis
• Stomal ulceration
• Small-bowel obstruction
• Occlusion of Roux limb
• Dumping

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Procedure-Specific Complications( gastric
banding)

• band slippage
• esophageal dilatation
• erosion of the band into the stomach
• band or port infections
• balloon or system leaks that can diminish weight
  loss

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Band Erosions
Partial
Complete
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Normal Absorption
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Risk of Vitamin and Mineral Deficiencies Post-op

• Calcium and Vitamin D
• Reduced absorption d/t bypassed duodenum,
  proximal jejunum (R-en-Y)
• Life-long supplements mandatory
• Iron
• Absorption decreased d/t decreased contact of
  food with gastric acid reduced conversion of
  iron from ferrous to ferric form (MVI)
• Vitamin B12
• Absorption decreased d/t decreased contact with
  intrinsic factor
• 60 of patients require long term supplementation
  of B12
• Thiamine
• Connection to Wernickes syndrome
• Cases not well documented

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Question and Comments