Gastric Bypass Patient Education

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Gastric Bypass Patient Education
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Treatment of Obesity
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Obesity Classification
Obesity has reached epidemic proportions in the
U.S. over the past 20 years¹
U.S. Pop
Classification
BMI
Overweight gt 25.0
64 Obese (Class I) 30.0 -
34.9 21 Obese (Class II) 35.0 -
39.9 Clinically Severe Obesity (Class III)
gt 40.0 6

1 CDC www.cdc.gov - accessed 2002 BMI Body
Mass Index weight/(height)2 kg/m2
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Obesity1 Trends Among U.S. Adults
1BMI gt 30, or 30 lbs. overweight for 54 person
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Multifactorial Disease
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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

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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

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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, 200085
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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.

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Medical Treatment of Obesity
Medical Complications of Pharmacotherapy
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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

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Who is Eligible for Bariatric Surgery?

• The NIH Consensus Panel recommends that
• Patients have a Body Mass Index gt 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
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Ineligible patients

• 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

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Bariatric Surgery
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Review of the Digestive System

• Esophagus
• Stomach
• Small Intestine
• (Duodenum, Jejunum, Ileum)
• Large Intestine

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Bariatric Surgery Today
Three Types of Most Commonly Performed Bariatric
Surgery Procedures
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Restrictive Surgery

• Relatively easy surgical procedure
• Less dietary deficiencies
• Less weight loss
• More late failures due to dilation
• Less effective with sweet eaters
• Significant dietary compliance

Adjustable Band Gastroplasty
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Malabsorptive Surgery

• Greater sustained weight loss with less dietary
  compliance
• Increased risk of malnutrition and vitamin
  deficiency
• Constant followup to monitor increased risk
• Intermittent diarrhea

Biliopancreatic Diversion w/ Duodenal Switch
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Roux-en-Y Gastric-Bypass

• Long term sustained weight loss
• No protein-calorie malabsorption
• Little vitamin or mineral deficiencies
• Technically difficult procedure

Roux en Y Gastric Bypass
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The Roux-en-Y Gastric Bypass

• 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.

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The Roux-en-Y Gastric Bypass
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Evolution of Laparoscopic Technique in Bariatric
Surgery

• Open
• 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

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Sustained Weight Loss
Excess Weight Loss as a function of time
Pories et al. Ann Surg 1998 May227(5)637-43
discussion 643-4 Schauer et al Ann Surg 2000
Oct232(4)515-29 Wittgrove et al Obes Surg
2000 Jun10(3)233-9
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Weight Loss Trend
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Bariatric Surgery as a Tool

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

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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 Oct232(4)515-29
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Open and Laparosopic Roux-en-YBypass
Complication Rates
Meta Analysis
Lap
Open
Mortality lt 1.5 lt 1.5 Leak Rate lt 3.1 lt 3.0
PE Rate lt 0.6 lt 1.5 Hernia Rate 6.6 - 18
lt 1.8 Wound Infection Rate 5 - 18 lt 2
Schauer and Ikramuddin, Surg Clin North Am, 2001
Oct81(5)1145-79 Kral, Clin Per Gastroenterology
2001 Sep/Oct295-305 Nguyen et al. Ann Surg,
2001234(3)279-291
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Possible Complications

• (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

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Possible Side Effects

• 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

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Post-Operative Summary

• 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.

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The Multidisciplinary Approach
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Pathway to Bariatric Surgery

• Patient Responsibilities
• Honesty, Responsibility, Cooperation
• Bariatric Program Responsibilities
• Honesty, Responsibility, Cooperation

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What will your care pathway look like?
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Who is my dedicated team ?

• Surgeon
• Registered Nurse Coordinator
• Registered Dietitian
• Psychologist / Social Worker
• Exercise Specialist
• Insurance Coordinator
• Administrative Assistant

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What Medical Specialists are Involved?

• Gynecology

• Gastroenterology

• Anesthesiology

• Reconstructive Surgery

• Internal Medicine

• Pulmonology

• Cardiology

• Endocrinology

Multidisciplinary Approach
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Support groups the heart of the program

1. Create fellowship through a common bond
2. Provide a source of up-to-date information about
   surgery and latest developments
3. Educate in nutrition, exercise, and post-op needs
4. Promote networking
5. Increase bariatric surgery success
6. Support life-style changes

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Support Groups
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Gastric Bypass Diet
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Pre-operative Diet Goals

• Begin creating healthy nutritional patterns
• Multivitamin and mineral intake
• Adequate fluid intake
• Quality versus quantity
• Avoiding the last supper syndrome

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Diet

• 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.

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Diet (cont.)

• 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.

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Foods that may be difficult to tolerate

• Bran cereal and other bran products
• Corn, whole beans, and peas
• Dried fruits and skins of fresh fruit
• Coconut
• Carbonated beverages

• Bread products
• Cow milk products
• Pasta products
• Fatty foods and fried foods
• Candy, chocolate, any sugary foods and beverages

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Fluids

• 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

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Vitamins, Minerals and Supplements

• 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

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Dumping Syndrome

• 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.

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Long-term Diet Goals

• Avoid concentrated sweets due to high calorie
  content and the possibility of dumping
• Low fat, heart healthy diet
• Maintain adequate water intake

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Patient Responsibilities
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Your Role Before Surgery

• 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

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Your Commitment

• 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.

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Questions?
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Gastric Bypass Patient Education