Download Preoperative evaluation of the Bariatric patient.

Preoperative evaluation of the
Bariatric patient.
William Bakhos,MD
Preoperative Focus
Multidirectional
Concomitant patient education
 Informed consent
 Medical evaluation for risk assessment
 Strategies for risk reduction
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Patient Education Content
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Health risks and medical hazards associated with
obesity.
Quality of life issues.
Low probability of success with dietary or other
non-surgical weight control programs.
Weight loss results of surgery, including failure
rates of the different types of procedures
Impact of weight loss.
Necessity for long-term follow-up.
Patient Education Content
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Possible complications
Mechanisms for weight loss
Post-operative alcohol restriction
Available and accepted operations for obesity
treatment,results,advantages,disadvantages,
operative risks and complications
Mortality rate (broken down by BMI and severe
medical problems)
Contraindications to Surgery
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High medical risk.
 Unable to understand the operation.
 Unrealistic expectations.
 Unresolved emotional illness.
 Drug abuse/alcoholism.
 Unwilling to sign follow-up contract.
 Does not have a support person.
Initial Screening
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H&P- Medical and Surgical History
 Family History/Social History
 Medications/Allergies
 Diet History
 Physical Exam- HT, WT, BMI, VS
Initial Screening
Labs
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Chemistry, liver function, renal function
 Lipid Profile
 CBC
 Iron Profile- TIBC, total iron, saturation
 B-1, B-12 levels
 HbA1c
 H-Pylori
 Drug Screen (optional)
Initial Screening
Radiology
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U/S liver/GB
CXR
UGI Swallow Study (optional)
Cardiac
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EKG
Venous Doppler Studies (optional)
Preoperative Evaluations
ASBS and SAGES Guidelines For Surgical
Treatment –Bariatric Surgery, Published in 2000:
The multidisciplinary approach includes
 Medical management of comorbidities
 Dietary instruction,
 Exercise training,
 Specialized nursing care and psychological
assistance as needed.
Having a multidisciplinary team who can address these
necessary components of bariatric patients’ needs is imperative.
Preoperative Behavior Change
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Preoperative exercise program.
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Patients sometimes asked to maintain body weight
or lose weight prior to surgery.
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Patients asked to quit smoking prior to surgery.
Reduces risk, establishes healthy habits,and tests
motivaiton and commitment.
Dietary Evaluation
Registered Dietitian
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Address dietary concerns and begin making
changes now
 Avoid the Last Supper Syndrome
 Diabetes Education
Exercise Evaluation
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Preoperative exercise program.
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Assessment .
Mobility Issues.
Physical Conditioning.
Education.
Motivation.
Gastro-Intestinal Evaluation.
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Endoscopy.
 Ulcers (Helicobacter pylori).
 Esophageal Disorders.
 Irritable Bowel Syndrome.
 Crohn’s Disease.
Birth control counseling.
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Absence of pregnancy.
Birth control.
Risky pregnancy in the early post-op. period (1-2
years).
Weight loss may improve fertility.
Cardiac Risk & Complication Rate
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One point assigned
per risk factor:
1- CAD
2- CHF
3- CVD
4- High-risk surgery
5- Diabetic requiring insulin
6- Pre-op creatinine >2.0
mg/dl
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Risk Class/
complication rate
Class I
Class II
Class III
Class IV
Zero
One
Two
Three
Lee TH, et al. Circulation. 1999;100:1043-49
0.4%
0.9%
6.6%
11.0%
Cardiac Risk Assessment.
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Stress Testing
Echocardiogram
Medication adjustment
Cardiac Clearance
Beta Blockade
Major criteria
Use Beta-blockers in patients meeting any of the
following criteria
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History of MI,current angina Or use of sublingual nitroglycerine
Positive exercise test results
Q waves on ECG
Patients who have undergone PTCA or CABG and who have chest
pain
History of TIA or CVA
Diabetes mellitus requiring insulin therapy
Chronic renal insufficiency, defined as a baseline creatinine level of
at least 2.0 mg/dL (177 µmol/L)
Lee TH et al. Derivation and prospective validation of a simple index for prediction of cardiac
risk of major noncardiac surgery. Circulation. 1999;100:1043-1049.
Beta Blockade
Minor Criteria
Use Beta -blockers in patients meeting any 2 of the
following criteria:
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Aged 65 years or older
Hypertension
Current smoker
Serum cholesterol concentration at least 240 mg/dL (6.2
mmol/L)
Diabetes mellitus not requiring insulin therapy
Mangano et al. Effect of atenolol on mortality and cardiovascular morbidity after
noncardiac surgery: Multicenter Study of Perioperative Ischemia Research Group.
N Engl J Med. 1996;335:1713-1720.
Pulmonary Evaluation.
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Obstructive Sleep Apnea (testing and treatment).
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Asthma.
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Smokers.
Endocrine Evaluation
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Diabetes Management.
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Diabetes Education.
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Thyroid disease.
DVT Prophylaxis
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Early ambulation
 Elastic stockings
 Intermittent pneumatic compression devices – IPC
 Inferior vena caval filters
 Low Dose Unfractionated Heparin
 Low Molecular Weight Heparin (LMWH)
IVC Filter placement
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Preoperative vena caval filter placement should be
considered in bariatric patients with
Prior pulmonary embolus
Prior deep venous thrombosis
Evidence of venous stasis
Known hypercoagulable state.
Keeling WB et al..Current indications for preoperative inferior vena cava filter insertion in
patients undergoing surgery for morbid obesity. Obes Surg. 2005 Aug;15(7):1009-12
Pre-Operative Visit
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Physical Exam.
 Changes to medications, condition, VS, WT, BMI.
 Check all Consult Notes.
 Photographs (optional).
 Educational Assessment Tools.
 Consents.
Pre-Operative Visit
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Preoperative Instructions
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Verbal and Written
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Be Explicit
Bowel Prep
Pre-Operative Visit
Patient Education
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Pre-admission orders including any bowel
preparation,meal restrictions, NPO instructions
When to arrive at the hospital and what to bring
What will take place prior to surgery
Waking up in the PACU after the operation and the
importance of early ambulation
Pain management
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Introduction of fluids and diet progression
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Pre-Operative Visit
Patient Education
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Maximizes the patient’s success potential.
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Decreases stress from lack of knowledge
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Helps Set appropriate expectations.
Pre-Operative Visit
Prophylactic ABx
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First Generation cephalosporin before induction
and 12 hours post-op.
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Vancomycin if allergic to penicillin.
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Same as any UGI Procedure.
Pre-Operative Visit
Preo-op Diet
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Low calorie,Low carb,High protein liquids for 2
weeks pre-op.
Helps control blood sugar peri-op.
Technically helps with the size of the liver.
Information Meetings/Support Groups.
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Help consolidate the informations about peri-op
expectations and care.
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Focus on the change in lifestyle and commitment
for better results.
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Sharing personal experience.
Psychological Evaluation
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The psychological evaluation can be used to
identify psychiatric disorders, provide treatment
referrals, and flag any contraindications for
surgery.
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It also provides an opportunity to educate patients,
resolve ambivalence, and build motivation.
Psychological Evaluation
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Accountability
Stability - Will surgery
disrupt it?
Situational vs. clinical
depression(treated/unt
reated)
pre op treatment)
History of eating
disorders
Anorexia/Bulimia
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Absence of mental
illness
 Setting goals &
realistic expectations
 Support system
 Ability & willingness to
make lifetime changes
 Safe setting
(domestic dynamics)
 Substance abuse
 Suicide attempts
Psychological Evaluation
Patient History
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History of any psychiatric problems.
History of dieting and binge eating.
Results of any previous evaluations or treatment.
Previous weight loss attempts.
Relevant personal and family information.
Medication and dietary supplements.
Psychological Evaluation
Patient Knowledge Gaps
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A significant minority of patients
- Believe that surgery makes it impossible to overeat (25%).
- Have unrealistic weight loss expectations (19% high and 30%
low).
- Do not know the symptoms of dumping (>20%).
- Believe there is no need to worry if depression occurred in
the postoperative period (27%).
Gonder-Frederick et. al., Bariatric Times, Nov./Dec. 2004
Psychological Evaluation
Possible contraindications for surgery
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Concerns about patient’s ability to give informed
consent or comply with behavior changes required
after operation.
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Current severe or uncontrolled psychopathology
such as alcoholism, schizophrenia, or bipolar
disorder
Psychological Evaluation
Possible contraindications for surgery
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patients who have ever had an Axis I clinical
disorder, especially mood or anxiety, exhibit
poorer weight outcomes 6 months after gastric
bypass than those who have never had an Axis I
disorder.
Kalarchian MA et al..Surg Obes Relat Dis. 2008 Jul-Aug;4(4):544-9
Psychological Evaluation
Patient Goals and Expectations
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Some patients may have unrealistic goals and
expectations for weight loss.
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Personal goals and expectations may affect
success at long-term weight control.
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The behavioral health provider may provide
psychoeducation, foster realistic expectations,
and build motivation.
Psychological Evaluation
Treatment Recommendations
Empirically supported treatments exist for many
psychiatric disorders potentially relevant to the
bariatric surgery patient.
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Eating disorders (e.g., binge eating).
Mood disorders (e.g., depression).
Anxiety disorders.
Borderline personality disorder.
Psychological Evaluation
What Psychologists can do ?
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Screen out inappropriate patients.
 Evidence not promising; research is needed
 Active substance abuse, psychiatric personality
disorder, suicide ideation
Teaching candidates to be good patients.
 Attend support groups, reading, learning
 What constitutes a “good patient?”
Psychological Evaluation
Possible Complicating Factors
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Poorly managed psychopathology
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Depression, Anxiety, Bi-polar, Bulimia etc..
Borderline personality disorder
Active alcohol or substance abuse
Recent hospitalization (mental disorder)
History of postoperative complications
Psychological Evaluation
Possible Positive Predictors or Factors
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Social/Emotional support network
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Family, Friends.
Optimism, positive attitude
Humor
Knowledge of surgery, diet, etc..
Compliance may be the best indicator of
successful outcome
Psychological Evaluation
What “Pre-Ops” Want ?
 Self-esteem
  Energy
  Happiness, optimism
  Depression
  Physical symptoms
  Medications
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Patients Report Dramatic Changes After
Surgery
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Able to breathe easily.
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Able to sleep & wake up
refreshed.
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Free from snoring & apnea.
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Off most pre-op meds.
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Free from joint pain.
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More active and less
fatigued
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Resolution of chronic
issues
like skin rashes.
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Relief from depression
Excited to start a new day
Happy to look in the mirror
when getting ready for
work
Experienced improvement
in work arena, i.e.
promotion,
new duties, raises etc.
Able to pursue new
hobbies and interests.
Self confident.
Psychological Evaluation
What “Post-ops” Get ?
Positives: Psychological
 Self esteem
  Happiness, optimism
  Body image
  Emotional access
  Depression
  Food obsession
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Psychological Evaluation
What “Post-ops” Get ?
Positives: Social
 Going out, trying new activities
  Socializing
  Intimacy
  Sex, libido
  Dating, flirting
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Psychological Evaluation
What “Post-ops” Get ?
Positives: Physical
 Health (general)
  Energy
  Mobility (activities of daily living)
  Physical symptoms (sleep dsrpt, arthritis)
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 Clothing
Psychological Evaluation
Psychosocial Outcomes
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Improvements in social relations and employment.
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Reductions in depression and anxiety.
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Decreases in binge eating.
Herpertz et. al, 2003; Bocchieri et. al, 2002
Conclusion
Clinical Decision Making
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There are no well-established predictors of
surgery outcome.
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There are few alternative treatments for individuals
who qualify for surgery
Conclusion
Decisional Balance
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CONS
Potential for
complications.
Careful medical
monitoring for life
Miss time from work
Feeling like a failure.
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PROS
Long-term weight
control.
I’ll have a tool to help.
me eat less food at
each meal.
Perform better at my
job.
Helps improve my
diabetes and reduce
my medications.
Postoperative Eating Problems
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Although surgery has a positive impact
overall,some patients do experience the onset of
eating disorders after bariatric surgery (or other
behavioral health concerns).
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Eating disorders may be most common among
those who had binge eating or other eating
problems prior to operation.