Download BMI >30

4/18/16
Good
Afternoon!!
Jarrod Phelps PA-C
Surgical Associates
Grinnell, IA
Objectives
Bariatric Terminology
Recognize common issues after
bariatric surgery
2)  Recognize the most serious clinical
situations
3)  Identify & describe treatment for the
various conditions
ž 
1) 
Bariatric Terminology
ž 
IBW: Ideal Body Weight:
Men: IBW = 50 kg + 2.3 kg/inch >5ft.
Women: IBW = 45.5 kg + 2.3 kg/inch >5ft
v 
If the actual body weight is greater than 30%
of the calculated IBW, calculate the adjusted
body weight (ABW):
ABW = IBW + 0.4(actual weight - IBW)
ž 
BMI: Body Mass Index
Obesity By Definition
EBW: Excess Body Weight
ž  EBW
= Current weight – IBW
ž  %EBWL:
lost
Percent excess body weight
BMI >30
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Calculating BMI
BMI Categories
ž  U.S.
ž  BMI
BMI Formula =
(weight in pounds * 703 )
height in inches²
Or
ž  Metric
Formula=
(weight in kilograms)
height in meters²
Obesity Mortality
Obesity Epidemic
ž 
Three in five
Americans are
overweight/obese
ž 
Among adults has
doubled since 1980,
among adolescents
has tripled
<18.5: Underweight
18.5-24.9: Healthy weight
ž  BMI 25-29.9: Overweight
ž  BMI 30-34.9: Obese (OB I)
ž  BMI 35-39.9: Morbid Obesity (OB II)
ž  BMI >40: Super Morbid Obesity (OB III)
ž  BMI
ž 
300,000+ premature
deaths annually
ž 
75% of obese
children become
morbidly obese
adults
Obesity Demographics- 1985
As your BMI increases your
mortality risk grows
exponentially!!
Obesity Demographics- 2009
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Prevalence of Self-Reported Obesity Among U.S. Adults
by State and Territory, BRFSS, 2011
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Obesity % By State- 2014
1: Arkansas
2: West Virginia
3: Mississippi
4: Louisiana
5: Alabama
6: Oklahoma
7: Indiana
8: Ohio
9. North Dakota
10: South Carolina
11: Texas
12: Kentucky
13: Kansas
14: (tie) Tennessee & Wisconsin
16: Iowa
17: (tie) Delaware & MIchigan
19: Georgia
20: (tie) Missouri, Nebraska, Pennsylvania
23: South Dakota
24: (tie) Alaska & North Carolina
26: Maryland
27: Wyoming
28: Illinois
29: (tie) Arizona & Idaho
31: Virginia
32: New Mexico
33: Puerto Rico
34: Maine
35: Oregon
36: Nevada
37: Minnesota
38: New Hampshire
39: Washington
40: (tie) New York & Rhode Island
42: New Jersey
43: Montana
44: Connecticut
45: Florida
46: Utah
47: Vermont
48: California
49: Massachusetts
50: Hawaii
51: District of Columbia
52: Colorado
Prevalence of Self-Reported Obesity Among U.S. Adults
by State and Territory, BRFSS, 2014
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Health Care Costs Of Obesity
• $200 billion obesity-related costs
annually
• 9.4% of national health budget
• 33% increase in inpatient and
outpatient spending
• 77% increase in medication use
• High cost drivers: Co-morbidities
with Obesity
Psychological Impact of Obesity
Social Implications of Obesity
• Depression
• Low self-esteem
• Social isolation
• Uncomfortable in public
• Lack intimacy
• Decreased libido
• Unable or Difficult to:
– Go to movies
– Sit on bus or in theater/plane seat
– Use seat belt
– Fit through turnstile
– Play/pick up children
– Maintain adequate hygiene
– Buy stylish clothes
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Obesity Consequences
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With BMI > 30
– 55% increase in mortality
– 70% increase in coronary artery disease
– 75% increase in stroke
– 400% increase in diabetes
Morbidly obese males between 25 and 35
have 12x the chance of mortality as normal
weight men
A morbidly obese adult has a 33% chance of
living to age 65 as that of a normal weight
person
Metabolic Syndrome
Common Comorbidities
Hypertension
Sleep Apnea
Osteoarthritis
Hyperlipidemia
Coronary Artery
Disease
Diabetes Mellitus
GERD
PCOS
Metabolic Syndrome
Stroke
DVT/PE
Depression
Venous insufficiency
Joint and Back Pain
Skin ulcers & infections
Infertility
Hypoventilation
Syndrome
Metabolic Syndrome
Obesity Treatment Options
• No Medical Intervention (most common)
• Behavioral Therapy
• Pharmaceutical
• Hypnosis
• Diet
• Endoscopic
• Surgical (Increasing Awareness and
Popularity)
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Non-Operative Treatment
Non-Operative Treatment
• Combinations of medical, dietary,
behavioral, pharmacologic, and exercise
–majority of studies of short duration
– average weight loss less than 20-25
lbs
– combined dietary/behavioral therapy
– sustained weight reduction
uncommon (<5%)
– lifelong behavior modification required
• Diet control works well for people not morbidly
obese
– ie 20-50 pounds over ideal body weight
– “yo-yo” effect poses health risks in
decreased immunity
– 95% of patients regain all or more weight
than was lost
In general, ineffective (and often harmful) for
morbidly obese patients
• Traditional bariatric surgery
– Effective, but very low utilization; 1:300 to
1:500 (Improving)
Hormonal Obesity Factors
GOAL of Bariatric Surgery
• Significant and Sustained Weight
Reduction
• Improve Health
• Improve Quality of Life
• Increase Lifespan
• Not Cosmetic—this is only a desired
additional effect
Comorbidity Improvement
Evolution of Obesity
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Criteria for Surgery
Bariatric Program Requirements
• BMI > 40 kg/m2
and/or
• BMI >35 kg/m2 with co-morbidities
• Patient has made attempts at nonoperative weight loss
• Patient willing to make healthy lifestyle
changes
Surgical Options
• Types of weight loss surgeries
A) Malabsorptive procedures shorten the
digestive tract
1) Biliopancreatic diversion with/without
duodenal switch aka BPD/DS
B) Restrictive procedures reduce how much the
stomach can hold
1) LAP-BAND
2) Sleeve Gastrectomy
C) Combined procedures shorten the digestive
tract and reduce how much the stomach can
hold
1) Roux-en Y Gastric Bypass
Common Side Effects after BPD/
DS
Biliopancreatic Diversion with
Duodenal Switch
The Duodenal Switch procedure (also called
vertical gastrectomy with duodenal switch,
biliopancreatic diversion with duodenal switch,
DS or BPD-DS) is performed by
approximately 50 surgeons worldwide. It
generates weight loss by restricting the
amount of food that can be eaten (removal of
stomach or vertical gastrectomy) and by
limiting the amount of food that is absorbed
into the body (intestinal bypass or duodenal
switch). It is more controversial because it has
a significant component of malabsorption
(bypass of the intestinal tract), which seems to
augment and help maintain long-term weight
loss. Of the procedures that are currently
performed for the treatment of obesity, it
seems to be the most powerful and effective,
but may also have more complications
associated with it. Because of this, some
insurance companies will not authorize it and
consider it investigational. Most surgeons do
not perform this procedure because of
concerns about the long term effects of
malabsorption.
Where are Nutrients Absorbed?
Area Between the lines indicate the bypassed portion of the
digestive system after BPD/DS
Increased incidence of nutritional
deficiencies
Increased protein deficiencies
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Normal vs Roux en Y
Roux en Y Gastric
Bypass
Roux-en-Y gastric bypass surgery: a
15-30 mL gastric pouch is created and
is anastomosed end-to-side to a Roux
limb to create the Roux limb, the
surgeon transects the jejunum at
approximately 30 cm from the ligament
of Treitz. The Roux limb is measured
75 cm distally, or 150 cm distally for the
massively obese patient, and a stapled
side-to-side anastomosis is created
with the proximal jejunal limb. The
enterotomy sites are stapled closed,
and the mesenteric defects of the
jejunum and transverse colon are
sutured closed. The Roux limb can be
brought to the pouch through or
anterior relative to the transverse
mesocolon and is either ante- or
retrogastric. Food no longer goes to the
larger portion of the stomach. Because
none of the original stomach is
removed, its secretions can travel to
the duodenum. The divided portion of
the jejunum is reconnected distally.
Acute Postop surgical issues/
Early complications
ž 
Serious
—  Anastomotic Leak
—  Internal Hernias
—  PE/DVT
—  Acute Hemorrhagic
Anemia
—  Acute Respiratory
Failure
—  Gastric Outlet
Obstruction
UGI
Others
—  Pneumonia
—  Atelectasis
—  Superficial Wound
Infections
—  Gastric Outlet
Stricture/Edema
—  Deep Space
Infections
—  Dehydration
Gastric Outlet Stricture before
and during balloon Dilatation
Late Complications
ž  Internal
Hernia
Ulcers
ž  Gastrogastric Fistula
ž  Dumping Syndrome
ž  Weight Regain
ž  Vitamin Deficiencies
ž  Marginal
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Peterson’s Internal Hernia
Marginal Ulcer
Gastrogastric Fistula
Dumping Syndrome Symptoms
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Vitamin Deficiencies
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Vitamin B12
Iron
Folate
Thiamin
Copper
Pyridoxine (B6)
Vitamin A
Vitamin K
Vitamin E
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Zinc
Magnesium
Vitamin D
Niacin
Selenium
Calcium
Protein
B12 Supplementation
ž  500
mcg-1 mg po q day
ž  If
compliant and still deficient consider
increasing to 2 mg po q day or 1000mcg
IM injections q week x 8 weeks, then
1000 mcg injection q month
Iron Supplementation
ž  Encourage
MVI choice with high Iron
content
ž  May need additional FeSO4 325 mg po
BID or Elemental Iron 65 mg po BID
ž  Consider Fe Infusions for refractory Fe
Deficient patients
Vitamin Supplementation
ž 
Sleeve/Lap Band
ž 
1 MVI with Folic Acid
Daily
ž 
Roux en Y
ž 
2 MVI Daily with
Folic Acid
Thiamin Supplementation
ž  B-Complex
Multivitamin Daily
ž  If
Neuro Symptoms- 100 mg IV and may
need repeat doses
Calcium & Vitamin D
Supplementation
ž  Vitamin
D 800-2000 IU Daily
—  Take 300-600 po tid
—  If refractory increase to 50,000 IU q week
ž  Calcium
1500-2000 mg daily
recommendation
—  Take 500-600 mg po tid
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Protein Supplementation
ž  60-80
grams per day
Sleeve Gastrectomy
Sleeve gastrectomy is a purely
restrictive procedure. It can be
used as a primary weight loss
operation or as a first-stage
operation in a 2-stage approach
in patients who are extremely
obese and may carry significant
risks to undergo a one step
definitive surgical approach.
The sleeve gastrectomy is an
operation in which the left side of
the stomach is surgically
removed. This results in a new
stomach which is roughly the size
and shape of a banana.
Lap Band
A gastric band with a small balloon
inside is attached around the top portion
of your stomach, forming a smaller
“gastric pouch”. The placement of the
band creates a small pouch at the top of
the stomach that holds up to
approximately 30 ml, which works out to
about 1/8 cup. You are inclined to eat
less because the pouch holds less food
than the whole stomach. As the upper
part of the stomach registers itself as
being full, it sends a message to the
brain saying that the entire stomach is
full. This is the main principle behind the
lap band procedure
Normal vs Lap Band
Lap Band
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WTF? – What To look For!!
Repair of Slipped Lap Band
Lap Band Tubing Causing Bowel
Obstruction
Slipped Lap Band
Repair Slipped Lap Band
Help Fight Obesity
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Sources
Sources
Scopinaro N, Gianetta E, Pandolfo N, et al. Biliopancreatic
bypass. Proposal and preliminary experimental study of a new
type of operation for the functional surgical treatment of obesity.
Minerva Chir. 1976;31:560–566.- retrieved 3/14/2016
Scopinaro N, Gianetta E, Adami GF, et al. Biliopancreatic
diversion at eighteen years. Surgery. 1996;119:261–268retrieved 3/14/2016
Hatzifotis M, Dolan K, Fielding G. Vitamin A deficiency following
biliopancreatic diversion. Obes Surg. 2003.- retrieved 3/14/2016
Cho M, Pinto D, Carrodeguas L, et al. Frequencyand
management of internal hernias after laparoscopic antecolic
antegastric Roux-en-Y gastric bypass without division of the
small bowel mesentery or closure of mesenteric defects:
Review of 1400 consecutive cases. SOARD 2006;2(2):87–91.retrieved 3/15/2016
Aills L, Blankenship J, Buffington C, et al. Allied Health Sciences
Section Ad Hoc Nutrition Committee. ASMBS Allied Health
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Obes Relat Dis. 2008;4(Suppl):S73–108.
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t1-0550329/- retrievded 3/16/2016
Taylor K. Metabolic and bariatric surgery [fact sheet]. American
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Iannelli A, Buratti MS, Novellas S, et al. Internal hernia as a
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Sources
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D'Haeninck A, De LP, Swinnen F. Internal herniation after Rouxen-Y gastric bypass: case reports and a review of the literature.
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Nguyen NT, DeMaria E, Ikramuddin S, et al., editors. The
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Marshall JS, Srivastava A, Gupta SK, et al. Roux-en-Y gastric
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