Download Bariatric Surgery Program - The Canadian Association of Critical

Bariatric Surgery
Program
The Ottawa Hospital
Weight Management Clinic
Agenda
Epidemiology
Etiology
Treatment Strategies
Complications and Monitoring
Sensitivity
Questions?
What does Overweight or Obese
look like?
Bulik et al., Int J Obes Relat Metab Disord, 2001, 25(10)
Obesity Trends Among Canadian Adults
Obesity Trends Among Canadian Adults
Obesity Trends Among Canadian Adults
Obesity Trends Among Canadian Adults
Obesity Trends Among Canadian Adults
Obesity in Canada: an Epidemic
(*BMI  30, or ~ 30 lbs overweight for 5’4” woman)
Adults 2004
No Data
Data from: Statistics Canada.
<10%
10% -14%
15 -19%
20%
4/33
Let’s Face The Facts






FACTS
2 in 3 Canadians are overweight
1 in 4 are obese
Obesity in children and adolescents has tripled
over 20 years
IMPLICATIONS
Obesity causes 1 in 10 premature deaths among
Canadian adults 20-64 years
Cost of obesity in Canada is estimated to be over
$2 billion a year
AND its getting worse .....
CMAJ Apr. 10, 2007 176(8) 1103
Energy in = Energy out + Energy
Stored….. Right?
The first law of thermodynamic
Energy
in
Energy
Out
Assessment and management of
Obesity
Factors Contributing to Obesity
Lifestyle
Poor diet
Meal skipping
Soft drink intake
Poor sleep
Snacking
Alcohol
Inactivity
Fructose
Artificial
Sweeteners
Psychosocial
Depression
Anxiety
Binge Eating
Boredom
Social Events
Income
Stress
Biomedical
Genetics
Metabolism
Medications
Injury
Mobility
BPA and other
environmental
toxins
Obesity System Map
http://kim.foresight.gov.uk/Obesity/Obesity.html
Health Consequences of Obesity
Depression
Sleep apnea
Coronary artery
disease
Fatty liver
Gallbladder disease
Incontinence
Brain tumors
Heart failure
Acid reflux disease
Diabetes
Hypertension
Cancer
Infertility
Osteoarthritis
Blood clots
Gout/Edema
Sharma, 2006
Weight Loss Strategies
 Lifestyle/Food Strategies
 Medications
 Surgery
Treatment Success
Change in Weight
Lifestyle (LS) ~3-5%
LS + Pharmacotherapy ~5-15%
LS + Surgery ~20-30%
Years
Sharma, A
Trends in Bariatric Surgery
Padwal CMAJ 2005;172(6):735
The Problem:
 Champlain LHIN has > 100,000 who would be
eligible for Bariatric Surgery
 Ontario has a limited capacity to perform Bariatric
surgery < 10,000 per year
Why the need?
 Huge expense on Ontario
tax payers


$60 million spent on out-ofcountry/province patients
$10-20 million spent in
province
 Saves money
$25,000
$19,000
 Growing referrals


December 2009 – MOHLTC
received >900/month
Since January 2010 – TOH
>1000 referrals
Surgery
NonSurgery
Who Qualifies for Surgery?





BMI >40
BMI>35 with serious weight related health condition
Non-smoker x6 months
Previous unsuccessful weight loss attempts
Be prepared to make significant lifestyle changes to
your diet and activity level after surgery
 Undergo medical exams, tests, and blood tests as
required before and after surgery
 Attend education sessions before and after surgery
Positive Outcomes
Surgery can affect the following:
 Improve Quality of Life
 Improvement in Chronic Conditions (i.e. Type 2
Diabetes, Hypertension, Arthritis, Sleep Apnea)
 Improved Mental Health
 Improved exercise tolerance
 Weight Loss
Preparing for Surgery
All patients:
 Undergo pre-surgical education classes
 Self manage chronic diseases (DM2, HTN)
 Smoke free
 Attempt lifestyle, eating, and physical activity changes
 Shrink liver prior to surgery (OPTIFAST)
- VLCD (Optifast) decreases liver size by 23%
- Decreases risk of complications post operatively
- Improves nutrition status pre-operatively

Avoid caffeine, carbonated beverages, alcohol and
NSAIDs for the rest of their lives
Types of Bariatric Surgery
Adjustable Gastric Band
 Not covered by
MOHLTC
 Offered privately
at approx. $18,000
 Demanding followups
 Not useful for longterm success
Roux-en-y Gastric Bypass
Sleeve Gastrectomy
Duodenal Switch
 Not covered by
MOHLTC
 Very high risk
 Numerous
complications
Complications & Risks
Death
ALL surgeries have a risk of death.
 Large research studies found between 0.2% and 2%
mortality for the RYGB
 The most common cause of death


Blood clot in the lung (pulmonary embolism)
Infections due to gastric leaks
TOH: 3 deaths / ~700 surgeries
Risks of Gastric Bypass
Early









Pain
Nausea / Vomiting
Constipation / Diarrhea
Stricture / Blockage
Heart and lung problems
Blood clots
Leaks
Infection
Organ failure
Late






Pain
Dumping syndrome
Constipation
Nutritional deficiencies
Gallbladder disease
Psychological disorders
Micro-nutrient Absorption
Calcium
Manganese
Iron
Molybdenum
Cyanocobalamin
Zinc
Thiamin
Magnesium
Vitamin C
Folate
Vitamin A, D, E, K
Phosphorus
Riboflavin
Chromium
Niacin
Selenium
Chloride
Copper
Pantothenate
Biotin
Nutritional Deficiencies Resulting from
Bariatric Surgery
Nutrient
LAGB
RYGB
BPD/DS
√√√
Macronutrients
√
√
Ironb
√√
√
Vitamin B12
√√√
√
Vitamin D
√√√
√√√
Thiamina
√
LAGB = Laparoscopic adjustable gastric banding;
RYGB = Roux-en-Y gastric bypass;
BPD/DS = biliopancreatic bypass/duodenal switch
awith persistent vomiting; bincreased with menstruation
Slide source: Kushner, R. (2009)
Real Results
 55 y.o female
 Wt: 261 lbs Ht: 5’6”
BMI: 43
 HTN, severe DM2, CAD, Dyslipidemia, OA, GERD,
diabetic retinopathy/neuropathy
 Levemir 16 units; Novorapid 2,2,4 + Metformin 1000 mg
 FBS: >15 mmol/L
 ++ hx of lifestyle modifications and numerous
wt. loss attempts
 Pre-surgery wt: 246 lbs
Treatment Success
Change in Weight
Lifestyle (LS) ~3-5%
LS + Pharmacotherapy ~5-15%
LS + Surgery ~20-30%
Years
Sharma, A
Real Results
 Most patients are off all insulin by the time they are
discharged from hospital
 Resolution or major improvement of weight related
conditions
 Will lose 50-80% of excess
 “I feel better than I have in my whole life”
 “This is the best thing I ever did for myself”
Nursing
Considerations
Emergency
Presentations
IF:
•Unstable vital signs
•
•
•
•
•
•
Fever > 38.3 Degrees C
Hypotension
Tachycardia > 120 bpm X 4h
Tachypnea
Hypoxia
Decreased Urine Output
•BRBPR/PO
•Abdo pain/colic > 4 h
•Nausea and or vomiting > 4 h
•Vomiting and Abdo pain > 4 h
Consider Anastamotic leak!
•Diagnose within 6 hours
•To OR within 12 hour
Thiamin
Deficiency can:
- take as little as 3 weeks to develop
- lead to a Wernicke-Korsakoff syndrome
IV Thiamin should be infused with RL or NS.
Infusion with IV dextrose increases the risk of
PERMANENT neurological damage
Symptoms of Wernicke’s include
•Wide gait
•Visual disturbances
•Nystagmus
•Peripheral paresthesia
NSAIDS
All NSAIDs with the exception of 81 mg ASA
should be avoided at all costs
COX-2 inhibitors may be given with caution. We
do discourage them (Meloxicam, Celebricox)
Other Medications
These medications increase risk of perforation or ulcer
•Steroids
•Plavix
ICU patient should be on a Proton Pump Inhibitor
Feeding and stomach
decompression
- Avoid “PO” volumes of > 180 mL (oral contrast)
-NEVER insert an NG tube blind
- NG Tube will not decompress the remnant stomach
- If Dx is anatamotic leak, wait 3 days to feed
- Very high Protein requirements
- Use Elemental Formulas and avoid fibre
*****Domperidone causes ventricular arrhythmias
and sudden cardiac death ************
Sensitivity
Weight Bias in Health Care
 Attitudes towards people living with obesity
 Non compliant, dishonest, unpleasant, lazy, sloppy
 Weight stigma
 Blame and intolerance
 Reduces QOL at all ages
 Results in serious psychological, social and physical health
consequences
 Consequences of stigma
 Unhealthy eating behaviours ie. binge eating
 Unhealthy wt control practices
 Avoidance of medical care
Puhl & Brownell, Obesity Rsh, 2001 9(12)
Questions?
Additional
AdditionalInformation
Information
Contact:
Contact:
Jeff P. Kilbreath, RN, BA, BScN
Advanced Practice Nurse, Bariatrics
Vanessa Helleur, NP, BScN, MN
[email protected] x 13953
Nurse Practitioner, Bariatric Surgery
Thanks to:
Jeff P. Kilbreath, RN, BA, BScN
Carolyn Kennelly, MSc., RN
Jennifer Brown, BSc., RD